Some treatments for lymphoma can reduce your fertility. This is more likely with certain chemotherapy drugs, high-dose chemotherapy used before a stem cell transplant, radiotherapy to the pelvis, and some antibody therapies.
Your specialist should advise you on whether your fertility is likely to be affected. Talk to them about fertility before you begin your treatment for lymphoma. If you are a parent of a child with lymphoma, speak to your child’s medical team before his or her treatment begins.
You might feel anxious or distressed at the thought of fertility problems. This is natural. Speaking to a counsellor, who can provide you with emotional support and help you to explore your thoughts and feelings, may be beneficial.
Chemotherapy drugs damage lymphoma cells or stop them from multiplying, but they also affect some of your healthy cells. This can cause side effects, including reduced fertility. The likelihood of your fertility being affected depends on several factors, including:
- the type of chemotherapy drugs you have,
- the total dosage of chemotherapy, and
- whether you are male or female.
The type of chemotherapy drugs you have
If there is a risk that your chemotherapy drugs could affect your fertility, your medical team should discuss it with you before you begin treatment. Different drugs can have different effects on your fertility:
- There is a low risk with some drugs, eg vincristine, methotrexate and bleomycin.
- There is a moderate risk with some drugs, eg doxorubicin, vinblastine and cisplatin.
- There is a high risk with some drugs, eg cyclophosphamide, chlorambucil and procarbazine.
Less is known about the effect of newer drugs on fertility, eg bendamustine.
The total dosage of chemotherapy drugs
The amount of drugs you have can also affect your fertility. Your total dosage depends on whether you have a drug on its own or as part of a chemotherapy regimen (combination with other drugs). It also partly depends on how many cycles (blocks) of treatment you have. In general, the higher the total dosage of chemotherapy drugs, the higher the risk to your fertility.
Having a stem cell transplant usually involves high doses of chemotherapy, which increases the risk of fertility problems.
Effects of chemotherapy on male fertility
Most chemotherapy drugs for lymphoma reduce a man’s fertility, at least temporarily. This is because quickly dividing cells (including sperm) are vulnerable to the effects of chemotherapy. Your general health also influences the number and quality of your sperm. A serious illness like lymphoma can lower your sperm count in the short-term even before you begin treatment.
In boys who have not yet started puberty, germ cells (which develop into sperm) are continually produced. They are therefore prone to damage or destruction by chemotherapy.
After a standard-dose chemotherapy regimen, your sperm count usually recovers and your fertility returns to its pre-treatment level. It can take a year or more after finishing treatment for this to happen. Even if your recovery is quicker, doctors advise against conceiving a baby within 3 months of completing chemotherapy. Use a reliable method of contraception during treatment and for 3 months after your treatment has finished.
If you’re about to start chemotherapy, techniques are available to help preserve your fertility. There are also ways to help if you have trouble conceiving after you’ve had treatment. Speak to a member of your medical team about your options before you begin chemotherapy.
You can read more about low sperm counts on NHS Choices.
Effects of chemotherapy on female fertility
Women are born with eggs in their ovaries. The number of eggs gradually decreases over time. Menopause is the last menstrual period. It occurs when there are not enough eggs left to keep regular menstrual cycles going. The average age of menopause in the UK is 51.
You can read more about how age affects fertility and about menopause on NHS Choices.
Chemotherapy can be damaging to eggs and can leave you with fewer eggs in your ovaries than you would otherwise have had. It is not possible to predict the exact effect chemotherapy will have on you. Some types of chemotherapy have a greater impact than others, especially when given at a high dose and over a long time. Chemotherapy does not, however, affect the ability of the uterus (womb) to carry a pregnancy.
It is very common for your periods to stop during chemotherapy. In younger women, they usually come back, although it may take many months for ovulation (the process of egg release) to begin again. If chemotherapy reduces the number of eggs in your ovaries to a very low number, you may have an early menopause.
