Summary of recommendations

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Fertility Preservation

• Impact on fertility
• Discussing risk
• Referral and service provision
• Psychological support
• Options for treatment

Reproduction

• Impact on pubertal development
• Contraception
• Conception
• Pregnancy

Fertility Preservation

Impact on fertility

Pregnancy and live birth

Evidence-based recommendation	Grade
It is recommended that health professionals inform all people diagnosed with cancer (or their parents in the case of children) that there is potential for cancer treatment to impact their fertility.	B

• Guidelines:COSA:Cancer fertility preservation guidelines/Pregnancy and live birth#Recommendation_1
• It is recommended that health professionals inform all people diagnosed with cancer (or their parents in the case of children) that there is potential for cancer treatment to impact their fertility.
• Recommendation

Ovarian function

Evidence-based recommendation	Grade
Health professionals should advise patients prior to cancer treatment of the risk of a reduction in their ovarian reserve after treatment. Patients of any age with a risk of infertility (or their families in the case of children) should be given the opportunity to discuss fertility preservation before cancer treatment.	A

• Guidelines:COSA:Cancer fertility preservation guidelines/Ovarian function#Recommendation_1
• Health professionals should advise patients prior to cancer treatment of the risk of a reduction in their ovarian reserve after treatment. Patients of any age with a risk of infertility (or their families in the case of children) should be given the opportunity to discuss fertility preservation before cancer treatment.
• Recommendation

Testicular function

Evidence-based recommendation	Grade
Health professionals should advise male patients with cancer about to receive cancer treatment of the risk of loss of testicular hormone function and a reduction in sperm count. Patients of any age with a risk of infertility (or their families in the case of children) should be given the opportunity to discuss fertility preservation before cancer treatment.	A

• Guidelines:COSA:Cancer fertility preservation guidelines/Testicular function#Recommendation_1
• Health professionals should advise male patients with cancer about to receive cancer treatment of the risk of loss of testicular hormone function and a reduction in sperm count. Patients of any age with a risk of infertility (or their families in the case of children) should be given the opportunity to discuss fertility preservation before cancer treatment.
• Recommendation

Consensus-based recommendation
Post-pubertal boys and men should have reproductive follow up from 12 months after completion of cancer treatment. Ongoing follow up should be dictated by pathology (which should include blood tests for testosterone, LH and FSH) and/or symptoms of hypogonadism.

• Guidelines:COSA:Cancer fertility preservation guidelines/Testicular function#Practice_point_1
• Post-pubertal boys and men should have reproductive follow up from 12 months after completion of cancer treatment. Ongoing follow up should be dictated by pathology (which should include blood tests for testosterone, LH and FSH) and/or symptoms of hypogonadism.
• Consensus based recommendation

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Discussing risk

Reproductive concerns

Evidence-based recommendation	Grade
All patients with cancer, regardless of age or relationship status, should receive age-appropriate information and support regarding the impact of specific cancer treatments on their future fertility.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Reproductive concerns#Recommendation_1
• All patients with cancer, regardless of age or relationship status, should receive age-appropriate information and support regarding the impact of specific cancer treatments on their future fertility.
• Recommendation

Practice point
Where possible, the desire of the person with cancer for future fertility should be taken into account when choosing systemic and local cancer treatments.

• Guidelines:COSA:Cancer fertility preservation guidelines/Reproductive concerns#Practice_point_1
• Where possible, the desire of the person with cancer for future fertility should be taken into account when choosing systemic and local cancer treatments.
• Good practice point

Health professional awareness

Evidence-based recommendation	Grade
Continuing education for health professionals about reproductive health, risk of infertility and fertility preservation options available for patients with cancer is essential.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Health professional awareness#Recommendation_1
• Continuing education for health professionals about reproductive health, risk of infertility and fertility preservation options available for patients with cancer is essential.
• Recommendation

Evidence-based recommendation	Grade
Fertility discussions should be implemented as part of the routine cancer plan for all patients. These discussions should be documented in the patient’s medical records. Age-appropriate materials should be provided to patients to assist with retention of information and for later reference.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Health professional awareness#Recommendation_2
• Fertility discussions should be implemented as part of the routine cancer plan for all patients. These discussions should be documented in the patient’s medical records. Age-appropriate materials should be provided to patients to assist with retention of information and for later reference.
• Recommendation

