• Insurance coverage: Currently, 13 states have insurance coverage mandates for infertility. Look into your state's laws as well as your insurance plan.
  
  
• Financing options: Many fertility clinics offer their own financing programs for their patients. Similar to a credit card or loan, you can finance the cost of fertility treatments through special programs with special rates specific to this type of medical care.
  
  
• Shared risk programs: Many fertility clinics offer their own shared risk programs for their patients. Shared risk means that you will pay a set fee.
  
  
• Financial assistance programs: Some nonprofit organizations have financial assistance programs available to help with the cost of fertility preservation and assisted reproductive technologies.

• American Society for Reproductive Medicine
  
  
• Fertile Hope
  
  
• Lance Armstrong Foundation
  
  
• Cancer.Net

• Age at time of retrieval
  
  
• Quantity and quality of eggs retrieved
  
  
• Quantity and quality of embryos frozen
  
  
• Stage of embryos frozen or used
  
  
• Experience and success rate of your reproductive center

Dr. Shell: I don't know if you are male or female, and I don't know if you are receiving radiation therapy, chemotherapy, or both at once. According to the literature, even when given in standard doses, certain types of chemotherapy can cause adverse affects on sperm-forming germ cells, such as azoospermia (low sperm counts) and difficulty with erections.

The sexual response in women (desire, excitement, expanding and lubricating of the vagina, and orgasm) is less well understood. If the anatomy or nerve structure of the clitoris or vagina is affected, or if other debilitation (fatigue) occurs because of cancer treatment, you may lose sexual desire. Painful intercourse may be another factor that can decrease or prevent orgasm. Women also tend to have more concerns about rejection from their partner.

Treatment side effects, such as fatigue, nausea and vomiting, pain and discomfort, and emotional concerns, may affect your sexual interest, ability, and feelings of self-esteem. A decreased or negative body image may result from dramatic weight loss or hair loss.

If you don't feel attractive and desirable because of cancer and its treatment, you may feel that you don't deserve the pleasure of giving and receiving sexual pleasure. However, what often happens instead is that your partner does desire sexual activity but feels guilty about having a sexual interest in you because you are ill. Therefore, what can happen is that both of you may avoid any intimate or sexual contact at a time when you may need it the most. Many patients with cancer report that they continue to enjoy being close, but there is a decrease in the desire for sexual intercourse until they regain strength and begin to feel more "normal." Please give yourself permission to take your time to heal and to simply enjoy a close relationship with your partner or spouse.

Question 2: Right now it is physically uncomfortable for me to have intercourse. Can you suggest some other ways my partner and I can be intimate?

Dr. Shell: Your sexuality is reflected in touching, smelling, hearing, tasting, and visual stimulation and sensations. Use all of these senses when being intimate with your partner.

What may be acceptable sexual expression for some may not be acceptable for you. You may want to read the information from the American Cancer Society about Sexuality & Cancer: For the Man and His Partner, or Sexuality & Cancer: For the Woman and Her Partner.

Alternatives to intercourse can include hugging, holding hands, caressing, kissing, nudity, and cuddling. A warm bath with candlelight, soft music, and wine may help soothe you and your partner and create closeness without the anxiety of performance.

It is also important to recognize when there are no acceptable alternatives for sexual expression in a relationship. Many couples remain intimate with each other simply through good communication and companionship. You may also choose to seek counseling from a therapist.

It is vital for you to understand your disease, the treatment options you have and how these will affect your sexuality and ability to function sexually. Ask many questions of your nurses and doctors. It may help if you ask them to use models or drawings to explain normal anatomy and how your treatment may affect how your body works. It is important to remember that just because one part of how you act sexually may be changed or damaged does not necessarily remove your entire ability to be sexual with your partner.

Question 3: Part of my husband's cancer treatment involved removal of a testicle. Now he says he does not "feel like a man" and has absolutely no desire for sex. He is only 56. How can I help him? I am trying to be supportive, but it is damaging our marriage.

