Pursue Fertility Preservation Research Articles

O-234 Indication for fertility preservation in patients with endometriosis

Abstract Endometriosis is a complex gynecological condition that not only causes debilitating symptoms but also significantly impacts fertility. As the disease affects approximately 10% of women of reproductive age, addressing fertility preservation strategies becomes paramount. The conventional treatments for endometriosis, such as medical therapy and surgery, often fail to fully address its adverse effects on ovarian reserve and reproductive potential. Consequently, there is a growing interest in exploring fertility preservation options, particularly oocyte cryopreservation (OOC), for endometriosis patients. Despite the prevalence and impact of endometriosis on fertility, comprehensive data and guidelines specifically tailored to fertility preservation in this population remain scarce. The available evidence suggests that endometriosis, particularly when it involves ovarian endometriomas, is associated with a significant reduction in ovarian reserve, as indicated by lower levels of anti-Müllerian hormone (AMH). Surgical interventions, often necessary for managing endometriosis-related complications, can further compromise ovarian function and diminish fertility prospects. However, recent studies have shed light on the potential benefits of OOC in preserving fertility for endometriosis patients. OOC offers a minimally invasive approach with no impact on ovarian reserve compared to other fertility preservation techniques. Despite the lack of randomized controlled trials, our retrospective data have demonstrated promising outcomes, with a notable number needed to treat (NNT) of 16 for one successful pregnancy. This underscores the significance of discussing and considering OOC as part of the treatment plan for endometriosis patients, especially those at risk of ovarian compromise due to the disease or its management. The decision to pursue fertility preservation through OOC should be made on a case-by-case basis, taking into account various factors such as disease severity, patient age, ovarian reserve, and treatment history. French guidelines recommend considering OOC for endometriosis patients with bilateral ovarian endometriomas larger than 3 cm or those with endometriomas on a single ovary. Initiating fertility preservation discussions early, preferably before surgical intervention, allows patients to make informed decisions regarding their reproductive future. It is crucial to acknowledge the challenges and uncertainties associated with fertility preservation in endometriosis patients. Socio-economic factors, patient preferences, and the lack of clear criteria for selecting candidates for OOC pose significant hurdles. Furthermore, the effectiveness and cost-effectiveness of OOC in this population warrant further investigation. In addition to OOC, alternative fertility preservation options, such as ovarian tissue preservation, could be considered, particularly in cases where ovarian stimulation is not feasible or declined by the patient. However, data on the efficacy and safety of ovarian tissue preservation specifically in endometriosis patients are limited, highlighting the need for further research in this area. In conclusion, fertility preservation, particularly through OOC, holds promise for mitigating the adverse effects of endometriosis on ovarian function and fertility. While uncertainties persist, integrating fertility preservation discussions into the comprehensive management of endometriosis is essential. This ensures that patients are empowered to make informed decisions about their reproductive health and maximizes their chances of achieving desired fertility outcomes despite the challenges posed by endometriosis.

Investigations of the quality of fertility preservation education provided to patients with cancer at a large community hospital.

e23087 Background: Infertility is a challenge many young cancer patients face as a consequence of aggressive treatments. Moreover, many eligible patients do not receive discussion about their fertility, and even fewer obtain referrals to fertility specialists. The goal of the investigation was to examine the frequency and quality of fertility preservation education provided to eligible patients at the Windsor Regional Cancer Program (WRCP). Methods: The first part of the investigation involved a retrospective chart review which identified 203 patients that presented to the WRCP between January 15, 2018 to January 15, 2020 under the age of 40. Amongst these patients, we identified 54 patients that were eligible for fertility preservation. These 54 patients were contacted to participate in the survey and we received 11 responses. The survey data collected include demographics and experience with fertility preservation. The data were analyzed using University of Windsor RedCap. Windsor Regional Hospital REB approval number: 22-426. Results: The retrospective chart review revealed that 34% of the 54 eligible patients did not receive documented fertility preservation counseling. Amongst the survey respondents that had fertility preservation discussions, 86% (6 patients) cited that it was initiated by a healthcare provider. In addition, we found that only 27% (3 patients) of survey respondents were interested in pursuing fertility preservation. The reasoning cited most often included not wanting children, already had children, and barriers such as finances, time and effort to pursue fertility preservation and fear of delaying fertility preservation. Moreover, the 3 survey respondents successfully pursued fertility preservation in the form of sperm collection (2 patients) and freezing eggs/embryos (1 patient). Conclusions: We identified the need to improve standardization of fertility preservation education in eligible patients. Moreover, we found that few patients desired fertility preservation. Although this is a small number of patients, providing appropriate fertility education is essential in cancer survivorship. Our next steps include piloting and implementing an improved fertility education program.

Disparities in fertility preservation among patients diagnosed with female breast cancer.

