Multidisciplinary Working Group convened by the British Fertility Society. A strategy for fertility services for survivors of childhood cancer

Perspectives and Knowledge about Fertility Preservation Strategies among Female Cancer Patients in Turkey

OBJECTIVES

To evaluate the knowledge level and perspectives of female cancer patients regarding fertility preservation techniques before gonadotoxic treatment. Material and Methods. This was a prospective observational survey-based study conducted between 2016 and 2020 in Izmir Economy University Medical Park Hospital. A total of 150 female cancer patients aged 18-42 years were included. The participants completed a 17-item questionnaire, developed by the research team to evaluate their knowledge and perspectives on fertility preservation techniques.

RESULTS

The mean age of the patients was 39.5 ± 4.9 years. Only 64.7% of the patients were referred to fertility counseling by a gynecologist, while 72.6% of the patients knew of the risk of infertility after cancer treatment. There was a significant correlation between the health status and cancer stage of the patient (p=0.003). The estimated future chance of becoming pregnant spontaneously or through fertility preservation techniques was significantly higher in patients with a higher education level (p=0.041 or 0.008, respectively). Satisfaction with the counseling process was reported as high or low by 66.7% or 20% of the patients, respectively.

CONCLUSIONS

The rate of referral of reproductive-age cancer patients to fertility preservation counseling is still not satisfactory. Education level was the only variable significantly associated with a motivation to become pregnant after cancer treatment, either spontaneously or through fertility preservation techniques.

White paper: Onco-fertility in pediatric patients with Wilms tumor

The survival of childhood Wilms tumor is currently around 90%, with many survivors reaching reproductive age. Chemotherapy and radiotherapy are established risk factors for gonadal damage and are used in both COG and SIOP Wilms tumor treatment protocols. The risk of infertility in Wilms tumor patients is low but increases with intensification of treatment including the use of alkylating agents, whole abdominal radiation or radiotherapy to the pelvis. Both COG and SIOP protocols aim to limit the use of gonadotoxic treatment, but unfortunately this cannot be avoided in all patients. Infertility is considered one of the most important late effects of childhood cancer treatment by patients and their families. Thus, timely discussion of gonadal damage risk and fertility preservation options is important. Additionally, irrespective of the choice for preservation, consultation with a fertility preservation (FP) team is associated with decreased patient and family regret and better quality of life. Current guidelines recommend early discussion of the impact of therapy on potential fertility. Since most patients with Wilms tumors are prepubertal, potential FP methods for this group are still considered experimental. There are no proven methods for FP for prepubertal males (testicular biopsy for cryopreservation is experimental), and there is just a single option for prepubertal females (ovarian tissue cryopreservation), posing both technical and ethical challenges. Identification of genetic markers of susceptibility to gonadotoxic therapy may help to stratify patient risk of gonadal damage and identify patients most likely to benefit from FP methods.

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

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

Fertility preservation knowledge, attitudes and intentions among children by proxy and adolescents with cancer

RESEARCH QUESTION

The current study aimed to assess knowledge, attitudes and intentions in relation to fertility preservation among children, by proxy, and adolescents with cancer. Although fertility preservation options have been developed to mitigate the adverse long-term effects of life-saving cancer treatment on fertility, fertility is difficult for children and adolescents to conceptualize, especially when they face a cancer diagnosis.

DESIGN

This was a descriptive, semi-quantitative analysis. Adolescents and parents of children or adolescents within 6 months of a cancer diagnosis and undergoing gonadotoxic treatment were invited to participate. Seventy-one families completed and returned the study's questionnaire (91 questionnaires) over a period of 26 months.

RESULTS

The vast majority of participants were aware of the gonadotoxic effects of cancer treatment (85%) and had positive attitudes towards fertility preservation (>90%), but only a portion of them (20%) were willing to take action towards this goal. Although adolescent-parent pairs had similar attitudes towards fertility preservation, adolescents tended to be more sceptical about experimental fertility preservation options. Male post-pubertal cancer patients were more likely to be offered fertility preservation counselling or referral to a specialist in comparison to their younger and female counterparts.

CONCLUSIONS

Fertility preservation care has advanced but there are still gender and age differences in counselling and treatment initiation in the paediatric and adolescent cancer population. Interventions to improve provider-patient-parent communication regarding fertility preservation and to help patients address the observed intention-behaviour gap in relation to fertility preservation options are needed.

