Fertility and Women With Cancer

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Preserving fertility in women with cancer

The following chart shows current options for preserving fertility before, during, and after cancer treatment. Ideally, fertility discussions should take place before treatment, but we know this is not always the case.

You can use this information to learn more and then discuss your fertility options with your doctor. In some cases, you and your doctor might decide to use more than one option to try to preserve your fertility, especially if one option has a low or unknown success rate. Be sure that you understand the risks and chances of success of any fertility option you are interested in, and keep in mind that no method works 100% of the time. Married women and those with long-term partners might want to include them in these discussions and decisions.

This chart can help you learn more about your current options. After the chart we discuss the details of the listed options in alphabetical order.

Fertility options for women with cancer

Before treatment

During treatment

After treatment

Egg (oocyte) freezing

Fertility-sparing surgical procedure (for certain women with ovarian cancer)

Adoption+

Embryo freezing

GnRH treatment*

Donor eggs

GnRH treatment*

Oral contraceptive (birth control pill) treatment*

Donor embryos

Oral contraceptive (birth control pill) treatment*

Ovarian shielding

Natural pregnancy

Ovarian tissue freezing*

Radical trachelectomy (for certain women with cervical cancer)

Surrogacy+

Ovarian transposition

 

Using your own frozen eggs – see Egg (oocyte) freezing

   

Using your own frozen embryos – see Embryo freezing

   

Using your own frozen ovarian tissue – see Ovarian tissue freezing*

* Experimental

+ May be available at any point in time

Adoption

Adoption is usually an option for anyone who wants to become a parent. Adoption can take place within your own country through a public agency or by a private arrangement, or internationally through private agencies. Some agencies specialize in placing children with special needs, older children, or siblings.

Most adoption agencies state that they do not rule out cancer survivors as potential parents. But agencies often require a letter from your doctor stating that you are cancer-free and can expect a healthy lifespan and a good quality of life. Some agencies or countries require a period of being off treatment and cancer-free before a cancer survivor can apply for adoption. Five years seems to be an average length of time.

There’s a lot of paperwork to complete during the adoption process, and at times it can seem overwhelming. Many couples find it helpful to attend adoption or parenting classes before adopting. These classes can help you understand the adoption process and give you a chance to meet other couples in similar situations. The process takes different lengths of time depending on the type of adoption you choose. Most adoptions can be completed in 1 to 2 years.

Costs of adopting vary greatly, from less than $4,000 (for a public agency, foster care, or special needs adoption) up to $50,000 (for some international adoptions, including travel costs).

You may be able to find an agency that has experience working with cancer survivors. Some discrimination clearly does occur both in domestic and international adoption. Yet, most cancer survivors who want to adopt can do so.

Donor eggs

Any woman who has a healthy uterus and can maintain a pregnancy can have in vitro fertilization (IVF; mature eggs are removed from a woman’s ovaries, joined with sperm in the lab, and then put in a woman’s uterus to develop) with donor eggs and a partner’s (or donor’s) sperm.

Donated eggs come from women who have volunteered to go through a cycle of hormone stimulation and have their eggs collected. In the United States, donors can be known or anonymous. Some couples find their own donors through programs at infertility clinics or on the Internet. Some women have a sister, cousin, or close friend who is willing to donate her eggs without payment.

Egg donors should have been screened carefully for sexually transmitted diseases and genetic illnesses. Every egg donor should also be screened by a mental health professional familiar with the egg donation process. These screenings are just as important for donors who are friends or family members. Everyone also needs to agree on what the donor’s relationship with the child will be, and be certain that the donor was not pressured emotionally or financially to donate her eggs. You want to be sure that everyone agrees about what the child will or will not be told in the future.

