Oncofertility in adult and pediatric populations: options and barriers

An update on oncofertility in prepubertal females

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

The potent paracrine effect of umbilical cord mesenchymal stem cells mediates mitochondrial quality control to restore chemotherapy-induced damage in ovarian granulosa cells

The basic principle of chemotherapy is to attack cells with fast growth, and cancer cells are targeted by anticancer drugs because they have a faster growth rate than normal cells. High doses of anticancer drugs may cause an irreversible decline in reproductive capacity, and novel approaches for fertility preservation and/or restoration after anticancer treatment are urgently needed. Here, we provide important insights into the recovery of human reproductive cells damaged by chemotherapy. We performed a detailed screening of the cytokines of various human mesenchymal stem cells (hMSCs) to select superior MSCs. Also, we analyzed the Ovarian granulosa cell (OGC)-)-specific functions for restoring function, apoptosis, and mitochondrial functions to confirm the recovery mechanism in damaged OGCs. As a result, we demonstrated that conditioned media (CM) of Umbilical cord mesenchymal stem cells (UC-MSCs) could restore the functions of damaged OGCs primarily through antiapoptotic and antioxidant effects. Furthermore, CM changed the phenotype of damaged OGCs to an energetic status by restoring mitochondrial function and enhanced the mitochondrial metabolic activity decreased by chemotherapy. Finally, we demonstrated that the restoration of mitochondrial function in damaged OGCs was mediated through mitochondrial autophagy (mitophagy). Our findings offer new insights into the potential of stem cell-based therapy for fertility preservation and/or restoration in female cancer patients.

Isolation and In Vitro Propagation of Human Spermatogonial Stem Cells (SSCs)

Preservation of human spermatogonial stem cells (SSCs) may be suitable for young male patients at risk of male infertility due to various causes, such as gonadotoxic treatment or genetic diseases. With optimal cryopreservation, cell viability can be retained to reestablish spermatogenesis in the future through autologous transplantation or in vitro differentiation of SSCs. This protocol outlines techniques to optimize the SSCs isolation and in vitro culture. With particular emphasis on the microscopic characteristics encountered, this protocol outlines a broader approach to processing tissues with varying morphologies among patients.

Filling the Gaps in Oncofertility Care by Addressing Challenges Faced by Patients and Providers

With enhanced technology and upcoming treatment strategies in the cancer field, the survival rates of patients have increased. We have now reached a stage in the treatment of cancer where we not only address the disease but also address complications that arise due to the disease and the side effects that present in the post-survival population due to its treatment. One of the primary consequences after oncotherapy is infertility, which is a major reason for distress for patients' post-survival, as they are afraid they may be deemed as less desirable, be rejected by their existing partner, or cannot grapple with the fact that they cannot have children of their own. This can be avoided by the implementation of proper oncofertility practices. The subject of oncofertility involves interactions between experts in the domains of cancer diagnosis, therapy, fertility preservation, and reproductive health. It attempts to investigate and broaden the possibilities for cancer survivors' reproductive future in order to suit their needs according to their ethical religious and sociocultural beliefs. However, these practices are often not implemented effectively due to ineffective doctor-patient communication, lack of knowledge, or partial knowledge of clinicians themselves regarding fertility care. This leads to a feeling of insecurity among clinicians hence resulting in them not referring patients. Lack of awareness among doctors of different oncofertility procedures available especially for patient groups like women and younger patients, hence leading to reduced referral in these groups. Improper coordination across health departments, patient ignorance regarding procedures, financial instability especially in a country with a lower sociodemographic index like India, and neglect or less importance given to the related ethical, social, and legal issues. In this article, we cover the effects of cancer and cancer treatment on fertility, the options available to adult and pediatric cancer patients to preserve their fertility like oocyte/ovarian tissue cryopreservation in females and sperm cryopreservation in males, techniques undergoing experimental studies that could be implemented in the future like spermatogonial stem culture and transplantation of testicular tissue, the obstacles that we face that hinder the proper implementation of such practices and what measures can we take to overcome these obstacles to improve patient care and be better healthcare providers.

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.

