Fertility preservation for young adults, adolescents, and children with cancer

Future perspectives of fertility protection

Reproductive health is of major importance for individuals, for the society and for the health of future generations. This includes physical and medical dimensions as well as psychosocial and ethical ones. Whenever the possibility of starting a family is compromised, either due to an oncological cytotoxic treatment or due to transgender hormone medication with the aim to align their secondary sexual characteristics or other medical or social conditions, one key aspect of reproductive health is fertility protection. However, as a very young field in medicine, there are still many research questions that need to be clarified to provide the best possible treatment for affected people. These include the optimization and safety of cryopreservation processes of germ cells in women, men, transgender people, adolescents and children. Another focus is on psychological care as well as ethical, economic and legal issues. The establishment and development of the center for fertility protection Ulm (FePro-Ulm) will focus on a detailed molecular biological and (epi)genetic understanding of the underlying processes in ovarian tissue, oocytes and sperm to improve and develop new diagnostic and therapeutic approaches. The individual needs of affected people, their partners and families will be evaluated by an interdisciplinary approach. The collaborations within FePro-Ulm will develop preventative and helpful interventions for affected people. In addition, a better awareness of this important topic of reproductive health and fertility protection will be addressed by including participation representatives and strengthen public relation works.

Experiencing fertility preservation in adolescence - a qualitative interview study indicating gender disparities in AYAs diagnosed with cancer

Introduction

Fertility counselling on options for fertility preservation is increasingly implemented for children and adolescents at time of cancer diagnosis. Sperm cryopreservation has been standard of care for male patients during several decades and the procedure is not expected to delay the onset of cancer treatment. However, oocyte cryopreservation in female adolescents remains controversial, the reasons include the need of ovarian stimulation, gynecological exams and interventions, in all a potentially distressing experience for patients without previous experience of this type of examination or without previous sexual debut. With this study we wished to investigate how adolescent cancer patients experience fertility preservation procedures aiming at semen banking or oocyte cryopreservation.

Methods

Adolescent patients diagnosed with cancer that underwent fertility preservation at the Reproductive Medicine Clinic of Karolinska University Hospital were invited to participate in the study. Inclusion required the ability to communicate in Swedish or English. Exclusion criteria were current age under 15 at time of the interview and ongoing cancer treatment. The study had a qualitative study design and phenomenological approach with semi-structured individual face-to-face interviews. Ten interviews with six female and four male study participants were conducted between June and August 2023.

Results

The analysis resulted in three identified main themes: Communication about the risk of infertility and the fertility preservation, Freezing gametes - the process and healthcare encounters, and The decision to preserve gametes for one's own sake. Gender specific gaps in communication about fertility risks and fertility preservation procedures were found, with young females expressing a wish for improved communication and reporting experiences of discomfort during the procedures needed for oocyte cryopreservation, whereas young men were generally satisfied with their experience. Limitations include a risk of responder bias since not all patients who were contacted agreed to interview.

Discussion

Although gender disparities were identified in this study, fertility preservation was perceived as a positive experience and mitigated fertility-related distress in both male and female adolescent patients. Our study adds to the scarce literature on adolescents of both sexes undergoing fertility preservation and underscores the importance of specialized communication in fertility counselling and treatment of AYAs diagnosed with cancer.

The era of increasing cancer survivorship: Trends in fertility preservation, medico-legal implications, and ethical challenges

Introduction

Global cancer cases are increasing, but fortunately, cancer is becoming more treatable. By 2050, the number of cancer cases is projected to reach 35 million. These numbers are certainly correlated with the aging population, early diagnoses due to screenings, and the broad current treatment options. However, life-saving therapies are often gonadotoxic, significantly impacting the lives of cancer patients. Fertility preservation following life-saving oncological treatments is one of the challenges faced by patients with cancer.

Material and method

We analyzed 73 articles to investigate the current state of fertility preservation in oncology, also evaluating the medico-legal implications.

Results

The data indicate a growing trend of cancer recoveries and survivorship with opportunities to access fertility preservation through various methods, which are not entirely known or consistently offered to patients in the appropriate manner.

Conclusions

The ethical and medico-legal aspects are numerous and seem to be still evolving.

