The most common treatments for cancer are chemotherapy, radiotherapy, surgery and hormone therapy. They can affect fertility in a variety of ways.
After cancer treatment, you may want to do some tests to see how your fertility has been affected. However, some people prefer not to know – it is up to you.
You may decide to wait until you feel physically and emotionally prepared to know the results – this may be months or even years later. A partner, friends, family or your medical team might provide support to you when you receive the results.
Topics on this page:
- Hormone therapy
- Other treatments
- Avoiding pregnancy during treatment
- Fertility outcomes
- Options before treatment
- Options after treatment
- Assessing fertility after treatment
- If cancer genes are present
Chemotherapy uses drugs to kill or slow the growth of cancer cells. These are called cytotoxic drugs. Chemotherapy drugs kill fast-growing cells such as cancer cells. The drugs can also affect other cells that grow quickly, such as the reproductive cells.
The risk of infertility depends on several factors:
- the types of chemotherapy drugs used – damage to eggs is more common with chemotherapy drugs in the alkylating class
- the dose and duration of chemotherapy treatment – the risk increases with higher doses and longer treatment duration
- your age – the number and quality of eggs start to decline naturally as a woman gets older.
Chemotherapy can also reduce the hormones produced by the ovaries. This may cause some women’s periods to become irregular, but they often return after treatment ends. For other women, periods may stop, which will bring on menopause. After menopause, women can’t conceive children with their own eggs. For more information, see Fertility outcomes.
Radiotherapy (also called radiation therapy) uses x-rays to kill cancer cells or damage them so they cannot grow and multiply. It can be delivered externally by external beam radiation, or given internally.
The risk of infertility will depend on the area treated and the dose (measured in grays) of the radiotherapy.
- External or internal radiotherapy to the pelvic area for cancer of the rectum, bladder, cervix or vagina can cause the ovaries to stop producing hormones, which results in temporary or permanent menopause.
- Treatment to the uterus can increase the risk of miscarriage, premature birth and low-birth-weight infant.
- Radiotherapy to the brain may damage areas that control the production of hormones that stimulate the ovaries to release
an egg each month.
If you have both chemotherapy and radiotherapy, the risk of infertility is higher.
Surgery that removes part or all of the reproductive organs, such as the ovaries, fallopian tubes, uterus and cervix, can cause infertility.
- Removal of the uterus (hysterectomy) – A hysterectomy may be used to treat gynaecological cancers, such as cancer of the cervix, ovary, uterus and endometrium (lining of the uterus), and sometimes, cancer of the vagina. After a hysterectomy, you will be unable to become pregnant and your periods will stop.
- Removal of the ovaries (oophorectomy) – If both ovaries are removed (bilateral oophorectomy), and if you haven’t already been through menopause, you will experience early menopause. You will no longer have periods or be able to become pregnant.
- Removal of the whole bladder (radical cystectomy) – If bladder cancer has spread to the abdominal area, the uterus, ovaries, a small portion of the vagina and the fallopian tubes may be removed. If you have not yet gone through menopause, this will cause your periods to stop and you will be unable to have children naturally.
Reducing the impact on organs
Sometimes, it’s possible to save the reproductive organs (known as fertility-sparing surgery). This may be an option for some types of early-stage gynaecological cancers.
Hormones are naturally produced in the body; however, they can cause some types of cancers to grow. The aim of hormone therapy is to slow down the growth of the cancer.
A hormone receptor is a protein in a cell. Hormone therapy is used for women who have hormone receptors on their cancer cells. This means the growth of cancer cells is affected by the female hormones oestrogen and progesterone. Cancer cells with hormone receptors on them are said to be hormone receptor positive. There are two types of hormone receptors: oestrogen receptors and progesterone receptors.
Hormone therapy blocks the same hormones required for fertility, so it will delay the opportunity to try for a baby. However, it may be possible to store eggs or embryos before hormone therapy – see Options before treatment.
Anti-oestrogen drugs (such as tamoxifen, goserelin and aromatase inhibitors) are used to treat oestrogen-sensitive cancers to reduce the risk of recurrence. Many anti-oestrogen drugs are taken for several years. During this time, pregnancy should be avoided, as there is a risk the drugs could harm an unborn child.
Other treatments for cancer include stem cell transplants, immunotherapy and targeted therapies.
