Summary of recommendations

From Cancer Guidelines Wiki

Infertility or sub-fertility is a significant and distressing side-effect of cancer treatment for some survivors of AYA cancers.

Given the known risk to fertility of many cancer treatments, and the fact that fertility preservation is often possible, it is essential that AYA patients are appropriately and fully informed of these risks and the options available for preserving their fertility.

The working group has assigned NHMRC grades of recommendation to assist users to distinguish between those based on strong evidence, and those based on weak evidence. The grade does not indicate the importance of the recommendation, but reflects the strength of the evidence supporting it.

Given the low volume and/or quality of evidence relating to some of the questions this guidance addresses, the working group identified several important practice recommendations for which there is not, nor is there likely to be, any research evidence. These are identified as Good Practice Points (GPP).

Read further information about grading.

Discussing fertility with AYAs diagnosed with cancer

Discuss fertility early and fully

Recommendation Grade
All AYAs with cancer requiring treatment that could compromise future fertility must be informed of the likely risk and options to protect or preserve fertility before treatment begins. B
Health professionals should be guided by institutional policies and protocols, if they exist, on when and how to discuss fertility with newly diagnosed patients, how to discuss procedures that may be investigational and/or costly to patients and their families, and how to make referrals to fertility or other specialists. PP

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Provide clear and complete information

Recommendation Grade
Health professionals involved in the care of AYAs with cancer need to provide information about fertility risks, preservation options and related issues in a clear and direct manner, with particular focus on:
  • making the discussion effective and age-specific
  • directing information and decisions to the AYA patient
  • identifying and addressing individual patient factors and concerns.
C
AYA patients and their families should be given written information about the issues discussed, and offered psychosocial support. PP

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Managing the fertility preservation process

Form a multidisciplinary fertility preservation team

Recommendation Grade
Cancer treatment teams, fertility specialists and other key stakeholders should work together to preserve and optimise the future reproductive capacity of young people diagnosed with cancer. PP

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Develop protocols and pathways to enable clear and timely communication

Recommendation Grade
Develop local protocols and pathways to enable clear and timely communication between all professionals and services involved in the fertility preservation process, and between the team and the patient and their family. PP

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Impact of cancer treatments on fertility

Recommendation Grade
All AYA patients should be informed of the potential risks to their fertility and reproductive health of the recommended treatment. B

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Options for fertility preservation

Recommendation Grade
The use of fertility preservation measures must be individualised and personalised in consultation with the patient and their family and the multidisciplinary treatment team. PP
The most effective and established means of preserving fertility in young people with cancer are:
  • oocyte and embryo cryopreservation where appropriate for females
  • sperm cryopreservation for males before cancer treatment starts.
B
If the efficacy of a particular treatment option is not established then this needs to be discussed with the AYA patient and their family. Where possible, investigational procedures should be undertaken in the context of a clinical trial. PP

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Oocyte and embryo freezing prior to chemotherapy and/or radiotherapy

Recommendation Grade
Embryo or oocyte cryopreservation is an established procedure.

It should be discussed with all young women about to undergo potentially sterilising chemotherapy or pelvic radiation. It may be suitable for young women who:

  • are medically fit for the procedure
  • are expected to be able to tolerate the treatment regimen
  • have sufficient time before the commencement of their cancer treatment and
  • are informed of the potential risks of hormonal treatment including the risks of cancer progression.
C

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Ovarian tissue freezing prior to chemotherapy

Recommendation Grade
Ovarian tissue must be tested for the presence of cancer cells or markers. B
Ovarian tissue cryopreservation is an investigational technique.

For young women at high risk of ovarian failure, or for whom other options may not be suitable, ovarian tissue storage may be considered.

B
Patients must be counseled that the use of preserved ovarian tissue to achieve pregnancy is not yet considered to be a routine clinical practice. B

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Ovarian suppression with GnRH analogues during chemotherapy

Recommendation Grade
Ideally GNRH analogues for ovarian protection should be used within the context of a clinical trial setting.

Where this is not possible, administration is supported provided the patient and family are fully informed of the lack of large randomised trials addressing the potential benefit.

B

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Cryopreservation of semen

Recommendation Grade
Sperm cryopreservation is the only well-established method of preserving fertility in post-pubertal adolescent and adult males. It must be offered to all adolescent and young adult males prior to chemotherapy or radiotherapy that may damage the testes. B
The procedure of epididymal or testicular aspiration or biopsy attempting to obtain sperm for cryopreservation should be offered to post-pubertal males who have an azoospermic ejaculate or who are unable to ejaculate. PP

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Long term follow up

Follow up after cancer treatment is essential

Recommendation Grade
All AYA cancer survivors should have access to systematic long-term follow-up of their reproductive, endocrine and sexual health. B

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Pregnancy after cancer

Recommendation Grade
Females who have had cancer treatment should be counseled that they may have a shortened reproductive life span. If they wish to have children and it is medically appropriate for them to consider having a family they should be referred to a fertility specialist with knowledge of cancer treatment. B
Pregnancy after cancer treatment should be managed as a high risk pregnancy, in a tertiary centre if possible. B

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Menopause due to cancer treatment

Recommendation Grade
HRT/tibolone should be avoided after breast cancer since both agents have been associated with increased risks of new breast cancers or recurrence in prospective randomised controlled trials. A
For non-hormone dependent cancers, HRT or tibolone can be considered provided there are no other contraindications. B

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Options for survivors who are infertile

Recommendation Grade
AYA cancer survivors who are infertile should be provided with information about assisted reproduction and other options for parenting such as sperm/egg/embryo donation, surrogacy and adoption, and offered infertility counselling. PP

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Psychosocial impact of infertility and sexual health issues

Recommendation Grade
The potential psychological and psychosocial impact on AYA cancer survivors of undertaking, or not undertaking, fertility prevention measures should be regularly assessed. Survivors should be offered fertility counselling and psychological support. B


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