Sperm Quality in 1252 Adolescents and Young Adults (AYAs) Undergoing Fertility Preservation Due to Cancer or Nonmalignant Diseases

Purpose: To investigate the quality of emergency-collected semen samples aimed at sperm cryopreservation provided by adolescents and young adults (AYAs) presenting with cancer or nonmalignant diseases. Methods: This is a prospective cohort study of postpubertal males referred for sperm cryopreservation who provided at least one semen sample for fertility preservation at the Reproductive Medicine Clinic of Karolinska University Hospital, Stockholm, Sweden, between January 2009 and January 2020. Sperm quality was assessed by total sperm count, concentration, and motility. Sperm quality by disease groups was compared with the reference population data of fertile men defined by the World Health Organization (WHO). Results: Among the 1252 patients who provided samples for cryopreservation, 1063 had cancer and 189 had nonmalignant diseases. The most common malignant indications included testicular cancers (n = 501) and Hodgkin lymphoma (n = 102). Among those with nonmalignant disease, 35% (n = 66) had testicular disease. Sperm quality was significantly lower in all groups of patients with cancer compared with the reference population. In total, azoospermia was found in 8% of the patients with cancer, in 9% of those with nonmalignant testicular disease, and in 3% of the remaining men with nonmalignant disease. Conclusion: Sperm quality in adult patients with cancer was significantly impaired compared with the WHO reference population standards for fertile men. For adolescent patients, standard reference values are lacking. AYAs wishing to preserve fertility should receive individualized counseling regarding sperm quality at the time of cryopreservation, and in selected cases, banking of additional samples should be recommended depending on the sperm quality parameters.

The complexity and challenges of fertility preservation in women with cervix cancer-A prospective cohort study reporting on reproductive outcome and overall survival

INTRODUCTION

Our objective was to assess the feasibility of fertility preservation (FP) in women referred for cervix cancer, the long-term reproductive outcome, and overall survival.

MATERIAL AND METHODS

Prospective cohort study of patients referred for FP counseling between 1999 and 2021 to the FP program of Karolinska University Hospital, Stockholm, Sweden. Baseline data included age, parity, disease stage, treatment characteristics, and FP methods applied. Data on reproductive outcomes and overall survival (by October 19, 2023) were retrieved from clinical registries and a population-based register.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NTC04602962.

RESULTS

In total, 91 women were referred, 67% with stage I cancers and 25%, 7%, and 1% with stages II, III, and IV, respectively. Cancers were diagnosed during pregnancy or postpartum in six cases. Cancer treatments included fertility-sparing surgery in 14%, hysterectomy in 30%, and radiochemotherapy in 79% of cases. The treatment modality did not rule out the possibility to undergo FP, and following counseling, 68 patients elected to undergo FP by cryopreservation of embryos or oocytes (N = 11), ovarian tissue (N = 54), or both (N = 3). After a mean follow-up of 8.1 years, 25 women (37%) returned to the center, five women achieved conception either spontaneously or through assisted reproduction, and 11 women became mothers through adoption or surrogacy. In the group of women receiving radical surgery or chemo/radiotherapy, no live births using cryopreserved specimens have yet been achieved. During follow-up, 7 women (10%) in the FP group and 5 women (24%) in the group without FP had died of their disease. Cancer recurrence was documented in 19 patients.

CONCLUSIONS

Our findings underscore the complexity and challenges associated with FP in the context of cervix cancer. Results of this study demonstrate that many women diagnosed with cervix cancer at reproductive age desire to achieve parenthood. While fertility-sparing surgery can allow pregnancy, those who undergo a hysterectomy are limited to adoption, surrogacy, or the emerging possibility of uterus transplantation.

Parenthood in a Swedish prospective cohort of 1,378 adolescents and young adults banking semen for fertility preservation at time of cancer diagnosis

Background

The possibility of future parenthood is a highly relevant issue for patients of reproductive age facing oncologic treatment. This study aimed to investigate how fatherhood was achieved in a patient cohort of adolescents and young adults (AYAs) banking semen at time of cancer diagnosis and to determine the effectiveness of cryopreservation aimed at fertility preservation in the cohort.