At the moment, there are no effective methods to prevent the damaging effects of chemotherapy on the ovaries. If you are of (or younger than) reproductive age, talk to your medical team about preserving your fertility before you begin treatment.
Radiotherapy uses radiation (high-energy X-rays) to destroy cancer cells. If received to the pelvic area (just below your belly button), it can cause temporary or permanent infertility.
Effects of radiotherapy on men’s fertility
In men, the pelvis is close to the testes that produce sperm and the hormone testosterone. Radiation received to or around the testes can cause temporary or permanent infertility by lowering the number and quality of sperm. It may be possible to shield this area during treatments to minimise this risk. However, if you have radiotherapy directly to your testes, you are very likely to become permanently infertile. Total body irradiation (TBI), which is used before a stem cell transplant, usually causes permanent infertility, too.
You should use a reliable method of contraception during and for some time after radiotherapy – your medical team will advise you for how long. Even if your fertility will be unaffected in the long-term, your sperm might be temporarily damaged after radiotherapy. This could cause abnormalities in a child conceived during, or soon after, your treatment.
Talk to your medical team about preserving your fertility before you begin treatment.
Effects of radiotherapy on women’s fertility
Pelvic radiotherapy (received to the pelvic area) is very damaging to eggs. Women who have pelvic radiotherapy treatment are likely to have fewer eggs afterwards. Depending on the dose of radiotherapy, they may have no egg reserve after treatment.
Pelvic radiotherapy also affects the blood supply to the uterus and causes scar tissue to develop. Both of these can have a significant impact on the ability of the uterus to carry a pregnancy.
Total body irradiation (TBI) also harms fertility because the pelvic area receives radiation during the process, affecting both the ovaries and the uterus. Women who have had TBI are often unable to carry a pregnancy.
If you are of (or younger than) reproductive age, talk to your medical team about preserving your fertility before you begin treatment.
The effects of biological therapies on fertility are, at this time, unknown. Doctors are also uncertain as to whether these treatments affect an unborn baby. Men and women are therefore advised to use contraception during treatment with antibodies and for 6 months afterwards.
If you are of (or younger than) reproductive age, discuss fertility with your medical team before you begin treatment for lymphoma. If your child has lymphoma, talk to your child’s medical team before their treatment begins.
Some of the techniques for preserving fertility have been used for many years; others are experimental. Fertility treatments are not always available on the NHS for people with cancer. Not all techniques are suitable for everyone.
Sperm banking is the main option for men who wish to preserve their fertility. Testicular tissue cryopreservation (testicular tissue freezing) may also be possible, but this new technique is considered experimental at the time of writing.
Sperm banking involves collecting and storing semen (the fluid that contains sperm). The National Institute of Health and Care Excellence (NICE) recommends that sperm banking is offered to all men whose treatment for cancer could affect their fertility.
With this technique, your semen is preserved and stored for use when you wish to have a baby. Because of the possible effects of treatment on the number and quality of your sperm, banking must happen before you start your treatment for lymphoma. A member of your medical team should explain the process of sperm banking to you. You should also be offered the opportunity to discuss sperm banking with a specialist counsellor.
Sperm banking may be an option for teenage boys who have gone through puberty. Scientists are investigating how to preserve the fertility of younger boys by freezing testicular tissue.
Before giving a sperm sample
- You have blood tests to check for infections including human immunodeficiency virus (HIV), hepatitis B and hepatitis C. If the results show that you have one or more of these infections (ie the results are positive), your sperm are banked at a specially designated centre.
- You are asked to give written consent for your sperm to be stored.
- You are then advised not to ejaculate (climax or orgasm) for up to 3 days before you give a sample. This ensures that your sperm count is as high as possible when you provide a sample.
Giving a sample
- You are asked to provide a sample of semen at a fertility clinic or at a hospital. You might feel embarrassed, but the staff at the clinic will try to put you at ease.
