A Review of the Oncology Patient's Challenges for Utilizing Fertility Preservation Services

An Examination of the Association Between Psychosocial Aspects of Fertility Issues and Demographic Characteristics of Unmarried Adolescent and Young Adult Cancer Survivors

Purpose: The purpose of this study was to examine the association between fertility issues and demographic characteristics of unmarried adolescent and young adult cancer survivors. Methods: We conducted a survey among cancer survivors who were 15-39 years old and unmarried at the time of cancer diagnosis and 20-45 years old at the time of the survey. Views on fertility issues, originally developed based on the results of a qualitative study conducted with the same inclusion criteria, were used to assess thoughts and feelings regarding fertility issues. Results: Through exploratory factor analysis of the 128 respondents who either had children or desired children, two factors related to fertility issues were identified: "anxiety related to the possibility of not being able to have children" and "pressure from others to have children." Multiple regression analysis was performed to examine the association between these factors and demographic characteristics. The analysis revealed that being male and having a partner were significant predictors for both factors for views on fertility issues. Additionally, younger age at the time of diagnosis was a significant predictor for the first factor. Conclusions: Greater fertility issues among unmarried cancer survivors were associated with younger age at diagnosis, having a partner, and being male. Surprisingly, contrary to previous findings, male cancer survivors experienced more significant fertility problems than women. This result may be attributed to the well-established gender roles in Japan, where men are predominantly considered the heirs and inheritors of the family.

The Status of Fertility Preservation (FP) Insurance Mandates and Their Impact on Utilization and Access to Care

Fertility preservation (FP) is the use of a specific medical intervention to protect the fertility of individuals whose disease or disease treatment may lead to infertility. These medical interventions include the cryopreservation of oocytes, embryos, ovarian tissue, sperm, and testicular tissue; oocyte and embryo cryopreservation are the most widely used interventions in the United States. Although guidelines recommend FP prior to undergoing gonadotoxic treatments, cost barriers are high. For example, the average cost of an oocyte cryopreservation cycle in the United States exceeds $10,000. High cost and lack of insurance coverage are two of the most cited reasons explaining the low Reproductive Endocrinology and Infertility (REI) referral rates and limited FP utilization. Broadening insurance mandates for FP prior to gonadotoxic treatments could improve utilization and provide cancer survivors with improved quality of life post treatment.

Pre-treatment fertility preservation and post-treatment reproduction in long-term survivors of adolescent and young adult (AYA) cancer

PURPOSE

To describe recall of fertility-related consultations and cryopreservation and to examine reproductive goals and reproduction post-treatment in long-term survivors of adolescent and young adult (AYA) (age, 18-39 years) cancer.

METHODS

This study included n = 1457 male and n = 2112 female long-term survivors (Mage = 43-45 years; 5-22 years from diagnosis) who provided self-report. Clinical data were supplied by the Netherlands Cancer Registry.

RESULTS

Most male survivors (72.7%) recalled fertility-related consultations and 22.6% completed sperm cryopreservation. Younger age (OR = 2.8; 95%CI [2.2-3.6]), not having children (OR = 5.0; 95%CI [3.2-7.7]), testicular cancer or lymphoma/leukemia (OR = 2.8/2.5 relative to "others"), and more intense treatments (OR = 1.5; 95%CI [1.1-2.0]) were associated with higher cryopreservation rates. Time since diagnosis had no effect. Of men who cryopreserved, 12.1% utilized assisted reproductive technologies (ART). Most men (88.5%) felt their diagnosis did not affect their reproductive goals, but 7.6% wanted no (additional) children due to cancer. Half of female survivors (55.4%; n = 1171) recalled fertility-related consultations. Rates of cryopreservation were very low (3.6%), but increased after 2013 when oocyte cryopreservation became non-experimental. Of women who cryopreserved, 13.2% successfully utilized ART. Most women (74.8%) experienced no effects of cancer on reproductive goals, but 17.8% wanted no (additional) children due to cancer.

CONCLUSIONS

Cryopreservation in men varied by patient/clinical factors and was very low in women, but data of more recently treated females are needed. Utilizing cryopreserved material through ART was rare, which questions its cost-effectiveness, but it may enhance survivors' well-being.

IMPLICATIONS FOR CANCER SURVIVORS

The extent to which cryopreservation positively affects survivors' well-being remains to be tested. Moreover, effects of cancer on reproductive goals require further attention, especially in women who refrain from having children due to cancer.

Experiences of Oncofertility Decision-Making and Care in a National Sample of Adolescent and Young Adult Cancer Patients and Parents

Purpose: Cancer and its treatments are known to compromise fertility in adolescents and young adults (AYAs). The emotional burden of possible infertility is reduced in those who receive supportive oncofertility care. In legal minors, provision of health care must consider the legal context and desire that AYAs have for autonomous decision-making, together with their competence to make health decisions. This has important implications for how oncofertility discussions may, or may not, involve parents. The aim of this study was to explore oncofertility decision-making and care experiences in a national Australian sample of AYA cancer patients and their parents. Methods: AYAs aged 15-25 years and parents were recruited from 17 cancer care sites and CanTeen Australia as part of a national AYA cancer care study. The cross-sectional survey included open-ended questions regarding oncofertility care experiences. We used reflexive thematic analysis to identify themes. Results: Data were available for 99 AYAs and 111 parents. Four themes were identified: emotional care needs; parent-AYA dynamics including AYA autonomy and agency; decision-making considerations including values and practicalities; and reflections on oncofertility care and follow-up. Both AYAs and parents placed importance on AYA autonomy in fertility decision-making, but many AYAs appreciated the role of parents in providing support and guidance throughout the process. Conclusion: Health care professionals are encouraged to autonomously engage AYAs around fertility decision-making, while concurrently offering opportunities that promote parental support. Better psychological support and follow-up oncofertility care are also needed.

Development, Usability Testing, and Implementation Assessment of Cancer Related Infertility Score Predictor, an Online Cancer Related Infertility Risk Counseling Tool

Purpose: Oncofertility counseling of female cancer patients lacks efficient access to tailored and valid infertility risk estimates to support shared decision-making on fertility preservation treatments. The objective was to develop, conduct user-centered design, and plan clinic-based implementation of the Cancer Related Infertility Score Predictor (CRISP), a web-based tool to support infertility risk counseling. Methods: Using a mixed methods design, literature review was undertaken to abstract data on infertility, primary ovarian insufficiency, and amenorrhea risks of common cancer treatments. The CRISP website was programmed to take user input about patient ages and cancer treatments and generate a risk summary. Using user experience methodology and semistructured interviews, usability testing and implementation assessment were conducted with 12 providers recruited from 5 medical centers in Southern California. Results: The web-based CRISP tool encompasses infertility risk data for 60 treatment regimens among 10 cancer types. Usability testing demonstrated that the tool is intuitive and informed minor modifications, including adding crowd-sourced submission of additional cancer treatments. Participants rated the tool as credible, advantageous over current provider methods to ascertain infertility risks, and useful for tailoring treatment planning and counseling patients. A key barrier was lack of information on some cancer treatments. Fit within clinical workflow was feasible, particularly with electronic health record integration. Conclusions: The novel, web-based CRISP tool is a feasible, acceptable, and appropriate tool to address provider knowledge gap about cancer related infertility risks and use for patient counseling. CRISP has significant potential to support tailored oncofertility counseling in the heterogeneous young cancer patient population.

Fertility preservation in reproductive-aged female patients with colorectal cancer: a scoping review

BACKGROUND

Colorectal cancer (CRC) incidence in adults younger than 50 years is steadily increasing in the USA, and treatment for CRC can impact future fertility. However, fertility decision-making in female patients with CRC can be complex, with fertility preservation (FP) counseling occurring inconsistently.

PURPOSE

The goal of this scoping review was to assess the literature regarding the frequency and quality of fertility preservation (FP) discussions taking place among oncology clinicians and their reproductive-age female patients with colorectal cancer (CRC) in order to identify existing gaps in care and inform future research, interventions, or potential changes in practice.

METHODS

A comprehensive literature search was conducted using the Ovid Medline, PsycInfo, and Scopus databases in order to identify studies pertaining to FP counseling in reproductive-age female patients with CRC. We used Covidence to screen studies for relevance and to extract data. Findings of interest included rate of fertility and/or FP discussions, patient characteristics associated with fertility discussions, initiators of discussions, rate of referrals to fertility specialists, patient utilization of FP services, and unmet fertility needs. We performed both quantitative and qualitative data synthesis.

RESULTS

We identified five studies that met our inclusion criteria, all published between 2007 and 2022. Frequency of fertility counseling discussions was low across studies, with a range of 15 to 52.5% of female patients with CRC receiving counseling. Patient characteristics which may be associated with likelihood of fertility discussion included age, parity, number of children, cancer location and stage, treatment type, and quality of life. The literature suggested that fertility discussions were initiated by clinicians about two-thirds of the time, and medical oncologists were the clinicians most likely to initiate. Studies did capture unmet fertility-related patient needs; participants who did not receive counseling often expressed desire for these discussions and regret that they did not occur.