Role of oncology services

Evidence-based recommendation

Grade

Cancer services should develop organised oncofertility programs aligned with the Australasian Oncofertility Charter so that fertility care is incorporated into essential cancer care. Oncofertility programs should provide resources (including age-appropriate decision aids where available) for patients, and education programs for staff, to ensure that patients are given clear, timely information about fertility risk and fertility preservation options. Oncofertility programs should have a clear governance process which include specific requirements for children.

C

• Guidelines:COSA:Cancer fertility preservation guidelines/Role of oncology services#Recommendation_1
• Cancer services should develop organised oncofertility programs aligned with the Australasian Oncofertility Charter so that fertility care is incorporated into essential cancer care. Oncofertility programs should provide resources (including age-appropriate decision aids where available) for patients, and education programs for staff, to ensure that patients are given clear, timely information about fertility risk and fertility preservation options. Oncofertility programs should have a clear governance process which include specific requirements for children.
• Recommendation

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Referral and service provision

Referral rates and decisional conflict

Evidence-based recommendation	Grade
Cancer health professionals should consider, where appropriate, referral to fertility preservation specialists. Patients with cancer should have an opportunity to meet with fertility counsellors to provide decision-making and psychological support.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Referral rates and decisional conflict#Recommendation_1
• Cancer health professionals should consider, where appropriate, referral to fertility preservation specialists. Patients with cancer should have an opportunity to meet with fertility counsellors to provide decision-making and psychological support.
• Recommendation

Referral pathways

Evidence-based recommendation	Grade
Cancer services are encouraged to establish referral pathways with fertility preservation services to enable rapid referral of newly diagnosed cancer patients for fertility preservation discussion and procedures. This may involve establishment of an internal fertility preservation program or the development of a relationship with an established fertility preservation service provider.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Referral pathways#Recommendation_1
• Cancer services are encouraged to establish referral pathways with fertility preservation services to enable rapid referral of newly diagnosed cancer patients for fertility preservation discussion and procedures. This may involve establishment of an internal fertility preservation program or the development of a relationship with an established fertility preservation service provider.
• Recommendation

Oncofertility service provision

Evidence-based recommendation

Grade

Cancer services should establish referral pathways with fertility preservation services to enable rapid referral of newly diagnosed cancer patients for fertility preservation discussion and procedures. Services planning on establishing their own oncofertility program are encouraged to refer to the International Oncofertility Competency Framework and the Australasian Oncofertility Consortium Charter.

C

• Guidelines:COSA:Cancer fertility preservation guidelines/Oncofertility service provision#Recommendation_1
• Cancer services should establish referral pathways with fertility preservation services to enable rapid referral of newly diagnosed cancer patients for fertility preservation discussion and procedures. Services planning on establishing their own oncofertility program are encouraged to refer to the International Oncofertility Competency Framework and the Australasian Oncofertility Consortium Charter.
• Recommendation

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Psychological support

Fertility counselling

Evidence-based recommendation	Grade
Fertility counselling should be offered to everyone with potentially curable cancer, ideally by a reproductive specialist and/or trained counsellor. Counselling should include education about fertility preservation options and support for patient decision-making.	B

• Guidelines:COSA:Cancer fertility preservation guidelines/Fertility counselling#Recommendation_1
• Fertility counselling should be offered to everyone with potentially curable cancer, ideally by a reproductive specialist and/or trained counsellor. Counselling should include education about fertility preservation options and support for patient decision-making.
• Recommendation

Decision making

Evidence-based recommendation	Grade
The use of decision support tools, such as fertility preservation decision aids, should be offered where available as they may assist people with cancer with the decision-making process.	A

• Guidelines:COSA:Cancer fertility preservation guidelines/Decision-making#Recommendation_1
• The use of decision support tools, such as fertility preservation decision aids, should be offered where available as they may assist people with cancer with the decision-making process.
• Recommendation

