Introduction
Infertility decreases the life quality in adults. Infertility is usually caused by some medical conditions and also by certain treatments that are prescribed during childhood and methods that are to preserve fertility. Structured fertility programs are initiated for counseling about the risks of infertility and methods of fertility preservation in pediatric patients. Usually, it includes pediatric patients who are undergoing or underwent fertility-threatening treatments at an early age. Guidance should be provided to the healthcare workers to involve fertility programs, as many institutes lack pediatric fertility preservation services. A team is set, and the mechanics to build the fertility preservation program are aimed to focus on the targeted population, fertility-preserving options, ethics, and opportunities for further research. There may be some barriers, such as financial issues and low referral rates, and solutions to overcome the barriers should be of concern in fertility preservation programs.
What Are the Steps in Developing the Pediatric Fertility Preservation Program?
The important step in developing the Pediatric Fertility Preservation Program is to choose a director or Head who advocates the whole program and makes a team of strong members. A physician typically fills this position. Some nurses or scientists may also be chosen for this role. Steps involved in developing the program include:
1. Organizing a Team
It requires a multidisciplinary approach, and thus, the team members should include specialists from various fields of medicine. This involvement of multiple specialties increases the success and referral rate of the pediatric fertility preservation program. The role of the Head is to choose champions from various specialties to develop a strong, successful program with a better outcome and result.
The program depends on referrals and workflow efficiency to minimize any treatment delay. Key factors responsible are timely consultation, engaging the patient, and coordination with the fertility preservation program. The important steps involved are:
- Assessment of infertility risk.
- Fertility preservation options are to be discussed.
- Specialist involvement.
- Coordination of the procedures involved in the fertility preservation program.
2. Target Population Identification
Once the establishment of the team is done, the population at risk of infertility is important to identify.
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Childhood cancers survivors
Pediatric patients who are suffering from cancer or are cancer survivors are at a risk of infertility development. During research, it has been found that compared with their siblings, female cancer survivors have risks during pregnancy. Similarly, in male survivors, the risk of infertility is higher when compared to their siblings. Education about infertility should be included in the overall treatment plan of cancer patients. In patients suffering from cancer, the chances of infertility are increased because of the removal of any reproductive organ or germ cell destruction. In male patients, azoospermia can lead to reproductive germ cell destruction. After therapies are given to treat cancers in pediatric patients, the chances of ovarian insufficiency can develop. If there is less damage caused to immature oocytes, the reproductive capacity of a pediatric female survivor may be retained but may attain menopause sooner, having a short reproductive window.
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Noncancer Population
Certain diseases that can cause the pediatric patient to develop infertility in adulthood include systemic lupus erythematosus, certain renal diseases, and vasculitis. Pediatric patients who undergo stem cell transplantation for treatment of nonmalignant diseases such as blood disorders should be counseled and educated about the risk of infertility development. Gender affirmation treatments involving testosterone and estrogen may also affect the chances of fertility in pediatric patients during adulthood. In the case of any genitourinary surgeries in childhood, the chances of risk of infertility increase.
What Are the Fertility Preservation Options?
A Fertility preservation program should offer options and counsel patients of all ages and at pubertal stages.
1. The Fertility Preservation Options for Females
The fertility preservation in female patients may include ovarian transposition and shielding while exposed to radiation.
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Embryo freezing:
Freezing of oocytes is experimental in the United States but is already performed as a fertility preservation program in Europe and also in Israel. It is an option that is widely used and offered abroad. GNRH analogs are commonly used for ovarian suppression, but this method is still under experimentation.
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Preservation of mature oocytes:
It is also considered an option and may also be beneficial in post-menopausal women. This method is also under experimentation. Patient counseling is considered important as there are very few cases of oocyte freezing for fertility preservation in female survivors. It is considered that for better results, the oocyte retrieval for freezing should be collected before exposure to any treatment. Freezing of ovarian tissue: Preservation of surgically removed ovarian tissue for hormone restoration is also an option. This method is carried out for several pediatric patients and is considered effective and safe with fewer complications.
2. Fertility Preservation in Males
The options for fertility preservation in males include shielding while exposed to radiation, sperm freezing, and TTC. In male survivors, the risk of infertility is higher than in females. The options available for male survivors are:
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Sperm freezing:
This option can be offered at all stages. The quality of semen and integrity of DNA may get compromised after being exposed to therapy. Adolescence is considered the best age for sperm freezing. The specimen is obtained mostly by masturbation or electroejaculation. Microsurgical sperm extraction is also considered as an option.
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Testicular Tissue Freezing:
In case of a lack of mature sperm, the options for fertility preservation are limited. This procedure has greater efficiency for the affected population. This option involves the removal of immature testicular tissue. This is considered best before exposure to any treatment. Children with adequate semen should be considered the best patients for this treatment option. Excisional biopsy is done with other surgical procedures. This is considered for future development of techniques for pediatric patients and the maturation of stem cells into sperm.
Conclusion
Fertility was initially thought to be non-concerning in pediatrics. The development of fertility programs has improved infertility at a later stage. Many pediatricians have issues and are facing financial barriers to carrying out this program efficiently. Referral for counseling on fertility preservation should be focused on, and educating the family and the survivor should be focused on. The efficient functioning of the program by a specialist team should work on breaking the barriers to provide the best results to the vulnerable population.
