Optimizing potential for fertility: fertility preservation considerations for the pediatric endocrinologist

Ethical, legal, social, and policy issues of ovarian tissue cryopreservation in prepubertal girls: a critical interpretive review

PURPOSE

Despite the increasing number of childhood cancer survivors, significant advances in ovarian tissue cryopreservation (OTC) technique and medical societies' recommendations, fertility preservation (FP) and FP discussions are not always offered as a standard of care in the pediatric context. The aim of this literature review is to understand what ethical, legal, social, and policy issues may influence the provision of FP by OTC in prepubertal girls with cancer.

METHODS

A critical interpretive review of peer-reviewed papers published between 2000 and January 2023 was conducted, guided by the McDougall's version of the critical interpretive synthesis (Dixon-Woods), to capture recurring concepts, principles, and arguments regarding FP by OTC for prepubertal girls.

RESULTS

Of 931 potentially relevant papers, 162 were included in our analysis. Data were grouped into seven thematic categories: (1) risks of the procedure, (2) unique decision-making issues in pediatric oncofertility, (3) counseling, (4) cultural and cost issues, and (5) disposition of cryopreserved reproductive tissue.

CONCLUSION

This first literature review focusing on ethical, legal, social, and policy issues surrounding OTC in prepubertal girls highlights concerns in the oncofertility debate. Although OTC is no longer experimental as of December 2019, these issues could limit its availability and the child's future reproductive autonomy. This review concludes that specific actions must be provided to enable the offer of FP, such as supporting families' decision-making in this unique and complex context, and providing pediatric patients universal and full access to free or highly subsidized OTC.

Sonographic evaluation of fetal scrotum, testes and epididymis

External male genitalia have rarely been evaluated on fetal ultrasound. Apart from visualization of the penis for fetal sex determination, there are no specific instructions or recommendations from scientific societies. This study aimed to review the current knowledge about prenatal diagnosis of the scrotum and internal structures, with discussion regarding technical aspects and clinical management. We conducted an article search in Medline, EMBASE, Scopus, Google Scholar, and Web of Science databases for studies in English or Spanish language that discussed prenatal scrotal pathologies. We identified 72 studies that met the inclusion criteria. Relevant data were grouped into sections of embryology, ultrasound, pathology, and prenatal diagnosis. The scrotum and internal structures show a wide range of pathologies, with varying degrees of prevalence and morbidity. Most of the reported cases have described incidental findings diagnosed via striking ultrasound signs. Studies discussing normative data or management are scarce.

Communication and ethical considerations for fertility preservation for patients with childhood, adolescent, and young adult cancer: recommendations from the PanCareLIFE Consortium and the International Late Effects of Childhood Cancer Guideline Harmonization Group

Patients with childhood, adolescent, and young adult cancer who will be treated with gonadotoxic therapies are at increased risk for infertility. Many patients and their families desire biological children but effective communication about treatment-related infertility risk and procedures for fertility preservation does not always happen. The PanCareLIFE Consortium and the International Late Effects of Childhood Cancer Guideline Harmonization Group reviewed the literature and developed a clinical practice guideline that provides recommendations for ongoing communication methods for fertility preservation for patients who were diagnosed with childhood, adolescent, and young adult cancer at age 25 years or younger and their families. Moreover, the guideline panel formulated considerations of the ethical implications that are associated with these procedures. Grading of Recommendations Assessment, Development and Evaluation methodology was used to grade the evidence and recommendations. In this clinical practice guideline, existing evidence and international expertise are combined to develop transparent recommendations that are easy to use to facilitate ongoing communication between health-care providers and patients with childhood, adolescent, and young adult cancer who might be at high risk for fertility impairment and their families.

Presence of Germ Cells in Disorders of Sex Development: Implications for Fertility Potential and Preservation

PURPOSE

We sought to determine the presence of germ cells in the gonads of patients with disorders of sex development to establish whether preservation of germ cells for future fertility potential is possible. We hypothesized that germ cells are present but vary by age and diagnosis.

MATERIALS AND METHODS

We reviewed histology from patients with disorders of sex development who underwent gonadectomy/biopsy from 2002 to 2014 at a single institution for pathological classification of the gonad, composition of gonadal stroma and germ cell presence.

RESULTS

A total of 44 patients were identified and germ cells were present in 68%. The presence and average number of germ cells per mm² were analyzed by gonad type and diagnosis. By gonad type all ovotestes, most testes, ovaries and dysgenetic testes, and 15% of streak gonads had germ cells present. By diagnosis germ cells were present in all patients with complete androgen insensitivity syndrome, Denys-Drash syndrome, SRY mutation, mixed gonadal dysgenesis, ovotesticular conditions and StAR (steroid acute regulatory protein) deficiency, in some patients with persistent müllerian duct syndrome, XO/XY Turner syndrome and disorders of sex development not otherwise specified, and in none with complete or partial gonadal dysgenesis. Germ cells were present in the gonads of 88% of patients 0 to 3 years old, 50% of those 4 to 11 years old and 43% of those older than 12 years.

CONCLUSIONS

Germ cells were present in the majority of our cohort and the presence decreased with age. This novel, fertility driven evaluation of germ cell quantity in a variety of disorders of sex development suggests that fertility potential may be greater than previously thought. Further studies must be done to evaluate a larger population and examine germ cell quality to determine the viability of these germ cells.

Fertility-preserving measures for boys and young men with cancer

BACKGROUND

Some types of cancer treatment entail a risk of reduced fertility and infertility. Fertility-preserving treatment can reduce the risk for some. The purpose of this article is to provide an overview of the risk of infertility after treatment of boys and young men with cancer and of fertility-preserving measures.

MATERIAL AND METHODS

The article is based on literature searches in the medical databases Medline, Pubmed and Scopus and on the experience of a Nordic medical network collaboration.

RESULTS

Cryopreservation of sperm is an established method for adult cancer patients in Norway. Vibratory stimulation of the penis and electroejaculation with subsequent freezing of sperm may be an option for young cancer patients who cannot manage to produce a semen sample with the aid of masturbation. Freezing of testicular biopsies may be an option for prepubertal boys who are not capable of producing mature sperm.

INTERPRETATION

There are established methods for cryopreservation of sperm for adult cancer patients. The other fertility-preserving measures for boys and young men with cancer are regarded as experimental at present.