Ovarian transposition in prepubescent and adolescent girls with cancer

Fertility-sparing strategy in a rare case of highly malignant Dicer-1-associated sarcoma of the cervix

INTRODUCTION

We present the rare case of an 18-year-old patient with a Dicer-1 mutation-associated sarcoma of the cervix uteri.

CASE

The patient presented with irregular vaginal bleeding in July 2022. The clinical examination showed an exophytic tumor of the cervix, uterus and ovaries were normal in sonogram. The tumor of the cervix was resected, followed by a diagnostic hysteroscopy and abrasion of the uterine cervix and cavity. Hysteroscopy showed normal findings of the cervix and uterus. After diagnosis of a highly malignant Dicer-1 mutation-associated sarcoma of the cervix, cryopreservation of oocytes was realized. Based on the principle of obtaining maximum oncological safety while preserving fertility in this 18-year-old patient, we recommended chemotherapy rather than radiation with its far severe implications on the patient´s reproductive organs. 4 cycles of chemotherapy consisting of doxorubicin and ifosfamide were applied until December 2022. After re-staging in December 2022 via CT scan and MRI, the abdomen and pelvis as well as control hysteroscopy and abrasion were unremarkable. Until now, the patient is tumor free.

DISCUSSION

Primary sarcomas of the cervix are very rare. Recent literature hints towards a distinct DICER-1 sarcoma entity characterized by specific mutational clusters. Limited follow-up data suggested that DICER1-mutant tumors might exhibit a less aggressive clinical course than DICER1-wild-type tumors.

CONCLUSION

Decision-making in case of rare histological entities with sparse recommendations in the literature poses a challenge to the treating physician. Treatment strategies should consider oncological safety as well as options of preserving fertility. Gonadotoxic potential of different strategies should be taken into consideration and discussed in detail with the affected patient.

Surgical Innovations to Protect Fertility from Oncologic Pelvic Radiation Therapy: Ovarian Transposition and Uterine Fixation

As oncologic therapy continues to advance, survivorship care has widened the realm of possibilities for quality-of-life improvements, including fertility preservation and restoration. We aim to summarize the current and future directions of fertility preservation techniques for patients facing gonadotoxic medical therapies who desire pregnancy after their condition is treated. This review of both ovarian and uterine transposition highlights the present roles, techniques, and fertility outcomes of the two fertility preservation treatment modalities designed to protect reproductive organs from harmful pelvic radiation. Current evidence shows that ovarian transposition preserves ovarian function for patients with localized pelvic radiation demonstrating the most successful return of fertility. Uterine transposition holds great promise for patients desiring to conceive and carry a full-term pregnancy after radiation therapy. With ongoing advancements in oncologic treatments leading to increased survival rates, fertility is increasingly becoming a key survivorship issue. Patients can anticipate counseling about these fertility preservation surgical techniques that protect both the ovaries as well as the uterus from harmful pelvic radiation.

Techniques and endocrine-reproductive outcomes of ovarian transposition prior to pelvic radiotherapy in both gynecologic and non-gynecologic cancers: A systematic review and meta-analysis

BACKGROUND

Premature ovarian failure may be a consequence of radiotherapy administered for the treatment of various female oncologic diseases. Before radiotherapy, fertility may be preserved through ovarian transposition (OT), which consists of moving the ovaries away from the radiation field.

OBJECTIVE

To ascertain all types of surgical techniques employed for OT, outline the endocrine and reproductive outcomes of each one, and discover if one works better than the others.

SEARCH STRATEGY

The authors performed a systematic search of the English literature looking for all studies related to OT before radiotherapy published up to June 2023. Nine studies were included.

SELECTION CRITERIA

The eligible studies were assessed based on the presence of a description of the surgical technique employed for OT before pelvic radiotherapy and a report of the endocrine and reproductive outcomes.

DATA COLLECTION AND ANALYSIS

Odds ratios (OR) with 95% confidence intervals were used to compare endocrine and reproductive outcomes The χ2 test was employed for the statistical analysis and a P value less than 0.05 was considered significant.

MAIN RESULTS

A total of 323 female patients aged between 7 and 51 years-198 (61.3%) with non-gynecologic cancer and 125 (38.7%) with gynecologic cancer-underwent OT, either bilateral (221, 68.4%) or unilateral (102, 31.6%), before radiotherapy. Essentially, two types of OT were employed: lateral and medial. A total of 71 (22%) patients underwent medial OT and 252 (78%) patients (127 with non-gynecologic tumors and 125 with gynecologic tumors) had a lateral OT. The latter was used in a similar percentage of cases for gynecologic (50.4%) and non-gynecologic (49.6%) tumors, whereas the medial approach was performed only for non-gynecologic cancers (Hodgkin's lymphoma). The difference between medial OT and lateral OT was not significant regarding the preservation of endocrine function (OR 0.65, P = 0.120). However, midline OT worked better in terms of reproductive outcomes. In fact, the percentage of patients with pregnancy (49.2%) and live births (45%) associated with medial OT was significantly higher than that associated with lateral OT, 6.5% and 13.4%, respectively, and the difference between such data was statistically significant (OR 7.04, P = 0.001 and OR 5.29, P = 0.003, respectively).

