Effect of Cancer Treatment on Fertility – Risks & Solutions

Posted on January 15th, 2020 by Hiba Farzin


Pregnancy is a very natural process. A lot of favorable conditions have to be met in both the male and the female partners for the natural happening of a pregnancy. Any kind of external disturbances like drugs or medication can sometimes interfere with the reproductive cycle. This may cause temporary or permanent infertility.

Cancer treatments like radiation and chemotherapy can cause infertility in men and women. In men, the damage of sperm-producing stem cells or testicles may lead to infertility. Women undergoing cancer treatments may lose fertility due to the damage of oocytes or maturing ova.

A woman will have all the oocytes for the lifetime in her ovary by birth. These oocytes later develop as mature ovum during ovulation. If the cancer treatment damages all the oocytes, the patient will no longer be able to reproduce.

The risk of infertility depends on various factors like:

  • age of the patient
  • type of cancer
  • the extent of spreading of the cancer cells
  • type of drugs used for the treatment
  • combination of drugs used
  • doses of drugs used
  • strength of radiation
  • the area where radiation is applied

The effect of cancer treatments on fertility will differ in men and women. Let’s see in detail how cancer treatments affect male and female fertility, preventive measures, and what can be done to have a baby after undergoing chemotherapy or radiation.

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Effect of Chemotherapy on Fertility

Chemotherapy is the method of treating cancer by using drugs that kills cancer cells and stops them from spreading. Different doses of drugs can be used individually or combined with other drugs to treat various types of cancers. Chemo drugs can circulate throughout the body along with the bloodstream. Thus it can be used to treat cancer affecting almost every part of the patient’s body.

Chemo drugs actually target fast-growing and multiplying cells. It destroys the cells that are in the process of splitting into two cells. The cancer cells grow and divide much more rapidly than normal cells in the body. This is the reason why chemotherapy can effectively identify and destroy tumors and cancer cells.

The chemo drugs may sometimes mistakenly identify normal cells as their target and may destroy them along with the cancer cells. Thus there is a high chance for damage to healthy tissues and organs. Damages caused to the reproductive tract, eggs, or sperm cells may lead to temporary or permanent infertility.

If the patient is undergoing chemotherapy directed to specific organs near the abdomen, the chances for severe fertility changes are higher. For example, Hyperthermic intraperitoneal chemotherapy (HIPEC) delivers highly concentrated and heated chemotherapy directly to the abdomen. The advantage of such organ-directed therapy is that it reduces the exposure of harmful levels of toxicity to other parts of the body.

Before starting the chemotherapy the patient and family should have a detailed discussion with the doctor regarding the possible consequences of chemotherapy. This would be helpful to plan ahead for the side effects. The doctor can explain what type of drugs will be used and what are the specific side effects for each of them. If the therapy uses drugs having a high risk of causing infertility, the patient should consider options for fertility preservation if necessary.

How chemotherapy affects fertility in men

Sperm production starts in men during puberty and it normally continues through the rest of their lives. Cancer treatments during childhood or early puberty can damage the testicles and stop them from producing sperms.

The sperm cells divide and multiply more rapidly compared to other cells in the body. As chemotherapy drugs work by identifying and destroying the cells that divide rapidly, it may mistakenly target the sperm cells. If all the immature cells in the testicles get damaged, no more maturing sperm cells can be produced. This can lead to permanent infertility.

Sperm production may slow down or stops completely after chemotherapy. In some patients, sperm production may return in 1 to 4 years, and sometimes it may take up to 10 years. However, if sperm production has not recovered within the first four years after chemotherapy, it is less likely to recover at all.

As per the studies of the American Cancer Society, some of the chemo drugs known to have the highest risk of male infertility are:

  • Actinomycin D
  • Busulfan
  • Carboplatin
  • Carmustine
  • Chlorambucil
  • Cisplatin
  • Cyclophosphamide (Cytoxan®)
  • Cytarabine
  • Ifosfamide
  • Lomustine
  • Melphalan
  • Nitrogen mustard (mechlorethamine)
  • Procarbazine

These drugs can cause permanent infertility if used at higher doses. If the male is undergoing chemotherapy over the abdomen or pelvic region, the risks of permanent fertility changes are even higher.

How chemotherapy affects fertility in women

Women infertility may be due to the following reasons:

  • Don’t have any healthy eggs
  • Eggs are unable to fertilize due to any damage in the reproductive tract
  • The fertilized egg is unable to implant and grow inside the uterus

The drugs used for chemotherapy can damage the eggs in the woman’s ovary causing permanent infertility. As per the studies of the American Cancer Society, some of the chemo drugs that have a higher risk of causing egg damage and infertility are:

  • Busulfan
  • Carboplatin
  • Carmustine (BCNU)
  • Chlorambucil
  • Cisplatin
  • Cyclophosphamide (Cytoxan ®)
  • Dacarbazine
  • Doxorubicin (Adriamycin®)
  • Ifosfamide
  • Lomustine (CCNU)
  • Mechlorethamine
  • Melphalan
  • Procarbazine
  • Temozolomide

Studies show that women who undergo cancer treatment before the age of 35 years have a greater chance for natural pregnancy after the treatment. At younger ages, women will have more ova in their ovaries. Thus there is a chance to have some undamaged ova even after the treatment. That is why young women who stop menstruating during their cancer treatments get periods a while after the chemo sessions are over.