Materials and methods

Observational cohort study examining AYAs with a cancer diagnosis who underwent semen banking for fertility preservation at Karolinska University Hospital 1988-2020, as part of the Stockholm regional fertility preservation program. This cohort is being prospectively followed since time of referral to the program, with most individuals included when presenting with primary cancers (Study Registration: ClinicalTrials.gov NTC04602962). Individuals achieving adulthood in the cohort were followed-up regarding their reproductive outcomes by linking to the Swedish Multi-generation Register, to identify fatherhood through natural conception or adoption, and to the Swedish National Quality Registry for Assisted Reproduction to identify parenthood through medical assistance, including the use of own sperm either cryopreserved or fresh, or donor sperm.

Results

Of the 1,378 patients referred during the study period, 1,357 were eligible for fatherhood analysis (aged >20 years at the end of follow-up, December 31, 2021). In total, 493 men became fathers following cancer treatment: 399 (81%) did so naturally, 87 (18%) via assisted reproductive techniques (including two using donor sperm), and 7 (1%) through adoption. Of the 92 patients who used their cryopreserved sperm for assisted reproductive techniques, 34 (37%) successfully fathered a child. The patients may have had children prior to cryopreservation.

Conclusion

A large proportion of AYA cancer survivors achieved fatherhood through natural conception in this cohort, whereas less than 1 in 5 survivors needed medical assistance to conceive. Although a low utilization rate of cryopreserved sperm was found in this cohort, its use was highly effective in the group that developed infertility. At present there are no standardized predictors of testicular toxicity after cancer treatment, and inter-individual variability is high. Further research is needed to identify patients at risk of infertility who would benefit from fertility preservation.

Review paper on fertility preservation in children and prepubertal adolescents with gynaecological cancer

Gynaecological cancer incidence in children and prepubertal girls is low but the risk of losing fertility potential is high due to the oncological treatments' toxicity. Consequently, fertility preservation is a top concern for survivors. This narrative review aims to summarize the best way of approaching each tumor treatment during prepubertal age with the goal of preserving fertility, and to discuss the latest methods used for fertility preservation for each gynaecological cancer. These procedures do not lack risks or uncertainities and offer a broad area of research.

Reproductive Concerns Among Young Adult Women With Breast Cancer: A Systematic Review and Meta-Analysis

OBJECTIVES

Systemic cancer treatments pose threats to fertility, leading to concerns regarding fertility and parenthood in young adult women with breast cancer (YAWBC). This systematic review aimed to synthesize existing evidence on reproductive concerns (RCs) among YAWBC and identify areas where further research in needed.

METHODS

A systematic review was conducted. Nine English and Chinese databases were searched for studies from inception to June 2023. A meta-analysis was employed to pool RC levels measured using the Reproductive Concerns After Cancer scale (RCAC scale; possible total scores: 18-90). Narrative synthesis was conducted in cases where a meta-analysis could not be performed.

RESULTS

Twenty-four cross-sectional studies across seven countries were included in this review. The prevalence of RCs among YAWBC ranged from 21.75% to 80%. The pooled mean total score on the overall RCAC scale was 55.84 (95% confidence interval: 53.26-58.43). "Personal health," "child's health," and "fertility potential" were the top three types of RCs among YAWBC. Sociodemographic, clinical, and psychosocial factors were found to be associated with RCs among YAWBC. Additionally, significant correlations among RCs, nonadherence to treatment, depression, and quality of life were also identified among YAWBC.

CONCLUSION

RCs are a common issue among YAWBC, and age, parenthood status, fertility desire, and chemotherapy treatment are important factors associated with RCs among these women. Further research is needed to clarify RC-related factors to provide evidence aimed at tailoring interventions to mitigate RCs among YWBC.

Fertility and reproductive concerns related to the new generation of cancer drugs and the clinical implication for young individuals undergoing treatments for solid tumors

The treatment landscape of solid tumors has changed markedly in the last years. Molecularly targeted treatments and immunotherapies have been implemented and have, in many cancers, lowered the risk of relapse and prolonged survival. Patients with tumors harboring specific targetable molecular alterations or mutations are often of a younger age, and hence future fertility and family building can be important concerns in this group. However, there are great uncertainties regarding the effect of the new drugs on reproductive functions, including fertility, pregnancy and lactation and how young patients with cancers, both women and men should be advised. The goal with this review is to gather the current knowledge regarding oncofertility and the different novel therapies, including immune checkpoint inhibitors, antibody-drug conjugates, small molecules and monoclonal antibody targeted therapies. The specific circumstances and reproductive concerns in different patient groups where novel treatments have been broadly introduced are also discussed, including those with melanoma, lung, breast, colorectal and gynecological cancers. It is clear, that more awareness is needed regarding potential drug toxicity on reproductive tissues, and it is of essence that individuals are informed based on current expertise and on available fertility preservation methods.