CONCLUSIONS

Ovarian transposition is an important method to preserve fertility before radiotherapy, considering the worldwide ongoing use of this treatment for various cancers arising in young women. The surgical method depends on the type of disease, but OT-especially medial OT when feasible-is effective in terms of ovarian function preservation and reproductive outcomes.

Fertility Assessment after Ovarian Transposition in Children and Young Women Treated for a Malignant Tumor

Ovarian transposition (OT) has been proposed as a protective measure against radiation-induced damage to ovarian function and fertility. Despite its historical use, limited research has focused on evaluating endocrine and exocrine ovarian function after OT performed in adolescents and young adults (AYAs) before or during puberty. The purpose of our study was to investigate the fertility, pubertal development, and ovarian function of women with a previous history of OT during childhood, adolescence or young adulthood. In an observational bicentric retrospective study, we included 32 young female cancer patients who underwent OT before the age of 26 between 1990 and 2015 at Lyon Léon Bérard Cancer Center or Nancy University Hospital. The mean age at the time of OT was 15.6 years with a cancer diagnosis at 15 ± 4.8 years. Among the 10 women attempting pregnancy post-treatment, 60% achieved successful pregnancies. After a mean follow-up of 9.6 ± 7 years, 74% (17 out of 23) of women recovered spontaneous menstrual cycles (seven out of eight evaluable women with OT before or during puberty). Notably, 35% of women who did not attempt pregnancy demonstrated adequate ovarian reserve. Ovarian reserve and function recovery were influenced by the specific chemotherapy received. Importantly, our findings suggest that OT's effectiveness on ovarian activity resumption does not significantly differ when performed before or during puberty compared to pubertal stages. This study contributes valuable insights into the long-term reproductive outcomes of young women undergoing OT, emphasizing its potential efficacy in preserving ovarian function and fertility across different developmental stages.

An update on oncofertility in prepubertal females

Cancer is a life-threatening event for pediatric patients. Treatment advancements in pediatric cancer have improved prognosis, but some of these treatments have gonadotoxic potential and may affect fertility in different ways. Due to the growing interest of the research community in the life prospects of young cancer survivors, there has been a demand to intersect reproductive medicine and oncology, which is referred to as "oncofertility". There are various fertility preservation options according to gender and pubertal status, and shared decisions must take place at the time of diagnosis. This study aims to provide a critical review of current and emerging strategies for preserving and restoring fertility in prepubertal females, ranging from established methods to experimental approaches that can be offered before, during, and after anticancer therapies. Additionally, the author aims to review how clinicians' awareness of oncofertility options and the latest advancements in this field, timely referral, and proper consultations with patients and their families are vital in addressing their concerns, providing emotional support, and guiding them through the decision-making process, as well as potential barriers that may hinder the fertility preservation process.

Is motherhood still possible after pelvic carbon ion radiotherapy? A promising combined fertility-preservation approach

INTRODUCTION

Preserving the endocrine and reproductive function in young female cancer patients undergoing pelvic radiation is a significant challenge. While the photon beam radiation's adverse effects on the uterus and ovaries are well established, the impact of pelvic carbon ion radiotherapy on women's reproductive function is largely unexplored. Strategies such as oocyte cryopreservation and ovarian transposition are commonly recommended for safeguarding future fertility.

METHODS

This study presents a pioneering case of successful pregnancy after carbon ion radiotherapy for locally advanced sacral chondrosarcoma.

RESULTS

A multidisciplinary approach facilitated the displacement of ovaries and uterus before carbon ion radiotherapy, resulting in the preservation of endocrine and reproductive function.

CONCLUSION

The patient achieved optimal oncological response and delivered a healthy infant following the completion of cancer treatment.

Reproductive surgery: revisiting its origins and role in the modern management of fertility

For years, reproductive surgery was the mainstay of reproductive care. With the evolution and ultimate success of in vitro fertilization (IVF), reproductive surgery became an adjuvant therapy, indicated mainly for severe symptoms or to enhance success rates with assisted reproductive technologies. As success rates for IVF have plateaued, and emerging data rekindles the enormous benefits of surgically correcting reproductive pathologies, there is renewed interest among reproductive surgeons in reviving research and surgical expertise in this area. In addition, new instrumentation and surgical techniques to preserve fertility have gained traction and will solidify the need to have skilled reproductive endocrinology and infertility surgeons in our practice.

ESTRO/ESGO/SIOPe guidelines for the management of patients with vaginal cancer

Primary vaginal malignancies are rare, comprising only 2% of all female genital tract malignancies in adults and 4.5% in children. As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) jointly with the European Society for Radiotherapy & Oncology (ESTRO) and the European Society of Pediatric Oncology (SIOPe) developed evidence-based guidelines in order to improve the management of patients with vaginal cancer within a multidisciplinary setting. ESTRO/ESGO/SIOPe nominated practicing clinicians who are involved in the management of vaginal cancer patients and have demonstrated leadership through their expertise in clinical care and research, their national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (13 experts across Europe comprising the international development group). To ensure that the statements were evidence based, the current literature was reviewed and critically appraised. In the case of absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 112 independent international practitionners in cancer care delivery and patient representatives and their comments and input were incorporated and addressed accordingly. These guidelines cover comprehensively the diagnostic pathways as well as the surgical, radiotherapeutical and systemic management and follow-up of adult patients (including those with rare histological subtypes) and pediatric patients (vaginal rhabdomyosarcoma and germ cell tumours) with vaginal tumours.