Another concern for women undergoing chemotherapy is that their fertility may not last long as some eggs will be damaged during the treatment. Women will be fertile only until the ovaries keep releasing mature ovum. Once all the ova are released, fertility ceases.

Also, even if the women’s menstruation returns after chemotherapy, their fertility may not be certain. Consulting a fertility expert might be helpful to assess fertility and to know how long the fertility window would last.

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Effect of Hormone Therapy on Fertility

Hormone Therapy is used to treat cancers that spread and grow by the help of hormones released within the body. By inhibiting the production of the specific hormone, the growth of cancer cells can be stopped. It may be helpful to prevent the growth of the tumor or to slow down the spreading of cancer cells. For some patients, hormone therapy may be done to reduce the chance for cancer to return after treating with other methods. For patients who are not able to undergo surgery or radiation therapy, hormone therapy may also be done to reduce their symptoms.

Hormone therapy is widely used for the treatment of prostate cancer and breast cancer as these types of cancers are closely associated with hormones. Hormone Therapy works either by blocking the body from producing specific hormones or interfering with the behavior of hormones within the body.

Hormone therapy can cause side effects depending on how the patient’s body reacts to the therapy. Doctors can help the patient understand what to expect during and after the treatment and to be prepared in advance.

Hormone Therapy and Male Fertility

Some hormone therapies like Androgen Suppression Therapy, that are used to treat cancer can affect fertility and sperm production in men. They may also cause temporary sexual issues like lower sex drive and erection problems. Usually, these side effects are overcome after the treatment is stopped.

Hormone Therapy and Female Fertility

Hormone Therapy is commonly used to treat breast cancer and other types of cancer that can affect fertility. Women undergoing hormone therapy should be careful to avoid getting pregnant during the treatment. The Selective Estrogen Receptor Modulator (SERM) drugs used for hormone therapy have a high risk of causing birth defects.

Some hormone therapy induces temporary menopause and prevents ovulation. It is good to discuss the risks of infertility before starting hormone therapy.

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How Bone Marrow Transplant affects fertility

Bone Marrow Transplant may be done for some type of cancer affecting the bone marrow, bloodstream, or other body parts. The patient will have to undergo conditioning therapy to remove the malignant cancer cells or damaged bone marrow before the transplant. Usually, high doses of radiation and chemotherapy are provided to remove the cancer cells and prepare the patient to receive the new bone marrow. In most cases, this can lead to permanent infertility of the patient.

  • In men, sperm production may be completely stopped or all the immature sperm cells may get damaged
  • In female patients, the immature ova and reproductive tract may get damaged

As women are born with all the oocytes, once these oocytes are damaged, it will cause permanent infertility. In most cases, the woman’s ovaries permanently stop releasing eggs after Bone Marrow transplant.

If the patient is planning to have a child in the future, it is important to discuss the risks of infertility and methods for fertility preservation before starting their treatment and conditioning therapy.

To know more about Bone Marrow Transplant in India, see Bone Marrow Transplant in India – Cost, Process, Best Doctors and Hospitals.

Effect of Radiation Therapy on Fertility

During radiation therapy, the patient’s body will be exposed to high energy radiations to kill cancer cells. These radiations may damage the ovaries or testicles of the patient. The risk of infertility depends on the strength of the radiation and the amount of radiation absorbed by the ovaries or testicles.

Radiation applied to the brain can also lead to fertility issues. This is because some hormones involved in the reproductive cycle, sperm production, and ovum release are controlled and coordinated by the brain.

Radiation Therapy and Male Fertility

If the testicles or pelvic area is directly exposed to intense radiations, there is a higher chance for fertility changes. High dose radiations may destroy the stem cells that produce sperms.

For some testicular cancers, one or both the testicles may have to be radiated. If only one testicle needs radiation therapy, it is best to shield the other testicle with a lead shield. Shielding can also be done to protect the testicles from scattered radiations while applying radiation therapy to the abdomen and nearby areas. This may help to preserve fertility.

In the case of radiating both the testicles, the damage of sperm-producing stem cells is unavoidable. In such cases, fertility preservation must be done if the patient ever wants to have a child in the future.

Radiation Therapy and Female Fertility

If the radiation is applied over the abdomen or pelvic area, the ovaries may be exposed to a huge amount of radiation, and lots of eggs may get damaged. In some women, all the eggs may be damaged, causing permanent infertility. Patients undergoing radiation therapy after minor surgery to move the ovaries away from the radiation sites are found to keep some eggs alive and retain their fertility.

