100 answers about cancer and fertility

30. What is premature ovarian failure (premature menopause)?

In addition to causing immediate infertility, cancer treatments can also cause you to go into menopause early. Premature ovarian failure is defined as menopause before the age of 40 years.

All women are born with a finite number of eggs—you do not grow new ones. As you age, your supply of eggs naturally diminishes until you no longer have many viable eggs, and you enter menopause. Cancer treatments such as chemotherapy, radiation, and surgery can speed up this process by damaging or destroying your eggs.

If your cancer treatments wipe out your entire ovarian reserve, you will be infertile and in menopause immediately after treatment. If only some of your eggs were damaged, you

may be fertile after treatment. Even if you are fertile after treatment, your egg supply may have been reduced, and this will cause you to go into menopause earlier than you would have without cancer treatment. For example, a woman might resume menstruation and be fertile after receiving chemotherapy at age 25 and then go into menopause at age 35. Another woman might receive chemotherapy at age 32 and go into menopause immediately.

When I told Nick the news, he said, “I’d rather not have kids than not have you.” Hearing him say that made me cry. Since I had been diagnosed, I felt a little like damaged goods, and after failing at the embryo thing, I really did. To Nick, however, I was still a catch. He had told me many times before that I was the most important thing in his life, but I also knew he really wanted to be a dad. I was telling him that may never happen, and he was completely unphased by it. “All I care about is you getting better,” he said. As much I loved him for saying that, I hated to think that I—that we—might not be able to have everything we wanted in life.

—Erin, Chronic Myelogenous Leukemia

31. Does age play a role in fertility?

Age always plays a significant role in fertility for women. As discussed in Question 30, you are born with a fixed supply of eggs that diminishes as you age. When you no longer have enough viable eggs left, you are in menopause. Cancer treatments can accelerate the process by which your egg supply diminishes and, therefore, affect fertility and cause premature ovarian failure. Generally, the older you are when you enter treatment, the fewer eggs you have in your ovaries and, therefore, the more likely you are to be infertile or in premature menopause after cancer treatment.

35. How do I decide which options are best for me?

Several factors will influence which type of fertility preservation method is right for you, including:

• Do you have a male partner to provide sperm?

• Are you willing to use donor sperm?

• How much time do you have before starting cancer

treatment?

• Is your cancer likely to spread to your ovaries?

• What are your specific treatment risks?

• Do you have an estrogen-sensitive cancer?

• Do you have cancer in or around your reproductive system (cervix, ovaries, endometrium, etc.)?

• Do you have ethical or religious concerns about using assisted reproductive technologies?

Knowing the answers to these questions will help you select the best option for you.

If having a family is extremely important to you, do what is necessary

to preserve your fertility. [Your] health is the most important piece of the equation. The two must be considered and balanced.

—Mary, Cervical Cancer

36. Will I have to delay my cancer treatments to preserve my fertility?

Fertility preservation options vary greatly, and so does the time necessary for each procedure. Egg freezing and embryo freezing require 2 to 4 weeks, whereas ovarian tissue freezing is a 1-day outpatient procedure. Some women have a 4- to 6-week hiatus between surgery and the onset of chemotherapy or radiation, which may provide a window of opportunity to preserve your fertility. If you need to start treatment immediately, you may not have time for some of the available options. If fertility preservation is something that you would like to consider, talk to your oncologist about it as early as possible so that you have sufficient time before beginning your cancer treatments.

PARENTHOOD AFTER CANCER

85. Will my children be at risk for birth defects because of my cancer treatments?

This is one of the most common questions asked by cancer survivors. There has not been a vast amount of research done on the subject, but what has been done is very reassuring. The rate of birth defects in children born to cancer survivors (who have been exposed to chemo and radiation) is the same as the general public, 2% to 3%.

86. Will my children have a higher risk of getting cancer because I had it?

In most cases, having a cancer diagnosis itself does not appear to increase your chances of having a child who will develop cancer. Your child’s risk of developing cancer appears to be the same as that of the general public, unless you have a geneti­cally linked cancer or cancer syndrome. A small percent of cancers of the breast, ovary, colon, pancreas, and kidney may be hereditary. The list of truly genetic cancers is constantly being updated. Check with your doctor or a genetic counselor to understand better whether your cancer is hereditary.

If you do have a genetic cancer and the gene that causes it is known, you may be able to use a test called preimplantation genetic diagnosis (PGD) to screen your embryos for that gene to avoid passing it on. For more information about PGD, please see Question 87.

87. What is preimplantation genetic diagnosis? How is it used for cancer survivors?

Preimplantation genetic diagnosis (PGD) is a technique used during the IVF process to test embryos for genetic disorders. After embryos are created, they are allowed to mature in the laboratory for 3 days. After the embryos reach a certain stage of development, a single cell can be removed from the embryo and tested for the presence of certain genetic disorders. The embryos that do not contain the disorder can then be trans­ferred to your uterus or frozen for future use. The embryos that contain the genetic defect can be discarded or donated to research. Alternatively, some couples may also choose to im­plant embryos with known genetic disorders. For example, if the genetic disorder will result in a predisposition for a disease, couples may still choose to implant those embryos. Currently, PGD testing is available for these cancer predispositions:

• Breast Cancer 1 Gene

• Breast Cancer 2 Gene

• Familial Adenomatous Polyposis

• Gorlin Syndrome (Basel Cell Nevus Carcinoma Syndrome)

• Lynch Syndrome (Hereditary Nonpolyposis Colorectal Cancer)

• Li-Fraumeni Syndrome

• Multiple Endocrine Neoplasia

• Neurofibromatosis Type 1

• Neurofibromatosis Type 2

• Rhabdoid Predisposition Syndrome

• Retinoblastoma

• Tuberous sclerosis Type 1

• Tuberous sclerosis Type 2

• Von Hippel-Lindau Disease

PGD makes it possible for individuals with serious genetic disorders to decrease the risk of having a child who is affected by the disorder. It is now possible to use this technique to help decrease the risk of passing on some cancer-related genes to your offspring. The list of detectable disorders is constantly being updated. Check with your reproductive specialist to see whether PGD can be used to identify the specific genetic disorder that you are concerned about. The average cost of PGD is $5,000 per cycle.

For more information on fertility after cancer, visit Fertile Hope.

Excerpted from "100 Questions & Answers About Cancer & Fertility," by Kutluk H. Oktay, MD, Cornell University Weill Medical College, New York Presbyterian Hospital, Weill Cornell Medical Center, Lindsay Nohr Beck, Fertile Hope, Joyce Dillion Reinecke, JD. Copyright 2007. Used by arrangement with Jones and Bartlett Publishers. All rights reserved.

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