ESTRO/ESGO/SIOPe Guidelines for the management of patients with vaginal cancer

Primary vaginal malignancies are rare, comprising only 2% of all female genital tract malignancies in adults and 4.5% in children. As part of its mission to improve the quality of care for women with gynecological cancers across Europe, the European Society of Gynaecological Oncology (ESGO) jointly with the European Society for Radiotherapy & Oncology (ESTRO) and the European Society of Pediatric Oncology (SIOPe) developed evidence-based guidelines in order to improve the management of patients with vaginal cancer within a multidisciplinary setting.ESTRO/ESGO/SIOPe nominated practicing clinicians who are involved in the management of vaginal cancer patients and have demonstrated leadership through their expertise in clinical care and research, their national and international engagement and profile as well as dedication to the topics addressed to serve on the expert panel (13 experts across Europe comprising the international development group). To ensure that the statements were evidence based, the current literature was reviewed and critically appraised.In the case of absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the international development group. Prior to publication, the guidelines were reviewed by 112 independent international practitionners in cancer care delivery and patient representatives and their comments and input were incorporated and addressed accordingly.These guidelines cover comprehensively the diagnostic pathways as well as the surgical, radiotherapeutical and systemic management and follow-up of adult patients (including those with rare histological subtypes) and pediatric patients (vaginal rhabdomyosarcoma and germ cell tumours) with vaginal tumours.

Fertility preservation is an imperative goal in the clinical practice of radiation oncology: a narrative review

With reduced cancer mortality in recent years, increased efforts must be put into safeguarding cancer survivors' long-term quality of life (QOL). Fertility preservation is recognised as a key component of QOL in survivorship. Concerns about fertility have been seen to significantly impact cancer patients' emotional and mental health as, generally, both malignancy and its treatment may cause a temporary or permanent reduction in infertility. This article reviews the primary effects of radiation therapy on male and female gonads and has further highlighted procedures through which the functioning of these organs can be protected before or during radiation treatment. We have also emphasised the importance of the establishment of multidisciplinary tumour boards and patient education regarding future reproductive function which is an important component of the care of individuals with cancer. This article highlights that infertility is a persistent and major concern that can add to long-term stress in cancer survivors, and education about fertility preservation before the initiation of any treatment is especially important.

Fertility after Cancer: Risks and Successes

The incidence of cancer in reproductive-aged women is 7%, but, despite the increased number of cancer cases, advances in early diagnosis and treatment have raised the survival rate. Furthermore, in the last four decades, there has been a rising trend of delaying childbearing. There has been an increasing number of couples referred to Reproductive Medicine Centers for infertility problems after one partner has been treated for cancer. In these cases, the main cause of reduced fertility derives from treatments. In this review, we describe the effects and the risks of chemotherapy, radiotherapy, and surgery in women with cancer, and we will focus on available fertility preservation techniques and their efficacy in terms of success in pregnancy and live birth rates.

Japan Society of Clinical Oncology Clinical Practice Guidelines 2017 for fertility preservation in childhood, adolescent, and young adult cancer patients: part 1

In 2017, the Japan Society of Clinical Oncology (JSCO) published the JSCO Clinical Practice Guidelines 2017 for Fertility Preservation in Childhood, Adolescent, and Young Adult Cancer Patients. These were the first Japanese guidelines to address issues of oncofertility. In this field of medicine, sustained close cooperation between oncologists and reproductive specialists is essential from the diagnosis of cancer until many years after completion of cancer treatment. These JSCO guidelines were intended to guide multidisciplinary medical staff in considering the availability of fertility preservation options and to help them decide whether to provide fertility preservation to childhood, adolescent, and young adult cancer patients before treatment starts, with the ultimate goal of improving patient survivorship. The guidelines are presented as Parts 1 and 2. This article (Part 1) summarizes the goals of the guidelines and the methods used to develop them and provides an overview of fertility preservation across all oncology areas. It includes general remarks on the basic concepts surrounding fertility preservation and explanations of the impacts of cancer treatment on gonadal function by sex and treatment modality and of the options for protecting/preserving gonadal function and makes recommendations based on 4 clinical questions. Part 2 of these guidelines provides specific recommendations on fertility preservation in 8 types of cancer (gynecologic, breast, urologic, pediatric, hematologic, bone and soft tissue, brain, and digestive).

Preservation of fertility in teenagers and young adults treated for haematological malignancies

As survival rates in teenagers and young adults diagnosed with haematological malignancies now exceed 70%, it is important that long-term quality of life, including measures to protect future fertility, are considered and discussed with patients and their families. Although discussion on the effect of planned cancer treatment on fertility is standard of care, knowledge of potential fertility treatment options and when they should be offered in haematological malignancies is not always so clear. In each case, the advice on the appropriate preservation of fertility depends upon a complex interplay of factors, weighing out the risk of future infertility against the risk of fertility preservation treatment, and recommendations must be made on a case-by-case basis. The aim of this Review is to evaluate the gonadotoxicity of treatments of prevalent haematological malignancies in teenagers and young adults, and provide an evidence-based framework to help with fertility discussion and management at the time of diagnosis, relapse or resistant disease, and in long-term follow-up settings.

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.