To investigate the association of specific patient factors with disparities in fertility preservation counseling and utilization of fertility preservation among patients ≤ 40years old diagnosed with female breast cancer. A retrospective chart review was conducted investigating patients diagnosed with breast cancer between January 2012 and December 2020 in a multi-site health system. Rates of fertility counseling and utilization of preservation services were compared based on age, race/ethnicity, parity, insurance type, and treatment site. Of the 6,783 patients diagnosed with female breast cancer, 306 (4.5%) were ≤ 40years old at the time of diagnosis. There was no significant difference between Black or African American and White patients in rates of fertility counseling (12.1% vs 17.4%; p = 0.285) or pursuit of fertility preservation (3.3% vs 4.2%; p = 0.508), nor was a difference observed when compared by insurance type. However, younger patients (< 30years of age), patients with 1 or no children, and patients treated in the more affluent county were more likely to undergo counseling and pursue fertility preservation than their matched counterparts. Age, parity, and location of breast cancer care may impact rates of fertility counseling and preservation among reproductive age women diagnosed with breast cancer. Thus, further attention to age discrimination, a patient's desire for future fertility, need for standardization in fertility preservation counseling, and perhaps implementation of comprehensive fertility coverage mandates across all states could help to improve gaps in fertility counseling and fertility preservation.

Knowledge and beliefs about oocyte cryopreservation for medical and social reasons in female students: a cross-sectional survey

BackgroundWith the increasing number of young women surviving cancer and a growing trend among highly educated women to postpone childbearing for educational or professional pursuits, there is a rising demand for egg freezing services to ensure a successful pregnancy. This study aims to assess the knowledge and beliefs surrounding oocyte cryopreservation, both for medical and social reasons, among female students in Tehran, Iran.MethodsAn online cross-sectional survey was carried out from March to August of 2022, involving a total of 1279 childless students pursuing master’s and doctoral degrees at universities in Tehran. The participants were between the ages of 18 and 38. Knowledge and beliefs about medical and social oocyte cryopreservation were assessed through Fertility Preservation Survey (FPS) instrument.ResultsThe mean age of the participants was 26.38 ± 4.9. The majority of students expected to be “30–34 years” when they become pregnant with their first child (41.1%, M: 30.3 ± 4.13 years) and “35–39 years” when they give birth to their last child (46.7%, M: 35.28 ± 4.18 years). The students agreed with preserving fertility with medical (93.3%) and social (86.9%) indications and believed the medical (95.1%) and social (87.4%) costs of cryopreservation should be covered by the healthcare system. Among the participants, 75.6% considered cost to be a definite or probable factor in their decision to pursue fertility preservation. The oncology team’s recommendation was identified as the most important factor in deciding on medical egg freezing (92.6%, M: 3.46 ± 0.71). The overall correct response rate for the knowledge questions was 57.7%. The majority of participants (95.5%) agreed that physicians should routinely provide information about egg freezing to women of childbearing age during their regular healthcare visits.ConclusionsThe research results revealed that female students in Tehran universities have a positive attitude towards medical and social egg freezing, but lack sufficient knowledge about the ideal timing of childbearing. Health professionals could provide detailed information about fertility preservation and age-related infertility as part of routine healthcare visits or reproductive health planning. Additionally, expanding supportive policies and incentives for childbearing established by the government to cover the costs of fertility preservation would be beneficial.

P-581 Family of origin cohesion and intention to pursue fertility preservation in transgender and non-binary people

