This information explains the options available to women to preserve fertility before treatment.
You will be starting cancer treatment that may affect your fertility and ovarian function. As a result, you may not be able to become pregnant naturally, or you may begin menopause at an early age. This booklet describes options that may be available to you to preserve your fertility potential and discusses issues to consider as you make decisions about these options.
Basic Reproductive Biology
Natural Conception of a Child
Many parts of the body are involved in conceiving a child (see Figure 1).
The ovaries contain eggs (oocytes) and secrete hormones. Each egg is in a sac called a follicle. Beginning at puberty, hormones from the brain stimulate the monthly menstrual cycle to begin. Some of the eggs begin maturing each month, and as they mature, the follicles get larger. The most mature follicles are large enough to see on an ultrasound. It takes 3 to 6 months for eggs to mature. Each month only 1 of these eggs fully matures.
The mature egg is released from the ovary into the fallopian tube. This is known as ovulation. If a woman has vaginal sex around the time of ovulation without using birth control, a sperm may fertilize the egg. The fertilized egg begins to divide forming an embryo which passes into the uterus. If it implants on the inner lining of the uterus (endometrium) pregnancy is achieved. The cells continue to divide forming a fetus. During pregnancy, the uterus expands to hold the fetus as it grows.
If the egg released during ovulation does not fertilize, or if the embryo does not implant in the lining of the uterus, hormone levels drop and cause the lining of the uterus to shed. This bloody discharge forms your monthly menstrual period. The cycle then begins again, with new eggs maturing each month.
Girls are born with about 1 million eggs. During a woman's lifetime, only about 400 to 500 eggs are released with ovulation. The other eggs degenerate naturally over time, so the number of eggs in the ovaries gradually declines. The term “ovarian reserve” refers to the number and quality of eggs a woman has at any point in time.
With fewer eggs, it is harder to become pregnant, and eventually there are so few eggs, that monthly menstrual periods stop and menopause begins. This reduction in ovarian reserve with age is shown in Figure 2.
Effects of Cancer Treatment on Fertility
Cancer treatment can impair fertility in a number of different ways.
- Surgery may require removal of the ovaries and/or the uterus.
- Some chemotherapy drugs destroy eggs in the ovary.
- The degree to which the ovaries are affected depends on the drugs used, the doses of the drugs given, and the age of the woman at the time of treatment.
- This loss of eggs in the ovaries from chemotherapy can effectively “age” the ovaries, reducing the chance for pregnancy in the same way that natural aging does. It may also cause early (premature) menopause, shortening the period of time during which a woman who is still fertile after treatment can become pregnant.
- During chemotherapy, monthly menstrual periods may stop.
- Even if periods begin again after treatment, some women will not have enough eggs to get pregnant naturally.
- Radiation therapy to the pelvis destroys eggs in the ovary in a similar way to chemotherapy, as described above.
- Radiation therapy to the pelvis at high doses may damage the uterus. The blood supply may be affected, and muscles and other tissues may lose their elasticity. As a result, an embryo may not be able to implant, or the uterus may not be able to expand to hold a growing fetus. This can result in complications during pregnancy, such as miscarriage or premature labor.
- Surgery or radiation therapy to the brain may affect the pituitary gland, the part of the brain that secretes hormones to stimulate the ovaries each month. Without these hormones, eggs may not mature. Pituitary gland surgery or radiation does not damage the eggs in the ovaries, and replacing hormones can often lead to pregnancy.
Not all cancer treatments impair fertility. It depends on:
- Your age
- The number and quality of eggs you have before treatment
- The type of surgery you have
- The type and dose of chemotherapy you receive
- The area of the body that is irradiated and the dose of radiation you receive
- Other fertility problems you may have
Because of the many factors that may affect fertility, it is difficult to predict with certainty how any one person will be affected. We cannot know for sure who will regain ovarian function after treatment is completed and who will not.
Fertility Preservation Options
A number of options are available that may preserve your fertility and increase the chance you will be able to conceive a biologic child in the future. Not all women starting cancer treatment will need or want to consider these options. We are not recommending that you pursue any of these, but we want you to know about what is available. Our goal is for you to make the best decision you can based on your personal situation so that you have no regrets in the future. We hope the information below will help you understand your options and decide if pursuing fertility preservation before treatment is the right choice for you.
