The effect of cancer treatment on female fertility and strategies for preserving fertility

A novel bioprinted microtumour model for studying acute-leukemia-cell- contaminated in ovarian tissue

Microtumor models, combining cancer and stromal cells within 3D hydrogels, are vital for testing anticancer therapies. Bioprinting hydrogel scaffolds allows tailored in vitro models. We created a 3D microtumor model using a bioprinter, with varying ratios of ovarian stromal cells and leukemia cells (HL-60). PEGylated fibrinogen and alginate hydrogel were used. Cell dynamics and proliferation were assessed via immunofluorescence staining. Microtumors with different HL-60 ratios (1:1, 1:10, 1:100) were cultured for 5 days. Results showed tumor development modulation by cell ratios and culture time. A significant cell density increase occurred in 1:1 ratio microtumors, indicating rapid cancer cell proliferation. No HL-60 cells were found in 1:100 ratio microtumors by day 5. The 1:10 ratio closely mimicked leukemia invasion in ovarian tissue, showing detectable cancer cells by days 3 and 5 without altering total cell density dynamics significantly. This bioprinted leukemia microtumor model offers better physiological relevance than 2D assays, promising applications in cellular analysis and drug screening.

Optimizing Decellularization of Bovine Ovarian Tissue: Toward a Transplantable Artificial Ovary Scaffold with Minimized Residual Toxicity and Preserved Extracellular Matrix Morphology

INTRODUCTION

The decellularized extracellular matrix (dECM) from ovarian tissue could be the best scaffold for the development of a transplantable artificial ovary. Typically, dECM from ovarian tissue has been obtained using sodium dodecyl sulfate (SDS), at a concentration of 1% for 24 h. However, SDS can leave residues in the tissue, which may be toxic to the seeded cells. This study aimed to obtain dECM from bovine ovarian tissue using SDS and NaOH at a minimum concentration in the shortest incubation time.

METHODS

The respective SDS and NaOH concentrations investigated were 1% and 0.2 m; 0.5% and 0.1 m; 0.1% and 0.02 m; and 0.05% and 0.01 m, with 24-, 12-, and 6-h incubation periods. After the incubation time, the tissue was washed in 50 mL of distilled water for 6 h.

RESULTS

Histological analysis confirmed decellularization and showed the conservation of collagen fibers in all samples following treatment. Furthermore, the lowest SDS and NaOH concentrations that showed no DNA remaining during electrophoresis analysis were 0.1% and 0.02 m when incubated for 24 and 12 h. DNA quantification resulted in <0.2 ng DNA/mg ovarian tissue using these protocols. Additionally, the coculture of dECM (obtained by 0.1% SDS and 0.02 m NaOH for 12 h) with ovarian cells showed that there was no toxic effect for the cells for up to 72 h.

CONCLUSION

The protocol involving 0.1% SDS and 0.02 m NaOH for 12-h incubation decellularizes bovine ovarian tissue, generating a dECM that preserves the native ECM morphology and is nontoxic to ovarian cells.

Low dose rate radiation impairs early follicles in young mice

Low-dose radiation is generally considered less harmful than high-dose radiation. However, its impact on ovaries remains debated. Since previous reports predominantly employed low-dose radiation delivered at a high dose rate on the ovary, the effect of low-dose radiation at a low dose rate on the ovary remains unknown. We investigated the effect of low-dose ionizing radiation delivered at a low dose rate on murine ovaries. Three- and ten-week-old mice were exposed to 0.1 and 0.5 Gy of radiation at a rate of 6 mGy/h and monitored after 3 and 30 days. While neither body weight nor ovarian area showed significant changes, ovarian cells were damaged, showing apoptosis and a decrease in cell proliferation after exposure to 0.1 and 0.5 Gy radiation. Follicle numbers decreased over time in both age groups proportionally to the radiation dose. Younger mice were more susceptible to radiation damage, as evidenced by decreased follicles in 3-week-old mice after 30 days of 0.1 Gy exposure, while 10-week-old mice showed reduced follicles only following 0.5 Gy exposure. Primordial or primary follicles were the most vulnerable to radiation. These findings suggest that even low-dose radiation, delivered at a low dose rate, can adversely affect ovarian function, particularly in the early follicles of younger mice.

Banking on Fertility Preservation: Financial Concern for Adolescent and Young Adult Cancer Patients Considering Oncofertility Services

Purpose: Financial concern is a major issue for adolescent and young adult (AYA) cancer patients. Furthermore, unaddressed oncofertility challenges (e.g., infertility) are linked to psychological distress and decreased overall quality of life. Little is known about how financial concern in terms of oncofertility (i.e., concern regarding affording fertility preservation [FP] services) impacts AYAs' decision making and experiences. Methods: AYA cancer patients (n = 27) aged 12-25 years whose cancer treatment conferred risk of infertility were recruited through electronic health record query. Participants completed semi-structured interviews, which were recorded, transcribed, and deductively coded for themes related to information needs, knowledge of treatment effects on fertility, and reproductive concerns after cancer. Emergent, inductive themes related to financial concern were identified. The Institutional Review Board at the University of Michigan approved this study (HUM#00157267). Results: Financial concern was a dominant theme across the qualitative data. Emergent themes included (1) varied access to health insurance, (2) presence of parental/guardian support, (3) reliance upon financial aid, (4) negotiating infertility risk, and (5) lack of preparation for long-term costs. AYAs relied heavily upon parents for out-of-pocket and insurance coverage support. Some participants sought financial aid when guided by providers. Several participants indicated that no financial support existed for their circumstance. Conclusions: Financial consequences in terms of oncofertility are a major issue affecting AYA cancer patients. The incidence and gravity of financial concern surrounding affording oncofertility services merits attention in future research (measuring financial resources of AYAs' parental/support networks), clinical practice (strategically addressing short- and long-term costs; tailored psychosocial support), and health care policy (promoting legislation to mandate pre- and post-treatment FP coverage).

Laparoscopic ovarian transposition prior to pelvic radiation in young women with anorectal malignancies: a systematic review and meta-analysis of prevalence

AIM

Young women undergoing radiotherapy (RT) for pelvic malignancies are at risk of developing premature ovarian insufficiency. Ovarian transposition (OT) aims to preserve ovarian function in these patients. However, its role in anorectal malignancy has yet to be firmly established. The aim of this review was to determine the effectiveness of laparoscopic OT in preserving ovarian function in premenopausal women undergoing neoadjuvant pelvic RT for anorectal malignancies.

METHODS

MEDLINE, Embase and CENTRAL were systematically searched from inception through to May 2022. Articles were included if they evaluated ovarian function after OT in women with anorectal malignancies undergoing pelvic RT. The primary outcome was ovarian function preservation. The secondary outcome was 30-day postoperative morbidity following OT.

RESULTS

From 207 citations, 10 studies with 133 patients with rectal or anal cancer who underwent OT prior to RT were included. Meta-analysis of pooled proportions of preserved ovarian function demonstrated an incidence of 66.9% (95% CI 55.0-79.0%, I2  = 43%). The 30-day postoperative morbidity rate was 1.2% (n = 1). There was heterogeneity in interventions and outcome reporting.

