METHODS
In this study, 146 females with breast cancer were studied. The eligibility criteria were: female patients
with breast cancer, to be in their reproductive age (between 14 to 45 years). Patients with at least one
of the following criteria were excluded from this study: Having received chemo-radiotherapy before
the current treatment, having received hormonal or pharmacological assisted reproductive treatments
previously and unwillingness to participate in this study.
RESULTS
Out of 146 patients, oncofertility counseling was requested for 55 eligible patients. Oocyte-egg cryopreservation
was successful in 16 patients (29.10%). In four patients (7.27%), the number of ovarian
follicles was inadequate. For 10 patients (18.18%), oncologists advised initiation of chemotherapy before
completion of preservation programs, and 25 patients (45.45%) decided not to continue their preservation
programs. Out of 91 patients not receiving oncofertility counseling, 76 patients (83.50%) declared
that their family planning was completed, 11 patients (12.10%) were in the early stages of breast cancer
and did not require chemoradiotherapy, and four patients (4.40%) were in metastatic stages. We also
found that contrary to the number of living children of patients, neither age nor marital status has an
impact on their decisions to participate in fertility preservation programs.
CONCLUSION
To improve the quality of lives of Iranian women suffering from breast cancer, it is of utmost importance
to raise awareness of oncofertility and to investigate the reasons for the under-implementation of fertility
preservation programs in cancer patients.
Keywords: Breast neoplasms; cryopreservation; fertility; neoplasms
In Iran, for females with breast cancer whose family planning is incomplete, oncofertility counseling is requested between the diagnosis of breast cancer and commencing neoadjuvant or adjuvant chemotherapy.
The objective of the present study is to introduce the importance of oncofertility and fertility preservation counseling in women with breast cancer and to discuss possible impacting factors regarding Iranian breast cancer patients" participation and the result of fertility preservation programs in them.
Cancer stages in the studied patients included: Stage 0 (in-situ) in 7 patients (4.79%). Stage I in 37 patients (25.34%). Stage II in 89 patients (60.95%). Stage III in 9 patients (6.16%). Stage IV in 4 patients (2.73%).
Cancer pathologies in the studied patients included: Invasive ductal carcinoma (IDC) in 130 patients (89.04%). Invasive lobular carcinoma (ILC) in 7 patients (4.79%). Ductal carcinoma in-situ (DCIS) in 7 patients (4.79%). Invasive mucinous carcinoma in 2 patients (1.36%).
Oncofertility and fertility preservation options were
presented to all patients before the beginning of their
cancer treatment. However, in 91 patients (62.30% of
all studied patients), oncofertility counseling was not
requested for the following reasons; 76 patients (83.5%)
declared that their family planning is already completed,
and they were unwilling to have more children (51 patients
in stage II (67.11%), 21 patients in stage I (27.63%),
2 patients in stage III (2.63%) and 2 patients in stage 0
(2.63%). In 11 patients (12.1%), due to breast cancer being
in the early stages, chemotherapy was not required (5
patients in stage 0 (45.5%), 4 patients in stage II in whom
chemotherapy plan was canceled after oncotype DX
(36.36%) and 2 patients in stage I (18.18%)). Therefore,
the oncofertility counseling option was only introduced
to them if they require it in the future. Four patients
(4.4%) had metastatic breast cancer (stage IV). Thus, the
priority of cancer treatment to oncofertility counseling
was explained to them, and subsequently, they decided
to initiate their neoadjuvant therapy. Consequently, for
55 patients (37.70% of all studied patients), oncofertility
counseling was requested before the initiation of their
therapy (Figs.
Out of 55 consulted patients, in 16 patients (29.1%),
oocyte or egg cryopreservation was successfully performed
(10 patients in stage II (62.5%), 4 patients in stage I (25%) and 2 patients in stage III (12.5%)). In
these patients, the average time, from the first day of
oncofertility consultation to the completion of oocyteegg
cryopreservation was 18.3 days (ranging from 12 to
30 days). In four patients (7.27%), due to an inadequate
number of ovarian follicles, cryopreservation of oocyte
or egg was unsuccessful (all in stage II). Because the
time-consuming process of cryopreservation (which
was approximately 21 days, according to previous reports
of the referral fertility preservation center) could
delay systemic therapy, in ten patients (18.18%) fertility
preservation program was halted by the order of oncologist
(8 patients in stage II (80%) and 2 patients in stage
I (20%)). Lastly, 25 patients (45.45%) did not complete
the fertility preservation program (12 patients in stage II
(48%), 8 patients in stage I (32%) and 5 patients in stage
III (20%)), declaring that they decided to allocate their
financial resources to their breast cancer treatment, as the fertility preservation costs were not covered by the
insurance companies (Fig.
