Recently, I was thinking about Breast Cancer Awareness Month, and I thought I would take a moment to answer some important questions when it comes to fertility after cancer and about fertility preservation.
Did you know that breast cancer is the most common cancer affecting women with 1 in 8 women developing breast cancer at some point in their lives? It is also the most common cancer among reproductive aged women with about 15% of breast cancer cases occurring before the age of 40. Given how common breast cancer is, it is very likely that you or someone you know will be diagnosed with breast cancer at some point. As a fertility doctor, whenever I hear “cancer,” I always think about life AFTER cancer as up to 91% of women diagnosed with breast cancer are still alive at 5 years. (1)
HOW DOES CHEMOTHERAPY AFFECT FERTILITY?
Well, it depends on the kind of chemotherapy being used. In general, the most common chemotherapies used for breast cancer age the ovaries by about 10 years. The earlier you are when you start the chemotherapy, the more likely you will be able to conceive after chemotherapy, but there is no guarantee. The BEST option to ensure future fertility is to freeze eggs or embryos for use later which is called fertility preservation.
HOW LONG DOES FERTILITY PRESERVATION TAKE?
At Kindbody, we make oncofertility patients a priority and will make sure any cancer patient can get in to see a Kindbody provider within 24-48 hours. After the initial consult, we can usually start the process growing eggs to freeze or fertilize within 1-2 days of seeing a patient and finish the process in as soon as 2 weeks. We understand the importance of moving forward with cancer treatment as quickly as possible, so we do everything in our power to minimize the delay before moving through with treatment.
WHAT IS INVOLVED IN FERTILITY PERSERVATION?
Preserving fertility for the future involves freezing either eggs or embryos for use later through the process of IVF or in vitro fertilization. In a normal menstrual cycle, women start to grow numerous eggs each month and 1 or maybe 2 eggs grow bigger than the rest and are chosen to be ovulated. When we do IVF, we try to get as many eggs as possible to grow and we take them out of the body just before ovulation.
To get the eggs to grow, we give medications called gonadotropins in the form of injections in the belly. There are usually multiple injections a day for about 2 weeks until the eggs get to the point where they are ready to be taken out of the body. An egg retrieval is done under anesthesia (so you are asleep) using a vaginal ultrasound probe with a tiny needle attached. The needle goes through the wall of the vagina and directly into the ovary, so you will not notice any incisions when you wake up. The eggs are floating in fluid in the ovary so we remove the fluid with the needle and give the fluid to the embryologist who identifies the eggs under the microscope.
If we are planning on freezing eggs, we do so within hours of the retrieval. If we are planning to make embryos, we use sperm from the patient’s partner or a sperm donor to attempt to fertilize the eggs. We find out how many eggs fertilized the day after the retrieval and we watch the eggs that do fertilize (now called embryos) for up to 7 days to see if they can make it to become a blastocyst which is the stage where we freeze the embryos. An embryo that makes it to the blastocyst stage has the best chance of becoming a baby, but is not a guarantee of a baby.
Some women/couples choose to do genetic testing of the embryos to see if the embryos have normal chromosomes which further increases the chance the embryo will be a baby, but still does not guarantee success.
WHAT IS THE DIFFERENCE BETWEEN FREEZING EGGS AND FREEZING EMBRYOS?
When we are doing an egg retrieval, we have the option of removing eggs and freezing them immediately or attempting fertilization and creating embryos. If eggs are frozen, they will need to be fertilized in the future before they can become an embryo and then a baby. In order to fertilize eggs, we need to have a sperm source.
Whenever a retrieval is done, we get a certain number of eggs, but not every egg that is retrieved is a good egg. We can only work with mature eggs. Of the eggs that are mature, we expect about 70% of them to fertilize and about 50% of those eggs that fertilize to make it to the blastocyst stage where the embryo can be frozen or transferred. At each stage in the process, you lose quantity, but gain quality.
When you freeze eggs, we expect about 90% of the eggs to survive when we thaw them. After thaw, we still expect around 65-70% to fertilize and 50% to make it to the blastocyst stage. Now, those numbers are averages and you never know how many embryos are going to make it to become a blastocyst until you attempt to fertilize them. It is recommended that a woman freeze 15-20 eggs for each child that she desires (again averages).
On the other hand, when we fertilize the eggs immediately after retrieval and create embryos, we will know how many eggs fertilize, how many made it to the blastocyst stage, and the quality of those embryos which allows us to predict much better the chances those embryos could become babies. While you may need 15-20 eggs for a good chance of a baby, you might only need 2-3 embryos if they are good quality embryos. Embryos also survive the freezing and thawing process a little better than eggs and it is expected that 95% of embryos frozen will survive.
If a woman has a partner with whom she would like to create embryos, it is generally recommended to create and freeze embryos rather than eggs because we will know up front if the eggs fertilized normally and have a better idea of the chance of pregnancy in the future
I HAVE A LOT OF EXPENSES RIGHT NOW, HOW MUCH WILL THIS COST?
For many women/couples who are interested in infertility treatment, they have time to save up funds in order to pay for the treatment, but this is not usually the case with cancer patients. Moving forward with fertility preservation usually needs to happen rapidly so that cancer treatment is not delayed. Fortunately, there are many programs available to help with the costs. LIVESTRONG and EMD Serono both have programs to help cancer patients obtain fertility medications for FREE. These programs do require an application and verification of the cancer diagnosis, but the applications are processed quickly and do not require too many hoops to jump through. Those programs may not cover all the medications needed for fertility preservation, but they do cover most of them.
At Kindbody Fertility Institute, we offer deeply discounted fertility preservation treatments. Our financial team can also work with patients on payment plans or loan options depending on the situation. We do not want cost to be the reason someone chooses not to pursue fertility preservation.
CAN I JUST DO IVF OR FERTILITY TREATMENTS AFTER I HAVE MY CANCER TREATED?
You can absolutely pursue fertility treatment after cancer treatment, but because the cancer treatment can age the ovaries, you may be less likely to have success if you wait until after the cancer is treated. It is impossible to know for sure how much your fertility will be impacted by cancer treatment. Some women are able to conceive spontaneously after treatment, but others, even those who were very young when they had treatment, may never be able to have genetic children even with aggressive fertility treatment.
THERE IS HOPE AND HELP FOR FERTILITY PRESERVATION
If you or someone you know has recently been diagnosed with cancer and has any desire to have a child or children in the future, I encourage a consultation with a fertility specialist BEFORE cancer treatment. You are under no obligation to pursue any kind of fertility preservation treatment, but a fertility specialist can make sure that you have all the information you need to make the best choice for you.
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Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the randomized trials. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). 2005, Lancet, pp. 365:1687-717.