SUPPORT CANADIANS LIVING WITH CANCER
Cancer and its treatment can damage the reproductive system. This damage can cause fertility problems that affect a woman’s ability to become or stay pregnant or a man’s ability to get a woman pregnant.
If you want to have children in the future, talk to your healthcare team before you start your cancer treatment. You can also ask to be referred to a fertility specialist or clinic. To have as many options as possible, fertility counselling should be done before your treatment starts. A fertility specialist can give you information about:
- how cancer treatment might affect your fertility
- the best fertility options for you
- the costs of the different fertility options, including long-term storage costs
- your chances of having children with assistive reproductive technologies (ART)
- your legal rights and obligations
If you are too ill to have fertility procedures done before you start your cancer treatment, there may be other options to help you with your fertility later. A fertility specialist can help you explore your options when you are ready to have children.
Oncofertility is a new medical speciality that focuses on ways to help people who want to have children after cancer treatment. There are some oncofertility specialists and clinics in Canada.
Funding for infertility treatments varies from province to province in Canada. Talk to your fertility specialist about what is covered in your province.
How cancer treatment affects your fertility depends on the type of treatment that you have. Other factors that affect fertility are your age and overall health, the type of cancer, how fertile you were before treatment and how much time has passed since you finished treatment.
Some surgeries for cancer can cause problems with fertility, or even permanent infertility.
In men, the testicles make sperm and the male sex hormones. Having 1 testicle removed with surgery shouldn’t affect your ability to have children, and it is rare that both testicles are removed. The prostate is a gland that makes fluid is mixed with sperm to form semen. If your prostate is removed, your body can’t make any semen. Surgery for bladder or prostate cancer can sometimes damage the nerves to the penis or prostate. This damage can cause problems in releasing semen or can cause erectile dysfunction, which means not being able to get and keep an erection firm enough to have intercourse.
In women, the ovaries make eggs and the female sex hormones. If both ovaries are removed, your body can’t make any eggs and you won’t be able to get pregnant. The uterus (womb) contains and nourishes a baby during pregnancy. If the uterus is removed, there is nowhere for a baby to develop and grow.
Radiation therapy to the pelvis or reproductive organs can cause temporary or permanent fertility problems. In general, higher amounts of radiation mean a greater chance that infertility will be permanent. Depending on the type of cancer and where it is, your healthcare team can try to preserve your fertility by shielding or protecting your organs during radiation treatments.
In men, radiation to the testicles can lower the number of sperm and affect a sperm’s ability to function normally. Radiation for prostate cancer may cause erectile dysfunction.
In women, radiation can cause permanent damage to the ovaries. This can lead to treatment-induced menopause and a loss of fertility. Radiation can also damage the uterus.
In both men and women, radiation therapy to the area of the brain that includes the pituitary gland can sometimes affect fertility. The pituitary gland makes hormones that stimulate the ovaries to make eggs and the testicles to make sperm.
Chemotherapy may cause fertility problems, depending on the type, dose and number of drugs used. In general, DNA damaging drugs called alkylating drugs can affect fertility the most. Although chemotherapy drugs can damage the ovaries, eggs and cells that make sperm, fertility may return when treatment is finished. Younger men and women usually have a better chance of becoming fertile again.
In men, many chemotherapy drugs can affect the testicles so they make less sperm. These drugs can also damage the sperm cells so they don’t function normally.
In women, chemotherapy drugs can stop the ovaries working properly and from releasing eggs (ovulation). The damaged ovaries and loss of healthy eggs can lead to early menopause. This may be temporary or permanent and depends on many individual factors. Age is a big factor – in general, the younger you are, the more likely you are to continue ovulating and remain fertile.
Hormonal drug therapy
Hormonal drug therapy used to treat some types of cancer may cause temporary loss of fertility.
In men, hormone therapy used for prostate cancer can stop the testicles from making sperm, or they may only make small amounts of sperm.
In women, hormone therapy used for breast and ovarian cancer stops the ovaries from releasing eggs.
Stem cell transplant
High doses of chemotherapy drugs and radiation therapy used during stem cell transplants often cause permanent infertility in both men and women.
Other cancer treatments
Newer therapies that are becoming more common to treat cancer include targeted therapy and immunotherapy. Because these types of therapy are just beginning to be used, we don’t know very much about their long-term effects on fertility. If you have been given one of these drugs as part of your cancer treatment, talk to your healthcare team about how these treatments may affect your fertility.
