Fertility Preservation Services Research Articles

On-Site Fertility Preservation Services for Adolescents and Young Adults in a Comprehensive Cancer Center.

Adolescents and young adults (AYAs) receiving cancer treatments that may impair fertility should receive counseling about risk of infertility and options for fertility preservation (FP) before treatment and/or during survivorship. Our objective was to define the AYA patient population referred to an on-site fertility consultation service within a comprehensive cancer center and determine factors associated with patients proceeding with FP treatment. We conducted a retrospective chart review of AYA women who completed a consultation at the MD Anderson Fertility Preservation and Family Building Service during the first year of service. Records of 154 referred AYA patients were reviewed for age, ethnicity, cancer type gravidity and parity, survivorship status, and decision to pursue FP treatment. Patients (mean age 29.7) were Caucasian (55%), Hispanic (23%), and African American (10%). The majority of women (67%) were seen for FP before cancer treatment and the remaining sought options for family building while in survivorship. The most common cancer types were hematologic (29%), breast (25%), and gynecologic (23%). Patients referred to an on-site fertility consultation service were medically and ethnically diverse. Interest in fertility counseling and treatment was apparent in both survivorship pre- and postcancer treatment. Although the referral group was ethnically diverse, Caucasian women were most likely to pursue FP treatment compared to women of other ethnicities.

Transgender Reproductive Choice and Fertility Preservation

Increasing numbers of young transgender people are now using medical technologies to achieve a physical gender transition. However, the procedures of physical gender transition might cause temporary or permanent sterility. Thus many transgender people are now using fertility preservation technologies. Nonetheless, they can experience dilemmas in making reproductive and family-building decisions and face challenges in gaining access to and utilizing fertility preservation services. Based on qualitative research conducted with transgender men and women who used reproductive technologies for preserving their fertility before or during their physical transition, this paper contributes to the discourse of reproductive choice by the inclusion of transgender people's experience.

Increase access to fertility preservation care using a patient navigator model

The main role of a fertility preservation patient navigator (PN) is to see reproductive aged patients in the comprehensive cancer center and other centers where gonadotoxic therapies are utilized. PN then reviews possible options for fertility preservation, helps facilitate consultations with reproductive specialists, and coordinates care between different specialties. Here we determine if the use of a Patient Navigator (PN) increases access to fertility preservation (FP) services and information.

A Review of the Oncology Patient's Challenges for Utilizing Fertility Preservation Services

The American Society of Clinical Oncology issued practice guidelines in 2006 to provide critical information about fertility impact to adolescents and young adults (AYA) at the time of cancer diagnosis. Survivors continue to express concerns about their long-term reproductive health after cancer therapy even as treatment options for fertility preservation evolve. An underutilization of fertility preservation methods by cancer patients continues to persist. A review of the literature cites barriers and challenges that limit fertility information and preservation options for AYA cancer patients. A review of medical literature was conducted to examine current practice for patients receiving fertility information and the barriers to patients receiving fertility preservation services. A total of 69 publications were included in this review. The review summarizes (1) patient experiences with receiving fertility information and (2) patient desires, barriers, and challenges to utilizing fertility preservation services. Despite advances in fertility preservation, there are challenges for patients to utilizing fertility preservation services. Barriers include the following: urgency to initiate treatment, inadequate information, clinic time constraints, and perceptions around patients' gender, age, cost, parity, race, relationship, and sociodemographic status influence whether patients receive fertility preservation consultation. Patients report a lack of adequate information to make informed fertility decisions.

Quebec public funding facilitates fertility preservation for male cancer patients.

Sperm cryopreservation remains the only clinically feasible option to preserve male fertility. The quality of counselling provided by the treating physicians and the cost of sperm cryopreservation can both influence a patient's decision about whether to preserve sperm. On 5 August 2010, the Quebec government introduced provincial coverage of assisted reproductive technologies, with sperm cryopreservation included as a covered service. The aim of the present study was to evaluate whether and how such a program affects the behaviour of cancer patients with respect to sperm cryopreservation. We analyzed the database derived from male patients undergoing sperm cryopreservation from August 2008 to August 2012 at our centre. The retrieved data included patient age, male infertility or oncologic diagnosis, sperm quality parameters, and details about the number of visits for sperm cryopreservation. The number of cancer patients who cryopreserved sperm before and after the policy change did not differ significantly, but a marked increase in the number of non-cancer patients was observed. Further analysis revealed that, after implementation of the public funding program, the total number of sperm cryopreservation sessions per patient increased significantly in cancer patients but not in non-cancer patients. It appears that cancer patients who are willing to freeze sperm are keen to return for more sessions of sperm banking when no fees are associated with the service. Those findings suggest that cost reduction is an important factor for improving delivery of fertility preservation services to male cancer patients.