How can we improve oncofertility care for patients? A systematic scoping review of current international practice and models of care

BACKGROUND

Fertility preservation (FP) is an important quality of life issue for cancer survivors of reproductive age. Despite the existence of broad international guidelines, the delivery of oncofertility care, particularly amongst paediatric, adolescent and young adult patients, remains a challenge for healthcare professionals (HCPs). The quality of oncofertility care is variable and the uptake and utilization of FP remains low. Available guidelines fall short in providing adequate detail on how oncofertility models of care (MOC) allow for the real-world application of guidelines by HCPs.

OBJECTIVE AND RATIONALE

The aim of this study was to systematically review the literature on the components of oncofertility care as defined by patient and clinician representatives, and identify the barriers, facilitators and challenges, so as to improve the implementation of oncofertility services.

SEARCH METHODS

A systematic scoping review was conducted on oncofertility MOC literature published in English between 2007 and 2016, relating to 10 domains of care identified through consumer research: communication, oncofertility decision aids, age-appropriate care, referral pathways, documentation, training, supportive care during treatment, reproductive care after cancer treatment, psychosocial support and ethical practice of oncofertility care. A wide range of electronic databases (CINAHL, Embase, PsycINFO, PubMed, AEIPT, Education Research Complete, ProQuest and VOCED) were searched in order to synthesize the evidence around delivery of oncofertility care. Related citations and reference lists were searched. The review was undertaken following registration (International prospective register of systematic reviews (PROSPERO) registration number CRD42017055837) and guidelines of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

OUTCOMES

A total of 846 potentially relevant studies were identified after the removal of duplicates. All titles and abstracts were screened by a single reviewer and the final 147 papers were screened by two reviewers. Ten papers on established MOC were identified amongst the included papers. Data were extracted from each paper and quality scores were then summarized in the oncofertility MOC summary matrix. The results identified a number of themes for improving MOC in each domain, which included: the importance of patients receiving communication that is of a higher quality and in different formats on their fertility risk and FP options; improving provision of oncofertility care in a timely manner; improving access to age-appropriate care; defining the role and scope of practice of all HCPs; and improving communication between different HCPs. Different forms of decision aids were found useful for assisting patients to understand FP options and weigh up choices.

WIDER IMPLICATIONS

This analysis identifies core components for delivery of oncofertility MOC. The provision of oncofertility services requires planning to ensure services have safe and reliable referral pathways and that they are age-appropriate and include medical and psychological oncofertility care into the survivorship period. In order for this to happen, collaboration needs to occur between clinicians, allied HCPs and executives within paediatric and adult hospitals, as well as fertility clinics across both public and private services. Training of both cancer and non-cancer HCPs is needed to improve the knowledge of HCPs, the quality of care provided and the confidence of HCPs with these consultations.

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

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

Disparities in Counseling Female Cancer Patients for Fertility Preservation

BACKGROUND

Female cancer patients who are exposed to gonadotoxic chemotherapy are at risk of future infertility. Research suggests that disparities in fertility preservation counseling (FPC) may exist. Previous research is limited by recall bias; therefore, this study examined objective electronic medical chart data regarding FPC at an academic medical center.

MATERIALS AND METHODS

This study included reproductive-aged women (18-45 years old) with a diagnosis of breast, gynecological, or hematological cancer and who were exposed to a gonadotoxic chemotherapeutic agent from 2009 to 2013. Chi-square and logistic regression analyses were utilized to analyze disparities in FPC.

RESULTS

Two hundred fifty-nine women met the study criteria. One hundred eighty-one women were diagnosed with breast cancer, 52 with hematological cancer, and 26 with gynecological cancer. 160/259 (62%) women had documented counseling for fertility preservation (FP), 60 (23%) women were not counseled as counseling was determined to be "not applicable," 16 (6%) women were not counseled and no explanation was given for the lack of counseling, and counseling was not documented in 23 (9%) charts. Age, marital status, and racial/ethnic background were related to counseling status. Patients with gynecological or hematological cancer were more likely to be counseled than other patients. Logistic regression results demonstrated that FPC was largely driven by cancer diagnosis.

CONCLUSIONS

Although cancer diagnosis was the greatest predictor of FPC, disparities were evident in the counseling of female cancer patients for FP treatment. Equality in counseling female patients for FP treatment is imperative to reduce the risk of emotional harm and future infertility.

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

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

TRADITIONAL CHINESE MEDICINE COMBINED WITH HORMONE THERAPY TO TREAT PREMATURE OVARIAN FAILURE: A META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

BACKGROUND

This meta-analysis aimed to provide critically estimated evidence for the advantages and disadvantages of Chinese herbal medicines used for premature ovarian failure (POF), which could provide suggestions for rational treatments.

