Fertility Preservation: Convergence of Newly Diagnosed Breast Cancer, Desired Fertility, and Polycystic Ovary Syndrome

Abstract

A 34-year-old nulliparous female presented with a self-discovered 4 cm, firm, mobile mass in the upper, outer quadrant of her right breast. Her mother is a breast cancer survivor, diagnosed at age 45, and was BRCA negative. The patient also had polycystic ovary syndrome based on a long history of irregular menstrual cycles, mild facial and lower abdominal hair, acne, and mild acanthosis nigricans on the nape of the neck. She last used hormonal contraception 4 years prior to initial presentation. Menstrual cycles were more regular in the past year. Current medications to treat anxiety and depression included sertraline, lamotrigine, and oxcarbazepine. She had no other medical illness in the past or at presentation. The patient and her husband were just beginning efforts to become pregnant at the time she discovered her breast mass.

Review Questions and Answers

• Q1. A 28-year-old woman was recently diagnosed with invasive ductal carcinoma limited to her left breast. She has a new boyfriend, but is not in a committed relationship. Her mother and maternal grandmother are both breast cancer survivors. She wants her cancer to be treated as soon as possible, but she also plans to have children in the future. How will you counsel this patient?

  • (a) Obtain informed consent advising her to begin chemotherapy immediately followed by surgery because saving her life is the main objective. She can take a GnRH agonist medication during chemotherapy to protect her eggs from the toxic effects of the medications. There will be time after her cancer treatment to consider her chances for having children.

  • (b) Inform her that her cancer treatment will include medications that can cause future infertility or sterility by damaging her eggs. In advance of starting chemotherapy, refer her to a reproductive specialist, advising her to undergo egg harvest and either select sperm from her boyfriend or an anonymous donor at a sperm bank, undergo IVF therapy, and freeze embryos for possible future use to have a child. The alternative of egg freezing is experimental and unreliable.

  • (c) Inform her that her cancer treatment will include medications that can cause future infertility or sterility by damaging her eggs. In advance of starting chemotherapy, refer her to a reproductive specialist who can counsel her about fertility preservation options. Given that she is not in a committed relationship with her current boyfriend, freezing some of her eggs in advance of chemotherapy may be her best option providing her with more control over her future reproduction with a partner committed to building a family together.

  • (d) Advise her that she should begin chemotherapy within the next 2 weeks. Although preserving her fertility by freezing eggs is an option, fertility drugs are known to cause breast cancer and can worsen her current breast disease. For this reason, you strongly advise her against fertility preservation and rely on GnRH agonist medication during chemotherapy to protect her eggs from the toxic effects of the chemotherapy medications.

• A1. (c). Both egg and embryo freezing are reliable strategies for fertility preservation. In 2012, the American Society for Reproductive Medicine (ASRM) announced that there was sufficient clinical outcome-based evidence to support egg freezing as a mainstream technology no longer designating it as experimental. Given her favorable reproductive age of 28 years and that she was not in a committed relationship with her male partner, egg freezing provided her with greater control over having a future child with the partner of her choice. If she carries a BRCA mutation, she should be advised that this mutation is associated with reduced ovarian reserve in terms of lower egg quantity, but not decreased egg quality. Ovulation induction strategy will need to take this into consideration either to increase the dose of gonadotropins during ovulation induction therapy or plan for more than one egg harvest event in advance of beginning chemotherapy.

• Q2. A 32-year-old woman was recently diagnosed with estrogen-positive invasive ductal carcinoma limited to her right breast. She wants her cancer to be treated as soon as possible, but she also would like the option to have children in the future. She does not want to undergo anything invasive and has refused egg harvest. How will you counsel this patient?

  • (a) Inform her that her cancer treatment will include medications that can cause future infertility or sterility by damaging her eggs. In advance of starting chemotherapy, refer her to a reproductive specialist who can counsel her about fertility preservation options.

  • (b) Inform her that her cancer treatment will include medications that can cause future infertility or sterility by damaging her eggs. Outside of egg harvest, there is nothing that can be done. Her young age makes infertility unlikely.

  • (c) Inform her that her cancer treatment will include medications that can cause future infertility or sterility by damaging her eggs. Start her on GnRH agonist, but warn her that the estrogen surge may increase her risk of malignancy relapse.

  • (d) Inform her that her cancer treatment will include medications that can cause future infertility or sterility by damaging her eggs. Start her on chemotherapy and tamoxifen. The tamoxifen should lower the risk of infertility and decrease the risk of relapse.

• A2. (a). All patients who wish to preserve their fertility should see a reproductive specialist. Many patients are apprehensive about egg and embryo freezing based on misunderstanding and the absence of accurate information. GnRH agonist medications have gonadal protective properties and should be presented as an adjunctive treatment option for the duration of gonadotoxic chemotherapy administration. GnRH agonists appear to be safe and in some studies reduce the risk of premature ovarian failure and menopause [5,6,7,8]. There is insufficient evidence to conclude GnRH agonists prevent reduction in fertility potential.