Leena Nahata

Low Fertility Preservation Utilization Among Transgender Youth

PURPOSEnResearch demonstrates a negative psychosocial impact of infertility among otherwise healthy adults, and distress among adolescents facing the prospect of future infertility due to various medical conditions and treatments that impair reproductive health. Guidelines state that providers should counsel transgender youth about potential infertility and fertility preservation (FP) options prior to initiation of hormone therapy. The purpose of this study was to examine the rates of fertility counseling and utilization of FP among a cohort of adolescents with gender dysphoria seen at a large gender clinic.nnnMETHODSnAn Institutional Review Board-approved retrospective review of electronic medical records was conducted of all patients with ICD-9/10 codes for gender dysphoria referred to Pediatric Endocrinology for hormone therapy (puberty suppression and/or cross-sex hormones) from January 2014 to Augustxa02016.nnnRESULTSnSeventy-eight patients met inclusion criteria. Five children were prepubertal, no hormone therapy was considered, and they were therefore excluded. Of the remaining 73 patients, 72 had documented fertility counseling prior to initiation of hormone therapy and 2 subjects attempted FP; 45% of subjects mentioned a desire or plan to adopt, and 21% said they had never wanted to have children.nnnCONCLUSIONSnUtilization rates of FP are low among transgender adolescents. More research is needed to understand parenthood goals among transgender youth at different ages and developmental stages and to explore the impact of gender dysphoria on decision-making about FP and parenthood. Discussions about infertility risk, FP, and other family building options should be prioritized in this vulnerable adolescent population.

Insulin Therapy in Pediatric Patients with Type I Diabetes: Continuous Subcutaneous Insulin Infusion versus Multiple Daily Injections

The goal of this article was to review studies comparing continuous subcutaneous insulin infusion (CSII) to multiple daily insulin injections (MDIs) in children and adolescents with type I diabetes on five parameters: glycemic control, adverse events, required insulin dosage, weight gain, and psychosocial implications. Two of the five studies (sample sizes 19-75 patients) showed that insulin pumps provided better glycemic control, fewer adverse events, and better psychosocial implications than MDIs. Three of the five showed a lower required insulin dosage in CSII and one of the five showed less weight gain with CSII. Studies 4 and 5, both done in preschoolers, showed no significant difference on any of the five parameters. The majority of the patients and families chose to continue with CSII after the completion of the studies, even in studies where insulin pumps showed no objective benefit. Insulin pumps appear to offer potential benefit over MDIs, but the efficacy, safety, and cost effectiveness of CSII versus MDIs as first-line therapy for type I diabetes in this population has not yet been clearly established. Until more data are available from large, randomized, controlled studies, MDIs may be used as first-line therapy and CSII should be considered in patients who have poor glycemic control or who are not compliant with multiple injections.

Fertility counseling and preservation practices in youth with lupus and vasculitis undergoing gonadotoxic therapy

OBJECTIVEnTo assess fertility counseling and preservation practices among children, adolescents, and young adults with rheumatic diseases undergoing cyclophosphamide (CTX) treatment.nnnDESIGNnRetrospective chart review (2006-2016).nnnSETTINGnAcademic pediatric center.nnnPATIENT(S)nMale and female patients with systemic lupus erythematosus, Wegeners granulomatosis/granulomatosis with polyangiitis, or other vaculitides, receiving CTX treatment.nnnINTERVENTION(S)nNone.nnnMAIN OUTCOME MEASURE(S)nDocumentation of fertility counseling and fertility preservation.nnnRESULT(S)nA total of 58 subjects met the inclusion criteria; 5 were excluded due to incomplete records, thus N = 53. Of these 75% were female (N = 40). Median age was 14xa0years at diagnosis and 15xa0years at first CTX treatment. A total of 51% of subjects (69% of males and 45% of females) had no documentation about potential fertility loss before CTX treatment. Among females where fertility counseling was documented, the only fertility preservation option discussed was leuprolide acetate (LA), which was pursued in all of these cases. Of 13 males (77% postpubertal), 3 were offered sperm banking, of whom 2 declined and the other attempted after treatment began and was azoospermic. Of 53 patients, 1 was referred to a fertility specialist. Mean cumulative CTX dose was 9.2xa0g in males and 8xa0g in females.nnnCONCLUSION(S)nBased on these findings, increasing awareness about infertility risk, fertility preservation options, and referral to fertility specialists is needed among pediatric rheumatologists. Prospective studies are needed to assess fertility outcomes in this patient population (including effectiveness of LA with regard to pregnancy rates [PRs]), as well as barriers/facilitators to fertility counseling and fertility preservation.