CONCLUSIONS

Laparoscopic OT in premenopausal patients undergoing pelvic radiation for anorectal malignancies might be an effective technique at reducing ovarian exposure to RT. The meta-analyses must be interpreted within the context of clinical heterogeneity of the included studies. Further studies are required to fully investigate the outcomes of OT in patients undergoing pelvic radiation for anorectal malignancies.

Capturing the lived experiences of women with lymphoma in pregnancy: a qualitative study

Lymphoma in pregnancy is a rare and challenging diagnosis that complicates ∼1:6000 pregnancies; posing a series of unique therapeutic, social, and ethical challenges to the patient, her family, and the medical professionals involved. These difficulties are compounded by the paucity of real-world data on the management of LIP, and a lack of relevant support systems for women in this setting. We conducted a retrospective multicenter qualitative study, interviewing women aged ≥18 years of age diagnosed with Hodgkin (HL) or non-Hodgkin lymphoma (NHL) during pregnancy or within 12 months postpartum, between 1 January 2009 and 31 December 2020 from 13 Australasian sites. Semi-structured telephone interviews were conducted, recorded, and analyzed using QSR Int NVivo 12 Pro (March 2020, USA) to quantify salient themes. Of the 32 women interviewed, 20 (63%) were diagnosed during pregnancy (16, 34, and 13% in the 1st, 2nd, and 3rd trimesters, respectively), while 12 (37%) were diagnosed post-partum. Women recalled that their chief concerns at diagnosis were the welfare of their child (n = 13, 41%) and a fear of dying (n = 9, 28%). Perceived diagnostic delay attributed to pregnancy was reported by 41% of participants. Other key themes were communication, educational materials, psychosocial supports, and oncofertility issues. To our knowledge this is the first report capturing the lived experiences of survivors of lymphoma during pregnancy, affording a unique opportunity to consider the management, psychosocial supports, and delivery of care to meet the needs of these women.What is the NEW aspect of your work? To our knowledge, this is the first report capturing and analyzing the healthcare experiences of survivors of Lymphoma in Pregnancy (LIP).What is the CENTRAL finding of your work? Women valued clear and empathic communication, provision of tailored educational materials, access to psychosocial supports (particularly childcare and financial supports), and timely oncofertility management in their healthcare journey.What is (or could be) the SPECIFIC clinical relevance of your work? Women's personal accounts of positive and negative experiences of LIP care provide insights into their specific concerns and needs which can shape healthcare policy and development of a specific framework for managing and supporting patients with LIP (and other cancers).

Oncofertility care and influencing factors among cancer patients of reproductive age from Saudi Arabia

Background

More cancer survivors and a greater burden of long-term side effects have resulted from rising cancer incidence, improved treatment modalities, and younger age at cancer diagnosis. Treatment- related Infertility (TRI) is a well-known sequelae. This study looked at current oncofertility support and fertility preservation (FP) in men and women of reproductive age with cancer in Saudi Arabia, where there is little knowledge on the subject.

Methods

A cross-sectional study included oncology patients of reproductive age from an academic hospital was conducted. Patients' characteristics, cancer type, treatment modalities and assessment of oncofertility support data were collected and examined to assess oncofertility support and potentially influencing factors.

Results

Our study included 135 patients (39.3% males and 60.7% females). Although 66.7% believed they were fertile at the time of diagnosis, and more than half planned to have children in the future, Unfortunately, only 37.8% have received fertility counseling, and only 17% have seen a fertility specialist. In male patients, the most common FP method was sperm cryopreservation (6.7%), while the majority of both genders (87.4%) did not use any FP method. Two-thirds of the patients are knowledgeable about TRI and FP methods. About half of the female patients (57.3%) were advised about the possibility of post-treatment amenorrhea while only 8.1% of the whole cohort received psychological support.

Conclusions

Despite patients' satisfactory knowledge of TRI and FP, oncologists infrequently referred their patients to a specialized fertility service. More than half of our patients expressed a desire to have children in the future, but this desire was impeded by limited oncofertility care and FP procedures. Several factors influenced the knowledge of TRI, fertility counseling and FP. It is critical to incorporate oncofertility into management planning as it has a significant impact on patients' quality of life.

Tissue Engineering in Gynecology

Female gynecological organ dysfunction can cause infertility and psychological distress, decreasing the quality of life of affected women. Incidence is constantly increasing due to growing rates of cancer and increase of childbearing age in the developed world. Current treatments are often unable to restore organ function, and occasionally are the cause of female infertility. Alternative treatment options are currently being developed in order to face the inadequacy of current practices. In this review, pathologies and current treatments of gynecological organs (ovaries, uterus, and vagina) are described. State-of-the-art of tissue engineering alternatives to common practices are evaluated with a focus on in vivo models. Tissue engineering is an ever-expanding field, integrating various domains of modern science to create sophisticated tissue substitutes in the hope of repairing or replacing dysfunctional organs using autologous cells. Its application to gynecology has the potential of restoring female fertility and sexual wellbeing.

Cryopreservation of oocytes and embryos for fertility preservation

Background: In recent years, the demand for fertility preservation for both oncologic and nononcologic reasons, as well as for personal reasons, has increased dramatically.Current Concepts: Currently, embryo and oocyte cryopreservation after ovarian stimulation are the mainstays of fertility preservation treatment in women. Embryo cryopreservation is an established and the most successful method of fertility preservation when sufficient time (approximately 2 weeks) is available to perform ovarian stimulation. Recent advances in freezing techniques (vitrification) have significantly improved the outcomes from oocyte cryopreservation that are comparable with those from embryo cryopreservation.Discussion and Conclusion: This review focuses on the indications for the two techniques of fertility preservation and their results. For women to receive timely opportunities to preserve fertility, it is necessary to raise awareness among all medical departments and the public.

"Queer Insights": Considerations and Challenges for Assessing Sex, Gender Identity, and Sexual Orientation in Oncofertility Research

This article addresses issues related to clinical and research approaches to oncofertility for adolescent and young adult (AYA) sexual and gender minority (SGM) cancer patients. Limited attention has been dedicated to understanding the extent to which oncofertility services are appropriately and equitably delivered to AYAs with diverse orientations toward sexual orientation, gender identity, and future family. Unresolved challenges to conducting research with this vulnerable population perpetuate a lack of adequate knowledge about SGM AYA oncofertility needs. Therefore, the purpose of this paper is to inform considerations of sex, gender identity, and sexual orientation for investigations that include SGM AYAs. In order to improve the knowledge base and clinical services for this population, we discuss (1) challenges to sampling this population; (2) categorization and survey logic (e.g., skip patterns) in light of fluid sexual orientation and gender identities; and (3) clinical implications of accurately assessing sex and gender for oncofertility research and practice. We also recommend strategies for producing inclusive and accurate assessments of sexual and gender identity categories in both research and clinical encounters with SGM AYAs. Incorporating "queer insights" into empirical research - that is, positioning queer theory at the center of oncofertility study design - is suggested as a future direction for oncofertility research and practice.

Post-Operative Functional Outcomes in Early Age Onset Rectal Cancer

BACKGROUND

Impairment of bowel, urogenital and fertility-related function in patients treated for rectal cancer is common. While the rate of rectal cancer in the young (<50 years) is rising, there is little data on functional outcomes in this group.

