Cancer treatment and fertility – information for women This information is an extract from the leaflet Cancer treatment and fertility – information for women. We can send you a copy free – see page 12.
Contents
Introduction Talking to your medical team about infertility Fertility in women Cancer treatments and fertility Contraception Preserving your fertility Possible risks Using donated eggs or sperm Other options Blood tests to measure your hormones Hormone replacement therapy Getting support
Introduction This information is about fertility (the ability to have children) and how it can sometimes be affected by cancer treatment. It talks about the effects of cancer treatment on women’s fertility and the possible ways of protecting or preserving it. It’s been written for women with cancer and their partners. Being told you have cancer and that treatment may make you infertile is often overwhelming. Sometimes the prospect of losing your fertility can be as difficult to accept as the cancer diagnosis itself. You may find it helpful to talk to someone about how you feel. There’s more information about this and the support that’s available on page 11.
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Cancer treatment and fertility – information for women
Talking to your medical team about infertility It’s important to talk to your cancer specialist or specialist nurse about the risk of infertility before treatment starts. This is an important discussion, so take time to think about what questions you want to ask so you can get all the information you need. If you have a partner, it’s a good idea to include them too. Doctors may not be able to predict exactly how your fertility will be affected. But factors like your age and the treatment you’re having can help them give you an idea of your individual risk. In some situations, it may be possible to reduce the effects of treatment on your fertility. Some women may be referred to a fertility expert to discuss ways of increasing their chances of getting pregnant in the future (fertility preservation). But this isn’t always possible for various reasons – for example, there may not be enough time if cancer treatment has to start immediately to get the best results. If you’ve already had cancer treatment and are having difficulty getting pregnant, your doctor can refer you to a fertility clinic. Women who have had chemotherapy are usually referred after six months of trying to get pregnant because of their risk of early menopause. The fertility specialist will tell you about the options available to you.
Fertility in women Fertility in women depends on having a supply of eggs from the ovaries and a healthy womb. You’re born with a large number of eggs and as you get older, particularly after 35, the number of eggs decreases. When there are very few left, you go through the menopause. To have a child, one of your eggs needs to be fertilised by a sperm. Once a month, from puberty to menopause, one of the ovaries produces and releases an egg. The egg moves along the fallopian tube to the womb, ready to be fertilised. If the egg is fertilised by a sperm it results in an embryo, which may bury itself in the lining of the womb and grow into a baby.
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Cancer treatment and fertility – information for women
Hormones (the body’s chemical messengers) are produced by the ovaries and prepare the lining of the womb for the fertilised egg. If the egg isn’t fertilised, you have a period.
Cancer treatments and fertility The main treatments for cancer are chemotherapy, radiotherapy, surgery and hormonal therapy. These treatments affect fertility in different ways. We don’t know exactly what effect new chemotherapy drugs or drugs belonging to a new type of cancer treatment called biological therapies have on fertility. Ask your cancer specialist for information about how your specific treatment is likely to affect your fertility.
Chemotherapy Chemotherapy affects the way the ovaries work and can result in fewer or no eggs being produced. Your periods may become irregular or stop for a while (temporary infertility). It may take up to two years for them to come back again. Chemotherapy sometimes causes permanent infertility and brings on an early menopause. The risk of infertility often depends on the following: • Your age – Younger women are more likely to remain fertile and their periods usually come back. Women over 35 already have a natural reduction in their chances of getting pregnant. The older you are, and the closer to your natural menopause you are, the higher the risk of infertility. • The drugs you have – Some chemotherapy drugs, for example cyclophosphamide and chlorambucil, have a higher risk of causing infertility. Some drugs have a medium risk (doxorubicin and cisplatin) and others have little or no risk (vincristine and methotrexate). We can send you fact sheets about individual chemotherapy drugs. • The dose – Higher doses of chemotherapy, especially with stem cell transplants, are more likely to affect fertility. In some cases, it may be possible to choose a chemotherapy treatment that’s less likely to affect fertility. Your cancer specialist will explain if this is an option for you. Chemotherapy can reduce the number of eggs you have. So even if a woman’s periods do come back, their menopause Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk
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Cancer treatment and fertility – information for women
may start 5–10 years earlier than usual. This means you have a shorter time than usual to try to get pregnant.
