Making Fertility Decisions

To gain a clearer picture of your fertility options after treatment is completed, consider these questions, or steps:

Step 1: What's your prognosis?

Talk to your doctor about the seriousness of your cancer condition. Is your prognosis relatively good? Do you feel encouraged to become a parent in the future? Or is your prognosis such that you don't want to take added risks?

When you ask your doctor for a general idea of your chances for living beyond breast cancer, this is the range of figures you may be given:

Five-year survival for invasive breast cancer
Stage I: 80-95% (cancer less than or equal to 2 centimeters, no lymph node involvement)
Stage II: 60-80% (cancer between 2 and 5 centimeters [1 to 2 inches], with or without lymph nodes involved)
Stage III: 40-60% (cancer greater than 5 centimeters, skin involved, with or without lymph nodes involved)
Stage IV: 0-20% (metastatic)

Step 2: How safe is it for you to become pregnant?

Discuss the safety of pregnancy as it relates to your particular kind of cancer. There is no definitive evidence that pregnancy affects the prognosis of women affected by breast cancer. But you might have a very unusual condition that suggests an exception.

Step 3: How can you preserve your fertility?

If your doctor says your prognosis is relatively good and that pregnancy would be relatively safe, then ask a fertility expert to outline your options for preserving your fertility. Take this action before starting breast cancer treatment.

Here are some questions to discuss with the fertility expert:

• Can you bank fertilized eggs now, in case you can't produce eggs later?
• Is ovarian stimulation (with in vitro fertilization) the only realistic option for getting enough eggs?
• Is there another type of fertility treatment that might be less risky for you?
• Should some of your ovarian tissue be frozen instead of, or in addition to, your eggs?
• Should you consider taking drugs to suppress your ovaries during chemotherapy?
• What are the demands and costs involved — medically, financially, and time-wise — with each approach?

After you discuss all the options with your doctor or specialist, ask yourself how hard and how long you are willing to work, at this particular time, to keep open the option of having a biological child.

Step 4: Can you postpone treatment?

Talk to your doctors about how safe it is for you to postpone chemotherapy and radiation therapy for at least six weeks to allow time for ovulation stimulation and in vitro fertilization.

Your oncologist will judge the safety of postponing your treatment based on how serious your cancer is.

Step 5: Are fertility drugs safe for you?

If your doctor says it's OK to postpone treatment, you need to discuss the safety of fertility drugs. Are the hormones that will be used to stimulate ovulation safe for you? Or might the high estrogen levels be dangerous?

Fertility drugs containing hormones usually are not recommended for women who have had breast cancer, because those hormones may affect breast cancer cell activity. If you're thinking of using fertility drugs for just one cycle, you and your doctor will have to evaluate how safe or risky it might be for you. Ask about using tamoxifen or an aromatase inhibitor with, or instead of, standard fertility drugs.

Step 6: Whose sperm will you use?

Eggs need sperm for fertilization. Where will the sperm come from? If you're already in a committed relationship with a man, you need to be sure both you and your partner are highly motivated to have children.

If you're single or in a lesbian relationship, you — or you and your partner — have to consider whether you're willing to pursue sperm donation.

If you have a male partner, make sure his sperm are tested and are healthy, before you start aggressive fertility treatment. Even if he has low sperm counts, the sperm can still be used for in vitro fertilization.

If there are no viable sperm — or no male partner — consider using a sperm bank.

Because of the legal and ethical issues involved, most in vitro fertilization centers won't accept a designated sperm donation from a boyfriend who's not in a committed relationship with you.

These same issues may make it difficult even if you ARE in a committed relationship with a man. The fertility centers don't want to be in the middle of a custody battle over embryos. The legal issues are more complex without a marriage in place.

Step 7: Consider options for having a child without using your eggs

Are you open to the idea of having a child born from someone else's egg, or using a surrogate mother? This is a woman you make a contract with to carry the baby for you.

Would you consider adopting a child? Quite a number of women choose adoption during the first few years after breast cancer diagnosis, when it's too soon to put their own bodies through the demands of fertility treatment and pregnancy.

Later on, when you're past the highest risk of recurrence and your overall health is strong again, you may decide to try to get pregnant yourself.

Step 8: Can you afford fertility procedures?

Do you have the money to pay for these procedures if your health insurance won't cover part or all of the cost? What are the laws in your state about paying for fertility treatment when you've been diagnosed with cancer? You might be able to negotiate with your insurer to get a portion of your expenses covered.

The cost of each ovarian stimulation combined with in vitro fertilization is approximately $8,000 to $12,000, plus several hundred dollars a year to maintain the embryos in the freezer. The cost for natural-cycle in vitro fertilization is about $8,000 (you save the cost of fertility drugs). The cost of the donor egg process is $20,000 if you're using a paid donor, or about $8,000 to $12,000 if the eggs are donated at no charge. Storage fees for frozen eggs or embryos are similar.