CONCLUSION

Despite increasing incidence of CRC in patients at younger ages, this scoping review found a dearth of research conducted on young female CRC patients' experiences with fertility counseling and referrals. Notably, the existing research reveals that relatively few of these patients are receiving appropriate counseling. Additional research is needed to clarify current FP counseling practices, patient and clinician perceptions about FP, and ways to improve the quantity and quality of FP counseling in this patient population.

Optimizing health literacy to facilitate reproductive health decision-making in adolescent and young adults with cancer

Despite being considered "standard of care" by many organizations, fertility and reproductive health communications and counseling practices remain inconsistent for adolescents and young adults (AYAs) newly diagnosed with cancer and during survivorship. One factor known to affect how information is provided and received in the medical setting is health literacy. Providers should consider health literacy to optimize reproductive health communication with AYAs as they cope with their diagnosis, understand what it means for their future, process information about treatment options, learn about their potential harmful effects on fertility, make quick decisions about fertility preservation, and navigate a future family planning course. Thus, the objectives of this manuscript are to (a) summarize literature on reproductive health literacy; (b) describe health literacy frameworks; (c) examine ways to assess health literacy; and (d) identify ways to enhance clinician-patient communication in the AYA oncofertility setting.

Body image disturbances in adolescent and young adult cancer patients confronting infertility risk and fertility preservation decisions

PURPOSE

Body image is a major psychosocial concern for all cancer patients but can affect the adolescent and young adult (AYA) population in distinct ways. Similarly, the prospect of infertility and the fertility preservation process can create additional stress during cancer treatment. Discussions regarding infertility inherently implicate the body and its reproductive function, but downstream effects on self-perception have not been previously described. The aim of this study was to explore the experiences of AYAs as they considered their risk of infertility and options for fertility preservation (FP), specifically the ways in which this impacted body image and FP decision-making.

METHODS

AYA cancer patients (n = 27) aged 12-25 years whose cancer and treatment conferred risk of infertility were recruited through electronic health record query at an NCI-Designated Comprehensive Cancer Center. Participants completed semi-structured interviews, which were recorded, transcribed, and deductively coded for themes related to information needs, knowledge of treatment effects on fertility, and reproductive concerns after cancer. Emergent, inductive themes related to body image were identified.

RESULTS

Body image concerns, related to both physical appearance and body functioning emerged. Common concerns included anticipating change as it pertains to the body and its functions, physical discomfort, fear of judgment, and meeting expectations of the body. While these themes are broad in nature, they have been previously explored in relation to body image in general and their emergence in the oncofertility space provides guidance for further optimization of infertility and fertility preservation discussions.

CONCLUSIONS

AYA cancer patients experience a multitude of body image related disturbances when faced with the possibility of infertility and fertility preservation. In identifying and exploring these themes, future opportunities for improving oncofertility practice and discussions among AYAs with a focus on body image positivity are called upon.

Sexual Health and Quality of Life in Cancer Survivors With Pelvic Radiation Injuries

BACKGROUND

Little knowledge exists on how late radiation tissue injuries (LRTIs) affect sexual health and health-related quality of life (HRQOL) in pelvic cancer survivors.

OBJECTIVE

To explore sexual health and HRQOL in cancer survivors with pelvic LRTI.

METHOD

A descriptive cross-sectional study was conducted, including 83 pelvic cancer survivors with LRTI. Data on sexual health, LTRIs, and HRQOL were collected by validated questionnaires, whereas medical variables were collected from medical records.

RESULTS

Participants' sexual health was severely impaired. Bowel and urinary LRTIs correlated with most of the symptoms of impaired sexual health (Pearson r = -0.241 to -0.376, P < .05-.01). Men and women reported different sexual challenges related to functional and symptomatic variables but not on the gender-neutral aspects of sexual health. Younger survivors, gynecological cancer survivors, or those who received external and internal radiation or additional chemotherapy reported significantly (P < .05-.001) higher levels of sexual impairment. Participants' HRQOL was impaired. Several dimensions of sexual health correlated significantly (P < .05-.001) with the functional dimensions of reduced HRQOL.

CONCLUSION

Cancer survivors with pelvic LRTIs experience severely impaired sexual health across genders, with negative consequences for their HRQOL.

IMPLICATIONS FOR PRACTICE

Healthcare professionals should include sexual health as an important part of individual patients' health and HRQOL throughout their treatment trajectory and follow-up, by screening sexual health, implementing measures and interventions to promote sexual health, and supporting survivors' coping and health-promoting strategies.

Fertility Preservation in Young Women With Breast Cancer: A Review

Fertility preservation is a major concern in young patients diagnosed with breast cancer and planning to receive multimodality treatment, including gonadotoxic chemotherapy with or without age-related decline through long-term endocrine therapy. Most breast cancer patients undergo multimodality treatments; many short-term and long-term side effects arise during these therapies. One of the most detrimental side effects is reduced fertility due to gonadotoxic treatments with resultant psychosocial stress. Cryopreservation of oocytes, embryos, and ovarian tissue are currently available fertility preservation methods for these patients. As an adjunct to these methods, in vitro maturation or gonadotropin-releasing hormone agonist could also be considered. It is also essential to communicate well with patients in the decision-making process on fertility preservation. It is essential to refer patients diagnosed with breast cancer on time to fertility specialists for individualized treatment, which may lead to desirable outcomes. To do so, a multimodal team-based approach and in-depth discussion on the treatment of breast cancer and fertility preservation is crucial. This review aims to summarize infertility risk related to currently available breast cancer treatment, options for fertility preservation and its details, barriers to oncofertility counseling, and psychosocial issues.

Websites about, not for, adolescents? A systematic analysis of online fertility preservation information for adolescent and young adult cancer patients

PURPOSE

Fertility preservation is an increasingly important topic in adolescent and young adult cancer survivorship, yet treatments remain under-utilized, possibly due to lack of awareness and understanding. The internet is widely used by adolescents and young adults and has been proposed to fill knowledge gaps and advance high-quality, more equitable care. As a first step, this study analyzed the quality of current fertility preservation resources online and identified opportunities for improvement.

METHODS

We conducted a systematic analysis of 500 websites to assess the quality, readability, and desirability of website features, and the inclusion of clinically relevant topics.

RESULTS

The majority of the 68 eligible websites were low quality, written at college reading levels, and included few features that younger patients find desirable. Websites mentioned more common fertility preservation treatments than promising experimental treatments, and could be improved with cost information, socioemotional impacts, and other equity-related fertility topics.

CONCLUSIONS

Currently, the majority of fertility preservation websites are about, but not for, adolescent and young adult patients. High-quality educational websites are needed that address outcomes that matter to teens and young adults, with a priority on solutions that prioritize equity.

IMPLICATIONS FOR CANCER SURVIVORS

Adolescent and young adult survivors have limited access to high-quality fertility preservation websites that are designed for their needs. There is a need for the development of fertility preservation websites that are clinically comprehensive, written at appropriate reading levels, inclusive, and desirable. We include specific recommendations that future researchers can use to develop websites that could better address AYA populations and improve the fertility preservation decision making process.

Websites about, not for, adolescents? A systematic analysis of online fertility preservation information for adolescent and young adult cancer patients

Purpose Fertility preservation is an increasingly important topic in adolescent and young adult cancer survivorship, yet treatments remain under-utilized, possibly due to lack of awareness and understanding. The internet is widely used by adolescents and young adults and has been proposed to fill knowledge gaps and advance high-quality, more equitable care. As a first step, this study analyzed the quality of current fertility preservation resources online and identified opportunities for improvement. Methods We conducted a systematic analysis of 500 websites to assess the quality, readability, and desirability of website features, and the inclusion of clinically relevant topics. Results The majority of the 68 eligible websites were low quality, written at college reading levels, and included few features that younger patients find desirable. Websites mentioned more common fertility preservation treatments than promising experimental treatments, and could be improved with cost information, socioemotional impacts, and other equity-related fertility topics. Conclusions Currently, the majority of fertility preservation websites are about, but not for, adolescent and young adult patients. High-quality educational websites are needed that address outcomes that matter to teens and young adults, with a priority on solutions that prioritize equity. Implications for Cancer Survivors: Adolescent and young adult survivors have limited access to high-quality fertility preservation websites that are designed for their needs. There is a need for the development of fertility preservation websites that are clinically comprehensive, written at appropriate reading levels, inclusive, and desirable. We include specific recommendations that future researchers can use to develop websites that could better address AYA populations and improve the fertility preservation decision making process.

Adolescent and young adult cancers: unmet needs and closing the gaps

PURPOSE OF REVIEW

There is a growing population of adolescent and young adult (AYA, ages 15-39 years) cancer patients and survivors, and the field of AYA oncology is rapidly evolving. Despite an increased focus on survival and quality of life for AYAs, gaps in knowledge remain. The current review focuses on what is known across several domains unique to AYA cancer care as well as areas of improvement and future directions in research and intervention.