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Options for treatment

Sperm cryopreservation

Evidence-based recommendation	Grade
It is essential to counsel post-pubertal adolescents and adult men about the potential impact of their cancer treatment on their future fertility, and to provide an opportunity to freeze semen samples (ideally multiple) before cancer treatment.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Sperm cryopreservation#Recommendation_1
• It is essential to counsel post-pubertal adolescents and adult men about the potential impact of their cancer treatment on their future fertility, and to provide an opportunity to freeze semen samples (ideally multiple) before cancer treatment.
• Recommendation

Practice point
Screening of patients with cancer for infectious diseases concurrently with sperm cryopreservation is encouraged. Suggested blood tests: HIV 1&2 Abs, Hep B sAg, Hep B cAb, Hep C Ab, Syphilis Ab, CMV IgM & IgG Ab, HTLV 1&2 Abs. Suggested urine PCR tests: Chlamydia, Gonorrhoea, Mycoplasma genitalium.

• Guidelines:COSA:Cancer fertility preservation guidelines/Sperm cryopreservation#Practice_point_1
• Screening of patients with cancer for infectious diseases concurrently with sperm cryopreservation is encouraged. Suggested blood tests: HIV 1&2 Abs, Hep B sAg, Hep B cAb, Hep C Ab, Syphilis Ab, CMV IgM & IgG Ab, HTLV 1&2 Abs. Suggested urine PCR tests: Chlamydia, Gonorrhoea, Mycoplasma genitalium.
• Good practice point

Testicular biopsy

Evidence-based recommendation

Grade

Health professionals should consider discussion about testicular tissue biopsy and cryopreservation in pre-pubertal boys, particularly if a general anaesthetic is planned as part of other diagnostic or therapeutic procedures. The surgical procedure is considered low risk (apart from boys with acute leukaemia) but there are no data on fertility outcomes. This treatment is currently regarded as experimental and should only occur within an established research/ethical framework. This invasive procedure should be balanced against the option of waiting until fertility is required, as recovery from testicular damage is possible and sperm extraction an option if natural fertility is not successful.

D

• Guidelines:COSA:Cancer fertility preservation guidelines/Testicular sperm extraction#Recommendation_1
• Health professionals should consider discussion about testicular tissue biopsy and cryopreservation in pre-pubertal boys, particularly if a general anaesthetic is planned as part of other diagnostic or therapeutic procedures. The surgical procedure is considered low risk (apart from boys with acute leukaemia) but there are no data on fertility outcomes. This treatment is currently regarded as experimental and should only occur within an established research/ethical framework. This invasive procedure should be balanced against the option of waiting until fertility is required, as recovery from testicular damage is possible and sperm extraction an option if natural fertility is not successful.
• Recommendation

Evidence-based recommendation	Grade
Health professionals should discuss the option of testicular sperm extraction and sperm cryopreservation in post pubertal boys and men who cannot produce a semen sample.	D

• Guidelines:COSA:Cancer fertility preservation guidelines/Testicular sperm extraction#Recommendation_2
• Health professionals should discuss the option of testicular sperm extraction and sperm cryopreservation in post pubertal boys and men who cannot produce a semen sample.
• Recommendation

Consensus-based recommendation
Health professionals should discuss the option of testicular sperm extraction and sperm cryopreservation with mid- and late pubertal boys (testis volumes ≥ 8 ml) and men who are unable to provide a semen sample and who are embarking on gonadotoxic cancer treatments, and in azoospermic men who have had gonadotoxic cancer treatments and are desiring fertility treatment.

