Public Science Insights: Oncofertility

Posted Sun, Jul, 10,2016

Although cancer represents the second cause of death in prepubertal children and adolescents, the 5-year survival rate has increased from less than 60% in the 1970s to 85% in the past years. This is translated into more than 420,000 childhood cancer survivors in the USA only. Both disease and treatment options are associated with life-altering, long-term side effects such as premature infertility that depends on various factors such as the age of the patient, the biology of the disease, the type and the dose of cytotoxic therapy, radiotherapy and surgery. There are great advantages associated with more conservative surgical procedures linked to a reduction in physical, functional and psychological short- and long-term morbidity related to conventional extirpative surgery, provided that the main intent remains not to jeopardize cancer control.

So how infertility could be addressed in these very young patients?

Infertility represents an essential part in the management of children and young adults with cancer who are more often being treated in specialized cancer centers. The up-to-date available data on fertility risk assessment and preservation strategies should be addressed prior to antineoplastic therapy.

There are surgical and non-surgical or medical procedures that could be offered to these young patients.

Female fertility preservation approaches include fertility-sparing surgery such as conservative unilateral salpingo-oophorectomy. Numerous studies have demonstrated the safety and possibility of unilateral (fertility sparing) compared to bilateral salpingo-oophorectomy (radical surgery) in cancer diseases of the ovaries. Although relapse is marginally increased if a fertility-sparing approach is chosen, comparable survival rates are reported in the clinical studies and represent the recommended approach.

Other fertility preservation approaches implemented today comprise ovarian transposition (laparoscopic rearrangement of the ovaries into a safer area in the abdomen e.g. to protect them from the toxicity of radiotherapy), orthotopic transplantation of cryopreserved ovarian tissue (removal and transplantation at a later date of fragments of ovarian cortex to protect oocytes from chemotherapy). Less investigated approaches that may be available in the context of clinical trials in some centers include ovarian implantation and uterine transplantation. Α medical preservation approach is available for the older subgroup of adolescent female patients and include ovarian protection by GnRH analogues.

Male fertility preservation approaches include mainly surgical methods as no effective gonadal function preserving drugs are so far available for use in male patients. The testis sparing surgery represents the most commonly applied approach as studies with considerable follow-up suggest that the organ-sparing approach stands for a viable treatment modality for testicular tumors of different histology in the pediatric and adolescent population. Other methods include testicle transposition to avoid the toxicity of radiotherapy and operative sperm retrieval strategies (testicular stem-cell transplantation).

In all occasions, the treatment options for each possible conservative procedures and fertility sparing should be discussed thoroughly with the patients and their families.

Dr. Anna Koumarianou is author of the recently published paper Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients, available for download now in Clinical Medicine Insights: Oncology.

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