Abstract Study question Is the relationship with the family of origins associated with parenthood plans and fertility preservation of transgender and non-binary people? Summary answer Family of origin characteristics, namely family cohesion, is associated with the transgender and non-binary people intention to undergo fertility preservation. What is known already Few studies have explored parenting intentions and decision to undergo fertility preservation (FP) in transgender and non-binary people. Most studies have focused on the barriers and facilitators of this decision, focusing on the procedures involved in FP, but no studies have assessed the role or psychological (namely relational) variables in the decision making regarding FP. Previous research indicates that family closeness is an important factor in the psychological adjustment of transgender people. Similarly, research indicates that more favorable family relationships were associated with parenting intentions. No studies have examined how relationship with family of origin may affect fertility preservation intentions. Study design, size, duration This is a cross-sectional study. Participants were surveyed online from January to April 2022. Dissemination of the study was performed through the social networks of LGBTQIA+ associations. Participants/materials, setting, methods Participants were 69 transgender and non-binary people, aged 18-39. The assessment protocol included a questionnaire assessing childbearing intentions, importance of genetic and non-genetic parental connectedness and intention to pursue FP. A validated measure assessing family relationships (Fertility Environment scale, Moos &amp; Moos, 1976) was used, evaluating family cohesion (degree of commitment and support family members provide for one another) and family expression (the extent to which family members are encouraged to express their feelings directly). Main results and the role of chance Participants were 40 transgender men (58%), 8 transgender women (11,6%) and 21 non binary (30.4). About 55,1% participants had already initiated hormonal therapy. Almost half of the sample (47,8%) considered having children in the future, while 13 (18.8%) were sure about not wanting children. Genetic connection was not very important (M = 19.51, from 0 -100). A total of 48,1% indicated that that would envision undergo FP in the future. A mediational model examining indirect effects were tested to examine whether family of origin relationship (cohesion and expression) would be associated with fertility preservation intention. A significant indirect effect was found, suggesting that family cohesion is associated with the intention to undergo fertility preservation through the effect on the importance of genetic parenting (estimate: 0.56, bootstrap bias-corrected 95% confidence interval 0.052; 1.199) That is, participants with high family cohesion in their family of origin highly valued genetic parenting and this was positively associated with the intention to undergo fertility preservation. The same indirect effects was tested regarding family expression, but no significant effects were found, that is, the expression of the family of origin is not associated with the intention to undergo PF (estimate: 0.604, bootstrap bias-corrected 95% confidence interval -0.077; 1.366). Limitations, reasons for caution The dissemination of the study and participants recruitment was throughout LGBT+ associations, so it is possible that some transgender people that are less prone to be involved in these associations were not reached. Wider implications of the findings The importance of the relationships with the family of origin may be an important factor to consider when counselling transgender and non-binary people regarding fertility preservation This may be markedly important when lower family cohesion may be limiting patients’ future options. Trial registration number Not applicable

The ticking “biological clock”: Reproductive assistance, costs, and elective fertility preservation in female oncologists and trainees.

11001 Background: Women in medicine are often in training during their peak fertility years. Many women defer childbearing until after training due to career concerns; in consequence, female physicians experience a higher rate of infertility than the general population. Experiences of infertility among female physicians and attitudes towards fertility preservation have not been well described. Methods: A novel 39 question survey was designed after comprehensive literature review to collect cross-sectional data on attitudes toward family planning and utilization of assisted reproductive technology (ART) among self-identified US female oncologists of all career levels. Descriptive statistics summarized frequencies of responses. Results: A total of 1005 responses were collected from female oncologists, of which 811 (81%) were attending/practicing physicians and 194 (19%) were trainees (192 residents/fellows and 2 medical students). 32% reported experiencing infertility. Of these 318 women, 9% reported no out-of-pocket expenses for ART while 39% spent more than $10,000 and 20% spent ≥$30,000. Side effects from infertility treatment required missing work for 22% and another 25% suffered mental health concerns related to infertility. Elective cryopreservation of eggs or embryos was reported by 6% of attendings and 4% of trainees. Among the 25 attendings who reported plans/desire to undergo fertility preservation in the future, most (76%) were unsure of feasibility. This was similarly reported in 72% of the 32 trainees with plans/desire to pursue fertility preservation. More trainees than practicing physicians (73% vs 65%) felt that fertility preservation should be discussed during medical training. Similarly, more trainees than attendings (58% vs 47%) felt that fertility concerns have a negative influence of their decision on when to start a family. While only 5% of all respondents reported using fertility preservation, an additional 6% were planning/considering using it and 21% felt that it would have benefitted them had it been available and affordable during training. Of the group that felt it would have been beneficial, 52% had experienced infertility. Conclusions: A third of surveyed female oncologists report experiencing infertility. Those that seek reproductive assistance can incur significant out of pocket costs with treatment related effects that can disrupt work or cause mental health concerns. Although fertility preservation was used by very few, one in five felt it could have been helpful to them if it was available and affordable. These results underscore the need to better support women in medicine to reduce the impact of infertility for female oncologists.

Ovarian reserve in reproductive-aged patients with cancer before gonadotoxic treatment: a systematic review and meta-analysis.

