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Pecker LH, Oteng-Ntim E, Nero A, Lanzkron S, Christianson MS, Woolford T, Meacham LR, Mishkin AD. Expecting more: the case for incorporating fertility services into comprehensive sickle cell disease care. Lancet Haematol 2023; 10:e225-e234. [PMID: 36708736 DOI: 10.1016/s2352-3026(22)00353-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/19/2022] [Accepted: 10/25/2022] [Indexed: 01/27/2023]
Abstract
Assisted reproductive technologies (ART) are not yet systematically available to people with sickle cell disease or their parents. Fertility care for these groups requires addressing sickle cell disease-associated infertility risks, fertility preservation options, pregnancy possibilities and outcomes, and, when needed, infertility treatment. People with a chance of having a child with sickle cell disease can use in-vitro fertilisation with preimplantation genetic testing to conceive a child unaffected by sickle cell disease. Also, parents of children with sickle cell disease can use this technology to identify embryos to become potential future matched sibling donors for stem cell transplant. In the USA, disparities in fertility care for the sickle cell disease community are especially stark. Universal screening of newborn babies' identifies sickle cell disease and sickle cell trait, guidelines direct preconception genetic carrier screening, and standard-of-care fertility preserving options exist. However, potentially transformative treatments and cures for patients with sickle cell disease are not used due to iatrogenic infertility concerns. In diversely resourced care settings, obstacles to providing fertility care to people affected by sickle cell disease persist. In this Viewpoint, we contend that fertility care should be incorporated into the comprehensive care model for sickle cell disease, supporting alignment of treatment goals with reproductive life plans and delivering on the promise of individualised high-quality care for people with sickle cell disease and their families. We consider the obligation to provide fertility care in light of medical evidence, with acknowledgment of formidable obstacles to optimising care, and powerful historical and ethical considerations.
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Affiliation(s)
- Lydia H Pecker
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Eugene Oteng-Ntim
- Women's Health Academic Centre, King's College London, London, UK; Women's Services, Guy's and St Thomas' NHS Foundation Trust, London, UK; London School of Hygiene and Tropical Medicine, London, UK
| | - Alecia Nero
- Division of Hematology-Oncology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Sophie Lanzkron
- Division of Hematology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mindy S Christianson
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Division of Reproductive Endocrinology & Infertility, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Teonna Woolford
- Sickle Cell Reproductive Health Education Directive, Washington, DC, USA
| | - Lillian R Meacham
- Aflac Cancer and Blood Disorders Center Children's Healthcare of Atlanta; Division of Hematology & Oncology, Department of Pediatrics Emory University, Atlanta, GA, USA
| | - Adrienne D Mishkin
- Blood and Marrow Transplantation and Cell Therapy Program, Division of Hematology & Oncology and Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
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Bedrick BS, Kohn TP, Pecker LH, Christianson MS. Fertility preservation for pediatric patients with hemoglobinopathies: Multidisciplinary counseling needed to optimize outcomes. Front Endocrinol (Lausanne) 2022; 13:985525. [PMID: 36353243 PMCID: PMC9638952 DOI: 10.3389/fendo.2022.985525] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/30/2022] [Indexed: 01/19/2023] Open
Abstract