Sperm banking is the main fertility option for men. Sperm banking can only be used if you have reached puberty and your testicles are making sperm.
Sperm is collected before cancer treatment starts. A man collects and gives samples of his sperm to a sperm bank. If a man has problems ejaculating to collect sperm, sperm may be collected by electroejaculation. A special probe is inserted into the man’s rectum and placed near the prostate. An electric current is used to make the man ejaculate. Another way of making a man ejaculate to collect sperm uses a vibrator instead of an electric current. The samples are tested to look at the number of sperm, their shape and their ability to move (or “swim”). The sperm is then frozen and stored to be used later.
Testicular sperm extraction (TESE) and percutaneous epididymal sperm aspiration (PESA) are 2 other techniques used to collect sperm. TESE is a surgical procedure that removes tiny pieces of tissue from the testicle. PESA is a less invasive procedure. It removes sperm cells from the epididymus (the coiled tube that sits on top of the testicle that stores sperm before ejaculation) using a very thin needle (called fine needle aspiration). TESE or PESA may be used in men or boys before they start cancer treatments like chemotherapy. . It may also be an option for some men who can no longer ejaculate after surgery for prostate or bladder cancer.
The tissue or fluid removed during TESE or PESE is examined for sperm cells. Any sperm cells found can be used right away for IVF or they can be frozen for future use.
When you are ready to have children, there are several different ways that sperm can be used to fertilize a woman’s egg.
In vitro fertilization (IVF) uses a man’s sperm to fertilize a woman’s egg in a test tube in the lab. The fertilized egg is later implanted into the woman’s uterus.
Intracytoplasmic sperm injection (ICSI) injects a single sperm into a single egg. The fertilized egg is later implanted into the woman’s uterus.
Intrauterine insemination inserts banked sperm into the woman’s uterus after ovulation.
Fertility options for women include egg or embryo freezing.
Before either of these options can be done, mature eggs have to be collected from the ovaries. Sometimes cancer treatment has to be delayed so that there are enough eggs available for collection. If you have to start cancer treatment as soon as you are diagnosed, you may not be able to have your eggs collected.
Women are usually given hormones called gonadotropins to increase the number of mature eggs in the ovaries. Having a larger number of eggs increases your chances of getting pregnant in the future.
If you have a type of cancer that grows with hormones, such as breast cancer, you may also be given a drug called letrozole (Femara). This drug may be given with or without other hormone pills. Both gonadotrophins and letrozole stimulate the ovaries to help eggs mature, but letrozole helps prevent the high levels of estrogen in the body from causing cancer cells to grow.
After about 2 weeks of taking drugs to increase the number of mature eggs, you have day surgery to remove the eggs from the ovaries. A transvaginal ultrasound is used to look at the ovaries and find the mature eggs. With a transvaginal ultrasound, the ultrasound wand or probe is placed into the vagina and aimed at the ovaries instead of placing the probe on the surface of the abdomen. A needle is guided through the upper part of the vagina and into the ovary to collect the eggs. The eggs are then frozen or fertilized and frozen.
An embryo is an egg that has been fertilized by a sperm. You can use a partner’s sperm or donor sperm. In vitro fertilization is used to create embryos. The embryos are frozen and stored (cryopreserved). The embryos are implanted in a woman’s uterus at a later date.
A partner who has contributed eggs or sperm to embryos has legal rights to the embryos. This means that if you and a partner create and freeze embryos, you both have to agree about when the embryos are used or donated to others. Decisions made about embryos created with donor sperm are the responsibility of the woman who had her eggs fertilized with the sperm.
Banking or freezing eggs
Banking or freezing eggs is also called oocyte freezing or cryopreservation. After a woman’s eggs have been removed they are frozen. The eggs are later thawed and then fertilized with a man’s sperm, when a woman is ready to have children.
In the past, it was found that eggs did not freeze or thaw as well as embryos. Fertility clinics are now using a fast-freezing technique called vitrification, which may cause less damage to the eggs.
Some clinics will only offer egg banking or freezing to women older than a certain age. This is because younger women have more, and likely healthier, eggs. Different clinics use different ages.
Freezing eggs doesn’t result in as many successful pregnancies as banking or freezing embryos. But it is an option for some women, such as women who don’t have male partners or women who don’t wish to use donor sperm.
