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Talbot L, Corkum KS, McCracken K, Cost NG, Aldrink JH. Oncofertility care for children, adolescents, and young adults at risk for treatment-related fertility loss. Pediatr Blood Cancer 2024:e31277. [PMID: 39138622 DOI: 10.1002/pbc.31277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024]
Abstract
As therapy for childhood malignancies becomes more sophisticated and survival has improved, long-term therapy-related sequelae have emerged. Loss of reproductive potential among childhood cancer survivors is one such concern that has become increasingly recognized among patients, families, and healthcare providers. The risk status for infertility based upon therapy received, state of current reproductive technology and outcomes, and an emphasis on adequate referral and counseling for fertility preservation options are reviewed. Contributing factors to infertility are discussed, and options for female and male preservation based upon age and pubertal status are summarized. This article highlights the current state of fertility opportunities for children and adolescents undergoing therapy for cancer. Providers caring for these young patients should be familiar with such options and should routinely initiate evaluations for eligibility of fertility preservation.
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Affiliation(s)
- Lindsay Talbot
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Kristine S Corkum
- Division of Pediatric Surgery, Department of Surgery, and the Surgical Oncology Program, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kate McCracken
- Section of Pediatric and Adolescent Gynecology, Division of Gynecology, Department of Obstetrics and Gynecology, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas G Cost
- Division of Pediatric Urology, Department of Urology, and the Surgical Oncology Program, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Rotz SJ, Hamilton BK, Wei W, Ahmed I, Winston SA, Ballard S, Bernard RJ, Carpenter P, Farhadfar N, Ferraro C, Friend BD, Gloude NJ, Hayashi RJ, Hoyle K, Jenssen K, Koo J, Lee CJ, Mariano L, Nawabit R, Ngwube A, Lalefar N, Phelan R, Perkins L, Rao A, Rayes A, Sandheinrich T, Stafford L, Tomlinson K, Whiteside S, Wiedl C, Myers K. Fertility Potential and Gonadal Function in Survivors of Reduced-Intensity Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2024; 30:534.e1-534.e13. [PMID: 38342136 PMCID: PMC11056299 DOI: 10.1016/j.jtct.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/05/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The use of reduced-intensity conditioning (RIC) regimens has increased in an effort to minimize hematopoietic stem cell transplantation (HCT) end-organ toxicity, including gonadal toxicity. We aimed to describe the incidence of fertility potential and gonadal function impairment in adolescent and young adult survivors of HCT and to identify risk factors (including conditioning intensity) for impairment. We performed a multi-institutional, international retrospective cohort study of patients age 10 to 40 years who underwent first allogeneic HCT before December 1, 2019, and who were alive, in remission, and available for follow-up at 1 to 2 years post-HCT. For females, an AMH level of ≥.5 ng/mL defined preserved fertility potential; an AMH level of ≥.03 ng/mL was considered detectable. Gonadal failure was defined for females as an elevated follicle-stimulating hormone (FSH) level >30 mIU/mL with an estradiol (E2) level <17 pg/mL or current use of hormone replacement therapy (regardless of specific indication or intent). For males, gonadal failure was defined as an FSH level >10.4 mIU/mL or current use of hormone replacement therapy. A total of 326 patients (147 females) were available for analysis from 17 programs (13 pediatric, 4 adult). At 1 to 2 years post-HCT, 114 females (77.6%) had available FSH and E2 levels and 71 (48.3%) had available AMH levels. FSH levels were reported for 125 males (69.8%). Nearly all female HCT recipients had very low levels of AMH. One of 45 (2.2%) recipients of myeloablative conditioning (MAC) and four of 26 (15.4%) recipients of reduced-intensity conditioning (RIC) (P = .06) had an AMH ≥.5 ng/m, and 8 of 45 MAC recipients (17.8%) and 12 of 26 RIC recipients (46.2%) (P = .015) had a detectable AMH level. Total body irradiation (TBI) dose and cyclophosphamide equivalent dose (CED) were not associated with detectable AMH. The incidence of female gonadal hormone failure was 55.3%. In univariate analysis, older age at HCT was associated with greater likelihood of gonadal failure (median age, 17.6 versus 13.9; P < .0001), whereas conditioning intensity (RIC versus MAC), TBI, chronic graft-versus-host disease requiring systemic therapy, and CED were not significantly associated with gonadal function. In multivariable analysis, age remained statistically significant (odds ratio [OR]. 1.11; 95% confidence interval [CI], 1.03 to 1.22) for each year increase; P = .012), Forty-four percent of the males had gonadal failure. In univariate analysis, older age (median, 16.2 years versus 14.4 years; P = .0005) and TBI dose (P = .002) were both associated with gonadal failure, whereas conditioning intensity (RIC versus MAC; P = .06) and CED (P = .07) were not statistically significant. In multivariable analysis, age (OR, 1.16; 95% CI, 1.06-1.27 for each year increase; P = .0016) and TBI ≥600 cGy (OR, 6.23; 95% CI, 2.21 to 19.15; P = .0008) remained significantly associated with gonadal failure. Our data indicate that RIC does not significantly mitigate the risk for gonadal failure in females or males. Age at HCT and (specifically in males) TBI use seem to be independent predictors of post-transplantation gonadal function and fertility status. All patients should receive pre-HCT infertility counseling and be offered appropriate fertility preservation options and be screened post-HCT for gonadal failure.
