Fertility Preservation Issues Research Articles

Current Status and Issues of Collaboration Between Physicians and Pharmacists in Fertility Preservation.

Purpose: This study addresses the critical issue of fertility preservation among young patients with cancer in Japan, recognizing the brief decision-making window and the need for comprehensive support. Pharmacists, well-versed in the side effects of anticancer drugs, can play a vital role in this support process. However, the extent of pharmacists' involvement in fertility preservation remains unclear. We aimed to investigate pharmacists' roles in addressing cancer treatment-induced fertility concerns and their collaboration with physicians, offering insights into enhancing pharmacist participation in fertility preservation. Methods: A survey conducted between April and July 2022 targeted doctors and pharmacists at cancer treatment hospitals, along with pharmacists affiliated with the Japanese Society of Pharmaceutical Health Care and Sciences. Results: Our findings indicated that although pharmacists had limited knowledge about gonadotoxicity and fertility, they expressed readiness to conduct research and provide information when consulted. Approximately 10%-20% of the pharmacists participated in explaining the primary disease at diagnosis. Pharmacists played a more prominent role after establishing chemotherapy regimens, with less involvement in its formulation. Notably, treatment decision case conferences emerged as crucial forums for gathering patient data, confirming treatment plans, and identifying those in need for fertility preservation information. Roughly half of the pharmacists attended these conferences, suggesting a need for increased participation. Conclusion: Enhancing physician-pharmacist collaboration could be pivotal for effective fertility preservation. This requires augmenting the knowledge and awareness of both professions and encouraging greater participation in case conferences to create a conducive environment for addressing this critical aspect of cancer care.

What are the most common controversial clinical issues in fertility preservation? A content analysis of a collaborative professional online consultation group

Research questionClinicians involved in fertility preservation (FP) are often required to make prompt and consequential decisions despite the absence of evidence-based data. We established a collaborative professional online consultation group for fertility preservation issues. We sought to determine the main controversial clinical issues in FP as raised by participants of this group.DesignContent analysis of a dedicated community of practice interacting via a messaging application (WhatsApp) and a survey of group participants.ResultsBetween January 2019 and July 2022, group members posed 39 clinical questions which were discussed and debated by the group. Common themes included management of oncofertility cases (33%), potential gonadotoxicity of various therapies (23%), fertility preservation in women and girls with premature ovarian insufficiency (POI) (18%), and technical aspects of ovarian tissue cryopreservation (10%). All but one query received prompt response (mean time for first response for 95% of queries 7.1 ± 9.0 min) from a mean of 5.4 ± 3.2 members.An anonymous online survey of group members was conducted during August 2022 (n = 31, response rate 94%). The majority of respondents stated they gained knowledge and assistance in clinical decision making from participation in the discussion group (90% and 58% of respondents, respectively).ConclusionsManagement of clinical oncofertility cases, potential gonadotoxic effect of therapeutics and fertility preservation in women and girls with POI were the most common controversial issues in our fertility preservation community of practice. Intra-professional collaborative communication via a messaging application can aid in clinical management of fertility preservation and augment clinician’s knowledge.

Effect of a web-based fertility preservation training program for medical professionals in Japan.

Our web-based training program called "Educating Medical Professionals about Reproductive Issues in Cancer Healthcare" aims to help healthcare professionals communicate promptly with patients and survivors who are adolescents and young adults, with information pertinent to reproductive health issues such as the risk of infertility and fertility preservation. The study participants were professional healthcare providers, including physicians, nurses, pharmacists, social workers, midwives, psychologists, laboratory technicians, genetic counselors, and dieticians. Pre- and post- and 3-month follow-up tests consisting of 41 questions were administered to measure changes in knowledge and confidence. The participants also received a follow-up survey that covered confidence, communication techniques, and practice habits. A total of 820 healthcare providers participated in this program. The mean total score from the pre-test to the post-test grew significantly (p < 0.01), and participants' self-confidence increased. In addition, there was a change in the behavior of healthcare providers, who began asking about patients' marital status and parity. Our web-based fertility preservation training program improved knowledge and self-confidence regarding fertility preservation issues among healthcare providers caring for adolescents and young adult cancer patients and survivors.