RECENT FINDINGS

Due to the developmental stages included in the AYA age range, a cancer diagnosis and treatment can affect relationships, education and employment, finances, and long-term health differently than diagnoses in younger or older populations. Recent studies that have focused on these unique aspects of AYA cancer care, including health-related quality of life (HRQoL), fertility, financial toxicity, barriers to clinical trial enrollment, genetic predisposition, and survivorship care are included in the current review.

SUMMARY

Although studies have described many of the challenges faced by AYAs across the cancer continuum from diagnosis to survivorship, more work is needed, particularly in systematically measuring HRQoL, eliminating barriers to clinical trial enrollment, addressing financial toxicity, and increasing access to fertility preservation and high-quality survivorship care.

Fertility preservation for women with breast cancer: a multicentre randomized controlled trial on various ovarian stimulation protocols

STUDY QUESTION

Does ovarian stimulation with the addition of tamoxifen or letrozole affect the number of cumulus-oocyte complexes (COCs) retrieved compared to standard ovarian stimulation in women with breast cancer who undergo fertility preservation?

SUMMARY ANSWER

Alternative ovarian stimulation protocols with tamoxifen or letrozole did not affect the number of COCs retrieved at follicle aspiration in women with breast cancer.

WHAT IS KNOWN ALREADY

Alternative ovarian stimulation protocols have been introduced for women with breast cancer who opt for fertility preservation by means of banking of oocytes or embryos. How these ovarian stimulation protocols compare to standard ovarian stimulation in terms of COC yield is unknown.

STUDY DESIGN, SIZE, DURATION

This multicentre, open-label randomized controlled superiority trial was carried out in 10 hospitals in the Netherlands and 1 hospital in Belgium between January 2014 and December 2018. We randomly assigned women with breast cancer, aged 18–43 years, who opted for banking of oocytes or embryos to one of three study arms; ovarian stimulation plus tamoxifen, ovarian stimulation plus letrozole or standard ovarian stimulation. Standard ovarian stimulation included GnRH antagonist, recombinant FSH and GnRH agonist trigger. Randomization was performed with a web-based system in a 1:1:1 ratio, stratified for oral contraception usage at start of ovarian stimulation, positive estrogen receptor (ER) status and positive lymph nodes. Patients and caregivers were not blinded to the assigned treatment. The primary outcome was number of COCs retrieved at follicle aspiration.

PARTICIPANTS/MATERIALS, SETTING, METHODS

During the study period, 162 women were randomly assigned to one of three interventions. Fifty-four underwent ovarian stimulation plus tamoxifen, 53 ovarian stimulation plus letrozole and 55 standard ovarian stimulation. Analysis was according to intention-to-treat principle.

MAIN RESULTS AND THE ROLE OF CHANCE

No differences among groups were observed in the mean (±SD) number of COCs retrieved: 12.5 (10.4) after ovarian stimulation plus tamoxifen, 14.2 (9.4) after ovarian stimulation plus letrozole and 13.6 (11.6) after standard ovarian stimulation (mean difference −1.13, 95% CI −5.70 to 3.43 for tamoxifen versus standard ovarian stimulation and 0.58, 95% CI −4.03 to 5.20 for letrozole versus standard ovarian stimulation). After adjusting for oral contraception usage at the start of ovarian stimulation, positive ER status and positive lymph nodes, the mean difference was −1.11 (95% CI −5.58 to 3.35) after ovarian stimulation plus tamoxifen versus standard ovarian stimulation and 0.30 (95% CI −4.19 to 4.78) after ovarian stimulation plus letrozole versus standard ovarian stimulation. There were also no differences in the number of oocytes or embryos banked. There was one serious adverse event after standard ovarian stimulation: one woman was admitted to the hospital because of ovarian hyperstimulation syndrome.

LIMITATIONS, REASONS FOR CAUTION

The available literature on which we based our hypothesis, power analysis and sample size calculation was scarce and studies were of low quality. Our study did not have sufficient power to perform subgroup analysis on follicular, luteal or random start of ovarian stimulation.

WIDER IMPLICATIONS OF THE FINDINGS

Our study showed that adding tamoxifen or letrozole to a standard ovarian stimulation protocol in women with breast cancer does not impact the effectiveness of fertility preservation and paves the way for high-quality long-term follow-up on breast cancer treatment outcomes and women’s future pregnancy outcomes. Our study also highlights the need for high-quality studies for all women opting for fertility preservation, as alternative ovarian stimulation protocols have been introduced to clinical practice without proper evidence.

STUDY FUNDING/COMPETING INTEREST(S)

The study was supported by a grant (2011.WO23.C129) of ‘Stichting Pink Ribbon’, a breast cancer fundraising charity organization in the Netherlands. M.G., C.B.L. and R.S. declared that the Center for Reproductive Medicine, Amsterdam UMC (location VUMC) has received unconditional research and educational grants from Guerbet, Merck and Ferring, not related to the presented work. C.B.L. declared a speakers fee for Inmed and Yingming. S.C.L. reports grants and non-financial support from Agendia, grants, non-financial support and other from AstraZeneca, grants from Eurocept-pharmaceuticals, grants and non-financial support from Genentech/Roche and Novartis, grants from Pfizer, grants and non-financial support from Tesaro and Immunomedics, other from Cergentis, IBM, Bayer, and Daiichi-Sankyo, outside the submitted work; In addition, S.C.L. has a patent UN23A01/P-EP pending that is unrelated to the present work. J.M.J.S. reported payments and travel grants from Merck and Ferring. C.C.M.B. reports her role as unpaid president of the National guideline committee on Fertility Preservation in women with cancer. K.F. received unrestricted grants from Merck Serono, Good Life and Ferring not related to present work. K.F. declared paid lectures for Ferring. D.S. declared former employment from Merck Sharp & Dohme (MSD). K.F. declared paid lectures for Ferring. D.S. reports grants from MSD, Gedeon Richter and Ferring paid to his institution; consulting fee payments from MSD and Merck Serono paid to his institution; speaker honoraria from MSD, Gedeon Richter, Ferring Pharmaceuticals and Merck Serono paid to his institution. D.S. has also received travel and meeting support from MSD, Gedeon Richter, Ferring Pharmaceuticals and Merck Serono. No payments are related to present work.

TRIAL REGISTRATION NUMBER

NTR4108.

TRIAL REGISTRATION DATE

6 August 2013.

DATE OF FIRST PATIENT’S ENROLMENT

30 January 2014.

Factors Associated with Adolescent and Young Adult Males with Cancer Attending Fertility Consultation: A Population-Based Cohort Study in Ontario, Canada

Purpose: Cancer and its treatment can impair fertility in men. It is recommended that they be referred for fertility consultation before the start of treatment. This study examined factors associated with men attending a fertility consultation within 30 days of diagnosis. Methods: Males 15 to 39 years of age, diagnosed with cancer in Ontario, Canada, between 2006 and 2019, were identified from the Ontario Cancer Registry. Linked administrative data were used to obtain other clinical and sociodemographic variables. The main outcome was a fertility consultation within 30 days of diagnosis, defined using Ontario Health Insurance Plan billing codes (606 or 628). A backward selection multivariate logistic regression was performed. Results: Of 13,720 cases identified, 8.5% attended a fertility consultation within 30 days of diagnosis. A more recent year of diagnosis (odds ratio [OR] = 5.5; 95% confidence interval [CI] 4.6-6.6), living in an urban area (OR = 1.3; 95% CI 1.0-1.8), receiving radiation therapy (OR = 1.4; 95% CI 1.2-1.6), chemotherapy (OR = 1.9; 95% CI 1.6-2.2), and reproductive organ-related cancer surgery (OR = 1.5; 95% CI 1.2-1.7) were associated with a greater likelihood of attending a consultation. Older age (OR = 0.2; 95% CI 0.1-0.2), living in a northern region (OR = 0.3; 95% CI 0.2-0.5), having a cancer with low (OR = 0.3; 95% CI 0.2-0.4) or moderate risk to fertility (OR = 0.6; 95% CI 0.5-0.7), and residing in a neighborhood with lower income (OR = 0.4; 95% CI 0.3-0.5) or residential instability quintile (OR = 0.8; 95% CI 0.6-1.0) were associated with being less likely to attend a consultation. Conclusion: Although rates of fertility consultation have increased over time, these remain low in various clinical and demographic groups. Funding for fertility preservation appears to have had an important impact on fertility consultation in young men with cancer.

Nurse’s perceptions of support for sexual and reproductive issues in adolescents and young adults with cancer

Adolescent and young adult (AYA) with cancer are at risk for developing sexual and reproductive problems; therefore, they have special needs. AYA with cancer treated in both pediatric and adult wards are a minority in Japan; thus, accumulating experience for supporting this unique patient population is difficult for nurses. Hence, this study aimed to clarify nurses’ perceptions on support for sexual and reproductive issues among AYA with cancer. A questionnaire survey was administered to nurses at designated cancer hospitals across Japan who had been working for at least 1 year in a department involved in the treatment or follow-up of patients aged 15–39 years. Nurses were asked regarding their perceptions on support for sexual and reproductive issues faced by AYA with cancer. A total of 865 nurses responded to this survey; nurses affiliated with adult departments, those with more experience in cancer nursing, those affiliated with cancer-related academic and professional societies, and certified nurse specialists or certified nurses significantly recognized insufficient support for sexual and reproductive issues. However, nurses were hesitant and found it difficult to intervene in such issues. Nurses recognized the importance of providing support for sexual and reproductive issues but faced difficulties in addressing them. They need to discuss these issues and improve the care provided to AYA with cancer.

