This information describes fertility preservation options for women who are starting cancer 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 resource describes options that may help you preserve your fertility and issues to consider as you make decisions about these options.
Basic Reproductive Biology
Understanding basic reproductive biology can be helpful as you make decisions about your fertility.
The female reproductive system includes a number of structures (see Figure 1).
The ovaries hold all your eggs (oocytes). Each egg is contained in a sac called a follicle. Beginning at puberty, hormones from the pituitary gland in the brain stimulate a group of eggs to mature each month. It takes 3 to 6 months for eggs to mature, and each month, only 1 is released into the fallopian tube. This process is called ovulation.
If a woman has vaginal sex around the time of ovulation without using birth control, a single sperm may fertilize the egg. The fertilized egg begins to divide, forming an embryo. If the embryo implants in the endometrium (inner lining of the uterus), pregnancy is achieved. The cells of the embryo continue to divide, and it eventually becomes a fetus. During pregnancy, the uterus expands to hold the fetus as it grows.
If the egg released during ovulation does not become fertilized, or if the embryo does not implant in the endometrium, 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 die naturally over time, so the number of eggs in the ovaries gradually declines. The term “ovarian reserve” refers to the number of eggs a woman has at any point in time. With fewer eggs, it is harder to become pregnant. Eventually, there are so few eggs that women become infertile (unable to get pregnant), monthly menstrual periods stop, and menopause begins. This reduction in ovarian reserve with age is shown in Figure 2.Back to top
Effects of Cancer Treatment on Fertility
Cancer treatments can impair fertility in a number of ways.
- Some chemotherapy medications destroy eggs, which may lead to infertility after treatment.
- The risk of infertility depends on the medications used, the doses given, and the age of the woman at the time of treatment. Older women have fewer eggs when they start treatment and so are more likely to become infertile after treatment.
- This loss of eggs in the ovaries from chemotherapy can “age” the ovaries, reducing the chance of pregnancy in the same way that natural aging does. Some women lose so many eggs that they become infertile immediately after treatment. Some women continue to have monthly menstrual periods after treatment, but may develop infertility and menopause at a young age.
- Radiation therapy to the pelvis destroys eggs in a similar way to chemotherapy, as described above. Radiation may also damage the uterus, causing fibrosis, or scarring, of the tissues. This may make it difficult to become pregnant or to carry a pregnancy to term (until the baby’s birth). Women who get pregnant after treatment that exposed their uterus to radiation are much more likely to have miscarriages or premature labor.
- Surgery or radiation therapy to the brain may affect the pituitary gland, which secretes hormones that stimulate egg maturation and ovulation. However, this does not damage the eggs in the ovaries, and medications that replace these hormones may lead to pregnancy.
- Surgery may require removal of the ovaries, uterus, or all 3.
Because of the many factors that can affect fertility, it is difficult to predict with certainty how any one woman will be affected by treatment. We cannot know for sure who will retain fertility after treatment is completed and who will not. We also cannot know for sure how long a woman will be fertile after treatment. If your oncologist has not discussed these issues with you, you may want to ask how your fertility may have been affected by treatment.Back to top
Fertility Preservation Options
A number of options are available that may preserve your fertility and increase the chance you will be able to have 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 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.
Standard fertility preservation options for women include:
- Embryo freezing, egg freezing, or both
- Ovarian transposition
- Alternative treatment for certain early state gynecologic cancers
Experimental fertility preservation options for women include:
- Ovarian suppression
- Ovarian tissue freezing
Embryo and egg freezing are procedures in which mature eggs are removed from your ovary to be frozen and stored for possible use in the future. They can be frozen as unfertilized eggs or fertilized with sperm and frozen as embryos. The process generally takes 2 to 3 weeks.
There are several steps in this process.
- Referral to a reproductive endocrinologist: Reproductive endocrinologists (RE) are gynecologists who specialize in fertility. We do not have REs at MSK but can make a referral for you. At your first visit, your RE will review your medical history and perform a physical examination. He or she will also perform a transvaginal ultrasound in which a thin probe is placed in your vagina. Sound waves from the probe bounce off the structures in your pelvis to create pictures of your ovaries and uterus. With this test, your RE can examine your ovaries and count the number of large, growing follicles in the ovaries.
You will also have blood tests to measure the levels of hormones related to fertility. These tests help determine how successful your egg retrieval may be. Your 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, you will start giving yourself hormone injections each day for about 10 days. A nurse at the fertility center will teach you how to give yourself these injections. These hormones will stimulate multiple eggs in your ovaries to mature. You do not need to be at any particular phase in your menstrual cycle to begin. During this period of stimulation, you will see the RE almost every day for blood tests and ultrasounds. These tests tell us how your ovaries are responding to the hormones. If needed, we may change the doses of the hormones. Once your eggs are fully mature, the egg retrieval will be scheduled.
