Decisional Regret in Female Oncofertility Decision Making-An Integrative Narrative Review

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.

Fertility preservation choices and decisional regret after gender-affirming surgery in transgender men or gender nonbinary persons

Objective

To investigate the prevalence of decisional regret regarding preoperative fertility preservation choices after gender-affirming surgery or removal of reproductive organs.

Design

Cross-sectional.

Setting

University-based pratice.

Patients

A total of 57 survey respondents identifying as transgender men or gender nonbinary with a history of gender-affirming surgery or removal of reproductive organs between 2014 and 2023 with the University of North Carolina Minimally Invasive Gynecology division.

Intervention

Survey or questionnaire.

Main Outcome Measures

The prevalence and severity of decisional regret regarding preoperative fertility preservation choices were measured with the use of the validated decisional regret scale (DRS) (scored 0-100). Secondary outcomes included patient-reported barriers to pursuing reproductive endocrinology and infertility consultation and fertility preservation treatment.

Results

The survey response rate was 50.9% (57/112). "Mild" to "severe" decisional regret was reported by 38.6% (n = 22) of survey respondents, with DRS scores among all respondents ranging from 0-85. Higher median DRS scores were associated with patient-reported inadequacy of preoperative fertility counseling regarding implications of surgery on future fertility or family-building (0 vs. 50) and fertility preservation options (0 vs. 12.5). No desire for future fertility at the time of fertility counseling was the most frequent reason (68.4%) for declining a referral to reproductive endocrinology and infertility for additional fertility preservation discussion.

Conclusions

Decisional regret regarding preoperative fertility preservation choices is experienced among transgender men or gender nonbinary persons after gender-affirming surgery or the removal of reproductive organs. Preoperative, patient-centered fertility counseling and fertility preservation treatments should be provided to reduce the risk of future regret.

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.

Determinants of Cochlear Implant Satisfaction and Decisional Regret in Adult Cochlear Implant Users

OBJECTIVE

Determine associations expected and actual cochlear implant (CI) outcomes, decisional regret, and satisfaction in experienced adult CI users.

STUDY DESIGN

Cross-sectional cohort study.

SETTING

Tertiary medical center.

PATIENTS

Thirty-nine adult CI users meeting traditional bilateral hearing loss indications with ≥12 months CI experience.

INTERVENTIONS/MAIN OUTCOME MEASURES

Patients completed the validated Satisfaction with Amplification in Daily Living and Decisional Regret instruments. Pre- and post-CI outcomes (CI Quality of Life [CIQOL]-Expectations; CIQOL-35 Profile; CNC words, AzBio Sentences) were obtained from a prospectively maintained clinical database.

RESULTS

Using established cutoff scores, 29% of patients reported a substantial degree of post-CI decisional regret. For each CIQOL domain, patients without decisional regret obtained post-CI outcome scores closer to pre-CI expectations compared with patients with decisional regret ( d = 0.34 to 0.91); similar results were observed with higher CI user satisfaction ( d = 0.17-0.83). Notably, the degree of pre- to post-CI improvement in CNC or AzBio scores did not differ between patients with and without decisional regret or with lower and higher satisfaction. Finally, greater pre-/postimprovement in CIQOL-35 Profile domain scores demonstrated far stronger associations with lower decisional regret and higher satisfaction than changes in speech recognition scores.

CONCLUSIONS

Patients with better alignment of their pre-CI expectations and post-CI outcomes and greater pre-/post-CIQOL improvement had lower decisional regret and higher satisfaction. This emphasizes the importance of evidence-based pre-CI counseling regarding real-world CI benefits and caution against assuming that improvements in speech recognition are related to patient satisfaction.

The potential role of GLP-1 receptor agonist targeting in fertility-sparing treatment in obese patients with endometrial malignant pathology: a call for research

INTRODUCTION

Most patients diagnosed with endometrial hyperplasia or cancer are obese. Obesity, along with polycystic ovarian syndrome (PCOS) and type-2 diabetes mellitus (T2DM), may act synergistically to increase risk of malignant endometrial pathology. Incidence of malignant endometrial pathology is increasing, particularly in reproductive aged women. In patients who desire future fertility, the levonorgestrel intrauterine device (LNG-IUD) is often utilized. If the first-line progestin therapy fails, there is not an effective second-line adjunct option. Moreover, pregnancy rates following fertility-sparing treatment are lower-than-expected in these patients.

AREAS COVERED

This clinical opinion provides a summary of recent studies exploring risk factors for the development of malignant endometrial pathology including obesity, PCOS, and T2DM. Studies assessing efficacy of fertility-sparing treatment of malignant endometrial pathology are reviewed and a potential new adjunct treatment approach to LNG-IUD is explored.

EXPERT OPINION

There is an unmet-need for a personalized treatment approach in cases of first-line progestin treatment failure. Glucagon-like peptide 1 receptor agonists are a class of anti-diabetic agents, but may have a role in fertility-sparing treatment of obese patients with malignant endometrial pathology by reducing weight, decreasing inflammation, and decreasing insulin resistance; these changes may also improve chances of subsequent pregnancy. This hypothesis warrants further exploration.

Quality of Life in Underrepresented Cancer Populations

This series of six articles (five original articles and one review) is presented by international leaders in health disparities research [...]

