Portal de Periódicos da CAPES

Fertility Preservation in Young Males at Risk for Infertility: What Every Pediatric Provider Should Know

2017; Elsevier BV; Volume: 60; Issue: 3 Linguagem: Inglês

10.1016/j.jadohealth.2016.12.015

1879-1972

Leena Nahata, Gwendolyn P. Quinn,

Reproductive Health and Technologies

Reproductive health is an essential but often overlooked topic in adolescent health care. To date, most literature regarding adolescent reproductive health has focused on prevention of sexually transmitted infections and unwanted pregnancy [1Breuner C.C. Mattson G. Committee on Adolescence; Committee on Psychosocial Aspects of Child and family HealthSexuality education for children and adolescents.Pediatrics. 2016; 138: e1-e11Crossref Scopus (149) Google Scholar, 2Burke P.J. Coles M.S. Di Meglio G. et al.Society for Adolescent Health and MedicineSexual and reproductive health care: A position paper of the Society for Adolescent Health and Medicine.J Adolesc Health. 2014; 54: 491-496Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar]. One topic that is rarely considered in the care of children and adolescents is fertility, yet a number of childhood medical treatments and conditions such as oncologic therapy (including chemotherapy and radiation), bone marrow transplantation for malignant and nonmalignant conditions, alkylating agents used to treat rheumatic and renal conditions, cross-sex hormonal therapy used among transgender youth, disorders of sex development, and other genetic syndromes such as cystic fibrosis and galactosemia have been shown to impact fertility. Exact rates are not known, but approximately 6.7 million women and 3.3–4.7 million men in the United States experience fertility impairment [[3]Chandra A. Copen C.E. Stephen E.H. Infertility and impaired fecundity in the United States, 1982-2010: Data from the National Survey of Family Growth.National Health Stat Report. 2013; 14 (11 p following 19): 1-18Google Scholar]. Nearly, 15% of the U.S. male population is affected by some form of infertility, with rates as high as 35%–55% among male survivors of childhood cancer [4Male Infertility Best Practice Policy Committee of the American Urological Association; Practice Committee of the American Society for Reproductive MedicineReport on optimal evaluation of the infertile male.Fertil Steril. 2006; 86: S202-S209PubMed Google Scholar, 5Practice Committee of American Society for Reproductive Medicine in collaboration with Society for Reproductive Endocrinology and InfertilityOptimizing natural fertility.Fertil Steril. 2008; 90: S1-S6PubMed Google Scholar, 6Brignardello E. Felicetti F. Castiglione A. et al.Endocrine health conditions in adult survivors of childhood cancer: The need for specialized adult-focused follow-up clinics.Eur J Endocrinol. 2013; 168: 465-472Crossref PubMed Scopus (100) Google Scholar]. Adolescents and young adults (AYAs) faced with potential infertility as a result of gonadotoxic treatments have reported distress and impaired quality of life, both at the time of diagnosis and also in survivorship [7Nilsson J. Jervaeus A. Lampic C. et al.'Will I be able to have a baby?' Results from online focus group discussions with childhood cancer survivors in Sweden.Hum Reprod. 2014; 29: 2704-2711Crossref PubMed Scopus (90) Google Scholar, 8Gilleland Marchak J. Elchuri S.V. Vangile K. et al.Perceptions of infertility risks among female pediatric cancer survivors following gonadotoxic therapy.J Pediatr Hematol Oncol. 2015; 37: 368-372Crossref PubMed Scopus (36) Google Scholar, 9Ellis S.J. Wakefield C.E. McLoone J.K. et al.Fertility concerns among child and adolescent cancer survivors and their parents: A qualitative analysis.J Psychosocial Oncol. 2016; 34: 347-362Crossref PubMed Scopus (46) Google Scholar, 10Klosky J.L. Simmons J.L. Russell K.M. et al.Fertility as a priority among at-risk adolescent males newly diagnosed with cancer and their parents.Support Care Cancer. 2015; 23: 333-341Crossref PubMed Scopus (84) Google Scholar]. Furthermore, infertility has been identified as one of the largest contributors to marital discord and a leading cause of depression in adults [[11]Luk B.H. Loke A.Y. The impact of infertility on the psychological well-being, marital relationships, sexual relationships, and quality of life of couples: A systematic review.J Sex Marital Ther. 2015; 41: 610-625Crossref PubMed Scopus (153) Google Scholar]. Assisted Reproductive Technologies have been developed to preserve gametes for future use, known as fertility preservation, including sperm cryopreservation for pubertal males and oocyte cryopreservation for postmenarchal females. Experimental options such as testicular and ovarian tissue preservation may be considered for prepubertal and premenarchal males and females. Several groups, such as the American Academy of Pediatrics, American Society of Clinical Oncology, and American Society for Reproductive Medicine, have published recommendations urging providers to discuss potential infertility and offer timely referrals to specialists to discuss these fertility preservation options among at-risk patients before starting treatment [12Fallat M.E. Hutter J. Preservation of fertility in pediatric and adolescent patients with cancer.Pediatrics. 2008; 121: e1461-e1469Crossref PubMed Scopus (175) Google Scholar, 13Fertility preservation and reproduction in patients facing gonadotoxic therapies: A committee opinion.Fertil Steril. 