Women's fertility and cancer treatment

Sunday 1 May, 2016

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On this page: Chemotherapy | Radiotherapy | Surgery | Hormone therapy | Other treatments | Avoiding pregnancy during treatment | Monica's story | Fertility outcomes | Key points

Related pages: Women's options before cancer treatment | Women's options after cancer treatment


This section provides an overview of cancer treatments and how they affect women’s fertility. The most common treatments for cancer are chemotherapy, radiotherapy, surgery and hormone therapy.

Chemotherapy

Chemotherapy uses drugs to kill or slow the growth of cancer cells. These are called cytotoxic drugs. Chemotherapy drugs kill fast- growing cells such as cancer cells. The drugs can also affect other cells that grow quickly, such as the reproductive cells.

The risk of infertility depends on several factors:

  • the types of chemotherapy drugs used – damage to eggs is more common with chemotherapy drugs in the alkylating class
  • the dose and duration of chemotherapy treatment – the risk increases with higher doses and longer treatment duration
  • your age – the number and quality of eggs start to decline naturally as a woman gets older.

Chemotherapy can also reduce the hormones produced by the ovaries. This may cause some women’s periods to become irregular, but they often return after treatment ends. For other women, periods may stop, which will bring on menopause. After menopause, women can’t conceive children with their own eggs. For more information, see fertility outcomes.

Some chemotherapy drugs can also affect your heart and lungs. If the drugs cause long-term muscle damage, this may complicate a future pregnancy and delivery. Your specialist will talk to you about what precautions to take during pregnancy.

To find out more see Understanding Chemotherapy or call Cancer Council 13 11 20. 

Radiotherapy

Radiotherapy (also called radiation therapy) uses x-rays to kill cancer cells or damage them so they cannot grow and multiply. It can be delivered externally by external beam radiation, or given internally.

The risk of infertility will depend on the area treated and the dose (measured in grays) of the radiotherapy.

  • External or internal radiotherapy to the pelvic area for cancer of the rectum, bladder, cervix or vagina can cause the ovaries to stop producing hormones, which results in temporary or permanent menopause.
  • Treatment to the uterus can increase the risk of miscarriage, premature birth and low-birth-weight infant.
  • Radiotherapy to the brain may damage areas that control the production of hormones that stimulate the ovaries to release an egg each month.

If you have both chemotherapy and radiotherapy, the risk of infertility is higher.

To find out more see Understanding Radiotherapy or call Cancer Council 13 11 20. 

Surgery

Surgery that removes part or all of the reproductive organs, such as the ovaries, fallopian tubes, uterus and cervix, can cause infertility.

Removal of the uterus (hysterectomy)

A hysterectomy may be used to treat gynaecological cancers, such as cancer of the cervix, ovary, uterus and endometrium (lining of the uterus), and sometimes, cancer of the vagina. After a hysterectomy, you will be unable to become pregnant and your periods will stop.

Removal of the ovaries (oophorectomy)

If both ovaries are removed (bilateral oophorectomy), and if you haven’t already been through menopause, you will experience early menopause. You will no longer have periods or be able to become pregnant.

Removal of the whole bladder (radical cystectomy)

If bladder cancer has spread to the abdominal area, the uterus, ovaries, a small portion of the vagina and the fallopian tubes may be removed. If you have not yet gone through menopause, this will cause your periods to stop and you will be unable to have children naturally.

Reducing the impact on organs

Sometimes, it’s possible to save the reproductive organs (known as fertility-sparing surgery). This may be an option for some types of early-stage gynaecological cancers. See some examples of fertility-sparing surgery.

To find out more see Understanding Surgery or call Cancer Council 13 11 20. 

Hormone therapy

Hormones are naturally produced in the body; however, they can cause some types of cancers to grow. The aim of hormone therapy is to slow down the growth of the cancer.

A hormone receptor is a protein in a cell. Hormone therapy is used for women who have hormone receptors on their cancer cells. This means the growth of cancer cells is affected by the female hormones oestrogen and progesterone. Cancer cells with hormone receptors on them are said to be hormone receptor positive. There are two types of hormone receptors: oestrogen receptors and progesterone receptors.

Hormone therapy blocks the same hormones required for fertility, so it will delay the opportunity to try for a baby. However, it may be possible to store eggs or embryos before hormone therapy.

Anti-oestrogen drugs (such as tamoxifen, goserelin and aromatase inhibitors) are used to treat oestrogen-sensitive cancers to reduce the risk of recurrence. Many anti-oestrogen drugs are taken for several years. During this time, pregnancy should be avoided, as there is a risk the drugs could harm an unborn child.

If you are on hormone therapy and want to become pregnant, talk to your treatment team or fertility specialist about the advantages and disadvantages of stopping hormone therapy.

Other treatments

Other treatments for cancer include stem cell transplants, immunotherapy and targeted therapies.

Stem cell transplants often require high doses of chemotherapy and, possibly, radiotherapy. This is given before the transplant to destroy cancer cells in the body and weaken the immune system so that it will not attack a donor’s cells during the transplant. High-dose chemotherapy or radiotherapy may affect fertility.

The effects of immunotherapy and targeted therapies on fertility and pregnancy are not yet fully understood. Early research suggests some targeted therapy drugs can cause ovarian failure. It is important to discuss your fertility options with your cancer treatment team or fertility specialist.

Avoiding pregnancy during treatment

Some cancer treatments, such as chemotherapy or radiotherapy, can harm an unborn baby or cause birth defects.

As you might be fertile during some types of treatment, you will need to use your preferred form of contraception to avoid pregnancy during treatment.

