FAMILY PLANNING AFTER BREAST CANCER Laxmi A Kondapalli, MD MSCE Assistant Professor, Reproductive Endocrinology & Infertility Director, Fertility Preservation Program Department of Obstetrics and Gynecology University of Colorado Denver

Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Disclosure  The speaker has no financial or other conflict of interest

Objectives  how does breast cancer and its treatment affect fertility?  what fertility preservation options are available before and after treatment?  how can I evaluate current fertility status?  is pregnancy safe after breast cancer? Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer

Fertility as a Survivorship Issue Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer 1 Armuand GM et al, Trottman L et al, Letourneu JM et al, 2012  40% of survivors do not recall discussing fertility impact of cancer treatment with oncologist 1  24% of young male cancer patients pursued sperm banking 2  4% of young female cancer patients pursued fertility preservation 3 1.6M new cancer cases with ~10% younger than 45 years

ASCO and ASRM Guidelines Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Discussion of fertility impact should be part of informed consent to cancer therapy

Loss of Eggs is Faster for Survivors Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Max potential in utero 7M 1-2M

Structure of the Ovary Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer

Estimated Risk of Gonadotoxicity Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Alkylating chemotherapy Cyclophosphamide, ifosfamide Busulfan, mephalan Total body irradiation, stem cell transplant High (>80%) Platinum-based chemotherapy Cisplatin, carboplatin Adriamycin Moderate Cell cycle dependent agents Methotrexate, vincristine, bleomycin Low (<20%)

Normal Periods ≠ Normal Fertility Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Letourneau et al. Cancer % 25%

How does the brain fit? Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer

Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Fertility preservation options before breast cancer treatment

Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer  Oophoropexy  Egg/embryo banking  Ovarian tissue banking  Donor eggs, adoption  Gestational carrier Established Options for Post-Pubertal Females

Oocyte & Embryo Cryopreservation

Is egg/embryo banking safe? Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Azim et al. JCO 2008

Emerging Options for Pre/Post-Pubertal Females use of GnRH agonists Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Mechanism unknown  Apoptosis  Impaired perfusion  Induce protective factors Conflicting results  Retrospective studies with historical controls  Use of surrogate outcomes (return of menses)  Need for RCT role in hematologic malignancies

Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Kondapalli & Gracia, 2010 no delay in treatment, can be combined with other procedures to minimize anesthesia Emerging Options for Pre/Post-Pubertal Females ovarian tissue cryopreservation

Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Emerging Options for Pre/Post-Pubertal Females ovarian tissue transplantation  No delay in treatment  Not appropriate in hematologic cancers  ~40 live births Silber et al. NEJM 2005

Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Fertility testing and options after breast cancer treatment

Assessing Fertility Status Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer  Special blood tests that are timed with your menstrual cycle  anti-mullerian hormone  FSH  estradiol  Pelvic ultrasound  Hysterosalpingogram

Assessing Fertility Status Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer

Fertility Treatment Options Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer  Fertility medications (oral, injections)  use of aromatase inhibitors  Artificial insemination  In vitro fertilization  Preimplantation genetic diagnosis  Comprehensive chromosomal screening

Preimplantation Genetic Diagnosis

Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Preimplantation Genetic Diagnosis

Oncofertility Resources Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer myoncofertility.org savemyfertility.org

Oncofertility Funding Academic Enrichment Fund NIH 5K12HD

FAMILY PLANNING AFTER BREAST CANCER Laxmi A Kondapalli, MD MSCE Assistant Professor, Reproductive Endocrinology & Infertility Director, Fertility Preservation Program Department of Obstetrics and Gynecology University of Colorado Denver