Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update

Fertility preservation in young breast cancer patients: A nationwide survey on knowledge, attitudes, and practices among breast surgical healthcare providers in China

PURPOSE

Fertility preservation (FP) is a critical concern for young breast cancer (YBC) patients receiving gonadotoxic treatments. Breast surgical healthcare providers (HCPs) play a pivotal role in discussing FP options and facilitating timely referrals. This study aimed to assess the knowledge, attitudes, and practices of breast surgical HCPs in China regarding FP, identify barriers to FP discussions, and examine factors influencing referral practices.

METHODS

A nationwide cross-sectional survey was conducted from March to June 2023 among board-certified breast surgeons and nurses across China using a 24-item questionnaire. Participants were recruited via WeChat through BestOnco, a professional platform for oncology HCPs. The survey assessed FP knowledge, attitudes, clinical practices, and perceived barriers. Multivariate logistic regression was performed to determine factors associated with FP referral practices.

RESULTS

A total of 355 valid responses were analyzed. The mean FP knowledge score was 6.05 ± 1.94 (range 0-10), with 49.3 % of HCPs never consulting FP guidelines. While 82.8 % expressed a favorable attitude toward FP, only 42.3 % routinely discussed FP options, and 44.7 % referred patients to reproductive specialists. Major barriers included poor prognosis concerns (87.0 %), treatment urgency (67.9 %), and financial burden (60.0 %). Multivariate analysis revealed that higher FP knowledge (OR = 1.23, p < 0.0001), longer clinical experience (OR = 2.93, p = 0.001), and hospital-based FP integration (OR = 1.83, p < 0.0001) were significant predictors of referral.

CONCLUSIONS

Notable gaps were identified in FP knowledge, discussions, and referrals among breast surgical HCPs in China. Targeted FP training programs, culturally informed shared decision-making strategies, and oncofertility navigation systems are recommended to enhance FP service delivery and improve patient outcomes.

Planned Immediate Chemotherapy and Cryopreservation of Oocytes or Embryos for Fertility Preservation in Women with Malignancies

Purpose: Oocyte and embryo cryopreservation before gonadotoxic treatment are established methods to increase the likelihood of live births. Although several sociodemographic factors were found to be associated with undergoing fertility preservation (FP) treatment, clinical characteristics such as planned immediate chemotherapy were not fully investigated. We aimed to investigate whether the planned immediate chemotherapy is related to the decision to undergo oocyte/embryo cryopreservation for FP with adjustment for other clinical characteristics. Methods: This institutional cohort study included 491 premenopausal women aged 19 years or older who visited the FP clinic at a tertiary medical center between 2006 and 2019. The primary outcome was whether the participants underwent oocyte/embryo cryopreservation. We evaluated the odds ratios (ORs) and corresponding 95% confidence intervals (CIs) of undergoing oocyte/embryo cryopreservation according to whether immediate chemotherapy was planned using univariable and multivariable logistic regression. Results: Women scheduled for immediate chemotherapy were much less likely to undergo oocyte/embryo cryopreservation than women not scheduled for immediate chemotherapy (OR = 0.46, 95% CI 0.27-0.76) in univariable logistic regression analysis. After adjustment for covariates such as marital status, type of malignancies, and calendar year period, women scheduled for immediate chemotherapy were still less likely to undergo oocyte/embryo cryopreservation than women not scheduled for immediate chemotherapy (OR = 0.31, 95% CI: 0.17-0.56). The association was not different according to the type of malignancies (p for interaction = 0.13). Regarding breast cancer, the OR for undergoing oocyte/embryo cryopreservation in women scheduled for immediate chemotherapy was robust compared with those not planned for immediate chemotherapy (OR = 0.25, 95% CI: 0.12-0.53). Conclusion: The present study demonstrated that planned immediate chemotherapy was negatively associated with undergoing oocyte/embryo cryopreservation. This information can be helpful for FP counseling.

A Report on Testicular Tissue Cryopreservation for Fertility Preservation in Children: Confirmation of Germ Cell Preservation and Few Surgical Complications

BACKGROUND

Testicular tissue cryopreservation (TTC) is an experimental method for fertility preservation in pediatric patients facing a fertility threatening treatment regimen or diagnosis. TTC requires a surgical procedure for the removal of testicular tissue, advanced tissue processing capabilities, and long-term tissue storage at a cryopreservation facility. The goal of this work is to evaluate the surgical and pathologic outcomes of patients enrolled in an ongoing clinical protocol for fertility preservation in children.

METHODS

Patients were prospectively enrolled in an IRB-approved protocol from 2015 to 2023 at a single institution. Children were eligible for enrollment if they possessed a fertility threatening diagnosis or required treatment that placed them at high level of increased risk for prolonged azoospermia. In this work we report patient characteristics, surgical outcomes, and pathologic findings of our cohort.

RESULTS

TTC was performed for 144 patients. The median age of patients was 8.89 years (Range: 0.3-24.5 years). Most patients were prepubertal (n=126, 87.5%) and carried a diagnosis of malignancy (n=117, 81.2%). Overall, 45.8% of patients received pre-operative chemotherapy. There was a low rate of TTC-related surgical complications (n=3, 2.1%). Germ cells were present in 97.9% (141/144) of samples. Malignancy was discovered in testicular tissue in 1.4% (n=2) of patients. Of the initially enrolled cohort, 89.4% (n=129) are living.

CONCLUSIONS

Testicular tissue cryopreservation is a safe and effective procedure for fertility preservation in the pediatric population. Germ cells were present in nearly all preserved tissue, providing the possibility of future fertility restoration in these children pending further scientific advancement.

LEVEL OF EVIDENCE

Level III - Prospective cohort study.

Approaches to Reduce Toxicity in Pediatric Brain Tumors

Pediatric central nervous system (CNS) tumor survivors are highly susceptible to long-term toxicity due to tumor location and also the treatment received. Advancements in treatment techniques, risk-adapted approaches to therapy with adjustments to treatment regimens-including de-escalation when feasible-along with the addition of supportive therapy and surveillance in these survivors, serve to minimize and manage late effects of therapy.

Oncological treatments have limited effects on the fertility prognosis in testicular cancer: A systematic review and meta-analysis

BACKGROUND

Testicular cancer is the most common solid tumour among young men in the reproductive phase. After completing cancer treatment, up to 77% of cancer survivors report an interest in paternity after completing cancer treatment. To preserve fertility, most guidelines recommend that physicians should counsel their patients about sperm cryopreservation before initiating gonadotoxic therapy. However, few studies have assessed fertility parameters after testicular cancer therapies over the last 20 years.

OBJECTIVES

To close the gap of data regarding gonadotoxicity of testicular cancer therapies to enable more accurate counselling regarding fertility preservation.

MATERIALS AND METHODS

A systematic literature search was conducted in Medline, Embase and Cochrane until December 2022. The systematic review included studies of men who had undergone all types of unilateral testicular cancer treatment, whereas the meta-analysis excluded studies with unspecified treatments, less than 10 patients for outcome evaluation or rare tumours. Infertility (i.e. azoospermia, failure to achieve paternity or the usage of cryosperm) was defined as outcome.

RESULTS

The qualitative analysis included 30 studies with a total of 13,718 men after unilateral testicular cancer. Treatment comprised active surveillance after unilateral orchidectomy (32.7%), radiotherapy (23.1%), standard- or low-dose chemotherapy (33.7%) and high-dose chemotherapy (1.4%). Post-treatment spermiograms were analysed in 17 studies. The quantitative synthesis included 23 studies, revealing an overall pooled prevalence of infertility (95% CI) of 14% (9%-21%). Azoospermia occurred in 8% (6%-12%). For good-prognosis patients who received standard therapy, the overall prevalence of infertility was only 4% (2%-10%).

CONCLUSION

So far, this very first meta-analysis of overall infertility prevalence provides the best approximation of fertility prognosis for men who have undergone testicular cancer therapy. Despite the low prevalence of infertility, it is still recommended to undergo sperm cryopreservation because of the uncertainty of the subsequent therapy and the lack of large longitudinal data on individual treatment effects.

The prevalence of parental cancer history and in vitro fertilization utilization

BACKGROUND

Advances in cancer treatment have led to an increased number of survivors who may subsequently have children. We aim to describe the prevalence of a parental cancer history with and without the utilization of in vitro fertilization (IVF) in several states in the United States.

METHODS

This study used data from IVF cycles resulting in live births reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System from 2004 to 2018. These were linked to birth certificates and cancer registries in 3 states (New York, Massachusetts, and North Carolina). For each IVF-conceived delivery, the subsequent 10 deliveries were used as the naturally conceived comparison group. A parent's cancer history was included if the diagnosis preceded the birth of the first child.

RESULTS

There were 814 658 births (82 544 IVF-conceived and 732 114 naturally conceived births) in our analysis. Among births conceived naturally, 0.5% of mothers and 0.4% of fathers had a cancer history compared with 1.2% of mothers and 1.8% of fathers among IVF-conceived births. The prevalence of cancer history increased over the study period (P ≤.004). The most common cancers among mothers were thyroid or endocrine (28.7%) and breast (12.2%) vs male genital (26.3%) and thyroid or endocrine (9.1%) among fathers. There were higher rates of male and female genital malignancies, female breast, and female lymphoid or hematopoietic cancers among parents who conceived with IVF (P < .001).

