Preserving Fertility in Females with Cancer

Certain cancers and their treatment can affect fertility in males and females. Read more about this in How Cancer and Cancer Treatment Can Affect Fertility. When a person with cancer wants to have children after treatment ends, some planning is needed. Sometime this involves fertility preservation. Fertility preservation is when eggs, sperm, or reproductive tissue are saved or protected so that a person can use them to have children in the future.

This information is for females with cancer. If you are a lesbian or transgender person, please talk to your cancer care team about any needs that are not addressed here.

Fertility preservation for females with cancer

Certain types of cancer surgery can result in removal of organs needed for a pregnancy, and certain treatments might change hormone levels or cause damage to a female's eggs. These effects result in some females losing their fertility during treatment that can be either temporary or permanent. Read more in How Cancer and Cancer Treatment Affect Can Fertility in Females. Some women may choose to take steps that might help preserve their fertility so they can try to have children after treatment.

It's best that discussions about preserving fertility take place before cancer surgery happens or before treatments begin.  Don't assume your doctor or nurse will ask you if fertility is important to you. They don’t always remember to bring this up, so you might have to bring it up yourself.

If you are considering taking steps to preserve your fertility, and it's possible to do so, 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.

It's also very important to talk to your cancer care team about if you can have unprotected sex both during and after cancer treatment. They may recommend waiting a number of months or longer before trying to have a child by natural means or until resuming unprotected sexual intercourse.

Experts recommend doctors who are part of the cancer care team be involved in talking about fertility with patients, including medical oncologists, radiation oncologists, gynecologic oncologists, urologists, hematologists, pediatric oncologists, surgeons, nurses, and others. The experts have the following recommendations:

• The cancer care team should talk about any possible fertility problems that might happen due to treatment as early as possible, either before surgery or before treatment starts.
• Patients who are interested in fertility preservation, might be thinking about it, or want to learn more, should be referred to a reproductive specialist.
• The cancer care team should start talking about preserving fertility as early as possible, too, meaning before treatment starts.
• Referrals to counseling should be made for people who may be anxious or distressed about fertility-related effects.

Learn more about how you can start talking about fertility with your cancer care team in How Cancer and Cancer Treatment Can Affect Fertility.

Possible natural pregnancy

In females who were fertile before treatment, the body may recover naturally after treatment. It may be able to keep or restore normal hormonal cycles. and produce mature eggs that can be fertilized and implanted into the uterus to become a fetus. The medical team may recommend waiting anywhere from 6 months to 2 years before trying to get pregnant. Waiting 6 months may reduce the risk of birth defects from eggs damaged by chemotherapy or other treatments. The 2-year period is generally based on the fact that the risk of the cancer coming back (recurring) is usually highest in the first 2 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 should 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.

Cryopreservation (freezing embryos or eggs)

Experts recommend freezing embryos or eggs, called cryopreservation, to help preserve fertility for certain females with cancer. It's important to find a fertility specialist and center that has experience in these procedures.

The process of collecting eggs for embryo and egg freezing are the same. However, the timing can be different. Collecting eggs for embryo cryopreservation typically takes several days or weeks, depending on where a woman is in her menstrual cycle. Injectable hormone medications are given for females when they are safe to give. For egg cryopreservation, the time of the menstrual cycle is not as important. For both procedures, a catheter is put through the upper part of the vagina and into the ovary to collect the eggs.

Costs vary for these procedures, so check with your insurance company about coverage and ask the fertility specialist what costs are involved with the process. Sometimes these costs can be $10,000 or more each time they are done which may or may not include storage fees. Be sure to ask for a list of all fees and charges, since these differ from one center to another.

If you have frozen eggs, embryos, or ovarian tissue, 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.

Embryo freezing

Embryo freezing, or embryo cryopreservation, is an effective way to help preserve fertility for females. Mature eggs are removed from the female and put in a sterile lab dish with several thousand sperm. The goal is for one of the sperm to then fertilize the egg. This is called in vitro fertilization (IVF). In vitro intracytoplasmic sperm injection (IVF-ICSI) involves taking a single sperm and injecting it directly into an egg to fertilize it. In both IVF and IVF-ICSI, the lab dish is observed and if the egg is fertilized, the embryo can be frozen. Later, after treatment ends and the woman is ready to try to get pregnant, the embryo is thawed and put back into the female's uterus to try to achieve a pregnancy.

A woman’s age and menopause status plays a large role in the chances of pregnancy, with a younger age at the time of egg retrieval resulting in higher potential for pregnancy.  The quality of the embryos also makes a difference. Some may not survive the thawing process. Some may not implant into the uterus correctly.

Egg (oocyte) freezing

Egg freezing (or oocyte cryopreservation) is also an effective way to help preserve fertility for women, although it has not been used as long as embryo freezing (described above). This may be a good choice for women who do not have a partner, do not want to use donor sperm to make a fertilized embryo, or if they have a religious conflict with freezing a fertilized embryo.

