Amr A Azim, MD, MSc, DSc, FACOG<br />Diplomate, American Board of Obstetrics & Gynecology<br /> Board Certified in Reprodu...
How Many Women are diagnosed…<br />Invasive breast cancer will affect 207,000 women in the US in 2010, <br />10% (1:80; 18...
Worldwide, 240,000 women <br />are diagnosed with breast cancer <br />each year are under the age of <br />45 years <br />...
Breast Cancer Treatment…<br />Surgery<br />1. Excision of the tumor<br />2. Healing period (4-6 weeks)<br />3. Combination...
Chemotherapy for Breast Cancer<br />Use of these drugs especially cyclophosphamide (C) markedly reduce the number of eggs ...
Even if menstrual cycle resumes…<br />When we attempted to         stimulate the ovaries of             women that were ex...
Age is also an important factor…<br />After treatment women are commonly asked to take      tamoxifen and other agents    ...
Nobody told you all that…<br />You and more that 50% of women in their reproductive ages were not told all that, according...
      Referrals were more likely among female physicians.
      Referrals were more likely when patients routinely ask about preservation of fertility.</li></ul>©2010 AmrAzim, NYCI...
Age is also an important factor…<br />After treatment women are commonly asked to take      tamoxifen and other agents    ...
Protection<br />So far, no convincing evidence that the effect of chemotherapy can be prevented or mitigated.<br />The ben...
Preservation of Fertility<br />Freezing of eggs and embryos (fertilized eggs) is the most practical method to preserve fer...
Embryo Cryopreservation<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
Embryo Cryopreservation<br />This method requires<br />Ovarian stimulation with fertility medication<br />Time; 2-3 weeks<...
Ovarian Stimulation in estrogen sensitive cancers<br />
Ovarian Stimulation & Breast Cancer<br />Ovarian stimulation causes marked increase in estrogen levels.<br />Although brie...
Ovarian Stimulation & Breast Cancer<br />     1          2          3          4          5          6          7         ...
Ovarian Stimulation & Breast Cancer<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
Ovarian Stimulation & Breast Cancer<br />There was no difference in breast cancer recurrence between women stimulated to p...
Timeline<br />Consultation with a fertility preservation specialist<br />Ovarian stimulation and egg retrieval<br />Embryo...
Pregnancy after Breast Cancer Treatment<br />Embryos can be replaced            in a gestational carrier.<br />If embryos ...
Pregnancy after Breast Cancer Treatment<br />	When all studies related to pregnancy after breast cancer were compiled (20,...
Low Estrogen Ovarian Stimulation<br />We have also reported the use of this procedure in women diagnosed with endometrial ...
Oocyte Cryopreservation<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
The Egg is a Unique Cell<br />It’s the largest cell in the body<br />It has a lot of water<br />Its cell membrane does not...
Slow Freezing			Vitrification<br />The temperature is dropped very slowly.<br />Low concentration of cryoprotectant  (a ch...
          Egg Freezing; Facts			<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
          Egg Freezing; Facts			<br />Caveats<br />Experience with vitrification is still small. Few babies were borne wor...
Ovarian Tissue Cryopreservation<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
Ovarian Tissue Cryopreservation<br />This method requires<br />No ovarian stimulation needed<br />Require a day surgery fo...
Ovarian Tissue Cryopreservation<br />One ovary is removed using laparoscopy (minimally access surgery ). The ovary then is...
Yes You Can<br />You can have your biological child after you were diagnosed with breast cancer.<br />Even if you have no ...
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Fertility on Ice

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Fertility on Ice

  1. 1.
