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Tan CY, Francis-Levin N, Stelmak D, Iannarino NT, Zhang A, Herrel L, Ellman E, Walling E, Moravek MB, Chugh R, Zebrack B. Differentiating gender-based reproductive concerns among adolescent and young adult cancer patients: A mixed methods study. J Psychosoc Oncol 2024; 42:526-542. [PMID: 38164962 DOI: 10.1080/07347332.2023.2291798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
INTRODUCTION Few studies have examined the distinct reproductive concerns (RC) of men and women in the adolescent and young adult (AYA) cancer patient population. The purpose of this mixed-methods study was to explore and differentiate the RC of AYAs. METHODS Participants completed the Reproductive Concerns After Cancer (RCAC) scale and participated in a semistructured interview. Interviews were deductively coded based on an analytic schema derived from the RCAC. RESULTS After identifying participants through the electronic health record, 27 younger AYAs, ages 12-25, enrolled in the study. Four inductive themes emerged and differed by gender. These include differential temporality, acceptance, and openness to alternatives, partner influence, and parental/guardian influence. AYA men reported fewer RC (M = 49.4, SD = 9.6) compared to AYA women (M = 56.8, SD = 8.4). CONCLUSIONS Oncofertility care providers are advised to account for short- and long-ranging concerns based on AYAs' gender. Future evaluations of patient-reported outcome measures specific to AYA RC are recommended.
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Affiliation(s)
- Chiu Yi Tan
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nina Francis-Levin
- Division of Metabolism, Endocrinology & Diabetes, University of Michigan, Ann Arbor, Michigan, USA
| | - Daria Stelmak
- School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nicholas T Iannarino
- Department of Language, Culture, and the Arts, University of Michigan-Dearborn, Dearborn, Michigan, USA
| | - Anao Zhang
- School of Social Work, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsey Herrel
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Erin Ellman
- Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Emily Walling
- Department of Pediatric Hematology/Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Molly B Moravek
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, Michigan, USA
| | - Rashmi Chugh
- Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Brad Zebrack
- School of Social Work, University of Michigan, Ann Arbor, Michigan, USA
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Matilionyte G, Forsyth G, Guo J, Rimmer MP, Hermann BP, Anderson RA, Mitchell RT. Granulocyte-colony stimulating factor does not prevent in vitro cisplatin-induced germ cell reduction in immature human and mouse testis. BMC Cancer 2023; 23:251. [PMID: 36922758 PMCID: PMC10018904 DOI: 10.1186/s12885-023-10702-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023] Open
Abstract
BACKGROUND Currently there are no established fertility preservation options for pre-pubertal boys facing cancer treatment. Granulocyte-colony stimulating factor (G-CSF) treatment has been proposed to be chemoprotective against spermatogonial cell loss in an alkylating chemotherapy model of busulfan treated adult mice. Having previously shown that exposure to the alkylating-like chemotherapy cisplatin resulted in a reduction in germ cell numbers in immature human testicular tissues, we here investigate whether G-CSF would prevent cisplatin-induced germ cell loss in immature human and mouse (fetal and pre-pubertal) testicular tissues. METHODS Organotypic in vitro culture systems were utilised to determine the effects of clinically-relevant concentrations of G-CSF in cisplatin-exposed immature testicular tissues. Human fetal (n = 14 fetuses) and mouse pre-pubertal (n = 4 litters) testicular tissue pieces were cultured and exposed to cisplatin or vehicle control for 24 hrs and analysed at 72 and 240 hrs post-exposure. Combined G-CSF and cisplatin exposure groups explored varying concentrations and duration of G-CSF supplementation to the culture medium (including groups receiving G-CSF before, during and after cisplatin exposure). In addition, effects of G-CSF supplementation alone were investigated. Survival of total germ cell and sub-populations were identified by expression of AP2γ and MAGE-A4 for human gonocytes and (pre)spermatogonia, respectively, and MVH and PLZF, for mouse germ cells and putative spermatogonial stem cells (SSCs) respectively, were quantified. RESULTS Exposure to cisplatin resulted in a reduced germ cell number in human fetal and mouse pre-pubertal testicular tissues at 240 hrs post-exposure. Germ cell number was not preserved by combined exposure with G-CSF using any of the exposure regimens (prior to, during or after cisplatin exposure). Continuous supplementation with G-CSF alone for 14 days did not change the germ cell composition in either human or mouse immature testicular tissues. CONCLUSIONS This study demonstrates that exposure to G-CSF does not prevent cisplatin-induced germ cell loss in immature human and mouse testicular tissues in an in vitro system.
