Fertility options for reproductive women with breast cancer

dr. Madhupriya

The magnitude of breast cancer in India has been steadily increasing for a long time. Statistics show that fertility problems in this group have also increased due to drastic lifestyle changes, lack of future fertility awareness and marriage delay. Awareness about breast cancer has spread to all age groups and therefore they have a chance of early detection. But our society needs to be made aware of the fertility issues surrounding cancer treatments and the available fertility-preserving treatments.

Before proceeding with the cancer treatment, the patient should be made aware of the possible consequences of the cancer treatment. It can result in the inability to conceive a child in the future and adverse reproductive outcomes such as poor egg quality and quality after cancer treatments, ovarian failure, early ovarian aging, inability to have their own biological child.

How do we generally identify female fertility problems?

When a woman is unable to give birth to a child after repeated attempts (usually after a year of trying), they are termed as subfertile. Fertility problems can usually occur when reproductive hormone levels are abnormally low or high or if gamete-producing organs have been removed or not functioning properly. Problems in the uterus, fallopian tubes and ovaries can also cause infertility. Scarcity of healthy eggs, sex hormone disruptions, blocked fallopian tubes caused by pelvic inflammatory disease, polycystic ovary syndrome (PCOS/PCOD), uterine fibroids, endometriosis, primary ovarian insufficiency (POI), and cancer treatments are among many other conditions.

Effects of Cancer on Female Fertility

Chemotherapy works by destroying cells in the body that are dividing abnormally quickly. In many cases, the possibility that cancer medication/surgery/radiation will cause more damage to female tissues and organs than cancer itself is very high. The radiation can interfere with the reproductive system and this can lead to underfertility or sterility, ie difficulties in conceiving a child naturally, in most cases permanently.

Egg cells (eggs) tend to divide quickly and are often destroyed by chemotherapy, eventually affecting fertility. Diversity of oncology surgeries, chemo drugs, and radiation treatments used to treat cancer can have different effects and the commensurate risk of infertility, and therefore varies. The common risk factors are:

the age and reproductive stage of the patient; e.g. before or after puberty/menopause, etc.

The type of treatment given (radiation therapy, chemotherapy, hormone therapy, targeted therapy, immunotherapy, stem cell transplant)

The dose and frequency of treatment

There are a variety of drugs associated with infertility risk: cisplatin, busulfan, carboplatin, doxorubicin, lomustine to name a few. In addition to the medication, the risk of sterility (permanent damage to egg production) increases if the radiation is given near the pelvic area.

Savita, a 33-year-old single woman, was diagnosed with a lump in her breast during her annual health checkup. Closer examination revealed that she had breast cancer that needed immediate medical attention. Before starting her cancer treatment, she was advised on the benefits of fertility preservation. As a result, she underwent fertility treatment and managed to store 18 mature eggs. Now, once she overcomes this disease and gets permission from her oncologist, Savita can undergo ICSI (IVF) with her future partner’s sperm and form embryos from her own eggs and undergo an embryo transfer to reproduce her own biological child.

Women should be made aware of all cancer and cancer procedure related fertility risks and the options available for fertility treatments. Her cancer care team should provide a detailed plan about what fertility options are open to her before or while planning her cancer treatment.

Women undergoing cancer treatment should be made aware of the impact of cancer treatment on reproduction and that it can be very harmful to the fetus if one becomes pregnant during cancer treatment, potentially leading to miscarriage. The logical step would be to maintain fertility, even if the woman waiting for cancer treatment is unsure at this point if she wants children in the future.

Fertility maintenance in breast cancer patients

Here are a few recommendations for preserving fertility in breast cancer patients that wouldn’t hinder their journey to become biological mothers.

Cryopreservation of embryos

Egg (Unfertilized Egg) Freezing: Women can freeze unfertilized mature eggs. This procedure is similar to freezing embryos, but the eggs are frozen without being fertilized by sperm. This is an option for younger unmarried women/women who currently do not have a male partner.

Ovarian Tissue Conservation: Here the ovarian tissues are surgically removed and frozen. The surgeon may transplant the tissue after cancer treatment. This may be the only option for girls who cannot undergo egg or embryo freezing, as some girls lack the time or sexual maturity. But unfortunately this is an experimental process and not a standard option.

Radiation shielding that protects the ovaries: There is a chance that women will receive less radiation, and this preserves fertility.

Cancer treatment is an extremely taxing procedure. Patients have to make many difficult decisions for themselves. The risk of infertility that could unexpectedly occur in the future will only put more pressure and stress on the patient, which can be a cause for concern. It is the job of the combined cancer care team along with the fertility team to point the way and provide viable options. It should be reiterated here (after considering all possible options) that embryo/oocyte freezing is the simplest and most effective way to enjoy biological motherhood, even after breast cancer treatment.

It is high time that reproductive women with breast cancer were made aware of these possibilities to preserve fertility, so that they can begin their journey to become cancer-free first and then become mothers without mental limitations. The patient should be made aware of all choices available to her. This process can be overwhelming, but we fertility experts will be there every step of your oncofertility journey to help you along the journey to parenthood.

(The writer is Fertility Consultant, Vadapalani and MRC Nagar, Nova IVF Fertility Chennai)

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