Hemoglobinopathies are autosomal recessive disorders that occur when genetic mutations negatively impact the function of hemoglobin. Common hemoglobinopathies that are clinically significant include sickle cell disease, alpha thalassemia, and beta thalassemia. Advancements in disease-modifying and curative treatments for the common hemoglobinopathies over the past thirty years have led to improvements in patient quality of life and longevity for those who are affected. However, the diseases, their treatments and cures pose infertility risks, making fertility preservation counseling and treatment an important part of the contemporary comprehensive patient care. Sickle cell disease negatively impacts both male and female infertility, primarily by testicular failure and decreased ovarian reserve, respectively. Fertility in both males and females with beta thalassemia major are negatively impacted by iron deposition due to chronic blood transfusions. Hematopoietic stem cell transplant (HSCT) is currently the only curative treatment for SCD and transfusion dependent beta thalassemia. Many of the conditioning regimens for HSCT contain chemotherapeutic agents with known gonadotoxicity and whole-body radiation. Although most clinical studies on toxicity and impact of HSCT on long-term health do not evaluate fertility, gonadal failure is common. Male fertility preservation modalities that exist prior to gonadotoxic treatment include sperm banking for pubertal males and testicular cryopreservation for pre-pubertal boys. For female patients, fertility preservation options include oocyte cryopreservation and ovarian tissue cryopreservation. Oocyte cryopreservation requires controlled ovarian hyperstimulation (COH) with ten to fourteen days of intensive monitoring and medication administration. This is feasible once the patient has undergone menarche. Follicular growth is monitored via transvaginal or transabdominal ultrasound, and hormone levels are monitored through frequent blood work. Oocytes are then harvested via a minimally invasive approach under anesthesia. Complications of COH are more common in patients with hemoglobinopathies. Ovarian hyperstimulation syndrome creates a greater risk to patients with underlying vascular, pulmonary, and renal injury, as they may be less able to tolerate fluids shifts. Thus, it is critical to monitor patients undergoing COH closely with close collaboration between the hematology team and the reproductive endocrinology team. Counseling patients and families about future fertility must take into consideration the patient's disease, treatment history, and planned treatment, acknowledging current knowledge gaps.
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Affiliation(s)
- Bronwyn S. Bedrick
- Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Taylor P. Kohn
- Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Lydia H. Pecker
- Department of Medicine, Division of Adult Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mindy S. Christianson
- Department of Gynecology and Obstetrics, Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Nickel RS, Maher JY, Hsieh MH, Davis MF, Hsieh MM, Pecker LH. Fertility after Curative Therapy for Sickle Cell Disease: A Comprehensive Review to Guide Care. J Clin Med 2022; 11:2318. [PMID: 35566443 PMCID: PMC9105328 DOI: 10.3390/jcm11092318] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 12/30/2022] Open
Abstract
Curative therapy for sickle cell disease (SCD) currently requires gonadotoxic conditioning that can impair future fertility. Fertility outcomes after curative therapy are likely affected by pre-transplant ovarian reserve or semen analysis parameters that may already be abnormal from SCD-related damage or hydroxyurea treatment. Outcomes are also likely affected by the conditioning regimen. Conditioning with myeloablative busulfan and cyclophosphamide causes serious gonadotoxicity particularly among post-pubertal females. Reduced-intensity and non-myeloablative conditioning may be acutely less gonadotoxic, but more short and long-term fertility outcome data after these approaches is needed. Fertility preservation including oocyte/embryo, ovarian tissue, sperm, and experimental testicular tissue cryopreservation should be offered to patients with SCD pursing curative therapy. Regardless of HSCT outcome, longitudinal post-HSCT fertility care is required.