2013; 100: 1224-1231Abstract Full Text Full Text PDF PubMed Scopus (220) Google Scholar, 14Loren A.W. Mangu P.B. Beck L.N. et al.Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update.J Clin Oncol. 2013; 31: 2500-2510Crossref PubMed Scopus (1126) Google Scholar]. Of the fertility preservation methods available to pediatric patients, sperm banking is the least invasive (with specimens usually collected by masturbation) and has been effectively used for decades; however, barriers such as financial constraints and ethical, social, and religious concerns of providers and families prevent widespread use of this technology [[15]Browne H. Nurudeen S. Armstrong A. et al.Ethical and psychological considerations in fertility preservation counseling.Cancer J. 2008; 14: 340-342Crossref PubMed Scopus (4) Google Scholar]. Of note, multiple studies have shown that: (1) many groups of pediatric providers feel inadequately trained in this area; (2) counseling practices about sperm banking are variable between providers and centers; and (3) a minority of AYA bank sperm [16Grover N.S. Deal A.M. Wood W.A. et al.Young men with cancer experience low referral rates for fertility counseling and sperm banking.J Oncol Pract. 2016; 12: 465-471Crossref PubMed Scopus (27) Google Scholar, 17Klosky J.L. Randolph M.E. Navid F. et al.Sperm cryopreservation practices among adolescent cancer patients at risk for infertility.Pediatr Hematol Oncol. 2009; 26: 252-260Crossref PubMed Scopus (49) Google Scholar, 18Nahata L. Ziniel S.I. Garvey K.C. et al.Fertility and sexual function: A gap in training in pediatric endocrinology.J Pediatr Endocrinol Metab. 2017; 30: 3-10Crossref PubMed Scopus (20) Google Scholar, 19Nahata L. Sivaraman V. Quinn G.P. Fertility counseling and preservation practices in youth with lupus and vasculitis undergoing gonadotoxic therapy.Fertil Steril. 2016; 106: 1470-1474Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 20Quinn G.P. Vadaparampil S.T. Fertility preservation and adolescent/young adult cancer patients: Physician communication challenges.J Adolesc Health. 2009; 44: 394-400Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar]. Many AYA males who have not banked sperm later report that they were given insufficient information about banking and then express regret about this missed opportunity [[21]Stein D.M. Victorson D.E. Choy J.T. et al.Fertility preservation preferences and perspectives among adult male survivors of pediatric cancer and their parents.J Adolesc Young Adult Oncol. 2014; 3: 75-82Crossref PubMed Google Scholar]. In this issue of Journal of Adolescent Health, a study completed by Klosky et al. [[22]Klosky J.L. Anderson L.E. Russell K.M. et al.Provider influences on sperm banking outcomes among adolescent males newly diagnosed with cancer.J Adolesc Health. 2017; 60: 277-283Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar] at eight different pediatric cancer centers demonstrates that adolescent males newly diagnosed with cancer were more likely to attempt sperm banking if their providers (mostly pediatric oncologists) were more comfortable discussing sperm banking with them. Furthermore, those who were referred to fertility specialists were five times more likely to bank sperm [[22]Klosky J.L. Anderson L.E. Russell K.M. et al.Provider influences on sperm banking outcomes among adolescent males newly diagnosed with cancer.J Adolesc Health. 2017; 60: 277-283Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar]. These findings are consistent with previous literature showing the positive impact of standardizing counseling practices on sperm banking rates [[23]Shnorhavorian M. Kroon L. Jeffries H. et al.Creating a standardized process to offer the standard of care: Continuous process improvement methodology is associated with increased rates of sperm cryopreservation among adolescent and young adult males with cancer.J Pediatr Hematol Oncol. 2012; 34: e315-e319Crossref PubMed Scopus (34) Google Scholar] and studies linking provider counseling with uptake of other risk prevention behaviors such as human papillomavirus vaccination [[24]Bratic J.S. Seyferth E.R. Bocchini Jr., J.A. Update on barriers to human papillomavirus vaccination and effective strategies to promote vaccine acceptance.Curr Opin Pediatr. 2016; 28: 407-412Crossref PubMed Scopus (36) Google Scholar]. Notably, Klosky et al. show that there was no significant difference between providers' self-reported comfort and the adolescent's rating of provider comfort; in other words, adolescents could sense when providers were uncomfortable discussing infertility risk and the process of sperm banking. Given that this discomfort was associated with lower sperm banking rates, these data strongly suggest that providers who are involved in the care of patients who are at risk for infertility should obtain training in this area and/or should place referrals to specialists who are comfortable guiding a patient and family through the sperm banking process [[22]Klosky J.L. Anderson L.E. Russell K.M. et al.Provider influences on sperm banking outcomes among adolescent males newly diagnosed with cancer.J Adolesc Health. 