Current Status of Fertility Preservation in Pediatric Oncology Patients

Cancer poses significant emotional challenges for children and adolescents, despite improvements in survival rates due to new therapies. However, there is growing concern about the long-term effects, including fertility issues. This review examines recent advancements and future directions in fertility preservation within a pediatric population subjected to oncological therapies. Worldwide, there is variability in the availability of fertility preservation methods, influenced by factors like development status and governmental support. The decision to pursue preservation depends on the risk of gonadotoxicity, alongside factors such as diagnosis, treatment, clinical status, and prognosis. Currently, options for preserving fertility in prepubertal boys are limited compared to girls, who increasingly have access to ovarian tissue preservation. Adolescents and adults have more options available, but ethical considerations remain complex and diverse.

Mesenchymal stem cells promote ovarian reconstruction in mice

BACKGROUND

Studies have shown that chemotherapy and radiotherapy can cause premature ovarian failure and loss of fertility in female cancer patients. Ovarian cortex cryopreservation is a good choice to preserve female fertility before cancer treatment. Following the remission of the disease, the thawed ovarian tissue can be transplanted back and restore fertility of the patient. However, there is a risk to reintroduce cancer cells in the body and leads to the recurrence of cancer. Given the low success rate of current in vitro culture techniques for obtaining mature oocytes from primordial follicles, an artificial ovary with primordial follicles may be a good way to solve this problem.

METHODS

In the study, we established an artificial ovary model based on the participation of mesenchymal stem cells (MSCs) to evaluate the effect of MSCs on follicular development and oocyte maturation. P2.5 mouse ovaries were digested into single cell suspensions and mixed with bone marrow derived mesenchymal stem cells (BM-MSCs) at a 1:1 ratio. The reconstituted ovarian model was then generated by using phytohemagglutinin. The phenotype and mechanism studies were explored by follicle counting, immunohistochemistry, immunofluorescence, in vitro maturation (IVM), in vitro fertilization (IVF), real-time quantitative polymerase chain reaction (RT-PCR), and Terminal-deoxynucleotidyl transferase mediated nick end labeling(TUNEL) assay.

RESULTS

Our study found that the addition of BM-MSCs to the reconstituted ovary can enhance the survival of oocytes and promote the growth and development of follicles. After transplanting the reconstituted ovaries under kidney capsules of the recipient mice, we observed normal folliculogenesis and oocyte maturation. Interestingly, we found that BM-MSCs did not contribute to the formation of follicles in ovarian aggregation, nor did they undergo proliferation during follicle growth. Instead, the cells were found to be located around growing follicles in the reconstituted ovary. When theca cells were labeled with CYP17a1, we found some overlapped staining with green fluorescent protein(GFP)-labeled BM-MSCs. The results suggest that BM-MSCs may participate in directing the differentiation of theca layer in the reconstituted ovary.

CONCLUSIONS

The presence of BM-MSCs in the artificial ovary was found to promote the survival of ovarian cells, as well as facilitate follicle formation and development. Since the cells didn't proliferate in the reconstituted ovary, this discovery suggests a potential new and safe method for the application of MSCs in clinical fertility preservation by enhancing the success rate of cryo-thawed ovarian tissues after transplantation.

Controlled ovarian stimulation in cancer patients under 18 years old; a case series

BACKGROUND

Fertility preservation for adolescent pubescent girls is a concern of the healthcare system and parents. Oocyte cryopreservation is regarded as a standard medical intervention for patients with a minimum age of 18 years. Evidence suggests that mature oocyte cryopreservation is possible for adolescent pubescent girls, although, ovarian stimulation for these patients remains a challenge.

CASES PRESENTATION

This case series is the first report regarding ovarian stimulation with oocyte cryopreservation in younger than 18 years cancerous girls, who refer to ROYAN institute, Tehran, Iran, prior to the start of the treatment of cancer (November 2015 to February 2021). The oocyte cryopreservation was carried out in the 7 patients (five patients with Hodgkin lymphoma, one patient with Ewing sarcoma, and one patient with osteogenic tumor), the embryo cryopreservation in one patient with dysgerminoma, and the oocyte and embryo cryopreservation in one patient with germ cell tumor. No oocytes were retrieved after ovarian stimulation in the patient with medulloblastoma. For one of the patients with Hodgkin lymphoma, half of the tissues of one ovary were cryopreserved prior to ovarian stimulation.

