Bangladesh Journal of Bioethics 2014; 5(3):6-17 6 Setting Up an Ethical Oncofertility Practice in Developing Countries Alma Linkeviciute 1 , Giovanni Boniolo 2 , Fedro A. Peccatori 3 1, 2, Dipartimento di Scienze della Salute, University of Milano, Italy & Department of Experimental Oncology, European Institute of Oncology (IEO), Milan, Italy. Email:1. alma.linkeviciute@ieo.eu 2. giovanni.boniolo@ieo.eu 3. Fertility and Procreation Unit, Gynaecologic Oncology Department, European Institute of Oncology, Milano, Italy. Email:fedro.peccatori@ieo.it Abstract: Fertility preservation for cancer patients is a relatively new field in medicine which requires interdisciplinary approach. Improving therapies and rising survival rates require to consider patient’s quality of life after cancer is cured which is relevant personal issue regardless of the individual income and the level of development of the country of origin. Fertility preservation offers possible solution but also raises ethical questions. We provide a summary of ethical principles embodied in professional guidelines together with options and restrictions to access fertility preservation in developing countries. We also make a suggestion that oncofertility counselling could be a pillar to address fertility preservation issues in cancer patients. Our proposed decisional support model is patient centred and focuses on patient values, personal philosophy and view of life emphasizing sensitivity to individual patient’s needs and wishes. Some fertility preservation concerns in oncology might be addressed mirroring already available expertise while some others will call for innovative and region specific solutions. Therefore, in addition to our proposal we also provide a list of organisations working in oncofertility field. Key words: fertility preservation, cancer, decisional support, ethical counselling, personal philosophy Introduction: Oncofertility stands for “an interdisciplinary field that bridges biomedical and social sciences and examines issues regarding an individual’s fertility concerns, options, and choices in light of cancer diagnosis, treatment, and survivorship” 1 . However, scientific literature does not always use this term and ‘oncofertility’ is referred to as ‘fertility preservation for cancer (oncology) patients’. Patrizio and Caplan simply call it: “Fertility preservation is a newly developed branch of reproductive medicine aimed at preserving the potential for genetic parenthood in adults of reproductive age or children, who are at risk of sterility, before undergoing anticancer treatment” 2 . Being a sensitive and complex issue, fertility preservation in cancer cannot be self standing but an interdisciplinary approach is necessary. Cancer patients do not usually suffer infertility as a direct cause of cancer. More often it is cancer treatment such as radiotherapy, chemotherapy or surgery, which results in reduced fertility or even sterility in cancer survivors. Infertility in cancer survivors and general population is commonly agreed to be the inability to conceive after one year of intercourse without contraception 3 . Ability to conceive and have children is an important aspect concerning life and its quality for people worldwide. Western countries have been working towards fertility preservation methods and establishing principles for mailto:alma.linkeviciute@ieo.eu mailto:giovanni.boniolo@ieo.eu mailto:fedro.peccatori@ieo.it Bangladesh Journal of Bioethics 2014; 5(3):6-17 7 ethical practices for a few years, while the situation in developing countries is less clear. Some of already existing expertise could be applied globally acknowledging that there might be new region and culture specific concerns which will require innovation and creative approach in order to reach a solution. This article aims to show that fertility preservation for cancer patients is globally relevant, because cancer incidence is increasing even in developing countries. The quality of life after cancer treatment is a relevant personal issue regardless the individual income and the level of development of the country of origin. Existing fertility preservation options allow cancer patients to have a possibility to enjoy parenthood in the future. However, it also raises a number of ethical concerns. Professional guidelines from around the globe reflect on a number of ethical principles which we present in a light of opportunities and restrictions patients in the developing countries might face. Considering global obstacles to access fertility preservation services, we suggest that a thorough oncofertility counselling for all cancer patients could be the first pillar to address fertility issues in cancer patients. We also provide a decisional support model which focuses on patient values and provide a short overview of resources available online to establish an effective oncofertility counselling service in oncology hospitals. Cancer Survival Worldwide: Cancer survival rates are increasing and life after cancer is a real possibility for many patients worldwide. This is why it is also important to speak about life after cancer and take steps to ensure a good quality of life for cancer survivors even before cancer treatment begins. In Europe about one third of adult cancers have a relative 5-year survival rate greater that 80% 4 , combined 5-year survival rates for all childhood cancers is ranging from 70% to 82% 5 . Similar 5-year survival rates for adult and childhood cancers are available from the United States, Canada and Australia 6,7,8,9 . China, South Korea, Singapore and Turkey have slightly