|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
© 2002 American Society for Clinical Oncology Knowledge and Experience Regarding Cancer, Infertility, and Sperm Banking in Younger Male SurvivorsByFrom the Departments of Behavioral Science and Pediatrics, University of Texas M.D. Anderson Cancer Center, and Scott Department of Urology, Baylor College of Medicine, Houston, TX; and Taussig Cancer Center, Cleveland Clinic Foundation, Cleveland, OH. Address reprint requests to Leslie R. Schover, PhD, Department of Behavioral Science, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Box 243, Houston, TX 77030-4009; email: lschover{at}mdanderson.org
PURPOSE: The goal of this study was to survey male patients aged 14 to 40 years at diagnosis and recently treated in two cancer centers to determine their knowledge, attitudes, and experiences regarding cancer-related infertility and sperm banking. PATIENTS AND METHODS: A postal survey about cancer-related infertility and sperm banking was offered to 904 men diagnosed with cancer within the previous 2 years. Eight percent opted out of the study. The others were sent the survey, with a cover letter stating elements of informed consent. RESULTS: Although the return rate was only 27%, yielding a sample of 201 men, responders did not differ significantly from nonresponders by institution, age, ethnicity, or cancer site. Overall, 51% of men wanted children in the future, including 77% of men who were childless at cancer diagnosis. Despite some anxieties about their own survival and risks to their children’s health, men felt that the experience of cancer increased the value they placed on family closeness and would make them better parents. Only 60% of men recalled being informed about infertility as a side effect of cancer treatment, and just 51% had been offered sperm banking. Those who discussed infertility with their physicians had higher knowledge about cancer-related infertility and were significantly more likely to bank sperm. Only 24% of men banked sperm, including 37% of childless men. Lack of information was the most common reason for failing to bank sperm (25%). CONCLUSION: All men who are about to receive cancer treatment that could impair fertility should be counseled about such side effects and given adequate information to make an informed decision about banking sperm.
ALTHOUGH INFERTILITY is a well-documented consequence of cancer treatment,1 very little research has focused on the psychosocial consequences for cancer survivors. Infertility after cancer treatment is particularly common for male survivors of childhood cancer2 and for testicular cancer survivors.3,4 Long-term survivors of testicular cancer or Hodgkin’s disease who did not have children at the time of their cancer diagnosis are likely to be distressed about fertility.3-5 In a previous pilot study, the first author (L.R.S.) surveyed a sample of both male and female cancer survivors diagnosed before age 35 about their attitudes and experiences related to having children after cancer.6 Respondents were an average of 5.5 years after diagnosis at the time of the survey, and had been treated at the Cleveland Clinic Foundation. Men were significantly less likely than women to participate in the survey (male response rate, 36%). Few other sex differences were found, with 76% of childless cancer survivors wanting to have children in the future, and only 6% feeling that their experience of cancer had decreased their wish for children. Over 80% of respondents felt that having had cancer would actually make them better parents, and 94% felt healthy enough to be a good parent. About a quarter of the respondents were quite distressed about infertility and only 57% recalled receiving information from a health care provider about the risks of infertility related to cancer treatment. Respondents also had many concerns that had typically not been addressed by health care providers about the risks of birth defects or cancer for their own children. One advantage for men diagnosed with cancer is the availability of sperm banking. With routine semen cryopreservation, the majority of men will have viable sperm available for infertility therapy, even though their semen quality is often somewhat impaired at the time of cancer diagnosis.7-9 Using newer in vitro fertilization techniques, only one sperm cell is needed to fertilize each oocyte recovered from the female partner, so that freezing even one ejaculate before starting cancer treatment provides a reasonable chance of having a biologic child.10 Although ovarian tissue cryopreservation is a new option for women, it has no track record of resulting in a successful, live birth,10,11 and is far more invasive and expensive than sperm banking. Both in Europe and in the United States, sperm banking is being advocated as an option that should be offered to any man before he begins cancer treatment that has the potential to impair his fertility.12-16 More attention is also being focused on offering sperm banking to adolescent cancer patients.17 In our pilot cohort, only 19% of men (including just 24% of men who were childless) had banked sperm. The most common reason for not banking (cited by 25% of men) was lack of information about it at the time of treatment planning.6 As part of a project to create a computerized, multimedia educational and decision aid on sperm banking for physicians and patients, we undertook a new, separate, and larger survey of young men recently treated for cancer to attempt to confirm and elaborate the results of our previous research.