CONCLUSIONS

Overall, 1.1% of all births and 3.0% of IVF-conceived births had at least 1 parent with a cancer history with an increasing prevalence over the study period, highlighting the importance of oncofertility programs.

Safety of laparoscopic surgery for ovarian tissue cryopreservation in pediatric patients

BACKGROUND

Ovarian tissue cryopreservation (OTC) is recognized as the only option for fertility preservation in children. However, surgery for OTC in pediatric patients carries risks differing significantly from those in adults, and little is known about its safety. As a representative fertility preservation center in Japan, we investigated safety and feasibility of surgery for OTC in children.

METHODS

The survey period was from November 2015 to November 2024. Data were collected retrospectively from the electronic medical records of 0- to 17-year-old girls who underwent OTC at our hospital. Age, primary disease, height, weight, comorbidities, operation time and blood loss, surgical complications, and changes in blood data of subjects were verified.

RESULTS

Mean age of the 110 patients was 8.9 ± 5.0 years. Of the patients, 89 (80.9%) had malignant diseases, with leukemia (n = 21. 19.1%) as the most common underlying disease. Twenty patients (18.1%) had recurrent disease and 84 (76.4%) were undergoing surgery during chemotherapy and/or radiotherapy. Mean body mass index was 17.0 kg/m2, and some patients were thin and had delayed physical development. Ninety-two patients (83.6%) showed low white blood cell counts immediately before surgery. Laparoscopic unilateral oophorectomy was performed in all cases, with an average operation time of 55.5 ± 14.3 min and an average blood loss of 2.9 ± 8.4 g. One patient (0.9%) developed fever as a surgical complication.

CONCLUSIONS

These results suggest that laparoscopic surgery for OTC in children can be performed safely with the cooperation of experts from multiple medical fields.

Fertility Preservation in People With Cancer: ASCO Guideline Update

PURPOSE

To provide updated fertility preservation (FP) recommendations for people with cancer.

METHODS

A multidisciplinary Expert Panel convened and updated the systematic review.

RESULTS

One hundred sixty-six studies comprise the evidence base.

RECOMMENDATIONS

People with cancer should be evaluated for and counseled about reproductive risks at diagnosis and during survivorship. Patients interested in or uncertain about FP should be referred to reproductive specialists. FP approaches should be discussed before cancer-directed therapy. Sperm cryopreservation should be offered to males before cancer-directed treatment, with testicular sperm extraction if unable to provide semen samples. Testicular tissue cryopreservation in prepubertal males is experimental and should be offered only in a clinical trial. Males should be advised of potentially higher genetic damage risks in sperm collected soon after cancer-directed therapy initiation and completion. For females, established FP methods should be offered, including embryo, oocyte, and ovarian tissue cryopreservation (OTC), ovarian transposition, and conservative gynecologic surgery. In vitro maturation of oocytes may be offered as an emerging method. Post-treatment FP may be offered to people who did not undergo pretreatment FP or cryopreserve enough oocytes or embryos. Gonadotropin-releasing hormone agonist (GnRHa) should not be used in place of established FP methods but may be offered as an adjunct to females with breast cancer. For patients with oncologic emergencies requiring urgent oncologic therapy, GnRHa may be offered for menstrual suppression. Established FP methods in children who have begun puberty should be offered with patient assent and parent/guardian consent. The only established method for prepubertal females is OTC. Oncology teams should ensure prompt access to a multidisciplinary FP team. Clinicians should advocate for comprehensive FP services coverage and help patients access benefits.Additional information is available at www.asco.org/survivorship-guidelines.

Recurrent spontaneous miscarriages from sperm after ABVD chemotherapy in a patient with Hodgkin's lymphoma: sperm DNA and methylation profiling

ABSTRACT

Lymphomas represent one of the most common malignant diseases in young men and an important issue is how treatments will affect their reproductive health. It has been hypothesized that chemotherapies, similarly to environmental chemicals, may alter the spermatogenic epigenome. Here, we report the genomic and epigenomic profiling of the sperm DNA from a 31-year-old Hodgkin lymphoma patient who faced recurrent spontaneous miscarriages in his couple 11-26 months after receiving chemotherapy with adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD). In order to capture the potential deleterious impact of the ABVD treatment on mutational and methylation changes, we compared sperm DNA before and 26 months after chemotherapy with whole-genome sequencing (WGS) and reduced representation bisulfite sequencing (RRBS). The WGS analysis identified 403 variants following ABVD treatment, including 28 linked to genes crucial for embryogenesis. However, none were found in coding regions, indicating no impact of chemotherapy on protein function. The RRBS analysis identified 99 high-quality differentially methylated regions (hqDMRs) for which methylation status changed upon chemotherapy. Those hqDRMs were associated with 87 differentially methylated genes, among which 14 are known to be important or expressed during embryo development. While no variants were detected in coding regions, promoter regions of several genes potentially important for embryo development contained variants or displayed an altered methylated status. These might in turn modify the corresponding gene expression and thus affect their function during key stages of embryogenesis, leading to potential developmental disorders or miscarriages.

Exploration of the Fertility Decision-Making Experiences of Women of Reproductive Age With Cancer: A Qualitative Systematic Review

Women of reproductive age with cancer face unique considerations in terms of fertility. The related decision-making process is complicated, and insufficient support can lead to decisional conflict. The aim of this qualitative systematic review was to identify and integrate qualitative evidence regarding the fertility decision-making process of women of reproductive age undergoing treatment for cancer. A qualitative systematic review was conducted following the Joanna Briggs Institute's methodology. Eight electronic databases were searched from inception to June 2023 for articles describing qualitative studies of the fertility decision-making process of women of reproductive age with cancer. Only original, full-text literature was examined, no limitation was placed on the publication language. Finally, 18 studies were included in a thematic analysis. We identified three analytical themes, namely "Perceived changes in fertility," "Influential participants in the decision-making process" and "Hard fertility decision-making processes of women," and nine descriptive themes that described the three analytical themes in detail. The results of qualitative synthesis emphasized that for women of reproductive age with cancer, fertility decision-making is a complex and dynamic process. These patients had experienced decisional conflict. Decision support from health care professionals was considered to be essential, and the use of patient decision aids in clinical settings was recommended. The synthesis results clarify women's fertility decision-making process, decision needs and the influencing factors, which offer evidence to guide the development of applicable patient decision aid tools to provide high-quality fertility services to women. TRIAL REGISTRATION: PROSPERO Registration Number: CRD42023434490.

Designing Patient-Reported Measures of Fertility: Cognitive Interview Findings from Adolescents and Young Adults with Cancer

Purpose: Fertility concerns (FC) are central to the well-being of many adolescent and young adult (AYA) cancer survivors. Clinical conversations about FC and fertility preservation are suboptimal, increasing patient distress. The goal of this project was to establish content validity and comprehensibility of self-report questions on FCs for AYAs with cancer. Methods: Following best practices, we conducted: (1) item identification, refinement, and generation; (2) translatability and reading level review; and (3) cognitive interviews. Items were reviewed by five AYAs in each round of cognitive interviews. Results: A systematic search yielded 63 measures and 873 items. Fifty items were subsequently modified to enhance clarity and relevance, representing subdomains of psychological and social/relational FC. Flesch-Kincaid analysis found 31 items written above the 6th grade level, which were subsequently revised. Translatability review resulted in the modification of 3 items. During cognitive interviews, 76% of AYAs found items easy to answer with 52% describing them as "very easy" and 24% as "somewhat easy." Sixty percent of participants indicated the items captured their experiences. The majority of those who reported items only somewhat reflected or did not reflect their experiences suggested items were simply not applicable for their particular case. Conclusion: This study is a critical step toward the foundation for an FC measurement system that is reliable, flexible, developmentally appropriate, comprehensible, translatable, and interpretable. Subsequent steps include psychometric testing to examine the construct validity and reliability of the FC items and calibration to enable the application of computer-adaptive testing and short form development. The evaluation will include potential item response bias by age range, gender identity, and race/ethnicity.

Nationwide Survey on the Status of Oncofertility in Japan and Involvement of Embryologists in the Practice of Fertility Preservation

Purpose: To investigate the actual status of fertility preservation techniques in oncofertility in Japan and to clarify the involvement of embryologists in this field. Methods: This survey was conducted online, targeting embryologists working at 622 facilities registered with the Japan Society of Obstetrics and Gynecology for assisted reproductive technology. Results: The response rate was 56.6%. In total, 56.8% of facilities used some form of cryopreservation as fertility preservation therapy for patients with cancer; patients' age range was widely defined at each facility. The most common renewal frequency of cryopreserved specimens for patients with cancer was at 1-year intervals. The most common renewal methods were during patient visits to the hospital and contact by letter. Knowledge levels regarding fertility preservation therapy were not high among many embryologists, but respondents recognized the important role of embryologists in oncofertility. Conclusions: This study is the first to clarify the importance of embryologists in oncofertility. Many embryologists felt that their knowledge of fertility preservation was limited and considered it necessary to improve their education, including public certification. Guidelines for long-term storage systems, including methods for renewal of cryopreservation, need to be established.

