Time to cancer treatment and reproductive outcomes after fertility preservation among adolescent and young adult women with cancer.

BACKGROUND: Fertility preservation (FP) may be underused after cancer diagnosis because of uncertainty around delays to cancer treatment and subsequent reproductive success. METHODS: Women aged 15 to 39 years diagnosed with cancer between 2004 and 2015 were identified from the North Carolina Central Cancer Registry. Use of assisted reproductive technology (ART) after cancer diagnosis between 2004 and 2018 (including FP) was assessed through linkage to the Society for Assisted Reproductive Technology. Linear regression was used to examine time to cancer treatment among women who did (n = 95) or did not (n = 469) use FP. Modified Poisson regression was used to estimate risk ratios (RRs) and 95% CIs for pregnancy and birth based on timing of ART initiation relative to cancer treatment (n = 18 initiated before treatment for FP vs n = 26 initiated after treatment without FP). RESULTS: The median time to cancer treatment was 9 to 33 days longer among women who used FP compared with women who did not, matched on clinical factors. Women who initiated ART before cancer treatment may be more likely to have a live birth given pregnancy compared with women who initiated ART after cancer treatment (age-adjusted RR, 1.47; 95% CI, 0.98-2.23), though this may be affected by the more frequent use of gestational carriers in the former group (47% vs 20% of transfer cycles, respectively). CONCLUSIONS: FP delayed gonadotoxic cancer treatment by up to 4.5 weeks, a delay that would not be expected to alter prognosis for many women. Further study of the use of gestational carriers in cancer populations is warranted to better understand its effect on reproductive outcomes.

Fertility-related experiences after breast cancer diagnosis in the Sister and Two Sister Studies.

BACKGROUND: Commonly used chemotherapies can be toxic to the ovaries. To the authors' knowledge, the majority of studies evaluating receipt of fertility counseling for women in their reproductive years have been performed in specific settings, thereby limiting generalizability. METHODS: A nationwide sample of US women diagnosed with breast cancer before age 45 years completed a survey assessing the prevalence of fertility counseling. Age-adjusted log-binomial regression was used to estimate prevalence ratios (PRs) and 95% CIs for fertility counseling. RESULTS: Among 432 survivors diagnosed between 2004 and 2011, 288 (67%) had not discussed the effects of treatment on fertility with a health care provider before or during treatment. Fertility discussion was associated with younger age (PR, 3.49 [95% CI, 2.66-4.58] for aged <35 years vs ≥40 years) and lower parity (PR, 1.81 [95% CI, 1.29-2.53] for parity 1 vs 2). Approximately 20% of respondents reported that they were interested in future fertility (87 of 432 respondents) at the time of their diagnosis, but not all of these individuals (66 of 87 respondents) received counseling regarding the impact of treatment on their fertility, and few (8 of 87 respondents) used fertility preservation strategies. Among 68 women with a fertility interest who provided reasons for not taking steps to preserve fertility, reasons cited included concern for an adverse impact on cancer treatment (56%), lack of knowledge (26%), decision to not have a child (24%), and cost (18%). CONCLUSIONS: Across multiple treatment settings, the majority of women of reproductive age who are diagnosed with breast cancer did not discuss fertility with a health care provider or use fertility preservation strategies. Discussing the potential impact of cancer treatment on future fertility is an important aspect of patient education.

Applying behavioral theory to understand fertility consultation uptake after cancer.

OBJECTIVE: The objective of this study was to examine the association between theoretical constructs from the Health Belief Model and fertility consultation status after cancer. METHODS: Reproductive-aged female cancer survivors self-reported their use of fertility consultation, perceived severity of and susceptibility to infertility, perceived barriers to and effectiveness of fertility consultation, and cues to action from family/peers and doctors, as well as demographics and cancer characteristics. Logistic regression was used to analyze the association between theoretical constructs and fertility consultation status. RESULTS: Fertility consultation uptake was more prevalent among survivors with higher incomes, those without children, those who wanted a (another) child, and those who were diagnosed more recently. In the final multivariate model, higher perceived severity of infertility, fewer perceived barriers to fertility consultation, and more cues to action from family/peers and doctors were significantly associated with fertility consultation uptake, controlling for income. Exploratory bivariate analyses of barriers to fertility consultation revealed that cost and trouble accessing services were significantly associated with not having a fertility consultation. CONCLUSIONS: The Health Belief Model is useful for understanding factors associated with fertility consultation uptake. Efforts should be made to reduce financial barriers and improve patient-centered assessment of family-building goals.

