1. Breast cancer and preserving fertility
2. No fertility preservation (‘waiting and seeing’)
3. Fertility preservation procedures
4. Possible risks of fertility treatment
5. Protecting the ovaries during chemotherapy
6. What happens at a fertility clinic?
7. Will I have to pay for fertility treatment?
If you’re concerned about how breast cancer treatment may affect your fertility, it’s important to discuss fertility issues with your specialist team before you begin your treatment.
A number of options are available that may preserve your fertility and increase the chance of you having your own children in the future.
Your options include:
- waiting to see if your fertility returns after treatment
- having fertility preservation procedures – freezing embryos (IVF), eggs or ovarian tissue – before starting treatment
- protecting the ovaries during chemotherapy.
Jackie speaks about how her breast cancer diagnosis and treatment affected her fertility, and her emotions and experiences surrounding the decisions to be made.
Laura talks about discussing fertility before having treatment for breast cancer.
Some younger women choose to start their cancer treatment and wait to see if fertility returns when treatment is over. This is sometimes referred to as ‘waiting and seeing’.
Very young women who are more likely to maintain their fertility after breast cancer treatment may want to discuss this option with their specialist team. Your fertility specialist can do some blood tests and an ultrasound scan to assess your fertility before your breast cancer treatment begins.
Kerry talks about fertility preservation before starting chemotherapy.
Several procedures may be available to you before you start your breast cancer treatment. Not all the procedures described here are available in every fertility clinic, and success rates can vary. Not all are available on the NHS. There may be costs for some procedures.
Some techniques are well researched in the general population but haven’t been fully researched in women who’ve had breast cancer. None of the methods for preserving fertility can guarantee you’ll get pregnant and have your own baby after breast cancer treatment.
However, lots of research into methods of preserving fertility is being carried out, and this is leading to improvements in the procedures currently available.
Your specialist fertility clinic will be able to advise you further. Your oncologist and fertility specialist should work together to help you decide the right option for you.
You can check the fertility preservation procedures your local fertility clinic offers on the HFEA website.
Stimulating the ovaries to produce more eggs
Fertility preservation can involve stimulating your ovaries to produce eggs. This is known as ovarian stimulation. Collecting more eggs will increase the chances of pregnancy in the future.
You will need daily injections of hormones to make your ovaries produce more eggs than normal. This will stop natural ovulation so that the eggs can be collected in the timeframe required by the fertility specialist.
The hormone injections increase the amount of oestrogen produced by your body. Some women worry about the effect these hormones might have on their breast cancer. Initial studies have not shown that ovarian stimulation affects the growth of breast cancer cells, but further research is needed before this can be proven.
Breast cancer drugs like letrozole and tamoxifen are often used along with the hormone injections. Using letrozole and tamoxifen increases the number of eggs produced and reduces the level of hormones circulating in the body during fertility treatment.
You can discuss any concerns you have with your fertility specialist.
Freezing embryos – in vitro fertilisation (IVF)
Embryo freezing is the most effective way of preserving fertility.
In vitro fertilisation (IVF) involves taking hormone drugs to stimulate the ovaries (ovarian stimulation). Several eggs are then removed, fertilised with sperm from your partner or a donor, and stored as embryos. These embryos can be frozen and stored for 10 years or longer before being implanted in the womb.
Once embryos are created using your eggs and your partner’s sperm they legally belong to both of you. You will both need to give consent to store and use any embryos. If you separate in the future and your partner withdraws his consent, you will not be able to use the embryos and they would have to be destroyed. Some women in new relationships store eggs as well as embryos to keep options available for the future.
Women without a partner who want to freeze embryos before starting cancer treatment may choose to use donor sperm. However, finding a suitable donor may not be easy and could cause a delay to your treatment. The staff at the fertility clinic can discuss this with you further.
The IVF process can occasionally delay chemotherapy for a short time. However, new fertility practices mean that the process can often be started at any time during a woman’s menstrual cycle and chemotherapy can usually go ahead as planned or with a minimal delay.
If you don’t have a partner and don’t want to use donor sperm, you may want to freeze your eggs. Eggs are collected after ovarian stimulation (see above). These eggs are then frozen. Frozen eggs can be stored for 10 years or longer. They can then be thawed and fertilised with sperm from a partner or donor before being implanted in the womb when you want to get pregnant.
This is a very delicate procedure and eggs are easily damaged in the freezing and thawing process. A method of freezing called vitrification has led to fewer eggs being damaged, but not all fertility clinics currently offer this technique.
Although the survival rate for eggs after thawing is improving, the current success rate of this technique is lower than when frozen embryos are used. The availability of egg freezing varies across the UK.
Find out more about freezing and storing eggs on the HFEA website.
Stages of egg or embryo freezing
These are the likely steps at the fertility clinic if you choose egg or embryo freezing. The techniques can vary according to your individual circumstances and the approach of your local clinic.
Step one: stopping the natural menstrual cycle
Many fertility clinics use a ‘random start’, which means that fertility treatment can begin at any point during the menstrual cycle. You may be given a short course of medication to temporarily stop your natural menstrual cycle, so that eggs can be collected in the timeframe required by the fertility specialists.
Step two: boosting the egg supply
Once your natural cycle is stopped, you will be given a fertility hormone called follicle stimulating hormone (FSH). This is a daily injection you give yourself, usually for about 10–12 days. You will be offered an appointment with a specialist nurse who will discuss how to give yourself the injections.
