Managing the fertility of male cancer patients. RCN guidance for nurses

Transcription

1 Managing the fertility of male cancer patients RCN guidance for nurses

2 Managing the fertility of male cancer patients Acknowledgements With thanks to the Royal College of Nursing Fertility Nursing Forum. This publication is due for review in December To provide feedback on its contents or on your experience of using the publication, please RCN Legal Disclaimer This publication contains information, advice and guidance to help members of the RCN. It is intended for use within the UK but readers are advised that practices may vary in each country and outside the UK. The information in this publication has been compiled from professional sources, but its accuracy is not guaranteed. Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it is impossible to predict all the circumstances in which it may be used. Accordingly, to the extent permitted by law, the RCN shall not be liable to any person or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what is contained in or left out of this information and guidance. Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN 2015 Royal College of Nursing. All rights reserved. Other than as permitted by law no part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or a licence permitting restricted copying issued by the Copyright Licensing Agency, Saffron House, 6-10 Kirby Street, London EC1N 8TS. This publication may not be lent, resold, hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it is published, without the prior consent of the Publishers. 2

3 Royal college of nursing Contents Introduction 4 Providing information 4 Counselling 4 Consent issues 5 HFEA consent forms 5 Developing a comprehensive information service 6 Recommendations for the referring unit 7 Conclusion 7 References and further reading 8 Glossary of terms 9 Appendix 1: Referral form 10 3

4 Managing the fertility of male cancer patients Introduction Advances in assisted reproduction techniques that involve the cryopreservation of gametes (spermatozoa, oocytes and ovarian tissue) offer greater opportunities to treat infertility in people with cancer. This means that nurses working with cancer patients have to manage many more issues at the time of a new diagnosis and referral. The aim of this guidance is to provide information for those oncology and haematology nurses who may be asked questions by patients about the preservation of gametes prior to starting cancer treatment. Managing the fertility of male cancer patients focuses specifically on the options available to men who may wish to freeze their sperm. This document does not include clinical guidance on dealing with patients under 16 years of age. Providing information Every patient has the right to comprehensive information about the fertility services available in their area. The services may be provided by the NHS or private practice, and will vary across the country. The Human Fertilisation and Embryology Authority (HFEA) provides information for the public about every licensed assisted reproduction unit in the UK. This guidance provides a framework for nurses to deliver a quality service within the current recommendations and HFEA evidence base. The service should be available to all patients whose fertility is potentially compromised by cancer treatment. The nurse providing their care should provide comprehensive information about their fertility options. This should be verbal, written and documented in the person s records. Counselling The freezing of gametes in the NHS has both ethical and cost implications, which should be clarified and discussed with the person before they accept fertility treatment. Counselling is an essential prerequisite for the process because the HFEA guidelines require HIV, hepatitis B and C screening for all gamete samples. Also, it is important to warn patients that their samples may be suboptimal and not suitable for freezing, or treatment when thawed. Return to contents 4

5 Royal college of nursing Consent issues It should be noted that at the time of publication of this document a number of issues with regard to consent may be changing, so please refer to the HFEA website for up to date information. Informed written consent for freezing spermatozoa is a legal requirement under the HFEA Act The consent process normally takes place in the fertility unit. Consent form HFEA Gamete Storage (GS) must be used for sperm storage. There may be other HFEA consents to sign depending on the planned treatment. Please ensure patients are advised to seek further consent advice from their clinic. Nurses must follow local NHS trust consent and proxy consent policies for patients who are under 16 years of age. With regard to children, currently, attempts are being made to store pre-pubertal testicular strips but this is still experimental and at first sign of puberty electroejaculation can be tried. Generally, the advice with children is to seek expert advice on gamete cryopreservation for pre-pubertal males from a paediatric cancer team or andrologist with expertise in paediatrics. HFEA guidelines also require HIV 1&2, Hepatitis B surface antigen and Hepatitis B core antibody and Hepatitis C screening for all gamete samples. Also, it is important to warn patients that their samples may be suboptimal and freezing their sperm may not be a suitable option. Nurses must follow HFEA guidelines and establish the patient s wishes during the counselling process that takes place prior to storage. HFEA consent forms Human Fertilisation and Embryology Authority (2015) GS Form HFEA: Your consent to the storage of your eggs or sperm ( Human Fertilisation and Embryology Authority (2015) Men s consent to treatment and storage form (IVF and ICSI) ( should be referred to. Sperm can be stored for as long as the patient consents up to 10 years then for further storage periods (with a medical practitioner s statement) for a further 10 years in increments up to 55 years, if the patient is found to be prematurely infertile. For every further 10 years extended storage consent it must be accompanied by a medical practitioner s statement to prove the patient is still premature infertile. 5 Return to contents

6 Managing the fertility of male cancer patients Resent research discussed by SCAAC in 2012 shows that the vitrification method of fast freezing are the preferred method leading to an increased survival rate of gametes and embryos. As a result, many clinics are now adopting this method of freezing. This is of interest to those patients who need to be made aware of these new practices. There may be some deteroration of the sample, therefore it is advisable to store as many straws as possible to maximise the chance of successful thaw at a later date. Developing a comprehensive information service Nurses should identify local NHS trust policy/guidelines for cryo-preservation of gametes.developing links with the local fertility services will provide a source of advice on local provision, support, education and continuing care. For UK-wide information about fertility units contact the HFEA. Human Fertilisation and Embryology Authority Finsbury Tower Bunhill Row London EC1Y 8HF Tel: Fax: enquiriesteam@hfea.gov.uk Information for patients on local services should include: locality unit/service co-ordinator hours of working contact names/numbers cost implications legal requirements. Return to contents 6