Subjects An introductory letter about the postal survey was sent to 820 men from the tumor registry of the University of Texas M.D. Anderson Cancer Center and 84 men from the patient registry of the Cleveland Clinic Foundation’s Taussig Cancer Center. Men were identified from the most recent 2 years of the tumor registries of the respective institutions. Men were included in the sample if they had a new diagnosis of cancer, were age 14 to 40 years at the time, and were currently living in the United States. Men were excluded if their cancer treatment did not include at least one of the following: chemotherapy; radiation to the whole body, pelvis, brain, or abdomen; or pelvic surgery. These treatments were chosen because they could potentially impact fertility.
Survey The actual questionnaire was sent with a cover letter that set forth the elements of informed consent and gave a number to call if the recipient wanted more information about cancer-related infertility. The letter mentioned that only some men treated for cancer had problems with fertility. Men were told that their questionnaires would be kept anonymous. A code number was provided in order to send one reminder letter to men who had not returned the questionnaire within the first several weeks, and to send a prepaid phone card worth $5 to men who returned their questionnaires. Men were assured that the code number would be removed from their questionnaire after it was received.
The questionnaire began with a 21-item true/false test of knowledge about cancer-related male infertility and sperm banking. Patients were also asked for demographic and medical information, including site of cancer treatment, current age, age at diagnosis, type of cancer, type of cancer treatment, educational level, religion, religious activity level, ethnicity, relationship status, and number of biologic children, stepchildren, and adopted children. Biologic children were classified as born before cancer diagnosis, conceived during cancer treatment, or conceived after cancer treatment was over. Other multiple-choice items assessed the following factors: whether or not infertility and sperm banking had been mentioned before cancer treatment and by whom; whether or not the man had banked sperm before cancer treatment, and if not, the reason(s); whether a family member or significant other had influenced this decision; how much the man would like a child in the future; whether he and a partner ever had trouble conceiving (after regular, unprotected intercourse for Men were asked how much they had worried that cancer could interfere with fertility, and to rate their current fertility compared with most men of their age. Items assessed the number of first-degree relatives with cancer, whether the man believed his cancer was inherited, and whether he had ever discussed with a health professional his children’s cancer risk or their health risks related to his cancer treatment. He was asked if he would seek genetic counseling if planning a pregnancy, and whether his experience of cancer had affected his wish to have children. Respondents were then asked how much they agreed on a five-point scale from "agree strongly" to "disagree strongly" with 21 statements about parenthood after cancer. Our previous survey suggested that important issues included the following: seeing a positive influence of the cancer experience on parenting skills; concern about one’s own future health or mortality affecting ability to parent; concern about the health of offspring; willingness to consider parenting a nonbiologic child; and practical barriers related to cancer, such as financial or marital limitations. These items are listed in Table 1 grouped by topic, but were presented in a mixed order in the questionnaire.
Statistical Analyses Statistical analyses were performed using the Statistical Package for the Social Sciences version 10.0 (SPSS, Inc, Chicago, IL). Analyses included descriptive statistics, such as mean, median, and SD. Categorical variables were compared among the groups of interest using the Pearson  2 test. Continuous variables were compared among groups using the Student’s t test to compare two groups or analysis of variance to compare multiple groups. All statistical tests were two-sided, and P < .05 was used to indicate statistical significance.