For egg freezing, mature eggs are removed from the female and frozen before being fertilized with sperm. This process might also be called egg banking. When the woman is ready to try to become pregnant, the eggs can then be thawed, fertilized by a partner's or donor's sperm, and implanted in her uterus to try to achieve pregnancy.

Ovarian tissue freezing

This procedure is still experimental. It involves all or part of one ovary being 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 in the pelvis (transplanted). Once the transplanted tissue starts to function again, the eggs can be collected and attempts to fertilize them can be done in the lab.

Ovarian tissue removal does not usually require a hospital stay. It can be done either before or after puberty.

Ovarian transposition

Ovarian transposition means moving the ovaries away from the target zone of radiation treatment. It’s a standard option for girls or young females 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. It’s usually best to do the procedure just before starting radiation therapy, since they tend to fall back into their normal position over time.

The success rates for this procedure vary. Because of radiation scatter, ovaries are not always protected, and patients should be aware that this technique is not always successful.

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.

Fertility-sparing surgery

For early-stage cervical cancer, the surgeon can sometimes remove the cervix (trachelectomy) without removing the entire uterus or ovaries. For early-stage ovarian cancer that only affects one ovary, the surgeon might be able to remove the one ovary that's affected and not the other. Both of these procedures can help preserve fertility. See the images below for more information.

Ovarian suppression

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. This is called ovarian suppression. The goal of this treatment is to shut down the ovaries during cancer treatment to help protect them from damaging effects. The hope is that reducing activity in the ovaries during treatment will reduce the number of eggs that are damaged, so women might be able to resume normal menstrual cycles after treatment. But, studies are not clear on the effects of this treatment as a way to preserve fertility. Experts do not recommend using ovarian suppression instead of cryopreservation or other proven fertility preservation methods.

The cost for the hormone injections can be high, and the drugs can weaken bones depending on how long they are used.  Because the drugs put a female into menopause, the most common side effect is hot flashes.

Progesterone therapy for early-stage uterine cancer

Younger women sometimes have endometrial hyperplasia (pre-cancerous changes in the cells that line the uterus) or an early-stage, slow-growing cancer of the lining of the uterus (adenocarcinoma). The usual treatment would be hysterectomy (surgery to remove the uterus). However, women with stage 1, Grade 1 endometrial cancer who still want to have a child might have the option to be treated instead with the hormone progesterone, via an intrauterine device (IUD) or as a pill. Many will go on to have removal of the uterus, fallopian tubes, and both ovaries after giving birth. Since they also have a high risk of ovarian cancer, many oncologists believe young women with uterine cancer should not freeze ovarian tissue and put it back into their bodies later on.

Options for women who are not fertile after cancer treatment

Donor eggs

Using donor eggs is an option for women who have a healthy uterus and are cleared by their doctors to carry a pregnancy but cannot conceive with their own eggs.  The process involves in vitro fertilization (IVF) (see above).

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. They can be paid or unpaid. Some women have a sister, cousin, or close friend who is willing to donate her eggs without payment. There are also frozen egg banks available from which women can purchase frozen eggs that are then sent to a fertility center for IVF.

Per regulations, egg donors are carefully screened for sexually transmitted infections and genetic diseases. 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. For known donors, 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.

The success of the egg donation depends on carefully timing hormone treatment (to prepare the lining of the uterus, if it's safe to give) to be ready for an embryo to be placed inside. The eggs are taken from the donor and fertilized with the sperm. Embryos are then transferred to the recipient to produce pregnancy. Continued hormone support might be needed until the placenta develops and can produce its own hormones.

It’s important that you research the experience and success rates of the IVF or fertility center you may use.

Donor embryos

A woman who has a healthy uterus and can maintain a pregnancy may be given the option to have in vitro fertilization (IVF) (see above) with donor embryos. These donated fertilized eggs do not have sperm or the egg of the couple trying to get pregnant. 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 had IVF and has extra frozen embryos.

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 usually free, so the cost to the cancer survivor involves the process to make the uterus ready to accept the embryo and having the embryo placed. But, there can be legal and medical fees that mount up.

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 or from egg or sperm donors. 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 male in the couple (or a sperm donor) 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.

Adoption

Adoption is usually an option for many people who want 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. Foster care systems and other agencies specialize in placing children with special needs, older children, or siblings.

Many adoption agencies or foster care systems state that they do not rule out cancer survivors as potential parents. But they may require you to be done with treatment, and likely will need some information about your type of cancer and quality of life. You may be able to find an agency that has experience working with cancer survivors. Cancer survivors have some legal protections (including against discrimination during adoption proceedings) under the Americans with Disabilities Act (ADA).

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.

Costs of adopting vary greatly, from around $6,000 (for a public agency, foster care, or special needs adoption) up to $35,000 to $50,000 (for private U.S. and some international adoptions, including travel costs).

You might 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.

Child-free living

Many couples, with or without cancer, decide they prefer not to have children. Child-free living allows a couple to pursue other life goals, such as career, travel, or volunteering in ways that help others. If you are unsure about having children, talk with your spouse or partner. If you are having trouble agreeing on the future, talking with a counselor or mental health professional may help you both think more clearly about the issues and make the best decision.