Desire for parenthood and reproductive health knowledge in adolescents and young adults with sickle cell disease and their caregivers

Using the consolidated framework for implementation research to identify challenges and opportunities for implementing a reproductive health education program into sickle cell disease care

BACKGROUND

As survival rates for individuals with sickle cell disease (SCD) increase, calls have been made to improve their reproductive healthcare and outcomes. The research team created a web-based program entitled Fertility edUcaTion to Understand ReproductivE health in Sickle cell disease (FUTURES). The study aim was to use the Consolidated Framework for Implementation Research (CFIR) during pre-implementation to identify challenges and opportunities from the individual to systems level of implementation to ultimately optimize the integration of FUTURES into clinical practice.

METHODS

Semi-structured interviews were conducted with clinicians, research team members, and adolescent and young adult (AYA) males with SCD and their caregivers who participated in pilot testing. Interviews (N = 31) were coded inductively and then mapped onto CFIR domains (i.e., outer setting, inner setting, characteristics of individuals, and intervention characteristics).

RESULTS

Research team interviews indicated the lack of universal guidelines for reproductive care in this population and gaps in reproductive health knowledge as key reasons for developing FUTURES, also highlighting the importance of collaboration with community members during development. Clinicians reported intraorganizational communication as essential to implementing FUTURES and discussed challenges in addressing reproductive health due to competing priorities. Clinicians, AYAs, and caregivers reported positive views of FUTURES regarding length, engagement, accessibility, and content. Suggestions for the best setting and timing for implementation varied.

CONCLUSIONS

Using CFIR during the pre-implementation phase highlighted challenges and opportunities regarding integrating this program into SCD care. These findings will inform adaptation and further testing of FUTURES to ensure effective implementation of this novel education program.

Experiences and outcomes of fertility testing in male adolescents with sickle cell disease

Adult males with sickle cell disease (SCD) may have abnormal semen parameters, raising the concern that SCD and/or treatments may impact fertility. Yet, studies that include adolescents are lacking. To determine if fertility testing is feasible in male adolescents with SCD, and to explore their experiences and outcomes of fertility testing, 33 adolescents who completed a web-based SCD reproductive health education program were offered a free semen analysis. Five (15%) obtained testing and each had abnormalities. Barriers to testing included lack of time and transportation and discomfort. Findings highlight the need for larger, longitudinal studies using innovative testing approaches.

Generation of two isogenic sickle cell disease induced pluripotent stem cell lines from testicular fibroblasts

Curative bone marrow transplantation (BMT) therapies for sickle cell disease (SCD) can cause infertility. The Fertility Preservation Program (FPP) in Pittsburgh cryopreserves testicular tissues for SCD patients prior to BMT in anticipation that those tissues can be thawed in the future and matured to produce sperm. Here, we generated and validated two isogenic patient-derived induced pluripotent stem cell (iPSC) lines from testicular biopsy fibroblasts of a 12-year-old SCD patient.

Family planning needs of young adults with sickle cell disease

Sexual and reproductive healthcare standards for adolescents and young adults with sickle cell disease (SCD) are not established. A total of 50 young adults entering adult SCD care completed a Family Planning Survey assessing sexual and reproductive health needs from March 2019 to July 2020. Clinical data were abstracted from respondents' electronic medical records. Linear and logistic regression was applied to explore associations between clinical characteristics and survey results. Few respondents (8%) wished to be pregnant in the coming year, and 46% answered yes to at least one of four needs assessment questions. Those who were not employed full time were more likely to endorse needing help with getting sickle cell trait testing for a partner (ORadj = 9.59, p-value = 0.05). Contraceptive use was associated with having an obstetrician-gynecologist (OR = 6.8, p-value = 0.01). Young adults with SCD entering adult care have diverse reproductive health needs, highlighting opportunities to provide multidisciplinary, SCD-specific reproductive healthcare.

Reproductive Health Counseling among Youth with Sickle Cell Disease

STUDY OBJECTIVE

Reproductive health counseling is important for youth with sickle cell disease (SCD) given they experience potential infertility risks from SCD and its treatments and high rates of unplanned pregnancies. Thus, the objective was to describe documented occurrences of reproductive health counseling among youth with SCD and examine differences in counseling by sociodemographic and treatment characteristics.

