Parenthood Options for Women

Two additional factors to consider when planning a family after cancer are cancer recurrence and overall health. The likelihood of cancer recurrence is much higher in the first two years after treatment. Ultimately, your health care team will best advise you on the appropriate time for you to wait to ensure you are as healthy as possible based on your own health and particular diagnosis.

If you are concerned that your children may get cancer, know that unless your cancer is genetically linked, your child’s risk of developing cancer is the same as that of the general public (two–three percent). Only a small percent of cancers are known to be hereditary. Genetic cancer can be detected through a test called preimplantation genetic diagnosis (PGD). If birth defects are a concern, research shows that the rate for women who have undergone chemotherapy or radiation is the same as the general public, which is only two-three percent. Discuss your concerns with your health care provider prior to pregnancy or meet with a genetic counselor to better understand your risk factors.

Pregnancy Health Risks

There are a number of long-term health risks associated with chemotherapy and radiation treatments, such as damage to the heart and lungs. While it may not be immediately evident after treatment has concluded, damage may surface due to the stress a pregnancy places on your body. Aggravated existing health complications can impede your ability to carry a pregnancy. It may also make a pregnancy too dangerous for you to attempt.

Before trying to become pregnant your health care provider may require you to undergo an echocardiogram to ensure your heart is strong. In cases where your health care provider feels the risks are too high, you may need to work with a high-risk obstetrician or contemplate alternative options such as surrogacy or adoption.

Parenthood Options

There are many ways to become a mother after cancer. Many cancer survivors are able to conceive naturally after cancer treatment. However, the likelihood of natural conception after treatment may have been diminished. It is recommended you have your fertility tested prior to trying to conceive, or if you aren’t pregnant after six months-one year of trying, you may want to see a reproductive endocrinologist.

A doctor can measure your fertility with hormone tests and ovarian ultrasounds, and based on the results and your ability to carry a pregnancy, the following may be options for you:

Options for:	Methods to Achieve Pregnancy
Fertility Followed by Early Menopause	Natural conception Fertility preservation options in case you enter menopause before you complete building your family Conception with the help of a doctor Using frozen embryos, eggs or ovarian tissue Donor eggs or embryos Gestational surrogacy Adoption
Compromised Fertility	Natural conception Conception with the help of a doctor Using frozen embryos, eggs or ovarian tissue Donor eggs or embryos Gestational surrogacy Adoption
Immediate Menopause	Using frozen embryos, eggs or ovarian tissue Donor eggs or embryos Gestational surrogacy Adoption

Using Frozen Embryos

If you froze embryos before your cancer treatments, you can work with your reproductive endocrinologist to have them thawed and transferred to your uterus to try to get pregnant. You may have to take medications to build the lining of your uterus so that the embryos will implant and grow better. Even if you are infertile or in menopause, you can carry a baby using your frozen embryos if the lining of the uterus can be appropriately prepared. If your uterus has been removed, you may seek treatment using a gestational surrogate.

Frozen embryos are usually stored as small groups in separate vials so that you do not have to thaw and use them all at the same time. For example, if you have ten embryos frozen, you may decide to thaw three and keep the rest frozen. The number of embryos that will be put into your uterus at one time depends on your age and the quality of the embryos. Generally, between three and six will be thawed and one-five will be transferred per cycle. There is a trend towards implanting no more than two embryos at a time to try to prevent multiples (e.g., twins, triplets, etc.).

Three out of four embryos are generally expected to survive the freezing and thawing process with 30–40 percent of transfers resulting in live birth. Success rates vary from center to center and can depend on maternal age. The costs of using your embryos to get pregnant will average $12,400 per cycle of IVF with storage costs of $400 per year.

Using Frozen Eggs

Similar to using frozen embryos, if you froze eggs before your cancer treatments, you can work with your reproductive endocrinologist to create embryos and then use them to try to get pregnant. You may have to take medications to build the lining of your uterus so that the embryos will implant and grow better. Even if you are infertile or in menopause, you can carry a baby using embryos created from your frozen eggs.

First, your eggs are thawed. Then, they are fertilized using your partner’s sperm or donor sperm to create embryos using intracytoplasmic sperm injection (ICSI). The resulting embryos are transferred to your uterus.

The cost of using your frozen eggs to get pregnant varies from center to center and averages $11,900 per cycle with storage costs of $300 per year. Medications can range from $2,500 to $5,000. Using frozen eggs is generally more expensive than using frozen embryos due to the added cost of fertilization. Clinical pregnancy rates are 36-61 percent per transfer.

