We asked Mr Stuart Lavery consultant gynaecologist at University College London NHS Trust and clinical director of Women’s Health for all the facts you need to know about what happens to your fertility if you’ve been diagnosed with breast cancer and what your options are for preserving it.
Breast cancer can be a devastating enough diagnosis to come to terms with, but you may also have to deal with important decisions about your fertility too – and in quite a short space of time.
‘Whether you already have children or not, a breast cancer diagnosis can mean you may have to think about taking steps to preserve your fertility before your treatment begins,’ says Mr Lavery.
‘It’s very important that you get the chance to have that discussion with your surgeon or oncologist before you start chemotherapy, so you can be referred to an NHS fertility preservation service if that’s what you decide you want.
‘Twenty years ago, we would struggle to get patients in for this conversation, but things have improved since then, although the service is still not available everywhere and it can be a bit of a regional postcode lottery.
‘Fertility preservation isn’t right for every breast cancer patient, but they should at least have the conversation with their team so they can make an informed decision based on knowing what all their options are.”
Q: Will chemotherapy damage my fertility?
Chemotherapy drugs may significantly affect ovarian reserve (the total number of healthy eggs left in your ovaries), reducing your chances of getting pregnant.i
Your periods may stop during chemotherapy and start again months, or up to a year or so later. You may get pregnant again naturally, but treatment may mean you may find it harder to get pregnant even though you are having periods, and you may have an earlier menopause.
Chemo can also damage a man’s sperm quality and the quantity produced and make sperm less likely to be able to fertilise an egg. This can be temporary or permanent.
The chemo drugs used for breast cancer most likely to damage your fertility include alkylating agents, including cyclophosphamide.
Q: Will radiotherapy for breast cancer damage my fertility?
There’s no evidence of this; radiotherapy is not directed at the ovaries or pelvis area for breast cancer treatment,’ says Mr Lavery.
Q: How can I preserve my fertility?
Options for preserving fertility include egg and sperm freezing and IVF fertility treatments to create frozen embryos.
Ovarian tissue freezing where the ovary or sections of it are removed and frozen and reimplanted after treatment has finished, is another option, but is considered more experimental.
‘Fertility preservation is normally free on the NHS if you have any type of cancer or any medical condition that may impact your reproductive options for the future,’ says Mr Lavery.
‘The restrictions that normally apply to IVF access for embryo freezing don’t apply in these circumstances for couples. So, for example, normally if you already have a baby, the NHS won’t fund your IVF fertility treatment, but having a baby is no barrier to fertility preservation on the NHS. Fortunately, the NHS has a different set of criteria for funding fertility preservation than for normal IVF.” Unfortunately, these more generous criteria are not uniformly applied throughout the country.
He added that fertility preservation funding for single women with breast cancer usually is funded.
Q: Won’t fertility treatment delay my treatment?
Fertility treatment can be arranged very quickly these days, says Mr Lavery.
‘Obviously it’s much more difficult to freeze your eggs than it is to freeze sperm, but there have been lots of advances in this field. We can normally complete an IVF cycle within 12 days. The other big advantage is previously we had to wait for a woman’s natural menstrual cycle to start before we could begin the treatment (to be in sync with the first day of the period). But we’ve now developed protocols where we can start hormone treatment at any stage in the menstrual cycle.
‘It’s also really important that if a woman is going to start treatment with chemotherapy, that we work with the oncology teams to make sure that they are happy for us to do this, and that our intervention is not going to harm her prognosis in any way, because the priority here is always, let’s get this woman better and give her the best chance possible. The fertility preservation is laid on top of that. So, the oncology team have to be supportive.”
Mr Lavery acknowledged though, there’ll still be some circumstances where chemotherapy can’t be delayed as survival will be the priority and take precedence over fertility treatment. ‘In some patients, it is absolutely appropriate to crack on and have that definitive treatment for their breast cancer,’ he adds.
Another option when women urgently need to start treatment is to opt for ovarian tissue cryotherapy where an ovary or sections of them, are removed and frozen before chemotherapy starts. The tissue can later be reimplanted when treatment is finished. This is still considered a more experimental approach.
Q: What is the success rate with fertility preservation?
‘There’s loads and loads of evidence that people overestimate their chances of success with fertility treatment, so sometimes we need to balance hope with realistic expectation,’ says Mr Lavery.
‘It wouldn’t be unusual for me to say to a woman in her early 40s, look, if we do this treatment, it may be that we’re only offering you a 20 per cent chance of having a baby are you sure that you want to put yourself through two weeks of hormone manipulation, surgery and anaesthesia, for only a 20 per cent chance?.’
Mr Lavery says it can be a difficult conversation to have as they don’t know if the patients will be in the lucky 20 per cent or the 80 per cent who don’t conceive.
‘A lot will depend on the patient’s age – a woman in her 40s who has IVF and then freezes her embryos has a 20 per cent chance of having a live baby. But a younger woman of say 34 who gets 20 eggs and then freezes them will have a 90 per cent chance of having a baby later in life, the success rate is much higher at a younger age.’
Q: Is embryo freezing more successful than egg freezing?
‘In the old days, freezing embryos was significantly more successful at giving us babies than freezing eggs, embryos were much tougher than eggs and more likely to survive the freezing process,’ says Mr Lavery.
‘But what’s happened in the last few years is that egg freezing has become much more successful, with the advent of a new technology called vitrification or flash freezing, so now there is only about a two per cent difference between the two.’
