|
Middle East Fertility Society Journal
Middle East Fertility Society
ISSN: 1110-5690
Vol. 12, Num. 3, 2007, pp. 153-157
|
Middle
East
Fertility
Society
Journal,
Vol.
12,
No.
3,
2007,
pp.
153-157
OPINION
Fertility
and
fertility
preservation
techniques
for
breast
cancer
patients
Fouzia
Memon,
M.B.B.S.
Research
Fellow,
Newcastle
upon
Tyne
NHS
Foundation
Trust,
UK.
Code
Number:
mf07028
ABSTRACT.
Breast
cancer
is
not
rare
in
younger
women.
There
has
been
remarkable
improvement
in
the
survival
rate
due
to
progress
in
cancer
treatment.
Those
treatments
often
cause
premature
ovarian
failure
due
to
massive
destruction
of
the
ovarian
reserve.
Early
loss
of
ovarian
function
not
only
puts
the
patient
at
risk
for
menopause-related
complications
at
a
very
young
age
but
is
also
associated
with
loss
of
fertility.
The
purpose
of
this
paper
is
to
review
the
incidence
of
gonadal
toxicity
associated
with
adjuvant
chemotherapy,
fertility
concerns,
and
the
options
to
preserve
fertility
in
young
breast
cancer
survivors.
Key
words: Breast
cancer,
premenopausal,
reproduction,
fertility
preservation.
INTRODUCTION
Breast
cancer
is
the
most
common
female
malignancy.
There
are
2.2
million
breast
cancer
survivors
and
approximately
25-30%
of
newly
diagnosed
breast
cancer
patients
each
year
are <50
year
of
age.
Sonmezer
et
al
(2006)
and
Ghafoor
et
al
(2003)
found
that
the
incidence
of
breast
cancer
has
increased
by
0.5%
per
year
over
the
past
decade,
whereas
the
death
rate
has
decreased
by
1.4%
per
year
during
the
same
period
(1,
2).
The
estimated
incidence
is
less
than
0.1
per
100,000
women
below
the
age
of
20
years,
increasing
to
1.4
for
women
20-40
years,
8.1
for
women
25-29
years
and
24.8
for
women
30-34
year
old
(3).
The
decline
in
mortality
is
more
remarkable
in
women
age <50
year
(4).
With
the
lower
mortality
and
longer
survival
rate
resulting
from
adjuvant
therapy,
chemotherapy
or
endocrine
therapy
may
be
recommended
to
women <50
year
of
age,
depending
on
the
stage,
prognostic
factors,
and
hormone
sensitivity
of
the
tumor.
The
use
of
adjuvant
cytotoxic
chemotherapy
for
the
treatment
of
breast
cancer
can
induce
ovarian
failure
and
infertility,
while
the
use
of
adjuvant
hormonal
therapy
is
a
contraindication
to
conception
during
therapy.
Further,
women
in
this
millennium
have
been
delaying
initiation
of
childbearing
to
later
in
life,
hence
the
preservation
of
fertility
in
female
patients
diagnosed
with
cancer
has
recently
been
an
area
of
intensive
investigation.
This
article
reviews
the
literature,
discusses
the
pathophysiology
and
effect
of
breast
cancer
treatment
on
fertility,
chances
of
spontaneous
pregnancy
and
summarizes
available
fertility
preservation
options
and
discusses
recently
published
data
concerning
experimental
methods.
The
problem:
gonadal
damage
induced
by
chemotherapy
Damage
to
the
gonads
by
chemotherapy
depends
on
the
patients
age
at
the
time
of
treatment,
total
dose
and
nature
of
chemotherapy
delivered.
The
exact
mechanism
of
ovarian
damage
is
not
fully
understood,
but
in-vitro
studies
suggest
apoptotic
changes
in
the
granulosa
cells
that
result
in
follicular
damage
(5).
Chemotherapeutic
drugs
used
in
various
combinations
for
the
treatment
of
breast
cancer,
such
as
three-drug
combination
of
cyclophosphamide
and
fluorouracil
with
either
methotrexate
(CMF)
or
an
anthracyclin
(CAF,
FAC)
(6).
The
addition
of
Paclitaxel
(taxanes)
in
addition
to
cyclophosphamide
have
been
shown
to
possibly
increase
gonadotoxicity
(7),
Although
earlier
on
Stone
in
2000
(8),
Swain
in
2005
(9)
and
Ball
in
2001
(10)
found
that
adjuvant
chemotherapy
in
women
(<45)
with
or
without
taxanes
resulted
in
a
slightly
lower
incidence
of
amenorrhea
in
young
women.
