Preserving fertility in girls and young women with cancer
BMJ 2016; 355 doi: https://doi.org/10.1136/bmj.i6145 (Published 30 November 2016) Cite this as: BMJ 2016;355:i6145All rapid responses
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Dear Editor of BMJ,
We read with interest the BMJ editorial “Preserving fertility in girls and young women with cancer” BMJ 2016;355:i6145.
We agree with Anderson et al that provision of fertility preservation is particularly haphazard across the UK and that there are substantial obstacles in terms of access and funding. We have recently carried out a UK wide survey to examine the provision of oocyte and/or embryo cryopreservation for female oncology patients prior to cancer treatments, the paper was accepted for publication in Human Fertility and it is currently in press. We found that the number of cases receiving this treatment is remarkably suboptimal.
We cannot agree with the authors, however, that we do not know how many women are undergoing fertility preservation since “UK data collection does not include the reason for oocyte cryopreservation”. HFEA data showed that only 154 cases of NHS funded oocyte cryopreservation were carried out in 2014.
With 8122 women in the UK between the ages of 15-39 annually diagnosed with a malignant form of cancer in between 2011-2013, (CancerResearchUK, 2011 - 2013), it is suggested that approximately half (4000) would receive oncology treatment that could affect their future fertility (Oktay & Sonmezer, 2008) and hence should be referred for timely fertility preservation consultation. Our survey data collected from individual centres in the UK suggest that approximately half of the women seen for a fertility preservation consultation proceed to embryo or oocyte cryopreservation, hence we would expect approximately 2000 cycles of embryo and oocyte cryopreservation to be undertaken annually. The 154 cases of NHS funded oocyte cryopreservation represent as little as 7.5% of this target number.
Whilst we do recognise that social oocyte cryopreservation may increase the overall number of oocyte cryopreservation, we believe this effect is not seen in the NHS funded oocyte cryopreservation, since the NHS categorically doesn’t fund social egg freezing. Therefore the 154 cases are likely to be mostly related to fertility preservation.
We also recognise that there is additional fertility preservation carried out in the form of embryo cryopreservation, However, as the authors also explain, embryo cryopreservation before cancer treatment has become a secondary option to oocyte cryopreservation after the advent of vitrification technology, whilst at the same time oocyte cryopreservation has the advantage over embryo storage of offering women more independence and autonomy over their fertility. Therefore, while it can be assumed that almost all 154 cases of NHS-funded oocyte cryopreservation are almost all cancer related, the same does not apply in embryo cryopreservation cases as the majority of the latter are carried out during the course of ordinary assisted conception treatment.
Additionally, we do recognise that there is also an additional small number of privately funded oocyte cryopreservation for fertility preservation. Our data looked at the funding of oocyte cryopreservation provided both by NHS and privately. Our data showed that the percentage of women whose cryopreservation prior to cancer treatment was NHS funded is estimated to be 65% to 76%. This may suggest that the overall fertility preservation is approximately 10% of the overall target at best estimate.
Given this low rate of fertility preservation provision, we agree with Anderson et al that improvements can be made in the number of referrals from oncology, the provision of cryopreservation treatment and of NHS funding provision. Developing a national fertility preservation network and close liaison with oncology and Clinical Commissioning Groups are recommended.
Yazan Abdallah (1), Jonathan Briggs (2), Cheryl T Fitzgerald (1)
1. Department of Reproductive Medicine, Saint Mary’s Hospital, Oxford Road, Manchester, M13 9WL UK
2. School of Medicine, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
References
CancerResearchUK. (2011 - 2013). Cancer Research UK, http://www.cancerresearchuk.org/health-professional/cancer-statistics/in... http://www.cancerresearchuk.org/health-professional/cancer-statistics/in....
HFEA. (2016). Fertility Treatment in 2014: Trends and Figures.
Oktay, K., & Sonmezer, M. (2008). Chemotherapy and amenorrhea: risks and treatment options. Curr Opin Obstet Gynecol, 20(4), 408-415. doi:10.1097/GCO.0b013e328307ebad
Competing interests: No competing interests
This article raises a number of important issues about fertility preservation among young women which do not currently get adequate attention. In many cases, this leaves young female patients struggling to (a) understand if and how fertility preservation may be possible and/or (b) live with the consequences of decisions about fertility preservation often made in haste.
At present, as the authors note, provision of fertility preservation for women undergoing cancer treatment in the UK is particularly haphazard. The fact that fertility preservation often falls between the cracks of oncology and infertility care provides great potential for confusion and lack of access to information and support. More fundamentally, however, at Shine Cancer Support, we are aware that many young people - both men and women - who are about to embark on cancer treatment are not given clear and adequate information about the way in which their fertility may be impacted by treatment. In a 2012 survey that we conducted, just over 50% of respondents felt that they had been inadequately supported to preserve their fertility. We are told stories on a regular basis about patients who are only told about the possibility of infertility as an afterthought or, often, after treatment has started.
