August 2004: Pregnancy and Fertility Issues

Fertility compromised due to chemo?

Question from Zoe: I am a 30-year-old woman just diagnosed with breast cancer Stage 2, estrogen-positive. If I was to go through chemotherapy, what is the likelihood of my fertility being compromised?

Answers —Kutluk Oktay, M.D.: This is going to depend on the combination therapy that you will receive. In general, the combination that involves CMF (Cytoxan, methotrexate, 5-Fluorouracil) tends to have a higher rate of ovarian failure and infertility compared to AC chemotherapy (Adriamycin and Cytoxan, with or without a taxane). For a 40-year-old woman, the likelihood of infertility within one year of chemotherapy is about 80%, whereas for the AC combination, it's about 40%. So the incidence doubles if you get CMF.

For a 30-year-old, this would be lower. But resumption of menstruation is not necessarily a good way to assess if you remain fertile, because regardless of the combination, the CMF results in significant damage to your eggs. If you're younger, you have a larger number of eggs, so you can tolerate it a lot better than an older woman. But that still doesn't mean you'll be fertile, even if you continues to menstruate.

Women are born with all the eggs in their ovaries that can mature and potentially be fertilized throughout their lives. The eggs that aren't mature yet and are waiting to grow are called reserve eggs, or primordial eggs. These are different from the eggs you can see on an ultrasound, the eggs that make hormones and are ready to be fertilized. The reserve eggs you can't see on an ultrasound. But they determine when a woman will go into menopause.

If the number of the reserve eggs has gone down because of chemotherapy, then the menopause will occur sooner. Chemo damage is done to the eggs, not the surrounding cells. These cells can be replaced, but the eggs cannot be replaced. So once the damage is done, there's no going back.

Marisa Weiss, M.D., president and founder: Is there anything a woman can do to protect her reserve eggs from the effects of chemo, besides choosing a chemotherapy regimen that is likely to be effective against the cancer and safer towards the ovaries?

Kutluk Oktay, M.D.: The primordial eggs are inert and do not respond to hormones. They don't need hormones, and we don't clearly know what makes them mature. Much has been debated about using drugs to put women into temporary menopause during chemotherapy. These drugs are called gonadotropin-releasing hormone agonists (for example, Lupron or Zoladex). However, the scientific evidence for their benefit is lacking.

What these drugs do is lower hormone levels, specifically one called Follicle Stimulating Hormone (FSH). However, since primordial eggs don't have a receptor for these hormones, the benefit of lowering these hormones is highly unlikely. We don't have any solid studies on this. So we don't have a proven medical treatment to protect ovaries from the effects of chemotherapy that we can trust.

Marisa Weiss, M.D., president and founder: So what is a woman to do who wants to maximize her chance of eventually having a baby?

Kutluk Oktay, M.D.: There are several strategies to preserve fertility. In other cancer types, there isn't enough time to utilize one of several assisted reproductive techniques to preserve fertility. But in breast cancer, there is usually a four-to-six week recess, or pause, between surgery and chemotherapy, which can make it possible to use some of the technologies that involve harvesting eggs and freezing embryos.

When to get pregnant after treatment?

Question from Nadia: How long does it take for a woman to become pregnant after she received breast cancer treatment?

Answers —Kutluk Oktay, M.D.: If I interpret this question correctly, you're asking how long you should wait after breast cancer to attempt pregnancy. This is a much-debated issue. However, recently it has been suggested that—especially with earlier stage breast cancers—pregnancy does not necessarily increase the risk of recurrence. People have suggested between two to five years to wait after completion of chemotherapy.

Marisa Weiss, M.D., president and founder: That's a long time to wait if you're already in your 30s and you want very much to start a family.

Kutluk Oktay, M.D.: Yes, that's why even in a 30-year-old or even someone in her 20s, the issue of chemotherapy and egg loss is important. Even though a younger patient may not be plunged into menopause immediately, her reproductive life is shortened. After those two to five years, which are often spent using tamoxifen when she's not allowed to get pregnant, she may then experience menopause and infertility as well as the added effects of age.