A Multicomponent Telehealth Intervention to Improve Oncofertility Care Delivery Among Young Cancer Patients: A Pilot Study

Purpose: Oncofertility care for pediatric, adolescent, and young adult cancer patients remains under-implemented across adult and pediatric oncology settings. We pilot tested an electronic health record (EHR)-enabled multicomponent oncofertility intervention (including screening, referral, and fertility consult) in an adult academic oncology program and systematically assessed intervention fit to pediatric and community oncology programs. Methods: Using surveys (n = 33), audits (n = 143), and interviews (n = 21) guided by implementation science frameworks, we pilot tested the EHR-enabled intervention for oncofertility care in young cancer patients at an adult oncology program and evaluated implementation outcomes. We interviewed health care providers from seven regional oncology and fertility programs about intervention fit to their clinical contexts. Results: We recruited 33 health care providers from an adult oncology setting and 15 health care providers from seven additional oncology and fertility settings. At the adult oncology setting, the intervention was found to be appropriate, acceptable, and feasible and improved the screening of fertility needs (from 30% pre- to 51% post-intervention); yet, some patients did not receive appropriate referrals to fertility consults. Providers across all settings suggested content and context modifications, such as adding options to the intervention or allowing the screening component to pop up at a second visit, to improve and adapt the intervention to better fit their clinical care contexts. Conclusions: We found that the EHR-enabled intervention increased the rate of goal-concordant oncofertility care delivery at an adult oncology program. We also identified facilitators, barriers, and needed adaptations to the intervention required for implementation and scaling-up across diverse oncology settings.

Fertility Preservation Practices at Pediatric Oncology Institutions in the United States: A Report From the Children's Oncology Group

PURPOSE

Fertility discussions are an integral part of comprehensive care for pediatric, adolescent, and young adult patients newly diagnosed with cancer and are supported by national guidelines. Current institutional practices are poorly understood.

METHODS

A cross-sectional survey was distributed to 220 Children's Oncology Group member institutions regarding fertility discussion practices. Descriptive statistics were calculated for all variables. The association between specific practices and selected outcomes on the basis of sex was examined via multivariable logistic regression.

RESULTS

One hundred forty-four programs (65.5%) returned surveys. Of these, 65 (45.1%) reported routine discussions of fertility with all female patients and 55 (38.5%) all male patients (P = .25). Ninety-two (63.8%) reported no specific criteria for offering females fertility preservation (FP), compared with 40 (27.7%) for males (P < .001). Program characteristics associated with fertility discussions included reproductive endocrinology and infertility on site (females odds ratio [OR], 2.1; 95% CI, 1.0 to 4.3), discussion documentation mandate (females OR, 2.3; 95% CI, 1.0 to 5.5; males OR, 3.5; 95% CI, 1.4 to 8.7), and cumulative institution-based FP infrastructure (which included [1] routine practice of documentation, [2] template for documentation, [3] mandate for documentation, and [4] availability of FP navigation; females OR, 1.6; 95% CI, 1.1 to 2.3; males OR, 2.3; 95% CI, 1.6 to 3.4). Utilization of practices unsupported by guidelines included offering sperm banking after treatment initiation (39/135 programs; 28.9%), gonadotropin-releasing hormone analogs for ovarian suppression/FP (75/144 programs; 52.1%), ovarian tissue cryopreservation at diagnosis for patients with leukemia (19/64 programs; 29.7%), and testicular tissue cryopreservation (23/138 programs; 16.7%) not part of a clinical trial.

CONCLUSION

Despite recommended guidelines, fertility discussions with patients/families before treatment initiation are not routine at Children's Oncology Group institutions. Standard criteria to determine which options should be offered to patients are more common for males than females.

Effect of Distance From Fertility Center on Utilization of Fertility Preservation Referral in Men

PURPOSE

Fertility preservation (FP) is underutilized in males with cancer or other diseases requiring gonadotoxic therapies. We sought to evaluate whether patient distance from FP center affected rates of providing a semen analysis after referral.

MATERIALS AND METHODS

We performed a retrospective analysis of all males who were referred for FP at a single institution between 2013 and 2021. A multiple logistic regression model was conducted with semen sample submission as the variable of interest. Predictor variables were disease type, distance, and payment method. Secondary outcomes were number of semen samples submitted and number of vials collected.

RESULTS

Records of 461 males referred to our center were analyzed. Of these patients, 326 (71%) provided a semen sample after referral and 135 (30%) did not. Further distance from our center was associated with lower odds of submitting a semen sample (OR, 0.85; 95% CI, 0.75 to 0.97; P < .05). For patients who submitted at least one sample, distance did not affect the total number of samples submitted but was associated with a small increase in total vials cryopreserved.