Fertility Preservation in Women: Indications and Options for Therapy

Fertility preservation (FP) is a vital issue for individuals in either reproductive or prepubescent stage of life when future fertility may be compromised. The objective of any FP intervention is to minimize or eliminate primary disease burden and to ensure maintaining or preserving reproductive health. Fertility potential can be affected by cancer therapy and numerous other factors, including advancing age, metabolic conditions, autoimmune diseases, specific surgical interventions, and sex affirmation procedures. A paradigm shift focusing on quality-of-life issues and long-term survivorship has emerged, especially because of advances in cancer diagnostics and treatment. Several FP techniques have been widely distributed, while others are still in the research stage. In addition, specific procedures and some potentially fertoprotective agents are being developed, aiming to minimize the hazards of gonadal damage caused by cancer therapy and decrease the need for more costly, invasive, and time-consuming FP methods. This review highlights the advances, indications, and options for FP, both experimental and well-established, in females of various age groups. An electronic search in PubMed, Embase, and Google Scholar databases was conducted, including retrospective studies, prospective clinical trials, meta-analyses, original reviews, and online abstracts published up to June 30, 2019. The search terms used included fertility preservation, oncofertility, embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation. The meeting proceedings of the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology were also hand searched.

Preserving fertility in female patients with hematological malignancies: a multidisciplinary oncofertility approach

Oncofertility is a new interdisciplinary field at the intersection of oncology and reproductive medicine that expands fertility options for young cancer patients. The most common forms of hematological malignancies that occur in girls and young women and therefore necessitate oncofertility care are acute lymphocytic leukemia, acute myeloid leukemia, non-Hodgkin's lymphoma, and Hodgkin's lymphoma. Aggressive gonadotoxic anticancer regimens including alkylating chemotherapy and total body irradiation are used often in treating girls and young women with hematological malignancies. The risks of gonadotoxicity and subsequent iatrogenic premature ovarian insufficiency and fertility loss depend mainly on the type and stage of the disease, dose of anticancer therapy as well as the age of the patient at the beginning of treatment. To avoid or at least mitigate the devastating complications of anticancer therapy-induced gonadotoxicity, effective and comprehensive strategies that integrate different options for preserving and restoring fertility ranging from established to experimental strategies should be offered before, during, and after chemotherapy or radiotherapy. A multidisciplinary approach that involves strong coordination and collaboration between hemato-oncologists, gynecologists, reproductive biologists, research scientists, and patient navigators is essential to guarantee high standard of care.

Carvacrol and Thymol Modulate the Cross-Talk between TNF-α and IGF-1 Signaling in Radiotherapy-Induced Ovarian Failure

Premature ovarian failure (POF) is a common cause of infertility in premenopausal women who are unavoidably exposed to cytotoxic therapy. Radiotherapy is one of the most effective cytotoxic treatments. However, the radiosensitivity of ovarian tissues limits its therapeutic outcome and results in the depletion of the primordial follicle and loss of fertility. Therefore, the need for an effective radioprotective therapy is evident especially when none of the current clinically used modalities for radioprotection succeeds efficiently. The present study investigated the potential radioprotective effect of carvacrol (CAR) (80 mg) or thymol (80 mg) on gamma- (γ-) irradiation-induced ovarian damage as well as their role in the cross-talk between IGF-1 and TNF-α signaling and antioxidative activity. In immature female Wister rats, a single dose of whole-body irradiation (3.2 Gy, LD₂₀) produced considerable ovarian damage, which was evident by histopathological findings and hormonal changes. Interestingly, pretreatment with CAR or thymol significantly enhanced the follicular development and restored the anti-Mullerian hormone (AMH), E2, and FSH levels. Both essential oils improved the irradiation-mediated oxidative stress and reduction in proliferating cell nuclear antigen (PCNA) expression. Moreover, irradiated rats exhibited an inverse relationship between IGF-1 and TNF-α levels two days post irradiation, which was further inverted by the pretreatment with CAR and thymol and ought to contribute in their radioprotective mechanisms. In conclusion, CAR and thymol showed a radioprotective effect and rescued the ovarian reserve mainly through counteracting oxidative stress and the dysregulated cross-talk between IGF-1 and TNF-α.

Fertility preservation strategies for rectal cancer in reproductive-age women

Despite rectal cancer being unusual before 40, fertility preservation (FP) remains a major concern for these reproductive-age women. Treatment usually involves pelvic radiotherapy, neoadjuvant chemotherapy, and surgery of rectum and mesorectum resection, at high risk of impairing fertility in women with risks of premature ovarian failure and radio-induced uterus damage. To date, there is no consensus on FP strategy for rectal cancer. We shared experiences between oncofertility experts from a French research network Groupe de Recherche et d'Etude en Cryoconservation Ovarienne et Testiculaire about a case of rectal cancer in a young woman. Indications, advantages and disadvantages of different FP strategies were discussed: ovarian transposition, cryopreservation of ovarian cortex and oocyte vitrification. This case was the starting point that led to the development of a French multidisciplinary e-meeting for sharing experiences and for suggesting the best strategy when faced with a complex oncofertility case.

