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Overview of infertility and pregnancy outcome in cancer survivors

Elyce H Cardonick, MD
Section Editors
Charles J Lockwood, MD, MHCM
Robert L Barbieri, MD
Patricia A Ganz, MD
Deputy Editor
Kristen Eckler, MD, FACOG


One of the strongest predictors of emotional well-being in cancer survivors, besides sexual function, appearance, and employability, is feeling healthy enough to be a good parent. Parenthood can represent normalcy, happiness, and life fulfillment. Cancer survivors are often fearful that their history of cancer or its treatment will have an adverse impact on offspring conceived after their cancer treatment, such as placing them at risk for malignancy, congenital anomalies, or impaired growth and development. They are also concerned about the risks of cancer recurrence, infertility, miscarriage, and achieving a successful pregnancy outcome.

Despite these concerns, surveys of female cancer survivors in California and Sweden reported that only about 50 percent recalled receiving reproductive health counseling [1,2]; the proportion is higher in male cancer survivors [2,3]. A subsequent study reported that receiving counseling about reproductive loss and the option to try to preserve fertility before treatment was important to survivors, even if they were unable to have children after chemotherapy [3]. Others have noted that the rate of elective pregnancy termination among female cancer survivors was higher compared to sibling controls because of the fear that their prior cancer therapy would affect their children [4]. Patient education regarding future reproductive function is thus an important component of the care of individuals with cancer [3].


Risk of infertility among cancer survivors — Infertility in cancer survivors can be caused by injury to the hypothalamic-pituitary-gonadal axis, as well as damage to the organs of the reproductive tract. Cytotoxic drugs, radiation therapy, surgery, and the disease process itself can all cause infertility, which may be temporary or permanent. The magnitude of risk depends on multiple factors, including:

Type and stage of cancer

Drug class and cumulative dose

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Literature review current through: Sep 2017. | This topic last updated: May 30, 2017.
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  1. Niemasik EE, Letourneau J, Dohan D, et al. Patient perceptions of reproductive health counseling at the time of cancer diagnosis: a qualitative study of female California cancer survivors. J Cancer Surviv 2012; 6:324.
  2. Armuand GM, Rodriguez-Wallberg KA, Wettergren L, et al. Sex differences in fertility-related information received by young adult cancer survivors. J Clin Oncol 2012; 30:2147.
  3. Letourneau JM, Ebbel EE, Katz PP, et al. Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer. Cancer 2012; 118:1710.
  4. Green DM, Whitton JA, Stovall M, et al. Pregnancy outcome of female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. Am J Obstet Gynecol 2002; 187:1070.
  5. Green DM, Kawashima T, Stovall M, et al. Fertility of male survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. J Clin Oncol 2010; 28:332.
  6. Green DM, Kawashima T, Stovall M, et al. Fertility of female survivors of childhood cancer: a report from the childhood cancer survivor study. J Clin Oncol 2009; 27:2677.
  7. Barton SE, Najita JS, Ginsburg ES, et al. Infertility, infertility treatment, and achievement of pregnancy in female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study cohort. Lancet Oncol 2013; 14:873.
  8. Green DM, Nolan VG, Kawashima T, et al. Decreased fertility among female childhood cancer survivors who received 22-27 Gy hypothalamic/pituitary irradiation: a report from the Childhood Cancer Survivor Study. Fertil Steril 2011; 95:1922.
  9. Sklar CA, Mertens AC, Mitby P, et al. Premature menopause in survivors of childhood cancer: a report from the childhood cancer survivor study. J Natl Cancer Inst 2006; 98:890.
  10. Brougham MF, Crofton PM, Johnson EJ, et al. Anti-Müllerian hormone is a marker of gonadotoxicity in pre- and postpubertal girls treated for cancer: a prospective study. J Clin Endocrinol Metab 2012; 97:2059.
  11. Miyoshi Y, Ohta H, Namba N, et al. Low serum concentrations of anti-Müllerian hormone are common in 53 female childhood cancer survivors. Horm Res Paediatr 2013; 79:17.
  12. Lunsford AJ, Whelan K, McCormick K, McLaren JF. Antimüllerian hormone as a measure of reproductive function in female childhood cancer survivors. Fertil Steril 2014; 101:227.
  13. Charpentier AM, Chong AL, Gingras-Hill G, et al. Anti-Müllerian hormone screening to assess ovarian reserve among female survivors of childhood cancer. J Cancer Surviv 2014; 8:548.
  14. Reintgen DS, McCarty KS Jr, Vollmer R, et al. Malignant melanoma and pregnancy. Cancer 1985; 55:1340.
  15. Grin CM, Driscoll MS, Grant-Kels JM. The relationship of pregnancy, hormones, and melanoma. Semin Cutan Med Surg 1998; 17:167.
  16. Peters MV. The effect of pregnancy in breast cancer. In: Prognostic factors in breast cancer, Forrest APM, Kunkler PB (Eds) (Eds), Williams and Wilkins, Baltimore 1968. p.65.
  17. Velentgas P, Daling JR, Malone KE, et al. Pregnancy after breast carcinoma: outcomes and influence on mortality. Cancer 1999; 85:2424.
  18. Danforth DN Jr. How subsequent pregnancy affects outcome in women with a prior breast cancer. Oncology (Williston Park) 1991; 5:23.
  19. Teh WT, Stern C, Chander S, Hickey M. The impact of uterine radiation on subsequent fertility and pregnancy outcomes. Biomed Res Int 2014; 2014:482968.
  20. Luke B, Brown MB, Missmer SA, et al. Assisted reproductive technology use and outcomes among women with a history of cancer. Hum Reprod 2016; 31:183.
  21. Chow EJ, Stratton KL, Leisenring WM, et al. Pregnancy after chemotherapy in male and female survivors of childhood cancer treated between 1970 and 1999: a report from the Childhood Cancer Survivor Study cohort. Lancet Oncol 2016; 17:567.
  22. Byrne J, Rasmussen SA, Steinhorn SC, et al. Genetic disease in offspring of long-term survivors of childhood and adolescent cancer. Am J Hum Genet 1998; 62:45.
  23. Li FP, Fine W, Jaffe N, et al. Offspring of patients treated for cancer in childhood. J Natl Cancer Inst 1979; 62:1193.
  24. Dodds L, Marrett LD, Tomkins DJ, et al. Case-control study of congenital anomalies in children of cancer patients. BMJ 1993; 307:164.
  25. Green DM, Fiorello A, Zevon MA, et al. Birth defects and childhood cancer in offspring of survivors of childhood cancer. Arch Pediatr Adolesc Med 1997; 151:379.
  26. Chiarelli AM, Marrett LD, Darlington GA. Pregnancy outcomes in females after treatment for childhood cancer. Epidemiology 2000; 11:161.
  27. Kenney LB, Nicholson HS, Brasseux C, et al. Birth defects in offspring of adult survivors of childhood acute lymphoblastic leukemia. A Childrens Cancer Group/National Institutes of Health Report. Cancer 1996; 78:169.
  28. Signorello LB, Mulvihill JJ, Green DM, et al. Stillbirth and neonatal death in relation to radiation exposure before conception: a retrospective cohort study. Lancet 2010; 376:624.
  29. Winther JF, Olsen JH, Wu H, et al. Genetic disease in the children of Danish survivors of childhood and adolescent cancer. J Clin Oncol 2012; 30:27.
  30. Signorello LB, Mulvihill JJ, Green DM, et al. Congenital anomalies in the children of cancer survivors: a report from the childhood cancer survivor study. J Clin Oncol 2012; 30:239.
  31. Boice JD Jr, Tawn EJ, Winther JF, et al. Genetic effects of radiotherapy for childhood cancer. Health Phys 2003; 85:65.
  32. Winther JF, Boice JD Jr, Thomsen BL, et al. Sex ratio among offspring of childhood cancer survivors treated with radiotherapy. Br J Cancer 2003; 88:382.
  33. Green DM, Peabody EM, Nan B, et al. Pregnancy outcome after treatment for Wilms tumor: a report from the National Wilms Tumor Study Group. J Clin Oncol 2002; 20:2506.