Acute Menopausal Symptoms in Young Cancer Survivors Immediately following Chemotherapy.

PURPOSE: The aim of this study was to evaluate the prevalence of menopausal symptoms in young cancer survivors immediately following the completion of chemotherapy. METHODS: This prospective cohort study followed 124 young females with a new diagnosis of cancer requiring chemotherapy to assess symptoms of menopause before treatment and immediately following chemotherapy. Symptoms were compared before and after treatment using the McNemar test and between cancer patients and 133 similar-aged healthy controls using Pearson χ2 and Fisher's exact tests. RESULTS: Participants undergoing cancer therapy reported more menopausal symptoms compared to controls prior to the initiation of any treatment (hot flashes or night sweats 33 vs. 7%, p < 0.01, trouble sleeping 57 vs. 31%, p < 0.01, headaches 50 vs. 35%, p = 0.02, and decreased libido 36 vs. 16%, p < 0.01) and also reported a greater prevalence of symptoms immediately after cancer therapy compared to pretreatment prevalence (vasomotor symptoms, p < 0.01, vaginal dryness, p < 0.01, decreased concentration, p < 0.01, and body aches, p = 0.01). Cancer patients with lower anti-Müllerian hormone (AMH) levels after treatment (<0.10 ng/mL) had an increased risk of vasomotor symptoms (OR 2.2, p = 0.04), mood swings (OR 2.4, p = 0.03), feeling sad (OR 2.2, p = 0.04), trouble sleeping (OR 2.7, p = 0.02), and decreased libido (OR 3.0, p = 0.03) when controlled for age and cancer type, and the incidence of these symptoms was not affected by the use of systemic hormones or psychiatric medications. Treatment length, use of alkylating agents, pelvic radiation, and marital status were also not associated with the prevalence of menopausal symptoms. CONCLUSIONS: Premenopausal women with a new cancer diagnosis have more menopausal symptoms than females of similar age before and after cancer treatment, the effects of which are not mitigated by systemic hormone use. Decreased AMH levels were associated with an increased likelihood of reporting physiologic symptoms after therapy. IMPLICATIONS FOR CANCER SURVIVORS: This information is imperative for counseling; ultimately, improved symptom management during and after cancer therapies will improve quality of life in young cancer survivors.

Infertile women who screen positive for depression are less likely to initiate fertility treatments.

STUDY QUESTION: Are infertile women who screen positive for depression less likely to initiate infertility treatments? SUMMARY ANSWER: Infertile women who screen positive for depression are less likely to initiate treatment for infertility. WHAT IS ALREADY KNOWN: Infertility imposes a psychological burden on many couples. Depression and anxiety have been demonstrated in ~40% of infertile women, which is twice that of fertile women. Further, the psychological burden associated with infertility treatment has been cited as a major factor for discontinuation of infertility care. STUDY DESIGN, SIZE, DURATION: Prospective, observational study in a clinical-based cohort of 416 women who completed a questionnaire after the new patient visit, from January 2013 until December 2014 inclusive. PARTICIPANTS/MATERIALS, SETTING, METHODS: All new female infertility patients (n = 959) seen between January 2013 and December 2014 at University of North Carolina Fertility received an electronic questionnaire to screen for mental health disorders and to evaluate their perception of mental health disorders on infertility. MAIN RESULTS AND THE ROLE OF CHANCE: Of 959 surveys sent, 416 women completed the questionnaire (43%). The prevalence screening positive for depression, using the NIH PROMIS screening tool, was 41%. Sixty-two percent of all women initiated infertility treatment, and of these, 81% did so within 4 months. In multivariate analysis, women who screened positive for depression had 0.55 times the odds of initiating treatment for infertility (95% CI: 0.31-0.95). Similarly, women who screened positive for depression had 0.58 times the odds of initiating infertility treatment within 4 months (95% CI: 0.35-0.97), which was the time of censoring from the most recent patient evaluated. Women who screened positive for depression were less likely to pursue treatment with oral medications or IVF (P = 0.01 and P = 0.03, respectively), as compared to women who did not screen positive for depression. LIMITATIONS, REASONS FOR CAUTION: Questionnaire-based evaluations may result in a lower prevalence of psychological disorder as some participants feign emotional well-being. Although we did not identify differences in women who responded to our survey and those who did not, responder bias may still be present. In addition, infertility is a couple's disease. However, this study only included psychological evaluation of the female partner. We have no information about the women's previous treatment. WIDER IMPLICATIONS OF THE FINDINGS: Screening for depression is important in the infertility patient population, as further evaluation and psychological interventions may improve compliance with fertility treatments, quality of life, and potentially, the overall chance of pregnancy. STUDY FUNDING/COMPETING INTERESTS: None.

