In the last decade, a great deal of progress has been made in terms of improving clinician-patient education, communication, and decision support with regard to oncofertility and fertility preservation. The Oncofertility Decision Tool Web Portal hosts decision tools designed to help health care providers navigate fertility preservation options discussions with their patients. 

 

Decision Tools

Decision Tools are designed to enable oncofertility stakeholders to take action. They provide information to help health care providers guide patients through their fertility preservation options and help them make the best decision based on their cancer treatment, lifestyle, values, and future fertility goals. 

Decision Tool Targeted Patient Population How Can Health Care Providers Use This Tool?

Adolescent Fertility Values Clarification Tool (AFVCT)

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Adolescent Oncology Patients (Aged 12-18 Years)  
  • Patient values and understanding assessment
  • Guide to discussing future quality of life, preservation options, and value of parenthood
  • Strategies and interventions
  • Designed and tested with adolescent oncology teens and their parents for reliability and validity

Female Oncofertility Decision Tree

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Post-Pubertal Female Oncology Patients  
  • Walks health care professionals through fertility preservation options for women with new cancer diagnoses
  • Highlights "decision points" where patients and providers need to make important decisions regarding cancer treatment and future fertility 

Male Oncofertility Decision Tree

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Post-Pubertal Male Oncology Patients  
  • Walks health care professionals through fertility preservation options for men with new cancer diagnoses
  • Highlights "decision points" where patients and providers need to make important decisions regarding cancer treatment and future fertility 

Future Decisions Tool

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Post-Pubertal Female Oncology Patients

 

A decision tree designed to guide physicians through conversations with female patients about fertility preservation future decisions and long-term effects, including:

  • Treatment timeline 
  • Finances
  • Storage 
  • Partner involvement or donor
  • Disposition (religious, social, & familial influences)
  • Parenthood

Treatment Guidelines for fertility preservation in young women at high risk for breast or ovarian cancer

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Young Women with Hereditary Cancer Predisposition Syndromes A decision tree specifically designed to help health care providers discuss fertility preservation options with young women at high-risk for developing breast and/or ovarian cancer due to hereditary cancer predispostion syndomes, like Hereditary Breast and Ovarian Cancer (HBOC) syndrome caused by deleterious mutations in BRCA1/2

Fertility Preservation Assessment and Discussion Algorithm for Patients with Cancer

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Post-Pubertal Oncology Patients  
  • Created by the American Society of Clinical Oncology
  • Outline of steps health care providers should take regarding fertility preservation for interested patients

Fertility Preservation Patient Navigation

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Pre- and Post-Pubertal Oncology Patients  
  • A flowchart demonstrating the pivotal role of the patient navigator in directing cancer patients toward fertility preservation services
  • Available fertiltiy preservation options for both females and males
  • May be useful to health care providers who do not have patient navigators at their institution, as it provides framework for guiding oncology patients through the fertility preservation process

FertiQoL

Access the Tool Online

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Patients with infertility

FertiQoL is an internationally validated self-report questionnaire physicians can administer to patients struggling with infertility (independent of infertility treatment status) in order to assess the quality of life of an individual with infertility. The tool has been designed to facilitate improvement in the quality of life of those with infertility. The questionnaire takes approximately 10-15 minutes to complete and covers four domains (overall, personal, interpersonal, and healthcare) and nine dimensions (emotional, psychological, physical, values, partner relationship, social network, occupational/work, medical, and psychoeducational). 

FertiQoL is available in: Dutch, English, Finnish, French, German, Italian, Portuguese, Russian, Spanish, and Swedish.

Learning About Cancer and Fertility: A Guide for Parents of Young Girls Adolescent females  Learning about Cancer and Fertility: A Guide for Parents of Young Girls is a decision aid designed for parents of young girls diagnosed with cancer.  Developers created this paper-based tool that focuses on the child's survival rather than future fertility, however it also outlines available fertility preservation options.  The focus of the tool is not just for making fertility preservation decisions but also serves as a guide to give parents information that will help them talk with their child's healthcare team now and in the future as she grows. 

Oncofertility Decision-Making Publications 

Many publications are available to providers interested in learning more about patient and provider oncofertility conversation starters, techniques, interventions, and assessments. 

Publication           Patient Population     How Can Health Care Providers Use this Publication?

