Things that can affect your fertility

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**Credit for illustrations above: Gemma Noble**

 

 

“How Treatment Can Affect Fertility – Women:

Cancer treatments can affect fertility in different ways:

  • Chemotherapy can affect the ovaries. It can cause fewer or no eggs to be produced. Chemotherapy can have a temporary or permanent effect on fertility.
  • Radiotherapy can affect egg production. It can also damage the ovaries or womb, and reduce hormone levels. Different types of radiotherapy have different effects on fertility.
  • Surgery to your womb, ovaries or pituitary gland can affect your fertility.
  • Hormonal therapy reduces or blocks the hormones in your body. The effects on fertility are usually temporary.
  • Targeted therapies may have an effect on fertility but not much is known about this yet.

Changes to fertility are permanent for some women, but temporary for others. Your doctor will be able to talk to you about any possible fertility risks with your treatment. You can speak to your doctor about having your fertility tested after you finish cancer treatment.

It is important to use contraception during cancer treatment as treatments could harm a developing baby.

 

The main  treatments for cancer are chemotherapy, radiotherapy, surgery, hormonal therapy and targeted therapy. These treatments affect fertility by:

  • damaging the eggs or ovaries
  • affecting hormone production
  • altering or removing the womb.

Chemotherapy and fertility

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:

  • Your age – younger women are more likely to remain fertile and their periods usually come back. Women over 35 already have a lower chance of getting pregnant as the number and quality of the eggs has started to decline naturally. The older you are, and the closer you are to your natural menopause, 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 have more information about individual chemotherapy drugs.
  • The dose – higher doses of chemotherapy, especially before 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 your periods do come back, your menopause may start 5–10 years earlier than usual. This means you have a shorter time to try to get pregnant.


Radiotherapy and fertility

Radiotherapy treats cancer by using high-energy rays to destroy cancer cells. It can have an effect on a woman’s fertility by:

  • affecting egg production
  • damaging the ovaries or womb
  • reducing hormones (oestrogen and progesterone).

Radiotherapy to the pelvis

Radiotherapy given directly to the ovaries or the womb will cause permanent infertility. Radiotherapy to the pelvic area 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 if the womb lining is damaged.

It may be possible to protect the ovaries with a lead shield when radiotherapy is given close to the ovaries. Occasionally, surgeons can do a minor operation to move the ovaries out of the way to protect them from the radiation. This is called ovarian transposition and can be done by keyhole surgery.

Your risk of infertility depends on the dose of radiotherapy you have and your age – the risk increases as you get older. There’s a higher risk of infertility when you have both radiotherapy and chemotherapy.

Total body irradiation (TBI)

TBI is radiation given to the whole body before a donor stem cell or bone marrow transplant. This usually causes permanent infertility.

Radiotherapy to the brain

Radiotherapy to the pituitary gland at the base of the brain can sometimes affect fertility. The pituitary gland controls the hormones (gonadotrophins) which make the ovaries produce oestrogen and progesterone.

If your pituitary gland has been affected, you can be given gonadotrophin injections to help you get pregnant.

Other types of radiotherapy

Radiotherapy to areas of the body that we haven’t mentioned here won’t cause infertility.


Surgery and fertility

Operations that can affect fertility are:

  • having your womb removed (hysterectomy)
  • having your ovaries removed
  • surgery to the pituitary gland.

Surgery to the womb or ovaries

For some cancers, surgery can involve removing the womb (hysterectomy), the ovaries or both.

Occasionally women with a very small, early cancer of the cervix can have an operation called a trachelectomy. This operation 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 a few hospitals by very experienced surgeons.

Young women with germ cell tumours of the ovary may sometimes have only the affected ovary removed to preserve their fertility.

Women who have both ovaries removed may be able to have eggs or fertilised eggs (embryos) frozen before surgery. Having your eggs collected may mean delaying the start of your cancer treatment, so it may not always be possible.

Women who have their womb removed may still have fertility options. This involves a surrogate (a woman who carries the baby in her womb for you).

Surgery to the pituitary gland

Surgery may be used to remove a tumour in the pituitary gland at the base of the brain. The pituitary gland controls the hormones (gonadotrophins) that make the ovaries produce oestrogen and progesterone.

Surgeons try to remove the tumour while leaving some of the pituitary gland. But this is not always possible, and in some cases the whole gland needs to be removed.

This can affect the hormones (gonadotrophins) that stimulate the ovaries. This can make you menopausal – not because you have run out of eggs but because your ovaries aren’t being stimulated to release them.

Gonadotrophin injections can be given to stimulate your ovaries to start producing eggs again.


