Fertility problems

Cancer and its treatments can damage the organs or glands in your body's sexual reproductive system. This damage sometimes affects your fertility, which is your ability to get or stay pregnant or to get someone pregnant and have a child.

Problems with fertility are sometimes temporary – they may happen only during cancer treatment or for some time after treatment. But other times, fertility problems do not go away. They are or can become permanent. This is often called infertility or permanent infertility.

Find out about the female sex organs and reproductive system and the male sex organs and reproductive system.

If fertility is important to you, try to talk about it with your healthcare team before you start cancer treatment. There are different types of fertility treatments that may help you. You may hear the terms assisted human reproduction or assisted reproductive technology. These terms refer to treatments and procedures used to achieve pregnancy. Your healthcare team may be able to plan your treatment in ways that increase your chances of staying fertile after treatment, for example, by choosing a treatment that starts later. And sometimes you can take steps in advance to plan for fertility problems, for example, by freezing your eggs or sperm.

Ask to be referred to a fertility specialist or clinic. 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 options, including long-term storage costs, and what is covered where you live
• your chances of having children using fertility treatments
• your legal rights and obligations

If your treatment needs to start right away or you are too ill to have fertility procedures done before starting treatment, a fertility specialist can help you explore your options after treatment. (When that time comes, it will be important to talk to your doctor about how long to wait before trying to get pregnant.)

If your child is being treated for cancer and is not old enough to discuss their future fertility, you can discuss fertility with your child's healthcare team. When you child is older or begins puberty, you can share this information with them. 

How cancer treatment affects your fertility depends on the type of treatment you have. Some surgeries for cancer can cause problems with fertility or even permanent infertility. For treatments other than surgery, the dose of treatment and the length of treatment may affect your fertility. Other things 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.

The following surgeries may affect your fertility.

If you have one ovary removed, you should be able to get pregnant because you have another ovary to make eggs and the hormones that you need for pregnancy. But if both ovaries are removed, your body can't make any eggs, so you won't be able to get pregnant using your own eggs. You will need to use an egg or embryo from a donor and fertility treatments.

If your uterus (womb) is removed, you cannot get pregnant because there is nowhere for a baby to develop and grow.

If you have one testicle removed, you can still get someone pregnant because you have another testicle that makes sperm and testosterone, the hormone that helps with erections and sexual desire. It is very rare to have both testicles removed, but if they are you will not be able to get someone pregnant by having sex. If you have sperm collected before both testicles are removed, you could get someone pregnant using fertility treatments.

If your prostate is removed, you will not be able to get someone pregnant by having sex. Your body needs the prostate to make semen. Without the prostate, you can still ejaculate when you have sex but it will be dry and won't have semen. (This is called dry orgasm or dry ejaculation.) But your body will still make sperm, which can be collected and used to get someone pregnant using fertility treatments.

Surgery for bladder or prostate cancer can sometimes damage the nerves to the penis or the prostate. This damage can cause erectile dysfunction, which means not being able to get and keep an erection firm enough to have intercourse. It can also cause dry orgasm or dry ejaculation, which means that there is no semen when you ejaculate. If you have either of these side effects, you will not be able to get someone pregnant by having sex. But your body will still make sperm, which can be collected and used to get someone pregnant using fertility treatments.

Radiation therapy to the pelvis or any of the reproductive organs can cause problems with fertility or permanent infertility. 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.

Radiation to the testicles can lower the number of sperm and affect the sperm's ability to work normally, which can make it harder for you to get someone pregnant by having sex.

Radiation for prostate cancer may cause erectile dysfunction, which means not being able to get and keep an erection firm enough to have intercourse.

Radiation to the ovaries can cause permanent damage that leads to treatment-induced menopause and a loss of fertility.

Radiation to the uterus can cause damage that affects your ability to stay pregnant.

Radiation 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. Fertility may return when treatment is finished. The younger you are, the better your chances of becoming fertile again.

In general, DNA damaging drugs called alkylating drugs can affect fertility the most.

Many chemotherapy drugs can affect the testicles so they make less sperm. These drugs can also damage the sperm cells so they don't work normally.

Chemotherapy drugs can stop the ovaries from working properly and releasing eggs (ovulation). The damaged ovaries and loss of healthy eggs can lead to treatment-induced menopause. This may be temporary or permanent and depends on many things, especially your age.

Hormone therapy used to treat some types of cancer may cause temporary loss of fertility during treatment and for a while after.

Hormone therapy for prostate cancer can stop the testicles from making sperm, or they may only make small amounts of sperm.

Hormone therapy for breast or ovarian cancer stops the ovaries from releasing eggs.

High doses of chemotherapy drugs and radiation therapy used during stem cell transplants often cause permanent infertility.

