Fertility after breast cancer

More and more South African women are being diagnosed with breast cancer in their childbearing years. Approximately 30% of women diagnosed in South Africa are younger than 35 years old. This raises important and often emotional questions regarding the affects of such a diagnosis, especially on how treatment will impact on plans for future pregnancies. Worldwide, research has shown that women newly diagnosed with breast cancer are more often than not, not given enough information and counselling regarding treatment risks to fertility.
How breast cancer affects fertility largely depends on three factors:

• Type of treatment used.

• Type and stage of breast cancer at diagnosis.

• Age of the patient.

Type of treatment

Not all breast cancer treatments will have an adverse effect on fertility. Breast surgery alone or surgery in combination with radiotherapy will not affect fertility.

However, chemotherapy is the main treatment that will have an impact on fertility. The risk of infertility is quoted as anything from 40% – 80% depending on which research is looked at. This seems to be largely due to the usage of a drug called Cyclophosphamide, a commonly used chemo drug used in combination with other drugs. Premature ovarian failure and menopause are possible side-effects. In fact, almost four out of five women treated with Cyclophosphamide develop ovarian failure. Other drugs that have a smaller impact on fertility include Cisplatin and Doxorubicin. Methotrexate, Fluorouracil and Vincristine appear to be safe. At this stage it is currently unclear what effect the newer chemo drugs like Taxol will have on long term fertility.

Because research in this area is limited, it can be dificult to give an individual woman an accurate idea of her chances of retaining her fertility. That’s why it is so important to talk to your doctor, as well as a fertility expert in order to get an idea of how your personal chemotherapy plan will impact on your fertility.

This is what we do know:

• Women under the age of 30 who are treated for cancer have the best chance of becoming pregnant after chemotherapy. Overall, the younger a woman is, the more likely the ovaries will produce fertile eggs after chemotherapy. Whilst on chemotherapy and for a while therafter, chemotherapy induced amenorrhea (CIA) may result. This is when menstruation stops temporarily due to chemotherapy. Menstruation can then resume in a few months or years after chemotherapy has been completed.

• Periods don’t always mean fertility. Even if your period starts after treatment, fertility may be uncertain. A fertility expert may need to be consulted in order to determine actual fertility.

• Women who get relatively high doses of chemotherapy may be more likely to be infertile after treatment.

• Chemotherapy medicines are usually given in combination, not each one by itself. When used in combination, the medicines’ effect on fertility may be different. It’s also important to know that the same medicine may be given in different doses in different combinations.

• When periods return after chemotherapy, it means that some eggs are maturing. But the number of eggs available may be smaller than it was before chemotherapy.

• Because chemotherapy may cause birth defects, doctors advise using birth control – but not birth control pills – throughout chemotherapy so that pregnancy does not occur during treatment.

• It’s important to wait between at least six months to two years before trying to fall pregnant after chemotherapy is finished. It is not advisable to fall pregnant with an egg that may be damaged by chemotherapy.

• After chemotherapy, fertility may be short-lived. This means that even women whose periods start again after chemotherapy are at some risk of early menopause.

• The closer one is to menopause – the average age is 51 – the more likely permanent  menopause after chemotherapy will commence. Pregnancy at this stage would then not be possible.

• Women who are 40 years old or older at the time of receiving chemotherapy are more likely to start menopause thereafter.

In some young patients with aggressive hormone sensitive cancers, ovarian shutdown has to be achieved as part of the treatment goals. Drugs like Zoladex can be used to achieve this. Like in the instance of  chemo drugs, fertility during its usage will be negatively affected.

Preserving fertility

Despite the fertility risks associated with breast cancer treatment, methods to preserve fertility prior to treatment offer hope to many patients.

To date, freezing embryos created by in vitro fertilisation (IVF) is the most widely used and effective method of preserving fertility. But there are potential downsides. IVF takes three to four weeks, a delay in cancer treatment that, depending on the stage and type of cancer, patients may or may not be able to afford. Sperm – either from a partner or donor – must be made available immediately to fertilise the eggs. And IVF is expensive – anywhere from R15000 to R30000 per cycle.

Another form of fertility preservation would be the harvesting and freezing of eggs only. While this is cheaper and less time consuming than IVF, it is still largely experimental, as egg quality after undergoing the thawing process, is not optimal. Neverless, it is available in certain select centers in South Africa.

A third technique currently under study would be the surgical removal of strips of ovary, freezing this and reimplanting it in a different part of the body for use later once treatment has been completed. It is not certain from current data, as yet, if this would be a viable option for future usage.

In the rarer instance of breast cancer in males, sperm can be frozen for later use in order to preserve fertility.

What of the frequently asked question that survivors ask: Will the chemotherapy or other treatment I underwent, increase the risk of birth defects in any of my future children?

The good news is that currently there is no evidence that this is true, as long as treatment is concluded at least six months after treatment has been completed.

MEET THE EXPERT

Dr Sumayya Ebrahim is a gynaecologist in private practice in Johannesburg. She is also a blogger. Check out her blog “vaginations by Dr E” on www.vaginations.co.za

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