In some women with very early stage cancers of the female reproductive system, doctors may be able to offer surgeries that are less likely to affect fertility. These less invasive surgeries are offered only if they will not affect your prognosis.
A radical trachelectomy may be offered to women with early stage cervical cancer. The standard treatment is to remove the uterus (a hysterectomy), which means a woman can no longer get pregnant. In a radical trachelectomy, the uterus stays in place and only the cervix, upper part of the vagina, and some of the structures and tissues near the cervix and lymph nodes are removed. Find out more about a radical trachelectomy.
Removing only one ovary may be an option for some women with early stage ovarian cancer.
Progestin therapy may be offered to women with early stage uterine cancer, instead of a hysterectomy. Progestin drugs can slow the growth of cancer cells. Women who receive progestin therapy are watched closely for signs that the cancer is not responding to the treatment or is growing larger. The risks linked with progestin therapy for uterine cancer are a high rate of recurrence and spread outside of the uterus.
Find out more about hormone therapy for uterine cancer.
Other ways to be a parent
You may wish to look into the following parenthood options. You may also want to check with adoption agencies or seek legal advice on adoption or surrogacy.
Having cancer doesn’t rule out the possibility of adoption. Some agencies may require that you wait for a certain amount of time after treatment before you can adopt a child. Agencies may also require input from your doctor.
A surrogate is a woman who carries and give birth to a child for someone else. Surrogacy is legal in Canada, but there are rules to be followed. It is important to talk to a lawyer who specializes in surrogacy law to make sure that any agreement with a surrogate is legal and protects both the surrogate and the future parents.
Using donor sperm or eggs
Some couples choose to use donor sperm or eggs in artificial insemination. The egg donor may be anonymous or known to the couple. Sperm donors are mostly anonymous and only frozen sperm are used. You may have to pay for using donated sperm or eggs.
Using donated embryos
Donated embryos usually come from a couple who used assisted reproductive techniques and who have extra frozen embryos. Surrogates can also be given donated embryos.
A woman can have IVF with a donated embryo as long as her uterus is healthy. If you use a donated embryo, you will have to get hormone treatments to prepare the lining of the uterus receiving the embryo. The embryo is thawed and transferred to your uterus. You will continue hormone treatments until the placenta is working on its own. This usually takes 8 to 10 weeks after the embryo is implanted.
There hasn’t been a lot of research on the success rates of embryo donation, so it’s important to find out the IVF success rates at the centre where the procedure is done. Research shows that frozen embryo transfers have a lower live birth rate than fresh embryos. (This means that there are fewer babies born using frozen embryo transfers than fresh embryos.) Live birth rates are also related to the age and health of the woman who is undergoing IVF. Cancer survivors may be older and less healthy than a surrogate carrier who undergoes IVF with a donated embryo. So, the chance of a live birth for a cancer survivor may be lower than for a surrogate.
Researchers are studying ways to help preserve fertility. The techniques described below are promising, but we need more research to find out how well they work and if they have long-term effects for the children born when these techniques are used. There are concerns that some of the experimental techniques, such as tissue freezing, could reintroduce cancer cells, but we need more research to find out if this happens.
These experimental fertility options may not be available to everyone in Canada.
Freezing immature eggs
Freezing immature eggs is being studied as a possible fertility option to improve on the current methods that rely on mature eggs. Many mature eggs that are removed from the ovaries and frozen for future use do not thaw very well. Immature eggs may freeze and thaw better than mature eggs. If they do, the advantage of this method is that a woman does not have to take hormone drugs and wait for her eggs to mature in her ovaries. There have not been any babies born (these are called live births) with this method in women who have had cancer treatment. But women with other diseases have had babies using this method.
In vitro maturation (IVM)
In vitro maturation (IVM) is a new technique that removes immature eggs from the ovary before cancer treatment starts. The eggs are then put into a special solution to mature. Once the eggs have matured, the eggs are fertilized and become embryos. The embryos can be frozen until after treatment is finished.
The advantage of IVM is that a woman does not have to delay treatment to have drugs to stimulate her ovaries to mature the eggs. Studies have found that women younger than 38 still have a large number of immature eggs in their ovaries. While there have been some successful births from IVM, it is not yet a standard fertility option that is widely used.
Ovarian tissue freezing
Collecting ovarian tissue before cancer treatment starts may help preserve fertility. The entire ovary or a part of ovarian tissue containing immature eggs is removed and frozen. The ovarian tissue is kept frozen until a woman is healthy and there is no sign of the cancer.
