Infertility in Female Childhood Cancer Patients

Infertility can be a side effect of certain childhood cancer treatments. Infertility is the inability to produce children after a year or more of regular sexual intercourse without using any birth control methods.

Before therapy starts, families are encouraged to discuss the impact of treatment on the patient’s fertility or future ability to become pregnant and give birth. The pediatric cancer center may also have a fertility specialist who can consult with the family.

The organs of the female reproductive system work together so a woman can get pregnant, carry a developing human until time for delivery, and give birth.

How the Female Reproductive System Works

To understand fertility, it’s helpful to understand how the reproductive system works. Females have two ovaries. They are located in a woman’s pelvic area.

During puberty, the pituitary gland in the brain signals the ovaries to start making more estrogen and progesterone. These are hormones necessary for the reproductive system to work.

A girl is born with all the eggs she will ever have. Once a month, the ovaries usually release one egg. If sperm from a male fertilizes the egg, the female becomes pregnant.

The organs of the female reproductive system work together so a woman can get pregnant, carry a developing human until time for delivery, and give birth.

How Cancer Treatment Affects Fertility in Females

Treatment that affects a patient’s pelvic area, reproductive organs, and pituitary gland may have an impact on a patient’s fertility. The treatment may decrease the number of eggs or affect the quality of the eggs.

Chemotherapy

Drugs known as alkylating agents and certain other chemotherapy can cause problems with fertility.

Alkylating Drugs	Heavy Metal Drugs
Busulfan Carmustine (BCNU) Chlorambucil Cyclophosphamide (Cytoxan®) Ifosfamide Lomustine (CCNU) Mechlorethamine (nitrogen mustard) Melphalan Procarbazine Thiotepa	Carboplatin Cisplatin
	Non-classical alkylators
	Dacarbazine (DTIC) Temozolomide

Radiation and Surgery

Radiation or surgery to the pelvic area or to the region of the brain that contains the pituitary gland can have an impact on fertility.

Take Action Before Treatment Starts

Before treatment begins, parents and the patient, if old enough, should talk with the care team about the effect cancer treatment could have on the patient’s ability to have children.

If the treatment could affect fertility, ask the medical team what actions can be taken to protect fertility.
Find out the cost of treatments and if it is covered by insurance. Ask a social worker at your center for information about financial support resources.

Will treatment affect fertility? Ask the medical team what actions can be taken to protect it.

How much do the fertility preservation treatments cost? Are they covered by insurance? Ask a social worker at your care center about financial resources.

Procedures That Can Preserve Fertility

Before puberty

Ovarian Tissue Freezing

Ovarian tissue freezing (cryopreservation) involves removing tissue from an ovary. The tissue is cut into slices and frozen. After cancer treatment, doctors can place a slice of thawed tissue back into the body.

There is a chance the tissue could contain cancer cells. As such, there is a risk the cancer cells could spread after being implanted.
After puberty

Egg (oocyte) freezing (cryopreservation)

Egg freezing (also called egg or oocyte cryopreservation) is a procedure in which eggs are removed from the ovary and frozen. The patient receives hormones to stimulate the ovaries to produce eggs. The eggs are removed. Later the eggs can be thawed, fertilized with sperm in the lab to form embryos, and placed in a woman’s uterus.

Egg freezing is only an option for girls who have started having menstrual cycles. This option is not always possible because cancer treatment must be delayed for a few weeks to harvest the eggs. It can also be a risk for patients with tumors that are sensitive to hormones.

Embryo freezing (cryopreservation)

Embryo freezing (cryopreservation) is another way of preserving fertility. But this option is only available for women who have gone through puberty. Also, it requires a sperm donor.

For this option, the woman undergoes a procedure called in vitro fertilization (IVF). The woman receives hormones to stimulate the ovaries to produce eggs. The eggs are removed. Embryos are created by joining together the sperm and eggs. They are frozen. Later in life, one or two embryos can be placed in the woman’s uterus (womb) with or without the help of medications.

Like egg freezing, this option requires a treatment delay and involves the use of hormones.

Ovarian transposition (oophoropexy)

This option is usually only offered if the patient is having another surgical procedure because it is quite invasive. During this procedure, surgeons move the ovaries away from the area receiving radiation therapy. The goal is to move the ovaries within the pelvis where they can still function but won’t be exposed to radiation.
Before or after puberty

Ovarian shielding

When patients have radiation treatment or imaging tests that involve radiation, the medical team can place a protective cover over the outside of the body to protect the ovaries from damage. This shield protects the ovaries from scatter radiation when other parts of the body receive radiation.

Questions to Ask Before Treatment Begins

Consider asking questions such as:

Could treatment increase the risk of, or cause, infertility?
Are there other recommended cancer treatments that might not cause fertility problems?
Which fertility preservation options would you advise for me?
What fertility preservation options are available at this hospital? At a fertility clinic?
Would you recommend a fertility specialist (such as a reproductive endocrinologist) that I could talk with to learn more?
Is birth control also recommended?
What are the chances that my fertility will return after treatment?