- Egg retrieval: This is an outpatient procedure, done with anesthesia, so you will be asleep. No incision (surgical cut) is needed. Once you are asleep, an ultrasound probe is placed in your vagina so your RE can see your ovaries. A very thin needle is passed through the wall of your vagina up to your ovary. Your RE will puncture each of the large follicles with this needle to withdraw the mature eggs (see Figure 3). The entire procedure takes only 10 to 20 minutes and most women are discharged within 1 hour. All of your eggs are brought to the laboratory to be examined and processed.
- Fertilization (if you are freezing embryos): Your mature eggs will be fertilized with sperm in the laboratory to create embryos. This is called in vitro fertilization, or IVF. The laboratory will use sperm from your male partner or from a sperm donor. If you are using donor sperm, you must select the donor far in advance. There are many donor sperm banks available, and your RE can recommend specific ones for you to use.
- Freezing (cryopreservation): Your unfertilized eggs or embryos will be frozen and 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, talk with your oncologist to be sure you can take the time to do this. Most patients only do 1 cycle 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.
Making a decision about freezing 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. Some women choose to freeze both eggs and embryos.
Egg freezing is a good option for single women who do not want to use donor sperm to fertilize their eggs. Women who have religious or ethical considerations about freezing embryos may also prefer to freeze eggs.
In young women who are treated at fertility centers experienced in freezing eggs, the success rates are generally the same as those for frozen embryos. Discuss this with your RE as you make a decision about freezing eggs or embryos.
Considerations for women with breast cancer
The hormone injections needed to stimulate your eggs to mature will cause your estrogen levels to rise for 2 to 3 weeks. To lower estrogen levels, we generally recommend that women with breast cancer take a medication called letrozole during stimulation, and for 1 to 2 weeks after the eggs are collected. Your RE will discuss this with you and prescribe the medication.
We cannot say for certain if undergoing egg or embryo freezing is safe; however, there have been no reports that women with breast cancer who do this are more likely to have the cancer return. Everyone’s situation is different and we encourage you to discuss this with your oncologist if you are considering this.
Freezing embryos and eggs is expensive, and unfortunately, most health insurance plans do not cover the cost. The cost varies among fertility centers but is generally about $12,000 to $15,000 for egg freezing and $15,000 to $18,000 for embryo freezing. This includes the hormone medication, the monitoring visits, the egg retrieval under anesthesia, fertilization of the eggs (if creating embryos), and the freezing. The storage fee is about $900 per year. There are additional costs when you are ready to thaw and use the embryos or eggs to attempt pregnancy. A financial specialist at the fertility center can determine what, if anything, will be covered by your health insurance and what you will have to pay yourself.
A number of fertility centers provide discounts to patients undergoing fertility preservation because of cancer. There are 2 programs that help people with cancer with the cost of embryo and egg freezing:
- LIVESTRONG Fertility works with REs who offer a discounted rate for their services and with a pharmaceutical company that provides free hormone injections. To find out if you are eligible, and to get an application, go to: images.livestrong.org/downloads/we-can-help/LF_App_Women_FINAL_v9.pdf?_ga=1.237964992.1902296531.1415306052. You must submit the application and obtain approval before you start ovarian stimulation.
- Heartbeat is a pharmaceutical company program that offers free hormone injections. To learn more, go to: www.ferringfertility.com/savings/heartbeat/.
Attempting pregnancy with frozen eggs or embryos
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.
If you no longer have regular periods, you may need to take hormones for several weeks before the transfer. This will help to prepare the lining of your uterus for implantation. You may also need to continue taking the hormones for several months afterward to support the pregnancy.
Your RE will transfer embryos into your uterus to help you achieve pregnancy. If you froze eggs, these will be thawed and fertilized with sperm to create the embryos; if you froze embryos, these will be thawed. You will decide with your RE how many embryos to transfer.
The embryos will be drawn up into a very thin, soft catheter that is passed through your vagina and cervix into your uterus. The embryos are released and the catheter is taken out. The procedure is done in an exam room. It does not hurt, so you will not need anesthesia.
You will return about 2 weeks later for a pregnancy test. If you have a positive result, you will have an ultrasound several weeks later to confirm the pregnancy. You will then start seeing an obstetrician (a doctor who specializes in pregnancy and childbirth) for your care during pregnancy.
Frequently asked questions about embryo and egg freezing
What is the chance I will be able to have a baby using frozen embryos or eggs?
The chance that you will be able to have a baby using one of these procedures (the success rates) varies based on a number of factors, including:
- Your age at the time of egg retrieval. Women who are under 35 years of age have higher success rates.
- The health of your partner’s sperm.
- The experience of the fertility team with whom you are working.
Not every egg collected will produce a live baby. For example, if 10 eggs are collected, 7 may fertilize to become embryos, 5 may survive the freeze-thaw cycle, and 2 to 3 may be healthy enough to transfer.