When a woman is ready to have children the ovarian tissue is returned to her body. It is usually placed close to a fallopian tube. To make it easier to collect the eggs later, the tissue may be placed in other areas of the body like the abdomen or arm. Once the eggs mature, they are removed and fertilized in the lab. The fertilized eggs are then placed in a woman’s uterus.
Researchers are studying freezing ovarian tissue as a way to preserve fertility in women who need to begin treatment right away and can’t wait to prepare for egg collection. This method can also be used for women who don’t want to have the drug therapies used to mature the eggs in the ovary. Women may also choose this option if they don’t want to use donated sperm to create embryos to store for future use. Freezing ovarian tissue may be an option for girls who have not reached puberty.
While there have been some successful live births from ovarian tissue freezing, it is still being studied as a fertility option.
Freezing testicular tissue
Testicular tissue, including the cells that make sperm, may be removed by surgery, frozen and stored. After cancer treatment has finished, the tissue can be transplanted back into one or both testicles. This may be an option to have children for young men who have not reached puberty and do not have testicles that make sperm. There have not yet been any births reported using this experimental treatment.
A gonadotropin is a hormone released by the pituitary gland that stimulates the ovaries. There are 2 types of gonadotropin-releasing hormone (GnRH) drugs – GnRH agonist drugs and GnRH antagonist drugs.
In women, GnRH agonist drugs increase the hormones that cause the eggs in a woman’s ovaries to mature. But then they cause lower hormone levels that can last for a period of time. GnRH antagonist drugs immediately lower the hormones to stop the eggs in a woman’s ovaries from maturing. They may be safer to use than GnRH agonist drugs because they seem to cause fewer side effects.
Some, but not all, research studies show that using GnRH drugs during chemotherapy may help protect a woman’s ovaries and protect her fertility. Research is also comparing GnRH agonists and GnRH antagonist drugs to see which type is better at protecting a woman’s fertility during cancer treatment.
In men, GnRH agonist drugs, GnRH antagonist drugs and anti-androgen therapy may put the testicles into a “resting” state similar to the time before puberty. Some doctors think these drugs may protect the testicles and lower the chance of infertility in men after chemotherapy or radiation therapy. More research that includes long-term follow-up is needed before hormone therapy can be recommended to preserve a man’s fertility.
With some cancer surgeries, a woman may have her uterus removed, which means that she is not able to get pregnant. Researchers have been looking at transplanting a donated uterus into a woman who no longer has her own uterus. A woman is given drugs to stop her body from rejecting the donated uterus. Once the uterus is in place and healthy, drugs are used to prepare the uterus to have an embryo implanted. The baby is born by a Cesarean section, and the uterine transplant is also removed. There have been some live births in women with a uterine transplant, but much more study is needed before uterine transplantation is commonly used as a way to restore a woman’s fertility.
The group of organs and glands involved with sexual reproduction (having children, or offspring).
In women, the reproductive system includes the ovaries, fallopian tubes, uterus (womb), cervix and vagina. The ovaries make eggs (called ova). The ovaries also make the hormones estrogen and progesterone.
In men, it includes the testicles, prostate and penis. The testicles make sperm. The testicles also make the hormone testosterone.
One of a pair of small, egg-shaped organs inside the scrotum (the pouch of skin below the penis) that produce sperm and the male sex hormones.
Testicular means referring to or having to do with the testicles, as in testicular cancer.
Also called testis or testes (plural).
the chestnut-shaped gland just below the bladder and in front of the rectum that surrounds the urethra (the tube that carries semen and urine to the outside of the body) and produces fluid that forms part of the semen.
also called prostate gland.
One of a pair of small, round organs in the pelvis of females (on each side of the uterus, or womb) that produce germ cells (eggs) and the female sex hormones.
Ovarian means referring to or having to do with the ovaries, as in ovarian cancer.
The lower part of the abdomen between the hip bones that contains the urinary system and reproductive system.
Pelvic means referring to or having to do with the pelvis, as in pelvic exam.
The permanent end of menstruation (menopause) caused by damage to the ovaries due to chemotherapy or radiation therapy or the surgical removal of the ovaries.
Treatment with drugs that stop the production or block the actions of androgens (male sex hormones).
Anti-androgen therapy may be used to treat prostate cancer.