Evaluation of a Mobile Health App Offering Fertility Information to Male Patients With Cancer: Usability Study

Background

Cancer and its treatment can adversely affect male fertility. Although sperm banking is an effective fertility preservation method, there is an unmet need for information and support surrounding these issues.

Objective

This usability study evaluates a mobile health app providing male patients with cancer with credible information about the impact of cancer and its treatment on fertility and fertility preservation.

Methods

Participants were recruited by a market research firm. Eligibility criteria were men who were 18-45 years of age, identified as male, diagnosed with new or recurring cancer within 1 year, not in fertility treatment, able to read and write in English or French, and had internet access. App usage was tracked for 2 weeks. After app use, participants provided qualitative feedback about their experiences using the app as well as quantitative data regarding their sperm banking decisions, perceived change in fertility knowledge, evaluation of the app’s information on the Information Assessment Method, and the app’s quality on the user version of the Mobile App Rating Scale.

Results

The sample included 40 men aged 27-45 years. Approximately 68% (27/40) indicated that no one had previously spoken to them about the impact of cancer on fertility, and 85% (34/40) had not received information on fertility preservation. Approximately 83% (33/40) found the app’s information relevant, and 85% (34/40) said that it increased their fertility knowledge. Approximately 23% (9/40) made a decision about sperm banking after using the app. Participants rated the app’s quality highly, with mean scores (out of 5) of 4.14 for information, 4.06 for functionality, 3.84 for aesthetics, and 3.63 for engagement.

Conclusions

The app proved to be useful for male patients with cancer, suggesting that mobile health resources could be beneficial to incorporate into clinical care to enable shared decision-making about fertility.

A Federated Blockchain Approach for Fertility Preservation and Assisted Reproduction in Smart Cities

Modern life is making people infertile. Giving birth later in life is wreaking havoc on our fertility and threatening human survival. Smart cities intend to optimize the quality of life of their citizens by utilizing technology for smarter living. This research first identifies the requirements and business opportunities of using advanced technology for smarter fertility preservation and assisted reproduction in smart cities. A federated blockchain approach is proposed for the alliance of integrated commercial egg banks (ICEBs). In particular, we designed a membership fee rebate (MFR) mechanism that offers incentives for blockchain creations in the egg banking alliance. We formulated the MFR problem into a leader–followers Stackelberg game whose objectives are (1) to maximize the benefits of forming the alliance (the leader) and (2) to maximize the benefits in each ICEB (the follower). We developed an iterative scheme that utilizes mathematical programming techniques to solve the two-level, Stackelberg game problem. With a given set of parameters of the alliance and membership fee function, and the average number of blocks generated for an oocyte, the iterative scheme achieves the optimal solution for the MFR rate per block created. A numerical example demonstrates the feasibility and applicability of the proposed iterative scheme. Numerical results show that it achieves good solutions in adding a small to medium-sized new ICEB to the existing alliance. The proposed federated approach lays the foundation for developing a blockchain-based egg banking platform.

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.

Study protocol for fertility preservation discussions and decisions: A family-centered psychoeducational intervention for male adolescents and emerging adults newly diagnosed with cancer and their families

Many childhood cancer survivors desire biological children but are at risk for infertility after treatment. One option for mitigating risk is the use of fertility preservation prior to gonadotoxic therapy. Adolescents and emerging adults may rely on their parents to help them decide whether to use fertility preservation. While this is often a collaborative process, it is currently unknown how parents can optimally support adolescents and emerging adults through this decision. To address this gap, we developed a family-centered, psychoeducational intervention to prompt adolescents and emerging adults to reflect on their future parenthood goals and attitudes towards fertility preservation, as well as to prompt their parents (or other caregivers) to reflect on their own and their child's perspectives on the topic. In this randomized controlled trial, families will be randomized to either the standard of care control group (fertility consult) or the intervention group. After their fertility consult, adolescents and emerging adults and parents in the intervention group will complete a fertility preservation values clarification tool and then participate in a guided conversation about their responses and the fertility preservation decision. The primary expected outcome of this study is that participation in the intervention will increase the use of fertility preservation. The secondary expected outcome is an improvement in decision quality. Chi-square analyses and t-tests will evaluate primary and secondary outcomes. The goal of this intervention is to optimize family-centered fertility preservation decision-making in the context of a new cancer diagnosis to help male adolescents and emerging adults achieve their future parenthood goals.

Fertility Preservation During the COVID-19 Pandemic: Modified But Uncompromised

Purpose: Throughout COVID-19, our clinic remained operational for patients requiring urgent fertility preservation (FP). This study aimed to characterize changes to clinical protocols during the first wave of COVID-19 and compare outcomes to historical controls.

Methods: We performed a retrospective cohort study at a university fertility center examining all patients who underwent medically indicated FP cycles during the American Society for Reproductive Medicine (ASRM) COVID-19 Task Force-recommended suspension of fertility treatment (March 17–May 11, 2020) and patients from the same time period in 2019. FP care was modified for safety during the first wave of COVID-19 with fewer monitoring visits and infection control measures. FP cycle characteristics and outcomes were compared across years.

Results: The volume of cycles was nearly 30% higher in 2020 versus 2019 (27 vs. 19). Diagnoses, age, and anti-Mullerian hormone were similar between cohorts. More patients elected to pursue embryo cryopreservation over oocyte cryopreservation in 2020 versus 2019 (45.8% vs. 5.2%, p < 0.005). Patients managed during COVID-19 had fewer monitoring visits (5 ± 1 vs. 6 ± 1, p = 0.02), and 37.5% of cycles utilized a blind trigger injection. There was no difference in total days of ovarian stimulation (11 ± 1 vs. 11 ± 2, p > 0.05), but 2020 cycles utilized more gonadotropin (4770 ± 1480 vs. 3846 ± 1438, p = 0.04). There was no difference in total oocytes retrieved (19 ± 14 vs. 22 ± 12, p > 0.05) or mature oocytes vitrified (15 ± 12 vs. 17 ± 9, p > 0.05) per cycle.

Conclusions: FP continued during COVID-19, and more cycles were completed in 2020 versus 2019. Despite minimized monitoring, outcomes were optimal and equivalent to historical controls, suggesting FP care can be adapted without compromising outcomes.

The evolving role of the Women's Health Specialist in cancer prevention and survivorship

IMPORTANCE AND OBJECTIVE

This review provides a framework for primary care physicians, internists, family doctors, NP's, PA's, and oncologists caring for women-henceforth referred to as Women's Health Specialists-to identify and screen patients who may be at high risk for inherited cancer syndromes; an intervention referred to as previvorship care. For women who undergo risk-reducing oophorectomy, survivorship care is critical to optimizing quality of life thereafter. In this paper, we review management of the unique survivorship needs and management options for women at risk for or with a cancer diagnosis, highlighting the importance of interdisciplinary care.

METHODS

To review the available previvorship and survivorship management strategies, a Pub Med search was performed using keywords "survivorship," "genetics," "cancer," "menopause," "hormone therapy," "screening" in addition to review of guidelines, position statements and expert, and committee opinions from the American College of OBGYN, the American Society of Clinical Oncology, The North American Menopause Society, the National Comprehensive Cancer Network , and the American Society for Reproductive Medicine.

DISCUSSION AND CONCLUSION

Women's Health Specialists are in a unique position to identify and screen women who may be at risk for inherited cancer syndromes as well as provide necessary survivorship management following transition from their oncologists' care.

A review of methods for preserving male fertility

Male infertility is responsible for 50% of men's health problems and has always been a concern for personal and social issues. A survey of global statistics suggests an increase in infertility rate as one of the critical issues documented in studies. There are different ways of maintaining fertility in men, depending on their age. In this paper, we review the preservation methods used for fertility treatment in Iran and other countries. Available data were reviewed from Google Scholar, PubMed, Scopus, Web of Science, IranMedex, MEDLIB, IranDoc and Scientific Information Database and searched for articles published up to 2018, using the medical subject heading (MeSH) terms for cryopreservation, sperm, testicular, spermatogonia stem cell, male infertility and/or Iranian and in the world, to provide evidence from evaluation of fertility preservation the methods. Based the search strategy, 274 manuscripts were found. After reviewing the titles, abstracts and manuscripts in their entirety, 119 articles were obtained and selected according to the eligibility criteria. The 85 studies mentioned above were divided into three categories (sperm, testis, and spermatogonia stem cells (SSCs)), and methods of fertility preservation were investigated. Ways to maintain male fertility were different depending on age, and included sperm, testicular, and SSC freezing. The number of studies on testicular tissue and SSCs was low for human samples, and more studies are still needed. Sperm freezing at infertility centres is the top for male fertility preservation.