Oncofertility care for children, adolescents, and young adults at risk for treatment-related fertility loss

As therapy for childhood malignancies becomes more sophisticated and survival has improved, long-term therapy-related sequelae have emerged. Loss of reproductive potential among childhood cancer survivors is one such concern that has become increasingly recognized among patients, families, and healthcare providers. The risk status for infertility based upon therapy received, state of current reproductive technology and outcomes, and an emphasis on adequate referral and counseling for fertility preservation options are reviewed. Contributing factors to infertility are discussed, and options for female and male preservation based upon age and pubertal status are summarized. This article highlights the current state of fertility opportunities for children and adolescents undergoing therapy for cancer. Providers caring for these young patients should be familiar with such options and should routinely initiate evaluations for eligibility of fertility preservation.

Trends in fertility preservation treatments in Japan until 2023: analysis of the Japan Oncofertility Registry

BACKGROUND

Fertility preservation for patients with cancer or other diseases who receive gonadotoxic treatment has gained importance as cancer survival rates increase. In Japan, a database for registering all fertility preservation patients, named the Japan Oncofertility Registry (JOFR), was established in 2018. This study aimed to analyze recent trends in fertility preservation in Japan utilizing data from the JOFR.

METHODS

Data was extracted from the JOFR for patients who consulted fertility preservation teams until May 2024. A descriptive analysis was conducted to examine trends in patient demographics, cancer types, fertility preservation treatments, complications, and outcomes. The data covered the period from diagnosis to fertility preservation and subsequent usage or disposal of frozen specimens.

RESULTS

A total of 11,510 patients were recorded, with 9491 undergoing fertility preservation treatments. The number of patients increased steadily after 2006. After 2021, the number of female patients was much higher than the number of male patients. The most common primary diseases were breast cancer among women and testicular tumors and leukemia among men. There were some complications including ovarian hyperstimulation syndrome (5.0%), bleeding (0.12%), and infections (0.05%) for women. Seven hundred and sixty clinical pregnancies were recorded, with 440 using preserved specimens. The discard rate was 16.3% for men and 3.7% for women.

CONCLUSION

The study highlights recent trends in the growing number of cases undergoing fertility preservation in Japan. It also identifies several issues to be solved in fertility preservation in Japan, regarding its efficacy and safety, as well as the medical provision system.

Behind closed doors: a qualitative study exploring the content of fertility discussions between oncologists and their adolescent and young adult cancer patients from the perspective of oncologists at an NCI-designated comprehensive cancer center

PURPOSE

To qualitatively explore the content of fertility discussions between oncologists and their adolescent and young adult (AYA; 15-39 years) cancer patients from the perspective of oncologists at an NCI-designated comprehensive cancer center.

METHODS

We recruited oncologists of various specialties employed at an NCI-designated comprehensive cancer center in California who treat AYAs at risk for infertility. We collected demographics and fertility-related information (if they discuss fertility with AYA patients and level of confidence doing so) via REDCap prior to conducting a semi-structured interview via HIPAA-compliant Zoom. Audio files were transcribed verbatim and reviewed for themes using an inductive codebook thematic analysis approach.

RESULTS

Oncologists (n = 12) were female (66.7%), of White or Asian race (41.7% each), and were on average in practice for 14.3 years (SD = 6.7). All endorsed discussing fertility with AYAs and were on average somewhat/fairly confident doing so. The detail with which oncologists reported discussing fertility with AYAs varied substantially and only some reported discussing costs associated with fertility preservation. Oncologists also reported assorted information they always mention, mention on a case-by-case basis, avoid, or feel is not necessary when discussing fertility.

CONCLUSION

This study provides a detailed description of information delivered by oncologists during fertility discussions to their AYA patients, revealing unstandardized oncofertility counseling. Fertility discussions were described to vary widely in depth and content, suggesting adherence to clinical practice guidelines limited. Interventions to increase provision of guideline-concordant counseling are needed to provide actionable pathways by which AYAs can proactively mitigate adverse reproductive health outcomes.

Oncofertility Barriers in Nurses Caring for Women with Breast Cancer

Despite the importance of oncofertility care in supporting women coping with fertility challenges after breast cancer, the practice of oncofertility care among nurses remains suboptimal. There is an urgent need to investigate oncofertility barriers faced by nurses caring for women with breast cancer. A cross-sectional online study was conducted among registered nurses caring for women with breast cancer. A self-developed questionnaire and the Oncofertility Barriers Scale (OBS) were used to assess participants' characteristics and self-perceived barriers. A score ≥ 3 indicates a high level of oncofertility barriers requiring further attention. 372 nurses completed the survey, with 45.54% reporting a score of ≥ 3 on the OBS. Notably, 85% of participants reported high levels of barriers in at least one domain and 27.42% reported barriers in all six domains of the scale. The most commonly reported barrier was "Stereotype of cancer patients" (71%). Nurses without fertility training, those who did not read fertility-related guidelines, and those in departments lacking such guidelines reported significantly higher barriers (all p < 0.05). The prevalence of oncofertility barriers among nurses is high. Educational programs should be developed to address these barriers, improving the quality of oncofertility care for women with breast cancer.

Long-Term Toxicities of Adolescent and Young Adults Who Underwent Radiation Therapy for Cervix Cancer: A Cross-Sectional Analysis

Purpose: Survivors of adolescent and young adult (AYA) cervical cancer who undergo radiation therapy are at risk of significant long-term health sequelae. We seek to evaluate long-term toxicities and their impacts on survivors. Methods: Patients treated for cervical cancer with radiation therapy between ages 18 and 39 in the years 2000-2010 in British Columbia were eligible. One hundred eligible patients were identified and mailed a package containing a questionnaire devised by a multidisciplinary team and validated patient-reported quality of life surveys for patients with cervical cancer, the European Organization for Research and Treatment of Cancer (EORTC) QLQ-30 and CX-24. Results: A total of 22 responses were received. The average time since treatment was 17.0 years (range 12-22). Fertility preservation prior to treatment was discussed with 41% of respondents and offered to 36%. A single respondent had a child after treatment through adoption. The mean EORTC Quality of Life score was rated as 63.9. Mean functional status scores include 84.4, 83.3, 67.1, 70.6, and 77 for physical, role, emotional, cognitive, and social functioning, respectively. Elevated symptom scores include sexual/vaginal functioning (53.5), sexual worry (55.6), diarrhea (38.1), body image concerns (41.7), peripheral neuropathy (39.7), and menopausal symptoms (38.1). Many patients (32%) indicated sexual and vaginal health symptoms impacting quality of life. Other common symptoms include permanent bowel changes (27%), bladder changes (27%), mood disorders (27%), and lymphedema (18%). Multiple respondents (18%) commented on regrets for not pursuing fertility preservation. Conclusions: Long-term survivors of AYA cervix cancer have significant concerns, mood disorders, premature menopausal symptoms, and fertility issues. Respondents indicated a desire for improved fertility counseling.

Impact of a Nurse Navigator Program on Referral Rates and Use of Fertility Preservation Among Female Cancer Patients: A 14-Year Retrospective Cohort Study

INTRODUCTION

Given the known detrimental impact of cancer treatment on fertility, fertility preservation (FP) is recommended for reproductive age patients who are newly diagnosed with cancer. However, the rate of referral to fertility specialists remains suboptimal. The objective of this study was to determine the impact of a dedicated Nurse Navigator Program (NNP) on the rate of referrals and utilization of FP services.

METHODS

A retrospective cohort study of all women ≥ 18 years old referred for FP consultation with a known cancer diagnosis from 2007 to 2021 at a single, large academic center was conducted. FP referrals for non-cancer indications were excluded. Descriptive statistics were performed including comparing referrals received per 30 days and FP utilization rates pre-NNP (October 2007-September 2013) to post-NNP (October 2013-December 2021).

RESULTS

A total of 176 patients were included pre-NNP and 990 patients post-NNP. Overall, the mean age at the time of referral was 31.5 ± 6.9 years. The referral rates post-NNP were higher among those without prior exposure to chemotherapy/radiation (0.33 pre-NNP vs. 2.75 post-NNP per 30 days, p < 0.01) and lower among those with prior exposure to chemotherapy/radiation (1.26 pre-NNP vs. 0.70 post-NNP per 30 days, p < 0.01).

CONCLUSIONS

After the launch of a dedicated fertility preservation nurse navigation program at our institution, we observed a higher number of referrals for FP as well as greater use of FP overall. While not the only variable that changed during this period, this program has optimized patient care and clinical workflow at our institution and serves as a model for such improvement.

Closing the Gap: The Need for Fertility Intervention for Young Adult Cancer Survivors

The current study identified the fertility-related needs of young adult (YA; ages 19-39) survivors. Participants (n = 94) completed the Adolescent and Young Adult Survivorship Psycho-Oncology Screening Tool-a screening tool developed to assess cancer-related concerns of YAs in survivorship. Approximately one-third of survivors endorsed fertility-related concerns. Frequency of fertility-related concerns was endorsed in descending order: "not knowing fertility status/options," "cost of fertility treatment," "discussing fertility with others," and "grief over fertility." Relationship between fertility concerns and other commonly reported survivorship concerns was identified. Findings highlight a gap in care for fertility-related needs in post-treatment survivorship care for YAs.

