Abstract
S
Medical advances in the preservation of both male and female fertility, and our ability to effect conception, continue to be scientific successes. The population of cancer patients that JAYAO represents is the group most likely to be affected by issues of fertility preservation. All AYA-aged cancer patients deserve a voice in decisions affecting their fertility; medical professionals must offer them the most up-to-date resources to preserve their possibility of conceiving children in their future. While healthcare professionals are correctly focused on patients' immediate survival, issues of long-term fertility preservation should never be neglected.
With exciting advances in the gynecological field of reproductive endocrinology and fertility, there are now options available to both male and female patients that can be explored and personalized to their unique medical, psychosocial, and cultural needs. In this issue of JAYAO, three articles focus on the concept of oncofertility—the preservation of fertility in spite of chemotherapy, radiation, surgery, or a combination of all three. When oncofertility is seen as a threat common to adolescents and young adults with all cancer diagnoses, the preservation of fertility becomes a central proposition and unifying issue in AYA oncology. Let us at least give patients the possibility that in survivorship they can decide to have a child.
The biological age of a patient—prepubescent, pubertal, or young adult (who may or may not have a significant partner)—determine which fertility preservation options are appropriate.
Although not technically AYAs, decisions made for prepubescent children does affect their future fertility when they become young adults. When pre-pubescent children are diagnosed with cancer, they may receive therapy that will endanger their chances of fertility as they age into teenagers and young adults. In the last few years, many new chemotherapeutic and targeted agents have reached the clinic, but the long-term effects of these agents on gonadal function is not fully understood. Today new options are becoming available for both boys and girls, including the ability to obtain testicular tissue in the prepubertal male and ovarian cryopreservation for girls. The science of prepubertal fertility preservation presumes that science will continue to evolve, so that when the prepubertal male or female patient reaches an age when they want to utilize that stored tissue, we will in fact be able to use it to successfully produce offspring.
This issue of JAYAO has an example of options for prepubertal patients in the Case Study by Peek and colleagues from the Radboud University in the Netherlands. A 10-year-old with Ewing sarcoma underwent ovarian cryopreservation as a prepubertal child, demonstrating that this technology is available, though currently only by utilizing an experimental protocol.
Prepubertal and pubertal young girls have the option of ovarian cryopreservation—and in some cases egg harvesting—whereas older young adults may also have the additional options of egg harvesting and embryo creation. In 2013, the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology determined that egg harvesting is no longer experimental, 1 and it is now covered by some insurers. In the United States, the coverage of egg harvesting may or may not be covered by state insurances under the new Affordable Care Act exchanges.
An adolescent or young adult may have no imminent wish for children, and may not have considered their future fertility, and it may be difficult to think beyond the cancer diagnosis. In young women in young adulthood, egg harvesting, embryo collection, and ovarian cryopreservation are real options and should be made available. All male patients should be offered sperm banking, even if at the time of diagnosis they may not have realized the implication of this decision. It is the responsibility of the healthcare professional to develop methods to communicate the importance sperm banking and provide an easy mechanism to collect and store sperm.
AYA cancer patients encompass the period of peak reproduction on the biologic timeline, starting at the time of puberty and ending at approximately 40 years of age (which is also commonly recognized as the upper age limit of ‘adolescent and young adult oncology’ in the United States). As their healthcare professionals, we need to ensure that all hospitals, all physicians, and all healthcare professionals make oncofertility options and choices available to all patients, thus making their consent to treatment truly informed.
The Society for Adolescent and Young Adult Oncology (SAYAO) believes strongly that we as an organization must lead in the implementation of fertility preservation options for all cancer patients around the world, whether they are a prepubertal boy or girl, an adolescent, or a young adult. This fall, SAYAO, in conjunction with the Oncofertility Consortium, the University of California, Irvine's Chao Family Comprehensive Cancer Center, and CHOC Children's Hyundai Cancer Institute, will host a meeting to take the initial steps toward creating the “Pediatric, Adolescent, and Young Adult Oncofertility Network,” an entity that will expand on previous oncofertility efforts to directly include the patient population seen in pediatric settings. SAYAO is also joining forces with an in-development adolescent and young adult fertility preservation group in Australia, led by Antoinette Anazodo, MBBS, to create an international fertility registry that will be used to define the issues that need to be understood to implement the vision of full adoption of preservation of fertility in the AYA population. These two initiatives will help create the infrastructure needed to expand our ability to deliver fertility preservation to all patients.