Marisa Weiss, M.D., president and founder: That's certainly true. For sure, as women grow older and we're in our 30s, our fertility naturally decreases with age, even separate from all the potential effects of breast cancer treatment.

Kutluk Oktay, M.D.: One more issue here is that many women want not just one child, but a bigger family. Even if younger women can squeeze one child into that shortened reproductive life after breast cancer treatment, there's the issue of a second or third child. So even patients in their 20s may have a justifiable reason to resort to a fertility preservation strategy.

Marisa Weiss, M.D., president and founder: That's an excellent point that many oncologists don't really focus on, and that is a woman's desire to have not just one child, but more, if at all possible.

Kutluk Oktay, M.D.: The idea is to have a family, not just be fertile on the books. So the purpose is to help women have the size of family they desire.

There's another reason women shouldn't get pregnant right away after treatment: Even if they have a favorable prognosis, we would wait at least six months after completion of chemotherapy, because there will be some eggs that may be damaged (from chemotherapy) that will remain in the ovaries, and can cause miscarriage and birth defects. That's why we want women to wait at least six months so the ovaries can cleanse themselves from these damaged eggs.

Marisa Weiss, M.D., president and founder: What if your prognosis is more serious: say you have lymph nodes involved, or the cancer is large in size, or the doctor says, "It looks aggressive?"

Kutluk Oktay, M.D.: In very aggressive cases where oncologists don't feel comfortable about allowing pregnancy in the near term or at all, the only choice might be to use a gestational carrier (surrogate mother). For aggressive cancers or advanced stage tumors, the level of comfort with pregnancy is much lower and the information is much less available. If pregnancy is not safe, there are ways to deal with that, as well.

Marisa Weiss, M.D., president and founder: You mean the pregnancy may be considered unsafe because your doctor wants to watch you for the first few years after treatment because of fear of recurrence—not that the pregnancy brings on the recurrence, but because they want to watch you carefully and make sure you're OK before you take on the physical challenge of pregnancy?

Kutluk Oktay, M.D.: That is true, or they may want you to be on tamoxifen or an aromatase inhibitor for a while.

Marisa Weiss, M.D., president and founder: You just hit on a very common difficult choice that women might have to face. That is, that if tamoxifen is likely to be a benefit, your doctor will want you to be on it for a significant length of time in order to get that significant benefit. And while you're on tamoxifen, your doctor will want you to avoid getting pregnant.

Kutluk Oktay, M.D.: Depending on your age when you receive chemotherapy, by the time your doctor feels comfortable with it, you may not feel comfortable about getting pregnant. In that case, you may want to use a gestational carrier (surrogate) if you have frozen embryos from before chemotherapy.

A gestational carrier is a person who can be related to you or contracted by you to carry your embryos, either generated with your egg and your partner's sperm, or with the carrier's egg.

Pregnancy increases chance of recurrence?

Question from Website Question: Does getting pregnant after breast cancer diagnosis/treatment really increase the chances of recurrence?

Answers —Kutluk Oktay, M.D.: More and more studies suggest that if the cancer was in its earlier stages pregnancy after breast cancer does not seem to have an effect on recurrence. Less is known about advanced cancers, and one of the reasons for that is that women with advanced stage cancers tend to attempt pregnancy less than women with less advanced cancers.

Marisa Weiss, M.D., president and founder: Is there a way to establish a registry study so we, as doctors, can learn more about these important issues a little faster?

Kutluk Oktay, M.D.: There is definitely a huge need and practical feasibility. We should establish such a registry, and I think it's feasible. We're almost doing it now. We refer a significant number of these patients, and it would be a great task and very useful.