CONCLUSIONS

Oocyte cryopreservation is a feasible option of fertility preservation in the adolescent's patients with cancer. However, only if reported acceptable fertilization rates, as well as the successful cases of live birth from oocyte cryopreservation at the ages under 18, this option of preserving fertility can be applied to this age range.

Clinical and self-reported markers of reproductive function in female survivors of childhood Hodgkin lymphoma

PURPOSE

To evaluate the impact of treatment for Hodgkin lymphoma (HL) on clinical reproductive markers and pregnancy outcomes.

METHODS

This study was embedded within the DCOG LATER-VEVO study; a Dutch, multicenter, retrospective cohort study between 2004 and 2014. Serum anti-Müllerian hormone (AMH), follicle stimulating hormone (FSH), inhibin B, antral follicle count (AFC), and self-reported (first) pregnancy outcomes were evaluated in female childhood HL survivors and controls.

RESULTS

84 HL survivors and 798 controls were included, aged 29.6 and 32.7 years old at time of assessment. Median age at HL diagnosis was 13.4 years. Cyclophosphamide equivalent dose (CED-score) exceeded 6000 mg/m2 in 56 women and 14 survivors received pelvic irradiation. All clinical markers were significantly deteriorated in survivors (odds-ratio for low AMH (< p10) 10.1 [95% CI 4.9; 20.6]; low AFC (< p10) 4.6 [95% CI 2.1; 9.9]; elevated FSH (> 10 IU/l) 15.3 [95% CI 5.7; 41.1], low Inhibin B (< 20 ng/l) 3.6 [ 95% CI 1.7; 7.7], p < 0.001). Pregnancy outcomes were comparable between survivors and controls (± 80% live birth, ± 20% miscarriage). However, survivors were significantly younger at first pregnancy (27.0 years vs 29.0 years, P = 0.04). Adjusted odds-ratio for time to pregnancy > 12 months was 2.5 [95% CI 1.1; 5.6] in survivors, p = 0.031. Adverse outcomes were specifically present after treatment with procarbazine and higher CED-score.

CONCLUSION

HL survivors appear to have an impaired ovarian reserve. However, chance to achieve pregnancy seems reassuring at a young age. Additional follow-up studies are needed to assess fertile life span and reproductive potential of HL survivors, in particular for current HL treatments that are hypothesized to be less gonadotoxic.

Fertility Preservation in Children and Adolescents during Oncological Treatment-A Review of Healthcare System Factors and Attitudes of Patients and Their Caregivers

Oncofertility is any therapeutic intervention to safeguard the fertility of cancer patients. Anti-cancer therapies (chemotherapy, radiation therapy, etc.) entail the risk of reproductive disorders through cytotoxic effects on gamete-building cells, especially those not yet fully developed. This literature review analyzes the available data on securing fertility in pediatric and adolescent populations to identify the methods used and describe aspects related to financing, ethics, and the perspective of patients and their parents. Topics related to oncofertility in this age group are relatively niche, with few peer-reviewed articles available and published studies mostly on adults. Compared to pubertal individuals, a limited number of fertility preservation methods are used for prepubertal patients. Funding for the procedures described varies from country to country, but only a few governments choose to reimburse them. Oncofertility of pediatric and adolescent patients raises many controversies related to the decision, parents' beliefs, having a partner, ethics, as well as the knowledge and experience of healthcare professionals. As the fertility of young cancer patients is at risk, healthcare professionals should make every effort to provide them with an opportunity to fulfill their future reproductive plans and to have a family and offspring. Systemic solutions should form the basis for the development of oncofertility in pediatric and adolescent populations.

