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100 answers about cancer and fertility

Approximately 130,000 of people diagnosed with cancer in the United States each year are in their reproductive years and 1,000,000 cancer survivors are diagnosed during their reproductive years. In "100 Questions & Answers About Cancer & Fertility," discover important answers to some of the most common questions. Read an excerpt:

Men
Understand that treating cancer is going to be the most important thing for a certain period of time, but there may come a day when you are in recovery and might then be glad that you [planned for] a child.

—Lisa, Wife of Esophageal Cancer Survivor

1. What is infertility in men?

For men, infertilityis the inability to father a child. It can be further defined as the inability to conceive after 1 year of unprotected

intercourse. In general, infertility occurs when you stop producing sperm or when your sperm is too damaged.

The World Health Organization has developed criteria to measure the normal quantity, speed, and shape of sperm. Anything below these numbers is considered low or compromised:

• Sperm concentration (quantity)—more than 20 million sperm per milliliter of ejaculate

• Sperm motility (speed)—more than 50% moving sperm in ejaculate

• Sperm morphology (shape)—more than 30% of sperm in ejaculate have normal shape

The average man has 60 to 80 million sperm per milliliter of ejaculate. Low or compromised fertility is defined as sperm concentrations of less than 20 million per cc of ejaculate, whereas sterility is generally defined as a complete absence of sperm (azoospermic). Some couples with slightly abnormal values may still be able to achieve pregnancy naturally or by using fertility treatments.

2. Is infertility the same as impotence?

Infertility is not the same as impotence. Infertility does not involve sexual functioning.

Not all cancers and cancer treatments cause infertility, but some do; thus, it is important to understand your individual risks. Cancer itself can cause infertility in men. For example, some men with testicular cancer and Hodgkin’s disease have low sperm counts before treatment starts. This could be due to the stress of cancer or the direct effects of the tumor.

Cancer treatments can also cause infertility. In general, the higher the dose and the longer the treatment, the higher the chance for reproductive problems. The following factors can influence your risk:

• Age

• Type and dose of medications

• Location and dose of radiation

• Surgical area

• Pre-treatment fertility status of patient

Chemotherapy, radiation, and surgery can all affect your reproductive

system. Table 1 in Appendix A shows whether your cancer treatments might put you at risk for infertility.

Chemotherapy

Chemotherapy kills rapidly dividing cells throughout the body—cancer cells and healthy cells, including sperm. Your age, the type of chemotherapy, and the dose of the medications can influence your risk. Certain chemotherapy agents are more damaging than others. Generally, alkylating agents are the worst.

Radiation

Radiation also kills rapidly dividing cells in or around its target area. For example, radiation to or near your testicles can cause infertility, but radiation to your chest will not. Radiation to your pituitary gland or hormone-producing areas

of your brain may cause infertility by interfering with normal hormone production. The location and dose of radiation will influence your risk.

Surgery

Surgery that removes all or part of the reproductive system, such as one or both of your testicles, may cause infertility. Accordingly, the location and scope of surgery influences your risk.

Bone Marrow and Stem Cell Transplants

Bone marrow transplants and stem cell transplants gen­erally involve high doses of chemotherapy, which increases the risk of infertility. Sometimes full-body radiation is used, which also presents a high risk. The combination of both of these treatments creates an extremely high risk for subse­quent infertility.

Gleevec (Imatinib)

Although research is limited, there seems to be no effect to men’s fertility from Gleevec, and it appears to be safe to father a child while you are taking Gleevec.

During my exam, the doctors found numerous tumors in my lymph nodes and spleen as well as a 6-inch tumor wrapped around my heart. I was shocked to hear the news about my tumors and then completely devastated when the oncologist told me that I might become sterile as a result of my cancer treatment.

—Brian, Hodgkin’s Lymphoma

4. Am I at risk?

Please refer to Table 1in Appendix A to better understand your risk of infertility after cancer. Research studies have not been conducted on every type of cancer and every type of treatment to evaluate reproductive outcome, and thus, it is not always possible to know your risk of infertility. If you have amore common type of cancer like non-Hodgkin’s lymphoma, testicular cancer, or leukemia, there may be studies to help calculate your risks. Discuss your individual risks with your cancer doctor.

