September 2008: Fertility and Pregnancy

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Pause treatment to get pregnant?

Question from FNichol: What advice would you give to a 39-year-old breast cancer survivor (stage II/III, node-negative, 100% ER/PR+) who has had a lumpectomy, radiation, and 2 years of tamoxifen who is considering taking a temporary break from hormonal therapy treatment to become pregnant with her first child?

Answer —Leslie Schover, Ph.D.: Well, that's always a difficult situation because most oncologists would say that it's optimal to stay on the tamoxifen for 5 years. But we also know at your age, you're reaching a time when it may be difficult for you to become pregnant, so you may not have 3 years. I think that it would be good for you to sit down with your oncologist and try to get some idea of your personal risks and try to make that very individual decision.

Risk of chemotherapy damaging eggs?

Question from DS20: I have had AC chemotherapy (Adriamycin [chemical name: doxorubicin]/Cytoxan [chemical name: cyclophosphamide]) followed by Taxol (chemical name: paclitaxel) plus Herceptin (chemical name: trastuzumab) and will complete 5 years of tamoxifen in a few weeks. I am delighted in now being able to consider the possibility of getting pregnant since I am still menstruating. However, I would like to know if there is any risk that my eggs would still be or could be damaged as a result of the chemotherapy from December 2002 to May 2003?

Answer —Kutluk Oktay, M.D.: Well, it's difficult to say there's no risk, but what we do know is that among children born to cancer survivors there has been no unusual risk of birth defects. Also there are probably some genetic repair mechanisms in eggs and most of that repair takes place in the first 2 years after chemotherapy. If you are able to get pregnant, there shouldn't be high concern about the child's health. It is possible the child could have a life-long increased risk of breast cancer, especially if there are other family members besides yourself. So if you're concerned about that and there is a family history, you may want to see a genetic counselor as part of the decision process.

OK to get pregnant after treatment?

Question from Patricia: I'm 31 years old. I had breast cancer 5 years ago. My treatment included goserelin. I've had menopausal symptoms -- irritability, hot flashes, no sexual appetite. Now I'm finished treatment. My period came back. What is your opinion about me becoming pregnant? My analysis results are OK so far and I will finish 5 years of tamoxifen in 2 months.

Answers —Kutluk Oktay, M.D.: First of all, we would need to know what kind of chemotherapy you received. If your treatment was only with goserelin (brand name: Zoladex) and no chemotherapy, you should be in good shape to get pregnant at this age. If you had chemotherapy then your fertility might be compromised. It's best that you see a specialist who can assess your current egg reserve by doing certain hormonal tests. You may need help conceiving.

Leslie Schover, Ph.D.: As with the previous questions, when the women have no positive lymph nodes and are treated for an early stage breast cancer, studies have not shown any negative effect of getting pregnant afterwards. Women who get pregnant live as long as women who do not get pregnant who are similar in other ways. Although, we would always like to see more research.

Kutluk Oktay, M.D.: Those studies also looked at lymph-node-positive and some of those studies did not find any difference between lymph-node-positive or negative patients as Dr. Schover said, as long as they receive proper treatment. In some studies they were found to be even better, though every study has its weakness.

Does radiation affect fertility?

Question from Kas: I am 38 years old and was recently diagnosed with adenoid cystic carcinoma of the breast. I had a lumpectomy with clear margins and no lymph nodes involved. I will be undergoing radiation but not chemotherapy. Does radiation affect fertility? How long would you recommend someone with my diagnosis wait before getting pregnant?

Answer —Kutluk Oktay, M.D.: Local radiation to the breast does not affect fertility. Breast cancer doctors have been arbitrarily using the wait-and-see for 2 years, however, this not based on scientific study. As a matter of fact, some of the studies show that pregnancy occurring as early as 6 months after treatment does not affect the likelihood of cancer coming back. But for practical reasons, oncologists would like to see patients not getting pregnant because many cancers carry the highest risk of recurrence in the first few years. Management of breast cancer during pregnancy is more complicated because you have to consider the fetus as well. Generally it's advised that these patients wait 2 years.

Pregnancy increases recurrence risk?

Question from Ellie: Can pregnancy give rise to a recurrence in hormone-receptor-positive breast cancer survivors? What data is available on the subject?