We also tested two hypotheses using Chi-Square
tests. The first hypothesis was to evaluate whether the
age of the illegible patients has an impact on their decision
to receive oncofertility consult before starting
their treatment. We found that mean age in patients
who decided not to receive consult was 36 years (±
3.3 years), while mean age in patients who showed
a desire to receive consult was 35 years (±3.6 years),
which were not significantly different (p-value 0.31)
(Table
Another hypothesis was that marital status could
affect patients" preference in receiving oncofertility
consult. The analysis demonstrated that a larger
proportion of unmarried patients preferred receiving
counseling. However, between these two groups,
the difference was not statistically significant (pvalue=
0.182) (Table
There are some studies about oncofertility in developing
countries which show the shortage of knowledge
of this field, alongside other obstacles in the way of implementing
its guidelines (including high expenses of
oncofertility services, oncologists" lack of awareness,
cultural restraints and negative attitudes towards fertility
preservation methods and clinicians and patients"
tendency to allocate all their financial resources to
their cancer treatment instead of fertility preservation
programs). These findings raise awareness when the
data show that approximately 50% of cancer patients in
developing countries are below 65 years old and many
are in their child-bearing age.[
Cancer is the second most prevalent non-communicable
disease in Iran [
It has been shown that 75% of women in reproductive
age who are diagnosed with cancer are interested
in childbearing.[
In our study, the majority of studied patients did
not receive oncofertility counseling from the beginning.
(62.3% of all patients) This was mainly because
they declared that their family planning had already
been completed, and they were not planning to have
any more children in the time of the study (83.5% of
patients not receiving counseling). We suspect that
stressful situations related to cancer diagnosis and its
upcoming treatment could be a contributory factor
in patients" decisions about participating in fertility
preservation programs, which is a matter that may
have negative impacts on their quality of life after completing
their cancer treatment.
Our study also showed that 25 out of 55 consulted
patients (45.45%) decided to prioritize their cancer
treatment and did not continue their fertility preservation
program. We suspect that similar to studies from
other developing countries [
Another contributory factor could be the lack of
adequate awareness in patients or social negative attitude
towards the cryopreservation of oocyte or egg.
All the mentioned possible factors require detailed
confirmatory studies in the future.
Regarding the success of fertility preservation programs,
we found the following results. Among the 55
patients referred to fertility preservation institutes, in
four patients, (7.27%) cryopreservation was not successful
because of inadequate ovarian follicle numbers.
Further studies and clinical trials are required to evaluate
if adequate follicle numbers could be achieved in
women with cancer using pharmacologic or hormonal
therapies before referring them to fertility institutes,
and subsequently, increase the rate of success of fertility
preservation programs.
Similarly, in the aforementioned group, in 10 patients
(18.18%) fertility preservation program was halted due
to oncologists" orders (the reason for which was the time
needed to complete the fertility preservation programs
would delay anticancer treatment). Regarding this matter,
recent studies have shown that delaying anti-cancer
therapy is not necessary when using ovarian stimulation
protocols.[
We also found that neither age nor the marital status
of breast cancer patients affects their decision to
receive oncofertility counseling before starting their
treatment. However, these findings could be biased
due to rather a small number of studied patients and
require further evaluation in future studies.
In addition, studies have shown that the number of
live children could impact patients" desires and decisions,
and patients who have at least one live child are
less likely to be determined about participating in fertility
preservation programs.[
Peer-review: Externally peer-reviewed.
Conflict of Interest: Authors declare no conflicts of interest in the preparation for the present study.
Ethics Committee Approval: This study was approved by Breast Disease Research Center Medical Ethics Committee.
Financial Support: All costs for this study were covered by the authors, and no external funding resources were used.
Authorship contributions: Concept - R.O.; Design - A.B.; Supervision - R.O.; Funding - R.O.; Materials - R.O.; Data collection and/or processing - A.B.; Data analysis and/or interpretation - A.B., M.A.B.; Literature search - N.N.; Writing - M.A.B.; Critical review - R.O.
