Fertility and reproductive health in children and teens

Pediatric (childhood) cancer has seen a significant rise in survival rates in the last decades. More than 80 percent of patients survive to adulthood. But success in using therapies such as radiation, chemotherapy, and surgical procedures has led to patients requiring medical attention for late and long-term effects. 

The potential negative impact of cancer treatment on the future reproductive health of childhood cancer survivors has placed fertility preservation at the forefront of survivorship care. 

Infertility risk

Some cancer treatments affect fertility (the ability to conceive a child naturally). The risk of infertility from cancer treatment is based on several factors, including a person’s age and the treatment type and dosage received. It is important to talk with members of your child's oncology team before treatment begins about the effects of their treatment.

Chemotherapy and radiation can cause side effects as well as long-term and late effects, which can appear months or years after treatment. When first diagnosed with blood cancer, your primary concern will be your child's upcoming treatment and long-term survival. You may not be thinking about whether they can one day become a parent. However, information about the potential effects of their treatment can help you take steps to maximize your ability to have a child in the future.

Not all cancer treatments affect fertility. Your risk depends on several factors, including:

• Age at the time of diagnosis
• The type and dosage of chemotherapy drug(s) they receive. Alkylating agents—for example, cyclophosphamide or procarbazine—have the most significant effect on fertility. Other drugs are generally less toxic to sperm-forming cells and eggs, but can also cause infertility, especially when used as part of a combination of therapies.
• The location and dosage of radiation:
  • Exposure to the testes may destroy cells that form sperm
  • Exposure to the ovaries may destroy eggs
  • Exposure to the pituitary gland in the brain may cause changes in secretion of hormones that regulate puberty and fertility
• Whether they receive a blood or marrow stem cell transplantation, which is associated with a high risk of infertility

Discussing fertility issues with your child 

Fertility is a complex concept, which may be hard to understand, especially for young children and adolescents. Parents may also find it difficult to discuss issues regarding sexuality and fertility with their children. Still, pediatric patients should be involved, as much as possible, in the discussion about how their cancer treatment can affect their future ability to have children. 

Parents can ask their child’s healthcare team to help them find age appropriate ways to explain and talk about these issues with their children. Many pediatric oncology centers have multidisciplinary teams that include oncologists, reproductive endocrinologists, nurses, psychotherapists, child-life specialists, and social workers who work together to help children and their families cope with disease, treatment, and survivorship issues.

Fertility preservation for children

The American Society of Clinical Oncology (ASCO) recommends that parents and guardians discuss the risk of infertility and fertility preservation options with members of their child’s healthcare team. This discussion should take place before treatment begins, if possible. The American Academy of Pediatrics (AAP) supports these recommendations, too. 

Some cancer treatments—such as chemotherapy with alkylating agents and radiation—can have long-term effects on a child’s future fertility. In addition, some therapies can affect the endocrine system--the glands and cells that control growth and development. 

Talk with your child’s doctor if your child seems to be going through puberty early (before age 9) or has not entered puberty by age 15. The doctor will want to evaluate them and may prescribe medicine to alleviate symptoms caused by hormone imbalance. 

Questions to ask your child's healthcare team

• Could the treatment plan affect my child’s ability to have children?
• Will this treatment affect my child’s ability to go through puberty?
• What are the chances this treatment will lead to early menopause?
• Can treatment affect some organs (such as the lungs or heart) in a way that will increase the risk of problems during pregnancy or labor?
• Are there any cancer treatment options that may not affect my child’s fertility?
• What options are available to preserve fertility before treatment begins? Will any of these options affect how well the cancer treatment works?
• Would it be helpful to see a fertility specialist before treatment begins? Can you make a recommendation?
• Who can help me with financial concerns about the cost of fertility preservation?
• After treatment, how will my child know if their fertility has been affected? 

Talk with your child’s healthcare team about the risk of infertility based on your child’s treatment plan. Many childhood cancer survivors go through puberty after cancer treatment and have children without medical intervention.

We offer a free survivorship workbook, Navigating Life During and After a Blood Cancer Diagnosis (PDF). You can use this book to collect all the important information you and your child need including fertility information, as you move through diagnosis, treatment and follow-up care. 

Possible effects on eggs

Females and people assigned female at birth are born with a finite number of eggs and do not produce new eggs. Therefore, the effect of treatment will depend on how many of your eggs remain after treatment. 

If all of the eggs are destroyed, ovarian function is lost immediately after treatment. Premature ovarian failure (POF), also called premature menopause, describes a loss of ovarian function in someone younger than 40. Unlike menopause, this is not a natural occurrence. When POF is caused by cancer treatment, it is unlikely that you will have subsequent menstrual periods or be able to become pregnant naturally again. 

Generally, POF is managed with hormone replacement therapy, including estrogen and progesterone. Those with POF are encouraged to eat a healthy diet and exercise regularly (aerobics and weight training) to decrease the health risks of osteoporosis and heart disease. Calcium and vitamin D supplements for bone health may also be prescribed. 

If some eggs remain after treatment, you may still menstruate regularly and remain fertile after treatment, but you may develop POF and lose ovarian function at a young age. If you are at risk for POF, you may want to start a family early. If you are fertile after treatment but not ready to start a family, you may want to consider egg or embryo freezing.

Radiation to the pelvic area can cause damage to the uterus, increasing the risk for infertility, miscarriage, or premature birth. 

Women and people assigned female at birth who undergo cancer treatment as children tend to have fewer fertility problems than those treated during the teen or adult years. 

Changes in their bodies or difficulty conceiving may or may not be related to the effects of  cancer treatment. Talk with your child's doctor if they have: 

• Irregular menstrual cycles
• Hot flashes
• Breast tenderness
• Painful intercourse
• Trouble getting pregnant
• A history of miscarriages
• Any other questions or concerns  

Possible effects on sperm  

Loss of sperm production can be temporary or permanent. If sperm production recovers, this can take one to five years. Analysis of a semen sample can indicate if you are making sperm. This can be done one year or later after treatment is completed. Talk with your doctor about how often to be evaluated.