CONCLUSION

Men referred for FP exhibit a high rate of sperm cryopreservation. Further distance from FP center was associated with decreased odds to provide semen sample after referral. Our model estimated a 15% decrease in odds of collection with every doubling of distance from our center. Efforts must be made to improve FP utilization for patients traveling far distances, but distance alone should not preclude referral.

Fertility preservation in uro-oncology

PURPOSE OF REVIEW

The purpose of this review is to highlight the demand for fertility preservation among cancer survivors and to draw attention to areas where healthcare workers need to improve. As technology advances, maximizing cryopreservation rates will be paramount to increase the ability individuals to conceive after cancer treatment.

RECENT FINDINGS

Guidelines recommending discussion of fertility for those diagnosed with cancer have been shown to increase patient satisfaction and overall quality of life. Our review demonstrated that increasing counseling rates remains an ongoing challenge and should remain an area of improvement for all healthcare professionals working in the oncology field. Formal programs to improve patient and provider education and access to fertility preservation increase uptake of fertility preservation. For men, many options exist to cryopreserve sperm; a slight delay to achieve fertility preservation has not been shown to lead to worse outcomes. Cryopreservation strategies differ based on puberty status and remain an active area of clinical research.

SUMMARY

Improving fertility outcomes for cancer survivors is possible with appropriate counseling techniques at the time of cancer diagnosis. Clinicians should challenge current barriers for patient access to fertility preservation surrounding cancer treatments.

Sperm and testicular tissue cryopreservation and assisted reproductive technology outcomes in male cancer patients: a 15-year experience

Objective

To explore the characteristics of cancer patients who cryopreserved sperm/testicular tissue samples in the Cryobank of Charité-Universitätsmedizin Berlin between 2004 and 2019, and the ART utilization rate with associated outcomes.

Methods

Retrospective data were available for 506 cancer patients, of which 46 (9.1%) had used their samples for artificial reproductive technologies (ART). Corresponding cycle information was collected from external fertility centers.

Results

Our cohort included 53/506 (10.5%) patients aged < 18 years at diagnosis. While adolescents and adults mainly banked sperm, adolescents showed higher rates of testicular tissue cryopreservation before (11.8%, 6/51 vs. 6.4%, 26/406) and after treatment (16.7%, 4/24 vs. 7.8%, 13/167). At study conduction, storage had been ended for 44.8% (269/601) of samples. The majority of samples used for ART were requested within the first 3 years after cryopreservation (71.5%, 28/39, range = 0–12 years). Pregnancy rate was 51.4% (19/37 cycles), resulting in 11 singleton births, 3 twin pairs, and 4 miscarriages.

Conclusion

With the new advantage of public health insurance coverage of fertility preservation (FP) in Germany, an increased utilization has already been noticed in our center, emphasizing the necessity of further knowledge for individual counseling. Adolescent cancer patients need to be addressed specifically, as these patients show especially low cryopreservation rates.

Oncofertility care and influencing factors among cancer patients of reproductive age from Saudi Arabia

BACKGROUND

More cancer survivors and a greater burden of long-term side effects have resulted from rising cancer incidence, improved treatment modalities, and younger age at cancer diagnosis. Treatment- related Infertility (TRI) is a well-known sequelae. This study looked at current oncofertility support and fertility preservation (FP) in men and women of reproductive age with cancer in Saudi Arabia, where there is little knowledge on the subject.

METHODS

A cross-sectional study included oncology patients of reproductive age from an academic hospital was conducted. Patients' characteristics, cancer type, treatment modalities and assessment of oncofertility support data were collected and examined to assess oncofertility support and potentially influencing factors.

RESULTS

Our study included 135 patients (39.3% males and 60.7% females). Although 66.7% believed they were fertile at the time of diagnosis, and more than half planned to have children in the future, Unfortunately, only 37.8% have received fertility counseling, and only 17% have seen a fertility specialist. In male patients, the most common FP method was sperm cryopreservation (6.7%), while the majority of both genders (87.4%) did not use any FP method. Two-thirds of the patients are knowledgeable about TRI and FP methods. About half of the female patients (57.3%) were advised about the possibility of post-treatment amenorrhea while only 8.1% of the whole cohort received psychological support.

CONCLUSIONS

Despite patients' satisfactory knowledge of TRI and FP, oncologists infrequently referred their patients to a specialized fertility service. More than half of our patients expressed a desire to have children in the future, but this desire was impeded by limited oncofertility care and FP procedures. Several factors influenced the knowledge of TRI, fertility counseling and FP. It is critical to incorporate oncofertility into management planning as it has a significant impact on patients' quality of life.