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Affiliation(s)
- Seth J Rotz
- Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, Ohio; Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Wei Wei
- Quantitate Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Ibrahim Ahmed
- Division of Pediatric Hem/Onc and BMT, Children's Mercy, Kansas City, Missouri
| | - Sameeya Ahmed Winston
- Center for Cancer and Blood Disorders, Children's National Health System, Washington, District of Columbia
| | | | - Robyn J Bernard
- Center for Cancer and Blood Disorders, Children's National Health System, Washington, District of Columbia
| | | | - Nosha Farhadfar
- Division of Hematology/Oncology, University of Florida College of Medicine, Gainsville, Florida
| | - Christina Ferraro
- Blood and Marrow Transplant Program, Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian D Friend
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital; Houston, Texas
| | - Nicholas J Gloude
- MD Division of Hematology Oncology, Department of Pediatrics, University of California San Diego, Rady Children's Hospital San Diego, California
| | - Robert J Hayashi
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Kerry Hoyle
- Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Kari Jenssen
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Jane Koo
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Catherine J Lee
- Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah
| | - Livia Mariano
- Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Rawan Nawabit
- Pediatric Hematology, Oncology and Blood and Marrow Transplantation, Cleveland Clinic, Cleveland, Ohio
| | | | - Nahal Lalefar
- Pediatric Hematology/Oncology/BMT, UCSF Benioff Children's Hospital, Oakland, California
| | - Rachel Phelan
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Laynie Perkins
- Pediatric immunology and Hematopoietic stem cell transplant program, University of Utah/Primary Children's Hospital, Salt Lake City, Utah
| | | | - Ahmad Rayes
- Pediatric immunology and Hematopoietic stem cell transplant program, University of Utah/Primary Children's Hospital, Salt Lake City, Utah
| | - Taryn Sandheinrich
- Division of Pediatric Hematology/Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Lauren Stafford
- Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | | | - Stacy Whiteside
- Department of Pediatric Hematology, Oncology, & Bone Marrow Transplantation, Nationwide Children's Hospital, Columbus, Ohio
| | - Christina Wiedl
- Center for Cancer and Blood Disorders, Children's National Health System, Washington, District of Columbia
| | - Kasiani Myers
- Division of Bone Marrow Transplantation and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Meacham LR, George S, Veludhandi A, Pruett MC, Haight AE, Arnold SD, Elchuri S, Stenger E, Krishnamurti L. Female Reproductive Health Outcomes after Hematopoietic Cell Transplantation for Sickle Cell Disease: Is Reduced Intensity Better Than Myeloablative Conditioning? Transplant Cell Ther 2023; 29:531.e1-531.e4. [PMID: 37169288 DOI: 10.1016/j.jtct.2023.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/01/2023] [Accepted: 05/02/2023] [Indexed: 05/13/2023]
Abstract
Curative therapy for sickle cell disease (SCD) through hematopoietic cell transplantation (HCT) is associated with a high level of risk for treatment-related gonadal dysfunction and future infertility. Both the myeloablative conditioning (MAC) and reduced-intensity conditioning (RIC) regimens used for SCD HCT are considered to carry a high risk for ovarian damage. Cyclophosphamide equivalent doses (CEDs) are thought to correlate with the degree of gonadal damage in pediatric oncology patients. We aimed to evaluate ovarian outcomes previously reported from our center, characterize the conditioning regimens as MAC or RIC, and calculate the CED for each regimen. The ovarian outcomes diminished ovarian reserve (DOR), as determined by an anti-Müllerian hormone (AMH) below the normal limits for age and assay or <5%, and premature ovarian insufficiency (POI), defined as a follicle-stimulating hormone (FSH) level >40 mIU/ML, are presented by conditioning regimen from 3 clinical studies from our center (2 published and 1 presented as an abstract in 2022). The studies were not mutually exclusive of patients. CEDs were calculated for each regimen. The CED ranged from 3388 to 9705 mg/m2 for MAC regimens and from 5600 to 18,750 mg/m2 for RIC regimens. DOR was observed in all regimens; however, in one study 2 patients had normal AMH levels after a fludarabine/melphalan regimen, and 1 patient had a normal AMH level after a fludarabine/melphalan/thiotepa regimen. Rates of POI were more variable and ranged from 40% to 100% after MAC regimens and from 0 to 100% after RIC regimens. Female patients with SCD who undergo HCT have very high rates of DOR after both MAC HCT and RIC HCT. Two of the 3 RIC regimens evaluated had higher CEDs than were seen in any of the MAC regimens evaluated. Rates of POI were more variable but may increase with time from transplantation. All SCD patients need to be counseled about the risk of infertility and provided information about fertility preservation.
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Affiliation(s)
- Lillian R Meacham
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia; Pediatric Endocrinology, Emory University, Atlanta, Georgia.
| | - Sobenna George
- Pediatric Endocrinology, Emory University, Atlanta, Georgia
| | - Anirudh Veludhandi
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia
| | - Megan C Pruett
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia
| | - Ann E Haight
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia
| | - Staci D Arnold
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia
| | - Swati Elchuri
- Ventura County Healthcare Agency, Ventura, California
| | - Elizabeth Stenger
- Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta/Emory University, Atlanta, Georgia
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