The
alkylating
agents
such
as
cyclophosphamide,
which
can
damage
resting
cells,
is
more
toxic
to
the
ovaries
than
cell
cycle
specific
agents,
such
as
methotrexate
and
fluorouracil,
whose
major
effect
is
on
ovarian
follicle
growth
and
maturation
(11,12).
Ovarian
biopsies
performed
in
women
undergoing
treatment
with
cyclophosphamide
showed
stromal
fibrosis,
marked
reductions
in
the
number
of
oocytes,
and
the
lack
of
follicular
maturation
(13).
Since
the
cell
cycle
specific
agents
damage
growing
follicles
therefore
sex
steroid
production
is
interrupted,
which
may
lead
to
disturbance
of
the
hypothalamic-pituitary-ovarian
axis,
with
eventual
irregular
menses,
amenorrhea,
and
menopausal
symptoms.
In
the
absence
of
ovarian
production
of
estradiol,
feedback
inhibition
on
the
pituitary
is
lost
and
follicle
stimulating
hormone
(FSH)
levels
rise
to
menopausal
levels.
Follicle
stimulating
hormone
levels
are
frequently
used
to
assess
ovarian
failure
and
ovarian
reserve
in
women
who
have
abnormal
menses
or
amenorrhea
after
receiving
chemotherapy.
Most
of
the
data
pertaining
to
the
likelihood
of
having
amenorrhea
with
adjuvant
chemotherapy
for
early
breast
cancer
from
women
having
cyclophosphamide,
methotrexate,
5-fluorouracil
(CMF)
and
these
results
may
not
be
directly
comparable
to
anthracycline-based
chemotherapy
regimens.
In
the
MD
Andersen
hospital
and
tumor
institute
series,
no
patient
Less
than
30
years
of
age
treated
with
a
doxorubicin-containing
regimen
stopped
menstruating
compared
with
33%
of
patients
aged
30-39
years
and
96%
of
those
aged
40-49
years
(14).
Tamoxifen,
a
selective
estrogen
modulator
with
antiestrogenic
actions
on
breast
tissue,
is
an
important
part
of
the
adjuvant
therapy
for
early-stage,
hormone-sensitive
breast
cancer.
In
addition
to
symptoms
associated
with
the
hormonal
changes
of
induced
menopause
due
to
antiestrogenic
effects,
endocrine
therapy
is
also
associated
with
a
variety
of
other
symptoms,
that
include
vasomotor
symptoms,
vaginal
complaints
(dryness,
itching,
discharge),
amenorrhea,
insomnia,
and
mood
disturbances
(15).
Adjuvant
therapy
with
tamoxifen
do
not
cause
permanent
amenorrhea,
but
tamoxifen
treatment
can
last
up
to
5
years,
during
which
pregnancy
is
contraindicated.
(16).
Spontaneous
pregnancy
after
chemotherapy
Overall,
at
least
half
of
women
under
35
years
of
age
resume
menses
at
some
time
after
completion
of
chemotherapy
(17,
18).
On
the
flip
side,
resumption
of
menstruation
after
chemotherapy
does
not
mean
that
fertility
has
been
preserved.
Studies
are
not
available
which
assess
actual
fertility
since
they
require
longer
follow-up,
determination
of
premorbid
fertility,
and
determination
of
the
percentage
of
patients
who
attempt
conception.
In
one
study
evaluating
119
women
aged
35
years
or
younger
who
had
been
treated
with
5-fluorouracil,
doxorubicin
and
cyclophosphamide
(FAC)
there
were
33
pregnancies
among
25
women
who
either
continued
or
resumed
menstruating
(21%).
The
median
age
of
those
who
became
pregnant
were
28
years
(range
22-33),
and
the
median
interval
between
the
last
chemotherapy
treatment
and
pregnancy
was
12
months
(Range
0-87).
The
overall
reproductive
potential
of
this
group
of
women
could
not
be
assessed,
since
no
attempt
was
made
to
determine
what
percentage
of
the
menstruating
women
attempted
conception
or
used
contraception.
Of
the
33
pregnancies
there
were
10
elective
abortions,
two
spontaneous
abortions,
19
full
term
pregnancies
and
two
women
were
pregnant
at
the
time
of
the
report.
