Podcast: Cancer Treatment & Fertility Preservation
Preserving Fertility Before Treatment
Patients' fertility can be affected both during cancer treatment – when an unplanned pregnancy could be a serious problem – and later, if the cancer treatment causes infertility. For patients who want to have children, this can be devastating.
It is important to know that you should prevent pregnancy during chemotherapy or radiation treatment and for at least six months after treatment. Although cancer treatment may lower a man's sperm count or cause a woman's menstrual period to stop, a pregnancy may still be possible. Talk to your doctor or nurse about the best method of birth control for you.
Chemotherapy drugs and radiation to the pelvis cause genetic changes in sperm and oocytes (eggs). Embryos with genetic damage often miscarry early in pregnancy. There is also a risk of having a baby with a birth defect, but so few babies have been conceived during cancer treatment that no statistics exist on the risk of birth defects.
If a woman is pregnant and her husband is having chemotherapy, using a condom will keep the medicines from reaching the fetus through intercourse. Also, during the first few days after having radioactive seed implants for prostate cancer, men may ejaculate a radioactive seed in their semen. The doctor can advise when it is safe to resume intercourse and whether to use a condom.
By six to 12 months after cancer treatment, the sperm that were exposed to chemotherapy or radiation have all been ejaculated. Eggs that are healthy enough to be ovulated are also more likely to be undamaged. In fact, both the eggs and the stem cells that produce sperm have some ability to repair genetic damage during the first several years after cancer treatment. However, genetic damage is common in human embryos, even when neither parent has had cancer treatment. A third of very early pregnancies miscarry because the embryo had genetic damage, often without a woman ever realizing she was pregnant.
If a woman already is pregnant at the time of cancer diagnosis, she may be able to continue the pregnancy and have a healthy baby even if she needs chemotherapy, particularly if the pregnancy is past the first three months when most organs are formed. This situation occurs occasionally in young women with breast cancer.
Causes of Infertility
Cancer treatment can interfere with fertility in many ways, as the medicines and treatments that work to kill cancer cells also affect other cells, organs and hormones in the body. Since every patient is different, your doctor may not be able to predict whether your cancer treatment will make you infertile. The effects from cancer treatment may be temporary or permanent. If fertility does recover, it won't necessarily happen right away.
Fertility after cancer treatment will be affected by age at the time of cancer treatment, especially for women; type of treatment; the type and dose of chemotherapy drugs used; amount and target area of radiation; type and extent of surgery; whether one or multiple cancer treatments are used; and how long treatment lasts.
Causes of Infertility in Women
Some cancer treatments, such as a hysterectomy, cause permanent infertility in women at any age. Total body irradiation causes very high rates of infertility, but a few young women have had babies afterward.
Another cause of infertility in women is premature ovarian failure, which is when menopause occurs before a woman is 40. Premature ovarian failure happens when both ovaries are surgically removed, and may also occur if the ovaries are damaged by chemotherapy. High-dose chemotherapy is more destructive than lower doses. Chemotherapy with alkylating agents, such as cyclophosphamide, is very toxic and can directly damage the ovaries. Radiation to the ovaries also can be damaging, resulting in temporary or permanent menopause.
Younger women and those who had lower doses of chemotherapy or radiation therapy are more likely to regain menstrual periods, though they may not occur regularly. Women over 35 are less likely to recover their fertility. This may be because a woman in her 30s has fewer eggs in reserve, so a larger percentage of eggs are destroyed. However, even young women are at risk for early infertility and menopause because eggs in the ovaries may be damaged or killed by cancer treatment.
Causes of Infertility in Men
Cancer treatment can cause temporary or permanent infertility in men, too. Men begin producing sperm cells at puberty and continue to be fertile the rest of their lives. To produce permanent infertility, a cancer treatment must eliminate all stem cells in the testicles that produce new, mature sperm cells. This can happen if both testicles are removed, if the testicles get a high dose of radiation, or if very high doses of alkylating chemotherapy drugs are given. Men with testicular cancer, who are typically young, are likely to be infertile before they are diagnosed with cancer, but about half recover good fertility despite having a testicle removed and undergoing chemotherapy.