lower relative 5-year cancer survival rates ranging between 44-82% 10 and Brazil below 60% 7 . There is no much data from African countries where survival does not exceed13-22%. In the Gambia and Uganda with exception of breast cancer survival reaching 43% 10 , reports on childhood cancer survival rates vary widely 11 . However, it is estimated that the number of cancer cases in African countries will increase significantly by 203012. Lower survival rates in developing countries are most likely due to late diagnosis and limited availability of standard treatments 13 , the same problem is reported in Eastern European countries 4,7 . Cancer is predominantly associated with older age, even though it also affects children, adolescents and young adults. Survival rates are known to be the highest for patients aged between 15 and 44 years old 4 . Childhood cancers represent 1% of all recorded malignancies 14 . Moreover, epidemiological data from the USA and Europe also suggests that there has been an increase in childhood cancer incidence by 1% each year15,16 and the most frequent single diagnoses in children are acute lymphoblastic leukaemia, astrocytoma, neuroblastoma, non-Hodgkin lymphoma, and nephroblastoma 17 . Fertility Preservation Solutions and Practices in Western Countries: Well established fertility preservation methods for women are embryo and oocytes cryopreservation and sperm Bangladesh Journal of Bioethics 2014; 5(3):6-17 8 cryopreservation for men. These methods are widely described in the literature 18,19,20 and recognised by professional guidelines such as American Society of Clinical Oncology (ASCO) 21 , American Society of Reproductive Medicine (ASRM) 22 and European Society of Medical Oncology (ESMO) 23 . Other fertility preservation methods are less well established and still considered experimental. Ovarian and testicular tissue cryopreservation is the sole fertility preservation method available for prepubertal children 21 . It is still highly experimental and there is no proven benefit that patients who had their fertility preserved using these methods will be able to benefit from them in the future. Ovarian tissue cryopreservation has been used as fertility preservation methods in adult women and nearly 30 live births have been reported using this method 24 . However, there is still no certainty if it can successfully be used when ovarian tissue was obtained from prepubertal ovaries. Following the guidelines, all cancer patients and /or their parents or guardians should be informed about cancer treatment effects on future fertility and physicians should discuss available options to preserve fertility. Usually there are time constrains to consider all available options because in many cases cancer treatment has to be initiated as soon as possible to achieve good health outcomes. However, despite available guidelines and established methods, recent review of oncologists’ attitudes and practices revealed that not all physicians are prepared to discuss fertility related issues with their patients indicating that concerns about patient’s prognosis, lack of knowledge and sometimes personal biases prevent them from addressing fertility preservation needs adequately 25 . Meanwhile, patients are interested to receive fertility preservation consultation and appreciate such information as part of shared decision making even if they choose not to preserve their fertility before cancer treatment commences26. A number of recent studies suggest that nearly half of cancer patients do not receive appropriate fertility preservation counselling 25,27 . Moreover, in many instances female patients are informed and proceed with fertility preservation less often than men 28, 29 . However, despite of fertility importance for female patients it has been reported that globally only less than 10 % would accept lower chances to survival in order to preserve fertility30. Ethical Implications of Currently Followed Practices: As it has been shown above, current fertility preservation practices for cancer patients are still far from perfection. Oncofertility field is still new and being multi-disciplinary requires innovative solutions and close cooperation among different healthcare providers. It brings up some new ethical issues but a good number of ethical concerns relating to fertility preservation in oncology are not new, they just have to be addressed in a different light 31 . The following questions are still lacking comprehensive answers in the literature but they could help to initiate a self reflection on developing a personal stand on fertility preservation issue in general. Medicine: How do we set treatment priorities? Is it appropriate to delay cancer treatment to preserve the chance to have biological child if patient survives? Could doctor’s suggestion to preserve fertility give false hopes about survival? Emotional wellbeing: What feelings, expectations, and wishes are held by patients and physicians? How do frustration, anxiety and fear affect quality of care? Bangladesh Journal of Bioethics 2014; 5(3):6-17 9 Sociology: What roles does fertility preservation play for patients’ identity during and after cancer treatment? Is there societal pressure to be a parent? Is infertility stigmatised? Law: How should storage of cryopreserved biomaterial be regulated? Can cryopreserved gametes be used posthumously? Who decides and under what circumstances? Who decides for the best interest of the child? Can law interfere with parental choices of children fertility preservation? Research ethics: What is the actual status of fertility preservation