Current Issues in Fertility Preservation Among Pediatric and Adolescent Cancer Patients.

Although fertility preservation is not yet fully integrated into the comprehensive cancer care of pediatric and adolescent patients, advances continue to take place. This review summarizes recent updates and trends for health care professionals caring for these patients. The creation of standardized infertility risk assessment guidelines offers the opportunity to provide greater consistency in clinical care and to provide a current baseline for future research studies seeking to refine risk stratification for individual patients. New agents are being introduced into cancer care; as their use increases, information about their impact on fertility is being studied. Ovarian tissue cryopreservation offers a new standard of care option for fertility preservation, but additional studies are needed to further assess efficacy and impact on ovarian reserve among pediatric and adolescent patients. Standardization of fertility preservation recommendations among certain sub-populations may also make it easier to provide greater consistency in clinical care. Advances continue to be made in the field of fertility preservation, but dissemination of this information is critical to moving toward fertility preservation truly being a part of comprehensive cancer care.

Fertilitätsprotektion bei onkologischen Erkrankungen: State of the Art

With advances in the field of oncology, the long-term survival of women and men with cancer has continuously been improved. At the same time, due to social changes family planning has shifted into later phases of life. Therefore, the issue of fertility preservation in oncological diseases is becoming more and more relevant. In recent years and decades, various fertility-preserving techniques have been established, which can be offered to women and men with newly diagnosed cancer. In addition to a de-escalation of the systemic therapy and an organ-preserving surgical approach, these include medicinal ovarian suppression, cryopreservation of oocytes and cryopreservation of ovarian tissue for women and for men the cryopreservation of sperm and/or testicular tissue via testicular sperm extraction (TESE). This overview article presents the current state of the art of the various fertility-preserving techniques with their basic principles as well as the advantages and disadvantages. All premenopausal women with newly diagnosed cancer as well as all men with cancer who may wish to have children in the future should be counselled about fertility preservation in the context of a multiprofessional team.

Fertility preservation in children and young adults with cancer.

The issue of fertility preservation has become increasingly relevant as survival rates of children with cancer exceeds 80% at 5 years. Fertility preservation options are being utilized alongside less gonadotoxic therapeutic regimens in the treatment of these patients. The purpose of this review is to summarize the recent advances in fertility preservation in the pediatric, adolescent, and young adult population. Education research involves both patient and provider; to increase understanding on both sides for improved adoption of techniques and higher rates of posttreatment fertility. Basic science research, specific to the pediatric population, has worked to further understanding of protective techniques and cryopreserved tissue transfer. Research on the techniques of preservation confirms the safety of surgical gonadal (ovarian and testicular) tissue retrieval for cryopreservation but a viable pathway for testicular tissue utilization, as it has for ovarian, has yet to be realized. Outcomes may be improving but it is apparent that robust registries are necessary to track patients long-term. Possibly the largest advancement in the recent past are group efforts, such as by PanCareLIFE, to create guidelines for these issues using larger cohorts and registries than were available. Current research implies the need for the development of a national strategy to ensure that pediatric patients undergoing gonadotoxic regimens are educated, alongside their family, about fertility options and outcomes thereafter.

Identifying Issues in Fertility Preservation for Childhood and Adolescent Patients with Cancer at Pediatric Oncology Hospitals in Japan.

Purpose: We conducted a questionnaire survey in 15 pediatric oncology hospitals in Japan to better understand the current status of fertility preservation in childhood and adolescents. Methods: The survey period was from September 2020 to December 2020. We mailed questionnaires to 64 departments involved in pediatric cancer treatments at the 15 hospitals. The primary outcomes were the timing of providing explanations on fertility preservation, presence of health care provider while providing explanations, cooperation between medical staff, and cooperation between hospitals. Results: The response rate was 100% (64/64). Regarding the time at which this information was provided, 79.6% of patients (43/54) received it before cancer treatment; 5.6% (3/54), after remission; and 14.8% (8/54), both time points. Nurses were mostly in attendance (70%) when oncologists provided information to patients. Nine (60%) hospitals did not have a reproductive department. Among these, 28.6% of the respondents referred patients to a reproductive facility that performed fertility preservation. Providing information about fertility preservation was challenging owing to the shortage of specific explanatory materials (35.1%) and the lack of cooperation between pediatric oncologists and reproductive endocrinologists (24.6%). Conclusion: Based on this survey, educational activities regarding fertility preservation centered on pediatric oncologists and nurses are needed. Furthermore, a system for providing explanatory materials for fertility preservation and encouraging cooperation at the physician and hospital levels is also needed (IRB No. H2020-111).

