Having cancer doesn’t mean not having children.

Most of us, at one time or another, think about having a family. While not everyone ends up deciding to have children, most people at least want the option.

Although many, many people who have had cancer and cancer treatment do not experience infertility, some people do. It depends upon the type of cancer treatment they receive and many other physical factors, such as their type of cancer, where it is located, their age, gender, and response to treatment. However, even if there is a likelihood of infertility due to cancer or its treatment, that doesn’t mean that having children is impossible. It may not happen in the traditional way, but if people with cancer can be flexible, they will find there are options to help.

Knowing this can lift the spirits of many people and actually give them a greater ability to cope with treatment (see the article in this issue, Antoinette Ramos survived Hodgkin lymphoma, and so did her chance of having children.), so it may help to remind your loved one of this.

Below are options your loved one may want to consider. All of these options, whether for men or women, should be carefully and fully discussed with a doctor or health care team so that the risks and chances of success are understood.

Sometimes physicians may not be well informed about problems with fertility, or may regard this issue as less important than saving the life of a person with cancer. However, new guidelines for physicians have just been released by the American Society of Clinical Oncology (see article in this issue), so, when you accompany your friend or loved one to the doctor, you will likely find him or her more receptive to discussions about the issue. Remember, your loved one has a right to get answers to his or her questions, even if it means asking for a second opinion or seeing a specialist. Together, you may want to talk to the oncologist, surgeon, OB/GYN doctor, nurse, or a reproductive endocrinologist or male infertility specialist.

Options for women:

Embryo freezing:

Embryo freezing is the most common and successful method of fertility preservation today. Embryo freezing involves surgically removing mature eggs from the woman's ovaries, fertilizing them in the lab, and then freezing them for future use after successful cancer treatment. This is called in vitro fertilization (IVF).

Since each egg can only produce one embryo at best, a woman will have a better chance of having a baby by storing several embryos. Normally, this means beginning a cycle of hormone shots on the third day of her menstrual cycle and continuing them for two to three weeks until multiple eggs are mature (often around a dozen in a woman under age 35).

This is not an option for everyone. Some women with fast-growing cancer cannot wait the necessary two to three weeks to begin treatment. Women with breast cancer may run the risk of their tumor growing during an IVF cycle because of the high levels of estrogen that result from the hormone shots. One option for these women is “natural cycle IVF” in which ultrasounds are used to follow the progress of normal ovulation, and one or sometimes two eggs can be collected. Recently, another option has been developed. It uses letrozole or tamoxifen during the hormone stimulation to prevent estrogen from encouraging cancer cells to grow. Although more studies are needed, results so far do not show any negative effect on women’s breast cancer treatment or survival.

The average cost of embryo freezing is more than $10,000 per cycle, but these costs can vary. Although most states do not make insurers cover IVF treatment, a letter from one’s oncologist to the insurance company explaining the need for fertility preservation can sometimes make a difference.

Egg freezing:

Egg freezing involves surgical removal of mature eggs, but the eggs are frozen without being fertilized with sperm. Egg freezing is still a relatively new and unstudied technique so there is less data on the procedure. However, 150 babies have been born as a result of egg freezing. The average cost of egg freezing is less than $10,000 per cycle.

Ovarian tissue freezing:

This, too, is an experimental option. In ovarian tissue freezing, all or part of one ovary is removed by laparoscopy. The tissue is usually divided into small strips, frozen, and stored for later transplanting back into the woman's body when she is ready to try to become pregnant.

When transplanted, the ovarian tissue can be placed close to the fallopian tubes or in another part of the body, like the abdomen or forearm. Usually, the eggs produced by the tissue need to be collected and fertilized in the lab. This outpatient procedure is experimental and has produced one or two live births to date. The ovarian tissue does grow a new blood supply and produces hormones after it is transplanted, but some of the tissue usually dies and the grafts only last for a few months or several years.

Ovarian tissue freezing costs vary greatly. In some cases, it can be done as part of another necessary surgery so that most of the cost is covered by insurance.

Ovarian transposition:

Ovarian transposition is a procedure that moves the ovaries away from the target zone of radiation treatment, usually during an outpatient laparoscopy. Surgeons will usually move the ovaries above and to the side of the central pelvic area. Ovarian transposition can be done either before or after puberty and may sometimes be done during another surgery that is covered by insurance. It is usually best to move the ovaries just before beginning radiation therapy, since they have a tendency to fall back into their old places over time.

