About 1 million women of reproductive age are diagnosed with cancer each year. Receiving a cancer diagnosis may cause feelings of fear and anxiety about the future — and women who want to start or grow a family may wonder how cancer treatment will impact their fertility.

“Even though certain treatments like chemotherapy, radiation, and gynecologic surgery can affect fertility, I want patients to know that receiving a cancer diagnosis does not mean that you won’t be able to be a parent.” says Dr. Paula Brady, a reproductive endocrinologist and the director of the Oncofertility Program at NewYork-Presbyterian/Columbia University Irving Medical Center. “Many people think that fertility preservation is a very long, complicated process, but it usually takes only about two to three weeks or less, and it is often covered by insurance.”

Health Matters spoke with Dr. Brady to better understand how cancer treatment can affect women’s reproductive health, the different methods of fertility preservation available, and how each one works.

How does cancer treatment affect fertility?

It can be hard to predict what a patient’s fertility will look like after cancer treatment because not all types of cancer treatment affect fertility the same way, and some do not affect fertility at all.

Generally speaking, conventional chemotherapy and pelvic radiation can significantly reduce a patient’s ovarian reserve, though it depends on the type of chemo and radiation field. Some treatments may reduce ovarian reserve so much that women will enter a premature menopause as a result (meaning the ovaries can no longer produce eggs). Certain cancers, such as gynecologic cancers, may involve surgery on reproductive organs, which can certainly impact the ability to produce eggs and carry a healthy pregnancy. Treatment involving radiation to the pelvis or surgical removal of the uterus and/or both ovaries often poses the highest risk to future fertility. We know much less about the fertility effects of immunotherapy and other newly developed medications for cancer treatment.

What are the benefits of starting fertility preservation before cancer treatment?

Fertility preservation is essentially a backup plan or “insurance policy” for patients who may want to have children after their cancer treatment is complete.

If cancer treatments are expected to reduce a patient’s egg supply, then egg retrieval before treatment will have the highest yield. Additionally, simply the time required to treat cancer and monitor afterwards may impact fertility, since fertility naturally changes with age. All women are born with a lifetime supply of eggs, which decreases gradually both in quantity and quality over time, particularly after age 35.

Depending on the type of cancer and the patient’s health, it might be a while post-treatment before their oncologist gives them clearance to become pregnant. We want to make sure a patient’s health is stable before trying to conceive, and generally, we are not able to conduct CT scans or some other types of diagnostic tests for cancer recurrence while a patient is pregnant. Depending on how old a patient is when they’re diagnosed, it may be difficult to conceive once they’re cleared to do so. Fertility preservation can improve their chances of getting pregnant after treatment.

After receiving a cancer diagnosis, how soon should patients consider fertility preservation?

If someone receives a cancer diagnosis and wants to have children one day, it’s crucial to seek a consultation regarding the potential fertility effects as soon as possible.

Even if your oncologist does not mention it, I encourage patients to bring it up themselves, both to kickstart the process and because speaking with a fertility specialist can assuage a lot of anxiety and fear. We will work together to figure out the best course of action based on the patient’s individual needs.

What are women’s options for fertility preservation?

It’s important to consult with your oncologist and fertility specialist to determine which approach to fertility preservation is right for you. They may suggest one or multiple of the following options:

• Ovarian tissue freezing
  • For children and adolescents, we don’t always have the option of freezing eggs because puberty hasn’t started or completed yet. For those patients, we may consider ovarian tissue freezing, which requires a laparoscopy to remove either a part of or the whole ovary, which is then frozen. Ovarian tissue has a very high density of eggs, and in the future, it can be put back into the pelvis for fertility treatment or to restore hormone production. Although this method is much less effective for patients older than their early 30s, the upside is that it only requires a single procedure to remove the tissue, so it may be recommended if there is not enough time for egg or embryo freezing.

• Gonadotropin-Releasing Hormone (GnRH) agonist therapy
  • Before starting chemotherapy, patients may receive a medication called a GnRH-agonist that can help protect their egg supply. This is a class of medications that suppresses ovarian function, and there is strong data (for those being treated for breast cancer) that it is effective in protecting ovarian reserve and future fertility. It is administered as an injection, usually once a month or every three months, for the duration of chemo. Side effects may include fatigue, hot flashes, joint or muscle aches, mood changes, and with prolonged use, reduced bone density. While this method may be helpful in protecting fertility, it is not recommended as the only method, if possible.

• Egg or embryo freezing
  • Egg or embryo freezing are considered the most effective options for fertility preservation, which can be used in addition to GnRH agonist therapy. Both require about two weeks of ovarian stimulation using self-administered injections, culminating in an egg retrieval, which is an ambulatory procedure performed under anesthesia. The eggs are then frozen and, in the future, can be thawed and fertilized to generate embryos. If a patient is partnered or has a sperm source or donor identified, the eggs can be fertilized after retrieval to make embryos before freezing. Both are great options and just depend on the patient’s situation and what they are most comfortable with.

How do patients know which option is best for them?

When deciding which approach is best for a particular patient, a lot of it comes down to timing. If we are not able to wait two to three weeks to perform egg or embryo freezing, for instance, then GnRH agonist therapy or ovarian tissue freezing may be the only options.

It also depends on the patient’s overall health status. Some patients are very ill at the time of their cancer diagnosis and may not be good candidates for fertility preservation procedures before starting cancer treatment. For patients who are not able to complete fertility preservation before treatment, it may be possible to attempt after cancer treatment depending on their ovarian reserve and age, among other factors. We can also assist patients who may need egg or embryo donation, or gestational carriers if they’re not medically able to carry a pregnancy themselves in the future.

While fertility preservation isn’t guaranteed to have a 100% success rate, it can help many cancer patients take control of their reproductive future, especially when initiated early.