The reason why many women are concerned about pregnancy increasing the risk of recurrence is that breast cancer by and large is dependent on estrogen to grow. Even the estrogen-receptor-negative cancers will have some percentage of estrogen receptors. A low level of these receptors may not be that important if you're dealing with normal levels of estrogen. But during pregnancy, those estrogen levels may be 100 times normal. So the concern is that if your tumor can feed on estrogen, if there are cancer cells floating around, will the high levels of hormones during pregnancy make them grow?

But there are probably hundreds of hormones that also increase during pregnancy. These extra hormones could be canceling each other out, so the estrogen will not necessarily have an effect. Pregnancy is not, therefore, a situation where you just have high estrogen and that is guaranteed to revive cancer cells.

Marisa Weiss, M.D., president and founder: Just for clarification, after surgery, chemotherapy, and radiation, the hope is that you are cancer-free. What we're talking about here is the situation where maybe there could possibly be some cancer cells lingering in the body that you might not know about. If you are, in fact, cancer free, then all the different hormones that increase during pregnancy will not have any effect on recurrence. But if there are some cancer cells still left in your body despite your prior treatment, then there is this theoretical concern that all the different hormones that rise during pregnancy may stimulate growth of those cells.

The concern is not that the hormones of pregnancy will start a brand new set of cancer cells, but rather that they may stimulate cells that may be left in the body. But, as Dr. Oktay noted, research has shown that in early-stage breast cancer there does not seem to be an increased risk of recurrence with pregnancy.

Leslie Schover, Ph.D.: If they have a pregnancy before age 40, women who are carriers of the BRCAI or BRCA2 mutations may be more likely to get breast cancer. But they are a small percentage of women, and they're women who carry the mutation but have not had breast cancer.

Still fertile if not menstruating after chemo?

Question from Susan: So if one's menstruation does not start again after chemo, then you mean you can still be fertile? If so, how is that tested?

Answers —Kutluk Oktay, M.D.: In many chemo drugs, even the ones we think are not that harmful, there may be a temporary cessation of menstruation. That's simply because the one or two eggs that have grown enough to make hormones are the ones that cause menstruation, and they're sensitive to any treatment. So the fact that menstruation stops does not mean the damage is irreversible.

But if menstruation has not come back after six to twelve months, the likelihood of permanent damage is higher, and it's a sign that the reserve eggs may also have been damaged. So if you received chemotherapy in the past six months and your period has not started again, we would wait for a year and also measure your follicle stimulating hormone levels to determine if your ovaries are recovering—or, more correctly, to see if you have a number of eggs left that continue to function.

Marisa Weiss, M.D., president and founder: How reliable are blood levels of FSH/LH and estradiol in predicting whether someone is in permanent or temporary menopause?

Kutluk Oktay, M.D.: They're good at predicting the bad news, but not as good at predicting the good news. If the levels are normal, they don't tell the number of reserve eggs. If they're raised, that pretty well tells us the reserve eggs are damaged. So if a patient has elevated FSH levels after one year, that's a pretty good indication that ovarian damage has occurred.

High levels of prolactin dangerous for pregnancy?

Question from Website Question: I'm writing from Bosnia and Herzegovina. Five years ago, I had breast cancer, mastectomy, chemotherapy, and radiation. Now I am 36 years old, and I want to have a baby. I'm felling very good, the only problem is very high prolactin. All other hormones are OK. Is it dangerous for me to have a baby?

Answers —Kutluk Oktay, M.D.: Hvala! High prolactin levels are not necessarily dangerous if you want to get pregnant, but they have to be investigated, because they can be caused by tumors in the brain. If there is a large tumor, that tumor can grow during pregnancy. You should have a brain MRI done to determine the origin.

Marisa Weiss, M.D., president and founder: Dr. Oktay is referring to a tumor of the pituitary gland (not a breast cancer that has spread to the brain). These pituitary gland tumors are usually fairly straightforward to treat, relative to the other scenario of breast cancer that spread to the brain.

