Fertility Evaluation and Fertility Preservation: Options for Women Who Have Completed Cancer Treatment

This information is for young women who have completed cancer treatment. It explains:

  • How cancer treatment may affect your fertility (the ability to become pregnant).
  • How your fertility can be evaluated after treatment.
  • How you may be able to preserve your fertility after treatment.

Basic Reproductive Biology

Understanding basic reproductive biology can be helpful as you make decisions about your fertility.

Conception and pregnancy

Figure 1. Female reproductive system

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.

Ovarian reserve

Figure 2. Reduction in ovarian reserve with age

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.

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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 and/or the uterus.

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.

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Fertility Evaluation

Some women want to know their fertility status after treatment. If you want to find out, specially trained gynecologists called reproductive endocrinologists (RE) can evaluate you. We do not have REs at MSK but can make a referral for you. We generally recommend that you wait at least 1 year after completing cancer treatment before having your fertility evaluated. This will give your ovaries time to recover from the effects of treatment.

An RE will do a number of tests to evaluate you. The tests may include:

  • 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 doctor can examine your ovaries and count the number of large growing follicles in the ovaries (called an antral follicle count).
  • Blood tests to measure the levels of hormones related to fertility, including follicle stimulating hormone (FSH) and anti-mullerian hormone (AMH).

Your RE will review the results of the evaluation with you and discuss your options for preserving your fertility and/or building a family in the future.

If you have never had a gynecologic exam before, your RE may be able to perform the ultrasound using a probe placed on your belly rather than in your vagina. You may find it helpful to review the following resource published by the American College of Obstetricians and Gynecologists before your first visit:

Your First Gynecologic Visit

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Fertility Preservation With Egg Freezing

Some women who are fertile after treatment but are at risk of losing fertility at a young age may want to consider undergoing egg freezing with the help of an RE. This involves removing mature eggs from your ovary to freeze and store for possible use in the future. If you are considering this, talk with your oncologist to be sure this would be safe for you. The process generally takes about 2 weeks. Several steps are involved, including:

  • Ovarian stimulation: On or around the second day of your period, you will start giving yourself hormone injections each day for about 10 days. A nurse will teach you how to do this. These hormones will stimulate multiple eggs in your ovaries to fully mature. During this period of stimulation, you will see your RE almost every day for blood tests and ultrasounds. These tests tell your RE how your ovaries are responding to the hormones. Once the eggs are fully mature, the egg retrieval will be scheduled.
  • Egg retrieval: This is an outpatient procedure done with short-acting anesthesia, so you will be asleep. No incision (surgical cut) is needed. Once you are asleep, an ultrasound probe will be placed in your vagina so your RE can see your ovaries. A very thin needle will be 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. The entire procedure takes 10 to 20 minutes (see Figure 3).
  • Freezing (cryopreservation): After the eggs are collected, they are brought to the laboratory to be examined and processed. The following day, the eggs that have fully matured are frozen. They can be stored for as long as you want.
Figure 3. Egg retrieval

If you use these eggs in the future, they will be thawed and fertilized with sperm to create embryos. These will be transferred into your uterus. If you are not able to carry a pregnancy yourself, they can be transferred to the uterus of another woman who can carry the pregnancy for you (called a surrogate, or gestational carrier). About 2 weeks later, a blood test is done to see if an embryo has implanted. About 2 weeks after that, an ultrasound is done to ensure the embryo is growing.

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Fertility Preservation With Embryo Freezing

Some women choose to freeze embryos rather than eggs. The process is the same as described above. However, after the egg retrieval, your eggs are fertilized with sperm in a laboratory. 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.

If you use these embryos in the future, they will be thawed and transferred into your uterus (or the uterus of a gestational carrier if you are not able to carry a pregnancy). About 2 weeks later, you will have a blood test to see if the embryos have implanted. About 2 weeks after that, you will have an ultrasound to ensure the embryo is growing.

Making a decision about freezing eggs or embryos

Many women wonder if they should freeze eggs, embryos, or a combination of both. One consideration is your age. In younger women, the success rate with frozen eggs is generally the same as with frozen embryos. However, the eggs of older women do not survive the process of freezing and thawing as well those of younger women, and freezing embryos may be more successful.

