CANCER IS THE THIEF that keeps on taking. At its very worst, of course, it can take your life. But even if it doesn’t, it can take a lot of other things—everything from your hair and your ability to enjoy a pizza to your energy, your sex drive, your memory, and your sense of confidence in yourself and your body. Some of those things you get back after cancer treatment, and some may never return entirely. (I’ve heard some people call cancer a gift, but if my cancer was a gift, I’d like to know where the return desk is.)
Just when you think you know all of the things cancer can steal from you, there’s another: your fertility. About half of all people diagnosed with cancer in their reproductive years receive treatments that can impair fertility: chemotherapy that can attack your supply of remaining eggs, radiation that zaps sperm inside the testicles, and hormonal treatments that shut down your menstrual cycle and throw you into premature menopause.
But when the doctor says, “It’s cancer” (don’t we all remember the exact moment when we first heard those words that yanked the rug right out from under us?), you’re not thinking, “What will this do to my ability to have children?” You’re thinking, “Oh my God, am I going to die?”
Then you’re thinking about more tests and biopsies and surgeries and chemotherapy appointments and whether you’re going to need a wig or not and are you going to be throwing up all the time and how are you going to tell parents, kids, bosses, and coworkers? You’re fretting about health insurance coverage. You’re worrying about whether the disease has spread to the lymph nodes or metastasized to other organs. You’re wondering if you’ll ever, ever go a minute or an hour—much less a day or a week—without the constant refrain of “IhavecancerIhavecancerIhavecancer” drumming away inside your head.
If you’re a parent with a young child who’s just been diagnosed with cancer, you’re enduring all of these worries for your child and at the same time wondering how you’re going to be strong for her when you can barely make it through the day without breaking down.
So at a time like this, it’s little wonder that a lot of people don’t stop to think about, or ask about, what cancer might mean for their ability to have children in the future—even though it’s something they may care deeply about. And most cancer specialists, who have to impart a lot of information about their patients’ illness and treatment options in a very short time, don’t focus on fertility either.
In fact, a national survey of oncologists conducted in 2008 found that although about two-thirds discuss the issue of fertility with newly diagnosed patients, less than 25 percent referred their patients to a fertility specialist or provided educational materials about what risks cancer treatment might pose to fertility and what options patients might have.1
Teresa Woodruff, who heads the national Oncofertility Consortium headquartered at Northwestern University, recommends that you ask your doctor—or your child’s—these five questions:2
The problem is, you don’t have a lot of time to educate yourself about what might happen to your fertility—or your child’s—as a result of cancer treatment. You’re making decisions about treatment with visions of a window that’s rapidly closing, fearing that every day you delay allows the cancer to spread. So you need information, and you need it fast. That’s what this book is for. Keep reading.
Just how does cancer affect your fertility? Sometimes, it’s the cancer itself that does the damage. For example, researchers have found that two of every three male patients with Hodgkin’s lymphoma have impaired sperm production before they even start treatment, although no one yet knows exactly why this is.3 Testicular cancer can also disrupt normal hormonal levels in men, leading to limited or abnormal sperm production; and at least one recent study has suggested that men with fertility problems may be at increased risk for developing testicular cancer in the first place.4 Experts have speculated that this could be because their mothers’ exposures to certain hormones during pregnancy triggered cell malformations that later showed up in the adult men as fertility problems and testicular cancer.
Women who carry the breast cancer 1 (BRCA1) mutation—the most common genetic mutation associated with breast cancer—may have impaired fertility even if they haven’t yet been diagnosed with an actual cancer. Recent research indicates that women with BRCA1 could have lower ovarian reserve (fewer eggs) than other women. Kutluk Oktay, MD, a pioneer in the field of cancer and fertility, has found that the ovarian reserve in his patients with breast cancer, but without a BRCA1 mutation, can be as much as thirty-eight times higher than the egg reserve in women with BRCA1.5 “The women in our study who had low response to ovarian stimulation were all thirty-three and older, so this is probably an effect that catches up in your thirties,” Oktay says. “For those who attempt pregnancy early on, it may not be a big issue, but if you delay childbearing, then it may catch up.” He advises women who want children and know they have a BRCA1 mutation to consult with a fertility specialist, even if they have not yet been diagnosed with cancer themselves.