METHODS

The REACCT international collaborative database was reviewed and data on eligible patients analysed. Inclusion criteria comprised patients with a histologically confirmed rectal cancer, <50 years of age at time of diagnosis and with documented follow-up including functional outcomes.

RESULTS

A total of 1428 (n=1428) patients met the eligibility criteria and were included in the final analysis. Metastatic disease was present at diagnosis in 13%. Of these, 40% received neoadjuvant therapy and 50% adjuvant chemotherapy. The incidence of post-operative major morbidity was 10%. A defunctioning stoma was placed for 621 patients (43%); 534 of these proceeded to elective restoration of bowel continuity. The median follow-up time was 42 months. Of this cohort, a total of 415 (29%) reported persistent impairment of functional outcomes, the most frequent of which was bowel dysfunction (16%), followed by bladder dysfunction (7%), sexual dysfunction (4.5%) and infertility (1%).

CONCLUSION

A substantial proportion of patients with early-onset rectal cancer who undergo surgery report persistent impairment of functional status. Patients should be involved in the discussion regarding their treatment options and potential impact on quality of life. Functional outcomes should be routinely recorded as part of follow up alongside oncological parameters.

Trainee-Led Quality Improvement Project to Improve Fertility Preservation Counseling for Patients With Cancer

PURPOSE

Oncofertility counseling regarding the reproductive risks associated with cancer therapy is essential for quality cancer care. We aimed to increase the rate of oncofertility counseling for patients of reproductive age (18-40 years) with cancer who were initiating systemic therapy at the Johns Hopkins Cancer Center from a baseline rate of 37% (25 of 68, June 2019-January 2020) to 70% by February 2021.

METHODS

We formed an interprofessional, multidisciplinary team as part of the ASCO Quality Training Program. We obtained data from the electronic medical record and verified data with patients by phone. We surveyed patients, oncologists, and fertility specialists to identify barriers. After considering a prioritization matrix, we implemented Plan-Do-Study-Act (PDSA) cycles.

RESULTS

We identified the following improvement opportunities: (1) oncologist self-reported lack of knowledge about counseling and local fertility preservation options and (2) lack of a standardized referral mechanism to fertility services. During the first PDSA cycle (February 2020-August 2020, disrupted by COVID-19), we introduced the initiative to increase oncofertility counseling at faculty meetings. From September 2020 to November 2020, we implemented a second PDSA cycle: (1) educating and presenting the initiative at Oncology Grand Rounds, (2) distributing informative pamphlets to oncologists and patients, and (3) implementing an electronic medical record order set. In the third PDSA cycle (December 2020-February 2021), we redesigned the order set to add information (eg, contact information for fertility coordinator) to the patient after-visit summary. Postimplementation (September 2020-February 2021), counseling rates increased from 37% to 81% (38 of 47).

CONCLUSION

We demonstrate how a trainee-led, patient-centered initiative improved oncofertility care. Ongoing work focuses on ensuring sustainability and assessing the quality of counseling.

Practices, Attitudes, and Knowledge Among Healthcare Providers and Oncologists in China Regarding Male Fertility Preservation

Objective

The purpose of this study was to help to promote a better understanding of the male fertility preservation status in China.

Methods

In this cross-sectional survey, 1,912 healthcare providers and oncologists were surveyed anonymously using 16 questions carried out at community oncology practices in China from September 2018 to April 2021. 16 questions were designed to evaluate their knowledge on male fertility preservation in cancer patients, assess the factors they considered when deciding whether to discuss male fertility preservation with their patients.

Results

Among the 1,912 healthcare providers (42.2% male), 1,713 (89.6%) considered that patients with cancer should be recommended for fertility preservation. 1,264 (66.1%) respondents were aware of male fertility preservation, but only 248 (13.0%) respondents knew the correct institutions. Whether a healthcare provide recommended fertility preservation to their patients depended on the provider's educational background, professional qualifications, hospital grade, area, department, and age. Among the healthcare providers, the three main factors for not recommending fertility preservation for patients with cancer were lack of suitability of the patient for fertility (28.2%), lack of knowledge of fertility preservation (28.6%), and lack of knowledge concerning the institutes that provide fertility preservation (25.4%).

Conclusion

Despite this, healthcare providers and oncologists in China showed a positive attitude toward fertility preservation in patients with cancer. Hence, the education of physicians should include fertility preservation, with the aim of increasing their knowledge and awareness. There should be more collaboration between oncologists and reproductive medicine specialists.

Factors Associated With Premature Ovarian Insufficiency in Young Women With Locally Advanced Rectal Cancer Treated With Pelvic Radiation Therapy

Purpose

Pelvic radiation therapy (RT) is standard of care for patients with locally advanced rectal cancer (LARC). Premature ovarian insufficiency (POI) in premenopausal women is a possible side effect. The purpose of our study was to evaluate factors associated with POI in women younger than 50 years, treated with pelvic RT for LARC, including those who underwent ovarian transposition (OT).

Methods and Materials

We retrospectively reviewed the records of women younger than 50 years treated with pelvic RT for LARC at our institution between 2001 and 2019. Clinical and hormonal data were used to determine ovarian function. The ovaries and uterus were contoured and dose volume histograms were generated. Association of clinical and dosimetric factors with POI within 12 months of RT was evaluated using Wilcoxon-rank sum test and Fisher's exact test.

Results

We identified 76 premenopausal women at time of RT with median age of 43 years (range, 20-49). Twenty-six women (34%) underwent OT. Neoadjuvant, concurrent, and adjuvant chemotherapy was administered in 56 (74%), 69 (91%), and 26 (34%) women, respectively. Median RT dose was 50 Gy/25 fractions. Among 75 women with 12 months of follow-up, 25% had preservation of ovarian function, all in the OT group. Ovarian function was preserved in 19 (76%) women who underwent OT. The median of ovarian mean dose was 1.7 Gy in the OT group versus 44.8 Gy in the non-OT group (P < .001). OT and age at RT were significantly associated with POI (P < .001). No patient with ovarian mean dose less than 1.36 Gy developed POI.

Conclusions

OT was significantly associated with reduced risk of POI by enabling lower radiation doses to the ovaries. OT should be considered in young patients undergoing pelvic RT. Although there appears to be a significant association between ovarian mean dose and POI, larger studies are needed to find a dosimetric threshold. Our results suggest keeping the dose to the ovaries as low as reasonably achievable in patients who undergo OT and pelvic RT.

Cervical Cancer Mortality in Romania: Trends, Regional and Rural–Urban Inequalities, and Policy Implications

Background and Objectives: Despite being largely preventable, cervical cancer mortality still remains an important public health problem globally, in Europe, and in Romania. The European Union member states are urged to implement systematic, population-based screenings for cervical cancer, but the programs developed by the countries remain very heterogeneous. This study aimed to investigate the differences in cervix cancer mortality between Romania and EU and within Romania over the last two decades and to reveal the major sources of inequalities and the policy implications. Materials and Methods: We analyzed the number of deaths and the mortality rates by cervical cancer, standardized using the direct method, over two decades (2001–2016 for the EU, and 2001–2019 for the national and sub-national analyses). Trends, mortality reduction over the years, and mortality differences at the beginning and end of the time interval have been calculated for the EU and Romania, at national and sub-national levels (rural–urban and regions). Results: Our results revealed differences in cervical cancer mortality between Romania and EU and within Romania (among regions and rural–urban areas). These differences used to be very high in the past and are still persisting. Conclusions: The country should revisit its national cervical cancer screening program, which has been implemented for many years, but with a very limited participation rate. Due to the similar problems existing in Central-Eastern Europe, targeted support from the EU for the members from this geographical area could contribute to the minimization of differences in cervical cancer mortality among the EU members.