- You are given a sterile container in which to collect your sample in a private room. You can take your partner and any visual aids with you to help stimulate you. You can’t use any lubricant or saliva (spit), as these can affect sperm.
- Your sample is then sent to a laboratory, where it is analysed to check your sperm count (how many sperm it contains per millilitre of semen), motility (ability of your sperm to swim strongly), and morphology (shape). Even if you have a low sperm count, you can still bank your sperm. It is possible to use samples with very low numbers of sperm to start a pregnancy using ICSI (intra-cytoplasmic sperm injection) as part of IVF treatment.
- Unless your medical team advise that you begin treatment immediately, you are likely to be asked to give more than 1 sample during the 1-2 weeks before you begin treatment.
Filtering and storing your sperm
- Your sample is prepared in the laboratory and usually split into several individual straws (batches). This process results in the storage of the healthiest sperm available.
- Your sperm are frozen and preserved in liquid nitrogen.
- As standard, sperm are stored for 10 years. At the end of this period, you may extend storage for another 10 years. You can store your sperm for up to 55 years. Some hospitals store sperm free of charge. Others charge according to the costs set by the local health authority. The fee sometimes depends on whether or not you already have children.
- If you change your address, you must tell the clinic (or wherever your sperm is stored). This is so that they can let you know when your storage period is coming to an end, and so that you can pay any storage fees. If they are unable to reach you, they may destroy your sperm.
Using your sperm to begin a pregnancy
- There are no known risks associated with using frozen sperm. Not all sperm survive the freezing process, though. Some may be damaged.
- When you would like to begin a pregnancy, your sperm are thawed. They can be used to fertilise your partner’s eggs by intrauterine insemination (IUI), in-vitro fertilisation (IVF) or intracytoplasmic sperm injection plus IVF (ICSI-IVF). The type of treatment you can have depends on the quality of sperm stored. It also depends on your partner’s age and fertility.
Testicular tissue freezing (testicular tissue cryopreservation) involves removing some of the tissue from your testicles (organs that produce sperm) and freezing it for later use. Researchers are studying the effectiveness of this technique. At the time of writing, no babies have been born through this procedure and it is still considered experimental. Testicular freezing is offered only for research purposes in a very small number of centres.
At the moment, testicular tissue freezing is the only option for young boys who have not yet reached puberty. Testicular tissue taken from these boys does not contain sperm; however, it does contain germ cells, which develop into sperm in puberty. After lymphoma treatment, cells from this tissue can be transplanted back to the donor, which might restore his fertility.
Researchers are also investigating the possibility of developing sperm from germ cells in the laboratory. These sperm may then fertilise an egg in the laboratory.
Testicular tissue freezing is currently offered only at a few locations in the UK. Your hospital specialist can advise you on facilities available in your area.
You can use the Human Fertilisation and Embryology Authority online database to search for fertility treatments, both NHS and private, across the UK.
The most common option for women is to freeze and store eggs. Embryo storage may also be an option if you have a long-term partner. Please note that if either of you withdraws consent to use the embryos, they must be destroyed.
You may be able to use frozen eggs to begin a pregnancy if you have:
- lost all of your eggs as a result of your lymphoma treatment
- had difficulty getting pregnant after treatment because of a very low number of eggs.
If you would like to freeze your eggs, it is important to discuss with your specialist whether you have time to do it. The process, from your first hormone injection to having your eggs frozen, takes approximately 2 weeks. This may be too long if your lymphoma treatment needs to start immediately.
Before freezing your eggs
- You have blood tests to check for infections including human immunodeficiency virus (HIV), hepatitis B and hepatitis C. If the results show that you have one or more of these infections (ie the results are positive), your eggs are stored at a specially designated centre.
- Your egg number is assessed to check that you are likely to respond to the hormone injections and develop enough eggs.
Freezing your eggs
- You have hormone injections for approximately 2 weeks. This encourages eggs to grow in the ovaries.