Response Rate Eight percent of 904 men contacted opted out of the survey. Of those sent a questionnaire, 201 completed and returned it, a response rate of 27% out of the original 904, excluding men who were deceased or whose mailing addresses were inaccurate. Response rates were not significantly different in men recruited from UTMDACC (26%) versus CCF (32%).
Demographic and Medical Characteristics of the Sample
Men in our sample were well educated, with only 3% having less than a high school education, 34% a bachelor’s degree, and 17% a postgraduate degree. We had no information on the education of men who did not respond, but there may well be bias towards higher education in the responders. Religious affiliation included 33% Catholic, 33% Protestant, 4% Jewish, 9% none, and 21% other. Thirty-five percent rated their religious practice as very active, 33% moderately active, 16% a few times a year, and 16% inactive. Sixty-nine percent of men were married, 7% separated or divorced, and 24% never married. Of the unmarried men, 25% were currently in a committed relationship with a partner. All men in the sample had at least had a consultation at UTMDACC and CCF, but in fact only 49% of the sample received most of their cancer treatment at UTMDACC and 9% at CCF. Others were treated at a total of 84 other institutions, with a wide geographic distribution. By self-report, 69% of men received most of their cancer treatment at a cancer center, 12% at a local hospital, and 19% at a private oncology clinic. Table 3 lists the types of cancer treatment that potentially affect fertility, and their frequency in the respondent sample. As expected from the selection criteria for our sample, all men had at least one type of cancer treatment with potential to impair fertility, and of course some had a combination of such treatments. We did not assess types or doses of chemotherapy drugs, or radiotherapy doses, because we were depending on men’s self-reports of their cancer treatment, and did not believe that detailed information on treatment protocols would be helpful to our aims.
Parental Status and Concerns about Infertility Table 4 lists men’s parental status. About half of the men had no biologic child at the time of their cancer diagnosis, and 15% were subsequently able to father biologic children. Adoption or donor insemination was only used by a small minority of men, at least at this relatively short-term follow-up. Men who had children at the time of cancer diagnosis were significantly older (mean ± SD, 32.99 ± 4.39 years v 27.94 ± 6.95 years; t[198] = 6.12, P < .001). They were more likely to be married ( 2[2] = 45.74, P < .001). Men with children also were more active in their religious practices (2[3] = 9.19, P = .027).
When asked how much they would like to have a child in the future, 41% of respondents definitely wanted a child, 11% probably wanted one, 12% were unsure, and 36% did not want a child. Men childless at the time of diagnosis were more likely to want children in the future [76% v 26% of men who already had children ( 2[4] = 55.95, P < .0001)]. As would be expected, men who wanted children in the future were more anxious about cancer-related infertility (2[16] = 100.17, P < .0001). For most men (68%), the experience of cancer had not influenced their wish to have children, but 16% felt it had increased their wish to be a father, and 16% felt it decreased their wish. Cancer was particularly likely to increase the wish to have children in men childless at the time of diagnosis [24% compared with 7% of men with children (2[2] = 10.09, P = .006]. Only 60% of men recalled someone on their health care team mentioning that infertility could be a side effect of their cancer treatment. The most common health professional to discuss cancer-related infertility was the physician treating the man’s cancer (55% of entire sample), followed by a nurse (21% of entire sample), or a family physician (8%). A family member or friend discussed infertility 12% of the time.
Since the cancer diagnosis, 32% of men had worried at least a fair amount about cancer-related infertility. Not surprisingly, men who were childless at cancer diagnosis worried more about fertility (
Genetic Issues
Issues Related to Sperm Banking Only 24% of all respondents chose to cryopreserve sperm before cancer treatment. Table 5 lists the most common reasons men gave for not banking sperm (men could check more than one reason, or write in their own response), stratified by whether or not the respondent had at least one child at cancer diagnosis, the time of the decision. The most frequent factor was that men were not given the information they needed by their health care team (25% combining those who had no recall of being offered the option to bank and those who could not get enough information about it to make a choice). As might be expected, the next most common reason for not banking sperm was already having all the children a man wanted (20% of men with children) or not wanting more children in the future (10% of men with children and 5% of childless men).