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Affiliation(s)
- Robert Sheppard Nickel
- Children’s National Hospital, Division of Hematology, Washington, DC 20001, USA;
- Children’s National Hospital, Division of Blood and Marrow Transplantation, Washington, DC 20001, USA
- School of Medicine and Health Sciences, The George Washington University, Washington, DC 20001, USA;
| | - Jacqueline Y. Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Pediatric and Adolescent Gynecology, National Institutes of Health, Bethesda, MD 20810, USA;
- Children’s National Hospital, Pediatric and Adolescent Gynecology Program, Washington, DC 20001, USA
| | - Michael H. Hsieh
- School of Medicine and Health Sciences, The George Washington University, Washington, DC 20001, USA;
- Children’s National Hospital, Division of Urology, Washington, DC 20001, USA
| | - Meghan F. Davis
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC 20001, USA;
| | - Matthew M. Hsieh
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20810, USA;
| | - Lydia H. Pecker
- Division of Hematology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 20810, USA
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Mishkin AD, Mapara MY, Barhaghi M, Reshef R. Fertility Concerns and Access to Care for Stem Cell Transplantation Candidates with Sickle Cell Disease. Biol Blood Marrow Transplant 2020; 26:e192-e197. [DOI: 10.1016/j.bbmt.2020.03.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/29/2020] [Accepted: 03/29/2020] [Indexed: 12/12/2022]
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Fertility preservation in patients with hematologic malignancies and recipients of hematopoietic cell transplants. Blood 2019; 134:746-760. [PMID: 31292116 DOI: 10.1182/blood.2018846790] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 05/30/2019] [Indexed: 02/07/2023] Open
Abstract
Patients with hematologic malignancies and those undergoing hematopoietic cell transplantation (HCT) face a complex set of challenges when considering options for fertility preservation (FP). There are no standard options for prepubertal children, and women with hematologic malignancies may not be eligible for standard FP options. Fortunately, initial therapies for most blood cancers are not highly gonadotoxic, affording an important opportunity for postremission counseling and referrals to fertility specialists. These patients face a high risk of relapse, and many will be referred for autologous or allogeneic HCT, which carries an extremely high risk of infertility. The expanding indications for HCT to include benign hematologic disorders as well as autoimmune diseases mandate that all hematologists are familiar with these risks. Oncofertility researchers are continually pushing the boundaries of what may be possible for our patients; in the meantime, communication and shared decision-making between hematologists and patients, as well as program-building, education, and outreach are essential to ensure that these patients, many of whom will be cured, maintain all of their options for a fulfilling life after intensive therapy.
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Hwee T, Bergen K, Leppke S, Silver A, Loren A. Hematopoietic Cell Transplantation and Utilization of Fertility Preservation Services. Biol Blood Marrow Transplant 2019; 25:989-994. [DOI: 10.1016/j.bbmt.2019.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 01/01/2019] [Indexed: 12/19/2022]
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Kapoor S, Little JA, Pecker LH. Advances in the Treatment of Sickle Cell Disease. Mayo Clin Proc 2018; 93:1810-1824. [PMID: 30414734 DOI: 10.1016/j.mayocp.2018.08.001] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 07/08/2018] [Accepted: 08/07/2018] [Indexed: 12/26/2022]
Abstract
Sickle cell disease (SCD) is a monogenic disorder that afflicts approximately 100,000 Americans and millions of people worldwide. It is characterized by hemolytic anemia, vaso-occlusive crises, relentless end-organ injury, and premature death. Currently, red blood cell transfusion and hydroxyurea are the major disease-modifying therapies available for SCD. Hematopoetic stem cell transplant is curative, but barriers to treatment are substantial and include a lack of suitable donors, immunologic transplant rejection, long-term adverse effects, prognostic uncertainty, and poor end-organ function, which is especially problematic for older patients. Gene therapy to correct the βs point mutation is under investigation as another curative modality. Deeper insights into the pathophysiology of SCD have led to the development of novel agents that target cellular adhesion, inflammation, oxidant injury, platelets and/or coagulation, vascular tone, and hemoglobin polymerization. These agents are in preclinical and clinical trials. One such agent, L-glutamine, decreases red blood cell oxidant injury and is recently US Food and Drug Administration approved to prevent acute pain episodes of SCD in patients 5 years of age or older. The purpose of this review is to describe the currently established therapies, barriers to curative therapies, and novel therapeutic agents that can target sickle cell hemoglobin polymerization and/or its downstream sequelae. A PubMed search was conducted for articles published up to May 15, 2018, using the search terms sickle cell disease, novel treatments, hematopoietic stem cell transplantation, and gene therapy. Studies cited include case series, retrospective studies, prospective clinical trials, meta-analyses, online abstracts, and original reviews.
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Affiliation(s)
- Sargam Kapoor
- Division of Hematology/Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH; Division of Hematology/Oncology, Case Western Reserve University, Cleveland, OH
| | - Jane A Little
- Division of Hematology/Oncology, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH; Division of Hematology/Oncology, Case Western Reserve University, Cleveland, OH
| | - Lydia H Pecker
- Division of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, MD.
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