Klinefelter syndrome diagnosed at autopsy and small-cell lung carcinoma

Klinefelter syndrome is characterized by endocrine abnormalities, gynecomastia, female-like body shape, and mild intellectual disability. However, the diagnosis of Klinefelter syndrome is often missed due to the lack of characteristic findings. Computed tomography revealed a mass in the left lung of a 66-year-old man. He was diagnosed with small-cell lung carcinoma. Chemotherapy was administered, but the disease progressed, eventually leading to death. No significant changes were observed in the external genitalia or breast, but the autopsy showed testicular atrophy. XXY cells were seen in fluorescence in situ hybridization, and Klinefelter syndrome was diagnosed. Although chemotherapy causes testicular atrophy, Klinefelter syndrome should be considered in cases of severe testicular atrophy.

"Management of andrological disorders from childhood and adolescence to transition age: guidelines from the Italian Society of Andrology and Sexual Medicine (SIAMS) in collaboration with the Italian Society for Pediatric Endocrinology and Diabetology (SIEDP)-Part-1"

PURPOSE

Andrological pathologies in the adulthood are often the results of conditions that originate during childhood and adolescence and sometimes even during gestation and neonatal period. Unfortunately, the reports in the literature concerning pediatric andrological diseases are scares and mainly concerning single issues. Furthermore, no shared position statement are so far available.

METHODS

The Italian Society of Andrology and Sexual Medicine (SIAMS) commissioned an expert task force involving the Italian Society of Pediatric Endocrinology and Diabetology (SIEDP) to provide an updated guideline on the diagnosis and management of andrological disorders from childhood and adolescence to transition age. Derived recommendations were based on the grading of recommendations, assessment, development, and evaluation (GRADE) system.

RESULTS

A literature search of articles in English for the term "varicoceles", "gynecomastia", "fertility preservation", "macroorchidism", "precocious puberty" and "pubertal delay" has been performed. Three major aspects for each considered disorder were assessed including diagnosis, clinical management, and treatment. Recommendations and suggestions have been provided for each of the mentioned andrological disorders.

CONCLUSIONS

These are the first guidelines based on a multidisciplinary approach that involves important societies related to the field of andrological medicine from pediatric to transition and adult ages. This fruitful discussion allowed for a general agreement on several recommendations and suggestions to be reached, which can support all stakeholders in improving andrological and general health of the transitional age.

Interventions to mitigate reproductive concerns in individuals with cancer: A systematic review

BACKGROUND

Individuals of reproductive age with cancer may experience reproductive concerns (RCs) due to impaired fertility and disrupted family planning, which can negatively impact their quality of life and psychological well-being. There is limited research on interventions that mitigate the negative effects of RCs among individuals with cancer.

OBJECTIVE

This systematic review aimed to identify and evaluate the effectiveness of interventions developed to mitigate RCs among individuals with cancer.

METHODS

This systematic review was conducted following the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. A systematic search of nine English and Chinese electronic databases including PubMed, Cochrane Library, CINAHL Plus, Embase, PsycINFO, Web of Science, Wan Fang Data, Chinese National Knowledge Infrastructure (CNKI), and SinoMed, was conducted for relevant studies from inception to November 2023. Intervention studies designed to mitigate RCs among individuals with cancer were included. Two reviewers independently performed study selection, data extraction, and quality appraisal where JBI Critical appraisal tools were used. Narrative syntheses were conducted to summarize the characteristics and effectiveness of interventions due to high heterogeneity across studies.

RESULTS

Nine studies were included. Interventions were categorized into psychoeducational interventions (n = 6), couple-based interventions facilitating open communication and intimate relationships (n = 2), and mindfulness-based interventions (n = 1). A statistically significant reduction in RCs was observed in five psychoeducational interventions, two couple-based interventions, and one mindfulness-based stress reduction intervention. The effect sizes (Cohen's d) of the interventions on RCs varied substantially from 0.08 to 5.66.

LINKING EVIDENCE TO ACTION

Psychoeducation, couple-based, and mindfulness-based interventions demonstrated promising findings in mitigating RCs among individuals with cancer. However, more randomized controlled trials with larger sample sizes and rigorous designs are warranted to strengthen the current evidence.

Long-term effects on fertility after central nervous system cancer: A systematic review and meta-analysis

Background

Central nervous system (CNS) cancer represents a common group of solid tumors in childhood and young adults, and less frequently in adults aged 30-40. Due to treatment advancements with increasing survival rates, disorders of the hypothalamus-pituitary axis have become increasingly relevant for patients' future fertility plans. Most guidelines recommend that physicians should counsel their patients about fertility prognosis before initiating gonadotoxic therapy. However, for fertility preservation measures, gonadal toxicity as the only relevant risk factor has not yet been systematically reviewed.

Methods

A systematic literature search was performed in MEDLINE, Embase, and Cochrane in January 2024. The systematic review included studies of patients who had undergone treatment for all types of malignant CNS cancer. The outcomes were defined as clinically relevant gonadal toxicity as well as preserved fertility. The study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

Results

The qualitative analysis included 31 studies with a total of 4590 patients after CNS cancer. The overall pooled prevalence of gonadal toxicity was found to be 20% (95% confidence intervals [CI]: 10%-34%). Preserved fertility was present in 75% (95% CI: 64%-83%) of the patients and was maintained after at least 5 years following treatment (75%, 95% CI: 46%-91%).

Conclusions

This initial meta-analysis provides a basis for fertility counseling after diverse CNS cancer treatments. Due to the high heterogeneity of the study population and lack of individual patient data on fertility outcomes, it is not possible to provide an exact estimation of the fertility prognosis following a specific treatment. Thus, fertility preservation measures should still be recommended.

Controlled Ice Nucleation With a Sand-PDMS Film Device Enhances Cryopreservation of Mouse Preantral Ovarian Follicles

Ovarian follicle cryopreservation is a promising strategy for fertility preservation; however, cryopreservation protocols have room for improvement to maximize post-thaw follicle viability and quality. Current slow-freezing protocols use either manual ice-seeding in combination with expensive programmable-rate freezers or other clinically incompatible ice initiators to control the ice-seeding temperature in the extracellular solution, a critical parameter that impacts post-cryopreservation cell/tissue quality. Previously, sand has been shown to be an excellent, biocompatible ice initiator, and its use in cryopreservation of human induced pluripotent stem cells enables high cell viability and quality after cryopreservation. This study applies sand as an ice initiator to cryopreserve multicellular microtissue, preantral ovarian follicles, using a simple slow-freezing protocol in the mouse model. Ovarian follicles cryopreserved using the sand partially embedded in polydimethylsiloxane (PDMS) film to seed ice in the extracellular solution exhibit healthy morphology, high viability, and the ability to grow similarly to fresh follicles in culture post-thaw. This sand-based cryopreservation strategy can facilitate convenient ovarian follicle cryopreservation using simple equipment, and this study further demonstrates the translatability of this strategy to not only single cells but also multicellular tissues.

Non-used cryopreserved sperm among oncological patients: extra-long-term follow-up and analysis

PURPOSE

To investigate factors influencing long-term utilization and disposal patterns of cryopreserved semen straws in oncological patients.

METHODS

This retrospective study included all men who cryopreserved semen due to cancer between October 1993 and December 2021. To assess non-used cryopreserved sperm straws, we investigated the following parameters: cryopreserved semen and usage for fertility treatments versus disposal, summarized by total non-used cases. A Kaplan-Meier curve was used to describe last usage and disposal requests over a 15-year analysis. A Log-rank test was applied to compare between age and paternal status categories.

RESULTS

The cohort consisted of 445 patients. Of these, 55 patients utilized thawed semen for fertility treatments, and 65 opted for disposals, leaving 325 patients who neither used nor disposed of their cryopreserved straws. Our findings revealed a distinct pattern based on age, with the youngest age group (< 25 years) exhibiting significantly lower utilization and disposal rates compared to older patient groups. Additionally, men without children exhibited significantly fewer disposal requests compared to fathers. The median cryopreserved straws were 10 (interquartile range, 6 to 17), while the median used straws were only 2 (interquartile range, 2 to 6).

DISCUSSION

Our study brings attention to the additional and needless burden of preservation from both patient and preserved straw perspectives. Implementing a policy based on a cost-effective approach, incorporating time and straw limits, and considering demographic characteristics, could enhance efficiency and necessitate patient consent before preservation.

Outcomes of female fertility preservation with cryopreservation of oocytes or embryos in the Netherlands: a population-based study

STUDY QUESTION

What are the reproductive outcomes of patients who cryopreserved oocytes or embryos in the context of fertility preservation in the Netherlands?

SUMMARY ANSWER

This study shows that after a 10-year follow-up period, the utilization rate to attempt pregnancy using cryopreserved oocytes or embryos was 25.5% and the cumulative live birth rate after embryo transfer was 34.6% per patient.

WHAT IS KNOWN ALREADY

Fertility preservation by freezing oocytes or embryos is an established treatment for women with a risk of premature ovarian failure (caused by a benign or oncological disease) or physiological age-related fertility decline. Little is known about the success of cryopreservation, the utilization rate of oocytes or embryos, or the live birth rates.