If a woman has an elevated prolactin level without a pituitary gland type of tumor producing it, does it need to be controlled for her to try to get pregnant?

Kutluk Oktay, M.D.: High prolactin levels will typically prevent ovulation, so this does need to be treated, but this can be done medically. And once you get pregnant, it doesn't interfere with the ability to carry the baby.

How to be certain no longer fertile?

Question from Website Question: How can I be certain that I am no longer fertile? I have not had a menstrual cycle since September 2003.

Answers —Kutluk Oktay, M.D.: You should see a reproductive endocrinologist in your area to have your FSH levels measured, and have an ultrasound so they can see your ovaries to determine if there is any egg loss taking place. The main concern here is whether chemotherapy resulted in early menopause.

Marisa Weiss, M.D., president and founder: Each one of us has had quite a few women in our practice that may stop menstruating for one or two years, and then resume menstruation. But as Dr. Oktay says, the number of additional years that menstruation will continue is likely to be less than normal. That means that even if you do resume menstruating, you may not menstruate as long as you would have, had you not had the chemotherapy.

Kutluk Oktay, M.D.: Also, some women may resume menstruation, but not be regular. Some of the bleeding might be from the endometrium (lining of the uterus) due to the effects of tamoxifen. So what you perceive as menstruation may be from other sources. If menstruation resumes after a long period of time, you should have a gynecological exam to make sure there are no other causes of bleeding.

Herbs, acupunture help ovary damage?

Question from Website Question: If there is ovarian damage due to chemotherapy (indicated by elevated FSH levels), is it possible for the ovary to recover through the use of Chinese herbs and acupuncture?

Answers —Leslie Schover, Ph.D.: We really have no Western medicine clinical trials to evaluate that.

Kutluk Oktay, M.D.: Our current knowledge dictates that once an egg is lost, nothing can bring it back. I haven't seen any scientific data or anything in my practice to support non-traditional ways to restore fertility.

Marisa Weiss, M.D., president and founder: If a woman's fertility level is marginal and she's pursuing fertility therapy, does acupuncture add value in that situation?

Kutluk Oktay, M.D.: Based on what we know now, you can't regenerate eggs or increase the quality of eggs with any medicine. So in my mind there's no benefit to using these remedies.

Marisa Weiss, M.D., president and founder: I think there was some study recently about it that's in the popular media.

Kutluk Oktay, M.D.: If your problem is low 'quality' of eggs, as opposed to lack of ovarian function, acupuncture treatment may be of some help, but it may be a matter of choice about what patients feel comfortable with. The only way I know of to protect women from chemotherapy-induced infertility is to preserve eggs prior to subjecting them to damage.

Stop medication to get pregnant?

Question from Vicki: I have metastatic breast cancer with mets in my spine and shoulder. I have been responding well to Femara and Aredia. I have not given up on the idea of having my own children. How should I be evaluating the risks of going off of medication for a time period?

Answers —Marisa Weiss, M.D., president and founder: If you have metastatic breast cancer, generally ongoing treatment is necessary to control the growth of the breast cancer, so there are a number of issues that your question raises. First, if you were to go off of your treatment for an extended period of time—long enough to get pregnant and carry a pregnancy—that would be about a year or so at least without anti-cancer treatment. Most doctors would consider that choice a dangerous one.

In addition, when there are known cancer cells in your body that may grow more rapidly in response to all the hormones that go along with pregnancy, that too poses a significant potential threat to your health.

Women in this situation that you're in may find another way to go that will allow them the experience of motherhood without stopping treatment and attempting pregnancy themselves. Adoption is an option, or an attempt to grow relationships with family members that are already in your life, where you can have a critical nurturing role that is deeply satisfying, and that goes along with continuing treatment to extend your own life.

