Fertility preservation for women diagnosed with breast cancer: looking beyond the horizon.

Abstract

Breast cancer is the most frequently malign tumor diagnosed globally (Ferlay et al. 2021). According to the World Health Organization (WHO), by the year 2040, there will be more than 3 million cases of the disease per year all around the world. Avoidable breast cancer deaths still remain a burden mainly in lowand middle-income countries, whereas in high-income countries the 5-year-survival rates have significantly increased in recent years, exceeding 90 percent (WHO 2023). As oncological therapeutics advance, other issues regarding cancer survivors’ well-being arise. Young women undergoing chemotherapy, radiation, and surgery may have their reproductive health threatened. Accordingly, clinicians and patients must be aware of future consequences on sexuality, body image, and fertility (Miaja, Platas, and Martinez-Cannon 2017). In recent years, the Oncofertility Consortium emerged as a global initiative to join experts in different fields to carry out good-quality research on fertility care of young patients with cancer (Woodruff 2010). Undoubtedly, when a cancer diagnosis arises, the main concern for both patients and oncologists is prompt treatment. In such scenarios, reproductive health issues may easily lose importance. However, qualitative data shows that supportive oncofertility care access diminishes the emotional burden experienced by oncological patients (Wang et al. 2020). In this context, the availability of a multidisciplinary team is of utmost importance. In addition to oncologists, surgeons, and psychologists, a specialist in reproductive medicine is also welcome to provide proper care and counseling (Shao et al. 2019). Current guidelines recommend that health-care providers discuss with patients the potential risks to fertility, make referrals to fertility specialists when appropriate, and allow patients the opportunity to undergo fertility preservation (ESHRE 2020). The sooner the interdisciplinary group acts, the better the overall prognosis is (Shao et al. 2019). Methods for preserving fertility in women include ovarian suppression and cryopreservation of oocytes, embryos, and ovarian cortex. Both oocyte and embryo cryopreservation are well-established techniques, and the first is usually the choice for women undergoing treatment for breast cancer. Although embryo freezing is a widely available and long-established part of Assisted Reproductive Technology (ART), the need for joint legal ownership with the male partner is an important consideration that may result in difficulties later on. Both methods require controlled ovarian stimulation (COS) and ultrasound monitoring of follicle development for 10–12 days. The oocyte retrieval aims to collect, in a safe way, a sufficient number of mature eggs within a limited time frame. Therefore, at least 2 weeks are needed before the patient can start oncological treatment (ESHRE 2020). Current data show that oocyte cryopreservation can be done in a timely manner without further delaying oncological treatment (ESHRE 2020). Ovarian tissue cryopreservation is a promising fertility preservation technique that can be applied before the beginning of gonadotoxic therapy, especially for patients who require immediate treatment and do not have enough time for controlled ovarian stimulation (Eijkenboom et al. 2022). For those patients, protecting ovarian function against the effect of oncological treatment would be the ideal option, though far from achievable. Using GnRH agonists during chemotherapy has been a practice for a long time. However, only recently, more robust data from randomized trials has shown the limited efficacy of this strategy on ovarian reserve protection (ESHRE 2020). While most patients appreciate the opportunity to undergo fertility preservation, some find it physically and emotionally challenging to deal with reproductive issues while simultaneously managing cancer. Other numerous barriers may prevent patients from receiving appropriate counseling and treatment: the unexpected monetary cost, lack of time for fertility preservation before cancer therapy, WOMEN & HEALTH 2023, VOL. 63, NO. 9, 681–683 https://doi.org/10.1080/03630242.2023.2261685