Fertility preservation services for women with newly diagnosed cancer: a national survey

Fertility preservation services for women with newly diagnosed cancer: a national survey

Fertility Attitudes and Cancer Treatment Study (FACTS).

112 Background: Approximately 140,000 people under 45 year old are diagnosed with cancer annually in the US. Survivorship is high and many of these individuals desire future fertility. Although fertility preservation (FP) services are increasing, utilization rates remain low. Methods: We conducted a 2-phase study to identify factors for FP decisions among newly diagnosed males and females receiving fertility consultation, 18-45 years old. Phase 1 was a chart review; Chi-square and t-tests were used to determine potential factors associated with FP decision. Phase 2 consisted of face-to-face interviews. Content analysis was used to identify relevant themes associated with reasons, priorities, support, and satisfaction for FP decision. Results: In Phase 1, 108 charts were reviewed; FP utilization rate was 50%. Those who chose FP were more likely to be male (73.6% vs. 26.4%, p < 0.001), Caucasian (90.6% vs. 9.4%, p = 0.042), have a solid tumor (98.1% vs. 1.9% p = 0.032), and a shorter time from diagnosis to fertility consult (29.5 vs. 58.8 days, p = 0.017). Age, relationship, education, parity, or treatment plan did not differ with FP decision. In phase 2, we assessed reasons why patients chose FP; 27 participants were interviewed. Primary reasons for choosing FP were: future fertility and access to FP services. Main reasons for not choosing FP were: concerns with future conception and lack of access to FP services. Cost ranked 4thamong reasons to not choose FP; however 50% of patients overcame the cost to prioritize future fertility. Males top priorities were: future parenthood, cancer treatment, and survivorship QOL. Females top priorities were: future parenthood, decisional conflict, and cancer treatment. Patients greatest concerns with FP were: birth defects, future conception, and success of FP. Conclusions: Future fertility is a priority for newly diagnosed young adults. All patients should receive a referral to a reproductive specialist, regardless of patient factors or diagnosis. While patients expressed feeling well-informed to make FP decisions following fertility consult, some still had concerns with the safety and success of FP. Adequate FP consultation should include discussion of all treatment options and concerns for FP.

Young Adults' Access to Fertility Preservation Services at National Cancer Institute Community Oncology Research Program Minority/Underserved Community Sites: A Qualitative Study.

This qualitative study aims to characterize the factors that influence access to fertility preservation (FP) resources and services after cancer diagnosis at NCI Community Oncology Research Program (NCORP) minority/underserved community sites, which serve patient populations comprising at least 30% racial/ethnic minorities or rural residents. Phone interviews were conducted from 2014 to 2015 with interested and knowledgeable healthcare providers practicing at NCORP minority/underserved community sites, using a semi-structured interview guide. Data were transcribed, de-identified, and analyzed using qualitative analysis software, Dedoose, to determine the most common themes in access to FP resources and services. Interviews were conducted with 10 board-certified physicians practicing at 10 of the 12 NCORP minority/underserved community sites; five respondents identified as oncologists, and five were reproductive endocrinology/infertility specialists (n = 4) or obstetricians/gynecologists (n = 1). Findings revealed highly variable access to FP resources at each site. Notable barriers to FP services were cost, time, provider education, lack of clinical guideline application, and perceptions among healthcare providers that negatively affect the discussion of options and risks with eligible patients. Clinical FP guidelines and resources for cancer patients and healthcare providers need to be better integrated into existing cancer networks that serve minority and underserved patient populations. Providers need more education regarding timely provision of FP services to all newly diagnosed cancer patients of reproductive age.

Factors associated with the receipt of fertility preservation services along the decision-making pathway in young Canadian female cancer patients.