Kutluk Oktay, M.D.: One thing that comes up in patients like this is if they receive chemotherapy but have not suffered from ovarian failure, can we stop these medicines for a brief period and then resort to one of the preservation procedures, and then put the patient back on the treatment so she can use the embryos for the gestational carrier? What if she stops for three months or so? That comes up all the time, and we don't have a good answer.

Leslie Schover, Ph.D.: There have been protocols where aromatase inhibitors are used along with fertility drugs that stimulate the ovaries. The aromatase inhibitors help stimulate the ovaries to produce more mature eggs and they may also offer protection against the high levels of fertility hormones.

Marisa Weiss, M.D., president and founder: Dr. Schover and Dr. Oktay, can you describe the steps a woman might go through to have her ovaries stimulated to produce ovulation?

Kutluk Oktay, M.D.: There may be a possibility to take you off the breast cancer medicines for several months, and for you to undergo ovarian stimulation with aromatase inhibitors. Aromatase inhibitors help stimulate the ovaries to result in extra egg production during a cycle. We can use these along with standard low-dose fertility drugs to make extra eggs that can be fertilized and saved, and then you may go back on your cancer treatment. And those embryos in the meantime can be used with a gestational carrier (surrogate).

Again, for breast cancer patients who have been diagnosed but have not undergone chemotherapy, another option is to use tamoxifen as a fertility drug. It was originally used as a contraceptive, but didn't work well because it increased ovulation.

There is a third and more experimental option, which is removing ovarian tissue before chemo and freezing it, and then transplanting it back into the body. There have been fewer than a dozen of these procedures done so far. We were able to get embryos from the patients who underwent the transplant, and we are working on a first pregnancy.

But if the patient does not have enough time to undergo ovarian stimulation, ovarian tissue freezing may be the only option. In summary, we can do ovarian stimulation with tamoxifen or an aromatase inhibitor, we can freeze your eggs by themselves or as fertilized embryos, or we can do ovarian tissue transplants.

Marisa Weiss, M.D., president and founder: There are so many emotional issues that go along with all these medical considerations. Dr. Schover, after a woman finishes her intensive breast cancer treatment, she has to deal with a whole other set of difficult issues that surround potential infertility. How do you counsel a woman with her partner or a woman without a partner to handle these tough issues?

Leslie Schover, Ph.D.: One thing that is very important is to acknowledge the grieving women go through. And for a young woman, the loss of her belief that she has a long future and that nothing that bad could happen to her is a trauma and a grief in itself. Then to have infertility on top of that is a real double whammy. Many people in a woman's own life try to minimize the importance of the infertility, saying things like, "You could adopt" or "You're lucky to be alive," and that can make a woman angry and make her feel misunderstood.

Doing realistic problem solving about the options—the risks and benefits of each—is necessary, and there's nothing easy here. There are potential barriers and things you have to confront. If you can have a natural pregnancy, you are very lucky, but we still can't say for sure that pregnancy won't increase chance of recurrence. The fear that you may have a daughter who could also have breast cancer is also a concern. And what if you don't live long enough to see your children grow up? These are all real concerns that need to be addressed.

For women who can't get pregnant, or decide not to, there are also concerns about barriers to adoption. How much should I tell the home care? Should I consider international adoption, since some countries are more favorable to cancer patients? Do I need a letter from my oncologist saying my prognosis is excellent? What about an egg donor? Who would be the donor, and would the child love the biological mother as well? If there is counseling available, that's a good place to talk out all the ambivalent feelings a woman may have.

Marisa Weiss, M.D., president and founder: Motherhood can take on so many forms. So much of being a mother is how you create the relationship with the person you bring into this world, either through your own body with your partner, or through adoption as an alternative. There is so much about motherhood that you create yourself, beyond how the baby came to you. That is where so much of the opportunity is for you to experience motherhood.

