Fertility preservation is a major issue for young cancer patients undergoing treatment. We spoke with Inken Hilgendorf, MD, about the recent changes in legislation in Germany as well as further challenges for young cancer patients. Dr Hilgendorf is a hematologist and oncologist at the University Hospital Jena, head of the working party AYA-Network of the German Society for Hematology and Oncology, member of the board of trustees of the German Foundation for Young Adults with Cancer, and member of the European Network for Teenagers and Young Adults with Cancer (ENTYAC).

Since July 2021, fertility preservation for young cancer patients in Germany gets covered by their medical insurance. Why is this a milestone in post-rehabilitation support?

The previous lack of reimbursement was a very stressful situation for young adults with cancer. Every year, about 16,500 young adults in Germany are faced with the diagnosis of cancer and its treatment. Fortunately, about 80% of these young patients can be cured. In this context, fertility preservation is a crucial component of cancer survivorship care and can enable cured cancer patients to have their own children later in life. Thanks to the initiative and the great commitment of the German Foundation for Young Adults with Cancer, the costs of fertility-preserving measures for cancer patients are now covered by the statutory health insurance. However, the costs of ovarian stimulation medication for girls below 18 years of age are not covered by the medical insurance. This question needs to be resolved urgently.

Cryoconservation, fertility and treatment (source: Deutsche Stiftung für junge Erwachsene mit Krebs)

Please tell us more about the interrelated aspects of fertility, cancer treatment and cryoconservation for young patients.

Most cancer treatments, like chemotherapy, radiotherapy or a combination of both, can damage the germinal tissue (ovaries/testicles) and germ cells (oocytes, sperm), putting adolescents and young adults with cancer at the risk of premature ovarian failure or azoospermia and subsequently of an irreversible loss of fertility. Therefore, fertility preservation should be proposed to young patients undergoing potentially gonadotoxic cancer treatment as early as possible. The different options of preserving fertility are shown in the figure below. The most appropriate option should be chosen depending on the individual characteristics of the patient (e.g., age, sex, diagnosis) and the planned treatment.

Methods of fertility preservation (source: Deutsche Stiftung für junge Erwachsene mit Krebs)

 What is the status quo of fertility preservation in pre-pubescents? Is there a need to act? What can be done?

Prepubertal patients with cancer are also at risk of infertility. Therefore, the possibility of infertility following cancer treatment should be discussed with the parents/guardians of those children early. In order to preserve the reproductive potential of young girls, ovarian tissue cryopreservation can be performed. If a targeted radiotherapy in the pelvic area is planned, the transposition of the ovaries can be another useful option. In prepubertal boys, testicular tissue cryopreservation can be offered, although this option should be considered investigational.

How are other countries dealing with the issue of fertility preservation for cancer patients?

Overall, 38% of respondents of an online survey conducted by the joint working group of the European Society for Medical Oncology (ESMO) and the European Society for Paediatric Oncology (SIOPE) reported that their adolescent and young adult patients did not have access to fertility specialists. This figure was 76% in Eastern, 48% in Southern, 28% in Northern and 22% in Western Europe, respectively.

What does the future of fertility preservation and cryoconservation look like?

The field of germinal tissue cryopreservation is advancing quickly and may be a promising way to expand this procedure. However, optimal counselling from healthcare professionals should always be warranted and offered to each young patient undergoing potentially gonadotoxic cancer treatment.

Many thanks for your insights and the interview.