A Call for Fertility and Sexual Function Counseling in Pediatrics.

* Abbreviation:n AAP — : American Academy of PediatricsnnDuring a pediatric endocrinology clinic visit, a 16-year-old boy presented with his family for evaluation of his endocrine axes due to history of bone marrow transplantation. He had previously been followed elsewhere; transfer records stated his family had been told that his fertility was likely to be impaired, but his parents had not shared this with him. It was also unclear from review of the notes whether any discussions regarding sexual function had occurred.nnHistorically, reproductive health in pediatrics has focused primarily on contraception and prevention of sexually transmitted infections. However, there is now a growing body of literature discussing the long-term impact of many pediatric conditions and treatments on fertility and sexual function, such as oncologic therapy, hematologic or autoimmune conditions requiring bone marrow transplantation, renal and rheumatologic disorders in which alkylators are used, cross-sex hormonal therapy used in the care of transgender youth, disorders of sex development, and other genetic syndromes such as galactosemia. Pediatric providers face dilemmas about the optimal approaches for assessing and discussing fertility and sexual function with patients and families, the type of guidance to give to parents about related communications with their children at each developmental stage, and ethical obligations regarding disclosure when parents are opposed to sharing sensitive information with their children.nnDecades ago, the nondisclosure approach to sensitive … nnAddress correspondence to Leena Nahata, MD, Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: leena.nahata{at}nationwidechildrens.org

Fertility perspectives and priorities among male adolescents and young adults in cancer survivorship

Infertility is a common and distressing late effect of cancer treatment among male survivors. Investigators examined desire for parenthood, prioritization of fertility compared to other life goals, and reports of fertility‐related discussions among a cohort of male adolescent and young adult survivors. Eighty percent desired a biological child, yet only 31% ranked having a child among their “top 3” life goals. Only 40% reported fertility‐related discussions with their health care providers in survivorship. Given the importance of biological children among this cohort, future guidelines should encourage a more proactive approach to providing fertility counseling and offering testing, to mitigate distress and prevent unplanned pregnancies.

Long-term follow-up of endocrine function among young children with newly diagnosed malignant central nervous system tumors treated with irradiation-avoiding regimens.

The adverse effects of irradiation on endocrine function among patients with pediatric brain tumor are well documented. Intensive induction chemotherapy followed by marrow‐ablative chemotherapy with autologous hematopoietic cell rescue (AuHCR) without central nervous system (CNS) irradiation has demonstrated efficacy in a proportion of very young children with some malignant CNS tumors. This study assessed the long‐term endocrine function of young children following chemotherapy‐only treatment regimens.

Fertility-related knowledge and reproductive goals in childhood cancer survivors: Short communication

