Logistics – who, when and how Milton Ka Hong Leong MDCM DSc(McGill) FRCS(C) FRCOG FACOG FHKCOG Director, IVF Centre HK Sanatorium & Hospitals Specialist in Reproductive Medicine Adjunct Professor, Department Obstetrics & Gynecology McGill University,Montreal, CANADA

Breast Cancer Patients Clinical Summaries

Patient RT age 37 Cancer: Left Stage II ductal carcinoma microinvasive in ¼ SLN dissection Date of surgery 25.7.2006 Day seen 8.8.2006 (LMP 18.7.2006) EC: one natural cycle 21.8.2006 2 letrazole cycles – 7.9.2006, 27.9.2006 3 eggs total collected (0, 1, 2) 3 eggs vitrified

Patient WM Age 32 Cancer: right breast stage 2A Date of surgery 25.11.2006 Day seen 11.2.2006 (LMP 27.11.2006) EC: natural cycle unstimulated on day 9 11 immature oocytes 4 fertilized 3 embryo frozen

Patient TW age 36 Cancer: right breast 2.1 cm Stage IIa 0/7 sentinel node positive ERO PRO Day of surgery 16.5.2007 Day seen 22.6.2007 (LMP 22.5.2007) Couple had 2 IVF treatments in London Stimulated cycle low dose FSH, 10 oocytes, 7 fertilized , 6 embryos frozen Antagonist treatment following egg collection

Patient WM age 35 Cancer: right breast 1.2 cm Gr III ductal carcinoma 3/24 axillary nodes positive Day surgery 1.11.2007 Day seen 20.11.2007 (LMP 3.11.2007) U/S showed follicles 17, 10 and 8 mm EC 22.11.2007 - 2 immature eggs, fertilized 2 embryos frozen

Patient TP age 36 Cancer: left breast 2.6 cm Gr III ductal carcinoma 0/6 axillary lymph nodes positive Date surgery: 20.1.2007 Date seen: 17.2.2007 (LMP 14.2.2007) U/S – small follicles. EC planned but patient had to settle business at home. When return 21.2.2007 preovulatory with large single follicle. Patient choose to delay chemotherapy Stimulated cycle 3/07: low dose FSH – antagonist given immediately 13 oocytes - 10 fertilized, 9 embryos frozen

Patient WY age 35 Cancer: stage IIB Left 4 cm Grade I ductal carcinoma 2/30 axillary node positive Date surgery 16.11.2005 Date seen 5.12.2005 (LMP 22.11.2005) U/S multiple antral follicles 4-7 mm EC 10.12.2005 18 oocytes obtained IVM 10/18 matured 6 embryos frozen

Patient BY Age 38 Cancer: left breast 1.4 GRII ductal carcinoma 0/3 axillary node positive Date surgery 1.4.2006 Day seen 22.4.2006 3.4.2006 Patient refused chemotherapy ??? for pregnancy Patient has history of subfertility, and 3 IVF at QMH, poor responder 8.5.2006 IVM, no stimulation, 3 oocytes 2 embryos frozen 22.8.2006 2 embryos thawed and replaced, no pregnancy

What We can Learn From Case Reports Breast cancer patients all Lead time 2-3 weeks Not optimised (cycle restriction)

Female Patients Cycle timing can make difference 2 collections v.s. 1 or none in the window between OT and Chemotherapy

Preservation Of Fertility Male cancer patients Semen collection – no time restriction Prepuberty – needs surgery No proof effective

Testicular Tissue Freezing Valid technique (Fischer Hamburg HKSH Data) For patients who has too low sperm count in ejaculate

Preservation of Fertility Female Patients Respect menstrual cycle Timing is critical

Preservation of Fertility Female patients Cryopreservation eggs Cryopreservation embryos Cryopreservation ovarian tissue Protection of ovaries from irradiation

Sperm cryopreservation for Cancer patients Year 1994-2007 Total no. cases 57 Age range 15-40 Outcome Still freezing 35 cases Thawed and used 3 cases Case 1- IVF twin with live birth Case 2- IVF singleton with live birth Case 3- Undergoing 1st IVF treatment Discarded Patient request - Patient diseased *14 cases 5 cases *Most have normal SA post Ca treatment

Oocyte cryopreservation slow freezing Year 2002-2007 Female Age (mean) 37.3 years No. oocyte freezing cases 13 - - all for unexpectedly failed sperm collection on day of OR No. oocyte thawing cases 10 No. oocyte thawing cycles 11 No. ET cycles 9 - total 12 embryos Survival rate 63.8% (44/69) Fertilization rate 46.5% (20/43) No. embryos transfer (mean) 1.3 Pregnancy rate per thawed oocyte 2.9% (2/69) Pregnancy rate per ET 22.2% (2/9)* Implantation rate 16.7% (2/12) * 1st live-birth in HK from cryopreserved oocyte Tjer et al Fert Steril 2005

HKSH experience Breast cancer patients: 7 Embryos cryopreservation: 6 Oocyt cryopreservation: 1 Used: 0 Semen cyropreservation for cancer patient: 9 Used: 1 Pregnancy: 1

Wish List An integrated comprehensive service which will coordinate and triage cancer patients’ need with treatment plan. Treatment plan will have full consideration of fertility preservation if patient so desires.

What can we do 24/7/365 Hotline or call no. Immediate counseling appointment Coordinate cycle, integrating cancer therapy and fertility treatment Public awareness