Stem cell transplants often require high doses of chemotherapy and, possibly, radiotherapy. This is given before the transplant to destroy cancer cells in the body and weaken the immune system so that it will not attack a donor’s cells during the transplant. High-dose chemotherapy or radiotherapy may affect fertility.
The effects of immunotherapy and targeted therapies on fertility and pregnancy are not yet fully understood. Early research suggests some targeted therapy drugs can cause ovarian failure. It is important to discuss your fertility options with your cancer treatment team or fertility specialist.
Avoiding pregnancy during treatment
Some cancer treatments, such as chemotherapy or radiotherapy, can harm an unborn baby or cause birth defects.
As you might be fertile during some types of treatment, you will need to use your preferred form of contraception to avoid pregnancy during treatment.
Your treatment team and fertility specialists may also advise you to wait between six months and two years before starting fertility treatment or trying to conceive naturally. This will depend on the type of treatment you’ve had. For example, some chemotherapy drugs may have damaged any developing eggs.
Many women are able to conceive after chemotherapy without medical assistance. However, about one in three women will experience one of the following issues.
Premature ovarian failure
During treatment, and for some time afterwards, you may go through premature ovarian failure. This means that your ovaries stop producing enough hormones or mature eggs. Premature ovarian failure may be temporary or permanent, and you will experience occasional or no periods, and symptoms similar to menopause.
Temporary ovarian failure increases the risk of permanent
ovarian failure or early menopause. However, if you have been
in ovarian failure for a number of years, the chances of your ovaries functioning normally again decrease.
Early menopause (premature permanent ovarian failure) is when you stop having menstrual periods because you have no eggs left. The eggs may have been destroyed or damaged by treatment.
While menopause means you won’t ovulate, it is still possible to carry a baby if you have a uterus and use stored eggs or donor eggs.
Symptoms of early menopause may include:
- a dry vagina
- a loss/reduction of interest in sex (low libido)
- hot flushes and night sweats
- sleep disturbance
- mood changes.
The sudden start of menopause can cause more severe symptoms than natural menopause because the body hasn’t had time to get used to the loss of hormones. Early menopause can also cause the bones to weaken (osteoporosis).
If your menopausal symptoms are severe, ask your doctor whether it is safe to use hormone replacement therapy (HRT). This replaces the hormones usually produced by the ovaries, and can be taken as tablets, creams or skin patches. Some women with a hormone-sensitive cancer may be advised not to take HRT.
There are also non-hormonal options, such as acupuncture, that you could try. Taking calcium and vitamin D tablets and performing some weight-bearing exercises to strengthen the bones can also relieve menopausal symptoms. Discuss the best options for your situation with your doctor.
Your feelings about early menopause
When cancer treatment causes early menopause, the impact can be dramatic. How you react may depend on your age.
If you are a young woman, experiencing menopause much earlier than you expected may affect your sense of identity or make you feel older than your age.
If you are an older woman, going through menopause earlier than you expected may be upsetting. On the other hand, you may feel relieved to not have to worry about regular periods and unintended pregnancy. This may lead to a new-found sense of freedom, confidence or control.
You may find it difficult to start new intimate relationships after going through menopause. Relationships and sexuality may provide some helpful information about support.
Options before treatment
Wait and see
What this is: When no methods are used to preserve fertility.
When this is used: When a woman decides to leave her future fertility to chance.
How this works: Requires no action.
Special considerations: Not known.
Pregnancy rate: Depending on age and
Egg or embryo freezing (cryopreservation)
What this is: The process of collecting, developing and freezing eggs or embryos as part of an in-vitro fertilisation (IVF) cycle.
When this is used: When you want to store eggs or embryos for the future. They can be stored for many years. In some states of Australia, you will need to apply for an extension after eggs have been frozen for 20 years and embryos for 10 years.
If you have frozen eggs, embryos or ovarian tissue, check the time limits with the fertility centre, pay any annual fees and keep your contact details up to date.
Once you are ready to have a child, the frozen sample is sent to your fertility specialist.
How this works: Egg and embryo freezing is part of IVF – the most common and successful method for preserving a woman’s fertility.
The cycle starts with your period, and you have an egg collection mid-cycle, usually around day 14. This is a minor procedure in an operating theatre.
Special considerations: Your specialists will plan to delay cancer treatment or stop it during IVF.