Usually, though, it’s the treatment that attacks your fertility, not the cancer itself and not a gene associated with it. Doctors tend to pursue the most aggressive treatments possible in younger cancer patients—because they have a lot more years of life to preserve, because younger and healthier patients are strong enough to withstand more intense side effects, and because cancer in young people is often more aggressive than cancer in older people. It makes perfect sense. But it also means that these toxic treatments have a particularly high chance of impairing fertility.
As you’re making treatment decisions, it’s important to know how individual drugs and treatment regimens can affect your ability to have children. You’re not going to refuse lifesaving chemotherapy or surgery just because they might damage your fertility—or you shouldn’t—but you may be able to choose modifications to your treatment regimen. And in the next chapter, we’ll talk about a growing list of fertility-preserving technologies available to both men and women, before and during treatment. Your decisions about whether to pursue some of these options might also be affected by just how toxic your particular treatments are likely to be.
Chemotherapy drugs are stupid drugs. That is, they attack blindly and indiscriminately, killing healthy and diseased cells alike. Their target: anything that’s dividing too rapidly. Cancer cells divide more rapidly than most other cells, but so do hair follicle cells and the cells that line your gastrointestinal tract—hence the baldies and the barfies that accompany many chemotherapy regimens.
The cells that nurse a woman’s eggs to maturity—the somatic cells—are also dividing more rapidly than other cells, while the immature eggs themselves are also particularly vulnerable to DNA damage. So chemotherapy can often put women into premature menopause. This chemopause is sometimes temporary and sometimes permanent. In general, the younger you are when you receive chemotherapy, the more likely you are to either maintain a normal menstrual cycle during treatment or get your periods back once chemo is over. That’s because the younger you are, the more eggs you have left. Women are born with all the eggs we’ll ever have—about a million at birth and about one hundred thousand by the time we reach puberty.
Sperm production is also very sensitive to chemotherapy. Men make millions of sperm every day, so it’s not like sperm are a finite resource (as with a woman’s eggs). But sperm are constantly developing, maturing, and reproducing, making them a prime target for those “stupid” chemotherapy drugs.
Not all chemotherapy drugs are created equal when it comes to fertility. The class of drugs that wreaks the most havoc on your ability to conceive children—whether you’re a man or a woman—is known as alkylating agents. The most commonly used of these drugs is called Cytoxan (cyclophosphamide). If you’re under forty-five and have had chemotherapy for breast cancer, you’ve almost certainly been given Cytoxan; it’s also used to treat lymphoma and some forms of leukemia. It can do irreversible damage to both immature eggs and sperm. The longer you take Cytoxan, or any of its sibling drugs, the more likely you are to have permanent damage to your fertility.
Other chemotherapy drugs can impair your fertility as well, but they’re much less toxic—to your gonads, at least. Adriamycin (doxorubicin), another very common breast cancer drug, is considered to be an intermediate, or moderate, fertility risk in women over forty and only a minimal risk for younger women. Methotrexate and 5-FU, often used to treat a host of cancers, are thought to pose very little threat to fertility—at least by themselves. These drugs are often delivered as part of a “chemo cocktail” with other medications that can have a greater fertility risk.
And then, of course, there’s a long list of drugs we just don’t know much about in terms of what they do to your ability to bear children. The taxanes—known as Taxol (paclitaxel) and Taxotere (docetaxel)—don’t appear to damage fertility at all, but doctors still don’t know for sure. The same can be said of oxaliplatin and irinotecan, used to treat ovarian cancer and colon cancer. See the chart starting on this page, “Chemotherapy Drugs and Fertility,” for more information.