A challenge of fertility preservation in the setting of cervical cancer - a clinical case

The issue of fertility preservation in patients with cervical cancer is getting more and more common considering the improved effectiveness of early diagnosis and treatment of cancer. There is a number of evidence-based tactics available to the patients with diagnosed cervical cancer. These tactics have been proved effective and include methods such as ovarian transposition; oocyte, embryo and ovarian tissue cryopreservation. Nonetheless, there are no existing medical algorithms to define the priority of actions that should be taken in such cases of restricted time. The objective of this clinical case report is to highlight an existing concern towards the decision-making process regarding fertility preservation in patients with cervical cancer.In this paper we report a clinical case of fertility preservation tactics in a patient undergone ovarian transposition. We pay attention to particular features of the controlled ovarian stimulation (COS) and oocyte retrieval process typical for such patients. The article discusses the subject of COS and oocyte retrieval effectiveness compared to patients who did not undergo ovarian transposition. The 35-year old patient presented 9 month after ovarian transposition to perform oocyte cryopreservation. As a result of COS 3 oocytes were aspirated, compared to 20 oocytes in another patient of comparable age and medical history, but with no ovarian transposition performed.Regarding particular conditions constraining ovarian stimulation and oocyte retrieval after ovarian transposition, we recommend to consider the possibility of performing oocyte/embryo cryopreservation before ovarian transposition in patients with cervical cancer. Prioritizing oocyte and embryo cryopreservation in case of having sufficient time before treatment could significantly improve possibilities of achieving genetically related offspring in a long-term perspective.

The Knowledge, Attitude, and Self-Reported Behaviors of Oncology Physicians Regarding Fertility Preservation in Adult Cancer Patients

There is a growing concern about the fertility preservation for adult cancer patients of reproductive age. Very little literature exists about fertility preservation of cancer survivors in Chinese text. This study is first to describe the knowledge level, attitude, and practice behaviors among physicians concerning fertility preservation in adult cancer patients in China. A cross-sectional survey with 30-item was conducted to assess Chinese oncology physicians’ knowledge, attitude, and behaviors regarding fertility issues. Of 360 oncology physicians, 206 (57.2%) submitted valid questionnaires. With possible overall scores for knowledge and attitude of 9 and 15, respectively, physicians’ responses to the questionnaires were 3.91 ± 1.67 and 12.29 ± 1.23. Only 49.5% of physicians routinely informed their cancer patients of childbearing age about the risk of infertility with cancer treatment. The knowledge score of the men physicians was 2-fold that of the women. Physicians aged 20–29 years were significantly more likely than other age groups to prioritize cancer treatment over fertility concerns. Men physicians were significantly more comfortable than the women discussing fertility preservation issues and cooperating with fertility specialists. The oncology physicians in China had limited knowledge of fertility preservation and rarely discussed these issues with their patients, although their attitude was positive. Results suggest that oncology physicians would welcome an in-house fertility-related training program.Key MessagesThis is the first study to address the topic of fertility preservation as it relates to the care that oncologists provide to cancer patients in China. These results revealed the importance of providing fertility-related training program to oncology physicians. Moreover, this study should provide useful information for other Asian countries, and highlight both the similarities and differences between China and Western countries concerning the reproductive rights of patients. This study should encourage international cooperation with institutions of scientific research and education.

Ethical and Social Issues in Fertility Preservation

Ethical and Social Issues in Fertility Preservation

Fertility preservation issues in pediatric hematopoietic stem cell transplantation: practical approaches from the consensus of the Pediatric Diseases Working Party of the EBMT and the International BFM Study Group.

