Pediatric fertility preservation: is it time to offer testicular tissue cryopreservation?

Oncologists’ Knowledge, Practice and Attitude toward Fertility Preservation: A National Survey

Background: Improved chemotherapy and radiotherapy treatment protocols, fortunately, increased the rates of cancer survivors over the years. However, these treatments may result in infertility or subfertility. Oncologists are considered the gateway for knowledge about cancer and its treatments’ effects. Several studies showed that many oncologists do not discuss fertility preservation with their patients. This study aimed to explore the perspective of oncologists in Oman on fertility preservation. Methods: A cross-sectional study of physicians and surgeons dealing with patients with cancer was conducted from June 2021 to December 2021. A standardized and validated questionnaire was used to collect data. Results: Participants reported that they are knowledgeable about sperm cryopreservation and gonadotropin-releasing hormone agonists use but not other methods of fertility preservation. About 94% of the participants reported that they need more knowledge about fertility preservation. More than half of the participants had never encountered cancer patients who used ovarian cryopreservation, testicular tissue cryopreservation, in vitro fertilization with embryo cryopreservation and oocyte cryopreservation. The majority (78%) agreed that discussing fertility preservation with newly diagnosed cancer patients is a high priority. Conclusions: Oncologists in Oman are supportive of fertility preservation. The lack of knowledge and unavailability of well-structured fertility preservation services in Oman hinders the initiation of fertility preservation discussions.

Assessment of DNA Repair Gene Expressions in Vitrified Mouse Preantral Follicles

Objective

Vitrification of the ovarian tissue is one of the techniques recommended for preserving the fertility of women who are dealing with infertility. Despite its benefits, our information about the molecular aspects of ovarian follicles vitrification is somehow ambiguous. Therefore, the aim of this study was to evaluate the expression pattern of DNA repair genes in vitrified preantral follicles.

Materials and Methods

In this experimental study, the isolated preantral follicles (n=906) from 14-16 days old mice (n=12) were divided into three groups: fresh, toxic and vitrified which were cultured in vitro for 12 days. Preantral follicles were vitrified using cryotop followed by exposure to equilibration solution for five minutes and vitrification solution (VS) for 30 seconds. In the toxic group, preantral follicles were only placed in equilibration and vitrification media and they were then placed in the warming solutions without exposure to liquid nitrogen. On the second and sixth days of the culture period, real-time quantitative reverse transcription-polymerase chain reaction (qRT-PCR) was carried out to evaluate expression of the selected genes involved in DNA repair, including Msh6 (MutS homolog 6), Mre11 (Meiotic recombination 11), Brca1 (Breast cancer type 1), Rad51 (RAD51 recombinase), Pcna (Proliferating cell nuclear antigen) and Atm (ATM serine/threonine kinase). In addition, developmental parameters including growth, survival rate, antrum cavity formation and ovulation were analyzed.

Results

The relative mRNA expression of Msh6, Mre11, Brca1, Rad51, Pcna and Atm on the second and sixth days of the culture period in vitrified group was significantly higher than those of the control and toxic groups, but there was no significant difference between the toxic and control groups. In addition, developmental parameters of follicles were similar in both toxic and control groups, while both were significantly higher than that of vitrified group.

Conclusion

Vitrification changes the expression pattern of DNA repair genes of the mouse preantral follicles.

Sperm DNA integrity in adult survivors of paediatric leukemia and lymphoma: A pilot study on the impact of age and type of treatment

Childhood cancer survivors (CCS) are more likely than siblings to report low sperm count and to use assisted reproductive technologies. Yet, it is still unclear if the sperm produced many years after remission of cancer display DNA and chromatin damage linked to male infertility and poor embryo development. As well, the importance of the age at diagnosis in relation to puberty is poorly understood. In this pilot study, we compared reproductive parameters and sperm damage from adult survivors of childhood leukemia and lymphoma, sub-divided into those diagnosed before or after puberty, to men with no history of cancer. Our data indicate that CCS, independently of the age of diagnosis, have a high risk of low sperm count and when sperm are present, chances of DNA and chromatin abnormalities appear similar to those seen in the general population. Exposure to alkylating agents is correlated with low sperm count whereas exposure to anthracyclines, and doxorubicin in particular, could have long-term consequences on sperm integrity. This study highlights the need for further research on fertility among male CCS and the importance of informing families about the potential long-term impact of chemotherapy on male fertility regardless of age at diagnosis.

Sperm DNA Damage in Cancer Patients

Fertility is a growing healthcare issue for a rising number of cancer survivors. In men, cancer itself and its treatment can negatively affect spermatogenesis by targeting the dividing spermatogonia and their cellular environment, ultimately leading to a reduction of testicular germ cells and sperm count. Experimental data and prospective longitudinal studies have shown that sperm production can recover after cancer treatment. But despite this, yet unpredictable, recovery in sperm production, cancer survivors are more at risk to produce sperm with aneuploidy, DNA damage, abnormal chromatin structure, and epigenetic defects even 2 years post-treatment. Sperm DNA alteration is of clinical concern, as these patients may father children or seek assisted reproduction technologies (ART) using gametes with damaged genome that could result in adverse progeny outcomes. Interestingly, large cohort studies revealed lower birth rate but no significant impact on the health of the children born from male cancer survivors (naturally or using ART). Nevertheless, a better understanding of how cocktail of chemotherapy and new anticancer agents affect spermatogenesis and sperm quality is needed to reduce side effects. Moreover, developing new fertility preservation strategies is essential as sperm cryopreservation before treatment is currently the only option but does not apply for prepubertal/young postpubertal patients.

