Fertility and Cancer: FAQ for Women

What is the difference between infertility and premature ovarian failure?

Premature ovarian failure is one cause of female infertility. Premature ovarian failure means that a woman’s ovaries stop producing hormones or mature eggs long before the normal age of menopause. The average age at menopause is 51.

A woman is born with all of the eggs she will ever have and cannot produce more. Over time and with each menstruation, the supply of eggs decreases until the ovarian reserve is empty and results in menopause. Premature ovarian failure may be temporary or permanent but is often a side effect of damage to the ovaries from chemotherapy or from radiation therapy that is aimed at the pelvic area.

How do chemotherapy, radiation and surgery lead to infertility and premature ovarian failure?

Cancer treatments like chemotherapy are designed to kill rapidly dividing cells throughout the body while leaving other cells intact. Cancer cells divide rapidly, but so do the cells surrounding the maturing eggs in women. Thus, infertility is a potential side effect of chemotherapy treatment because damage to the ovaries can occur. Individual factors like patient age, drug type, drug combinations and total drug dose affect the chance of becoming permanently infertile. Generally, younger women have a better chance of regaining fertility.

Radiation therapy also kills rapidly dividing cells, but only in or around its target area. If the radiation field includes the brain, it may affect fertility by damaging areas that control hormone production. Radiation therapy aimed close to, or at the pelvic areas of the body can also cause infertility by directly damaging the ovaries. In some cases, a shield can be used to protect the reproductive system, or the ovaries may be moved out of the way in a minor surgery. The location of the radiation field and the total dose will affect each individual somewhat differently.

Surgery to remove part or all of the reproductive system can cause infertility. It is important to understand which organs will be impacted or removed and the subsequent effect on fertility. It may be helpful to ask your treatment team to show you diagrams of your operation and ask them to explain what to expect in terms of future fertility.

What is the difference between an egg and an embryo?

An egg, also called an oocyte, is a female reproductive cell. An egg contains only the genetic material of a woman. An embryo is an egg that has been fertilized with a sperm, which means it contains genetic material from both a woman and a man.

Will I have to delay my cancer treatments to preserve my fertility?

With some diagnoses there may be a window of time before you start treatment when you can preserve your fertility. For example, women with breast cancer could have a six-week hiatus between surgery and chemotherapy that could be used to preserve fertility. With other diagnoses there is only a short period of time before starting cancer treatments, so it is important to talk to your health care team about your options as soon as possible. The time required for fertility preservation treatment differs depending on the type you choose and your personal cycle. The average time is between two and six weeks, but it could be less. Sometimes your health care team may agree to delay your treatment so that you can undergo fertility preservation.

How long can eggs, embryos and ovarian tissue be frozen?

Eggs, embryos and ovarian tissue can be frozen indefinitely. Any potential damage occurs during freezing and thawing, so once frozen they can be frozen for many years. There are case reports of patients who froze embryos for more than 10 years and were able to to achieve pregnancy.

Does fertility ever return? If so, how long will it take?

If your period is going to return, it usually takes six months to one year, but it can take longer. The absence or presence of your period is not a definitive indicator of your fertility. If your period has not returned or is very irregular more than a year after treatment, you may want to consider fertility testing.

If I get my period back after treatment, does that mean that I’m fertile?

Getting your period back after cancer treatment is a good sign and may be an indication of fertility. However, it does not necessarily mean that you are still fertile. For example, there are hundreds of women at fertility clinics every day who get their periods but are struggling with infertility.

Loss of menstruation marks the beginning of menopause, but fertility begins declining approximately 10 to 15 years before menopause. In other words, you may resume menstruation but have trouble conceiving. It is important to remember that while producing and releasing normal eggs is an essential component of fertility, other abnormal conditions not associated with cancer treatment can lead to infertility. Testing your blood levels of FSH (follicle stimulating hormone) can help determine your ovarian health.

Does age play a role in fertility after cancer?

Yes, age plays an important role in a woman’s fertility. You are born with a fixed number of eggs that diminish as you age. When you no longer have any eggs in your ovaries or when your ovaries lose the ability to release eggs, you have entered menopause. Cancer treatments can accelerate this process by damaging your egg supply, which can cause premature ovarian failure and impact fertility.

How do I treat premature menopause after cancer?

If you are in premature menopause after cancer, it may be necessary for you to take hormone replacement therapy (HRT). Birth control pills provide sufficient HRT for most young adult cancer survivors, but other HRT options are also available. Taking HRT is a very personal decision, and you should discuss the benefits and risks of HRT with your physician. The safety of taking HRT may vary based on your cancer type.

Additionally, it is often recommended that young women experiencing menopause exercise and take calcium and vitamin D supplements. Bone density measurements should be done periodically and if thinning of the bone is detected, bisphosphonate (bone thickening drugs) treatment may be recommended. Ask your health care provider about bisphosphonates if you are considering pregnancy later with donor eggs or embryos.

If I am in menopause, can I carry a baby?