Seventeen percent of men reported that a family member or significant other had very much influenced their decision to bank sperm. Of these 31 men, 27 said that the person influencing them was a wife or fiancee, and five named a parent. One mentioned a brother.
Other factors correlated with having banked sperm included the following: being childless at diagnosis (37% of childless men banked v 11% of those with children; Fisher’s exact test = 18.61, P < .001); having a greater desire for future children (
Factors that did not correlate significantly with sperm banking included ethnicity, marital status, and religious activity level. Men whose religious affiliation was either Jewish or none were more likely to bank than those who were Protestant, Catholic, or other, however (
Knowledge About Cancer-Related Infertility Men who had been informed about the potential for cancer-related infertility by their health care providers scored higher on knowledge (mean ± SD, 15.51 ± 2.50 for uninformed men and 16.38 ± 2.47 for informed men; t[196] = -2.42, P = .017), suggesting that they received a more comprehensive education about the issues. Knowledge scores did not covary significantly with having been informed of the option of sperm banking, but men who chose to bank sperm scored significantly higher on the test than men who did not bank (t[196] = -3.08, P = .002).
Attitudes About Being a Parent After Cancer A large majority of the respondents see the cancer experience as having increased the value of family life and enhanced their parenting skills. Men who have children were significantly more likely to agree with three of these five items. More ambivalence is seen in responses about future health and parenting. Ninety-two percent of men see themselves as healthy enough to be good fathers and 66% would want to be a parent even if they died prematurely. On the other hand, 66% worry about living to see their children grow up and 73% would not want to die and leave their spouse to face single parenthood. Men with children were significantly more likely to agree that they would want to be a parent even if they died young, and to worry about surviving to see their children grow up. Less than a quarter of men see their cancer as having handicapped them for parenthood financially or in finding a mate, although 22% of childless men compared with only 7% of men with children report trouble attracting the right mate to start a family. Eighty-four percent say that having had cancer makes them more anxious about the health of their children. Despite the lack of scientific evidence for health risks for the offspring of cancer survivors, 24% of men believe their children may be at risk because of the father’s cancer treatment, and 31% worry about increased cancer risk for their children. Many men are also unsure whether these risks apply. Being a parent already does not significantly influence risk estimation. Only a minority of men would let these concerns interfere with having a biologic child, however. If they were infertile and did not have the option of having a biologic child, 61% of men would be willing to consider having a child through adoption and 23% through donor insemination (23%). In general, childless men expressed more positive attitudes to donor insemination. A factor analysis using the maximum likelihood extraction method and Direct Oblimin (Delta = 0.5) with Kaiser normalization for rotation of correlated factors was performed using the responses of 201 men to the 21 attitude questions. A three-factor solution was revealed that explained 35% of the variance in men’s responses. Table 6 lists the items and their weighting on the factors. Two items did not load at a level of at least 0.300 on any of the factors, and were deleted. Cronbach’s alpha coefficient was calculated for each of the three factors. Only factor 1 achieved an acceptable level of 0.7739. Cronbach’s alpha coefficient was 0.4058 for factor 2, and 0.3091 for factor 3. The factors appeared to measure cancer enhancing the value of parenthood, health-related anxieties, and investment in biologic parenthood. In the future, this scale may be refined and validated with both men and women for use as a measurement of attitudes toward parenthood after cancer.
Despite the suboptimal internal consistencies of two of the factors, t tests were calculated using scores on each factor to compare the responses of men who banked sperm and men who did not bank sperm. Men who had banked sperm were significantly more likely to have health-related anxieties than men who did not (t[159] = -3.077, P = .002). We also compared men who were childless at cancer diagnosis with those who had children. Men with children were significantly more likely to see cancer as having enhanced the value they placed on parenthood (t[160] = 2.778, P = .006).