Preserving Fertility in Women
There are several ways to try to preserve fertility in women, but most remain experimental, with unknown success rates. Some options are not appropriate for certain patients, depending on the type of cancer.
Embryo Freezing: Eggs are removed from the patient and fertilized in a test tube with the sperm of a partner or donor. The resulting embryos are then frozen and stored. It takes about two weeks from the start of a woman's menstrual cycle to get eggs to use for in vitro fertilization; waiting may be a problem with a fast-growing cancer like acute leukemia. Also, the hormones given so that more than one of a woman's eggs will ripen may stimulate breast cancer cells to grow, so researchers are trying to use different hormone combinations to make hormonal stimulation safer. Another option would be to simply harvest the one egg that ripens in a natural menstrual cycle, but the chance that the egg will fertilize, survive freezing and produce a live birth when transferred to the woman's uterus is less than 10%. Insurance rarely covers these procedures, and they often cost $5,000 to $8,000.
Some women opt to have the eggs frozen unfertilized, particularly if they are not in a committed relationship. Later, the eggs can be thawed and in vitro fertilization attempted. Egg-freezing remains experimental and has resulted in fewer than 200 live births around the world.
Some women have parts of their ovaries removed surgically and frozen before cancer treatment. Although some centers are banking ovarian tissue before cancer treatment, this technique is still experimental and has resulted in only a few pregnancies worldwide.
For women receiving chemotherapy, one option may be to take a hormone that puts the ovaries into temporary menopause during treatment. However, many infertility specialists doubt that the hormones truly prevent the chemotherapy from damaging the ovaries. The hormone shots are expensive, and it is possible that they could have some impact on the success of chemotherapy.
For women receiving radiation treatment, it may be possible to move the ovaries out of the radiation area surgically. Sometimes they can be relocated at the sides of the pelvis, out of the radiation target field. There is a 50% chance that women will resume menstruating after this procedure.
Other options for becoming a mother after cancer treatment include using donor embryos or eggs, having a surrogate (where another woman carries the child), or adoption.
Preserving Fertility in Men
Fertility preservation is much easier, cheaper and more effective for most men. It simply involves collecting a sample of semen and freezing it. Sperm must be banked before any chemotherapy or pelvic radiation therapy begins in order to avoid storing damaged sperm. The sperm can be thawed later and used for intrauterine insemination or in vitro fertilization.
Many young men diagnosed with cancer have poor sperm quality because of the illness, recent anesthesia or stress. Even if a man has only a few live sperm in his semen, they can be used for in vitro fertilization to provide a good chance of pregnancy. In this situation, when the sample is thawed, the healthiest sperm are captured and injected into the woman's harvested eggs using a robotic microscope in the laboratory.
Insurance generally does not cover the cost of the sperm banking, and storing one ejaculate for five years averages around $500. Some sperm banks have special payment plans for cancer patients. For men who no longer ejaculate semen but would like to bank sperm, a urologist may be able to collect sperm from the storage areas above the testicles or even from tissue inside the testicles with outpatient surgery.
Recovery of Fertility After Cancer Treatment
For some people, fertility does return after cancer treatment. However, it may take a long time.
For women, the return of menstruation may or may not signal fertility, but getting blood tests for hormones and other tests performed by an infertility specialist can give a better answer.
Women who have had chemotherapy or have had radiation treatment to the pelvic or abdominal area should consult an obstetrician before trying to get pregnant, to make sure that their heart, lungs and uterus are healthy enough to avoid pregnancy complications. For example, when a girl or young woman has radiation that includes the uterus, it is important to know whether the uterus is normal in size and can expand enough during pregnancy.