Dr. Shell: Cancer will add a tremendous level of stress that may drain energy and raise questions about adequacy and self-worth. If your husband has the seminoma-type of testicular cancer, his treatment may have included removal of the affected testicle followed by bilateral retroperitoneal lymphadenectomy (removal of a lymph node chain) and radiation therapy. If he had cancer elsewhere in his body, he also may have to have chemotherapy. Some nerves can be damaged when these lymph nodes are removed, and this may result in "dry orgasms" (no sperm present) due to retrograde ejaculation (sperm goes into the bladder).

After orchiectomy (removal of the testicle), concerns with arousal and orgasmic difficulty, a decrease in libido, and embarrassment from the loss of the testicle are normal feelings; therefore, if you understand this, you may be better able to support him and cope with his lack of desire for the present time. If this lack of desire lasts for more than a few months, I would encourage you to seek help from a sex therapist familiar with the needs of cancer patients.

Various treatments (surgery, chemotherapy, and radiation therapy) can be devastating, and the effects of treatment can cause changes in body image even when no outward change in appearance may be obvious. The sense of being masculine may be hindered from pain and antinausea medications and general feelings of fatigue.

One other thought is that for some people, the mere process of being ill may cast doubt on their sexual identity and response, which in turn will reflect on their sense of adequacy. Because of the seriousness of their illness, patients with cancer are often too embarrassed to raise questions about their sexual concerns. They may feel that worrying about such a relatively unimportant matter as sex is unjustified.

Holding, touching, caressing, kissing, and other expressions of affection are all important behaviors to keep in mind; your husband can be encouraged to focus on his positive attributes and on the methods of expression that remain available to you as a couple during recovery.

An excellent resource for the cancer patient and his partner is written by Leslie Schover, PhD, (2001) and published by the American Cancer Society.

Question 4: A social worker at the cancer center where I am seen suggested that my wife and I see a sexual therapist. What should we look for regarding the therapist's background, training, etc. What will likely happen during the sessions?

Dr. Shell: You should look for a therapist with AASECT (American Association of Sex Educators, Counselors, Therapists) credentials and/or a marriage and family therapist with experience with people with cancer. Many large cancer centers have these types of therapists.

You can also go online to www.TherapistLocator.net to see if there are any marriage and family therapists in your area. The Oncology Nursing Society is also a good resource for cancer nurse practitioners in your area with this type of expertise.

A session is typically around an hour, and in the first session, the therapist will do an assessment to find out what your particular concerns happen to be. In subsequent sessions, there may be homework assignments and dialogue between you, your partner, and the therapist.

It is ok, if you find someone you think might be appropriate for the two of you, to interview him or her with the thought in mind of exactly what you would like to accomplish. Depending on what your issue is and how severe it is affecting your relationship, you may need between six and eight sessions.

Question 5: I am a 63-year-old breast cancer survivor. I am fortunate to be cancer-free and to have a wonderful husband who is caring and patient. For most of our marriage, we had a good sex life. Now, however, I do not find pleasure in sex. I miss the enjoyment of sex, something I used to take for granted, and would like to find a way to get that back. Is this a problem associated with age, cancer treatment, or a combination of both?

Dr. Shell: Women in general have problems with low sexual desire during cancer treatment. Older women who have undergone menopause already may have discovered some normal changes, such as a general slowing and a decrease in the intensity of the sexual response cycle. However, because of hormone replacement therapy (HRT), these women have been able to continue to experience normal sexual libido.

Even more than estrogen, androgens (testosterone) are a stimulant for desire in women. When cancer treatments such as chemotherapy create a hormone-deficient condition, along with hot flashes and poor vaginal lubrication, women often experience decreased sexual desire. You may also experience desire issues if you suffer from fatigue, from the cancer itself, or from the anemia associated with cancer treatments. If you experience depression, you may have problems with low sexual desire. If you are on hormone therapy, you may experience a decrease in your ability to have an orgasm and/or it may be less intense.

If you experience hot flashes, talk with your doctor about nonhormonal alternatives or antidepressants.

Many women who experience painful intercourse use a lubricant or moisturizers. Talk with your doctor or nurse for suggestions. Avoid the use of petroleum jelly, as this may obstruct the urethra (opening to the bladder).

Positive and realistic expectations are important in maintaining a healthy sexual relationship. Don't compare your sexuality at age 63 with your sexuality at age 23. Focus on quality and pleasure, not quantity and performance.