  34. Ståhl O, Boyd HA, Giwercman A, et al. Risk of birth abnormalities in the offspring of men with a history of cancer: a cohort study using Danish and Swedish national registries. J Natl Cancer Inst 2011; 103:398.
  35. Green DM, Whitton JA, Stovall M, et al. Pregnancy outcome of partners of male survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. J Clin Oncol 2003; 21:716.
  36. Reulen RC, Zeegers MP, Wallace WH, et al. Pregnancy outcomes among adult survivors of childhood cancer in the British Childhood Cancer Survivor Study. Cancer Epidemiol Biomarkers Prev 2009; 18:2239.
  37. Critchley HO, Wallace WH. Impact of cancer treatment on uterine function. J Natl Cancer Inst Monogr 2005; :64.
  38. Sanders JE, Hawley J, Levy W, et al. Pregnancies following high-dose cyclophosphamide with or without high-dose busulfan or total-body irradiation and bone marrow transplantation. Blood 1996; 87:3045.
  39. Signorello LB, Cohen SS, Bosetti C, et al. Female survivors of childhood cancer: preterm birth and low birth weight among their children. J Natl Cancer Inst 2006; 98:1453.
  40. Green DM, Lange JM, Peabody EM, et al. Pregnancy outcome after treatment for Wilms tumor: a report from the national Wilms tumor long-term follow-up study. J Clin Oncol 2010; 28:2824.
  41. James WH. Occupations associated with low offspring sex ratios. Am J Ind Med 1994; 25:607.
  42. Egeland GM, Sweeney MH, Fingerhut MA, et al. Total serum testosterone and gonadotropins in workers exposed to dioxin. Am J Epidemiol 1994; 139:272.
  43. James WH. Evidence that mammalian sex ratios at birth are partially controlled by parental hormone levels around the time of conception. J Endocrinol 2008; 198:3.
  44. Wo JY, Viswanathan AN. Impact of radiotherapy on fertility, pregnancy, and neonatal outcomes in female cancer patients. Int J Radiat Oncol Biol Phys 2009; 73:1304.
  45. Hawkins MM, Smith RA. Pregnancy outcomes in childhood cancer survivors: probable effects of abdominal irradiation. Int J Cancer 1989; 43:399.
  46. Pridjian G, Rich NE, Montag AG. Pregnancy hemoperitoneum and placenta percreta in a patient with previous pelvic irradiation and ovarian failure. Am J Obstet Gynecol 1990; 162:1205.
  47. Norwitz ER, Stern HM, Grier H, Lee-Parritz A. Placenta percreta and uterine rupture associated with prior whole body radiation therapy. Obstet Gynecol 2001; 98:929.
  48. Critchley HO, Bath LE, Wallace WH. Radiation damage to the uterus -- review of the effects of treatment of childhood cancer. Hum Fertil (Camb) 2002; 5:61.
  49. Smith RA, Hawkins MM. Pregnancies after childhood cancer. Br J Obstet Gynaecol 1989; 96:378.
  50. Watanabe T, Matsubara S, Saito Y, et al. Pregnant woman with an extremely small uterus due to pelvic irradiation in childhood. J Obstet Gynaecol Res 2012; 38:559.
  51. Larsen EC, Schmiegelow K, Rechnitzer C, et al. Radiotherapy at a young age reduces uterine volume of childhood cancer survivors. Acta Obstet Gynecol Scand 2004; 83:96.
  52. Li FP, Gimbrere K, Gelber RD, et al. Outcome of pregnancy in survivors of Wilms' tumor. JAMA 1987; 257:216.
  53. Holm K, Nysom K, Brocks V, et al. Ultrasound B-mode changes in the uterus and ovaries and Doppler changes in the uterus after total body irradiation and allogeneic bone marrow transplantation in childhood. Bone Marrow Transplant 1999; 23:259.
  54. Winther JF, Boice JD Jr, Svendsen AL, et al. Spontaneous abortion in a Danish population-based cohort of childhood cancer survivors. J Clin Oncol 2008; 26:4340.
  55. Lie Fong S, van den Heuvel-Eibrink MM, Eijkemans MJ, et al. Pregnancy outcome in female childhood cancer survivors. Hum Reprod 2010; 25:1206.
  56. Anderson C, Engel SM, Mersereau JE, et al. Birth Outcomes Among Adolescent and Young Adult Cancer Survivors. JAMA Oncol 2017; 3:1078.
  57. Mueller BA, Chow EJ, Kamineni A, et al. Pregnancy outcomes in female childhood and adolescent cancer survivors: a linked cancer-birth registry analysis. Arch Pediatr Adolesc Med 2009; 163:879.
  58. Madanat-Harjuoja LM, Malila N, Lähteenmäki PM, et al. Preterm delivery among female survivors of childhood, adolescent and young adulthood cancer. Int J Cancer 2010; 127:1669.
  59. Critchley HO, Wallace WH, Shalet SM, et al. Abdominal irradiation in childhood; the potential for pregnancy. Br J Obstet Gynaecol 1992; 99:392.
  60. Bath LE, Critchley HO, Chambers SE, et al. Ovarian and uterine characteristics after total body irradiation in childhood and adolescence: response to sex steroid replacement. Br J Obstet Gynaecol 1999; 106:1265.
  61. O'Donnell RL, Warner P, Lee RJ, et al. Physiological sex steroid replacement in premature ovarian failure: randomized crossover trial of effect on uterine volume, endometrial thickness and blood flow, compared with a standard regimen. Hum Reprod 2012; 27:1130.
  62. Krause MS, Johnson MS, Delaney AA, et al. Successful increase in uterine volume and subsequent pregnancy in a patient with a history of radiation and chemotherapy. Am J Obstet Gynecol 2014; 211:e1.
  63. Reulen RC, Bright CJ, Winter DL, et al. Pregnancy and Labor Complications in Female Survivors of Childhood Cancer: The British Childhood Cancer Survivor Study. J Natl Cancer Inst 2017; 109.
  64. Wobbes T. Effect of a breast saving procedure on lactation. Eur J Surg 1996; 162:419.
  65. Findlay PA, Gorrell CR, d'Angelo T, Glatstein E. Lactation after breast radiation. Int J Radiat Oncol Biol Phys 1988; 15:511.
  66. Higgins S, Haffty BG. Pregnancy and lactation after breast-conserving therapy for early stage breast cancer. Cancer 1994; 73:2175.
  67. Sankila R, Olsen JH, Anderson H, et al. Risk of cancer among offspring of childhood-cancer survivors. Association of the Nordic Cancer Registries and the Nordic Society of Paediatric Haematology and Oncology. N Engl J Med 1998; 338:1339.
  68. Mulvihill JJ, Myers MH, Connelly RR, et al. Cancer in offspring of long-term survivors of childhood and adolescent cancer. Lancet 1987; 2:813.