  2. 2. Amr A Azim, MD, MSc, DSc, FACOG<br />Diplomate, American Board of Obstetrics & Gynecology<br /> Board Certified in Reproductive Endocrinology & Infertility<br /> 400 East 56 Street, Suite #1 www.nycivf.org<br /> New York, NY 10022 www.preservationoffertility.org Tel: 800•853•7595 nycivf@nycivf.org <br /> Fax: 800•780•6167 www.twitter.com/nycivf<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  3. 3. How Many Women are diagnosed…<br />Invasive breast cancer will affect 207,000 women in the US in 2010, <br />10% (1:80; 18,000 to 21,000 cases) <br />are under the age of 45<br /> (ACS, 2010 )<br />2.9 breast cancer survivors by 2010<br />65% survive >5y<br />Will increase 30% by 2015<br /> (DeAngelis 2009 ) <br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  4. 4. Worldwide, 240,000 women <br />are diagnosed with breast cancer <br />each year are under the age of <br />45 years <br /> (Globocan 2002)<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  5. 5. Breast Cancer Treatment…<br />Surgery<br />1. Excision of the tumor<br />2. Healing period (4-6 weeks)<br />3. Combination of three drugs <br /> (4-6 months)<br />4. Radiation of the axilla<br />5. Tamoxifen for 5 years for hormone receptor positive cancer<br />Chemotherapy<br />Radiation<br />Hormonanal treatment<br />Other treatments<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  6. 6. Chemotherapy for Breast Cancer<br />Use of these drugs especially cyclophosphamide (C) markedly reduce the number of eggs remaining in the ovary. The effect is unpredictable but its related to age, dose and type of drug used.<br />(Petrek 2006, Lee 2006)<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  7. 7. Even if menstrual cycle resumes…<br />When we attempted to stimulate the ovaries of women that were exposed to chemotherapy and regained menstrual cycles after chemotherapy and has normal markers of ovarian function, they still exhibited reduced ability to produce eggs compared to women that sought preservation of fertility before chemotherapy. (Azim 2006)<br />11.7<br />4.9 oocytes retrieved<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  8. 8. Age is also an important factor…<br />After treatment women are commonly asked to take tamoxifen and other agents for 2-5 years. <br />Oncologists also advice a period of observation of two years before attempting pregnancy. The natural loss of eggs during these periods compounds the effect of chemotherapy (Broekmans 2007)<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  9. 9. Nobody told you all that…<br />You and more that 50% of women in their reproductive ages were not told all that, according to national surveys (Quinn 2009)<br />survey of 613 oncologists practicing in the US regarding knowledge, practice behavior and attitudes concerning preservation of fertility in cancer patients indicated<br /><ul><li> 47 % of respondents routinely refer cancer patients of childbearing age to a reproductive endocrinologist.
  10. 10. Referrals were more likely among female physicians.
  11. 11. Referrals were more likely when patients routinely ask about preservation of fertility.</li></ul>©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  12. 12. Age is also an important factor…<br />After treatment women are commonly asked to take tamoxifen and other agents for 2-5 years. <br />Oncologists also advice a period of observation of two years before attempting pregnancy. The natural loss of eggs during these periods compounds the effect of chemotherapy (Broekmans 2007)<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  13. 13.
  14. 14. Protection<br />So far, no convincing evidence that the effect of chemotherapy can be prevented or mitigated.<br />The benefit of medications that suppresses the ovary (leuprolide, zoladex) is unproven. <br />5; primordial follicles<br />Chemotherapy mainly damage the very small follicles. These are not responsive to hormones in the blood.<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  15. 15. Preservation of Fertility<br />Freezing of eggs and embryos (fertilized eggs) is the most practical method to preserve fertility.<br />Those can be later thawed and transferred to the uterus (own or carrier)<br />Eggs can also be frozen within the ovary (ovarian tissue freezing)<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  16. 16. Embryo Cryopreservation<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  17. 17. Embryo Cryopreservation<br />This method requires<br />Ovarian stimulation with fertility medication<br />Time; 2-3 weeks<br />Sperm source (partner or donor)<br />A special method of ovarian stimulation <br />is used for safer stimulation in women <br />diagnosed with breast cancer.<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  18. 18. Ovarian Stimulation in estrogen sensitive cancers<br />
  19. 19. Ovarian Stimulation & Breast Cancer<br />Ovarian stimulation causes marked increase in estrogen levels.<br />Although brief, this may increase the growth of cancer<br />We have developed and tested a protocol for ovarian stimulation that prevents increase in estrogen during stimulation <br />(Azim 2008)<br />Letrozole is a medication that prevents the ovary from making estrogen. Its approved by FDA for treatment of breast cancer<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  20. 20. Ovarian Stimulation & Breast Cancer<br /> 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 cycle days<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  21. 21.