The success of the egg donation depends on carefully timing hormone treatment (to prepare the lining of the uterus) with the removal and fertilization of the donor’s eggs. If the woman receiving the donor eggs has ovarian failure (she’s in permanent menopause), she must take estrogen and progesterone to prepare her uterus for the embryo(s). The eggs are taken from the donor and fertilized with the sperm. Embryos are then transferred to the recipient to produce pregnancy. After the transfer, the woman will continue to need hormone support until the placenta develops and can produce its own hormones.

Egg donation is often a successful treatment for infertility in women who can no longer produce healthy eggs. The entire process of donating eggs, fertilizing them with sperm, and implanting them usually takes 6 to 8 weeks per cycle. The major health risk for cancer survivors and babies is the risk of having twins or triplets. Responsible programs may transfer only 1 or 2 embryos to reduce this risk, freezing extras for a future cycle. The price of a donor egg cycle should include the price of IVF plus any payment to the egg donor, but it’s good to find out all the costs beforehand (see “Insurance and financial concerns” in the section called “Other fertility-related issues to think about”).

Donor embryos

Any woman who has a healthy uterus and can maintain a pregnancy can have in vitro fertilization (IVF) with donor embryos. (IVF; a fertilized egg, an embryo, is put in a woman’s uterus to develop.) This approach lets a couple experience pregnancy and birth together, but neither parent will have a genetic relationship to the child. Embryo donations usually come from a couple who has used assisted reproductive technology and has extra frozen embryos. When that couple has conceived or for some other reason chooses not to use those frozen embryos, they might decide to donate them.

One problem with this option is that the couple donating the embryo may not agree to have the same types of genetic testing as is usually done for egg or sperm donors, and they may not want to supply a detailed health history. On the other hand, the embryos are free, so the cancer survivor only needs to pay the cost of getting her uterus ready and having the embryo placed.

Most women who use the donor embryo procedure must get hormone treatments to prepare the lining of the uterus and ensure the best timing of the embryo transfer. The embryo is thawed and transferred to the woman’s uterus to develop and grow. After the embryo is transferred, the woman stays on hormone support until blood work shows that the placenta is making hormones on its own.

There’s no published research on the success rates of embryo donation, so it’s important that you research the IVF success rates of the centers you may use.

Egg (oocyte) freezing

Egg freezing (or oocyte cryopreservation) is an established method of preserving fertility in women, although it has not been used as long as embryo freezing (described below). This may be a good choice for women who do not have a partner.

For egg freezing, mature eggs are removed and frozen before being fertilized with sperm. This process may also be called egg banking. When the woman is ready to become pregnant, the eggs can then be thawed, fertilized, and implanted in the uterus.

Collecting the eggs typically takes several weeks. Hormones can be used to ripen several eggs at once. In most women, this means starting a cycle of hormone shots 3 days before their menstrual cycle and continuing them for 2 to 3 weeks until many eggs are mature (often about 12 eggs in a woman under age 35). The eggs are then collected during outpatient surgery, usually with a light anesthetic (drugs are given to make you sleepy while it’s done). An ultrasound is used to guide a needle through the upper part of the vagina and into the ovary to collect the eggs.

Some women might not be able to follow the schedule of hormone shots above. This could include women who have fast-growing cancers (who cannot wait 2 to 3 weeks to begin treatment) and women with breast cancer, who might be at risk of their tumors growing because of the high levels of estrogen caused by the hormone shots. One option for these women is to follow the natural cycle of the maturing egg. To do this, ultrasound is used to follow the progress of normal ovulation, and 1 or sometimes 2 eggs can be collected. Another option for women with breast cancer is to use drugs such as aromatase inhibitors or tamoxifen during the hormone stimulation to keep the estrogen from helping cancer cells to grow. More studies are needed, but results so far do not show that this has any harmful effects on women’s breast cancer treatment or survival.

Less is known about egg freezing than embryo freezing, but the methods and success rates have greatly improved in the past several years and it’s being done more often in the US. Some fertility centers have reported success rates much the same as using unfrozen eggs, especially in younger women.

Some doctors freeze eggs at the same time they freeze embryos.