Hormonal therapy and fertility

Hormonal therapy reduces the levels of hormones in the body or blocks their effect on cancer cells. It is usually used to treat breast cancer. Hormonal therapy can affect your fertility but any effects are usually temporary. The drugs commonly used are tamoxifen and goserelin (Zoladex®).Zoladex will stop your periods, but they usually come back again about six months after you stop taking it. But if you’re close to your natural menopause, your periods 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 treatment as there’s a risk it may harm an unborn baby. Tamoxifen is often taken for at least five years, which may be a concern if you want to get pregnant sooner. You can talk about any concerns with your cancer doctor.Some women go through their natural menopause while taking hormonal therapy. You may not be aware of this because the side effects of hormonal therapy are similar to the symptoms of the menopause.

Targeted therapies and fertility

Targeted therapies are a newer type of cancer treatment. It’s not yet known exactly what effect they have on fertility. However, the drug bevacizumab (Avastin ®) is known to increase the risk of infertility.If you’re taking a targeted drug, you will be advised not to get pregnant during treatment and for a while after. Talk to your cancer doctor about this.

Contraception during cancer treatment

It’s important to use effective contraception during cancer treatment to avoid getting pregnant. This is because the treatments may harm a developing baby. Even if your periods stop during treatment, this doesn’t mean you can’t get pregnant as they could start again.If you’ve had breast cancer, your doctor will advise you not to take the contraceptive pill or use a medicated coil (IUD) which contains hormones. This is because they could encourage breast cancer cells to grow. Your cancer doctor or specialist nurse will give you more advice about this.

After treatment

There is no evidence that cancer treatments harm children that you have after treatment. But doctors usually advise you to carry on using contraception for about a year after treatment.

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 getting pregnant it’s a good idea to talk to your cancer doctor first.


Getting your fertility tested

You might decide to have tests done after your cancer treatment is finished to check your fertility. Women who have had cancer treatment are usually referred for testing after six months of trying to get pregnant. This is because of their risk of early menopause.Your doctor will ask you about your periods and take some blood tests. These tests can show how many eggs you have left in your ovaries (ovarian reserve) or how close to your menopause you are. Taking the contraceptive pill or hormone replacement therapy (HRT) can affect the results of these tests. Let your doctor know if you’re taking either of these.If you are having periods, you can have a blood test to measure a hormone called follicle stimulating hormone (FSH). This can only be done on certain days in your menstrual cycle as FSH levels change during the month. Another test can measure anti-Mullerian hormone (AMH). This can be done at any time in the menstrual cycle and even if you’re not having periods.Some women’s periods can come back months or years after cancer treatment. This is more likely if you’re younger but it also depends on the treatment you’ve had. If your periods change, you can have these tests repeated. Your fertility specialist will talk to you about the options available to you. 

“How Treatment Can Affect Fertility – Men:

Cancer treatments can affect fertility in different ways. You will be able to have your sperm tested after your treatment to see if you are producing healthy sperm.

  • Chemotherapy can slow down or stop sperm production. The effect it has will depend on the drugs you are having. You should still be able to get an erection and enjoy sex.
  • Radiotherapy can affect sperm production. It can also cause problems with erection and can reduce the levels of the male hormone, testosterone. Different types of radiotherapy have different effects on fertility.
  • Surgery can cause problems with erections and ejaculation, and can also reduce the levels of the male hormone, testosterone.
  • Hormonal therapy reduces the level of testosterone. This can cause a loss of sex drive and problems with erections.

These issues are permanent for some men, but temporary for others. Your doctor will be able to talk to you about any possible problems in your situation.

Cancer treatments and fertility

The main treatments for cancer are chemotherapy, radiotherapy, surgery, hormonal therapy and targeted therapy.They affect fertility in different ways. Some treatments can:

  • stop or slow down sperm production
  • damage the cells (germ cells) that produce sperm
  • damage nerve endings or blood vessels in the pelvic area, leading to problems with erections or ejaculation
  • affect hormone (testosterone) production.

After treatment, you can have your sperm tested regularly to find out if you’ve started to produce healthy sperm again.

Being able to get an erection and ejaculate does not always mean that you are fertile. Sometimes the semen may not have sperm in it.


Effects of chemotherapy on fertility

Chemotherapy can cause infertility by slowing down or stopping sperm production. For most men this is temporary, but for others it can be permanent. The effect will depend on:

  • which drugs you have – some chemotherapy drugs affect fertility more than others
  • the dose – higher doses of chemotherapy, especially with stem cell transplants, are more likely to affect fertility
  • whether you have a combination of drugs – different drugs given together may be more likely to affect fertility than a single drug.

In some situations, it may be possible to choose a chemotherapy treatment that’s less likely to affect your fertility. Your cancer doctor will explain if this is an option for you.

After chemotherapy, it may take two years or more for your fertility to return to normal. Problems with sperm production should not stop you from getting erections or enjoying sex.