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Affiliation(s)
- Gabriele Matilionyte
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, Scotland, UK
| | - Grace Forsyth
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, Scotland, UK
| | - Jingtao Guo
- State Key Laboratory of Stem Cell and Reproductive Biology, Institute of Zoology, Chinese Academy of Sciences, Beijing, 100101, China
- Beijing Institute for Stem Cell and Regenerative Medicine, Beijing, 100101, China
- University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Michael P Rimmer
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, Scotland, UK
| | - Brian P Hermann
- Department of Neuroscience, Developmental and Regenerative Biology, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
| | - Richard A Anderson
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, Scotland, UK
| | - Rod T Mitchell
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, Scotland, UK.
- Royal Hospital for Children & Young People, 50 Little France Crescent, Edinburgh, EH16 4TJ, Scotland, UK.
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Delgouffe E, Braye A, Goossens E. Testicular Tissue Banking for Fertility Preservation in Young Boys: Which Patients Should Be Included? Front Endocrinol (Lausanne) 2022; 13:854186. [PMID: 35360062 PMCID: PMC8960265 DOI: 10.3389/fendo.2022.854186] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 02/11/2022] [Indexed: 12/11/2022] Open
Abstract
Due to the growing number of young patients at risk of germ cell loss, there is a need to preserve spermatogonial stem cells for patients who are not able to bank spermatozoa. Worldwide, more and more clinics are implementing testicular tissue (TT) banking programs, making it a novel, yet indispensable, discipline in the field of fertility preservation. Previously, TT cryopreservation was predominantly offered to young cancer patients before starting gonadotoxic chemo- or radiotherapy. Nowadays, most centers also bank TT from patients with non-malignant conditions who need gonadotoxic conditioning therapy prior to hematopoietic stem cell (HSCT) or bone marrow transplantation (BMT). Additionally, some centers include patients who suffer from genetic or developmental disorders associated with prepubertal germ cell loss or patients who already had a previous round of chemo- or radiotherapy. It is important to note that the surgical removal of TT is an invasive procedure. Moreover, TT cryopreservation is still considered experimental as restoration methods are not yet clinically available. For this reason, TT banking should preferably only be offered to patients who are at significant risk of becoming infertile. In our view, TT cryopreservation is recommended for young cancer patients in need of high-risk chemo- and/or radiotherapy, regardless of previous low-risk treatment. Likewise, TT banking is advised for patients with non-malignant disorders such as sickle cell disease, beta-thalassemia, and bone marrow failure, who need high-risk conditioning therapy before HSCT/BMT. TT retrieval during orchidopexy is also proposed for patients with bilateral cryptorchidism. Since patients with a medium- to low-risk treatment generally maintain their fertility, TT banking is not advised for this group. Also for Klinefelter patients, TT banking is not recommended as it does not give better outcomes than a testicular sperm extraction later in life.
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Eugeni E, Arato I, Del Sordo R, Sidoni A, Garolla A, Ferlin A, Calafiore R, Brancorsini S, Mancuso F, Luca G. Fertility Preservation and Restoration Options for Pre-Pubertal Male Cancer Patients: Current Approaches. Front Endocrinol (Lausanne) 2022; 13:877537. [PMID: 35784573 PMCID: PMC9244702 DOI: 10.3389/fendo.2022.877537] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/25/2022] [Indexed: 12/12/2022] Open
Abstract
Fertility preservation for prepubertal male patients undergoing gonadotoxic therapies, potentially depleting spermatogonial cells, is an expanding necessity, yet most of the feasible options are still in the experimental phase. We present our experience and a summary of current and novel possibilities regarding the different strategies to protect or restore fertility in young male patients, before proceeding with chemotherapy or radiotherapy for malignances or other diseases. Adult oncological patients should always be counselled to cryopreserve the semen before starting treatment, however this approach is not suitable for prepubertal boys, who aren't capable to produce sperm yet. Fortunately, since the survival rate of pediatric cancer patients has skyrocketed in the last decade and it's over 84%, safeguarding their future fertility is becoming a major concern for reproductive medicine. Surgical and medical approaches to personalize treatment or protect the gonads could be a valid first step to take. Testicular tissue autologous grafting or xenografting, and spermatogonial stem cells (SSCs) transplantation, are the main experimental options available, but spermatogenesis in vitro is becoming an intriguing alternative. All of these methods feature both strong and weak prospects. There is also relevant controversy regarding the type of testicular material to preserve and the cryopreservation methods. Since transplanted cells are bound to survive based on SSCs number, many ways to enrich their population in cultures have been proposed, as well as different sites of injection inside the testis. Testicular tissue graft has been experimented on mice, rabbits, rhesus macaques and porcine, allowing the birth of live offspring after performing intracytoplasmic sperm injection (ICSI), however it has never been performed on human males yet. In vitro spermatogenesis remains a mirage, although many steps in the right direction have been performed. The manufacturing of 3D scaffolds and artificial spermatogenetic niche, providing support to stem cells in cultures, seems like the best way to further advance in this field.