STUDY DESIGN, SIZE, DURATION

A retrospective observational study was performed in the Netherlands. Data were collected between 2017 and 2019 from 1112 women who cryopreserved oocytes or embryos more than 2 years ago in the context of fertility preservation in 10 IVF centers in the Netherlands.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 1112 women were included in this study. Medical files and patient databases were used to extract data. Women were categorized based on indication of fertility preservation: oncological, benign, or non-medical. To indicate statistical differences the t-test or Mann-Whitney U test was used. Kaplan-Meier analyses were used for time endpoints, and log-rank analyses were used to assess statistical differences. The study protocol was approved by the medical ethics committee.

MAIN RESULTS AND THE ROLE OF CHANCE

Fertility preservation cycles have been performed increasingly over the years in the Netherlands. In the first years, less than 10 cycles per year were performed, increasing to more than 300 cycles per year 10 years later. Initially, embryos were frozen in the context of fertility preservation. In later years, cryopreservation of oocytes became the standard approach. Cryopreservation of oocytes versus embryos resulted in comparable numbers of used embryos (median of 2) for transfer and comparable live birth rates (33.9% and 34.6%, respectively). The 5-year utilization rate was 12.3% and the 10-year utilization rate was 25.5%. The cumulative clinical pregnancy rate was 35.6% and the cumulative live birth rate was 34.6% per patient. Those who had fertility preservation due to benign diseases returned earlier to use their cryopreserved embryos or oocytes.

LIMITATIONS, REASONS FOR CAUTION

The follow-up period after the fertility preservation procedure varied between patients in this study and not all frozen oocytes or embryos had been used at the end of this study. This might have led to underestimated outcomes reported in this study. Furthermore, intention to treat cannot be fully determined since women who started the fertility preservation procedure without success (cancellation due to low response) were not included in this study.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides data on the reproductive outcomes after various indications of fertility preservation. This knowledge can be informative for professionals and future patients to improve counseling and informed decision making regarding ovarian stimulation in the context of fertility preservation.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was obtained for this study. The authors have no conflicts of interest to declare related to this study. V.T.H. received grants paid to the institute for studies outside the present work from AstraZeneca, Gilead, Novartis, Eli Lily, Pfizer, and Daiichi Sankyo. V.T.H. received consulting fees from Eli Lily outside the present work. M.G. received grants paid to the institute for studies outside the present work from Guerbet and Ferring. E.M.E.B. received a grant from The Dutch Network of Fertility Preservation for a study outside the present work.

TRIAL REGISTRATION NUMBER

N/A.

Nicotinamide mononucleotide improves the ovarian reserve of POI by inhibiting NLRP3-mediated pyroptosis of ovarian granulosa cells

BACKGROUND

Premature ovarian insufficiency (POI) is a common clinical problem, but there is currently no effective treatment. NLRP3 inflammasome-induced pyroptosis is thought to be a possible mechanism of POI. Nicotinamide mononucleotide (NMN) has a certain anti-inflammatory effect, providing a promising approach for the treatment of POI.

METHODS

Thirty female Sprague Dawley rats were randomly divided into a control group (n = 10) and a POI group (n = 20). Cyclophosphamide (CTX) was administered for 2 weeks to induce POI. Then the POI group was divided into two groups: the CTX-POI group (n = 10), which was given saline; and the CTX-POI + NMN group (n = 10), which was given NMN at a dose of 500 mg/kg/day for 21 consecutive days. At the end of the study, the serum hormone concentrations of each group were determined, and each group was subjected to biochemical, histopathological, and immunohistochemical analyses. In the in vitro experiment, cell pyroptosis was simulated by using lipopolysaccharide (LPS) and nigricin (Nig), and then KGN cells were treated with NMN, MCC950, and AGK2, and the levels of Nicotinamide adenine dinucleotide (NAD+) and inflammatory factors Interleukin-18(IL-18) and Interleukin-1β(IL-1β) in the cell supernatants were detected, and the levels of pyroptosis-related factors in the cells were determined.

RESULTS

In POI rats, NMN treatments can improve blood hormone levels and partially improve the number of follicles, enhance ovarian reserve function and ovarian index.The evidence is that the increase in NAD+ levels and the activation of SIRT2 expression can reduce the expression of NLRP3, Gasdermin D (GSDMD), Caspase-1, IL-18, and IL-1β in the ovary.

CONCLUSION

NMN improves CTX-induced POI by inhibiting NLRP3-mediated pyroptosis, providing a new therapeutic strategy and drug target for clinical POI patients.

The Role of lncRNAs in the Protective Action of Tamoxifen on the Ovaries of Tumor-Bearing Rats Receiving Cyclophosphamide

Infertility due to ovarian toxicity is a common side effect of cancer treatment in premenopausal women. Tamoxifen (TAM) is a selective estrogen receptor modulator that prevented radiation- and chemotherapy-induced ovarian failure in preclinical studies. In the current study, we examined the potential regulatory role of long noncoding RNAs (lncRNAs) in the mechanism of action of TAM in the ovaries of tumor-bearing rats receiving cyclophosphamide (CPA) as cancer therapy. We identified 166 lncRNAs, among which 49 were demonstrated to be differentially expressed (DELs) in the ovaries of rats receiving TAM and CPA compared to those receiving only CPA. A total of 24 DELs were upregulated and 25 downregulated by tamoxifen. The identified DELs shared the characteristics of noncoding RNAs described in other reproductive tissues. Eleven of the identified DELs displayed divergent modes of action, regulating target transcripts via both cis- and trans-acting pathways. Functional enrichment analysis revealed that, among target genes ascribed to the identified DELs, the majority were involved in apoptosis, cell adhesion, immune response, and ovarian aging. The presented data suggest that the molecular mechanisms behind tamoxifen's protective effects in the ovaries may involve lncRNA-dependent regulation of critical signaling pathways related to inhibition of follicular transition and ovarian aging, along with the suppression of apoptosis and regulation of cell adhesion. Employing a tumor-bearing animal model undergoing chemotherapy, which accurately reflects the conditions of mammary cancer, reinforces the obtained results. Given that tamoxifen remains a key player in the management and prevention of breast cancer, understanding its ovarian-specific actions in cancer patients is crucial and requires detailed functional studies to clarify the underlying molecular mechanisms.

Navigating the Complexities of Radiation Injuries: Therapeutic Principles and Reconstructive Strategies

Radiation injuries, particularly those resulting from therapeutic or accidental exposure, present complex challenges for medical management. These injuries can manifest localized skin damage or extend to deeper tissues, presenting as various clinical entities that require treatment strategies, ranging from conservative management to complex surgical interventions. Radiation treatment constitutes a fundamental component of neoplastic management, with nearly two out of three oncological instances undergoing it as an element of their therapeutic strategy. The therapeutic approach to radiation injury consists of expanding prophylactic measures while maintaining the efficacy of treatment, such as conservative treatment or local debridement followed by reconstruction. The armamentarium of reconstructive methods available for plastic surgeons, from secondary healing to free tissue transfer, can be successfully applied to radiation injuries. However, the unique pathophysiological changes induced by radiation necessitate a careful and specialized approach for their application, considering the altered tissue characteristics and healing dynamics. The therapeutic strategy is guided by both the severity and progression of the injury, with the primary aim of restoring functionality and aesthetic aspects while simultaneously minimizing the risk of complications. This paper explores the various conditions encompassed by the term "radiation injury," reviews both non-surgical and surgical therapeutic strategies for managing these injuries, and highlights the unique challenges associated with treating irradiated tissues within specific oncological contexts.

Fertility in young-onset colorectal patients with cancer: a review

Although the overall incidence and mortality of colorectal cancer have declined, diagnosed cases of young-onset colorectal cancer have increased significantly. Concerns about future fertility are second only to concerns about survival and may significantly affect the quality of life of young cancer survivors. Fertility preservation is an important issue in young-onset colorectal patients with cancer undergoing oncotherapy. Here, we discussed the effects of different treatments on fertility, common options for fertility preservation, factors affecting fertility preservation and improvement measures, and the relationship between fertility and pregnancy outcomes in young-onset colorectal patients with cancer.

Clinical Practice Guideline-Inconsistent Management of Fertility Preservation in Pediatric Cancer Patients in Community Settings: A Children's Oncology Group Study

Background: The primary objective was to measure adherence to clinical practice guideline (CPG) recommendations for fertility preservation (FP) in pediatric cancer patients treated in National Cancer Institute Community Oncology Research Program (NCORP) sites. Secondary objectives were to describe factors such as site size associated with CPG-inconsistent care delivery and cryopreservation completion. Methods: This retrospective, multicenter study included patients 15 to 21 years old with a first cancer diagnosis from January 2014 through December 2015 who were previously enrolled to a Children's Oncology Group (COG) study and received care at a participating NCORP site. Patients were randomly selected from a list generated by the COG for chart review by participating sites. Primary outcome was care delivery that was inconsistent with a strong CPG recommendation on FP, namely discussion and offering of FP options before cancer treatment initiation, as adjudicated centrally by a panel. Results: A total of 129 patients from 25 sites were included. Among these, 48% (62/129) received CPG-inconsistent care. Most CPG-inconsistent care was due to lack of FP discussion documentation (93.5%, 58/62). Small site size, treatment at a pediatric (vs mixed adult/pediatric) site, and female sex were associated with higher odds of CPG-inconsistent care delivery. Conclusions: Newly diagnosed pediatric cancer patients often received CPG-inconsistent care for FP, with disproportionate gaps noted for females, and those treated at smaller or pediatric NCORP sites. The primary reason for CPG-inconsistent care is lack of FP discussion from clinicians. Opportunities to improve FP CPG implementation are highlighted.

