|
Fact File
Fertility issues for by Rebecca Foster, Senior Sister, Cancer Research Team, Mid Yorkshire Hospitals NHS Trust. Rebecca Foster is a senior sister in the cancer research team at the Mid Yorkshire Hospitals NHS Trust working at Dewsbury, Pinderfields and Pontefract hospitals, for the past 6 months. Prior to that time she was a sister in the day case chemotherapy unit at Pinderfields. Her interest in fertility started whilst working with patients for whom fertility was an issue, and she found that there was no written information for them. She devised an information leaflet, which won the Royal College of Nursing Award in 2000, for nursing innovation. Her work has taken her to Milan, and this summer she is presenting a poster on fertility options for cancer patients at the 13th international cancer conference in Sydney, Australia. We should also like to thank Helen Greenwood, Haematology Clinical Nurse Specialist, Dewsbury Hospital, Mid Yorkshire Hospitals NHS Trust for her professional input and advice. A diagnosis of Hodgkin lymphoma (formerly known as Hodgkin’s disease) or non-Hodgkin lymphoma may be given as a result of finding a lump, or enlarged lymph node. This diagnosis can rock the very foundations of people’s lives, provoking fear and uncertainty. The purpose of this article is to answer some of the questions that you or a loved one may have when a diagnosis of lymphoma is made. For patients who have had lymphoma, being infertile can have a negative effect on their quality of life in the long term. Advances in treatments for infertility have created new possibilities of conception for young men and women who have survived cancer and, with these, comes hope for the future for them and their families. Therapy effects on men and women Unfortunately, many types of cancer treatment physically damage people’s sexual functioning and fertility. Sexual problems are especially likely after cancers of the breast and prostate, the most common types of cancer in women and men, respectively1. The likelihood that chemotherapy will affect a patient’s fertility depends in part on the patient’s gender, age, and the specific drug and dose. Men’s fertility The impact of chemotherapy drugs on sperm production in men is similar in many ways to the effect of radiation. Chemotherapy damages the rapidly dividing, ripening sperm cells. If damage is severe, the stem cells (mother cells) die as well. The higher the total dose of a damaging chemotherapy drug, the more slowly the recovery of sperm cell production, or the more likely it is to stop permanently. In fact, the worst damage to fertility occurs when men are treated with a combination of radiation therapy to the abdomen or pelvis and chemotherapy that includes drugs damaging to fertility. Some chemotherapy drugs seem to have little impact on sperm cell production. The effects of others are not yet fully understood. The most commonly recognised chemotherapy-related impact on male fertility results from use with the drugs known as alkylating agents - substances which interfere with cell metabolism and growth and which are used to treat some cancers (table 1). Treatment with single-agent cyclophosphamide or chlorambucil results in dose-related low sperm counts or no sperm. However, the majority of information we have is on drugs used in combinations (table 2). These are commonly used chemotherapy combinations for Hodgkin lymphoma and non-Hodgkin lymphomas; the patient’s doctor or nurse will be able to clarify the likely side-effects of any of these drugs offered for therapy.
