If your child has cancer, it can be hard to think about his or her adult years. But now, 4 out of every 5 children survive their cancer. As these children grow into adults, the effects of cancer or its treatment on fertility, the ability to have children, becomes something to think about.
Some cancer treatments do not affect a child’s growing reproductive system. Others can damage a girl’s ovaries, which contain eggs, or a boy’s testes, which contain sperm. This damage may make it impossible to have a baby for a short period after completing cancer therapy or for the rest of the person’s life.
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Many types of chemotherapy, radiation therapy, and surgery can affect the reproductive organs and have long-term effects on a child’s reproductive health. These kinds of side effects from cancer treatment are called late effects. Your child’s risk of having late effects depends on his or her cancer type and treatment plan. Your child’s doctor can tell you if the planned treatments might have short- or long-term effects on your child’s reproductive health.
Cancer treatments and fertility
Chemotherapy. A type of chemotherapy known as alkylating agents is more likely affect fertility than others. Examples of these drugs include:
- Cyclophosphamide (Neosar)
- Ifosfamide (Ifex)
- Procarbazine (Matulane)
- Busulfan (Busulfex, Myleran)
- Melphalan (Alkeran)
Other drugs, like vincristine (Vincasar PFS) and methotrexate (multiple brand names), are less likely to affect fertility. Some of these drugs may cause short-term effects on a girl’s menstrual cycle (often called “period”), but do not cause early menopause (the time of life when menstrual periods stop). The damage to egg reserve and sperm and whether this may result in future infertility depends on the type and dose of cancer drug. In general, high doses of alkylating agents will cause permanent damage. Treatment plans for pediatric cancers often use the lowest doses of alkylating agents as possible. This lowers the risk of permanent damage to the reproductive organs. For many cancers, alkylating agents are not used at all.
Radiation. Radiation treatments can damage the ovaries or testes. The risk is greatest when the radiation is focused around the pelvic area, abdomen, spine, or whole body. Radiation therapy may damage eggs and affect the release of female hormones (ovarian insufficiency), which may initially appear as irregular or no menstruation. In boys, radiation can also damage sperm and affect the release of male hormones, which may result in infertility during adulthood. Children who have radiation therapy to their brains may also have fertility side effects because the signaling between the brain and the reproductive organs may be altered. However, this can be easily treated with hormones if the reproductive organs are not damaged.
Surgery. Sometimes cancer is found in the reproductive organs. In these cases, the doctor might suggest surgery to remove part or all of these organs. These surgeries may affect a person’s fertility.
Talking to your child about fertility
You and your child’s health care team need to discuss the risk of fertility side effects of cancer and its treatment. You will also need to talk about this with your child in a way that is appropriate for his or her age and development. Ask your child’s doctors and nurses to help and support you with this hard discussion. This talk should happen when you feel your child is ready and will understand the news.
Fertility is a complex idea, especially for children. But if a child is old enough to understand fertility before starting treatment, he or she should be involved in the discussion about how treatment may affect fertility. Ask if he or she wants to have any procedures that are intended to help preserve fertility. Children and teens are not able to give full legal consent because of their age. However, a child who can understand must generally agree (called “assent”) before these procedures can be done. Parents also must give consent before the procedure. Consent should only be given after you have been told about a procedure’s risks, potential complications, and success and failure rates.
Fertility options for children
Most parents want to make sure their children can have children of their own. There are options to help preserve fertility.
Current fertility-preserving options are limited for children who are diagnosed with cancer before puberty. The costs of these options can be high, too. Read the ASCO guidelines for fertility preservation.
Radiation therapy to the pelvic area may damage the uterus. Scarring from radiation therapy can slow blood flow to the uterus. This means that the uterus will not be able to enlarge during a pregnancy. This could make pregnancy difficult later in life or increase the risk of miscarriage and premature or low-birth-weight babies.
If radiation therapy is planned for the abdomen, sometimes the ovaries can be protected by surgically moving them away from the radiation area. If preventing damage to the ovaries is not possible, there are some other options, including freezing eggs, embryos, or ovary tissue.
