Commentary Barriers to Fertility Preservation in Male Adolescents With Cancer: It’s Time for a Multidisciplinary Approach that Includes Urologists Leena Nahata, Laurie E. Cohen, and Richard N. Yu A cancer diagnosis can be devastating news for a child and his or her family. Fortunately, ad- vances in the treatment of childhood cancers have resulted in 5-year survival rates close to 80%. 1 Late effects of cancer treatment, such as infertility, have thus become an active area of research; a recent study found that male cancer survivors were only half as likely to sire a pregnancy as healthy males. 2 Surgery, chemotherapy, and radiation exposure can all result in temporary or permanent damage to sperm production, and fertility may be compromised soon after treatment has begun. 3,4 In addition to preserving reproductive capacity, sperm cryo- preservation in young adults appears to have other ben- efits; for example, sperm banking has been reported to help young men endure the emotional battle against cancer. 5 For all of these reasons, boys who are able to produce a semen sample are encouraged to bank sperm before starting oncological treatment. Fertility preservation has been identified as a priority for practitioners, patients, and parents. However, a mi- nority of patients actually pursue sperm banking, 6,7 and many barriers appear to exist. One study showed that although 51% of male cancer patients showed interest in having children in the future and were given a choice to bank, only 24% of them actually banked sperm. 7 Factors such as socioeconomic status 8,9 and religious concerns 8 have been reported as barriers, but the data are inconsis- tent and these variables are difficult to change. In com- parison, the role of the practitioner and the quality of counseling provided have repeatedly been reported as the most significant factors in the decision to bank sperm, 7,10-12 particularly in adolescents who may have difficulty making decisions about their future and father- hood. 13 Unfortunately, there is no universal approach regard- ing fertility preservation counseling for adolescents with cancer, resulting in many inconsistencies between health care centers and practitioners. A 2002 study showed that even though 91% of health professionals acknowledged that sperm banking should be offered to all patients at risk, 48% of them stated that they never or rarely initiate the discussion. 7 To address these discrepancies, recom- mendations were made by the American Society of Clin- ical Oncology (ASCO) in 2006 14 and the American Academy of Pediatrics (AAP) in 2008 15 to offer cryo- preservation of sperm to male patients of reproductive age. However, the current sperm banking rates remain at or under 25%, suggesting that there is a disconnect between these guidelines and the actual frequency with which sperm banking is being offered and pursued. 8 This commentary highlights the major barriers to fertility pres- ervation in this unique population of patients. Awareness of these issues and development of a multidisciplinary approach, with the inclusion of urologists, may ultimately increase the number of adolescents who choose to pre- serve fertility. PRACTITIONERS HAVE LITTLE TIME AND INADEQUATE KNOWLEDGE ABOUT THIS TOPIC Semen cryopreservation was first established as a safe and effective method of fertility preservation in adults. Dur- ing interviews with adult male cancer survivors, the amount of guidance that had been given by their health care providers was identified as the most important factor in the decision to bank sperm. The cancer survivors felt that practitioners should be clear and direct when dis- cussing the risk for infertility, and should emphasize the importance of sperm banking. Patients who had not received this guidance often did not bank sperm and later expressed regret. 10 Schover et al found that men who had no memory of being told about sperm banking were Financial Disclosure: The authors declare that they have no relevant financial interests. From the Division of Endocrinology, Department of Medicine, Children’s Hospital Boston, Boston, MA; and the Department of Urology, Children’s Hospital Boston, Boston, MA Reprint requests: Leena Nahata, M.D., Division of Endocrinology, Children’s Hospital Boston, 300 Longwood Avenue, Boston, MA 02115. E-mail: leena.nahata@ childrens.harvard.edu Submitted: December 29, 2011, accepted (with revisions): February 20, 2012 1206 © 2012 Elsevier Inc. 0090-4295/12/$36.00 All Rights Reserved doi:10.1016/j.urology.2012.02.035