1. Fertility, Pregnancy and Family Planning after a Cancer Diagnosis
Terri Lynn Woodard, MD
Assistant Professor
MD Anderson Cancer Center

2. The Objective
Some described brand as an intangible asset, and a promise that conveys who you are, what you do, and why that matters.
Others felt that a brand captures the persona of an organization and represents its very soul or essence.
Yet others identified brand in terms of not only what is projected but also what is perceived.
Last, brand was seen as a source of efficiency because it acts as a time-saving device, providing a shortcut in the decision making of potential investors, customers, clients, and partners.
Brands can initiate action and create emotional connections. They can focus efforts and attract attention. Attention from potential members, donors, volunteers and media. And a strong brand ensures this attention will last a lifetime.

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. Impact of Breast Cancer Treatment on Fertility
Age
Depends on type of therapy
Chemotherapy
The risk of amenorrhea after receiving typical adjuvant chemotherapy regimens in women under 40 is 21-71% versus % for those over 40.
Baseline fertility status
Type
Dose

5. Impact of Breast Cancer Treatment on Fertility
Endocrine therapy: Tamoxifen
Selective Estrogen-Receptor Modulator
Used in the treatment of premenopausal estrogen-receptor positive breast cancers
Teratogen
Recommended for years
Age becomes the biggest obstacle!

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

8. 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?
When should I try to conceive
What are the different ways that I can build my family?

9. What is My Current Fertility Status?

10. Fertility Status
MENSES
FERTILITY ≠

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

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

13. Antral Follicle Count Poor antral follicle count
Good antral follicle count
Photos used with permission from Texas Children’s Hospital Family Fertility Center

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
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. 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)

16. Is it “Safe” for Me to Become Pregnant?

17. Safety of Pregnancy 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
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

18. Will Pregnancy Affect My Prognosis?

19. Pregnancy and Prognosis
Previously, pregnancy was thought to be contraindicated
More recent data has been reassuring

20. 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: ), favoring survivors with subsequent pregnancy
Valachis et al
9 studies
Pooled hazard ratio of death was 0.51 (95% CI: ), favoring survivors with subsequent pregnancy
Similar findings for women with estrogen-receptor positive tumors
Limitations of the data
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: ), favoring survivors with subsequent pregnancy
Valachis et al
9 studies
Pooled hazard ratio of death was 0.51 (95% CI: ), favoring survivors with subsequent pregnancy
Similar findings for women with estrogen-receptor positive tumors
Limitations of the data

21. Can My Future Children Be Affected?

22. Impact on Offspring 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

23. When Should I Try to Conceive?

24. Timing of Conception
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

25. What are the different ways that I can build my family?

26. 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

27. Ovulation Induction with Intrauterine Insemination
$ ($ with monitoring and medication)

28. ART: In Vitro Fertilization (IVF)
Picture used with permission from MD Anderson Cancer Center

29. 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
Requires ovarian stimulation
Success rates approximately 30-35%
Success rates rapidly improving: 25%
$13, medications
$ medications

30. Preimplantation Genetic Diagnosis (PGD)
Biopsy of Day 3 or Day 5 Embryos
Testing for Genetic Mutation
(No transfer)
Mutation +
(Transfer) -
Testing embryos for their genetic profile prior to embryo transfer

31. “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

32. 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
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

33. 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

34. 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)

35. 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+++

36. 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+++

37. Psychosocial Aspects

38. Resources RESOLVE Livestrong
American Society for Reproductive Medicine (ASRM)
Reproductivefacts.org

39. 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!