Fertility Preservation in Breast Cancer Dr s.Hosseini SBMU Summer 2019

INTRODUCTION Breast cancer is the most common type of cancer among young adult women Quality of life for cancer survivors is important because of the high survival rate due to early diagnosis and improvements in cancer treatment

why preservation? Gonadotoxic chemotherapy Long –lasting adjuvant therapies Non-pharmacologic ovarian suppression Radiation therapy ?

introduction ASCO guidelines recommend : health care providers should inform cancer patients about the possibility of infertility Should also be prepared to discuss FP options and /or to refer all potential patients to appropriate reproductive specialists

introduction more than 90% of young breast cancer patients showed to be concerned about the potential risk of developing chemotherapy- induced premature ovarian insufficiency and/or infertility only 12% of them decided to access cryopreservation strategies

effect of chemotherapy Patient age Familial ovarian history Ovarian follicle reserve History of previous ovarian and pelvic surgery Previous chemotherapy Previous pelvic and abdominal radiotherapy Persistent high level of FSH Class of the chemotherapeutic agent(alkylating vs nonalkylating) Concomitant other diseases Dosing and length of chemotherapy

endocrine therapy While young women are more likely to have TN or HER2 amplified breast cancer, a large proportion of women have estrogen receptor positive (ER+) breast cancer Endocrine therapy has resulted in a significant increase in disease- free and overall survival for women with ER+ breast cancer

endocrine therapy 5 year or 10 year In ER positive cancer Postpone pregnancy

Fertility Preservation Strategies Oocyte Cryopreservation Embryo Cryopreservation Ovarian tissue Cryopreservation GnRh suppression

ovarian stimulation oocyte and embryo cryopreservation need ovarian stimulation, which results in increased serum estradiol levels that may accelerate breast cancer growth. In order to avoid estradiol elevation, the protocol of ovarian stimulation with aromatase inhibitor (AI) was proposed as the protocol is unlikely to increase recurrence

A recent systematic review of letrozole for ovarian hyperstimulation demonstrated: adequate oocyte yield low estradiol levels no effect on breast cancer recurrence rates.

Time? Random start ovarian stimulation

Oocyte cryopreservation Mature oocytes Immature oocytes( in vitro maturation)

Ovarian cryopreservation The cumulative clinical and LB + OG rates were 57.5% and 37.7%, respectively, and the endocrine restoration rate was 63.9%. Success rates with cryopreserved OTT have reached promising levels. Given these recent data, ovarian tissue cryopreservation should be considered as a viable option for FP.

The efficacy of GnRH therapy for fertility preservation is difficult to assess because many studies have used unreliable or non-suitable surrogate outcomes. most of the studies have assessed the treatment in women with different types of diseases

Fertility preservation with ART was not associated with treatment delay in patients with breast cancer who were referred to reproductive specialists before cancer treatment