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Fertility & Cancer

Many women and men of childbearing age who have been diagnosed with cancer think that preserving their fertility is important and want information about their options. However,

  • Patients may not feel comfortable bringing up fertility issues.
  • Patients may not be aware of their options for preserving fertility.
  • Patients may be focused on their cancer diagnosis and unable to think about fertility or the possibility of having a future family.

Understanding that there are fertility preservation options available and referring at-risk patients to specialists can improve patients’ emotional outlook and future quality of life.

Options for women include:

  • Embryo Freezing
  • Egg Freezing
  • Ovarian Tissue Freezing (Experimental)
  • Radiation Shielding
  • Ovarian Transposition
  • Surgical Ovarian Suppression (Experimental)

Options for men include :

  • Sperm freezing prior to cancer therapy
  • Radiation shielding of the testes during radiation therapy

Women

Why is it important to think about your fertility when you have cancer?

Fertility—a woman’s ability to get pregnant or maintain a pregnancy—can be damaged by some cancer treatments. Many young women facing a cancer diagnosis want to have children in the future. Some may not know they have options to protect their fertility. The best time to preserve your fertility is before cancer treatment starts.

Ask your doctor about fertility-saving options as soon as possible after your cancer diagnosis. Sometimes your doctors can choose a treatment plan that does less harm to your fertility.

How does cancer treatment affect fertility?

Girls are born with all the eggs they will ever have. Women cannot grow or make new eggs. Chemotherapy, radiation therapy, and some surgeries can harm or destroy the eggs or cause other fertility problems.

Chemotherapy can damage your eggs, ovarian follicles (sacs in the ovaries that contain the eggs), and sex hormones. Radiation can do the same damage when treatment is to your whole body or near certain organs. These include your reproductive organs and the pituitary gland (a hormone-producing gland at the base of the brain).

Often, chemotherapy or radiation therapy can stop your periods for a while or make them irregular. Your periods may continue or return after treatment, but you should know that having periods does not always mean that you are fertile. In some cases periods may never return. There is still a small chance of pregnancy even if you are not having periods.

Chemotherapy or radiation therapy can cause infertility right away, or years later by causing you to go into menopause early. Premature menopause is the end of your menstrual periods before age 40. Surgery that removes both ovaries causes menopause right away.

Your cancer treatment may affect your ability to carry a pregnancy. For instance, high-dose radiation to the pelvic region can raise the risk of a future miscarriage or cause premature birth. Women who have had a hysterectomy (surgery that removes the uterus) cannot become pregnant.

What is the chance of infertility?

Not all women become infertile after cancer treatment. The impact that cancer treatment may have on fertility depends on many factors. These include:

  • Cancer type and stage (how much it has spread)
  • Type and total dose (amount) of chemotherapy
  • Dose and location of radiation therapy
  • Site of surgery
  • Your age (risk of infertility rises as you age)
  • Your fertility status before treatment

If you plan to have chemotherapy, ask your oncologist about options that are less likely to damage your fertility.

What are the options for fertility preservation?

Your doctor may refer you to a reproductive endocrinologist, a doctor who is a fertility specialist.

Fertility-saving options vary by person, type and stage of cancer, and how quickly you must start cancer treatment. Standard methods include:

Embryo banking. Freezing of embryos (fertilized eggs) may be an option. You may need fertility drugs (usually daily injections) to boost egg production. Your eggs are “harvested” (removed surgically) and combined with your partner’s (or donor’s) sperm in a laboratory dish. This is called in vitro fertilization, or IVF. The embryos stay frozen, or “banked,” until you need them.
Pelvic shielding during radiation therapy. It may be possible to shield one or both ovaries to protect them from radiation during treatment.

Ovarian transposition. Before radiation treatment to the pelvic region, a surgeon moves one or both ovaries to another spot in your body outside the treatment field. If it is not possible to get pregnant naturally with the ovary in its new spot, you may need to have it moved again or use IVF to become pregnant.

Ovarian-sparing (conservative) surgery. The standard treatment of gynecologic cancers such as endometrial (uterine) or ovarian cancer is to remove both ovaries and the uterus. Some women may be able to keep their ovaries if their cancer is early stage (stage I) and low grade, meaning a low risk of spreading.
Removal of the cervix but not the uterus. Women with cervical cancer most often have their uterus and cervix surgically removed. Those with early-stage cancers of the cervix may choose to have just the cervix taken out.

Medical treatment of endometrial cancer. Early, low-risk endometrial cancers can often be successfully treated without surgery. Instead, doctors can use hormonal drugs, such as a progestin, to shrink the tumor.