Management of Breast Cancer Survivors by Gynecologists

Breast cancer patients commonly present to their OBGYN during the process of diagnosis and treatment of breast cancer both for specific gynecologic needs and for primary care follow up. These patients require counseling on contraception, hormone use, and fertility at diagnosis. During treatment and survivorship, patients will face a variety of side effects from treatments leading to vasomotor symptoms, vulvovaginal discomfort, sexual dysfunction, osteoporosis, and vaginal bleeding. This chapters aims to enlighten providers on the unique range of issues a gynecologist may face when caring for breast cancer patients.

Psychometric properties of the Fertility Intention Scale among breast cancer patients of childbearing age in mainland China

Objective

There are no valid assessment instruments assessing fertility intention among breast cancer survivors in mainland China. Therefore, this study aims to examine the psychometric properties of the Taiwanese version of the Fertility Intention Scale (FIS) among female patients with breast cancer of childbearing age in mainland China.

Methods

Two hundred and sixty-four female patients with breast cancer of childbearing age were recruited from two tertiary hospitals in Tianjin and Baoding, of which 32 patients completed the survey twice. Confirmatory factor analysis was adopted to assess construct validity. Correlations between the Reproductive Concerns After Cancer scale and FIS scores were calculated using Spearman correlation for convergent validity. The known-group validity of the FIS was verified using Mann–Whitney U test to compare the FIS scores between patients with or without the intention to conceive. Moreover, reliabilities were examined using Cronbach's alpha and intra-class correlation coefficient.

Results

Confirmatory factor analysis showed a good model fit to previous factor structures (χ²/df = 3.19, root mean square error of approximation = 0.091, comparative fitting index = 0.980, Tucker–Lewis index = 0.975), and no FIS item was dropped. The FIS scores were weak negatively correlated with the Reproductive Concerns After Cancer scale scores (r = –0.172, P < 0.01). The convergent validity of FIS was not satisfactory. Differences were noted between patients with or without the intention to conceive (50.62 ± 6.35 vs. 45.98 ± 7.19, P < 0.01). The FIS showed acceptable known-group validity. The internal consistency (Cronbach’s α = 0.824) and the test-retest reliability (r = 0.863, P < 0.01) of the FIS were also acceptable.

Conclusions

Overall, the FIS provides a comprehensive evaluation of the fertility intention among patients with breast cancer of childbearing age in mainland China. However, the convergent validity was not satisfactory; thus, further revision and validation may be required in the future.

Fertility preservation in female cancer sufferers: (only) a moral obligation?

PURPOSE

Advances in cancer diagnostics and therapeutics have thankfully led to high numbers of young cancer survivors, although some interventions may sometimes threaten fertility. The authors aimed to assess how evidence-based oncofertility counselling can be adequately fulfilled for the sake of female cancer patients, in light of its complexities and multidisciplinary nature, which require thorough counselling and consent pathways.

MATERIALS AND METHODS

A search has been conducted in the databases PubMed/MEDLINE, Web of Science, Scopus, EMBASE and Google Scholar via search strings such as fertility preservation, reproductive counselling, oncofertility, cancer survivors, in order to identify relevant meaningful sources spanning the 2010-2021 period.

RESULTS

Counselling needs to be implemented in compliance with international guidelines, so as to avoid medicolegal repercussions. Albeit fertility preservation is supported by most health care institutions, actual conditions at health care facilities often reflect several lingering difficulties in the oncofertility process. Oncofertility counselling should foster access to fertility preservation procedures. To best serve that purpose, it should be implemented in a manner consistent with ethical and legal standards, so that patients can make an informed decision based on comprehensive and relevant data.

CONCLUSIONS

Counselling needs to be rooted in a close cooperation of oncologists, reproductive endocrinologists, mental health counsellors and clinical researchers. The provision of oncofertility services is grounded in the moral obligation to uphold individual autonomy, which is essential in a free society, unless the exercise thereof could pose a risk to the children conceived or to others.

Melatonin prevents cyclophosphamide-induced primordial follicle loss by inhibiting ovarian granulosa cell apoptosis and maintaining AMH expression

Cyclophosphaty -45mide (Cyc) chemotherapy in young female cancer patients is associated with an increased risk of premature ovarian insufficiency (POI). This study was designed to investigate the protective role of melatonin (Mel) as an adjuvant against Cyc-induced POI. Female mice received a single intraperitoneal (i.p.) dose of Cyc (75 mg/kg). Mel protection was achieved in mice after i.p. injection of melatonin (50 mg/kg) every 24 h for four consecutive days prior to chemotherapy initiation and for 14 additional days. Ovarian reserve testing, hormonal assays for follicle-stimulating hormone, luteinizing hormone, and anti-Müllerian hormone (AMH), assessment of the oxidative stress status, and measurement of the relative expression of genes in PTEN/AKT/FOXO3a and mitochondrial apoptosis pathways were performed. The results showed that treatment with 50 mg/kg Mel significantly prevented Cyc-induced over-activation of primordial follicles by maintaining the plasma level of AMH and subsequently preventing litter size reduction in mice treated with Cyc chemotherapy. Importantly, Mel treatment significantly prevented ovarian granulosa cell loss by inhibiting the mitochondrial apoptotic pathway. Identifying the protective actions of Mel against Cyc-induced primordial follicle loss has important implications for fertility maintenance in young cancer patients undergoing chemotherapy.