Radical trachelectomy:

Radical trachelectomy is an option for cervical cancer patients who have very small, localized tumors. The cervix is removed, but the uterus and the ovaries are preserved. It appears that trachelectomy is just as successful as radical hysterectomy in removing cervical cancer when women are carefully chosen. Although pregnancies can occur after the surgery, women remain at risk for miscarriage and premature birth because of the weakened opening to the uterus, and they need specialized obstetrical care.

Fertility-sparing surgical procedure:

This procedure can be used in women who have had ovarian cancer that is classified either as borderline, low malignant potential, germ cell tumors, or stromal cell tumors. Sometimes, only one ovary is affected by the cancer, so a surgeon will try to remove just the cancerous ovary, leaving the healthy one and the uterus in place.

GnRH Analog Treatment:

This experimental option utilizes Gonadotropin-releasing hormones or GnRH. GnRH are long-acting hormones intended to induce a short-term menopause. They are usually given in a monthly shot, starting a couple of weeks before chemotherapy or pelvic radiation therapy and continuing for as long as a woman is receiving the cancer treatment. The hope is that reducing activity in the ovary will reduce the number of damaged eggs, therefore reducing the chance of infertility.

While oncologists are using this treatment, it is still not proven effective. It is expensive ($1,000 for a monthly dose) and can cause a woman’s bones to weaken if used for more than six months. Women who want to try this treatment might wish to find a clinical trial that is using the treatment for their type of cancer.

Options for men:

Sperm banking:

Sperm banking is an effective way for men who have gone through puberty to store sperm for future use. Many men can store sperm even if they have reduced sperm quality or quantity. In sperm banking, a man provides a sample of his semen. Once a sample is given, it is tested to see how many sperm cells it contains (sperm count), what percentage of them is able to swim (motility), and how many are normal in shape (morphology).

Once sperm cells are donated, they are frozen and stored. Several donations are recommended, but even a few sperm cells that survive freezing and thawing may be enough for conception using a technique called IVF-ICSI, or in vitro fertilization with intracytoplasmic sperm injection. The success rates of infertility treatments using frozen sperm vary and depend on the quality of the sperm once thawed. In general, pregnancy rates from the sperm collected before men’s cancer treatment is just as likely to start a pregnancy as sperm from men without cancer. Sperm banking has resulted in thousands of pregnancies, without any unusual rates of birth defects or health problems in the children.

Sperm banking is a good option for men who want to have children after completing cancer treatment. It is also a good option for a man who may want children in the future, but isn't sure. The average cost of sperm banking is usually more than $1,000, which includes three sperm donations and several years of storage. Many sperm banks offer financing and payment plans for cancer patients to help with the yearly costs.

Sperm extraction:

Epididymal sperm aspiration or testicular sperm extraction are options for men who do not have mature sperm cells in their semen, either before or after cancer treatments. Either requires minor surgery done by a specialist. In micro-epididymal sperm aspiration (MESA), a tiny opening is made in the epididymis and sperm are sucked out through a needle. In testicular sperm extraction (TESE), tiny pieces of tissue are removed from the testicles and examined for sperm cells. If found, the sperm can be used immediately for IVF-ICSI or frozen for future use. The cost of testicular sperm extraction is usually less than $10,000. Insurance rarely covers the costs.

Testicular tissue freezing:

For boys who are not yet at the age of puberty, testicular tissue freezing is the only current option, and it is completely experimental, with no live births so far. Some tissue from the testicles is collected with a biopsy needle. Hopefully, the tissue will contain stem cells that can later produce mature sperm. The tissue is frozen with the hope that in future years, it can be used for infertility treatment. The tissue might be grafted on to the young man’s testicle or stem cells might be isolated and injected into the testicle. No average cost of testicular tissue freezing has been established. A few centers may be doing research studies that pay for the costs.

Radiation shielding:

Fertility may sometimes be saved in men by using modern radiation therapy techniques that focus the rays on a very small area. For some radiation to the pelvis, the testes can be protected with a lead shield. Seed implants for prostate cancer do not give a large dose of radiation to the testicles, and most men will remain fertile or recover sperm production.