MATERIALS AND METHODS

The databases searched included MEDLINE, EMBASE, CNKI, VIP, China Dissertation Database, China Important Conference Papers Database, and online clinical trial registry websites. Published and unpublished randomized controlled trials of traditional Chinese medicine (TCM) combined with hormone therapy (HT) and HT alone for POF were assessed up to December 30, 2015. Two authors extracted data and assessed trial quality independently using Cochrane systematic review methods. Meta-analysis was used to quantitatively describe serum hormone levels and Kupperman scores associated with perimenopause symptoms.

RESULTS

Seventeen randomized controlled trials involving 1352 participants were selected. Compared with HT alone, although no significant effects were observed in the levels of luteinizing hormone, therapy with TCM combined with HT compared to HT alone effectively altered serum hormone levels of follicle stimulating hormone (P<0.01) and estradiol (P < 0.01), and improved Kupperman index scores (P< 0.01).

CONCLUSIONS

The reported favorable effects of TCM combined with HT for treating POF patients are better than HT alone.However, the beneficial effects derived from this combination therapy cannot be viewed conclusive. In order to better support the clinical use, more rigorously designed trials are required to provide.

Fertility preservation in children, adolescents, and young adults with cancer: Quality of clinical practice guidelines and variations in recommendations

BACKGROUND

Fertility preservation care for children, adolescents, and young adults (CAYAs) with cancer is not uniform among practitioners. To ensure high-quality care, evidence-based clinical practice guidelines (CPGs) are essential. The authors identified existing CPGs for fertility preservation in CAYAs with cancer, evaluated their quality, and explored differences in recommendations.

METHODS

A systematic search in PubMed (January 2000-October 2014); guideline databases; and Web sites of oncology, pediatric, and fertility organizations was performed. Two reviewers evaluated the quality of the identified CPGs using the Appraisal of Guidelines for Research and Evaluation II Instrument (AGREE II). From high-quality CPGs, the authors evaluated concordant and discordant areas among the recommendations.

RESULTS

A total of 25 CPGs regarding fertility preservation were identified. The average AGREE II domain scores (scale of 0%-100%) varied from 15% on applicability to 100% on clarity of presentation. The authors considered 8 CPGs (32%) to be of high quality, which was defined as scores ≥60% in any 4 domains. Large variations in the recommendations of the high-quality CPGs were observed, with 87.2% and 88.6%, respectively, of discordant guideline areas among the fertility preservation recommendations for female and male patients with cancer.

CONCLUSIONS

Only approximately one-third of the identified CPGs were found to be of sufficient quality. Of these CPGs, the fertility preservation recommendations varied substantially, which can be a reflection of inadequate evidence for specific recommendations, thereby hindering the ability of providers to deliver high-quality care. CPGs including a transparent decision process for fertility preservation can help health care providers to deliver optimal and uniform care, thus improving the quality of life of CAYAs with cancer and cancer survivors. Cancer 2016;122:2216-23. © 2016 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society.

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.

Fertility preservation program before ovarotoxic oncostatic treatments: role of the psychological support in managing emotional aspects

Fertility preservation programs (FPPs) based on oocyte or ovarian tissue cryostorage may be offered to women facing oncostatic treatments at risk of precocious ovarian insufficiency. The way in which FPPs are presented to patients affects their decision to join them. We studied herein 48 young women to whom a FPP was proposed, aiming at clarifying the emotional aspects involved. A psychologist attended the consultations in which the FPP was offered to patients; at the end of the talk, a questionnaire was administered and a semi-structured interview was carried out. Finally, the STAI test was administered to measure trait (TAI) and state (SAI) anxiety, both immediately after consultation, and later on, when patients returned home. We observed that the possibility to join a FPP implied important emotional aspects, and that the presence of a psychologist was helpful to integrate technical information and emotions as well as to reduce trait and state anxiety levels. Our study suggests that the presence of a psychologist during the meeting in which a FPP is offered improves communication between doctors and patients, and helps these women to get a full awareness before choosing to join the FPP.

A national study of the provision of oncofertility services to female patients in Canada

OBJECTIVE

This study aimed to gain a better understanding of the fertility preservation services provided by Canadian fertility clinics to women with cancer.

METHODS

We invited a total of 76 fertility clinics across Canada to complete a mailed questionnaire related to the availability, accessibility, affordability, and utilization of fertility preservation services for oncology patients.