Embryo and Oocyte Cryopreservation
Embryo and egg freezing are procedures in which mature eggs are removed from your ovary and frozen. They can be frozen as unfertilized eggs, or as embryos after fertilization with sperm. They are stored for you to use in the future if you need them.
What is involved?
The process for this generally takes two to three weeks, depending on where you are in your menstrual cycle. Several steps are involved.
- Referral to a reproductive endocrinologist: Reproductive endocrinologists (RE) are gynecologists who specialize in fertility. We do not have reproductive endocrinologists at MSKCC but can make a referral for you. At your first visit, the RE will review your medical history and perform a physical examination. You will have blood tests to check your hormone levels and a transvaginal ultrasound to count the number of potential follicles in your ovaries. These tests help determine how successful you may be in collecting eggs. The RE will also want to consult with your oncologist to make sure it is safe for you to proceed with egg collection.
- Ovarian stimulation: If you decide to proceed, at the best time during your menstrual cycle (often on or around the second day of your next period), you will start giving yourself daily hormone injections. This medicine stimulates your ovaries so that those eggs that would normally be lost during the cycle will mature (rather than the single egg that fully matures naturally each month). You will need the injections for about 10 days. If you are not at the right time of the menstrual cycle, you can be given medicine to get you to the point where you are able to start sooner. A nurse will teach you how to give yourself these injections. While you are taking these, you will see the RE almost every day for blood tests and transvaginal ultrasounds. These indicate how your ovaries are responding to the stimulation so the dose of the hormones can be changed if needed. As the eggs mature, the follicles get larger. Once they reach a certain size, another injection (HCG) will stimulate final egg maturation. Egg collection (retrieval) will be scheduled about 35 hours later.
- Egg retrieval: This is an outpatient procedure, done with anesthesia so you will be asleep. No surgical incision is needed. Once you are asleep, an ultrasound probe is placed in your vagina so the RE can see your ovaries. A very thin needle is passed through the wall of the vagina up to your ovary. The needle punctures each of the large follicles and withdraws the mature eggs. The entire procedure takes 10 to 20 minutes (see Figure 3).
- Fertilization: If you are going to freeze embryos, your eggs are fertilized with sperm in a laboratory (in vitro fertilization, IVF). One method is to mix each egg with thousands of sperm, one of which enters each egg. Another method is to inject a single sperm into each egg (intracytoplasmic sperm injection, ICSI). ICSI is often used because it is more successful at ensuring the eggs are fertilized. The laboratory will use sperm from your male partner or from a sperm donor if you so choose. If donor sperm is to be used, you must select the donor well in advance from one of many commercial donor sperm banks.
- Freezing (cryopreservation): The day after fertilization, the zygotes (newly fertilized eggs still at the 1 cell stage) will be frozen or they can be monitored in the laboratory for three to five days and frozen as embryos. If you are going to freeze eggs, they are not fertilized and the mature eggs are frozen soon after retrieval. The embryos or unfertilized eggs are stored for as long as you would like. Some of these may be damaged during the freezing and thawing process; however, no known damage occurs while they are frozen.
Before beginning embryo or egg freezing, speak with your oncologist to be sure you can take the time to do this. Most patients only do 1cycle of stimulation before their cancer treatment. If you are considering a second cycle, speak with your oncologist first to be sure this will not delay your cancer treatment longer than is safe to do so.
Is this safe for patients with breast cancer?
The hormone injections needed to stimulate egg maturation will cause your estrogen levels to rise for 2 to 3 weeks. We cannot say for certain if this is safe. To lower estrogen levels, we generally recommend that patients with breast cancer take a medication called letrozole during stimulation, and possibly for a short time after the eggs are retrieved. The RE will discuss this with you.
Should I freeze embryos or eggs?
Embryo freezing is a good option for patients in a stable long term relationship. However, keep in mind that you will not be able to use the embryos without your partner's permission, which could be a problem if the relationship comes to an end. For single women who do not want to use donor sperm to ferilize their eggs, and for those with religious or ethical concerns about freezing embryos, egg freezing is a good option.
How much does it cost to freeze embryos or eggs?
Embryo and egg freezing is expensive. The cost includes many different services and procedures, and each fertility center charges different amounts for these. The cost in the New York area is generally about $10,000 to $15,000. In addition, the hormone medication to stimulate your ovaries generally costs $3,500 to $4,500, and the annual storage of the embryos or eggs generally costs $700 to $800. You will have additional costs when you are ready to thaw the embryos or eggs and use them to attempt a pregnancy.
