by Samantha Yee, Co-Editor CKN OFRN Content, Social Worker, Centre for Fertility and Reproductive Health (CFRH), Mount Sinai Hospital. Doctoral Program, Factor-Inwentash Faculty of Social Work, University of Toronto
Some cancer types, cancer treatments and cancer drugs have side effects on the reproductive system, and may temporarily or permanently affect your ability to have children. The risks to fertility vary, and are highly dependent on your gender, your age at diagnosis, your cancer treatment and doses of drugs, and your past reproductive history. For males, it means they may have more difficulty getting their partner pregnant. For females, it means they may have more difficulty conceiving and carrying a pregnancy.
While not all cancer treatments pose a risk to fertility, it is important to ask your doctor if your cancer treatment could compromise your chance of having children in the future, and what you can do to preserve your fertility. Even if the idea of parenthood seems to be far ahead in the future and you are not thinking about having children now, or you have a partner but you are uncertain about having children, it is still important to think about fertility now so you can leave all options open just in case you change your mind.
Effects of cancer treatments on fertility
All girls are born with about one million of immature eggs in their ovaries, and the female body does not produce new eggs after birth. When a girl starts having periods (puberty), about 300,000 immature eggs remain although only a few hundred of them would mature into eggs. During a woman’s reproductive life, the ovaries will release one egg every month around day 10-14 starting from the first day of her period (menstrual cycle). The lining of the uterus also starts to build up so as to prepare the womb to carry a baby. If she has sexual intercourse during this time period, the egg may be fertilized with sperm to create an embryo, which may attach to the womb to begin the pregnancy process. Otherwise, the egg will be discharged with the womb’s lining as a period. The menstrual cycle is controlled naturally by hormones released in the pituitary gland until a woman stops having periods (menopause).
Some cancer treatments have negative side effects on reproduction and may cause changes in the hormone levels that control the menstrual cycle. The ovaries may slow down or shut down completely, failing to release eggs (premature ovarian failure), the periods may become shorter and irregular, and they may stop and not restart again (early onset of menopause or perimenopause). Also, some treatments can change the womb environment, making it more difficult for the embryo to grow and the baby to develop.
In some cancer types, such as breast cancer, it is not uncommon for patients to be on drugs to suppress their hormone levels for several years to reduce the chance of cancer recurrence. These drugs have a detrimental impact on pregnancy, therefore contraception is highly recommended to avoid getting pregnant by accident. However, by the time the patient finishes the drug therapy and is ready to have a baby, there will be a natural decline of fertility due to age.
When a boy reaches puberty, the pituitary gland starts to release hormones to stimulate the male reproductive organs to produce sperm, which are then stored in the testicles (the balls). A hormone called testosterone, which is released from the pituitary gland, controls sexual desire and arousal. When a male is sexually aroused, he has an erection. When an erect penis is stimulated through masturbation or sexual activity, he will eventually reach climax and a bodily fluid (semen) will release from the penis with millions of sperm (ejaculation).
Some cancer treatments may diminish sperm quality and quantity, or permanently prevent sperm formation or ejaculation. Following cancer treatment, some men may have low sex drive or have difficulties achieving an erection; some are able to ejaculate although there may be less sperm or in some cases, no sperm at all.
Fertility preservation options
While not all cancer treatments pose a threat to the reproductive system, you should consider preserving your fertility through banking your gametes (egg or sperm) or embryos (egg fertilized by sperm) before starting cancer treatment (fertility preservation or cryopreservation). Fertility preservation before cancer treatment should be considered regardless of your relationship status (single, partnered or married) and sexual orientation (straight, LGBTQ, or others). The decision is completely yours although preserving fertility prior to cancer treatment is highly recommended by cancer societies and oncology medical bodies.
Fertility doctors are medical specialists and a doctor’s referral is required. The medical appointments and basic fertility investigations are covered by provincial health care, and there is no cost for you to see a fertility doctor to discuss the side effects of cancer treatment on your fertility, and your cryopreservation options. Most fertility clinics give priority to cancer patients and you might be able to get an appointment within a few days.
Retrieving eggs from the ovaries for fertility preservation purposes requires the use of in-vitro fertilization (IVF), which is a time-sensitive procedure that takes about 2 weeks starting from the first day of a period until the day of egg retrieval. As timing is crucial to preserve fertility and to avoid delaying cancer treatment, it is important to ask your doctor to make a referral as soon as possible. For a list of fertility clinics providing fertility preservation services to cancer patients, please click here.
IVF involves the use of fertility drugs to stimulate follicle production in the ovaries. The process is monitored by blood tests to check the hormone levels, and ultra-sounds to track the follicle development in the ovaries. Once the eggs are retrieved from the ovaries, they will be fertilized with sperm in a laboratory to create embryos (day 3) or blastocysts (day 5 or day 6). The bank will assess the quality of the embryos and assign them a grade before freezing.
Frozen embryos offer a better chance to have a successful pregnancy than frozen eggs. For women (singles or lesbian couples) who do not have a male partner to provide sperm at the time of cancer diagnosis, donor sperm could be used to create embryos. The fertility clinics will provide you with information on sperm banks that have Canadian compliant donors. The decision to cryopreserve eggs or embryos is completely yours. If you are in a relationship, you can also choose to freeze embryos created using your partner sperm, and also freeze some of your eggs to maximize your parenthood options. For other fertility preservation options for women, please look here.