• Guidelines:COSA:Cancer fertility preservation guidelines/Testicular sperm extraction#Practice_point_1
• Health professionals should discuss the option of testicular sperm extraction and sperm cryopreservation with mid- and late pubertal boys (testis volumes ≥ 8 ml) and men who are unable to provide a semen sample and who are embarking on gonadotoxic cancer treatments, and in azoospermic men who have had gonadotoxic cancer treatments and are desiring fertility treatment.
• Consensus based recommendation

Embryo cryopreservation

Evidence-based recommendation	Grade
Women of reproductive age at risk of gonadotoxicity from cancer treatment should be offered the opportunity to cryopreserve embryos before cancer treatment.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Embryo cryopreservation#Recommendation_1
• Women of reproductive age at risk of gonadotoxicity from cancer treatment should be offered the opportunity to cryopreserve embryos before cancer treatment.
• Recommendation

Oocyte cryopreservation

Evidence-based recommendation	Grade
The opportunity to freeze oocytes should be offered to post-pubertal girls and women at risk of gonadotoxicity from cancer treatment.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Oocyte cryopreservation#Recommendation_1
• The opportunity to freeze oocytes should be offered to post-pubertal girls and women at risk of gonadotoxicity from cancer treatment.
• Recommendation

Safety of ovarian stimulation

Evidence-based recommendation	Grade
Women with low-risk breast cancer disease can be reassured that ovarian stimulation for fertility preservation is unlikely to contribute to cancer recurrence after treatment.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Safety of ovarian stimulation#Recommendation_1
• Women with low-risk breast cancer disease can be reassured that ovarian stimulation for fertility preservation is unlikely to contribute to cancer recurrence after treatment.
• Recommendation

Ovarian tissue cryopreservation

Evidence-based recommendation	Grade
Ovarian tissue cryopreservation should be considered for pre-pubertal girls, and for young women at significant risk of premature ovarian insufficiency from gonadotoxic cancer treatments. Referral to a fertility service and laboratory with experience in tissue cryopreservation is recommended. The safety of grafting in leukemia patients has not been demonstrated.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Ovarian tissue cryopreservation#Recommendation_1
• Ovarian tissue cryopreservation should be considered for pre-pubertal girls, and for young women at significant risk of premature ovarian insufficiency from gonadotoxic cancer treatments. Referral to a fertility service and laboratory with experience in tissue cryopreservation is recommended. The safety of grafting in leukemia patients has not been demonstrated.
• Recommendation

Ovarian transposition

Evidence-based recommendation	Grade
Ovarian transposition prior to radiotherapy to the pelvis may preserve ovarian function and may be considered for pre-menopausal women with pelvic cancers wanting to preserve their fertility.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Ovarian transposition#Recommendation_1
• Ovarian transposition prior to radiotherapy to the pelvis may preserve ovarian function and may be considered for pre-menopausal women with pelvic cancers wanting to preserve their fertility.
• Recommendation

Ovarian suppression with GnRH analogues

Evidence-based recommendation	Grade
Pre-menopausal women with breast cancer should be offered GnRHa before commencement of chemotherapy (given at least one week prior to chemotherapy) to reduce the risk of primary ovarian insufficiency.	A

• Guidelines:COSA:Cancer fertility preservation guidelines/Ovarian suppression with GnRH analogues#Recommendation_1
• Pre-menopausal women with breast cancer should be offered GnRHa before commencement of chemotherapy (given at least one week prior to chemotherapy) to reduce the risk of primary ovarian insufficiency.
• Recommendation

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Reproduction

Impact on pubertal development

Pubertal development

Evidence-based recommendation	Grade
Health professionals should be aware of the potential impact of cancer treatment on the pubertal development of children diagnosed with cancer. It is important that children with a history of cancer receive appropriate follow-up care, with paediatric endocrinology and gynaecology/andrology to monitor pubertal development and treat pubertal delay.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Pubertal development#Recommendation_1
• Health professionals should be aware of the potential impact of cancer treatment on the pubertal development of children diagnosed with cancer. It is important that children with a history of cancer receive appropriate follow-up care, with paediatric endocrinology and gynaecology/andrology to monitor pubertal development and treat pubertal delay.
• Recommendation

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Contraception

Contraception during cancer treatment

Consensus-based recommendation
Health professionals should discuss the need for contraception with cancer patients of reproductive age before,during and after cancer treatment.