Because younger women have more eggs, and the eggs are likely to be healthier, some facilities cut off the age for egg freezing in the mid-thirties. This varies by facility.

If you are looking at egg freezing, ask how many live births the facility has had using frozen eggs. You might also want to ask how many eggs it takes, on average, to produce a single live birth. You will want to know the cost of the procedure (including all the medicines), annual storage costs of the frozen eggs, and the estimated costs of fertilizing and implanting later. Egg freezing usually costs less than embryo freezing.

An important note about freezing

If you have frozen eggs, it’s important to stay in contact with the cryopreservation facility to be sure that any yearly storage fees are paid and your address is updated. Once a couple is ready to have a child, the frozen eggs are sent to their fertility specialist.

Cryopreservation of immature oocytes

It’s thought that immature eggs might freeze better. Because they are less developed and less fragile, they might stand up to the freezing and thawing processes better than mature eggs. Immature oocytes can be collected at any time – no hormone stimulation is needed. Because of this, researchers are also looking at whether immature oocytes can be harvested, matured in the lab (instead of in the woman), and then frozen. This keeps the woman from having to get hormone stimulation and then wait for eggs to mature naturally in her body.

Immature oocytes are removed through a needle that’s put through the vagina and into the ovary. Ultrasound is used to guide the needle. Immature eggs are sucked into the needle and then frozen or matured and frozen. When the woman is ready, her immature eggs are thawed, matured in the lab (if not done before freezing), fertilized, and then implanted in her uterus. Researchers are studying this, and at this time it’s still considered to be experimental. Few reports have been published so far showing this method results in live births.

Embryo freezing

Embryo freezing, or embryo cryopreservation, is the most common and successful method of preserving a woman’s fertility today. Mature eggs are removed from the woman’s ovaries and fertilized in the lab. This is called in vitro fertilization (IVF). The embryos are then frozen to be used after cancer treatment. This option works well for women who already have a partner, though single women can still freeze embryos using donor sperm.

The process of collecting eggs for embryo freezing is much the same as for egg freezing (see above). Eggs are collected during outpatient surgery, usually with a light anesthetic (drugs are given to make you sleepy while it’s done). An ultrasound is used to see the ovaries and the fluid sacs (follicles) that contain ripe eggs. A needle is guided through the upper vagina, into each follicle to collect the eggs. The eggs are fertilized, then frozen and stored.

Since each egg can most likely produce a single embryo at best, a woman will have a better chance of a successful pregnancy if several embryos are stored. Hormones can be used to ripen several eggs at once. In most women, this means starting a cycle of hormone shots within 3 days of starting their menstrual cycle and continuing them for 2 to 3 weeks until many eggs are mature (often about 12 eggs in a woman under age 35).

But some women who have fast-growing cancers cannot wait 2 to 3 weeks to begin treatment. And women with breast cancer may risk some growth of their tumors during IVF cycles because of the high levels of estrogen caused by the hormone shots. In cases like this, one option is “natural cycle IVF” in which ultrasounds are used to follow the progress of normal ovulation, and 1 or sometimes 2 eggs can be collected. Another option for women with breast cancer is to use drugs such as aromatase inhibitors or tamoxifen during the hormone stimulation to keep the estrogen from helping cancer cells to grow. More studies are needed, but results so far do not show that this has any harmful effects on women’s breast cancer treatment or survival.

Successful pregnancy rates vary from center to center. Centers with the most experience usually have better success rates. Costs vary, too, see “Insurance and financial concerns” in the section called “Other fertility-related issues to think about” for more on this.

An important note about freezing

If you have frozen embryos, it’s important to stay in contact with the cryopreservation facility to be sure that any yearly storage fees are paid and your address is updated. Once a couple is ready to have a child, the frozen embryos are sent to their fertility specialist.