Other methods are experimental. Their safety and how well they work are still under study. They include:

Egg banking (freezing unfertilized eggs): Like embryo banking, you may need fertility shots or other drugs to boost egg production. Your eggs are then harvested and frozen.

Ovarian tissue banking: This method involves removing small pieces of the ovary and storing the tissue frozen. A surgeon may be able to re-implant the tissue after cancer treatment. This may not be a safe option for women with leukemia or certain other types of cancers because there could be cancer cells in the tissue. The tissue might also be used to mature the follicles and enclosed eggs and fertilize the eggs outside of the body, but no children have been born using this method yet.

Medical treatments: Certain medications may be used to try to protect the ovaries during chemotherapy. These drugs can shut down the ovaries during treatment. It is not clear if they improve fertility after cancer treatment.

Will fertility preservation delay your cancer treatment?

Some methods of preserving fertility may delay the start of cancer treatment. For embryo and egg freezing, you most often will need about 2 weeks of medication to increase egg production, starting from when you get your period. After your eggs are harvested, you can begin cancer treatment.

What are the success rates and costs of fertility preservation?

Many young women who had cancer treatment have a child in the future. Fertility success rates vary by treatment and each woman’s situation. Your doctor will be able to give you more information about your chances for success.

The cost of fertility preservation also varies but may be expensive. Insurance companies may not cover the cost of certain fertility treatments. Financial help is available from some organizations.

Is pregnancy safe after cancer treatment?

In general, pregnancy is safe after cancer treatment ends and you are in remission. Research shows that pregnancy does not cause a cancer recurrence.

However, your doctor may suggest you wait 6 months or more after you stop treatment before you try to get pregnant. That is because if cancer recurs, it is most likely to do so in the first 2 years. In general, it is not safe to become pregnant during cancer treatment. Talk to your doctor about the birth control options that are right for you, even if you think you’re infertile, until your doctor tells you that you may try to become pregnant.

Some cancer treatments may cause heart or lung damage and complicate a future pregnancy. Ask your doctor if it’s safe for you get pregnant.

What are the options if you are infertile?

If pregnancy is not possible after cancer treatment, there are other options to build a family. These include getting embryos or eggs from a donor, using a surrogate mother to carry a pregnancy (where it is legal), and adoption. Some adoption agencies may have restrictions on adoptions by cancer survivors, but others do not.

It is common to feel sad or angry about not being able to have a child. You may find it helpful to talk to a counselor or join an infertility support group.

How quickly do I need to start cancer treatment?

Your doctors may not discuss fertility preservation. You should raise this issue if fertility is a concern for you. Here are some questions to ask your doctor:

  • Will my cancer or its treatment affect my future fertility?
  • What are my options to preserve fertility?
  • Do any of these options make my cancer treatment less effective or raise the chance of a recurrence?
  • I am not in a relationship but still want a child; what are my options?
  • If my prognosis is poor, may I still bank embryos or eggs?

Men

Why is it important to think about your fertility when you have cancer?

A man’s fertility—the ability to get a woman pregnant—can be damaged by some cancer treatments. Even before treatment, some cancers, such as testicular cancer and Hodgkin’s lymphoma, can lower sperm counts. Many men facing cancer want to have children in the future. Some men may not know they have options to protect their fertility. The best time to do this is before cancer treatment.

Ask your doctor about your fertility-saving options as soon as possible after your cancer diagnosis. Sometimes your doctors can choose a treatment plan that does less harm to your fertility.

How does cancer treatment affect fertility?

Chemotherapy, radiation therapy, and some surgeries can cause fertility problems. Infertility may occur right away or in a few months. It can last for months or years, or be permanent.

Chemotherapy can reduce or stop sperm production, which affects your ability to father a child. Also, hormone therapy for prostate cancer often harms sperm production.

Radiation therapy can lower sperm production when treatment is to your whole body, testicles, or certain other areas. These sites include your pelvis (near the testicles), pituitary gland (a small hormone-producing gland at the base of the brain), and brain. The brain works with the pituitary gland to signal the testicles to make sperm and testosterone, the main male sex hormone.

Surgery that removes both testicles stops sperm production forever. Removal of just one testicle to treat testicular cancer can lower the amount of sperm the body makes. Despite this, men with testicular cancer may still be able to father a child unless the remaining testicle does not produce sperm.

Surgery of the prostate, bladder, large intestine, spine, or rectum may damage nerves and make a man unable to ejaculate—eject semen (the fluid carrying sperm) from the penis. Sometimes this type of operation makes the semen go backward into the bladder. Called retrograde ejaculation, this problem means little or no sperm exits the penis.