Question 6: Are there times during cancer treatment when it is not safe to have sex?

Dr. Shell: Yes, there are times during cancer treatment when it is not safe to have sexual intercourse. Primarily, your safety has to do with low blood counts. When blood counts become very low, you may become extra tired and even short of breath (caused by low red blood cells), which (understandably) decreases interest in sex. If your platelets are low (< 20,000), there is concern about bleeding, and if white blood cells are low (< 1000), the possibility of infection increases.

Women being treated with radiation therapy for gynecological cancer may have vaginal discomfort after about two weeks of radiation therapy. Women may continue to have intercourse during treatment, unless it becomes too uncomfortable. Intercourse can be resumed when the vaginal area is healed. Semen can cause vaginal burning when the vagina becomes irritated from radiation therapy; therefore, your partner should try to withdraw before ejaculation or use a condom. Oral sex is also not advisable because you are more prone to infection from oral bacteria until the vagina is healed.

Please check back next week for more answered questions. In addition, feel free to post a question.

More Information

Sexual and Reproductive Health

Sexual Dysfunction, ASCO's curriculum

Moderator: On behalf of the American Society of Clinical Oncology (ASCO), welcome to the Cancer.Net Ask the ASCO Expert chat on Cancer, Sexual Health, and Fertility, a live question-and-answer session hosted by Leslie Schover, PhD.

During this hour, Dr. Schover will answer as many questions as possible. Due to an increasing number of chat participants and number of questions submitted for each chat event, time simply does not allow us to address all of your questions, and we encourage you to consult your doctor and cancer care team.

Some questions may be adapted so that Dr. Schover's answers can help as many people as possible.

Dr. Schover will take questions from 2:00 - 3:00 PM ET. As you prepare your questions, please keep in mind that Dr. Schover is unable to give individual medical advice in this setting, nor is she able to address questions that include information specific to one person's medical profile.

The information presented here is for informational and educational purposes only and is not intended to substitute the professional medical advice or treatment recommendations provided by your doctor.

This forum is neither intended nor appropriate to serve as a means of obtaining a second opinion on cancer diagnosis or treatment. In response to questions about specific drugs, Dr. Schover's comments will focus only on the state of current research and clinical trials.

It is advised that you do not delay seeking professional medical advice based on any information received during this chat event.

The chat is governed by all terms and conditions of the Cancer.Net website. Participation in this chat event means that you fully understand and agree to abide by the terms and conditions of the Cancer.Net website.

Good afternoon and welcome. Thank you for joining us. Dr. Schover will now begin taking questions.

Leslie Schover, PhD is a professor of behavioral science at M.D. Anderson Cancer Center at the University of Texas.

Her career has focused on the reproductive consequences of cancer treatment, including psychosocial aspects of sexual dysfunction and infertility. She is the author of numerous scientific journal articles, book chapters, and patient education booklets.

Dr. Schover, thank you for taking the time to join us today.

Dr. Schover: I am glad to be here and hope this will provide helpful information.

Guest64: What are the chances of a 40-year-old man being able to have children if he underwent chemotherapy for leukemia at age 17?

Dr. Schover: The results of chemotherapy on a man's fertility are fairly individual, but luckily there is an easy way of finding out his current ability to father children. He can have an analysis of his semen.

The semen analysis tells how many sperm cells are in the sample, their activity, and whether they are shaped normally. The results give a good idea of whether he is likely to start a pregnancy with intercourse, or whether infertility treatment would be needed.

Only about 10% of men have no sperm cells in their semen. Some of them may still have sperm production in the testicle, but a minor surgery would be needed to try to obtain sperm.

Guest20: As a follow-up to the first question, if my husband and I were to have children, would they be at risk for having birth defects from the chemotherapy?

Dr. Schover: Based on the children of cancer survivors that have been studied, there is no evidence of an increased rate of birth defects. Since the number of children is limited, there may be a small increase that has not been detected. The usual rate of birth defects is about 3% and it should not be more than 6% for parents who are survivors.