This survey confirms the importance of fatherhood to younger men surviving cancer. Over half of men would like to have a child in the future, including three fourths of men who were childless at diagnosis. For the great majority of men, the experience of cancer increases the importance they put on family closeness, as well as enhancing their self-confidence in being good parents. Men who already had children at the time of their diagnosis are particularly likely to perceive their cancer experience as having increased their emotional investment in parenting as well as their parenting skills. Despite men’s anxieties about surviving to see their children grow up and about health risks to their children, 24% of childless men felt that having cancer had increased their wish to have children. Infertility was a common stressor for our respondents. About a third of men had worried at least a fair amount about their fertility. These anxieties were especially strong for childless men. Fifty-three percent of men perceived their fertility as decreased. In general, results from this survey were strikingly similar to our previous pilot findings.6 Almost exactly as in our pilot study,6 19% of respondents had experienced trouble conceiving a child, despite regular attempts for a year or more, but only 5% had sought infertility treatment. Men surveyed in this sample had a shorter follow-up than those in our previous study (3 v 5.5 years), but in general, cancer patients may be somewhat less likely to seek treatment than those with other causes of infertility.6,18,19 It is striking that in this group of men, selected because they were likely to have had cancer treatment that could impair fertility, only 60% recalled a health provider having discussed fertility before cancer treatment began. Even fewer recalled being given the option of banking sperm (51%), having had a discussion about health risks to children conceived after their cancer treatment (26%), or having been given information about the risk of cancer for their children (43%). Unfortunately, a companion survey of oncologists at the same institutions suggests that these patients are not just forgetting information that was provided to them, but rather that their physicians often failed to discuss these topics.20 This failure of communication has clear consequences. Men who were counseled about infertility by their oncology team (typically the oncology physician or, less commonly, a nurse) had significantly better knowledge about cancer-related infertility. Those who were told about sperm banking by their providers were far more likely to cryopreserve semen (36% v 11% of men who found out about sperm banking through other means). Having more knowledge about infertility also covaried positively with deciding to bank sperm. Men treated at private oncology clinics were the most likely to have been informed about sperm banking as an option, followed by those treated at cancer centers, and then those seen at private hospitals. It is important to remember, however, that all men surveyed had at least been evaluated either at UTMDACC, one of the largest and most prestigious cancer centers in the United States, or at CCF, a highly regarded tertiary referral center with its own in-house sperm bank. Thus, men in our sample were probably more likely than the average cancer survivor to receive information about cancer-related infertility. Cancer type also made a difference, with men with Hodgkin’s disease by far the most likely to bank sperm, perhaps because of their typically young age and good prognosis, although we have no explanation why twice as many men with Hodgkin’s disease banked sperm as men with testicular cancer, a group even more at risk for cancer-related infertility.3,4,12,18 Men who banked sperm were also more likely to have been childless (37% v 10% of men who already had at least one child) and, not surprisingly, were younger and more highly educated. Although religious devoutness in general was not related to the decision to bank sperm, Jewish men and those with no religious affiliation were somewhat more likely to bank, perhaps because of more liberal attitudes about the acceptability of assisted reproductive techniques. Very few men reported that they refused sperm banking because of religious or ethical concerns, however. As in our previous survey,6 the most common barrier to sperm banking was not having been informed about the option. Twenty percent of our sample cited lack of information as the reason for not having banked sperm, and another 5% had known about the possibility, but were unable to get the information they needed in time. The other frequent reasons for not banking sperm were that a man had finished having children, or believed he would not want children in the future. Some of these decisions are later regretted, as noted by one of our respondents who had divorced after his cancer and wished he had banked sperm so that he could have a child in a new relationship. It is interesting that the cost of sperm banking