QuestionDear Dr Ramirez, I am writing to you from London, UK. Thank you for reading my e-mail.
It would be easier if I start from the beginning. When 6 years ago, just before my 40th birthday I was diagnosed with Grade 1, stage 1 Breast Cancer. After the initial shock my first thoughts were how to preserve my fertility as I had not had any children as was engaged to be married. After surgery I was referred to an amazing Oncologist who specializes in pre menopausal breast cancer who taylor made my treatment to save my fertility at all costs We decided to go for 2 years of Zoladex injection along with tamoxifen. As the breast cancer was hormonally sensitive is was not a good idea to stimulate eggs to freeze.
After treatment finished and I got married and my periods went back to normal, I tried to get pregnant naturally but after 6 months it didnt happen and I was 45 years old. I consultant a Gynoclogist who undertook hormone profiling and tubal patency test, were fine. We started Clomid and after the first round I complained of back pains, but was told that I must have put my legs in the stirrups incorrectly and pinch a nerve in my back, this pain didnt stop and my Oncologist was so worried she send me for a MRI, which was thankfully clear however they suggested they could see sign of PCOS. After the 2nd round of Clomid and my Gynecologist then sent me for an indepth pelvic scan which relived severe Endometriosis with obliteration of POD. If course I am very upset as we have wasted almost a year and alot of money on a treatment that was never going to work with this diagnosis.
What I wanted to ask you was considering my age, Breast Cancer Treatment, also having one miscarriage and one early termination in the past would it not have been prudent for my gynecologist to have recommended a laporoscapy prior to starting on Clomid to be 100% sure? obvioulsy I am very upset and angry at the moment. Look forward to receiving your views.
Angie
AnswerHello Angela from the U.K.,
I am very sorry to hear that you had breast cancer at such an early age, but I send my prayers along with hopes that it is resolved. The good news is that most estrogen receptor positive breast cancers have an excellent remission/cure rate at the stage that you had.
Secondly, let me say that I recently had a very young patient (27 years old) that had breast cancer and previous treatment. She came to me after they found a very small borderline tumor that they thought might be a recurrence. As a result, and the fact that she was recently married, she came for consultation regarding preserving her eggs for a future pregnancy. I then extensively researched what her risks would be with ovarian stimulation to retrieve eggs. I have found, and further discussed it with colleagues, that there are no studies or data that show any increased risk of recurrent breast cancer in patients that undergo ovarian stimulation or in vitro fertilization. So, you should not be worried if you choose to go through that procedure.
In answer to your question, it is always easier to evaluate something retrospectively. As we say, hindsight is 100%. Therefore, I don't think that a laparoscopy should necessarily have been done prior to your Clomid cycles, unless your doctor suspected endometriosis as that time. By the way, endometriosis can ONLY be diagnosed by laparoscopy. Neither ultrasound nor MRI can detect endometriosis unless it is in its severest stage and there is an endometriotic tumor present. So, I am not quite convinced that you have endometriosis based on what you told me. I would have to review the medical records and findings.
What I find to be the most distressing in your case, is that you were not counseled to consider IVF immediately solely based on your age. Infertility testing and Clomid cycles were a waste of time because of the very low chances of a pregnancy after the age of 40, and especially 45 years old. We call this the age related egg factor, and it is well known that the quality of eggs deteriorate with age and hence the fertility rate decreases as well. Your chances of pregnancy at 40 were 1% per month (10% per year# and at 45 are almost 0 #probably a little higher than zero). There is no place to do a minimal infertility treatment like Clomid at this age.
At this point, the only realistic option that you have is to attempt IVF with your own eggs, if you so desire, however, there is a high chance that it will not be successful. Pregnancies with IVF in 45 year olds are rare. The better option is to use donor eggs in conjunction with IVF. The other advantage of this choice is that your ovaries won't have to undergo stimulation so if there is any risk at all for your breast cancer, that is avoided.
I know I have given you more information than you asked for but I hope that it will be helpful to you.
Good Luck,
Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.
for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf
