1. 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

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

3. 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

4. Fertility as a Survivorship Issue Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer 1 Armuand GM et al, 2012 2 Trottman L et al, 2007 3 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

5. 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

6. 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

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

8. 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%)

9. Normal Periods ≠ Normal Fertility Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer Letourneau et al. Cancer 2012 60% 25%

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

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

12. 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

13. Oocyte & Embryo Cryopreservation

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

16. 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

17. 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

18. 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

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

20. 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

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

22. 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

23. Preimplantation Genetic Diagnosis

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

25. Oncofertility Resources Oncofertility Program | Department of Obstetrics & Gynecology Expanding parenthood options for life after cancer http://arm.coloradowomenshealth.com/service/oncofertility myoncofertility.org savemyfertility.org

26. Oncofertility Funding Academic Enrichment Fund NIH 5K12HD001271-13

27. 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