Frozen eggs and embryos can be stored indefinitely, and there are currently no laws in Canada to restrict the maximum length of time to keep the eggs and embryos in storage. On the consent form, you will be asked to provide advance instructions on how you want to manage your frozen eggs or embryos if the clinic is unable to reach you by any means, if you are mentally incapable of making treatment decisions, or in the event of death (advance directive of disposition options). Please note that providing advance directive is a standard procedure for the clinic, and it has nothing to do with your cancer diagnosis. On the consent form, you can select either discarding your frozen eggs or embryos, or donating them to research or medical training. You can change your decision at any time after the banking by signing a new consent form. It is very important for you to keep in touch with the clinic and to ensure that they have your current contact information on record.
Unlike cancer treatments, the costs to preserve fertility through IVF are not covered by public health except in the province of Quebec. In general, the cost per IVF procedure is around $7000-$10,000, but most fertility clinics offer discounts to cancer patients. There is also an annual storage fee following that to keep the frozen eggs or embryos in storage. Financial subsidies are available for low income families through Fertile Future’s Power of Hope Program. Pharmaceutical companies also offer compassionate fertility drugs to help those who do not have group insurance to cover medication costs. You can speak to your fertility doctors to get more information about compassionate drugs.
The most effective way to preserve fertility for adolescents and young men is to bank sperm before starting cancer treatment. Most fertility clinics provide sperm banking services to cancer patients. Speak to your doctor to find out the location of sperm banks near you. For a list of fertility clinics providing sperm banking services to cancer patients, please click here.
Most sperm banks do not need a doctor’s referral. You can call on your own, or ask your doctor to refer you. Almost all sperm banks give priority to cancer patients and you can get an appointment within a day to a few days.
Unlike cancer treatments, the sperm banking fees are not covered by public health except in the province of Quebec. The estimated cost per banking is a few hundred dollars, including the first year storage fee, and there is an annual storage fee following that to keep the samples in the bank. Financial subsidies are available to help people with low income.
Producing a sample by masturbation in an unfamiliar environment could create stress and anxiety. Some adolescents find that visual stimulation aids (e.g. swimwear or lingerie catalogues, soft pornography) are helpful to relax the mind to achieve an erection. Although the banks usually have magazines and DVDs available in the room, you may want to bring your own magazines to the appointment to make the process easier for you.
The bank will conduct a semen analysis to check the quantity (how many) and quality (size, shape) of the sperm sample before freezing. Sperm can be frozen indefinitely, and there are currently no laws in Canada to restrict the maximum length of time to keep the sperm in storage.
The staff will also ask you to do a routine blood test, and to sign a consent form to authorize the banking. On the consent form, you will be asked to provide advance instructions on how you want to manage your sperm samples if the bank is unable to reach you by any means, if you are mentally incapable of making treatment decisions, or in the event of death (advance directive of disposition options). Please note that advance directive is a standard procedure for the bank, and it has nothing to do with your cancer diagnosis. On the consent form, you can select either discarding the sperm samples, or donating them to research or medical training. You can change your decision at any time after the banking by signing a new consent form. It is very important for you to keep in touch with the bank and to ensure that they have your current contact information on record.
As long as you can produce sperm samples by masturbation, you do not need to involve your parents in the consent process. Your information is kept confidential and the staff will not discuss your case with anyone, including your parents, unless you have given them the permission to do so by written consent. Therefore it is entirely your decision as to how you want your parents or other family members to be involved in the banking process.
If it is not feasible for you to produce a sperm sample by masturbation, testicular tissue banking and testicular sperm extraction are methods to extract sperm to preserve fertility. However, these surgical procedures are invasive, and are considered experimental, with lower pregnancy success rates compared to using sperm produced by masturbation. For other fertility preservation options for men, please click here.
Fertility testing and family planning
After you are done with your cancer treatment, you can ask your doctor to conduct tests to check your fertility. For females, this involves blood tests to check hormone levels, and ultra-sounds or other diagnostic tools to assess uterus and ovarian functions. For males, it involves producing a sperm sample for analysis. The decision to have a fertility check-up or not is completely yours, although most people find it helpful to know their fertility status after cancer treatment. If your tests confirm no changes, you may want to think about how long you want to continue keeping your frozen gametes or embryos in storage. If the results show that your fertility is below normal levels, you may want to consider having children sooner rather than later.
Whenever you are ready to start your family using your frozen gametes or embryos, you can book an appointment to meet with a fertility specialist to discuss your fertility treatment plan. Although subsequent fertility cannot be guaranteed, many people who have undergone fertility-compromising cancer treatments are able to have babies through the use of assisted reproductive treatment (ART). Even if you are unable to use your own gametes or to carry a pregnancy on your own, you can still be a parent through adoption or using third party reproduction (donor eggs, donor sperm, donor embryos, or gestational surrogacy). The fertility clinics will be able to provide you with more information about different family building alternatives. In terms of the costs, Quebec is the only province that provides universal health coverage for ART services to all residents.
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