Does cancer itself, before any gonadotoxic treatment, affect ovarian function in reproductive-aged patients? Our study revealed that women with cancer may have decreased ovarian reserve markers even before cancer therapy. With the field 'oncofertility' improving rapidly, cancer therapy-mediated ovarian damage is well characterized. However, there is a controversy about whether cancer itself affects ovarian function before gonadotoxic treatment. We conducted a systematic meta-analysis investigating the association between cancer and ovarian function prior to gonadotoxic treatment. Titles or abstracts related to ovarian reserve (e.g. anti-Müllerian hormone (AMH), antral follicle count (AFC), or basal follicle-stimulating hormone (FSH)) combined with titles or abstracts related to the exposure (e.g. cancer*, oncolog*, or malignan*) were searched in PubMed, Embase, and Web of Science databases from inception to 1 February 2022. We included cohort, case-control, and cross-sectional studies in English that examined ovarian reserve in reproductive-aged patients (18-45 years) with cancer compared to age-matched controls before cancer treatment. The quality of the included studies was assessed by ROBINS-I. Fixed or random effects were conducted to estimate standard or weighted mean difference (SMD or WMD, respectively) and CI. Heterogeneity was assessed by the Q test and I2 statistics, and publication bias was evaluated by Egger's and Begg's tests. The review identified 17 eligible studies for inclusion. The results showed that cancer patients had lower serum AMH levels compared to healthy controls (SMD = -0.19, 95% CI = -0.34 to -0.03, P = 0.001), especially women with hematological malignancies (SMD = -0.62, 95% CI = -0.99 to -0.24, P = 0.001). The AFC was also decreased in patients with cancer (WMD = -0.93, 95% CI = -1.79 to -0.07, P = 0.033) compared to controls, while inhibin B and basal FSH levels showed no statistically significant differences. Serum AMH and basal FSH levels in this meta-analysis showed high heterogeneity, and the small number of studies contributing to most subgroup analyses limited the heterogeneity analysis. Moreover, the studies for specific cancer subtypes may be too small to draw conclusions; more studies are needed to investigate the possible impact of cancer type and stage on ovarian function. Our study confirmed the findings that cancer per se, especially hematological malignancies, negatively affects serum AMH level, and AFC values of reproductive-aged women. However, the lower AMH levels and AFC values may also be due to the changes in ovarian physiology under oncological conditions, rather than actual lower ovarian reserves. Based on the meta-analysis, clinicians should raise awareness about the possible need for personalized approaches for young women with cancer who are interested in pursuing fertility preservation strategies before anticancer treatments. This work was financially supported by the National Natural Science Foundation of China (nos 81873824, 82001514, and 81902669) and the Applied Basic Research Program of Wuhan Municipal Bureau of Science and Technology (2019020701011436). The authors declare that they have no conflicts of interest. PROSPERO (CRD42021235954).

Reflecting on the Importance of Family Building and Fertility Preservation: Transgender People's Experiences with Starting Gender-Affirming Treatment as an Adolescent

Purpose: We aimed to investigate how adults, who started gender-affirming hormone treatment during adolescence, reflect on their reproductive decisions. Methods: We recruited transgender and gender-diverse (TGD) people who visited our gender identity clinic and commenced medical treatment in adolescence at least 9 years ago. We collected data through an online survey. Results: The cohort consisted of 89 participants (66 TGD people assigned female at birth (AFAB) and 23 TGD people assigned male at birth (AMAB) with a mean age of 32.4 years (range 25.5–51.2) at the time of study, and 15.6 years (range 11.5–20.6) at the start of medical treatment. All participants initiated medical treatment before 2014, when laws requiring sterilization for legal gender recognition were still in place, and only 30% of participants reported to have received information about fertility preservation, which none of them pursued. In addition, 96% of participants underwent gonadectomy and thus became permanently infertile, which was troublesome for 27%. With today's knowledge, 44% of TGD people AFAB and 35% of TGD people born AMAB would pursue fertility preservation. The percentage of participants with a (future) desire for children increased from 34% at the start of medical treatment (at adolescent age) to 56% at the time of this study (at adult age), of whom 23% had currently started a family. Conclusion: It is important to inform transgender adolescents about the effect of medical treatment on fertility and the options for fertility preservation since many may develop a desire for (biological) children when they reach adulthood.

Parental perspective on the risk of infertility and fertility preservation options for children and adolescents with sickle cell disease considering hematopoietic stem cell transplantation.

Allogeneic hematopoietic stem cell transplantation (HCT) performed in children from human leukocyte antigen (HLA)-identical related donors is associated with very high survival rates and disease-free survival. Patients are exposed to gonadotoxic alkylating agents or irradiation in the HCT conditioning regimen. Consequently, infertility is a major long-term complication of HCT for sickle cell disease (SCD). We sought to understand how caregivers perceive the risk of infertility from HCT, how they perceive the options for fertility preservation, and how this risk perception impacted their decision-making to pursue HCT. We conducted qualitative interviews with primary caregivers after a consultation for HCT for SCD. Data were analyzed using descriptive qualitative analysis. We interviewed 19 primary caregivers who had attended a consultation with an HCT physician (female, age 25-59 [median 39] years). Eleven participants reported that their child had an available HLA-matched donor. Analysis revealed that (i) mothers were worried about death and graft-versus-host disease from HCT, more than about the risk of infertility; (ii) parents have a realistic understanding of the risk of infertility after HCT and take it into consideration in decision-making; (iii) parents report multiple barriers to fertility preservation. For parents actively considering HCT for their child with SCD, the risk of infertility while important was not a barrier to pursuing HCT. Inconvenience and invasiveness of fertility preservation procedures are some of the barriers to pursuing fertility preservation for their child. Future research must aim at addressing these barriers to fertility preservation.