Polycystic ovarian syndrome (PCOS), related symptoms/sequelae, and breast cancer risk in a population-based case-control study.

PURPOSE: Despite the overlap between the clinical symptoms/sequelae of polycystic ovarian syndrome (PCOS) and many known reproductive risk factors for breast cancer, the relationship between PCOS and breast cancer remains unclear, possibly because of the complex heterogeneity and challenges in diagnosing PCOS over time. We hypothesized that PCOS, specific PCOS-related symptoms/sequelae, or clusters of PCOS-related symptoms/sequelae may be differentially associated with pre- versus postmenopausal breast cancer risk. MATERIALS AND METHODS: Cases were 1,508 women newly diagnosed with a first primary in situ or invasive breast, and the 1,556 population-based controls were frequency-matched by age. RESULTS: History of physician-diagnosed PCOS was reported by 2.2 % (n = 67), among whom oral contraceptive (OC) use, irregular menstruation, and infertility due to ovulatory dysfunction were common. Using unconditional logistic regression, adjusted odds ratios (95 % CI) for PCOS were increased for premenopausal [2.74 (1.13, 6.63)], but not postmenopausal breast cancer [0.87 (0.44, 1.71)]. We used cluster analysis to investigate whether risk among all women varied by PCOS-related symptoms/sequelae, such as reproductive irregularities, OC use, and components of insulin resistance. In the cluster analysis, odds ratios were elevated among premenopausal women who had a history of OC use and no ovulatory dysfunction [1.39 (1.03, 1.88)], compared to those with fewer number of PCOS-related symptoms/sequelae. CONCLUSION: PCOS and associated PCOS-related symptoms/sequelae including OC use may play a role in the development of premenopausal breast cancer. Our findings require confirmation in studies with a larger number of premenopausal women with systematically applied diagnostic criteria for PCOS.

Young female cancer survivors' use of fertility care after completing cancer treatment.

PURPOSE: The purpose of the present study is to investigate factors associated with female young adult cancer survivors' (YCSs) use of fertility care (FC), including consultation or fertility treatment, after completing their cancer treatment. METHODS: In this cross-sectional study, females between that ages of 18 and 35 years who had been diagnosed with childhood, adolescent, or young adult cancers completed a 20-min web-based survey that included demographics, reproductive history, use of FC, fertility-related informational needs, and reproductive concerns. RESULTS: A total of 204 participants completed the survey. Participants' mean age was 28.3 ± 4.5 years. Thirty (15 %) participants reported using FC after cancer treatment. The majority of participants recalled not receiving enough information about fertility preservation options at the time of cancer diagnosis (73 %). In multivariable analysis, those with higher concerns about having children because of perceived risk to their personal health (P = 0.003) were less likely to report use of FC after cancer treatment. Those who had used FC before cancer treatment (P = 0.003) and who felt less fertile than age-matched women (P = 0.02) were more likely to use FC after their cancer treatment. CONCLUSIONS: While most YCSs in this cohort believed that they did not receive enough information about fertility and most wanted to have children, the vast majority did not seek FC. The findings of this study offer further evidence of the need for improved education and emotional support regarding reproductive options after cancer treatment is completed. Targeted discussions with YCSs about appropriate post-treatment FC options may improve providers' capacity to help YCSs meet their parenthood goals.