FSH increases the number of eggs your ovaries produce in a given month. This means more eggs can be collected and possibly fertilised. You are also likely to receive the breast cancer medication letrozole or tamoxifen to reduce the levels of oestrogen in your body.
Step three: checking progress
You will have transvaginal ultrasound scans (where a scan probe is gently placed inside the vagina) to check your ovaries, and sometimes blood tests. About 34–38 hours before your eggs are due to be collected, you'll have a final hormone injection that helps your eggs to mature.
Step four: collecting the eggs
You'll be sedated and your eggs will be collected using a needle that's passed through the vagina and into each ovary under ultrasound guidance. This takes about 15–20 minutes and some women experience cramps after this procedure. If you are freezing your eggs, they are then frozen.
Step five: fertilising the eggs (if you are freezing embryos)
The collected eggs are mixed with your partner's or the donor's sperm in a laboratory. The fertilised eggs (embryos) continue to grow in the laboratory for one to six days before being frozen.
The diagram below shows these steps in the form of a timeline.
Freezing ovarian tissue
This technique is in the early stages of research. A section of tissue from the ovaries is removed and frozen. This procedure involves an operation. It can be carried out as a day case, which means you won’t have to stay in hospital overnight, but must be done before chemotherapy begins.
The tissue can be thawed at a later date and can either be re-implanted onto the ovary to start functioning and allow natural conception, or at a different site in the body so the process of IVF can take place. Ovarian tissue freezing is not an option for women at high risk of developing ovarian cancer.
This procedure is not widely available and only a few babies in the world have been born using this method.
In vitro maturation (IVM)
This is a newer technique and is not widely available. It involves removing immature eggs from ovaries that have not been stimulated by the use of hormone drugs. These are then matured in the laboratory before being fertilised from either a partner’s or donor’s sperm, and then frozen. The embryos are then transferred to the womb at a later date.
Pre-implantation genetic diagnosis (PGD)
Women who are known to have inherited an altered breast cancer gene and are concerned about passing this on to future children may want to talk to their genetic counsellor about the possibility of pre-implantation genetic diagnosis.
This involves going through an IVF cycle and checking the embryos for the inherited altered gene before freezing them. Only the embryos that are not affected by the altered breast cancer gene are used.
For more information about inherited breast cancer see our Breast cancer, genes and family history webpages.
You may want to ask your fertility specialist what the risks are with each fertility treatment option. Many children have been born from stored embryos and there doesn’t seem to be any health risk to the child. We don’t know yet if there is any risk with egg and ovarian tissue freezing as these are fairly new techniques, but specialists believe any risk is likely to be very small.
Currently there is no evidence that fertility preservation increases the risk of breast cancer coming back, but research in this area is ongoing.
Ovarian suppression can be used to try to protect the ovaries during chemotherapy. It temporarily ‘shuts down’ the ovaries (which means your periods will stop). It involves monthly injections with a drug like goserelin (Zoladex), starting before chemotherapy and continuing throughout your chemotherapy treatment.
Your periods should usually start again within three to six months of stopping the hormone treatment, unless your natural menopause has occurred during your treatment. However, even if your periods do return this doesn’t necessarily mean you have preserved your fertility.
Some experts believe that ovarian suppression may have an effect on how well chemotherapy works.
The effectiveness of ovarian suppression for preserving fertility is still debated and it’s not considered as effective as egg and embryo freezing. As the evidence about ovarian suppression is mixed, we need more research to establish whether it can preserve fertility.
The first appointment at the fertility clinic is often quite long and you will normally be given verbal and written information. If you have a partner, it’s recommended that they come with you. You will have the opportunity to ask questions and will be offered specialised counselling. You will be able to discuss the options for preserving fertility, the likely success of any fertility treatments, what the procedure involves and the risks.
If you are currently taking oral contraception, you may be asked to stop this soon after diagnosis. However, it is still important to use contraception – see Contraception during and after treatment for alternative methods.
If you decide to go ahead with fertility preservation, you will need to have some tests. This will include blood tests for HIV, hepatitis B and hepatitis C.
Sometimes a blood test will be done to check the level of a hormone called AMH (anti-mullerian hormone). You may also have a transvaginal ultrasound scan, where a scan probe is gently placed inside your vagina. This can check your current fertility.
These tests may happen at your first appointment. The results of these tests will help the fertility team decide whether you will be able to have the fertility treatment suggested.
If you are hoping to freeze embryos, your partner will also need to have blood tests and give a sperm sample.
Before any fertility treatment starts, you (and your partner) will need to complete a number of consent forms. You will have to state what you would like to happen to the eggs or embryos if you or your partner were to die or lose the mental ability to make your own decisions. As the egg donor, if you wish them to be donated for the treatment of others you must complete a consent form.
While the usual criteria for funding fertility preservation on the NHS may not apply when you have breast cancer, there may be some parts of the treatment that you will need to pay for. This can depend on:
- where you live
- if either you or your partner already has children
- your age.
If you’ve been told that you’ll need to pay for some or all of your fertility treatment, you can discuss this during your appointment with the fertility specialist. It may also be possible for you and your doctor to apply for ‘exceptional funding’ if you don’t meet the funding criteria.
If you have health insurance, check whether your cover includes such treatment. Paying for treatment privately may also be an option for you.
To store your eggs or embryos in an NHS setting, usual funding criteria will apply.