But even if you get the most toxic of chemotherapy drugs, that doesn’t mean your ability to conceive a child will vanish forever. Your hair almost always comes back, even after the most toxic chemo (although it often looks different); sometimes, your reproductive abilities can too.
For women, most of the time it’s a numbers game—that is, it’s all about age (frustrating, but true). When I was treated for breast cancer in 2004, at thirty-six, my doctor, an expert on young women with cancer, told me that I had about a fifty-fifty chance of coming out of chemopause within a few months of treatment ending. Had I been in my early thirties or younger, she said, she’d have given me even better odds. The closer a woman gets to forty, or even older, the lower her chances are of getting her period back or conceiving a child, she said.
But since then, some studies have come out that are more encouraging. An Israeli study released at the 2009 meeting of the American Society of Clinical Oncology found that almost all of a group of sixty-five breast cancer patients thirty-eight and younger got their periods back after treatment, and about a third of them—nearly 34 percent—became pregnant.6
The picture is cloudier, though, for women undergoing chemo over age forty—studies indicate that the chances of getting your menstrual cycle back at this age are anywhere from 5 to 20 percent.7 In general, if you’re a woman diagnosed with cancer at or after age forty and still want to have children after treatment, the odds are pretty strong that you won’t be able to conceive spontaneously—you’ll likely either have to use assisted reproduction methods, adoption, or surrogacy.
But if you’re under forty at diagnosis and treatment, your chances of getting pregnant later on may be better than you think. Michelle Rommelfanger, already the mother of twin boys, was twenty-nine when she was diagnosed with stage II breast cancer. She underwent the classic breast cancer treatment for young women like her: four rounds of Adriamycin (doxorubicin) and Cytoxan and four rounds of Taxol, followed by radiation and the hormonal drug Tamoxifen. While on Tamoxifen, she discovered that her IUD had failed and she was pregnant. She later delivered a healthy baby girl, Mira (short for miracle) Eliana.
“It was a very scary and hard road for a couple of weeks, but she is a miracle baby!” she says. “I was excited and scared all in one, but I refuse to live in fear of the beast. This happened for a reason—this baby was determined to be here!” (There’ll be more on Michelle later in the book.)
For men, age is not as much of an issue. Since new sperm are constantly being “born,” it’s not like chemotherapy can kill off all of a guy’s remaining swimmers. “The number of sperm produced with every heartbeat is like ten to the fifth power, so even if you damage half of that, it’s not a huge impact,” says Dr. Woodruff. “There certainly are treatments that can be completely sterilizing for a man, no matter what his age, but men are generally less vulnerable to chemotherapy than women when it comes to fertility.”
Whether you’re a man or a woman, twenty-eight or thirty-eight, can you ask not to be given a specific drug that’s known to be particularly bad for fertility? For example, the “gold standard” chemotherapy regimen for breast cancer is known as AC-T: a combination of Adriamycin (doxorubicin) and Cytoxan, followed by a taxane (Taxol or Taxotere). The only drug in this cocktail that’s known to do significant damage to your chances of bearing children is Cytoxan—so can you ask your doctor just to drop the C and give you the A-T instead?
You can ask, but your doctor will most likely say no—at least for right now. Some doctors have proposed a breast cancer regimen without the Cytoxan, to preserve fertility—it was brought up at the San Antonio Breast Cancer Symposium in 2007, for example—but for now, AC-T remains the gold standard for most younger women with invasive breast cancers. “Today, they’re still going to use it,” says Dr. Woodruff. Similarly, other cancers may have multiple chemo modalities, but there may be a very good reason that your oncologist insists you must receive the one that is more toxic to your fertility. “But ultimately,” reassures Dr. Woodruff, “yes, we want to come up with smarter chemotherapies that can treat the disease and leave the rest of the body alone.”