MP54-17 FERTILITY PRESERVATION RATES AMONG TRANSGENDER GIRLS IN A MULTIDISCIPLINARY TRANSGENDER PROGRAM

You have accessJournal of UrologyCME1 Apr 2023MP54-17 FERTILITY PRESERVATION RATES AMONG TRANSGENDER GIRLS IN A MULTIDISCIPLINARY TRANSGENDER PROGRAM Nir Tomer, Eva Baldisserotto, Alexandra Siegal, Benjamin Eilender, Erin Miller, Mabel Yau, Matthew Oransky, Joshua Safer, and Neha Malhotra Nir TomerNir Tomer More articles by this author , Eva BaldisserottoEva Baldisserotto More articles by this author , Alexandra SiegalAlexandra Siegal More articles by this author , Benjamin EilenderBenjamin Eilender More articles by this author , Erin MillerErin Miller More articles by this author , Mabel YauMabel Yau More articles by this author , Matthew OranskyMatthew Oransky More articles by this author , Joshua SaferJoshua Safer More articles by this author , and Neha MalhotraNeha Malhotra More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003307.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fertility preservation (FP) should be an important step in health care prior to initiating gender affirming hormonal therapy (GAHT) or puberty blockade in transgender and gender diverse (TGD) people. However, FP is often not integrated into comprehensive gender affirming care. Prior studies show low rates of FP in transgender youth. The aim of this study was to understand how the integration of a pediatric urology team into our Center for Transgender Medicine and Surgery program would impact the overall number of transgender girls who pursue fertility preservation. METHODS: To assess the success of fertility preservation, we performed a retrospective review of a database of all TGD patients who were 18 years or younger with testes, and sought GAHT. Patients were evaluated and followed in our Center for Transgender Medicine and Surgery from 4/2022 through 10/2022. Demographics, age, hormonal treatment, Tanner stages, and FP use were recorded from the medical record. Successful sperm banking was defined as freezing >1 vial of sperm. RESULTS: Twenty seven patients ranging from ages 10-17 years old were referred to pediatric urology for FP. Of patients referred to the clinic, 20 (74.1%) were interested in pursuing/are in the process of sperm banking. Of the patients who didn’t pursue FP, 1 (3.7%) of the patients were prepubertal (Tanner I), 4 (14.8 %) patients declined to attempt FP because they wanted to avoid masturbation, and 2 (7.4%) patients declined referral altogether. Twelve patients began the process of FP with sperm banking - ten of whom successfully froze sperm within WHO reference ranges of semen parameters and 2 children were azoospermic. Upon review, these 2 patients with azoospermia were found to already have started hormonal suppression. CONCLUSIONS: Our data suggest that a large percentage of patients may be interested in fertility preservation. The integration of a pediatric urology team can help to increase access to this service. Importantly, that the children who already started pubertal suppression were azoospermic highlights the importance of the integration of pediatric urology and FP into the health care process prior to pubertal suppression therapy. In our program, counseling on GAHT and puberty blockers’ impact on fertility is introduced early and pediatric urology consultation is offered concurrently or even prior to endocrinology consultation. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e760 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nir Tomer More articles by this author Eva Baldisserotto More articles by this author Alexandra Siegal More articles by this author Benjamin Eilender More articles by this author Erin Miller More articles by this author Mabel Yau More articles by this author Matthew Oransky More articles by this author Joshua Safer More articles by this author Neha Malhotra More articles by this author Expand All Advertisement PDF downloadLoading ...

Coverage of Fertility Preservation and Treatment Among Surgical Trainees in the United States of America

Surgery trainees spend their prime fertility years in training, which leads to delays in childbearing, accompanying infertility challenges, and high-risk pregnancies. Literature report of institutional support for fertility preservation (egg/sperm freezing) and treatment is lacking. The cost is particularly prohibitive while receiving a resident physician salary. This study aimed to assess availability of fertility resources and institutional coverage of fertility services to US General Surgery Residents (GSR) and Breast Fellows. We composed and distributed a 26-question survey to GS residency and fellowship program directors nationwide to survey residents and fellows. Summary and descriptive statistics were tabulated, and categorical variables were analyzed using Pearson's chi square test. A total of 234 US surgical trainees (male n = 75, female n = 155, unreported n = 4) completed the survey. Total of 12 % of trainees reported having been counseled on family planning/fertility treatment during training, and only 5.1% were counseled on fertility preservation. Perceived lack of support from program (p = 0.027) and counseling of fertility preservation (p = 0.009) were significantly associated with female gender. A minority (12.5%) reported having insurance coverage for fertility preservation and 26% had coverage of fertility treatment. In addition, 2.6% respondents pursued fertility preservation while in training and 33% reported they would pursue fertility preservation if it was covered by insurance. Fertility preservation is rarely discussed in US General Surgery residency programs. The large majority of GSR lacks awareness of insurance coverage of fertility preservation and treatment. Strong efforts are necessary to improve fertility education for GSR and insurance coverage to meet trainee's needs.

