How does cancer therapy efect fertility?

In a woman of reproductive age, one of the two ovaries begins to

develop 15-2 immature eggs !oocytes" within follicles !cells
which support its development" every month# $nly one of these
oocytes is permitted to fully develop and become a mature oocyte
!the rest die", at which point it is released into the fallopian tube
for possible fertili%ation in the uterus# & woman has a limited
number of oocytes in her lifetime, with the highest number being
present prior to birth !about ' million at ' months gestation"# (his
number then slowly decreases from appro)imately 2 million at
birth, to menopause, when appro)imately only 1, oocytes
remain and stop maturing# $ver a lifetime, appro)imately *-
5 mature oocytes are released into the fallopian tubes# If the
immature oocytes stored within the ovary are damaged by cancer
treatment, fertility is at ris+# ,amage can be to the undeveloped
oocytes or to the follicles re-uired to develop them# In addition, a
woman needs to be able to carry a pregnancy to term# ,amage to
the uterus or cervi) can compromise this ability#
It is important to understand that chemotherapy wor+s by +illing
rapidly dividing cells# .hemotherapy is able to destroy large
numbers of cancer cells because they are rapidly dividing and
abnormally reproducing# /any other cells in our bodies are also
constantly dividing, including those lining the gastrointestinal
tract, hair follicles, and germ cells !including sperm and oocytes
or eggs"# 0ecause these cells also become targets, we see side
efects related to their destruction, such as diarrhea, mouth sores,
hair loss, and infertility, respectively#
$ne other piece to the pu%%le is the pituitary gland, located in the
brain# (his gland produces special hormones !1H and 23H", which
in turn stimulate the ovary to develop and release a mature
female oocyte# 4adiation therapy to the brain can damage the
pituitary gland, ultimately afecting the ovulation cycle, which
may then result in a shorter luteal phase !days after ovulation
during which fertili%ation occurs"# (his can usually be 5)ed with
supplemental hormones#
.hemotherapy and fertility
6redicting the ris+ of infertility to each individual is often
impossible# 4is+ is dependent on the drug!s" used, dosage
received, duration of use, and the woman7s age at the time of
administration# 4arely does a person receive only one
chemotherapy agent, and combining various agents ma+es
predicting fertility a greater challenge# Higher doses and longer
duration of treatment cause the highest ris+ of infertility# $lder
age at time of administration leads to a higher li+elihood of
infertility and amenorrhea !loss of menstruation"# &s age
increases, smaller doses of chemotherapy are needed to result in
infertility#
2ertility loss is also dependent on the si%e of the follicle pool !or
number of oocytes" prior to chemotherapy# 8iven that this
number decreases with age, the older the woman, the higher the
ris+ of infertility becomes, because there are fewer oocytes at the
outset# 9nfortunately, there is no way to +now for certain how
many oocytes a woman has at any point in life, although some
tests can estimate this number# &ge can act as a guideline, but it
is not an e)act science# !3ee assessment of ovarian function
below" 2or e)ample, a study of amenorrhea in breast cancer
survivors who received cyclophosphamide, methotre)ate, and
:uorouracil !./2" found that ;5-*< of women under age * did
not regain menses, but as many as =->5< of those over * did
not# (his means that somewhere between 5 and 2< of women
over * ,I, regain menstruation, even though they were not
e)pected to do so#
/any studies loo+ at the resumption of the menstrual cycle as a
predictor of fertility# &lthough pregnancy can not occur without
resumption of menses, menstruation alone is not a guarantee of
fertility# 3ome studies have reported pregnancy rates in survivors,
but it is di?cult to +now how many were actually attempting to
conceive# $ne must also consider other variables, including rates
of intercourse, partner fertility issues, cancer therapies received,
and time since therapy# @omen who do regain menses after
therapy are still at ris+ of entering menopause earlier than women
who did not have chemotherapy or radiation#
@ith all of this in mind, we +now that the group of chemotherapy
agents called al+ylating agents poses the greatest ris+# (hese
include cyclophosphamide, ifosfamide, 0.A9, ..A9,
chlorambucil, melphalan, and busulfan# 3ome agents +nown to
have a low ris+ of infertility are vincristine, methotre)ate, and
:uorouracil !5-29"# (here is not enough data on newer agents,
including ta)anes and targeted therapies, to address fertility after
these agents# (herapies used in preparation for stem cell and
bone marrow transplant are li+ely to cause infertility in women,
although studies have found that pre-pubescent girls treated for
