Introduction
Infertility secondary to chemotherapy, radiation therapy, and/or
myeloablative conditioning regimen prior to hematopoietic stem cell
transplantation (HSCT) is an important cause of morbidity and
psychosocial distress among pediatric cancer patients [1]. Although
there are several options for fertility preservation, they are often
overlooked and deemed less important than other therapy related late
effects [2]. Infertility is one of the primary concerns of cancer
survivors who report symptoms of post-traumatic stress disorder (PTSD)
related to infertility as long as 10 years post therapy [3].
Therefore, it is essential for the treating providers to discuss
infertility risk and fertility preservation options with all female and
male patients undergoing gonadotoxic therapy, and their families, before
treatment starts [4].
Alkylating chemotherapy agents, such as cyclophosphamide, present the
greatest risk of infertility as determined by the cyclophosphamide
equivalent dose (CED). Additionally, dose dependent radiation therapy to
the ovaries or testes, gonadectomy and myeloablative conditioning
regimens (e.g., Busulfan) for HSCT present another significant fertility
risk [5]. Meacham et al recently developed a standardized
risk assessment for gonadal insufficiency and infertility secondary to
treatment in children, adolescents, and young adults with cancer
compared to the general population [5].
Fertility preservation options for males include sperm banking,
testicular sperm extraction (TESE) and testicular tissue
cryopreservation (TTC). Sperm banking is only available for
post-pubertal males and must be completed before any therapy is started,
otherwise the semen is only to be used as last resort due to potential
effects on DNA[6]. TESE is an option for post-pubertal males who
cannot produce a semen sample[6], and TTC is the only option
available for pre-pubertal males undergoing gonadotoxic therapy, and it
is still considered experimental at this time [7].
Fertility preservation options for females include oocyte and embryo
cryopreservation, ovarian tissue cryopreservation (OTC) and ovarian
transposition for those undergoing pelvic radiation therapy [8].
Oocyte and embryo cryopreservation are only available for post-pubertal
females, and embryo cryopreservation requires the availability of sperm,
which is not feasible for many teenagers and young adults. OTC is the
only option available for pre-pubertal females undergoing gonadotoxic
therapy, and based on recent American Society of Reproductive Medicine
(ASRM) practice committee opinion, it is no longer considered
experimental [9]. Additionally, the 2019 ASRM guidelines include
general recommendations on fertility preservation options for patients
undergoing gonadotoxic therapy[9],