Clinical case 3

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Fertility Preservation Challenges in Pregnancy-Associated Cancer

A 34 year old woman, married and nulliparous, was diagnosed at 32 weeks of gestation stage-II, triple negative brast cancer (ER negative, PR negative, HER2 Negative).
Past history: no previous illnesses, medications, or allergies.
Past operations: none
Family history: maternal grandmother with ovarian cancer;  father with prostate cancer.
Genecology history: age at menarche: 13 years; regulare menstrual cycles; past use of oral contraceptives.

Oncology recommendation:  Neoadjuvant chemotherapy including alkylating agents (chemotherapy during pregnancy to be considered), followed by surgery and radiotherapy after delivery. Genetic screening for BRCA mutations is advised. The patient was referred for fertility preservation and high-risk pregnancy consultations.

 

Fertility preservation considerations
This case raises several important points for discussion:
1. To what extent is the patient at risk of significant ovarian damage?
2. How can ovarian reserve be assessed at this stage?
3. Should a fertility preservation procedure be performed during pregnancy? If so, which one?
4. Would early delivery be advisable, and for what reasons?
5. Is it recommended to initiate chemotherapy during pregnancy at this stage?
Scenario A. Post-delivery of a healthy baby. The patient received alkylating agents until delivery and did not undergo fertility preservation beforehand.
1. Would you recommend fertility preservation after delivery in this patient? Which options are available, and at what timing?
2. Would ovarian tissue cryopreservation be appropriate? What about IVF with oocyte or embryo cryopreservation?
Scenario B. Post-delivery of a healthy baby. The patient did not receive chemotherapy during pregnancy. Oncology plans to start neoadjuvant chemotherapy shortly after delivery, and no fertility preservation was performed before delivery.
3. Would you recommend fertility preservation after delivery in this patient? Which options are feasible, and when?
4. Is the patient expected to respond to ovarian stimulation post-delivery?
5. Which gonadotrophin regimen would you select?
6. Would you add tamoxifen or letrozole to the stimulation protocol, and how might this affect the results?
7. Would you recommend using a long-acting GnRH agonist during chemotherapy?
8. Would you advise pursuing egg or embryo cryopreservation one year or more after chemotherapy?
9. What fertility preservation outcomes can be expected one year or more post-chemotherapy?
Scenario C. The patient is found to be BRCA positive.
1. Would this change your recommendations for fertility preservation procedures?
2. Would you recommend PGT-M for BRCA in this patient? Would this differ from your approach to other BRCA carriers?
General considerations
1. Would you consider future pregnancy a safe option for this patient, or would surrogacy be preferable?
2. Would the information provided alter your recommendations for fertility preservation?
ISFP welcomes fellow clinicals to share their perspectives and responses to any of the questions raised in this case

Comments

Debra Gook

Member of the board
02/10/2025 at 07:11

I'm not a clinican but from a scientific laboratory stand point. If the medical team is going to hold off on chemotherapy until delivery, then at CSection tissue and or aspiration of antral follicles with subsequent IVM would be my suggestion. We know that numerous antral follicles are present on the ovary during pregnancy so this is a good candidate for IVM. The eggs that mature could be frozen for later use.

I would not suggest the creation of embryos at that time, due to the stress that the couple about to go through with cancer treatment and that it is ethically much easier to discard eggs in the future, if they don't want to have another child or the women does survive.

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