was not a frequent barrier cited by patients, despite the perception of oncology physicians that it is a common obstacle.20 Although only a small minority of our respondents were likely to belong to a family with an inherited cancer syndrome, 31% believed their children would definitely be at increased risk for cancer and 62% would consider having genetic counseling if planning a future pregnancy with their spouse. A somewhat smaller percentage, about one fourth, worried that their past cancer treatment could affect the health of children conceived afterward. The wish to have a biologic child was strong, however, despite concerns about health risks, and only 20% of men considered not having children because of these worries. It was even less common for men to choose adoption or donor insemination as alternatives to having a genetic child who might face unusual health risks, although childless men were more receptive to using donor insemination. We have observed similar preferences for having biologic children despite genetic risks in couples with male factor infertility.21,22 The most important weakness of this survey was the low response rate of 27%. It was even somewhat less than the response rate for men in our previous pilot study,6 perhaps because the current cohort of men was diagnosed more recently and less likely to have recovered full health. We followed principles of survey research designed to enhance return rates, sending an introductory letter from a trusted institution, using a reminder letter, and offering a small incentive for participating.23,24 It is somewhat reassuring that there were no obvious biases in ethnicity, age, or cancer site in the men who did respond. We would hypothesize that men who participated were probably more likely to be interested in the issues of infertility. Men who had completed their families before being diagnosed with cancer may have been less likely to fill out the survey. Thus, we may be overestimating the percentage of men who are distressed about infertility. Although our results were quite similar to those in our pilot study, this sample of men was larger and more diverse than those who participated in the pilot,6 including a higher percentage of minorities (16% v 9% in our previous sample), and men from the registries of two cancer centers rather than just one. Given the high educational level of our sample, however, and the low frequency of indigent patients seen at the two cancer centers, we are probably overestimating the knowledge about infertility and the rate of sperm banking for cancer survivors generally across the United States. In fact, these data suggest that men treated in smaller hospitals are less likely than men treated in private clinics or cancer centers to receive counseling about infertility and sperm banking. In conjunction with our past pilot survey,6 and our survey of oncology physicians about sperm banking,20 we believe these data make a strong case that oncology health care providers are not routinely meeting men’s needs for information about infertility and sperm banking. Men continue to value parenthood despite their experience of cancer, and are often distressed about cancer-related infertility, especially if they are childless. Therefore, every man about to begin cancer treatment that might impair his fertility should be given adequate information to make an informed decision about banking sperm. Concerns about fertility and about the health of actual and potential children should also be routinely discussed when cancer survivors receive follow-up care. We would like to see these procedures become a standard of care in fact, as well as in theory.
Supported by grant no. 1 R25 CA 88088-1 from the National Cancer Institute, Bethesda, MD (to L.R.S.). We thank Valorie Rose for help in data collection from the Cleveland sample. The patient population was identified through a search of the tumor registry database maintained by the Department of Medical Informatics, University of Texas M.D. Anderson Cancer Center.
1. Meistrich ML, Vassilopoulou-Sellin R, Lipshultz LI: Gonadal dysfunction, in De Vita VT, Hellman S, Rosenberg SA (eds): Cancer: Principles and Practice of Oncology (ed 5). Philadelphia, PA, Lippincott-Raven, 1997, pp 2758-2773 2. Nicholson HS, Byrne J: Fertility and pregnancy after treatment for cancer during childhood or adolescence. Cancer 71: 3392-3399, 1993 (suppl 10)[CrossRef][Medline] 3. Rieker PP, Fitzgerald EM, Kalish LA: Adaptive behavioral responses to potential infertility among survivors of testis cancer. J Clin Oncol 8: 347-355, 1990[Abstract] 4. Aass N, Fossa SD: Paternity in young patients with testicular cancer: Expectations and experience. Prog Clin Biol Res 269: 481-491, 1988[Medline]
5.
Cella D, Najavits L: Denial of infertility in patients with Hodgkin’s disease. Psychosomatics 27: 71, 1986 (letter) 6. Schover LR, Rybicki LA, Martin BA, et al: Having children after cancer: A pilot survey of survivors’ attitudes and experiences. Cancer 86: 697-709, 1999[CrossRef][Medline]
7.
