"No doctor could say whether chemo would make me infertile."(ELISSA THORNER)Elissa Thorner battled breast cancer at 23 and ended up facing one of the biggest issues for many young women with the disease: the potential effects of chemotherapy on fertility.

"I always wanted a houseful of children, and I thought my dream was gone after my diagnosis," recalls Thorner, who lives outside Baltimore. "I talked to several doctors, all of whom had no interest in speaking to me about fertility. When I pushed one oncologist about the topic, he said, 'Do you want to live or do you want to have children?' I responded, 'I want to live so I can have children.' "

Thorner talked to more and more doctors about her options, weighing her age and family history, but no consensus emerged. "Usually oncologists are pretty sure of themselves," Thorner says. "But for me they said, 'We don't really know what to do.' No doctor could say whether chemo would make me infertile."

More about chemo

The fact that Thorner had at least 20 more years of exposure to natural estrogen and progesterone to look forward to—which could be a risk factor for other cancers—led some doctors to advocate chemo. But because chemo effectively shuts down those hormones, there's always the risk that the hormones—and one's fertility—will never come back after treatment.

Next Page: Making her decision [ pagebreak ]After many sleepless nights, Thorner decided not to have chemo. She got married in spring 2008 and plans to begin trying for a baby.

"It's important that I do so sooner rather than later," Thorner says, adding that given her profile, an oophorectomy and hysterectomy may be in her future.

Many doctors find it challenging to manage the precarious balance of powerful treatment with fertility concerns in younger patients. "We're not great at predicting" whose fertility will return after chemo and whose won't, says Ann H. Partridge, MD, a medical oncologist specializing in breast cancer in young women at Dana-Farber Cancer Institute in Boston.

But some chemo regimens are less toxic than others to the ovaries. For instance, Partridge says she doesn't recommend the so-called CMF combination (cyclophosphamide, methotrexate, and 5-fluorouracil) because there are regimens that are equally or more effective but less harmful. A woman who wants to be able to have children might instead be given Adriamycin and Cytoxan (AC) for a shorter period of time, maybe with a taxane drug like Taxol or Taxotere.

An alternative method for younger women that is the subject of ongoing research involves combining tamoxifen treatment with ovarian suppression, a therapy that temporarily stops the functioning of the ovaries and halts the production of estrogen. Because the risks involved in the combination are not fully understood, doctors usually recommend that it be done in the setting of a clinical trial.