1. 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

3. 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

4. The Truth about Fertility in Women We are born with all the eggs we are ever going to have Fertility declines with age

5. 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

6. 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!

7. In an Ideal World: Fertility Preservation Discussion should be encouraged Various methods available ART Ovarian tissue cryopreservation Ovarian Suppression Some challenges and limitations

9. 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

10. 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)

11. What is My Current Fertility Status? MENSES ≠ FERTILITY

12. How We Assess Ovarian Reserve Hormones Follicle Stimulating Hormone (FSH), estradiol, inhibin B Antimullerian Hormone (AMH) Ultrasound Ovarian volume, antral follicle count

13. Antral Follicle Count http://www.cherish-uk.com/fertility-scans-birmingham.html

14. 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

15. 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

16. Will Pregnancy Affect My Prognosis? Previously, pregnancy was thought to be contraindicated More recent data has been reassuring

17. 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

18. 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

19. 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

20. 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

21. Ovulation Induction with Intrauterine Insemination $300-700 ($1500-4000 with monitoring and medication)

22. ART: In Vitro Fertilization (IVF)

23. Embryos or Oocytes? EmbryosOocytes Most common and successfulExperimental label removed Need a partner or donor spermNo partner required; provides reproductive autonomy; Bypasses some religious objections Takes approximately 2 weeks Requires ovarian stimulation Success rates approximately 30-35%Success rates rapidly improving: 25% $13,000 + medications $9000 + medications

24. Preimplantation Genetic Diagnosis (PGD) Testing embryos for their genetic profile prior to embryo transfer

25. “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

26. 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

27. 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

28. 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)

29. 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+++

30. 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+++

31. Psychosocial Aspects

32. Resources Resolve Livestrong American Society for Reproductive Medicine (ASRM) Reproductivefacts.org

33. 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!