Radiations and female fertility

Hundreds of thousands of young women are diagnosed with cancer each year, and due to recent advances in screening programs, diagnostic methods and treatment options, survival rates have significantly improved. Radiation therapy plays an important role in cancer treatment and in some cases it constitutes the first therapy proposed to the patient. However, ionizing radiations have a gonadotoxic action with long-term effects that include ovarian insufficiency, pubertal arrest and subsequent infertility. Cranial irradiation may lead to disruption of the hypothalamic-pituitary-gonadal axis, with consequent dysregulation of the normal hormonal secretion. The uterus might be damaged by radiotherapy, as well. In fact, exposure to radiation during childhood leads to altered uterine vascularization, decreased uterine volume and elasticity, myometrial fibrosis and necrosis, endometrial atrophy and insufficiency. As radiations have a relevant impact on reproductive potential, fertility preservation procedures should be carried out before and/or during anticancer treatments. Fertility preservation strategies have been employed for some years now and have recently been diversified thanks to advances in reproductive biology. Aim of this paper is to give an overview of the various effects of radiotherapy on female reproductive function and to describe the current fertility preservation options.

Ovarian effects of radiation and cytotoxic chemotherapy damage

Oncologic therapy including chemotherapy and radiation can have a significant impact on ovarian function for young women and girls. Poor health outcomes and loss of fertility are major considerations. The effect of radiation and chemotherapy on ovarian function varies depending on patient age, therapy type and dosage, and cancer type. Surgical and medical interventions are available to reduce the morbidity of premature ovarian failure associated with cancer-directed therapy. Fertility preservation is an important consideration, and several options are available for it; therefore, early consultation with a reproductive or oncofertility specialist is an essential part of oncologic care in young women or girls. This chapter will focus on the effects of radiation and chemotherapy on ovarian function and strategies to improve the reproductive care in women with cancer.

Single-port laparoscopic ovarian transposition in an 11-year-old girl

Ovarian transposition was the first procedure proposed for children with cancer to preserve ovarian function from damage caused by abdominal and pelvic radiotherapy. In this paper, we describe the first paediatric case of single-port laparoscopic ovarian transposition.

Fertility preservation in children and adolescents: current options and considerations

PURPOSE OF REVIEW

The purpose of this review is to outline current pediatric fertility preservation options, and discuss ethical and financial considerations impacting this rapidly expanding field.

RECENT FINDINGS

With the improvement in treatment of pediatric malignancies and medical conditions that threaten fertility, survival rates are increasing. Therefore, minimizing long-term morbidities such as gonadal damage and infertility is of utmost importance. Impaired fertility not only has a significant negative impact on patient's quality of life; in women, gonadal damage puts patients at risk for premature menopause, and increased risk of cardiac, skeletal, and cognitive issues. Fortunately, fertility preservation options exist for both female and male prepubertal and pubertal patients, and discussion of such options with patients and their families prior to the initiation of therapy and/or before further deterioration of gonadal function is crucial. A multidisciplinary approach to fertility counseling, with attention to the patient's goals and cultural beliefs, is ideal.

SUMMARY

Although several national organizations support integrating a fertility consultation into routine care, fertility preservation is still underutilized. Continued research is needed to understand barriers for patients/families and reduce the number of missed opportunities for fertility preservation.

Practical recommendations for fertility preservation in women by the FertiPROTEKT network. Part II: fertility preservation techniques

Purpose

In addition to guidelines focusing on scientific evidence, practical recommendations on fertility preservation are also needed.

Methods

A selective literature search was performed based on the clinical and scientific experience of the authors. This article (Part II) focuses on fertility preservation techniques. Part I, also published in this journal, provides information on disease prognosis, disease-specific therapy, and risks for loss of fertility.

Results

Ovarian stimulation including double stimulation and freezing of oocytes is the best-established therapy providing live birth chances in women < 35 years with high ovarian reserve of around 30–40%. Ovarian tissue freezing is especially useful in young women with good ovarian, if spontaneous conception is favoured and if < 1 week until chemotherapy is provided. Data on success rates are still limited, but this further evolving technique will possibly reach similar success rates as ovarian stimulation. GnRH agonists seem to reduce the risk of premature ovarian failure up to 50%; however, the effect is possibly not long-lasting. Ovarian transposition can easily be combined with freezing of ovarian tissue and is the preferred technique before pelvic radiotherapy. Other techniques, such as in vitro maturation, are limited to women with high ovarian reserve and remain less effective. In addition, procedures such as in vitro growth of follicles, etc. are still experimental.

Conclusions

Fertility preservation in women provides realistic chances of becoming pregnant. The choice of technique needs to be based on the time required, the woman’s age, its risks and efficacy, and the individual preference of the patient.

Practical recommendations for fertility preservation in women by the FertiPROTEKT network. Part I: Indications for fertility preservation

Purpose

Most guidelines about fertility preservation are predominantly focused on scientific evidence, but are less practically orientated. Therefore, practically oriented recommendations are needed to support the clinician in daily practice.

Methods

A selective literature search was performed based on the clinical and scientific experience of the authors, focussing on the most relevant diseases and gynaecological cancers. This article (Part I) provides information on topics that are essential for the fertility preservation indication, such as disease prognosis, disease therapy and its associated risks to fertility, recommending disease-specific fertility preservation measures. Part II specifically focusses on fertility preservation techniques.