- While you are under sedation, a fine needle is passed through your vagina into the ovaries. Fluid containing the eggs is collected from follicles (small, cyst-like sacs). The procedure takes about 10 minutes and you can go home afterwards.
Storing your eggs
- You are asked to give written consent for your eggs to be stored.
- Several eggs are frozen from a single cycle of treatment.
- As standard, eggs are stored for 10 years. At the end of this period, you may extend storage for another 10 years. You can store your eggs for up to 55 years.
- If you change your address, you must tell the clinic (or wherever your eggs are stored). This is so that they can let you know when your storage period is coming to an end, and so that you can pay any storage fees. If they are unable to reach you, they may destroy your eggs.
You can find up-to-date information about egg storage from the Human Fertilisation and Embryology Authority (HFEA).
Using your stored eggs to begin a pregnancy
When you wish to use your stored eggs, you need an appointment in the fertility clinic. Your eggs are then thawed and injected with a single sperm from your partner (or sperm donor) using ICSI.
The likelihood of pregnancy depends on your age at the time of egg freezing. Generally, younger women have more eggs available to freeze and respond better than older women to the stimulation drugs. Additionally, the quality of eggs in younger women is higher, increasing the chances of pregnancy from each frozen egg.
For women under 35, the chance of pregnancy from a single stimulation cycle in approximately 1 in 3. It is rare to freeze eggs from women over 40. This is because the chance of a pregnancy is extremely small.
Egg freezing is a relatively new procedure and little information about the long-term development of babies born using this technique is available at the time of writing. What is known, however, is reassuring. Studies show no increase in rates of abnormality in babies conceived using frozen eggs.
An embryo develops from a fertilised egg. Embryo freezing (cryopreservation) is a safe procedure that has been used for over 30 years.
The process of freezing embryos is very similar to that of freezing eggs and the time scales are the same. The key difference is that on the day of egg collection, laboratory staff try to fertilise each egg with your partner’s sperm. On average 60–70 out of every 100 eggs fertilise.
Before embryo freezing
- You, and the person who is providing sperm, have blood tests to check for infections including human immunodeficiency virus (HIV), hepatitis B and hepatitis C. If the results show that you have one or more of these infections (ie the results are positive), storage happens at a specially designated centre.
- You are asked to give written consent for your embryos to be frozen and stored.
Storing your embryos
- There is no limit on the number of embryos you can store.
- As standard, embryos are stored for 10 years. At the end of this period, you may extend storage for another 10 years. You can store your embryos for up to 55 years.
- If you and your partner separate, your partner may withdraw his consent for the embryos to be used. Should this happen, the embryos must be destroyed.
Using your embryos to begin a pregnancy
- There are no known risks associated with using stored embryos, although some embryos may not survive the freezing and thawing process.
- When you want to use them, your embryos are thawed and transferred into your uterus.
- The process for using embryos depends on the protocol of your fertility clinic and whether or not you have regular periods. Ask your medical team for more information.
The likelihood of pregnancy with an embryo that has been frozen is slightly lower compared to using a fresh embryo. However, how long the embryo has been frozen for does not have any effect.
Similar to egg freezing, the chance of a future pregnancy depends on your age at the time when the embryos are created. It also depends on the quality of the frozen embryo. For women under 35, success rates are approximately 1 in 3 per cycle.
The National Institute of Health and Care Excellence recommends that women:
- are offered the opportunity to discuss fertility with a specialist before starting oncology (cancer) treatment.
- proceed to egg or embryo storage if they are clinically able and they wish to do so.
Funding for embryo storage varies between areas. Discuss your options with your specialist. Where funding is available, you can store eggs or embryos on the NHS. However, when you wish to use the embyro, to get NHS funding, you are likely to need to meet IVF eligibility criteria. Alternatively, you may need to fund the treatment yourself.
You can read more about IVF and about ICSI from the Human Fertilisation and Embryology Authority.