Some women with advanced or hormone-sensitive cancer risk their cancer growing during hormone stimulation. In this case, tamoxifen, or more commonly, letrozole (anti-oestrogen drugs) may be used to prevent cancer growth. It may also be possible to skip hormone stimulation and collect a few eggs during the woman’s natural ovulation cycle or early in a cycle (in-vitro maturation of oocytes). More research is being done, so talk to a fertility specialist.
Pregnancy rate: Depending on your age, the success rate of the fertility unit, and the stage the embryos are stored at, there may be up to a 25–40% chance per cycle of an embryo developing into a pregnancy. About 10–12 mature eggs are collected during a cycle and these create an average of up to 4 embryos. Many thousands of babies have been born from mature eggs that have been frozen, and millions of babies have been born from frozen embryos. A modern technique called vitrification means that freezing eggs is equally as effective as freezing embryos. Some women prefer to freeze eggs, particularly as partners may change.
Ovarian tissue freezing (cryopreservation)
What this is: The process of removing, slicing and freezing a piece of tissue from the ovary.
When this is used: If there isn’t a lot of time before treatment, if hormone stimulation is unsafe, or if the patient hasn’t gone through puberty.
How this works: Tissue is removed during keyhole surgery (laparoscopy). Under general anaesthetic, a small cut is made near the bellybutton to access the pelvic area. If you are having pelvic or abdominal surgery as part of your cancer treatment, it can be done during this procedure. Tissue is frozen until needed. When you are ready to conceive, the ovarian tissue slices are transplanted (grafted) back into your body. Tissue can start to produce hormones, and eggs can develop.
Special considerations: The grafts may last a relatively short time (several months to several years), so this option is usually only suitable if you are ready to try for a pregnancy soon.
Pregnancy rate: To date, over 40 births worldwide.
Ovarian transposition (oophoropexy)
What this is: A type of fertility-sparing surgery.It involves moving one or both ovaries to preserve their function.
When this is used: When the ovaries are in the path of radiotherapy treatment.
How this works: One or both of the ovaries are moved higher in the abdomen – sometimes as high as the lowest ribs.
Special considerations: Not known. May cut off blood supply to the ovaries, causing loss of function.
Pregnancy rate: Depends on your age, the amount of radiation that reaches the ovaries in the new position and if you start menstruating again.
What this is: A type of fertility-sparing surgery. It involves removing the cervix, upper part of the vagina and lymph nodes in the pelvis to preserve reproductive organs.
When this is used: For small, localised tumours in the cervix.
How this works: The cervix is removed. The uterus is left in place. A stitch or band is used to partially close the uterus and work as the cervix. This opening is used for menstruation and for sperm to enter.
Special considerations: Mid-trimester miscarriage and premature delivery are more common. Women may be advised to have a stitch placed in the cervix to reduce miscarriage.
Pregnancy rate: Possible to become pregnant after a trachelectomy.
GnRH analogue treatment
What this is: Gonadotropin-releasing hormones (GnRH) are long-acting hormones used to cause temporary menopause. Reducing activity in the ovaries may protect eggs from being damaged.
When this is used: During chemotherapy or pelvic radiotherapy.
How this works: Hormones are given by injection 7–10 days before cancer treatment starts or within the first week of treatment. Injections continue every 1–3 months until cancer treatment has finished.
Special considerations: May be recommended as a backup to other fertility options, such as egg or embryo cryopreservation, or as the only form of infertility protection.
Pregnancy rate: Some studies suggest this treatment helps women under 35 but results are not yet clear.
Options after treatment
Fertility options after cancer treatment may be limited. Your ability to become pregnant may depend on the effects of cancer treatment on fertility, your age and whether you have been through premature ovarian failure or early menopause.
Before trying to conceive, you may want to have your fertility checked, see Assessing fertility after treatment.
If you harvested and stored eggs or embryos, you may choose to use them after treatment is finished. If your ovaries are still functioning after treatment ends, it is possible to freeze eggs or embryos then.
Some women are able to conceive naturally after finishing cancer treatment. This will only be possible if your body is producing eggs and you have a uterus. Your medical team will do tests to assess your fertility and will encourage you to try for a baby naturally if they think it may be possible to fall pregnant.
