Let's not forget that many prepubertal girls do have other options besides ovarian tissue cryopreservation

Ethical, legal, social, and policy issues of ovarian tissue cryopreservation in prepubertal girls: a critical interpretive review

PURPOSE

Despite the increasing number of childhood cancer survivors, significant advances in ovarian tissue cryopreservation (OTC) technique and medical societies' recommendations, fertility preservation (FP) and FP discussions are not always offered as a standard of care in the pediatric context. The aim of this literature review is to understand what ethical, legal, social, and policy issues may influence the provision of FP by OTC in prepubertal girls with cancer.

METHODS

A critical interpretive review of peer-reviewed papers published between 2000 and January 2023 was conducted, guided by the McDougall's version of the critical interpretive synthesis (Dixon-Woods), to capture recurring concepts, principles, and arguments regarding FP by OTC for prepubertal girls.

RESULTS

Of 931 potentially relevant papers, 162 were included in our analysis. Data were grouped into seven thematic categories: (1) risks of the procedure, (2) unique decision-making issues in pediatric oncofertility, (3) counseling, (4) cultural and cost issues, and (5) disposition of cryopreserved reproductive tissue.

CONCLUSION

This first literature review focusing on ethical, legal, social, and policy issues surrounding OTC in prepubertal girls highlights concerns in the oncofertility debate. Although OTC is no longer experimental as of December 2019, these issues could limit its availability and the child's future reproductive autonomy. This review concludes that specific actions must be provided to enable the offer of FP, such as supporting families' decision-making in this unique and complex context, and providing pediatric patients universal and full access to free or highly subsidized OTC.

Public Awareness and Acceptability of PGT-M in Cancer Predisposition Syndromes

Cancer Predisposition Syndromes (CPSs), also known as Hereditary Cancer Syndromes (HCSs), represent a group of genetic disorders associated with an increased lifetime risk of developing cancer. In this article, we provide an overview of the reproductive options for patients diagnosed with CPS, focusing on the emerging role of Preimplantation Genetic Testing for Monogenic disorders (PGT-M). Specifically, we conducted a literature review about the awareness and acceptability of its application to CPSs. Based on the available data, the awareness of the applicability of PGT-M for CPSs appears to be limited among both patients and physicians, and a heterogeneous set of factors seems to influence the acceptability of the procedure. Our findings highlight the need for increasing education about the use of PGT-M for CPSs. In this context, guidelines developed by professional or institutional bodies would represent a useful reference tool to assist healthcare professionals in providing proper preconception counseling.

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

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

Fertility preservation in pediatric healthcare: a review

Survival rates for children and adolescents diagnosed with malignancy have been steadily increasing due to advances in oncology treatments. These treatments can have a toxic effect on the gonads. Currently, oocyte and sperm cryopreservation are recognized as well-established and successful strategies for fertility preservation for pubertal patients, while the use of gonadotropin-releasing hormone agonists for ovarian protection is controversial. For prepubertal girls, ovarian tissue cryopreservation is the sole option. However, the endocrinological and reproductive outcomes after ovarian tissue transplantation are highly heterogeneous. On the other hand, immature testicular tissue cryopreservation remains the only alternative for prepubertal boys, yet it is still experimental. Although there are several published guidelines for navigating fertility preservation for pediatric and adolescent patients as well as transgender populations, it is still restricted in clinical practice. This review aims to discuss the indications and clinical outcomes of fertility preservation. We also discuss the probably effective and efficient workflow to facilitate fertility preservation.

Fertility Counseling in Survivors of Cancer in Childhood and Adolescence: Time for a Reappraisal?

Genetic predisposition could have an important role in the pathogenesis of cancers in children and adolescents. A recent study by our group showed that, among female survivors of cancers in childhood and adolescence, the proportion of cases involving a possible genetic predisposition was sizable (at least one in five). Our sample is too small to be representative of the general population, but it gave us an opportunity to reappraise this issue. Women with a genetic predisposition can transmit the risk of cancer to their offspring, and their awareness of this may influence their reproductive and fertility preservation choices. In our experience, a predisposition to cancer receives little attention in the fertility counseling and decision-making process unless a patient already has a definitive molecular diagnosis of a hereditary cancer syndrome. We feel it is essential to empower women on this issue, particularly as there are ways to overcome the problem, including preimplantation genetic testing (PGT-M) in definitively diagnosed cases, egg donation and adoption. In the context of fertility counseling for survivors of cancer in childhood and adolescence who have reached adulthood, the risk of transmitting a predisposition to cancer should be discussed with patients, if relevant and desired.

Fertility preservation in childhood and adolescent female tumor survivors

OBJECTIVE

To assess the proportion of female childhood and adolescent tumor survivors who could benefit from oocyte cryopreservation.

DESIGN

Case series of female childhood and adolescent tumor survivors referred for fertility counseling.

SETTING

A referral cancer center and an infertility unit of an academic hospital.

