Oncofertility counseling & fertility preservation strategies.pdf

Oncofertility counseling with the patient or couple, fertility preservation strategies, the steps for each approach, and the safety of post-treatment pregnancies are discussed

1. Oncofertility counseling &
fertility preservation strategy:
Good clinical practices
Tevfik Yoldemir MD, BSc, MA, PhD
Co-chair of the Council of Affiliated Menopause Societies – CAMS
Associate Editor of Climacteric
[email protected]
profdr.tevfikyoldemir

2. I have no financial relationships to disclose.

3. Oncofertility programs for breast cancer
Limited versus optimum resource settings
Journal of Assisted Reproduction and Genetics (2022) 39:505–516

4. Annals of Oncology Volume 31 - Issue 12 - 2020

5. Hum Reprod Open. 2020 Nov 14;2020(4):hoaa052.
doi: 10.1093/hropen/hoaa052.
Checklist for patients’ assessment and selection for fertility
preservation (FP) interventions

6. Evolution of prevalence of amenorrhea and mean AMH level
over time.

Patients received six courses of chemotherapy over a 18-week period.
Measurements were performed at the beginning of the 2nd cycle (C2), 4th cycle (C4)
and 6th cycle (C6), then every 3 months after the end of chemotherapy for 1 year
(M3, M6, M9 and M12), and finally 24 months after the end (M24) of chemotherapy


Int. J. Cancer. 2022;150:1850–1860

7. Clinical Breast Cancer. Vol. 23, No. 3, 241–248
DOİ:10.1016/j.clbc.2023.01.006
Fertility Preservation for Young Women With Breast Cancer

8. Schematic overview of the options for female fertility preservation

Hum Reprod Open. 2020 Nov
14;2020(4):hoaa052.
doi: 10.1093/hropen/hoaa052.

9. Strategies for Preservation of Fertility and/or Ovarian Function in
Women with Breast Cancer Diagnosed During Reproductive Years

Breast Cancer: Targets and Therapy 2021:13

10. Breast Cancer: Targets and Therapy 2021:13

11. Annals of Oncology Volume 31 - Issue 12 - 2020

12. Risk of Treatment-induced Gonadotoxicity Associated With the
Main Systemic Anticancer Therapies


(F)EC/(F)AC = 5-fluoruracil, epirubicin, doxorubicin, cyclophosphamide; T = docetaxel; P = paclitaxel

Clinical Breast Cancer, Vol. 23, No. 3, 241–248
DOİ:10.1016/j.clbc.2023.01.006

13. Critical Reviews in Oncology / Hematology 166 (2021) 103461
Alkylating agents are generally
associated with the highest risk for
POF.

Fluorouracil or methotrexate are the
least gonadotoxic.

Anthracycline-based and taxane-
based regimens are considered
intermediate-low risk agents.

Notably, no difference in
gonadotoxicity has been reported
between standard or dose-dense
schedules

Risk of treatment induced amenorrhea

14. POST-TREATMENT PREGNANCIES IN CANCER SURVIVORS

Annals of Oncology Volume 31 - Issue 12 - 2020

15. Half-Life of the Main Therapies Administered in Patients With
Early Breast Cancer and Their Indication

Cancer J 2022;28: 176–182

16. Suggested washout period following oncological treatments
to attempt pregnancy in women with breast cancer

Cancer J 2022;28: 176–182

17. Patient re-assessment before attempting pregnancy

Hum Reprod Open. 2020 Nov
14;2020(4):hoaa052.
doi: 10.1093/hropen/hoaa052.

18. Checklist Reproductive options after fertility preservation
for cancer patients

Hum Reprod Open. 2020 Nov 14;2020(4):hoaa052.
doi: 10.1093/hropen/hoaa052.

19. Disease recurrence
following ovarian suppression (2.1.1)
ovarian stimulation with cryopreservation (2.1.2) or
a combination of ovarian suppression and
cryopreservation (2.1.3)
European Journal of Obstetrics and Gynecology 287 (2023) 8–19
doi: 10.1016/j.ejogrb.2023.05.030
Fertility preservation’s impact on disease status in premenopausal
women with breast cancer
Fertility preservation was associated
with a reduced rate of disease
recurrence (OR 0.63 (95% CI 0.49–0.81)).