There is also no evidence that the children have an increased lifetime risk of cancer, unless there is an inherited gene mutation in the family, for example, in some cases of breast or colon cancer.

Jane: I have had surgery, chemotherapy, and internal and external radiation therapy for endometrial cancer. While many sources say that if you were once orgasmic, you can be so again. What about the quality and quantity of orgasms? I find it very hard to climax, and they are weak. The treatment has apparently affected the blood flow to my legs from the external and internal iliac.

Dr. Schover: It is possible that the weaker orgasms relate to damage to the nerves in the sensory system, as a secondary part of the reduced blood flow. However, it is more common that the trouble reaching orgasm relates to having less desire for sex than before, and having a hard time focusing on pleasure during sex. Another issue is medication. Many drugs used to treat pain, nausea, depression, and anxiety can interfere with orgasm, so check that first, since type and dose of drugs can be changed.

Guest149: My sister's husband has prostate cancer. Is it possible for him to pass cancer cells onto her when they have sex? I am so worried for her.

Dr. Schover: That is an excellent question. The answer is NO! Each cell is individual like a snowflake and cancer cells from one person cannot take root and grow in someone else because the genes in the cell do not match. The cancer cell would just die without doing harm.

Guest39: I have always worked hard to look good and was proud of my physical appearance. Since my mastectomy, however, I am having a very difficult time accepting my "new" body. Any suggestions for ways I can cope?

Dr. Schover: Accepting changes in your appearance is a gradual process. First, focus on all the ways in which you still are just as attractive, rather than on the changes that you view as negative. It may help to look at yourself in the mirror and tell yourself at least three things you like about the way you look.

If you have a partner, the partner's expression of love and attraction also can help a lot. Try not to push your partner away, or reject compliments. If you do not have a partner, consider dating again when you feel ready. There is nothing more affirming than feeling that someone new still finds you lovable. You may wish to consider breast reconstruction, but that is a very individual choice.

It also may help to think about the normal changes in a woman's life cycle – aging, pregnancy, weight changes ­– we are very harsh judges of our attractiveness.

Guest79: I am exhausted from my cancer treatments. I have little energy for daily life, let alone sex. My husband tries to be supportive, but I know he is frustrated. How can I find a way to take care of my husband, my marriage, and myself?

Dr. Schover: That is a very insightful question. You realize that to enjoy sex, rather than to feel like you are "servicing" your husband's needs, you need to feel rested and that you have had time for yourself. This can be tough, especially if you work fulltime and/or still have children living at home. Try to take some special time just to relax and enjoy something for yourself.

It is also important to try to make time for sex when you are least tired–perhaps on a weekend morning or on a day off from work during lunchtime. It also helps to make the room restful, with low lighting, or perhaps to start by taking a shower together or giving each other backrubs so that you have time to relax and feel more aroused. Make sure your partner gives you enough caressing so that you can feel ready for sex.

Guest59: Can you address some of the common misconceptions/myths about cancer and sex?

Dr. Schover: One myth was just mentioned–that cancer is contagious through sex. It is true that some viruses, such as human immunodeficiency virus (HIV) (which causes AIDS) and human papillomavirus (HPV) (which causes genital warts and abnormal pap smears) are transmitted during sex and may promote some types of cancer, but cancer is not contagious.

Another myth is that many couples divorce because one spouse can't cope with the other's cancer. Divorce rates are not higher for couples after one partner's cancer. In fact, about 2/3 of couples say the cancer brought them closer emotionally.

Another myth is that because sex is "dirty" or "bad," having sex would make cancer return. Being sexually active does not increase the risk of a cancer recurrence.

Betty: I have had lung cancer and as a result can't have any strenuous activity because I get too winded. This has basically ruled out sex. What can I do?

Dr. Schover: It sounds like you and your partner need to talk about ways to make love that involve your partner doing more of the "work." You may find you can breathe easier if you are sitting up against some pillows and do not have to move a lot. Also, intercourse is not the only way to make love, and if the movement or weight of a partner's body makes you winded, consider other ways of pleasuring each other such as using different types of caressing to help each other reach orgasm.

mbregenzer: At our cancer treatment facility, we have programs and group supports for sexuality issues, however, many patients are reluctant to talk about or address sexuality issues. Does anyone have any suggestions?