Most health insurance plans do not cover embryo or egg freezing for fertility preservation. Call your insurance company to find out about your coverage. Explain that you have not been diagnosed with infertility, but that you will be starting treatment for cancer. Your doctor has explained that treatment may cause you to become infertile and has recommended egg collection before treatment.
Sometimes the insurance company is not clear about what they will cover. They may need specific “CPT codes” to decide. A financial specialist at the fertility center can provide these codes to them. Only then will you know for sure what will be covered and what you will have to pay yourself.
Is there financial assistance for patients with cancer who want to freeze embryos or eggs?
LIVESTRONG has a financial assistance program for embryo and egg freezing called Fertile Hope. Participating REs offer a discounted rate for their services and the hormone injections are provided without charge. This is only offered to patients who are freezing embryos or eggs before treatment. To find out if you are eligible, and to get an application, look on their web site (http://www.fertilehope.org/financial-assistance/egg-and-embryo-freezing.cfm). You must submit the application and obtain approval before you start ovarian stimulation.
How are my frozen embryos or eggs used to attempt pregnancy?
Before attempting pregnancy, talk to your oncologist. Ask if the timing is right for you or if there are any medical reasons that would make it unsafe for you to become pregnant.
Your RE will help you use your frozen embryos or eggs. If you no longer have regular periods, you will most likely need to take hormone medication for about 2 weeks to prepare the inner lining of your uterus for implantation. If you froze embryos, depending on your age when you froze the embryos, up to 6 may be thawed. If you froze eggs, again depending on your age when you froze the eggs, up to 10 may be thawed and then fertilized with sperm from your partner or a donor to create embryos.
Placing the embryos in your uterus (embryo transfer) is a very simple painless procedure so there is no need for anesthesia. The RE places a speculum inside the vagina like during a routine gynecologist visit. The cervix is washed with moistened gauze, which feels much like a PAP smear. The embryos are drawn up into a very thin soft catheter which is passed through your vagina and cervix into you uterus. The embryos are released, and the catheter is withdrawn.
You will be scheduled to return 12 to14 days later for a pregnancy test. If you have a positive result, you will have an ultrasound several weeks later to verify the pregnancy is normal and show how many embryos implanted. If necessary, you will continue to take hormones to support the pregnancy for several months. If you are pregnant, you will transfer your care to an obstetrician.
What is the chance I will be able to have a baby using frozen embryos or eggs?
The success rates of these procedures vary based on a number of factors, including:
- Your age (success rates are higher in women under 35 years of age)
- The health of your partner's sperm
- The experience of the fertility team you are working with
Not every egg collected will produce a live baby. For example, if 10 eggs are collected, 7 may fertilize, 5 may survive the freeze-thaw cycle, and 2 to 3 may be good enough to transfer. The Society for Assisted Reproductive Technologies (SART) reported 2010 national success rates based on age for patients undergoing IVF for infertility using thawed embryos as follows:
You can go to www.sart.org to see success rates for specific fertility centers. However, to understand your personal chance of success, speak with your RE.
Can I consider freezing embryos or eggs if I will not be able to carry a pregnancy after my treatment is completed?
If it is very important for you to have a biologic child, you can still freeze embryos or eggs and later arrange for another woman to carry a pregnancy for you. This is called using a gestational carrier. Embryos created from your eggs are transferred to the carrier's uterus. You are the “intended parent” and the child is given to you after delivery. The carrier will have no genetic relationship to the child.
In deciding if this would be a good option for you, it is important to know that laws relating to surrogacy and gestational carriers vary by state. In some states, the process is very difficult or even illegal. Costs vary widely and can be up to $100,000. If you are considering this, it is important to let your RE know in advance since some specific testing and screening is required by the FDA to enable you to use a gestational carrier. You should also consult with a lawyer in your state who specializes in reproductive medicine.
Ovarian Tissue Cryopreservation
Ovarian tissue freezing is an experimental procedure in which an entire ovary, or pieces of an ovary, are removed during a surgery. After the ovary is removed, the outer layer of tissue (cortex) is cut into small pieces, frozen, and stored. One option for using this tissue in the future is to re-implant it into your body. As of 2012, fewer than 25 babies have been born using this technique. This may not be an option if you have a type of cancer in which there is a risk of re-implanting cancer cells that may be present in the frozen ovarian tissue. Another option for using this tissue is to mature eggs in the laboratory (in vitro maturation) and then fertilize them to create embryos. As of 2012, no babies have been born using this technique. If you would like to learn more, ask your oncologist to refer you to a RE who performs ovarian tissue freezing.