20. Recurrence rate in patients undergoing COS
Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

21. Recurrence rate among patients undergoing COS before
neoadjuvant chemotherapy compared to patients who did not
receive fertility preservation techniques

Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

22. Recurrence rate among patients undergoing COS before adjuvant
chemotherapy compared to patients who did not receive fertility
preservation techniques

Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

23. Recurrence rate in survivors that performed assisted
reproductive technologies

Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

24. Breast Cancer Research and Treatment (2021) 186:429–437
Recurrence in breast cancer
patients who elected FP vs those
who did not
Recurrence in ER-positive breast
cancer patients who elected FP vs
those who did not
Recurrence in ER-positive
vs. ER-negative breast cancer
patients who elected FP
Recurrence in HER2-positive breast
cancer patients who elected FP vs
those who did not

25. following ovarian suppression (3.1.1)
or ovarian stimulation with cryopreservation
(3.1.2)
European Journal of Obstetrics and Gynecology 287 (2023) 8–19
doi: 10.1016/j.ejogrb.2023.05.030
Disease free survival
Fertility preservation’s impact on disease status in premenopausal
women with breast cancer
There was no significant difference
in disease free survival (OR 0.88
(95% CI 0.74–1.05)) between the
fertility preservation group and
those who had not undergone
fertility preservation.

26. Event-free survival in patients undergoing COS

Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

27. JAMA Oncol. 2022 Oct; 8(10): 1438–1446
doi: 10.1001/jamaoncol.2022.3677

(G1) cryopreservation of oocytes
and/or embryos using hormonal
stimulation (hormonal FP) and
(G2) cryopreservation of ovarian
tissue without hormonal
stimulation (nonhormonal FP).
A combination of both methods
was categorized as hormonal FP.

Hormonal stimulation was
further stratified by
coadministration of letrozole or
standard stimulation protocols.

BC-specific survival rate

There was no statistically significant difference in the rate of relapse or death
among women who underwent hormonal FP vs women who underwent
nonhormonal FP

28. Relapse-free survival rate

JAMA Oncol. 2022 Oct; 8(10): 1438–1446
doi: 10.1001/jamaoncol.2022.3677

29. Assessing overall survival
following ovarian suppression (4.1.1)
or ovarian stimulation with
cryopreservation (4.1.2)

European Journal of Obstetrics and Gynecology 287 (2023) 8–19
doi: 10.1016/j.ejogrb.2023.05.030
Fertility preservation’s impact on disease status in premenopausal
women with breast cancer
There was no significant difference
in overall survival (OR 0.9 (95% CI
0.74–1.10)) between the fertility
preservation group and those who
had not undergone fertility
preservation.

30. Annals of Surgical Treatment and Research 2024;106(4):189-194
Safe and successful
pregnancy following
breast cancer treatment
A total of 107 patients were enrolled in this study. Thirteen
patients (12.1%) conceived and successfully delivered.

31. Event-free survival in hormone-receptor positive disease in
patients undergoing controlled ovarian stimulation

Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

32. Event-free survival in survivors that performed ARTs.

Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

33. Controlled ovarian stimulation for the purpose of FP does delay the initiation
of systemic treatment but does not affect recurrence or survival.

Cancer 2021;127:3872-3880

34. Mortality rate in patients undergoing COS.

Human Reproduction, Vol.37, No.5, pp. 954–968, 2022
Meta-analysis (n=15)

35. No significant difference reported between categories.

Breast Cancer Research and Treatment (2021) 186:429–437

36. Fertil Steril 2024 10.1016/j.fertnstert.2024.04.031

After adjustment for age, parity, type of chemotherapy administration, and endocrine therapy,
only multiparity at diagnosis and absence of chemotherapy were positive predictive factors of
pregnancy after cancer.
Fertility outcomes several years after urgent fertility preservation
for patients with breast cancer
Live birth
Pregnancy

37. Fertility outcomes for all fertility preservation techniques

European Journal of Obstetrics and Gynecology 287 (2023) 8–19
doi: 10.1016/j.ejogrb.2023.05.030
When broken down by subgroups, the
fertility preservation group showed
significantly higher Return of
Menstruation (OR 4.39 (95% CI 3.77–
5.12)), and pregnancy rates (OR 2.90
(95% CI 1.84–4.57)). There was no
significant difference in live birth rates
between the fertility preservation and
control groups who did not undergo
fertility preservation

38. Time from first attempt to pregnancy occurrence in months
RBMO VOLUME 44 ISSUE 6 2022
doi:10.1016/j.rbmo.2021.12.019 1472-6483
With a median follow-up of 26.9
months after the end of
treatments, 133 pregnancies had
occurred in 85 patients (16.4%),
including 20 unplanned
pregnancies (15.0%).
Most of the pregnancies were
natural conceptions (n = 113,
87.6%), while 16 (12.4%)
required medical interventions.
517 BC patients
236 (45.6%) patients were offered
specialized oncofertility counselling
181 patients underwent at least one
fertility preservation procedure
(FPP); 125 (24.2%) underwent one
or more FPP with material
preservation

39. Pregnancy after breast cancer remains possible, especially spontaneously without
exposing patients to an increased risk of disease recurrence.

