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Case History

image A 34-year old woman presented with a 4-week history of an enlarging lump in her right breast. She had no past medical history and was not taking any regular medications. She had no relevant family history. She was working full time as a primary school teacher, lived alone and had been in a one year relationship with her male partner. She was smoking and drinking socially. In regard to her gynaecological history, she was nulliparous with no previous pregnancies, had her menarche at the age of 13 and was having regular periods at the time of her diagnosis.

Triple assessment investigations revealed a 6 cm, grade 2, oestrogen receptor (ER) positive (Allred scale 7/8), progesterone receptor (PgR) positive (4/8), HER2 negative invasive ductal carcinoma with two pathological axillary lymph nodes on imaging and no distant metastases (TNM staging T3N1M0). The recommended treatment plan during her initial oncology appointment was for neo-adjuvant chemotherapy followed by wide local excision (WLE) with sentinel lymph node biopsy (SNLB) and targeted axillary dissection depending on response to chemotherapy, followed by radiotherapy and endocrine therapy for 10 years. In view of this treatment plan, the patient expressed her wish to preserve her fertility, and raised her concerns on how chemotherapy would affect her.

She was referred to the assisted conception unit (ACU) where she had assessment and counselling regarding her future fertility. Transvaginal ultrasound (TVUS) and anti-müllerian hormone (AMH) levels were performed. She was found to have an antral follicle count of 20 and good ovarian reserve with an AMH of 25.5 pmol/l.

She underwent stimulation with a short antagonist cycle with 300 iu of FSH daily. After 12 days of stimulation, ovulation was triggered with a GnRH agonist and 18 eggs were collected. A total of 16 eggs were mature and suitable for freezing. She commenced chemotherapy two days after the egg collection.

What is the chance of this patient becoming infertile after cancer treatment?

How long does it take for egg/embryo cryopreservation to take place?

Does the ovarian stimulation worsen the prognosis of ER positive breast cancer?

What should this patient be advised to store, eggs or embryos?

What is the chance of this patient becoming infertile after cancer treatment?

The gonadotoxic effect of chemotherapy has been well recognized and varies among different treatments1. Gonadotoxicity is also known to be age-dependent in women undergoing chemo-therapy due to a decreasing ovarian reserve; older women are therefore at higher risk for premature ovarian insufficiency (POI). However, the risk of POI cannot always be quantified based on parameters such as toxicity of chemotherapeutic agent and patient’s age at the time of treatment; it also depends on each patient’s ovarian reserve. Ovarian reserve can be assessed by a fertility specialist during pre-chemotherapy fertility counselling by TVUS (this aims to determine antral follicle count) and/or by AMH levels. The advantage of these two tests is that they ...

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