Desire for children and fertility preservation in transgender and gender-diverse people: A systematic review.

The decision to pursue one's desire for children is a basic human right. For transgender and gender-diverse (TGD) people, gender-affirming care may alter the possibilities to fulfill one's desire for children due to the impact of this treatment on their reproductive organs. We systematically included 76 studies of varying quality describing the desire for children and parenthood; fertility counseling and utilization; and fertility preservation options and outcomes in TGD people. The majority of TGD people expressed a desire for children. Fertility preservation utilization rates were low as there are many barriers to pursue fertility preservation. The most utilized fertility preservation strategies include oocyte vitrification and sperm banking through masturbation. Oocyte vitrification showed successful outcomes, even after testosterone cessation. Sperm analyses when banking sperm showed a lower quality compared to cis male samples even prior to gender-affirming hormone treatment and an uncertain recovery of spermatogenesis after discontinuing treatment.

Ethical Need for a Fertility Decision-Aid for Transgender Adults of Reproductive Age

Ethical Need for a Fertility Decision-Aid for Transgender Adults of Reproductive Age

Fertility Preferences and Practices Among Young Women With Breast Cancer: Germline Genetic Carriers Versus Noncarriers

Young women with breast cancer who carry germline genetic pathogenic variants may face distinct fertility concerns, yet limited data exist comparing fertility preferences and practices between carriers and noncarriers. Participants in the Young Women's Breast Cancer Study (NCT01468246), a prospective cohort of women diagnosed with breast cancer at ≤40 years, who completed a modified Fertility Issues Survey were included in this analysis. Of 1052 eligible participants, 118 (11%) tested positive for a pathogenic variant. Similar proportions (P=.23) of carriers (46%, [54/118]) and noncarriers (37%, [346/934]) desired more biologic children prediagnosis, and desire decreased similarly postdiagnosis (carriers, 30% [35/118] vs. noncarriers, 26% [244/934], P=.35). Among those desiring children postdiagnosis (n=279), concern about cancer risk heritability was more common among carriers (74% [26/35] vs. noncarriers, 36% [88/244], P < .01). Carriers were more likely to report that concern about cancer risk heritability contributed to a lack of certainty or interest in future pregnancies (20% [16/81] vs. noncarriers, 7% [49/674], P=.001). Similar proportions (P=.65) of carriers (36% [43/118]) and noncarriers (38% [351/934]) were somewhat or very concerned about infertility post-treatment; utilization of fertility preservation strategies was also similar (carriers, 14% [17/118] vs. noncarriers, 12% [113/934], P=.78). Carriers were similarly concerned about future fertility and as likely to pursue fertility preservation as noncarriers. Concern about cancer risk heritability was more frequent among carriers and impacted decisions not to pursue future pregnancies for some, underscoring the importance of counseling regarding strategies to prevent transmission to offspring, including preimplantation genetic testing.

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

<h3>Purpose/Objective(s)</h3> Survivors of adolescent and young adult (AYA) cervical cancer who undergo radiation therapy are at risk of significant long-term health sequelae. This study seeks to evaluate long-term toxicities and their impacts on survivors. <h3>Materials/Methods</h3> Patients treated for cervical cancer with radiation therapy between ages 18-39 in the years 2000-2009 from any center in our province were eligible. 100 patients with current mailing addresses were identified and mailed a package containing a questionnaire devised by a multi-disciplinary team including open-ended questions, and validated patient-reported quality of life surveys for cervical cancer patients, the EORTC QLQ-30 and CX-24. <h3>Results</h3> A total of 22 responses were received. The mean age of respondents was 53.1 years (range: 41-62). The mean age at treatment was 35.6 years (range: 25-40), and the average time since treatment was 17.0 years (range: 12-22). The majority (73%) were married or common-law. A relationship status change following cancer treatment was reported by 32%, and 60% noted a change in sexual function/desire as the cause. Most respondents (77%) had children prior to treatment, with a mean of 2 children (range: 1-4). A single respondent had a child after treatment through adoption. Fertility preservation prior to treatment was discussed with 41% of respondents and offered to 36%. Nearly all respondents (86%) had used hormone replacement (HRT) therapy since treatment completion, with 23% still using HRT. EORTC scores are calculated on a scale of 0-100 with higher scores being positive for quality of life and functioning and worse for symptoms. Mean Quality of Life score was rated as 63.9. Most patients maintained adequate functional status, with mean scores of 84.4, 83.3, 67.1, 70.6, and 77 for physical, role, emotional, cognitive, and social functioning. 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). A wide array of bothersome symptoms were reported by patients in the open-ended questions. Most frequent (32%) was symptoms related to sexual and vaginal health. 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 or explicit statements that more thorough fertility counselling should be offered prior to treatment. <h3>Conclusion</h3> Long-term survivors of AYA cervix cancer who participated in this study have significant late toxicities. Many patients experience ongoing sexual health concerns, GI issues, body image concerns, mood disorders, premature menopausal symptoms and fertility issues. Respondents in our study indicated a desire for improved fertility counselling.