Some doctors have suggested ovarian suppression and other chemical means of protecting fertility during chemotherapy, but the science just isn’t there yet (see chapter 2, this page). In the meantime, there are fertility-preserving measures you can take before undergoing chemotherapy, which we will discuss in the next chapter.
CHEMOTHERAPY DRUGS AND FERTILITY
What are some of the most common chemotherapy drugs and treatment regimens, and what might they do to your fertility? Find out here.8 (The chart also includes a few medications that are not technically chemotherapy but are instead monoclonal antibodies and other targeted therapies.)
Drug: ABVD (a combination of Adriamycin, bleomycin, vinblastine, and dacarbazine)
Used for: First-line treatment of Hodgkin’s lymphoma
Risk: Minimal for both men and women. Less than 20 percent of women develop permanent amenorrhea after treatment, and men usually have a temporary loss of sperm production.
Drug: AC (Adriamycin and cyclophosphamide)
Used for: Breast cancer
Risk: Low risk for women under forty, with less than a 20 percent chance of permanent infertility. For women over forty, estimates vary; you may have between a 30 and 70 percent chance of losing fertility permanently after AC. (AC is not generally used in cancers affecting men.) But keep in mind that most of the time, AC is delivered in combination with P or T—Paclitaxel or Taxotere, taxane drugs that can have an additional impact on fertility. When the regimen is AC-T or AC-P, risk of loss of fertility rises to between 29 and 42 percent for women under forty, and 66 to 77 percent for women over forty.
Drug: BEAM (BCNU, etoposide, cytosine arabinoside,
melphalan) and any other chemotherapy regimen used to prepare for bone marrow transplantation
Used for: Preparation for bone marrow transplantation, in cancers such as leukemias, lymphomas, and some solid tumors
Risk: High for both men and women. Most chemotherapy regimens associated with bone marrow transplants present a major risk of permanent infertility.
Drug: Bevacizumab (Avastin)
Used for: Colon cancer and non-small-cell lung cancer
Risk: There is still limited research information on precisely how bevacizumab may affect fertility, but in animal studies, bevacizumab disrupts menstrual cycles and interferes with follicular development, a side effect that at least sometimes persists after treatment. The drug’s manufacturer lists impaired fertility as a known side effect. How significant the risk of permanent infertility or sterility is remains unknown.
Drug: CAF (cyclophosphamide, doxorubicin, 5-FU),
CEF (cyclophosphamide, epirubicin, 5-FU), or CMF (cyclophosphamide, methotrexate, 5-fluorouracil)
Used for: Breast cancer
Risk: Low risk of permanent loss of fertility in women under thirty (less than 20 percent). Intermediate risk in women in their thirties (30 to 70 percent). For women over forty, this combination is high risk, causing amenorrhea in more than 80 percent of patients.
Drug: Cetuximab (Erbitux)
Used for: Colon cancer, head and neck cancer
Risk: Very little is known about cetuximab’s impact on fertility in humans. Some animal studies have shown interference with menstrual cycles, including an absence of cycles altogether, but it’s not known how long that lasts after treatment is discontinued.
Drug: CHOP (cyclophosphamide, doxorubicin,
vincristine, prednisone)
Used for: Non-Hodgkin’s lymphoma
Risk: Low risk.
Drug: COPP (cyclophosphamide, vincristine, procarbazine, prednisone) and COPP/ABVD
Used for: Hodgkin’s lymphoma
Risk: Both regimens pose a very high risk to fertility, leaving 80 percent of women with permanent amenorrhea and men with prolonged loss of sperm production.
Drug: Cyclophosphamide alone, at higher doses, or for bone marrow transplant conditioning
Used for: Sarcoma, non-Hodgkin’s lymphoma, acute lymphocytic leukemia (ALL), and neuroblastoma
Risk: There is a high risk of permanent infertility or sterility for both men and women.
Drug: Docetaxel (Taxol, Taxotere)
Used for: Breast cancer
Risk: Not completely researched, but so far all the taxane drugs seem to pose relatively low risk to fertility.