Your treatment team and fertility specialists may also advise you to wait between six months and two years before starting fertility treatment or trying to conceive naturally. This will depend on the type of treatment you’ve had. For example, some chemotherapy drugs may have damaged any developing eggs.

Monica’s story

"I was diagnosed at age 29 with oestrogen-receptive breast cancer. My partner and I had been dating for a year and a half. Our relationship was strong and I wanted kids in the next 1–2 years. My older sister was having problems conceiving, so I didn’t want to wait and discover that I had the same problems.

From day one, the health professionals talked about fertility with us. However, when I mentioned to the medical oncologist that I was going to see a fertility specialist, her response was, 'A lot of people are concerned about their fertility, but we need to save your life.' I found her cold, but I didn’t want to regret not exploring my options.

The fertility specialist harvested eggs through the IVF process. We were able to use a drug that didn’t introduce more oestrogen to my body. The timing of the egg harvest also worked well with my cycle, so it was only a two-week delay before I could start chemotherapy. This timing made the medical oncologist more positive.

They can’t say how successful the IVF process is going to be – unfortunately, for me, they could only harvest one mature egg.

At this point, my partner and I had to decide: do we freeze my egg, or a combination of the two of us in an embryo? We needed to consider what would happen if we didn’t stay together for the long term. You know, it takes a lot of courage to acknowledge these difficult questions.

We decided to freeze an embryo, because the success rates of having a live birth from an embryo are slightly better than a frozen egg. We feel we will be together for a long time, so hopefully the embryo will give us the best chance possible when we want to have a baby."

Fertility outcomes

Many women are able to conceive after chemotherapy without medical assistance. However, about one in three women will experience one of the following issues.

Premature ovarian failure

During treatment, and for some time afterwards, you may go through premature ovarian failure. This means that your ovaries stop producing enough hormones or mature eggs. Premature ovarian failure may be temporary or permanent, and you will experience occasional or no periods, and symptoms similar to menopause (see below).

Temporary ovarian failure increases the risk of permanent ovarian failure or early menopause. However, if you have been in ovarian failure for a number of years, the chances of your ovaries functioning normally again decrease.

Early menopause

Early menopause (premature permanent ovarian failure) is when you stop having menstrual periods because you have no eggs left. The eggs may have been destroyed or damaged by treatment.

While menopause means you won’t ovulate, it is still possible to carry a baby if you have a uterus and use stored eggs or donor eggs.

"Having to go through menopause at a young age was unfair. I feel like I’m just this old washed-up woman." – Kate

Symptoms of early menopause may include:

  • a dry vagina
  • a loss/reduction of interest in sex (low libido)
  • hot flushes and night sweats
  • sleep disturbance
  • mood changes.

The sudden start of menopause can cause more severe symptoms than natural menopause because the body hasn’t had time to get used to the loss of hormones. Early menopause can also cause the bones to weaken (osteoporosis).

If your menopausal symptoms are severe, ask your doctor whether it is safe to use hormone replacement therapy (HRT). This replaces the hormones usually produced by the ovaries, and can be taken as tablets, creams or skin patches. Some women with a hormone-sensitive cancer may be advised not to take HRT.

There are also non-hormonal options, such as acupuncture, that you could try. Taking calcium and vitamin D tablets and performing some weight-bearing exercises to strengthen the bones can also relieve menopausal symptoms. Discuss the best options for your situation with your doctor.

"It feels like menopause is discussed as a treatment side effect, not as this massive impact on who you are as a person. I’m facing menopause 20 years earlier than my friends. It’s devastating." – Denise
Your feelings about early menopause

When cancer treatment causes early menopause, the impact can be dramatic. How you react may depend on your age.

If you are a young woman, experiencing menopause much earlier than you expected may affect your sense of identity or make you feel older than your age.

If you are an older woman, going through menopause earlier than you expected may be upsetting. On the other hand, you may feel relieved to not have to worry about regular periods and unintended pregnancy. This may lead to a new-found sense of freedom, confidence or control.

You may find it difficult to start new intimate relationships after going through menopause. See relationships and sexuality for some helpful information about support.

Key points

  • Treatments may cause premature ovarian failure and/or early menopause. This could be permanent or temporary.
  • Chemotherapy is drug treatment that can damage the ovaries and age them.
  • Radiotherapy, given externally or internally, may damage the reproductive organs and cause infertility or future miscarriage.
  • Surgery could remove the reproductive organs or cause scarring that impacts fertility.
  • Other treatments, including hormone therapy, can affect fertility.
  • You will be advised to avoid becoming pregnant during cancer treatment and for a period of time afterwards.

Reviewed by: Prof Roger Hart, Medical Director of Fertility Specialists of Western Australia and Professor of Reproductive Medicine, School of Women’s and Infant Health, University of Western Australia, WA; Dr Antoinette Anazodo, Paediatric and Adolescent Oncologist, Sydney Children’s and Prince of Wales Hospitals, Director of the Sydney Youth Cancer Service, NSW; Brenda Kirkwood, 13 11 20 Consultant, Cancer Council Queensland, QLD; Dr Michael McEvoy, Director of Clinical Services, Flinders Fertility, SA; Eden Robertson, Research Officer, Behavioural Sciences Unit, Sydney Children’s Hospital, NSW; Kayla Schmidt, Consumer; A/Prof Kate Stern, Head of Fertility Preservation Service, The Royal Women’s Hospital and Melbourne IVF, Head Endocrine and Metabolic Service, Royal Women’s Hospital and Clinical Director, Melbourne IVF, VIC; and Prof Jane Ussher, Centre for Health Research, Western Sydney University, NSW.