How effective is digital educational content in shaping fertility awareness? An interventional, cross-sectional study.

To determine whether exposure to digital educational content affects fertility awareness and attitudes towards fertility preservation treatments? A total of 957 women ages 20 to 45years participated in this internet-based, interventional, cross-sectional study. A questionnaire assessing knowledge of the reproductive span and attitudes towards fertility preservation treatment was completed by these women before and after exposure to online educational content on ovarian reserve and fertility preservation treatments. Responses before and after exposure to the educational content were compared. Knowledge about female age-related fertility decline improved significantly after exposure to educational content (51.6% vs. 79.6%, p < 0.001). Increased willingness to pursue fertility preservation treatments (38.6% vs. 42.9%, p < 0.001) and to recommend fertility preservation treatments to friends (55% vs. 65.2%, p < 0.001) was observed. Participants who desired to conceive were more positively influenced by the exposure to educational content in their attitudes towards fertility treatments compared to those who do not desire to conceive. Online educational content has the potential to improve fertility awareness and shape a more positive attitude towards fertility preservation treatments for the public.

Factors Associated With Fertility Preservation in a Pediatric, Adolescent and Young Adult Population.

To determine the patient characteristics associated with pursuing fertility preservation (FP) before gonadotoxic therapy in a pediatric, adolescent and young adult patient population. This is a retrospective cohort study of patient data at Cincinnati Children's Hospital Medical Center. Demographics, clinical diagnoses, and treatment characteristics were compared between participants that selected FP versus those that declined. Variables were analyzed separately for males and females by logistic regression. Patients with a hematologic cancer were less likely to be eligible for preservation: 53.9% of ineligible males, P <0.001, and 51.8% of ineligible females, P <0.0001. Among patients who were candidates for FP, those receiving high-risk therapy were more likely to elect for FP (65.3% males, P <0.0001, and 87.5% of females, P <0.0001). Pubertal males were more likely to undergo preservation than prepubertal males (70.5% vs. 29.5%, P <0.0001; however, this trend was not demonstrated among female patients. In both males and females, race, ethnicity, religion, primary language, and insurance status were not shown to be statistically significant factors in predicting utilization of FP. Risk of infertility, type of cancer, and developmental status influenced decisions on pursuing FP in pediatric, adolescent and young adult patients facing iatrogenic infertility.

P-506 Reflecting on the Importance of Family Building and Fertility Preservation: Transgender People’s Experiences with Starting Gender-affirming Treatment as Adolescent

Abstract Study question To investigate how adults of reproductive age (± 30 years), who started gender-affirming treatment during adolescence, reflect on their reproductive wishes. Summary answer Views regarding fertility and family building change over time, which may be related with reduced levels of gender dysphoria, matured intellectual and emotional cognitions. What is known already Within the last two decades, gender-affirming care for transgender youth has become widely available. One of the topical debates in adolescent transgender care concerns the difficulty of making decisions regarding fertility at an early age, since medical treatment for gender dysphoria negatively affects reproductive function. In transgender adolescents, data on the potential change in wishes and desires regarding fertility, family building and the importance of biological parenthood, when coming of reproductive age, are lacking. Hereby, the long-term consequences of acquired infertility in transgender adolescents who have now reached adulthood remain still unknown. Study design, size, duration This was a questionnaire study. Gender diverse adolescents who presented between 1989 and 2000 and started medical transition, were recruited for participation. As well as gender diverse adolescents who commenced medical treatment with gonadotropin-releasing hormone agonist (GnRHa) prior to gender affirming hormone treatment (GAHT), at least 9 years ago. 89 participants were eligible for inclusion in the study cohort. Participants/materials, setting, methods Data were collected through an online survey, and a subsequent telephonic interview to validate the provided answers in the survey. The fertility questionnaire focused on different themes, such as fertility counseling at initiation of medical treatment, decision-making about fertility preservation, current feelings about infertility, and a potential desire to have children. Main results and the role of chance The cohort consisted of 89 participants, among whom 66 trans masculine and 23 trans feminine people. Participants had a mean age of 32.4 years (SD 6.6, range 25.5-51.2) at time of the study, and 15.6 years (SD 2.2, range 11.5-20.6) at time of start of medical treatment. Since all participants initiated medical treatment before 2014, at that time laws requiring sterilization for legal gender recognition were still in place. Only 30% of participants received information about the options for fertility preservation, and none of them pursued fertility preservation. In addition, 96% of participants underwent gonadectomy and thus became permanently infertile. 27% of participants found becoming infertile troublesome, and 21% stated that they were not able to make decisions regarding fertility and future family building during adolescence. With today’s knowledge, 14% of trans masculine and 17% of trans feminine people would not have chosen to undergo gonadectomy. In addition, 44% of trans masculine and 35% of trans feminine people would pursue fertility preservation. The percentage of participants with a (future) desire for children changed from 34% at start of medical treatment to 56% at time of this study, of whom 23% had already started a family. Limitations, reasons for caution Since the participants reflect on a period in time in which fertility counseling was not offered on a structural basis and preservation options were not widely available, results of this study may not be fully translatable to current practice. Wider implications of the findings Transgender adolescents should be counselled on fertility and the options for fertility preservation, even in the absence of a desire for children upon initiation of treatment. Views on future family building might change over time, fertility counseling should be repeated at each step of the transition. Trial registration number na