Radiotherapy Radiotherapy treats cancer by using high-energy rays to destroy cancer cells. Some types of radiotherapy may affect a woman’s fertility. Radiotherapy to the pelvis Radiotherapy given directly to the ovaries or the womb will cause permanent infertility. When radiotherapy is given to the pelvic area, it may indirectly damage the ovaries or the womb. This may stop the ovaries from working or cause an increased risk of miscarriage or premature birth. The risk of infertility depends on the dose of radiotherapy you have and your age – the risk increases the older you are. There’s a higher risk of infertility when radiotherapy is given with chemotherapy. It may be possible to protect the ovaries with a lead shield when radiotherapy is given close to, but not directly to, the ovaries. Occasionally, an operation can be done to move the ovaries out of the way to protect them from the radiation. Total body irradiation (TBI) TBI is given with chemotherapy to treat leukaemia or lymphoma. It usually causes permanent infertility. Radiotherapy to the brain Radiotherapy to the brain that includes the pituitary gland at the base of the brain, can sometimes affect fertility. The pituitary gland stimulates the ovaries to produce the hormones oestrogen and progesterone. Other types of radiotherapy Radioactive iodine is a type of radiotherapy used to treat thyroid cancer. It doesn’t usually affect fertility. Radiotherapy to areas of the body that we haven’t mentioned here won’t cause infertility.
Hormonal therapy Hormonal therapy is usually used to treat breast cancer. It can affect your fertility but any effects are usually temporary. The drugs commonly used are tamoxifen and goserelin (Zoladex®).
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Cancer treatment and fertility – information for women
Zoladex will stop your periods, but they usually come back again six months after you stop taking it. But if you’re close to your natural menopause, they may not come back. Tamoxifen can make your periods irregular or stop, but they usually start again a few months after you’ve finished taking it. However, taking tamoxifen can also increase your fertility, so it’s important to use effective contraception during your treatment (see page 6) as there’s a risk it may harm an unborn baby. Tamoxifen is often taken for five years, which may be a concern if you want to get pregnant sooner. You can talk about your concerns with your cancer specialist. Some women may go through their natural menopause while they’re taking hormonal therapy. You may not be aware of this because the side effects of hormonal therapy are similar to the effects of the menopause.
Surgery Operations to the pelvic area that can affect fertility are: • having your womb removed (hysterectomy) • having both ovaries removed (bilateral oophorectomy) • some types of surgery to the cervix, vulva and vagina. Occasionally women with a very small, early cancer of the cervix can have an operation called a trachelectomy, which removes most of the cervix but leaves the womb. It may then be possible to become pregnant and have a baby afterwards. This is a specialised operation and it’s only done in some hospitals by very experienced surgeons. During the operation a permanent stitch is put in the bottom of the womb to close it. Any babies will then be born by a Caesarean section. Women who have this operation will have regular checks during pregnancy because there’s an increased risk of miscarriage or premature birth. However, many healthy babies have been born to women who have had this operation. It may be possible to keep the ovaries after removing the womb in women with early cancer of the cervix. This means you’ll still be producing hormones and eggs. Some women may decide to have a baby using their own eggs and a surrogate, a woman who carries the baby in her womb and has the baby for you (see page 10).
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Cancer treatment and fertility – information for women
Contraception Although this information is about infertility, it’s important to understand why pregnancy should be avoided during cancer treatment and for a while afterwards.
During treatment It’s important to use effective contraception during chemotherapy and radiotherapy, and if you’re taking cancer drugs like tamoxifen (hormonal therapy) or any biological therapies. These treatments may harm a baby if you do get pregnant. Even if your periods stop during treatment, this doesn’t mean you can’t get pregnant as they could start again. It’s still important to use effective contraception. If you’ve had breast cancer, you’ll be advised not to take the contraceptive pill or use coils (IUDs) containing hormones as these could encourage breast cancer cells to grow. Your cancer specialist or specialist nurse will give you more advice about this.
After treatment There’s no evidence that cancer treatments harm children that you have after treatment. But doctors usually advise people to carry on using contraception for about a year after chemotherapy or radiotherapy. If you’re taking another type of anti-cancer drug, ask your specialist how long you should wait after you’ve stopped taking it before trying to get pregnant. For example, doctors usually advise waiting at least three months after stopping tamoxifen. Some women may be advised to wait up to two years after treatment before trying to get pregnant. This is because if a cancer is going to come back, it’s often within this time. If you’re thinking of trying to get pregnant it’s a good idea to talk to your cancer specialist first.