Early referral makes the decision-making about fertility preservation easier: a pilot survey study of young female cancer survivors.

PURPOSE: The purpose of the study was to investigate the association between patients' decision-making about fertility preservation (FP) and time between cancer diagnosis and FP consultation in young female cancer survivors. METHODS: This is a pilot survey study of women aged 18-43 years seen for FP consultation between April 2009 and December 2010. RESULTS: Among 52 women who completed the survey, 15 (29 %) had their FP consultation more than 2 weeks after their cancer diagnosis (late referral group) and 37 (71 %) were within 2 weeks of their cancer diagnosis (early referral group). In univariate analysis, the only difference between the late referral and early referral groups was a higher decisional conflict scale (DCS) in late referral group (p = 0.04). In multivariable analysis, late referral group was more likely to have high DCS (>35) compared to early referral group (odds ratio 4.8, 95 % confidence interval 1.5, 21.6) after adjusting for age, center, and type of cancer. CONCLUSION: Early referral to a fertility specialist can help patients make better decision about FP. This is the first study to suggest that early referral is important in patients' decision-making process about FP treatment. Our finding supports the benefit of early referral in patients who are interested in FP which is consistent with prior studies about FP referral patterns.

Emergent Oocyte Cryopreservation with a Novel Ovarian Transposition Technique in a Colorectal Cancer Patient: A Combined Approach for Fertility Preservation. A Case Report.

BACKGROUND: Fertility preservation has become a standard of care in reproductive-age oncology patients. However, research has demonstrated that the knowledge of the provider and referral practice patterns remain suboptimal. Fertility preservation should be discussed with oncology patients of reproductive age, with the full knowledge of the individual. A combined medical and surgical approach may further ensure their reproductive successes in the future. CASE: A 38-year-old, nulliparous woman with colorectal cancer desired fertility preservation prior to cancer therapy. She underwent a laparoscopic ovarian transposition using a novel percutaneous suturing technique after emergent ovarian stimulation, followed by oocyte retrieval and cryopreservation. One year after chemotherapy and pelvic radiation the patient resumed regular menstrual cycles. CONCLUSION: A combined approach using emergent oocyte cryopreservation and a novel laparoscopic ovarian transposition is an optimal fertility preservation strategy in women with colorectal cancer. Fertility preservation success is dependent upon a multidisciplinary approach of well-informed medical teams consisting of an oncologist, a surgeon, a radiation oncologist, and a reproductive specialist.

Fertility preservation in patients with haematological disorders: a retrospective cohort study.

This study investigated the factors associated with utilization of fertility preservation and the differences in treatments and outcomes by prior chemotherapy exposure in patients with haematological diseases. This study included all 67 women with haematological diseases seen for fertility preservation consultation at two university hospitals between 2006 and 2011. Of the total, 49% had lymphoma, 33% had leukaemia, 7% had myelodysplastic syndrome and 4% had aplastic anaemia; 46% had prior chemotherapy; and 33% were planning for bone marrow transplantation, 33% pursued ovarian stimulation and 7% used ovarian tissue banking; and 48% of patients did not pursue fertility preservation treatment. All five cycle cancellations were in the post-chemotherapy group: three patients with leukaemia and two with lymphoma. Patients with prior chemotherapy had lower baseline antral follicle count (10 versus 22) and received more gonadotrophins to achieve similar peak oestradiol concentrations, with no difference in oocyte yield (10.5 versus 10) after adjustment for age. Embryo yield was similar between those who had prior chemotherapy and those who had not. Half of the patients with haematological diseases who present for fertility preservation have been exposed to chemotherapy. While ovarian reserve is likely impaired in this group, oocyte yield may be acceptable.