METHODS

Data were abstracted from 167 electronic medical records (age=14-21, 54% female) with SCD (1/01/2015-12/31/19) at two sites (Nationwide Children's Hospital [NCH] and Hassenfeld Children's Hospital at NYU Langone [HCH]). Descriptive statistics, Point-biserial correlations and Chi Square tests were used to examine sample characteristics and relationships between sociodemographic factors, clinical characteristics, site, and reproductive health counseling (fertility, contraception, and genetic counseling).

RESULTS

Seven of 167 (4%) youth had documented discussions about potential impacts of SCD on fertility. Fertility counseling was also low among those who received a bone marrow transplant (BMT) or hydroxyurea (n=1/2; 50% and n=1/104; 1% respectively). Only 57% of youth received contraception counseling and only 55% of sexually active youth used birth control; birth control use was associated with older age (p=0.028), severe clinical disease (p=0.003), and documentation of contraception counseling (p=0.047). Most youth received genetic counseling (80%), though more genetic counseling occurred at NCH (p<0.001). There was no association between gender and any type of counseling.

CONCLUSION

Findings suggest reproductive health counseling gaps in this population with important implications for future infertility distress and unplanned pregnancies. Future research should examine barriers to counseling, explore fertility impacts of SCD and treatments, and inform evidence-based guidelines for reproductive health care in SCD.

Pediatric hematology providers' contraceptive practices for female adolescents and young adults with sickle cell disease: A national survey

BACKGROUND

Adolescent and young adult (AYA) women with sickle cell disease (SCD) have increased pregnancy-related health risks and are prescribed potentially teratogenic medications, yet limited data are available regarding pediatric SCD provider contraceptive practices. We aimed to assess pediatric hematology providers' beliefs, practices, motivators, and barriers for providing contraceptive care to female AYAs with SCD.

METHODS

Guided by the Health Belief Model (HBM), we developed a 25-question, web-based survey to assess practices. Survey links were distributed nationwide to pediatric SCD and/or general hematology providers through their publicly available emails and by request to directors of U.S.-accredited Pediatric Hematology-Oncology fellowship programs for distribution to their SCD providers. Data analysis included descriptive statistics, chi-square analysis, and logistic regression.

RESULTS

Of 177 respondents, 160 surveys meeting inclusion criteria were analyzed. Most providers reported counseling (77.5%) and referring female AYA patients for contraception (90.8%), but fewer reported prescribing contraception (41.8%). Proportionally fewer trainees provided counseling compared with established providers (54% vs. 85%, p < .001), with a similar trend for prescribing (p = .05). Prescription practices did not differ significantly by provider beliefs regarding potential teratogenicity of hydroxyurea. Key motivators included patient request and disclosure of sexual activity. Key barriers included inadequate provider training, limited visit time, and perceived patient/parent interest.

CONCLUSION

Provider contraceptive practices for female AYAs with SCD varied, especially by provider status. Health beliefs regarding teratogenic potential of hydroxyurea did not correlate with contraceptive practices. Clinical guidelines, provider training, and patient/parent decision-making tools may be tested to assess whether provider contraceptive practices could be improved.

Associations of Reproductive Health Concerns, Health-Related Quality of Life, and Stress Among Adolescents and Young Adults with Chronic Illness

OBJECTIVE

Adolescents and young adults (AYA) living with chronic illness are as sexually active and interested in having children as healthy peers. Few studies have examined the intersection of managing chronic illness and concerns about realizing reproductive goals, including fertility, pregnancy, childbirth, and parenting. Even less is understood regarding how these concerns might be associated with psychological distress. This study examines associations between the reproductive health concerns (RHC) and health-related stress of AYA patients living with chronic conditions including rheumatologic, cardiac, pulmonology, gastrointestinal disorders, and solid organ transplant.

METHODS

A total of 140 patients aged 15 to 20 years (68% female; 81% Hispanic/Latinx) recruited from a transition program located at a safety-net pediatric institution completed surveys examining multiple dimensions of RHC and health-related quality of life (life satisfaction, illness burden, and illness-related anxiety) and condition-related stress. Exploratory factor analyses of RHC variables yielded 3 factors used in regression analyses to identify convergent validity of RHC factors with health-related mental health measures.

