Recent advances in oncofertility care worldwide and in Japan

Current Status and Issues of the Japan Oncofertility Registry

Purpose: Fertility preservation (FP) is becoming increasingly common among child, adolescent, and young-adult (CAYA) patients with cancer. However, Japan has long lacked definite estimates of utilization rates for FP services among CAYA patients with cancer, and little is known about disease/FP outcomes among users. Therefore, the Japan Society for Fertility Preservation (JSFP) launched the Japan Oncofertility Registry (JOFR) in 2018 and started the online registration of information regarding primary disease, FP, and data on prognosis and pregnancy outcomes. This study reports the analytical results of FP data registered in the JOFR as of 2021. Methods: Data about patients' primary disease(s), treatment courses, cancer and pregnancy outcomes, and specific procedures were extracted from the JOFR and analyzed. Results: In 2021, 1244 patients received counseling or treatment related to FP (540 males, 704 females). While the numbers of males in each age group were approximately equal, most females were aged between 31 and 40 years. In total, 490 male and 540 female patients underwent FP procedures. Leukemia, testicular cancer, and malignant lymphoma accounted for the majority of male cases seeking treatment, whereas breast cancer was the primary disease in two-thirds of the females. Since 1999, 395 patients have accumulatively experienced subsequent pregnancy. Conclusions: As of January 2022, >7000 cases from >100 fertility facilities have been registered in the JOFR. In the future, maintaining JOFR to disseminate information on cancer prognoses, pregnancy rates, and other oncofertility outcomes is expected to drive further expansion of oncofertility services in Japan.

Effects of naturalistic decision-making model-based oncofertility care education for nurses and patients with breast cancer: a cluster randomized controlled trial

Purpose

This study examined the effects of an oncofertility education program on decisional conflict in nurses and patients with breast cancer.

Methods

A cluster randomized controlled trial was conducted with 84 nurses of five breast care units. Three units were randomly selected from the five as the nurse experimental group. Nurses at the experimental group accepted the oncofertility education based on the naturalistic decision-making (NDM) model, while those at the control group accepted the other non-oncofertility education. We also collected data from female patients before and after the nurses’ educational training, respectively. The decisional conflict was measured using the Chinese version of the decisional conflict scale.

Results

Nurses in the experimental group had less decisional conflict after the oncofertility educational intervention than those in the control group. After the intervention, nurses with higher infertility knowledge scores had significantly lower decisional conflict. Single nurses had significantly higher decisional conflict than married nurses. A higher perceived barrier score was significantly associated with a higher decisional conflict score. Among patients with the same fertility intention scores, those in the experimental group had lower decisional conflict scores than those in the control group.

Conclusions

Our work demonstrates that NDM-based oncofertility care education is feasible and acceptable to improve nurse and patient decisional conflict. Educational training based on the NDM model decreased the decisional conflict regarding oncofertility care.

Trial registration.

ClinicalTrials.gov Identifier: NCT04600869.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-022-07279-w.

Case Report: Young Adults With Breast Cancer: A Case Series of Fertility Preservation Management and Literature Review

Breast cancer comprised at least 21.8% of the overall cancer among young adult (YA) women and became the leading cancer in this group in Japan, with 50% adolescent and YAs being diagnosed and 15–44-year-old women showing excellent 5-year survival. Surgical-chemoradiation therapy often results in excellent survivorship with an increased incidence of treatment-induced subfertility. Therefore, adding fertility preservation (FP) to the primary cancer treatment is necessary. Herein, we reported a series of cases of YA women with breast cancer who opted for FP, where their option was tailored accordingly. To date, the selection of oocytes, embryos and ovarian tissue is widely available as an FP treatment. PGT could reduce the risk of BRCA mutation transmission amongst BRCA carriers before pregnancy planning. Otherwise, gonadotropin-releasing hormone analog has no gonadoprotective effect and thus should not be considered as an FP option.

Oncofertility in Islam: The Malaysian Perspective

The implementation of oncofertility services is of great importance among cancer survivors of reproductive age to ensure a good quality of life. However, the uptake of this service among Muslim patients is very challenging because of inconclusive laws or evidence based on the Islamic perspective. Hence, we summarized the limited evidence available to consolidate current recommendations for oncofertility practices in the Muslim population in Malaysia. The available “fatwa” and “muzakarah” regarding reproductive procedures and gamete cryopreservation in Islam was searched from the recommendations of local and international bodies, including published and unpublished sources. The relevant information was then extracted according to the current understanding of dilemmas in oncofertility practices in Malaysia, tabulated, and consolidated. Most of the available “fatwa” has been revised by recent “muzakarah” to suit current oncofertility practices. Most Islamic organizations support the practice of oncofertility in Muslim hence indicates that oncofertility services are permissible. Therefore, proper recommendations and counseling are paramount to ensure understanding among Muslim patients.