Fertility preservation is an urgent challenge in the transplant setting. A panel of transplanters and fertility specialists within the Pediatric Diseases Working Party of the European Society for Blood and Marrow Transplantation (EBMT) and the International BFM Study Group provides specific guidelines. Patients and families should be informed of possible gender- and age-specific cryopreservation strategies that should be tailored according to the underlying disease, clinical condition and previous exposure to chemotherapy. Semen collection should be routinely offered to all postpubertal boys at the diagnosis of any disease requiring therapy that could potentially impair fertility. Testicular tissue collection might be offered to postpubertal boys; nevertheless, its use has been unsuccessful to date. Oocyte collection after hormonal hyperstimulation should be offered to postpubertal girls facing gonadotoxic therapies that could be delayed for the 2 weeks required for the procedure. Ovarian tissue collection could be offered to pre-/post-pubertal girls. Pregnancies have been reported after postpubertal ovarian tissue reimplantation; however, to date, no pregnancy has been reported after the reimplantation of prepubertal ovarian tissue or in vitro maturation of pre-/post-pubertal ovarian tissue. Possible future advances in reproductive medicine could change this scenario. Health authorities should prioritize fertility preservation projects in pediatric transplantation to improve patient care and quality of life.

SEOM Clinical Guideline of fertility preservation and reproduction in cancer patients (2016).

Chemotherapy and radiotherapy often result in reduced fertility in cancer patients. With increasing survival rates, fertility is an important quality-of-life concern for many young cancer patients. Around 70–75% of young cancer survivors are interested in parenthood but the numbers of patients who access fertility preservation techniques prior to treatment are significantly lower. Moreover, despite existing guidelines, healthcare professionals do not address fertility preservation issues adequately. There is a critical need for improvements in clinical care to ensure patients are well informed about infertility risks and fertility preservation options and to support them in their reproductive decision-making prior to cancer treatment.

Long-Term Safety of Letrozole and Gonadotropin Stimulation for Fertility Preservation in Women With Breast Cancer.

There has been increased attention to the issue of fertility preservation (FP). We aimed to investigate the long-term safety of FP via controlled ovarian stimulation with letrozole supplementation (COSTLES) prior to breast cancer treatment. This is a prospective, nonrandomized, controlled study conducted between the years 2002 and 2014. A total of 337 women diagnosed with stage 3 or less invasive breast cancer were enrolled during a FP consultation before chemotherapy. Of those, 120 elected to undergo COSTLES for FP prior to chemotherapy (FP group). The remaining 217 patients did not undergo any FP procedure and served as the controls. The primary end point was cancer recurrence defined as the detection of locoregional tumor (chest wall, regional nodal disease), distant metastases, or contralateral invasive breast cancer. The baseline characteristics at enrollment were similar between the FP and control groups except for the less frequent lymph node involvement (P = .02) in the former. The mean follow-up after diagnosis was 5.0 years in the FP group and 6.9 years in the control group. In the FP group, the hazard ratio for recurrence after ovarian stimulation was 0.77 (95% confidence interval 0.28–2.13), and the survival was not compromised compared with controls (P = .61). Neither BRCA gene mutation status (P = .57) nor undergoing FP before or after breast surgery (P = .44) affected survival outcomes in the FP group. Likewise, none of the tumor characteristics including the estrogen receptor status affected the survival rates after the COSTLES. COSTLES is unlikely to cause a substantially increased recurrence risk in breast cancer during the 5 years after diagnosis.

Setting Up an Ethical Oncofertility Practice in Developing Countries

Fertility preservation for cancer patients is a relatively new field in medicine which requires interdisciplinary approach. Improving therapies and rising survival rates require to consider patient’s quality of life after cancer is cured which is relevant personal issue regardless of the individual income and the level of development of the country of origin. Fertility preservation offers possible solution but also raises ethical questions. We provide a summary of ethical principles embodied in professional guidelines together with options and restrictions to access fertility preservation in developing countries. We also make a suggestion that oncofertility counselling could be a pillar to address fertility preservation issues in cancer patients. Our proposed decisional support model is patient centred and focuses on patient values, personal philosophy and view of life emphasizing sensitivity to individual patient’s needs and wishes. Some fertility preservation concerns in oncology might be addressed mirroring already available expertise while some others will call for innovative and region specific solutions. Therefore, in addition to our proposal we also provide a list of organisations working in oncofertility field. DOI: http://dx.doi.org/10.3329/bioethics.v5i3.21532 Bangladesh Journal of Bioethics 2014 Vol.5 (3): 6-17.