The effects on fertility by drugs used in the last ten years such as fludarabine and monoclonal antibodies are as yet unknown, but will become apparent in the near future. However, patients would be advised to use a barrier method of contraception whilst on these therapies. Sperm banking before cancer treatment For men the option is to store sperm before any treatment begins, but research has shown that it can be done within a few days after treatment begins. Before banking sperm, it is essential that the man does not have sex (or ejaculate) for at least two days. Generally, one to three samples are collected at two to three day intervals, but this is not necessarily strictly adhered to. Ideally three samples should be frozen. Frozen sperm can be safely stored for up to 10 years, or to the age of 55. However, patients should be aware that a diagnosis of lymphoma could affect their ability to produce a sperm sample for banking, due to the psychological stress of the situation. In some cases, a man’s fertility will recover despite treatment. If this was not the case and the man had been unable to produce sperm to be banked prior to treatment, an alternative available to him is for his female partner to achieve pregnancy by using the sperm from a donor. Women’s fertility In contrast to men, the age of a woman is an important predictor of treatment-induced sterility. The ageing ovary has progressively fewer germ cells (the immature cells which form eggs), which are not replaced. Therefore, women over the age of 30 are less likely to regain ovarian function because they have fewer eggs (or oocytes). Women who are approaching menopausal age are more susceptible to an acceleration of the onset of menopause than are younger women. In other words, when compared with their older counterparts, younger women can tolerate higher doses of chemotherapy before the stopping of their periods (amenorrhoea) becomes irreversible. Women might need information on coping with ovarian dysfunction and guidance on managing hot flushes and vaginal dryness. Prior to starting chemotherapy, the specialist nurse or haematologist may advise you of your options. An option for women/girls under the age of 25 would be ovarian tissue cryopreservation (preservation by freezing) but research is very much in its infancy. This procedure involves surgical removal of a strip of ovarian tissue with its corresponding follicles. The specimen is then frozen, to be implanted at a later date. A young woman who has a partner when her lymphoma is diagnosed might have the option of banking fertilised embryos before treatment begins. This involves delaying treatment for a month or two while she takes powerful hormones to stimulate her ovaries to ripen multiple eggs. Her partner then produces a sperm specimen and the sperm fertilises the egg. However, as this option would mean a delay in starting cancer treatments she would need to discuss this with her doctor as a delay can be risky in itself, depending on the type of lymphoma. Unfortunately, timing might be a problem for patients who present with a diagnosis of very acute forms of lymphoma needing immediate treatment, often initiated shortly after diagnosis. It is imperative that the patient is aware of the effects of the chemotherapy agents on his or her reproductive system, which might affect the ability of having children in the future. Contraceptive advice Although many patients experience reproductive dysfunction during chemotherapy, information should still be given about the possibility of conception and the effects that could occur during chemotherapy administration. A woman might remain fertile during chemotherapy, even if her menstrual cycles become irregular or stop. She should still use effective contraception during chemotherapy or she should avoid sexual activity. Female haematology patients may possibly still be able to use the contraceptive pill, but should discuss all aspects of contraception with their GP, specialist nurse or haematologist prior to the commencement of chemotherapy. Intrauterine devices are not recommended when the patient is experiencing low white blood counts, or a low platelet count since infection or bleeding could occur. Careful attention should be paid to the insertion technique of diaphragms, sponges, vaginal inserts and to the use of condoms; personal hygiene should be maintained after use. A water-based lubricant might be required if vaginal dryness is experienced prior to intercourse. In general, most chemotherapy agents are excreted from the body in the first 72 hours following administration. For patients for whom fertility or pregnancy is not an issue, it will still be necessary to use condoms and to avoid oral sex during this period in the event that semen or vaginal secretions might contain chemotherapy particles. Pregnant women For women who are already pregnant and must receive chemotherapy, few implications have been reported, provided the drugs are given in the second and third trimester (a ‘three month’ block of time). The alkylating agents administered during the first three months cause damage to the embryo (teratogenesis)2. However, as chemotherapy agents are known to cross the placental barrier, second or third trimester chemotherapy exposure might result in low birth-weight or premature babies 3, 4. In general, it might be advisable to wait at least two years after completion of therapy before attempting parenthood. The main reason for a waiting period is that most recurrences of lymphoma can happen within two years1 and if conception does occur within three months after the last course of chemotherapy, there may be damage to the foetus5. Common problems during chemotherapy Sex and cancer are two words that do not seem to belong in the same sentence. Sex is a very important part of most people’s lives whether or not they have a partner. The