During a well-child exam on a 4-year-old boy, you identify an abdominal mass and are concerned that it could be a Wilms tumor.
A 15-year-old girl comes to your office complaining of extreme fatigue, nosebleeds and bruising. Your initial bloodwork suggests leukemia.
With cancer affecting one in 285 U.S. children younger than 20 years, most pediatricians will encounter a new diagnosis of cancer during their career.
The good news is the majority of children with cancer will survive the disease. However, the treatment regimens for malignancies often leave children infertile. This has a tremendous impact on the hundreds of thousands of adult survivors, many of whom will want to have children.
Consideration of fertility preservation at the time of the initial diagnosis has the potential to change the course for these children, allowing them to maximize the chance of an open reproductive future as adults.
An updated AAP clinical report explains the risks for infertility based on the type of cancer treatment and the patient’s pubertal stage. It also reviews the medical aspects of fertility preservation, ethical considerations and the steps pediatricians can take to optimize the care of their patients at the time of a cancer diagnosis.
The report, Fertility Preservation for Pediatric and Adolescent Cancer Patients: Medical and Ethical Considerations, from the Committee on Bioethics, Section on Hematology/Oncology and Section on Surgery, is available at https://doi.org/10.1542/peds.2019-3994 and will be published in the March issue of Pediatrics.
Options exist, but timing critical
In some cases, treatment must be initiated urgently, with no time available to consider fertility preservation. However, this is rarely the case.
Clinically proven options for fertility preservation are available for postpubertal girls and boys, including oocyte and sperm cryopreservation.
For prepubertal children, the options are more limited, and in many cases are considered experimental. There have been successful births in women who froze ovarian tissue as girls, and this can be offered to girls as young as 2 years of age. For prepubertal boys, the options are more limited, and a number of these should be considered only under an institutional review board-approved protocol.
Vital to the success of fertility preservation modalities is the coordination of these options as early as possible following a diagnosis. Pediatricians are crucial in this effort, as they often are the first to suspect a cancer diagnosis and to coordinate care. They can have a profound impact as they help children and their caregivers navigate the process of accessing care at this critical, stressful time. Additionally, discussing a time after the cancer, when children can move forward and look to the future, provides hope during this period of grief.
Even when fertility preservation cannot be undertaken, pediatricians should counsel patients and families on the effect of cancer treatment on future fertility.
Key recommendations
- Physicians providing cancer treatment to children should be able to counsel patients and their families regarding the risk of infertility and the availability of fertility preservation options.
- When medically effective fertility preservation options exist, patients and their families should receive timely referral to centers and providers offering these options. This may include delaying treatment to allow for fertility preservation, as long as the delay does not compromise the success of the cancer therapy.
- An institutional policy should guide evaluation for candidacy for fertility preservation. Such policies should be informed by a team of specialists that may include a pediatric oncologist, a reproductive medicine specialist, a urologist with expertise in male fertility, a radiation oncologist, an ethics consultant, an expert in reproductive law and a mental health professional.
- Cryopreservation of sperm and oocytes should be offered whenever possible to postpubertal patients or families of adolescents, dependent on the predicted gonadotoxicity of the prescribed treatment.
- In considering actions to preserve a child’s fertility, parents should consider a child’s assent, the details of the procedure and whether such procedures have proven utility or are experimental.
Dr. Klipstein, a lead author of the report, is the former liaison from the American College of Obstetricians and Gynecologists to the AAP Committee on Bioethics. Dr. Fallat is a lead author of the report, former chair of the Committee on Bioethics and immediate past chair of the Section on Surgery Executive Committee.