5. Is fertility important to me?

If you are at risk for infertility caused by your cancer treatments,

it is important to think about the significance of parenting to you. You may want to consider whether you want to be a father one day and, if so, whether having a child genetically related to you is important. A few sample questions to ask might be as follows:

• Have I always wanted children?

• Would I prefer adoption to other parenthood options?

• Does it matter to me whether my children are biologically related to me?

• Am I open to using donor sperm or donor embryos?

• How many children do I want to have?

• How does my partner/spouse feel about all of these issues?

Understanding how you feel about parenthood will help you decide whether options such as sperm banking are worthwhile for you. For example, if you would like to have a biological child with your partner, sperm banking may be the best way for you to preserve that dream; however, if you have always wanted to adopt a child or to be a foster parent, then you might decide not to bank your sperm. It is important for you to think these decisions through because they may affect your parenting options for the rest of your life.

WOMEN

When I was first diagnosed, I thought that the only thing that mattered was surviving, but as the weeks ticked by and we were still waiting for the trial to open, I started thinking that there was a possibility that someday this whole cancer thing would be behind me—or at least on the very back burner. I knew if that were thecase, I would really want to have children. I also knew that my treatment might screw that up for me. I didn’t want to be greedy and start thinking about kids before I even took my first dose of Gleevec, but I also didn’t want to look back and regret not doing whatever I could to prevent that from happening.

—Erin, Chronic Myelogenous Leukemia

29. What is infertility in women?

Infertility is when you no longer produce mature eggs for ovulation or when you have some other condition that prevents you from getting pregnant or maintaining a pregnancy. Infertility is commonly defined as the inability to conceive after 1 year of regular unprotected intercourse; however, this definition does not always apply to cancer patients. Women who have been exposed to fertility-threatening treatments should not necessarily wait 1 year. Cancer survivors are usually advised to seek counseling before trying to conceive or after 6 months of unsuccessful efforts to get pregnant.

30. What is premature ovarian failure (premature menopause)?

In addition to causing immediate infertility, cancer treatments can also cause you to go into menopause early. Premature ovarian failure is defined as menopause before the age of 40 years.

All women are born with a finite number of eggs—you do not grow new ones. As you age, your supply of eggs naturally diminishes until you no longer have many viable eggs, and you enter menopause. Cancer treatments such as chemotherapy, radiation, and surgery can speed up this process by damaging or destroying your eggs.

If your cancer treatments wipe out your entire ovarian reserve, you will be infertile and in menopause immediately after treatment. If only some of your eggs were damaged, you

may be fertile after treatment. Even if you are fertile after treatment, your egg supply may have been reduced, and this will cause you to go into menopause earlier than you would have without cancer treatment. For example, a woman might resume menstruation and be fertile after receiving chemotherapy at age 25 and then go into menopause at age 35. Another woman might receive chemotherapy at age 32 and go into menopause immediately.

When I told Nick the news, he said, “I’d rather not have kids than not have you.” Hearing him say that made me cry. Since I had been diagnosed, I felt a little like damaged goods, and after failing at the embryo thing, I really did. To Nick, however, I was still a catch. He had told me many times before that I was the most important thing in his life, but I also knew he really wanted to be a dad. I was telling him that may never happen, and he was completely unphased by it. “All I care about is you getting better,” he said. As much I loved him for saying that, I hated to think that I—that we—might not be able to have everything we wanted in life.

—Erin, Chronic Myelogenous Leukemia

31. Does age play a role in fertility?

Age always plays a significant role in fertility for women. As discussed in Question 30, you are born with a fixed supply of eggs that diminishes as you age. When you no longer have enough viable eggs left, you are in menopause. Cancer treatments can accelerate the process by which your egg supply diminishes and, therefore, affect fertility and cause premature ovarian failure. Generally, the older you are when you enter treatment, the fewer eggs you have in your ovaries and, therefore, the more likely you are to be infertile or in premature menopause after cancer treatment.

35. How do I decide which options are best for me?

Several factors will influence which type of fertility preservation method is right for you, including:

• Do you have a male partner to provide sperm?

• Are you willing to use donor sperm?

• How much time do you have before starting cancer

treatment?

• Is your cancer likely to spread to your ovaries?

• What are your specific treatment risks?

• Do you have an estrogen-sensitive cancer?