majority of those with a cancer may experience some sexual difficulty at some time or another. For some patients the physical and emotional discomforts of cancer treatments often interfere with staying sexually active. During and after lymphoma treatment, a patient might have periods of chronic fatigue, nausea or pain. It can be difficult to get in the mood for sex if you feel miserable, nauseous or if your self-esteem is low. On the other hand, if your symptoms are relatively mild, a relaxed and sensual session of lovemaking might help to distract you from feeling ill. All patients need to be counselled about decreased libido due to fatigue or lack of sexual desire, and these symptoms are all normal side-effects of cancer treatments1. Providing information that cancer is not contagious is important for many couples, and knowing that chemotherapy agents are not transferred by hugging or cuddling is reassuring and can help patients come to terms with their feelings about lymphoma and sexuality. The emotional stress of lymphoma can create many difficulties in sexual relationships. However, a variety of psychological and medical treatments are available to restore sexual function. Most people do not need much psychotherapy or medical treatment to recover satisfying sex lives after lymphoma treatment. Rather they do require accurate information on what to expect, and how to make the most of the available options for help. Body image Body image disruption is the major factor involved in the sexual problems of cancer6,7,8. Patients who have lost their hair or have had surgery to remove a lump often need advice and reassurance before they leave hospital or before resuming sexual relationships. This advice can be very simple. Patients who have lost their hair might feel more confident by wearing a wig, even in bed. Being able to talk about sex with his or her partner is a crucial step for the patient to recover a satisfying sex life after treatment. Conclusion For many people who have had lymphoma the prospect of potential infertility after treatment can be the cause of much anguish and in the long term this can have an impact on the quality of their lives and the lives of their families. However, there is hope, in particular with the advent of new chemotherapies and the development of new technologies and treatments for infertility. The emotional stress of cancer can cause difficulties in sexual relationships, but there are psychological and medical treatments available to help restore good sexual function. Accurate and timely information can help people to make the most of the options available. For people diagnosed with cancer, acquiring information may be particularly relevant to helping them cope with the disease9. A patient information leaflet written by Rebecca Foster is available through the Helpline; information is also available on the cancer websites below. Rebecca would particularly like to thank her trust for all their support and encouragement and the very generous support of pharmaceutical companies for their financial sponsorship.
References Further reading: Sexuality and cancer. Written by Andrew Stanway and published by CancerBACUP Your guide to infertility. This HFEA Directory of Clinics 2003/2004 also provides answers to some of the most frequently asked questions about treatment and is very readable. You can obtain your free guide by contacting the HFEA on 020 7377 5077. Alternatively, you can request a copy by e-mailing to admin@hfea.gov.uk and providing details of your name and address. You can also download a copy of the guide from their website: www.hfea.gov.uk Useful websites www.cancerhelp.co.uk is the patient information site of Cancer Research UK, CancerHelp UK is a free information service about cancer and cancer care for people with cancer and their families. The search button on the home page can take you to the webpage on ‘Sex, fertility and Hodgkin lymphoma’. www.hfea.gov.uk The Human Fertilisation & Embryology Authority (HFEA) is a non-departmental government body that regulates and inspects all UK clinics providing IVF, donor insemination or the storage of eggs, sperm or embryos. The HFEA also licenses and monitors all human embryo research being conducted in the UK. The website has a section providing information for patients on clinics and frequently asked questions There is also a useful links page. Contact them on 020 7291 8200 (also please see book reference in further reading above). www.bica.fsnet.co.uk The British Infertility Counselling Association (BICA) is a professional Association for infertility counsellors and counselling in the UK. BICA is committed to the total wellbeing of people with fertility problems before, during and after treatment for infertility and those who choose not to undergo any kind of medical intervention for infertility. They can provide you with details of your nearest infertility counsellor (0114 263 1448) email info@bica.net for information. www.dcnetwork.org The site of the Donor Conception Network, a group established by and for parents of children conceived with donated sperm, eggs or embryos; also for adult offspring conceived in this way and those undergoing treatment for infertility. The site has an interesting booklist suitable for helping to explain to children conceived through donor conception about their origins (0208 245 4369). Useful contact Infertility Network UK is a national charity created by the merger of CHILD, The National Infertility Support Network, and iSSUE, The National Fertility Association. It is the largest network in the UK for those experiencing fertility problems, offering face to face and telephone support and information. Telephone: 01424 732361. An evening telephone counselling service is available on 01922 722888. Email: admin@InfertilityNetworkUK.com March 2004
|
||||||||||||||||||||||||||||||||||||