RESULTS

The total response rate was 59.2%: 72.4% for IVF clinics and 51.1% for fertility centres without on-site IVF. Not all the responding IVF centres accepted oncology referrals for women. Six clinics without on-site IVF accepted cancer patients for consultation. The medical consultation fees are covered by public health insurance in all provinces. The majority of respondents expedited the referrals to schedule an initial medical appointment within three days. Despite that, the referral volume reported by respondents was markedly low for all except two facilities. With over 4000 young women of reproductive age given a diagnosis of cancer each year in Canada, the findings suggest that cancer patients are severely under-served by fertility clinics.

CONCLUSION

There is a need to develop a stronger partnership between the fields of oncology and reproductive medicine to further improve access of patients with cancer to fertility preservation services. Development of evidence-based practice guidelines covering medical, clinical, psychosocial, ethical, and legal aspects geared to the Canadian health care system would help to avoid ambiguity relating to the roles and responsibilities in the provision of fertility preservation services. Such processes would ensure optimization of services so that all young cancer patients would receive the best care in protecting their fertility.

Risk of premature menopause after treatment for Hodgkin's lymphoma

BACKGROUND

Modern treatment of Hodgkin's lymphoma (HL) has transformed its prognosis but causes late effects, including premature menopause. Cohort studies of premature menopause risks after treatment have been relatively small, and knowledge about these risks is limited.

METHODS

Nonsurgical menopause risk was analyzed in 2127 women treated for HL in England and Wales at ages younger than 36 years from 1960 through 2004 and followed to 2003 through 2012. Risks were estimated using Cox regression, modified Poisson regression, and competing risks. All statistical tests were two-sided.

RESULTS

During follow-up, 605 patients underwent nonsurgical menopause before age 40 years. Risk of premature menopause increased more than 20-fold after ovarian radiotherapy, alkylating chemotherapy other than dacarbazine, or BEAM (bis-chloroethylnitrosourea [BCNU], etoposide, cytarabine, melphalan) chemotherapy for stem cell transplantation, but was not statistically significantly raised after adriamycin, bleomycin, vinblastine, dacarbazine (ABVD). Menopause generally occurred sooner after ovarian radiotherapy (62.5% within five years of ≥5 Gy treatment) and BEAM (50.9% within five years) than after alkylating chemotherapy (24.2% within five years of ≥6 cycles), and after treatment at older than at younger ages. Cumulative risk of menopause by age 40 years was 81.3% after greater than or equal to 5Gy ovarian radiotherapy, 75.3% after BEAM, 49.1% after greater than or equal to 6 cycles alkylating chemotherapy, 1.4% after ABVD, and 3.0% after solely supradiaphragmatic radiotherapy. Tables of individualized risk information for patients by future period, treatment type, dose and age are provided.

CONCLUSIONS

Patients treated with HL need to plan intended pregnancies using personalized information on their risk of menopause by different future time points.

Referral for fertility preservation counselling in female cancer patients

STUDY QUESTION

What changes can be detected in fertility preservation (FP) counselling (FPC) over time and what are the determinants associated with the referral of newly diagnosed female cancer patients, aged 0-39 years, to a specialist in reproductive medicine for FPC?

SUMMARY ANSWER

Although the absolute number of patients receiving FPC increased over time, only 9.8% of all potential patients (aged 0-39 years) were referred in 2011 and referral disparities were found with respect to patients' age, cancer diagnosis and healthcare provider-related factors.

WHAT IS KNOWN ALREADY

Referral rates for FPC prior to the start of gonadotoxic cancer treatment are low. Determinants associated with low referral and referral disparities have been identified in previous studies, although there are only scarce data on referral practices and determinants for FPC referral in settings with reimbursement of FP(C).

STUDY DESIGN, SIZE, DURATION

We conducted a retrospective observational and questionnaire study in a Dutch university hospital. Data on all female cancer patients counselled for FP in this centre (2001-2013), as well as all newly diagnosed female cancer patients aged 0-39 years in the region (2009-2011) were collected.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Data were retrieved from medical records (FPC patients), cancer incidences reported by the Dutch Cancer Registry (to calculate referral percentages) and referring professionals (to identify reasons for the current referral behaviour).

MAIN RESULTS AND THE ROLE OF CHANCE

In 2011, a total of 9.8% of the patients were referred for FPC. Patients aged 20-29 years or diagnosed with breast cancer or lymphoma were referred more frequently compared with patients under the age of 20 years or patients diagnosed with other malignancies. The absolute numbers of patients receiving FPC increased over time. Healthcare provider-related determinants for low referral were not starting a discussion about fertility-related issues, not knowing where to refer a patient for FPC and not collaborating with patients' associations.