Yes, it is possible to carry a baby if you are in menopause. You will not be able to become pregnant naturally, but you can use previously frozen eggs, embryos or ovarian tissue, or you can consider donor eggs or embryos. As long as your reproductive system is otherwise healthy, you should be able to carry a pregnancy.

Does pregnancy after cancer cause recurrence?

Research in this area is limited, but reassuring. Current available research suggests that pregnancy after cancer does not cause or increase the risk of recurrence, even after breast cancer.

Do cancer survivors have a higher rate of miscarriage?

This is primarily a concern for women who have had radiation to the pelvic area. Miscarriage, pre-term delivery and low birth-weight infants are more common in women who have received radiation to their uterus. A specialist can evaluate whether there is damage to your uterus. To date, research does not suggest a higher rate of miscarriage rate after exposure to chemotherapy or radiation to other parts of the body.

Are there additional health risks associated with pregnancy for cancer survivors?

There are a variety of long-term health risks associated with chemotherapy and radiation treatments, such as damage to your heart or lungs, which could interfere with or reduce your ability to carry a pregnancy. To understand your specific health risks, you should ask your health care team about the possible side effects of your treatment before getting pregnant. If you are at risk for pregnancy complications, you may need to work with a high-risk obstetrician.

What is preimplantation genetic diagnosis (PGD)?

Preimplantation genetic diagnosis (PGD) is a technique used during in-vitro fertilization (IVF) to test embryos for genetic disorders. PGD makes it possible for individuals with serious inheritable disorders to decrease the risk of having a child who is affected by the disorder. For example, it is now possible to use this technique to help decrease the risk of passing on a cancer-predisposing gene to your offspring.

Does insurance cover fertility preservation or assisted reproduction treatments?

There are many insurance policies that fully or partially cover infertility treatments; you should call your insurance company to find out about your coverage. However, it is less likely that your insurance will cover fertility preservation as part of this coverage due to requirements associated with the diagnosis of infertility. A cancer patient generally will not meet that definition, since the patient is not infertile at the time of diagnosis. As a result, even if they have fertility coverage, they may be denied benefits because they do not meet the definition of “infertile.” Some patients with existing fertility coverage have successfully petitioned for coverage on the following grounds:

– Infertility is a side effect of a necessary medical treatment. Coverage for the testing, prevention and treatment of all other side effects for this treatment are covered. Fertility treatments should be treated equally in this scenario.
– Fertility treatments are covered by the plan, but only at the point that the patient is diagnosed with infertility. As a cancer patient, one has the unfortunate foresight to know they will be infertile and therefore the coverage should start prior to the diagnosis.

Here is an example of a drafted petition letter.

More and more legislators and insurance providers are considering this coverage. For more information about insurance laws in your state, please see the American Society for Reproductive Medicine’s website. And for more information insurance coverage read the Fertility and Insurance article.

What strategies can help me cope with the emotional aspects of infertility in addition to cancer?

Many cancer patients feel like cancer-related infertility is a double blow. Feelings of anger, denial, depression, resentment, blame, and lack of control are common and understandable. You may experience a wide array of emotions as you deal with fertility issues during your cancer journey. You may find it helpful to talk to trusted members of your support system or to a professional counselor or social worker to help you process these feelings. Learn more about finding a counselor.

If I didn’t preserve my fertility before my cancer treatments, is it too late to conceive, or do I have options?

It can depend on your type of cancer and treatment. You should seek specific answers to this question from your oncologist and have an evaluation by a reproductive endocrinologist.

Having regular menstrual cycles is a good sign that you may be able to conceive a pregnancy; however, a period does not always equate to fertility. If you are unable to conceive naturally, there are assisted reproductive technologies (ART) like in vitro fertilization (IVF) that can help you have a child. Other options include the use of donor eggs, donor embryos or adoption.

After cancer, how do I know if I am fertile?

This is best discussed with your oncologist initially and may require consultation with a reproductive endocrinologist. If you have been attempting to become pregnant for six to 12 months or longer without success, you may be experiencing infertility. Depending on your individual situation, including cancer type and treatment history, simple tests such as a blood test to measure pituitary gonadotropins may provide valuable insight.

For women, several factors can be considered. First, physical signs like resuming menstruation or menopausal symptoms can be helpful indicators. However, neither are guaranteed ways of knowing fertility status. Second, you may have hormonal tests such as FSH (follicle stimulating hormone) to gauge your ovarian reserve and reproductive capacity. The hormones can tell you if you are in a fertile, pre-menopausal or menopausal state. Hormone levels fluctuate and test results may vary greatly from month to month, so it is often recommended that you repeat the test several times with a reproductive endocrinologist to get the most precise results to help determine your parenthood options.

After cancer, how long should I wait to try to conceive?