Mr Lavery says this is a massive step forward for women’s autonomy because when you freeze eggs you have sole control of how they are stored and used, but this is not the case with embryos unless you use donor sperm. Freezing embryos is a joint venture which requires a partner’s consent, and sometimes people change their minds about wanting to go ahead. You don’t have this problem with egg freezing.
‘This is very reassuring for single women as it means they don’t need to go and get a sperm donor, they can just freeze their eggs,’ says Mr Lavery.
‘Sometimes women choose to hedge their bets – if they get 20 eggs, they freeze 10 and fertilise 10 with their partner’s sperm, and store both, and the NHS is very happy to do this for them.’
Q: I want to start fertility preservation treatment what should I do?
Your surgical or oncology team should refer you to a fertility preservation clinic. This is recommended by the National Institute for Health and Care Excellence (NICE).
‘This is a dedicated service that allows rapid access,’ says Mr Lavery.
‘At my clinic we always have open spaces, we don’t turn anybody away, and often we’ll overrun really late. Everybody in that clinic is really committed to the work that we do.
‘It means we can get the patient in very quickly and we can start treatment, literally on that day or the next day.’
There are around 75 NHS fertility preservation centres in England and six in Scotland, according to estimates.
Mr Lavery says patients are counselled about their options at the clinic, and if some decide against going ahead, that’s fine.
Q: Could I get pregnant again naturally after my treatment has finished?
‘Yes – some women find their periods do come back and they conceive naturally, but this isn’t guaranteed,’ says Mr Lavery.
‘This is less likely if you are older as fertility declines after age 35. This why some women decide to freeze their eggs, so they have a plan B if they don’t conceive naturally.’
He says women don’t all experience the same risks to their fertility. For example, younger women who go into chemotherapy with more eggs are less likely to be impacted than perhaps say somebody in their late 30s or early 40s, whose fertility has already started to decline.
‘It’s really important to try and individualise the advice, because many, many, women will have babies the old-fashioned way after chemotherapy. Many women think they will definitely go to into an early menopause, after chemotherapy but that’s simply not true.’
Q: How long should I wait to start trying for a baby after chemotherapy?
‘We usually recommend waiting two years after chemotherapy has finished before trying to get pregnant,’ says Mr Lavery.
The American Cancer Society say the reasons for waiting this long include the risk of cancer recurrence dropping after two years, as well as the risk of miscarriage and birth defects due to chemotherapy damaging eggs reducing after six months.
If you are taking hormone treatments such as tamoxifen or aromatase inhibitors such as anastrozole and letrozole, you will be advised against getting pregnant while taking the drug. Some women decide to take a break from treatment to have a pregnancy.
Q: I’m pregnant and I’ve been diagnosed with breast cancer… what happens now?
‘You know, that is a really, really, difficult one. We have experienced that. And it really depends on what stage of the pregnancy you are at and how aggressive and advanced the cancer,’ says Mr Lavery.
‘It’s quite common for women very early in the pregnancy to be advised to consider termination, because it’s thought leaving it so long to allow the baby to grow to maturity and deliver would have a really negative impact on that woman’s chance of recovery.
‘Equally, if you discover you have breast cancer quite late in the pregnancy, then you might say let’s try and get you to 36 weeks, and let’s do a delivery. The most difficult thing is when a woman is in the middle of the pregnancy, that’s a really, really, agonisingly difficult choice to make.’
Mr Lavery stresses that counselling and fetal medicine and oncology support services would be available in these circumstances.
‘At the end of the day, this is about recognising a woman’s autonomy and a really important part of autonomy is informed decision making. The right judgement is the one that’s made by the woman after she’s been appropriately advised and counselled.
Q: I have a hormone sensitive type of breast cancer – would fertility treatment or pregnancy be dangerous for me?
‘So, this is a question at the forefront of many patients’ minds. Women are aware that sometimes their breast cancer may be oestrogen sensitive, and that both fertility treatment and pregnancy, in fact, can raise oestrogen levels. And so, there’s an understandable anxiety,’ says Mr Lavery.
‘The good news is that pregnancy after breast cancer does not worsen prognosis or increase the risk of recurrence. There is absolutely rock-solid evidence from over 30 years of experience now to give women that reassurance.’
Mr Lavery says methods of IVF have also been developed which do not raise oestrogen levels.
‘We’ve offered fertility preservation IVF for about 20 years. While full certainty requires decades more data, current evidence shows no increased risk of cancer recurrence and suggests the treatment is safe, though ongoing monitoring continues.
‘To be really honest, before we can be 100 per cent certain about that, we’re probably going to have to wait for all these women to get into their 70s, before we have that convincing longitudinal data.’
References
Further information
Future Dreams hold a range of support groups, classes, workshops and events to help you and your carers during your breast cancer diagnosis. These are held both online and in person at the London-based Future Dreams House. To see what’s on offer and to book your place, see here.
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The information and content provided in all guest articles is intended for information and educational purposes only and is not intended to substitute for professional medical advice. It is important that all personalised care decisions should be made by your medical team. Please contact your medical team for advice on anything covered in this article and/or in relation to your personal situation. Please note that unless otherwise stated, Future Dreams has no affiliation to the guest author of this article and he/she/they have not been paid to write this article. There may be alternative options/products/information available which we encourage you to research when making decisions about treatment and support. The content of this article was created by Dr Tasha Gandamihardja, an oncoplastic breast surgeon and podcaster and we accept no responsibility for the accuracy or otherwise of the contents of this article.
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