Woman

Pregnancy after breast cancer, the testimony of a mother who made it

While until a few years ago the focus was above all, and rightly so, on the survival of the patient, in recent years, given the progress of medicine which has allowed a continuous decrease in the death rates linked to the pathology, and the progress in assisted fertilization techniques, not the issue of fertility and its preservation can no longer be neglected.

Many women at diagnosis do not think about fertility , because they are obviously worried about the urgency of defeating the disease. However, the oncologist’s task is also to show the patient the existing possibilities of retaining her ability to become a mother once she is cured. All cancer patients should be informed in this sense, not doing it, or doing it the wrong way, would be a serious shortcoming.

It is a team work between oncologists and gynecologists expert in assisted reproduction from the PMA center of the nearest hospital, a consultancy that must

  • explain to the patient the effects of chemotherapy, radiotherapy or hormone therapy on her reproductive capacity
  • offer all possible possibilities to preserve fertility.

Briefly recall that the probability of entering into secondary amenorrhea or permanent menopause after chemotherapy increases, the more the woman’s age increases (10% for women under the age of 35, 50% for women aged between 35 and 40 years, 85% for women over 40). Not all chemotherapy has the same effects and even if the menstrual cycle resumes it is not said that the woman will become fertile again.

Even if hormonal/endocrine therapies do not cause permanent amenorrhea, they last 5-10 years and during these years no pregnancies can occur. A study, called POSITIVE, is currently underway to evaluate whether it is safe to stop anti-hormone treatment in young women with hormone-sensitive breast cancer who want to become pregnant. The study will involve 500 patients worldwide over 4 years. Patients will be followed up for 10 years after enrollment in the study.

The study foresees the treatment with endocrine therapy for 18-30 months, the interruption of the therapy, a 3-month break and another 2 years to attempt the search for pregnancy. Then the resumption of therapy is expected for 5-10 years.

How to preserve fertility before cancer therapy?

Currently there are two techniques out of all:

  • Cryopreservation of ovarian tissue (not indicated for some types of cancer)
  • Oocyte cryopreservation (the most used at the moment)

The witness

I know my current partner at 33 years old. After several relationship flops, things finally go well. At the age of 34, the fortuitous and casual discovery of an infiltrating breast cancer, her2 positive, reactive to hormones + “dirty” sentinel lymph node. In practice, a non-huge malignant tumor (just over 1 cm), but with a high growth rate fomented by estrogen. Summer has just begun, there is little time. They immediately suspended the pill, chose not to subject me to any stimulation, activated the cycle suppression protocol with triptorelin (decapeptyl) and laparoscopically removed 1/3 of my ovarian tissue from both sides. 

In practice, of the different possible methods in my case, given the good starting amh reserve (3.06 out of a range of 1.3-4) and given the relative short time (diagnosis at the beginning of July, Quadrantectomy in August, chemotherapy in October ) opt for the more experimental one, the vitrification of ovarian tissue. 

The reason for the choice is still not clear to me, but I think I was referred to that center only to increase the number of patients studied by the team at the time. I say this because at the time no one told me that the center of Bologna was a stone’s throw from me and, as far as I know, the only ones in Italy to have obtained their first pregnancy with reimplantation in 2018. 

More than two years after the start of chemotherapy (which was followed by radio, trastuzumab and tamoxifen) I try to understand with my oncologist, who has been close to me personally as well as professionally along this path, if it is possible to stop triptorelin and tamoxifen to give you a window in which to try to get pregnant. The opinions differ, the head physician would not like it but she accepts. She knows that having a child has always been a priority for me,  and she espouses the idea that pregnancy does not negatively affect the possible recurrence of cancer. The choice is not light, but I am convinced of it. Months later, the cycle resumes, with bad hormonal values: amh fluctuates from 0.43 to 0.76, fsh on the third day at 25. Here the conflicting opinions begin. 