Most patients are told to wait two years. This number stems from a few different factors. First, most cancers that come back do so in the first two years. Second, eggs exposed to chemotherapy and/or radiation may suffer genetic damage. For eggs, this damage is believed to repair itself within six months to two years. However, each individual’s situation is different. It is important to consult with your medical team to determine your circumstances. You will also want to consider your age and risk of premature ovarian failure. In general, women in their late thirties have a more difficult time getting pregnant. Some women who resume their menstrual cycles after cancer treatment may still be at risk for early menopause.

Is it safe to get pregnant and/or undergo in vitro fertilization (IVF) after breast cancer?

IVF does temporarily raise estrogen levels to above normal, which theoretically could cause breast cancer cells to grow and multiply. Some infertility treatments use hormones to mature multiple eggs during a menstrual cycle. This is called standard stimulation. These hormones can raise a woman’s estrogen levels, which is a special concern for breast cancer patients. Many breast tumors are sensitive to estrogen, and higher estrogen levels may speed the growth of cancer cells.

Hormones are not needed for all infertility treatments, but they are usually needed for embryo freezing and egg freezing. Some doctors may approve standard stimulation for breast cancer patients if chemotherapy starts immediately afterward. Breast cancer patients can also choose from alternative stimulation methods that may be safer. It is important to consult with both your oncologist and a reproductive endocrinologist to learn about all of your options and make the best treatment decision for you.

Estrogen levels are also high during pregnancy, but not as high as peak levels during IVF. Studies to date do not show that pregnancy after breast cancer triggers cancer recurrence.

If I froze eggs or embryos prior to treatment, but am still fertile after treatment, should I use the frozen eggs or embryos or try to conceive naturally?

This decision should be made with the help of a reproductive endocrinologist. Most fertility specialists would recommend that cancer survivors who recover fertility should try to conceive naturally with the eggs they are producing, given that we do not have any proof of an increased risk of birth defects in children born after cancer treatment. Fresh eggs are generally preferred over frozen eggs or embryos, but there are other factors to consider in individual situations.

If I froze eggs, embryos or ovarian tissue prior to cancer treatments, but I never use them, or I have some that I don’t plan to use, what do I do with them?

If you choose not to use eggs, embryos or ovarian tissue, you generally have three choices:
– Discard them
– Donate them to research
– Donate them to another person or couple who is trying to conceive

This is a very personal decision. Generally, prior to freezing any of these tissues your fertility specialist will ask you to decide what you would like done in the event of your death, divorce or any other unforeseen circumstances. For example, if in the event of death you would like to leave frozen eggs or embryos to your partner or another family member, you would need to create an advance medical directive outlining these wishes. It is always recommended that you speak with a licensed professional counselor or social worker when considering your options. If your fertility center does not offer these services, you can seek out a medical social worker, faith leader or personal counselor. You may also consider speaking with a legal representative to discuss your rights and options.

Are birth defect rates in children born to cancer survivors who underwent chemotherapy and/or radiation higher than the rates of birth defects in children whose parents have had no such treatment?

Rates of birth defects in the general population are two to three percent. Studies strongly suggest that children born to cancer survivors are no more likely than the general population to have birth defects. A few types of cancer (approximately five to 10 percent of all cancers) involve a mutated gene that can be passed from parent to child. If you have a strong family history of cancer you may want to consult a geneticist or genetic counselor to see if your children would have higher lifetime cancer risks than usual. Research suggests that no unusual cancer risk exists in the offspring of cancer survivors except in families identified with true genetic cancer syndromes, for example, inherited retinoblastoma.

Do other diseases or treatments lead to infertility?

Yes, hundreds of other diseases and treatments can lead to infertility. For example, lupus, multiple sclerosis and rheumatoid arthritis patients may undergo chemotherapy and therefore be at risk for infertility and premature ovarian failure. Even common diseases like diabetes and health risks such as obesity or smoking can contribute to infertility. It is important to ask your medical team about the effects of any diseases or treatments that may negatively impact your reproductive system.

Do cancer survivors have trouble adopting given their medical history?

There is no published research on this subject. Anecdotally, most adoption agencies state that they do not rule out cancer survivors as parents. However, adoption agencies often require medical examinations and/or a complete medical history. Most want a letter from an oncologist saying that the survivor has a good prognosis. Some also require that a cancer survivor wait until reaching their five-year cancer-free anniversary before being eligible to adopt. Some of the countries that allow international adoption will not work with cancer survivors, or require a certain number of cancer-free years. Adoption methods vary greatly from public to private and domestic to international. It is important to research and understand the health restrictions of the agencies you choose to work with. 

My child is prepubescent. Are the options available now viable for long-term fertility?

For prepubescent girls, ovarian tissue or immature eggs can be frozen. Treatments are still experimental with limited data on success rates, especially when used for children. Currently those treatments are the only options available for prepubescent girls undergoing chemotherapy. For prepubescent girls undergoing radiation to the reproductive area, ovarian transposition is another option that could preserve fertility. You can learn more about pediatric cancer and fertility in our articles Fertility for Prepubescent Boys with Cancer and Fertility for Prepubescent Girls with Cancer.