Leslie Schover, Ph.D.: Although I agree with you, I think that can sometimes be the kind of statement women aren't ready to hear. There is such a sense of loss at not being able to do what it seems that every other woman around you can do, which is to get pregnant and carry your own child. It's true that social parenting is very important and there are joyful ways to be around children. But often when women are infertile, they don't have the ability to enjoy some of those other ways, because they're so busy with the negative thoughts about not being able to have a child themselves. So it may take time to be able to be a wonderful aunt or teacher or foster parent.

Marisa Weiss, M.D., president and founder: As a parent, if you have a child yourself, or if you adopt a child, or if you take on stepchildren, so much of motherhood in each of those contexts is a day-to-day, week-to-week, year-to-year relationship that you create and build. I wasn't so much referring to other types of relationships where nurturing is important. But I do agree that giving up the hope of having a baby yourself represents a huge disappointment to most women who desire that. As you grieve and move on through the process, and as you come to terms with your situation, new possibilities can present themselves.

Is egg freezing still experimental?

Question from LNB: Is egg freezing still experimental?

Answers —Kutluk Oktay, M.D.: Egg freezing is experimental because so far there have only been about 100 pregnancies around the world from frozen unfertilized mature eggs. However, this is a technology that is on the rise. In the future, it may be considered less experimental than it is viewed at the present time.

Marisa Weiss, M.D., president and founder: The method that's been the most successful so far is extracting the eggs, fertilizing them out side the body, which is called "in vitro fertilization," and freezing the embryos.

Able to adopt while being treated for cancer?

Question from LNB: Will adoption agencies let you adopt if you are actively being treated for cancer?

Answers —Leslie Schover, Ph.D.: That's a good question. There is almost no information out there about what adoption agencies will actually do. Most of them appear to want a letter from your physician saying you are free of cancer and will have a normal life span. I think it would be unusual for an adoption agency to allow a woman to adopt while she is undergoing cancer treatment, although there are many forms of adoption. You could consider a special needs adoption for an older child, or one with physical or emotional problems who may really need a loving home and not have many potential adoptive parents.

Marisa Weiss, M.D., president and founder: Which countries are most likely to be friendly toward a woman with a history of breast cancer?

Leslie Schover, Ph.D.: There is a very interesting online group at yahoo.com called adoption-after-cancer and most of the people in that group have investigated international adoption. I know from listening in on the group that Russia is one of the more difficult countries, because they want a letter saying you are five years free of disease before they'll let you adopt. But other people have adopted from South American countries or China, so all countries are different.

What is the effect of tamoxifen on fertility?

Question from Website Question: What is the effect of tamoxifen on fertility?

Answers —Kutluk Oktay, M.D.: Tamoxifen does not have any permanent effects on fertility, even though some claims have been made. However, while taking tamoxifen for breast cancer treatment, because it constantly stimulates the ovaries, it can result in ovarian cysts and may make the ovary temporarily dysfunctional. It may increase fertility for a time, but reduce it later, because it's being used constantly, as opposed to the way it's used in fertility treatments, which is usually at high doses for five days.

But once you stop taking tamoxifen for breast cancer treatment, ovarian function is expected to go back to where it was before, which is unlike chemo drugs. Tamoxifen does not reduce ovarian reserve beyond what happens with age.

Marisa Weiss, M.D., president and founder: That's a good point, since some women may be on tamoxifen for up to five years, so age can have a significant impact on fertility if taken that long.

Leslie Schover, Ph.D.: Another concern is that tamoxifen may at least theoretically cause birth defects if taken during pregnancy. So while women are taking tamoxifen, they are advised to use birth control and avoid getting pregnant.

Kutluk Oktay, M.D.: Excellent point. Even though there are few case reports and the abnormalities don't resemble each other, tamoxifen should still be avoided during pregnancy.

Safest way to prevent pregnancy on tamoxifen?

Question from Website Question: For someone with breast cancer and taking tamoxifen, what do you think is the safest and most effective way to prevent pregnancy?