Fertility preservation in cancer patients: the global framework.

Cancer treatment is the most frequent cause of reduced fertility in cancer patients, with up to 80% of survivors affected. None of the established or experimental fertility preservation methods can assure parenthood, rather they may provide a future opportunity to overcome treatment induced sterility. Around 70-75% of young cancer survivors are interested in parenthood but the numbers of patients who access fertility preservation techniques prior treatment are significantly lower. Moreover, despite existing guidelines, healthcare professionals do not address fertility preservation issues adequately. Lack of time and knowledge about existing options, delay in potentially useful treatment, patient's age, partnership status, existing children, sexual orientation and socioeconomic situation are the main barriers to effective fertility preservation. Patient's fears, expectations and priorities shaped by personal values have to be addressed in the framework of medical necessities, realistic survival probabilities, socio-cultural environment and resources availability. We call for a need of patient centred fertility counselling within a framework that should include patients understanding of medical aspects of their cancer, realistic fertility preservation options, preferences based on personal values and goals. Optional support services could also include legal guidance, psychological and spiritual support and financial counselling.

Attitude of Italian oncologists toward fertilty preservation in patients with early breast cancer.

e11547 Background: Patient’s desire for fertility preservation is a frequently underestimated problem in oncology clinical practice. Even if several different approaches have been suggested to maintain fertility in early stage breast cancer patients undergoing adjuvant chemotherapy, few women undergo to such procedures or are referred to a specialized team. Methods: Between April and July 2011, an electronic questionnaire regarding the treatment attitude in early breast cancer in premenopausal women was submitted to Italian oncologists, and 611 (female 52%, age range 25-65, 81% from general hospitals, 19% from research institute) filled in the questionnaire. Among the items, we explored also the issue of fertility preservation in women candidate for adjuvant chemotherapy and hormones. We compared the survey results (examined according to sex, age, working institution and geographic origin) with the recommendations available from guidelines of oncology and gynecology societies. Results: A pregnancy test before starting chemotherapy is considered mandatory only by 49.5% of oncologists, independently from age and type of treatment. In order to maintain fertility, several guidelines recommend eggs or embrio freezing, whereas the use of LHRH-analogs is recommended only in the contex of research trials. In our survey, the eggs freezing is considered the preferred method by 24,8% of Italian oncologists only, while 6% suggest cryopreservation of ovarian tissue. Embrio freezing is preferred by &lt;1% of oncologist. However, the majority of Italian oncologists considers the administration of LHRH-analog the treatment of choice to maintain fertility (independently from the hormone receptor status of the tumor in 83% of cases). No significant differences as by type of institution, geographic location, and physician’s age has been observed. Conclusions: The use of LHRH-analog is the preferred method by Italian oncologists for fertility preservation. A recent analysis of literature regarding the use of LHRH-analogs by Italian Society for Medical Oncology using the GRADE method suggest an important role of this drugs, even if not yet conclusive for their efficacy (level of evidence 1+, Recommendation “slightly positive”).