Drug: Erlotinib (Tarceva)
Used for: Non-small-cell lung cancer, pancreatic cancer
Risk: Little is known about Tarceva’s risk to fertility in either men and women. In animal studies, the drug did not impair fertility in either male or female rats.
Drug: Imatinib (Gleevec)
Used for: Chronic myeloid leukemia (CML), gastrointestinal stromal tumor (GIST)
Risk: There has not been a lot of research on fertility after Gleevec, but a number of women have become pregnant after being treated with this drug. Interestingly, Gleevec may also have potential in fertility preservation during cancer treatment—see chapter 2 for more on this.
Drug: MOPP (nitrogen mustard, vincristine, procarabazine, prednisone) or MVPP (nitrogen mustard, vinblastine, prednisone, procarbazine)
Used for: Hodgkin’s lymphoma
Risk: High risk of permanent loss of fertility.
Drug: NOVP (mitoxantrone, vincristine, vinblastine,
prednisone)
Used for: Hodgkin’s lymphoma
Risk: There is a low risk of permanent loss of fertility.
Used for: Ovarian cancer, colon cancer
Risk: There has not been a lot of research on the fertility effects of oxaliplatin, but preclinical studies in animals did show some negative impact on menstrual cycles and testicular function, which could persist after treatment.
Drug: Procarbazine
Used for: Hodgkin’s lymphoma
Risk: There is a high risk of permanent infertility.
Drug: Trastuzumab (Herceptin)
Used for: Breast cancer
Risk: Not a lot of research has been done on Herceptin and fertility, but experts note that it is a very selective drug and there is no evidence that it damages eggs.
Radiation is a much more targeted treatment than chemotherapy. Radiation oncologists design your radiation field so that it will hit the cancer cells as precisely as possible and spare the surrounding tissues and organs. But when the cancer is within your reproductive organs, or very nearby, it’s hard to keep the radiation from damaging them.
Types of cancer that can require radiation to the pelvic area include
Irradiating a woman’s gynecologic organs can impair fertility in a couple of different ways. First, it can actually injure the ovaries and prevent them from releasing healthy, mature eggs for fertilization. Radiation can also scar the uterus, making it harder to sustain a pregnancy once it’s conceived and putting you at increased risk of miscarriage and other complications. Just as with chemotherapy, the higher the dose of radiation you get, and the longer you get it, the likelier you are to have impaired fertility.
“The location of the tumor makes a big difference in whether fertility is damaged by radiation,” explains Karine Chung, MD, the founder and director of the fertility preservation program at the University of Southern California. “For example, if you’re having radiation to the breast or the spine at neck level, we can protect you from radiation scatter with shielding. But if the tumor is in the abdomen, right next to the ovaries, it’s very difficult to shield them.”9
A man’s testicles are particularly vulnerable to radiation damage. Even very low doses can impact sperm production and formation, and the longer the dose of radiation, the greater and longer-lasting the damage is. Extremely high doses of radiation to the pelvic area can leave a man totally sterile.
Radiation dosage is measured in grays (Gy). In men, direct radiation to the testicles of more than 2.5 Gy cumulatively poses a high risk for permanent sterility; but if the radiation is directed at another part of the body—say, the abdomen—and the testicles only get scattered radiation, doses as high as 5 or 6 Gy may not leave a man permanently sterile. In adult women, abdominal or pelvic radiation doses of 6 Gy or greater pose a high risk for permanent infertility.
Some cancers, like leukemias, may also be treated with total body irradiation (TBI), which can be devastating to the ability to father or bear children. Research has found that the younger a man is when he receives TBI, the more likely it is that he may recover some ability to generate healthy sperm.10
Sometimes radiation can affect fertility even if it’s not aimed at your pelvis. If you’re receiving radiotherapy for a brain tumor or another type of head and neck cancer, for example, the radiation could affect the functioning of your pituitary gland, which helps to control your ovarian cycle.
