Cancer Survivors Increasingly Face Fertility Issues—What Can Be Done to Help? New

Allison Rosen was 32 years old when she was diagnosed with colorectal cancer. At the time, she was single, but she knew that one day, she’d want to have children. However, her treatment, which would involve pelvic radiation, would very likely affect her fertility.

Following a detailed discussion with her oncologist and care team, Rosen decided to delay her cancer treatment for a few weeks to harvest and freeze her eggs. But the day before the extraction, Rosen started bleeding profusely and was taken to the emergency room. There, she and her doctor decided that her cancer treatment couldn’t wait. They’d start the next day, meaning she’d have to abandon the plans to cryopreserve her eggs. “I thought, if I’m not alive, what is the purpose of having these eggs?” said Rosen, today a colorectal cancer survivor and patient advocate. “It was one of the most difficult decisions I had to make.”

After a year of treatments, including radiation, chemotherapy, and multiple surgeries, Rosen became cancer-free. She went to see a fertility specialist, and following a barrage of tests, she received confirmation of what she’d expected: She was no longer able to bear children.

As the incidence of early-onset cancers—particularly those occurring in people during their 30s and 40s—rises, a growing number of people are faced with this type of dilemma.¹ Advances in diagnostics and treatments have improved survival rates, enabling people to live longer. At the same time, many life-saving cancer therapies, such as radiation, chemotherapy, and surgery, can be damaging to the reproductive organs.²

“The good news is, most teens and young adults will survive their cancer,” said John Salsman, a clinical psychologist and social scientist at the Wake Forest University School of Medicine. “But they’ll be at increased risk of late- and long-term effects, recurrence, second primary cancers, and a host of psychosocial related issues that are ripple effects from (being) diagnosed with cancer.”

One of those ripple effects can be infertility. Both researchers and clinicians are increasingly turning their attention to this issue, as more people develop cancer during their reproductive years. Fertility preservation is important to patients, but oncologists often don’t address it, said Alison Loren, an oncologist at the University of Pennsylvania Perelman School of Medicine. “It’s a huge need that significantly impacts well-being and life satisfaction after treatment is finished.”

The Aftereffects of Cancer Treatment

Cancer treatments, though lifesaving, can have detrimental effects on the reproductive system. But these effects can vary greatly with the type of cancer and the specific treatment.

Researchers have found that, in both male and female patients, treatments such as alkylating agents, a type of chemotherapy drug that prevents cells from making copies of themselves, pelvic radiation, and hemopoietic cell transplantation (stem cell or bone marrow transplants) can have detrimental effects on the reproductive organs.^3–7 In female patients, one of the primary effects is the disruption—or in some cases, failure—of ovarian function. For male patients, these cancer therapies can impair sperm production and other sexual functions, such as ejaculation.^8–9 In both sexes, treatment can also disrupt the production of hormones that help maintain fertility.

Although much progress has been made in understanding how cancer treatments affect fertility, for certain cancers, such as colorectal cancer, there is limited data on how toxic specific therapies are to the reproductive organs, said Andreana Holowatyj, a translational scientist at Vanderbilt University. For this reason, insurance companies often don’t cover fertility preservation for colorectal cancer, meaning patients can often face a high financial burden. To address this gap, Holowatyj and her team are currently running the Preserving Fertility After Colorectal Cancer (PREFACE) study, which is aimed at gathering evidence on how therapies for colorectal cancer affect reproductive health.

On top of that, when it comes to newer anticancer treatments, such as immunotherapy, evidence regarding the effects of this treatment on fertility remains an open question. Animal studies suggest that these drugs may affect fertility. One 2022 study in mice found that immune checkpoint inhibitors, a type of immunotherapy that boosts the activity of specific cancer-killing immune cells, caused inflammation in ovaries and depleted oocyte reserves.¹⁰ “There is still a lot to learn about how cancer and its treatments affect fertility,” said Terri Woodard, a reproductive oncologist at MD Anderson Cancer Center.

In some patients, the effects of treatment on fertility may not appear until years after they’ve gone into remission. For instance, many young women don’t immediately lose their reproductive capacity after chemotherapy, according to Loren. “They resume menstrual periods, and their blood tests show normal range measures of hormones, but they then experience menopause at a much earlier age.”

Together, these factors make it difficult to determine the prevalence of fertility problems in cancer survivors. Each individual also has their own reproductive potential that varies across individuals, and there are no reliable ways to measure this, Loren said.

Finding Ways to Preserve Fertility Prior to Cancer Treatment

For those who do choose to preserve their fertility before cancer treatment, there are several available options. For both men and women, the current gold standard is freezing sperm or eggs, relatively straightforward procedures where patients provide samples that are collected and frozen for storage. There are also other, more invasive options, such as testicular sperm extraction—a surgical procedure where sperm is directly taken from the testes, and ovarian transposition, which involves surgically moving these organs to another part of the body to protect them from the effects of treatments such as radiation.

But these options aren’t always available to every patient. Boys who haven’t yet undergone puberty, for example, do not make sperm. Currently, the only fertility preservation option available in these cases is testicular tissue cryopreservation (TTC), where sperm-producing stem cells are extracted from the testicular tissue, in hopes of restoring fertility by transplanting the excised tissue back into the patient in the future.

