Long-term survival following hematopoietic stem cell transplant (HSCT) in childhood continues to improve and patients are thus increasingly faced with the late effects of treatment. Infertility is very common for both males and females following HSCT and is one of the most distressing sequelae. Adoption and surrogate egg or sperm donation are possibilities for some patients but post-HSCT reversal of gonadal failure is not possible. We have recently initiated an onco-fertility program with a dedicated practitioner with specific expertise in this area. Our practice is for her to meet with all families and age-appropriate patients during the pre-HSC T evaluation period. This allows patients and families both to be accurately informed about the expected treatment-related infertility risk and the available options for fertility preservation. Sperm banking and egg or embryo cryopreservation are established approaches but are not achievable for many children and adolescents. Recently the harvesting and cryopreservation of ovarian and testicular tissue represents a novel surgical option that allows for the possibility of fertility preservation to be extended to children of all ages. The purpose of this investigation is to evaluate the safety of these procedures proximal to conditioning therapy and HSCT.
Retrospective report on a consecutive cohort of all patients aged 0-25 who after discussion with our onco-fertility specialist chose to undergo surgical fertility preservation (laparoscopic unilateral oophorectomy or testicular biopsy) at our institution between 3/2018 and 4/2020. These procedures occurred under general anesthesia at the time of central line placement prior to the initiation of HSCT conditioning. We assess the safety of the procedures in terms of post-operative complications and impact on HSCT course.
22 patients underwent fertility preservation surgical procedures. Thirteen patients (59%) were female, median age of 13 years (1-22 years,) and nine (41%) were male, median age of 8 years (5-12 years). Fourteen (63%) were pre-pubertal and 8 (36%) pubertal. HSCT indications were hematologic malignancies/solid tumor (40%) and non-malignant diseases (60%). Most received an allogenic graft (68%) and 81% had myeloablative conditioning (MAC). All subjects became neutropenic at a median of 10 days (0-51 days) from the surgical procedure; one was neutropenic at the time of TTC. The mean duration for the procedures performed including OTC or TTC were 98 minutes (49-260 min) and 97 minutes (56-178min) respectively. Estimated blood loss was minimal and no post-operative site infections occurred. One post-procedure, blood culture negative fever was reported without an identifiable source; patient completed 48 hours of antibiotics with resolution of fever. Sixty-two percent of females and 56% of males started conditioning within 24 hours of OTC/TTC (15 hours-113 days, median= 1 day). The median time to engraftment was 22 days (9-33 days) in females and 17 days (11-67 days) in males, consistent with our institutional benchmarks. One patient with aplastic anemia had primary graft failure, attributed to low cell dose. This patient engrafted after a second transplant from an alternative donor but ultimately died of multi-organ failure. He was neutropenic for over 60 days and never experienced surgical site infection. There were no procedure related delays to start of conditioning or to discharge.
Children of all ages can now be offered the possibility of fertility preservation following HSCT for benign and malignant conditions. Our review suggests that these procedure for both females and males can be performed close to the start of conditioning which allows for coupling with central access placement. These procedures appear to be safe and do not add to transplant-related morbidity.

Copyright © 2021. Published by Elsevier Inc.
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