Hodgkin Lymphoma's Effects on Fertility and Pregnancy

doctor showing sonogram to patient
Hero Images/Getty Images

Hodgkin lymphoma (HL) is a cancer of the white blood cells that can affect young adults of reproductive age. In fact, although HL represents only about 10 percent of all lymphomas, it is one of the most common lymphoma subtypes diagnosed during pregnancy. This is due to the fact that the peak incidence of HL coincides with female reproductive age.

Keeping the Fetus Safe

Some of the signs and symptoms from HL, such as fatigue and shortness of breath, can overlap with common signs and symptoms seen during pregnancy, which can complicate matters, but staging of the HL is done so as to provide enough information to guide management while limiting the risks to the fetus.

For instance, when a chest x-ray is done, the abdomen is shielded in order to protect the baby. To evaluate the abdomen, MRI and ultrasound may be done. A bone marrow biopsy can still be done safely during pregnancy if needed.

Management of HL during pregnancy means balancing the chance of cure and minimizing the potential harm to the developing baby. Many pregnant women with HL diagnosed during pregnancy undergo therapy. Combination chemotherapy such as ABVD has been successfully administered in the first trimester. Studies looking at outcomes of births in moms treated for HL have been encouraging, showing no difference in birth weight or congenital malformations compared with infants born to mothers not undergoing treatment. In selected women, treatment may be deferred until the baby can be safely delivered.

Fertility After Treatment for Hodgkin Lymphoma

According to an article published in the November 2011 issue of “Haematologica,” something called premature ovarian failure—essentially early menopause—can occur in 5 to 25 percent of women undergoing treatment who are under the age of 30.

The risk of infertility increases with the cumulative dose certain chemotherapies called alkylating agents.

Chemotherapy has also been linked to damage to the ovaries. So-called myeloablative therapy increases the risk that a woman will not be able to conceive after treatment. This type of therapy uses high-dose chemotherapy that kills cells in the bone marrow, including cancer cells.

It also reduces the counts of normal blood-forming cells in the bone marrow, which can contribute to serious side effects. When myeloablative chemotherapy is used, this is often followed by a bone marrow or stem cell transplant to restore the function of the bone marrow.

A study by Meirow and colleagues showed that premature ovarian failure is more frequent in women over 30 years of age, and that the particular chemotherapeutic regimen and the particular dose of pelvic irradiation are relevant factors in fertility. Especially toxic to the ovarian tissue are alkylating agents.

Numerous studies have looked into the fertility in patients following HL treatment. One finding has been that the dose-escalated BEACOPP regimen has been linked to a higher incidence of secondary amenorrhea than the ABVD regimen. Secondary amenorrhea is defined as the absence of menstrual bleeding in a woman who had been menstruating but later stops menstruating for three or more months—and the lack of a menstrual period is not due to pregnancy, nursing an infant, cycle suppression with systemic hormonal contraceptive (birth control) pills, or menopause.

The components of the above regimens are:

  • BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone, where the alkylating agents are cyclophosphamide and procarbazine)
  • ABVD (doxorubicin, vinblastine, dacarbazine, and bleomycin, where an alkylating agent is dacarbazine)

While such modern therapies are often effective against HL, they can take a toll on the gonads and the ovaries in particular. For doctors who study this phenomenon, the condition is usually described as “chemotherapy induced diminished ovarian reserve,” or chDOR.

The chDOR involves having a low number of eggs in a woman’s ovaries but can also impact the development of the existing eggs. Symptoms include secondary amenorrhea and infertility. Complete depletion of the follicles in the ovaries can also lead to what’s called premature ovarian failure, which is more technically defined as loss of ovarian function before the age of 40.

There is some evidence that administration of gonadotropin-releasing hormone analogues (GnRH-a) during chemotherapy may help protect the ovaries. The mechanism as to how this might work, however, is still incompletely understood.

What About Male Fertility?

Male patients are not without fertility impact from therapy, either. The testes are highly susceptible to the toxic effects of cancer therapy at all stages of life. According to research by Jahnukainen and colleagues, young male cancer survivors are approximately half as likely as their siblings to sire a pregnancy. The same paper cites radiation therapy to the testes and high cumulative dose of alkylating agents as the major factors decreasing the probability of fertility.

A Word From Verywell

The field of cancer treatment and of fertility preservation is rapidly expanding. New anti-cancer therapies emerge very frequently, and so both the treatment of lymphoma and the management of potential side effects, including infertility, are in a constant state of evolution. Speak with your doctor to determine what the best treatment path for you is.

Sources:

Harel S, Fermé C, Poirot C. Management of fertility in patients treated for Hodgkin’s lymphoma. Haematologica. 2011;96(11):1692-1699.

Hutchings M. How does PET/CT help in selecting therapy for patients with Hodgkin lymphoma? Hematology Am Soc Hematol Educ Program. 2012;2012:322-7.

Meirow D, Biederman H, Anderson RA, Wallace WH. Toxicity of chemotherapy and radiation on female reproduction. Clin Obstet Gynecol. 2010;53:727–39.

Continue Reading