Preserving Fertility in Children With Cancer

Approved by the Cancer.Net Editorial Board, 04/2018

Some cancer treatments may affect how a girl’s ovaries or a boy’s testes work. This may last for a short time after completing cancer treatment. Or it may last a lifetime and cause infertility. Infertility is the inability to have biological children.

Infertility from cancer treatment is called a late effect. Your child's risk of late effects depends on the cancer type and treatment plan. Ask your child's doctor if planned treatments might have short- or long-term effects on reproductive health.

Cancer treatments that may affect fertility

The following types of cancer treatment may have long-term effects on your child’s fertility.

Chemotherapy. Alkylating agents affect fertility more commonly than other types of chemotherapy.

Examples of these drugs:

  • Cyclophosphamide (Neosar)

  • Ifosfamide (Ifex)

  • Procarbazine (Matulane)

  • Busulfan (Busulfex, Myleran)

  • Melphalan (Alkeran)

Other drugs may cause short-term effects on a girl's menstrual cycle. These include vincristine (Vincasar PFS) and methotrexate (multiple brand names). However, these drugs don’t cause early menopause. Menopause is when menstrual periods stop.

In general, high doses of alkylating agents will cause permanent damage. However, doctors typically use the lowest possible doses for children. This lowers the risk of permanent damage to reproductive organs. Doctors treat many pediatric cancers without alkylating agents.

Radiation therapy. Radiation therapy can damage the ovaries or testes. The risk is greatest when the radiation is focused in these areas:

  • The pelvis

  • The abdomen

  • The spine

  • The whole body

In girls, radiation therapy may damage eggs and affect hormone production. This is called ovarian insufficiency. Girls who have not yet begun menstruation may experience delayed puberty. Girls who have begun menstruation may experience irregular or halted menstruation. Scarring from radiation therapy to the uterus slows blood flow, preventing the uterus from enlarging during a pregnancy. This could make pregnancy difficult later in life. It could also increase the risk of miscarriage and premature or low-birth-weight babies.

In boys, radiation therapy may damage sperm and affect their hormone production.

Children who have radiation therapy to the brain may also have fertility side effects. In these cases, treatment damages the brain’s communication with the reproductive organs. However, if reproductive organs are not damaged, hormone treatment helps fix this problem.

Surgery. Sometimes cancer is found in the reproductive organs. In these cases, the doctor might suggest surgery to remove part or all of these organs. These surgeries may affect fertility.

Learn more about the effects of cancer treatment on fertility in women and men.

How to talk with your child about fertility

Fertility is a complex idea, especially for children. Still, children who understand it should be involved in the discussion about how treatment may affect fertility. Find age-appropriate ways to discuss the topic with your child. The health care team can help you with this.

Ask your child if he or she wants procedures intended to preserve fertility. Children and teens cannot give full legal consent because of their age. However, a child who can understand must generally agree before a procedure. This is called assent. Parents also must give consent before the procedure. Only give consent after learning about:

  • The procedure’s risks

  • The potential complications

  • The success and failure rates

Fertility options for children

Families have options to help preserve a child’s fertility. The American Society of Clinical Oncology (ASCO) recommends that parents and guardians discuss the risk of infertility and fertility preservation options with their child’s doctors as soon as possible before cancer treatment begins. Options are limited for children diagnosed with cancer before puberty. Moreover, the costs of these options can be high.

Fertility options for girls

Certain methods may help prevent or lower the risk of damage for girls. For example, doctors may use a treatment plan that avoids or reduces doses of chemotherapy that are linked to infertility. For some girls who need radiation therapy, an oophoropexy may be an option. A surgeon moves one or both ovaries where radiation won’t reach them. The surgeon may put them back in place after treatment. However, it’s not always possible to prevent damage to the ovaries.

ASCO’s recommendations for preserving fertility in girls include:

Oocyte (unfertilized egg) freezing. A girl who has gone or is going through puberty can freeze her eggs. Puberty usually occurs between ages 9 and 15. This method requires about 2 weeks of fertility drug treatment. Then, the health care team collects the eggs from the ovaries.

Sometimes, girls need to begin cancer treatment right away. This doesn’t allow time for the 2-week fertility treatment. Instead, egg collection may occur after only brief fertility treatment. Or even without it. However, these eggs will not have fully matured in the ovaries. The eggs must then undergo in vitro maturation. This means that the eggs mature in a laboratory.

Researchers are still learning about in vitro maturation. Success rates are lower than when freezing eggs that matured in the ovaries.

Ovarian tissue freezing followed by transplantation. Freezing eggs is not an option for girls who have not gone through puberty. Freezing ovarian tissue for later transplantation may be an option for these girls. This method is sometimes called ovarian cryopreservation. Previously considered experimental, this procedure is improving and becoming a more standard option.

It’s done as an outpatient laparoscopic surgery. Laparoscopy uses a thin, lighted tube called a laparoscope to remove ovarian tissue. The laparoscope is inserted through a small cut made in the abdominal wall by the surgeon. The surgery lasts about an hour.

Later, ovarian tissue can be transplanted during an outpatient procedure. The tissue can be transplanted to the pelvis or under the skin.

A limited number of experts offer ovarian tissue freezing. For some types of cancer, the doctor may advise against tissue freezing. There may be concern that transplanted tissue could carry cancer cells back into the body.

Ask a fertility specialist to help you evaluate this option.

Talk with your daughter’s health care team about the risk of infertility based on her treatment plan. You may decide against fertility-preserving techniques with cancer treatments that have a low risk of affecting fertility. Many girls go through puberty after cancer treatment and have children naturally.

Fertility options for boys

Certain methods prevent or lower the risk of damage in boys. For example, the health care team can shield a boy’s testicles during radiation therapy. They may also use a treatment plan that avoids or reduces doses of chemotherapy that are linked to infertility.

When damaging the testicles cannot be avoided, ASCO recommends the following options to help preserve fertility:

Sperm banking. This is also called cryopreservation. It is a common, noninvasive option. However, it’s only possible with boys who have gone through puberty. Most boys have some sperm in their semen by about age 13.

This method involves collecting and freezing sperm. The sperm are then stored at a special center.

Some hospitals have sperm bank programs. And some clinics specialize in sperm banking.

Testicular tissue freezing. For boys who have not gone through puberty, freezing testicle tissue may help preserve fertility. This is still an experimental approach.

This method would involve collecting and freezing some testicle tissue. Hopefully, the tissue would contain stem cells that would later produce mature sperm. The health care team would then place the thawed tissue into the testicle. Or they would inject stem cells taken from the frozen tissue.

Researchers are still learning about all these options. There haven’t been reports of testicular transplants in patients.

For some types of cancer, the doctor may advise against tissue freezing. There may be concern that transplanted tissue could carry cancer cells back into the body.

Read more about ASCO’s recommendations for preserving fertility, found on ASCO’s website.

Questions to ask the health care team

Talk with your child’s health care team about how treatment may affect fertility. Consider asking these questions:

  • Could my child’s treatment plan affect his or her ability to have children?

  • Will this treatment affect my child’s ability to go through puberty?

  • For daughters: What are the chances this treatment will lead to early menopause? Can treatment affect some organs (like the lungs or heart) in a way that will increase the risk of problems during pregnancy or labor?

  • Are there other effective treatments that are not as risky?

  • What options are available to preserve fertility before treatment begins? Will they affect how well the cancer treatment works?

  • Would it be helpful to see a fertility specialist before treatment begins?

  • I’m worried about the costs of preserving my child’s fertility. Who can help me with these concerns?

  • After treatment, how will we know if my child's fertility has been affected?

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