  22. 22. Ovarian Stimulation & Breast Cancer<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  23. 23. Ovarian Stimulation & Breast Cancer<br />There was no difference in breast cancer recurrence between women stimulated to preserve their eggs or embryos and those who declined stimulation (median follow up 2 years)<br />Length of stimulation was 9.87 days. Peak E2 levels 405.94 pg/mL<br />An average of 10.3 oocytes were retrieved, and 5.97 embryos or oocytescryopreserved per patient<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  24. 24. Timeline<br />Consultation with a fertility preservation specialist<br />Ovarian stimulation and egg retrieval<br />Embryo or oocyte freezing<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  25. 25. Pregnancy after Breast Cancer Treatment<br />Embryos can be replaced in a gestational carrier.<br />If embryos are placed in a breast cancer survivor, pregnancy does not increase the odds for breast cancer recurrence.<br />A waiting period after treatment of 6 months to 2 years is advised <br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  26. 26. Pregnancy after Breast Cancer Treatment<br /> When all studies related to pregnancy after breast cancer were compiled (20,000 women and 1,400 pregnancies), those who became pregnant after treatment had a much lower risk of death due to breast cancer (Azim 2010)<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  27. 27. Low Estrogen Ovarian Stimulation<br />We have also reported the use of this procedure in women diagnosed with endometrial cancer and other estrogen sensitive cancers e.g thyroid cancer<br />
  28. 28. Oocyte Cryopreservation<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  29. 29. The Egg is a Unique Cell<br />It’s the largest cell in the body<br />It has a lot of water<br />Its cell membrane does not allow water to pass easily<br />Chromosomes are spread on a spindle<br />A special expertise is required to freeze an egg!<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  30. 30. Slow Freezing Vitrification<br />The temperature is dropped very slowly.<br />Low concentration of cryoprotectant (a chemical added to the freezing conctail to reduce ice crystal formation during freezing).<br />The temperature is dropped very fast.<br />High concentration of cryoprotectant is used.<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  31. 31. Egg Freezing; Facts <br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  32. 32. Egg Freezing; Facts <br />Caveats<br />Experience with vitrification is still small. Few babies were borne worldwide and long term outcomes are not known yet. It is still considered experimental. <br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />More recent reports on vitrification report better results, with each thawed egg yielding a pregnancy rate of 10%. The transfer of 2 or 3 embryos can result in a reasonable chance for pregnancy and delivery. <br />
  33. 33. Ovarian Tissue Cryopreservation<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  34. 34. Ovarian Tissue Cryopreservation<br />This method requires<br />No ovarian stimulation needed<br />Require a day surgery for harvesting ovarian tissue<br />Require only few hours to accomplish<br />This is an experimental method for <br />fertility preservation.<br />Potential risk: <br />transmission of malignant cells after <br />transplantation<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  35. 35. Ovarian Tissue Cryopreservation<br />One ovary is removed using laparoscopy (minimally access surgery ). The ovary then is cut into thin slices and frozen.<br />After cancer cure the strips are thawed and transplanted in the abdominal cavity (orthotopic) or under the skin (heterotopic).<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  36. 36. Yes You Can<br />You can have your biological child after you were diagnosed with breast cancer.<br />Even if you have no male partner<br />Even if you have no time<br />Even if you do not or cannot get pregnant yourself<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />
  37. 37. Yes just need to..<br />Get timely information about risks and benefits early after your diagnosis, before starting treatment<br />Information is available<br />You are, however, less likely to get the information unless you ask<br />Preservationoffertility.org<br />©2010 AmrAzim, NYCIVF. www.nycivf.org<br />

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