Fertility preservation in lymphoma patients treated with immunochemotherapy regimens with or without radiotherapy: results of a retrospective multicenter Italian study (Ferty care)

This is a retrospective, multicentric study, aimed to describe the real-life application of fertility preservation methods during treatment in female lymphoma patients, aged 18-40 years old, diagnosed between Oct 1st/2010 and May 31st/2018. Among 414 women included, median age was 28 years old, histologies were: HL 74%, PMBCL 13%, DLBCL 10%, others 3%. First line treatments were: ABVD in 295 (71%), R-CHOP like in 102 (25%), higher intensity regimens in 17 (4%) cases. Fertility preservation strategies were: GnRHa in 315 (78%), Oral Contraceptive in 41 (10%), oocytes and ovarian tissue cryopreservation in 55 and 42 patients, respectively. After therapy, we observed a restored regular period in 293 (70%) and premature ovarian failure (POF) in 33 (8%), Furthermore we recorded 43 pregnancies, all spontaneous with 5 years median follow-up. Median age at diagnosis and number of lines of treatment correlate with higher rate of amenorrhea, risk of POF and menopause (p < 0.001).

Clinical dilemmas in ovarian tissue cryopreservation

Ovarian tissue cryopreservation (OTC) is increasingly offered globally as a fertility preservation strategy for both postpubertal women and prepubertal girls, with subsequent reimplantation of cryopreserved ovarian cortex resulting in a rapidly growing number of live births. There remains very limited evidence of efficacy from tissue stored when the patient was prepubertal or from conditions affecting the ovary directly, e.g., Turner syndrome. Although OTC is becoming a more established practice, several clinical dilemmas remain from a practical and ethical standpoint. This review discusses the challenges regarding optimal patient selection for the procedure, the use of OTC in patients with a poor prognosis, the potential of reimplantation of tissue contaminated with malignant cells, and the role of OTC in those with an intrinsic ovarian disorder.

Disparities in fertility preservation discussions among sexual and gender minority cancer patients and their cancer care providers

BACKGROUND

Cancer providers are advised to inform their reproductive aged patients about fertility preservation given the potential for treatment-related infertility. How consistently fertility preservation discussions (FPDs) occur is understudied in sexual and gender minority (SGM) cancer patients. The effects of bias and heteronormativity may reduce the rate of FPDs. We identified the frequency and correlates of FPD in a sample of SGM cancer patients.

METHODS

Data were from the cross-sectional 2020 OUT National Cancer Survey. The sample was restricted to those diagnosed with cancer between the ages of fifteen and forty-five. FPD was measured with a single item. Multivariable logistic regression was conducted to determine factors significantly associated with FPDs.

RESULTS

Average age at cancer diagnosis was 34.97 (SD = 8.34). Respondents were mostly non-Hispanic white (77.6%) and college-educated (63.4%), and 32.6% reported FPDs. In the multivariable model, identifying as lesbian (Adjusted odds ratio [aOR] = 0.49; 95% CI: 0.24-0.99), pansexual (aOR = 0.34; 95% CI:0.12-0.94), or queer (aOR = 0.24; 95% CI: 0.08-0.70) was negatively associated with FPDs compared to bisexuals. Being treated more than ten years ago (aOR = 0.47; 95% CI:0.26-0.85) was also negatively associated with FPDs.

CONCLUSION

Findings suggest potential bias against some SGM patients based on sexual orientation identity in FPDs, though changes over the past decade may have increased the frequency of FPD with patients more broadly. More research is needed to investigate why some SGM patients of reproductive age are not being counseled about fertility preservation.

Preconception and antenatal care for women with a history of haematopoietic stem cell transplantation: Results of a UK clinician survey

Background

Female childhood cancer survivors with history of bone marrow transplant with or without total body irradiation have increased pregnancy risks. Preconception counselling and early referral to appropriate clinical pathways may improve pregnancy outcomes.

Methods

UK-wide survey of clinicians, promoted via social media and conferences, jointly funded by Action Medical Research/Borne.

Results

Forty responses received between 22 October 2020 and 21 October 2021: 43% reviewed this group monthly, 15% annually, 15% less than annually, and 27% never (for O & G only: 13%, 13%, 26%, and 48%, respectively).Pre-pregnancy, most discussed potential fertility/pregnancy implications.Early pregnancy discussions included late miscarriage (34%), preterm birth (44%), fetal growth restriction (31%), and health risks other than cancer (30%).During pregnancy: 80% refer to specialist clinics; 87% offer extra investigations; 33% prescribed aspirin; 20% offered cervical cerclage; and 13% prescribed progesterone.

Conclusions

Evidence of variation in care. As previous observations suggest pregnancy outcomes improve when managed in specialist clinics, clearer guidance is required.

Geographic Access to Fertility Counseling among Adolescent and Young Adult Women with Cancer in North Carolina

BACKGROUND

Fertility counseling is recommended for adolescent and young adult women facing gonadotoxic cancer therapy. However, fertility care is subspecialized medical care offered at a limited number of institutions, making geographic access a potential barrier to guideline-concordant care. We assessed the relationship between geographic access and receipt of fertility counseling among adolescent and young adult women with cancer.

METHODS

Using data from the North Carolina Central Cancer Registry, we identified women diagnosed with lymphoma, gynecologic cancer, or breast cancer at ages 15 to 39 years during 2004 to 2015. Eligible women were invited to complete an online survey on various topics, including fertility counseling. Geographic access was measured, using geocoded addresses, as vehicular travel time from residence to the nearest fertility clinic available at diagnosis. Multivariable regression models were used to examine the association between travel time and receipt of fertility counseling by provider type: health care provider versus fertility specialist.

RESULTS

Analyses included 380 women. The median travel time to a fertility clinic was 31 (IQR: 17-71) minutes. Overall, 75% received fertility counseling from a health care provider and 16% by a fertility specialist. Women who lived ≥30 minutes from a clinic were 13% less likely to receive fertility counseling by a health care provider (prevalence ratio: 0.87; 95% confidence interval, 0.75-1.00) and 49% less likely to receive counseling by a fertility specialist (prevalence ratio: 0.51; 95% confidence interval, 0.28-0.93).

CONCLUSIONS

Women who lived further away from fertility clinics were less likely to receive fertility counseling.

IMPACT

Interventions to improve access to fertility counseling should include strategies to alleviate the burden of geographic access.

Fertility outcomes in stage I ovarian immature teratomas

OBJECTIVE

To evaluate the impact of adjuvant chemotherapy, type of ovarian surgery, and the surgical approach on fertility in patients with stage I immature teratoma of the ovary.

METHODS

Clinicopathologic data were retrospectively collected and analyzed from a cohort of 47 patients with childbearing desire treated for a stage I immature teratoma of the ovary at IRCCS San Gerardo dei Tintori Hospital, Monza, Italy. Multivariate logistic regression was used to address the influence of chemotherapy and type of surgery on the outcome.

RESULTS

Among the patients included, 78.7% (37/47) were able to get pregnant, with a live birth rate of 80.9% (51/63 pregnancies). These rates were not different between adjuvant chemotherapy versus surveillance group (62.5% (5/8) and 82.0% (32/39), respectively; p=0.22) nor between the type of ovarian surgery (cystectomy vs unilateral salpingo-oophorectomy; p=0.57) and surgical approach (laparotomy or laparoscopy; p=0.18). A statistically significant difference was found for stage of disease (a decrease in pregnancy rate from 86.5% (32/37) for stage IA to 50.0% for stage IC (5/10); p=0.02), but it was not confirmed in the multivariate analysis. After relapse diagnosis and management, a total of 62.5% (5/8) of patients conceived and had at least one live birth baby.

CONCLUSIONS

The fertility-sparing approach is feasible in this population, and fertility does not depend on surgical approach or post-operative treatment. However, adjuvant chemotherapy should be carefully evaluated in this setting.

Fertility outcomes several years after urgent fertility preservation for patients with breast cancer

OBJECTIVE

To study the fertility outcomes of women who tried to conceive after breast cancer (BC) treatment and fertility preservation.

DESIGN

Retrospective observational, bicentric cohort study.

SETTING

University hospital.

PATIENTS

Patients with BC.

INTERVENTION

All patients who had undergone fertility preservation before BC treatment between January 2013 and July 2019 were included (n = 844). The endpoint date was March 1, 2022. Patients with missing data on pregnancy attempts after a cancer diagnosis (n = 195) were excluded from the pregnancy analysis.

MAIN OUTCOME MEASURES

Cumulative incidences of pregnancy and live birth (LB) were calculated. For women who became pregnant, the time to conception was calculated between the first fertility preservation consultation and the estimated day of conception. For those who did not conceive, we considered the time between the first fertility preservation consultation and the endpoint date, or the date of patient death. A Cox regression model was used to study the predictive factors for pregnancy and LB.

