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Approximately 10% of newly diagnosed cancers in the UK occur in individuals aged between 15 and 49 years.1 Owing to the increase in cancer incidence with age, the trend towards delayed childbirth means that there is a higher chance of being diagnosed with cancer before families are complete. In 2015, over half (53%) of all live births in England and Wales were to mothers aged 30 and over, and two-thirds (68%) of fathers were aged 30 and over.2 Furthermore, improvements in treating cancer have resulted in greater numbers of survivors for whom fertility is an important issue.

Many cancer treatments can affect fertility, either directly through gynaecological surgery or through targeting of rapidly dividing cells by systemic therapies, affecting the reproductive organs and endocrine system.3 The effects of surgery, chemotherapy and radiotherapy on reproductive function have been the most extensively documented; however, other treatments can have direct or indirect effects on fertility. Chemotherapy and radiotherapy can cause temporary, long-term or permanent reduction in sperm counts. Radiation and alkylating agents are most likely to cause long-term or permanent azoospermia.4 Recovery of sperm production depends on the survival of spermatogonial stem cells and can take years. It is therefore important to counsel patients that fertility can recover eventually and therefore contraception should still be considered.

Radiation can also affect female reproduction in a variety of ways, either by disrupting the functioning of the hypothalamic-pituitary axis, causing ovarian failure, or causing damage to the uterus that prevents gestation of a fetus to full term.3 Chemotherapy causes direct toxicity to the ovaries and may cause permanent or temporary cessation of menses.3 The risk of amenorrhoea varies according to the chemotherapy regimen used and the woman's age at treatment. To complicate matters further, treatments such as tamoxifen, while not adversely affecting fertility, are teratogenic and are therefore contraindicated during pregnancy and prior to conception. During the extended 5-10 years of tamoxifen therapy a woman's fertility is likely to decline significantly.

Many national and international guidelines have been created which advise on the implications and management of fertility issues in patients with cancer.3-6 Most of the guidance, however, is based on cohort and case-control studies due to the lack of randomized evidence in this area. This chapter will focus on how fertility concerns affect patients with cancer and how physicians can improve the assessment, discussion and management of fertility issues in patients undergoing cancer therapy.

Importance of fertility to patients

While survival from cancer is a priority, fertility issues have been shown to be hugely important for cancer patients.7 Increased concerns about fertility have been correlated with increased psychological morbidity.8 One study of 131 women with early-stage breast cancer showed that recalled reproductive concerns were an independent predictor of consistent depressive symptoms (p=0.04).8

Many cancer survivors report ...

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