Another consideration is your relationship status. Embryo freezing is a good option for a woman 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. Egg freezing is a good option for single women who do not want to use donor sperm to fertilize their eggs. Egg freezing may also be preferred by those with religious or ethical concerns about freezing embryos. It is important to discuss this with your RE as you make this decision.

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Cost of Fertility Preservation

Freezing eggs and embryos 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-$15,000 for egg freezing and $15,000-$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. A number of centers provide discounts to cancer survivors. There are additional costs when you are ready to thaw and use the eggs or embryos to attempt pregnancy.

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Other Family-Building Options

Some women will not be able to preserve their fertility after treatment and some may choose not to for personal reasons. It is important to keep in mind that there are other ways of building a family after cancer treatment.

  • Donor eggs or embryos: Eggs are given by young women who undergo a cycle of ovarian stimulation and egg retrieval. These are fertilized with sperm from your partner or a donor, and the embryos are transferred into your uterus. The cost of using donor eggs is about $35,000. Embryos are usually given by couples who underwent infertility treatment, have completed building their families, and have embryos stored that they do not want to discard. The cost of using donor embryos is much lower than that of donor eggs. With donor eggs and embryos, the child will not have your genes, but you will be able to experience pregnancy and childbirth.
  • Adoption: Adoption is another way of building your family after cancer treatment. Having a history of cancer does not prevent you from being able to adopt, as long as you are healthy now and have been cancer-free for at least 3 to 5 years. There are many things to think about when considering adoption. Do you want to adopt a newborn baby, or are you comfortable adopting an older child? Do you want to adopt a child of the same race and ethnicity as you, or are you comfortable adopting outside your race? Would you consider adopting a child who has special health needs? It’s important to know what you are comfortable with before proceeding with adoption. Adopting a newborn baby in the United States costs about $30,000 to $40,000.
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Making a Decision About Fertility Preservation

It can be difficult to make a decision about egg or embryo freezing because of the lack of certainty involved. We cannot predict exactly how or if treatment will affect your fertility over time, and even if you undergo egg or embryo freezing, there are no guarantees that this will be successful.

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 egg or embryo freezing.
  • The importance to you of having a biologic child (from your own eggs).
  • Your comfort with receiving hormones to stimulate your ovaries.
  • The likelihood of success in having a baby if you pursue egg or embryo freezing.
  • Your feelings about being able to cope with the effort it will take to undergo egg or embryo freezing.
  • 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 or embryos, or through adoption.
  • Your comfort with the possibility of not having children or having no more children.
  • Your partner’s thoughts and wishes.
  • The support of your friends and family.
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Questions to Ask Your Doctor

If you have not discussed fertility with your doctor, you may find it helpful to ask some of the questions below:

  • Have other women been able to get pregnant naturally after receiving the same treatment that I received?
  • Will I be able to carry a pregnancy based on the treatment I received?
  • Am I at risk for infertility or early menopause from the treatment I received?
  • If I’m at risk for infertility or early menopause, but I am not ready to have children yet, can I freeze eggs or embryos now to preserve my fertility for the future?
  • If I carry a pregnancy, are there any risks to me or my baby based on the treatment I received?
  • Are there any risks to the health of my children based on the type of cancer I had?
  • Would a future pregnancy increase the chance of my cancer coming back?
  • Are there specialists you can refer me to for help in addressing these issues?
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Additional Resources

Our goal is for you to have all the information you need to make the best decision about pursuing fertility evaluation and fertility preservation. Regardless of the outcome, we do not want you to have regrets. A number of resources are available to help you as you make this decision. If you would like more information or support, ask your doctor or nurse to refer you to our fertility nurse specialist or our Counseling Center.

MSK’s website has information and resources on fertility for cancer survivors. For more information, go to: www.mskcc.org/cancer-care/survivorship/fertility

A number of professional organizations provide information and support on all options for building a family. Search within the websites for specific topics.

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