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Affiliation(s)
- Elena Eugeni
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Department of Medicine and Medical Specialties, Division of Medical Andrology and Endocrinology of Reproduction, University of Terni, Terni, Italy
- *Correspondence: Elena Eugeni,
| | - Iva Arato
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Rachele Del Sordo
- Division of Anatomic Pathology and Histology, Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Angelo Sidoni
- Division of Anatomic Pathology and Histology, Department of Experimental Medicine, University of Perugia, Perugia, Italy
| | - Andrea Garolla
- Unit of Andrology and Reproductive Medicine, Department of Medicine, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Alberto Ferlin
- Unit of Andrology and Reproductive Medicine, Department of Medicine, School of Medicine and Surgery, University of Padua, Padua, Italy
| | - Riccardo Calafiore
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Stefano Brancorsini
- Section of Pathology (Terni), Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Francesca Mancuso
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Giovanni Luca
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
- Department of Medicine and Medical Specialties, Division of Medical Andrology and Endocrinology of Reproduction, University of Terni, Terni, Italy
- International Biotechnological Center for Endocrine, Metabolic and Embryo-Reproductive Translational Research (CIRTEMER), Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Lopes F, Tholeti P, Adiga SK, Anderson RA, Mitchell RT, Spears N. Chemotherapy induced damage to spermatogonial stem cells in prepubertal mouse in vitro impairs long-term spermatogenesis. Toxicol Rep 2020; 8:114-123. [PMID: 33425685 PMCID: PMC7782321 DOI: 10.1016/j.toxrep.2020.12.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/24/2020] [Accepted: 12/21/2020] [Indexed: 11/27/2022] Open
Abstract
Chemotherapy can affect testis development of young boys with cancer, reducing the chances of fatherhood in adulthood. Studies using experimental models are needed to determine the damage caused by individual chemotherapy drugs in order to predict the risk of infertility and direct patients towards appropriate fertility preservation options. Here, we investigated the individual role of two drugs, cisplatin and doxorubicin, using an in vitro culture model of prepubertal (postnatal day 5) mouse testis that supports induction and maintenance of full spermatogenesis. Twenty-four hour exposure with either drug at clinically-relevant doses (0.25, 0.5 or 0.75 μg/mL for cisplatin, or 0.01, 0.03 or 0.05 μg/mL for doxorubicin), induced an acute significant loss of spermatogonial stem cells (SSCs; PLZF+), proliferating SSCs (PLZF+BrdU+), total germ cells (MVH+), and spermatocytes (SCP3+) one week after chemotherapy exposure. By the time of the first (Week 4) and second (Week 8) waves of spermatogenesis, there was no longer any effect on SSC or proliferating SSC numbers in drug-exposed testis compared to untreated tissue: however, the populations of total germ cells and spermatocytes were still lower in the higher-dose cisplatin treated groups, along with a reduced frequency of round and elongated spermatids in both cisplatin- and doxorubicin-treated testis fragments. Overall, this study details a direct impairment of germ cell development following acute chemotherapy-induced damage during the prepubertal phase, most likely due to an effect on SSCs, using an in vitro culture system that successfully recapitulates key events of mouse spermatogenesis.
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Affiliation(s)
- Federica Lopes
- Biomedical Sciences, University of Edinburgh, Edinburgh, UK
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Prathima Tholeti
- Biomedical Sciences, University of Edinburgh, Edinburgh, UK
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Satish K. Adiga
- Department of Clinical Embryology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, India
| | | | - Rod T. Mitchell
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Norah Spears
- Biomedical Sciences, University of Edinburgh, Edinburgh, UK
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Kotzur T, Benavides-Garcia R, Mecklenburg J, Sanchez JR, Reilly M, Hermann BP. Granulocyte colony-stimulating factor (G-CSF) promotes spermatogenic regeneration from surviving spermatogonia after high-dose alkylating chemotherapy. Reprod Biol Endocrinol 2017; 15:7. [PMID: 28077131 PMCID: PMC5225630 DOI: 10.1186/s12958-016-0226-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 12/28/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The lifesaving chemotherapy and radiation treatments that allow patients to survive cancer can also result in a lifetime of side-effects, including male infertility. Infertility in male cancer survivors is thought to primarily result from killing of the spermatogonial stem cells (SSCs) responsible for producing spermatozoa since SSCs turn over slowly and are thereby sensitive to antineoplastic therapies. We previously demonstrated that the cytokine granulocyte colony-stimulating factor (G-CSF) can preserve spermatogenesis after alkylating chemotherapy (busulfan). METHODS Male mice were treated with G-CSF or controls before and/or after sterilizing busulfan treatment and evaluated immediately or 10-19 weeks later for effects on spermatogenesis. RESULTS We demonstrated that the protective effect of G-CSF on spermatogenesis was stable for at least 19 weeks after chemotherapy, nearly twice as long as previously shown. Further, G-CSF treatment enhanced spermatogenic measures 10 weeks after treatment in the absence of a cytotoxic insult, suggesting G-CSF acts as a mitogen in steady-state spermatogenesis. In agreement with this conclusion, G-CSF treatment for 3 days before busulfan treatment exacerbated the loss of spermatogenesis observed with G-CSF alone. Reciprocally, spermatogenic recovery was modestly enhanced in mice treated with G-CSF for 4 days after busulfan. These results suggested that G-CSF promoted spermatogonial proliferation, leading to enhanced spermatogenic regeneration from surviving SSCs. Similarly, there was a significant increase in proportion of PLZF+ undifferentiated spermatogonia that were Ki67+ (proliferating) 1 day after G-CSF treatment. CONCLUSIONS Together, these results clarify that G-CSF protects spermatogenesis after alkylating chemotherapy by stimulating proliferation of surviving spermatogonia, and indicate it may be useful as a retrospective fertility-restoring treatment.