Addressing Barriers to Fertility Preservation for Cancer Patients: The Role of Oncofertility Patient Navigation

BACKGROUND

Infertility is a common late effect for cancer survivors. Whereas assisted reproductive technology has made it possible for survivors to take steps to preserve fertility before starting treatment, only a minority of patients proceed with preservation. Patient-, provider-, health system-, and societal-level barriers to fertility preservation (FP) exist. Oncofertility patient navigation is a valuable resource for addressing FP barriers.

OBJECTIVES

To highlight the critical role of oncofertility patient navigation in addressing barriers to FP within an academic oncofertility program.

METHODS

The role of the oncofertility patient navigator in reducing FP barriers, promoting informed decision-making, and ensuring program sustainability is described. Program metrics illustrating the impact of oncofertility patient navigation on referrals for FP counseling and access to FP in the last year also are provided.

DISCUSSION

The oncofertility program at our academic adult and pediatric medical centers aims to facilitate rapid referral to fertility counseling and preservation services for postpubertal cancer patients. The patient navigator is integral to the success of the program. The navigator ensures that patients are: (1) well-informed about the potential impact of cancer on fertility and FP options, (2) aware of available resources (eg, financial) for pursuing FP, (3) able to access FP services if desired, and (4) well supported in making an informed FP decision. The inclusion of the patient navigator has led to an almost 2-fold increase in referrals for FP counseling in the past year over the historic annual average.

CONCLUSIONS

Our institution's oncofertility program, with patient navigation at the core, provides a potential model for increasing patient access to oncofertility care and promoting program sustainability. Oncofertility patient navigation is a valuable resource for providing patients and families with education and support regarding FP decision-making, as well as addressing the multilevel barriers to FP.

Oncofertility Knowledge and Communication: Comparison Between Medical and Surgical Oncologists and Breast Cancer Patients in Academic Chinese Centers

Background: As cancer has become a major public health issue in China, fertility preservation remains limited despite the wide application of Assisted Reproductive Technology (ART) throughout the country.

Objective: This study aimed to identify gaps in knowledge and communication as well as referrals in the previous year regarding oncofertility among medical and surgical oncologists and breast cancer patients (BCPs) in Chinese academic settings to target areas of needed improvement.

Materials and Methods: A WeChat online questionnaire was designed, distributed, and compared between medical and surgical oncology specialists and reproductive age BCPs in academic teaching settings in Shanghai.

Results: Sixty-one medical and surgical oncologists and 125 BCPs responded to the survey. 63.3% of oncologists were familiar with the term “oncofertility” compared to 25.6% of BCPs (p < 0.001). Oncologists were more likely to correctly know the costs associated with treatment (59.0 vs. 32.0%, p < 0.001); patient did not have to be married to undergo oncofertility treatment (50.8 vs. 24.8%, p < 0.001). Both oncologists and BCPs were similarly unlikely to know when patients could utilize cryopreserved tissue in the future (37.7 vs. 22.2%, p = 0.056). While oncologists reported they discussed all oncofertility options (41.0%) and offered psychological counseling (98.4%), significantly fewer BCPs reported receiving information on all options and offered counseling (3.2%, p < 0.001 and 85.6%, p < 0.01). Knowledge of oncofertility was the most important predictor for providing and receiving counseling from oncologists [OR = 6.44 (95% CI = 1.59–26.1, p = 0.009] and BCPs (OR = 3.73 95% CI: = 1.36–10.2, p = 0.011). Overall, 57.4% of oncologists referred <10 patients and none referred more than 25 patients in the past year.

Conclusion: Data suggests a significant knowledge gap and ineffective communication/comprehension exists between academic Chinese oncologists and BCPs. Continued education and raised awareness are needed to optimize utilization of oncofertility services in China.

An Integrative Review of the Role of Nurses in Fertility Preservation for Adolescents and Young Adults With Cancer

PROBLEM IDENTIFICATION

Adolescents and young adults (AYAs) with cancer commonly report future fertility as an important issue in care. Despite long-standing guidelines on fertility counseling and the trusting relationship between nurses and patients, little is known about the nurse's role in fertility preservation (FP) for AYAs with cancer.

LITERATURE SEARCH

The authors conducted a literature search of articles published through 2020 focused on nursing involvement in FP for AYAs with cancer.

DATA EVALUATION

85 studies were identified. In total, 11 articles met inclusion criteria and were critically appraised in the review.

SYNTHESIS

Although well positioned to improve FP care among AYAs with cancer, nurses currently have a minimal role because of provider, institutional, and patient-related barriers.

IMPLICATIONS FOR PRACTICE

Interventions to enhance nurses' knowledge about FP, improvements in electronic health record documentation, and facilitation of institutional support are needed to support the nurse's role in FP for AYAs with cancer.

Predictive factors for fertility preservation in pediatric and adolescent girls with planned gonadotoxic treatment

PURPOSE

To characterize female pediatric and adolescent patients seen for fertility preservation consultation at an academic medical center and to describe the association between demographic or clinical factors and the use of fertility preservation treatment (FPT).

METHODS

This is a retrospective chart analysis of female pediatric and adolescent patients seen for fertility preservation consultation at an academic fertility center over a 14-year period from 2005 to 2019.

RESULTS

One hundred six females aged 3-21 years were seen for fertility preservation consultation with a mean age of 16.6 years. Diagnoses included hematologic malignancies (41.5%), gynecologic malignancies (9.4%), other malignancies (31.1%), non-malignant hematologic disease (14.2%), and non-malignant conditions (3.8%). Overall, 64.2% of subjects pursued fertility preservation, including oocyte cryopreservation (35.8%) and ovarian tissue cryopreservation (23.6%). Overall, age, minority race, diagnosis, time since diagnosis, and median household income were not significantly associated with odds of completing an FPT procedure. Among all patients, those who underwent gonadotoxic therapy prior to consultation had a lower odds of receiving FPT (OR= 0.24, 95% CI 0.10-0.55). Among patients without chemotherapy exposure, no factors were associated with FPT.

CONCLUSIONS

Among pediatric and adolescent patients at an academic center undergoing a fertility preservation consultation, there were no socioeconomic or clinical barriers to FPT use in those who had not yet undergone gonadotoxic therapy. The only factor that was negatively associated with odds of pursuing FPT was prior chemotherapy exposure.

A call to action: unified clinical practice guidelines for oncofertility care

By 2030, WHO estimates that 1.4 million reproductive-aged women will be diagnosed with cancer annually. Fortunately, cancer is no longer considered an incurable disease in many cases. From 2008-2014, 85% of women under the age of 45 years diagnosed with cancer survived. This increase in survival rate has shifted attention from focusing exclusively on preserving life to focusing on preserving quality of life after treatment. One aspect of this is preserving the ability to have a biological family. Oncofertility, the field that bridges oncology and reproductive endocrinology with the goal of preserving fertility, offers these patients hope. Though it is clear that ASCO and ASRM recognize the importance of fertility preservation as an aspect of comprehensive oncology care, there are not yet unified guidelines for oncologists and fertility specialists for treating oncofertility patients. First, we identify the need for reproductive counseling prior to cancer treatment, as many patients report that their fertility preservation concerns are not addressed adequately. We then delineate multi-modal fertility preservation options that are available and appropriate for different patients with corresponding outcomes using different treatments. We discuss the unique challenges and considerations, including ethical dilemmas, for delivering timely and comprehensive care specifically for oncofertility patients. Finally, we address the multidisciplinary team that includes oncologists, reproductive endocrinologists, surgeons as well as their staff, nurses, genetic counselors, mental health professionals, and more. Since oncofertility patient care requires the coordination of both physician teams, one set of unified guidelines will greatly improve quality of care.

Childbearing vs. clinical trial participation: is it one or the other?

Recent advances have shed light on the importance of early therapeutic intervention for neurodegenerative diseases. Primary prevention trials present a potential disease-modifying strategy for pre-symptomatic patients of autosomal dominant neurodegenerative diseases (ADND), such as early onset familial Alzheimer's disease (AD) and Huntington's disease (HD). As trials target earlier disease stages, however, prospective participants face new ethical and logistical challenges, namely childbearing and reproductive health decisions. Since pregnancy is an exclusion criteria for such trials, participants of reproductive age must choose between participating in research and having a family. Such decisions carry significant burdens for ADND patients that if left unaddressed could impact patient well-being and the field as whole. We use our perspective as scientists, advocates, and ADND family members to highlight current shortcomings in the field regarding trial participation and family planning issues for ADND patients and call for the establishment of a normative standard to address these concerns.