Men often have low sperm counts or motility (movement) at the time their cancer is diagnosed, but this may improve after treatment. Sperm quality may rise for several years following cancer treatment, depending on the drugs used, the doses and each person's individual recovery. Even though men may produce sperm, the number and motility may not be enough to conceive without some medical help. A semen analysis, in which a man's semen is examined under a microscope, can indicate whether a pregnancy is likely through intercourse, or what type of infertility treatment will be needed. Because each person's situation is different, it is important to talk to your doctor before trying to start a pregnancy.
Questions to Ask Your Doctor
If you wish to have children after cancer treatment, discuss the issue with your doctor as soon as possible. You also may want to talk to a counselor familiar with cancer and fertility to prepare yourself for challenges and decisions.
Here are some questions you may want to ask:
Is there anything that can be done before starting my cancer treatment to increase the likelihood that I will be able to have children?
I am interested in freezing eggs or embryos. Is this an option for me? Could you please give me more information?
I am interested in sperm banking. Is this an option for me? Could you please give me more information?
I stopped having my period, but could I still get pregnant? Should I be using birth control?
For how long will we need to prevent pregnancy during cancer treatment? Are condoms the best method for us?
My partner is pregnant. Is there any special reason to avoid sex during my cancer treatment?
Will my cancer treatment cause me to be infertile? Do you expect this to be temporary or permanent?
Now that my cancer treatment has ended, I would like to have children. Is it OK for us to try to become pregnant?
We have been trying to get pregnant without success. Should we talk to an infertility specialist?
Fertility preservation using IVF with PGD-M is helping end stomach cancer in my family
When I learned six years ago that I carry a genetic mutation called CDH1, my initial response was anger. I had just gotten married, and my husband and I were looking forward to starting a family. That discovery put a serious monkey wrench in our plans.
But the mutation was bad news not only because it significantly increased my own risk of developing breast and stomach cancers. It also meant that any children we might have could share in this terrible legacy. That thought was really hard to accept.
My risk of developing stomach cancer was so high that the recommended course of action was to have my stomach surgically removed, even if I didn’t have cancer yet. I put it off at first, but got so tired of worrying about it that I finally had it done at MD Anderson in 2017.
Today, I’m really glad that I did. Because the pathology report showed early cancer cells were already present in my stomach. And having the surgery first gave me time to learn about IVF with PGD-M. That has enabled my husband and me to protect both our unborn son and any future children we might have from CDH1 — and to give my family some peace of mind.
Exploring our options leads to IVF with PGD-M
My surgeon, Dr. Paul Mansfield, wanted to make sure I’d completely recovered from my gastrectomy before trying to conceive. So, I waited about 18 months to reach out to MD Anderson’s Oncofertility Consult Service.
There, I met with Dr. Terri Woodard, who told me about the various options available to start a family. One was IVF with PGD-M (in-vitro fertilization with preimplantation genetic testing for monogenic or single-gene defects). I had heard of it before, but didn’t really know much about it.
It turns out that PGD-M allows embryos created through IVF to be tested for specific genetic conditions prior to transfer to a uterus. That reduces the chances of passing on defective genes. If we did it, there was at least a chance we could eliminate this threat — both in our children and in generations to come.
Elated to be pregnant with our first child
You might think the decision to proceed with IVF with PGD-M was an easy one. But I had some misgivings about it initially. So, my husband and I prayed about it and talked it over with our family and friends. Ultimately, we decided this was the best way for us to have children.
Once we’d made our decision, we contacted a fertility center close to our home in Michigan. We started working closely with a reproductive endocrinologist, a genetic counselor and various reproductive lab technicians in early 2019. They guided us through the process of egg retrieval and transfer.
First, we completed two rounds of egg retrieval. Then, each egg was fertilized with my husband’s sperm and given time to grow in the lab. Embryos that survived the first five or six days were frozen, and a few of their cells were extracted and sent to a lab in Chicago. Technicians there then tested the cells, looking specifically for the CDH1 mutation and any other chromosomal defects.