Ovarian suppression involves taking medication to block hormones that stimulate the ovaries. This prevents eggs from maturing with the hope that this protects them from the effects of chemotherapy. Research evaluating this approach has been done primarily in women with breast cancer and lymphoma. The results have been conflicting, so we do not know if this will be helpful to you. Some doctors feel it may help; others feel that it has no benefit. If you are interested in this option, speak with your oncologist.
The medication is given as an injection, either once a month or in a larger dose every 3 months. We generally start it 1 to 2 weeks before the first chemotherapy treatment and continue until your treatment is completed. Side effects of the medication may include symptoms similar to those of menopause, like hot flashes, mood changes, difficulty sleeping, and vaginal dryness.
Ovarian transposition is an outpatient surgical procedure that moves the ovaries outside of the pelvic field of radiation therapy. The surgery is done laparoscopically through several small incisions in your abdominal wall. Even when the ovaries are moved outside of the field of treatment, they may still be exposed to some radiation. Some of the eggs may still be damaged. If you will also be getting chemotherapy, this can increase the likelihood that eggs will be destroyed. Because of this, you may also want to collect eggs before your treatment in addition to having this surgery.
Alternative Treatment for Certain Early Stage Gynecologic Cancers
For patients with certain early-stage gynecologic cancers it may be possible to do limited surgery, or in some cases take medication. This means your doctor may be able to leave one or both of your ovaries and/or your uterus intact. For example, some patients who have early cervical cancer can have their cervix removed while leaving the uterus in place. This procedure is called radical trachelectomy and may enable you to get pregnant and carry a fetus. Not all patients are eligible for these limited surgeries. It depends on the location and size of your tumor. If you are interested, ask your gynecologic surgeon if you are a candidate.
Alternative Options for Building a Family
Many women chose not to pursue fertility preservation before cancer treatment. This does not shut the door on having children in the future. Some women will be able to get pregnant naturally without medical help. Some may have a low ovarian reserve and need treatment by a RE. Other options for parenthood you can consider if you have impaired fertility in the future are use of donor eggs and adoption. To learn more about these options, ask your nurse for the MSKCC booklet Building Your Family After Cancer Treatment: Options for Women.
Making a Decision about Fertility Preservation
It can be difficult to decide about fertility preservation because of the lack of certainty involved. We cannot predict exactly how or if treatment will affect fertility, and even with fertility preservation, there are no guarantees that these procedures will result in the ability to have a biologic baby. In addition to the uncertainties involved is the pressure to make a decision quickly.
Some women are very clear about whether or not they want to pursue fertility preservation. Others have a harder time making this decision. Below are some things to consider as you make a decision for yourself:
- The opinion of your oncologist about the risk of infertility from your treatment
- The opinion of your oncologist about the safety of undergoing fertility preservation if this means you need to delay treatment for about 3 weeks, receive hormones to stimulate your ovaries, and/or undergo a procedure under anesthesia
- Your comfort with delaying treatment for about 3 weeks
- Your comfort with receiving hormones to stimulate your ovaries
- The importance of having a biologically-related child
- The likelihood of success in having a baby if you pursue one of these options
- The degree of distress you are feeling from the cancer diagnosis and planned treatment
- Your feeling about being able to cope with the effort it will take to preserve fertility
- Your religious, ethical, and personal beliefs about using reproductive technology
- Your financial resources to pay for these options
- The support of your friends and family
- Your comfort with the possibility of having a child using donor eggs, a gestational carrier, or adoption
- Your comfort with the possibility of having no children or having no more children
- Your faith or belief that whatever happens is meant to be
Our goal is for you to feel you have the information you need to make the best decision you can for yourself. Regardless of the outcome, we want to be sure you have no regrets.
A number of resources are available to help you as you make this decision. First, speak with your oncologist to ensure that it is safe for you to pursue fertility preservation. If you would like more information about the options available or support as you consider the issues, ask them to refer you to our fertility clinical nurse specialist or our Counseling Center.
Additional Resources on Fertility Preservation
A number of internet sites have information that may be helpful.
Sites specific to cancer and fertility:
Sites with general information about cnfertility and its treatment: