Download Having Children after Cancer* Fertility

Having Children after Cancer:
Fertility, Pregnancy and
Family Planning
Sisters Network Inc.
Annual National African American Breast Cancer
10 City Conference Tour Kickoff
October, 2014
Terri L. Woodard, MD
Assistant Professor
Director of Reproductive Services
Department of Gynecologic Oncology and Reproductive Medicine
The University of Texas MD Anderson Cancer Center
Breast Cancer, Fertility and
Family Building
• Approximately 6% of women diagnosed with
breast cancer are of reproductive age (<40
years)
• Many will not have started/completed their
childbearing plans
• Importance of addressing fertility and family
building issues
The Truth about Fertility
in Women
• We are born with all the eggs we are ever
going to have
• Fertility declines with age
Impact of Breast Cancer
Treatment on Fertility
• Depends on type of therapy
• Chemotherapy
• Age
• The risk of amenorrhea after receiving typical
adjuvant chemotherapy regimens in women
under 40 is 21-71% versus 49-100% for those over
40.
• Baseline fertility status
• Type
• Dose
Impact of Breast Cancer
Treatment on Fertility
• Hormonal therapy: Tamoxifen
• Selective Estrogen-Receptor Modulator
• Used in the treatment of premenopausal
estrogen-receptor positive breast cancers
• Teratogen
• Recommended for 5-10 years
• Age becomes the biggest obstacle!
In an Ideal World: Fertility
Preservation
• Discussion should be encouraged
• Various methods available
• ART
• Ovarian tissue cryopreservation
• Ovarian Suppression
• Some challenges and limitations
Doing Your Due Diligence
• What is my current fertility status?
• Safety
• Is it “Safe” for me to become pregnant?
• Will pregnancy affect my prognosis?
• Can my future children be affected?
• Timing
• Window of highest recurrence
• Wash out drugs
Special Considerations for
BRCA1/2 Mutation Carriers
• Some suggest lower ovarian reserve
• Increased risk for development of ovarian
cancer
• Recommendation is to have a risk-reducing
bilateral salpingo-oophorectomy (RRBSO)
• Can transmit mutation to offspring
• Role of Pre-implantation Genetic Diagnosis
(PGD)
What is My Current Fertility
Status?
MENSES
≠
FERTILITY
How We Assess Ovarian
Reserve
• Hormones
• Follicle Stimulating Hormone (FSH), estradiol,
inhibin B
• Antimullerian Hormone (AMH)
• Ultrasound
• Ovarian volume, antral follicle count
Antral Follicle Count
http://www.cherish-uk.com/fertility-scans-birmingham.html
Interpreting the Testing:
Odds and Probabilities
• Must be considered in the context of age and
your medical history
• Does not predict ability to become pregnant
• Just tells us how easy or difficult it might be
Is it “Safe” for Me to Become
Pregnant?
• No guarantees about anything
• Must consider effects of treatment on other
aspects of health
• Pregnancy in general is a stressful condition
• Consultation with a Maternal Fetal Medicine
(MFM) Specialist
• Preconception counseling
• Management of medication
• Management of coexisting medical conditions
Will Pregnancy Affect My
Prognosis?
• Previously, pregnancy was thought to be
contraindicated
• More recent data has been reassuring
Pregnancy after Breast
Cancer
• Survivors who become pregnant do not appear to suffer worse
outcomes than those who do not
• Meta-analyses
•
Azim et al
•
•
•
14 studies with 1244 cases and 18,145 controls
For overall survival, pooled relative risk was 0.59 (95% CI: 0.50-0.70), favoring
survivors with subsequent pregnancy
Valachis et al
•
•
9 studies
Pooled hazard ratio of death was 0.51 (95% CI: 0.42-0.62), favoring survivors
with subsequent pregnancy
• Similar findings for women with estrogen-receptor positive tumors
• Limitations of the data
Can My Future Children Be
Affected?
• No increased risk of birth defects
• No increased risk of vertical transmission
• Exception: Genetic syndrome: Pre-implantation
Genetic Diagnosis (PGD)
• Higher risk for cesarean section, pre-term
delivery, low birth weight infants and delivery
complications
When Should I Try to
Conceive?
• It depends… requires thoughtful discussion
with you and your health care providers
• Usually recommended once you are out of
window of early relapse/recurrence
• Must have period of adequate treatment
washout
Building Your Family
• Sometimes requires you to reshape the way you thought about
building your family
• Range of options
• Natural intercourse
• Ovulation induction +/- intrauterine insemination
• Assisted Reproductive Technology (ART)
• Oocyte cryopreservation (“egg freezing”)
• In vitro fertilization (IVF)
• Third-party Reproduction
• Donor Egg
• Donor Embryo
• Surrogacy
• Adoption
Ovulation Induction with
Intrauterine Insemination
• $300-700 ($1500-4000 with monitoring and medication)
ART: In Vitro Fertilization
(IVF)
Embryos or Oocytes?
Embryos
Oocytes
Most common and successful
Experimental label removed
Need a partner or donor sperm
No partner required; provides
reproductive autonomy; Bypasses some
religious objections
Takes approximately 2 weeks
Takes approximately 2 weeks
Requires ovarian stimulation
Requires ovarian stimulation
Success rates approximately 30-35%
Success rates rapidly improving: 25%
$13,000
+ medications
$9000 + medications
Preimplantation Genetic
Diagnosis (PGD)
• Testing embryos for their genetic profile prior
to embryo transfer
“Third-party
Reproduction”
• the use of eggs, sperm, or embryos that have
been donated by a third person (donor) to
enable an infertile individual or couple
(intended recipient) to become parents
• May be known or anonymous
• Complex
Third-party Reproduction:
Donor Egg
• Picking donor versus using an egg bank
• Identifying a donor
• Evaluating a donor
• Evaluating the intended parent(s)
• Donor stimulation/Recipient preparation
• Success rates >50%
• Cost: $25,000-30,000
Third-party Reproduction:
Donor Embryo
• “Embryo Adoption”
• Evaluating the intended parent(s)
• Recipient preparation
• Legal counsel VITAL
• No good stats on success rates
• Cost: $15,000-35,000
Third-party Reproduction:
Surrogacy
• Traditional Surrogacy: woman is biologically
related to the pregnancy she is carrying
• RISKY!!!
• Gestational Carrier: no biological relationship;
carries the intended parents’ embryo(s)
Third-party Reproduction:
Gestational Surrogacy
• Selection of gestational carrier (GC)
• Evaluation of GC and intended parent(s)
• Counseling
• Legal
• Recipient preparation
• Cost: $60,000 to 100,000+++
Adoption
• Various types
• Lifelong process
• Process:
•
•
•
•
•
Application
Home study
Identification of child (or being ID’ d)
Supervisory period
Legal adoption
• Special considerations for survivors
• Cost: $0-$50,000+++
Psychosocial Aspects
Resources
• Resolve
• Livestrong
• American Society for Reproductive Medicine
(ASRM)
• Reproductivefacts.org
Conclusions
• Building a family after a breast cancer diagnosis is
possible
• There are many different options that are
available
• Sometimes you have to reframe how you think
about building your family
• Assert yourself; be proactive!
• Advocate!