Introduction 1 2 Premature ovarian failure 3 4 5 6 4 4 5 Fertility preservation techniques 1 Table 1 Fertility preservation options for women with malignancies Method Benefits Limitations In vitro Fertilization (IVF) Most successful, widespread Delay of therapy, use of fertility medications Frozen oocytes No partner is needed Difficult to preserve Ovarian tissue preservation Less tissue damage from freezing, can be used in pre-menarchal and young women Experimental Transposition of ovarian tissue Less radiation exposure Limited to women having radiation therapy Pharmacological protection Limit damage to ovarian tissue Adequate prospective studies needed In vitro fertilization (IVF) 7 One concern about ovarian stimulation with IVF is that it requires a delay of therapy, which could impact growth rate of tumors and survival rates. In addition, concerns have been voiced that the medications used to stimulate ovarian production could impact on estrogen-receptor positive tumors such as breast carcinoma. Anti-estrogens, such as tamoxifen, or aromatase inhibitors, (e.g. letrozole), have both been used in ovarian stimulation in breast cancer patients to maintain low estradiol levels during IVF cycles. Frozen oocytes 8 Ovarian tissue cryopreservation 9 10 Ovarian transposition 11 Pharmacological protection 12 13 Male fertility 14 15 16 16 17 18 Pregnancy after cancer Once a woman has recovered from cancer treatment, no clear guidelines exist about the length of time to wait before attempting to become pregnant. Effect of cancer treatment on pregnancy 19 20 21 Women who have completed treatment for breast cancer are often placed on selective estrogen receptor modulators (SERMs) such as tamoxifen to reduce the incidence of a second cancer. However, tamoxifen use during pregnancy is to be avoided because it is potentially teratogenic. Effect of pregnancy on cancer 22 23 BRCA1 BRCA2 24 BRCA2 BRCA1 25 Risk to offspring 26 27 Risk of cancer in offspring 26 BRCA1 BRCA2 28 Summary All women should be counseled about the impact of cancer treatment on fertility prior to undergoing chemotherapy, ovarian surgery or BMT, and offered fertility preservation options, of which ovarian stimulation with IVF is the most successful. Once women achieve pregnancy, the risk for birth defects or genetic conditions is not increased because of either radiation or chemotherapy. Because treatment options may increase the risk for adverse pregnancy outcome, review of therapy records is essential for determining potential risk to the pregnancy. For most young cancer survivors, fertility can be preserved and a successful pregnancy achieved, but discussing these issues prior to treatment is essential.