childhood cancers have a good chance of regaining ovarian
function# (ransplant regimens utili%ing busulfan andBor
cyclophosphamide are more to)ic to a woman7s fertility than
those utili%ing melphalan#
4adiation (herapy and 2ertility
,amage to fertility caused by radiation therapy is dependent on
the dosage received, area of the body treated, and the woman7s
age at time of treatment# &s with chemotherapy, the si%e of the
follicle pool before treatment is directly related to the number of
oocytes remaining after therapy# Counger women are more li+ely
to have a larger pool and therefore are less li+ely to enter
permanent menopause at the time of therapy# & dose of only 5 or
D 8y can cause ovarian failure in a woman over *, but larger
doses !28y" are re-uired to cause failure in women under ;5# In
women who received 2-; 8y of radiation to the abdomen as
children, >'< e)perienced ovarian failure or developed
menopause earlier than normal !average age at menopause was
2; years in these survivors"# &s a reference, 5 8y is typically
recommended for the treatment of common gynecologic cancers#
Counger women who do regain menses after radiation therapy are
not out of the woods# (hese women are at ris+ of entering
menopause earlier than women who did not have radiation or
chemotherapy# 6redicting when this menopause will occur is
di?cult, putting pressure on younger women who wish to pursue
a natural pregnancy# &s with chemotherapy, women who resume
menses have no guarantee of fertility#
(otal body irradiation !(0I" is a techni-ue used for preparation for
stem cell and bone marrow transplants in which the entire body is
irradiated# It is estimated that =5->< of women who undergo (0I
will have permanent ovarian failure, with only 1-1*< regaining
menses# 6regnancy rates in women who received (0I for
transplant are reportedly around 2< !although as high as 12< in
aplastic anemia survivors"# 8irls who have received (0I prior to
puberty are more li+ely to regain ovarian function than those who
received it post-puberty#
4adiation therapy to the abdomen or pelvis can cause damage to
the uterus andBor cervi), leading to di?culty carrying a pregnancy
to term# 3tudies have found that radiation can cause changes to
the musculature, blood :ow, and si%e of the uterus# (his may
prevent an embryo from implanting# $ther complications that
occur in higher rates in women who received radiation to the
uterus includeE miscarriage !;=< vs# 12< in the general
population", preterm labor !D2< vs# ><", and low birth weight
babies !D2< vs# D<"# ,espite these ris+s, the ris+ of
malformations of the fetus are not increased, so long as radiation
is not given during pregnancy#
3urgery and 2ertility
3urgery that removes both ovaries or the uterus, cervi), andBor
fallopian tubes will afect fertility in some way# ,epending on the
involvement and stage of the cancer, some women may be
eligible for fertility-preserving surgeries and should discuss these
options with their surgeon#
Hormone (herapy
(amo)ifen can temporarily stop or alter menstruation, but this
does not happen in all women# It is possible to become pregnant
while on tamo)ifen, so women should use two forms of birth
control to prevent this# If a woman becomes pregnant while on
tamo)ifen, the drug should be stopped immediately due to the
ris+ for the fetus# In addition, tamo)ifen can alter estradiol and
23H levels, ma+ing it di?cult to assess ovarian function in women
on the drug !see assessment of ovarian function below"#
&ssessment of $varian 2unction after (herapy
/any studies conducted in the oncology community use the
resumption of menses as a measure of ovarian function# 2ertility
e)perts +now this is not a good predictor of fertility, and although
there is no foolproof predictor, there are a few tests that can help
unravel the mystery# 2ollicle stimulating hormone !23H" and
estradiol !F 2 " are hormone levels which can be chec+ed by a
blood test on the ; rd day of menstruation# (hese levels are used
to assess ovarian follicle reserve and fertility# In a menstruating
woman, an 23H above 12mI9 indicates severely impaired fertility,
as does an F 2 level above '5pgBml#
(hese levels, however, cannot predict e)actly how many follicles
remain or how long before infertility will develop# $ne hormone,
anti-/ullerian hormone !&/H", is produced by early follicles and is
a good predictor of the follicle reserve# 9sing ultrasound to count
the number of antral follicles !those oocytes that are maturing" on
the ; rd day of the menstrual cycle can also be a good mar+er of
follicle reserve# (he fraction of follicles maturing is proportionate
to the number that remain# @hile tamo)ifen afects the levels of
23H and F 2, it does not afect the antral follicle count, so may be
useful in predicting future fertility in women ta+ing tamo)ifen#
If a woman still ovulates, is there any danger or ris+ to becoming
pregnant after therapy?