Dr. Schover: Sex is very private, and although a group is normally a great way to get support during and after cancer, I find that people feel more comfortable with sexual counseling in a one-to-one format, or just with their partner and a counselor. We also have trained peer counselors to talk with other survivors who have had similar types of cancer. This often works with patients who are members of minority groups that hold sex especially private.

wisgirl3: What is the most common sexual health complaint among women diagnosed with ovarian cancer?

Dr. Schover: There are really two common sexual problems after ovarian cancer treatment (and they are also the most common after almost any type of cancer treatment). One is feeling a loss of interest in sex and trouble getting excited and feeling pleasure with sexual touch. The second is having pain with sexual touch because of vaginal dryness and tightness.

jerome: Can you please address the issue of erectile dysfunction and cancer?

Dr. Schover: Erectile dysfunction (trouble getting and keeping erections) is the most common sexual problem men report after cancer treatment. The problem is most often caused by physical damage to the nerves that direct blood flow into the penis, or to the small blood vessels themselves. Occasionally, however, anxiety plays a role in the problem. Some men can use the newer pills for erectile dysfunction, like sildenafil (Viagra), vardenafil (Levitra), etc. but after prostate cancer surgery or radiation therapy, for example, pills may not be strong enough to create a firm, reliable erection.

Men often are more reluctant to use an injection in the penis, vacuum pump, or to have surgery to implant a bionic "penile prosthesis" pump, but all of these treatments can be very effective. The partner's agreement is also crucial. Many men try a treatment, but give up if the partner cannot accept it or no longer enjoys sex.

Moderator: Transcripts of today's chat will be available April 25, 2006, on Cancer.Net by 12:00 PM ET. More information about receiving transcripts will be provided at the end of the chat.

kj75: You mentioned cultural issues before. How do you talk about cancer and sexual health if one person doesn't want to address them?

Dr. Schover: In many couples one partner is more open to talking about sex and trying to resolve the problem. Sometimes it helps to find a nurse, social worker, peer counselor, etc., who is the same gender and ethnicity as the shy partner, and can relate to him or her from a culturally sensitive perspective. Sometimes you just have to start with the partner who is willing to change, and try to reach out through that partner to the other one.

Guest224: Is there a way to figure out how fertile you are before cancer treatment? It might make a difference to me. I'm a 29-year-old woman with no kids. Thanks.

Dr. Schover: Most 29 year old women with normal menstrual cycles are fertile, unless you have a special reason to think you are not (like having tried and failed to become pregnant or having a history of pelvic infection or polycystic ovaries). Your gynecologist can draw blood on day three of your menstrual cycle and test a hormone called follicle stimulating hormone (FSH). If it is high, you may be in premature menopause but that would be unusual. Other tests can see if your tubes are blocked, etc., but would not be done unless there was a reason to suspect a problem.

Guest118: My husband underwent treatment for testicular cancer almost two years ago. While his doctor says he should be able to resume sexual activity, his interest in this area has dramatically decreased. When I try to talk to him, he shuts down. What should I do?

Dr. Schover: It is not typical for a man to lose interest in sex after testis cancer, since the remaining testicle usually makes enough testosterone (the male sex hormone) to keep desire normal. However, a minority of men have an abnormal remaining testicle. You could ask your husband's doctor (with your husband's consent) to test his testosterone and make sure he has a normal level in his blood. You could tell your husband that this is an important health issue, not just for sex, but for fatigue, loss of bone strength, etc.

Loss of desire for sex is also a hallmark of depression. Maybe your husband has other symptoms of depression that have not been recognized and need some treatment. Look for changes in sleep patterns (insomnia, waking up at 4 AM, sleeping too much), changes in appetite for food, lethargy, loss of pleasure in life, and angry or depressed mood.

Guest218: I am a childhood cancer survivor, now 28, and have been trying to become pregnant for more than 18 months. I have had no luck. I am pretty depressed about the whole situation. What can I do to improve my outlook and hopefully conceive?

