Fertility preservation in the pediatric cancer patient.

PURPOSE OF REVIEW: Long-term survival rates from childhood cancers approach 85% with many of these patients now reaching adulthood and facing the consequences of prior cancer treatment including infertility. This highlights the importance of discussing fertility risk and presenting fertility preservation options prior to initiation of cancer treatment. This article reviews the current literature on fertility preservation in adolescents, young adults, and prepubertal patients. RECENT FINDINGS: Sperm banking remains the gold standard for fertility preservation in adolescents and young adults. Testicular sperm extraction and electroejaculation may also be utilized in patients that are unable to produce a semen sample. Fertility preservation options for prepubertal patients remain experimental but recent data illustrate the potential to restore spermatogenesis using spermatogonial stem cells. SUMMARY: Fertility risk and fertility preservation options for pediatric patients should be routinely discussed at the time of cancer diagnosis. Sperm preservation should be routinely offered to adolescents and young adults at risk for infertility from cancer treatment. Preservation of prepubertal spermatogonial stem cells can be offered as an experimental option.

Delayed childbearing: determining responsibilities for prime gamete quality.

Delayed parenting affects fertility in women and in men, and cryopreservation of oocytes and sperm is becoming the latest trend as a solution for those who want or need to postpone procreation, in an attempt to avoid the damage medical conditions or time itself produces in gametes. Although "social freezing" is considered legitimate, its ethical and social aspects are in need of an overdue medical, public and legal debate. Assisted reproduction and cryopreservation, in combination with womb outsourcing, have opened the door to biological ectogenesis and the subsequent question of whether delayed childbearing means we should formally separate procreation from sexual activity. This article briefly summarizes what cryotechniques are capable of presently and in the near future, to separate fact from fiction. It names the implications for and discusses the practically virgin subject of the underlying responsibilities of delayed parenting techniques towards the child-to-be-not only the unborn but also the not-yet-conceived child. Considering the medical, economic, legal and social consequences of these rapidly growing developments in reproduction, several reasons point at the need to formally separate procreation from sexual activity, specifying responsibilities in the first while respecting personal choice in the second.

Parents' choices in banking boys' testicular tissue.

Researchers are working to derive sperm from banked testicular tissue taken from pre-pubertal boys who face therapies or injuries that destroy sperm production. Success in deriving sperm from this tissue will help to preserve the option for these boys to have genetically related children later in life. For the twin moral reasons of preserving access and equity in regard to having such children, clinicians and researchers are justified in offering the option to the parents of all affected boys. However, some parents may wish to decline the option to bank tissue from their boys because the technique may seem too unfamiliar or unusual, but over time people may become more comfortable with the technique as they have done with other novel assisted reproductive treatments (ARTs). Other parents may wish to decline the option because of moral or religious reasons. A prominent natural law theory holds, for example, that the ARTs that would be involved in using sperm derived from banked tissue to produce a child are morally objectionable. Some parents might not want to bank tissue in order to shield their son from using ARTs they see as objectionable. Clinicians and researchers should respect parents who wish to decline banking tissue, but parents should ordinarily embrace choices that protect the possible interests their sons may have as adult men, including the wish to have genetically related children.

The ethics and role of AI with fresh and frozen semen in dogs.

The use of artificial insemination (AI) with fresh semen has resulted in many benefits for the management of dog breeding, but there are disadvantages that can sometimes be overlooked. Furthermore, poorer quality semen arising as a result of cryopreservation necessitates uterine insemination, which raises the potential for surgical insemination. A number of significant ethical concerns have been raised by key stakeholders (such as The Kennel Club and the Royal College of Veterinary Surgeons) about AI per se, but particularly about the use of surgical insemination. This paper discusses the technological development of AI and explores a number of the ethical issues raised by its application to dog breeding. An Ethical Matrix method is used to map the potential ethical issues for key interest groups, namely dogs, breeders, owners, veterinarians and wider society. There are national variations in the way in which institutions have evaluated potential ethical impacts, and this is reflected in the different regulatory frameworks governing the use of AI in dogs. In order to facilitate decision-making and reduce some of the ethical risks associated with this technology, the veterinary research community could take several proactive steps including: (i) clarifying clinical decision-making processes, (ii) enhancing informed choice among clients and (iii) increasing the knowledge-base of potential impacts of AI.

[Oocyte cryopreservation].

Oocyte cryopreservation is an important method in the field of infertility. This procedure can benefit the cancer patient wishing to preserve fertility before initiation of any destructive chemotherapy or radiation therapy. It is a substitute for embryo cryopreservation and thereby avoids associated ethical issues. Oocyte cryopreservation technology can lead to the establishment of "oocytes banks" and provides solutions to ovarian failure patients. Technical obstacles were the main cause for the slow progress of oocyte cryopreservation. When compared to embryos and sperm cryopreservation technologies which are in common use worldwide, the reports on oocyte cryopreservation-derived pregnancies, were sporadic and with low success rates. However, in recent years we are witnessing more and more publications and increasing success rates in this important and fascinating field. Improvement in the freezing protocols and the introduction of vitrification procedures increased the survival rates and led to the birth of more then 100 healthy newborns. In the future we believe this method will be part of daily work in the fertility world. This review describes the methods available today and the clinical reports published in this field.