Egg or embryo freezing. After a girl has gone through puberty, she can have her eggs or embryos frozen. Puberty usually occurs between the ages of 9 and 15. Embryo freezing is a technique in which eggs are taken from the ovaries, fertilized in a laboratory, and then frozen and stored. This technique is not often used in girls and teens because it requires sperm from a partner or donor. A more practical and increasingly successful option is to freeze eggs. Experts now are able to freeze eggs from girls as young as 12. This method requires about 2 weeks of fertility drug treatment, so girls who need to start cancer treatment right away cannot freeze mature eggs. When there is not enough time for ovarian stimulation, eggs can be collected with brief or no medication treatment. This yields immature eggs that need to be matured in a laboratory. This is called in vitro maturation and is being investigated. Success rates with this method are lower than when you freeze mature eggs with full ovarian stimulation.
Ovary tissue freezing followed by transplantation. It is not practical to perform ovarian stimulation to freeze eggs in girls who have not gone through puberty. One way to preserve fertility is to freeze ovary tissue in girls who have not gone through puberty and then transplant it later in life.
One experimental procedure involves removing ovary tissue and freezing it for future use. This usually is done with outpatient laparoscopic surgery and takes about an hour. . Laparoscopy uses a thin, lighted tube called a laparoscope. The laparoscope is inserted through a small incision in the abdominal wall to remove ovary tissue. When the girl wants to become pregnant, the tissues can be transplanted back into the pelvis during an outpatient procedure. If the surgeons do not think the pelvis is best for transplantation, tissues can even be transplanted under the skin. This method is sometimes called ovarian cryopreservation.
Because this technique is relatively new, a limited number of experts offer ovarian tissue freezing in the United States and around the world. For some types of cancer, it may not be recommended because of concerns that the ovarian tissue may contain cancer cells. A fertility specialist who has experience in ovarian tissue freezing and transplantation should determine whether you or your child is the right candidate for this procedure.
You may also decide not to take any action to preserve your daughter’s fertility if cancer treatment has a low risk of affecting fertility.
It is possible to prevent or lower the risk of damage in boys, too. For example, if your son is getting radiation therapy, his testicles could be shielded. There are a few other fertility options available, including sperm banking, testicular tissue freezing, and sperm aspiration.
Sperm banking. Sperm banking, also called cryopreservation, is a common, noninvasive option. It is only possible with boys who have gone through puberty. Most boys have some sperm in their semen by about age 13. Sperm are collected and frozen. The sperm are then stored in a special facility. Some hospitals have sperm bank programs. There are also clinics that specialize in sperm banking.
Testicular tissue freezing. Boys who have not gone through puberty may be able to save sperm by freezing testicle tissue. This is an experimental approach and is still being studied, so its chance of success is not known. Some tissue from the testicles is collected and frozen. Hopefully, the tissue contains stem cells that will later produce mature sperm. The thawed tissue might then be put into the young man’s testicle. Or stem cells might be taken out of the frozen tissue and injected into the testicle. Currently, all of these options are being investigated. There have been no reports of testicular transplants in patients. For some types of cancer, your doctor may advise against tissue freezing because frozen testicle tissue could carry cancer cells back into the body.
Sperm aspiration. This is another option that is being studied for boys who have not gone through puberty. During this procedure, immature sperm cells are removed and stored for future use. The sperm would then be used to fertilize an egg in the laboratory by in vitro fertilization (IVF). After IVF, the fertilized embryo is put into a woman’s uterus.
You may also decide not to take any action to preserve your son’s fertility if cancer treatment has a low risk of affecting fertility. Many boys go through puberty after cancer treatment and are able to have children naturally. After puberty starts, a doctor can check your son’s semen to see if he is making sperm.
Questions to ask the doctor
Talk with your child’s doctor about how the treatment plan may affect fertility. Consider asking the following questions:
- Could my child’s treatment plan affect his or her ability to have children?
- Will this treatment affect my child’s ability to go through puberty?
- For daughters: What are the chances this treatment will lead to early menopause? Can treatment affect some organs (like the lungs or heart) in a way that will increase the risk of problems during pregnancy or labor?
- Are there other treatments that are not as risky but just as effective?
- What options are available to preserve fertility before treatment begins? Will they affect how well the cancer treatment works?
- Would it be helpful to see a fertility specialist before treatment begins?
- I’m worried about the costs of preserving my child’s fertility. Who can help me with these concerns?
- After treatment, how will we know if my child’s fertility has been affected?
Moving Forward Video: Fertility for Young Adults with Cancer