Approved by the Cancer.Net Editorial Board, 04/2018
Many cancer treatments affect fertility temporarily or permanently. Fertility is the ability to become pregnant. Infertility is an inability to become pregnant or maintain a pregnancy.
Before treatment begins, talk with your health care team. Ask how treatment could affect your fertility. And ask about your options for preserving fertility.
How cancer treatments affect fertility
Fertility problems from cancer or cancer treatment occur in 2 main ways:
- Damage to organs involved in reproduction, such as the ovaries, fallopian tubes, uterus, and cervix
- Damage to organs involved in hormone production, such as the ovaries
The ovaries store a woman’s eggs. Damage to these organs can decrease the ovarian reserve. The ovarian reserve is the total number of immature eggs in both ovaries. Women are born with all the eggs they will have. Once these eggs are lost, they cannot be replaced. Loss of healthy eggs causes infertility and early menopause.
Cancer treatments that affect fertility
These cancer treatments have known or possible fertility-related side effects:
Chemotherapy. Chemotherapy—particularly drugs called alkylating agents—may affect fertility. These drugs can affect fertility:
- Busulfan (Busulfex, Myleran)
- Carmustine (BiCNU)
- Chlorambucil (Leukeran)
- Cyclophosphamide (Neosar)
- Doxorubicin (Adriamycin)
- Lomustine (CeeNU)
- Mechlorethamine (Mustargen)
- Melphalan (Alkeran)
- Procarbazine (Matulane)
Radiation therapy. Radiation therapy to these body parts may affect fertility:
- The abdomen
- The pelvis
- The lower spine
- The ovaries and areas near the ovaries
- The uterus
- The pituitary gland in the brain
- The entire body, for bone marrow transplantation
Surgery. Surgical removal of these reproductive organs may affect fertility:
- The uterus, in a procedure called a hysterectomy
- The cervix, in a hysterectomy or a procedure called a trachelectomy, which preserves the uterine body
- One or both ovaries, in a procedure called an oophorectomy
Additionally, surgery to remove pelvic lymph nodes may affect fertility.
How to find help with fertility issues
Consider meeting with a reproductive endocrinologist. This is a doctor who specializes in conditions affecting fertility. Some reproductive endocrinologists specialize in cancer-related fertility issues.
Assessing menstruation and fertility after cancer treatment
Women with menstrual periods after cancer treatment may become pregnant. However, menstruation is not proof that you are fertile.
In some women, cancer treatments stop menstrual periods. This is called early menopause. It causes permanent infertility.
Other women’s menstrual periods stop during treatment but return later. Women who have periods after chemotherapy may still have lowered fertility. Even a woman who menstruates during treatment and remains fertile afterward might have lowered fertility or early-onset menopause.
It generally takes longer for older women and those who had higher doses of radiation therapy or chemotherapy to start menstruating again. Also, menstrual cycles are less likely to restart after treatment in these women.
Your health care provider can refer you for ovarian reserve testing. This is tested with sensitive hormonal tests, such as the anti-Müllerian hormone.
Children and younger women have a larger ovarian reserve than older women. They’re less likely to experience immediate menopause and infertility after chemotherapy. However, this does not mean younger women won’t lose their fertility. With radiation therapy to the pelvis and lower abdomen and strong chemotherapy, even children can experience immediate menopause.
Pregnancy after cancer treatment
To become pregnant without reproductive assistance, you need:
- At least one healthy ovary with enough remaining eggs
- One healthy fallopian tube
- A healthy uterus where the baby can grow
- An ideal level of specific hormones
However, your health care team may recommend waiting before trying to become pregnant. The amount of time depends on:
- Type and stage of cancer
- Type of treatment
- Your age
For example, women taking hormonal treatments may need to delay pregnancy.
Delay can further reduce fertility because women lose eggs through aging. If you experience delay, consider fertility-preserving options.
Learn more about having a baby after cancer.
Recommendations for preserving fertility
The American Society of Clinical Oncology (ASCO) recommends that all women with cancer discuss the risk of infertility and fertility preservation options with their doctors as soon as possible before cancer treatment begins. If you are interested in preserving fertility, you should ask for a referral to a reproductive specialist, even if you are unsure whether you want to have children in the future.
The options depend on several factors:
- Relationship status (having a partner who could provide sperm)
- Physical and sexual maturity
- Personal preferences
ASCO’s recommendations for preserving fertility include:
Embryo freezing. This is the most successful method of fertility preservation. It’s also called in vitro fertilization.
A woman takes fertility drugs for about 2 weeks. Then, a member of the health care team collects her eggs. These are fertilized by sperm in a laboratory. The resulting embryos are frozen until later.
Oocyte (unfertilized egg) freezing. This procedure is similar to embryo freezing. However, the eggs are frozen without being fertilized by sperm.
This is an option for women without a male partner. But it is slightly less successful than embryo freezing.
Fertility-preserving surgery. Some types of cervical or ovarian surgery can preserve fertility.
- Surgery for cervical cancer: Sometimes, surgeons can remove the cervix while keeping the uterus. This allows a woman to deliver a baby by C-section. It’s an option for some women with early-stage cervical cancer.
- Surgery for ovarian cancer: Sometimes, surgeons can remove only 1 ovary. It’s an option for some women with early-stage cancer located in 1 ovary. This preserves the healthy ovary for reproduction and prevents early menopause.
Radiation therapy that protects the ovaries. Some women may receive radiation to only 1 ovary. This preserves fertility. Another option is a procedure called an oophoropexy. A surgeon moves 1 or both ovaries where radiation won’t reach them. Then, the surgeon puts them back in place after treatment. However, this method isn’t always successful. Radiation isn’t precise and may still reach the ovaries or the ovarian blood supply.
Ovarian suppression. This is an investigational approach to fertility preservation. It involves taking hormones that suppress ovarian function. This may protect eggs from treatment.
Researchers have not yet demonstrated this strategy’s effectiveness. It’s generally not recommended over other standard fertility preservation options when those are available.
Ovarian tissue preservation. This involves surgically removing and freezing ovarian tissue. Then, the surgeon transplants the tissue after cancer treatment.
This may be the only option for young girls who cannot undergo oocyte or embryo freezing. For example, some girls may lack time or sexual maturity.
Many pregnancies have occurred with this technique, and researchers are continuing to evaluate this option.
Read more about ASCO’s recommendations for preserving fertility, found on ASCO’s website.
Evaluating fertility preservation options
These options for protecting fertility aren’t appropriate for everyone. Consider these factors:
- Health insurance may not cover the cost of fertility-preserving procedures
- Their effectiveness varies
- They may be an added stress in an already stressful time
You may benefit from counseling for fertility-related decisions.
Questions to ask your health care team before treatment
Consider asking your health care team these questions:
- What is the risk of infertility from the recommended treatments?
- Would potential infertility be temporary or permanent?
- Are there other effective treatments that do not pose as high a risk?
- What options do I have to preserve my fertility?
- Will these options postpone the start of my treatment? If so, what effect could this delay have on my chance of recovery?
- Will these fertility preservation options increase the risk that the cancer may come back?
- Should I talk with a fertility specialist or a reproductive endocrinologist?
- What clinical trials are available for me?
- Where can I find support for coping with fertility issues?
- Where can I find help for talking with my partner about fertility?
- How will I know if I am fertile after cancer treatment?
© 2018 American Society of Clinical Oncology. All rights reserved. Retrieved from https://www.cancer.net/navigating-cancer-care/dating-sex-and-reproductio... October 27, 2018. Reprinted with permission.