Fertility Preservation Practices Among Ontario Oncologists

This study explores the attitudes, knowledge, and referring behaviors in fertility preservation among Ontario physicians providing adult cancer care. Ontario physicians with specialties in medical oncology, radiation oncology, gynaecologic oncology, and urology were invited to complete a 48-item questionnaire. A total of 152 questionnaires were available for analysis with a response rate of 23.7%. Seventy-four percent of the physicians indicated that they rarely or never modified cancer treatment due to concern about future fertility. Differences were found in fertility preservation knowledge among respondents in different medical specialties (p < 0.01) and clinical settings (p < 0.05). The frequency of initiating a referral was strongly associated with knowing where to refer patients (p < 0.001). The odds of knowing where to refer cancer patients was higher for physicians who work in a teaching hospital (p < 0.01) and a cancer centre (p < 0.01) compared with those who primarily work in a community setting. About 45% did not know where to refer female patients, and 69.7% rarely ever made a fertility preservation consultation referral for their female patients. The majority of respondents had positive attitudes despite their lack of current knowledge in cryopreservation services and fertility preservation options through assisted reproductive technologies. Our findings provide further insights of the relevance of considering physicians' medical backgrounds and practice settings when designing training modules to raise their awareness in fertility preservation issues.

P5-23-04: Gonadotrophin-Releasing Hormone Analogues for Ovarian Function Preservation in Women with Premenopausal Breast Cancer Undergoing Adjuvant Chemotherapy: A Systematic Review and Meta-Analysis.

Abstract Background: Breast cancer, the most common female malignancy, is also the most frequent tumor in women of reproductive age. Young women with breast cancer usually present adverse prognostic features and higher rates of recurrence when compared with their older counterparts. Adjuvant chemotherapy is usually recommended for this group of patients and premature ovarian failure (POF) is a potential complication. Material and Methods: We conducted a systematic search in MEDLINE, EMBASE, Cochrane Systematic Reviews databases and ***ClinicalTrials.gov from their inception until June 2011. The search was conducted to include published peer-reviewed studies on the issue of fertility preservation in women with breast cancer undergoing adjuvant chemotherapy. The search terms were tailored individually for each database to include the following Medical Subject Headings (MeSH) and text words: gonadotropin releasing hormone, breast neoplasms, drug therapy, premature ovarian failure and fertility. No language restriction was applied. We also searched for additional studies by reviewing the reference lists of retrieved articles, and studies presented in abstract form were also located in this manner. The main outcomes were return of spontaneous menstruation, ovulation and pregnancy rate. Results: We found 8 RCTs that met the inclusion criteria. Data were extracted from 3 RCTs. Data were only available for resumption of ovulation. There were no data available for markers of ovarian function, rate of ovulation and pregnancy. The rate of women with spontaneous menstruation demonstrated a statistically significant difference in favor of the use of GnRH-a (OR 3.11;95% CI, 2.04-472). Discussion: Use of GnRH concomitant to adjuvant chemotherapy in premenopausal breast cancer women aiming to reduce rates of POF has been subject of controversy during the last decade. Evidence from recently presented RCTs suggests there is a benefit of GnRH for ovarian function protection in this setting. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-23-04.

Oncofertility and preservation of reproductive capacity in children and young adults

With increasing numbers of survivors from cancer at a young age, the issue of fertility preservation has assumed greater importance. This review describes normal ovarian and testicular function and summarizes what is known about the effect of chemotherapy and radiotherapy on the gonads and uterus. All young patients with cancer or leukemia should have their fertility prognosis discussed before the initiation of treatment. Sperm and embryo cryopreservation should be considered standard practice and be widely available for those at significant risk of infertility. For prepubertal girls, ovarian tissue cryopreservation should be considered if the risk of premature menopause is high, but for the prepubertal boy there are no established techniques in current practice.

Medical Treatment for Uterine Myomas

Uterine myomas are the most common benign tumors in the female reproductive tract. Most women with myomas are asymptomatic. Therefore, expectant observation and follow-up are often recommended for these myoma patients. However, myomas may cause menstrual symptoms, pelvic pain, pressure complaints, subfertility or pregnancy-related complications, with resultant requests for a definitive treatment. The management of myomas has become multidisciplinary in the past 20 years. Basically, the choice of treatment depends on the patient's age, the reason for treatment, the issue of fertility preservation, and the patient's preference. The treatment spectrum includes an expectant management, medical therapy, surgical intervention, uterine artery embolization or ablative techniques. Medical therapy is an option for women with symptomatic myomas who prefer non-surgical treatment, consider fertility preservation, or expect a less aggressive operation after shrinkage of the uterine volume. This review will summarize the recent well-documented drugs for the management of uterine myomas.