• Do you have cancer in or around your reproductive system (cervix, ovaries, endometrium, etc.)?

• Do you have ethical or religious concerns about using assisted reproductive technologies?

Knowing the answers to these questions will help you select the best option for you.

If having a family is extremely important to you, do what is necessary

to preserve your fertility. [Your] health is the most important piece of the equation. The two must be considered and balanced.

—Mary, Cervical Cancer

36. Will I have to delay my cancer treatments to preserve my fertility?

Fertility preservation options vary greatly, and so does the time necessary for each procedure. Egg freezing and embryo freezing require 2 to 4 weeks, whereas ovarian tissue freezing is a 1-day outpatient procedure. Some women have a 4- to 6-week hiatus between surgery and the onset of chemotherapy or radiation, which may provide a window of opportunity to preserve your fertility. If you need to start treatment immediately, you may not have time for some of the available options. If fertility preservation is something that you would like to consider, talk to your oncologist about it as early as possible so that you have sufficient time before beginning your cancer treatments.

PARENTHOOD AFTER CANCER

85. Will my children be at risk for birth defects because of my cancer treatments?

This is one of the most common questions asked by cancer survivors. There has not been a vast amount of research done on the subject, but what has been done is very reassuring. The rate of birth defects in children born to cancer survivors (who have been exposed to chemo and radiation) is the same as the general public, 2% to 3%.

86. Will my children have a higher risk of getting cancer because I had it?

In most cases, having a cancer diagnosis itself does not appear to increase your chances of having a child who will develop cancer. Your child’s risk of developing cancer appears to be the same as that of the general public, unless you have a geneti­cally linked cancer or cancer syndrome. A small percent of cancers of the breast, ovary, colon, pancreas, and kidney may be hereditary. The list of truly genetic cancers is constantly being updated. Check with your doctor or a genetic counselor to understand better whether your cancer is hereditary.

If you do have a genetic cancer and the gene that causes it is known, you may be able to use a test called preimplantation genetic diagnosis (PGD) to screen your embryos for that gene to avoid passing it on. For more information about PGD, please see Question 87.

87. What is preimplantation genetic diagnosis? How is it used for cancer survivors?

Preimplantation genetic diagnosis (PGD) is a technique used during the IVF process to test embryos for genetic disorders. After embryos are created, they are allowed to mature in the laboratory for 3 days. After the embryos reach a certain stage of development, a single cell can be removed from the embryo and tested for the presence of certain genetic disorders. The embryos that do not contain the disorder can then be trans­ferred to your uterus or frozen for future use. The embryos that contain the genetic defect can be discarded or donated to research. Alternatively, some couples may also choose to im­plant embryos with known genetic disorders. For example, if the genetic disorder will result in a predisposition for a disease, couples may still choose to implant those embryos. Currently, PGD testing is available for these cancer predispositions:

• Breast Cancer 1 Gene

• Breast Cancer 2 Gene

• Familial Adenomatous Polyposis

• Gorlin Syndrome (Basel Cell Nevus Carcinoma Syndrome)

• Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer)

• Li-Fraumeni Syndrome

• Multiple Endocrine Neoplasia

• Neurofibromatosis Type 1

• Neurofibromatosis Type 2

• Rhabdoid Predisposition Syndrome

• Retinoblastoma

• Tuberous sclerosis Type 1

• Tuberous sclerosis Type 2

• Von Hippel-Lindau Disease

PGD makes it possible for individuals with serious genetic disorders to decrease the risk of having a child who is affected by the disorder. It is now possible to use this technique to help decrease the risk of passing on some cancer-related genes to your offspring. The list of detectable disorders is constantly being updated. Check with your reproductive specialist to see whether PGD can be used to identify the specific genetic disorder that you are concerned about. The average cost of PGD is $5,000 per cycle.

For more information on fertility after cancer, visit

Excerpted from "100 Questions & Answers About Cancer & Fertility," by Kutluk H. Oktay, MD, Cornell University Weill Medical College, New York Presbyterian Hospital, Weill Cornell Medical Center, Lindsay Nohr Beck, Fertile Hope, Joyce Dillion Reinecke, JD. Copyright 2007. Used by arrangement with Jones and Bartlett Publishers. All rights reserved.

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