Fertility issues

Overview

Any procedure or medication that interferes with the functioning of the testes or ovaries affects fertility. The choices made before cancer treatment begins can determine whether the patient will remain fertile after treatment. Prior to deciding on a treatment plan, it is important for the patient to discuss the issue of fertility with the treatment team so that all options, with their associated risks, can be considered.

Conventional cancer treatments and their effects on fertility

Cancer is usually treated with surgery, chemotherapy , and/or radiation, with the type and stage of the cancer dictating the treatment regimen recommended. While some physicians may routinely take into consideration alternatives to spare a patient's fertility, others may not, feeling that to differ from the treatment norm may compromise the patient's best chances for survival. Patients for whom fertility preservation is important, or for whom fertility-sparing measures could compromise treatment outcome, must discuss this issue fully with their treatment team.

Surgery

Surgery for cancer usually involves removal of the cancerous area, with some sampling of the adjacent area and lymph nodes to check for metastasis . If surgery must involve the removal of both of the testes or ovaries, the man will not be able to provide his own sperm, and the woman her own egg, towards the development of a biologic child. (A couple may be able to use donated sperm or egg when attempting a future pregnancy, however.) Fertility-sparing surgery may be an option for some individuals, depending on the type and stage of their cancer. For example, a woman with ovarian cancer contained to one ovary may be able to have just that one removed. The same is true for a man with testicular cancer contained to one testicle. In the case of testicular cancer, removal of retroperitoneal lymph nodes during surgery may damage the nerves affecting ejaculation. Men may wish to discuss nerve-sparing surgery and their concerns for fertility with their surgeon prior to surgery.

Chemotherapy

Chemotherapy affects the whole body, but certain drugs are less harmful to the reproductive tract than others. The drugs used in chemotherapy are highly toxic, in order to kill any cancer cell. However, they are not very selective, meaning that in addition to cancerous cells, normal cells are killed as well. It may take a few years after chemotherapy has finished to understand its temporary or permanent effect on fertility. It is generally recommended that women wait about two years after chemotherapy before attempting to become pregnant, to avoid the risk of a pregnancy that may end in miscarriage or a fetal malformation. Men who have had chemotherapy can have their sperm analyzed after treatment has finished to check sperm counts and motility.

There is a concern that individuals may delay treatment in order to undergo various fertility-preserving measures, such as sperm banking or egg retrieval and cryop-reservation, and that this delay could result in a poorer treatment outcome. Some women undergo attempts at egg retrieval and embryo cryopreservation after an initial dose of chemotherapy. Some treatment centers offer the option of doing the chemotherapy in stages. The first stage of chemotherapy uses medications that are considered less toxic. Then the more intensive treatment follows after the harvesting of egg or sperm. However, it is still not yet clear what kind of damage may have been endured by tissue harvested right after some chemotherapy.

Radiation

Radiation is known to damage the highly sensitive sperm and eggs. Just as chemotherapy attacks healthy cells, so does radiation. However, radiation technology is able to focus very tightly on the cancerous area, which decreases risk to healthy tissue. When radiation for cancer does not involve the pelvic area, it may be possible to successfully shield the reproductive organs to preserve fertility. If the area needing irradiation is the pelvis, the reproductive organs are at great risk of damage.

When radiation is done to the pelvic area, women often experience a pause in menstruation, along with other symptoms of menopause. There may also be vaginal dryness, itching , and burning. Radiation may affect sexual desire as well. Men may experience a decrease in sperm count and motility, and difficulty in having or maintaining an erection. These changes may be temporary or permanent, and it may take up to a few years to determine if the effects were temporary or permanent. Sperm banking or cryopreservation of eggs may allow the individual reproductive success in the future.

Since radiation can be harmful to the fetus, pregnancy during radiation therapy is contraindicated, and because the full effect of the radiation on fertility cannot be predicted, individuals should use contraception during sexual relations while receiving radiation therapy.

Bone marrow transplant

A bone marrow transplant (BMT) may be part of the suggested treatment regimen. If so, patients need to understand its potential impact on future fertility. While the actual BMT does not jeopardize fertility, chemotherapy or radiation done prior to the BMT in preparation for the body's receiving of the new marrow can damage fertility. This pretreatment can destroy cells in the reproductive organs, rendering the individual infertile. While each case is unique, patients may wish to discuss the impact of their treatment on their reproductive future, and consider sperm banking or egg cryopreservation.

Children's cancers and future fertility

In the case of children, chemotherapy and radiation for childhood cancer can cause permanent damage to the ovaries or testes. In boys who have become sexually mature, sperm banking may provide future reproductive options. Options such as sperm aspiration, and cryopreservation of female ova are still considered experimental in children. While they may be effective, researchers are concerned that parents and their children may be unrealistic in their hopes for future fertility, and that the reintroduction of the harvested tissue may return latent cancer cells into the body. While research may bring new options, obtaining true informed consent involving children and their parents is an issue of moral and practical concern.

