General and Supportive CareFertility preservation in cancer patients: The global framework
Introduction
Cancer is predominantly associated with older age, but it also affects children, adolescents and young adults. Survival rates are known to be the highest for patients aged between 15 and 44 [1], with 5-years survival ranging from 60 to 82% according to age, tumour site and country of treatment [1], [2], [3], [4], [5], [6]. Cancer therapies, nevertheless effective, often come with undesirable side effects, some of which are for a lifetime. Among these, infertility may affect up to 80% of cancer survivors as a result of treatments [7].
Cancer itself is rarely a direct cause of infertility [8], [9]. Chemotherapy, radiotherapy or surgical removal of reproductive organs are the most frequent determinants of infertility in cancer survivors [10].
Section snippets
Cancer treatment effects on fertility
Male germ cells are sensitive to injury caused by cytotoxic drugs [11]. Leydig cells are resistant to chemotherapy [8], thus infertility rather than impaired sexual function is more frequently reported after oncological treatments. In females, ability to conceive can be affected by previous exposure to chemotherapy, radiotherapy or surgery. Adequate follicular reserve, a functioning hypothalamic-pituitary-ovarian axis and a normal uterus are all necessary for a normal pregnancy [8]. Many
Fertility preservation options for male patients
Sperm cryopreservation is the only established method for male fertility preservation [15]. Usually 3 semen samples are frozen, with at least 48-h abstinence periods between each collection. However, if there is an urgent need to start cancer therapy, fewer samples can be cryopreserved [16]. Single intracytoplasmic sperm injection (ICSI) is now commonly used in assisted reproduction, thus allowing the successful use of samples with few spermatozoa [16], [17]. It has been reported that 21% of
Fertility preservation options for female patients
Embryos cryopreservation is the most established and successful method for female fertility preservation. It requires delaying cancer treatment by 2–3 weeks and the availability of a partner. If a partner is not available or embryo cryopreservation is not permitted by law, oocytes cryopreservation is a valid alternative [16]. Oocyte cryopreservation is not considered experimental since 2013, when the American Society of Clinical Oncology (ASCO) and the European Society of Medical Oncology (ESMO)
What do patients think about fertility preservation and what happens in the real world?
Retrospective surveys of cancer patients’ views suggest that the majority have a strong desire to be informed about fertility preservation and available options [31], [38], [39], [40]. Moreover, concerns about infertility are not limited to patients who are young and childless or/and have a partner [41]. It has been reported that up to 70–75% of young cancer survivors would like to have a child [39], [42] with up to 29% of women refusing life saving treatment because of fear to become infertile
Healthcare professionals’ attitudes towards fertility consultation in oncology patients
It is suggested that individual plans for fertility preservation must take into account both patient’s priorities and medical necessities [15], especially when healthcare systems are run on limited resources. There is also a need to create a functional infrastructure for oncofertility services. However, even countries with established services for patients face problems. For instance, in the United States fertility preservation services are currently available to most patients who are under the
Practicalities to consider in oncofertility consultation
Fertility preservation consultation is an additional concern on top of cancer treatment, but addressing fertility issues in cancer care should become a standard practice (Table 1). Discussing treatment consequences on sexuality and fertility might involve more parties than just patients and physicians. Children have parents to represent their best interests, patients in committed relationships might want to have their partners involved in decision making, some cultures and faiths might find
Conclusions
In most cases the main cause of infertility in cancer patients is treatment, not the disease. Therefore, consultation for fertility preservation should take place before cancer treatment. The established and experimental methods to preserve fertility are now available in many centres and cancer patients demonstrate interest in fertility preservation. Nonetheless, a significant number of patients worldwide are not given information about the detrimental effects on fertility of cancer treatments
Conflict of interest
The authors do not have any disclosure to make, nor any conflict of interest.
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