We have been writing a series on “cancer and sexuality” for past few weeks and hopefully this series helped people with cancer to better understand how it affects the sexuality. In part 1 of this series we covered about the question what is sexuality and how cancer affects it.  In part 2 we covered what type of cancer treatments exist and how they bring changes in woman and man’s sexuality. Finally in the previous article part 3 we cover various remedies available for changes in sexuality due to cancer.

This will be the last article on the series cancer and sexuality in which we would discuss the following topcis:

• Cancer treatment and its effect on relationships
• Cancer treatment effect on fertility
• Additional Resources for questions and concerns

We start with the first topic on cancer treatment and its effect on personal relationship with the partner

Effect on relationships

At a time when your need for closeness and intimacy is greater than ever, you may feel as if you and your partner are being split apart. It’s important to remember that even though your life has changed, you have not lost the ability to love and be loved.

Cancer and its treatment may change your outward appearance, but they cannot change the essence of who you are as a person. If you have experienced love and affection before cancer treatment, there is every reason to think that your partner, family members, and friends will continue to love and value you now. In fact, most partners are supportive, and often patients are more concerned about loss of attractiveness than their partners are. When partners do hesitate to initiate sexual activity, it is usually out of fear of being pushy or accidentally causing pain. Thus, communication is essential.

If you are in a relationship with another person, then you may have discovered that being close to someone involves many different things. Your sexuality depends on your sexual organs, brain, and hormones. It involves communication, intimacy, and physical elements. Sitting with your partner and sharing your feelings, holding hands, hugging, cuddling, and kissing can provide the intimacy and social support you need.

This section contains more information to help you keep your relationship healthy and positive:

• Advice for Single Patients
• Advice for Patients in a Relationship
• Advice for Partners

Advice for Single Patients

If you are single, you may have concerns about dating during or after cancer treatment. Questions about what to tell someone, or when to tell someone, become a major issue. Your doctor, nurse, social worker, therapist, or chaplain is available to listen to your concerns and give you advice.

Single patients who begin dating after cancer treatment often say that they develop a powerful “radar” around new people. They are able to tell the difference between people who are interested in only a temporary, casual affair and those who enjoy their company because of who they are.

When you have established trust and friendship, go ahead and tell your new partner about your cancer and cancer treatment. This needs to happen early enough so that your relationship can be based upon honesty, confidence, and acceptance.

It is normal to fear being rejected. If a partner rejects you because of your cancer, however, she or he may not be the person you want in your life. Every person has flaws, and a healthy, quality relationship should be formed with someone who accepts yours—just as you would accept your partner’s.

Many people find that their love and commitment to a partner deepen when facing the challenge of cancer. Opportunities may arise for you to give and receive love in ways that will enrich all your new relationships.

Advice for Patients in a Relationship

As patients cope with their cancer, cancer treatment, and their own sexuality, they also need to consider how best to share feelings with their partners. This can be incredibly difficult for some people, especially those who didn’t communicate well about their relationships before cancer.

If there is too much pressure on you or your partner, it may make either or both of you reluctant to initiate or participate in sexual activities. You may feel uncomfortable or nervous about your “first time” during or after cancer treatment. Your partner may be afraid of hurting you or afraid that the sexual part of your relationship is over. This may lead to mixed signals, arguments, or avoiding one another physically.

The good news is that with solid communication and realistic expectations, patients and their partners can develop a relationship that is fulfilling, sometimes even more than what was experienced before cancer. Some men or women even find sex comforting during cancer treatment because they need to feel close to a partner.

The following advice for sharing your needs and worries with your partner may help you become closer:

• Sometimes it’s easier to face challenges when you know ahead of time what they are. Learn how the cancer and its treatment may affect your sexual relationship. Talk with your partner, and plan together how you will handle problems. This may help you both feel more in control at a time when many things seem to be out of your control.
• When discussing serious topics, pick a time and place that foster relaxation and privacy. Focus on one or two specific things you would like to change in your relationship, and ask for the changes in a positive way.
• Encourage your partner to share his or her feelings. He or she may need some of your encouragement to know that it’s OK to talk about concerns. Invite your partner to share in conversations with your doctor or nurse, or talk to your partner about what you have learned when you come home. This will help him or her feel involved, and you both will feel that you are working as a team.
• Often, when people don’t have sexual intercourse, they quit all forms of affection. It is important to continue with physical affection even if other sexual activity has stopped. Maintain your loving feelings together by kissing, hugging, cuddling, and caressing one another. Physical touch is extremely therapeutic and may even boost the healing process. If you want your partner to touch you in a certain way, show or tell him or her. Touch your partner when you feel tired, even if you aren’t ready to have sexual intercourse. This sets the stage for more physical intimacy later when you do have energy and feel better.
• Be patient with yourself and with each other. Give yourself time to heal, physically and emotionally. If you have a day when you feel bad, allow yourself to have some space, and see how you feel the next day.
• Consider counseling. You and your partner may have a history of difficult communication, or perhaps your partner also may be grieving about the changes in your body, which is normal. Your doctor can refer you to a social worker or psychologist to meet together for some “coaching.”