Oncofertility care in young women and the outcomes of pregnancy over the last 5 years

Aim:

To ascertain the actual outcomes of oncofertility care in young women to provide more appropriate care.

Materials & methods:

We analyzed the data of 67 female patients under 43 years of age who underwent oncofertility care between January 2015 and September 2019.

Results:

There were 28 patients with breast cancer, 19 patients with hematologic cancer and 20 patients with other cancer diagnoses. Breast cancer patients tended to take longer than hematologic cancer patients to initiate oncofertility treatment. Despite undergoing oncofertility care, seven of nine pregnant patients did not choose assisted reproductive technology (ART).

Conclusion:

As spontaneous pregnancies were more common than ART pregnancies in our study, pregnancy by not only ART but also non-ART method is a viable option for young cancer survivors.

We conducted a study about oncofertility care and pregnancy outcomes in female cancer survivors under 43 years old. Even after chemotherapy, pregnancy by not only assisted reproductive technology (ART) but also non-ART method is a viable option for young cancer survivors. Social support as well as ART advancement is important for young cancer survivors and the low marriage rate may contribute to the low pregnancy rate.

In vitro maturation with letrozole priming: Can it be a solution for patients with cancerophobia? A pilot study

Objective:

To investigate whether letrozole priming could be used efficiently in patients undergoing in vitro maturation (IVM) as compared with follicle-stimulating hormone (FSH) priming.

Materials and Methods:

This is a retrospective analysis of 63 patients who underwent IVM due to the high risk of Ovarian Hyperstimulation syndrome (OHSS) (n=39), cancerophobia (n=16), and desire for IVM after failed in vitro fertilization attempts (n=8). Forty-two patients received FSH priming and 21 patients received letrozole priming.

Results:

The patients who had FSH or letrozole priming were statistically similar with respect to age, body mass index, duration of infertility, basal antral follicle count, serum anti-Müllerian hormone levels, and IVM indications (p>0.05 for all). When compared with the FSH priming group, the number of germinal vesicle oocytes, metaphase II and fertilized oocytes were significantly higher (p=0.003, p=0.001, and p=0.016, respectively), but the number of metaphase I oocytes was significantly lower in the letrozole priming group (p=0.002). The patients who received FSH and letrozole priming had statistically similar rates of implantation (33.3% vs 37.0%, p=0.709), clinical pregnancy (31.5% vs 33.3%, p=0.848), twinning (1.9% vs 3.7%, p=0.611), and live birth (24.1% vs 29.6%, p=0.682).

Conclusion:

Potential indications for IVM include patients with increased risk for OHSS and contraindication for hyperestrogenism. Aromatase inhibitors can be used to preserve the fertility of patients with estrogen-sensitive cancers. Letrozole priming appears to be an efficient approach in patients who undergo IVM, with likely less cost than FSH priming.

Advances in the Treatment and Prevention of Chemotherapy-Induced Ovarian Toxicity

Due to improvements in chemotherapeutic agents, cancer treatment efficacy and cancer patient survival rates have greatly improved, but unfortunately gonadal damage remains a major complication. Gonadotoxic chemotherapy, including alkylating agents during reproductive age, can lead to iatrogenic premature ovarian insufficiency (POI), and loss of fertility. In recent years, the demand for fertility preservation has increased dramatically among female cancer patients. Currently, embryo and oocyte cryopreservation are the only established options for fertility preservation in women. However, there is growing evidence for other experimental techniques including ovarian tissue cryopreservation, oocyte in vitro maturation, artificial ovaries, stem cell technologies, and ovarian suppression. To prevent fertility loss in women with cancer, individualized fertility preservation options including established and experimental techniques that take into consideration the patient's age, marital status, chemotherapy regimen, and the possibility of treatment delay should be provided. In addition, effective multidisciplinary oncofertility strategies that involve a highly skilled and experienced oncofertility team consisting of medical oncologists, gynecologists, reproductive biologists, surgical oncologists, patient care coordinators, and research scientists are necessary to provide cancer patients with high-quality care.