How Do Cancer Patients Learn About Fertility Preservation? Five Trajectories of Experience

Snyder KA & W Pearse

Oncofertility Communication (2014)

Female Post-Pubertal Oncology Patinets

This chapter from Oncofertility Communication (2014) describes a study of 67 women with recent breast cancer diagnoses assessing how they learn about fertility preservation. The analysis focused on:

  • The potential of breast cancer treatment to impair fertility
  • The availability of fertility preservation treatment options

Five trajectories emerged as to how patients learn about fertility preservation and the inhibiting and facilitating factors were also assessed. Read more to learn how you can empower your patients by providing fertility preservation information.

Communicating Across Diverse and Differently Literate Audiences

Mersereau JE & AR Brandon

Oncofertility Communication (2014)

Pre- and Post-Pubertal Oncology Patients

This chapter from Oncofertility Communication (2014) describes the unique communication challenges with fertility preservation and suggests:

Patient and Family Tools to Aid in Education and Decision-Making About Oncofertility

Quinn GP, Vadaparampil ST, Sehovic I, & ML Clayman

Oncofertility Communication (2014)

Adolescent and Young Adult Oncology Patients

This chapter from Oncofertility Communication (2014) assesses several oncofertility-related educational materials and decision aids. It also contains:

Cancer-Related Infertility and Young Women: Strategies for Discussing Fertility Preservation

Snyder KA & A Tate

Oncofertility Communication (2014)

Female Post-Pubertal Oncology Patients

In this chapter from Oncofertility Communication (2014), read about a series of retrospective focus groups conducted with adult women who were diagnosed with various forms of cancer between ages 14 and 20. Highlights include:

  • Primary concerns at diagnosis
  • Missing information about fertility preservation
  • Patient role in decision-making
  • Sexual health

The chapter also provides health care providers with strategies for fertility preservation counseling.

Fertility Communication and High-Risk Patients

Llarena NC & JS Jeruss

Oncofertility Communication (2014)

Women with hereditary cancer predisposition syndromes

This chapter from Oncofertility Communication (2014) is specifically written to help health care providers discuss fertility preservation options with women who have hereditary cancer predisposition syndromes, or "previvors", who are 1) at increased risk of developing premenopausal breast or ovarian cancer and 2) may require a risk-reducing intervention prior to menopause that poses a threat to future fertility. The chapter addresses:

  • Who are high-risk patients?
  • How do we estimate 5-year and lifetime risk of breast cancer?
  • What are the accepted prophylactic interventions for high-risk patients?
  • How do we communicate with high-risk patients?
  • What are the treatment guidelines for fertility preservation in young women at high risk for breast or ovarian cancer?

The chapter also includes two case examples providers can read to familiarize themselves with the unique situation of high-risk women.

Incorporating Partners and Spouses in Oncofertility Communication

Johnson Shen M & H Badr

Oncofertility Communication (2014)

Oncology patients with partners

This chapter from Oncofertility Communication (2014) addresses the issue of communication between patients and their partners. Learn about the impact of fertility preservation and infertility on couples and the communication needs of adult cancer patients and their partners. Encourage your patients and their partners to consider the following issues when approaching oncofertility communication:

  • What is the impact of potential infertility on cancer patients, their partners, and the couple’s relationship?
  • What are the fertility preservation options available to women and men and how might these options affect the couple?
  • What are the ethical and legal concerns of fertility preservation faced by couples?
  • How should partners be involved in oncofertility communication and decision-making?
  • How can couples’ communication surrounding fertility preservation and potential infertility be improved in order to promote shared decision-making and reduce marital distress caused by fertility issues related to cancer treatment? 

Genetic Counselors: Bridging the Oncofertility Information Gap

Goetsch A, Volk A, & TK Woodruff

Oncofertility Communication (2014)

Oncology patients with or at risk for hereditary cancer predisposition syndromes This chapter from Oncofertility Communication (2014) suggests ways genetic counselors can aid oncologists and reproductive endocrinologists by addressing fertility preservation concerns with patients with family histories of cancer and/or hereditary cancer predisposition syndromes.