Adult cancer patients and parents of younger cancer patients have little information about fertility preservation: a survey of knowledge and attitude

Background

Impaired fertility is one of the side effects of effective cancer therapy. Saving the potential or storing the material to enable people to have biological children after cancer treatment can be of high importance to many cancer survivors. Therefore, we designed a study to determine knowledge and attitudes to fertility preservation (FP) in adult cancer patients and the parents of patients with cancer. Participants who completed this survey were a convenience sample of 384 parents of cancer patients < 18 years and cancer patients ≥ 18 years from two large referral hospitals. A 25-item self-administered questionnaire measured knowledge and attitudes to FP. Responses were yes/no, or on a 4-point Likert scale (greatly, usually, rarely, never) scored from 1 for never to 4 for greatly.

Results

Most parents and most cancer patients were unaware of the FP methods of embryo cryopreservation (96.3% and 88.4%, respectively) and sperm cryopreservation (97.5% and 89.0%, respectively). Attitudes among cancer patients and parents to use of FP options, based on a 4-point Likert scale, were determined by financial cost, lack of access and information on FP options.

Conclusion

Of concern in this sample of Iranian adult cancer patients and their parents is that knowledge of the fertility risk associated with cancer therapy and knowledge of FP treatment options was generally poor, particularly among the parents. To enable cancer patients or their parents to make the best decisions about using FP services, oncologists and fertility specialists should discuss FP options during their consultation.

Cancer during pregnancy: A qualitative study of healthcare experiences of Australian women

OBJECTIVES

To identify features enhancing the quality of healthcare experiences for women with gestational cancer, and explore the impact of the heterogeneous Australian healthcare system on those experiences.

METHODS

Semi-structured, qualitative interviews were conducted with women diagnosed with any cancer during pregnancy in the last five years. Recruitment occurred during 2018-2019 via social media and professional, clinical and community networks. Questions related to women's experiences of their healthcare, wellbeing and psychosocial needs. Interviews were analysed thematically.

RESULTS

Study participants (n = 23) received treatment in the private sector (n = 10), public sector (n = 8), or both (n = 5). Five interview themes were found: Control over healthcare; Trust in clinicians, hospitals and systems; Coordination of care; An uncommon diagnosis; Holistic, future-oriented care. Women were most likely to have had a positive healthcare experience when (a)care was well-coordinated and adjusted to meet their unique needs/challenges, and (b)women perceived their care went beyond their immediate medical needs and encompassed future psychosocial wellbeing, including preparation for postpartum challenges.

CONCLUSION

Existing 'usual care' in the public and/or private sector for both the pregnancy and the cancer is insufficient to meet these women's needs. Prioritising psychological wellbeing including psychosocial needs, and communication and planning around fertility and postnatal challenges are essential for this population.

The Effects of Negative Elements in Environment and Cancer on Female Reproductive System

With the development of human society, factors that contribute to the impairment of female fertility is accumulating. Lifestyle-related risk factors, occupational risk factors, and iatrogenic factors, including cancer and anti-cancer treatments, have been recognized with their negative effects on the function of female reproductive system. However, the exact influences and their possible mechanism have not been elucidated yet. It is impossible to accurately estimate the indexes of female fertility, but many researchers have put forward that the general fertility has inclined through the past decades. Thus the demand for fertility preservation has increased more and more dramatically. Here we described some of the factors which may influence female reproductive system and methods for fertility preservation in response to female infertility.

Practical consensus recommendations on fertility preservation in patients with breast cancer

Young women diagnosed with cancer today have a greater chance of long-term survival than ever before. Successful survivorship for this group of patients includes maintaining a high quality of life after a cancer diagnosis and treatment; however, lifesaving treatments such as chemotherapy, radiation, and surgery can impact survivors by impairing reproductive and endocrine health. Expert oncologists along with reproductive medicine specialists discuss fertility preservation options in this chapter since fertility preservation is becoming a priority for young women with breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Extracellular vesicles miRNA-21: a potential therapeutic tool in premature ovarian dysfunction

Chemotherapy induces an irreversible premature ovarian dysfunction (POD). Amniotic fluid mesenchymal stem cells (AFMSCs) can rescue fertility; however, the notion that stem cells can rejuvenate follicles is highly controversial due to the predetermined ovarian reserve. This study aims to isolate AFMSC-derived extracellular vesicles (EVs) and investigate their abundancy for the anti-apoptotic miRNA-21 as a means of ovarian restoration. Female rats were divided into healthy controls and POD-induced groups. The POD induced groups were subdivided into three groups according to the therapies they received: placebo-treated POD, AFMSC and EVs groups. Rats were assessed for serum anti-Müllerian hormone (AMH) levels, ovarian caspase 3 and PTEN protein levels in the ovarian lysate. Total follicular counts (TFCs) were estimated from stained ovarian sections. Functional recovery was investigated through daily vaginal smears and mating trials. In vitro chemical transfection of the AFMSCs with selective miRNA-21 mimics/inhibitors followed by isolation of EVs for therapy was conducted in two additional groups. At the interval points studied, treatment with AFMSCs and EVs equally restored TFC, AMH levels, regular estrous cycles and fruitful conception, while it both diminished caspase 3 and PTEN levels. EVs carrying miRNA-21 mimics recapitulated the short-term effects. Placebo-treated POD or EVs carrying miRNA-21 inhibitors showed augmented ovarian follicular damage demonstrated the low AMH levels, TFC and high levels of PTEN and caspase 3. miRNA-21 allowed regeneration by modulating PTEN and caspase 3 apoptotic pathways. Our findings exemplify that EVs could serve as an innovative cell-free therapeutic tool functioning through their miRNA content and that miRNA-21 has a chief regenerative role through modulating PTEN and caspase 3 apoptotic pathways.

Information Needs About Cancer Treatment, Fertility, and Pregnancy: Qualitative Descriptive Study of Reddit Threads

BACKGROUND

A reproductive health implication of the increasing incidence of cancer among women is the impact of cancer treatment on fertility.

OBJECTIVE

As patients are increasingly using the internet, particularly online forums, to seek and share experiences, our objective was to understand information needs about cancer treatment, fertility, and pregnancy of women with cancer as well as their caregivers.

METHODS

We searched threads (original posts and responses) on four subreddit sites of Reddit ("r/Cancer," "r/TryingForABaby," "r/BabyBumps," and "r/Infertility") over a 5-year period between February 4th, 2014 and February 4th, 2019. Threads with original posts involving a lived experience or question regarding cancer treatment and female fertility and/or pregnancy or parenting/having children from the perspective of either patient or caregiver were included in our analysis. We analyzed threads using thematic analysis.