Answers —Kutluk Oktay, M.D.: Tamoxifen can increase the risk of blood clots, and obviously breast cancer patients don't want to use hormonal contraceptives. So that's one thing you'd want to avoid while you're taking tamoxifen. That doesn't leave us with many choices except the barrier method, specifically condoms, diaphragms, and spermicides. IUDs (intra-uterine devices) can also be used, although they're not very popular in the United States.

Marisa Weiss, M.D., president and founder: For some women who may be experiencing some vaginal dryness, it may be uncomfortable for you if your partner uses a condom. You can get around this sometimes by just using lubricant. Many women learn how to use the diaphragm with contraceptive jelly. Initially it's awkward, but you can get the hang of it. Many women will also rinse out the vagina afterwards with a little water and handheld douche to keep the contraceptive jelly from leaking out after the diaphragm has been removed (five to six hours after intercourse is finished).

Herceptin causes ovarian damage, menopause?

Question from Susan: Does Herceptin cause ovarian damage or early menopause?

Answers —Kutluk Oktay, M.D.: No. It's a very selective drug, and there's no evidence that it causes damage to eggs.

Marisa Weiss, M.D., president and founder: Your question raises a good point, which is when any new chemotherapy or other form of therapy is put into use, it's very important for studies to look at the possible impact that each of these treatments might have on a woman's fertility. In the past, this was not routinely studied. In the future, studies need to pay very close attention to this important issue.

Difference of infertility, premature ovarian failure?

Question from LNB: What is the difference between infertility and premature ovarian failure?

Answer —Kutluk Oktay, M.D.: These are just different shades of the same problem. Usually menopause is the last stage of the process of losing ovarian function. Infertility comes first typically, and then menopause occurs. But if the treatment is strong enough, they can happen simultaneously.

How to find fertility doctor?

Question from LNB: Where can I find resources/referrals in my area to find a fertility doctor that can help me—now or after cancer?

Answers —Leslie Schover, Ph.D.: One way that you might be able to do that is to contact the organization Fertile Hope. Although their offices are in New York, they're an advocacy group that has a special focus on fertility in cancer. They may have a list of people around the country who have a special interest in cancer and fertility.

Another source is the organization Resolve, which is an advocacy agency for people with fertility problems, and again, has a list of referrals. The American Society for Reproductive Medicine (ASRM) is another possibility. They can tell you where the IVF clinics are in your area.

Marisa Weiss, M.D., president and founder: It's hard to get an appointment quickly with a busy infertility practice. Do you have any suggestions on how to push your way into the schedule quickly, so you can seek infertility evaluation before starting chemotherapy or hormonal therapy?

Leslie Schover, Ph.D.: Ask your oncologist to intervene for you, especially if s/he has a special relationship with any of the reproductive endocrinologists in your area.

Kutluk Oktay, M.D.: That's a very practical problem. The real solution to that is a reproductive endocrinologist who specializes in fertility preservation in cancer patients.

Leslie Schover, Ph.D.: But realistically, outside of major medical centers, you won't find someone like that.

Kutluk Oktay, M.D.: Yes, that's a problem. So if you're near a major multidisciplinary medical center, you'd have a better chance of finding someone like this. In my practice, we see our patients within 24-48 hours, depending on the patients' circumstances. But usually doctors will do a better job of convincing other doctors to see their patients.

Marisa Weiss, M.D., president and founder: Medical insurance often pays for medication to help manage side effects of chemo, like anti-pain or anti-nausea medications. Will medical insurance help pay the cost of infertility when it is likely to be a side effect of breast cancer treatment?

Kutluk Oktay, M.D.: We oftentimes argue this exact point with insurance companies, and some of them do buy the arguments and some of them don't. Some patients end up putting up a lengthy fight, and some give up. But my suggestion is that if every patient makes the same argument, we may be able to change their minds on this issue. Unfortunately, some insurance companies don't follow this logic.

Marisa Weiss, M.D., president and founder: It's certainly worth pushing.