The Educational Program for Healthcare Providers Regarding Fertility Preservation for Cancer Patients: a Systematic Review

The emerging discipline of oncofertility advocates for the timely provision of fertility preservation (FP) to all cancer patients of childbearing age by healthcare providers. A lack of practice due to limited FP-related knowledge was found among healthcare providers. A systematic review was undertaken on the educational programs on FP for healthcare providers. An initial search was performed in MEDLINE, PsycINFO, CINAHL, Web of Science, PubMed, and Scopus databases in October 2019. This review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Among the 160 articles that were identified, five relevant articles published between 2009 and 2019 were reviewed. Of the five studies, three were quantitative nonrandomized studies, one was a randomized controlled trial, and one was a qualitative study. Three programs were relevant to oncology nurses, one was relevant to social workers as well as nurses, and one was relevant to oncology fellows and residents. The four programs significantly increased healthcare providers' knowledge about FP, but clinical practice was only improved in the Educating Nurses about Reproductive Issues in Cancer Healthcare program (P < 0.01). Nevertheless, most of the studies used a self-made questionnaire or tool to assess the effects of the training programs. The educational programs improved the FP-related knowledge of healthcare providers but lacked the high-quality randomized controlled trials needed to provide robust evidence on the effectiveness of training programs using standard tools. More training projects should be developed based on learning theories or models to improve oncofertility care in clinical practice.

Effective fertility counselling for transgender adolescents: a qualitative study of clinician attitudes and practices

OBJECTIVE

Fertility counselling for trans and gender diverse (TGD) adolescents has many complexities, but there is currently little guidance for clinicians working in this area. This study aimed to identify effective strategies for-and qualities of-fertility counselling for TGD adolescents based on clinicians' experiences.

DESIGN

We conducted qualitative semi-structured individual interviews in 2019 which explored clinician experiences and fertility counselling practices, perspectives of the young person's experience and barriers and facilitators to fertility preservation access. Data were analysed using thematic analysis.

SETTING

This qualitative study examined experiences of clinicians at the Royal Children's Hospital-a tertiary, hospital-based, referral centre and the main provider of paediatric TGD healthcare in Victoria, Australia.

PARTICIPANTS

We interviewed 12 clinicians from a range of disciplines (paediatrics, psychology, psychiatry and gynaecology), all of whom were involved with fertility counselling for TGD adolescents.

RESULTS

Based on clinician experiences, we identified five elements that can contribute to an effective approach for fertility counselling for TGD adolescents: a multidisciplinary team approach; shared decision-making between adolescents, their parents and clinicians; specific efforts to facilitate patient engagement; flexible personalised care; and reflective practice.

CONCLUSIONS

Identification of these different elements can inform and hopefully improve future fertility counselling practices for TGD adolescents, but further studies examining TGD adolescents' experiences of fertility counselling are also required.

Long-term effectiveness of an online decision aid for female cancer patients regarding fertility preservation: Knowledge, attitude, and decisional regret

INTRODUCTION

The decision, whether to undergo fertility preservation or not is highly demanding for cancer patients. Decision aids may act as an additional source of support. So far, only a limited number of decision aids regarding fertility preservation for female cancer patients exist and have been evaluated systematically. This paper presents the results of secondary analyses of the first randomized controlled trial evaluating an online decision aid for female cancer patients affected by different types of cancer. It focuses on fertility-related knowledge, attitude toward fertility preservation, and long-term effectiveness regarding decisional regret.

MATERIAL AND METHODS

Young female cancer patients between 18 and 40 years of age were recruited after fertility counseling with a reproductive specialist. They were assigned to either the control group (counseling only) or the intervention group (counseling followed by the additional use of the decision aid). Both groups had to complete a questionnaire after counseling as well as 1 and 12 months later, covering topics such as fertility-related knowledge, attitude towards fertility preservation, decisional conflict and regret. Recruitment was ongoing during 18 months in eight fertility centers located in Switzerland and Germany.

RESULTS

Mean age of participating women was 29.31 years (SD 4.57). Of the entire sample (n = 51) 53% were affected with breast cancer, 27.4% with lymphoma, and 19.6% with various other types of cancer. Knowledge regarding the most common fertility preservation methods was high and comparable in both groups. Positive attitude significantly exceeded negative attitude among all participants (p = 0.001). Although the altogether low scores for decisional regret were on a higher level in the control group (T2: mean = 19.00, SD = 13.24; T3: mean = 22.0, SD = 20.67) than in the intervention group (T2: mean = 14.12, SD = 11.07; T3: mean = 12.94, SD = 13.24), there were no statistically significant differences between and within both groups. There was a positive association between decisional conflict and decisional regret at T3 (p = 0.001, r = 0.510).

CONCLUSIONS

This decision aid was suitable as an additional source of knowledge and may positively impact decisional regret in the long term. Results suggest that the provision of an online decision aid as a complement to fertility counseling may facilitate decision-making.

Impact of a novel family-centered values clarification tool on adolescent sperm banking attempts at the time of a new cancer diagnosis

PURPOSE

Over half of males experience fertility impairment after childhood cancer therapy, which often causes psychosocial distress. Yet, fertility preservation (FP) remains underutilized. The goals of this study were to determine the feasibility and impact of implementing a family-centered FP values clarification tool on sperm banking attempts among adolescent males newly diagnosed with cancer, and identify key determinants of banking attempts.

METHODS

A prospective pilot study was conducted among families of males (12-25 years old), prior to cancer therapy. Thirty-nine of 41 families agreed to participate (95%); 98 participants (32 adolescents, 37 mothers, 29 fathers) completed the Family-centered Adolescent Sperm banking values clarification Tool (FAST). Analyses assessed the impact of the FAST on banking attempts and examined associations between demographic/medical characteristics, FAST subscales (perceived threat, benefits, barriers), and banking attempts.

RESULTS

Twenty-three (59%) adolescents attempted to bank, compared to 8 adolescents (33%) during baseline assessment (p=.04). Significant associations were identified between banking attempts and adolescents' report of perceived threat (r_pb=.45, p=.01) and benefits (r_pb=.57, p=.01). Only mothers' proxy reports of adolescent perceived threat (r_pb=.42, p=.01) and benefits (r_pb=.47, p=.003) were associated with banking attempts, while fathers' self-reported perceived benefits (r_pb=.43, p=.03), self-reported barriers (r_pb=.49, p=.01), and proxy reports of adolescent perceived threat (r_pb=.38, p=.04) and benefits (r_pb=.59, p=.02) were associated with banking attempts.

CONCLUSION

Adolescent sperm banking attempt rates significantly increased after implementation of a family-centered FP values clarification tool prior to cancer treatment. Findings underscore the importance of targeting both adolescents and their parents, particularly fathers, in FP efforts.

Fertility-a human right worthy of mandated insurance coverage: the evolution, limitations, and future of access to care

We review the history, current status, and potential future of state infertility mandates and focus on the business implications of mandates and on the inadequacies and reproductive injustice resulting from gaps between legislative intent and practical implementation. Nineteen states have passed laws that require insurers to either cover or offer coverage for infertility diagnoses and treatment. The qualifications for coverage, extent of coverage, and exemptions vary drastically from one state to another, resulting in deficiencies in access to care even within mandated states for certain groups, such as single individuals, patients in same-sex relationships, and patients pursuing fertility preservation. Although insurance coverage of fertility services in the United States has expanded as an increasing number of states have enacted infertility mandates, significant gaps in implementation and access remain even among states with existing mandates. Provider, patient, and legislative advocacy is warranted in the name of reproductive justice to expand insurance coverage and, in turn, maximize reproductive outcomes, which have been shown to improve as financial barriers are lifted.

Do cancer therapies damage the uterus and compromise fertility?

BACKGROUND

As cancer survival rates improve, understanding and preventing the adverse off-target and long-term impacts of cancer treatments, including impacts on fertility, have become increasingly important. Cancer therapy-mediated damage to the ovary and depletion of the primordial follicle reserve are well characterised. However, our knowledge of the full extent of damage to the rest of the female reproductive tract, in particular the uterus, is limited.

OBJECTIVE AND RATIONALE

Improving our understanding of the off-target effects of cancer therapies on the entire female reproductive tract is a critical step towards developing truly effective strategies to protect the fertility of cancer survivors. The objective of this narrative review was to critically evaluate the available literature regarding the capacity for the uterus to sustain a healthy pregnancy following exposure to radiotherapy or chemotherapy.

SEARCH METHODS

The authors performed PubMed (Medline) searches using the following key words: uterus, cancer survivors, radiotherapy, chemotherapy, pregnancy outcome, fertility preservation, infertility. There were no limits placed on time of publication.

OUTCOMES

Overall, there were major limitations to the current available literature, meaning that interpretations should be taken with caution. Despite these drawbacks, data suggest that the uterus may sustain off-target damage, with the extent of damage dependent on the type of cancer treatment and patient age. Specifically, uterine growth is stunted and resistant to hormone replacement therapy in prepubertal girls receiving abdominal, pelvic or whole-body radiotherapy. In contrast, females treated with radiotherapy post-puberty can benefit from hormone replacement therapy, as demonstrated by increased uterine volume and function. No live births have been reported in women previously exposed to radiotherapy after transplantation of cryopreserved ovarian tissue, even when menstruation returns. However, this technique has proven to be a successful fertility preservation method for women previously treated with chemotherapy. Obstetricians commonly report that women who maintain sufficient ovarian function can achieve pregnancy naturally following radiotherapy, but they have thin and/or fibrotic myometrium at delivery, compromising safe delivery and subsequent pregnancy. Furthermore, women exposed to either radiotherapy or chemotherapy have a higher prevalence of preterm birth and low birth weight infants, even in those with normal ovarian function or when oocyte donation is utilised. The mechanisms of potential uterine damage are poorly understood. While the myometrium, vasculature and endometrial progenitor cells are possibly targets, further studies are clearly required and well-controlled animal models could provide the best avenue for these types of future investigations.