RESULTS

From 963 Reddit threads identified, 69 were analyzed, including 56 with original posts by women with cancer and 13 with original posts by caregivers. From threads made by patients, we identified themes on becoming a part of an online community, impacts of cancer treatment and fertility concerns on self and social relationships, making family planning decisions, and experiences with medical team. We also identified a theme on the impact of cancer treatment and fertility concerns on caregivers.

CONCLUSIONS

Reddit provided a rich pool of data for analyzing the information needs of women facing cancer. Our findings demonstrate the far-reaching impacts of cancer treatment and fertility on physical, mental, and psychosocial health for both patients and their caregivers.

Successful Full-term Pregnancies After High-dose Pelvic Radiotherapy for Ewing Sarcoma: A Case Report

Survivors of childhood cancer are at risk of long-term sequelae that arise as a consequence of cancer treatment. Radiation and chemotherapy treatment in pediatric female patients can have detrimental impacts on fertility, particularly in those with pelvic tumor involvement. We report 2 successful natural full-term pregnancies with vaginal delivery in a woman 12 years after biopsy, irradiation (55.5 Gy), and multi-agent chemotherapy for treatment of pelvic Ewing sarcoma. Both children were born healthy, with no complications in pregnancy or delivery. Fertility preservation and risk assessment following chemotherapy/radiation therapy is evolving, providing new data to effectively counsel and treat young women.

Protective effect of curcumin on busulfan-induced renal toxicity in male rats

AIM

The aim of this study was to evaluate the effects of curcumin in an experimental model of busulfan-induced renal toxicity with emphasis on importance of histological alterations.

METHODS

In this study, we utilized 32 adult male Wistar rats (250 ± 10 g). All the animals were divided into four experimental groups randomly: (I) Control; (II) Busulfan (40 mg/kg); (III) Olive oil; and (IV) Curcumin (80 mg/kg/day). Finally, the rats were euthanized and kidney tissues were taken for histopathology experiments, serum BUN, and creatinine level, reactive oxygen species (ROS) production and glutathione disulfide (GSH) activity.

RESULTS

Our result showed that the reduction in body weight and kidney weight in busulfan groups in comparison with the control and curcumin groups. The result in this study also showed that the reduction in BUN, creatinine, and ROS production in curcumin groups in comparison with the busulfan group together with an increasing of GSH activity compared to busulfan induced rats.

CONCLUSION

Our results of this study indicated that that the reduction in body weight, kidney weight, total volume of kidney, total length of nephron tubules, and numerical density of glomeruli and nephron tubules in busulfan groups in comparison with the control and curcumin groups However, curcumin can be an alternative choice for therapeutically and research purposes in the disturbing kidney after treatment with busulfan.

Lymphoma Occurring During Pregnancy: Current Diagnostic and Therapeutic Approaches

PURPOSE OF REVIEW

Pregnancy-associated lymphoma (PAL) is an uncommon entity that lacks detailed prospective data. It poses significant management challenges that incorporate maternal and fetal risks associated with treatment or delayed intervention. Herein, we review the current literature for the diagnosis, management, and supportive care strategies for PAL.

RECENT FINDINGS

Establishment of a multidisciplinary team, including hematology-oncology, maternal-fetal medicine, and neonatology, is critical in the management of PAL. For staging, ultrasound and MRI are preferred modalities with use of computerized tomography in select situations. Data for the safety and effectiveness of therapy for PAL is largely based on retrospective studies. The timing of lymphoma-directed antenatal systemic therapy depends on the trimester, gestational age, lymphoma subtype and aggressiveness, and patient wishes. Therapy in the first trimester is usually not advocated, while treatment in the second and third trimesters appears to result in similar outcomes for PAL compared with non-pregnant patients with lymphoma. An overarching goal in most PAL cases should be to plan for delivery at term (i.e., gestational age > 37 weeks). For supportive care, most antiemetics, including agents such as neurokinin-1 receptor antagonists, have been used safely during pregnancy. For prevention or treatment of infections, particular antibiotics (i.e., macrolides, cephalosporins, penicillins, metronidazole), antivirals (i.e., acyclovir, valacyclovir, famciclovir), and antifungals (amphotericin B) have demonstrated safety and with use of growth factors reserved for treatment of neutropenia (vs. primary prophylaxis). Therapy for PAL should be individualized with goals of care that balance maternal and fetal well-being, which should include a multidisciplinary care team and overall intent for term delivery in most cases.

Quality of life and fertility preservation counseling for women with gynecological cancer: an integrated psychological and clinical perspective

Purpose: Relational and sexual problems are frequent in patients with a diagnosis of gynecological cancer, because this disease has a strong negative impact on female identity and sexuality. Psychological and sexual functioning is affected by inauspicious diagnosis. Furthermore, therapies may compromise reproductive function. The aim of this study is to propose a general overview on the impact of gynecological cancer on quality of life and psychological and sexual functioning, as well as on the importance of adequate counseling related to fertility preservation techniques.Materials and methods: We provide a narrative overview of the recent literature about quality of life and fertility preservation counselling in women with gynecological cancer.Results and conclusions: According to recent studies, 75% of women between 18 and 45 years with a diagnosis of cancer wish to have children. When cancer affects the reproductive system, the psychological distress is even stronger because there is a loss of menstrual function and fertility. Currently, fertility preservation techniques in women with gynecological cancer are beneficial and lead to an improvement in the quality of life.

Preservation of Childbearing Potential in Cancer Survivors: a Survey of Gynecologists' and Embryologists' Current Knowledge, Attitude, and Practice

Cancer is one of the life-threatening diseases, and cancer therapy may produce severe side effects such as impaired fertility. Saving childbearing potential after cancer treatment is of high importance to cancer survivors. This study assessed gynecologists' and embryologists' current practice, knowledge, and attitude concerning fertility preservation (FP) in cancer survivors. This current survey was performed on a convenience sample of 277 gynecologists and embryologists who attended large international congresses held across Iran. A 23-item self-administered questionnaire that included questions on knowledge, attitudes, and practice was used. Questions had either yes/no responses, or were answered based on a 4-point (1 to 4) Likert scored scale. Total mean score for knowledge of all FP options was 2.97 ± 0.62. Total mean scores for knowledge of all FP options in gynecologists and embryologists were 3.03 ± 0.65 and 2.95 ± 0.61, respectively (p = 0.33). These scores were above the median value of 2.5 obtained using the 4-point Likert scale. Participants regarded the patient age as the most important reason for discussing FP with patients (mean scores 3.74 ± 0.71 and 3.73 ± 0.52 for gynecologists and embryologists, respectively; p = 0.93). The majority of the participants (i.e., 95.2% (79 gynecologists) and 92.2% (166 embryologists)) referred cancer patients to centers providing FP services (p = 0.15). This sample of Iranian gynecologists and embryologists had considerable information on FP methods to develop appropriate attitudes and practices in relation to FP for cancer patients in order to prevent loss of fertility.

The impact of vaccination on gender equity: conceptual framework and human papillomavirus (HPV) vaccine case study

BACKGROUND

Although the beneficial effects of vaccines on equity by socioeconomic status and geography are increasingly well-documented, little has been done to extend these analyses to examine the linkage between vaccination and gender equity. In this paper, evidence from the published literature is used to develop a conceptual framework demonstrating the potential impact of vaccination on measures of gender equity. This framework is then applied to human papillomavirus (HPV) vaccination in three countries with different economic and disease burden profiles to establish a proof of concept in a variety of contexts.