Cancer fertility preservation: a report from a Brazilian social program

OBJECTIVE

To present clinical and laboratory data of a Brazilian social program for cancer fertility preservation.

METHODS

We carried out a descriptive observational study between July 2011 and December 2018. 246 patients were included from a social program in a private assisted reproduction clinic in Santo André/Brazil for oocyte cryopreservation before starting oncological treatment.

RESULTS

246 cancer patients resorted to fertility preservation before initiating cancer treatment. These were diagnosed with 27 different types of cancer, and the breast type is the most prevalent. 2528 MII oocytes (mean of 10.3 oocytes per patient) were vitrified. Four patients thawed their oocytes to submit in vitro fertilization, three had embryos transferred and one achieved pregnancy.

CONCLUSION

Preservation of fertility offers patients, especially at reproductive age, a viable way to perform their cancer treatment without compromising future gestation. It is important that professionals duly counsel oncological patients so, if they wish, they can have the possibility to guarantee her fertility preserved.

Preservation of fertility in patients with hematological malignancies

Oncofertility is the medical field that bridges oncology and reproduction that seeks to give healthcare providers and patients the opportunity to optimize residual fertility. The treatment for hematological malignancies carries gonadal toxicity, so that the preservation of fertility should be considered in all patients in childhood, adolescence and young adulthood. Most patients who receive only chemotherapy remain fertile, whereas those who receive regimens consisting of high-dose alkylating agents or total body irradiation can develop permanent infertility. In postpubertal patients, there are established methods for preserving fertility, such as the cryopreservation of sperm, oocytes and embryos. Although ideally performed before the initiation of gonadotoxic treatment, these procedures for fertility preservation can be performed any time prior to the loss of gonadal function. In contrast, a standard option is not available in prepubertal patients, and the preservation of fertility must be sought through experimental methods. Future advances in reproductive medicine may overcome this limitation. Gonadal tissue cryopreservation might be performed in the hope that sperm or mature oocytes could later be extracted from cryopreserved tissue. Healthcare providers, including hematologists, reproductive endocrinologists, nurses, clinical psychotherapists and embryologists, need to optimize the patient's fertility through shared decision-making while always remaining aware of the rapidly progressing developments in reproductive medicine.

Oncofertility Treatment Among Breast Cancer Women: A Paradigm Shift of Practice After a Decade of Service

Purpose: Our center is known as a pioneer center initiating oncofertility service since 2010 in Japan. We demonstrate our transition of this service in regional university hospitals ingenuously. Methods: We compared two phases of service: initial phase (2011 and 2012) and current phase (2019). The comparison included the number of women attending the oncofertility unit, diversity of breast cancer cases, the acceptability of preservation service, and the type of fertility preservation (FP) option offered in between these phases. Results: A total of 58 women were seen during the initial phase as compared with 41 women in the later phase. The mean age at diagnosis was not significantly different between the two periods. The majority of them were married and diagnosed with stage II luminar type. The current phase had a tendency to have a higher anti-Müllerian hormone level although not reaching significance. At least 50% of them declined FP and 84.5% never received ovarian control stimulation in the initial phase. Otherwise, 61% used aromatase inhibitor in the current phase. Only 15.5% in the initial phase received control ovarian stimulation whereas 63.4% in the current phase received it. The ovarian tissue cryopreservation was highly chosen during the initial phase (25.9%), whereas embryo cryopreservation (39%) was highly opted for during the current phase. All of our parameters are comparable between these two phases (p > 0.05). Conclusion: The significant changes of oncofertility practice were observed mainly due to the understanding of the oncofertility concept among reproductive physicians and the acceptance environment, including standard guidelines, supportive society, as well as advancements in cryobiology technique.

Association between spontaneous ovulation and serum anti-Müllerian hormone levels in a premature ovarian insufficiency patient after a multimodal treatment for breast cancer

The high toxicity of chemotherapy can damage a patient's gonadal function, leading to premature ovarian insufficiency (POI). Here, we report the case of a patient suffering from POI after chemotherapy for breast cancer, who 3 years later ovulated spontaneously and became pregnant. The patient, a 31-year-old infertile women, nulligravida, was diagnosed with breast cancer. The Anti-Müllerian Hormone (AMH) level in her serum was 1.85 ng/mL before multimodal treatment for cancer. She later visited our hospital for amenorrhea and 2 years after cancer treatment, she was diagnosed with POI. Her AMH level at that point was less than 0.1 ng/mL. One year after the diagnosis of POI, the patient's AMH level increased slightly to 0.14 ng/mL and she ovulated spontaneously. The patient later became pregnant using Assisted Reproductive Technology on the fourth attempt.During the course of treatment for infertility at our hospital, the AMH levels in her serum changed along with the recovery of ovarian function. These findings suggest the possibility that ovulation and pregnancy could be predicted by the chronological changes of the AMH levels in the patient's serum.