Ultimately, three frozen embryos were deemed good candidates for transfer. We transferred the first one on Feb. 25, 2020, and I am now almost six months pregnant with our first child. Our son is due on Nov. 12, 2020, and we could not be more excited.
Why it’s all been worth it
Starting a family this way was not easy. The egg retrieval process alone required hundreds of shots, lots of medication, countless ultrasounds and a bunch of lab work. Being pregnant during the COVID-19 pandemic is no picnic, either.
But knowing that my son will not have CDH1 — and that his risk for cancer will be no higher than the average person’s — means everything to me. Now, I’ll be able to rest easier whenever he throws up or complains of a tummy ache, knowing he isn’t any more likely to develop stomach cancer than any other child. That alone makes it all worth it.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
MD Anderson helped me achieve my family dream after non-Hodgkin lymphoma treatment
In 2016, my husband and I were trying to expand our family. A swollen lymph node almost derailed our plans entirely.
I’d felt the lump in my neck by chance one day, when I rubbed my hand along the underside of my jaw. I thought it was an abscess caused by a failed root canal.
It turned out to be advance stage high grade B cell lymphoma, a subtype of non-Hodgkin lymphoma.
Though grateful not to be pregnant at the time, I was still devastated by the thought of not being able to have more children. I knew certain cancer treatments could leave me infertile, and my husband and I had always planned to have three kids. We were hoping to give our two little boys a sister.
Fortunately, I went to MD Anderson for my non-Hodgkin lymphoma treatment. My doctors there not only gave us hope that we could still have more children — they also gave us options to maximize our chances.
Exploring fertility-preserving options before non-Hodgkin lymphoma treatment
I was already 35 at the time of my non-Hodgkin lymphoma diagnosis, so I wasn’t sure how much my age would affect my fertility. Cancer patients are usually advised to wait at least two years after completing chemotherapy before trying to conceive. That timeline would put me just shy of my 38th birthday.
I wasn’t interested in freezing my eggs, but wanted to explore my options. So my oncologist, Dr. Hun Ju Lee, referred me to reproductive endocrinologist Dr. Terri Woodard to discuss my fertility preservation options. Ultimately, my husband and I decided on one of the least-invasive: leuprolide injections. These are an experimental type of therapy designed to shut down the ovaries, theoretically making them less vulnerable to damage from chemotherapy drugs.
I received the first leuprolide injection in July 2016, a few weeks before starting my chemotherapy infusions. I got a second injection in October 2016.
We waited the full two years before trying for a baby again. Our daughter was conceived just two months later, in February 2019. She was born that November, perfectly healthy.
I knew I was in good hands
My husband and I were pretty surprised that I got pregnant so quickly. But once I did, I felt like this baby was meant to be.
I hadn’t even been sure of what I wanted anymore, family-wise, or what was possible after I finally achieved remission. And I struggled with fears of the physical toll another pregnancy might have on me, as well as any possible risks to the baby, due to my health history.
Still, I knew I was in good hands at MD Anderson. Its doctors have so much experience with cancer. They really have seen all types and kinds. And they also have tremendous research efforts going on, which are helping other cancer patients through clinical trials. I’d been living in Houston for 10 years by the time I was diagnosed with lymphoma, so it felt like I was supposed to be there.
After six cycles of chemotherapy and surgery to remove the affected lymph node, my cancer is still in remission. So, I know MD Anderson was the right choice for me. My family is complete now. And I feel great.
Request an appointment at MD Anderson online or by calling 1-877-632-6789.
Fertility and cancer: 10 things to know
Patients' fertility can be affected both during cancer treatment – when an unplanned pregnancy could be a serious problem – and later, if the cancer treatment causes infertility. For patients who want to have children, this can be devastating. But new advances are giving hope – and options – to patients who want to have children.
