Breast cancer awareness month is a time to celebrate the many advances made in the treatment of this dreaded disease. However, I’d like to focus on one area in need of greater attention – fertility preservation. Many patients are unaware that chemotherapy for breast and other cancers could result in permanent ovarian damage or even complete ovarian failure. Medically, this outcome is known as premature ovarian failure or POF – a tragic consequence occurring in up to 50% of younger women surviving cancer treatment and in much higher percentages in older pre-menopausal women. Unfortunately, this outcome is sometimes never mentioned before starting treatment.
We now have access to four methods to address the negative effects chemo may have on a woman’s reproductive choices. The first two choices focus on elective pre-chemo egg freezing or pre-chemo ovarian tissue freezing. A controversial third choice initiates ovarian suppression (temporary medically induced menopause) using depo-Lupron injections prior to and during chemotherapy to possibly provide ovarian chemo-protection. Although promising, not all studies support a beneficial outcome using this technique. Fourth, using donor eggs in the future remains a choice for patients that don’t want to use other techniques or for patients who aren’t candidates for preservation or chemoprotection methods.
So, are you a candidate for any ovarian sparing treatment? Not always. A patient should have reasonable ovarian reserve to consider egg freezing or chemoprotective injections. You need to know that all of your eggs are made and stored before birth – what remains years later is considered to be your reserve. By the time you are 30 years old, your eggs are also 30 years old and 90% of them are gone forever – before chemotherapy damages a percent of the remaining eggs. Unlike many cells in the rest of your body, eggs cannot recuperate from the damaging effects of chemo nearly as well. No new eggs are ever made. But, all women are different. We can make a relatively accurate assessment of an individual’s egg reserve by checking a blood AMH level and by counting follicles in the ovaries using ultrasound before chemo is prescribed. These are quick tests. If results are good we can feel more confident that egg/ovarian tissue freezing could be effective methods. However, if results are poor, the process would be less cost effective. The patient will need to make some tough decisions. In addition to AMH and ovarian ultrasound, we also need to simply consider age – a woman over 35 years old and especially near 40 often times will not do well freezing eggs or ovarian tissue. Yet, there are always exceptions. We must remember that your age at time of egg/ovarian tissue freeze determines the quality of the eggs when they are thawed. Also, not all clinics offering egg or ovarian tissue freezing have mastered the difficult techniques involved or have been responsible for inducing many pregnancies from the technology. If they are not technically skilled with the process there will be no way to do it over later. You want to choose a clinic that not only has great experience with egg or ovarian tissue freezing but also has demonstrated skill with either egg thaw or ovarian tissue transplantation after the fact. As an example, our clinic (Reproductive Biology Associates) has created over 2,000 live born babies over the past 6 years using egg freezing technology applied in the donor egg setting. This is the exact same technology we use when freezing eggs in our cancer patients. As a result, they can feel confident that our clinic will actually know how to use the eggs years later to generate a reasonable chance of success.
Overall, every woman facing chemo should be educated about possible ovarian failure. As doctors, we need to individualize our counseling and realize that these techniques are best considered before chemo ever begins. We can complete treatment in as little as two weeks from seeing a patient.
Scott M. Slayden, M.D.