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.

Many people are able to get pregnant or get someone pregnant after cancer treatment. Your best chance for being fertile after treatment is by taking steps to preserve your fertility before treatment starts. Your fertility specialist can help you decide what the best options are for you, including the use of fertility treatments, depending on your age, the cancer type and your treatment plan.

Egg freezing removes mature eggs from your ovary and freezes them. When you are ready to become pregnant, your eggs can be thawed, fertilized with sperm in the lab (called in vitro fertilization, or IVF) and implanted in your uterus. Egg freezing is also called egg cryopreservation or oocyte cryopreservation.

You will be given hormone injections to increase the number of mature eggs that develop in your ovaries. After about 10 to 14 days, mature eggs are collected using a needle through the vagina to the ovary.

Embryo freezing removes mature eggs from your ovary and fertilizes them with sperm in the lab (IVF) to form embryos. The embryos are frozen and stored and can be implanted in your uterus when you are ready to get pregnant. Embryo freezing is also called embryo banking or embryo cryopreservation.

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. If you create embryos using sperm from an anonymous donor, the embryos are your responsibility.

Fertility-sparing surgery may be an option for you if the cancer you have is at a very early stage. Early stage cervical cancer may be treated with a radical trachelectomy, which removes the cervix and tissue from around the cervix, instead of a hysterectomy, which removes the uterus including the cervix. Early stage ovarian cancer may be treated by removing only one ovary.

Gonadotropin-releasing hormone (GnRH) drugs stop the release of the luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are made by the pituitary gland, and make you go into menopause for a short time. This helps to protect the ovaries and fertility during chemotherapy. These drugs are given as an injection a few weeks before treatment.

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, they are fertilized and become embryos. The embryos can be frozen until after treatment is finished.

While some babies have been born from IVM, it is not yet a standard fertility option.

Ovarian tissue freezing removes part or all of the ovary, freezes it and stores it. It can be done before or after puberty. When you are ready to become pregnant the ovarian tissue is implanted in your body, either on the other ovary or on another part of the body. Once the eggs mature, they can be removed, fertilized in the lab (IVF) and then placed in the uterus.

Ovarian shielding protects your ovaries or uterus or both from radiation therapy using a shield to help reduce any damage.

Ovarian transposition is surgery to move the ovaries to another area of the body to help protect them from radiation treatment. After treatment the ovaries are moved back to their original place. Ovarian transposition is also called oophoropexy.

Progesterone therapy involves taking the hormone progesterone. It may be used instead of a hysterectomy to treat early stage uterine cancer.

Sperm freezing collects and then freezes your sperm so that it can be used for pregnancy later. If you can't ejaculate in order to collect the sperm, there are other ways it can be collected:

• Electroejaculation uses an electric current to make you ejaculate by inserting a probe into the rectum near the prostate.
• Testicular sperm extraction (TESE) is a surgical procedure that removes tiny pieces of tissue and sperm cells from the testicle.
• Percutaneous epididymal sperm aspiration (PESA) uses a fine needle to remove sperm cells from the epididymis (the coiled tube that sits on top of the testicle, which stores sperm before ejaculation).

There are different ways to use sperm that has been frozen to fertilize an egg:

• Intrauterine insemination (IUI) uses a tube (catheter) in the vagina to insert sperm into the uterus around the time that the ovary releases an egg. IUI may also be called artificial insemination (AI).
• IVF places several thousand sperm with an egg in a sterile dish in the lab.
• IVF with intracytoplasmic sperm injection (IVF-ICSI) injects a sperm directly into each egg in the lab.

Testicular tissue freezing removes tissue from the testicles, freezes it and stores it. After cancer treatment has finished, the tissue can be transplanted back into one or both testicles.

Testicular transposition is surgery to move the testicles to another area of the body to help protect them from radiation treatment. After treatment the testicles are moved back to their original place.

You may wish to look into the following parenthood options.

Some people choose to use donor sperm or eggs using AI or IVF. The egg donor may be anonymous or known to you. Sperm donors are mostly anonymous and only frozen sperm are used. You may have to pay for using donated sperm or eggs.

Donated embryos usually come from a couple who have extra frozen embryos when they have finished their fertility treatments.

As long as you have a healthy uterus, you can have IVF with a donated embryo. If you use a donated embryo, you will have to get hormone treatments to prepare the lining of the uterus to receive 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. Live birth rates are also related to the age and health of the person having IVF. The chance of a live birth for a cancer survivor may be lower than for a surrogate because cancer survivors tend to be older and less healthy.

A surrogate is someone who gets pregnant and gives 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.

Surrogates can also be given donated embryos.

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.