RESULTS

Three RHC factor loadings emerged: concern about availability to raise children (timing/future), impact of condition/medication on fertility and childbearing (pregnancy/fertility), and impact of condition on motivation to have children (motivation/decision-making). Positive associations were found between all RHC factors and illness-related anxiety; condition-related stress was associated with motivation/decision-making.

CONCLUSION

RHC, health-related anxiety, and stress can impede healthy sexual and reproductive health and development of AYA living with chronic conditions. Providers' proactive exploration of patients' concerns about their reproductive future can offer critical support as they navigate the unique existential challenges of early adulthood.

Exploring Reproductive Health Decision Experiences and Preferences of Women With Pediatric-Onset Inflammatory Bowel Diseases

Background

Women with inflammatory bowel diseases (IBDs), such as Crohn's disease or ulcerative colitis, face several disease-specific concerns related to their reproductive health decisions. This study explored the reproductive health decision-making experiences and preferences of women with IBD to discover ways to improve this aspect of comprehensive care.

Methods

We recruited women ages 18-44 years with IBD to participate in individual, semistructured interviews exploring their experiences and attitudes toward parenthood, pregnancy, contraception, and family planning care. Two independent coders performed analysis using an inductive and deductive coding approach and identified key themes.

Results

Twenty-one women with IBD participated in interviews (average age 24.7 ± 5.9 years, range 18-43 years; average age of diagnosis 14.1 ± 2.0 years). We identified 4 key themes: (1) Nulliparous women who do not currently desire pregnancy appear to lack reproductive health knowledge; (2) Women with IBD lack clarity regarding the role IBD plays in contraceptive choice; (3) Related to pregnancy, women are concerned about the heredity of IBD, antepartum disease activity, and the safety of their current medications; (4) Women with IBD typically default to their reproductive health provider for reproductive health care and counseling, but they expect their gastroenterologist to initiate relevant reproductive health discussions with them and to provide information in the context of their disease.

Conclusions

Women have concerns about the effects of IBD on pregnancy, parenthood, and contraceptive choice; however, many have had limited or no discussion with their gastroenterologist about the topic.

Ovarian reserve in nigerian women with sickle cell anaemia: a cross- sectional study

INTRODUCTION

Sickle cell disease is the most common monogenetic disorder worldwide. There have been reports of endocrine dysfunction and gonadal failure among affected individuals, especially in males. The findings on ovarian reserve and failure in women with sickle anaemia have been inconsistent.

AIM AND OBJECTIVE

The aim of this study was to determine and compare the ovarian reserve of Nigerian women with and without sickle cell anaemia attending a University Teaching Hospital.

STUDY DESIGN

This cross-sectional study was carried out at the Adult Sickle Cell Clinic and the Community Health Clinic of the Lagos University Teaching Hospital.

METHODOLOGY

A total of 166 participants who met the selection criteria, were recruited for the study. The study population consisted of two groups of women matched for age: 83 women with HbSS and 83 women with HbAA. The haemoglobin phenotype of each participant was determined on alkaline electrophoresis (pH 8.4) before analysis. Serum Anti-Mullerian Hormone (AMH) was determined using Enzyme-linked immunosorbent assay (ELISA) method (Calbiotech Inc. USA, Catalog no AM448T).

RESULTS

The mean ± SD of serum AMH level in women with HbSS was 3.64 ± 0.65 ng/mL and was lower than that of women with HbAA 7.35 ±1.19 ng/mL (p < 0.001). Serum AMH negatively correlated with age in both study groups (HbAA and HbSS). Also, a significant negative correlation was found between serum AMH and BMI in women with HbAA.

CONCLUSION

The study showed diminished ovarian reserve in women with HbSS when compared to age-matched women with HbAA.

Provider Attitudes, Preferences, and Practices Regarding Sexual and Reproductive Health for Adolescents and Young Adults With Sickle Cell Disease

PURPOSE

With improvements in life expectancy, adolescents and young adults (AYAs) with sickle cell disease (SCD) increasingly face sexual and reproductive health (SRH) concerns. As subspecialists often serve as primary care providers for those with chronic disease, this study examines pediatric SCD providers' practices and attitudes related to SRH of AYA women with SCD.

