How cancer treatment can affect fertility in women This information is an extract from the booklet Cancer treatment and fertility information for women. You may find the full booklet helpful. We can send you a free copy see page 8. Contents Cancer treatments and fertility Contraception Getting your fertility tested Hormone replacement therapy Getting support Cancer treatments and fertility 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 damaging or removing the womb. When I was diagnosed, we were trying for a baby and fertility was a big concern for me. I wanted to freeze my eggs but my doctor said that it would take some time to do and that we shouldn t delay treatment. He said I should focus on my life, not on a future life that might one day exist and he was right. Jenny Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk Page 1 of 8
Chemotherapy Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy cancer cells. It 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 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 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 Radiotherapy treats cancer by using high-energy rays to destroy cancer cells. It can cause fertility problems by: affecting egg production damaging the ovaries or womb reducing hormones (oestrogen and progesterone). Page 2 of 8 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk
Radiotherapy to the pelvis Radiotherapy given directly to the ovaries or the womb will cause permanent infertility. Pelvic radiotherapy 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. If radiotherapy is given close to the ovaries, it may be possible to protect the ovaries with a lead shield. Occasionally, surgeons can move the ovaries out of the way to protect them from the radiation. This is a minor operation called ovarian transposition, which 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) that 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. We have more information on gonadotrophin injections in the Cancer treatment and fertility information for women booklet. Radiotherapy to areas of the body not mentioned here won t cause infertility. Surgery 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 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk Page 3 of 8
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. Having your eggs collected may mean delaying the start of your cancer treatment, so it may not always be possible. We have more information on preserving your fertility in the Cancer treatment and fertility information for women booklet. 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 gland, but this isn t always possible. When the whole gland is removed, this affects the hormones (gonadotrophins) that stimulate the ovaries. This can make you menopausal. This is not because you have run out of eggs, but because your ovaries aren t being stimulated to release them. You may be given gonadotrophin injections to stimulate your ovaries to start producing eggs again. Hormonal therapy Hormonal therapy reduces the levels of hormones in your 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 ). Page 4 of 8 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk
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 (see below). This is because 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 therapy 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 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 coil (IUD) that 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. Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk Page 5 of 8
After treatment There is no evidence that cancer treatments harm children that you have after treatment. But doctors usually advise you to use 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. Page 6 of 8 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk
Hormone replacement therapy (HRT) How cancer treatment can affect fertility in women If you have an early menopause because of cancer treatment, you may be offered 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 may increase the risk of it coming back or of getting another breast cancer. 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. There are organisations that support women who have an early menopause, such as The Daisy Network (visit daisynetwork.org.uk). Getting support Infertility can be very distressing to live with. It may seem especially hard when you re already coping with cancer. Not knowing if your fertility will come back can be difficult 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. 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 alone. 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. Our cancer support specialists can also tell you about organisations that can help. You can talk things over with our cancer support specialists free on 0808 808 00 00, Monday Friday, 9am 8pm. Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk Page 7 of 8
More information and support More than one in three of us will get cancer. For most of us it will be the toughest fight we ever face. And the feelings of isolation and loneliness that so many people experience make it even harder. But you don t have to go through it alone. The Macmillan team is with you every step of the way. To order a copy of Cancer treatment and fertility information for women or any other information mentioned here, visit be.macmillan.org.uk or call 0808 808 00 00. We make every effort to ensure that the information we provide is accurate and up to date but it should not be relied upon as a substitute for specialist professional advice tailored to your situation. So far as is permitted by law, Macmillan does not accept liability in relation to the use of any information contained in this publication, or thirdparty information or websites included or referred to in it. Macmillan Cancer Support 2013. 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 NOVEMBER 2013 Planned review in 2016 Page 8 of 8 Questions about cancer? Ask Macmillan 0808 808 00 00 www.macmillan.org.uk