To preserve or not to preserve: how difficult is the decision about fertility preservation?

BACKGROUND: The decision to pursue fertility preservation (FP) after a cancer diagnosis is complex. We examined the prevalence of high decisional conflict and specific factors that influence this decision using the Decisional Conflict Scale (DCS). METHODS: The FIRST project is a web-based survey of female cancer survivors (ages 18-44 years) who have undergone gonadotoxic treatment. We evaluated the association between recalled decisional conflict and referral to FP counseling and demographic, socioeconomic, and cancer variables. RESULTS: Of 208 participants, 115 subjects (55%) had scores consistent with high decisional conflict (DCS score >37.5 of 100), and 43 (21%) were in the moderate range (25-37.5). In unadjusted analysis, high decisional conflict was associated with lack of referral to FP consultation, not undergoing FP treatment, concerns regarding FP cost, length of survivorship, lower income, education, partner status, and cancer type. In multivariable analysis, significantly higher prevalence of high decisional conflict was observed in participants who were not referred for FP consultation (prevalence ratio [PR], 1.25; 95% confidence interval [CI], 1.06-1.47), as well as in participants who reported cost of FP services to be prohibitive (PR, 1.16 [95% CI, 1.03-1.31]). Prevalence of high DCS was lower for women who underwent FP treatment (PR, 0.67 [95% CI, 0.52-0.86]). CONCLUSIONS: In this study of female young adult cancer survivors, the majority recalled significant decisional conflict about FP at cancer diagnosis. Increasing access to FP via referral for counseling and cost reduction may decrease decisional conflict about FP for young patients struggling with cancer and fertility decisions.

Fertility preservation consultation for women with cancer: are we helping patients make high-quality decisions?

To investigate the efficacy of the current fertility preservation consultation process in patients' decision-making and socio-demographic and cognitive factors that may affect patients' decision-making, a prospective pilot survey was conducted at university-based IVF centres and included women aged 18-43 years seen for fertility preservation between April 2009 and December 2010. Patients' views on consultation and decision-making about fertility preservation were measured. Among 52 women who completed the survey, more than half (52%) requested their consultation. All patients answered that consultation was a helpful resource of information, and 73% made their decision about treatment after consultation. Decisional conflict was lower in patients who felt strongly that they were given opportunities to ask questions during the consultation (P=0.001) and higher those who reported that cost was strongly influential in the treatment decision (P<0.001) and who did not receive treatment (P<0.001). Although consultation appeared to play a critical role in patients' decision-making about fertility preservation, the referral rate for consultation by oncologists is still poor. Decision-making appears to be significantly impaired in patients grappling with financial concerns and when the opportunity to ask questions is not felt to be sufficient.

Pregnancy attempts among adolescent and young adult cancer survivors.

OBJECTIVE: To examine whether demographic and cancer-related characteristics and factors such as fertility discussion with a medical provider and fertility preservation use are associated with attempting pregnancy after adolescent and young adult cancer. DESIGN: Cross-sectional online survey. SETTING: Not applicable. PATIENT(S): Women with lymphoma, breast cancer, thyroid cancer, or gynecologic cancer diagnosed at 15-39 years from 2004 to 2016 were identified from the North Carolina Cancer Registry and the Kaiser Permanente Northern and Southern California health care systems and responded to an online survey addressing survivorship concerns, including fertility and reproductive outcomes. EXPOSURES: Demographic characteristics, cancer characteristics, fertility discussion with a medical provider or fertility specialist between cancer diagnosis and starting cancer treatment, use of fertility preservation strategies (freezing embryos or oocytes) after cancer diagnosis. MAIN OUTCOME MEASURE(S): Pregnancy attempt after cancer diagnosis, defined by either a pregnancy or 12 months of trying to become pregnant without pregnancy. RESULT(S): Among 801 participants who had not reached their desired family size at diagnosis, 77% had a fertility discussion with any medical provider between cancer diagnosis and treatment initiation, and 8% used fertility preservation after cancer diagnosis. At survey (median =7 years after diagnosis; interquartile range, 4-10), 32% had attempted pregnancy. Neither fertility discussion with any medical provider nor fertility counseling with a fertility specialist was significantly associated with pregnancy attempts. However, the use of fertility preservation was significantly associated with attempting pregnancy (prevalence ratios = 1.74; 95% confidence interval: 1.31-2.32). Other characteristics positively associated with pregnancy attempts included younger age at diagnosis, longer time since diagnosis, having a partner (at diagnosis or at survey), and having a history of infertility before cancer diagnosis. CONCLUSION(S): Use of fertility preservation strategies was uncommon in our cohort but was associated with attempting pregnancy after cancer. Ensuring access to fertility preservation methods may help adolescent and young adult cancer survivors to plan and initiate future fertility.