Answers —Kutluk Oktay, M.D.: There is really no evidence that receptor-positive patients will have higher risk of cancer coming back after pregnancy. Overall, women with breast cancer -- whether receptor-negative or positive -- who become pregnant seem to have similar or better outcomes compared to those who did not get pregnant.

Leslie Schover, Ph.D.: It's important to say that these are women who were successfully treated for their cancer, had no evidence of the disease, and then got pregnant.

Reconstruction options with a baby?

Question from Chris: Is it good to have an implant or to have reconstruction when you have a baby?

Answer —Kutluk Oktay, M.D.: In terms of the problems occurring during pregnancy, implants are better, especially if the reconstruction is done using tummy muscles, or TRAM-flap. That kind of reconstruction removes muscles that will contain the growing uterus, so in some cases, hernias and sometimes organ compression may occur, though this is extremely rare. Also, after reconstruction with tummy muscles, if the woman lactates, there may be asymmetry between breasts as the reconstructed breast will not go through similar changes. Obviously, with implants they can consider bilateral implants, so that may be perhaps more fixable. That's one of the things that needs to be considered.

Birth control pill increases genetic risk?

Question from AWT: Hello. I am turning 39 in 1 week and I'm BRCA1-positive. My aunt and mother both contracted cancer at ages 37 and 38. Both had double mastectomies and are survivors. I have always wanted children yet do not have a partner. I have not been on the pill in 19 years. Will taking the pill now increase my risk?

Answers —Kutluk Oktay, M.D.: The answer that I can give on women with BRCA1 risk is that birth control pills do slightly increase the risk of breast cancer. We’re unaware of specific studies that show whether the BRCA1 gene increases that.

Leslie Schover, Ph.D.: It might be relevant that, in general, women with BRCA1 mutations have some of the same increases in breast cancer risk from other hormone factors as women with non-inherited breast cancer.

Kutluk Oktay, M.D.: We know that birth control pills reduce the risk of ovarian cancer, but again, I'm not aware of a specific study looking at BRCA1-positive patients and use of birth control pills to reduce the risk of cancer. Overall, since birth control pills reduce the risk of ovarian cancer it may actually be beneficial in that sense.

Leslie Schover, Ph.D.: At age 39, if in your particular family there've been cases of ovarian cancer, you're at an age where they start recommending you get your ovaries removed because it's so hard to screen in order to catch it early enough.

Kutluk Oktay, M.D.: The current recommendation for oophorectomy is between 40 and 45 for someone at high risk. But depending on the family history and how early it developed with family members and whether you've completed your child-bearing, this can be done sooner or later (in general, I mean). One other thing is that there is some evidence that birth control pills reduce the risk in ovarian cancer mutation carriers, but potentially increasing the risk of early-onset breast cancer. So in that sense, it may be a wash. There's also another controversial treatment -- having tubal ligation. Some studies show that having your tubes tied if you're BRCA1-positive may reduce your risk of ovarian cancer. This is also controversial. For a patient like you, if you're still not ready to have children, it might be wise to undergo an in vitro fertilization (IVF) cycle to freeze your embryos. This kind of fertility treatment can even be done with medication such as letrozole (brand name: Femara; an aromatase inhibitor) to reduce the estrogen exposure during fertility treatments.

Leslie Schover, Ph.D.: You would have the option of either freezing unfertilized eggs, which has less chance of success later, or, since you have no partner, using sperm from a donor to create embryos because that has a better success rate for pregnancy.

Kutluk Oktay, M.D.: Another advantage of IVF, if in the future you do want to make sure you're not transmitting the gene to your children, is that the embryos (either derived from frozen eggs or donated sperm) can be genetically tested before being transferred back to your womb to make sure they do not carry the mutation. The other thing that I find here, women with BRCA mutations may increase their risk of breast cancer by becoming pregnant before age 40 years, but breastfeeding may decrease that risk somewhat regardless of patient’s age. So clearly there are complex interactions at play, thus issues with a patient with BRCA mutations are complex.

Leslie Schover, Ph.D.: If you are considering having bilateral prophylactic mastectomy yourself, like the other women in your family, you may want to do that soon, since you're at the same age that they developed their cancer. And then you would be less at risk to get breast cancer if you had a pregnancy.