Postmortem parenthood and the need for a protocol with posthumous sperm procurement.

OBJECTIVE: Posthumous sperm procurement involves harvesting gametes from a recently deceased man for cryopreservation and future use in ART. This paper discusses the practical and ethical role of posthumous sperm procurement in medical practice and society and submits possible solutions, including the establishment of formal policies and protocols. DESIGN: English-language literature review and bioethical discussion. RESULT(S): In the United States, an increase in requests and protocols has been documented. International requests and regulation are variable. CONCLUSION(S): Posthumous sperm procurement is fraught with ethical dilemmas, including informed consent, privacy, inheritance, and child welfare. To establish appropriate medical practice, it is important to consider all stakeholders in the decision-making process. We believe that an acceptable and ethical resolution can be obtained only through the collaborative input of all involved parties. We have looked to U.S. and international sources for guidance in current practice and to gain insight into the formulation of future policies.

[Posthumous sperm procurement and use--ethical and legal dilemmas]. / Etické a legislativní otázky odberu a uzití spermií zemrelého.

OBJECTIVE: To present a review of bioethical discussion and recommendations concerning posthumous sperm procurement and postmortem parenthood. DESIGN: Review article. SETTING: Department of Obstetrics and Gynecology, Masaryk University, Brno, Department of Obstetrics and Gynecology, Palacky University, Olomouc. SUBJECT AND METHOD: Literature search in Database of Abstracts of Reviews of the Evidence (DARE) and MEDLINEplus. Posthumous sperm procurement and cryopreservation must be performed within 36 hours after death. To established appropriate medical practice, it is important to consider all stakeholders in the decision-making process: the deceased, the requesting party, the child, the physician and the society. There are only few legislative measures concerning postmortem parenthood and posthumous sperm procurement. The essential elements for postmortem reproduction are: judicial order, ethics committee approval, bereavement period of at least 6 month before use. CONCLUSION: Posthumous sperm procurement is fraught with ethical and legal implications. All stakeholder should be considered. Society for reproductive medicine should prepare acceptable standard protocol.

[Post mortem semen acquisition: not without 'informed consent']. / Semenafname post mortem: niet zonder 'informed consent'.

Recently, two requests for post-mortem semen acquisition were evaluated and rejected. The first request was from the wife of a man who died after the wedding night. In the second case, the wife requested that electroejaculation be done on a man who was brain dead because of a gunshot wound in the head. In both cases, the fact that there was no written consent from the men involved before they died was the deciding reason not to grant the requests. Written consent is legally and ethically seen as the final episode of a period in which persons have considered the consequences of the acquisition, storage and use of semen after the death of the husband.

[Strategies for fertility preservation after anti-cancer therapy]. / Zabezpieczenie plodnosci pacjentów po leczeniu choroby nowotworowej.

A tremendous advance in the field of cancer therapy resulted in a substantial improvement of long-term survival of oncological patients. The most frequent side effect of either chemotherapy or radiotherapy is a partial or complete lost of fertility potential. This paper reviews current knowledge on the fertility preservation strategies for patients facing oncological problems and the risks of iatrogenic infertility. The cryopreservation of spermatozoa or testicular tissue combined with assisted reproductive technology is the optimal solution for male patients. In the case of female patients, the use of ovarian transposition, ovarian suppression and ovarian tissue cryopreservation seem to be the valuable options for fertility prevention. The cryopreservation of embryos is another possible solution, although this procedure is only limited to the couples. On the other hand, there are still controversies regarding the ethical issues concerning gametes and embryos banking.

Posthumous assisted reproduction.

Cryopreservation of gametes and embryos allows for children to be conceived after the death of their genetic parents through the process of posthumous assisted reproduction (PAR). Although the techniques are routine, the moral and ethical details are controversial and remain unsettled. Furthermore, there are numerous medicolegal implications that complicate matters. The principal parties to be considered are the decedent, the child who will be born of PAR, the significant other requesting the procedure, other living children, and even society at large. Numerous case studies exist and expert opinions have been published recognizing PAR as a vexing ethical issue. Most experts agree that explicit written consent forms signed at the time of cryopreservation are the best method to minimize some of the controversy involved with PAR.

Postmortem sperm retrieval: the Canadian perspective.

Postmortem sperm retrieval has been used worldwide. Following retrieval, sperm can then be used (usually by the surviving partner) to produce a child related to the now-deceased male. This paper describes a request for postmortem sperm retrieval made by the family of a man who had suffered trauma leading to his death. The man had not given written consent for the retrieval and use of his sperm before his accidental death. The case illustrates some of the complex ethical and legal issues occurring in Canada and describes the new Canadian regulations, which prohibit postmortem sperm retrieval unless explicit written consent has been provided by the deceased.

Is posthumous semen retrieval ethically permissible?

It is possible to retrieve viable sperm from a dying man or from a recently dead body. This sperm can be frozen for later use by his wife or partner to produce his genetic offspring. But the technical feasibility alone does not morally justify such an endeavour. Posthumous semen retrieval raises questions about consent, the respectful treatment of the dead body, and the welfare of the child to be. We present two cases, discuss these three issues, and conclude that such requests should generally not be honoured unless there is convincing evidence that the dead man would want his widow to carry and bear his child. Even with consent, the welfare of the potential child must be considered.