The live birth rate - Leproux et al 19.7%, Kopeika et al. 18% , Assogba et al. 9.5%

The pregnancy rate - Leproux et al 18% , Assi et al. 25%, Partridge et al. 24%, Ives
et al. 5%, Hamy et al. 12.7%, Blakely et al. 13%, and Gerstl et al. 14%.
Breast Cancer Research and Treatment (2021) 188:593–600
Pregnancy after breast cancer
The live births rate achieved spontaneously or by ART

40. Cancer 2021;127:1021-1028
Pregnancy After Breast Cancer

Among 130 women who attempted to become pregnant, 90
(69.2%) conceived; and, among 896 women who did not
attempt to conceive, 18 (2.0%) became pregnant

embryo cryopreservation (n = 84),
oocyte cryopreservation (n = 28),
gonadotropin-releasing hormone agonist (n = 41), and
ovarian tissue cryopreservation (n = 1)

41. 1
ICSI, COS followed by ICSI and fresh ET;
2
ICSI PGT-M, COS followed by ICSI, pre-implantation genetic testing for
monogenic disorders and ET;
3
MNC, managed natural cycle IVF/ICSI;
4
OI and TI, ovulation induction and timed
intercourse;
5
FET after COS, frozen embryo transfer following COS as FP method;
6
FET after OTO-IVM, frozen
embryo transfer following ex vivo IVM as FP method;
7
WOET, frozen transfer of an embryo generated using ICSI of a
warmed oocyte following OTO-IVM as FP method.
Human Reproduction, Vol.35, No.11, pp. 2524–2536, 2020

42. Reproductive Outcomes of Pregnancies in Breast Cancer
Survivors and in Healthy Women From the General Population
A total of 5333 breast cancer patients
and 4,809,084 healthy women from the
general population with at least 1
pregnancy were included in this
descriptive analysis.

Most breast cancer patients (55.9%)
completed their pregnancies.

The rate of spontaneous abortion was
12.5% in breast cancer survivors and
14.7% in healthy women from the
general population, respectively.

No apparent differences in terms of
congenital abnormalities were reported
in breast cancer survivors and in healthy
women (4.7% vs. 4.3%, respectively).

Cancer J 2022;28: 176–182

43. TAKE HOME MESSAGES -1
Oncofertility Counseling of Young Breast Cancer Patients

Breast Cancer: Basic and Clinical Research
2020 Volume 14: 1–12 doi:10.1177/1178223420954179
2024 Volume 18: 1–10 doi: 10.1177/11782234241261429

44. Oncofertility Counseling of Young Breast Cancer Patients
Breast Cancer: Basic and Clinical
Research 2020 Volume 14: 1–12
Doi:10.1177/1178223420954179

TAKE HOME MESSAGES -2

45. Oncofertility Counseling of Young Breast Cancer Patients
Breast Cancer: Basic and Clinical
Research 2020 Volume 14: 1–12
Doi:10.1177/1178223420954179

TAKE HOME MESSAGES -3

46. Breast Cancer: Basic and Clinical Research 2020 Volume 14: 1–12
Doi:10.1177/1178223420954179

Oncofertility Counseling of Young Breast Cancer Patients
TAKE HOME MESSAGES -4

47. Oncofertility Counseling of Young Breast Cancer Patients


Breast Cancer: Basic and Clinical
Research 2020 Volume 14: 1–12
Doi:10.1177/1178223420954179

TAKE HOME MESSAGES -5

48. Checklist for clinicians to cover the information needs of
patients undergoing fertility preservation counselling

Hum Reprod Open. 2020 Nov 14;2020(4):hoaa052.
doi: 10.1093/hropen/hoaa052.

49. Fertility-preservation resources for patients and health care providers

CMAJ 2020 August 31;192:E10039

50. Thank you for your attention.

[email protected]
TevfikYoldemirMDBBAM profdrtevfikyoldemir Tevfik-Yoldemir