Kutluk Oktay, M.D.: The studies did not look at mutations in those patients; these were much earlier studies predating the era of BRCA testing. Currently we don't know if being pregnant after having been treated for BRCA-positive cancer will be as safe as in those women who conceive after BRCA-negative cancer.

Fertility help after cancer treatment?

Question from Whoopsiedoodles: We have been trying to get pregnant since a year after I ended my treatment (chemotherapy, surgery, and radiation). It will be 3 years since my diagnosis as of September 29th. We've had no luck (obviously), and I tried to get in to see a fertility specialist. They turned me away, saying they prefer I am at least 5 years out of treatment. Is this standard? Where do I turn for help if a fertility clinic won't help?

Answers —Kutluk Oktay, M.D.: There's absolutely no scientific data to support one has to wait 5 years before entering pregnancy. Each case should be individualized, but studies have shown that conceiving as early as 6 months after successful treatment of breast cancer does not increase risk of recurrence.

Leslie Schover, Ph.D.: It sounds like you need to find a different infertility specialist who's more familiar with treating women with cancer.

Kutluk Oktay, M.D.: Fertility preservation is a sub-specialty within reproductive endocrinology. You should seek out a physician who is experienced in treating fertility issues of cancer patients.

Leslie Schover, Ph.D.: It may not be so easy if you do not live near a major city, but since you usually have to pay for your infertility treatment out of your own pocket, unless you're lucky enough to have insurance coverage, it might be worth doing some traveling to find an expert. There are also websites that offer fertility information -- FertileHope.org and FertilityPreservation.org.

Kutluk Oktay, M.D.: Also, some experts offer phone consultations, so it might be worth it to get an opinion over the phone with a competent expert who will look at your medical facts and make a recommendation. Experts as such usually communicate with the patient's oncologist to jointly decide that treatment is safe for them.

Stop fertility treatments after diagnosis?

Question from Corallee: I don't know what to do. I've been having fertility treatments and was diagnosed with DCIS. Do I have to stop my fertility treatments? I'm 43 and this might be my last chance to have a child.

Answers —Kutluk Oktay, M.D.: A patient like you should freeze your embryos until your treatment is complete, which may be just surgery. Then after that, you could use those embryos to get pregnant. Having said that, some oncologists may even agree to allow the woman to get pregnant immediately after full surgical treatment of DCIS, because the disease is not invasive. So at the least you should consider freezing your embryos if the doctors want you to delay child bearing. The reason for that is you're 43 and your fertility is already diminished. If you keep waiting by just aging alone you will be less fertile. You need full evaluation and treatment without delay, because whatever chance you have now is going to be even less 3 months or 6 months from now. And at age 45, your chances will go down to near zero.

Leslie Schover, Ph.D.: Although it's not usually a woman's first choice, it might be worth remembering that you could still be a good candidate for carrying a pregnancy that was conceived with an egg from a donor and your husband's sperm.

Success of freezing eggs?

Question from MirandaL: If I freeze my eggs, what are the chances that I can get pregnant and have a healthy baby? Or do you have a better chance by using someone's donor eggs?

Answer —Kutluk Oktay, M.D.: The success rate of egg-freezing depends on the patient’s age. For somebody in her mid-30s, the success rate per attempt appears to be about half of the success rates with in vitro fertilization (IVF) using unfrozen eggs either from the patient herself or from a donor. If you just look at success rates, using unfrozen eggs, either from yourself or a donor, will give you a higher chance. But if you're a young patient, depending on age, and can produce lots of eggs, that also might give you a reasonable chance. If you're much older than 35 to 37, the rate of success of egg-freezing is probably not very high. So you should make your decision based on your age, your desire as to whether you want to have your own biological children, and finances, since egg donation costs more.

How does egg collection work?

Question from AhlLee: How are eggs removed from the ovaries? Does it take a long time to recover from the surgery?

Answers —Kutluk Oktay, M.D.: If this question refers to egg collection during an in vitro fertilization (IVF) cycle, the woman is put under a light anesthesia and a needle is put through her upper vagina, guided with ultrasound images to the surface of the ovaries where the eggs are removed from the follicles. The procedure lasts around 10 to 15 minutes typically and is done as an office procedure, and the patient usually recovers within half an hour and is discharged. It's a simple, minimally invasive procedure and does not interfere with much of your activities for a long time.