STUDY QUESTIONnDo young adult survivors of childhood cancer know their fertility status, in the context of their parenthood goals and screening for gonadal functioning?nnnSUMMARY ANSWERnWhile 80% of survivors (who were without children) wanted children in the future, most did not know their fertility status, and screening for gonadal functioning was underutilized.nnnWHAT IS KNOWN ALREADYnSurvivors of childhood cancer are at risk for infertility, but fertility counseling and assessment are underutilized. Separate studies indicated that survivors fertility-related knowledge is poor and that they often wanted to have children. Yet, studies have not investigated the intersection of both issues, as well as potential distress if parenthood goals are not met.nnnSTUDY DESIGN, SIZE, DURATIONnYoung adult male and female survivors of childhood cancer (N = 149) completed cross-sectional surveys, and data for those without children (n = 105, 70.5%) are presented here.nnnPARTICIPANTS/MATERIALS, SETTING, METHODSnParticipants were 20-40 years old (M = 26.5), diagnosed 5-33 years prior to study participation, and completed questionnaires online. Knowledge of fertility status, parenthood goals, and potential distress if survivors were unable to have children were assessed. Medical records were reviewed for hormone levels as indicators of screening for gonadal functioning.nnnMAIN RESULTS AND THE ROLE OF CHANCEnMost survivors (n = 81; 77.1%) did not know their fertility status, while over 80% (n = 89) wanted children (neither aspect varied by socio-demographic/cancer-specific factors). Two-thirds of survivors indicated they would be distressed if parenthood goals remained unfulfilled; especially female (versus male, t = 2.64; P = 0.01) or partnered (versus single, t = -3.45; P < 0.001) survivors. Forty survivors (38.1%) had documented assessments of gonadal functioning, of which 33 (82.5%) reported not knowing their fertility status.nnnLIMITATIONS, REASONS FOR CAUTIONnRelevant risk factors may have not been identified owing to limited sample size and missing treatment information. The underutilization of screening for gonadal functioning needs further exploration in other pediatric centers.nnnWIDER IMPLICATIONS OF THE FINDINGSnMost adult childhood cancer survivors want to become parents, but do not know their fertility status, which could cause significant psychological distress. Healthcare providers should continuously address fertility among survivors, but more research is needed on how to implement routine fertility counseling and/or testing.nnnSTUDY FUNDING/COMPETING INTEREST(S)nThis study was funded by the Research Institute at Nationwide Childrens Hospital (V.L.) and Dutch Cancer Society (RUG2009-4442, M.A.T.). All authors have no conflict of interest to declare.

Disorders of Sex Development: Pediatric Psychology and the Genital Exam

ObjectivenTo provide suggestions for clinical care of youth with disorders of sex development (DSD) and their families, by drawing on preexisting pediatric psychology literature with a particular focus on child sexual abuse (CSA) genital exams.nnnMethodnRelevant peer-reviewed papers published since 1990 in the CSA literature were systematically reviewed, as well as an illustrative sample of general pediatric psychology papers.nnnResultsnEmpirical research from the CSA literature provided information on prevalence of distress and the impact of provider behavior, the importance of preparation, and proposed interventions. Expert recommendations from CSA literature and general findings gleaned from pediatric psychology also address these issues.nnnConclusionsnPsychological findings in the CSA pediatric population suggest that fears and anxieties are not universal and can be linked to a number of variables. Based on this review, we make a number of recommendations for potential interventions for youth with DSD and their families, emphasizing the need for further clinical research.

New promising strategies in oncofertility

ABSTRACT Introduction: Approximately 70,000 adolescent and young adults (AYA) are diagnosed with cancer each year. While advancements in treatment have led to improved prognosis and survival for patients, these same treatments can adversely affect AYA reproductive capacity. Localized treatments such as surgery and radiation therapy may affect fertility by removing or damaging reproductive organs, and systemic therapies such as chemotherapy can be toxic to gonads, (ovaries and testicles), thus affecting fertility and/or endocrine function. This can be traumatic for AYA with cancer as survivors often express desire to have genetic children and report feelings of regret or depression as a result of infertility caused by cancer treatments. Areas covered: Emerging technologies in the field of assisted reproductive technology offer new promise for preserving the reproductive capacity of AYA cancer patients prior to treatment as well as providing alternatives for survivors. The following review revisits contemporary approaches to fertility preservation as well newly developing technologies. Expert commentary: There are several advances in ART that hold promise for patients and survivors. However there are challenges that inhibit uptake including poor communication between providers and patients about risks and fertility preservation options; high costs; and lack of insurance coverage for fertility preservation services.

Fertility counseling for transgender AYAs.

Transgender adolescents and young adults may wish to use cross-sex hormones as a means to achieve identity goals. However, these hormones may impair future reproductive functioning. This case explores the complexities related to clinical decision making concerning fertility and the use of cross-sex hormones in adolescent and young adult transgender populations.