WIDER IMPLICATIONS

Female cancer survivors experience greater rates of early pregnancy loss and complications, suggesting that cancer therapy-induced damage to the uterus contributes to infertility. Despite clinical reports dating back to 1989, we highlight a surprising lack of detail in the literature regarding the precise nature and extent of off-target damage inflicted to the uterus in response to cancer therapies. Young women requiring cancer treatment, and the clinicians treating them, must be equipped with accurate information to aid informed decision-making regarding cancer treatment regimens as well as the development and use of effective fertility preservation measures. As the current literature on the impacts of cancer treatments is limited, we hope that our narrative review on this subject will stimulate more research in this important field.

Equal opportunity for all? An analysis of race and ethnicity in fertility preservation in New York City

Purpose

To compare the racial and ethnic make-up of patients who accessed medically indicated fertility preservation services (MIFP) against the overall racial diversity (including Hispanic origin) across women of reproductive age diagnosed with cancer in New York City (NYC).

Methods

All patients who completed at least one MIFP between January 2017 and December 2018 were reviewed. Race was self-reported. A calculation of the expected racial distribution across women of reproductive age with cancer in NYC was determined using the most recent NYC census data. Statistical analysis included chi-square goodness of fit and test for independence and Kruskal-Wallis H test, with p < 0.05 considered significant.

Results

A total of 107 patients who accessed MIFP were included. A total of 55 (51.4%) identified as White, 3 (2.8%) as Black, 13 (12.2%) as Asian, 6 (5.6%) as Hispanic, 3 (2.8%) as other, and 27 (25.2%) did not report. A total of 78.5% of patients had insurance. There was no significant difference in racial distribution by cancer type (p = 0.255). A subgroup analysis excluding the BRCA+ patients and races not reported by the census (n = 69) was then performed, showing a statistically significant difference between observed (O) and expected (E) cases of fertility preservation (FP) by race at our center—White 47O/32E, Black 3O/15E, Asian 13O/7E, and Hispanic 6O/15E (p < 0.001). A statistically significant difference in racial distribution by FP type was observed.

Conclusions

There is a difference in the observed vs expected racial distribution of patients accessing MIFP. Further studies are needed to identify modifiable factors to better ensure equal opportunity to all patients.

Fertility-Related Concerns and Uncertainties in Adolescent and Young Adult Childhood Cancer Survivors

Purpose: This study aimed to uncover the fertility-related concerns and uncertainties in adolescent and young adult (AYA) childhood cancer survivors. Methods: In this qualitative study, participants were recruited from an oncohematology outpatient clinic at a university hospital in Brazil. Twenty-four AYA cancer survivors, aged 18- 24 years (13 men and 11 women), participated in individual semistructured interviews focusing on two parts-sociodemographic and clinical variables and guiding questions that enabled understanding of the concerns and uncertainties regarding the risks of infertility and their impact on relationships and the need for guidance. Data were analyzed using inductive thematic analysis. Results: Four themes were identified from the data-(1) knowledge about fertility, (2) emotional impact and fertility-related uncertainty, (3) sharing the possible risk of infertility with partners, and (4) need for information on possible loss of fertility. Conclusion: The meanings attributed to the loss of fertility after cancer treatment uncovered the need for health professionals to organize survivor services in line with the survivors' needs, and include reproductive concerns and uncertainties in this planning. The study results provide insights for the development of health care services that meet the real needs of this particular population that has long-term follow-up demands.

Integrative Review of Reproductive Decision Making of Women Who Are BRCA Positive

OBJECTIVE

To synthesize research findings about reproductive decision making among women who are BRCA positive.

DATA SOURCES

PubMed and CINAHL.

STUDY SELECTION

Articles published in English between 2000 and June 28, 2020, about the reproductive decision making of women with a confirmed BRCA1 or BRCA2 mutation.

DATA EXTRACTION

We extracted data about participants, study design, analysis, follow-up, and results. We used the modified Downs and Black checklist and Kennelly's qualitative data analysis to rate studies for quality and applicability by using.

DATA SYNTHESIS

We included five of 257 screened articles in our synthesis. The total sample size of the five studies was 1,468 women. The most prevalent factors related to reproductive decision making were the impending decisions regarding childbearing and family choices, including decisions about biological children, preventive surgery, preimplantation genetic diagnosis, and prenatal diagnosis to prevent further transmission of a BRCA mutation, and family planning.

CONCLUSION

A lack of knowledge exists about the reproductive decision-making processes of women who are BRCA positive. A better understanding of this process would provide nurses and other clinicians with the knowledge needed to support these women through their reproductive life choices.

Higher reproductive concerns associated with fertility consultation: a cross-sectional study of young adult male cancer survivors

PURPOSE

This study examined associations between fertility consultation (FC) and multiple dimensions of reproductive concerns among young adult (YA) male cancer survivors.

METHODS

One hundred and seventy YA male cancer survivors (age 18 to 35) across the USA completed an online survey between 2016 and 2018. Participants reported demographics, receipt of FC, and reproductive concerns. Reproductive concerns were measured multidimensionally using the Reproductive Concerns after Cancer-Male scale. We used log binomial regression to examine associations between FC and high reproductive concerns across multiple domains.

RESULTS

In multivariate analyses adjusting for desire for children, FC was associated with higher likelihood of having at least one high reproductive concern (relative risk [RR] 1.4, 95% CI 1.2-1.7). Across subscales, FC was associated with greater likelihood of having high concerns about fertility potential (RR 1.7, 95% CI 1.0-3.0), achieving pregnancy (RR 3.5, 95% CI 1.3-9.5), their (potential) child's health (RR 1.5, 95% CI 1.1-2.2), and disclosing infertility to a partner (RR 2.7, 95% CI 1.8-4.1). In contrast, associations were not observed between FC and likelihood of high concerns about personal health (RR 1.4, 95% CI 0.5-3.8) or acceptance of infertility (RR 1.8, 95% CI 0.8-3.9).

CONCLUSIONS

YA male cancer survivors who received FC were more likely to have high reproductive concerns than those who did not receive FC. Men who seek out FC after cancer diagnosis may need additional support for their reproductive concerns. Research is needed to identify strategies to alleviate these concerns among this population.

Oncofertility: Knowledge, Attitudes, and Barriers Among Indian Oncologists and Gynecologists

Purpose: Recommendations from the American Society of Clinical Oncology (ASCO) emphasize the critical need to understand current trends in fertility preservation (FP) among the two sets of primary health care providers involved in oncofertility: the oncologists and the gynecologists. This study is aimed at understanding the health care providers' knowledge, attitudes, and barriers in oncofertility across India. Methods: An 18-item oncofertility survey was designed and directed to 77 oncologists and 214 gynecologists across India. The responses were analyzed by using descriptive statistical methods, and the oncofertility trends between the two groups were studied. Results: The total response rate was 34%, with 49 of 214 oncologists (23%) and 49 of 77 gynecologists (64%) participating in the survey. The awareness of ASCO FP guidelines among oncologists and gynecologists was 53% and 59.5%, respectively. About 48% of oncologists felt knowledgeable about sperm banking, whereas 52% knew about oocyte freezing but not about other options. On the other hand, among gynecologists, 38% reported inadequate knowledge of testicular or ovarian tissue cryopreservation. About 85% of oncologists reported routine referral of cancer diagnosed patients for FP, whereas 75% of gynecologists reported routine FP discussion with patients. Health care providers from both groups perceived the major barriers in oncofertility to be, "financial burden on the patient" (73%-86%) and, "lack of patient awareness" (71%-79.5%). Conclusion: Effective collaboration between oncologists and gynecologists is essential to establish a successful FP program. Economic burden on the patient and lack of patient and physician awareness are limiting factors that need to be overcome.

"We Can Always Adopt": Perspectives of Adolescent and Young Adult Males with Cancer and Their Family on Alternatives to Biological Parenthood

Purpose: Approximately half of male childhood cancer survivors experience impaired fertility, which is known to cause psychological distress. Yet, less than 50% of at-risk adolescent and young adult (AYA) males pursue fertility preservation (FP) at diagnosis. Alternatives to biological parenthood (e.g., adoption/sperm donation) may be considered, but little is known about perspectives regarding these alternatives among AYA males and their families. Methods: Families of AYAs were recruited for a mixed-method study examining FP decisions at cancer diagnosis. One month later, 48 participants from 20 families (18 male AYAs, 12-22 years of age, 19 mothers, 11 fathers) completed semistructured interviews, including two questions about: (a) alternative routes to biological parenthood, and (b) their knowledge about the processes involved and/or challenges associated with such alternatives. Verbatim transcripts were coded for thematic content using the constant comparison method. Results: Three main themes were identified, of which two represent both ends of considering alternative parenthood: (a) Willingness to consider alternatives to biological parenthood, primarily adoption; (b) No consideration/discussion of alternative family building options; and (c) Variable knowledge of alternatives and/or associated challenges. Notably, more AYAs than parents mentioned a specific preference for biological children. Conclusions: One-month postcancer diagnosis, most parents reported willingness to consider alternatives to biological parenthood for their sons, while AYA males were less knowledgeable or open to these options. Future research should prospectively examine how these attitudes affect FP decisions before treatment. Medical and psychosocial providers should counsel patients and survivors accordingly to optimize reproductive outcomes and prevent psychosocial distress if parenthood goals are unfulfilled.