METHODS

We conducted a literature review examining evidence on the linkage between health outcomes and dimensions of gender equity. We utilized the Papillomavirus Rapid Interface for Modelling and Economics (PRIME) model to estimate cervical cancer incidence and deaths due to HPV types 16/18 by age in each country. We estimated labor force participation and fertility effects from improvements in health, and converted these into inputs consistent with those used to calculate the United Nations Gender Inequality Index to assess gender equity.

RESULTS

In our case study, we found that HPV vaccination among girls could help narrow socioeconomic gender disparities by quantifying the main pathways by which HPV vaccination improves health, which enables improvement in gender equity indicators such as labor force participation and maternal mortality ratios. While these improvements are small when averaged over the entire population, the components measured - labor force participation and maternal mortality ratio - account for 50% of the index scores.

CONCLUSIONS

This proof of concept model is a starting point to inform future health and economic analyses that might incorporate the impact of gender equity as an additional impact of vaccination in improving the health and well-being of the population.

Neoadjuvant chemotherapy plus surgery versus concurrent chemoradiotherapy in stage IB2-IIB cervical cancer: A systematic review and meta-analysis

The optimal treatment strategy for stage IB2-IIB cervical cancer is controversial. This systematic review with meta-analysis evaluated the efficacy of concomitant chemoradiotherapy (CCRT) and neoadjuvant chemotherapy followed by radical surgery (NACT+S). Studies that evaluated NACT+S versus CCRT for patients with Federation of Gynecology and Obstetrics stage IB2-IIB cervical cancer were searched in MEDLINE, EMBASE, and the Cochrane Library database. Hazard ratios (HRs) with their respective 95% confidence intervals (CIs) were calculated using a random-effects model. Toxicity was also evaluated. Six qualified retrospective studies and one randomized controlled trial (2270 patients) were included in this review. The results suggested that compared with CCRT, NACT+S did not improve overall survival in all patients (HR 0.73, 95% CI 0.52-1.02) or stage IIB patients (HR 0.83, 95% CI 0.61-1.15). NACT+S did not improve disease-free survival (DFS) in stage IIB patients (HR 1.10, 95% CI 0.70-1.71). In the analysis of DFS in all patients, a high degree of heterogeneity was detected (I2 = 84%). Sensitivity analysis that eliminated these heterogeneous data suggested that CCRT could improve DFS over NACT+S (HR 1.47, 95% CI 1.12-1.93). Diarrhea and rectal and bladder complications occurred at a lower rate in the NACT+S group than in the CCRT group. NACT+S had no survival advantage for patients with stage IB2-IIB cervical cancer compared with CCRT but was associated with fewer side effects. Further prospective studies with a larger sample size of treatment protocols for locally advanced cervical cancer are needed.

Icariin exerts a protective effect against d-galactose induced premature ovarian failure via promoting DNA damage repair

Icariin is one of the most common active ingredients in traditional Chinese medicine, while its function against Premature ovarian failure (POF) has not been explored. POF animal model was induced by d-galactose, and icariin at different doses was administered. Ovarian structure and follicle counting were observed via hematoxylin and eosin staining. The levels of serum hormones were measured by ELISA. Primary ovarian granulosa cells were cultured to compare the protective effects of icariin on cell aging, and DNA damage markers including γH2AX and 53BP1 were assessed by Western Blot. Administration of icariin promoted ovary/body weight, follicles numbers and fertility outcomes. In addition, icariin downregulated the levels of follicle stimulating hormone and luteinizing hormone, and upregulated the levels of estradiol and anti-Müllerian hormone. Icariin protected ovarian granulosa cells from d-galactose induced aging, with increased cell viability and lower endogenous β-galactosidase activity. The alterations of expression level of γH2AX and 53BP1 by icariin indicated that the protection is via promoting DNA damage repair. In this study we tested the biological function of icariin against the d-galactose induced POF. Our results demonstrated that icariin effectively attenuated ovarian injury via promoting DNA damage repair, suggesting that icariin can be developed as a protective agent against POF.

Patterns of Referral for Fertility Preservation Among Female Adolescents and Young Adults with Breast Cancer: A Population-Based Study

Purpose: To assess the fertility preservation (FP) referral rates and patterns of newly diagnosed breast cancer in female adolescent and young adult (AYA) patients.

Methods: Women aged 15–39 years with newly diagnosed breast cancer in Ontario from 2000 to 2017 were identified using the Ontario Cancer Registry. Exclusion criteria included prior sterilizing procedure, health insurance ineligibility, and prior infertility or cancer diagnosis. Women with a gynecology consult between cancer diagnosis and chemotherapy commencement with the billed infertility diagnostic code (ICD-9 628) were used as a surrogate for FP referral. The effect of age, parity, year of cancer diagnosis, staging, income, region, neighborhood marginalization, and rurality on referral status was investigated.

Results: A total of 4452 patients aged 15–39 with newly diagnosed breast cancer met the inclusion criteria. Of these women, 178 (4.0%) were referred to a gynecologist with a billing code of infertility between cancer diagnosis and initiation of chemotherapy. Older patients, prior parity, and advanced disease were inversely correlated with referrals. Referral rates also varied regionally: patients treated in the south-east and south-west Local Health Integration Networks (LHINs) had the highest probability of referral, and patients covered by north LHINs had the lowest (central LHIN as reference). General surgeons accounted for 36.5% of all referrals, the highest percentage of all specialists. Referral rates significantly increased over time from 0.4% in 2000 to 10.7% in 2016.

Conclusion: FP referral rates remain low and continue to be influenced by patient demographics and prognosis. These findings highlight the need for further interdisciplinary coordination in addressing the fertility concerns of AYA with newly diagnosed breast cancers.

Reproductive Outcomes After a Childhood and Adolescent Young Adult Cancer Diagnosis in Female Cancer Survivors: A Systematic Review and Meta-analysis

Improvements in cancer therapy for childhood and adolescent and young adult (AYA) survivors have increased in excess of 80% among pediatric patients and in excess of 85% among AYA cancer patients. Our research group explored the late effects consequences of cancer treatment on pregnancy and birth outcomes subsequent to a childhood (0-14 years) or AYA (15-25 years) diagnosis of cancer in female cancer survivors. Embase and Medline databases were searched. There were 17 review (n = 10 matched and n = 7 unmatched) studies that met the inclusion criteria. Subanalyses were conducted on 10 matched studies. The median age for all studies for patients at diagnosis and birth was 11 and 27 years, respectively. In matched cohort studies, female childhood and AYA cancer patients, who received chemotherapy alone, had a pooled estimated rate of 18% of experiencing a live birth compared with 10% of females who received radiotherapy alone and subsequently had a live birth. Females who received surgery alone reported higher pooled estimated rates of 44% for a live birth. For matched retrospective review studies, 79% (n = 973) of women experienced a live birth, of which 22% of these babies were born preterm. This meta-analysis found lower birth rates for survivors. Access to fertility-related information and discussions around fertility preservation options and oncofertility psychosocial support should be offered to all cancer patients and their families before starting cancer treatment.

