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    Expert Nurse
    Avatar photoKrista Rubin

      Now that nivolumab is approved in the adjuvant setting, and more than likely BRAF/MEK is also likely to follow, how has/will this change your practice in terms of recommendations regarding family planning for appropriate patients?

      I feel we have entered unchartered territory……

      Expert Nurse
      Avatar photoLisa Kottschade

        I would completely agree. Just recently had a patient who recurred in the lymph nodes underwent surgical resection and now will start adjuvant nivolumab. Had to have a very difficult discussion about discontinuation of breast feeding as well as future fertility as she really would like to have more children. Not a conversation that came easily.

        I believe in the patients for whom this is applicable this will be an important discussion upfront and included in the pretreatment teaching as with any other expected side effect.

        Great question!

        Expert Nurse
        Avatar photoVirginia Seery

          This is a very relevant issue, especially in the adjuvant setting. This came up for us recently when a 34 year old woman with Stage IV melanoma resected to NED (no evidence of disease) was going to start adjuvant ipilimumab. She was recently married and asked about having children. In discussion with her PCP, she was referred to a fertility specialist who felt immunotherapy itself would not impact her ovarian reserve, but her advancing age could as she awaits completion of therapy and then more time to ensure she does not recur. For that reason, embryo cryopreservation could be considered. One of our concerns was that development of hypophysitis from I/O therapy may make in vitro fertilization difficult, but that was not felt to be a major concern as gonadroptropins would be used in this setting.

          Here is another related question – what are your recommendations about pregnancy for females with a history of Stage III or Stage IV melanoma resected to NED?

          Expert Nurse
          Avatar photoMollie Reed

            This is such a challenging issue. We had a patient on adjuvant ipi who developed hypophysitis. She has been off treatment for almost a year, and she would now like to conceive. This is definitely unchartered territory for us, her OB and her Reproductive Endocrinologist. Beyond the hypophysitis, we know that the immune system plays a pivotal role in pregnancy and that there are checkpoints involved (PD-1/PDL-1 being one of them) to prevent the mom’s immune system from attacking the fetus. If a patient is having a durable response to immunotherapy, is the mom’s immune system, in that case, going to be too upregulated to sustain a pregnancy?…….There are certainly lots of unknowns in this realm.

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