In my hospital there is only one laboratory for couple infertility which is limited to IUI. It does not communicate in the least with oncology, so I only learn of its existence much later. 

I went to the closest MAP center in Veneto where they told me that ovulation was impossible for them given these values. Finally, I went back to the hospital where they had taken my ovarian tissue to request reimplantation and, second nasty surprise, I was advised against it. To be kept as a last resort because, according to them, the damage that the tissue had suffered, together with the further damage during the reimplantation operation, was very extensive and could not give different results from those of my spontaneous cycle. 

It was a hard blow to realize how things really were, a wrongly conducted operation like this could have precluded all chances of becoming a mother. Instead I was lucky… despite everything, there was something left of my ovarian tissue, even if only a little.

After an IUI without results the gynecologist who followed me, and to whom I owe a lot, not without a consultation with the Ieo (European Institute of Oncology) who was conducting studies on cases like mine, referred me to a new hospital to undergo to a particular ICSI cycle: we would have tried classic hormonal stimulation combined with the use of letrozole to buffer an excessive rise in blood hormones (again due to the high sensitivity of my carcinoma to estrogen) 

A gynecologist contacted by mine would have followed me but, another surprise, the hospital ethics commission a few days before the presumed start of therapy refused to manage my case, so I was “passed” to Bologna. 

After other preliminary visits, just the month in which I should have started the therapy, my period has not arrived. I took a pregnancy test just for the sake of it and you can imagine the surprise in realizing that I was pregnant… it all happened naturally , when we really didn’t think about it because we knew we would have followed other paths, and – irony of fate – when I hadn’t put no “strategy” in place to facilitate conception. 

With an AMH of 0.50, an FSH at the menopause level, an LH value that was almost not detected by the ovulation sticks, I would never have believed it possible, and instead it happened.

The pregnancy went smoothly until the 7th month, when my ca (tumor marker) levels suddenly skyrocketed. 

There are controversial opinions on the usefulness of this marker, but as a practice I have been measured for years. I came to have high values ​​(96 when the reported limit is < 23) that my doctors didn’t know how to interpret. Given the conflicting opinions we turned again to Dr. Alessandro Peccatori, and when he himself said that he had never witnessed such an increase, we made the decision to induce the birth as soon as possible: at 36 weeks, in order to then be able to check for any recurrences via CT scan. 

So after 30 hours of labor, my son was born at 8 months . Nothing emerged from the CT scan and, already the day after the birth, the marker was halved, demonstrating that its increase was attributable to pregnancy alone. 

All’s well that ends well, even if I felt guilty thinking about the stress to which I subjected my baby… born weighing 2 kg, hospitalized for a week in the NICU under oxygen for initial respiratory distress and with a heavy penalization of natural breastfeeding given that initially he was only able to feed on bottles and never fully got used to the breast (only one, but functional) . But I know that I could not have made a different decision at the idea of ​​a repeat offender. 

It is not rhetorical when it is said that the joy that comes from a child is so great that one can sense it, but not understand it if one does not feel it. It’s a visceral love, which didn’t strike me at birth despite the great emotion, but which is growing day after day in living together and accompanying this new human being in what his life path will be. I consider myself very lucky and if I went back, even with the fear of the return of the tumor, I would do it all again. 

I hope the current mentality of mere survival changes. I hope that, in the specifics of each different case and first of all in the protection of women’s health, greater effort is put into trying to find solutions also for women who, after being forced to give up part of their femininity, at least not they are denied that splendid possibility which is motherhood and which completes our being. 

To get started, more information between departments and the proposal of paths to think about together would be enough.

Kathryn Barlow is an OB/GYN doctor, which is the medical specialty that deals with the care of women's reproductive health, including pregnancy and childbirth.

Obstetricians provide care to women during pregnancy, labor, and delivery, while gynecologists focus on the health of the female reproductive system, including the ovaries, uterus, vagina, and breasts. OB/GYN doctors are trained to provide medical and surgical care for a wide range of conditions related to women's reproductive health.

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