This study investigated the factors associated with the receipt of fertility preservation (FP) services along the decision-making pathway in young Canadian female cancer patients. The roles of the oncologists were examined. A total of 188 women who were diagnosed with cancer between the ages of 18-39 after the year 2000 and had finished active cancer treatment by the time of the survey (2012-2013) participated in the study. Logistic regression models and Pearson χ (2) tests were used for analyses. The mean ages of participants at diagnosis and at survey time were 30.2 (SD = 3.7) and 33.9 (SD = 5.9). One quarter (n = 45, 23.9%) did not recall having a fertility discussion with their oncologists. Of the three quarters who had a fertility discussion (n = 143, 76.1%), discussions were equally initiated by oncologists (n = 71) and patients (n = 72). Of the 49 women (26%) who consulted a fertility specialist, 17 (9%) underwent a FP procedure. Fertility concern at diagnosis was the driving force of the receipt of FP services at all decision points. Our findings suggest that not only was the proactive approach of oncologists in initiating a fertility discussion important, the quality of the discussion was equally critical in the decision-making pathway. Oncologists play a pivotal role in the provision of fertility services in that they are not only gate keepers, knowledge brokers, and referral initiators of FP consultation, but also they are catalysts in supporting cancer patients making important FP decision in conjunction with the consultation provided by a fertility specialist.

Cumulative alkylating agent exposure and semen parameters in adult survivors of childhood cancer: a report from the St Jude Lifetime Cohort Study

Few data define the dose-specific relation between alkylating agent exposure and semen variables in adult survivors of childhood cancer. We undertook this study to test the hypothesis that increased exposure to alkylating agents would be associated with decreased sperm concentration in a cohort of adult male survivors of childhood cancer who were not exposed to radiation therapy for their childhood cancer. We did semen analysis on 214 adult male survivors of childhood cancer (median age 7·7 years [range 0·01-20·3] at diagnosis, 29·0 years [18·4-56·1] at assessment, and a median of 21·0 years [10·5-41·6] since diagnosis) who had received alkylating agent chemotherapy but no radiation therapy. Alkylating agent exposure was estimated using the cyclophosphamide equivalent dose (CED). Odds ratios (ORs) and 95% CIs for oligospermia (sperm concentration >0 and <15 million per mL) and azoospermia were calculated with logistic regression modelling. Azoospermia was noted in 53 (25%) of 214 participants, oligospermia in 59 (28%), and normospermia (sperm concentration ≥15 million per mL) in 102 (48%) participants. 31 (89%) of 35 participants who received CED less than 4000 mg/m(2) were normospermic. CED was negatively correlated with sperm concentration (correlation coefficient=-0·37, p<0·0001). Mean CED was 10 830 mg/m(2) (SD 7274) in patients with azoospermia, 8480 mg/m(2) (4264) in patients with oligospermia, and 6626 mg/m(2) (3576) in patients with normospermia. In multivariable analysis, CED was significantly associated with an increased risk per 1000 mg/m(2) CED for azoospermia (OR 1·22, 95% CI 1·11-1·34), and for oligospermia (1·14, 1·04-1·25), but age at diagnosis and age at assessment were not. Impaired spermatogenesis was unlikely when the CED was less than 4000 mg/m(2). Although sperm concentration decreases with increasing CED, there was substantial overlap of CED associated with normospermia, oligospermia, and azoospermia. These data can inform pretreatment patient counselling and use of fertility preservation services. US National Cancer Institute, American Lebanese Syrian Associated Charities.

Assessment of society for assisted reproductive technology (SART) fertility clinic websites for male infertility information and resources

Assessment of society for assisted reproductive technology (SART) fertility clinic websites for male infertility information and resources

