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How Cancer Treatment Affects Fertility
Cancer treatment saves lives. It can also damage the cells and organs responsible for reproduction. Understanding which treatments pose the highest risk helps you and your medical team make informed decisions about preservation.
For Women and People with Ovaries
Your ovaries contain a finite supply of eggs — you were born with all the eggs you'll ever have. Cancer treatments can damage or destroy these eggs, reduce ovarian reserve, or disrupt the hormonal signaling that drives ovulation. The impact depends on several factors:
- Chemotherapy drugs: Alkylating agents (cyclophosphamide, ifosfamide, busulfan) carry the highest risk. The risk also increases with higher cumulative doses and with age at the time of treatment.
- Radiation therapy: Radiation directed at or near the pelvis can damage the ovaries. Total body irradiation before bone marrow transplant carries very high risk. Radiation to other body areas has minimal direct ovarian impact.
- Surgery: Removal of one or both ovaries, the uterus, or the cervix directly affects fertility. Some cancers require surgery that disrupts reproductive anatomy.
- Endocrine therapy: Tamoxifen and aromatase inhibitors for hormone-receptor-positive breast cancer don't directly damage eggs, but the years of treatment delay childbearing — which matters because fertility declines with age.
For Men and People with Testes
Sperm production is continuous (unlike the fixed egg supply), which means it can often recover after treatment — but not always. Chemotherapy, particularly alkylating agents, can reduce or eliminate sperm production temporarily or permanently. Radiation to the pelvis or testes can damage sperm-producing cells. Surgery that removes or damages the testes, prostate, or nerves involved in ejaculation directly affects fertility.
Fertility Preservation: Options Before Treatment
If you're reading this before starting cancer treatment, you have the most options. The gold standard recommendation from ASCO (updated in 2025) is to discuss fertility preservation with a reproductive endocrinologist as early as possible after diagnosis.
🥚 Egg Freezing
Ovarian stimulation with hormones over 10–14 days, followed by egg retrieval under sedation. Eggs are vitrified (flash-frozen) and stored. Can typically be completed before treatment begins. Oncofertility patients produce comparable oocyte numbers to non-cancer patients.
Established🧬 Embryo Freezing
Same stimulation and retrieval process as egg freezing, but retrieved eggs are fertilized with partner or donor sperm before freezing. Historically has had slightly higher survival rates than unfertilized eggs, though modern vitrification has largely closed this gap.
Established🧊 Sperm Banking
One or more semen samples are collected and frozen. Simple, fast, and inexpensive compared to egg freezing. Can be done in a single appointment. Strongly recommended for all males of reproductive age before chemotherapy or radiation.
Established🫀 Ovarian Tissue Freezing
A portion of the ovarian cortex is surgically removed and frozen before treatment, then reimplanted after treatment is complete. No longer considered experimental since 2019. Especially valuable for prepubertal patients who can't undergo ovarian stimulation.
Established (since 2019)💊 GnRH Agonists
Medications like leuprolide (Lupron) temporarily suppress ovarian function during chemotherapy, potentially protecting eggs from chemical damage. Evidence is mixed but generally supportive, particularly for breast cancer. Can be used alongside egg freezing.
Supportive therapy🔬 In Vitro Maturation (IVM)
Immature eggs are collected without full ovarian stimulation and matured in the laboratory. Useful when there isn't time for a full stimulation cycle before treatment must begin. No longer considered experimental as of 2021.
Established (since 2021)A full egg freezing cycle takes about 10–14 days from start to retrieval. Many oncologists can accommodate a two-week delay before starting treatment. If that window doesn't exist, in vitro maturation (IVM) or ovarian tissue freezing may be faster alternatives. For males, sperm banking can be completed in a single day. The key is to have the conversation with your oncologist immediately — even if you're not sure you want children.
After Treatment: Assessing What's Changed
Once your cancer treatment is complete and your oncologist clears you, a reproductive endocrinologist can assess where things stand. For women, this typically includes blood tests for AMH (anti-Müllerian hormone) and FSH (follicle-stimulating hormone) levels, plus an antral follicle count via ultrasound. For men, a semen analysis measures sperm count, motility, and morphology.
The results can fall into a wide range:
- Full recovery: Some patients resume normal fertility after treatment. Periods return, hormone levels normalize, and natural conception is possible. This is most common in younger patients who received lower-dose chemotherapy.