Leslie Schover, Ph.D.: You might have some soreness in your pelvic area for a day or two.

Breastfeeding safe after treatment?

Question from Medtech: I was diagnosed with HER2-positive, stage II breast cancer 5 years ago. Went through chemotherapy, radiation, and Herceptin (chemical name: trastuzumab) and have had no evidence of disease since the end of treatment. I'm now pregnant and overjoyed, but am worried about breastfeeding because of the treatment. Is it safe for me to breastfeed?

Answers —Kutluk Oktay, M.D.: There's no such evidence that breastfeeding after completing your cancer treatment would hurt the baby. And, in fact, it may have some mild preventative effect for future cancers.

Leslie Schover, Ph.D.: One thing that women may find interesting is that for a breast that has had lumpectomy and radiation, about a quarter of women are still able to get some breast milk on that side.

Tamoxifen dangerous during pregnancy?

Question from SusannaL: How can tamoxifen be used as a fertility treatment? It increases ovulation, but is dangerous to the fetus -- all at the same time? How can that be?

Answer —Kutluk Oktay, M.D.: Tamoxifen, just like its cousin the infertility drug Clomid (chemical name: clomiphene), is used to induce ovulation in women prior to pregnancy. And thus, because they're not used once the patient ovulates and discontinues before the pregnancy, there's no risk of exposure of the drug to the fetus. There's no significant risk. Tiny amounts of the drug may still be present once pregnancy occurs -- or during the first few days of pregnancy -- but there's no evidence it causes an increased risk of birth defects. While tamoxifen should not be used during pregnancy, there have been very few birth defects reported in women who accidentally took tamoxifen while pregnant. Thus, if there is a risk, it is probably very small.

Marriage problems with infertility?

Question from Regina: I'm really concerned about my marriage not dealing well with infertility caused by my treatment. I got breast cancer just one year after we got married. Any suggestions on how other couples have dealt? I somehow feel guilty.

Answer —Leslie Schover, Ph.D.: Those are very natural feelings to have. One suggestion I would make is to seek some counseling with a mental health professional who has worked with cancer patients. Your fears may be greater than the distress that your husband feels. But if it's hard for you two to talk about it, seeing a counselor together may help the two of you communicate in a safe atmosphere. There is no evidence that women who get breast cancer divorce more than other women. Even if you're not able to have a child in the future, there are other alternatives like adoption or having a child through egg donation, and it is important to look at all the options and take the time to make decisions.

Pregnancy how soon after Herceptin?

Question from Taylor: Hi. I am 34 years old and have HER2-positive cancer. I am taking Herceptin until next March. I do want to have a baby after I am done. How soon can I get pregnant?

Answer —Kutluk Oktay, M.D.: Again, studies have not shown any increased risk of breast cancer in women who conceive as early as 6 months after completion of their treatment for breast cancer. Herceptin (chemical name: trastuzumab) should not be used during pregnancy. Because data only tells us what happens after 6 months after completing treatment, I would wait 6 months.

Permanent infertility with chemo?

Question from Pilar: With 4 cycles of Adriamycin (chemical name: doxorubicin) and Cytoxan (chemical name: cyclophosphamide), how likely is it that a 30-year-old woman would become permanently infertile?

Answer —Kutluk Oktay, M.D.: The issue is that this type of chemotherapy results in loss of significant number of eggs from the woman's ovaries. While you may still menstruate after the treatment, your ovaries would behave like an older woman's ovaries. That means that you will have a smaller number of reproductive years to have children. Therefore, you should not waste time getting pregnant, and if you have difficulty you should seek advice from a specialist as soon as possible. If you're considering delaying childbearing further, you may also consider freezing your eggs if you're single or embryos if you have a partner because you will experience much earlier menopause than women who did not receive chemotherapy.

Risk to fetus while on tamoxifen?

Question from Arka: I was taking tamoxifen and then found out I was pregnant! I stopped taking tamoxifen when I found out, but I think I had been pregnant for 2 weeks before I took the pregnancy test. Is there anything I should be worried about?

Answer —Kutluk Oktay, M.D.: Again, going back to the previous answer, in the very early part of pregnancy, organ development has not started yet. Therefore, if the exposure was very early on, the likelihood of a birth defect would be very low. However, you may be followed by a high risk OBGYN/pregnancy specialist and may have ultrasound evaluations of the fetus to make sure that no anomalies are developing. But again, this is very unlikely.