Results

In breast cancer patients, fertility preservation such as ovarian tissue and oocyte cryopreservation is especially recommended in low-stage cancer and in women < 35 years of age. In Hodgkin’s lymphoma, the indication is mainly based on the chemotherapy regime as some therapies have very low, others very high gonadotoxicity. In borderline ovarian tumours, preservation of fertility usually is achieved through fertility sparing surgery, ovarian stimulation may also be considered. In cervical cancer, endometrial cancer, rheumatic diseases and other malignancies such as Ewing sarcoma, colorectal carcinoma, non-Hodgkin lymphoma, leukaemia etc., several other factors must be considered to enable an individual, stage-dependent decision.

Conclusion

The decision for or against fertility preservation depends on the prognosis, the risks to fertility and individual factors such as prospective family planning.

Fertility counseling and preservation: considerations for the pediatric endocrinologist

Infertility is a distressing consequence of numerous pediatric medical conditions and treatments. The field of pediatric fertility preservation has expanded rapidly over the past decade, and clinical guidelines emphasize the importance of discussing infertility risk and fertility preservation options with patients and families in a timely manner. Understanding the various mechanisms and presentations of fertility issues across diagnoses is imperative to provide counseling to patients and families, and identify individuals who may benefit from fertility preservation. The goals of this manuscript are to outline current fertility preservation options in pediatrics, review populations at-risk for infertility that are seen in pediatric endocrinology, and discuss other important issues related to fertility preservation including ethical considerations.

Fertility-sparing for young patients with gynecologic cancer: How MRI can guide patient selection prior to conservative management

Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

Adolescent oncofertility discussions: Recommendations from a systematic literature review

BACKGROUND

Increasing cancer incidence and survivorship rates have made late-term effects, such as effects on fertility, a salient issue for adolescent cancer patients. While various barriers make it difficult for health care professionals to discuss oncofertility with adolescents and their parents, there are numerous reasons to hold such discussions, based on professional obligations and the ethical principles of respect for autonomy and beneficence. This systematic literature review presents and critically examines recommendations for adolescent oncofertility discussions.

METHODS

Conducted according to PRISMA guidelines, this systematic literature review includes English, French, and German articles published up until December 31, 2014. Articles were sought via a combination of search terms in four databases.

RESULTS

Eighty of 96 articles included in this review address recommendations for improving adolescent oncofertility discussions. These recommendations deal with how, when, what, and with whom professionals ought to have these discussions, as well as various systemic barriers and ways to address them.

CONCLUSIONS

Based upon the principles of beneficence, respect for autonomy, and justice, we endorse several recommendations for oncofertility discussions with adolescents and their parents, including having a specific professional on the health care team initiate these discussions with all newly diagnosed patients; regularly doing so before, during, and after treatment; allowing adolescents to decide for themselves whom they wish to include in such discussions; employing various forms of communication; obtaining both adolescent assent and parental consent for fertility preservation (FP) procedures, especially at each stage (e.g., procurement and use); properly educating and training professionals to discuss oncofertility; promoting interdisciplinary collaboration; creating and implementing guidelines and policies; and ensuring equity of access to FP.

Operative techniques and complications of extraction and transplantation of ovarian tissue: the Erlangen experience

PURPOSE

Extracting ovarian tissue before oncologic therapy and transplanting it afterwards are increasingly being used to preserve fertility in women. This study describes standardized and safe operative procedures, with few complications, and reports the resulting ovarian function and pregnancy rates.

METHODS

The standardized operative techniques for removing and transplanting ovarian tissue used at the Erlangen center are: for tissue removal, one-third to half of the tissue from one ovary is excised with scissors, without tissue coagulation; for subsequent transplantation, pieces of ovarian tissue are placed in a retroperitoneal pocket without closure of the pocket.

RESULTS

Between January 2007 and December 2015, ovarian tissue was extracted in 399 women and transplanted following cancer therapy in 38. No surgical complications were observed within 28 days. To date, there have been ten pregnancies and nine live births after transplantation in seven different women; 26 of the 38 women developed hormonal activity, confirmed by a menstrual cycle or raised serum estradiol levels.

CONCLUSIONS

The techniques for laparoscopic removal and transplantation of ovarian tissue described here provide a standardized method with a very low risk of complications. The pregnancy rate after ovarian tissue transplantation, currently 15-30%, can be expected to rise further in the near future.

Fertility considerations and the pediatric oncology patient

Recent years have witnessed marked improvement in cytotoxic treatments with a parallel increase in patient survival. Despite efforts done to minimize long-term side effects of these treatment regimens, it is estimated that 40% of survivors of pediatric cancer will suffer from those. Some will be mild whereas others such as impaired fertility will be a heavy load on parents׳ expectations and patient׳s quality of life. Gonadal damage and severe loss of function is not a rare condition among children cured for cancer. Despite the young age of those patients, methods exist to try to reduce gonadal insult or to preserve gonadal function. Some of them are well studied and controlled; others are more experimental with encouraging results so far. This article aims to summarize all the procedures that can be offered to young patients treated for cancer in order to protect, as possible, their fertility potential.

Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients

Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients.

Updates in preserving reproductive potential of prepubertal girls with cancer: Systematic review

INTRODUCTION

With increasing numbers of adult female survivors of childhood cancers due to advances in early diagnosis and treatment, the issue of preserving the reproductive potential of prepubertal girls undergoing gonadotoxic treatments has gained greater attention.

