IVF after breast cancer

Dear Professor Winston
I was diagnosed age 32 with aggressive invasive breast cancer ER 8/8 PR 8/8 HER – with 11/17 lymph nodes. My husband and I were due to have IVF that very week. We/they still went ahead and froze 4 embryos day 2. They said they would take all 4 out to thaw? Is that the best thing to do? And is transferring 2 embryos the best option? Now I’m 36, I am cancer free, been on tamoxifen for 3 years. I desperately want to try for a baby now. I can’t be in limbo any longer. It’s taken over our life for 10yrs now. If I need another fresh cycle will the IVF drugs put me at too high a risk? Unless I’m told it is categorically too high a risk then I have to try. Thank you any help on this greatly appreciated. Hardest decision of my life. S.

Dear S,
I am reluctant to take responsibility for advising you without a much clearer knowledge of your situation, so I think ultimately this is something you must discuss with your oncologist. For one thing you need to be very clear about whether pregnancy would be a serious risk for you. If your cancer specialist feels that is not, then I would have thought your best chance would be to have embryos thawed singly or in pairs. I would worry slightly about the risk of twins in any previously totally healthy individual if two embryos were transferred, and presumably a twin pregnancy may be a slightly increased risk in your case. On the whole much depends on the stage of development when the embryos were frozen. A thawed blastocyst transfer would presumably increase your chances of implantation. And because your embryos were frozen when you were only 32, the chance of their viability will be higher.

If your oncologist feels that a pregnancy does not materially carry a great risk to you (and there is much evidence to support this view), then I see little harm in having a fresh cycle or cycles in future. The level of oestrogen which is raised in your blood by having the standard injections of FSH to induce ovulation is relatively transient and insignificant compared with the hormonal changes that occur during a full pregnancy. So I don’t think this is necessarily a very hard decision if a stimulated cycle is required. There is no serious evidence that drugs to induce ovulation seriously increase the risk of breast cancer in ‘normal’ women (1. Sergentanis et al 2014) and this is almost certainly true in your case after a breast cancer, although a number of IVF doctors are nervous about this after an invasive lesion of the kind you describe. I must add that a few younger women like yourself have a genetic predisposition to develop cancer; for example, the BRACA1 gene is not common but I do not know whether the presence of that mutation may greatly increase your risk over normal levels – but probably not.

The chance of pregnancy after breast cancer treatment seems to be equal to that in women who have not had a cancer, (2. Oktay et al 2015). It is very clear from this paper that most of these women had more than one embryo transferred simultaneously as almost 40% of them had twins, but that may alleviate your fears in this respect a bit. Finally, Dr Goldrat and colleagues (3) recently published on a series of nearly 200 women who had IVF or fertility treatment after breast cancer and they found no evidence that produced an increased risk of the cancer returning in their patients. These findings are in broad agreement with reports from other centres. Goldrat and colleagues treated patients had had different forms of breast malignancy; those with hormone dependent breast cancers and those who had not suffered with cancers associated with hormone sensitivity and found no difference in outcome or risk with these different breast cancers. This is a very reassuring publication.

I hope that helps,
Robert Winston
1. Sergentanis TN et al. (2014) “IVF and breast cancer: a systematic review and meta-analysis” Human Reproduction Update. Jan-Feb;20:106-23.
2. Oktay K et al. (2015) “Fertility preservation success……” J Clin Oncology 33, 2424-9
3. Goldrat O.,. et al (2015) “Pregnancy following breast cancer using assisted reproduction and its effect on long-term outcome”. European Journal of Cancer, 51, 1490-6