PATIENT(S)

Young female childhood and adolescent tumor survivors who received gonadotoxic treatments.

INTERVENTION(S)

Patients were prescribed tests of ovarian reserve and a personalized counseling was given. Oocyte cryopreservation was considered in subjects aged ≥18 years who were diagnosed with diminished ovarian reserve (DOR) (antimüllerian hormone level <2 ng/mL or total antral follicle count ≤10).

MAIN OUTCOME MEASURE(S)

Rate of women with DOR who stored their oocytes.

RESULT(S)

Ninety out of 126 evaluated women completed the assessments. We documented preserved ovarian reserve, DOR, and premature ovarian insufficiency in 36 (40%), 35 (39%), and 19 (21%) cases, respectively. Overall, 13 subjects with DOR were eligible for oocyte cryostorage, of whom 9 (69%) underwent the procedure. Considering the whole cohort of evaluated young women (n = 90), the rate of those who had egg freezing was 10%. Finally, nine women started seeking pregnancy after the counseling (six with DOR), and seven of them became pregnant. When the data were analyzed separately according to most gonadotoxic treatments, considerable differences emerged but the evidence did not support the idea that counseling should be restricted to particular subgroups of women.

CONCLUSION(S)

Ovarian reserve impairment is common in female childhood and adolescent tumor survivors. Postcancer oocyte cryopreservation may be part of the armamentarium of fertility preservation options.

Does open ovarian biopsy in prepubertal age affect ovarian reserve in a rat model?

BACKGROUND

Partial resection of the ovary carries a possible risk of fertility reduction. We studied the influence of open ovarian biopsy on ovarian reserve, including anti-Müllerian hormone and follicle-stimulating hormone serum level evaluation, in a prepubertal rat model.

METHODS

Interventions - the initial surgery was unilateral ovarian biopsy (38 rats, group B1, B2) or unilateral ovarian biopsy and ovarian resection of the contralateral gonad (38 rats, group BR1, BR2). The second operation was bilateral ovarian resection and total resection of the remaining ovary. All rats had hormone serum levels evaluated. The control group had only a blood test taken and bilateral ovarian resection done at the second intervention (30 rats, group C1, C2). The collected tissue was examined estimating follicle count and anti-Müllerian hormone immunoexpression.

RESULTS

Anti-Müllerian hormone levels were significantly lower at the second intervention in the group BR2 but significantly higher in the group C2. Follicle-stimulating hormone levels were significantly higher in all but one group (BR2).

CONCLUSIONS

Biopsy itself might not reduce ovarian reserve if done properly but we should know its possible negative effects in the case of a single remaining ovary.

Impact of legislation and public funding on oncofertility: a survey of Canadian, French and Moroccan pediatric hematologists/oncologists

BACKGROUND

Chemotherapy and/or radiotherapy treatments may cause premature ovarian failure and irreversible loss of fertility. In the context of childhood cancers, it is now acknowledged that possible negative effects of therapies on future reproductive autonomy are a major concern. While a few options are open to post-pubertal patients, the only immediate option currently open to pre-pubertal girls is cryopreservation of ovarian tissue and subsequent transplantation. The aim of the study was to address a current gap in knowledge regarding the offer of fertility preservation by Ovarian Tissue Cryopreservation (OTC) for prepubescent girls with cancer, and to explore current practices and attitudes of Canadian, French and Moroccan pediatric heme oncologists. The comparative perspective is relevant since legal frameworks surrounding fertility preservation and funding offered by the healthcare system vary greatly.

METHODS

An online survey was sent to the 45 pediatric oncology centers in Canada, France and Morocco.

RESULTS

A total of 39 centers responded (86.6%). OTC is offered by almost all pediatric heme oncologists in France (98%), very few in Canada (5%), and none in Morocco (0%). For pediatric hematologists/oncologists who do not propose fertility preservation in Canada, the reasons are: the technique is still experimental (54%), it is not available locally (26%) and cost of the technique for the family (14%). 97% of Canadian and 100% of Moroccan pediatric hematologists/oncologists think OTC should be funded by the healthcare system as it is in France and in the province of Quebec in Canada.

CONCLUSIONS

The results of this study show tremendous diversity in the provision of OTC across countries, whereby its offer is correlated with legislation and funding. We argue that the current reality, in which this technology is often not offered to families, raises ethical issues related to justice and equity of access, as well as informed consent and future reproductive autonomy.