LIMITATIONS, REASONS FOR CAUTION

Actual referral rates may slightly differ from our estimation as there may have been patients who did not wish to receive FPC. Sporadically, patients might have been directly referred to other regions or may have received ovarian transposition without FPC. By excluding skin cancer patients, we will have underestimated the group of women who are eligible for FPC as this group also includes melanoma patients who might have received gonadotoxic therapy.

WIDER IMPLICATIONS OF THE FINDINGS

The low referral rates and referral disparities reported in the current study indicate that there are opportunities to improve referral practices. Future research should focus on the implementation and evaluation of interventions to improve referral practices, such as information materials for patients at oncology departments, discussion prompts or methods to increase the awareness of physicians and patients of FP techniques and guidelines.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the Radboud university medical center and the Radboud Institute for Health Sciences. The authors have declared no conflicts of interest with respect to this work.

TRIAL REGISTRATION NUMBER

Not applicable.

Oncofertility in Canada: cryopreservation and alternative options for future parenthood

BACKGROUND

Cancer can be a devastating diagnosis. In particular, malignancy and its indicated treatments have profoundly negative effects on the fertility of young cancer patients. Oncofertility has emerged as a new interdisciplinary field to address the issue of gonadotoxicity associated with cancer therapies and to facilitate fertility preservation. In Canada, these fertility issues are often inadequately addressed despite the availability of resources. The goal of this four-part series is to facilitate systemic improvements in fertility preservation for adolescent and young adult Canadians with a new diagnosis of cancer.

METHODS

This article reviews fertility preservation options that use cryopreservation techniques. It also outlines some of the alternative options for future parenthood.

RESULTS

Cryopreservation of a woman's gametes and gonadal tissue may involve embryo, oocyte, and ovarian tissue cryopreservation with or without ovarian stimulation. Similarly, male gametes and gonadal tissue may be cryopreserved. Techniques and success rates continue to improve. Third-party assistance through gamete donation, gestational carriers, and adoption are also alternative options for parenthood.

CONCLUSIONS

Cryopreservation techniques are especially feasible options for fertility preservation in the newly diagnosed cancer patient.

Oncofertility in Canada: an overview of Canadian practice and suggested action plan

BACKGROUND

Cancer can be a devastating diagnosis. In particular, malignancy and its indicated treatments have profoundly negative effects on the fertility of young cancer patients. Oncofertility has emerged as a new interdisciplinary field to address the issue of gonadotoxicity associated with cancer therapies and to facilitate fertility preservation. In Canada, these fertility issues are often inadequately addressed despite the availability of resources. The goal of this four-part series is to facilitate systemic improvements in fertility preservation for adolescent and young adult Canadians with a new diagnosis of cancer.

METHODS

Here, we describe the services currently available in Canada and the challenges associated with their utilization. Finally, we outline strategies to help maximize and facilitate fertility preservation in the young cancer patient.

RESULTS

Despite an existing infrastructure to the oncofertility system in Canada, the ability of that system's components to function together and to coordinate patient care is a challenge. Areas of weakness include poor access and referral to fertility services, a lack of readily available education for patients and health care providers, and inconsistent interdisciplinary coordination in patient care.

CONCLUSIONS

The implementation of a framework for multidisciplinary resource allocation, education, patient referral, and established lines of communication may facilitate a functional oncofertility system in Canada.

Fertility preservation in female classic galactosemia patients

Almost every female classic galactosemia patient develops primary ovarian insufficiency (POI) as a diet-independent complication of the disease. This is a major concern for patients and their parents, and physicians are often asked about possible options to preserve fertility. Unfortunately, there are no recommendations on fertility preservation in this group. The unique pathophysiology of classic galactosemia with a severely reduced follicle pool at an early age requires an adjusted approach. In this article recommendations for physicians based on current knowledge concerning galactosemia and fertility preservation are made. Fertility preservation is only likely to be successful in very young prepubertal patients. In this group, cryopreservation of ovarian tissue is currently the only available technique. However, this technique is not ready for clinical application, it is considered experimental and reduces the ovarian reserve. Fertility preservation at an early age also raises ethical questions that should be taken into account. In addition, spontaneous conception despite POI is well described in classic galactosemia. The uncertainty surrounding fertility preservation and the significant chance of spontaneous pregnancy warrant counseling towards conservative application of these techniques. We propose that fertility preservation should only be offered with appropriate institutional research ethics approval to classic galactosemia girls at a young prepubertal age.