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Cancer treatment and fertility – information for women
Preserving your fertility Some women, depending on their age and type of cancer, may be referred to a fertility clinic for advice. This is to look at ways that may allow them to have a baby in the future (fertility preservation), even when their ovaries aren’t producing eggs. This means stimulating your ovaries to produce eggs and then freezing embryos (fertilised eggs) if you have a partner, or unfertilised eggs if you don’t. It can take 3–6 weeks depending where you are in your menstrual cycle. It’s not always possible to delay cancer treatment to have this done. Sometimes, depending on the cancer and its stage, your specialist may advise you to start treatment straight away. A new and extremely experimental technique, which doesn’t involve egg collection, is removing and freezing tissue containing eggs from an ovary. There is more information about this on pages 8–9. At the fertility clinic, you’ll be assessed and given information and counselling about treatments and success rates. Sometimes the NHS pays for storage of embryos, but there may be a charge in some areas. You may also have to pay for donor eggs or sperm, and for new and experimental treatments that aren’t available on the NHS.
Egg collection You start by having injections of hormones to stimulate your ovaries to produce more eggs than usual. Collecting as many eggs as possible, usually at least six, increases your chances of a pregnancy in the future. Your eggs are collected through a fine needle that the doctor will guide into the ovaries using ultrasound, which uses sound waves to make an image. This is usually done with a local anaesthetic to make it less uncomfortable. You can also have an injection to help you relax. Ovarian stimulation involves taking the hormone oestrogen. If you have breast cancer, there may be concerns about the possible effects of this on the cancer, although there’s no evidence that it’s harmful. Although it may be possible to collect one or two eggs without stimulating the ovaries, this reduces the chances of getting pregnant later on.
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Cancer treatment and fertility – information for women
So women with breast cancer may be offered a single cycle of ovarian stimulation in the usual way. Another approach is to give high doses of a hormonal drug, such as letrozole (Femara®), which is used to treat breast cancer, at the same time as the hormones to stimulate the ovaries. This means you can still increase the number of eggs produced, and it’s hoped that letrozole will protect women from high oestrogen levels. This is still experimental and we don’t know if there are risks involved. Your cancer specialist can talk this over with you.
Freezing embryos This is the most effective way of preserving fertility. After your eggs have been collected, they’re placed in a test tube with your partner’s or a donor’s sperm to see if they fertilise. This is called in vitro fertilisation (IVF). The eggs that are fertilised grow into tiny embryos, which are frozen and then stored. When you’re ready to try to get pregnant after treatment, the embryos are thawed and placed in the womb to see if they implant. Usually, no more than one or two are placed in at a time. Although pregnancy rates using frozen embryos are lower than when embryos are implanted immediately, lots of babies have been born using this technique.
Freezing eggs If you don’t have a partner you may want to freeze your eggs and have them fertilised later when you’ve met someone. This is still experimental but techniques are improving. It’s available privately and on the NHS in some units. Eggs are collected as usual (see page 7) and are frozen and stored. When you’re ready to try to get pregnant, the eggs are thawed and fertilised by injecting a single sperm directly into an egg. This is called intra-cytoplasmic sperm injection (ICSI). If any eggs are successfully fertilised, the resulting embryos are placed in the womb to see if a pregnancy develops. Freezing eggs and ICSI is much less likely to result in a pregnancy than embryo storage, but success rates are improving.
Freezing tissue from an ovary This technique is very experimental and only a few babies in the world have been born using this method. It may be suitable for women who don’t have time to freeze embryos
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Cancer treatment and fertility – information for women
or eggs. It may also be suitable for women who can’t use fertility drugs and girls who haven’t reached puberty. Before treatment starts, small pieces of tissue containing eggs are taken from an ovary and are frozen and stored. After treatment, the tissue can be put back into the body to allow eggs to develop.
Possible risks Many children have been born as a result of using stored embryos and it doesn’t seem to cause an increased risk of harm to them. The long-term risks to children conceived using new techniques, such as freezing eggs and ICSI, aren’t yet known. But at the moment specialists think the risks are very small. Storing ovarian tissue is still too early and experimental a technique for us to know about long-term risks. There’s no evidence that fertility preservation methods cause an increased risk of your cancer coming back, but not a lot of research has been done in this area. If you’re concerned about any possible risks, talk to the staff at the fertility clinic.
Using donated eggs or sperm Some women may choose to use donated eggs or sperm. This isn’t funded by the NHS in all areas and there’s also a shortage of donors, so it may not be an easy option. Women without a partner who want to freeze embryos rather than eggs before their cancer treatment may choose to use donor sperm. It can take a while to find a suitable donor and this may cause too long a delay to cancer treatment. Women who are permanently infertile and didn’t have their own eggs stored before cancer treatment may consider using donor eggs. Everyone who donates eggs or sperm is carefully selected. Egg donors are matched as closely as possible to your eye and hair colour, physical build and ethnic origin. Donors have to be fit and healthy with no medical problems and are tested for different infectious diseases.