Communicating Oncofertility to Children: A Developmental Perspective for Teaching Health Messages

Wartella E, Lauricella AR, & LB Hurwitz

Oncofertility Communication (2014)

Pediatric Oncology Patients This chapter from Oncofertility Communication (2014) contains:
  • A developmental perspective about what children already know about their bodies and reproductive systems
  • How media communicates health messages to children 
  • Recommendations for how oncofertility experts can use media to educate young audiences

Disparities in Adolescent Patient-Provider Communication Regarding Fertility Preservation Care

Fuchs AB & RE Brannigan 

Oncofertility Communication (2014)

Adolescent Oncology Patients This chapter from Oncofertility Communication (2014) addresses the barriers to discussing fertility preservation with adolescents and the disparities that currently exist in communicating the topic of fertility preservation to the adolescent patient population.

Fertility Communication to Cancer Patients: A Hematologist-Oncologist's Perspective

S Barnato Giordano

Oncofertility Communication (2014)

Pre- and Post- Pubertal Oncology Patients

This chapter from Oncofertility Communication (2014) addresses the many barriers physicians face providing patients with fertility preservation options. 

An Interprofessional Approach to Shared Decision Making: What it Means and Where Next

Legare F & D Stacey

Oncofertility Communication (2014)

 

Oncology Patients

This chapter from Oncofertility Communication (2014) discusses effective ways health care providers can involve patients in shared decision making, including use of:

Oncology Communication Tools for Professionals and the Public

Foster LaBrecque S, Wallach H, & KE Waimey

Oncofertility Communication (2014)

Oncology patients 

Learn about the many available ways health care providers and the public can learn about oncofertility in this chapter from Oncofertility Communication (2014). The following communication tools are discussed:

  • Education tools for scientific and medical professionals
    • Professional web sites
    • Virtual Meetings
    • Mobile tools
  • Tools to disseminate oncofertility information to the public
    • Pubic-facing websites
    • Social media
  • Future directions

Potential Future Decisions Regarding Fertility Preservation

Quinn GP & ST Vadaparampil 

Am J Obstet Gynecol. 2013 Aug;209(2):98-102.

Post-Pubertal Oncology Patients

A decision tree designed to guide physicians through conversations with patients about fertility preservation future decisions and long-term effects, including:

  • Treatment 
  • Finances
  • Storage 
  • Partner 
  • Disposition 
  • Parenthood

Using a patient-centered approach to develop a fertility preservation brochure for pediatric oncology patients: a pilot study

Murhpy D, Sawczyn KK, & GP Quinn

J Pediatr Adolesc Gynecol. 2012 Apr; 25(2):114-21

Pediatric Oncology Patients

This study involved the creation of two versions of gender concordant brochures on fertility preservation desgined for pediatric oncology patients and their parents. Feedback was obtained and incorporated into the final version of the brochures.

Health care providers can use the brochures to facilitate fertility preservation discussions with male and female pediatric patients.

View the Female Brochure

View the Male Brochure

The Birds and the Bees and the Bank: Talking with Families About Future Fertility Amidst a Cancer Diagnosis

Quinn GP, Knapp CA, & D Murphy

Oncofertility Medical Practice (2012) Clinical Issues and Implementation

Adolescent Oncology Patients and their Families

Face-to-face communication between health care providers and patients is the most effective way to convey complex information regarding cancer treatment and fertility. This Chapter from Oncofertility Medical Practice Clinical Issues and Implementation (2012) describes how clinicians can more effectively conduct discussions about fertility with patients who have received a recent cancer diagnosis. Contains:

  • A 10 item Reproductive Concerns Scale (RCS) adapted specifically for use with adolescents
  • Adolescent Fertility Values Clarification Tool: a priming tool for future-decision making that uses open-ended statements to encourage dialogue that allows adolescents to process the idea of having children before discussing the effects of cancer treatment on fertility

Communication Between Oncofertility Providers and Patients

Jennifer Mersereau

Oncofertility Medical Practice (2012) Clinical Issues and Implementation

Post-Pubertal Oncology Patients This chapter from Oncofertility Medical Practice Clinical Issues and Implementation (2012) suggests ways to address the existing oncofertility information gap through improved communication and facilitation of better decision-making. Helpful tools include:
  • Characteristics associated with an increased concern about future fertility (women <41 years with a diagnosis of breast cancer; n=657)
  • Top 10 most-common fertility-related questions asked by women with a cancer diagnosis
  • ASCO points of discussion regarding fertility preservation
  • 5 fertility questions cancer patients could ask their providers
  • Suggestions for improved educational methods
  • unresolved ethical and practical issues