• Guidelines:COSA:Cancer fertility preservation guidelines/Contraception during cancer treatment#Practice_point_1
• Health professionals should discuss the need for contraception with cancer patients of reproductive age before,during and after cancer treatment.
• Consensus based recommendation

Contraception after cancer treatment

Consensus-based recommendation
Health professionals should discuss sexual health and contraception with people with cancer. Caution should be exercised regarding the use of combined hormonal contraceptive methods (containing estrogen and progestin) for women undergoing cancer treatment and in the immediate post-treatment phase due to the risk of VTE.

• Guidelines:COSA:Cancer fertility preservation guidelines/Contraception after cancer treatment#Practice_point_1
• Health professionals should discuss sexual health and contraception with people with cancer. Caution should be exercised regarding the use of combined hormonal contraceptive methods (containing estrogen and progestin) for women undergoing cancer treatment and in the immediate post-treatment phase due to the risk of VTE.
• Consensus based recommendation

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Conception

Interrupting hormone therapy to conceive

Consensus-based recommendation
Limited existing data are reassuring for low-risk breast cancer patients who wish to interrupt hormone therapy to conceive. Health professionals should examine and discuss the current evidence with patients before considering the interruption of treatment to conceive.

• Guidelines:COSA:Cancer fertility preservation guidelines/Interrupting hormone therapy to conceive#Practice_point_1
• Limited existing data are reassuring for low-risk breast cancer patients who wish to interrupt hormone therapy to conceive. Health professionals should examine and discuss the current evidence with patients before considering the interruption of treatment to conceive.
• Consensus based recommendation

Assisted reproduction and risk of cancer recurrence

Consensus-based recommendation

Discussion with the treating oncologist to clarify an individual patient’s risk profile is required when considering pregnancy. Women with low-risk disease can be reassured that it is generally safe to attempt pregnancy, either spontaneously or with ART. Consideration must be given to minimise the duration of time off adjuvant endocrine treatment in women being treated for receptor positive breast cancer.

• Guidelines:COSA:Cancer fertility preservation guidelines/Assisted reproduction and risk of cancer recurrence#Practice_point_1
• Discussion with the treating oncologist to clarify an individual patient’s risk profile is required when considering pregnancy. Women with low-risk disease can be reassured that it is generally safe to attempt pregnancy, either spontaneously or with ART. Consideration must be given to minimise the duration of time off adjuvant endocrine treatment in women being treated for receptor positive breast cancer.
• Consensus based recommendation

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Pregnancy

Pregnancy and risk of cancer recurrence

Evidence-based recommendation	Grade
Women treated for low-risk breast cancer should be informed that pregnancy does not appear to increase the risk of disease recurrence or mortality.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Pregnancy and risk of cancer recurrence#Recommendation_1
• Women treated for low-risk breast cancer should be informed that pregnancy does not appear to increase the risk of disease recurrence or mortality.
• Recommendation

Evidence-based recommendation	Grade
Women treated for lymphoma and melanoma should be informed that pregnancy does not appear to increase the risk of disease recurrence. Women with a history of other cancers should seek specialist advice regarding the potential impact of pregnancy on cancer recurrence.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Pregnancy and risk of cancer recurrence#Recommendation_2
• Women treated for lymphoma and melanoma should be informed that pregnancy does not appear to increase the risk of disease recurrence. Women with a history of other cancers should seek specialist advice regarding the potential impact of pregnancy on cancer recurrence.
• Recommendation

Risk of pregnancy complications

Evidence-based recommendation	Grade
Women with a history of cancer should be informed of the increased risk of pregnancy and birth complications, and care should be provided in an appropriate facility.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Risk of pregnancy complications#Recommendation_1
• Women with a history of cancer should be informed of the increased risk of pregnancy and birth complications, and care should be provided in an appropriate facility.
• Recommendation

Evidence-based recommendation	Grade
It is recommended that cancer patients be reassured that their children are unlikely to have an increased risk of congenital anomalies. It is advisable that cancer patients be offered pre-pregnancy counselling.	C

• Guidelines:COSA:Cancer fertility preservation guidelines/Risk of pregnancy complications#Recommendation_2
• It is recommended that cancer patients be reassured that their children are unlikely to have an increased risk of congenital anomalies. It is advisable that cancer patients be offered pre-pregnancy counselling.
• Recommendation

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