What is the chance of infertility?

Not all men become infertile after cancer treatment. The impact that cancer treatment may have on fertility depends on many factors. These include:

  • Type and dose (amount) of chemotherapy
  • Dose and location of radiation therapy
  • Site of surgery
  • Your age (risk of infertility rises with age)
  • Your fertility status before treatment

Some cancer drugs are more likely to cause infertility than others. If you plan to have chemotherapy, ask your cancer doctor (oncologist) about drugs that are less likely to damage your fertility.

What are the options for fertility preservation?

Your doctor may refer you to a physician who specializes in treating male fertility problems. This may be a urologist or endocrinologist.

Male fertility-saving treatments include:

Sperm banking. Freezing (cryopreservation) of sperm is the most successful way for men to preserve fertility before cancer treatment. The most common way to collect the semen sample is through masturbation. Men who cannot ejaculate may have vibrational or electrical stimulation to help them do so. The sperm stay frozen, or “banked,” until you need them. Freezing—even for many years—does not damage sperm.

Testicular sperm extraction. Even if a man’s semen has no sperm, he may still have sperm in the testicles. In testicular sperm extraction, a surgeon removes small pieces of testicular tissue (biopsy) while the patient is sedated or under local or general anesthesia. If the tissue contains sperm, the sperm are either frozen or used to fertilize a female partner’s eggs. This technique may be an option before or after cancer treatment.

Shielding of testicles during radiation therapy. It is sometimes possible to shield the testicles to protect them from radiation during treatment.

What are the success rates and costs of fertility preservation?

Many men who had cancer treatment go on to have children. Fertility success rates vary by treatment. The chance of pregnancy with banked sperm improves with higher numbers and quality of sperm. Advanced fertility treatments now may allow pregnancy with just one sperm.

Fertility preservation can be expensive. Besides procedure costs, there may be a yearly fee for storing frozen sperm. Insurance companies might not cover the cost of certain fertility treatments. Financial help is available from some organizations.

How long should you wait after cancer treatment before trying to have a baby?

If you had chemotherapy or radiation, your doctor may suggest you wait 1 to 2 years or more after you stop treatment before you try to start a family. It can often take this long for healthy sperm production to start up again. Until then, use a condom or other form of birth control, even if you think you are infertile.

What are the options if you are infertile?

When fertility does not return after cancer treatment, there are other ways to build a family. These include getting sperm from a donor and adoption. Some adoption agencies may have restrictions on adoption by cancer survivors, but others do not.

It is common to feel anger or a sense of loss about not being able to have a child. You may find it helpful to talk to a counselor or join an infertility support group (see Resources below).

What are the effects of cancer treatment on male hormones?

Cancer treatment can lower or stop testosterone production. Lower-than-normal testosterone is called hypogonadism or androgen deficiency. Removal of the testicles, radiation, or chemotherapy can cause low testosterone. So can androgen deprivation therapy (hormone therapy) for prostate cancer.

Some symptoms of low testosterone are:

  • Reduced sex drive
  • Poor erections
  • Low sperm count
  • Low energy
  • Tender, enlarged breasts
  • Hot flashes

What are the long-term health effects of low testosterone?

Over time, low testosterone can cause health problems. They include:

  • Loss of muscle mass (size) and strength
  • Osteoporosis—thinning of bones, making them more likely to break
  • Mood changes and depression
  • Increased body fat

What are the options to treat symptoms of low testosterone?

Testosterone replacement therapy can improve sexual desire and erections as well as mood, energy, bone density, and muscle size. Men should not take testosterone if they have prostate cancer or breast cancer. Also, do not use this treatment if you and your partner are trying to get pregnant because it reduces sperm production.

Another type of hormone therapy is human chorionic gonadotropin (hCG). This fertility treatment is an option for men who want to father a child but have low sperm counts and testosterone due to a problem with the pituitary gland or brain. This problem can occur with radiation therapy or a pituitary or brain tumor.

For men who cannot take testosterone, other treatments are available for depression and osteoporosis. Your doctor can help you find a treatment that’s right for you.

What should you do with this information?

Your doctor may not bring up the topic of fertility preservation or low testosterone. You should raise the issue if you have concerns. Here are some questions to ask your doctor:

  • How quickly do I need to start cancer treatment?
  • Will my cancer or its treatment affect my future fertility?
  • What can I do now if I want to have children in the future?
  • Do any of these treatment options make my cancer treatment less effective or raise the chance of a recurrence?
  • May I still bank sperm even if I already started cancer treatment?
  • Will my cancer treatment cause low testosterone? If so, what can I do about it?