7 Royal college of nursing Develop a clear system of referral that includes: individual identification, including demographics/social details individuals understanding of diagnosis and prognosis type of treatment and start date current state of patient s health, including bloods screens for HIV, hepatitis B and C. Recommendations for the referring unit Cancer patients have a better opportunity of preserving their gametes if they are referred promptly after their diagnosis. The following recommendations, combined with a multi-professional approach drawing on specialist expertise, can facilitate this process: early recognition and prompt referral at initial diagnosis dedicated area for counselling and communication with patients appropriate training and education for all the multi-professional team involved in providing gonadotoxic treatment availability of an independent therapeutic counsellor establish a working relationship between the clinical area and the fertility service provider ensure fertility is a key issue in the care pathway for cancer patients implement audit to ensure guidelines are adhered to collaboration in the development of written patient information including local and national guidelines. Conclusion Fertility is a critically important issue for many women and men, however, it is not always considered when faced with a cancer diagnosis. It is important for all nurses, especially those working in oncology and haematology, as well as nurses working in 7 Return to contents

8 Managing the fertility of male cancer patients wider areas of practice to be aware of the risks to fertility of treatments for cancer, and the options available to patients before treatment commences. Help is available locally via fertility services or from the Human Fertilisation and Embryology Authority at References and further reading British Medical Association (2007) Advance decisions and proxy decisionmaking in medical treatment and research: Guidance from the BMA s Medical Ethics Department, London: BMA. Available at: (accessed 23 June 2015) Department of Health (2001) Reference guide to consent for examination or treatment, London DH. Available at: General Medical Council (2008) Consent: patients and doctors making decisions together, London: GMC. Available at: (accessed 23 June 2015) Human Fertilisation and Embryology Authority (2015) Code of Practice: HFEA Code of Practice: Guidance Note 5. Consent to treatment, storage, donation, training and disclosure of information (version 5.0), London: HFEA. Human Fertilisation and Embryology Authority (2015) Code of Practice: HFEA Code of Practice, London: HFEA. National Institute for Clinical Excellence (2013) Fertility: assessment and treatment for people with fertility problems (NICE guidelines), London: NICE. Available at: (accessed 23 June 2015) Hoong WG, Williamson E, Davies M and Spoudeas H (2011) Sperm cryopreservation in adolescent minors with cancer: factors predicting pretreatment semen quality in 79 minors aged years over 10 years, Endocrine Abstracts 27 OC2.1. Available at: (accessed 23 June 2015) Nursing and Midwifery Council (2015) The Code of Professional standards of practice and behaviour for nurses and midwives, London: NMC. Available at: (accessed 23 June 2015) Cancer Research UK (2015) Preserving fertility when you have breast cancer (web), Available at: (accessed 23 June 2015) Return to contents 8

9 Royal college of nursing Glossary of terms Artificial insemination with husband sperm (AIH) Prepared sperm are placed at the entrance of the cervix at the time of ovulation. Artificial insemination with donor sperm (AID) Similar to AIH but using donated sperm. Gamete intra fallopian transfer (GIFT) Similar to IVF but harvested eggs are placed in the tube with prepared sperm where fertilisation should occur. Intra-uterine insemination (IUI) Drug stimulation is used to promote follicular growth of one to two follicles. Prepared sperm are then transferred into the uterus following the induction of ovulation. In vitro fertilisation (IVF) Hormone therapy is used to produce several follicles and eggs.the eggs are collected and fertilised in the laboratory. Once fertilisation has occurred up to two embryos (under 40s) and three embryos (over 40) are returned into the uterus. Intracytoplasmic sperm injection (ICSI) This involves injecting a single sperm into the harvested egg. This is a treatment for male infertility that is frequently used by cancer patients. Ovulation Induction (OI) This is a drug treatment to establish ovulation in women who do not ovulate regularly. Women must be carefully monitored during a treatment cycle to avoid the risk of multiple pregnancy. Surgical sperm retrieval (SSR) Sperm are retrieved from testicular tissue and then used to fertilise an egg with ICSI. 9 Return to contents

10 Managing the fertility of male cancer patients Appendix 1: Referral form Patient label GP label Consultant details: Print name/department/hospital/contact number Reason for storage Chemotherapy* Radiotherapy* Surgery Other (specify) *Details Diagnosis Date of initial diagnosis Additional information Patient mobile Wife/partner Informed of fees Children yes/no yes/no yes/no yes/no PLEASE NOTE Screening tests detailed below must be performed by the referring department prior to OFU appointment as failure to do so may compromise the storage procedure Date bloods taken Results (hard copies must be forwarded) HIV HEP C HEP B surface antigen HEP B core antiboby positive/negative positive/negative positive/negative positive/negative If the patient is under 16-years-of-age is it your opinion that he is Gillick competent and has reached Tanner Stage 2 of puberty? yes/no Administration of fertility compromising surgery and/or gonadotoxic therapy In my opinion there is a risk that the fertility of this man has or is likely to become impaired and I recommend that he has sperm cryopreserved. Referring clinician signed Print name Date Appointment date Produced by Lynne Iley Oxford Fertility unit Return to contents 10

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