Here Terri Woodard, M.D., who leads the MD Anderson Oncofertility Consult Service, answers 10 questions she often gets about fertility and cancer.
1. Can cancer treatment cause infertility?
Some cancer treatments can, while others do not. The most common types of treatments that affect fertility include surgery that involves removal of the reproductive organs, certain types of chemotherapy and radiation to the abdomen and pelvis. We do not know how some newer treatments may affect fertility.
2. How will cancer treatment affect my fertility?
How cancer treatment affects your fertility depends on many things, including the type of treatment you receive, your age and your current fertility status. Some people might be temporarily infertile while others may have permanent infertility. Your doctor can help estimate your individual risk.
3. How long will we need to prevent pregnancy during cancer treatment?
You should abstain or use a reliable form of birth control while you are receiving cancer treatment. You also shouldn’t try to conceive within six months of finishing chemotherapy because it may increase the chances of miscarriage or having a baby with a genetic complication.
4. After cancer treatment, how long should I wait to conceive?
Determining when it is OK to conceive requires thoughtful discussion between you and your health care team. The timing varies between patients and types of cancer. Generally, women should wait at least two years before trying to conceive. This allows enough time for you to get beyond the window of an early cancer recurrence and allows your body to recover from the effects of treatment. If your cancer treatment has caused late effects that might make handling pregnancy more difficult, it may be recommended that you see a maternal-fetal medicine specialist prior to trying to conceive.
5. My partner is pregnant. Is there any reason to avoid sex during my cancer treatment?
Chemotherapy can be excreted in semen and vaginal secretions, so a condom should be used to prevent your partner from being exposed to it. It is possible that exposure could cause fetal abnormalities. If your white blood cell counts or platelet counts are low, your oncologist may advise you to abstain from intercourse because you may be at increased risk for infection or bleeding.
6. What fertility preservation options are available for women preparing for cancer treatment?
There are several different ways that we can preserve fertility for women. The most common and accepted way to do this it to use assisted reproductive technologies (ART) to freeze eggs and/or embryos. For patients who will receive high doses of radiation to the abdomen and pelvis, ovarian transposition is a surgical procedure that moves the ovaries out of the radiation field so that they are not harmed.
Another option is suppressing the ovaries with medication to make them more resistant to the effects of chemotherapy; this is considered experimental.
Freezing ovarian tissue is the only option for girls who have not gone through puberty yet. It is also considered experimental, though children have been born using this method.
7. What fertility preservation options are available for men preparing to undergo cancer treatment?
For men, the most common and accepted way to preserve fertility is to bank sperm before starting cancer treatment.
For boys who haven’t gone through puberty yet, the only option for fertility preservation is to freeze pieces of testicular tissue. This is considered an experimental procedure.
8. I stopped having my period. Could I still get pregnant?
It depends. Some cancer treatments cause women to stop having periods, but this may be temporary or permanent. Thus, a woman may become pregnant if she ovulates (releases an egg) before her periods come back. If her periods stop permanently, she is in premature menopause, and it is highly unlikely that she will become pregnant.
9. What should I ask my doctor about cancer and fertility?
You should ask if your treatment might cause infertility and, if so, what your personal risk is. You should also ask about ways to preserve or protect your fertility before you start treatment. If you would like to learn more, ask your doctor to refer you to a fertility specialist, who can counsel you about your risk and provide fertility preservation treatments. If you’re a patient at MD Anderson, ask for a referral to the MD Anderson Oncofertility Consult Service.
10. When should I talk to my doctor about my fertility?
You should talk to your doctor about your fertility concerns as early as possible in the course of diagnosis and definitely before you start treatment. The earlier you have the conversation, the more options you have if you decide to pursue fertility preservation treatment. However, even if you did not have the opportunity to discuss your concerns prior to treatment, you should still talk to your doctor about them because you can still think about your plans for parenthood after cancer.