During cancer treatment, patients have important and complex issues to consider, including present and future fertility.

During cancer treatment, patients have important and complex issues to consider, including present and future fertility. Because 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.

To begin, patients can ask their oncologist or other treating doctor for a referral to a reproductive endocrinologist. According to Emily S. Jungheim, MD who specializes in reproductive endocrinology and infertility at Washington University in St. Louis, patients should also ask about the possible effects their treatment could have on sexual function, reproductive function, and their future potential for having children. Woman can also ask about the possibility of premature menopause. “The options available for birth control during treatment may also be important for some,” Dr. Jungheim said. “If 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.”

John Lucas, MD, assistant professor of obstetrics and gynecology at Vanderbilt University Medical Center in Nashville, said survival rates for most cancers common to young people are approximately greater than 80% and that one in 250 adults are survivors of a childhood cancer. “Patients about to undergo cancer treatment are; therefore, curious about how treatment will impact future fertility. Surveys indicate that 76% of cancer survivors wish to have children,” Dr. Lucas explained. The 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. Jungheim 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. In 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

Joanne Franke Kelvin, RN, MSN, AOCN, clinical nurse specialist in fertility preservation at Memorial Sloan-Kettering Cancer Center in New York City, advises patients to be prepared when meeting with an oncologist or specialist. “The focus at consultation will be on confirming your diagnosis and determining the best options for treating your cancer,” Kelvin said. But the impact of treatment on your reproductive health can be important, as well.

If you are interested in future fertility, some specific questions you can ask during this meeting include:

• Will my treatment affect my ability to have children in the future?
• Are there steps I can take before beginning treatment to preserve my fertility?
• What are the options available if I decide I want to have children in the future and my treatment may affect that ability?
• How long after treatment should I wait before trying to get pregnant?

Additional questions for women to ask include:

• Is it safe for me to delay my cancer treatment to preserve my fertility?
• Will I be able to carry a pregnancy safely after treatment?
• Will my treatment affect my monthly menstrual cycle or the age at which I develop menopause?

These questions may also be useful for parents of children with cancer to ask.

How Some Treatments Impact Reproductive Health

Cancer treatment may affect reproductive health in a variety of ways; however, it is important to recognize that not all patients encounter fertility problems after treatment. Knowing who will have trouble is difficult. “This 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. Fertility problems that do develop may be temporary or permanent.” Kelvin said.

Kelvin offers a breakdown of reproductive effects based on gender:

For men and/or boys:

• Surgery of reproductive structures may result in erectile dysfunction or retrograde ejaculation, leading to inability to release sperm naturally into the vagina.
• Radiation to the testes and some chemotherapy drugs can impair your ability to produce healthy sperm. You may recover from this after treatment; however, this may take months or even years. Predicting who will regain sperm production and who will not is difficult.
• Radiation or surgery to certain areas of the brain may reduce development of the pituitary gland hormones that stimulate sperm production.

For women and/or girls:

• Surgery may require removal of organs needed to become pregnant or maintain a pregnancy (for example, hysterectomy, removal of ovaries).
• Radiation to the pelvis and some chemotherapy drugs may destroy eggs in the ovary, making it more difficult or impossible to become pregnant. In addition, monthly menstrual periods may stop. Menstruation may start again after some months, but some women develop premature (early) menopause. These women stop ovulating and are not able to become pregnant. Again, predicting who will be affected is difficult.
• Radiation to the pelvis may cause changes in the uterus. As a result, an embryo may not be able to implant, or the uterus may not be able to expand to hold a growing fetus. This can result in complications during pregnancy such as miscarriage, preterm (early) birth, or low birth weight babies.
• Radiation 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.

Fertility Preservation

Men

Kelvin says fertility preservation for men involves collecting and freezing semen before beginning cancer treatment. The sperm can later be thawed and used to fertilize eggs of a partner when they are ready to start a family.

For boys who have not reached puberty, said Dr. Jungheim, testicular tissue banking is available at a handful of centers, but experts do not know how successful this procedure is. It should be done under the guidance of an institutional review board if it is going to be done, she advised.

Women

According to Kelvin, fertility preservation for women involves collecting eggs before beginning cancer treatment, a procedure performed by a reproductive endocrinologist. The standard approach is called embryo freezing (cryopreservation).

She said the first step is to stimulate the ovaries using medication so that multiple eggs will mature. When the eggs have matured, the woman undergoes egg retrieval during an office visit. The eggs are fertilized with sperm to create embryos (in vitro fertilization). The embryos are monitored for several days and then frozen and stored. Embryos can be stored for many years. The embryos can later be thawed and transferred into that woman’s uterus or into the uterus of another woman (or “gestational carrier”).

Kelvin said freezing unfertilized eggs is not currently a standard treatment and is officially considered investigational.

Children With Cancer

Even for young children, options may be available to preserve chances for reproduction, said Dr. Jungheim. For example, ovarian tissue banking is available for pre-pubertal girls, although again there is not a lot of information on how successful this technique is. “If a girl is affected, she may be a candidate at some point for a donor oocyte or donor embryo. If 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. Jungheim 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.

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