Women who have had chemotherapy or pelvic radiotherapy are at risk of sudden menopause, even after periods resume. If menopause is permanent, it means you will no longer be able to conceive naturally.
If you would like to try to fall pregnant naturally, speak with your cancer specialist first. You may be advised to wait between six months and two years before trying to conceive. The length of time will depend on the type of cancer and the treatment you had.
Donor eggs and embryos
If you have ovarian failure after cancer treatment, using donor eggs or embryos may be the only way for you to try for a pregnancy. These options are available to women with a healthy uterus who can be pregnant, although there may be an age limit of about 51.
Hormones may be given to prepare your body to receive the donor egg or embryo, and until the pregnancy is viable. For this reason, women who have a hormone-sensitive cancer may not be able to carry a donor egg or embryo. If you’d like to consider other options, see Other paths to parenthood.
Finding information about the donor
In Australia, laws about collecting donor information vary between states and territories. In most cases, donors are required to be open donors. This means they must provide their name, address, date of birth, medical history, including genetic test results.
By law, all donor-conceived people are entitled to access identifying information about the donor once they turn 18.
In some states and territories, a central register has been established to allow people under 18 to apply for non-identifying information about their donor parent. Other states and territories require the clinics to maintain the data.
If you’d like to use donor eggs or embryos, speak with a fertility counsellor or lawyer who can discuss the implications for donor-conceived children.
Using donor eggs
Most IVF units in Australia have access to donor eggs. You can also ask a family member or friend to donate eggs. Regardless of where the egg comes from, the donor completes blood tests, answers questions about their genetic and medical information, and goes through a counselling process.
When the egg is removed from the donor’s body, it is fertilised by your partner’s sperm or donor sperm to create an embryo. After a period of quarantine, the embryo is inserted into your uterus. See Options before treatment for more information about the general IVF process.
Egg donation is more expensive than standard IVF, as you may be paying costs related to the donor hormone stimulation process.
Using donor embryos
If you use a donated embryo, you can become pregnant without having a genetic relationship to the baby.
Your body will be prepared for pregnancy using hormones, then a thawed embryo will be transferred into your uterus through the IVF process.
Embryo donations usually come from couples who had fertility treatments and have spare frozen embryos that they don’t wish to use themselves. Embryos may be donated for ethical reasons (instead of destroying the embryos) or compassionate reasons (to help someone with infertility).
Assessing fertility after treatment
Your cancer or fertility specialist can talk to you about your likely fertility status after treatment, but there are no tests that can reliably predict whether you will be able to fall pregnant and if the pregnancy will be successful.
Follicle-stimulating hormone (FSH) – A blood test can measure FSH, which may indicate how close to menopause you are. FSH levels need to be measured on specific days of the menstrual cycle – usually the first couple of days – as levels change throughout the month.
Transvaginal ultrasound – An ultrasound scanner may be inserted into the vagina to examine the structure of the uterus, fallopian tubes and ovaries.
Antral follicle count (AFC) – A transvaginal ultrasound can be used to view the ovaries and follicles, and measure how many eggs you have. This test is done early in the menstrual cycle. Anti-Müllerian hormone (AMH) – This blood test measures AMH, which is a hormone secreted by the developing egg sacs (follicles). The level of AMH in a woman’s blood is an estimate of the number of eggs left in the ovaries.
Ovarian volume – A transvaginal ultrasound shows the volume of the ovaries. Usually the combined volume is about 10 mL. Women with small ovarian volume (less than 4 mL) often find it challenging to become pregnant.
If cancer genes are present
A small number of people have a greater risk of developing certain cancers, such as breast, ovarian or bowel cancer, because they carry a changed gene. You can discuss the risk of your future children inheriting a predisposition to cancer with your doctor or a genetic counsellor.
If you have a faulty gene, you may want to consider having a pre-implantation genetic diagnosis (PGD) test.
In PGD, a woman goes through the IVF cycle. While the embryos are developing in the laboratory, a few cells are removed from each embryo and tested for genetic conditions. Only unaffected embryos are implanted into the woman’s uterus, increasing the chance of the faulty gene not being passed onto the child. You can discuss this option with your fertility specialist.
If you are concerned about your family history of cancer, visit a familial cancer centre for advice about the possibility of genetic testing. Usually these centres do not need a doctor’s referral and can be found in most major public hospitals.