Advice for Partners

If you are a partner of a patient, you need to realize the importance of expressing tenderness and affection frequently. The best cancer treatment that you can provide is “hug treatment.” Love and affection will reduce the feelings of “aloneness” and fear that most cancer patients have while going through cancer treatment. Some research scientists believe that sharing physical touch and closeness boosts the immune system and may contribute to good health.

So that your partner understands your expectations, it is important for him or her to know that a hug may be “just a hug” and not a request for sex. Enjoy touch for its own sake, even though it may not be sexual or an invitation to engage in sexual activity.

Conversation starters:

• We haven’t been holding hands or cuddling lately. Let’s take a stroll or watch a movie and act like we used to when we were dating.
• I haven’t held your hand during a movie in a long time. How about if we go (or rent) a movie, so that I can hold your hand?
• I know you feel alone, but so do I. Can we talk?
• I don’t always know where to touch you to make you feel good, but if you show me, then I’ll feel less nervous.
• How about a hug?
• I feel a little unsure about our physical relationship because I’m worried about hurting you. Would it be OK if we talked to the doctor together at your next appointment? I think that would help me feel more comfortable.

• I know you don’t have much energy today. Is there anything I can do for you?

• This is a difficult time for both of us, but I love you just as much now as I ever have. What could we do together to help us feel better?
• You are just as sexy to me today as you ever have been.

Cancer treatment effect on fertility

Patients’ fertility can be affected both during cancer treatment—when an unplanned pregnancy could be a serious problem—and later, if the cancer treatment causes infertility. For patients who want to have children, this can be devastating.

First, it is important to know that you should prevent pregnancy during chemotherapy or radiation treatment and for at least six months after treatment. Although cancer treatment may lower a man’s sperm count or cause a woman’s menstrual period to stop, a pregnancy may still be possible. Talk to your doctor or nurse about the best method of birth control for you.

Chemotherapy drugs and radiation to the pelvis cause genetic changes in sperm and oocytes (eggs). Embryos with genetic damage often miscarry early in pregnancy. There is also a risk of having a baby with a birth defect, but so few babies have been conceived during a parent’s cancer treatment that no statistics exist on the risk of birth defects.

If a woman is pregnant and her husband is having chemotherapy, using a condom will keep the medicines from reaching the fetus through intercourse. Also, during the first few days after having radioactive seed implants for prostate cancer, men may ejaculate a radioactive seed in their semen. The doctor can advise when it is safe to resume intercourse and whether to use a condom.

By six to 12 months after cancer treatment, the sperm that were exposed to chemotherapy or radiation have all been ejaculated. Eggs that are healthy enough to be ovulated are also more likely to be undamaged. In fact, both the eggs and the stem cells that produce sperm have some ability to repair genetic damage during the first several years after cancer treatment. However, genetic damage is common in human embryos even when neither parent has had cancer treatment. A third of very early pregnancies miscarry because the embryo had genetic damage, often without a woman’s ever realizing she was pregnant.

If a woman already is pregnant at the time of cancer diagnosis, she may be able to continue the pregnancy and have a healthy baby even if she needs chemotherapy, particularly if the pregnancy is past the first three months, when most organs are formed. This situation occurs occasionally in young women with breast cancer.

The following pages provide information about fertility after cancer treatment:

• Causes of Infertility
• Preserving Fertility in Women
• Preserving Fertility in Men
• Recovery of Fertility After Cancer Treatment
• Questions to Ask Your Doctor

Causes of Infertility

Cancer treatment can interfere with fertility in many ways, as the medicines and treatments that work to kill cancer cells also affect other cells, organs, and hormones in the body. Since every patient is different, your doctor may not be able to predict whether your cancer treatment will make you infertile. The effects from cancer treatment may be temporary or permanent. If fertility does recover, it won’t necessarily happen right away.

Fertility after cancer treatment will be affected by age at the time of cancer treatment, especially for women; type of treatment; kind and dose of chemotherapy drugs used; amount and target area of radiation; type and extent of surgery; whether one or multiple cancer treatments are used; and how long treatment lasts.