Patient Navigation and Coordination of Care for the Oncofertility Patient: A Practical Guide

Smith K, Efymow B, & C Gracia

Oncofertility Medical Practice (2012) Clinical Issues and Implementation

Pre- and Post- Pubertal Oncology Patients

This chapter from Oncofertility Medical Practice Clinical Issues and Implementation (2012) describes ways to improve the fertility preservation consult using teams of providers that are unifed by allied health professionals, with emphasis on the role of patient navigators and nursing in the care of the oncofertility patient. Read about:

  • The challenges to providing fertility preservation patient care 
  • How to improve access to fertility preservation care
  • The role of patient navigators
  • The role of the clinical nurse coordinator
  • The role of the researcher nurse coordinator

Nonmalignant Diseases and Treatments Associated with Primary Ovarian Failure: An Expanded Role for Fertility Preservation

Hirshfeld-Cytron J, Gracia C, and TK Woodruff

Journal of Women's Health (2011) 20 (10): 1467-1477

Women with non-malignant conditions

This article reviews several fertility-threatening conditions, treatments, and current established and experimental fertility preservation options. Some of the nonmalignant diseases and treatments that can impact reproductive function include:

  • gastrointestinal diseases
  • rheumatologic disorders
  • nonmalignant hematologic diseases
  • renal disease
  • neurologic disorders
  • gynecologic conditions
  • metabolic disorders

Using decision trees to enhance interdisciplinary team work: the case of oncofertility 

Gardino SL, Jeruss JS, & TK Woodruff

J Assist Reprod Genet (2010) 27:227–231 

 

Post-Pubertal Oncology Patients
  • Female decision tree designed to assist fertility preservation decisions
  • Male decision tree designed to assist fertility preservation decisions
  • Highlights specific "decision points" that patients are faced with and guides providers through options discussions

Oncofertility and Informed Consent: Addressing Beliefs, Values, and Future Decision Making

Felicia Cohn

Oncofertility (2010) Ethical, Legal, Social, and Medical Perspectives

Pre- and Post-Pubertal Oncology Patients

This chapter from Oncofertility Ethical, Legal, Social, and Medical Perspectives (2010) focuses on the ability to account for the immediate and long-term implications of oncofertilty decisions, including:

  • Immediate risk for future benefit
  • Emotional implications of the decision-making process
  • Future decisions regarding stored material

Bioethics and Oncofertility: Arguements and Insights from Religious Traditions

Zoloth L, & AA Henning

Oncofertility (2010) Ethical, Legal, Social, and Medical Perspectives

Pre- and Post-Pubertal Oncology Patients 

Patients may consult, invoke, or defer to religious beliefs, sources, or leaders when making decisions about their own medical treatment or treatment for a surrogate (e.g., a chld or incompetent parent or partner), including decisions about whether to seek access to oncofertility reserach protocols or technologies and determining which types of research protocols or technologies they wish to pursue. Therefore, understanding a patient's religious commitments is one critical part in oncofertility discussions so that physicians and family members may better communicate with a patient who draws upon religion to cope with an illness or make medical care decisions. This chapter briefly explores the following religous traditions and their anticipated or potential contributions to the ethical discourse surrounding oncofertility:

  • Catholic
  • Evangelical Christian
  • Muslim
  • Jewish
  • Hindu
  • Buddhist

As a health care provider, you can read about preliminary responses that may guide each religion's tranditional stances toward reproductive technologies and procreation in this chapter from Oncofertility Ethical, Legal, Social, and Medical Perspectives (2010).

