April 11, 2011
Cancer and the Chance of Children
How Cancer Treatments Affect Your Fertility
Gina M. Shaw
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 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 my book, Having Children After Cancer, is for.
- Ask Your Doctor
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
- 1. How is my cancer affecting my health right now?
2. How quickly do I need to start treatment?
3. Will my cancer or its treatment affect my future fertility?
4. What fertility options are out there?
5. Can I have a child after my cancer?
What Cancer Does to Your Fertility
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 Having Children After Cancer, I 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.
What You Can Do
After learning 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 started reading this article. But Having Children After Cancer will walk you through the good stuff--how you can have children as a cancer survivor.
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. Having Children After Cancer talks about all of these different paths to parenthood. 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. Having Children After Cancer will tell you how.
- Quinn, G.P., et al. Physician referral for fertility preservation in oncology patients: A national study of practice behaviors. Journal of Clinical Oncology 27, no. 35 (December 10, 2009): 5952-57.
- Woodruff, T. In conversation with author. November 24, 2009.
- Rueffer, U., et al. Male gonadal dysfunction in patients with Hodgkin's disease prior to treatment. Annals of Oncology 12, no. 9 (September 2001): 1307-11.
- Jacobson, R., et al. Risk of testicular cancer in men with abnormal semen characteristics: Cohort study. British Medical Journal 321 (September 30, 2000): 789-92.
- Oktay, K., et al. Association of BRCA1 mutations with occult primary ovarian insufficiency: A possible explanation for the link between infertility and breast/ovarian cancer risks. Journal of Clinical Oncology 28, no. 2 (January 10, 2010): 240-4.
- Adapted with permission from Having Children After Cancer: How to Make Informed Choices Before and After Treatment and Build the Family of Your Dreams, Copyright © 2011 by Gina M. Shaw, Celestial Arts, an imprint of Ten Speed Press, a division of the Crown Publishing Group, Berkeley, CA.