This section contains more on:

• Causes of Infertility in Women
• Causes of Infertility in Men

Causes of Infertility: Women

Some cancer treatments, such as a hysterectomy, prevent pregnancy in women at any age.

Another cause of infertility in women is premature ovarian failure, which is when menopause occurs before a woman is 40. Premature ovarian failure happens when both ovaries are surgically removed, and it may also occur if the ovaries are damaged from chemotherapy or pelvic radiation therapy. Higher doses are more destructive than lower doses. Chemotherapy with alkylating agents, such as cyclophosphamide, is the most toxic and can directly damage the ovaries. Total body irradiation, typically used before a stem cell or bone marrow transplant, causes very high rates of infertility. However, a few young women have been able to have babies afterward.

Younger women and those who had lower doses of chemotherapy or radiation therapy are more likely to regain menstrual periods, though the periods may not occur regularly. Women over 35 are less likely to recover their fertility. This may be because a woman in her 30s has fewer eggs in reserve, so a larger percentage of eggs are destroyed. However, even young women are at risk for early infertility and menopause because the eggs in the ovaries may be damaged or killed by cancer treatment.

Causes of Infertility: Men

Cancer treatment can damage fertility, temporarily or permanently, in men, too. Men begin producing sperm cells at puberty and continue to be fertile for the rest of their lives. To produce permanent infertility, a cancer treatment must eliminate all of the stem cells in the testicles that produce new, mature sperm cells. This can happen if both testicles are removed, if the testicles get a high dose of radiation, or if very high doses of alkylating chemotherapy drugs are given. Men with testicular cancer, who are typically young, are likely to be infertile before they are diagnosed with cancer, but about half recover good fertility despite having a testicle removed and undergoing chemotherapy.

Preserving Fertility in Women

There are several ways to try to preserve fertility in women, but most remain experimental, with unknown success rates. Some options are not appropriate for certain patients, depending on the type of cancer.

• The most widely available and successful way of preserving fertility before cancer treatment is embryo freezing. This includes removing the eggs, fertilizing them in vitro (in a test tube) with the sperm of your partner or a donor, and then freezing and storing the embryos. It takes about two weeks from the start of a woman’s menstrual cycle to get eggs to use for in vitro fertilization; waiting may be a problem with a fast-growing cancer like acute leukemia. Also, the hormones given so that more than one of a woman’s eggs will ripen may stimulate breast cancer cells to grow, so researchers are trying to use different hormone combinations to make hormonal stimulation safer for these young women. Another option would be to simply harvest the one egg that ripens in a natural menstrual cycle, but the chance that the egg will fertilize, survive freezing, and later produce a live birth when transferred to the woman’s uterus is less than 10 percent. Insurance rarely covers these procedures, and they often cost $5,000 to $8,000.
• A woman who has lost her uterus but still has at least one ovary could go through in vitro fertilization (IVF) to use her eggs and sperm from a partner or donor to create embryos. Another woman could then carry the pregnancy (surrogate or gestational carrier).
• Some women opt to have the eggs frozen unfertilized, particularly if they are not in a committed relationship. Later, the eggs can be thawed and in vitro fertilization attempted. Egg-freezing remains experimental and has resulted in fewer than 500 live births around the world.
• Some women have parts of their ovaries removed surgically and frozen before cancer treatment. Although some centers are banking ovarian tissue before cancer treatment, this technique is still experimental and has resulted in only a few pregnancies around the world.
• For women receiving chemotherapy, one option may be to take a hormone that puts the ovaries into temporary menopause during the cancer treatment. However, many infertility specialists doubt that the hormones truly prevent the chemotherapy from damaging the ovaries. The hormone shots are expensive, and it is possible that they could have some impact on the success of chemotherapy.
• For women receiving radiation treatment, it may be possible to move the ovaries out of the radiation area surgically. Sometimes they can be relocated at the sides of the pelvis, out of the radiation target field. There is a 50 percent chance that women will resume menstruating after this procedure.
• Adoption is another option.

Preserving Fertility in Men

Fertility preservation is much easier, cheaper, and more effective for most men. It simply involves collecting a sample of semen and freezing it. Sperm must be banked before any chemotherapy or pelvic radiation therapy begins in order to avoid storing damaged sperm. The sperm can be thawed later and used for intrauterine insemination or in vitro fertilization.

Many young men diagnosed with cancer have poor sperm quality because of the illness, recent anesthesia, or stress. Even if a man has only a few live sperm in his semen, however, they can be used with in vitro fertilization to give a good chance of a pregnancy. In this situation, when the sample is thawed, the healthiest sperm are captured and injected into the woman’s harvested eggs using a robotic microscope in the laboratory.