Fertility Management for the Hemato-Oncologist

For cancer survivors, social parenthood buffers distress and improves quality of life. It is important that physicians dealing with treatment of malignancies are aware of this patient perspective. This review deals with risks of infertility with hematological malignancies and chemotherapy, modes of fertility preservation interventions, time and barriers to referral to specialists offering these interventions. This review aims to guide the hemato-oncologist to make an informed decision with the patient and the partner about fertility preservation at the right time.

Perspectives in Pediatric Pathology, Chapter 23. Testicular Pathology Secondary to Physical and Chemical Injury

Testicles can be damaged by a variety of physical and chemical agents, ranging from trauma suffered in accidents or athletic activities, to diverse drugs or radiation used in cancer treatment. The immediate and long-term effects of these damaging agents at the testicular morphologic and functional levels are quite varied and may have significant impact on the fertility of the pediatric patient once reproductive age is reached.

Testicular Tissue Cryopreservation and Ethical Considerations: A Scoping Review

Testicular tissue cryopreservation (TTCP) aims to preserve the future option of genetic reproduction for prepubescent cancer patients who are at risk of infertility as a result of their cancer therapies. This technology is experimental and currently only offered in the research context. As TTCP moves towards becoming more widely available, it is imperative that healthcare providers recognize the complex ethical issues surrounding this technology. This scoping review study identifies and assesses the range and depth of ethical concerns related to this testicular tissue cryopreservation technology. At present, no such scoping review of ethical concerns exists in the TTCP literature. The forty-three full-text articles included in this study yielded twenty-two different ethical considerations discussed in relation to TTCP. It was observed that these ethical considerations fit within a mainstream Principlism approach to bioethics. Accordingly, there are ethical gaps in the TTCP literature that can be identified with alternative moral lenses. In particular, it was found that ethical concerns related to context and relational aspects of identity were absent in nearly all ethical examinations of TTCP. Furthermore, only 9 per cent of articles reviewed in this study focused primarily on the ethics of TTCP, thus demonstrating a need for further in depth ethical analyses of this technology. The results of this study are important for supporting the ethical provision of TTCP and can contribute to policy and guideline development. The findings of this study demonstrate the need for greater depth and diversity in analyses of ethical considerations related to this technology.

Male reproductive health after childhood, adolescent, and young adult cancers: a report from the Children's Oncology Group

The majority of children, adolescents, and young adults diagnosed with cancer will become long-term survivors. Although cancer therapy is associated with many adverse effects, one of the primary concerns of young male cancer survivors is reproductive health. Future fertility is often the focus of concern; however, it must be recognized that all aspects of male health, including pubertal development, testosterone production, and sexual function, can be impaired by cancer therapy. Although pretreatment strategies to preserve reproductive health have been beneficial to some male patients, many survivors remain at risk for long-term reproductive complications. Understanding risk factors and monitoring the reproductive health of young male survivors are important aspects of follow-up care. The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) were created by the COG to provide recommendations for follow-up care of survivors at risk for long-term complications. The male health task force of the COG-LTFU Guidelines, composed of pediatric oncologists, endocrinologists, nurse practitioners, a urologist, and a radiation oncologist, is responsible for updating the COG-LTFU Guidelines every 2 years based on literature review and expert consensus. This review summarizes current task force recommendations for the assessment and management of male reproductive complications after treatment for childhood, adolescent, and young adult cancers. Issues related to male health that are being investigated, but currently not included in the COG-LTFU Guidelines, are also discussed. Ongoing investigation will inform future COG-LTFU Guideline recommendations for follow-up care to improve health and quality of life for male survivors.

Cryopreservation and fertility: current and prospective possibilities for female cancer patients

With the evolution of the treatment of malignant neoplasms, the survival rates of patients undergoing chemo- or radiotherapy are increasing. The continuous development of techniques of assisted human reproduction has led to important strategies in an attempt to maintain reproductive function in patients subjected to treatment of neoplastic diseases, among them cryopreservation of embryos, gametes, and ovarian cortical tissue. The freezing of ovarian tissue is currently being proposed with the primary purpose of preserving ovarian function in these patients. Currently, the major challenge of groups working with preservation of fertility is the use of cryopreserved ovarian tissue after disease remission. The main alternatives presented today are the implantation of hetero- or orthotopic tissue and isolation of immature follicles from ovarian tissue followed by in vitro maturation and assisted reproduction procedures.

Fertility preservation: state of the science and future research directions

OBJECTIVE

To identify issues related to fertility preservation, discuss the state of the science, and make specific recommendations to guide future research supported by the U.S. National Institutes of Health in the field of fertility preservation.

DESIGN

A 1-day meeting of an expert advisory panel convened by the Eunice Kennedy Shriver National Institute of Child Health and Human Development on January 23, 2007, at the National Institutes of Health in Bethesda, Maryland. The panelists represented the disciplines of reproductive endocrinology and infertility, urology, neurobiology, physiology, radiation oncology, pediatrics, genetics, behavioral science, surgery, and occupational health.

CONCLUSION(S)

The panel members recognized the emerging focus on fertility preservation to help women and men have biological children. Among those who might benefit from research in this area are those at risk for impaired fertility or infertility, including not only cancer survivors but also others with genetic predispositions to infertility, environmental occupational exposure to hazardous substances or conditions, or reproductive diseases such as endometriosis. The panelists highlighted the need for education and awareness among health-care providers to help people understand options for preserving fertility, the need for technologic advances, the lack of data on long-term consequences of fertility preservation, and emerging ethical and social questions. This report describes the process for developing a multidisciplinary, collaborative approach for research in this area, summarizes the discussions of the panelists, and outlines the recommendations for future research.