Triptorelin for Fertility Preservation in Adolescents Treated With Chemotherapy for Cancer

BACKGROUND

Triptorelin, a gonadotropin releasing hormone analogue, can be administered to postpubertal female individuals with cancer who receive chemotherapy to obtain menstrual suppression and decrease the risk of hemorrhage caused by thrombocytopenia. Our goal was to assess whether triptorelin also has a protective role against the gonadotoxicity of chemotherapy.

PATIENTS AND METHODS

This retrospective observational study includes all postmenarchal female patients who presented to our Unit from 2000 to 2015 and received chemotherapy for cancer. They were administered depot triptorelin. We evaluated long-term ovarian function in order to detect clinical signs of ovarian damage, miscarriages, and pregnancies. Laboratory follow-up consisted in dosing serum follicle stimulating hormone, luteinizing hormone, prolactin, estradiol, and progesterone. Ultrasound of the ovaries was performed as well.

RESULTS

Of 36 evaluable patients, 9 received hematopoietic stem cell transplantation (HSCT). The remaining 27 patients maintained normal ovarian function at clinical, laboratory, and ultrasound assessment. Five of them achieved spontaneous physiological pregnancy. Four of the 9 patients who underwent HSCT developed premature ovarian failure.

CONCLUSION

Our study suggests that gonadotropin releasing hormone-a administered during chemotherapy can prevent premature ovarian failure in patients treated without HSCT and that it is not enough to preserve the ovarian function during HSCT. Hence, a prospective randomized trial with a larger population would be recommended.

The DNA Damage Checkpoint Eliminates Mouse Oocytes with Chromosome Synapsis Failure

Pairing and synapsis of homologous chromosomes during meiosis is crucial for producing genetically normal gametes and is dependent upon repair of SPO11-induced double-strand breaks (DSBs) by homologous recombination. To prevent transmission of genetic defects, diverse organisms have evolved mechanisms to eliminate meiocytes containing unrepaired DSBs or unsynapsed chromosomes. Here we show that the CHK2 (CHEK2)-dependent DNA damage checkpoint culls not only recombination-defective mouse oocytes but also SPO11-deficient oocytes that are severely defective in homolog synapsis. The checkpoint is triggered in oocytes that accumulate a threshold level of spontaneous DSBs (∼10) in late prophase I, the repair of which is inhibited by the presence of HORMAD1/2 on unsynapsed chromosome axes. Furthermore, Hormad2 deletion rescued the fertility of oocytes containing a synapsis-proficient, DSB repair-defective mutation in a gene (Trip13) required for removal of HORMADs from synapsed chromosomes, suggesting that many meiotic DSBs are normally repaired by intersister recombination in mice.

Fertility Preservation in Young Female Cancer Patients: Development and Pilot Testing of an Online Decision Aid

PURPOSE

Impairment of fertility is a common sequela of successful cancer treatment. Therefore, fertility preservation (FP) should be discussed with all young cancer patients. Decisions about FP are challenging. Patients wish more specific support and the first results concerning the helpfulness of decision aids (DA) were promising. Aside from describing the process of development and the content of an online DA in German, the objective of this study was to pilot test users' satisfaction with the DA and its effect on knowledge about FP and decisional conflict (DC).

METHODS

In this prospective consecutive study, a control group (n = 20, fertility counseling) was followed by and compared with an intervention group (n = 20, counseling and additional use of the DA, developed by an interdisciplinary team) of recently diagnosed female cancer patients between 18 and 40 years.

RESULTS

Nearly all participants who applied the DA considered it helpful for decision-making and recommendable. Knowledge about FP was high with regard to FP techniques women went for. DC was moderate according to the mean score (M = 27.92, standard deviation = 13.27) and only in 20%, the score was above the threshold for high DC. There was no difference between the control and intervention group for knowledge and DC.

CONCLUSION

The DA seems to serve as additional and well-accepted support tool in decision-making for patients and professionals. Referral to a reproductive specialist is crucial to warrant comprehensive information. These results need to be confirmed with the current ongoing randomized controlled study.

Ovarian function following targeted anti-angiogenic therapy with bevacizumab

Improvements in cancer therapy have enabled further insight into the long-term effects of treatment, including the highly prevalent gonadal failure. The focus of treatment has been shifted to the preservation of fertility, which may be achieved by preventing ovarian toxicity. To this end, new molecular-targeted agents, including monoclonal antibodies, have been developed and used in a standard procedure for managing different cancers. However, the prolonged antitumor activity of these drugs may cause the emergence of new toxic effects. The aim of the present review was to discuss the leading toxic effect of the anti-angiogenic agent bevacizumab on ovarian function in female patients of reproductive age, which may be observed and expected during in clinical practice. The majority of bevacizumab-induced side effects are expected to be transient and eliminated within the anticipated drug clearance time frame; however, fundamental investigations on these effects are required for generating more evidence-based practice guidelines.

Observational study of the development and evaluation of a fertility preservation patient decision aid for teenage and adult women diagnosed with cancer: the Cancer, Fertility and Me research protocol

INTRODUCTION

Women diagnosed with cancer and facing potentially sterilising cancer treatment have to make time-pressured decisions regarding fertility preservation with specialist fertility services while undergoing treatment of their cancer with oncology services. Oncologists identify a need for resources enabling them to support women's fertility preservation decisions more effectively; women report wanting more specialist information to make these decisions. The overall aim of the 'Cancer, Fertility and Me' study is to develop and evaluate a new evidence-based patient decision aid (PtDA) for women with any cancer considering fertility preservation to address this unmet need.

METHODS AND ANALYSIS

This is a prospective mixed-method observational study including women of reproductive age (16 years +) with a new diagnosis of any cancer across two regional cancer and fertility centres in Yorkshire, UK. The research involves three stages. In stage 1, the aim is to develop the PtDA using a systematic method of evidence synthesis and multidisciplinary expert review of current clinical practice and patient information. In stage 2, the aim is to assess the face validity of the PtDA. Feedback on its content and format will be ascertained using questionnaires and interviews with patients, user groups and key stakeholders. Finally, in stage 3 the acceptability of using this resource when integrated into usual cancer care pathways at the point of cancer diagnosis and treatment planning will be evaluated. This will involve a quantitative and qualitative evaluation of the PtDA in clinical practice. Measures chosen include using count data of the PtDAs administered in clinics and accessed online, decisional and patient-reported outcome measures and qualitative feedback. Quantitative data will be analysed using descriptive statistics, paired sample t-tests and CIs; interviews will be analysed using thematic analysis.

ETHICS AND DISSEMINATION

Research Ethics Committee approval (Ref: 16/EM/0122) and Health Research Authority approval (Ref: 194751) has been granted. Findings will be published in open access peer-reviewed journals, presented at conferences for academic and health professional audiences, with feedback to health professionals and program managers. The Cancer, Fertility and Me patient decision aid (PtDA) will be disseminated via a diverse range of open-access media, study and charity websites, professional organisations and academic sources. External endorsement will be sought from the International Patient Decision Aid Standards (IPDAS) Collaboration inventory of PtDAs and other relevant professional organisations, for example, the British Fertility Society.

TRIAL REGISTRATION NUMBER

NCT02753296; pre-results.