RESULTS

Among the 649 patients with available data on pregnancy attempts after BC diagnosis, 255 (39.3% [35.5-43.2]) tried to conceive (median follow-up of 6.5 years). Overall, 135 (52.9% [46.6-59.2]) of these patients achieved a pregnancy, mainly through unassisted conception (79.3% [72.8-84.8]), and 99 reported an LB (representing 38.8% of patients who attempted conception). In our cohort, 48 months after the first fertility preservation consultation, the cumulative incidence of pregnancy was 33.1% ([27.6-37.9]). After adjustment for age, parity, type of chemotherapy administration, and endocrine therapy, only multiparity at diagnosis and absence of chemotherapy were positive predictive factors of pregnancy after cancer. Of the 793 patients who had vitrified oocytes and embryos, 68 used them (27% [21.3-32.5] of the patients who tried to conceive), resulting in 8 LBs (11.8% [5.2-21.9]). Women who used their cryopreserved oocytes and embryos were older at the first consultation of fertility preservation (hazard ratio 1.71 [1.42-2.21]), and chose more often to vitrify embryos (hazard ratio 1.76 [1.28-2.23]).

CONCLUSION

Although pregnancy rates after fertility preservation for patients with BC are low, most conceptions are achieved without medical assistance. Our findings provide useful information to advise women on the different techniques of fertility preservation, their efficacy, and safety, as well as the relatively high chances of unassisted conception.

The habits of European urologists in the field of cryopreservation before the urological cancers treatment

INTRODUCTION

Treatments against urogenital cancers frequently have fertility side-effects. The strategy to preserve fertility after oncologic treatments is still a matter of debate with a lack of evidence and international guidelines. The aim of this study is to investigate fertility preservation practices before urogenital cancer treatments and to compare national habits.

MATERIAL AND METHODS

An online anonymous survey was submitted from January to June 2021 to six European urological societies. The 31-items questionnaire included questions about demography, habits of evaluation, and management of fertility preservation in case of urogenital cancer treatments.

RESULTS

Two hundred twenty-eight urologists from six urological societies in five different countries (Belgium, The Netherlands, Luxembourg, France, Finland) filled out the survey. Three quarter (74%; n = 166) usually propose a cryopreservation before orchidectomy. In case of oligo/azoo-spermia, the technique performed for the sperm extraction during orchidectomy varies among the sample: 70.5% (n = 160) of the responders do not perform a Testicular Sperm Extraction (TESE) nor a Percutaneous Epididymal Sperm Aspiration (PESA). The cryopreservation for prostate cancer treatments is never proposed in 48.17% (n = 105) of responders but conversely it is always proposed in 5.05% (n = 11). The cryopreservation before bladder cancer treatments is not commonly proposed (67.5%, n = 154).

CONCLUSION

Our study showed variable country specific tendencies in terms of fertility preservation in the period of treatment of urological cancers. These differences seem to be related to national guidelines recommendations. Standardization of international guidelines is urgently needed in the field of fertility for urological cancer patients.

Racialized inequities in live birth after cancer: A population-based study of 63,000 female adolescents and young adults with cancer

INTRODUCTION

Fertility after cancer is a top concern for adolescents and young adults with cancer (AYAs) (15-39 years old at diagnosis). The authors characterized live births after cancer by race and ethnicity ("race/ethnicity") in a population-based sample of female AYAs.

METHODS

This study used Texas Cancer Registry data linked to birth certificates (1995-2016) to estimate cumulative incidence of live birth, based on first live birth after cancer, and compared differences by race/ethnicity. Proportional subdistribution hazards models were used to estimate associations between race/ethnicity and live birth, adjusted for diagnosis age, cancer type, stage, year, and prior live birth, overall and for each cancer type.

RESULTS

Among 65,804 AYAs, 10-year cumulative incidence of live birth was lower among non-Hispanic Black AYAs than other racial/ethnic groups: 10.2% (95% confidence interval [CI], 9.4-10.9) compared to 15.9% (95% CI, 14.1-17.9) among Asian or Pacific Islander, 14.7% (95% CI, 14.2-15.3) among Hispanic, and 15.2% (95% CI, 14.8-15.6) among non-Hispanic White AYAs (p < .01). In the adjusted overall model, Black AYAs were less likely to have a live birth after cancer than all other groups. In adjusted models for each cancer type, live birth was significantly less likely for Black AYAs with gynecologic cancers or lymphomas (compared to White AYAs) or thyroid cancers (compared to Hispanic AYAs).

CONCLUSION

Black AYAs are less likely than AYAs of other races/ethnicities to have a live birth after cancer, in contrast to patterns of live birth in the general population. Research and action to promote childbearing equity after cancer are imperative.

Testicular sperm extraction for fertility preservation in young patients with cancer

Background

Cancer survivors in the adolescent and young adult generation often experience marriage, pregnancy, and childbirth after treatment; thus, fertility preservation is very important. In male patients, testicular sperm extraction (TESE) is sometimes performed due to azoospermia. Such a procedure is called oncological TESE (onco-TESE). In the present study, we aimed to define onco-TESE as TESE for fertility preservation in cancer patients, including those receiving gonadotoxic treatment.

Methods

Seventeen male patients with cancer who had undergone onco-TESE for fertility preservation at Yokohama City University Medical Center between April 2014 and March 2023 were included in the study.

Results

Motile testicular sperm were acquired by TESE in 9 out of 17 cases. Among patients who had initiated chemotherapy before surgery, Motile sperm could be acquired by onco-TESE in 3 out of 9 cases. In chemotherapy-naive patients, Motile sperm were acquired by onco-TESE in 6 out of 8 cases. In the end, sperm cryopreservation was performed in 10 patients. Cryopreserved sperm were used in 2 of the 10 cases, and live birth was achieved after intracytoplasmic sperm injection in both cases.

Conclusions

Before starting gonadotoxic treatment, it is important to confirm whether the patient desires to bear children. If having a baby is desired, a referral to a reproductive medicine doctor is recommended. Fertility preservation before starting gonadotoxic treatment is preferable, but fertility preservation could be considered even after such a treatment.

Onset and resolution of ovarian toxicity with nirogacestat treatment in females with desmoid tumors: Updated safety analyses from the DeFi phase 3 study

INTRODUCTION

Nirogacestat is a targeted gamma secretase inhibitor approved in the United States for adults with progressing desmoid tumors. In the phase 3 DeFi study (NCT03785964) of nirogacestat, ovarian toxicity (OT) was identified as a safety signal among females of reproductive potential (FORP). This analysis further describes the incidence, presentation, and resolution of OT.

METHODS

Patients were randomized to twice-daily oral nirogacestat (150 mg) or placebo, taken in continuous 28-day cycles. Investigator-identified OT in FORP was based on abnormal reproductive hormone values or perimenopausal symptoms (or both). Adverse event follow-up was conducted to assess OT resolution. Post hoc analyses included return of menstruation and return of follicle-stimulating hormone (FSH) to within normal limits (WNL) (≤20.4 mIU/mL).

RESULTS

Of 92 randomized females, 73 in the safety population were FORP (n = 36 nirogacestat, n = 37 placebo). OT was identified in 75% (27 of 36) receiving nirogacestat and 0% (0 of 37) receiving placebo. As of October 24, 2022, investigators reported OT resolution in 78% (21 of 27) of patients, with median OT duration of 19.1 weeks. Off-treatment resolution was reported in all 11 patients (100%) who stopped nirogacestat treatment; of these, all nine with available menstruation information experienced return of menstruation and eight had FSH WNL at last reported assessment. Resolution was reported in 10 of 14 (71%) while on nirogacestat; of these, all 10 experienced return of menstruation and seven had FSH WNL. Two patients were lost to follow-up.

CONCLUSION

Most FORP treated with nirogacestat experienced OT, with the majority resolving, including all who stopped treatment, suggesting that OT is transient.

Analysis of assisted reproductive outcomes for gynecologic cancer survivors: a retrospective study

OBJECTIVE

To examine the reproductive outcomes of assisted reproductive technology (ART) in gynecologic cancer patients and to assess maternal and neonatal complications.

METHODS

Women diagnosed with gynecologic cancer who underwent their first in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) treatment between 2013 and 2021 at Shanghai Ji Ai Genetics and IVF Institute were included in this study. Infertile women without any history of cancer were matched to the cancer group. The primary outcome was the cumulative live birth rate. Baseline and follow-up data were compared between groups using Student's t-tests for normally distributed variables and with Chi-square test for categorical variables. A propensity score-based patient-matching approach was adopted to ensure comparability between individuals with and without specific cancer type.

RESULTS

A total of 136 patients with a history of gynecologic cancer and 241 healthy infertile controls were included in this study. Endometrial cancer constituted 50.70% of the cases and cervical cancer constituted 34.60% of the cases. The cancer group exhibited significantly shorter duration of stimulation, lower levels of estradiol, lower number of retrieved oocytes, day-3 embryos, and blastocysts compared to the control group (P < 0.05). The cumulative live birth rate of the gynecologic cancer group was significantly lower than that of the control group (36.10% vs. 60.50%, P < 0.001). Maternal and neonatal complications did not significantly differ between the groups (P > 0.05). The endometrial cancer and cervical cancer groups showed significantly lower cumulative live birth rates than their matched controls (38.60% vs. 64.50%, P = 0.011 and 24.20% vs. 68.60%, P < 0.001, respectively).