(he concern of possible birth defects caused by e)posure of
oocytes to cancer therapies is a common one# 3tudies have found
no increase in birth defects in the children of cancer survivors, nor
do these children have higher rates of cancer themselves !this
does not include families with genetic cancer syndromes"#
(he ,A& of oocytes can be damaged by cancer therapies, but this
damage repairs itself by si) months after treatment !the e)act
time to repair is un+nown"# 2or this reason, and to get beyond the
highest ris+ of recurrence, women are counseled to wait 2 years
after therapy before becoming pregnant# Individual women should
discuss their own case with their oncology team and may bene5t
from consulting with a fertility specialist who wor+s with cancer
patients#
2or breast cancer survivors, there has always been concern that
pregnancy after treatment could increase the ris+ of recurrence,
particularly in estrogen receptor-positive tumors# 2ew studies
have loo+ed at this ris+, but those that have studied this found
that pregnancy does not appear to increase the ris+ of recurrence#
(hese studies did not ta+e under consideration if the tumors were
F4 or 64 positive, an issue which re-uires more investigation#
3tudies have not e)amined if it is safe for breast cancer survivors
to ta+e fertility medications if they are unable to conceive
naturally#
$ptions for fertility preservation
(here are fewer well established options for fertility preservation
in women compared to in men# (he maGority of techni-ues re-uire
time, resulting in delays in treatment, which may not be possible
for many women# 2or women without a partner or a desire to use
donor sperm, the techni-ues are less reliable# 1et7s review the
available options and some still in development#
Fgg or Fmbryo .ryopreservation
.ryopreservation !free%ing" of eggs or embryos re-uires the same
collection process, which can ta+e 2-* wee+s# 2ertility-stimulating
drugs are given in order to allow the release and collection of
several mature oocytes# (here is concern about women with
potentially hormone-sensitive tumors receiving these drugs#
3tudies are loo+ing at giving an estrogen-bloc+ing drug, such as
tamo)ifen or letro%ole, concurrently with the ovary stimulation to
be safer in these women, and early studies loo+ promising#
2or embryo cryopreservation, the egg must be fertili%ed with
sperm# (his presents a problem for women without a partner or
willing donor# ,onor sperm can be used, but not all women 5nd
this acceptable# (his techni-ue has a pregnancy rate of 2-25<
once the embryo is thawed and implanted# (here is considerable
cost associated with this, ranging from H=-12,, which does not
include the cost of storage !appro)imately H;5Byear", thawing,
and implanting#
.ryopreservation of eggs does not re-uire sperm because these
eggs are fro%en unfertili%ed# 9nfertili%ed eggs are more sensitive
to the free%ing process, and therefore pregnancy rates are much
lower# (here is appro)imately a 2< chance of pregnancy for each
thawed egg# (he costs are essentially the same as embryo
cryopreservation#
$ophorope)y !$varian (ransposition"
(his procedure can be used to decrease the ovaries7 e)posure if
pelvic radiation is needed# (ypically, one ovary is surgically moved
to another area out of the radiation 5eld# (his is often done in
conGunction with a therapeutic surgery for the cancer, but can be
performed laparoscopically for women who do not re-uire other
surgery# (his procedure has been performed for more than *
years, with success rates reported anywhere between 1D and
><# It is thought that damage to the blood vessels feeding the
ovaries and IscatterJ radiation !small amounts of radiation out of
the main 5eld" reaching the ovary may be to blame for lower
success rates# @omen have been able to conceive after this
procedure, but in some cases a second procedure is needed to
return the ovary to its normal location, particularly when in-vitro
fertili%ation is needed# (he cost for oophorope)y is uncertain, but
if it is done during a cancer surgery, there may be very little cost
associated with it#
$varian (issue 2ree%ing
$varian tissue free%ing is still in the investigational stages, with