There
were
no
preterm
deliveries
and
no
fetal
abnormalities
among
the
19
live
offspring
(18).
Fertility
preservation
strategies
There
is
a
recognized
need
to
discuss
fertility
and
options
to
preserve
fertility
before
adjuvant
chemotherapy
for
young
women
with
breast
cancer.
Surveys
of
cancer
patients
reveal
a
very
strong
desire
to
be
informed
of
available
options
for
fertility
preservation
and
future
reproduction
(19).
The
desire
for
biologic
motherhood
and
a
genetically
related
child
is
an
important
issue
for
many
cancer
survivors.
In
breast
cancer,
many
clinicians
recommend
that
women
should
wait
to
consider
pregnancy
for
2-3
years
after
completion
of
cancer
treatment
because
of
the
highest
risk
for
early
recurrence
in
these
years.
The
decision
will
depend
on
the
patients
medical
status
and
prognosis,
her
partner
status,
her
age,
whether
reproduction
can
safely
occur
for
patient
and
reproductive
options
available
to
them.
The
management
of
the
gonadal
toxicity
of
adjuvant
chemotherapy
for
breast
cancer
is
complex.
It
is
important
to
consider
the
possibility
of
preventing
ovarian
toxicity
and
the
therapeutic
options
available
if
infertility
occurs.
Potential
options
for
fertility
preservation
include
cryopreservation
of
mature
oocytes,
embryo
cryopreservation
following
in-vitro
fertilization
(IVF)
and
ovarian
tissue
cryopreservation
(20,
21).
To
date
the
most
effective
approach
is
embryo
cryopreservation,
because
the
human
embryo
is
the
most
resistant
to
damage
caused
by
cryopreservation.
This
method
requires
in
vitro
fertilization
and
a
male
partner
(22).
However,
cryopreservation
of
embryos
or
mature
oocytes
is
frequently
not
a
feasible
option
for
reasons
that
include
the
unknown
risk
of
the
hormonal
stimulation
required
for
oocyte
harvest
and
the
inherent
delay
in
starting
chemotherapy.
Cryopreservation
of
oocytes
is
not
a
clear
option
because
of
poor
outcomes
related
to
cryodamage
of
the
oocyte
in
the
process,
arrested
embryonic
development,
and
increased
chromosomal
abnormalities
in
fertilized
cryo-preserved
oocytes.
The
exceptionally
low
pregnancy
rate
does
not
justify
the
use
of
this
option
for
routine
clinical
practice.
The
overall
published
live
birth
rate
per
cryopreserved
oocyte
is
seldom-greater
than1%
to
5
%
(23)
which
is
much
lower
than
with
IVF
using
fresh
oocytes.
It
has
been
postulated
that
suppression
of
germ
cell
stimulation
may
lead
to
the
protection
of
oocytes
and
ovarian
follicles
from
toxic
effects
of
chemotherapy.
Although
preliminary
data
about
using
gonadotropins
releasing
hormone
agonists
concomitantly
with
the
chemotherapy
suggest
that
ovarian
protection
may
be
possible
(24),
there
have
been
contradictory
results
regarding
their
use
also
(25).
Many
clinical
trials
using
oral
contraceptives
or
GnRH
antagonists
to
suppress
ovarian
function
during
chemotherapy
have
had
disappointing
results
(26).
One
possible
reason
for
the
lack
of
protection
by
GnRH
analogue
may
be
that
the
need
for
timely
treatment
of
the
cancer
does
not
allow
for
the
complete
suppression
of
the
ovarian
germinal
epithelium.
The
use
of
oral
contraceptives
prior
to, or
during
adjuvant
chemotherapy
for
breast
cancer
may
stimulate
growth
of
occult
micro
metastases.
Other
considerations
include
potentially
increasing
the
risk
of
venous
thrombosis
that
is
seen
in
women
receiving
adjuvant
chemotherapy
for
breast
cancer
and
blockage
of
pituitary
releasing
factors
that
may
result
in
reflex
stimulation
of
ovarian
oestrogen
production
(27).
There
has
been
recent
interest
in
banking
ovarian
tissue
(22),
rather
than
oocytes
alone,
with
auto
grafting
of
the
stored
tissue
following
chemotherapy.
This
technique,
too,
requires
further
investigation
before
it
can
be
recommended
to
patients.