Assisted Reproductive Technology

Assisted Reproductive Technologies (ART) is the general term used to describe a number of different fertility treatments used by an OB/GYN or reproductive expert to assist you in achieving pregnancy. Post-cancer, if you are not yet menopausal but your fertility has been compromised, ART may be able to help. For example, if you are still menstruating and have normal hormone levels but you and your partner are struggling to conceive on your own, ART treatments may include:

Artificial Insemination/Intrauterine Insemination (IUI)

IUI is a short procedure (usually 5–10 minutes) during which a health care professional injects sperm into a woman’s uterus. The sperm is carefully prepared and put in the woman’s uterus at the time of ovulation (when the egg(s) are released). It can be performed in conjunction with a natural cycle or with fertility drugs. Fertility drugs generally increase the chances of success. The sperm will be put directly into your uterus through your cervix using a catheter. Sperm can be fresh or previously frozen and from your partner or a donor.

On average the success rates are 10–40 percent per cycle and 50–70 percent after six IUI cycles. There are no national statistics on live birth rates using IUI. Many couples choose this as the first step in treatment because it is less invasive and less expensive that other treatment options such as in vitro fertilization.

The average cost of IUI in the U.S. is between $300 and $750 per cycle. Monitoring and medications can be an additional $2,500–$5,000.

In Vitro Fertilization (IVF)

IVF is when your eggs are fertilized with sperm in the lab. The procedure takes approximately two weeks from the onset of your period. It includes daily, self-administered injections of hormones for approximately 10–12 days to stimulate egg development, as well as frequent blood work and ovarian ultrasounds to monitor your hormone levels and the development of your eggs.

This process causes ovaries to mature more eggs than they would in a natural menstrual cycle. For example, during a normal menstrual cycle one or two eggs mature whereas with ovarian stimulation as many as 10, 20 or 30 eggs could mature.

The eggs are retrieved through a 10–20 minute surgical procedure under general anesthesia. It is done vaginally by needle aspiration, so there are no scars. Once the eggs are collected, they can be fertilized in one of two ways. First, the sperm and eggs can be mixed together allowing the sperm to find and penetrate the eggs on their own. Second, through Intracytoplasmic Sperm Injection (ICSI), one sperm (usually the highest quality sperm as seen through a microscope) can be injected with a needle into the egg. The fertilized eggs create embryos that develop in the lab for three–five days. Usually one–three embryos will be transferred into your uterus and the remaining can be frozen for future use.

The success rates per embryo transfer (meaning live babies born from the procedure) is 30–40 percent in the U.S. and varies by maternal age and reproductive center.

On average, IVF costs $12,400 per cycle, not including medications which can range from $2,500–$5,000 or storage that can cost up to $400 a year.

Each one of these treatments has its own success rates, which vary based on several factors:

• Age at time of retrieval
• Quantity and quality of eggs retrieved
• Quantity and quality of embryos frozen
• Stage of embryos frozen or used
• Experience and success rate of your reproductive center

Using Frozen Ovarian Tissue

There are several ways to use ovarian tissue after cancer treatments. It can be re-implanted to one of the following three locations:

• Pelvic area (its original location)
• Under the skin in forearm
• Under the skin in the abdomen

There are two benefits to transplanting the tissue back into your body. First, the tissue can restore normal hormone function in your body. Second, eggs in the tissue will start maturing and can be used with IVF.

The average cost of transplanting the tissue back into your body may range from $10,000–$15,000. From there, the costs of using the resulting egg(s) to try to achieve pregnancy are similar to standard IVF, which averages $12,400 per cycle, not including the medications which can range from $2,500–$5,000.

Ovarian tissue freezing is an experimental procedure, and research is still being conducted on the risks of reintroduction of cancerous cells after transplanting tissue back into the body.

Ovarian Transposition

When the ovaries are moved away from the radiation field to minimize exposure and damage, their blood supply may be compromised and the ovaries may still receive some radiation. After transposition, there is a 79–100 percent rate of protection of ovarian function from the effects of pelvic radiation.

Radical Trachelectomy

For cervical cancer patients, the cervix is removed and the uterus is preserved prior to cancer treatment. However, undergoing radical trachelectomy results in an increased risk of miscarriage, early delivery or low birth weight after treatment.

Ovarian Suppression

The success rates of Gonadotropin Releasing Hormone (GnRHa) treatments are unknown. Some studies have suggested that GnRHa may be a successful option; however, there is skepticism in the medical community about its effectiveness due to limited research.

Donor Embryos

If you are infertile or in menopause after cancer treatment but would like to carry a pregnancy, the use of donor embryos might be an option. Embryo donation is relatively new and allows a couple to experience pregnancy and birth together but neither will have a genetic relationship to the child.

Most commonly, donated embryos come from another couple undergoing assisted reproductive technologies. Multiple embryos are frequently frozen, and when the couple chooses not to use their extra embryos, they may decide to donate them to another couple. It is less common to create embryos strictly from donor eggs and donor sperm. Either way, a thorough evaluation or screening of each potential egg donor is of critical importance, whether the donor is known to the recipient (e.g., a sister) or anonymous.