Fertility-sparing surgery (for ovarian cancer)

This type of surgery might be an option in young women with ovarian cancer in only one ovary. The cancer must be one of the types that’s slow-growing and less likely to spread, like borderline, low malignant potential, germ cell tumors, or stromal cell tumors (typically grades 1 and some grade 2 epithelial ovarian cancers).

In this case, the surgeon can remove just the ovary with cancer, leaving the healthy ovary and the uterus (womb) in place. Studies have found that this does not affect long-term survival, and allows future fertility. If there’s a risk of the cancer coming back, the remaining ovary may be removed later, after the woman has finished having children.

GnRH agonist treatment (ovarian suppression)

The goal of this treatment is to shut down the ovaries during cancer treatment to help protect them from the damaging effects of treatment. The hope is that reducing activity in the ovaries during treatment will reduce the number of eggs that are damaged, so women will resume normal menstrual cycles after treatment.

Gonadotropin-releasing hormone (GnRH) agonists are long-acting hormone drugs that can be used to make a woman go into menopause for a short time. These hormones are usually given as a monthly shot starting a couple of weeks before chemo or pelvic radiation therapy begins. GnRH treatment is given each month the whole time a woman is getting the cancer treatment.

Studies suggest that this method might help prolong fertility in some women, especially those 35 and younger, but results are not clear and more research is needed to prove it works.

This treatment is experimental, and women who want to try it might want to look into a clinical trial that’s testing GnRH treatment. If this treatment is used, it’s best done with a back-up method of preserving fertility like embryo freezing.

This treatment costs a lot and the drugs can weaken a woman’s bones if used for more than 6 months.

Natural pregnancy

After cancer treatment, a woman’s body may recover naturally and produce mature eggs that can be fertilized. The medical team may recommend waiting anywhere from 6 months to 5 years before trying to get pregnant. This is often based on the fact that the risk of the cancer coming back (recurring) is usually highest in the first 2 to 5 years after treatment. The length of time depends on the type of cancer and the treatment used.

But women who have had chemo or radiation to the pelvis are also at risk for sudden, early menopause even after they start having menstrual cycles again. Menopause may start 5 to 20 years earlier than expected. Because of this, women older than 35 might want to talk to their doctors about how long they should wait to try to conceive and why they should wait. It’s best to have this discussion before going on with a pregnancy plan.

Oral contraceptive (birth control pill) treatment

Some oncologists prescribe oral contraceptives (birth control pills) before and during cancer treatment, hoping they will reduce activity in the ovary and save eggs. The concept is similar to that for GnRH agonist treatment (described above), but there’s little scientific evidence for this, and more research is needed. Some published studies suggest that it does not reduce infertility.

Still, oral contraceptives can sometimes be useful during chemo: They may help control menstrual bleeding when a woman’s blood counts are low and help reduce the risk of accidental pregnancy during treatment.

Note that the hormones in birth control pills are not recommended for women with cancers that could be fueled by hormones, such as breast cancer. Oral contraceptives can also increase the risk of blood clots, which may already be high because of the cancer and its treatment effects.

Ovarian shielding

This method of protecting the ovaries may be used during the total body radiation that’s sometimes part of stem cell or bone marrow transplant. A lead barrier, or shield, is placed over the patient’s lower abdomen (belly) to help keep radiation from directly affecting the ovaries.

A few small studies have found that ovarian shielding preserves ovarian function and does not appear to increase the risk of cancer relapse. But it does decrease the radiation dose to the pelvis, and it has been suggested that shielding not be done in women with active leukemia.

More studies are needed to know if ovarian shielding works and if it’s safe.

Ovarian tissue freezing

Ovarian tissue freezing is experimental and can be done in young girls who have not reached puberty. All or part of one ovary is removed by laparoscopy (a minor surgery where a thin, flexible tube is passed through a small cut near the navel to reach and look into the pelvis). The ovarian tissue is usually cut into small strips, frozen, and stored.