Alternative and complementary therapies

Individuals undergoing cancer treatment may turn to alternative therapies for a number of reasons. Techniques such as meditation, therapeutic touch, yoga, t'ai chi, and guided imagery can be very helpful in reducing stress and its effects on the body. Acupuncture has been shown through research studies to be effective in reducing the nausea and vomiting associated with chemotherapy. However, a study reported in the March 1999 issue of the medical journal Fertility and Sterility investigated several herbal remedies and their effect on sperm and ova. While this study was involved in animal research, the finding that high concentrations of St. John's wort, an herbal supplement used for mild to moderate depression , Echinacea, and ginkgo biloba damaged reproductive cells raises concern for its effect on humans. In particular, St. John's wort was found to be mutagenic to sperm cells.

Special concerns

Some cancers, such as testicular cancer, affect primarily young men. Most men diagnosed with testicular cancer are between the ages of 15 and 40. Sperm banking is highly recommended for these men. The method intracytoplasmic sperm injection uses just one sperm to fertilize one egg, by injecting the sperm directly into the egg. This can result in a fertilized egg for insemination, even when the sperm has decreased motility. It has a success rate of 30%.

Fertility issues and the development of cancer

Fertility issues can also play a role in the development of cancer. For example, women having their first child after 30 are at slightly higher risk of developing ovarian cancer than those having their first child before age 30. The number of ovulatory cycles a woman experiences also appears to affect her risk for ovarian cancer. A longer reproductive period (early menarche and late menopause) appears to raise the risk, while having children (there is no ovulation during pregnancy), breastfeeding (there is some suppression of ovulation during breastfeeding), and the use of oral contraceptives for at least five years decreases the risk.

Women who used the infertility medication clomiphene citrate without becoming pregnant were found in some studies to have a greater risk of developing a low malignancy potential ovarian cancer. In a November 1999 issue of the medical journal Lancet, researchers reported that women whose infertility remained unexplained were found to have more ovarian and uterine cancers, irrespective of whether or not they had been treated for the infertility. Also, more breast cancers were detected in the first year after treatment for infertility terminated than was expected. The lead author of the study speculated that these cancer diagnoses may be due to closer medical supervision that resulted in early detection. In some cases it was believed that the infertility was a symptom of the undiagnosed cancer.

Resources

BOOKS

Coleman, C. Norman. Understanding Cancer. Baltimore, Maryland: The Johns Hopkins University Press, 1998.

McGinn, Kerry A. and Pamela J. Haylock. Women's Cancers: How to prevent them, how to treat them, how to beat them. Alameda, California: Hunter House, 1998.

Runowicz, Carolyn D., Jeanne A. Petrek, and Ted S. Gansler. The American Cancer Society: Women and Cancer. New York: Villard Book, 1999.

Schover, Leslie R., Ph.D. Sexuality and Fertility After Cancer. New York: John Wiley & Sons, Inc., 1997.

Teeley, Peter and Philip Bashe. The Complete Cancer Survival Guide. New York: Doubleday, 2000.

PERIODICALS

Venn, Alison et al. "Risk of cancer after use of fertility drugs with in-vitro fertilization." The Lancet. (November 6, 1999):190.

ORGANIZATIONS

American Cancer Society. (800) ACS-2345. <http://www.cancer.org>.

Esther Csapo Rastegari, R.N., B.S.N., Ed.M.

KEY TERMS

Cryopreservation

—The process of freezing sperm, ova, or embryos to preserve them for future use.

Oocyte retrieval

—The process of obtaining eggs from a woman's ovary for future reproduction.

Sperm banking

—Sperm banking is a process of freezing, or cryopreserving, sperm for use in the future. The sperm may be obtained via ejaculation, or by aspiration. The process of sperm banking may take one to two weeks to complete. The method of aspirating the sperm directly from the testicle is called testicular semen aspiration.

Treatment team

—An interdisciplinary group of professionals whose focus is to collaborate on and coordinate the care of the patient. For the cancer patient this team might be comprised of a surgeon, oncologist, radiologist, gynecologic oncologist, urologic oncologist, nurse specialists, and social workers.

QUESTIONS TO ASK THE DOCTOR

• What is the type and stage of my cancer?
• What treatment options do I have that would retain my fertility?
• Is my survival compromised if I choose fertility-sparing treatment?
• Would the health of future child/children be compromised if I undergo this treatment?
• Can you provide me with research studies of others who had this treatment and went on to have children?
• How long should I wait after treatment before attempting a pregnancy?
• If treatment is successful, what can I expect in terms of survival and quality of life?
• If treatment is unsuccessful, what can I expect in terms of survival and quality of life?
• What is the type and stage of my child's cancer?
• Does the treatment of this cancer have a risk of developing another cancer later on?
• How will this treatment affect my child's development during puberty?
• What effect will this treatment have on my child's future fertility?