The impact of hiring a full-time fertility navigator on fertility-related care and fertility preservation at a pediatric institution

Fertility navigators (FNs) are important in communicating infertility risk and fertility preservation (FP) options to patients receiving gonadotoxic therapies. This retrospective study examined electronic medical records of patients with fertility consults at a large pediatric institution (2017-2019), before and after hiring a full-time FN. Of 738 patient encounters, 173 consults were performed pre-navigator and 565 post-navigator. Fertility consults for long-term follow-up cancer survivors increased most substantially: pre-navigator (n = 7) and post-navigator (n = 387). Across diagnoses, females had a larger increase in consults compared to males (χ² [3, N = 738] = 8.17, p < .05). Findings highlight FNs' impact on counseling rates, particularly in survivorship.

Effect of Neuroendocrine Neoplasm Treatment on Human Reproductive Health and Sexual Function

Neuroendocrine neoplasms (NEN) are characterized by a wide clinical heterogeneity and biological variability, with slow progression and long survival in most cases. Although these tumors can affect young adults, there are few studies that focus on the sexual and reproductive system. The aim of this review was to evaluate the effect of NEN treatment, including somatostatin analogues (SSA), targeted therapy (Everolimus and Sunitinib), radiolabeled-SSA and chemotherapy, on male and female reproductive systems and sexual function. This narrative review was performed for all available prospective and retrospective studies, case reports and review articles published up to March 2022 in PubMed. To date, few data are available on the impact of SSA on human fertility and most of studies come from acromegalic patients. However, SSAs seem to cross the blood–placental barrier; therefore, pregnancy planning is strongly recommended. Furthermore, the effect of targeted therapy on reproductive function is still undefined. Conversely, chemotherapy has a well-known negative impact on male and female fertility. The effect of temozolomide on reproductive function is still undefined, even if changes in semen parameters after the treatment have been described. Finally, very few data are available on the sexual function of NEN treatment.

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.

Infrastructure of Fertility Preservation Services for Pediatric Cancer Patients: A Report From the Children's Oncology Group

PURPOSE

Fertility preservation (FP) services are part of comprehensive care for those newly diagnosed with cancer. The capacity to offer these services to children and adolescents with cancer is unknown.

METHODS

A cross-sectional survey was sent to 220 Children's Oncology Group member institutions regarding institutional characteristics, structure and organization of FP services, and barriers to FP. Standard descriptive statistics were computed for all variables. The association between site-specific factors and selected outcomes was examined using multivariable logistic regression.

RESULTS

One hundred forty-four programs (65.5%) returned surveys. Fifty-three (36.8%) reported a designated FP individual or team. Sperm banking was offered at 135 (97.8%) institutions, and testicular tissue cryopreservation at 37 (27.0%). Oocyte and embryo cryopreservation were offered at 91 (67.9%) and 62 (46.6%) institutions, respectively; ovarian tissue cryopreservation was offered at 64 (47.8%) institutions. The presence of dedicated FP personnel was independently associated with the ability to offer oocyte or embryo cryopreservation (odds ratio [OR], 4.7; 95% CI, 1.7 to 13.5), ovarian tissue cryopreservation (OR, 2.7; 95% CI, 1.2 to 6.0), and testicular tissue cryopreservation (OR, 3.3; 95% CI, 1.4 to 97.8). Only 26 (18.1%) participating institutions offered all current nonexperimental FP interventions. Barriers included cost (70.9%), inadequate knowledge or training (60.7%), difficulty characterizing fertility risk (50.4%), inadequate staffing (45.5%), and logistics with reproductive specialties (38%-39%).

CONCLUSION

This study provides the most comprehensive view of the current landscape of FP infrastructure for children and adolescents with cancer and demonstrates that existing infrastructure is inadequate to offer comprehensive services to patients. We discuss modifiable factors to improve patient access to FP.

Medical therapies causing iatrogenic male infertility

Primum non nocere. As physicians, our goal is to treat illnesses and alleviate suffering; however, in doing so, we can generate new problems in a game of medical whack-a-mole. For some patients, certain consequences or side effects are tolerable, while others may believe they have no alternative. For a male patient with infertility, a thorough history is imperative to elucidate whether the patient has been or is currently being exposed to medications that will harm libido, spermatogenesis, ejaculation, or the hypothalamic-pituitary-testosterone axis. This article will review the most common medications causing iatrogenic male infertility as well as options to minimize or even reverse their impact.