In the event that radiation must be directed toward the pelvis, there is an option for surgically moving the ovaries out of the line of fire. This procedure, called ovarian transposition, is discussed in the next chapter (see this page).
There are a number of cancers that involve the reproductive organs—cervical, ovarian, and endometrial cancer for women and prostate and testicular cancer for men. Surgery for any of these cancers can mean taking out something that’s vital to getting pregnant or getting someone else pregnant. Uterine cancer, for example, almost always requires a complete hysterectomy. Women with ovarian cancer and men with testicular cancer, depending on the stage of the disease, might lose only one ovary or testicle to surgery, or both might have to be removed. For information on possible fertility-sparing surgical options—including removing only one ovary or testicle, avoiding a radical hysterectomy, or waiting to remove the uterus until after a pregnancy—see chapter 2, this page, this page, and this page.
Thinking way ahead, surgery for breast cancer can also damage the breast’s ability to lactate. If you are planning a lumpectomy and want to preserve the prospect of nursing a child later, ask your surgeon if he or she can make a surgical plan that will spare the milk ducts as much as possible. Most, if not all, young women who have breast-conserving surgery also have radiation, which damages the breast’s ability to lactate. (You’ll learn more about this in chapter 6.) So it may be unlikely that you’ll be able to breast-feed on that side anyway. If this is very important to you, however, it’s worth at least asking your doctor about your options. And remember, some women have very successfully nursed with only one fully lactating breast!
If you’ve been diagnosed with the kind of breast cancer that is stimulated by the levels of female hormones in the body—specifically, estrogen and progesterone—you’ll probably be prescribed hormonal therapies for at least a year, and up to five years, after your initial treatment, to reduce your risk of recurrence. Premenopausal women usually take a drug called Tamoxifen, although there are other drugs that are options after menopause.
It’s not yet know whether or not Tamoxifen damages fertility. It might reduce ovarian reserves over time, and studies are now being done to try to answer this question. In at least some cases, though, it does the opposite. At higher doses, Tamoxifen is sometimes used as a fertility treatment, because it often increases ovulation. About 20 percent of women taking Tamoxifen will experience irregular periods while on the drug, but cycles usually go back to normal once Tamoxifen therapy stops, unless you were on the verge of menopause anyway.
The problem is that it is not considered safe to take Tamoxifen while pregnant. (Women who use this drug to amp up ovulation stop taking it once they conceive.) So that means that if you’ve been prescribed Tamoxifen, you have to wait until the end of your time on the drug to try to have a baby—and most doctors put women on Tamoxifen for five years. If you’re already in your mid-thirties, waiting that long could close your window of fertility entirely.
Some women do put off hormonal treatments for cancer in order to get pregnant. That’s what Jilda Nettleton did. She was diagnosed with breast cancer the day before her thirty-eighth birthday and underwent a lumpectomy and started radiation treatment the same month. But she had already been trying to get pregnant for over a year and decided to forego Tamoxifen until the next year, when her first daughter was born.
After a year on Tamoxifen, she went off the drug again and began to try to conceive her second child. A year later, her second daughter was born—and less than a year after that, she had a cancer recurrence and opted for a mastectomy. “Did I get a second cancer because of two pregnancies and only one year of Tamoxifen? Who knows?” she asks.
