Sexual and Reproductive Issues After Childhood Cancer
What is the risk?
Fertility and sexual function after cancer therapy is a very complex topic. It is related to the doses and types of medications received, if radiation or surgery to reproductive organs was performed, and the age at time of treatment. With all of these variables, it is sometimes difficult to predict a survivor's reproductive health.
Chemotherapy agents that are most strongly tied to infertility include: alkylating agents, temozolomide (in men), cytarabine (Cytoxan), vinca alkaloids, and bortezomib. Radiation fields that include the testes, brain or TBI (total body irradiation) can also affect fertility. In general higher doses mean a higher risk of infertility (for example cytoxan over 8g/m2 or ifosfamide over 60mg/m2).
Symptoms/When to Call
Women who do not have/resume a normal (monthly) menstrual period after cancer therapy should be evaluated.
Survivors and their families may have concerns about sexual development (going through puberty) because of cancer treatment. Your oncology or primary care provider should assess sexual development with follow-up exams. While these can be sensitive topics, do not hesitate to talk with your oncology team about these common concerns.
Men or women who have concerns about sexual function (loss of libido, vaginal dryness, erectile dysfunction) should discuss these with their oncology team or a gynecologist/urologist.
Any survivor who is interested in having a fertility evaluation OR a survivor who is trying to conceive (male or female) and is unsuccessful after one year, should speak with a fertility specialists or survivorship clinic.
Prevention and Treatment
Fertility sparing chemotherapy is offered at diagnosis and relapse when providers are able to safely offer this option. In addition, many patients are offered sperm banking or egg/embryo preservation at the time of initiation of therapy to help address future fertility when able. Sometimes the need to begin chemotherapy quickly or the age of the child at diagnosis makes these options unavailable at the time of diagnosis.
Survivors who wish to assess their fertility after treatment completion should consider seeing a reproductive specialist who has experience working with cancer survivors. There is testing a specialist can perform to help evaluate fertility, including certain hormone levels, folicle counts in woman, and sperm samples in men. The Oncofertility Consortium provides education, resources and referrals related to oncofertility. The National Infertility Association’s website, Resolve, also offers information on fertility treatments and testing, adoption and deciding to not have children. They also have information on individual state laws about fertility coverage by insurers. Of note, survivors should assume they are fertile until proven otherwise and use birth control with sexual activity.
For men and women who have decreased sex hormone levels after therapy (called premature ovarian failure in women and hypogonadism in men), hormone replacement is an option. Women can be treated with estrogen replacement (by pill, patch or combination) and men with testosterone replacement therapy (by topical or injection therapy).
Treatment for sexual dysfunction is complicated and depends on the underlying cause. Medications (topical or oral) and behavioral therapy may be used in combination. Survivors should speak with their gynecologist/urologist about these concerns.