Ovarian tissue contains eggs. Freezing ovarian tissue (ovarian cryopreservation) is a way of storing immature eggs that can be fertilised later. This technique is still considered experimental at the time of writing. To date, very few babies have been born using this technique.
Ovarian tissue freezing involves removing all or part of one ovary during a minor operation. The tissue is usually divided into strips before being frozen and stored. Ovarian strips can be transplanted back into your body at a later date should you wish to have a baby. Your options for becoming pregnant then may include IVF, in vitro maturation (IVM) or ICSI.
You can read more about IVF, IVM and ICSI from the Human Fertilisation and Embryology Authority.
Ovarian tissue freezing may be suitable for girls who have not yet reached puberty and do not have mature eggs to collect for freezing. Immature eggs have the potential to mature later. Fertilisation can happen either in a laboratory or in the body, after the ovarian tissue is restored to the donor.
Ovarian tissue storage is not widely available in NHS hospitals and is still considered experimental. You may be able to access it through a clinical trial or a private clinic.
Your hospital specialist can advise you on the options available to you. You can also use the Human Fertilisation and Embryology Authority online database to search for fertility treatments, both NHS and private, across the UK.
You might have heard of ‘ovarian transposition’ (moving the ovaries higher up into the abdominal [tummy] area). This aims to protect the eggs against the damaging effects of radiotherapy. The evidence to show how effective this is isn’t very clear. It may also have some risks.
Many people go on to have a family after having treatment for lymphoma.
Your medical team should advise you on how long you should wait after finishing treatment for lymphoma before you try for a baby. Most people are advised to wait for up to 2 years. One reason is to give your body time to recover from treatment. Another is that the chances of lymphoma relapsing (returning) is usually highest in the first 2 years. Women are often advised not to wait too long after the recommended timeframe, in case of early menopause.
You are often advised to first try for a baby naturally. It isn’t routine practice to have fertility tests after treatment for lymphoma. Investigations, such as measurement of hormone levels, are usually only done if you have not conceived after about a year of trying. However, as women tend to have fewer eggs number after all chemotherapy treatments, it is sensible to seek the advice of a fertility specialist earlier than if you had never had treatment.
Are there any risks related to having a baby after treatment for lymphoma?
There is strong evidence that there is no increased risk of birth defects if you conceive after treatment for lymphoma. There is also much evidence that babies born to people who have had cancer are not at an increased risk of developing lymphoma themselves.
For both men and women, there is a possibility that lymphoma could relapse (return). Consider the implications of this risk on pregnancy or having a baby. The members of your medical team can best advise you on your risk of relapse.
Some chemotherapy drugs can cause damage to your heart or lungs in the long term. For women, pregnancy could place an additional strain on your system. Your hospital specialist can advise you on whether to have your heart function and lung function tested before you decide to try to conceive.
After your treatment, you are generally advised to first try to conceive naturally. You’ll give yourself the best chance of pregnancy if you have sex every 2 or 3 days. If you do not achieve a pregnancy within a year of trying, seek advice.
Tests can be arranged to see if you are producing sperm. If you are, you may be able to have fertility treatment using your sperm. If the results show that there is a problem with your sperm, you may be advised to use the sperm you stored before you had treatment for lymphoma.
The following techniques may be available to you if you have had difficulties conceiving naturally:
- In-vitro fertilisation (IVF): your thawed sperm is combined with your partner’s eggs in a laboratory. If the eggs are successfully fertilised by the sperm, 1 or 2 of the embryos that develop are inserted into your partner’s uterus to begin a pregnancy.
- Intracytoplasmic sperm injection (ICSI): a single thawed sperm is injected into a single mature egg in the laboratory. Around 6 out of 10 of these eggs form an embryo. An embryo is inserted into the uterus as in IVF (so you may hear this called ICSI-IVF). This technique can be useful when there are very few sperm available.
- Intrauterine insemination (IUI): your thawed sperm are directly inserted into your partner’s uterus. The chance of pregnancy using sperm within IUI treatment varies significantly between couples. You can discuss this with a fertility expert at the time of treatment.