Understanding Fertility Attitudes and Outcomes Among Survivors of Adolescent and Young Adult Cancers in a Low-Resource Setting: A Registry-Based Computer-Assisted Telephone Interview Survey

Purpose: To establish the extent of self-reported reproductive failure associated with cancer treatment, and attitudes toward fertility among adolescent and young adult (AYA) cancer survivors in Uganda. Methods: A registry-based computer-assisted telephone interview survey was conducted in Uganda. The survey population were survivors of childhood, adolescent and early adulthood cancers diagnosed between 2007 and 2018. The survey explored fertility outcomes, experiences of oncofertility and fertility attitudes of AYA cancer survivors. Results: Thirty-four (female = 14 and male = 20) interviews were completed. Survivors were 18-35 years of age. The median age at cancer diagnosis was 23.5 for females and 17.5 for males. Kaposi's sarcoma contributed to 44% of primary cancer diagnoses. All the survivors had received chemotherapy alone or in combination with other modalities and 79% of survivors had not received satisfactory information about future fertility before cancer treatment. Twenty one percent of males and 46% females met the criteria for infertility and 60% of these had met this criterion after their cancer diagnosis. Eighty two percent wanted to raise a biologically related child. Forty seven percent would be dissatisfied with their lives if they were unable to have a child or additional children. Conclusion: AYA cancer survivors in this low-resource setting reported reproductive failure, despite a strong fertility desire. Information and counseling provided on therapy-related problems before cancer treatment was insufficient and reinforces the need to build capacity for oncofertility resources within the region.

The Late Effects of Cancer Treatment on Female Fertility and the Current Status of Fertility Preservation-A Narrative Review

Fertility counseling should be offered to all individuals of young reproductive age early in the patient's trajectory following a cancer diagnosis. Systemic cancer treatment and radiotherapy often have an inherent gonadotoxic effect with the potential to induce permanent infertility and premature ovarian failure. For the best chances to preserve a patient's fertility potential and to improve future quality of life, fertility preservation methods should be applied before cancer treatment initiation, thus multidisciplinary team-work and timely referral to reproductive medicine centers specialized in fertility preservation is recommended. We aim to review the current clinical possibilities for fertility preservation and summarize how infertility, as a late effect of gonadotoxic treatment, affects the growing population of young female cancer survivors.

Thymoquinone ameliorates bleomycin-induced reproductive toxicity in male Balb/c mice

Bleomycin (BL) is a powerful chemotherapy drug that has devastating effects on spermatogenic function and may make cancer survivors at risk of infertility. Protective effects of thymoquinone (TQ), a phytochemical compound with antioxidant and anticancer influences, were investigated on sperm parameters, testicular structures, and sexual hormones in BL-treated mice. Forty-eight adult male Balb/c mice were randomly divided into six groups. Control group received normal saline; BL group received 10 mg/kg BL; TQ7.5 group received 7.5 mg/kg TQ; TQ15 group received 15 mg/kg TQ; BL+TQ7.5 group received 10 mg/kg BL and 7.5 mg/kg TQ; BL + TQ15 group received 10 mg/kg BL and 15 mg/kg TQ. BL was intraperitoneally used every day through 35 days, and TQ was intraperitoneally injected 3 days before administration of BL and continued twice per week for 35 days. Results showed that BL significantly decreased count, viability, morphology, maturity, and progressive movement of sperm, testosterone, seminiferous tubule diameters, the ratio of testis weight to body weight, number of spermatogonia, spermatocytes, spermatids, and Sertoli cells per tubule, and expression of Bcl2l1 and Bcl2l1/Bax ratio, and increased the non-progressive movement and immotile sperm, intermediate and immature sperm, LH, FSH, and malondialdehyde levels, and tunica albuginea thickness compared to the control group (p < .05). TQ at a level of 7.5 mg/kg ameliorated BL-induced toxicity on measured parameters and returned most of them to the level of the control group. These data suggested TQ in a dose-dependent manner may have positive effects on BL-induced toxicity of the testis in mice model.

Fertility-related information received by young women and men with cancer - a population-based survey

BACKGROUND

Infertility is a well-known sequela of cancer treatment. Despite guidelines recommending early discussions about risk of fertility impairment and fertility preservation options, not all patients of reproductive age receive such information.

AIMS

This study aimed to investigate young adult cancer patients' receipt of fertility-related information and use of fertility preservation, and to identify sociodemographic and clinical factors associated with receipt of information.

MATERIALS AND METHODS

A population-based cross-sectional survey study was conducted with 1010 young adults with cancer in Sweden (response rate 67%). The inclusion criteria were: a previous diagnosis of breast cancer, cervical cancer, ovarian cancer, brain tumor, lymphoma or testicular cancer between 2016 and 2017, at an age between 18 and 39 years. Data were analyzed using logistic regression models.

