Looking at these statistics, it is clear that breast cancer treatment today has to deal with not only treatment of the cancer and survival of these young women but also quality of life which for these young women in their reproductive age include fertility issues.
Recent surveys indicate that the majority of breast cancer survivors who have no children at the time of diagnosis would like to have them in the future. Surveys also indicate that survivors who already have children would like to have more. Yet, many report that they did not receive adequate information about their future fertility and how to preserve it at the time of their cancer diagnosis and when they were making decisions about their treatment.
Before we can discuss how to preserve fertility in these breast cancer survivors, we need to learn about what effects breast cancer treatments have on fertility.
Chemotherapy drugs work by targeting rapidly dividing cells. These rapidly dividing cells not only include cancer cells but also normal cells such as those in the sperm, egg and/or hormone producing cells that are important in reproduction. Often, these chemotherapy drugs render a breast cancer patient infertile or leave her with decreased overall ovarian reserve (decreased egg that can reproduce).
Radiation used in breast cancer treatment also target rapidly dividing cells but is usually limited to tissues that surround the breast. This means that the radiation used to treat breast cancer usually does not affect the ovaries which are located in the pelvis. However, for those young women who receive radiation to these abdominal/pelvic region for other cancers can damage the uterus and ovaries.
Males who receive radiation for a cancer in these regions can suffer damage to their testicles causing infertility. Radiation to certain areas of brain can also result in infertility by affecting cells that regulate hormone production which is necessary for reproduction.
Surgery to remove the reproductive organs can obviously render a person infertile.
However, there are options in preserving fertility for these patients. The feasibility, safety and suitability of different types of fertility preservations option depend on the patient’s age, type of cancer and treatment and whether or not the patient has a significant other.
Other factors that are important in preserving fertility also include the cost of the procedure, availability of the procedure and success rate or the procedure. Thus, you need to talk to your doctor about what suits you the best. This fertility preservation is highly person and needs to be individualized to ensure best result.
Since we are discussing breast cancer survivors and their fertility, we’ll limit our discussion to those methods that are suitable for females.
Embryo freezing is a method in which mature eggs are collected from the patient and fertilized in vitro (egg and sperm are combined in a laboratory dish and allowed to fertilize). This requires a partner or donor sperm. This embryo is then frozen for future use. In order to allow harvesting of most viable eggs, the patient usually is given hormones to stimulate her ovaries to produce multiple eggs.
These eggs are then collected using a needle that is guided into the ovary by ultrasound or by laparoscopic surgery. Embryo freezing is one of the most successful techniques available and safer for patients with hormone sensitive breast cancers. Egg or oocyte freezing involves collection of mature eggs and freezing these them without fertilizing them. This may be good for women who do not have a partner or do not wish to use donor sperm at the time of freezing. Success rate of this procedure varies.
Ovarian tissue freezing involves surgical removal of the ovarian tissue, cutting it into small pieces and freezing them for later. This tissue, when the person is ready, is then transplanted back into the woman’s body. This is experimental and success rate varies.
Gonadotropin releasing hormone (GnRH) analog treatment involves treatment the woman with GnRH analogs during chemotherapy which theoretically renders the woman’s body to think that she is before puberty. This reduces damage to her reproductive tissue and help preserve fertility. This has not shown to be very promising.
So, what happens when one of these techniques are used to preserve fertility and the survivor is pregnant? Let’s look at some data regarding possible risks to the fetus and children conceived this way.
Current research indicates that children of cancer survivors are not more likely to have birth defects of chromosome abnormalities, although data is limited. In addition, these children do not have higher rate of cancer development.
Many of above fertility-preserving techniques are fairly new. Therefore, there is not much available data. However, the data that is available show little evidence that there is increased risk of birth defects of developmental problems in these children. However, these survivors are at an increased risk of having multiple births (e.g. twins, triples…etc.).
There is also increased risk of having a premature baby, low birth weight, miscarriage and infant death even when only one fetus is conceived using these techniques. In addition, pregnancy may aggravate organ damage caused by cancer treatment. Some breast cancer treatments especially chest radiation and/or chemotherapy can damage the cardiovascular structures.
The demands on these structures during pregnancy can be significant, especially if they are not healthy due to damage suffered during your cancer treatment. Thus, all breast cancer survivors who become pregnant are at an increased risk for pregnancy related complications and must be cared for by a specialist who can monitor and treat any complications that may arise.
Most cancer survivors worry about whether pregnancy after breast cancer increases their chance of cancer coming back and/or decreased survival if this recurrence does occur. Data is limited and there is a lot of controversy regarding pregnancy in these breast cancer survivors. However, current studies indicate that their risk of recurrence is not increased and that their survival rate is not diminished with pregnancy. In addition, data suggests that these fertility preserving options do not decrease the success of cancer treatment.
However, keep in mind that the data is limited and whether or not you should or should not bear children after your breast cancer treatment needs to be decided after careful counseling by your doctor and fertility specialist as this decision may be impacted by the type of your cancer and the type of treatment you received.
The optimal timing of when to get pregnant after breast cancer treatment is not clear.
Most studies indicate waiting 2-5 years after treatment to make sure that your treatment has been successful and your chance of recurrence is low during pregnancy. Again, preparation is the key. Know your facts and your risks about getting pregnant. Don’t put yourself and your baby at risk if pregnancy isn’t right for you.
Dr. Yoon earned her medical degree from Washington University School of Medicine, St. Louis, MO. Following her graduation from medical school, Dr. Yoon completed her residency training in Radiology at Mallinckrodt Institute of Radiology Washington University School of Medicine, St. Louis, MO. She has completed a fellowship in Breast Imaging from Mallinckrodt Institute of Radiology. She has also completed a fellowship in High Risk OB Ultrasound at Vanderbilt University. She is board certified in diagnostic radiology. Dr. Yoon serves as the Women’s Section Chief for RSF.