Lass A, Akagbosu F, Abusheikha N, et al: A programme of semen cryopreservation for patients with malignant disease in a tertiary infertility centre: Lessons from 8 years’ experience. Hum Reprod 13: 3256-3261, 1998
8.
Naysmith TE, Blake DA, Harvey VJ, et al: Do men undergoing sterilizing cancer treatments have a fertile future? Hum Reprod 13: 3250-3255, 1998 9. Padron OF, Sharma RK, Thomas AJ, et al: Effects of cancer on spermatozoa quality after cryopreservation: A 12-year experience. Fertil Steril 67: 326-331, 1997[CrossRef][Medline] 10. Opsahl MS, Fugger EF, Sherins RJ, et al: Preservation of reproductive function before therapy for cancer: New options involving sperm and ovary cryopreservation. Cancer J Sci Am 3: 189-191, 1997[Medline] 11. Posada MN, Kolp L, Garcia JE: Fertility options for female cancer patients: Facts and fiction. Fertil Steril 75: 647-653, 2001[CrossRef][Medline]
12.
Foley SJ, De Winter P, McFarlane JP, et al: Storage of sperm and embryos: Cryopreservation of sperm should be offered to men with testicular cancer. BMJ 313: 1078, 1996 (letter)
13.
Lass A, Akagbosu F, Brinsden P: Sperm banking and assisted reproduction treatment for couples following cancer treatment of the male partner. Hum Reprod 7: 370-377, 2001 14. Koeppel KM: Sperm banking and patients with cancer: Issues concerning patients and healthcare professionals. Cancer Nurs 18: 306-312, 1995[Medline] 15. Hallak J, Sharma RK, Thomas AJ, et al: Why cancer patients request disposal of cryopreserved semen specimens posttherapy: A retrospective study. Fertil Steril 69: 889-893, 1998[CrossRef][Medline] 16. Sweet V, Servy EJ, Karow AM: Reproductive issues for men with cancer: Technology and nursing management. Oncol Nurs Forum 23: 51-58, 1996[Medline] 17. Schover LR, Agarwal A, Thomas AJ: Cryopreservation of gametes in young patients with cancer. J Pediatr Hematol Oncol 20: 426-428, 1998[CrossRef][Medline] 18. Fossa SD, Aass N, Molne K: Is routine pretreatment cryopreservation of semen worthwhile in the management of patients with testicular cancer? Br J Urol 64: 524-529, 1989[Medline] 19. Audrins P, Holden CA, McLachlan RI, et al: Semen storage for special purposes at Monash IVF from 1977 to 1997. Fertil Steril 72: 179-181, 1999[CrossRef][Medline]
20.
Schover LR, Brey K, Lichtin A, et al: Oncologists’ attitudes and practices regarding banking sperm before cancer treatment. J Clin Oncol 20: 1890-1897, 2002
21.
Schover LR, Thomas AJ, Falcone T, et al: Attitudes about genetic risk of couples undergoing in-vitro fertilization (IVF). Hum Reprod 13: 862-866, 1998 22. Schover LR, Thomas AJ, Miller KF, et al: Preferences for intracytoplasmic sperm injection (ICSI) versus donor insemination (DI) in severe male factor infertility: A preliminary report. Hum Reprod 11: 101-104, 1996
23.
Eaker S, Bergstrom R, Bergstrom A, et al: Response rate to mailed epidemiologic questionnaires: A population-based randomized trial of variations in design and mailing routines. Am J Epidemiol 147: 74-82, 1998 24. Ransdell LB: Maximizing response rate in questionnaire research. Am J Health Behav 20: 50-56, 1996 Submitted August 30, 2001; accepted December 13, 2001. This article has been cited by other articles:
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
TOP
ABSTRACT
INTRODUCTION
12 months); history of infertility treatment; and history of voluntary sterilization, including whether the decision was cancer-related. 
