How much does chemo impact fertility?

The pre-treatment talk

When Daniel Bral was diagnosed with non-Hodgkin lymphoma, he certainly wasn’t thinking about starting a family. He was 11. Sixteen years after that diagnosis, however, fertility is now becoming more relevant.

“I’m sort of at the ignorance-is-bliss stage,” said Bral, 27, now a medical student and chairman of the Young People’s Advisory Committee for Teen Cancer America. “I don’t want to know, because I’m not sure I can handle knowing that I can’t have children and I was never given the opportunity to prevent that.”

Bral, who was not offered fertility preservation options when he was diagnosed, said Chow’s study brings up a “really important question.”

“It’s an issue that’s even more important in teen and young adult cancer treatment, a demographic which may not have fertility and childbearing at the forefront of their consciousness,” he said. “Health care providers need to become more comfortable with having the conversations frankly with their patients.”

Unmarried and currently living in Ft. Lauderdale, Bral said he does wonder about his fertility status.

“As a man who is excitedly looking forward to having children and a family of my own, it’s a sensitive and difficult topic to deal with head-on,” he said. “It does bother me on some level that I may have had my fertility impacted although again, I’m not sure to what extent, if at all, it’s been affected.”

Chow said parents of recently diagnosed teens should definitely talk to their child’s health care team about options.

“It’s hard to do anything if you’ve already started treatment,” he said. “But if you have questions, your oncology team should be able to talk to you about it and make recommendations. At Seattle Children’s, we have a group that will help patients and families with fertility preservation options. This is also a topic we bring up with patients and families after they’ve finished treatment and we’re seeing them now in our cancer survivor clinic.”

He also suggested female survivors may want to start thinking early about whether or not they want children.

“The general take-home message for women who’ve had cancer as children is if they want to have kids, it’s probably not a bad idea to talk with a reproductive fertility specialist earlier rather than later,” he said. “Especially if they’re thinking about delaying childbirth to their mid- or late 30s. Not everyone should go out and freeze their eggs — that’s expensive — but they should be aware that their window of fertility may be smaller after having cancer treatment.”

Caveats and questions

Along with Fred Hutch, Seattle Children’s and St. Jude (Fred Hutch is the data and statistics center for the CCSS), the study involved researchers from Memorial Sloan Kettering Cancer Center, Stanford University, the Children’s Hospital of Philadelphia, Boston Children’s Hospital, Columbia University and MD Anderson Cancer Center. Study participants came from 27 cancer treatment centers across the U.S. and Canada.  

Chow readily acknowledged the report’s limitations.

It relied on self-reported data regarding pregnancy from both patients and their siblings, for instance. And it didn’t take into consideration whether the study participants were actually trying — and failing — to become pregnant or not.

“Having children is a complicated thing,” he said. “You have to want kids, number one. And you have to have a partner, typically. And those are things we weren’t able to measure. It’s certainly possible that the reduced rate of pregnancy seen in women ages 30 to 45 may be related to issues other than ovarian function.”

The amount of chemo given a particular patient also posed new questions, he said.

Men who’d been given high cumulative doses of alkylating agents such as cyclophosphamide, ifosfamide and procarbazine — along with the agent cisplatin — were linked with a significantly reduced likelihood of fertility. Previous studies have suggested these drugs lower sperm count and reduce testicular volume.

“We identified a strong association between cisplatin and reduced fertility in male survivors which will need to be studied further,” Chow said, adding that this finding may influence guidelines.

"This could have an effect on guidelines on screening survivors for fertility-related issues, with regards to chemotherapy dose thresholds that are associated with higher risk of fertility-related issues," he said. "I think these results also will stimulate more research into the effects of some of these newer agents on a biologic/physiologic level, especially in relation to spermatogenesis [sperm-cell development] and male fertility."

Fertility preservation options for prepubescent kids also needs further investigation, the researchers said.

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How much does chemo impact fertility?