Disparities in fertility preservation use among adolescent and young adult women with cancer.

PURPOSE: Women face multiple barriers to fertility preservation after cancer diagnosis, but few studies have examined disparities in use of these services. METHODS: Women aged 15-39 years diagnosed with cancer during 2004-2015 were identified from the North Carolina Central Cancer Registry and linked to the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System. Women who cryopreserved oocytes or embryos for fertility preservation (n = 96) were compared to women who received gonadotoxic treatment but did not use fertility preservation (n = 7964). Conditional logistic and log-binomial regression were used to estimate odds ratios (ORs) or prevalence ratios (PRs) and 95% confidence intervals (CIs). RESULTS: Few adolescent and young adult women with cancer in our study (1.2%) used fertility preservation. In multivariable regression, women less likely to use fertility preservation were older at diagnosis (ages 25-29 vs. 35-39: OR = 6.27, 95% CI: 3.35, 11.73); non-Hispanic Black (vs. non-Hispanic White: PR = 0.44, 95% CI: 0.24, 0.79); and parous at diagnosis (vs. nulliparous: PR = 0.24, 95% CI: 0.13, 0.45); or lived in census tracts that were non-urban (vs. urban: PR = 0.12, 95% CI: 0.04, 0.37) or of lower socioeconomic status (quintiles 1-3 vs. quintiles 4 and 5: PR = 0.39, 95% CI: 0.25, 0.61). CONCLUSIONS: Women with cancer who were older, non-Hispanic Black, parous, or living in areas that were non-urban or of lower socioeconomic position were less likely to use fertility preservation. IMPLICATIONS FOR CANCER SURVIVORS: Clinical and policy interventions are needed to ensure equitable access to fertility services among women facing cancer treatment-related infertility.

Meeting the demand for fertility services: the present and future of reproductive endocrinology and infertility in the United States.

The field of reproductive endocrinology and infertility (REI) is at a crossroads; there is a mismatch between demand for reproductive endocrinology, infertility and assisted reproductive technology (ART) services, and availability of care. This document's focus is to provide data justifying the critical need for increased provision of fertility services in the United States now and into the future, offer approaches to rectify the developing physician shortage problem, and suggest a framework for the discussion on how to meet that increase in demand. The Society of REI recommend the following: 1. Our field should aggressively explore and implement courses of action to increase the number of qualified, highly trained REI physicians trained annually. We recommend efforts to increase the number of REI fellowships and the size complement of existing fellowships be prioritized where possible. These courses of action include: a. Increase the number of REI fellowship training programs. b. Increase the number of fellows trained at current REI fellowship programs. c. The pros and cons of a 2-year focused clinical fellowship track for fellows interested primarily in ART practice were extensively explored. We do not recommend shortening the REI fellowship to 2 years at this time, because efforts should be focused on increasing the number of fellowship training slots (1a and b). 2. It is recommended that the field aggressively implements courses of action to increase the number of and appropriate usage of non-REI providers to increase clinical efficiency under appropriate board-certified REI physician supervision. 3. Automating processes through technologic improvements can free providers at all levels to practice at the top of their license.

Trends of socioeconomic disparities in referral patterns for fertility preservation consultation.