The Society for Assisted Reproductive Technologies (SART) reported the success rates for patients who used thawed embryos. The 2012 national success rates based on age are in the table below.
|Age||Younger than 35||35-37||38-40||41-42||Older than 42|
|Percent of transfers that resulted in a live birth||42%||40%||34%||26%||18%|
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 you are not able to carry a pregnancy, you can arrange for another woman to carry a pregnancy for you. This is called “surrogacy with a gestational carrier.” Embryos created from your eggs are transferred to your carrier’s uterus. You are the “intended parent” and the child is given to you after delivery. The carrier will have no biologic relationship to the child.
Surrogacy can be a good option for many women, but the laws are complicated and vary in each state. It will be important to work with an agency or attorney who knows about surrogacy laws. In addition, surrogacy is very expensive and can cost as much as $120,000.
If you are considering surrogacy, let your RE know in advance. The FDA requires that you have special testing and screening in order to use a gestational carrier.
Ovarian transposition may be an option if you are receiving radiation therapy to the pelvis. This is an outpatient surgical procedure that moves your ovaries outside of the field of treatment. The surgery is done through several small incisions in your abdominal wall. To learn more go to: www.mskcc.org/cancer-care/patient-education/resources/ovarian-transposition.
Even when your ovaries are moved, they may still be exposed to some radiation. If you will also be getting chemotherapy, some of the eggs in your ovaries will be destroyed. If having a biologic child is important to you, you may also want to undergo egg or embryo freezing before treatment.
We cannot move your uterus to prevent radiation exposure, and after treatment, you may have damage to your uterus. You may not be able to get pregnant after pelvic radiation, and you may be at risk of miscarriage or early labor. Ask your radiation oncologist about your ability to carry a pregnancy after having radiation therapy to the pelvis, and for a referral if you are interested in ovarian transposition or embryo or egg freezing.
For women with certain early-stage gynecologic cancers, it may be possible to do limited surgery, or in some cases take medication to preserve fertility. This means your doctor may be able to leave one or both of your ovaries, your uterus, or all 3 intact.
For example, some women who have early-stage cervical cancer can have their cervix removed but have their uterus left in place. This procedure is called radical trachelectomy and may enable you to get pregnant and carry a fetus. To learn more about radical trachelectomy, go to: www.mskcc.org/cancer-care/patient-education/resources/radical-trachelectomy.
Not all women 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.
Ovarian suppression involves taking monthly injections of a medication called leuprolide to block hormones that stimulate your ovaries. This prevents eggs from maturing, with the hope that this will protect them from the effects of chemotherapy.
The injections usually start 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, such as hot flashes, mood changes, difficulty sleeping, and vaginal dryness. If you are able to take hormones, low-dose birth control pills can be prescribed to prevent these symptoms. To learn more, go to: www.mskcc.org/cancer-care/patient-education/resources/leuprolide-acetate-fertility-preservation.
It is important to note that ovarian suppression has been studied mostly in women with breast cancer and lymphoma. Based on the results of these studies, it is not certain that this medication preserves fertility, so this is considered an experimental treatment. We do not know if this will be helpful for 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.
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 the ovary 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, with the hope that eggs in the tissue will mature and be released with ovulation. As of 2015, about 30 babies have been born after re-implantation of 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. No babies have yet been born using this technique
Ovarian tissue freezing may not be an option for all women. If you would like to learn more, ask your oncologist to refer you to a RE who performs ovarian tissue freezing.Back to top
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 but will be able to get pregnant with fertility treatment by an RE. Other options to consider include the use of donor eggs and adoption. To learn more go to: www.mskcc.org/cancer-care/patient-education/resources/building-your-family-options-for-women-who-have-completed-cancer-treatment.Back to top
Making a Decision about Fertility Preservation
It can be difficult to make a decision about fertility preservation because there is a lot of uncertainty. We cannot predict exactly how or if treatment will affect your fertility. If you do pursue fertility preservation, there are no guarantees that it will be successful. There is also 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, or undergo a procedure under anesthesia.
- Your comfort with delaying treatment for about 3 weeks.
- Your comfort with receiving hormones to stimulate your ovaries.
- How important it is to you to have a biologic child (from your own eggs).
- The likelihood of success in having a baby if you pursue one of these options.
- How anxious you are feeling about your cancer diagnosis and treatment plan.
- 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.
- Your comfort with accepting whatever happens.
- 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 partner’s thoughts and wishes.
- The support of your friends and family.
There is no “right” decision. Our goal is for you to have all the information you need to make the best decision you can for yourself. Regardless of the outcome, we do not want you to have regrets.Back to top
A number of resources are available to help you make decisions about fertility preservation. First, speak with your oncologist to make sure 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 your oncologist to refer you to our fertility nurse specialist or our Counseling Center.
If you have any questions or concerns, talk with a member of your healthcare team. You can reach them Monday through Friday from 9:00 am to 5:00 pm at ____________________. After 5:00 pm, during the weekend, and on holidays, please call____________________. If there’s no number listed, or you’re not sure, call 212-639-2000.