only a few live births reported to date# $ne potential advantage
for this techni-ue is that it may be an option for young girls who
have not reached puberty when receiving cancer therapy# 9sing a
laparoscopic techni-ue, multiple fragments of ovarian tissue are
ta+en prior to the start of therapy# It is reported that 5 tissue
fragments can yield ;5 follicles, which is necessary since up to
D< of follicles are lost to the free%ing process#
(here are several possible ways to utili%e this tissue# $varian
tissue can be implanted bac+ into the woman !called auto-
transplant", either orthotopically !in the same location it was
ta+en from" or heterotopically !in a diferent location, for e)ample,
the forearm"# &fter implantation, the tissue matures and oocytes
can be collected and utili%ed through in-vitro fertili%ation
procedures# (his is the only tissue-preserving method that has
produced live human births to date#
&nother techni-ue being tested is )enotransplantation, where the
ovarian tissue is implanted in another species !usually mice" and
allowed to mature, leading to obvious ethical concerns# (he last
and most promising option is in vitro maturation, which matures
the tissue in the laboratory, then utili%es the mature oocytes for
fertili%ation and implantation into the woman# (his techni-ue has
lead to live births in mice and cows, but not in humans yet#
/any fertility clinics ofer ovarian tissue free%ing, but woman
should be aware of the investigational nature and lac+ of proven
success of this techni-ue#
4adical (rachelectomy K .onservative 3urgery
4adical trachelectomy is a procedure used in the treatment of
cervical cancer, as an alternative to the more standard surgical
treatment of hysterectomy# It is estimated that almost 5< of
women diagnosed with cervical cancer under the age of * are
eligible for some type of fertility-sparing procedure#
(rachelectomy removes the cervi) but leaves the uterus intact,
and is best applied to early stage cases !stages I& and I0"# It can
be performed vaginally or through the abdomen# (here is an
estimated 5;< chance of pregnancy over 5 years for women who
have had the procedure, and there have been over 1 live births
to date# (hese women will re-uire cerclage !a techni-ue to stitch
the uterus closed to prevent premature birth or miscarriage"#
(here is still a ris+ of premature deliveries or late miscarriages,
and women may re-uire IL2 because of di?culty getting pregnant
due to the lac+ of a cervi)# (hese pregnancies are considered
high-ris+, and will re-uire .-sections due to the cerclage and the
lac+ of a cervi)# Ao randomi%ed studies e)ist, but recurrence rates
appear to be similar in women who have undergone
hysterectomy#
&nother conservative surgical approach for cervical cancer is cone
e)cision, which removes only a portion of the cervi), and is only
appropriate in very early stage cases# 2or very early stage
endometrial cancers, ,K. may be su?cient, but these cases
re-uire careful e)amination and an e)perienced physician for
successful outcomes# 3everal small studies used hormone therapy
to treat early stage endometrial cancers# (hese studies closely
followed the women for recurrence and performed hysterectomy
if needed# (hey reported that some patients had no evidence of
disease after treatment with hormone therapy and documented
pregnancies in 2 patients# In cases of ovarian cancer limited to
one ovary, it may be possible to maintain the healthy ovary and
uterus# 3tudies have reported survival rates similar to those
treated with more radical surgery# (hese options are clearly
limited to only early stage disease, but can be a wonderful option
in those women with early stage disease wanting to preserve
fertility#
$ther (echni-ues
$ne other method that has been tested is +nown as
gonadoprotection# (his wor+s on the theory that germ cells are
damaged by chemotherapy because they are rapidly dividing and
reproducing# 0y administering medication to stunt the
reproduction of these cells, perhaps they would be protected from
the damage of chemotherapy# Investigators have attempted to do
this with gonadotropin-releasing hormone !8n4H" agonists and
antagonists or birth control pills# 3tudies have had mi)ed results
and were small, ma+ing it hard to apply the results# 1arger
randomi%ed studies are loo+ing at these techni-ues#
2inancial Issues
2ertility-preserving techni-ues for women come at a sometimes
signi5cant cost# (he maGority of patients will not have coverage
for fertility-sparing procedures through their health insurance#
Fleven states now re-uire insurance companies to cover infertility
diagnosis and treatment, but this still does not always cover all of
the necessary tests and procedures# (he Aational Infertility
&ssociation has a website that includes up-to-date information on
each state7s laws# @omen should tal+ to their insurance
companies or human resource representatives to e)plore what is
covered#
3haring Hope is a program administered by 2ertile Hope that
ofers discount rates for cancer patients at participating fertility
clinics# 2ertile Hope also has a section on 5nancial options for
fertility preservation# @omen should understand that rates can
vary greatly and it may be worth shopping around# (his might be
a Gob to give to a friend who ofers to help, as it can be a time-
consuming efort#
(he 2uture
@e have a long way to go in helping women facing cancer
therapy to preserve their fertility# (he future may see advances in
tissue cryopreservation or new techni-ues to protect the ovaries
and gynecologic organs from the damage of current therapies# &
5rst step is ma+ing sure women +now the options currently
available to them, which is unfortunately not always done#
3ome (erminology
&menorrheaE an absence of menstruation or periods
&ntral 2ollicleE 5nal stage of growth of the oocyte
.ryopreservationE free%ing at e)tremely low temperatures to
preserve something !-1>5 degrees .elsius in this case"
2ollicleE :uid-5lled sac in the ovary that nurtures the developing
oocyte
2ollicle or oocyte poolE number of follicles or oocytes remaining
in the ovary
2ollicle reserveE number of remaining follicles, this naturally
decreases with age
8CE 8ray, international unit of absorbed radiation dose
$ocyteE an unfertili%ed egg
$varian failureE a condition in which the ovaries stop wor+ing,
resulting in decrease in hormone production, and cessation of
menses and ovulation#
---
How cancer treatments can affect fertility in women
A lot of things must take place for a couple to make a baby, and a system malfunction at any point can lead to
infertility. Cancer, or more often cancer treatments, can interfere with some part of the process and affect your
ability to have children. Different types of treatments can have different effects.
.hemotherapy
(argeted and biologic !immune" therapies
0one marrow or stem cell transplant
4adiation therapy
3urgery
$ther treatments
Chemotherapy
Most chemotherapy or chemo! drugs can damage a woman"s eggs and#or affect fertility. $emember a woman is
born with all the eggs she will ever have and they"re stored in her ovaries.! %he effect will depend on the woman"s
age, the types of drugs she gets, and the drug doses. %his makes it hard to predict if a woman is likely to be fertile
after chemo.
%he chemo drugs most likely to cause egg damage and infertility are&
0usulfan
.arboplatin
.armustine !0.A9"
.hlorambucil
.isplatin
.yclophosphamide !.yto)an
M
"
,acarba%ine
,o)orubicin !&driamycin
M
"
Ifosfamide
1omustine !..A9"
/echlorethamine
/elphalan
6rocarba%ine
(emo%olomide
'n the other hand, the chemo drugs that have a low risk of damaging the eggs include&
5-:uorouracil !5-29"
0leomycin
.ytarabine
,actinomycin
,aunorubicin
2ludarabine
8emcitabine
Idarubicin
/ethotre)ate
Linblastine
Lincristine
%alk to your doctor about the chemo drugs you will get and the fertility risks that come with them. (f you"d like
more information on a drug used in your treatment or a specific drug mentioned in this section, see our Guide to
Cancer Drugs , ask a member of your health care team, or call us with the names of the medicines you"re taking.
Chemo and pregnancy
Age makes a difference: )omen who are treated for cancer before they are *+ have the best chance of becoming
pregnant after treatment. ,oung women who stop having menstrual periods during treatment often start having
periods again after they are off chemo for a while.
After chemo, fertility may not last as long: -irls who had chemo before puberty the time when periods begin! or
young women whose menstrual periods start back after chemo are at risk for early premature! menopause. )hen a
woman stops having periods long before the average age about +.!, it"s considered premature menopause. /he
becomes infertile because her ovaries stop releasing eggs. 0arly menopause also means that the ovaries stop making
the female hormones estrogen and progesterone.
Periods dont always mean fertility: 0ven if a woman"s periods start back after cancer treatment has stopped, her
fertility is still uncertain. 1sually some eggs are destroyed by cancer treatment. ,ou may need a fertility e2pert to
help you find out if you are fertile.
Avoid getting pregnant during chemo: Many chemo drugs can hurt a developing fetus, causing birth defects or
other harm. ,ou might be fertile during some types of chemo, so you"ll need to use very effective birth control. %alk
with your doctor about this.
It can harm the baby if you get pregnant too soon after chemo: )omen are often advised not to get pregnant
within the first 3 months after chemo because the medicine may have damaged the eggs that were maturing during
treatment. (f a damaged egg is fertili4ed, the embryo could miscarry or develop into a baby with a genetic problem.
/tudies about this are hard to find. %his is something you should talk to your doctor about before trying to become
pregnant.
/ee Understanding Chemotherapy: A Guide for Patients and Families for more information on chemotherapy.
Targeted and biologic (immune) therapies
%argeted drugs attack cancer cells differently from standard chemo drugs. 1se of these medicines has increased a lot
in recent years, but little is known about their effects on fertility or problems during pregnancy.
5evaci4umab Avastin
6
! is one e2ception 7 studies have found that this drug can cause ovarian failure, and some
women"s ovaries never recover.
Another group of drugs that are of concern are targeted drugs called tyrosine kinase inhibitors %8(s! such as
imatinib -leevec
6
!, which cause birth defects in lab animals. At this time the recommendation is that women talk to
their doctors before becoming pregnant while taking %8(s.
/ee Targeted Therapy and mmunotherapy to learn more about these cancer treatments.
Bone marrow or stem cell transplant
5one marrow or stem cell transplant usually involves high doses of chemo and sometimes radiation to the whole
body before the transplant. (n most cases, this permanently stops a woman"s ovaries from releasing eggs. %alk with
your doctor or nurse about this risk before starting treatment. /ee the Chemotherapy above! and $adiation
therapy below! sections for more on these parts of the transplant.
(f you"d like to learn more about transplants, see !tem Cell Transplant "Peripheral #lood$ #one %arrow$ and Cord
#lood Transplants&.
Radiation therapy
$adiation treatments use high9energy rays to kill cancer cells. %hese rays can also damage a woman"s ovaries. :or a
woman getting radiation therapy to the abdomen belly! or pelvis, the amount of radiation absorbed by the ovaries
will determine if she becomes infertile. ;igh doses can destroy some or all of the eggs in the ovaries and might
cause infertility or early menopause.
0ven if the radiation is not aimed right at the ovaries, the rays can bounce around inside the body and might still
damage the ovaries.
)hen radiation is directed inside the vagina, the ovaries absorb a high dose of radiation.
$adiation to the uterus can cause scarring, which restricts fle2ibility and blood flow to the uterus. %hese problems
can limit the growth and e2pansion of the uterus during pregnancy, and increase the risk of miscarriage, low9birth
weight infants, and premature births.
/ometimes radiation to the brain affects the pituitary gland. %he pituitary gland normally signals the ovaries to make
hormones, so interfering with these signals can affect ovulation the release of eggs from the ovaries!. %his might or
might not affect fertility depending on the focus and dose of the radiation.
,ou may be fertile when you start getting radiation treatments, but it"s important not to become pregnant until
treatment is completed because radiation can harm the fetus. %alk with your doctor about this.
,ou can get more details about this type of treatment in Understanding 'adiation Therapy: A Guide for Patients
and Families.
Surgery
/urgery on certain parts of the reproductive system can cause infertility. :or some cancers, a hysterectomy is part of
the treatment. A hysterectomy is surgery to remove the uterus womb! either through the vagina or through a cut
made in the abdomen belly!. 'nce the uterus is removed, a woman cannot carry a child.
%he ovaries might be removed called an oophorectomy! at the same time the uterus is taken out. )ithout ovaries, a
woman can"t get pregnant because she no longer has any eggs. (n some women with early stage ovarian or cervical
cancer, the surgeon will try to save one ovary, if possible, to preserve eggs, which might still allow a woman to
become pregnant. 8eeping at least one ovary also preserves the hormones that prevent menopause symptoms like
hot flashes and vaginal dryness.
/ome women with small cervical cancers can have a surgery called a trachelectomy, which removes the cervi2 but
leaves the uterus behind so a woman can carry a pregnancy. /ee $adical trachelectomy in the section <reserving
fertility in women with cancer.!
/ometimes surgery can cause scarring in the fallopian tubes. %hese scars may block the tubes and prevent eggs from
traveling to meet the sperm. %his means they can"t become fertili4ed and move on to the uterus to implant in the
lining.
Understanding Cancer !urgery: A Guide for Patients and Families gives you more information on surgery as a
cancer treatment.
Other treatments
;ormone therapies used to treat breast cancer or other cancers can affect your ability to have a child. %he effect of
some other treatments on fertility and pregnancy is not yet known. (t"s always best to talk to your doctor, nurse, or
other member of your health care team about your treatment and any possible effects on your se2ual function and
fertility.
--
Cancer and ertility
During cancer treatment, patients have important and comple2 issues to consider, including
present and future fertility. 5ecause many cancer treatments can damage future fertility, patients
who are or will be at a childbearing age or parents of children with cancer! should ask their
cancer care team about the possible impact treatment might have on their ability to have children
so they can discuss their options.
%o begin, patients can ask their oncologist or other treating doctor for a referral to a reproductive
endocrinologist. According to 0mily /. =ungheim, MD who speciali4es in reproductive
endocrinology and infertility at )ashington 1niversity in /t. >ouis, patients should also ask
about the possible effects their treatment could have on se2ual function, reproductive function,
and their future potential for having children. )oman can also ask about the possibility of
premature menopause. ?%he options available for birth control during treatment may also be
important for some,? Dr. =ungheim said. ?(f the patient is interested and is a candidate for fertility
preservation options, they should ask about the risks of these treatments, what is known about
the success of these treatments, and the costs.?
=ohn >ucas, MD, assistant professor of obstetrics and gynecology at @anderbilt 1niversity
Medical Center in Aashville, said survival rates for most cancers common to young people are
appro2imately greater than BCD and that one in E+C adults are survivors of a childhood cancer.
?<atients about to undergo cancer treatment are therefore curious about how treatment will
impact future fertility. /urveys indicate that F3D of cancer survivors wish to have children,? Dr.
>ucas e2plained. %he impact of cancer treatment is affected by the age of the patient, the
chemotherapy drugs or agents and dosages used, and the underlying cancer itself, he added.
Dr. =ungheim said that because of the different variables that must be considered, patients should
be referred to reproductive specialists who can collaborate with the oncologists and other
members of the cancer treatment team. (n addition to the types of chemotherapy used, patients
and their doctors must also consider surgical or radiation therapies when discussing how
treatment will specifically affect reproductive health.
A Starting Point
=oanne :ranke 8elvin, $A, M/A, A'CA, clinical nurse specialist in fertility preservation at
Memorial /loan 8ettering Cancer Center in Aew ,ork City, advises patients to be prepared when
meeting with an oncologist or specialist. ?%he focus at consultation will be on confirming your
diagnosis and determining the best options for treating your cancer,? 8elvin said. 5ut the impact
of treatment on your reproductive health can be important, as well.
(f you are interested in future fertility, some specific Guestions you can ask during this meeting
include&
@ill my treatment afect my ability to have children in the
future?
&re there steps I can ta+e before beginning treatment to
preserve my fertility?
@hat are the options available if I decide I want to have
children in the future and my treatment may afect that
ability?
How long after treatment should I wait before trying to get
pregnant?
Additional Guestions for women to ask include&
Is it safe for me to delay my cancer treatment to preserve
my fertility?
@ill I be able to carry a pregnancy safely after treatment?
@ill my treatment afect my monthly menstrual cycle or the
age at which I develop menopause?
%hese Guestions may also be useful for parents of children with cancer to ask.
How Some Treatments mpact Reproducti!e Health
Cancer treatment may affect reproductive health in a variety of waysH however, it is important to
recogni4e that not all patients encounter fertility problems after treatment. 8nowing who will
have trouble is difficult. ?%his depends on the type of surgery performed, the type and dose of
chemotherapy received, and the dose of radiation delivered and the area of the body that is
irradiated. :ertility problems that do develop may be temporary or permanent.? 8elvin said.
8elvin offers a breakdown of reproductive effects based on gender&
:or men and#or boys&
3urgery of reproductive structures may result in erectile
dysfunction or retrograde eGaculation, leading to the inability
to release sperm naturally into the vagina#
4adiation to the testes and some chemotherapy drugs can
impair your ability to produce healthy sperm# Cou may
recover from this after treatmentN however, this may ta+e
months or even years# 6redicting who will regain sperm
production and who will not is di?cult#
4adiation or surgery to certain areas of the brain may reduce
development of the pituitary gland hormones that stimulate
sperm production#
:or women and#or girls&
3urgery may re-uire removal of organs needed to become
pregnant or maintain a pregnancy !for e)ample,
hysterectomy, removal of ovaries"#
4adiation to the pelvis and some chemotherapy drugs may
destroy eggs in the ovary, ma+ing it more di?cult or
impossible to become pregnant# In addition, monthly
menstrual periods may stop# /enstruation may start again
after some months, but some women develop premature
!early" menopause# (hese women stop ovulating and are not
able to become pregnant# &gain, predicting who will be
afected is di?cult#
4adiation to the pelvis may cause changes in the uterus# &s
a result, an embryo may not be able to implant, or the
uterus may not be able to e)pand to hold a growing fetus#
(his can result in complications during pregnancy such as
miscarriage, preterm !early" birth, or low birth weight babies#
4adiation or surgery to certain areas of the brain may reduce
development of pituitary gland hormones that stimulate the
ovaries each month, disrupting the monthly menstrual cycle
and interfering with ovulation#
"ertility Preser!ation
#en
8elvin says fertility preservation for men involves collecting and free4ing semen before
beginning cancer treatment. %he sperm can later be thawed and used to fertili4e eggs of a partner
when they are ready to start a family.
:or boys who have not reached puberty, said Dr. =ungheim, testicular tissue banking is available
at a handful of centers, but e2perts do not know how successful this procedure is. (t should be
done under the guidance of an institutional review board if it is going to be done, she advised.
$omen
According to 8elvin, fertility preservation for women involves collecting eggs before beginning
cancer treatment, a procedure performed by a reproductive endocrinologist. %he standard
approach is called embryo free4ing cryopreservation!.
/he said the first step is to stimulate the ovaries using medication so that multiple eggs will
mature. )hen the eggs have matured, the woman undergoes egg retrieval during an office visit.
%he eggs are fertili4ed with sperm to create embryos in vitro fertili4ation!. %he embryos are
monitored for several days and then fro4en and stored. 0mbryos can be stored for many years.
%he embryos can later be thawed and transferred into that woman"s uterus or into the uterus of
another woman or ?gestational carrier?!.
8elvin said free4ing unfertili4ed eggs is not currently a standard treatment and is officially
considered investigational.
Children $ith Cancer
0ven for young children, options may be available to preserve chances for reproduction, said Dr.
=ungheim. :or e2ample, ovarian tissue banking is available for pre9pubertal girls, although again
there is not a lot of information on how successful this techniGue is. ?(f a girl is affected, she may
be a candidate at some point for a donor oocyte or donor embryo. (f a young girl has radiation
therapy to her pelvis, it may affect the function of her uterus and she may need a gestational
carrier when she is ready for childbearing,? Dr. =ungheim said.
As the effects on reproduction of some new treatments are still unfolding, and as investigational
options for fertility preservation may become available or more established, it is important first
and foremost to discuss this topic with your cancer care team.