Infertility and cancer
Infertility, particularly in the context of cancer, is defined as the inability to achieve pregnancy after one year of unprotected intercourse, and it can be either temporary or permanent due to cancer or its treatments. The causes of infertility in men often relate to decreased sperm production and quality, while in women, infertility may arise from issues with egg fertilization or implantation, as well as maintaining a pregnancy. Various risk factors influence infertility rates, including the type and location of cancer, treatment methods, and individual factors such as age and pre-existing fertility status.
Cancer treatments, particularly chemotherapy and radiation, can significantly impact fertility. Chemotherapy may damage the stem cells responsible for producing sperm and eggs, with certain drugs being more harmful than others. Radiation therapy's effects depend on dosage and targeted areas, with high doses to specific regions posing a greater risk. Surgical interventions could result in irreversible infertility or necessitate assisted reproductive technologies for conception.
Symptoms of infertility typically surface when an individual or couple attempts to conceive, often leading to diagnostic procedures such as semen analysis for men and hormonal evaluations or imaging studies for women. Although direct treatment of infertility may not always be possible, many cancer survivors may still pursue assisted reproductive technologies, including in vitro fertilization (IVF) and surrogate arrangements. It's essential for cancer patients to discuss fertility preservation options with their healthcare providers prior to treatment to explore potential strategies, such as sperm or egg freezing, which can facilitate future family planning.
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Subject Terms
Infertility and cancer
ALSO KNOWN AS: Subfertility, subfecundity
RELATED CONDITIONS: Sterility, premature menopause
DEFINITION: Infertility is the inability to achieve pregnancy after one year of intercourse without contraception. Infertility, as it relates to cancer, refers to the temporary or permanent loss of fertility due to cancer or its treatment. Infertility in men is caused by an absence of or decrease in sperm production. A deficiency in sperm quality is affected by changes in sperm morphology, motility, or DNA integrity or an inability to deliver sperm through ejaculation. Female infertility occurs when an egg cannot be successfully fertilized, a fertilized egg cannot implant in the uterus, or a pregnancy cannot be maintained.
Risk factors: The risk of infertility depends on the type of cancer and its location; the cancer treatment, including the type, dose, location, and method of administration; and the use of any fertility preservation or sparing procedures before or during treatment. The risk of infertility is also affected by the person’s age, general health, and pretreatment fertility status. Testicular cancer and Hodgkin's disease are associated with pre-and-post-treatment infertility in men.
Etiology and the disease process: Cancer-related infertility is usually caused by the effects of treatment rather than the actual disease. Chemotherapy can damage the stem cells that make sperm or immature eggs (oocytes) and mature eggs. The effects of chemotherapy are drug-specific and dose-dependent, with alkylating agents causing the most damage.
The effect of radiation on fertility depends on the dose and the location. Patients receiving very high doses delivered through total body irradiation or radiation focused on the abdomen, pelvis, or cranium are at the highest risk for infertility. Radiation can kill sperm stem cells or oocytes, damage reproductive structures, or alter the pituitary gland.
Surgery to remove reproductive structures may cause intractable infertility (sterility) or require the use of assisted reproductive technologies to assist in conception. Unintended side effects of surgery, such as nerve damage, scarring, or vascular changes, can also cause infertility.
Incidence: The occurrence of infertility is highly variable based on patient- and cancer-related factors. Data quantifying infertility in all cancer patients are scant.
Symptoms: Infertility is not often detected until a person attempts to conceive. After cancer treatment, men may be unable to ejaculate (anejaculation) or may experience retrograde ejaculation, in which little or no semen is produced. Women may have an absence or cessation of menstruation, have irregular menstrual cycles, or experience painful intercourse.
Screening and diagnosis: Screening for infertility occurs if there is difficulty conceiving or high- to medium-risk cancer treatments are used. Male infertility is diagnosed primarily through semen analysis to assess the number and quality of the sperm. Infertility in women is diagnosed by assessing hormone levels, an ultrasound examination for ovulation, or visualization of reproductive structures through an ultrasound, a hysterosalpingogram, or laparoscopic surgery. The cause of infertility is sometimes indeterminable.
Treatment and therapy: The underlying cause of infertility often cannot be treated, but many cancer survivors are candidates for assisted reproductive technologies to enable the conception of a child biologically related to both parents. Men with low sperm count or low sperm motility may be able to father a child through intrauterine insemination (IUI), in vitro fertilization (IVF), or in vitro fertilization using intracytoplasmic sperm injection (IVF-ICSI). If the ejaculate lacks sperm, surgeons may retrieve sperm from the testicles or epididymis using extraction techniques. Surgery, medications, or the use of mechanical or electrical stimulators can address anejaculation or retrograde ejaculation. Women may take fertility medications to induce ovulation. The eggs can be fertilized through sexual intercourse, IUI, or IVF. Scarring or vascular changes affecting female reproductive structures may be treatable by surgery. If a woman’s eggs can be fertilized but pregnancy cannot be maintained, a surrogate mother may be used.
Prognosis, prevention, and outcomes: Cancer patients should discuss options to preserve or spare fertility with their oncologists before treatment and consult a fertility specialist. Patients can freeze sperm before treatment begins to use later in IUI, IVF, or IVF-ISCI procedures. However, this may not be an option for men with testicular cancer or Hodgkin's disease, whose sperm is already compromised. Researchers are investigating whether sperm production can be restored by freezing testicular tissue and later grafting the tissue onto the testicle or using it to isolate stem cells.
Women can collect their eggs and fertilize them with partner or donor sperm. The resulting embryos are frozen for future implantation. Unfertilized eggs or ovarian tissue may also be frozen for later use in IVF procedures or transplantation back into the body, respectively. Patients may benefit from options sparing fertility during treatment. These include protecting or shielding reproductive organs from radiation, conservative surgery when possible, and experimental hormonal therapy.
Bibliography
Cancer Council Australia, and N.S.W. Cancer Council. Fertility and Cancer: A Guide for People with Cancer, Their Families and Friends. Cancer Council, 2022.
Choudhuri, Sharmistha, et al. "A Review on Genotoxicity in Connection to Infertility and Cancer." Chemico-Biological Interactions, vol. 345, 2021. doi.org/10.1016/j.cbi.2021.109531.
Dizon, Don S. One Hundred Questions and Answers About Ovarian Cancer. 4th ed., Jones and Bartlett, 2022.
"How Cancer and Cancer Treatment Can Affect Fertility in Females." American Cancer Society, 6 Feb. 2020, www.cancer.org/cancer/managing-cancer/side-effects/fertility-and-sexual-side-effects/fertility-and-women-with-cancer/how-cancer-treatments-affect-fertility.html. Accessed 20 June 2024.
Lee, S. J., et al. “American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients.” Journal of Clinical Oncology, vol. 24, no. 18, 2006, pp. 2917-2931.
Zini, Armand, and Ashok Agarwal. Sperm Chromatin: Biological and Clinical Applications in Male Infertility and Assisted Reproduction. Springer, 2011.