Options for preserving fertility before and during treatment

If you’re concerned about how breast cancer treatment may affect your fertility, it’s important to discuss fertility issues with your treatment 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:

1. No fertility preservation
2. Having fertility preservation procedures – freezing embryos (IVF), eggs or ovarian tissue – before starting treatment
3. Ovarian suppression

Before you start your breast cancer treatment you’ll need to decide if you want to preserve your fertility, or if you would prefer not to have any fertility treatment.

Some women know what they want to do, while others have a harder time making a decision. Your religious and moral beliefs may also affect how you feel about fertility preservation. It’s important to choose what’s right for you.

Talking to a fertility specialist and finding out what options are available can help you come to a decision. It might also help to talk everything through with your partner (if you have one), breast cancer team, family and friends. You should also be offered counselling support at your fertility centre.

A few women consider declining chemotherapy if they’re concerned about their fertility. Talk to your consultant about the benefit of having chemotherapy or the effects that different chemotherapy combinations may have on your fertility.

You may want to look at the Cancer, fertility and me website for further information about fertility preservation.

Some younger women do not want children or 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 treatment team. Your fertility specialist can do some blood tests and an ultrasound scan to assess your fertility before your breast cancer treatment begins. They can also monitor your fertility after treatment.

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 have not 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 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.

There’s more detail about fertility preservation procedures in our booklet Fertility, pregnancy and breast cancer which you can order or download.

Stimulating the ovaries to produce more eggs

Fertility preservation can involve stimulating your ovaries to produce eggs and help them mature. This is known as ovarian stimulation. Collecting more eggs will increase the chances of pregnancy in the future.

You’ll need daily injections of hormones to help 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 in your body. Some women worry about the effect this 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. 

This procedure can delay chemotherapy for a short time. You can discuss any concerns you have with your fertility specialist.

Embryo freezing – in vitro fertilisation (IVF)

Embryo freezing is the most effective way of preserving fertility. Success rates for in vitro fertilisation (IVF) have been increasing year on year.

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 to create embryos. In some cases intracytoplasmic sperm injections (ICSI), where sperm is injected directly into the egg, may be offered. 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’ll both need to give consent to store and use any embryos. If you separate in the future and your partner withdraws his consent, you’ll not be able to use the embryos and they would have to be destroyed. Some women in relationships store eggs as well as embryos to keep options available for the future.

If you’re single or in a same sex relationship you 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. Though 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.

Find out more about in vitro fertilisation and using donated sperm on the HFEA website.

Egg freezing

If you do not have a partner and do not 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 try to get pregnant.

This is a very delicate procedure as 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

Ovarian tissue freezing

This technique is in the early stages of research. It can be suitable if you do not have time to freeze your eggs or embryos. A section of tissue, which contains a number of immature eggs, from the ovaries is removed and frozen. This procedure involves an operation. It can be carried out as a day case, which means you'll not 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.

This procedure is not widely available and only a few babies in the world have been born using this method.

Ovarian tissue freezing is not an option for women at high risk of developing ovarian cancer; those who carry an altered BRCA1 or BRCA2 gene.

Pre-implantation genetic diagnosis (PGD)

Women who are known to have inherited an altered breast cancer gene that increases the risk of breast cancer 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 does not seem to be any health risk to the child. We do not 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 does not necessarily mean you have preserved your fertility.

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.

For more information, see our web pages on ovarian suppression and goserelin (Zoladex).

The first appointment at the fertility clinic is often quite long and you'll normally be given verbal and written information. It’s normal to feel a bit anxious before attending. If you have a partner, it’s recommended that they come with you. You’ll have the opportunity to ask questions and will be offered specialist counselling. You’ll 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’re currently taking oral contraception, you’ll be asked to stop this soon after diagnosis. However, it’s still important to use contraception – see contraception during and after treatment for alternative methods.

If you decide to go ahead with fertility preservation, you’ll need to have some tests. This will include blood tests for HIV and hepatitis.

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’ll be able to have the fertility treatment suggested.

If you’re 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’ll have to state what you’d 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.

NHS funding may be available, but the amount of funding and the criteria for treatment varies between Clinical Commissioning Groups and different regions. This can depend on:

1. Where you live
2. If either you or your partner already have children
3. Your age

If you’re not entitled to NHS-funded treatment, you may want to fund the treatment yourself. It may also be possible for you and your fertility specialist to apply for ‘exceptional funding’ if you do not meet the funding criteria.

To store your eggs or embryos in an NHS setting, usual funding criteria will apply.

If you have health insurance, check whether your cover includes such treatment. Paying for treatment privately may also be an option for you.

Donor Conception Network

dcnetwork.org

A supportive network for people through donor conception.

Human Fertilisation and Embryology Authority (HFEA)

hfea.gov.uk

This organisation monitors and licenses all IVF clinics in the UK. It produces a list of centres providing IVF and leaflets on IVF, egg donation and egg freezing.

Whatever your feelings, you do not have to cope alone. You may find it helpful to share your thoughts with another person whose fertility has been affected by breast cancer treatment.

• Our Someone Like Me service can put you in touch with someone who’s had a similar experience to you - please see below
• Chat to other people with breast cancer on our online forum
• Meet other women at one of our Younger Women Together support events - see below
• Join the private Facebook group, set up by younger women with breast cancer, Younger Breast Cancer Network (YBCN). To access the group you’ll need a Facebook account and send a message to the group

You can also call our free helpline below to talk to one of our trained nurses.