Chemotherapy-related damage to ovarian reserve in childhood cancer survivors: interpreting the evidence

Chemotherapy during childhood damages ovarian reserve and can affect future fertility. However, recent large epidemiological studies showed that the detrimental impact on fertility is less severe if women seek for pregnancy at a younger age. To explain this observation, we hypothesize that the detrimental effects of previous chemotherapy on the ovarian reserve may be attenuated in young adults for two main reasons. Firstly, recent evidence showed that the amount of ovarian reserve is not a critical factor for effective natural conceptions. Provided that the residual ovarian reserve allows regular ovulatory cycles, the chances of pregnancy are similar in women with intact or reduced ovarian reserve. Secondly, ovarian reserve depletion appears to be a phenomenon that is inversely related to the residual ovarian reserve rather than to age. From a mathematical perspective, this kind of regulation intrinsically attenuates the effects of an early loss of a significant amount of primordial follicles. In conclusion, the detrimental effects of chemotherapy on natural fertility may be less severe if women with a history of chemotherapy during childhood seek for pregnancy early. This information should be part of the counseling.

Nurses' experiences of undertaking fertility-related discussions with teenagers and young adults with cancer: An interpretive phenomenological analysis

AIMS

The aim of this study was to explore and interpret nurses' experiences, feelings and associated meanings attached to undertaking fertility-related discussions with teenagers and young adults with cancer. The study also aims to advance an understanding of factors which facilitate or hinder such discussions, to progress clinical practice.

BACKGROUND

Improved cancer treatments have increased survival rates for many teenagers and young adults. However, as a side-effect of treatment, infertility may result. International and UK studies suggest this patient population may not be provided with adequate opportunities to discuss this important issue. Little is known about nurses' experiences of undertaking fertility-related discussions.

DESIGN

Qualitative Interpretive Phenomenological Analysis.

METHODS

Eleven semistructured interviews were conducted between February and May 2016 with purposively selected nurses working in a Teenage Cancer Trust Unit in a UK hospital. Interviews were recorded and transcribed verbatim. Data were analysed using Interpretive Phenomenological Analysis.

FINDINGS

Nurses experienced a perceived lack of knowledge resulting in avoidance of raising fertility issues. Nurses expressed a specific need for more knowledge and education which was viewed as an essential prerequisite to their participation in discussions. The limited time frame for female patients to preserve fertility prior to commencement of treatment was felt to inhibit both fertility-related discussion and fertility preservation.

CONCLUSION

Ongoing education and support for nurses may ensure teenage and young adult cancer patients' reproductive needs are met. Nurses need to consider ways to ensure female patients benefit from improved information regarding infertility risks and preservation options to support their reproductive needs.

Successful controlled ovarian stimulation and vitrification of oocytes in an adolescent diagnosed with myelodysplastic/pre-malignant clone with monosomy 7

An improvement in long-term outcomes for malignancies and non-malignant conditions, together with a review of the NICE Guideline, has led to a need to provide clinical services to deal with the sequelae of disease, its treatment, and subsequent survival of young people diagnosed with cancer. In this article, we describe fertility preservation in an adolescent female diagnosed with Myelodysplastic/pre-malignant Clone with Monosomy 7 with pathophysiology like that of chronic myeloid leukaemia (CML) with known genetic markers in the tumour cells. We used random start controlled ovarian stimulation (COS) leading to oocyte collection and vitrification of metaphase II oocytes. Despite successful COS and vitrification, there remain numerous ethical considerations that merit more focussed discussion. Not least, in determining best practice for informed consent, but consideration of individualised protocols for ovarian stimulation, monitoring follicular development, together with prevention of ovarian hyperstimulation syndrome (OHSS) when considering most appropriate trigger for oocyte maturation. Random-start controlled ovarian stimulation and oocyte vitrification for adolescent girls diagnosed with cancer can be safely achieved through a collaborative, multidisciplinary and expert team approach. This case study offers a promising approach to fertility preservation, and would minimise the risk of introducing malignant cells after recovery.

Egg Freezing in Childhood and Young Adult Cancer Survivors

Fertility preservation in prepubertal and young adolescent girls scheduled for chemotherapy is a demanding situation. Despite the recent impressive improvements of ovarian cortex cryopreservation, significant limitations persist. The technique remains experimental, it exposes the girl to the risks of surgery and to an iatrogenic insult to the ovarian reserve, and there is no guarantee of use because not all girls will undergo re-implantation. Moreover, it is impossible to respect all the requested conditions for a valid informed consent. The girl is minor, the time for decision is very short, and the prospect of not surviving clouds both the girl and her relatives. An alternative but neglected option is oocyte cryopreservation after the end of cancer treatments, when the girl reaches adulthood. This possibility can overcome some of the limitations of ovarian cortex freezing and may be considered for girls scheduled for a chemotherapy at low or medium risk of ovarian reserve impairment. In this case report, we describe the case of a young female patient with cancer who survived 2 chemotherapies for 2 distinct cancers and who was diagnosed with reduced ovarian reserve. The patient underwent 3 cycles of ovarian hyperstimulation and ultimately stored 19 oocytes. The success obtained in this girl suggests consideration of egg freezing as an alternative fertility-preservation procedure in prepubertal and young adolescent girls scheduled for chemotherapy. However, cryopreservation of ovarian tissue remains the only option for those scheduled for chemotherapies at high risk of ovarian reserve impairment.