Barriers and Facilitators to Fertility-Related Discussions with Teenagers and Young Adults with Cancer: Nurses' Experiences

Introduction: Improvements in cancer survival rates for teenagers and young adults (TYAs) have resulted in quality-of-life issues into survivorship becoming increasingly important. However, infertility is a potential late side effect of cancer treatment, which can negatively impact on quality of life. Advances in assisted reproductive technologies have resulted in increasingly effective fertility preservation (FP) options. Purpose: This study aimed to explore nurses' experiences of undertaking fertility-related discussions with TYAs with cancer aged 13-24 years. Methods: An interpretive phenomenological analysis (IPA) approach was used. Eleven purposively selected nurses working on a specialist TYA cancer unit participated in semistructured interviews. Data were analyzed using IPA. Results: Parents/family were experienced as self-appointed informal gatekeepers who were perceived to hold the power to control nurses' access to communicate with young people about fertility issues. Nurses adopted a supportive role, which was enhanced by the positive nature of their relationship with the TYA. Uncertainty was expressed over whether the TYA had been fully informed of their infertility risk and potential FP options. Conclusions: Nurses should manage parental involvement sensitively if TYAs are to make informed decisions regarding their future reproductive health. There is a need for clear role delineation in fertility discussions to ensure that TYAs are provided with the opportunity to discuss infertility risk and be referred to a specialist before initiating cancer treatment. Nurses should cultivate the primacy of the nurse-TYA relationship to improve fertility care. Further research into the factors that TYAs may consider beneficial within the nurse-patient relationship is required.

Taboo Topics in Adolescent and Young Adult Oncology: Strategies for Managing Challenging but Important Conversations Central to Adolescent and Young Adult Cancer Survivorship

Research on adolescents and young adults (AYAs) with cancer has flourished over the past decade, underscoring the unique medical and psychosocial needs of this vulnerable group. A cancer diagnosis during adolescence and young adulthood intersects with the developmental trajectory of AYAs, derailing critical physical, social, and emotional development. AYAs face these abrupt life changes needing age-appropriate information and resources to offset these challenges. Greater attention is needed to address AYA-specific concerns on reproductive and sexual health, financial security and independence, emotional well-being, social support, and end-of-life care. If these unique needs are unaddressed, this can adversely affect AYAs' health care engagement and overall quality of life, increasing their risk for cancer-related morbidity and early mortality. In particular, health care decisions made during treatment have important implications for AYA patients' future health. Oncology clinicians are well positioned to address AYA patients' concerns by anticipating and addressing the challenges this age group is likely to face. In this paper, we explore several core topics that affect AYAs' quality of life and that can be challenging to address. Starting from the moment of diagnosis, through cancer treatment and post-treatment survivorship, and into end of life, each section highlights critical developmental-centric life domains that are affected by the cancer experience. Specifically, we discuss resources, tools, and strategies to navigate these challenging conversations. Taking a risk-reduction approach that invites two-way communication and facilitates referral to age-appropriate resources would help destigmatize these experiences and, in turn, would support the provision of compassionate and effective age-concordant care to this vulnerable group.

Prognostic role of preimplantation genetic testing for aneuploidy in medically indicated fertility preservation

OBJECTIVE

To investigate the use of preimplantation genetic testing for aneuploidy (PGT-A) among patients pursuing embryo banking (EB) for medically indicated fertility preservation (FP).

DESIGN

Retrospective cohort.

SETTING

University-affiliated fertility center.

PATIENTS

All patients who underwent in vitro fertilization with or without PGT-A for medically indicated FP between January 2014 and April 2018.

INTERVENTIONS

None MAIN OUTCOME MEASURES: EB cycle characteristics, subsequent cycle pursuit/outcomes, and frozen embryo transfer (FET) outcomes.

RESULTS

A total of 58 medical EB cycles were compared; 34 cycles used PGT-A. Of the EB patients with breast cancer, 67% used PGT-A; other indications were evenly divided between PGT-A (FP/PGT-A) and no PGT-A (FP). PGT-A use increased over the study period. Groups were similar in age, days of stimulation, and days from initial FP consultation to treatment initiation. Number of oocytes (14.5 [2-63] FP vs. 17.5 [1-64] FP/PGT-A), 2PN zygotes (7 [1-38] FP vs. 9 [0-36] FP/PGT-A), and blastocysts (5.5 [0-22] FP vs. 5 [0-18] FP/PGT-A) cryopreserved were similar between groups. Equal numbers cryopreserved both oocytes and embryos (5 vs. 3). Five FP/PGT-A patients underwent a second EB cycle. Among FP/PGT-A patients, an average of 6.7 ± 5 blastocysts underwent PGT-A, with 3.5 ± 3 (48.2%) euploid embryos cryopreserved for future FET compared to an average of 7.2 ± 7 untested embryos in the FP group.

CONCLUSION

PGT-A in medical EB cycles increased over time and did not limit the use of other FP methods such as oocyte cryopreservation. In some cases, poor PGT-A results informed patients to pursue a second EB cycle. When counseling patients, the prognostic benefits of PGT-A must be weighed against the financial costs and potential for "terminal" fertility diagnosis.

Two Successful Sperm Aspirations in High-Risk Adolescent and Young Adult Lymphoma Patients Before Initiation of Emergent Therapy

As survival rates for adolescent and young adult (AYA) cancer patients improve, fertility preservation has gained increased attention. Many AYAs report significant concerns about fertility potential after therapy. Preservation at diagnosis may be the only opportunity for future genetic parenthood for many patients. Time constraints, concerns about treatment delays, and difficulty accessing resources are reported as reasons for providers not providing counseling. In addition, some pubertal males are unable/unwilling to produce a sample through self-stimulation. Testicular sperm aspiration/extraction with sperm cryopreservation can be successfully performed in "high-risk" pubertal males with significant barriers to traditional collection before initiation of emergent chemotherapy.

Use of fertility preservation services in female reproductive-aged cancer patients

OBJECTIVE

The objective of the study was to determine the rates and predictors of fertility preservation services among reproductive-aged women with common cancers in the United States.

STUDY DESIGN

We used the MarketScan database to identify women 18-45 years of age with lung, breast, colorectal, or cervical cancer who underwent surgery and chemotherapy from 2009 through 2016. Services from 3 months before to 3 months after chemotherapy for evaluation for fertility preservation, laboratory testing for fertility evaluation, and fertility-preserving procedures were captured. Multivariable models were used to assess the factors associated with the use of fertility-preservation services.

RESULTS

A total of 18,781 women, including 386 cervical, 1372 colorectal, 246 lung, and 16,777 with breast cancer, were identified. In women 18-35 years old, 11.7% underwent evaluation for fertility preservation, 13.7% underwent laboratory testing, and 6.3% pursued fertility-preserving procedures. The rates of office evaluation, laboratory testing, and performance of procedure were 3.3%, 7.5%, and 1.9 % in women aged 36-40 years and 0.5%, 7.2%, and 0.3% in those aged 41-45 years, respectively. The rate of fertility preservation evaluation rose from 1.0% in 2009 to 5.5% in 2016 (risk ratio, 4.66, 95% confidence interval, 2.38-9.11) while use of fertility-preserving procedures increased from 1.0% to 4.6% (risk ratio, 3.84, 95% confidence interval, 1.94-7.59) during the same time period. In a multivariable model, use of any fertility-preserving interventions were more common in patients with breast cancer (adjusted risk ratio, 2.30, 95% confidence interval, 1.30-4.06), those in the Northeast (adjusted risk ratio, 1.24, 95% confidence interval, 1.10-1.40), and in younger women (18-35 years) (adjusted risk ratio, 2.59, 95% confidence interval, 2.32-2.89).

CONCLUSION

Although limited by lack of information regarding cancer stage and desire for future fertility, only a small fraction of reproductive-aged female cancer patients receiving chemotherapy are evaluated in a nationwide sample for fertility preservation or undergo fertility-preserving procedures.

Oncofertility: Meeting the Fertility Goals of Adolescents and Young Adults With Cancer

Adolescents and young adults aged 15 to 39 years who are diagnosed with cancer (AYA survivors) undergo a range of therapies for cancer cure but subsequently may be at risk of treatment-related infertility, and for female AYA survivors, adverse pregnancy outcomes. Future fertility is important to AYA survivors. Meeting their fertility goals requires awareness of this importance, knowledge of cancer treatment-related fertility risks, appropriate fertility counseling on these risks, and access to fertility care. Epidemiologic and dissemination and implementation research are needed to estimate more precise risks of traditional and novel cancer therapies on fertility and pregnancy outcomes and improve the delivery of fertility care.