However, damage to ova can cause early menopause. The patient’s fertility may not last long even if the patient is able to retain fertility after the treatment. It is good to discuss the risks of infertility before starting radiation therapy.

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Effect of Immunotherapy and Targeted Therapy on Fertility

Targeted Therapy and Immunotherapy uses drugs different from traditional chemotherapy drugs. Targeted drugs work by targeting cancer-specific proteins, genes, or the tissue environment that contributes to the growth of cancer. The use of targeted drugs has increased recently. However, there is not enough information available about their effects on fertility.

Studies have shown that a particular targeted drug called Bevacizumab (Avastin®) can cause ovarian failure. Drugs like Thalidomide and Lenalidomide have a high danger of causing birth defects and are not recommended for pregnant women. Women who are treated using these drugs are often asked to use two effective methods of birth control during the treatment.

Immunotherapy works by attacking cancer cells or slowing down their spreading. Immunotherapy drugs make it easier for the patient’s immune system to kill the cancer cells. Sometimes these drugs may cause the immune system to mistakenly attack healthy cells of the body, which can cause side effects including fertility changes.

How to preserve male fertility

Compared to women, it’s much easier to preserve male reproductive cells or sperm. Fertility preservation is not a compulsory thing that one must do before commencing cancer treatment. It’s all up to the choice and priorities of the patients and their partners.

If the patient has reached the age of producing healthy and mature sperm cells, they can be retrieved and preserved for Assistive Reproduction Techniques in the future. This can be helpful in case of any undesirable fertility changes after the cancer treatment. Sperm retrieval may be done by ejaculation or by an outpatient procedure to collect cells directly from where they are stored.

Parents of children who undergo cancer treatment also must consider fertility issues and possible fertility preservation methods. Boys who survive cancer may face fertility issues when they grow old and reaches their reproducing age. If boys have reached puberty and sperm production has started, it is easy to retrieve the sperm cells and store them frozen. In cases of patients who have not reached puberty, cryopreservation of testicular tissue is feasible. However, this method is still experimental.

Just as preserving fertility, it is also important to prevent pregnancy during chemotherapy and radiation treatments. It is recommended to avoid unprotected sexual intercourse and pregnancy for atleast 6 months to 2 years after completing the treatment. This is because some patients will remain fertile even during the treatments, but there is a high chance that their sperms are damaged due the exposure to drugs and radiation. Pregnancy from such damaged sperms can cause serious birth defects to the child. Feel free to talk to your doctor about the best methods of birth control.

How to preserve female fertility

For women in their reproductive phase who are about to start cancer treatment, it is important to know about the possible consequences and fertility issues of the treatment. They must be counseled regarding their risks for permanent infertility and their options to preserve fertility before starting with the cancer treatment. Fertility preservation in female patients is more complex and requires invasive procedures for ovum retrieval.

In women at their reproducing age, only one ovum matures and gets released during a normal menstrual cycle. For fertility preservation, multiple ova are to be preserved to ensure success. Retrieving the ovum one by one as they mature naturally is not practically possible. Follicles are stimulated using hormones to produce multiple mature ova simultaneously. Hence the commencement of the cancer treatment can be delayed due to the need for hormone administration and medication for follicle stimulation.

The retrieved ova may be either preserved as such or fertilized using sperms and preserved as frozen embryos. If the patient is in a committed relationship or married, it is always better to go for embryo preservation as IVF using frozen ovum is less common and has a lesser success rate.

In girls who have not reached the age of ovulation, or have no time to wait for ovum maturation, the immature ovum, called oocytes can be retrieved from their ovary. The retrieved oocytes will be provided favorable conditions to mature in a laboratory environment. After in vitro maturation, the ova can be frozen and preserved for future use.

Another method for fertility preservation in females is oophoropexy. By this procedure, one or both the ovaries and the fallopian tubes will be moved away from the site of the application of radiation before the therapy begins. This may be done by suturing the ovaries and fallopian tubes to the abdominal wall. The procedure is also known as ovarian transposition.

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Importance of Fertility Preservation

Cancer patients and their loved ones will have to show immense courage to fight the painful disease. They might have to face unexpected hurdles in their journey of cancer treatment. People who survive cancer deserves to have a normal life with all the happiness. It’s quite natural that cancer survivors might feel like having a child after getting out of their fight with the disease.

At the initial stage of the disease and before starting treatments like chemotherapy or radiation, the patient will have options to preserve fertility. Later on, if the disease gets worse or the treatment has started, they may not have as many options or have no means at all. So, it is mandatory to put up a discussion with the doctor regarding the risks of infertility at the initial stage of diagnosis and treatment.

It might sometimes be hard for the patients and their families to consider the idea of fertility preservation while they are still trying to accept the reality of the disease and the treatments they have to go through. If the patient is not too old and has a chance to need a child ever in the future, they should consider their options.

Besides fertility preservation, there are options like adoption or using donor eggs/sperms. The choice is always up to the wish of the patient and their family.