Dr. Bill Meyer, Carolina Conceptions
Two hundred cases of invasive breast cancer may be detected in women under the age of 40 in North Carolina this year. As almost one quarter of women who are going to have a baby in North Carolina this year are between 30 and 40 years of age, many of these women will not be able to have a baby. In fact, less than 10% of women in this age range will have a baby after the diagnosis of breast cancer. What can we do as infertility specialists?
We encourage cancer treating physicians to be concerned about the best way of eradicating your disease, but also to introduce fertility preservation into their initial discussions with patients. Surprisingly only half of young women feel their concerns about fertility are addressed adequately in their consultations with their breast surgeon and oncologists.
At Carolina Conceptions, we have coordinated and developed a streamlined process to get recently diagnosed patients into Carolina Conceptions within days of an appointment request. Coordination of care between your breast cancer surgeon/oncologist and your fertility doc is essential. We also offer discounted treatment and work with pharmaceutical companies that offer generous discounts on medications.
The following options are currently available for fertility preservation in breast cancer patients:
- Medicines like Lupron (GnRH agonists) to induce a temporary menopause in an attempt to protect a woman’s eggs from chemotherapy
- Freezing of ovarian tissue
- Freezing of eggs or embryos
We encourage our patients facing breast cancer to consider freezing eggs or embryos. Carolina Conceptions’ embryologists are quite skilled in freezing eggs. In fact, our embryologists have passed the requirements to freeze donor eggs for a prestigious egg bank. This required weeks of testing and supervision from experts in the area of egg vitrification.
The first stage of freezing eggs or embryos begins with ovarian stimulation. We use two hormones called gonadotropins to stimulate a woman’s ovaries to produce eggs within follicles. It usually requires 10 days of subcutaneous injections and we monitor her progress with ultrasounds. We also add a pill called letrozole (Femara) which will limit the rise of estrogen during her cycle in women with estrogen receptor positive breast cancer.
When the eggs are mature, we cause them to go through one final maturation step using HCG, the hormone of pregnancy. Then 36 hours later we harvest the eggs in our office under anesthesia, a 15-minute procedure. After egg retrieval, we will often consider starting our breast cancer patients on Depo Lupron, a medicine that will shut the ovaries off for three months at a time. This may limit the ability of the chemotherapeutic agent to damage remaining eggs. We will work with the patient’s breast cancer doctor to decide if this is warranted.
Now that we have harvested the eggs, we can do one of two thing: freeze the eggs, or fertilize them and freeze the resulting embryos. First we clean the egg, or strip it of all additional cells so that we can either freeze it by vitrification or fertilize it by injecting a sperm. Sperm may be from a significant other or from a donor. If fertilization is performed, then the embryo is cultured for five days and frozen as a 100 celled embryo called a blastocyst. The blastocysts can remain frozen indefinitely and thawed out five+ years later when the patient is cancer free. Our current live birth rates using thawed embryos for women under age 35 is about 40%.
If the woman has decided to freeze her eggs instead of embryos, this is done hours after egg harvest. This is an alternative to embryo storage and ideal for women who do not a partner and do not wish to use donor sperm. Despite current and increased success with egg vitrification, it is still challenging, because the egg is in a stage of development that is extremely sensitive to temperature changes. Since the egg is such a large cell, it is more difficult to freeze. Despite these hurdles, frozen eggs (once thawed) are yielding pregnancy rates that are starting to approach those seen with frozen embryos.
Eggs and embryos can stay frozen indefinitely with no reported damage seen with increased storage duration. In five years, these frozen eggs can be thawed and injected with sperm from the patient’s current partner.
In summary, egg and embryo freezing present an immediate means for women to preserve their fertility potential. The main goal is to produce a healthy infant after the woman is cancer free.