Female Fertility Preservation through Stem Cell-based Ovarian Tissue Reconstitution In Vitro and Ovarian Regeneration In Vivo

Historically, approaches designed to offer women diagnosed with cancer the prospects of having a genetically matched child after completion of their cytotoxic treatments focused on the existing oocyte population as the sole resource available for clinical management of infertility. In this regard, elective oocyte and embryo cryopreservation, as well as autologous ovarian cortical tissue grafting posttreatment, have gained widespread support as options for young girls and reproductive-age women who are faced with cancer to consider. In addition, the use of ovarian protective therapies, including gonadotropin-releasing hormone agonists and sphingosine-1-phosphate analogs, has been put forth as an alternative way to preserve fertility by shielding existing oocytes in the ovaries in vivo from the side-effect damage caused by radiotherapy and many chemotherapeutic regimens. This viewpoint changed with the publication of now numerous reports that adult ovaries of many mammalian species, including humans, contain a rare population of oocyte-producing germ cells-referred to as female germline or oogonial stem cells (OSCs). This new line of study has fueled research into the prospects of generating new oocytes, rather than working with existing oocytes, as a novel approach to sustain or restore fertility in female cancer survivors. Here, we overview the history of work from laboratories around the world focused on improving our understanding of the biology of OSCs and how these cells may be used to reconstitute "artificial" ovarian tissue in vitro or to regenerate damaged ovarian tissue in vivo as future fertility-preservation options.

Gonadotropin-releasing hormone agonists during chemotherapy for ovarian function and fertility preservation for patients with early-stage breast cancer

Breast cancer remains the most common cancer among women worldwide. Many patients, especially in our region, are affected while young and during their child-bearing years. Chemotherapy, more commonly used in this age group, may result in premature ovarian failure and thus negatively impact their fertility. Several fertility-preservation methods are currently in use in this age group. Unfertilized ova cryopreservation and in vitro fertilization plus embryo cryopreservation are widely used in clinical practice. More recently, ovarian tissue cryopreservation is gaining in popularity. Several clinical trials and meta-analyses have shown that premenopausal women who received ovarian function suppression with gonadotropin-releasing hormone agonists while on chemotherapy were less likely to experience ovarian failure and had higher rates of menses resumption compared to those who did not. Some studies have also shown higher rates of successful pregnancies among treated patients. Given the conflicting results of the reported clinical trials and even the many published meta-analyses, this approach continues to be controversial and should only be used when other established fertility preservation methods cannot be utilized. The current review seeks to provide an updated summary on this controversial topic by reviewing all recently published clinical trials and meta-analyses.

Oocyte collection and in vitro maturation after train transportation of human follicular fluid aspirated from resected non-stimulated ovaries of patients with endometrial adenocarcinoma

PURPOSE

Immature human oocytes from resected ovaries can be used for research and fertility preservation, though it is unknown whether it is feasible to transport oocytes for these purposes. This study examined in vitro maturation (IVM) outcomes after the transportation of human follicular fluid (HFF) containing oocytes.

METHODS

Fourteen patients with endometrial adenocarcinoma were enrolled. Oocytes obtained from the resected ovaries of seven patients were transported with HFF by railway (transportation group). Samples of HFF from the other seven patients were not transported, and IVM was performed promptly (non-transportation group). The results of oocyte retrieval and IVM were compared.

RESULTS

The average ages in the transportation and non-transportation groups were 40.1 ± 2.0 and 39.6 ± 1.8 years, respectively, and the average numbers of collected oocytes were 8.1 ± 8.4 and 5.1 ± 5.1, respectively. There was a significant negative correlation between the number of collected oocytes and age. The proportions of oocytes that reached meiosis II (maturation rate) after IVM were 38.6% and 69.2% in the transportation and non-transportation groups, respectively (P = 0.013).

CONCLUSION

In this preliminary study, the usefulness of the transportation of HFF was limited. Further studies on maintaining oocyte normality during transportation are necessary for becoming the effective method for research and clinical use.