METHODS

According to PRISMA guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English throughout the past 15 years to explore the significant updates in preserving the reproductive potential of prepubertal girls with cancer.

RESULTS

The two established fertility preservation options, embryo freezing and egg freezing, cannot be offered routinely to prepubertal girls as these options necessitate prior ovarian stimulation and subsequent mature oocytes retrieval that are contraindicated or infeasible before puberty. Therefore, the most suitable fertility preservation options to prepubertal girls are (1) ovarian tissue freezing and autotransplantation, (2) in vitro maturation, and (3) ovarian protection techniques. In this review, we discuss in detail those options as well as their success rates, advantages, disadvantages and future directions. We also suggest a new integrated strategy to preserve the reproductive potential of prepubertal girls with cancer.

CONCLUSION

Although experimental, ovarian tissue slow freezing and orthotopic autotransplantation may be the most feasible option to preserve the reproductive potential of prepubertal girls with cancer. However, this technique has two major and serious disadvantages: (1) the risk of reintroducing malignant cells, and (2) the relatively short lifespan of ovarian tissue transplants. Several medical and ethical considerations should be taken into account before applying this technique to prepubertal girls with cancer.

Tissue Expander Placement to Prevent the Adverse Intestinal Effects of Radiotherapy in Malignant Pelvic Tumors

We herein report the findings of 3 patients with primary Ewing sarcoma in a pelvic lesion who underwent the placement of a tissue expander (TE) before radiation therapy to prevent the adverse effects of radiotherapy. The simulation study showed that the TE drastically reduced volume of the intestine that was irradiated at all dose levels. All patients could receive the scheduled dose of radiotherapy without any acute and late complications such as diarrhea, melena, the dislodging of the TE, infection, or the formation of fistulae. In the 4-year (minimum) observation period, we did not observe intestinal complications in any of our patients. TE placement is considered to be a safe and effective method for preventing the adverse effects of radiotherapy in pediatric malignant pelvic tumors.

Primordial Follicle Transplantation within Designer Biomaterial Grafts Produce Live Births in a Mouse Infertility Model

The gonadotoxic effects of chemotherapy and radiation may result in premature ovarian failure in premenopausal oncology patients. Although autotransplantation of ovarian tissue has led to successful live births, reintroduction of latent malignant cells inducing relapse is a significant concern. In this report, we investigated the design of biomaterial grafts for transplantation of isolated ovarian follicles as a means to preserve fertility. Primordial and primary ovarian follicles from young female mice were extracted and encapsulated into biomaterials for subsequent transplantation into adult mice. Among the formulations tested, aggregated follicles encapsulated within fibrin had enhanced survival and integration with the host tissue following transplantation relative to the fibrin-alginate and fibrin-collagen composites. All mice transplanted with fibrin-encapsulated follicles resumed cycling, and live births were achieved only for follicles transplanted within VEGF-loaded fibrin beads. The extent to which these procedures reduce the presence of metastatic breast cancer cells among the isolated follicles was evaluated, with significantly reduced numbers of cancer cells present relative to intact ovaries. This ability to obtain live births by transplanting isolated primordial and primary follicles, while also reducing the risk of re-seeding disease relative to ovarian tissue transplantation, may ultimately provide a means to preserve fertility in premenopausal oncology patients.

Fertility Preservation in Children and Adolescents

Fertility preservation is the process by which either oocytes (eggs) or sperm undergo an intervention to preserve their use for future attempts at conception. Consideration of fertility preservation in the pediatric and adolescent population is important, as future childbearing is usually a central life goal. For postpubertal girls, both oocyte and embryo cryopreservation are standard of care and for postpubertal boys, sperm cryopreservation continues to be recommended. Although all the risks are unknown, it appears that fertility preservation in most cases does not worsen prognosis, allows for the birth of healthy children, and does not increase the chance of recurrence.

Late toxicity of brachytherapy after female genital tract tumors treated during childhood: Prospective evaluation with a long-term follow-up

PURPOSE

To prospectively assess the long-term toxicities of brachytherapy in female survivors with localized genital tract tumors.

PATIENTS AND METHODS

The data concerning 42 patients treated at Gustave Roussy between 1971 and 2004, were both retrospectively and prospectively analyzed. Strictly confidential constructed surveys based on the LENT SOMA/SF-36v2 questionnaires were mailed and 51% were completed. Complications were recorded throughout the follow-up period and graded according to CTCAE, version 4.0.

RESULTS

The median age at diagnosis was 1.7 years (range, 0.6-16.6) and most patients (69%) had rhabdomyosarcomas. Treatments included brachytherapy delivered in all patients, chemotherapy (88%), surgery (31%), and external beam radiotherapy (5%). At a median follow-up of 15.5 years, 41/42 patients were alive. A total of 160 late effects were identified in 32/42 (76%) patients: 72% G1-2, and 28% G3-4 (the mean number of all grade late effects per patient: 4 [median: 2.5; range, 0-16] and the mean number of G3-4 late effects per patient: 1[median: 0; range, 0-8]). The most common all grade late toxicities were gynecological (75/160; 47%) and G3-4 were urinary (24/45; 53%). Sixteen patients (38%) required surgical treatment of late complications. The 15-year actuarial incidence rate of G3-4 late effects was 51%. The total number of all grade and G3-4 late effects was significantly increased in patients treated before 1990 (p=0.005 and p=0.008), when the cumulative dose was higher (p=0.03 and p=0.02), when the maximal dose was delivered to the ovaries (p=0.002 and p=0.04), and when the brachytherapy volume was larger (p=0.03 and p=0.02). Quality of life was good or very good in 91% of patients who completed the surveys.