Effects of radiotherapy on fertility

Radiotherapy treats cancer by using high-energy rays to destroy cancer cells. It can cause fertility problems by:

  • affecting sperm production
  • causing problems with erections
  • reducing testosterone.

Radiotherapy to the pelvis

Radiotherapy destroys cancer cells in the treated area, but it can also affect some surrounding healthy tissue. Radiotherapy to the pelvic area close to the testicles can lead to infertility, which may be temporary or permanent. Sometimes the radiographer may use special ‘shielding cups’ to cover and protect the testicles from radiation.

Intensity modulated radiotherapy (IMRT) might be used. This is a specialised way of giving radiotherapy which shapes the beams to fit the outline of tumours more precisely. This means lower doses can be given to the healthy tissue surrounding the tumour. This can reduce the risk of damage and side effects.

If you have radiotherapy directly to the testicles, it will cause permanent infertility by affecting sperm production. It may also reduce the amount of testosterone you produce, which can affect your sex drive and your ability to get an erection.

After pelvic radiotherapy, the amount of semen you produce is reduced. This means that, when you ejaculate, you may notice that only a small amount of fluid comes out. Radiotherapy may also affect the quality of the sperm in the semen. Some men don’t produce any semen at all, and this is known as a dry ejaculation.

Some men develop problems with erections (erectile dysfunction) after radiotherapy to the pelvis. This may be due to nerve damage or narrowing of the blood vessels to the penis. Although you may feel embarrassed, you should talk to your doctor if you’re having problems. There are treatments for erectile dysfunction caused by pelvic radiotherapy.

Radiotherapy can also reduce the amount of testosterone that’s produced. This can lower your sex drive and ability to get an erection. You can taketestosterone replacement therapy to treat this. However this therapy might affect your sperm production. If you want to have children, speak to your fertility doctor before starting it.

The risk of infertility is generally related to the dose of radiotherapy given to the pelvic area. Fertility may never return or might return slowly. It can take up to five years for your fertility to come back. If you’re not producing sperm after this time, it’s unlikely that your fertility will return.

Total body irradiation (TBI)

TBI is radiotherapy given to the whole body before a donor stem cell or bone marrow transplant. This usually causes permanent infertility. Your cancer specialist can talk to you about this.

Radiotherapy to the brain

Radiotherapy to the pituitary gland at the base of the brain can sometimes affect fertility. The pituitary gland controls the hormones (gonadotrophins) that stimulate the testicles to produce testosterone.

Low levels of testosterone can be treated by replacement therapy.  But this therapy might affect your sperm production. Sometimes gonadotrophin injections can be used to stimulate the testicles to start producing sperm again. If you want to have children, speak to your fertility doctor before starting replacement therapy.

Other types of radiotherapy

Radioactive iodine is a type of radiotherapy used to treat thyroid cancer. It doesn’t usually affect fertility, although there is a slightly increased risk for men who have several treatments with radioactive iodine.

Radiotherapy to other areas of the body not mentioned here won’t cause infertility.


Effects of surgery on fertility

Surgery can affect fertility by causing problems with erections, ejaculation or by reducing testosterone.

Surgery to the testicles

Having one testicle removed for testicular cancer shouldn’t affect your fertility. But having both testicles removed, which may happen if the cancer comes back, causes permanent infertility.

Men with testicular cancer may have a retroperitoneal lymph node dissection. This is an operation to remove lymph nodes in the abdomen (tummy). It may cause a problem called retrograde ejaculation. This is when your semen and sperm go backwards into your bladder instead of coming out of your penis when you orgasm. However, this is becoming less common as surgeons use new nerve-sparing techniques to help protect the nerves. It doesn’t affect your ability to get an erection or have an orgasm.

Surgery to the pelvic area or abdomen

Some operations to the pelvic area or to the spine may damage nerves and blood vessels, making it impossible to get an erection.

Surgery to the pituitary gland

Surgery may be used to remove a tumour in the pituitary gland at the base of the brain. The pituitary gland controls the hormones that stimulate the testicles to produce testosterone and sperm.

Surgeons try to remove the tumour while leaving some of the gland but this isn’t always possible. When the whole gland is removed, this affects the hormones. Gonadotrophin (hormone) injections may be used to stimulate the testicles to start producing sperm again.


Effects of hormonal therapy on fertility

Doctors may use hormonal therapy to treat prostate cancer and breast cancer in men. It works by lowering the level of testosterone which can help stop cancer cells growing. Side effects can include loss of sex drive and problems getting or keeping an erection. These often return to normal after stopping treatment, but some men continue to have problems.There are different techniques that may help improve these problems – your cancer or fertility doctor can give you more information.” – Source Macmillan

 

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