TTC is still an experimental procedure: To date, there have not been any reports of the successful restoration or sperm production of pregnancies involving people who have undergone this procedure. Scientists have, however, demonstrated successful pregnancies after TTC in animals. In 2019, researchers reported a successful pregnancy in a rhesus macaque that had undergone the procedure.¹¹

A similar option exists for female patients: ovarian tissue cryopreservation, a procedure in which the egg-producing region of the ovary is removed and frozen for reimplantation into the patient at a future date. This treatment is much more established. Clinical studies in recent years have revealed that after the transplantation, many patients experienced a restoration in ovarian function, and many individuals became pregnant.¹²

Researchers are also investigating so-called “gonadoprotective agents,” such as gonadotropin-releasing hormone agonists that are meant to suppress function during treatment. In men, there is no evidence that this procedure is effective, and groups such as the American Society of Clinical Oncology (ASCO) do not recommend their use. In women, however, its use is much more controversial. There is some preliminary evidence suggesting that this procedure could be effective. In one 2019 systematic review, researchers concluded that, based on 12 randomized control trials involving more than 1,000 women diagnosed with cancers of the breast, ovaries, and lymphatic system, the evidence supported the procedure’s ability to protect the ovaries during chemotherapy, but that it was insufficient to determine the effects on fertility.¹³

For people who cannot engage in any other fertility preservation measures, such as those with certain blood cancers, this can sometimes be the only option, according to Loren. Many of these individuals are often too sick to undergo the one- to two-week waiting period that’s needed before extracting eggs for freezing, and removing tissue may also not be an option due to bleeding risk or the possibility of cancer cells inadvertently being extracted during the procedure.¹⁴ “I personally feel that for those situations, if it’s an emergency, there’s no harm in giving these hormones,” Loren said. She added while there have been a limited number of studies on this intervention to date, and only in people with breast cancer—these find few side effects associated with gonadoprotective agents, especially when used for a short time.¹⁵

“If a person with ovaries has the ability to engage in another fertility preservation technique, they should do that,” Loren said. “You should never rely on hormones alone as your sole method of fertility preservation, because there’s just not enough evidence to show that it really works.”

Several other options are also available. For instance, there are various procedures that are specific to cancers, such as fertility-sparing surgeries in people with tumors in their reproductive organs.

Raising Fertility Awareness Among Patients Diagnosed with Cancer

Although the understanding how cancer affects fertility—and the options for fertility preservation—have grown, one of the biggest challenges is awareness about these issues among both patients and providers.

In a 2024 study, Holowatyj, Rosen, and their colleagues found that—based on patient reports—almost 50 percent of people who were diagnosed with an early-onset cancer did not discuss fertility preservation with their health care providers prior to starting treatment. Rates varied significantly across cancer: The highest proportion of people reporting they did have fertility-related conversations were those diagnosed with testicular cancer (more than 90 percent) as well as Hodgkin lymphoma (a type of cancer that arises in the lymphatic system) and breast cancer (both over 70 percent). On the flip side, only four percent of people with thyroid cancer and around 20 percent of those with lung or ovary conservations reported having these discussions.¹⁶

There are likely several different reasons for the observed differences across cancer types—and understanding what those are will be important to improving access to fertility preservation for patients, Holowatjy said. The team is currently following up on that study to look at how much patients knew about the infertility risk after receiving an early-onset cancer diagnosis.

According to work by Salsman and his colleagues, one of the barriers clinicians have when it comes to having conversations about fertility with cancer patients is time: both in relation to the time they have during patient meetings and how quickly treatment must be initiated. For patients with very late-stage cancers, some clinicians may feel that having a conversation about having children is not appropriate. Preserving fertility can often mean delaying treatment and balancing the risks and benefits can be a challenge, especially when considering additional factors such as finances, Salsman said.

But studies show that there’s a significant amount of variability in how patients assess risk that isn’t necessarily linked to their cancer diagnoses.¹⁷ “The way people evaluate and consider risk really varies as a function of individual personality,” Salsman said. “The same percentage of risk does not always confer the same sort of decision-making.”

Earlier this year, ASCO updated their guidelines on fertility preservation for people with cancer.² In it, they recommend that patients should be counselled about this topic both at the time of diagnosis and “during survivorship.” They also emphasize that research shows that patients see this conversation as critical regardless of factors such as age, cancer prognosis and financial ability.

Several groups are currently working on tools to provide more cancer patients with fertility-related information. Salsman and his colleagues, for one, are working on developing a digital fertility navigator for patients in regions where hospitals lack the resources typically available at large, comprehensive cancer centers. Similarly, teams led by Woodard, Holowatyj, and others are also working on making such tools.¹⁸ “We know from decades of research that it’s hard to change provider behavior,” Salsman said. “So, we’ve been shifting toward putting more emphasis on empowering the patient.”

Receiving a cancer diagnosis itself can be emotionally trying—so adding in the topic of possibly losing the ability to have children after treatment can be very mentally taxing. But even though these discussions can be difficult, they need to be a standard part of the initial discussion a patient has with a provider when they receive their diagnosis, Rosen said. “It needs to be a started part of the conversation, because it can really affect your quality of life.”