Fertility Issues Following Hematopoietic Stem Cell Transplantation

André Tichelli; Alicia Rovó

Disclosures

Expert Rev Hematol. 2013;6(4):375-388. 

In This Article

Abstract and Introduction

Abstract

With the improvement of the outcome, the number of long-term survivors of hematopoietic stem cell transplantation (HSCT) is continuously increasing. However, there is still a high burden of late morbidity and mortality. Two-thirds of the transplant survivors develop at least one late effect interfering with their physical or psychological health. Infertility is common after myeloablative HSCT conditioned with total body irradiation and high doses of gonadotoxic drugs. Other factors, such as the age of the patient at transplantation, the treatment modality received before HSCT or the onset of chronic graft versus host disease, may play an additional role. Accordingly, the number of pregnancies observed after HSCT is very low when compared to a general population in childbearing age. Furthermore, complications during pregnancy and at delivery occur significantly more frequently, probably because of the uterine damages caused by irradiation therapy. However, there is no excess of congenital abnormalities observed among newborn children. Today there are good possibilities for fertility preservation. In male patients cryopreservation of sperm, and in female patients cryopreservation of fertilized embryos or of mature oocytes, are well-established treatment options. Patients' and physicians' attitude toward discussion on fertility issues play a key role in the success of fertility preservation after HSCT.

Introduction

Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for defined malignant and non-malignant hematological disorders. With improvement of the outcome and increasing number of transplants performed yearly, long-term survivorship becomes an important issue. The aim of HSCT is to cure the patient from the primary disease and to restore complete physical and mental health condition. Despite the improvement of HSCT, long-term survivors still have a higher mortality rate compared to a matched general population[1] and are at risk for late complications interfering with health condition and quality of life.[2–4] Two third of transplant survivors develop at least one chronic health condition, and 20% of the long-term survivors develop life-threatening conditions.[5]

Late effects after HSCT are complications with relevant long-term consequences in recipients. The time of their appearance may be very diverse, depending on the type of complication and the risk factors involved. Late effects, despite often not life threatening, may significantly affect quality of life in long-term survivors, with impairment of physical and mental conditions. Fertility issues have a unique place in the care of HSCT long-term survivors. Transplant-induced infertility does not per se produce physical symptoms and clinical manifestations but can be associated with significant psychological distress in long-term survivors and their respective partner if they wish to conceive a child.[6] Despite infertility is an early complication after transplantation, fertility issues become relevant for the transplant survivor later, at a point time when survivors have recovered from HSCT. Finally, infertility is closely linked with endocrine dysfunction, which in turn can cause serious symptoms and physical conditions.

The present review will address female and male infertility issues after HSCT, including screening recommendations and option for fertility preservation. We will also discuss patients' and doctors' attitudes toward fertility issues, as well as ethical and legal considerations on infertility and fertility preservation after HSCT. Because of the strong correlation between cancer treatment and HSCT in respect of fertility issues, the present review will also refer to studies of cancer treatment.

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