Read more about Oncofertility in Muslim Communities and Muslim Women and Oncofertility as Devotion

Read more about Oncofertility and Catholic Tradition

Read more about Jewish Perspectives on Oncofertility

 

Shared Decision Making: Fertility and Pediatric Cancers

 

Clayman ML, Galvin KM, & P Arntson

Oncofertility (2007) Fertility Preservation for Cancer Survivors

Pediatric oncology patients

This chapter from Oncofertility Fertility Preservation for Cancer Surivors (2007) discusses how the key constructs from family systems theory and the shared decision-making model are used to understand how families whose children are newly diagnosed with cancer can make informed choices about the future fertility of their children. Includes:

  • The key phases of family decision making
  • How to use shared decision-making in pediatrics and cancer

The Psychosocial Context of Cancer-Related Infertility

Loscalzo MJ & KL Clark

Oncofertility (2007) Fertility Preservation for Cancer Survivors

Post-Pubertal Oncology Patients

This chapter from Oncofertility Fertility Preservation for Cancer Surivors (2007) discusses the psychosocial implications of fertility loss due to cancer treatment. Includes:

  • A suggested introduction to fertility preservation conversation
  • How psychosocial screening can beneft patients with infertility concerns
  • An IRB-approved self-administered biopsychosocial screening instrument: How Can We Help You and Your Family?
  • A suggested Triage process for patients who expressed concerned about their ability to have children on the biopsychosocial screening instrument

Validation of a New Scale for Measuring Concerns of Women Undergoing Assisted Reproductive Technologies (CART)

Klonoff-Cohen H, Natarajan L, & E Klonoff

J Health Psychol (2007) 12:352

Patients with Infertility

Klonoff-Cohen et al. (2007) discuss the psychological and physical stress of undergoing assisted reproductive technologies (ART) and the developemnt of the Concerns of Women Undergoing Assisted Reproductive Technologies (CART) instrument. 

The CART captures unique concerns experienced by women undergoing IVF or GIFT (gamete intrafallopian transfer), prior to, during, and after treatment, which are not evaluated by other existing instruments. Validity and reliability are adequate, and the instrument does not appear to be related to demographic factors.

 

Clinical Guidelines, Recommendations, Policy Statements & Opinions

As a health care provider who treats patients interested in fertility preservation options, it is important to stay up to date regarding the published clinical guidelines, recommendations, and opinions of professional organizations involved with the care and treatment of fertility preservation patients.

Resource Professional Society or Organization Category Publication Year How Can Health Care Providers Use This Resource?
Evidence-Based Recommendations for Fertility Preservation Options for Inclusion in Treatment Protocols for Pediatric and Adolescent Patients Diagnosed with Cancer Association of Pediatric Hematology/Oncology Nurses (APHON) Evidence-Based Recommendation 2014

APHON published a comprehensive synthesis of current evidence and recommendations regarding fertility preservation options for children, adolescents, and young adults undergoing cancer treatment. Health care providers may find this resource beneficial because it provides medical information, evidence tables, psychological considerations, and summary recommendations regarding fertility preservation options for both pre- and post-pubertal male and female patients, including:

  • Embryo cryopreservation
  • Oocyte cryopreservation
  • Oophoropexy
  • Ovarian tissue cryopreservation
  • Hormone suppression
  • Sperm banking via masturbation
  • Sperm banking via alternative methods
  • Testicular tissue cryopreservation
Female age-related fertility decline American Society for Reproductive Medicine (ASRM) Practice Committee Opinion 2014

Education and enhanced awareness of the effect of age on fertility are essential in counseling the patient who desires pregnancy. Given the anticipated age-related decline in fertility, the increased incidence of disorders that impair fertility, and the higher risk of pregnancy loss, women older than 35 years should receive an expedited evaluation and undergo treatment after 6 months of failed attempts to conceive or earlier, if clinically indicated. In women older than 40 years, more immediate evaluation and treatment are warranted. This practice committee opinion can assist with fertility preservation discussions by providing you with age-related fertility rates. 

Ovarian tissue cryopreservation: a committee opinion American Society for Reproductive Medicine (ASRM) Practice Committee Opinion 2014
  • Indications for ovarian tissue cryopreservation
  • Laboratory techniques
  • Transplantation outcomes
  • Safety concerns
  • Alternative treatments
Adolescent and Young Adult (AYA) Oncology National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology  2014
  • Screening, assessment, and evaluation of AYA patients 
  • Age appropriate care
  • Treatment-related issues
  • Fertility/Endocrine related issues
  • Psychosocial/behavioral considerations
  • Survivorship
  • Disease-specific issues related to age
  • Screening recommendations for AYA survivors
  • Palliative care and end-of-life considerations
  • Online resources for AYA patients and survivors
Survivorship National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology 2014

These guidelines focus on the vast and persistent impact both the diagnosis and treatment of cancer have on the adult survivor. This includes the potential impact on health, physical and mental states, health behaviors, professional and personal identity, sexuality, and financial standing.