Improvements in Clinical Trials Information Will Improve the Reproductive Health and Fertility of Cancer Patients

There are a number of barriers that result in cancer patients not being referred for oncofertility care, which include knowledge about reproductive risks of antineoplastic agents. Without this information, clinicians do not always make recommendations for oncofertility care. The objective of this study was to describe the level of reproductive information and recommendations that clinicians have available in clinical trial protocols regarding oncofertility management and follow-up, and the information that patients may receive in clinical trials patient information sheets or consent forms. A literature review of the 71 antineoplastic drugs included in the 68 clinical trial protocols showed that 68% of the antineoplastic drugs had gonadotoxic animal data, 32% had gonadotoxic human data, 83% had teratogenic animal data, and 32% had teratogenic human data. When the clinical trial protocols were reviewed, only 22% of the protocols reported the teratogenic risks and 32% of the protocols reported the gonadotoxic risk. Only 56% of phase 3 protocols had gonadotoxic information and 13% of phase 3 protocols had teratogenic information. Nine percent of the protocols provided fertility preservation recommendations and 4% provided reproductive information in the follow-up and survivorship period. Twenty-six percent had a section in the clinical trials protocol, which identified oncofertility information easily. When gonadotoxic and teratogenic effects of treatment were known, they were not consistently included in the clinical trial protocols and the lack of data for new drugs was not reported. Very few protocols gave recommendations for oncofertility management and follow-up following the completion of cancer treatment. The research team proposes a number of recommendations that should be required for clinicians and pharmaceutical companies developing new trials.

Psychological impact of fertility preservation techniques in women with gynaecological cancer

Gynaecological cancer is a very stressful experience for women and treatments can compromise fertility and reproductive capacity. Fertility preservation techniques in women with gynaecological cancer can play an important role in improving the quality of life of these patients but, in many cases, the information about this type of treatment is not adequate. It is important to further investigate this topic in order to reduce the impact of gynaecological cancer on the quality of life of survivors as much as possible.

The positive effect of a dedicated adolescent and young adult fertility program on the rates of documentation of therapy-associated infertility risk and fertility preservation options

PURPOSE

Minimal data exist regarding documentation of therapy-associated infertility risk (IR) and fertility preservation (FP) options during the initial oncology consultation prior to systemic therapy. This study investigated factors affecting IR/FP documentation and assessed the effect of implementation of an Adolescent and Young Adult (AYA) program on documentation rates.

METHODS

A retrospective review of charts of patients receiving gonadotoxic therapy was undertaken for documentation of IR/FP pre- and post-implementation of an AYA program. Change in documentation rates was assessed using univariate and multiple logistic regression.

RESULTS

A total of 173 charts were reviewed. On univariate analysis, IR/FP documentation was less likely if patients had metastatic disease (P < 0.01, P < 0.01), by tumor type (P < 0.01, P < 0.01), received less intensive chemotherapy (P = 0.03, P = 0.06), were older (P = 0.14, P < 0.01), had more children (P < 0.01, P < 0.01), or lacked AYA program involvement (P < 0.01, P < 0.01). FP discussion was more common in males (P = 0.02). On multivariable analysis, more children (P = 0.01, P = 0.03), older age (P < 0.01, P < 0.01), tumor type (P < 0.01, P = 0.01), stage (P = 0.02, NS), relationship (P = 0.03, NS), and lack of AYA involvement (P < 0.01, P < 0.01) were associated with lower rates of IR/FP documentation. Following AYA program implementation, IR/FP rates increased from 56% (CI 46-65%) to 85% (CI 74-92%, P < 0.01) and 54% (CI 45-64%) to 86% (CI 75-93%, P < 0.01), respectively. The effect of AYA program implementation on IR/FP documentation was most noticeable in leukemia, lymphoma, and breast groups (P < 0.01).

CONCLUSIONS

Implementing an AYA consultation service at an adult cancer institution had a positive effect on the rates of IR/FP documentation. Specific programming can improve service delivery to AYA cancer patients, and fertility counseling should be integrated for patients undergoing gonadotoxic therapy.

Fertility Preservation Decisions Among Newly Diagnosed Oncology Patients: A Single-Center Experience

OBJECTIVES

To evaluate fertility preservation decisions and compare controlled ovarian stimulation (COS) and assisted reproductive technology (ART) outcomes between newly diagnosed cancer patients and age-matched healthy controls.

METHODS

Our retrospective study was conducted at Columbia University's Center for Women's Reproductive Care between 2005 and 2012. Forty-nine women elected to undergo ART with COS for either oocyte or embryo cryopreservation before commencement of cancer therapy. Demographic and descriptive characteristics were collected from the cohort of patients. Treatment outcomes were compared with randomly selected, healthy, age-matched controls undergoing ART with COS during the same time period.

RESULTS

Single women began fertility preservation cycles in half the time of married women (10.4 vs. 22.9 d). All 21 married women chose embryo cryopreservation, whereas 17 of the 28 (61%) single women chose embryo over oocyte cryopreservation. Baseline anti-Mullerian hormone levels and body mass indices were similar among fertility preservation patients and controls. Despite elevated baseline estradiol (E2) levels and luteal phase cycle starts in some cycles to avoid delay of cancer treatment, no significant differences were noted when comparing days of stimulation, total gonadotropins prescribed, numbers of oocytes and mature oocytes retrieved, fertilization rate, or cancellation rate to controls.

CONCLUSIONS

Our experience shows that, with appropriate counseling and multidisciplinary care, newly diagnosed cancer patients desiring fertility preservation experience similar outcomes as age-matched healthy controls. These women can pursue oocyte or embryo cryopreservation with likely minimal disruption to the flow of their oncologic care.

Decision-making about fertility preservation-qualitative data on young cancer patients' attitudes and needs

The aim of the study was to get deeper insight into the significance of fertility in cancer patients, their attitude towards fertility preservation (FP), decisional conflicts, and patient's needs in the decision-making process. Focus groups with 12 female cancer survivors were held and revealed that the significance of fertility was high and attitude towards FP positive. Religious and ethical reservations were not negligible. Standardized decision aids were considered helpful. More support is highly in demand and specific tools would be beneficial.

DNA damage responses in mammalian oocytes

DNA damage acquired during meiosis can lead to infertility and miscarriage. Hence, it should be important for an oocyte to be able to detect and respond to such events in order to make a healthy egg. Here, the strategies taken by oocytes during their stages of growth to respond to DNA damaging events are reviewed. In particular, recent evidence of a novel pathway in fully grown oocytes helps prevent the formation of mature eggs with DNA damage. It has been found that fully grown germinal vesicle stage oocytes that have been DNA damaged do not arrest at this point in meiosis, but instead undergo meiotic resumption and stall during the first meiotic division. The Spindle Assembly Checkpoint, which is a well-known mitotic pathway employed by somatic cells to monitor chromosome attachment to spindle microtubules, appears to be utilised by oocytes also to respond to DNA damage. As such maturing oocytes are arrested at metaphase I due to an active Spindle Assembly Checkpoint. This is surprising given this checkpoint has been previously studied in oocytes and considered to be weak and ineffectual because of its poor ability to be activated in response to microtubule attachment errors. Therefore, the involvement of the Spindle Assembly Checkpoint in DNA damage responses of mature oocytes during meiosis I uncovers a novel second function for this ubiquitous cellular checkpoint.