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Affiliation(s)
- Travis Kotzur
- Department of Biology, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249 USA
| | - Roberto Benavides-Garcia
- Department of Biology, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249 USA
| | - Jennifer Mecklenburg
- Department of Biology, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249 USA
| | - Jamila R. Sanchez
- Department of Biology, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249 USA
| | - Matthew Reilly
- Departments of Biomedical Engineering and Ophthalmology, The Ohio State University, 1080 Carmack Road, Columbus, OH 43210 USA
| | - Brian P. Hermann
- Department of Biology, The University of Texas at San Antonio, One UTSA Circle, San Antonio, TX 78249 USA
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Muñoz M, Santaballa A, Seguí MA, Beato C, de la Cruz S, Espinosa J, Fonseca PJ, Perez J, Quintanar T, Blasco A. SEOM Clinical Guideline of fertility preservation and reproduction in cancer patients (2016). Clin Transl Oncol 2016; 18:1229-1236. [PMID: 27896641 PMCID: PMC5138251 DOI: 10.1007/s12094-016-1587-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022]
Abstract
Chemotherapy and radiotherapy often result in reduced fertility in cancer patients. With increasing survival rates, fertility is an important quality-of-life concern for many young cancer patients. Around 70–75% of young cancer survivors are interested in parenthood but the numbers of patients who access fertility preservation techniques prior to treatment are significantly lower. Moreover, despite existing guidelines, healthcare professionals do not address fertility preservation issues adequately. There is a critical need for improvements in clinical care to ensure patients are well informed about infertility risks and fertility preservation options and to support them in their reproductive decision-making prior to cancer treatment.
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Affiliation(s)
- M Muñoz
- Servicio de Oncología Médica, Translational Genomics and Targeted Therapeutics in Solid Tumors, IDIBAPS, Hospital Clínic de Barcelona, Villarroel, 170-08036, Barcelona, Spain.
| | - A Santaballa
- Hospital Universitari I Politècnic la Fe, Valencia, Spain
| | - M A Seguí
- Corporació Sanitària Parc Taulì, Sabadell, Spain
| | - C Beato
- Hospital Universitario Virgen Macarena, Seville, Spain
| | - S de la Cruz
- Complejo Hospitalario de Navarra, Pamplona, Spain
| | - J Espinosa
- Hospital General de Ciudad Real, Ciudad Real, Spain
| | - P J Fonseca
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J Perez
- Hospital General Universitario de Elche y Vega Baja, Elche, Spain
| | - T Quintanar
- Hospital General Universitario de Elche y Vega Baja, Elche, Spain
| | - A Blasco
- Hospital General Universitario de Valencia, Valencia, Spain
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Zavras N, Siristatidis C, Siatelis A, Koumarianou A. Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients. CLINICAL MEDICINE INSIGHTS-ONCOLOGY 2016; 10:49-57. [PMID: 27398041 PMCID: PMC4927042 DOI: 10.4137/cmo.s32811] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/22/2016] [Accepted: 05/26/2016] [Indexed: 12/15/2022]
Abstract
Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients.
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Affiliation(s)
- Nikolaos Zavras
- Unit of Pediatric and Adolescent Surgery, Third Department of Surgery, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Charalampos Siristatidis
- Assisted Reproduction Unit, Third Department of Obstetrics and Gynecology, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Argyris Siatelis
- Urology Department, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Koumarianou
- Consultant in Medical Oncology, Hematology-Oncology Unit, Fourth Department of Internal Medicine, Attikon Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
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