CONCLUSIONS

These findings highlight the decreased occurrence of pregnancy and live birth in female gynecologic cancer patients undergoing ART, particularly in endometrial cancers and cervical cancers. These findings have important implications for counseling and managing gynecologic cancer patients undergoing ART.

Oncofertility and Fertility Preservation for Women with Gynecological Malignancies: Where Do We Stand Today?

Oncofertility is a growing medical and research field that includes two main areas: oncology and reproductive medicine. Nowadays, the percentage of patients surviving cancer has exponentially increased, leading to the need for intervention for fertility preservation in both men and women. Specifically, gynecological malignancies in women pose an additional layer of complexity due to the reproductive organs being affected. In the present review, we report fertility preservation options with a cancer- and stage-specific focus. We explore the drawbacks and the necessity for planning fertility preservation applications during emergency statuses (i.e., the COVID-19 pandemic) and comment on the importance of repro-counseling for multifaceted patients during their oncological and reproductive journey.

Future Fertility Among Pediatric Cancer Patients: Experiences and Perspectives of Health Workers in a Low-Resource Setting

Purpose:Although fertility preservation for patients with childhood and adolescent cancer is considered standard of care in the high-resource settings, it is rarely offered in low-resource settings. This study explores the experiences and perspectives of oncology health care professionals in Uganda to identify contextual barriers and facilitators to addressing oncofertility in low-resource settings. Methods: Using ground theory, we conducted in-depth face-to-face interviews of health care professionals managing pediatric patients at the Uganda Cancer Institute (UCI). Using a systematic, semi-structured interview guide, participants were asked open-ended questions about their understanding of fertility preservation and their perspectives on implementing this care at their institution. Although all the eligible health care providers were interviewed, interview transcripts were uploaded into NVivo version 12 and openly coded as per theoretical requirements. Codes were refined into categories and later into structured themes. Results: Twelve health care professionals were interviewed. Most participants identified as female (n = 9). Their role in the medical team varied from nurses (n = 6), medical officers (n = 3), pediatric oncologists (n = 2), and pediatric oncology fellow (n = 1). Six themes were noted as follows: (1) importance of information, (2) importance of future fertility, (3) inadequate consideration to future fertility, (4) communication barriers, (5) inadequate knowledge, and (6) resource barriers. Conclusion: Although health care providers at the UCI face contextual barriers to addressing future fertility among patients with pediatric cancer, they value preserving fertility in this population. Future initiatives that aim to introduce oncofertility care in low-resource settings should prioritize educating providers and building capacity to meet the oncofertility needs in this setting.

A Systematic Review of the Gonadotoxicity of Osteosarcoma and Ewing's Sarcoma Chemotherapies in Postpubertal Females and Males

Data on gonadotoxicity of chemotherapies are essential to better counsel young females and males about the risk of infertility and to better indicate fertility preservation measures before cancer therapies. However, such data have not recently been reviewed for bone cancer. Therefore, a systematic literature search was conducted considering papers published since 2000. This study is part of the FertiTOX® project, which aims to improve the lack of data regarding gonadotoxicity of cancer therapies to enable more accurate counseling regarding fertility preservation. Only relapse-free women and men were included. Gonadotoxic therapy-induced suspected infertility was defined as very low anti-mullerian hormone, high gonadotropin concentration, amenorrhea, oligomenorrhea, azoospermia, or oligozoospermia. The quality of the individual studies was assessed using the Newcastle-Ottawa Scale (NOS). In total, 11 out of 831 studies were included in the review. Suspected infertility was found in 10/190 (5.1%, range 0%-66%) of female patients with osteosarcoma (six studies), in 24/46 (52.2%, range 46%-100%) of male patients with osteosarcoma (three studies), in 18/138 (13.0%, range 3%-18%) of female patients with Ewing's sarcoma (three studies), and in 34/38 (89.5%) of male patients with Ewing's sarcoma (one study). A risk calculation in relation to specific chemotherapies was not possible. Risk of suspected infertility tends to be higher in Ewing's sarcoma in which all patients received chemotherapies with alkylating agents. Two of the 11 included studies received a high NOS quality score, whereas the remaining nine studies received a low quality score, mainly because of the lack of a comparator group. Published data are too limited for precise estimation of the gonadotoxicity. However, data indicate clinically relevant risk for infertility, supporting counseling patients before chemotherapy about fertility preservation measures.

Websites about, not for, adolescents? A systematic analysis of online fertility preservation information for adolescent and young adult cancer patients

PURPOSE

Fertility preservation is an increasingly important topic in adolescent and young adult cancer survivorship, yet treatments remain under-utilized, possibly due to lack of awareness and understanding. The internet is widely used by adolescents and young adults and has been proposed to fill knowledge gaps and advance high-quality, more equitable care. As a first step, this study analyzed the quality of current fertility preservation resources online and identified opportunities for improvement.

METHODS

We conducted a systematic analysis of 500 websites to assess the quality, readability, and desirability of website features, and the inclusion of clinically relevant topics.

RESULTS

The majority of the 68 eligible websites were low quality, written at college reading levels, and included few features that younger patients find desirable. Websites mentioned more common fertility preservation treatments than promising experimental treatments, and could be improved with cost information, socioemotional impacts, and other equity-related fertility topics.

CONCLUSIONS

Currently, the majority of fertility preservation websites are about, but not for, adolescent and young adult patients. High-quality educational websites are needed that address outcomes that matter to teens and young adults, with a priority on solutions that prioritize equity.

IMPLICATIONS FOR CANCER SURVIVORS

Adolescent and young adult survivors have limited access to high-quality fertility preservation websites that are designed for their needs. There is a need for the development of fertility preservation websites that are clinically comprehensive, written at appropriate reading levels, inclusive, and desirable. We include specific recommendations that future researchers can use to develop websites that could better address AYA populations and improve the fertility preservation decision making process.

A Cross-Sectional Survey of Healthcare Professionals' Knowledge, Attitude and Current Behaviours towards Female Fertility Preservation Services within the UK

(1) Background: This study aims to establish the knowledge, attitudes and current behaviours towards female fertility preservation (FP) services amongst healthcare professionals (HCPs) in the UK. (2) Methods: An online survey was advertised publicly on the social media platform Instagram between 25 February 2021 and 11 March 2021. (3) Results: In total, 415 participants fulfilled the inclusion criteria and completed the survey. The majority of HCPs discussed FP techniques either never 39.5% (n = 164), once a year 20.7% (n = 86) or once a month 17.8% (n = 74). The majority rated their knowledge of each type of FP method as 'very poor' or 'poor' and strongly disagreed 14.2% (n = 59) or disagreed 42.2% (n = 175) with the statement they 'felt confident to counsel a patient on FP'. The majority either agreed 37.8% (n = 157) or strongly agreed 22.2% (n = 92) that it was their responsibility to discuss FP and 38.1% (n = 158) agreed or strongly agreed 19.5% (n = 81) they considered the desire for future fertility when planning treatment. The majority 87.2% (n = 362) had not experienced formal training on FP. (4) Conclusions: Discrepancies in knowledge remain regarding techniques of FP, referral pathways, awareness of facilities offering services and existing educational resources. Many HCPs recognise the importance of FP and their responsibility to initiate discussions. The knowledge that FP may not delay the treatment of cancer has also improved; however, training in FP is scarce.

Pharmacological methods for ovarian function and fertility preservation in women with cancer: A literature review

Oncofertility is an extremely significant topic that is increasingly being discussed owing to increased evidence indicating that fertility preservation does not affect the treatment outcomes of patients with cancer but significantly contributes to preserving life quality. The effect of chemotherapy can range from minimal effects to complete ovarian atrophy. Limited data are available on the effects of monoclonal antibodies and targeted therapies on the ovaries and fertility. Temporary ovarian suppression by administering a gonadotropin-releasing hormone agonist (GnRHa) during chemotherapy decreases the gonadotoxic effect of chemotherapy, thereby diminishing the chance of developing premature ovarian insufficiency (POI). At present, the concomitant administration of GnRH analogs during chemotherapy is the only accepted pharmacological method for preserving ovarian function. Notably, most randomized studies on the effectiveness of luteinizing hormone-releasing hormone agonists during chemotherapy in preventing POI have been conducted in women with breast cancer, with a considerably small number of studies on patients with hematological malignancies. Furthermore, most randomized controlled trials on breast cancer have revealed a decrease in treatment-induced POI risk, regardless of the hormone receptor status. In addition, studies on hematological malignancies have yielded negative results; nevertheless, the findings must be interpreted with caution owing to numerous limitations. Current guidelines from the American Society of Clinical Oncology and ESMO Clinical Practice Guidelines recommend sperm, oocyte, and embryo cryopreservation as a standard practice and only offering GnRHa to patients when proven fertility preservation methods are not feasible. In this manuscript, we present a comprehensive literature overview on the application of ovarian suppression with GnRHa during chemotherapy in patients with cancer by addressing preclinical and clinical data, as well as future perspectives in this field that upcoming research should focus on.