Fertility Preservation for Patients With Cancer  American Society of Clinical Oncology (ASCO) Clinical Practice Guideline Update 2013  
  • Key recommendations regarding fertility preservation conversations for health care providers who care for oncology patients
  • Summaries of the established and experimental fertility preservation options for men, women, and children
  • Infertility and fertility preservation discussion points for provider and patient communication
  • Fertility preservation assessment and discussion algorithm for patients with cancer
Fertility preservation and reproduction in patients facing gonadotoxic therapies: a committee opinon American Society for Reproductive Medicine (ASRM) Ethics Committee Opinion 2013
  • Descriptions of onoclogy and fertility specialists' roles in preserving fertility
  • Safety and Efficacy of procedures 
  • Fertility preservation options for minors
  • Experimental procedures in minors
  • Directions for disposition of stored gamete, embryos, and gonadal tissue
  • Prenatal diagnosis and preimplantation genetic diagnosis (PGD) for heritable cancers
Mature oocyte cryopreservation: a guideline American Society for Reproductive Medicine (ASRM) & Society for Assisted Reproductive Technology (SART) Practice Committee Opinion 2013
  • Mature oocyte cryopreservation technology overview
  • Success of in vitro fertilization (IVF) with cryopreserved oocytes compared with fresh oocytes
  • Impact of maternal age on oocyte cryopreservation success
  • Pregnancy Risks
  • Medical indications for mature oocyte cryopreservation
Fertility Preservation in Cancer Patients American Society of Clinical Oncology (ASCO) Clinical Practice Guideline 2006

 

Guidance to practicing oncologists about available fertility preservation methods and related issues in people treated for cancer, including:

  • Infertility Risk Estimation
    • Effects of different antitumor agents on sperm production in men
    • Risks of permanent amenorrhea in women treated with chemotherapy and radiation
  • Flow diagram to guide initial discussions with patients
  • Discussion points between patient and provider
  • Summaries of fertility preservation options in males & females
Ovarian Tissue and Oocyte Cryopreservation American Society for Reproductive Medicine (ASRM) & Society for Assisted Reproductive Technology (SART) Committee Opinion 2006  
  • Indications for female fertilty preservation
  • Ovarian tissue cryopreservation
    • Potential risks 
    • Clinical study data
  • Oocyte cryopreservation
    • Laboratory methods
    • Potential risks
    • Clinical study data
Long Term Follow-Up for Survivors of Childhood, Adolescent, and Young Adult Cancer  Children's Oncology Group Clinical Practice Guideline 2006

 

Risk-based, exposure-related clinical practice guidelines which provide recommendations for screening and management of late effects in survivors of pediatric, adolescent, or young adult malignancies. Clinicians can look up the late effects associated with the patient’s specific treatment or therapeutic agent(s). The guidelines are not specific to risks of infertility, however they do provide limited fertility information.

Fertility Preservation and reproduction in cancer patients American Society for Reproductive Medicine (ASRM) Ethics Committee Report  2005

 

The ASRM Ethics Committee Report includes:

  • Description of the role of the cancer specialist and fertility specialist in preserving fertility
  • Established and experimental methods of fertility preservation in both male and female patients. 
  • Directions for disposition of stored gametes, embryos, and gonadal tissue
  • Posthumous use of stored reproductive tissue
  • Risks to offpring and the ethical acceptabilty of PGD for hereditary cancer syndromes
A strategy for fertility services for survivors of childhood cancer British Fertility Society Multidisciplinary Working Group Recommendation 2003

 

The British Fertility Society recommendations are organized and specific for oncology units, assisted conception units, and the government. Recommendations regarding fertility services for cancer survivors, include:

  • Treatment recommendations and descriptions
  • Psychosocial support
  • Ethical and legal considerations.
  • Risk levels associated with different cancer types and treatments
  • Inclusion criteria for offering gonadal tissue cryopreservation

Preservation of Fertility in Pediatric and Adolescent Patients with Cancer

 

 

American Academy of Pediatrics Policy Statement 2008  

Fertility preservation and reproduction in patients facing gonadotoxic therapies: a committee opinion

 

 

American Society of Reproductive Medicine Policy Statement 2013  

 

 

 

 

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