Adolescent Mental Health and Risky Sexual Behavior: A Canadian Perspective

lists, expert consultation, and conference abstracts. Eligible studies focused on pediatric and adolescent oncology patients or survivors, their parents, and/or pediatric oncology providers and their knowledgeof, beliefs about, orattitudes toward fertility preservation aftera cancer diagnosis. Studies were assessed for methodological quality, datawas extracted using a standardized form, and synthesized using the Cochrane guidelines for multi-level, simultaneous syntheses of quantitative and qualitative data. Results: 1233 papers were identified and 36 were included in the final review. 24 studies provided quantitative data (patients: 8, parents: 4, providers: 7, multiple perspectives: 5). 11 studies were qualitative (patients: 7, parents: 0, providers: 3, multiple perspectives: 2). The majority of cancer patients wanted information about treatment related fertility effects and fertility preservation options early in their course of their cancer treatment. Patients recalled receiving this information 30-87% of the time. A higher proportion of patients had heard about fertility issues before treatment in later studies. Many patients (35-64%) were dissatisfied with the information received and identified ways of improving the provision of fertility preservation information. Examples include offering options for parental involvement in initial discussions and offering continued support for fertility preservation decision-making before, during, and after cancer treatment. Parents of pubertal and pre-pubertal cancer patients find many fertility preservation options acceptable despite being experimental, especially if they do not cause a delay in treatment. Providers are aware of the importance of fertility issues for their patients and their families, they are knowledgeable about fertility preservation options, and identify age, pubertal status, critical illness, and uncertainty as potential barriers to communication about and referral for fertility preservation services. Conclusions: Adolescent oncology patients and their parents desire candid and timely fertility preservation related information and referral for fertility preservation procedures. Providers are aware of fertility preservation options and resources, but identify systemrelated and personal barriers to discussionswith adolescent patients and families regarding fertility preservation. Future research should focus on patients and families to determine the optimal setting, method, and delivery of fertility preservation related information. Sources of Support: None.

To preserve or not to preserve

The decision to pursue fertility preservation (FP) after a cancer diagnosis is complex. We examined the prevalence of high decisional conflict and specific factors that influence this decision using the Decisional Conflict Scale (DCS). The FIRST project is a web-based survey of female cancer survivors (ages 18-44 years) who have undergone gonadotoxic treatment. We evaluated the association between recalled decisional conflict and referral to FP counseling and demographic, socioeconomic, and cancer variables. Of 208 participants, 115 subjects (55%) had scores consistent with high decisional conflict (DCS score >37.5 of 100), and 43 (21%) were in the moderate range (25-37.5). In unadjusted analysis, high decisional conflict was associated with lack of referral to FP consultation, not undergoing FP treatment, concerns regarding FP cost, length of survivorship, lower income, education, partner status, and cancer type. In multivariable analysis, significantly higher prevalence of high decisional conflict was observed in participants who were not referred for FP consultation (prevalence ratio [PR], 1.25; 95% confidence interval [CI], 1.06-1.47), as well as in participants who reported cost of FP services to be prohibitive (PR, 1.16 [95% CI, 1.03-1.31]). Prevalence of high DCS was lower for women who underwent FP treatment (PR, 0.67 [95% CI, 0.52-0.86]). In this study of female young adult cancer survivors, the majority recalled significant decisional conflict about FP at cancer diagnosis. Increasing access to FP via referral for counseling and cost reduction may decrease decisional conflict about FP for young patients struggling with cancer and fertility decisions.

A National Study of the Provision of Oncofertility Services to Female Patients in Canada

ObjectiveThis study aimed to gain a better understanding of the fertility preservation services provided by Canadian fertility clinics to women with cancer. MethodsWe invited a total of 76 fertility clinics across Canada to complete a mailed questionnaire related to the availability, accessibility, affordability, and utilization of fertility preservation services for oncology patients. ResultsThe total response rate was 59.2%: 72.4% for IVF clinics and 51.1% for fertility centres without on-site IVF. Not all the responding IVF centres accepted oncology referrals for women. Six clinics without on-site IVF accepted cancer patients for consultation. The medical consultation fees are covered by public health insurance in all provinces. The majority of respondents expedited the referrals to schedule an initial medical appointment within three days. Despite that, the referral volume reported by respondents was markedly low for all except two facilities. With over 4000 young women of reproductive age given a diagnosis of cancer each year in Canada, the findings suggest that cancer patients are severely under-served by fertility clinics. ConclusionThere is a need to develop a stronger partnership between the fields of oncology and reproductive medicine to further improve access of patients with cancer to fertility preservation services. Development of evidence-based practice guidelines covering medical, clinical, psychosocial, ethical, and legal aspects geared to the Canadian health care system would help to avoid ambiguity relating to the roles and responsibilities in the provision of fertility preservation services. Such processes would ensure optimization of services so that all young cancer patients would receive the best care in protecting their fertility.