Any woman with a viable uterus who can sustain a pregnancy can try to achieve pregnancy with donor embryos. However, many IVF programs limit the upper age to 50–55 for medical and social reasons. Most recipients require hormonal treatments to predictably mature the lining of the uterus for the precise timing and coordination of the embryo transfer. Recipients with ovarian failure will require uterine preparation with estrogen and progesterone since they lack ovarian function. The embryos are thawed and transferred to the recipient to achieve a pregnancy. Following the transfer, the recipient continues hormone support until blood work shows that the placenta is self-sufficient, usually at eight–10 weeks.

There is limited information regarding the success rates of embryo donation, thus it is important to understand the IVF success rates of the centers you research. Frozen embryo transfer success rates vary by maternal age and average a 30–40 percent live birth rate.

The price of donor embryos average $5,000. The cost of using them to achieve pregnancy, as well as any necessary medications, are additional.

Donor Eggs

If you are infertile or in menopause after cancer treatments but would like to use your partner’s sperm and carry a pregnancy, the use of a donor egg may be an option. You may have to take medications to build the lining of your uterus so that the embryos will implant and grow. The resulting baby will be genetically related to the partner whose sperm was used and the egg donor.

Eggs can be donated to you from a known donor, for example, a friend or relative. They also can be donated from an anonymous donor. Egg donors can be found through your fertility clinic or through an egg donation agency. You can choose a donor based on physical characteristics, ethnic background, educational background or other criteria that you may value. Most donors are between 21 and 34 years old and have undergone basic psychological, medical and genetic screening. It is important to ask how candidates are screened, as some centers do more extensive tests and background checks than others. A thorough evaluation of each potential egg donor is of critical importance.

The eggs are retrieved from the donor, fertilized with sperm from the recipient’s partner or donor sperm and transferred to the recipient to achieve pregnancy. Following the transfer, you continue hormone support until blood work shows that the placenta is self-sufficient, usually at 8–10 weeks.

The success rates of using donor eggs range from 35 percent (using frozen eggs)–55 percent (using fresh eggs). The price of a donor egg cycle averages $22,000 for IVF, which includes the donated eggs, costs of fertility treatments and medications. Donor egg agency fees may also increase these costs.

Surrogacy or Gestational Carrier

Surrogacy is an option for women who do not want to or cannot carry a pregnancy. Surrogacy can entail use of the surrogate’s uterus and eggs or only her uterus.

Traditional surrogacy is when a fertile surrogate mother is artificially inseminated with the male partner’s sperm. The child will have the genes of the male and the surrogate, not the female partner. The female partner usually has to adopt the baby after birth. Traditional surrogacy is becoming less and less common.

Gestational surrogacy is when a woman carries a pregnancy for you but has no genetic relation to the child. The child is the genetic offspring of the couple, not the surrogate. Gestational surrogates may also carry babies created using both donor eggs and donor sperm.

The success rates are about the same as standard IVF, 30–40 percent. The costs of surrogacy vary greatly and can range from $60,000–$80,000. It is important to identify and understand the costs upfront. Surrogacy laws vary from state to state, and surrogacy is illegal in some states, so it is important to understand the laws where you live.

Adoption

Adoption is a viable option that can be considered by anyone seeking parenthood.

Adoption can be domestic, international, open or closed. Open adoption refers to a process in which the birthmother is known to you and you to her. The possibility for contact before and after the birth is possible. Closed adoptions are private in that you and the birthmother will have limited information about one another and no information about one another’s identities. You also may consider foster care with the possibility of adoption.

Regardless of which route you take, every state has laws that regulate adoption. In most cases, state-certified social workers will assist you in the process. Adoption agencies may be private nonprofit organizations, such as Jewish Family and Children’s Services or Catholic Charities. They may be local or state government bodies such as county child welfare service agencies. There are also for-profit organizations and lawyers that specialize in coordinating domestic and/or international adoptions.

Most adoption agencies report that they do not rule out cancer survivors as potential parents, especially with documentation from a doctor stating that lifespan and quality of life are expected to be good. However, some agencies do require a certain amount of time to pass before allowing a survivor to be eligible (e.g., five years). The adoption process takes time (six months–two or three years) and costs vary greatly, from $0–$40,000.

Adoption Tax Credit: To help reduce the financial burden of adoption, the United States government has established an Adoption Tax Credit. For the 2013 tax year, the credit per child is $12,970.For more information about the Adoption Tax Credit, see the IRS website.

The following organizations offer programs and services to help increase access to adoption:

• China Care Foundation provides low-interest loans and grants to families adopting special needs children or older children from China.
• Helpusadopt.org provides grants toward adoption expenses to qualified couples and individuals.
• The National Adoption Foundation provides direct grants to families trying to adopt.