A national study of the provision of oncology sperm banking services among Canadian fertility clinics

The purpose of this study was to survey the current state of oncology sperm banking services provided by fertility clinics across Canada. A total of 78 Canadian fertility facilities were invited to complete a questionnaire related to the availability, accessibility, affordability and utilisation of sperm banking services for cancer patients. The total response rate was 59%, with 20 (69%) in vitro fertilisation clinics and 26 (53%) other fertility centres returning the survey. A total of 24 responding facilities accepted oncology sperm banking referrals. The time frame to book the first banking appointment for 19 (79%) facilities was within 2 days. Inconsistent practice was found regarding the consent process for cancer patients who are of minority age. Eight (33%) facilities did not provide any subsidy and charged a standard banking fee regardless of patients' financial situations. Overall, the utilisation of oncology sperm banking services was low despite its availability and established efficacy, suggesting that Canadian cancer patients are notably underserved. The study has highlighted some important issues for further consideration in improving access to sperm banking services for cancer patients, especially for adolescents. Better collaboration between oncology and reproductive medicine to target healthcare providers would help to improve sperm banking rates.

Parental attitudes toward fertility preservation in boys with cancer: context of different risk levels of infertility and success rates of fertility restoration

OBJECTIVE

To measure the parental attitudes toward fertility preservation in boys with cancer.

DESIGN

Retrospective cohort study.

SETTING

Questionnaire survey via regular mail.

PATIENT(S)

A total of 465 families whose sons were already treated for cancer.

INTERVENTION(S)

The questionnaire was designed for two groups based on child's age at the time of cancer diagnosis: <12 and ≥12 years old.

MAIN OUTCOME MEASURE(S)

Descriptive statistics regarding a positive or negative attitude of parents toward fertility preservation options in the context of different risk levels of infertility and success rates of fertility restoration.

RESULT(S)

The response rate was 78%. Sixty-four percent of parents of boys ≥12 years old would agree to store sperm obtained by masturbation and/or electroejaculation, and 54% of parents of boys <12 years old would agree to store a testicular biopsy. If the risk of infertility or the success rate of fertility restoration were ≤20%, more than one-fourth of parents would still opt for fertility preservation.

CONCLUSION(S)

All parents should be counseled about the risks of infertility due to cancer treatment, because many parents want to preserve their son's fertility even if the risk of becoming infertile or the chances on fertility restoration are low.

Fertility preservation practices among Ontario oncologists

This study explores the attitudes, knowledge, and referring behaviors in fertility preservation among Ontario physicians providing adult cancer care. Ontario physicians with specialties in medical oncology, radiation oncology, gynaecologic oncology, and urology were invited to complete a 48-item questionnaire. A total of 152 questionnaires were available for analysis with a response rate of 23.7%. Seventy-four percent of the physicians indicated that they rarely or never modified cancer treatment due to concern about future fertility. Differences were found in fertility preservation knowledge among respondents in different medical specialties (p < 0.01) and clinical settings (p < 0.05). The frequency of initiating a referral was strongly associated with knowing where to refer patients (p < 0.001). The odds of knowing where to refer cancer patients was higher for physicians who work in a teaching hospital (p < 0.01) and a cancer centre (p < 0.01) compared with those who primarily work in a community setting. About 45% did not know where to refer female patients, and 69.7% rarely ever made a fertility preservation consultation referral for their female patients. The majority of respondents had positive attitudes despite their lack of current knowledge in cryopreservation services and fertility preservation options through assisted reproductive technologies. Our findings provide further insights of the relevance of considering physicians' medical backgrounds and practice settings when designing training modules to raise their awareness in fertility preservation issues.

Physiological sex steroid replacement in premature ovarian failure: randomized crossover trial of effect on uterine volume, endometrial thickness and blood flow, compared with a standard regimen

BACKGROUND

Premature ovarian failure (POF) is currently managed by non-physiological sex steroid regimens which are inadequate at optimizing uterine characteristics. Previous short-term studies have demonstrated some benefits of a sex steroid replacement (SSR) regimen devised to replicate the physiological cycle. This study aimed to directly compare the effects of longer-term administration of physiological SSR (pSSR) and standard SSR (sSSR) regimens on the uterine volume, blood flow and endometrial thickness (ET) in women with POF.

METHODS

In a controlled crossover trial, 34 women with POF were randomized to receive 12 months of 4-week cycles of transdermal estradiol and vaginal progesterone (pSSR) followed by 12 months of 4-week cycles of oral ethinylestradiol and norethisterone (sSSR), or vice versa. Each treatment period was preceded by a 2-month washout period. At 0, 3, 6 and 12 months of each treatment period, transvaginal ultrasound examined the uterine volume and ET, as primary end-points, and uterine artery resistance (UARI) and pulsatility indices (UAPI), as secondary end-points. Serum estradiol, progesterone and gonadotrophins were also measured.