Most doctors strongly recommend taking Tamoxifen for at least two years after initial treatment before stopping the drug and trying to become pregnant, no matter how much you might want to try sooner. Research has shown that the overall duration of hormone therapy is important in helping to reduce late recurrences of breast cancer, so keep this in mind. Your doctor will also be able to give you more specific advice about what a “break” from Tamoxifen to get pregnant may mean for you as an individual, given factors such as your stage at diagnosis and the biology of your tumor. “Ideally, you should complete five years of Tamoxifen, but the reality is that a lot of women who want to get pregnant don’t have that luxury of time,” says M. Catherine Lee, MD, a breast specialist who focuses on fertility and breast cancer at Florida’s H. Lee Moffitt Cancer Center. “There’s no data to offer about ‘taking a break’ from Tamoxifen after two or three years and getting pregnant. We just don’t know. For some women, that unknown is too much. Others say the clock is ticking. It’s your body and your life, and you have to live it.”11
Christina Demosthenous, diagnosed with stage I breast cancer at age thirty-two, did just that. After a lumpectomy, chemotherapy, radiation, and two years of Tamoxifen, she got pregnant on her first try. “I was never regular to begin with, and my cycles had stopped toward the end of chemo but returned two months later,” she says. “I think some Tamoxifen in the beginning is better than none. The first few years after the diagnosis are critical.”
In chapter 6, you’ll read more about Michelle Rommelfanger, who became pregnant while taking Tamoxifen, and two other women who became pregnant while on other cancer therapies.
Here’s where things get really murky. If you think there’s not enough research out there on what standard treatments like chemotherapy do to your ability to have children, you haven’t seen anything yet. Monoclonal antibodies—new, “smart” drugs that attack specific cancer-causing mutations like heat-seeking missiles—have revolutionized the treatment of some cancers, but we don’t yet know for sure what they do to fertility, if anything.
It makes sense to think that these drugs—which include Herceptin for breast cancer, Avastin for colon and lung cancers, and Erbitux for colon and head and neck cancers—might not affect fertility at all. After all, they’re not stupid drugs like chemotherapy. They’re designed to hit their target and not damage other cells just because they happen to be growing fast. “These treatments are really specific,” says Dr. Woodruff. “Our instinct is that cancer patients who take these drugs should be in a better position to retain their fertility.”
Another newer drug, Gleevec, has had a dramatic impact on the lives of people with chronic myelogenous leukemia, many of them young. Gleevec is taken on a long-term basis—years at a stretch—and often induces a complete remission of the disease. As compared to other treatments for leukemia, Gleevec appears to do little to no harm to the reproductive system. It also seems to be safe to conceive while taking the drug, but because it’s not considered safe to take while pregnant, you’d have to go off Gleevec—and risk going out of remission (and potentially having trouble returning to remission once you start taking the drug again).
Since these drugs are all relatively new, less is known about all the side effects that may be identified once hundreds of thousands of patients have taken them over a number of years. Herceptin, for example, can do damage to heart function in a very small but still significant percentage of the women who take it. It’s taken thousands of women and lots of clinical trials to discover that important fact, and it will take a lot longer and a lot more patients to know with certainty if any of these targeted therapies have any effect on fertility. In general, though, if you ask most cancer specialists today, they’ll tell you that these drugs are not likely to do long-term damage to your ability to bear or father children.
The picture for all of these treatments is a little different when it involves cancer in children, especially those who haven’t yet reached puberty.
By far the most common childhood cancer is leukemia, which accounts for about one out of every three cancer cases in kids under the age of fifteen. Other common childhood cancers include central nervous system (CNS) malignancies, lymphomas, soft tissue sarcoma, renal cancer, and bone tumors. Almost all of these cancers are treated with alkylating chemotherapy, the most toxic to fertility in both men and women. For some young people with acute myelogenous leukemia (AML), a bone marrow transplant is lifesaving but can completely eradicate fertility.
Because they are much younger, girls do have a better chance than adult women of retaining their ability to bear children after cancer treatment—but they’re still at risk. A large study of more than three thousand survivors of childhood cancer and their siblings found that girls who’d been treated for cancer were thirteen times more likely to go into premature menopause as adults than their sisters were.12 Now, let’s put that in perspective: it means 8 percent of cancer survivors went into premature menopause, which also means that 92 percent of them didn’t. Just as with adults, the biggest risks are toxic chemotherapies (alkylating agents) and pelvic radiation—girls who had these treatments had a 30 percent chance of going through premature menopause.
