Elsevier

Cancer Treatment Reviews

Volume 40, Issue 8, September 2014, Pages 1019-1027
Cancer Treatment Reviews

General and Supportive Care
Fertility preservation in cancer patients: The global framework

https://doi.org/10.1016/j.ctrv.2014.06.001Get rights and content

Highlights

  • 70–75% of young cancer survivors desire parenthood, but fertility is reduced in most of them.

  • Fertility preservation methods do not assure parenthood, but may offer an opportunity to overcome sterility.

  • Healthcare professionals lack knowledge and have biases, which prevent addressing fertility preservation issues adequately.

  • We call for a patient-centred fertility counselling, decision support and personalization based on personal values and goals.

Abstract

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.

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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