Insurance generally does not cover the cost of the sperm banking, and storing one ejaculate for five years averages around $500. Some sperm banks have special payment plans for cancer patients. For men who no longer ejaculate semen but would like to bank sperm, a urologist may be able to collect sperm with outpatient surgery to retrieve them from the storage areas above the testicles or even from tissue inside the testicles.

Recovery of Fertility After Cancer Treatment

For some people, fertility does return after cancer treatment. However, it may take a long time.

For women, the return of menstruation may or may not signal fertility, but getting blood tests for hormones and other tests performed by an infertility specialist can give a better answer.

Women who have had chemotherapy or have had radiation treatment to the pelvic or abdominal area should consult an obstetrician before trying to get pregnant, to make sure that their heart, lungs, and uterus are healthy enough to avoid pregnancy complications. For example, when a girl or young woman has radiation that includes the uterus, it is important to know whether the uterus is normal in size and can expand enough during pregnancy.

Men often have low sperm counts or motility (the movement of the sperm) at the time their cancer is diagnosed, but this may improve after cancer treatment. Sperm quality may rise for several years following cancer treatment, depending on the drugs used, the doses, and each person’s individual recovery. Even though men may produce sperm, the number and their ability to move may not be enough to conceive without some medical help. A semen analysis, in which a man’s semen is examined under a microscope, can indicate whether a pregnancy is likely through intercourse or what type of infertility treatment will be needed. Because each person’s situation is different, it is important to talk to your doctor before trying to start a pregnancy.

Questions to Ask Your Doctor

If you wish to have children after your cancer treatment, discuss the issue with your doctor as soon as possible. Understandably, thinking about the future and having children can be incredibly difficult while coping with a cancer diagnosis. But most options to preserve fertility need to take place before you begin chemotherapy or radiation therapy. You also may want to talk to a counselor familiar with cancer and fertility to prepare yourself for challenges and decisions.

Here are some questions you may want to ask:

• Is there anything that can be done before starting my cancer treatment to increase the likelihood that I will be able to have children after cancer treatment?
• I am interested in freezing eggs or embryos. Is this an option for me? Could you please give me more information?
• I am interested in sperm banking. Is this an option for me? Could you please give me more information?
• I stopped having my period, but could I still get pregnant? Should I be using birth control?
• For how long will we need to prevent pregnancy during cancer treatment? Are condoms the best method for us?
• My partner is pregnant. Is there any special reason to avoid sex during my cancer treatment?
• Will my cancer treatment cause me to be infertile? Do you expect this to be temporary or permanent?
• Now that my cancer treatment has ended, I would like to have children. Is it OK for us to try to become pregnant?
• We have been trying to get pregnant without success. Should we talk to an infertility specialist?

Additional Resources

Often patients are not sure what to expect from their doctor or nurse when talking about sexual health or fertility during cancer treatment. Even healthcare providers in oncology sometimes do not know much about sex or fertility after cancer. If your doctor or nurse seems uncomfortable or dismisses your concerns, ask to see a specialist. This could be a mental health professional trained to treat sexual problems or a urologist or gynecologist with such training.

For more information about sexuality and cancer, you may call the National Cancer Institute’s Cancer Information Service toll free at (800) 422-6237. A trained cancer information specialist will answer your questions.

Classes to improve your appearance during cancer treatment are available to help you look good and feel better. Contact the American Cancer Society toll-free at (866)-228-4327 to find out about classes near you.

More information on sexuality and cancer is available on following websites:

American Cancer Society: Sexuality
The website covers side effects of different treatments that affect an individual’s sex life and ways to relieve some common problems. It also links to Web pages that address this issue and men and women separately.

National Cancer Institute: Sexuality and Reproductive Issues
The site addresses the effect cancer and cancer treatment can have on all aspects of an individual’s sexuality, including sexual desire and physical and psychological sexual dysfunction.

Lance Armstrong Foundation: Physical Effects of Cancer
Provides links to different physical effects, including sexual dysfunction in men and women and fertility.

Cancerbackup: Sexuality and Cancer
From the United Kingdom, an information and referral service for those who have been diagnosed with cancer. The following link provides information on aspects of sexuality and cancer.

Fertile Hope
Nonprofit organization dedicated to helping cancer patients who are faced with infertility. Provides links to resources, including financial assistance for treatment.

United Ostomy Associates of America
Organization offers guidebooks and fact sheets about having sex for those with an ostomy.