The younger a girl is when she receives treatment, the more ovarian reserve she has—and the better chance she has of recovering her fertility as an adult. For instance, depending on the type of treatment, a girl treated for Hodgkin’s disease before age fifteen has only about a 13 percent risk of permanent ovarian failure. From age fifteen to about age thirty, the risk is about 60 percent. Although some studies have found a very high risk of permanent menopause—nearly 100 percent—for women treated for Hodgkin’s disease beyond age thirty, more current treatment regimens appear to be improving these odds.13
It’s different with radiation—here, the younger a girl is, the more vulnerable she is to damage, because the uterus has not yet fully developed. Girls who haven’t yet gone through puberty are more likely to have their uterus permanently damaged by radiation.
Just like with adult males, chemotherapy can damage boys’ ability to produce sperm. It appears that boys who get chemotherapy prior to puberty have a better chance of recovering than those who get it after puberty, but they’re vulnerable no matter what their age. Amazingly, though, some young men have recovered sperm production as many as fourteen years after cancer treatment.
Even when fertility returns after chemotherapy and radiation, these treatments often lead to early menopause. So if you finished chemo and radiation at age thirty, and all the parts seem to be working fine now, don’t assume that your “fertile window” is the same as that of your cancer-free friends. Odds are that you will enter menopause earlier than you otherwise would have. Just how much earlier, no one can say. Most doctors will tell you that, to get a crystal-ball look at how old you’ll be when you hit menopause, look at how old your mom was when she did. (An exception: if your mom was a regular smoker and you’re not, or vice versa, she’s not a good predictor for you anymore. Yep, cigarette smoking has that much of an effect on ovarian function.) So, if your mom went into menopause at forty-five, take a few years off that figure for the effects of chemotherapy and radiation. You’ll want to think about that when you start figuring out when you should try to conceive.
After this litany of all the things that cancer and cancer treatment can do to lay waste to your body and leave you unable to have a baby, you might be even more depressed than when you picked up this book. But don’t stop reading, because from now on, we’re going to be talking about the good stuff.
Here’s a little-known secret: almost everyone who’s undergone treatment for cancer as a younger person can still find a way to be a parent. Whatever route you take, it probably won’t be easy. The process can be infuriating and frustrating and seem like insult added to very serious illness if you’re watching all of your friends start or add to their families at the same time you’re tossing your cookies in the toilet, peeing orange from the latest round of chemotherapy, and getting ultrasounds to check for metastases rather than to find out the gender of a growing baby.
But it can be done. And let’s face it—is there anything about being a parent that’s ever easy? Plus, we’ve had cancer: we already know about fighting uphill battles against difficult odds. Don’t tell us we can’t do it.
First, your chances of conceiving spontaneously after chemotherapy, radiation, surgery, or other treatments might be better than you think. I figured that there was no way in the world I could get pregnant at age forty, after being slammed with chemotherapy at thirty-seven. But we conceived my son the first month we started trying. (With my younger daughter, it took two months.) We were far from alone. At a recent follow-up visit, my oncologist had just come from meeting with another patient who was thirty-seven weeks pregnant and had conceived without any assistance, several years after being treated for breast cancer.
There is also an ever-growing array of options for preserving your fertility before and during treatments and for assisting with conceiving a child afterward. Some of them are well known and reliable and some are still experimental, but you have more choices than ever before—you just have to know about them!
Even if pregnancy is not a possibility for you or your partner, adoption can be. You might be afraid that an expectant mother considering adoption would never pick you as a cancer survivor or that no country would ever approve you for international adoption—but a lot of the time, you’d be wrong.
And we’re not done yet. There’s also surrogacy, embryo adoption and donation, and foster care. We’ll talk about all of these different paths to parenthood in the next few chapters. So no matter what treatment you’re about to face, or how cancer may have ravaged your reproductive capabilities, if you have love to give to a child, you can find a way or make one. The rest of this book will tell you how.