There is much work to be done for both young men and young women to improve the information and support that they are given prior to starting cancer treatment. The authors note that National Institute for Health and Care Excellence (NICE) guidelines on fertility recommend offering oocyte or embryo cryopreservation to women of reproductive age (including adolescent girls) before cancer treatment that is likely to make them infertile provided that they are well enough, it will not worsen their condition, and enough time is available; for too many young women receiving cancer treatment, this information is not provided clearly and they are not made to feel that they are in control of the decisions made about whether or not they are able - or indeed should - seek to oocyte or embryo cryopreservation. This needs to change.
Competing interests: No competing interests
Re: Preserving fertility in girls and young women with cancer
Fertility preservation – Don’t forget the boys!
For young people undergoing potentially gonadotoxic treatments, counselling on fertility and the options for fertility preservation is imperative. The editorial by Anderson and Davies highlights recent success with fertility preservation in females using ovarian tissue cryopreserved before commencing cancer treatment. This, coupled with embryo and oocyte freezing and the well-established option of semen cryopreservation for adult men offers a realistic possibility for future fertility for girls and postpubertal men and women. However, for males treated during childhood, for whom long term survival rates are increasing, there are no established options to preserve fertility. Unlike adult men, the prepubertal testis does not contain viable gametes for storage. Current NICE guidance on cryopreservation to preserve fertility in patients diagnosed with cancer does not include options for prepubertal boys (1).
In recent years a number of centres have begun to store cryopreserved testicular tissue from boys prior to potentially sterilising therapy (2). Whilst this offers the possibility of long-term storage of tissue the practice remains experimental as there have been no studies to demonstrate the production of viable gametes or offspring using stored testicular tissue from prepubertal boys, although animal studies are promising (2). As a result testicular tissue cryopreservation should only be undertaken as part of an ethically approved research study. In the UK there are currently two centres (Edinburgh and Oxford) undertaking testicular tissue cryopreservation for prepubertal boys who are due to receive treatments with a high-risk of subsequent infertility (3). It is important that oncologists are aware of such developments in fertility preservation in order that patients can be counselled and offered intervention where appropriate. It is clear that counselling regarding future fertility and awareness of the options for fertility preservation can vary across the UK (4).
The recent birth of the first baby in the UK following ovarian tissue cryopreservation comes 20 years after the pioneering ovarian tissue cryopreservation programme started in Edinburgh. During this time there have been more than 60 live births reported worldwide using transplanted ovarian tissue (5). Many of the issues highlighted in the editorial such as patient selection, risks of surgery and re-implantation, and equitable access to services apply equally to testicular cryopreservation. The clinical, scientific and regulatory knowledge gained during the development of ovarian cryopreservation must be used to allow us to reach the goal of developing viable fertility preservation methods for prepubertal boys at the earliest opportunity.
Whilst sperm cryopreservation has been an established and effective fertility preservation option for pubertal males for decades, there are barriers that prevent its widespread use among adolescent males. Patients may be unable or unwilling to consider sperm banking as a result of the physical and emotional stress of a new cancer diagnosis and urgency to start cancer treatment. Furthermore, whilst NICE recommend that semen cryopreservation is available to cancer patients at risk of infertility (1) the availability of free access to this service varies across the UK.
Fertility counselling before and after oncologic therapy must be optimised as an important part of clinical care for young people with cancer. In addition, further research is needed to develop fertility preservation technologies and examine their outcomes in this patient group.
rod.mitchell@ed.ac.uk
References:
1) National Institute for Clinical Excellence. Fertility: assessment and treatment for people with fertility problems. http://publicationsniceorguk/fertility-cg156. 2013.
2) Picton HM, Wyns C, Anderson RA, Goossens E, Jahnukainen K, Kliesch S, Mitchell RT, Pennings G, Rives N, Tournaye H, Van Pelt AMM, Eichenlaub-Ritter U, Schlatt S – On behalf of the ESHRE Task Force On Fertility Preservation In Severe Diseases. A European Perspective On Testicular Tissue Cryopreservation For Fertility Preservation In Prepubertal And Adolescent Boys. Human Reproduction. 30(11):2463-75. 2015.
3) Anderson RA*, Mitchell RT*, Thomas W Kelsey, Norah Spears, Evelyn E Telfer, W Hamish B Wallace. Cancer treatment and gonadal function: experimental and established strategies for fertility preservation in children and young adults. The Lancet Diabetes and Endocrinology 3(7):556-67. 2015. (*denotes equal contribution)
4) Anderson RA, Weddell A, Spoudeas HA, Douglas C, Shalet SM, Levitt G, Wallace WH. Do doctors discuss fertility issues before they treat young patients with cancer? Human Reproduction. 23(10):2246-51. 2008.
5) Donnez J, Dolmans MM. Ovarian cortex transplantation: 60 reported live births brings the success and worldwide expansion of the technique towards routine clinical practice. Journal of Assisted Reproduction and Genetics 2015;32:1167–1170.
Competing interests: No competing interests