Guidelines for fertility preservation in newly diagnosed cancer patients have been updated to include oocyte preservation as a standard practice rather than an experimental option, according to the American Society of Clinical Oncology.
With the exception of the recommendation on oocyte preservation, however, the update is essentially comparable to the one that ASCO issued in 2006. The latest guidelines also include literature updates used to create a framework for physician-patient discussions of fertility preservation. The guidelines appear in the May 28 online edition of the Journal of Clinical Oncology (doi: 10.1200/JCO.2013.49.2678).
The discussion of fertility preservation needs to occur early, as part of education and informed consent before treatment. "Current evidence suggests that discussions about fertility and fertility preservation are of great importance to patients with cancer," wrote Dr. Alison Loren, cochair of the guidelines update panel, and her colleagues. "Discussing infertility and introducing the possibility of fertility preservation lead to improved quality of life and diminished distress in all patient populations."
"It may be difficult for physicians to know how important fertility preservation is to their patients unless they ask, because many patients may not bring up the topic," wrote Dr. Loren of the University of Pennsylvania, Philadelphia, and her colleagues. "They may be overwhelmed by and focused exclusively on the cancer diagnosis, they may be unaware that potential fertility loss may occur, or they may be concerned that pursuing fertility preservation will delay their treatment, leading to increased morbidity or mortality."
"There is evidence to suggest that, at least among women, patients may make cancer treatment decisions based on fertility concerns. ... [In a recent study,] 29% of women with breast cancer reported that infertility concerns influenced their treatment decisions," the panel wrote.
The panel examined 18 recent randomized controlled trials; 6 systematic reviews, meta-analyses, and previous guidelines; and dozens of narrative reviews, case series, case studies, and editorials. From this review, they produced guidelines for fertility preservation in men, women, and post- and prepubertal children.
Such discussions should occur with all cancer patients of reproductive age (and with parents or guardians of children and adolescents) before treatment starts when infertility is a potential risk of therapy. Discussions should address whether fertility preservation might have an impact on successful cancer treatment. Those interested in fertility preservation, including ambivalent patients, should be referred to reproductive specialists and the discussion documented in the medical record. Distress about potential infertility warrants a referral to a psychosocial provider. Those who opt for fertility preservation should be encouraged to participate in registries and clinical studies.
For men
Men who choose to move ahead with sperm cryopreservation can usually do so expeditiously with no cancer treatment delay.
Sperm cryopreservation is the only established fertility preservation method; sperm is usually easy to obtain, and samples can be recovered every 24 hours. Testicular hormone suppression and testicular tissue or spermatogonial freezing for later transplanting – including testis xenografting – are experimental and unproven in humans. Men should be advised of a potentially higher risk of genetic damage in sperm collected after initiation of chemotherapy.
For women
"Fertility preservation options in females depend on patient age, diagnosis, type of treatment, presence or participation of a male partner, and/or patient preferences regarding the use of banked donor sperm, time available, and likelihood that cancer has metastasized to her ovaries," the panel wrote. Timing is an issue: Oocyte and embryo cryopreservation are proven methods, but the ovarian stimulation needed to accomplish these generally takes at least 2-4 weeks. Prior worries about hormonal stimulation and its possible effect on hormone-sensitive cancers have been somewhat allayed.
Letrozole combined with standard fertility drugs can induce ovulation without spiking estrogen; the number of eggs and embryos from these inductions appears no different from those obtained with traditional drugs.
Ovarian transposition (oophoropexy) is an option when pelvic radiation therapy is performed as cancer treatment.
Ovarian suppression with gonadotropin-releasing hormone agonists doesn’t seem to have any significant benefit in fertility preservation, according to the panel. No differences have been noted in post-treatment resumption of menstruation or in hormonal or imaging markers of fertility.
Ovarian tissue cryopreservation for the purpose of future transplantation is still experimental. At least 19 live births have been reported using frozen ovarian tissue transplanted after treatment. "There is a theoretic concern with re-implanting ovarian tissue and the potential for reintroducing cancer cells depending on the type and stage of cancer, although so far there have been no reports of cancer recurrence in humans."
For teens and children
Postpubertal adolescents can choose to freeze eggs or sperm, a process that requires consent from both the teen and the parents.