Fertility Counseling in Routine Practice: Why, When, and How?

As cancer therapies advance and long-term survival rates improve, many adolescents and young adults face a future of treatment-related infertility. The National Cancer Institute estimates that 250,000 current cancer survivors are women of reproductive age, including adolescents and young adults aged 20–30 years old. It is estimated that by the year 2026, in the United States, the population of cancer survivors overall will increase to 20.3 million, with 10.3 million being female survivors and 900,000 of those being in the reproductive age range. Furthermore, there is a trend toward delayed childbearing, resulting in women facing a cancer diagnosis in their latter reproductive years with subsequent gonadotoxic treatments that can lead to premature ovarian failure. Data shows that cancer-related infertility is distressing to women, with nearly 50% of surveyed survivors finding it “significantly burdensome” that they may never have a child in the future due to their cancer treatment. The American Society of Clinical Oncology (ASCO) published updated guidelines in 2018 to encourage healthcare providers to discuss the potential for treatment-related infertility for those receiving gonadotoxic therapies and provide prompt, pretreatment referral to reproductive specialists for individuals who are interested in or ambivalent about fertility preservation; reproductive specialists can further facilitate discussion of fertility preservation options and help patient’s make well-informed decisions—engaging patients in their treatment plan in this manner not only improves long-term quality of life but also decreases decisional regret moving forward. Despite clear recommendations, many patient and physician barriers exist, preventing broad implementation of personalized oncofertility counseling for women who are newly diagnosed with cancer. Often, patient fears about cancer recurrence or worsening of disease prevents them from even broaching discussion of the topic with their healthcare provider team. Recent data shows that for women with a variety of cancer types (including breast, gynecologic, and hematologic malignancies) undergoing controlled ovarian hyperstimulation (COH), in both a random start or cycle-specific start fashion for oocyte and/or embryo cryopreservation, the approximate 2 week delay to initiation of cancer therapy is neither clinically significant nor impactful on long-term outcomes and risk of recurrence. This data can be used to calm patient fears as well as healthcare provider misconceptions about the timing and safety of fertility preservation so that patients can take advantage of the most effective options that are available to them. Various tools exist for fertility preservation counseling, including decision aids and decision trees. Patients may also benefit from the availability of a patient navigator to initiate discussions about fertility and coordinate appointments with fertility specialists during the uniquely stressful short time period between diagnosis and treatment initiation. While oocyte and embryo cryopreservation through COH remain first-line therapies, ovarian transposition and ovarian tissue cryopreservation (OTC) are also options for patients, specifically for those who receive pelvic radiation and prepubertal girls. Ultimately, some survivors may not choose to pursue fertility preservation options for various reasons (i.e., urgency of treatment, financial constraints, and moral considerations) and others may not desire future pregnancy at the time of diagnosis. It is important to make patients aware of other strategies for family planning, including adoption, gestational surrogacy, and use of donor gametes/embryos. With more survivors living into their reproductive years and beyond, fertility preservation counseling for women of reproductive age is not only ideal but also a cornerstone of comprehensive cancer care.