Cancer treatments can leave individuals at risk of gonadal failure and infertility. Loss of fertility is associated with distress and lowered self-esteem and quality of life in cancer survivors.26
Predicting who will become infertile as a result of specific therapies is difficult due to individual variability in fertility outcomes.27 Infertility incidence varies by regimen and may differ between males and females.13 The extent of dysfunction depends on the agent, dose, length of exposure and age of the individual.
Gonadotoxic antineoplastic agents include:27
- Alkylating agents:
- Platinum agents:
The impact of ionising radiation on infertility also depends on age at exposure, site and extent and type of radiotherapy.26 Radiation doses as low as 1.2 Gy may result in impaired spermatogenesis, and radiation more than 4 Gy will result in complete sterility.27 Total body irradiation and high dose pelvic radiotherapy are associated with the greatest risk to fertility.
AYA should receive fertility information early in the diagnostic phase of cancer treatment so they have time to review materials, ask questions, and make a decision.13, 27 The most effective and established means of preserving fertility in young people with cancer includes:3
- oocyte and embryo cryopreservation where appropriate for females
- sperm cryopreservation for males before cancer treatment starts.
Inclusion of health professionals with reproductive fertility expertise in multidisciplinary teams has been suggested to promote access to fertility preservation.13
Private conversations with AYA are recommended to allow adolescents to ask questions they might be uncomfortable asking in their parents' presence.27
Barriers which prevent fertility preservation at time of diagnosis include:27
- lack of time
- health professionals' failure to discuss risks to fertility
- cost of preservation
- significant parental anxiety at diagnosis.
Fertility preservation for AYAs diagnosed with cancer: guidance for health professionals.3 AYA cancer fertility preservation guidance working group (2014)
Livestrong fertility. Livestrong Foundation
Antineoplastic agents affect testicular function by damaging somatic and germ cells, resulting in reduced sperm production. Permanent sterility has been reported in men receiving more than 7.5 g/m2 BSA total dose of cyclophosphamide for sarcomas.28
Radiation doses as low as 1.2 Gy may result in impaired spermatogenesis, and radiation more than 4 Gy will result in complete sterility.27
Some men may change from azoospermic to oligospermic or normospermic after several years, but this is unpredictable and not reliable.28
Sperm donation is a highly effective method of preserving fertility.26 Most commonly collected through masturbation, the semen is processed and cryopreserved. Semen preservation success rates of between 42% and 64.5% have been reported.27 More invasive methods of semen collection include epididymal sperm aspiration, penile vibration and electroejaculation.27
Fertility preservation for adolescent and young adult males.29 Andrology Australia (2013)
Antineoplastic agents and radiotherapy speed up the loss of follicles, and bring forward the onset of menopause in females. Ovarian atrophy and a marked loss of the primordial follicle pool are seen on histological examination.26
Pelvic and abdominal irradiation poses the greatest threat to the ovaries. Irradiation at 6 Gy may cause irreversible ovarian failure, and doses at 2 Gy may halve the oocyte population. Radiotherapy damage, such as impaired uterine growth and blood flow, may also lead to later obstetric complications such as early pregnancy loss, low birth weight, and premature labour.26
Gonadotoxicity in females may be acute and cumulative and the potential of ovarian recovery is unpredictable. It is known that advancing age is a major disadvantage, and is related to ovarian reserve.26
Currently, there are no proven methods of protecting ovarian function from the effects of antineoplastic agents or radiotherapy, other than to surgically remove the ovaries from the irradiated field.30
There is some evidence that gonadotropin-releasing hormone (GnRH) agonists may play a role in protecting ovarian function from antineoplastic agents, but this is yet to be established.13, 27
Embryo cryopreservation is a viable technique but is only available for women in a stable relationship or for those who consider sperm donation. Due to the need for ovarian hyperstimulation for egg recovery, this method is contraindicated in the case of cancers which are hormone-sensitive.
Oocyte cryopreservation also requires ovarian hyperstimulation but offers a chance for AYA without partners to preserve fertility. Ovarian harvest and autologous transplantation has shown resumption of ovarian endocrine function and follicular development. More research is needed in this area.27
Using the following headings, outline how the following factors would be considered in determining eligibility for fertility preservation.
- Tanner stage.
- Treatment modality.
- Discuss options that would be available for fertility preservation for Justin prior to treatment for osteosarcoma.
- Describe the role of a fertility counsellor and their function within the MDT.