METHODS

We developed an adapted survey to identify SCD provider attitudes and practices in addressing menses, sexual activity, contraception, and pregnancy for their female patients. We electronically distributed this survey to the American Society of Pediatric Hematology/Oncology SCD interest group. We used descriptive statistics to analyze results.

RESULTS

A total of 78 pediatric SCD providers completed the survey. A majority (95%) rated SRH discussions as moderately important or higher, with 89% agreeing this care should be standardized. Most respondents reported discussing SRH, such as menses (78%), teratogenic medications (61%), and contraception (90%), with their female patients with SCD at least annually. Although most refer AYAs with SCD for birth control (83%), 39% endorsed a preferred method, with 33% of these favoring levonorgestrel intrauterine devices in this population and 40% injectable contraception. Approximately half of respondents (57%) reported that the use of combined hormonal contraceptives was unacceptable despite published guidelines that support potential benefits outweighing theoretical risk in AYAs with SCD.

CONCLUSIONS

The range of SRH conversations and contraceptive recommendations for AYAs from pediatric SCD providers is broad. SCD providers and AYAs with SCD would benefit from improved evidence and educational resources related to contraception as well as coordinated SRH counseling.

Are healthcare providers and young people talking about sexuality? A scoping review to characterize conversations and identify barriers

BACKGROUND

Conversations about sexuality with healthcare providers (HCPs) are critical to youth's positive development, including youth with disabilities or chronic conditions. Yet, little is known about the characteristics of sexuality conversations with youth in healthcare settings. This scoping review examined the nature and extent of sexuality conversations between HCPs and youth (with and without a disability or chronic condition) and aimed to identify barriers to these conversations.

METHODS

Scoping review methodology using rapid review principles was employed.

INCLUSION CRITERIA

studies published between 2009 and 2019; examined conversations between HCPs and youth aged 21 and below; addressed sexuality; and took place in a healthcare setting. Study characteristics were described and clustered into thematic groups.

RESULTS

Of the 5543 identified, 32 articles were included. Articles addressed (i) the content of sexuality conversations, (ii) prevalence of sexuality conversations and (iii) barriers to discussing sexuality. The content of sexuality discussions was largely biologically focused. The prevalence of sexuality discussions varied, with some discrepancy between youth-reported and HCP-reported rates. Seven barriers (three personal and four systemic) were identified. Youth with disabilities or chronic conditions were vastly under-represented in the published literature.

CONCLUSIONS

This study highlighted that sexuality is an underexplored topic between HCPs and young people, especially young people with disabilities and/or chronic conditions. Given the importance of sexuality to young people's mental and physical health, research addressing barriers to these discussions and development of evidence-informed resources to support HCPs and youth to engage in conversations about sexuality should be a priority.

Development of an Online Reproductive Health Intervention for Individuals with Sickle Cell Disease or Trait

The purpose of this article is to describe the method of developing an internet-based reproductive options intervention to increase informed reproductive decision-making among individuals with sickle cell disease (SCD) or sickle cell trait (SCT). An interprofessional team of graphics and media specialist, nurses, physicians, and researchers collaborated to develop the intervention. Individuals from the community served as advisory board members who reviewed and advised on webpage design, content, delivery, and media. The intervention was theory based, delivered online, and experientially oriented for young adults of reproductive age with SCD or SCT. The intervention was culturally specific, supporting individuals with SCD or SCT in making informed reproductive decisions about transmission of SCD or SCT to their offspring. The intervention could be strengthened to include content on implementing behaviors concordant with informed reproductive decisions. Health care providers can use the result of this study to enhance their knowledge about the complexity of parenting options.

Sexual health of French adolescents with sickle cell disease

PURPOSE

Focussing on sickle cell disease (SCD), the objective of this study was to assess adolescents' sexual heath experience in the context of their chronic illness.

MATERIALS AND METHODS

We included teenagers from 14 to 19 years old followed for SCD in a hospital located in Créteil (France) from March 2017 to February 2018. Their sexual health experience was assessed by a self-questionnaire with three key themes: contraceptive experience, awareness of sexuality with chronic disease and level of information on the genetic transmission of the disease.