Artificial insemination by donor (AID): uses the same process as IUI, except for using a donor’s sperm instead of your own. If you did not bank sperm, AID could be an option for you.
Success rates for these techniques also vary significantly depending on the age of the woman. According to the Human Fertilisation and Embryology Authority, 2015:
- for women under 35, the chance of a livebirth is around 1:3 (about 35 out of every 100 cycles)
- for women between 35–39, the chance of a livebirth is around 1:4 or 5 (about 20-25 of every 100 cycles)
- for women between 40–42, the chance of a livebirth is around 1:10 (around 10-12 out of every 100 cycles).
After your treatment, you are generally advised to first try to conceive naturally. You’ll give yourself the best chance of pregnancy if you have sex every 2 or 3 days. If you do not achieve a pregnancy within a year of trying, seek advice.
Tests can be arranged to look at your uterus, to check whether eggs are being released regularly and to look at the number of eggs in your ovaries following your lymphoma treatment. If you have enough eggs, it may be possible to have fertility treatment using the eggs remaining in your ovaries. If you have a low number of eggs, you can use eggs or embryos that you stored before you had treatment for lymphoma.
If your egg number is low and you did not store any eggs or embryos before your lymphoma treatment, you may consider fertility treatment using donated eggs. These eggs can be fertilised with your partner’s sperm or sperm from a donor.
If you have problems conceiving, using ovarian tissue may be an option. This involves thawing the tissue and transferring it back into your body. If the tissue starts to produce eggs again, natural conception may be possible. To date, very few babies have been born using this technique and it is still considered experimental.
If your uterus is damaged, which can happen after pelvic radiotherapy, you might consider surrogacy (where another woman carries and gives birth to a baby). Surrogacy is not routinely funded by the NHS and comes with emotional and legal aspects, which you should consider before making a decision. If you have suffered damage to your uterus following lymphoma treatment, seek advice from a fertility specialist to discuss your options.
Other possibilities for having children
Adoption and fostering are possibilities for people who wish to have a family but are unable to conceive. You can find out more about adoption and fostering on NHS Choices.
Fertility problems and their investigations and treatment can cause emotional distress. The National Institute of Health and Care Excellence (NICE) recommend that ‘people having problems conceiving are offered counselling before, during and after investigation and treatment for their fertility problems’. If you are interested in finding out more about counselling or you have not been offered it, ask a member of your medical team. Your Clinical Nurse Specialist is likely to be a good person to ask. You can also find out about the potential benefits of counselling from the Human Fertilisation and Embryology Authority.
For some people, meeting others who can identify with their experience is a helpful source of emotional support. The Lymphoma Association buddy scheme may be able to put you in touch with someone whose experience is similar to yours.
Useful resources and organisations
We have listed a few national organisations that you might find useful if you are experiencing fertility problems. You may also wish to use our online forums to get in touch with others affected by lymphoma and fertility problems. Your nurse specialist is a good person to ask about any local organisations that may be useful to you. You can also call our helpline on 0808 808 5555 for help with finding support in your area or if you wish to talk through any aspect of your lymphoma.
The British Infertility Counselling Association provides information and support on all aspects of infertility and assisted conception. They offer access to trained counsellors who can help you to explore and process your thoughts and feelings.
Healthtalk.org is an online resource that provides information on a range of health issues. You can watch videos of people talking about their experiences of fertility treatment and sharing their decision making processes.
Human Fertilisation and Embryology Authority (HFEA) is a government agency that regulates UK fertility clinics and fertility research. On their website, you can read more about fertility treatments, search availability using their online database and read patient stories.
Infertility Network UK offers information, support and advice to people who are struggling to conceive. They run support groups across the UK.
NHS Choices is a website that provides information on health issues, including fertility tests and treatments.
The Daisy Network provides support, information and a friendly support network for women with Premature Ovarian Insufficiency (POI).