Think Beyond Cancer

The premise:

  • Certain types of cancer treatments can affect fertility (a woman's ability to conceive a child or maintain a pregnancy and a man's ability to father a child).
  • There are various options to help preserve fertility in men and women.
  • Before treatment begins, talk with your doctor about the possible fertility-related side effects of your treatment and the available options for preserving fertility.

Infertility can be a temporary or permanent side effect of some cancer treatments. Today, there are many options to help people diagnosed and treated for cancer to preserve their fertility, and the chances of maintaining your fertility are greatest if you discuss your options as early as possible with your health care team.

How cancer treatment affects the body
Various cancer treatments - including surgery, chemotherapy, and radiation therapy-can cause infertility under certain circumstances. Surgery to the sex organs or areas around these organs may reduce fertility. The risk of infertility from chemotherapy depends on the type and dose of drug, as well as how it's given, while the risk of infertility from radiation therapy depends on the dose of radiation and the area of the body that is exposed to radiation.

The endocrine glands and endocrine - related organs-such as the ovaries, testes, thyroid, and adrenal gland-release hormones that stimulate puberty, control fertility, and regulate growth throughout the body. Problems occur when cancer or the cancer treatment damages one of these glands or organs or alters the part of the brain that controls the endocrine glands. For example, chemotherapy and radiation therapy may reduce a man's number of sperm cells or limit their mobility. In women, chemotherapy and radiation therapy may affect a woman's menstrual cycle, possibly causing her to stop ovulating or to enter premature menopause.

People past the age of puberty may be at greater risk for infertility than younger children. For example, a man's testes are more vulnerable to the damaging effects of chemotherapy and radiation therapy than a boy's testes. In the same way, girls' ovaries can often tolerate higher doses of chemotherapy than women's ovaries.

Because it is possible for a woman to become pregnant or for a man to impregnate a woman during chemotherapy or radiation therapy, both men and women should talk with their doctor about birth control methods if they are sexually active during this time. Chemotherapy and radiation therapy may cause birth defects or harm the fetus.

Some treatments that can cause infertility in men:

- Chemotherapy: Sperm cells divide rapidly, so they are an easy target for damage by chemotherapy. If all the stem cells in the testicles are damaged and no longer produce maturing sperm cells, it leads to a permanent fertility. The risk of infertility depends on the type of drug and the doses used. After chemotherapy, sperm production slows down or may stop completely. It usually returns in 1 to 4 years, but can even take up to 10 years. Men older than 40 may also be less likely to recover their fertility.

- Radiotherapy: If the radiation aims at testicles, man fertility can be affected: radiation at high doses kills the stem cells that produce sperm. When the patient has another type of cancer in the abdomen or pelvis, the radiations he will receive can also touch the testicles.

- Sometimes radiation to the brain may affect the pituitary gland which signals the testicles to make hormones. This hormones act on testicles and sperm production. Whole body radiation used before bone marrow transplant also usually causes permanent infertility.

Testicles ablation: If only one testicle is removed, the patient may continue to make sperm after surgery. If both testicles are removed, the patient will no longer be fertile. This kind of surgery may be necessary in prostate cancer, because all the testosterone production has to be stopped to slow the growth of prostate. It's also done when the patient develops cancer in both testicles, but it's very rare.

Prostate surgery: If the cancer isn't spread too much, the treatment is a surgery that removes the prostate gland and seminal, both organs that produce semen. The testicles still make sperm, but the vas deferens is cut. With sexual stimulation, many men still can have all the feeling of orgasm, but without ejaculation.

Other surgeries: Removing lymph nodes in the pelvis, which may be part of the surgery for testicular cancer, and some operations for colon cancer, can damage nerves, and this causes problems with

Ejaculation: the patient still makes semen, but it does not come out of the penis at orgasm.

Generally, before you start treatment, you must talk to your doctor about the possible affect on your sexual function and fertility.

Cancer treatment and fertility-preserving options
Discussions about how to attempt to preserve your fertility need to happen before cancer treatment. Age, gender, physical and sexual maturation, and, in some cases, relationship status (for example, whether a woman currently has a partner) affect the options available for fertility preservation. Your doctor and/or a reproductive endocrinologist (a doctor who specializes in fertility issues) can help you learn about your options.

Unfortunately, not all options are available or appropriate for everyone. Fertility-preserving procedures may be stressful during an already difficult time, and they are not always effective. Many options, including in vitro fertilization (a process that involves collecting a woman's eggs and fertilizing them with sperm outside her body, then transferring the embryo back into her body for it to develop) and embryo cryopreservation (freezing fertilized eggs for later reimplantation), may be costly. In addition, some people may face ethical questions about various options, so it is important to talk with your doctor to find the information you need to make the best decision. You may also consider speaking with a counselor for guidance about these decisions.