RESULTS

Of the 29 women eligible for the uterine analysis, 17 completed the entire study protocol, but 25 women contributed data to statistical analysis of treatment effect. There was a greater estimated mean ET with the use of pSSR (4.8 mm) compared to that with standard therapy (3.0 mm), with an estimated difference of 1.8 mm [95% confidence interval (CI), 0.7 to 2.8, P=0.002]. The estimated mean uterine volume was also greater during physiological treatment (24.8 cm(3)) than during standard treatment (20.6 cm(3)), but the estimated difference of 4.2 cm(3) (95% CI -0.4 to 8.7) was not statitsically significant, P=0.070. The small differences between the two treatments in the mean UARI and mean UAPI were not statistically significant. The estimated treatment differences were fairly constant across the treatment periods, suggesting that prolonged treatment does not increase response.

CONCLUSIONS

pSSR has a greater beneficial effect upon ET in women with POF in comparison with standard therapy. A similar trend was seen for uterine volume. Further studies are required to optimize treatment and to assess pregnancy rate and outcome. Trial Registration www.ClinicalTrials.gov, NCR00732693.

Fertility preservation for cancer patients: a review

Infertility can arise as a consequence of treatment of oncological conditions. The parallel and continued improvement in both the management of oncology and fertility cases in recent times has brought to the fore-front the potential for fertility preservation in patients being treated for cancer. Oncologists must be aware of situations where their treatment will affect fertility in patients who are being treated for cancer and they must also be aware of the pathways available for procedures such as cryopreservation of gametes and/or embryos. Improved cancer care associated with increased cure rates and long term survival, coupled with advances in fertility treatment means that it is now imperative that fertility preservation is considered as part of the care offered to these patients. This can only be approached within a multidisciplinary setting. There are obvious challenges that still remain to be resolved, especially in the area of fertility preservation in prepubertal patients. These include ethical issues, such as valid consent and research in the area of tissue retrieval, cryopreservation, and transplantation.

Psychosocial distress in young cancer survivors

OBJECTIVES

To review existing literature about the psychosocial reactions of cancer patients and provide information about the needs of patients wishing to preserve fertility.

DATA SOURCES

Journal articles, research studies.

CONCLUSION

The desire for biological parenthood is an important issue for cancer survivors. Patients may not receive accurate, timely information about fertility-sparing options; those not receiving this information are at increased risk for psychological distress.

IMPLICATIONS FOR NURSING PRACTICE

Fertility-preservation decisions are complex and a team approach may identify patients at risk for psychological distress and provide opportunities for discussion of psychosocial issues involved. Nurses must be informed about the emotional reactions and informational needs of their patients.

Four successful pregnancies in a patient with mucopolysaccharidosis type I treated by allogeneic bone marrow transplantation

To date, little is known about the fertility of women suffering from mucopolysaccharidosis type I (MPS I). We report on a female patient with MPS I treated by allogeneic bone marrow transplantation (BMT) at the age of 4 years (after a conditioning regimen containing busulfan 16 mg/kg and cyclophosphamide 100 mg/kg) who had four successful pregnancies without any reproductive assistance. Clinical and biological examinations of the children were normal. On the basis of this case, we discuss the fertility counselling of female MPS I patients at the time of BMT.

Female fertility preservation: practical and ethical considerations of an underused procedure

PURPOSE

Cancer treatments for young women can permanently or temporarily affect fertility. The purpose of this retrospective analysis was to present the clinical experience and ethical considerations of fertility preservation in female oncology patients in a tertiary gynaecological department.

METHODS

Since 2002, in 37 patients fertility preservation was performed according to an institutional review board approved protocol in a University hospital in the Netherlands; 33 patients were not treated.

RESULTS

Embryo cryopreservation was performed in 10 patients, ovarian tissue cryopreservation in 24, and an ovarian transposition was performed in 3 patients; in one patient combined with an ovarian transplantation and in one patient with ovarian tissue cryopreservation.

DISCUSSION

Approved protocols and timing are essential in performing female fertility preservation. Referral for ovarian tissue and embryo cryopreservation is minimal in the Netherlands. Future research focuses on the psychosocial aspects of fertility preservation and explores patients' and professionals' expectations and attitudes regarding fertility preservation and aims to be in line with technical developments.

