This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Nakayama, K. Articles by Ueno, N. T. Search for Related Content PubMed PubMed Citation Articles by Nakayama, K. Articles by Ueno, N. T.

American Society of Clinical Oncology Recommendations on Fertility Preservation Should Be Implemented Regardless of Disease Status or Previous Treatments

Departments of Stem Cell Transplantation and Cellular Therapy and Breast Medical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, TX

To the Editor:

We read with great interest the article by Lee et al¹ in the June 20, 2006, issue of the Journal of Clinical Oncology. The recent improvements in survival rates after cancer treatment, especially among young patients, have made this a topic of considerable interest, and the American Society of Clinical Oncology's (ASCO) recommendations provide important and timely information for practicing oncologists. The recommendations will certainly raise oncologists' awareness of the importance of providing information on fertility preservation for individuals undergoing cancer treatment.

In this article, Lee et al suggested that oncologists should discuss the availability of fertility preservation with patients at the earliest possible opportunity. The ideal time for such a discussion, of course, would be before any treatment is administered; however, in reality many patients referred to oncologists have already had some kind of anticancer treatment. Some may have not received any information about the risks of infertility, and some may have only received information about infertility but not about possible ways of preserving their fertility. Therefore, oncologists should be prepared to ask patients about their desire to retain their fertility, to evaluate their remaining gonadal function, and to offer some fertility-preservation options even after patients have received cytotoxic chemotherapy or other forms of treatment.

Some female patients will not have cyclic menstruation at the time of consultation with the oncologist. However, this does not necessarily mean that these women have lost their reproductive capacity completely. Likewise, elevated gonadotropin levels do not necessarily indicate permanent gonadal failure in men and women. In male patients, sperm production can sometimes be restored even after post-treatment azoospermia. Therefore, oncologists should keep in mind that reproductive function in some patients can be retained or restored after treatment. Certainly, patients who have retained some gonadal function (as evidenced by the presence of cyclic menstruation or sperm ejaculate samples, for example) could be referred to reproductive specialists if patients are interested. As Thewes and colleagues² recently reported, patients' need for information on infertility- and menopause-related issues does not decline even after treatment.

Oncologists should also be prepared to offer information on infertility and fertility options to their patients throughout the entire treatment period. Sperm can occasionally be obtained for cryopreservation during chemotherapy for men who experience oligospermia during the treatment.^3,4 Even for patients who have ejaculatory azoospermia after chemotherapy, testis sperm extraction and intracytoplasmic sperm injection may be other options,^5,6 although these techniques are usually done in the context of a clinical trial. Use of semen collected during chemotherapy may carry some genetic risks. Nevertheless, patients should be informed sufficiently about possible options including such risks. Cryopreservation may also be an option for female patients after commencement of treatment; as noted in the ASCO recommendations, two pregnancies have been reported after cryopreserved ovarian transplantation in women who experienced ovarian failure after chemotherapy.^7,8 Although this approach is still investigational, oncologists should be aware of the existence of this and other approaches, and oncologists should not hesitate to refer patients to reproductive specialists if the patients wish to consider having children after chemotherapy.

Delivering information on fertility preservation options up front although desirable, will not be possible in all cases. Patients presenting with acute leukemia, for example, may need to be treated immediately for potentially life-threatening coagulopathies arising from thrombocytopenia or disseminated intravascular coagulation (DIC). However, treatments can lead to remission in many cases, and thus the best time to offer information on fertility preservation techniques may depend on the individual case.

Finally, we would like to emphasize that patients receiving high-dose chemotherapy or high-dose radiotherapy (such as that given in preparation for hematopoietic stem-cell transplantation) should be informed about infertility and, if possible, be referred to reproductive specialists. Because most patients who undergo such treatment, especially with conventional myeloablative conditioning regimens, will experience permanent infertility, providing accurate and detailed information before undergoing such therapies will be important.

In short, we wish to emphasize that the ASCO recommendations presented by Lee and colleagues should be implemented regardless of disease status or previous treatments.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Lee SJ, Schover LR, Partridge AH, et al: American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients. J Clin Oncol 24 : 2917 -2932, 2006[Abstract/Free Full Text]

2. Thewes B, Meiser B, Taylor A, et al: Fertility- and menopause-related information needs of younger women with a diagnosis of early breast cancer. J Clin Oncol 23 : 5155 -5165, 2005[Abstract/Free Full Text]

3. Carson SA, Gentry WL, Smith AL, et al: Feasibility of semen collection and cryopreservation during chemotherapy. Hum Reprod 6 : 992 -994, 1991[Abstract/Free Full Text]

4. Shin D, Lo KC, Lipshultz LI: Treatment options for the infertile male with cancer. J Natl Cancer Inst Monogr 48-50, 2005

5. Damani MN, Master V, Meng MV, et al: Postchemotherapy ejaculatory azoospermia: Fatherhood with sperm from testis tissue with intracytoplasmic sperm injection. J Clin Oncol 20 : 930 -936, 2002[Abstract/Free Full Text]

6. Chan PT, Palermo GD, Veeck LL, et al: Testicular sperm extraction combined with intracytoplasmic sperm injection in the treatment of men with persistent azoospermia postchemotherapy. Cancer 92 : 1632 -1637, 2001[CrossRef][Medline]

7. Donnez J, Dolmans MM, Demylle D, et al: Livebirth after orthotopic transplantation of cryopreserved ovarian tissue. Lancet 364 : 1405 -1410, 2004[CrossRef][Medline]

8. Meirow D, Levron J, Eldar-Geva T, et al: Pregnancy after transplantation of cryopreserved ovarian tissue in a patient with ovarian failure after chemotherapy. N Engl J Med 353 : 318 -321, 2005[Free Full Text]

This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Nakayama, K. Articles by Ueno, N. T. Search for Related Content PubMed PubMed Citation Articles by Nakayama, K. Articles by Ueno, N. T.