- Reduced but functional: Diminished ovarian reserve or reduced sperm count, but natural conception may still be possible or achievable with IUI or mild interventions.
- Severely impaired: Very low or undetectable ovarian reserve, premature ovarian insufficiency, or azoospermia (no sperm in ejaculate). IVF with previously frozen eggs/embryos/sperm, donor gametes, or gestational surrogacy may be needed.
The POSITIVE Trial: Pregnancy After Breast Cancer
For years, one of the most agonizing questions for young breast cancer survivors was whether pausing endocrine therapy (tamoxifen, aromatase inhibitors) to try to get pregnant was safe. These drugs are typically prescribed for 5–10 years after treatment, and pregnancy is contraindicated during their use.
In 2023, the landmark POSITIVE trial published in the New England Journal of Medicine provided an answer. The study enrolled over 500 women under 42 with hormone-receptor-positive early breast cancer who wanted to attempt pregnancy. Participants temporarily paused their endocrine therapy for up to two years.
This doesn't mean pausing treatment is right for everyone — it's a deeply personal decision that should be made with your oncologist and reproductive endocrinologist together. But the POSITIVE trial removed one of the biggest fears from the equation: it showed that trying for a baby doesn't appear to increase the risk of the cancer coming back.
Paying for Fertility Preservation
Cost is one of the most significant barriers to fertility preservation for cancer patients. Here's the current landscape:
Insurance Coverage
As of late 2025, 21 states and Washington D.C. mandate that private insurers cover fertility preservation for patients undergoing treatments that may impair fertility. At least five states expanded coverage in 2025 alone. Key states with mandates include Connecticut, Delaware, Illinois, Maryland, New Hampshire, New York, Rhode Island, Colorado, California, and New Jersey, among others.
Even in states without mandates, many insurers will cover fertility preservation when it's documented as medically necessary before gonadotoxic treatment. The critical step: get a written referral from your oncologist that explicitly states fertility preservation is recommended prior to gonadotoxic therapy.
Financial Assistance Programs
LIVESTRONG Fertility
Partners with fertility clinics nationwide to offer discounted or free egg freezing, embryo freezing, and sperm banking for cancer patients. One of the most widely used programs.
The SAMFund
Grants and scholarships for young adult cancer survivors to help with costs of rebuilding life after treatment, including fertility preservation.
Alliance for Fertility Preservation
Maintains a state-by-state guide to insurance mandates and connects patients with financial resources. Tracks legislative efforts across all 50 states.
Medication Assistance
EMD Serono's Compassionate Care and Ferring's HeartBeat programs provide free or reduced-cost fertility medications for cancer patients undergoing preservation.
Family-Building After Cancer: Other Paths
If natural conception isn't possible after treatment, there are other ways to build your family:
- IVF with frozen eggs/embryos: If you preserved before treatment, these are used as planned. Success rates depend on the age at which eggs were frozen and the number stored.
- Donor eggs or sperm: If your own gametes are no longer viable, donor options provide a biological connection to one partner.
- Gestational surrogacy: If radiation or surgery has affected the uterus, your biological embryo can be carried by a gestational carrier.
- Adoption and foster care: Many cancer survivors build beautiful families through adoption. Some agencies have specific programs supporting cancer survivors.
What to Do Right Now
Depending on where you are in your cancer journey, here are the specific next steps:
Tell your oncologist you want to discuss fertility preservation before treatment begins. Ask for a referral to a reproductive endocrinologist. Check if your state mandates insurance coverage. Contact LIVESTRONG Fertility for financial assistance. Time matters — have this conversation at your next appointment.
If you didn't preserve before treatment, ask your oncologist about GnRH agonist therapy to protect remaining ovarian function during chemo. After treatment, a reproductive endocrinologist can assess your fertility and discuss next steps.
Schedule an appointment with a reproductive endocrinologist for a full fertility assessment (AMH, FSH, antral follicle count for women; semen analysis for men). This gives you a clear picture of where things stand. Bring your complete treatment history including drugs, doses, and radiation fields.
Books and Resources
If you want to learn more about navigating fertility through and after cancer treatment, these books offer valuable guidance:
- It Starts with the Egg by Rebecca Fett — covers the science of egg quality, including protocols relevant to cancer survivors doing IVF.
- Oncofertility: Fertility Preservation for Cancer Survivors — clinical reference covering the full scope of preservation techniques.
- Having Children After Cancer by Gina Shaw — personal stories and practical guidance for family building after treatment.