I would restart IMATINIB 400 mg again. I would perform a cytogenetic study to check her response and I would expect her to recover the complete molecular response.

I would evaluate the possibility of pregnancy at the time by IVF.

Monitor bcr abl during pregnancy every month according to the patient's access to better detect the moment of starting treatment with INF.

My position is:
Restart imatinib 400
Allow the patient to conceive on imatinib but to stop imatinib as soon as the pregnancy test is positive , before organogenesis starts.
Monitor monthly bcr-abl during pregnancy
Discuss interferon whenever bcr-abl trancrpts increase above 1% with a rapid kinetics

Difficult. It’s hard to believe that someone in DMR for 15 years would have such a rapid molecular relapse within 3 months.

To answer the question, she is very likely to lose CCyR and CHR, but hard to know how quickly this will happen. Ideally she should return to a TKI, perhaps one more potent than imatinib, re-establish her deep response and try again in a couple of years.
If she is adamant that she will not re-start I would suggest another 3 months off drug. If pregnant by that time, do nothing and just monitor counts and PCR. Try to get to the 3rd trimester before starting any treatment and if necessary, at that time, try imatinib. If she needs treatment before then maybe seek advice according to rate of rise of PCR
If not pregnant, I would recommend re-starting a TKI. If they have access to an IVF unit, refer her because any further attempt could be speeded up with fresh or frozen embryos. If she won’t re-start then she must understand that she is at risk of disease progression.

Request for advice from a physician based in India, regarding a difficult CML and pregnancy case. The request is as follows:

28 year old female diagnosed 15 years back, in deep molecular response after one year of starting on Imatinib. She was kept off Imatinib since 3 months as she expressed her concern for pregnancy.
Bcr abl became detectable after 1 month of stopping the drug and by the end of 3rd month, it’s 0.3. Latest CBC shows total leukocyte count of 11000 with left shift, no basophils or blasts. She has not yet conceived but wishes to go ahead and plan for pregnancy.

What best advise should be given? In how many months, is a loss of chr expected, and how can we predict any hyperleukostasis that can complicate her pregnancy before it’s safe to terminate.