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Cancer treatment and fertility – information for women
Choosing to use donated eggs or sperm is a difficult decision and it isn’t going to suit everyone. The staff at the fertility clinic can discuss this with you further.
Other options Some women may consider adoption or surrogacy, which is when another woman carries a baby for you. If you have had your womb removed or radiotherapy directly to the womb, adoption or surrogacy are the only options available to you if you want to have a child. The Human Fertilisation and Embryology Authority (HFEA) has information about surrogacy on its website, hfea.gov.uk Some women choose not to have fertility treatment, adoption or surrogacy and go on to enjoy life without children. Everyone is different. You can read more about adoption and surrogacy in our booklet Relationships, sex and fertility for young people affected by cancer.
Blood tests to measure your hormones Some women’s periods can come back months or years after chemotherapy. This is more common if you’re younger but it also depends on the treatment you’ve had. Your specialist can do a blood test to measure a hormone called follicle stimulating hormone (FSH). The results of this test can help find out how many eggs you have left in your ovaries (ovarian reserve) or how close to your menopause you are. FSH levels change throughout the month, so it has to be measured on specific days. AMH (anti-mullerian hormone) is a new blood test that may give more accurate information about your fertility and how many eggs you have left. It can be taken at any time because the level of anti-mullerian hormone found in the blood doesn’t fluctuate throughout the month. It could be an accurate predictor of whether you are still fertile and how many eggs you have left in your ovaries.
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Cancer treatment and fertility – information for women
If you’re having difficulty getting pregnant and didn’t have any fertility preservation before treatment, your doctor can refer you to a fertility clinic for these blood tests. Women who’ve had chemotherapy are usually referred after six months of trying to get pregnant because of their risk of early menopause. The fertility specialist will tell you about the options available to you.
Hormone replacement therapy If you have an early menopause as a result of cancer treatment, you may be offered hormone replacement therapy (HRT). This helps prevent problems associated with the menopause, such as thinning of the bones (osteoporosis) and heart disease. HRT is not recommended after breast cancer because it increases the risk of it coming back or of getting another breast cancer. There are organisations that support women who have an early menopause, such as The Daisy Network (daisynetwork.org.uk) Some women’s fertility comes back while they’re on HRT, so if you don’t want to get pregnant, use reliable contraception. Some women may be able to take the oral contraceptive pill instead of HRT. The pill replaces your hormones and also prevents pregnancy. You can discuss this in more detail with your doctor.
Getting support Infertility can be very distressing to live with. It may seem especially hard when you’re already coping with cancer. The uncertainty of not knowing if your fertility will come back or not is also hard to cope with. Some women find it helpful to talk things over with their partner, family or friends. Others may prefer to talk to a counsellor. Your GP or cancer specialist can arrange this for you. Many hospitals also have specialist nurses who can offer support, and fertility clinics usually have a counsellor you can talk to. Talking to other women in a similar position may help you feel less isolated. Some fertility support organisations can arrange Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk
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Cancer treatment and fertility – information for women
this as well as specialist advice and counselling (call 0808 808 00 00 for contact details). Or you can talk to people online. Our online community at macmillan.org.uk/community is a good place to talk to other women who may be in a similar situation.
More information and support If you have any questions about cancer, ask Macmillan. If you need support, ask Macmillan. Or if you just want someone to talk to, ask Macmillan. Our cancer support specialists are here for everyone living with cancer, whatever you need. Call free on 0808 808 00 00, Monday–Friday, 9am–8pm www.macmillan.org.uk To order a copy of Cancer treatment and fertility – information for women, or any of the other booklets or leaflets mentioned in this information, visit be.macmillan.org.uk We make every effort to ensure that the information we provide is accurate but it should not be relied upon to reflect the current state of medical research, which is constantly changing. If you are concerned about your health, you should consult your doctor. Macmillan cannot accept liability for any loss or damage resulting from any inaccuracy in this information or third party information such as information on websites to which we link. © Macmillan Cancer Support 2010. Registered charity in England and Wales (261017), Scotland (SC039907) and the Isle of Man (604). Registered office 89 Albert Embankment, London, SE1 7UQ
REVISED IN JANUARY 2012
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