Fertility preferences, concerns, and preservation among young women with breast cancer who carry germline genetic pathogenic variants compared with non-carriers.

10607 Background: Young women with breast cancer who carry germline genetic pathogenic variants predisposing to breast and other cancers, including BRCA1 or BRCA2, may face unique challenges when making fertility decisions. Limited data exist on differences in fertility preferences, concerns, and preservation strategies between carriers and non-carriers. Methods: Participants in the Young Women’s Breast Cancer Study, a prospective cohort of women diagnosed with breast cancer at ≤ 40 yrs, who completed a baseline survey with a modified Fertility Issues Survey were included in this analysis. Genetic variant status was determined by medical record review complemented by survey self-report. We excluded carriers whose test date was after baseline survey completion or unknown. Fisher exact and Wilcoxon signed-rank tests were used to compare categorical and continuous variables, respectively, between carriers and non-carriers. Results: Of 1052 eligible women, 118 (11%) tested positive for a pathogenic variant (59% BRCA1, 32% BRCA2, 4% TP53, and 5% other unique pathogenic mutations) and 934 (89%) tested negative or were not tested. Carriers’ median age was 36 yrs (range 23-40) vs 37 (range 17-40, p = 0.01) in non-carriers. Similar proportions (p = 0.67) of carriers (38%, [45/118]) and non-carriers (37%, [343/934]) desired more biologic children before diagnosis. Desire declined after diagnosis similarly in both groups (carriers, 25% [29/118] vs non-carriers, 26% [242/934], p = 0.46). Among these women (n = 271), concern about passing on cancer risk to offspring was common and, although numerically higher among carriers, this difference was not statistically significant (carriers, 55% [16/29] vs non-carriers, 40% [96/242], p = 0.12). In contrast, among those not interested in or unsure about future fertility (n = 738), concern about cancer risk heritability was infrequently reported as affecting fertility decisions (carriers, 11% [9/83] vs non-carriers, 9% [56/655], p = 0.54). The same proportions (p = 0.89) of carriers (36% [43/118]) and non-carriers (36% [339/934]) were somewhat or very concerned about becoming infertile after cancer treatment, and fertility preservation strategy utilization was similar between groups (carriers, 11% [13/118] vs non-carriers, 12% [111/934], p = 0.21). Conclusions: Young women with breast cancer who carry germline pathogenic variants are similarly concerned about future fertility and as likely to pursue fertility preservation as non-carriers. Concern about cancer risk heritability was common among both carriers and non-carriers desiring future fertility, suggesting a gap between perceived and actual risk. Genetic counseling should be included in fertility discussions for all young women with breast cancer, with tailored, risk-mitigating recommendations for those who carry genetic variants.

Fertility Preservation for Transgender Males: Counseling and Timing of Treatment.

Fertility-preservation counseling in the transgender patient population is recommended by multiple organizations, including the American Society for Reproductive Medicine, the World Professional Association for Transgender Health, and the Endocrine Society. The optimal time to pursue fertility preservation has not been established, and data on potential effects of testosterone therapy on future reproductive potential are limited. This Current Commentary seeks to elucidate the most appropriate time to perform oocyte cryopreservation in relation to time on and off testosterone therapy, age of the individual, and emotional effect of treatment. Although there have been multiple studies that have demonstrated successful oocyte cryopreservation regardless of testosterone exposure, the data on live-birth rates after oocyte cryopreservation are limited. Moreover, the process of oocyte cryopreservation may have a significant negative emotional effect on the transgender male given the feminizing effects of gonadotropin stimulation, as well as the invasiveness of pelvic ultrasonograms and the oocyte-retrieval procedure. With our review, we demonstrate that a comprehensive, individualized approach to fertility-preservation counseling and timing to pursue treatment are essential. Postponing fertility-preservation procedures until patients have reached early adulthood might be considered to avoid the potential effect on mental health, without compromising outcomes.