Fertility preservation in men: a contemporary overview and a look toward emerging technologies

Cancer and oncologic therapies can have significant adverse effects on male reproductive potential, leaving many men permanently infertile. Fertility preservation has emerged as a key survivorship issue over the past 20 years, and numerous professional societies have published guidelines calling for fertility preservation to become a routine component of oncologic care. Most males with cancer are able to produce a semen specimen for fertility preservation, but numerous other methods of sperm procurement are available for patients who cannot provide a sufficient sample. Despite these options, fertility preservation will remain a challenge for prepubertal boys and men without sperm production. For these patients, experimental and investigational approaches offer the hope that one day they will translate to the clinical arena, offering additional pathways for successful fertility preservation care.

A decellularized oocyte-derived scaffold provides a "sperm safe" to preserve mammalian spermatozoa

BACKGROUND

Although only one spermatozoon is needed to create a zygote, a significant challenge is the storage and recovery of germ cells when sperm counts are extremely low.

OBJECTIVES

We engineered an oocyte-derived biomaterial-the zona pellucida (ZP)-as a "sperm safe" for storing spermatozoon. The ZP is a glycoprotein matrix that surrounds the mammalian oocyte.

MATERIALS AND METHODS

We made a hole in the ZPs using a Piezo drill and mechanically separated them from the oocyte cytoplasm. A subset of ZPs were further purified through decellularization. Using a modified ICSI approach, we injected sperm heads into purified ZPs and tested the efficacy of cryopreservation and recovery of spermatozoon as well as function.

RESULTS

Between 1-6 sperm heads were injected into purified ZPs (average 2.7 ± 1.7 sperm heads/ZP), which were then cryopreserved. Upon thawing, an average of 2.5 ± 1.4 sperm heads/ZP were observed, and in 11 of 12 thawed "sperm safes," we recovered all spermatozoa. Decellularized "sperm safes" maintained their three-dimensional structure and had a denser matrix relative to untreated controls as assessed by scanning and transmitted electron microscopy. The efficacy of "sperm safe" derived spermatozoon was evaluated by ICSI. Spermatozoon stored in either untreated or decellularized "sperm safes" elicited egg activation-associated calcium transients and zinc sparks when injected into eggs. Of the resulting zygotes, >80% of them formed pronuclei irrespective of the sperm source. 26.8 ± 4.6% and 18.1 ± 7.0% of the pre-implantation embryos generated from spermatozoon recovered from untreated or decellularized "sperm safes" developed to the blastocyst stage, respectively. Although this development was lower than that using fresh spermatozoon (59.3 ± 19.3%) or conventionally frozen-thawed spermatozoon (28.4 ± 1.7%), these differences were not significant.

DISCUSSION AND CONCLUSION

Purified ZPs represent a natural biomaterial for the efficient preservation and recovery of small sperm numbers.

Is fertility preservation a part of comprehensive cancer care in the USA? A study of NCI-designated cancer center websites

PURPOSE

The delivery of oncofertility care remains challenging, and cancer patients increasingly utilize online health information to fill knowledge gaps in their fertility care. The purpose of this study was to evaluate the website content of NCI-designated cancer centers to assess the quantity and quality of patient-oriented information pertaining to fertility preservation (FP).

METHODS

We systematically abstracted, evaluated, and compared website content for NCI-designated cancer centers (CC) and comprehensive cancer centers (CCC) pertaining to oncofertility and fertility preservation for both male and female cancer patients. Readability of each website was evaluated using the Flesch-Kincaid grade level and Flesch reading ease score.

RESULTS

Overall, 72% of websites mentioned the effect of cancer or cancer therapy on fertility potential. Only 56% of websites had a page devoted solely to the effect of cancer on fertility. Information for female patients was more common than for male patients (59% vs. 50%). CCC websites were more likely to include information about the effects of cancer treatment on fertility, the option for FP and details for FP methods. The majority of websites did not address risks and benefits of FP, moral and ethical considerations, or details about the success rates or costs. The median readability score correlated with a 12th grade reading level.

CONCLUSION

Patient-directed information pertaining to oncofertility and FP is inadequate on the majority of websites, and represents a gap in comprehensive cancer care and survivorship planning. Patients who rely primarily on internet-based information regarding oncofertility may not be well-informed about FP options in the critical period between cancer diagnosis and treatment.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer patients and survivors interested in future fertility should be referred to reproductive specialists, when possible, for a comprehensive discussion about fertility preservation prior to cancer therapy and fertility options after completing cancer therapy.