2018 ASCO Guideline Update: Fertility Preservation in Patients With Cancer

Healthcare providers caring for adult and pediatric patients with cancer should address the possibility of infertility as early as possible, refer patients who express an interest in fertility preservation to reproductive specialists, and document the discussions in medical records, according to fertility preservation guidelines from the American Society of Clinical Oncology (ASCO).

2018 recommendations:

ASCO first published its clinical practice guidelines for fertility preservation in 2006, with updated guidelines being published in 2013. To develop current and updated guidelines, a multidisciplinary expert panel analyzed data from PubMed and the Cochrane Library on randomized controlled trials, systematic reviews, meta-analyses, and clinical practice guidelines from January 1, 2013 through Mach 29, 2017. Following review of the data, the panel made no significant changes to the 2013 recommendations: 2 recommendations for adult women were updated, and several clarifications to other recommendations were made.Adult men

According to guidelines, sperm cryopreservation is effective, and healthcare providers should discuss sperm banking with postpubertal males receiving cancer treatment. The guidelines advise against hormonal gonadoprotection, stating that hormonal therapy in men is not successful in preserving fertility. Other methods, such as testicular tissue cryopreservation and reimplantation or grafting of human testicular tissue, should be performed only as part of clinical trials or approved experimental protocols.

Postchemotherapy, men should be informed of a potentially increased risk of genetic damage in sperm collected after receiving treatment.

Adult women

In adult women, embryo cryopreservation is an established method of fertility preservation, and is routinely used for storing surplus embryos after in vitro fertilization. Cryopreservation of unfertilized oocytes are an option, and may be particularly beneficial for women who do not have a male partner, do not have an interest in donor sperm, or have objections to embryo freezing.

Updated: According to the guidelines, there is conflicting evidence to recommend gonadotrophin-releasing hormone agonists (GnRHa) and other methods of ovarian suppression. The guidelines state: “The panel recognizes that, when proven fertility preservation methods such as oocyte, embryo, or ovarian tissue cryopreservation are not feasible, and in the setting of young women with breast cancer, GnRHa may be offered to patients in the hope of reducing the likelihood of chemotherapy-induced ovarian insufficiency.”

Updated: Ovarian tissue cryopreservation for the purpose of future transplantation does not require ovarian stimulation and can be performed immediately. It does not require sexual maturity, which may represent the only method available for children. However, further investigation is needed to determine if the method is safe in patients with leukemias.

Children

The guidelines recommend established methods of fertility preservation—semen or oocyte preservation—for postpubertal children, with patient assent and parent of guardian consent. For prepubertal children, the only fertility preservation options are ovarian and testicular cryopreservation, which are investigational.

Role of the provider

According to the guidelines, all oncologic healthcare providers should be prepared to discuss the possibility of infertility resulting from treatment, and this discussion should happen as soon as possible following a cancer diagnosis. Providers are advised to encourage patients to participate in registries and clinical studies and refer patients interested in fertility preservation to a specialist as soon as possible. When patients are distressed, providers should refer them to psychosocial providers.