RESULTS

A majority of men (81%) and women (78%) reported having received information about the potential impact of cancer/treatment on their fertility. A higher percentage of men than women reported being informed about fertility preservation (84% men vs. 40% women, p < .001) and using gamete or gonadal cryopreservation (71% men vs. 15% women, p < .001). Patients with brain tumors and patients without a pretreatment desire for children were less likely to report being informed about potential impact on their fertility and about fertility preservation. In addition, being born outside Sweden was negatively associated with reported receipt of information about impact of cancer treatment on fertility. Among women, older age (>35 years), non-heterosexuality and being a parent were additional factors negatively associated with reported receipt of information about fertility preservation.

CONCLUSION

There is room for improvement in the equal provision of information about fertility issues to young adult cancer patients.

A Prospective Study on Fertility Preservation in Prepubertal and Adolescent Girls Undergoing Hematological Stem Cell Transplantation

Background

Hematological stem cell transplantation (HSCT) is an established method which has markedly increased the survival rate of hematologic malignancies since its introduction in the 1980’s. The conditioning for HSCT has known gonadotoxic effects and often leads to premature loss of fertility. In this study we have prospectively followed a cohort of girls undergoing HSCT and studied the outcomes of fertility preservation treatments performed before or after HSCT, as well as the long-term reproductive outcome.

Methods

In this one-center prospective study, 39 girls counselled for fertility preservation prior to or after conditioning for HSCT for malignant or benign diseases at childhood or adolescence between 1990 and 2017 were included. The patients were presented with the option to undergo cryopreservation of ovarian tissue or oocytes depending on their age and the time available. Follicle counts of the ovarian tissue and number of oocytes collected before or after HSCT were compared between patients treated for benign and malignant diseases. Hormone measurements post HSCT treatment, including FSH and AMH, reproductive outcomes and overall survival until January 2021 were investigated.

Results

In total, 34 girls and adolescents underwent fertility preservation before or after HSCT. Before HSCT, ovarian tissue was cryopreserved in 15 patients and two patients had oocytes preserved. Thirteen patients cryopreserved ovarian tissue after HSCT and seven patients returned to cryopreserve oocytes. Follicles were present in all tissue samples collected prior to HSCT, and in more than half of the samples collected post-HSCT. Half of the patients had spontaneous menarche or resumed menstruation post HSCT. Overall, 35 patients had survived at end of follow up and 7 patients had achieved parenthood.

Conclusions

Since fertility loss is common following HSCT, fertility preservation should be offered to all patients. Fertility preservation treatments can be performed both before and after HSCT.

Clinical Trial Registration

https://clinicaltrials.gov/show/NCT04602962, identifier NTC04602962

Hot Topics on Fertility Preservation for Women and Girls-Current Research, Knowledge Gaps, and Future Possibilities

Fertility preservation is a novel clinical discipline aiming to protect the fertility potential of young adults and children at risk of infertility. The field is evolving quickly, enriched by advances in assisted reproductive technologies and cryopreservation methods, in addition to surgical developments. The best-characterized target group for fertility preservation is the patient population diagnosed with cancer at a young age since the bulk of the data indicates that the gonadotoxicity inherent to most cancer treatments induces iatrogenic infertility. Since improvements in cancer therapy have resulted in increasing numbers of long-term survivors, survivorship issues and the negative impact of infertility on the quality of life have come to the front line. These facts are reflected in an increasing number of scientific publications referring to clinical medicine and research in the field of fertility preservation. Cryopreservation of gametes, embryos, and gonadal tissue has achieved quality standards for clinical use, with the retrieval of gonadal tissue for cryopreservation being currently the only method feasible in prepubertal children. Additionally, the indications for fertility preservation beyond cancer are also increasing since a number of benign diseases and chronic conditions either require gonadotoxic treatments or are associated with premature follicle depletion. There are many remaining challenges, and current research encompasses clinical health care and caring sciences, ethics, societal, epidemiological, experimental studies, etc.