BACKGROUND: While oncologists are aware that cancer treatments may impact fertility, referral rates for fertility preservation consultation (FPC) remain poor. The goal of this study was to identify predictors associated with FPC referral. METHODS: This is a retrospective, cohort study of women aged 18-42 years diagnosed with a new breast, gynecologic, hematologic or gastrointestinal cancer at our institution between January 2008 and May 2010. Exclusion criteria included history of permanent sterilization, documentation of no desire for future children, stage IV disease, short interval (<4 days) between diagnosis and treatment and treatment that posed no threat to fertility. Demographic, socioeconomic and cancer variables were evaluated with respect to FPC. Logistic regression was used to determine the odds of referral for FPC based on specified predictors. RESULTS: One hundred and ninety-nine patients were eligible for FPC and of those, 41 received FPC (20.6%). Women with breast cancer were 10 times more likely to receive FPC compared with other cancer diagnoses [odds ratio (OR) 10.1; 95% confidence interval (CI) 3.8-26.8]. The odds of FPC referral were approximately two times higher for Caucasian women (OR 2.4; 95% CI 0.9-6.2), three times higher for age <35 years (OR 3.3; 95% CI 1.4-7.7) and four times higher in nulliparous women (OR 4.6; 95% CI 1.9-11.3). There was no association between BMI, income, distance to our institution, being in a relationship and referral for FPC. CONCLUSIONS: Overall referral rates for FPC are low, and there appear to be significant discrepancies in referral based on ethnicity, age, parity and cancer type. This highlights a need for further provider education and awareness across all oncologic disciplines.

The current fertility preservation consultation model: are we adequately informing cancer patients of their options?

BACKGROUND: There is very limited information about the amount of information that cancer patients retain after a fertility preservation (FP) consultation (FPC). Our objective was to assess patients' knowledge following FPC and to examine predictors of increased knowledge. METHODS: We conducted a multi-center, cross-sectional, web-based survey at academic IVF centers, including women aged 18-43 years seen for comprehensive FPC between April 2009 and December 2010. The primary outcome measure was a knowledge score designed to assess comprehension of FP options. Analysis was performed to assess which patient variables were associated with higher knowledge scores. A 13-item knowledge tool about FP was developed (Kuder-Richardson 20=0.64). RESULT(S): Among 90 eligible subjects, 66 were successfully contacted and 52 completed the survey (79% response rate). Participant's median age was 30.7 (interquartile range (IQR) 24.9-36.9) years and most were Caucasian, college graduates, nulliparous and in a committed relationship. The median knowledge post-FPC score was 6 (IQR: 5-9). Higher knowledge scores were associated with a college education, higher income, a primary diagnosis of breast cancer, additional contact with the FP specialist following the initial FPC and use of specific reference websites such as www.fertilehope.org. Parity, marital status and completion of FP treatment were not associated with knowledge scores. CONCLUSIONS: FP knowledge following comprehensive FPC remains limited. Modifications to the current single visit FPC, such as a standard follow-up visit or additional educational tools, may be needed to improve patient comprehension of complex FP treatment options. Further research is needed to validate the knowledge scale in broader populations of cancer patients receiving FPC.

Fertility Preservation and Financial Hardship among Adolescent and Young Adult Women with Cancer.

BACKGROUND: Financial hardship among adolescents and young adults (AYA) with cancer who receive gonadotoxic treatments may be exacerbated by the use of fertility services. This study examined whether AYA women with cancer who used fertility preservation had increased financial hardship. METHODS: AYA women with cancer in North Carolina and California completed a survey in 2018-2019. Cancer-related financial hardship was compared between women who cryopreserved oocytes or embryos for fertility preservation after cancer diagnosis (n = 65) and women who received gonadotoxic treatment and reported discussing fertility with their provider, but did not use fertility preservation (n = 491). Multivariable log-binomial regression was used to estimate prevalence ratios and 95% confidence intervals (CI). RESULTS: Women were a median age of 33 years at diagnosis and 7 years from diagnosis at the time of survey. Women who used fertility preservation were primarily ages 25 to 34 years at diagnosis (65%), non-Hispanic White (72%), and had at least a Bachelor's degree (85%). In adjusted analysis, use of fertility preservation was associated with 1.50 times the prevalence of material financial hardship (95% CI: 1.08-2.09). The magnitude of hardship was also substantially higher among women who used fertility preservation: 12% reported debt of ≥$25,000 versus 5% in the referent group. CONCLUSIONS: This study provides new evidence that cryopreserving oocytes or embryos after cancer diagnosis for future family building is associated with increased financial vulnerability. IMPACT: More legislation that mandates insurance coverage to mitigate hardships stemming from iatrogenic infertility could improve access to fertility preservation for young women with cancer.