2017; 60: 277-283Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar].See Related Article on p. 277 See Related Article on p. 277 Conversations between health care providers, adolescents, and their parents about sperm banking (including masturbation) and parenthood goals, particularly in the context of a new cancer diagnosis, are understandably challenging. In previous studies, parents of at-risk patients reported feeling awkward and embarrassed when trying to bring this topic up with their sons and health care providers and were hoping the physician would initiate the conversation [9Ellis S.J. Wakefield C.E. McLoone J.K. et al.Fertility concerns among child and adolescent cancer survivors and their parents: A qualitative analysis.J Psychosocial Oncol. 2016; 34: 347-362Crossref PubMed Scopus (46) Google Scholar, 21Stein D.M. Victorson D.E. Choy J.T. et al.Fertility preservation preferences and perspectives among adult male survivors of pediatric cancer and their parents.J Adolesc Young Adult Oncol. 2014; 3: 75-82Crossref PubMed Google Scholar]. Furthermore, de Vries et al. [[25]de Vries M.C. Bresters D. Engberts D.P. et al.Attitudes of physicians and parents towards discussing infertility risks and semen cryopreservation with male adolescents diagnosed with cancer.Pediatr Blood Cancer. 2009; 53: 386-391Crossref PubMed Scopus (44) Google Scholar] found conflict between providers' desires to discuss infertility and sperm banking with male patients privately, versus parents' desires to participate and control the amount of information shared with their son. Although evidence shows the importance of family support in sperm banking decisions [10Klosky J.L. Simmons J.L. Russell K.M. et al.Fertility as a priority among at-risk adolescent males newly diagnosed with cancer and their parents.Support Care Cancer. 2015; 23: 333-341Crossref PubMed Scopus (84) Google Scholar, 26Wyns C. Collienne C. Shenfield F. et al.Fertility preservation in the male pediatric population: Factors influencing the decision of parents and children.Hum Reprod. 2015; 30: 2022-2030Crossref PubMed Scopus (61) Google Scholar], this study and others have demonstrated that parents may be poor proxy decision makers regarding fertility preservation for their children diagnosed with cancer and that adolescents want to participate in decision-making and do not want to be left out of these discussions [27Quinn G.P. Murphy D. Knapp C. et al.Who decides? Decision making and fertility preservation in teens with cancer: A review of the literature.J Adolesc Health. 2011; 49: 337-346Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 28Quinn G.P. Knapp C. Murphy D. et al.Congruence of reproductive concerns among adolescents with cancer and parents: Pilot testing an adapted instrument.Pediatrics. 2012; 129: e930-e936Crossref PubMed Scopus (41) Google Scholar]. In summary, to provide effective fertility counseling, providers must be knowledgeable about infertility risk and the logistics of sperm banking, and other Assisted Reproductive Technologies, and also be skilled at initiating these discussions in a sensitive manner with both adolescents and their families. All these studies have implications for many different pediatric providers and subspecialists, including hematologists/oncologists, rheumatologists, nephrologists, endocrinologists, adolescent medicine specialists, and pediatric urologists and gynecologists, as all these providers may encounter AYAs at risk for infertility, pregonadotoxic or postgonadotoxic therapy [18Nahata L. Ziniel S.I. Garvey K.C. et al.Fertility and sexual function: A gap in training in pediatric endocrinology.J Pediatr Endocrinol Metab. 2017; 30: 3-10Crossref PubMed Scopus (20) Google Scholar, 19Nahata L. Sivaraman V. Quinn G.P. Fertility counseling and preservation practices in youth with lupus and vasculitis undergoing gonadotoxic therapy.Fertil Steril. 2016; 106: 1470-1474Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 20Quinn G.P. Vadaparampil S.T. Fertility preservation and adolescent/young adult cancer patients: Physician communication challenges.J Adolesc Health. 2009; 44: 394-400Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar, 29Miller S.D. Li Y. Meyers K.E. et al.Fertility preservation in paediatric nephrology: Results of a physician survey.J Ren Care. 2014; 40: 257-262Crossref PubMed Scopus (10) Google Scholar]. Survival rates for childhood diseases are improving (e.g., >80% five-year survival rates for childhood cancer [[30]Howlader N. Noone A. Krapcho M. SEER cancer statistics review, 1975–2010, based on November 2012 SEER data submission, posted to the SEER website; Bethesda, MD: National Cancer Institute.2013Google Scholar]), and there is increasing awareness about the number of pediatric populations who may be at risk for future infertility [[31]Hirshfeld-Cytron J. Gracia C. Woodruff T.K. Nonmalignant diseases and treatments associated with primary ovarian failure: An expanded role for fertility preservation.J Womens Health (Larchmt). 2011; 20: 1467-1477Crossref PubMed Scopus (33) Google Scholar]. This is thus a critical time to integrate fertility into existing reproductive and sexual health curricula, offer more training opportunities for pediatric providers and subspecialists, and incorporate fertility counseling and preservation into disease specific guidelines for clinical care. Provider Influences on Sperm Banking Outcomes Among Adolescent Males Newly Diagnosed With CancerJournal of Adolescent HealthVol. 60Issue 3PreviewThe purpose of this study was to examine provider communication and sociodemographic factors which associate with sperm banking outcomes in at-risk adolescents newly diagnosed with cancer. Full-Text PDF