Fertility, Pregnancy and Family Planning after a Cancer Diagnosis Terri Lynn Woodard, MD Assistant Professor MD Anderson Cancer Center

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Breast Cancer, Fertility and Family Building Approximately 6% of women diagnosed with breast cancer are of reproductive age (<40 years) Many will not have started/completed their childbearing plans Importance of addressing fertility and family building issues

Impact of Breast Cancer Treatment on Fertility Age Depends on type of therapy Chemotherapy The risk of amenorrhea after receiving typical adjuvant chemotherapy regimens in women under 40 is 21-71% versus 49-100% for those over 40. Baseline fertility status Type Dose

Impact of Breast Cancer Treatment on Fertility Endocrine therapy: Tamoxifen Selective Estrogen-Receptor Modulator Used in the treatment of premenopausal estrogen-receptor positive breast cancers Teratogen Recommended for 5-10 years Age becomes the biggest obstacle!

In an Ideal World: Fertility Preservation Discussion should be encouraged Various methods available ART Ovarian tissue cryopreservation Ovarian Suppression Some challenges and limitations

Doing Your Due Diligence… What is my current fertility status? Safety Is it “Safe” for me to become pregnant? Will pregnancy affect my prognosis? Can my future children be affected? When should I try to conceive What are the different ways that I can build my family?

What is My Current Fertility Status?

Fertility Status MENSES FERTILITY ≠

The Truth about Fertility in Women We are born with all the eggs we are ever going to have Fertility declines with age

How We Assess Ovarian Reserve Hormones Follicle Stimulating Hormone (FSH), estradiol, inhibin B Antimullerian Hormone (AMH) Ultrasound Ovarian volume, antral follicle count Hormones Follicle Stimulating Hormone (FSH), estradiol, inhibin B Antimullerian Hormone (AMH) Ultrasound Ovarian volume, antral follicle count

Antral Follicle Count Poor antral follicle count Good antral follicle count Photos used with permission from Texas Children’s Hospital Family Fertility Center

Interpreting the Testing: Odds and Probabilities Must be considered in the context of age and your medical history Does not predict ability to become pregnant Just tells us how easy or difficult it might be Must be considered in the context of age and your medical history Does not predict ability to become pregnant Just tells us how easy or difficult it might be

Special Considerations for BRCA1/2 Mutation Carriers Some suggest lower ovarian reserve Increased risk for development of ovarian cancer Recommendation is to have a risk-reducing bilateral salpingo-oophorectomy (RRBSO) Can transmit mutation to offspring Role of Pre-implantation Genetic Diagnosis (PGD)

Is it “Safe” for Me to Become Pregnant?

Safety of Pregnancy No guarantees about anything Must consider effects of treatment on other aspects of health Pregnancy in general is a stressful condition Consultation with a Maternal Fetal Medicine (MFM) Specialist Preconception counseling Management of medication Management of coexisting medical conditions No guarantees about anything Must consider effects of treatment on other aspects of health Pregnancy in general is a stressful condition Consultation with a Maternal Fetal Medicine (MFM) Specialist Preconception counseling Management of medication Management of coexisting medical conditions

Will Pregnancy Affect My Prognosis?

Pregnancy and Prognosis Previously, pregnancy was thought to be contraindicated More recent data has been reassuring

Pregnancy after Breast Cancer Survivors who become pregnant do not appear to suffer worse outcomes than those who do not Meta-analyses Azim et al 14 studies with 1244 cases and 18,145 controls For overall survival, pooled relative risk was 0.59 (95% CI: 0.50-0.70), favoring survivors with subsequent pregnancy Valachis et al 9 studies Pooled hazard ratio of death was 0.51 (95% CI: 0.42-0.62), favoring survivors with subsequent pregnancy Similar findings for women with estrogen-receptor positive tumors Limitations of the data Survivors who become pregnant do not appear to suffer worse outcomes than those who do not Meta-analyses Azim et al 14 studies with 1244 cases and 18,145 controls For overall survival, pooled relative risk was 0.59 (95% CI: 0.50-0.70), favoring survivors with subsequent pregnancy Valachis et al 9 studies Pooled hazard ratio of death was 0.51 (95% CI: 0.42-0.62), favoring survivors with subsequent pregnancy Similar findings for women with estrogen-receptor positive tumors Limitations of the data

Can My Future Children Be Affected?

Impact on Offspring No increased risk of birth defects No increased risk of vertical transmission Exception: Genetic syndrome: Pre-implantation Genetic Diagnosis (PGD) Higher risk for cesarean section, pre-term delivery, low birth weight infants and delivery complications

When Should I Try to Conceive?

Timing of Conception It depends… requires thoughtful discussion with you and your health care providers Usually recommended once you are out of window of early relapse/recurrence Must have period of adequate treatment washout

What are the different ways that I can build my family?

Building Your Family Sometimes requires you to reshape the way you thought about building your family Range of options Natural intercourse Ovulation induction +/- intrauterine insemination Assisted Reproductive Technology (ART) Oocyte cryopreservation (“egg freezing”) In vitro fertilization (IVF) Third-party Reproduction Donor Egg Donor Embryo Surrogacy Adoption

Ovulation Induction with Intrauterine Insemination $300-700 ($1500-4000 with monitoring and medication)

ART: In Vitro Fertilization (IVF) Picture used with permission from MD Anderson Cancer Center

Embryos or Oocytes? Embryos Oocytes Most common and successful Experimental label removed Need a partner or donor sperm No partner required; provides reproductive autonomy; Bypasses some religious objections Takes approximately 2 weeks Requires ovarian stimulation Success rates approximately 30-35% Success rates rapidly improving: 25% $13,000 + medications $9000 + medications

Preimplantation Genetic Diagnosis (PGD) Biopsy of Day 3 or Day 5 Embryos Testing for Genetic Mutation (No transfer) Mutation + (Transfer) - Testing embryos for their genetic profile prior to embryo transfer

“Third-party Reproduction” The use of eggs, sperm, or embryos that have been donated by a third person (donor) to enable an infertile individual or couple (intended recipient) to become parents May be known or anonymous Complex

Third-party Reproduction: Donor Egg Picking donor versus using an egg bank Identifying a donor Evaluating a donor Evaluating the intended parent(s) Donor stimulation/Recipient preparation Success rates >50% Cost: $25,000-30,000 Picking donor versus using an egg bank Identifying a donor Evaluating a donor Evaluating the intended parent(s) Donor stimulation/Recipient preparation Success rates >50% Cost: $25,000-30,000

Third-party Reproduction: Donor Embryo “Embryo Adoption” Evaluating the intended parent(s) Recipient preparation Legal counsel VITAL No good stats on success rates Cost: $15,000-35,000

Third-party Reproduction: Surrogacy Traditional Surrogacy: woman is biologically related to the pregnancy she is carrying RISKY!!! Gestational Carrier: no biological relationship; carries the intended parents’ embryo(s)

Third-party Reproduction: Gestational Surrogacy Selection of gestational carrier (GC) Evaluation of GC and intended parent(s) Counseling Legal Recipient preparation Cost: $60,000 to 100,000+++

Adoption Various types Lifelong process Process: Application Home study Identification of child (or being ID’ d) Supervisory period Legal adoption Special considerations for survivors Cost: $0-$50,000+++

Psychosocial Aspects

Resources RESOLVE Livestrong American Society for Reproductive Medicine (ASRM) Reproductivefacts.org

Conclusions Building a family after a breast cancer diagnosis is possible There are many different options that are available Sometimes you have to reframe how you think about building your family Assert yourself; be proactive! Advocate!