It
is
anticipated
that
ovarian
tissue
will
be
thawed
and
implanted
after
cancer
treatment
as
an
auto
graft
or
to
a
heterotrophic
site
or
that
technique
for
maturing
oocytes
in
vitro
will
be
developed
in
the
future.
With
ovulation
and
creation
of
a
human
embryo
from
ovarian
tissue
transplanted
to
the
arm
and
live
birth
from
a
antilogous
ovarian
transplant
already
reported
(22,
28),
further
successes
in
the
future
are
likely.
In
July
2005,
a
case
report
was
published
of
a
successful
pregnancy
and
birth
in
a
woman
with
a
history
of
non-Hodgkins
lymphoma
using
transplantation
cryopreserved
ovarian
tissue
and
in-vitro
fertilization
(29)
although
according
to
the
authors
they
cannot
rule
out
that
the
egg
came
from
the
native
ovary
rather
than
transplanted
tissue,
however
the
patients
24
month
history
of
amenorrhea
after
chemotherapy
and
hormonal
profile
argue
that
the
fertilization
was
related
to
the
transplanted
tissue.
For
women
who
are
infertile
following
chemotherapy,
reproductive
choices
remain
limited.
In
a
step
forward
researchers
from
United
Kingdom
have
successfully
generated
primitive
sperm
cells
from
human
bone
marrow
derived
stem
cells
(30).
Although
the
use
of
such
gamete
is
currently
illegal
in
United
Kingdom;
such
work
offers
the
hope
that
derived
oocytes
and
sperms
may
yet
be
possible.
Finally
for
breast
cancer
survivors
who
rendered
menopausal
or
with
severely
damaged
ovaries
following
treatment
adoption
or
childlessness
may
still
be
considered.
There
remains
however
the
possibility
of
egg
donation,
which
through
the
IVF
process
can
offer
excellent
chances
of
a
successful
pregnancy.
CONCLUSION
The
diagnosis
of
breast
cancer
can
be
devastating
to
young
patients
who
desire
future
fertility.
This
review
identifies
the
physical
damage
the
breast
cancer
treatment
has
on
young
breast
cancer
survivors.
Breast
cancer
chemotherapy
especially
alkylating
agents
cause
destruction
of
primordial
follicles
resulting
in
reversible
amenorrhea,
irregular
menses,
or
irreversible
amenorrhea
(ovarian
failure-menopause).
Younger
women
have
a
lower
risk
for
amenorrhea
with
chemotherapy
because
of
good
ovarian
reserve,
although
the
gonadal
toxicity
may
result
in
an
earlier
than
expected
menopause.
The
standard
therapy
for
breast
cancer
treatment
often
result
in
sterility
either
temporary
or
permanent.
The
chances
of
spontaneous
pregnancy
still
exist
after
cancer
treatment.
although
a
bit
reduced.
Currently
there
is
uncertainty
over
the
most
effective
and
appropriate
strategies
for
preserving
and/or
restoring
an
individuals
fertility.
There
are
several
considerations
of
fertility
preservation
for
women
who
are
interested
in
having
biological
child
after
a
diagnosis
of
breast
cancer.
The
decisions
of
whether
to
resort
to
fertility
preservation
and
which
method
to
use
depend
on
a
number
of
factors
including
patients
age,
the
type
of
adjuvant
therapy,
and
the
time
available
before
chemotherapy
and
the
length
of
delay
to
childbearing
post
chemotherapy.
The
most
recognized
option
for
fertility
preservation
at
present
is
embryo
freezing.
To
conclude,
knowledge
of
pathways
by
which
chemotherapy
causes
injury
to
reproductive
function
may
help
in
the
development
of
treatment
strategies
for
reproductive
organ
protection
as
well
as
fertility
preservation
techniques.
The
improvements
of
these
techniques
as
well
as
better
characterization
of
their
success
rates
and
risks
await
further
investigations.
Summary
box
1
Recognized
methods
of
fertility
preservation
* Embryo
cryopreservation
following
in-vitro
fertilization
* Oocyte
cryopreservation
Experimental
methods
of
fertility
preservation
* Ovarian
tissue
banking
* Hormonal
manipulation
e.g.
GnRH
analogue,
GnRH
antagonists
or
oral contraceptive
pills.
Future
strategies
* Gamete
formation
from
human
stem
cells
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Sonmezer
Murat,
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Oktay.
Fertility
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The
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2006,
Vol.11,
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May,
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