Addressing Oncofertility Needs: Views of Female Cancer Patients in Fertility Preservation

A total of 41 questionnaires were returned from 64 respondents who consented to receive a questionnaire through the mail. Almost all valued the opportunity to receive consultation to address their fertility concerns and discuss fertility preservation options. Psychological stress, time pressure, and costs were identified as main factors affecting respondents’ decision to proceed with in-vitro fertilization to cryopreserve oocytes or embryos. About one third indicated that the discussion of fertility matters was initiated by themselves, their friends, and families rather than their health care providers. The findings have identified several major barriers encountered by female cancer patients when seeking fertility preservation services.

Racial, socioeconomic, and demographic disparities in access to fertility preservation in young women diagnosed with cancer

This study seeks to examine the relation between sociodemographic characteristics and the utilization of fertility preservation services in reproductive age women diagnosed with cancer. A total of 1041 women diagnosed with cancer between the ages of 18 and 40 years responded to a retrospective survey on demographic information and reproductive health history. Five cancer types were included: leukemia, Hodgkin disease, non-Hodgkin lymphoma, breast cancer, and gastrointestinal cancer. Nine hundred eighteen women reported treatment with potential to affect fertility (chemotherapy, pelvic radiation, pelvic surgery, or bone marrow transplant). Student t test, linear regression, and multivariate logistic regression were used where appropriate to determine the relation between sociodemographic characteristics and the odds of using fertility preservation services. Sixty-one percent of women were counseled on the risk of cancer treatment to fertility by the oncology team. Overall, 4% of women pursued fertility preservation. In multivariate analysis, women who had not attained a bachelor's degree (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.5-0.9) were less likely to be counseled. Trends also suggested possible disparities in access to fertility preservation with age older than 35 years (OR, 0.1; 95% CI, 0.0-1.4) or previous children (OR, 0.3; 95% CI, 0.1-1.1) at diagnosis. Disparities in access to fertility preservation based on ethnicity and sexual orientation were also observed. Sociodemographic health disparities likely affect access to fertility preservation services. Although awareness of fertility preservation has improved in the past decade, an unmet need remains for reproductive health counseling and fertility preservation in reproductive age women diagnosed with cancer.

Improved Fertility Preservation Care for Male Patients With Cancer After Establishment of Formalized Oncofertility Program

Survival to reproductive age among men with cancer has steadily increased and yet cancer therapy and cancer itself may carry the risk of infertility. Since 2006, we have used a formalized fertility preservation program with expedited fertility care at our institution. We assessed the impact of this program by comparing the frequency of sperm cryopreservation and patient characteristics before and after its implementation. Men 18 to 55 years old diagnosed with cancer at our institution from 2002 to 2010 were included in our study. We retrospectively reviewed patient charts to identify those who were offered and subsequently used fertility preservation services before and after program formalization. From 2002 to 2010 at our institution 4,818 men 18 to 55 years old were diagnosed with cancer, of whom 411 were offered fertility preservation consultation and 249 underwent sperm cryopreservation. Since program implementation, the annual number of men receiving fertility preservation consultation and undergoing sperm cryopreservation increased by 2.4 and 2.7-fold, respectively, while the total number diagnosed with cancer remained fairly constant. Upon substratifying patients into the more conventional reproductive age range of 18 to 40 years 23.4% of all men with cancer in this group were offered consultation before formalization vs 43.3% after formalization (p <0.05). The overall sperm use and discard rates were 8.4% and 14.8%, respectively. A formalized institutional fertility preservation program significantly increased the overall number and percent of male patients with cancer who received fertility preservation consultation and pursued sperm cryopreservation. These increases were seen in men with all types of cancer and across all demographics assessed at our institution.

Fertility preservation as a public health issue: an epidemiological perspective

Over the past decade, fertility preservation has become an increasingly viable option for patients diagnosed with diseases such as cancer and systemic lupus erythematosus (SLE), whose treatment often results in impaired fertility. This review summarizes current epidemiological trends that have caused cancer-related and SLE-related infertility to be an important and growing public health burden, which may be reduced by improving access to fertility preservation services. In the United States alone, over 130 000 men and women below the age of 45 were afflicted by cancer in 2008. The compromised fertility that will be faced by many of these patients can result in significant psychosocial stress and reduced quality of life, even long after the disease has been successfully treated. Although the use of fertility preservation services may help alleviate this burden, access to these services is often inadequate, because of logistical barriers and a lack of appropriate patient referral by healthcare providers. Increases in cancer survival rates and the average age at which a mother will have her first child has put added emphasis on the need for fertility preservation services. Enhanced provider and patient education, as well improved coordination of oncological-reproductive care, may promote patient access to fertility preservation services.