After cancer treatment, the ovarian tissue can be thawed and placed close to the fallopian tubes or in another part of the body, like the abdomen (belly) or forearm. Once the transplanted tissue starts to function again, the eggs can be collected and fertilized in the lab. In another approach, the whole ovary is frozen with the idea of putting it back in the woman’s body after treatment, but this has not yet been done in humans.

Ovarian tissue removal does not usually require a hospital stay. It can be done either before or after puberty. Still, it’s experimental and has produced only a small number of live births so far. Doctors are studying it now to learn the best methods for success. Faster freezing of the tissue (called vitrification) has greatly improved outcomes over the older, slow-freezing methods.

The ovarian tissue does grow a new blood supply and produces hormones after it’s transplanted, but some of the tissue usually dies and it may only last for a few months to several years. Because they last such a short time, ovarian tissues are usually only transplanted when a woman is ready to try for a pregnancy.

At this time, ovarian tissue freezing and transplant is not recommended for women with blood cancers (such as leukemias or lymphomas) or ovarian cancer due to the risk of putting cancer cells back in the body with the frozen tissue.

Ovarian tissue freezing costs vary a lot, so you will want to ask about the freezing and annual storage costs as well as removal and transplant expenses. In some patients, ovarian tissue can be removed as part of another necessary surgery so that some of the cost is covered by insurance.

Ovarian transposition

Ovarian transposition means moving the ovaries away from the target zone of radiation treatment. It’s a standard option for girls or women who are going to get pelvic radiation. It can be used either before or after puberty.

This procedure can often be done as outpatient surgery and does not require staying in the hospital (unless it is being done as part of a larger operation). Surgeons will usually move the ovaries above and to the side of the central pelvic area.

The success rates for this procedure have usually been measured by the percentage of women who regain their menstrual periods, not by being able to have a live birth. Typically, about half the women start menstruating again.

It’s hard to estimate the costs of ovarian transposition, since this procedure may sometimes be done during another surgery that is covered by insurance. It’s usually best to move the ovaries just before starting radiation therapy, since they tend to fall back into their old places over time.

Radical trachelectomy

Radical trachelectomy is an option for cervical cancer patients who have very small, localized tumors. The cervix is removed but the uterus and the ovaries are left, and the uterus is connected to the upper part of the vagina. A special band or stitch is wrapped around the bottom of the uterus to act as the cervix. A small opening allows blood from your period to flow out and sperm to enter the uterus to fertilize an egg. This is done during the surgery to treat cervical cancer, so insurance should cover some of the costs. Talk to your doctor about this.

Trachelectomy appears to be just as successful as radical hysterectomy (removal of the uterus and cervix) in treating cervical cancer in certain women. Women can become pregnant after the surgery, but are at risk for miscarriage and premature birth because the opening to the uterus may not close as strongly or tightly as before. These women will need specialized obstetrical care while they are pregnant, and the baby will need to be delivered by Cesarean section (C-section).

Surrogacy

Surrogacy is an option for women who cannot carry a pregnancy, either because they no longer have a working uterus, or would be at high risk for a health problem if they got pregnant. There are 2 types of surrogate mothers:

    A gestational carrier is a healthy female who receives the embryos created from the egg and sperm of the intended parents. The gestational carrier does not contribute her own egg to the embryo and has no genetic relationship to the baby.

    A traditional surrogate is usually a woman who becomes pregnant through artificial insemination with the sperm of the man in the couple who will raise the child. She gives her egg (which is fertilized with his sperm in the lab), and carries the pregnancy. She is the genetic mother of the baby.

Surrogacy can be a legally complicated and expensive process. Surrogacy laws vary, so it’s important to have an attorney help you make the legal arrangements with your surrogate. You should consider the laws of the state where the surrogate lives, the state where the child will be born, and the state where you live. It’s also very important that the surrogate mother be evaluated and supported by an expert mental health professional as part of the process. Very few surrogacy agreements go sour, but when they do, typically this step was left out.


Last Medical Review: 11/06/2013
Last Revised: 11/06/2013