How long after MammoSite to conceive?

Question from Wellness: How long after MammoSite radiation do I need to wait until trying to conceive again?

Answers —Kutluk Oktay, M.D.: This appears to cause less radiation to surrounding organs, and since giving standard radiation is not a problem in terms of ovarian function, MammoSite treatment should not affect your future fertility.

Leslie Schover, Ph.D.: You would probably want to wait the standard 6 months that we've referenced here tonight as well.

Mammograms safe while pregnant?

Question from DanielleB: I'm pregnant and have a breast lump. My doctor says it's safe for me/my baby if I get a mammogram -- is that true?? I don't know if I can go through with it. Is there anything else I could do that would be as effective?

Answer —Kutluk Oktay, M.D.: The radiation exposure may be small, especially with newer machines. You may consider an ultrasound of the breast or MRI, instead of X-ray study.

Infertility certain after CMF?

Question from Margaux: I'm having CMF chemotherapy treatments for 6 months -- that's a long time. That has to affect my fertility, right? I'm 40 but I still hold out hope for a pregnancy after treatment.

Answers —Leslie Schover, Ph.D.: Unfortunately, after CMF (Cytoxan [chemical name: cyclophosphamide], methotrexate, and fluorouracil), about 90% of women over age 35 go into permanent menopause. So it is probably unlikely that you would be able to have your own biological child afterward. However, again, this is a situation where you could use a donor egg and there are certainly other ways to get a child.

Kutluk Oktay, M.D.: If you have not started your treatments, you might undergo ovarian stimulation with aromatase inhibitors (letrozole [brand name: Femara]), which allows your estrogen levels to remain low while you freeze your eggs or embryos for future use, because getting pregnant with your own eggs after this treatment will be extremely unlikely.

Insurance covers egg freezing?

Question from LindaNY: Does insurance pay for freezing your eggs?

Answer —Kutluk Oktay, M.D.: Typically, no. However, some insurance companies ask for medical necessity and if they see this is addressing a complication of cancer treatment, rarely they may extend coverage.

Increase libido to get pregnant?

Question from Calla: I know this is about fertility, but it is so difficult to think about having sex when I've lost my interest. We want to get pregnant now for fear my cancer may return, but I can't seem to get any interest in being intimate. I'm only 36 and feel terrible about this.

Answer —Leslie Schover, Ph.D.: Many women find that their desire for sex decreases after their breast cancer treatment and there are many different reasons why that could be so. Sometimes there are hormone changes, but if you are having regular menstrual cycles, that's unlikely. Many women have low energy for months after chemotherapy and radiation, and may also have a mild depression. These problems can interfere with your desire for sex. Also, if you're taking any medicines, especially for depression, anxiety, or pain, talk to your doctor about whether those medications could be interfering with your desire for sex. If so, perhaps the dose or type of medicine could be changed. It takes an effort to begin to feel sexual again, so you may want to see a counselor who is familiar with these problems to give you some suggestions. Sometimes, it helps to watch a sexy movie, read a sexy book, take extra time in your foreplay, and do things to feel good about your body. Take a bubble bath, go dancing, things that perhaps used to put you in the mood for sex.

Nursing on treated breast?

Question from Alannaconroy: I'm finally pregnant and thrilled. Now my hope is to be able to breastfeed. I had a lumpectomy and radiation. Any advice on things I can do to increase the chances on nursing on that breast?

Answer —Leslie Schover, Ph.D.: I think that the statistics say that about a quarter of women who've had lumpectomy and radiation can nurse on that breast. The treatment does not affect being able to nurse from an untreated breast, if there was no surgery or radiation on the other side. In general, keep on trying on both sides, because sometimes it takes a while for the milk glands to start producing. Stimulation of the nipple by the baby's mouth can help increase milk production if you're patient and keep trying. Some results may depend on how much radiation the breast received, however.

Pregnancy for ER- increases risk?

Question from LBB: I'm ER-negative and would like to get pregnant. Does pregnancy increase my chances of recurrence? I'm stage II and finished treatment 17 months ago.

