How Blood Cancer and Its Treatments Affect Fertility

Effect of Chemotherapy and Radiation Therapy on Ferility and Options Available

What do you need to know about infertility as a side effect before you start cancer treatment?. Istockphoto.com/Stock Photo©Rohappy

How does cancer affect fertility?  What do I need to know before cancer treatment in order to plan ahead?

Although fertility problems are fairly well-known side effects of cancer and cancer therapy, they are often dismissed as an unfortunate consequence that nobody has any control over. Many people are unaware of how fertility is affected by these treatments or has an understanding of what can be done ahead of time to be fully prepared.

The truth of the matter is that while many blood cancer therapies can cause infertility, this is not the case for all treatments, and there may be something you can do about it. Your mind may be more focused on treating your cancer but take time to think about your fertility now.  It's thought that among young cancer survivors fertility ranks high in concerns - second only to hoping to survive the disease.

What Causes Infertility in Cancer Patients?

Cancer-related infertility can be temporary or permanent. Your ability to have children can be impacted by many factors:

  • The disease itself
  • Treatment side effects
  • Type of therapy you receive
  • Your age
  • Other medications or health problems you might have
  • Availability of fertility preservation techniques
  • Your religious or cultural beliefs about assisted reproduction (eg; in vitro fertilization and the like)

There is also a concern for some people that pregnancy could put a strain on a woman's body that would not be wise following cancer treatment.

How Do Blood Cancers Effect Fertility

Though more common in people of advanced age, some leukemias and lymphomas are common in young individuals of reproductive age or even children. Many blood cancer patients occur at an age when people haven't yet had the opportunity to start, or even think about starting, a family.

In the case of blood cancers, infertility is not usually caused by the disease itself, but more often by its treatment. The exception is Hodgkin lymphoma, which may cause a very low sperm count in males.

How Does Chemotherapy Effect Fertility?

Chemotherapy can impact both male and female fertility, but not all medications have the same effect. In men, chemotherapy can cause sperm to be absent in the semen (azoospermia). In women, it can cause an inability of the ovaries to release an egg cell (ovarian failure or early menopause).

For the most part, the total amount of a chemotherapy drug given over the weeks and months of treatment has a greater impact on fertility than the amount of the drug given in a single dose. Combination chemotherapy is more likely to cause damage to the reproductive system than single drug therapy.

In both men and women, the group of medications that are most likely to impact fertility are the alkylating agents. Some examples of alkylating agents include Cytoxan (cyclophosphamide), Ifex or Mitoxana (ifosfamide), Alkeran (melphalan), Myleran or Busulfex (busulfan) and Matulane (procarbazine.)

Since there are many factors which influence fertility in cancer patients, in addition to the medications you receive, it is difficult for specialists to be able to say for certain who will be affected.

How Does Radiation Therapy Effect Fertility?

Radiation therapy is often given in small doses (fractions) over a long period of time to reduce side effects and toxicities. Unfortunately, "fractionation" causes more damage to the reproductive organs than administering one large dose. When administering radiation, every attempt is made to shield reproductive organs when possible.

Even in small doses, radiation to the testes can decrease sperm count. This effect may be temporary or may be permanent if higher doses are used. Radiation may also cause a decrease in testosterone levels.

In women, the ovaries may be directly in the radiation field. In this case, the physician may choose to surgically move the ovary to another area of the body so it less likely to be damaged by the radiation. Young women are more likely than older women to regain their fertility after radiation.

Total body irradiation, as is sometimes used in preparation for stem cell transplant, will usually cause a permanent impairment in fertility of both men and women.

Fertility Preservation

It's important to consider the options you have if you should develop infertility before you begin treatment.  There are several options, but the choices among these are very personal.  Options that are available include:

Preparing for Male Infertiity

Thankfully, methods for freezing sperm are quite successful, making sperm banking a viable option for many men once they have reached puberty.  Options for men may include:

  • Sperm banking - freezing sperm for later use.
  • Sperm extraction - sperm may be extracted directly from the testicle if the sperm in semen are not mature, and either frozen or used for in vitro fertilization.
  • Testicular tissue freezing - It's still in the experimental stages, but scientists are looking at the potential to remove a testicle or part of a testicle for freezing, then reimplanting it in the body in the future.

Preparing for Female Infertility

Preserving female fertility is more difficult than in males, as techniques to freeze eggs have not been as successful as those to freeze sperm.  Options may include:

  • Freezing embryos/in vitro fertilization - freezing embryo's to either implant back in a woman's body after treatment or in a surrogate, has been used successfully for many women who have suffered infertility due to cancer treatment. Of course, this requires planning, and creating and freezing the embryo(s) before cancer treatment begins.
  • Freezing eggs - Attempts to freeze eggs have only resulted in a few hundred pregnancies, and the technique is limited by the ability to successfully freeze and thaw eggs without damage. 
  • Ovarian tissue preservation - This technique, as is freezing eggs, is still experimental, but involves removing an ovary or part of an ovary with hope that the tissue could be reimplanted after completing cancer treatment.

Questions to Ask Your Doctor

It is not uncommon for blood cancer treatment to cause infertility in both men and women. While this may seem like the furthest thing from your mind, it is important that you discuss your fertility options with your healthcare provider as soon as possible after your diagnosis.

Here are a few questions you may want to ask your doctor:

  • Is this therapy likely to affect my fertility?
  • Do you expect that this side effect will be temporary or permanent?
  • Is there anything that can be done to prevent infertility during my treatment?
  • Are there other treatment options that are less likely to cause infertility?
  • Will I have time before my treatment begins to explore my fertility preservation options?
  • Can I be referred to a fertility specialist to discuss my fertility preservation options?  (You don't need to know all about infertility treatment before cancer treatment, but a specialist can guide you through everything you should know at this time.)
  • If I remain fertile, will my future children be affected by my treatment?
  • How will I know if I am fertile or not?

Summing Up

Many people who have been faced with a life threatening condition experience a greater appreciation for the gift of life and the ability to create life. There are many factors that can influence the impact cancer treatment will have on your fertility. In many cases, it is impossible for doctors to predict. While it may be difficult, or even impossible, to get the most effective treatment for your cancer while preventing infertility, there may be options for you to preserve your fertility before beginning therapy.

It is important that you discuss all of your questions and concerns about becoming pregnant or fathering a child in the future before you begin treatment.

Sources

American Society of Clinical Oncology. Cancer.Net. Fertility Concerns and Preservation for Men. 03/2014. http://www.cancer.net/navigating-cancer-care/dating-sex-and-reproduction/fertility-concerns-and-preservation-men

Kim, SY., Kim, SK., Lee, J., and T. Woodruff. Toward precision medicine for preserving fertility in cancer patients: existing and emerging fertility preservation options for women. Journal of Gynecologic Oncology. 2016. 27(2):e22.

Krebs, L. “Sexual and Reproductive Dysfunction” in Yarbro, C., Frogge, M., Goodman, M., and Groenwald, S. eds. (2000) Cancer Nursing: Principles and Practice 5th ed.Jones and Bartlett: Sudbury MA. (pp.831- 854).

Lee, S., Schover, L. Partridge, A. et al. American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients. Journal of Clinical Oncology 2006;24(18):2917- 2931.

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