RESULTS

99 questionnaires were analysed. Only six SCD adolescents (one girl and five boys) reported being sexually active. Despite a very regular follow-up of their illness, only 13% of the boys and girls had received information on contraception at the hospital. Most adolescents (85% of boys and 81% of girls) did not think that the disease would interfere with sexual intercourse. The genetic pattern was well known (85% of boys and 87% of girls).

CONCLUSION

Young people with SCD need more information on contraception. Clinicians caring for them should be aware of the need for sexual health information in order to propose prevention actions adapted to these young people with chronic disease.

Reproductive intentions in mothers of young children with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) is an autosomal recessive hemoglobinopathy associated with morbidity and mortality. We sought to understand family planning intentions of parents of young children with SCD including the awareness of three reproductive options (adoption, in vitro fertilization with egg/sperm donation [IVFD], in vitro fertilization [IVF] with preimplantation genetic testing [IVF/PGT]) to decrease the risk of having a child with SCD.

PROCEDURE

Qualitative, semistructured, one-on-one interviews with 18 female parents of young children with SCD at an urban, tertiary care pediatric hospital.

RESULTS

Half of the parents knew their hemoglobinopathy status or their partner's status before pregnancy. Eight parents chose to have no further children because of fear of SCD in another child. Awareness of reproductive options prior to study enrollment was limited. After brief introduction, 7 parents would consider adoption, 2 IVFD, and 10 IVF/PGT. Desire for a biological child, fear of parental jealousy, ethical or religious considerations, and cost affected the acceptability of these options. Participants universally wanted information about reproductive options available to others prior to pregnancy.

CONCLUSIONS

There is limited awareness and variable acceptability of alternative reproductive options available to decrease the risk of a future child having SCD. Participants universally endorsed the need for education regarding hemoglobinopathy status, SCD, and reproductive options prior to pregnancy because for many participants having a child with SCD affected their reproductive intentions. Educational interventions to ensure informed reproductive decision making should be sensitive to desires for a biological child, and ethical and financial considerations.

Reproductive Attitudes and Behaviors Among Transgender/Nonbinary Adolescents

PURPOSE

The aim of the study was to examine reproductive health attitudes and behaviors related to contraception use, provider counseling, parenthood goals, and fertility preservation (FP) in TNB adolescents.

METHODS

A 24-item survey was administered to 44 TNB adolescents aged 12-19 years.

RESULTS

Contraceptive use was variable even among the 46% who reported sexual activity. Half denied or were unsure if they had been offered options from their provider to prevent sexually transmitted infections, and more than one third denied or were unsure about the offer of pregnancy prevention options. Importantly, the majority did not desire more information about contraceptive options. Few used FP, although many thought their feelings about parenthood may change in the future.

CONCLUSIONS

TNB adolescents are at risk for sexually transmitted infections, unplanned pregnancies, and future infertility, yet many do not desire more information about contraception or FP. Tailored counseling strategies should be developed and researched to protect this vulnerable group of youth.

Perspectives on fertility preservation and parenthood among transgender youth and their parents

OBJECTIVE

The aim of this study was to investigate the views of young people (YP) with gender dysphoria and their parents concerning fertility preservation and reproductive and life priorities.

DESIGN

A cross-sectional questionnaire-based study assessed knowledge of potential effects of treatments for gender dysphoria on fertility, current and future life priorities and preferences regarding future fertility/parenting options among YP and parents.

RESULTS

A total of 79 YP (81% assigned female at birth [AFAB], 19% assigned male at birth [AMAB], aged 12-18 years, 68% between ages 16 years and 18 years) and 73 parents participated. The top current life priority for YP among eight options was being in good health; the least important priority was having children. Anticipated life priorities 10 years from now were ranked similarly. Parents' rankings paralleled the YP responses; however, parents ranked having children as a significantly higher priority for AFAB compared with AMAB YP in 10 years. The majority of YP (66% AFAB, 67% AMAB) want to be a parent in the future. However, most do not envision having a biological child. A large majority (72% AFAB, 80% AMAB) were open to adoption. None of the YP surveyed pursued fertility preservation.

CONCLUSION

Fertility is a low current and future life priority for transgender YP. The majority of YP wish to become parents but are open to alternative strategies for building a family. These data may explain in part the reported low rates of fertility preservation among this population. Further studies are needed to assess if life priorities change over time.