Hope for the Future
Preserving Fertility in the Face of Cancer
by Laxmi A. Kondapalli, MD, MSCE
With cancer survival rates steadily increasing, what was once considered a “terminal illness” now allows people to imagine a life after cancer with expectations beyond survival. However, some of the new life-saving treatments contributing to increased survival can negatively affect fertility, causing delays in childbearing or even compromising a person’s ability to have children in the future. Fortunately, over the last several decades, the emergence of the medical discipline of oncofertility and the development of new fertility preservation techniques have made the dream of building a biological family a reality for many cancer survivors. With this in mind, it’s important to discuss with your oncologist the possibility of infertility and ask about your fertility preservation options as early in the treatment planning process as possible.
How does cancer treatment affect fertility?
Women are born with all the oocytes (eggs) they will have in their lifetime. A woman’s ovary contains thousands of follicles, called the ovarian reserve, and each follicle contains a single egg. During each menstrual cycle, a group of immature follicles begins to grow, but only one goes on to fully develop and release its egg during a process called ovulation. The number of follicles in the ovarian reserve naturally declines with age, but cancer treatments like chemotherapy and radiation can destroy the follicles in the ovary, accelerating the natural decline of the ovarian reserve. As a result, some women may face temporary or early menopause.
For women who have gone through puberty, the established methods for fertility preservation are embryo and oocyte banking.
Some chemotherapy drugs only affect developing follicles and the eggs inside them. Therefore, a woman may stop her menstrual cycle during treatment, but because she still has immature follicles in her ovarian reserve, she may start having her period again when treatment ends. However, other kinds of chemotherapy, especially alkylating agents, can also damage the immature follicles that are resting in the ovary. Once these follicles are destroyed, women cannot make new ones. Consequently, these therapies can cause early menopause in young women or even delayed puberty in girls. Further, in addition to damaging the follicles, radiation to the abdomen or reproductive organs can damage the uterus, which may make it difficult to carry a healthy pregnancy.
A man’s fertility depends on his ability to make healthy sperm. Cancer treatments, including chemotherapy, radiation, and surgery, can affect a man’s sperm and cause infertility. In fact, these treatments may affect not only the amount of sperm that a man can produce but also the quality of the sperm. In addition to having a low sperm count, having slow moving or abnormal sperm can affect a man’s fertility.
Discuss with your oncologist the possibility of infertility and ask about your fertility preservation options as early in the treatment planning process as possible.
What fertility preservation options are available?
For women who have gone through puberty, the established methods for fertility preservation are embryo and oocyte banking, or cryopreservation. Both embryo and egg banking require women to take hormonal injections to stimulate the ovaries to produce multiple mature eggs over the course of one to two weeks. These hormone injections may not be appropriate for women with certain types of cancer, so it’s important to ask your doctor if this is an option for you. The process is closely monitored through blood tests and a series of pelvic ultrasounds. When the follicles reach a certain size, an egg retrieval procedure is performed, often in a doctor’s office with minimal anesthesia. The mature eggs collected during the procedure can be frozen individually and stored for future use, or they can be fertilized with a partner’s or donor’s sperm to form embryos, which also can be frozen and stored to achieve a pregnancy in the future. Once the egg retrieval is completed, a woman can begin her cancer treatment.
Be sure to ask your oncologist …
- Will my cancer or its treatment affect my future fertility?
- What are my fertility preservation options?
- How quickly do I need to start treatment?
- Is it safe for me to have a child after my treatment?
- Can you refer me to a fertility specialist?
If a female is too young or is not a candidate for egg or embryo banking, she may consider ovarian tissue cryopreservation, an investigational procedure by which the outer layer of the ovary, which contains immature follicles, is surgically removed and then frozen and stored. This ovarian tissue can be thawed and transplanted back into the woman’s body to restore fertility, or individual ovarian follicles can be grown in a petri dish.
For women receiving abdominal or pelvic radiation, a minor surgical procedure called ovarian transposition can be performed to move the ovaries outside the field of radiation.
The best way to preserve a man’s fertility is to collect a semen sample prior to radiation or chemotherapy. In some cases, a surgical procedure is needed to collect sperm directly from the testes. Sperm can be frozen and used in the future for intrauterine insemination or in vitro fertilization. Even if a man’s sperm count is low or there are other concerns, banking sperm before starting treatment is a good back-up plan in case his fertility is affected by his cancer treatment.
Not all cancer treatments affect fertility the same way for everyone. It’s important to talk with your doctor about how your course of treatment might affect your fertility. If you’ve already started treatment, keep in mind that some of these fertility options may still be available even after cancer treatment. Additionally, there are many other ways to start a family, such as by using donor eggs, embryos, or sperm. Surrogacy or adoption may also be feasible options. Consider meeting with a reproductive endocrinologist who specializes in fertility issues to help you navigate your many options for parenthood after cancer.
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Dr. Laxmi Kondapalli is an assistant professor in the Division of Reproductive Endocrinology and Infertility and director of the Oncofertility Program at the University of Colorado in Denver, CO.
This article was originally published in Coping® with Cancer magazine, March/April 2014.