Answers —Kutluk Oktay, M.D.: No, not according to current studies. Please see the answers to previous questions. The transcript will be available next week on Breastcancer.org.

Leslie Schover, Ph.D.: Women who are successfully treated for breast cancer and then get pregnant appear to have the same survival as similar women who did not get pregnant.

Chances of conceiving after treatment?

Question from Rhoda: I had a mastectomy with reconstruction in my right breast, and implants will be put in my left and right breasts after treatment -- chemotherapy and Herceptin (chemical name: trastuzumab). I am 36 years old. My husband and I have been married for 2 years and would like to have at least one child. I have an intrauterine device (IUD) in me as a barrier. Once the doctor gives us the green light to start having a kid, I will have the IUD removed. What are my chances of conceiving?

Answers —Leslie Schover, Ph.D.: The breast reconstruction has no influence of your chances of getting pregnant. It is often hard to give a statistic on an individual woman. Your chances of being able to get pregnant depend on the chemotherapy drugs you're getting, the total dose you get, and your age. Many women who are over 35 do go into a permanent menopause, but some do not. It is hard to make a clear prediction for you as a person rather than a group of women.

Kutluk Oktay, M.D.: Not going into menopause does not mean that you are fertile.

Leslie Schover, Ph.D.: In other words, even if your periods return, you still may not be as fertile as most 36-year-old women.

Kutluk Oktay, M.D.: I would say, even if your periods return, you may have lost your fertility. Women in their perimenopausal years may continue to menstruate without having a chance of pregnancy. If you will be receiving one of the standard chemotherapy regimens such as ACT (Adriamycin [chemical name: doxorubicin), Cytoxan [chemical name: cyclophosphamide], and Taxol [chemical name: paclitaxel]) or CMF (Cytoxan, methotrexate, and fluorouracil), your ovaries will behave after chemotherapy as if you're in your 40s. And based on this expert’s experience and studies, you will have a very small chance of conceiving. If there's a possibility, any woman in this situation should consider freezing eggs or embryos before treatment has begun.

Risk of recurrence for pregnant survivors?

Question from Lm: Can women with estrogen, progesterone, and HER2-positive breast cancer, and who’ve been treated with mastectomy/chemotherapy/Herceptin (chemical name: trastuzumab) and hormone therapy, go on to have safe pregnancies without inducing a recurrence in the cancer?

Answers —Leslie Schover, Ph.D.: It's always nice to have more research, but from the big studies that have been done so far, if a woman is able to get pregnant after successful breast cancer treatment, her risk of a recurrence or dying from breast cancer is no greater than that of a similar woman who did not get pregnant. In fact, there is what you call the “healthy mother effect.” It seems that women who do get pregnant after breast cancer may actually have better survival than their peers. Maybe this is because the women who have the best chance of a healthy future are the ones who try to get pregnant.

Kutluk Oktay, M.D.: Even though some studies did control for things like health standards to make sure that it is not the healthier woman attempting pregnancy, therefore if they’re pregnant the likelihood of recurrence is lower. So it is not necessarily clear that if some women do better if they get pregnant after breast cancer treatment has been completed, that this is merely due to the fact that they were healthier to begin with. Nevertheless, it will be impossible to perform an ideal study, as we cannot randomly ask women to get pregnant or not to get pregnant. Therefore, the best evidence is what we have, which is unlikely to be improved by further studies.

Infertility risk affecting dating?

Question from Madison: I'm single, have breast cancer, and am taking tamoxifen. It is difficult in the dating scene to tell them that you not only have breast cancer, but may also not be able to have kids. I really don't have money to go to a therapist, but am having a difficult time being brave enough to talk to single men.

Answer —Leslie Schover, Ph.D.: This is a very normal and common concern that single women have after breast cancer. It might help to join an online support group: for example, organizations like The Wellness Community or Cancer Care have either telephone or online support groups where you can share your feelings with other women like you. You also may want to look at web sites like Breastcancer.org or the Young Survival Coalition, an organization just for younger breast cancer survivors. There you can find information and stories from other women like you. There also are now a couple of online dating sites just for cancer survivors. One of them is called C is for Cupid. I would not say that you should only date people who have had cancer, but it is a good way to practice talking to some single guys who are likely to be very understanding of what you've gone through. The more you practice, the more comfortable you may feel in other dating situations.