State laws and regulations addressing third-party reimbursement for infertility treatment: implications for cancer survivors

To examine codified state policies related to infertility and assess their implications for cancer patients. Lack of insurance is often identified as a barrier to use of fertility preservation (FP) services. None. A keyword search was developed to identify statutes and administrative regulations of insurance coverage for FP in the United States. N/A. N/A. Laws addressing the general population but pertaining to FP were compiled using Lexis-Nexis. Data were analyzed by reviewing the "plain meaning" of the text, legislative/administrative history, and annotated case law. Legal reasoning and common rules of statutory construction and legislative interpretation were used. Fifteen states (29.4%) had laws relating to insurance coverage for infertility or in vitro fertilization (IVF) procedures and two states (CA and IL) specifically excluded IVF from a mandatory offer of coverage. No state laws or regulations addressed insurance coverage for FP methods specific to cancer patients. There is an argument for policies that require coverage for FP for cancer survivors before treatment.

Development and implementation of a turnkey national fertility preservation program between a reproductive tissue bank and infertility treatment centers

OBJECTIVE: A prototype program was developed to make male fertility preservation services nationally accessible to those in need and to increase awareness of these options in the oncology community.DESIGN: Development of a turnkey fertility preservation program.MATERIALS AND METHODS: The first stage of development includes research of potential locations whose populations would benefit from fertility preservation. These locations include major metropolitan areas near oncology institutes and remote areas where services are not provided. Next is the selection of an infertility center to become a service provider in the given location. The center must meet the criteria of excellent patient service, Andrology laboratory capacity, appropriate accreditations and a passion for fertility preservation. An agreement is established between both parties on operational components. These components include: laboratory services rendered to patients, consultative and administrative duties, alignment of SOPs, specimen transfer coordination and verification of protocol acceptance. The tissue bank's responsibilities include: patient consultation via phone, billing, managing infectious disease test results and long-term specimen storage. Concurrent consumer and physician fertility preservation awareness campaigns are launched in selected location. Partnerships between tissue bank and young adult oncology support organizations such as Fertile Hope and I'm Too Young For This! are essential in raising awareness of these options.RESULTS: 70,000 young adults are diagnosed annually with cancer. The creation of the turnkey fertility preservation program and implementation of its first service provider has generated interest and support in both the oncology and fertility fields. Subsequent service providers will be added across the nation.CONCLUSIONS: The service provider turnkey program raises awareness of male fertility preservation options and accessibility to these services for both oncology physicians and patients. OBJECTIVE: A prototype program was developed to make male fertility preservation services nationally accessible to those in need and to increase awareness of these options in the oncology community. DESIGN: Development of a turnkey fertility preservation program. MATERIALS AND METHODS: The first stage of development includes research of potential locations whose populations would benefit from fertility preservation. These locations include major metropolitan areas near oncology institutes and remote areas where services are not provided. Next is the selection of an infertility center to become a service provider in the given location. The center must meet the criteria of excellent patient service, Andrology laboratory capacity, appropriate accreditations and a passion for fertility preservation. An agreement is established between both parties on operational components. These components include: laboratory services rendered to patients, consultative and administrative duties, alignment of SOPs, specimen transfer coordination and verification of protocol acceptance. The tissue bank's responsibilities include: patient consultation via phone, billing, managing infectious disease test results and long-term specimen storage. Concurrent consumer and physician fertility preservation awareness campaigns are launched in selected location. Partnerships between tissue bank and young adult oncology support organizations such as Fertile Hope and I'm Too Young For This! are essential in raising awareness of these options. RESULTS: 70,000 young adults are diagnosed annually with cancer. The creation of the turnkey fertility preservation program and implementation of its first service provider has generated interest and support in both the oncology and fertility fields. Subsequent service providers will be added across the nation. CONCLUSIONS: The service provider turnkey program raises awareness of male fertility preservation options and accessibility to these services for both oncology physicians and patients.