Sperm quality in transgender women before or after gender affirming hormone therapy-A prospective cohort study

BACKGROUND

Due to recent changes in the legal framework, access to fertility preservation (FP) for transgender individuals has opened up in several countries. In Sweden and the Nordic countries, fertility preservation for medical reasons is fully reimbursed as part of the established tax-funded healthcare services. As this issue is relatively new, procedures for FP have seldom been reported in the transgender patient population. The very limited literature has indicated that transgender women may have poorer sperm quality than cisgender men when assessing samples aimed at semen banking.

OBJECTIVES

To assess sperm quality parameters of semen samples provided for FP by transgender women before or after gender affirming hormone therapy (GAHT), and to compare sperm quality with a reference population of unscreened men defined by the World Health Organization (WHO). Additionally, we aimed to describe referral patterns over calendar time and estimate time from referral to semen cryopreservation.

MATERIAL AND METHODS

Prospective cohort study of 212 transgender women referred for FP to the Reproductive Medicine Clinic of Karolinska University Hospital, Sweden, between 2013 and 2018. Among 177 individuals that provided semen samples for cryopreservation, 16 had previously received GAHT.

RESULTS

Individuals with previous GAHT presented with significantly lower total sperm count than individuals without GAHT (p = 0.002). However, higher proportions of sperm abnormalities were also noted among individuals who had not undergone previous GAHT, compared to the WHO reference population (p < 0.001). Referrals of transgender women for FP increased over time. The median time from referral to semen cryopreservation was 27 days.

CONCLUSIONS

A high occurrence of sperm abnormalities was found in transgender women, especially among individuals who had previously received GAHT. The results underline the importance of thoroughly discussing parenthood options and FP with patients early after diagnosis and referring the patients for semen banking preferably before starting GAHT.

Fertility preservation for prepubertal boys: lessons learned from the past and update on remaining challenges towards clinical translation

BACKGROUND

Childhood cancer incidence and survivorship are both on the rise. However, many lifesaving treatments threaten the prepubertal testis. Cryopreservation of immature testicular tissue (ITT), containing spermatogonial stem cells (SSCs), as a fertility preservation (FP) option for this population is increasingly proposed worldwide. Recent achievements notably the birth of non-human primate (NHP) progeny using sperm developed in frozen-thawed ITT autografts has given proof of principle of the reproductive potential of banked ITT. Outlining the current state of the art on FP for prepubertal boys is crucial as some of the boys who have cryopreserved ITT since the early 2000s are now in their reproductive age and are already seeking answers with regards to their fertility.

OBJECTIVE AND RATIONALE

In the light of past decade achievements and observations, this review aims to provide insight into relevant questions for clinicians involved in FP programmes. Have the indications for FP for prepubertal boys changed over time? What is key for patient counselling and ITT sampling based on the latest achievements in animals and research performed with human ITT? How far are we from clinical application of methods to restore reproductive capacity with cryostored ITT?

SEARCH METHODS

An extensive search for articles published in English or French since January 2010 to June 2020 using keywords relevant to the topic of FP for prepubertal boys was made in the MEDLINE database through PubMed. Original articles on fertility preservation with emphasis on those involving prepubertal testicular tissue, as well as comprehensive and systematic reviews were included. Papers with redundancy of information or with an absence of a relevant link for future clinical application were excluded. Papers on alternative sources of stem cells besides SSCs were excluded.

OUTCOMES

Preliminary follow-up data indicate that around 27% of boys who have undergone testicular sampling as an FP measure have proved azoospermic and must therefore solely rely on their cryostored ITT to ensure biologic parenthood. Auto-transplantation of ITT appears to be the first technique that could enter pilot clinical trials but should be restricted to tissue free of malignant cells. While in vitro spermatogenesis circumvents the risk linked to cancer cell contamination and has led to offspring in mice, complete spermatogenesis has not been achieved with human ITT. However, generation of haploid germ cells paves the way to further studies aimed at completing the final maturation of germ cells and increasing the efficiency of the processes.

WIDER IMPLICATIONS

Despite all the research done to date, FP for prepubertal boys remains a relatively young field and is often challenging to healthcare providers, patients and parents. As cryopreservation of ITT is now likely to expand further, it is important not only to acknowledge some of the research questions raised on the topic, e.g. the epigenetic and genetic integrity of gametes derived from strategies to restore fertility with banked ITT but also to provide healthcare professionals worldwide with updated knowledge to launch proper multicollaborative care pathways in the field and address clinical issues that will come-up when aiming for the child's best interest.