Fertility-preserving options for men
Protection of the testes from radiation therapy: In men, it is possible to shield the testes from radiation if the cancer is present in other parts of the pelvis.

Sperm cryopreservation (sperm banking): This procedure involves freezing and storing of semen for men who wish to father children later in life. It is an option for most men who have reached sexual maturity.

Testicular-tissue cryopreservation and reimplantation: This investigational option involves the removal, freezing, and storage of testicular tissue that is surgically reimplanted after cancer treatment.

Hormonal gonadoprotection: This approach uses hormone therapy to protect testicular tissue during chemotherapy or radiation therapy, and it is still investigational.

Cancer treatments that can cause infertility in women:

- Chemotherapy: Many chemotherapy drugs can damage or destroy some of the eggs stored in the ovaries. The effect will depend on the type and dose of chemotherapy treatment and the patient's age.

- Radiation treatments: The ionizing rays can also damage woman's ovaries. High-enough doses can destroy all the eggs in the ovaries and cause premature menopause. Even if the radiation is not aimed right at the ovaries, there is a risk for them to be damaged.

Sometimes radiation to the brain may affect the pituitary gland, which signals the ovaries to make hormones responsible for ovulation, but this not always causes infertility.

- Surgery: For some cancers in women, a hysterectomy (uterus ablation) or/and ovaries ablation are part of the treatment. After those surgeries, a woman cannot carry a child.

Sometimes surgery can cause scars in the fallopian tubes, and this may prevent the ovules of going across the tubes to be fertilized and moving to the uterus to be implanted.

Fertility-preserving options for women
Protection of the ovaries from radiation therapy: For women receiving radiation therapy to the pelvic region, it can be difficult to shield one or both ovaries. If both ovaries receive radiation treatment, infertility may be permanent. However, in many cases, both ovaries do not receive radiation treatment, so any resulting infertility may not be permanent. Another option is oophoropexy, which involves surgically moving one or both ovaries out of the radiation field.

Embryo cryopreservation: This is the process of harvesting eggs for in vitro fertilization and freezing the embryos for later use in women of reproductive age. Some ethical issues-such as what to do with unused fertilized embryos-arise with this technique and require careful discussion.

Oocyte (unfertilized egg) cryopreservation: Freezing unfertilized eggs is currently investigational.

Ovarian-tissue preservation: This method is currently investigational; it requires the surgical removal, preservation, and reimplantation of ovarian tissue both before and after puberty. This may not be a practical option for girls younger than age 18 because of informed consent issues.

Gonadotropin-releasing hormones (GnRH) analog treatment: In this investigational approach, GnRHs are given along with chemotherapy to potentially reduce the possible harmful effects of chemotherapy on the reproductive organs and to lower the risk of infertility after treatment.

Abdominal radical trachelectomy: Recent research shows that women with cervical cancer who have surgery to remove the cervix while keeping the uterus intact may become pregnant. In such cases, the baby would be delivered by cesarean section.

Oral contraception: Some research shows that women who take oral contraceptives (birth control pills) during chemotherapy may conserve eggs following treatment. This approach is still investigational and may not be recommended for a woman with a tumor that is sensitive to hormones (such as some types of breast cancer).

Questions to ask the doctor about cancer treatment and fertility

It is important to talk with your doctor (or your child's doctor) as early as possible in the treatment process about how cancer treatment may affect fertility. Many interventions to preserve fertility need to take place before cancer treatment begins.

Consider asking your doctor the following questions:

  • What are the short-term and long-term effects of cancer treatment on my (or my child's) fertility?
  • What is the risk of permanent infertility associated with the treatments recommended for my type, stage, and grade of cancer? Are there other treatments that could be considered that do not pose as high a risk but are equally effective?
  • What are the options for preserving my fertility before treatment?
  • What are the options for preserving my fertility during or after treatment?
  • Do any of these fertility preservation options make my cancer treatment(s) less effective?
  • Do any of these fertility preservation options increase the risk that the cancer may come back?
  • Can I become pregnant (women) or impregnate someone (men) while receiving chemotherapy or radiation therapy? What happens if pregnancy results during treatment? What is the risk of birth defects and/or harm to the fetus and/or mother?
  • How long must I wait after treatment before trying to become pregnant (women) or to impregnate someone (men)?
  • Is it appropriate for me to consult a specialist in reproductive endocrinology?
  • Where can I find support for coping with fertility issues?
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