Ovarian cryopreservation for fertility preservation: indications and outcomes

Female fertility preservation provides significantly different challenges to that for the male, with the only established method being cryopreservation of embryos thus necessitating the involvement of a male. Other, experimental, options include oocyte or ovarian tissue cryopreservation. The latter has been regarded as a potential method for more than a decade, but has resulted in the birth of only five babies. It is not possible to be certain how many women have had ovarian tissue cryopreserved. Oocyte cryopreservation also remains experimental, but approximately 100-fold more babies have been born through this technique over the last two decades. Ovarian tissue cryopreservation has the potential advantages of preservation of a large number of oocytes within primordial follicles, it does not require hormonal stimulation when time is short and indeed may be appropriate for the pre-pubertal. Disadvantages include the need for an invasive procedure, and the uncertain risk of ovarian contamination in haematological and other malignancies. We here review this approach in the context of our own experience of 36 women, highlighting issues of patient selection especially in the young, and uncertainties over the effects of cancer treatments on subsequent fertility. Of these 36 women, 11 have died but 5 have had spontaneous pregnancies. So far, none have requested reimplantation of their stored ovarian tissue. Ovarian cryopreservation appears to be a potentially valuable method for fertility preservation, but the indications and approaches best used remain unclear.

Fertility preservation in cancer patients

Fertility preservation is an important but often neglected need of cancer patients. There are several options available but many are considered experimental or are unproven. Most require interventions that can postpone the initiation of cancer treatment. The options include surgical procedures to move the ovaries out of the path of a radiation field, prophylactic medical therapy with gonadotropin-releasing hormone agonists and storage of gametes, embryos or gonadal tissue. Embryo freezing after conventional in vitro fertilization has a high success rate. Experimental fertility preservation procedures such as oocyte freezing and ovarian tissue cryopreservation/transplantation should be offered to cancer patients only under institutional review board oversight. Laparoscopic ovarian transposition is a viable option if radiotherapy is to be used alone. Oncologists, reproductive endocrinologists and other healthcare professionals should be part of a multidisciplinary team that offers cancer patients options to preserve their reproductive potential if they desire to do so.

Subfertility in children and young people treated for solid and haematological malignancies

Children treated for cancer may exhibit impaired fertility in later life. A number of chemotherapeutic agents have been identified as being gonadotoxic, and certain treatment regimens are particularly associated with subsequent infertility. Radiotherapy can also cause gonadal damage, most notably after direct testicular or pelvic irradiation or following total body irradiation. Because of the varied nature of the cytotoxic insult, it can be difficult to predict the likelihood of infertility in later life. Currently, cryopreservation of spermatozoa, oocytes or embryos is the only method of preserving fertility in patients receiving gonadotoxic therapy. This is only applicable to postpubertal patients and can be problematic in the adolescent age group. At present there is no provision for the prepubertal child, although there are a number of experimental methods being investigated. However, in addition to the many scientific and technical issues to be overcome before clinical application of such techniques, a number of ethical and legal issues must also be addressed to ensure a safe and realistic prospect for future fertility in these patients.

Fertility preservation for young patients with cancer: who is at risk and what can be offered?

Estimates suggest that by 2010, one in 715 people in the UK will have survived cancer during childhood. With increasing numbers of children cured, attention has focused on their quality of life. We discuss the causes of impaired fertility after cancer treatment in young people, and outline which patients are at risk and how their gonadal function should be assessed. With the report of a livebirth after orthotopic transplantation of cryopreserved ovarian tissue and the continued development of intracytoplasmic sperm injection for men with poor sperm quality, we assess established and experimental strategies to protect or restore fertility, and discuss the ethical and legal issues that arise.

Spontaneous conception in a young woman who had ovarian cortical tissue cryopreserved before chemotherapy and radiotherapy for a Ewing's sarcoma of the pelvis: Case report

We report the case of a 14 year old girl who presented with a non-metastatic Ewing's sarcoma involving her superior pubic ramus. She received 14 courses of alkylating agent-based chemotherapy and direct radiation to her hemi-pelvis (55 Gy) and is alive and disease-free 8 years later. Multiple biopsies of ovarian cortical tissue were cryopreserved, with her written consent, before treatment began. Ovarian failure was confirmed on completion of treatment with cessation of menses and persistently elevated serum gonadotrophin and low estradiol levels on repeated measurement over 2 years. HRT was initiated. Irregular vaginal bleeding occurred due to radiation vaginitis. Reimplantation of ovarian cortical tissue was considered at 19 years as fertility was desired, but the decision deferred. A spontaneous conception occurred 1 year later and a healthy boy (birthweight 2.9 kg, 3rd-10th centile) was delivered at term by elective Caesarean section. This is the first case of a spontaneous conception occurring in a young woman with documented ovarian failure in whom ovarian cortical tissue had been cryopreserved. Clinicians should be aware of the possibility of spontaneous conception despite confirmed ovarian failure in young women successfully treated for cancer.