Sperm morphology from the actual inseminated sample does not predict clinical pregnancy following intrauterine insemination.

OBJECTIVE: To determine the effect of sperm morphology from the specific sample used for intrauterine insemination (IUI) on clinical pregnancy rates (CPR). DESIGN: Prospective cohort study. SETTING: Academic fertility clinic. PATIENTS: Couples undergoing IUI July 2016-January 2017. INTERVENTIONS: Morphology slides were prepared from the semen sample produced for IUI. MAIN OUTCOME MEASURES: CPR was measured by detection of cardiac activity. Multiple logistic regression modeling was performed to determine the association of sperm morphology with CPR, controlling for age, antimüllerian hormone level, and post-wash total motile sperm count. RESULTS: Semen analyses, including Kruger strict criteria for morphology from the actual sample inseminated, were reviewed for 155 couples, comprising 234 total treatment cycles. The percent normal morphology significantly differed between the preliminary semen analysis and the IUI sample (-2.0% +3.7% (95% CI -2.55, -1.53). Of the total 234 treatment cycles, 8.6% resulted in clinical pregnancy. When categorized by strict morphology >4%, <4%, and <1%, the CPR was 6.6%, 9.8%, and 10.9%, respectively. In couples with otherwise normal semen parameters (isolated teratospermia), CPR by >4%, <4%, and <1% normal forms was 7.2%, 9.8%, and 11.1%, respectively. There was no significant association between the percent normal morphology and CPR in multivariate analysis. CONCLUSIONS: This study evaluating the morphology of the actual inseminated sample did not find differences in CPR following IUI among couples with normal and abnormal sperm morphology, including severe teratospermia. Abnormal sperm morphology should not exclude couples from attempting IUI.

The Adolescent and Young Adult (AYA) Horizon Study: An AYA Cancer Survivorship Cohort.

BACKGROUND: In the United States, >45,000 adolescent and young adult (AYA) women are diagnosed with cancer annually. Reproductive issues are critically important to AYA cancer survivors, but insufficient information is available to address their concerns. The AYA Horizon Study was initiated to contribute high-quality, contemporary evidence on reproductive outcomes for female cancer survivors in the United States. METHODS: The study cohort includes women diagnosed with lymphoma, breast, melanoma, thyroid, or gynecologic cancer (the five most common cancers among women ages 15-39 years) at three study sites: the state of North Carolina and the Kaiser Permanente health systems in Northern and Southern California. Detailed information on cancer treatment, fertility procedures, and pregnancy (e.g., miscarriage, live birth) and birth (e.g., birth weight, gestational length) outcomes are leveraged from state cancer registries, health system databases and administrative insurance claims, national data on assisted reproductive technology procedures, vital records, and survey data. RESULTS: We identified a cohort of 11,072 female AYA cancer survivors that includes >1,200 African American women, >1,400 Asian women, >1,600 Medicaid enrollees, and >2,500 Hispanic women using existing data sources. Active response to the survey component was low overall (N = 1,679), and notably lower among minority groups compared with non-Hispanic white women. CONCLUSIONS: Passive data collection through linkage reduces participant burden and prevents systematic cohort attrition or potential selection biases that can occur with active participation requirements. IMPACT: The AYA Horizon study will inform survivorship planning as fertility and parenthood gain increasing recognition as key aspects of high-quality cancer care.