CONCLUSION

Long-term effects decreased with advances in treatment. Stringently controlled brachytherapy parameters should allow us to pursue improvements in order to prevent or minimize long-term sequelae.

Adnexal Incarceration in a Posterior Pelvic Peritoneal Defect Mimics Ovarian Torsion

Surgery for suspected ovarian torsion sometimes reveals unexpected sources of pelvic pain, such as internal hernias, adhesions, or anatomic defects. A 23-year-old nulligravida with Alagille syndrome was taken to the operating room with suspected ovarian torsion. Intraoperatively, the right adnexa bulged out of a right-sided, posterior peritoneal cleft that incarcerated most of the enlarged ovary. No ovarian torsion was identified. The left adnexa appeared to be normal; however, it dwelled within a left-sided posterior peritoneal cleft. The bilateral posterior peritoneal defects that housed the adnexa were likely of congenital etiology. Although adnexal incarceration is a rare finding at surgery for suspected ovarian torsion, it should be part of the differential diagnosis when evaluating acute pelvic pain.

[Thoraco-abdomino-pelvic surgery for tumors in children: Postoperative sequelae]

Thoracic surgery for pediatric tumors may induce a large variety of sequelae that mainly concern skin, muscles and bones (ribs), thoracic nerve and spinal cord and respiratory system. Muscle-sparing thoracotomy, intrathoracic expanders inserted after right pneumonectomy, early orthopedic evaluation and follow-up are useful preventive proceedings able to decrease postoperative sequelae. Surgery for abdominal tumors in children is part of a sequence where each therapeutic treatment can induce its own sequelae possibly potentiated by other therapies. Scars and occlusions represent classic effects, others like diarrhea, intestinal ischemia may require specific and sometimes partially effective long-term treatment. The pelvic cavity is characterized by an anatomy dedicated to urinary and digestive continence and reproductive functions. The oncologic resection of tumors developed in this region exposed to significant risk of sequelae that may strongly affect the quality of life. The development of conservative approaches for local treatment and of fertility preservation techniques has significantly reduced this morbidity and must be known by the surgeon to optimize the therapeutic strategy.

Critical Review of Clinical Practice Guidelines for Fertility Preservation in Teenagers and Young Adults with Cancer

Purpose: The 5-year survival of teenagers and young adults (TYAs; 13-24 years old) with cancer has continued to rise, but as a result more patients experience late effects of treatment, such as infertility. Advice regarding fertility preservation in relation to cancer is provided in numerous clinical practice guidelines, but the rigor of their development is unclear. Methods: A systematic search was undertaken for clinical practice guidelines regarding fertility preservation in TYAs with cancer. All guidelines were reviewed according to the Appraisal of Guidelines for Research and Evaluation (AGREE-II) criteria. Five out of 13 identified guidelines scored over 75% in the "rigor of development" section and were further appraised. Content, scope, and consistencies between recommendations were also examined. Results: All five of the reviewed guidelines encouraged oncologists to have discussions with their patients about potential fertility issues associated with treatment and available fertility preservation methods. The cryopreservation of sperm, oocytes, and embryos were all recommended as first-line interventions in postpubertal patients. Recommendations surrounding pre- or peripubescent adolescents were few, with many techniques only recommended as part of a clinical trial. The risk of subfertility associated with different treatment regimens was poorly described. Conclusions: The methodology and development of guidelines describing fertility preservation in TYA cancer patients varied greatly. Methodological quality did not clearly influence key recommendations. Those involved with the development of guidelines are encouraged to clearly define their development methods to allow users to be confident of the quality.

Sexual dysfunction and infertility as late effects of cancer treatment

Sexual dysfunction is a common consequence of cancer treatment, affecting at least half of men and women treated for pelvic malignancies and over a quarter of people with other types of cancer. Problems are usually linked to damage to nerves, blood vessels, and hormones that underlie normal sexual function. Sexual dysfunction also may be associated with depression, anxiety, relationship conflict, and loss of self-esteem. Innovations in cancer treatment such as robotic surgery or more targeted radiation therapy have not had the anticipated result of reducing sexual dysfunction. Some new and effective cancer treatments, including aromatase inhibitors for breast cancer or chemoradiation for anal cancer also have very severe sexual morbidity. Cancer-related infertility is an issue for younger patients, who comprise a much smaller percentage of total cancer survivors. However, the long-term emotional impact of being unable to have a child after cancer can be extremely distressing. Advances in knowledge about how cancer treatments may damage fertility, as well as newer techniques to preserve fertility, offer hope to patients who have not completed their childbearing at cancer diagnosis. Unfortunately, surveys in industrialised nations confirm that many cancer patients are still not informed about potential changes to their sexual function or fertility, and all modalities of fertility preservation remain underutilised. After cancer treatment, many patients continue to have unmet needs for information about restoring sexual function or becoming a parent. Although more research is needed on optimal clinical practice, current studies suggest a multidisciplinary approach, including both medical and psychosocial treatment options.