Dr. Schover: You do not mention if you have seen an infertility specialist. At this point, you need an expert to do some tests and see whether your ovaries are producing eggs, and if some type of infertility treatment could help. In many states, insurance does not cover infertility care, but a letter from your oncologist saying the infertility is cancer-related may help. Also, some organizations offer financial help to cancer survivors. Check out the website for Fertile Hope for all kinds of useful information: www.fertilehope.org.

Also, consider adoption (there is a great adoption online group on Yahoo.com called Adoption-after-cancer that provides many resources on how to adopt as a survivor), or even using donated eggs to have a baby. Counseling can also help with the grief of loss, since fertility is a very real loss.

guest123: I underwent cancer treatment and would like to start dating again but am afraid that being a cancer survivor and at risk for a cancer recurrence will scare the opposite sex away. What can I do?

Dr. Schover: If you never get out there and try to meet people, you will certainly never meet a loving partner. Think of it this way–sure some potential mates may reject you out of fear you will become ill again, or concern about fertility or other issues. However, would you reject someone worthwhile for such reasons? Those who are not interested in you because of your cancer history are not the type of dating partners you would like to find!

Margaret: I am 62 years old, a cancer survivor, and a very private person. Who would you suggest I talk to about problems with sexuality?

Dr. Schover: You may wish to start with your gynecologist, oncologist, or an oncology nurse or social worker. However, some of these professionals do not have a clue about how to help with sexual problems after cancer. The best bet is to find a mental health professional who has some knowledge about sex and cancer. Your confidentiality is assured, and you can feel safe discussing your concerns. One problem, however, is that many insurance policies limit your counseling to a "panel of providers." Often none of the people on the panel are expert in this area, so a good place to start is at a cancer center.

Guest50: I have prostate cancer. Where can I find comprehensive information on sex after cancer treatment?

Dr. Schover: Here are some suggestions: On the American Cancer Society's website, they now have their extensive brochure: Sexuality after Cancer: A Guide for the Man with Cancer and His Partner. It addresses many of the issues about prostate cancer. There are several books published on sex after prostate cancer by survivors. Making Love Again by Virginia Laken and her husband is one, and Ralph Alterowicz and his wife wrote another. There are books by urologists too, but all tend to overestimate how often men recover erections, and may give too rosy a picture of couple's satisfaction with treatments they try.

Guest248: I'm single and a breast cancer survivor. I had a double mastectomy as part of my treatment. It's been almost 1.5 years, but I still haven't made peace with my "unfeminine" appearance. How do I warn a potential partner that my body has disfiguring scars? I was never nervous about dating before my cancer, and now my fear of rejection is really beginning to take a toll on my confidence. Is this normal?

Dr. Schover: It is very normal to feel self-conscious about dating after a mastectomy. First it is important for you to feel as good about your body as possible, before you venture out to find a partner. See some of the suggestions above, or look at the American Cancer Society's female booklet on their website. Also, timing is an issue. You may not want to disclose your cancer history on the first date, but you also do not want to wait until you are in the bedroom taking your clothes off with a new love. It is best to feel that someone is a caring friend, and then bring up the topic and discuss it together.

Guest114: Are there support groups available for people who lose fertility?

Dr. Schover: To find a support group for people who lose fertility, I'd start by contacting Fertile Hope, the advocacy group for cancer survivors, either on the web or by phone. Cancer Care in New York also has many online or phone groups on specialized topics (www.cancercare.org). You could also check out the Virtual Wellness Community, or for breast cancer survivors, the Young Survival Coalition.

Moderator: The chat is now ending. Thank you for your thoughtful questions.

We hope this discussion has been valuable, and we regret not being able to answer every question. We want to thank Dr. Schover for lending us her time and expertise.

TRANSCRIPTS: The full text of today's chat will be available on Cancer.Net (www.cancer.net) April 26, 2006, by 12:00 PM ET. To receive a copy of the transcript by e-mail, please send a message to contactus@cancer.net.

SAVE THE DATE: Please join Cancer.Net for a live chat about Caring for a Loved One with Cancer on May 10, 2006, from 2:00 – 3:00 PM ET.

The featured expert is Betty Ferrell, PhD, FAAN, of City of Hope National Medical Center.

The chat room is now closed. Thanks again for joining us.