Fertility preservation in children and adolescents with oncological diseases

"Oncology" and "children" are not very compatible concepts, but although rarely, we still come across such a combination. We are getting ahead of ourselves to share the good news with you – these days 80% of young patients with malignancies achieve a complete cure.

The questions come one after another: "Will my child still be a complete person after the cure?", "Will they be able to have children of their own?" The answer to both questions is YES. To make it happen, you need to take some quick measures.

Getting ahead of your third question – NO, these measures will not harm your child's health and development, and will not be a liability to his or her cancer treatment.

Cancers in children and adolescents are rather specific, and we need to be aware of certain features.

First of all – a young person is unique. He/she is not a miniaturized version of the adult, but a magical world filled with excitement, trepidation and anxiety that often remains hidden or unrecognized.

This is why all current recommendations encourage treatment and its implications, including fertility preservation treatments, to be discussed with both parents and the patients themselves.

Second – cancers in children and adolescents are rare, and very different.

In medical literature, malignant diseases in these patients are included in the so-called CAYA (Childhood, Adolescent, Young Adults Cancer), divided into three subgroups - children, teenagers and young adults with malignancies that would normally occur in adults. This distinction is necessary because each age group is associated with predominant diseases, corresponding treatments, additional care by the treating multidisciplinary team (treating physician - oncologist/hematologist, surgeon, reproductive specialist, endocrinologist, psychologist, and others), and a very different fertility preservation strategy.

The most common in children and teenagers are hematological diseases (leukemias and lymphomas), followed by some solid tumors such as central nervous system tumors, neuroblastoma, nephroblastoma (Wilms tumor), and various types of sarcomas.

Epithelial tumors, such as thyroid cancer, breast cancer and testicular cancer, are much rarer and occur primarily in teenagers and in the group of so-called 'young adults'. Their diagnosis at an early age sometimes requires genetic counseling to identify or rule out genetic mutations.

Third, the young person has not yet completed their development and growth.

Most of the children we see are already in puberty, but for some of our patients this stage is yet to come. Effective therapy, unfortunately, frequently comes with its adverse consequences. Radiotherapy of the head, for example, can affect the pituitary and hypothalamic axis, resulting in growth retardation, or pubertal delay. The development of the bone system is also subject to hormonal synthesis. Radiation over the pelvis in the area around the sexual organs can lead to loss of reproductive functions in the future and problems in sexual development.

 Chemotherapy in girls can affect the ovaries and cause their function to stop, which we call premature ovarian failure. This affects both the future production of eggs and their quality and the release of the hormone estradiol, which is associated with development of female features (secondary sex characteristics).

In boys, chemotherapy affects testicular function, which can be expressed in reduced levels of the hormone testosterone and reduced sperm production – oligo- or azoospermia.

Side effects depend on many factors, the most important of which are the type of disease and the type of chemotherapy, its duration, and the age of the patient. There is still no definitive data on the impact of target therapy on reproductive functions, but modern medicine considers it relatively safe.

We are not writing this to give you a scare you, or to discourage you. Reading them, you should be aware that the described adverse events may become transient side effects in the future, if certain precautions are taken in a timely manner. This phrase, “in a timely manner”, is perhaps the most important in the entire chapter. There is a solution, which is well-established as a routine practice in the modern world. It is affordable and SAFE – preservation of eggs/sperm, or ovarian tissue/testicular tissue prior to the start of active treatment.

To rephrase – give us a call,  we will provide you with an immediate consultation and a solution.

Which treatments are most risky for future reproductive problems?

Quite logically, surgical treatment in which the ovaries or uterus are removed, ranks first. In recent years, there has been an increasing resort to the so-called fertility-sparing surgery, which in certain indications allows the removal of only one ovary, or a part of it, not compromising the treatment outcome. Always ask if this is an option for your child.

The second option is radiotherapy to the pelvic region, which may need to be carried out in case of solid tumors in this part of the body, and for hematological diseases, such as lymphomas. Radiotherapy doses > 10-15 Gy applied over the pelvis usually result in infertility.

The toxicity of chemotherapy depends on both the regimen used and the specific dose of chemotherapeutics. High-dose chemotherapy regimens used before hematopoietic stem cell transplantation are the riskiest ones. Often these regimens contain alkylating chemotherapeutics (the most toxic to the ovaries and testes), such as cyclophosphamide, busulfan and others, in combination with whole-body radiation, which unfortunately leads to infertility in a very large proportion of patients. High-risk regimens are also those used in the treatment of Ewing's sarcoma, osteosarcomas, tumors of the central nervous system, and some regimens for treatment of lymphomas.

When and how could I consult a reproductive specialist?

It is recommended that the consultation should be done before start of treatment. Just give us a call, you will have your consultation appointment the very next day. Oncology patients are consulted with priority so that their therapy is not delayed.

How am I to decide which fertility sparing strategy is right for my child?

Our reproductive specialists, who will work with your oncohematologist/oncologist, will help you with this. If necessary, we will provide a consultation with an oncology specialist from our hospital. The preservation procedure will be fully tailored to the cancer, the time until therapy begins. and the age of your child.

Can fertility preservation methods harm my child?

You are in a difficult situation and it is normal to be scared of everything. Put your trust in us, and we will help you, using global established and state-of-the-art practices. Your care will be provided by [specialists at the peak of their professional prowess. We have a lot of experience, and we do this for the future of our children. Every step will be discussed with you and your child.

Can I afford fertility preservationfrom a financial standpoint?

We will preserve eggs completely free of charge. You only have to pay for the medications needed for the procedure and the surgery, if needed.  

In conclusion – bad things happen, but there is always hope things will get better, and when those days come, we will be happy together; knowing that we have taken good care of one of the most important things – your child having children, and the circle of life continuing.

Fertility preservation options

Methods for fertility sparing depend on whether the patient has entered puberty, and the time interval until start of treatment. Global recommendations are that all young people facing cancer treatment should be consulted by a reproductive specialist.

Fertility sparing in boys and girls before puberty

Fertility preservation in pubertal boys and girls

★★★  - most commonly used approach, highest success rate ★★ - less frequently used approach, lower success rate  ★ - rarely used approach