technologies? Is there a difference between experimental and innovative treatment? Should they be developed further? How should they be introduced for patients? Communication: Why some physicians feel uncomfortable about discussing fertility preservation? Decision making: When is child mature enough to make his/her own decision? When is patient too ill for fertility preservation? Can fertility preservation be denied on the grounds of low prospects to survive? Are there age limits for candidates to preserve fertility? Should there be such limits? Economics: Should preserving fertility for cancer patients be paid by society? Who should bear the costs: healthcare system, private insurance, individual, charity funds? Commercialisation of reproductive technologies: Could the interests of fertility clinics overweight patients’ best interest? Are fertility clinics selling fertility preservation services and future hope which is sometimes false hope? Human rights: Does having cancer create a right for fertility preservation? Does European Convention on Human Rights (Art.12) ‘right to found a family’ have exceptions in case of cancer? Interests of potential future children: Does cancer patient’s/survivor’s right to have a child comes at the expense of the rights of a child to be born? Answers to the questions above could be different and could be influenced by one’s culture, religion, personal values and beliefs. Medical professionals are still lacking knowledge and skills on how to approach personal biases in order to be able to address cancer patients’ needs. Strengthening communication skills and developing counselling services are the possible solutions 3,25,27,32 . Guiding Principles in Fertility Preservation for Cancer Patients: A number of guidelines appeared in the last couple of years proposing that informing cancer patients about cancer treatment effects on fertility should be a standard 21,22,23,33 . In Europe, the European Society of Human Reproduction and Embryology (ESHRE) has been publishing ethical considerations on human reproduction related issues since 2001. Their task force on Ethics and Law does not seem to look at oncofertility related issues and takes a broader view when releasing considerations on posthumous reproduction, cryopreservation, pre-implantation genetic diagnosis. Overall consensus of currently available guidelines is that clinicians should: Bangladesh Journal of Bioethics 2014; 5(3):6-17 10 Inform patients about fertility preservation options and future reproduction before treatment starts 21,22,23,33,34 ; Parents may act to preserve fertility for minors 22 ; Pre-implantation genetic diagnosis (PGD) to avoid offspring inheriting high risk of cancer is acceptable 22 ; Concerns about welfare of resulting offspring are not sufficient reasons to deny assistance in reproduction 22 ; Patients should be referred to mental health, genetic and financial counsellors if needed 21,22,34 ; Fertility preservation discussion should allow time for reflection and involve partner, if present 33 . In bioethics literature fertility treatment is not always seen as a positive right where every individual is enabled to procreate 35 . However, right to reproduce is often defended as ability to bear autonomy, personal identity, self-determination and possession of dignity where infertility can be addressed as disability 36 . Concerns can be raised that the hype of fertility preservation options give patients the false hope of survival and future fertility even if the goal of cancer treatment is to cure with the least amount of damage and side effects. Moreover, when physician feels that risks of doing so outweighs the benefits, fertility preservation procedures could be denied or patient referred to another physician 37 . The currently established clinical pathway is based on informing the patients about cancer treatment effects on fertility, illustrating how fertility can be preserved and referring patients to fertility specialists and support services as soon as possible. Support services include decision coaching 32 , psychosocial support 21 or ethical counselling 25 . Options and Restrictions for Fertility Preservation in Developing Countries: Technologies and skills can travel easily around the globe but sometimes restrictions including cultural and religious acceptability, financial constraints and lack of local expertise or regulation are met. Unfortunately, there is very little data on available services and how often cancer patients in developing countries use them. As resources in developing countries are usually scarce, it could be argued that fertility preservation is not a primary health concern, because it is not a medically necessary procedure. However, people without children, especially women, can often be seen as having lower social status and experience ostracism by other members of their society38. This implies that fertility preservation is an important and relevant issue globally and should not be ignored. Nonetheless, the following obstacles are found in the developing world. Cultural and religious obstacles: Difficulties with particular aspects of fertility preservation and its acceptance can be detected in most religious traditions. Oncofertility field is new and views on procreation in different religions may vary. Embryo’s right to life, duty to procreate, attitudes towards Bangladesh Journal of Bioethics 2014; 5(3):6-17 11 adoption, meaning of sexual intercourse and acceptable ways on how a new human life can be conceived may assume different values in different cultural context 39 . Financial obstacles: Fertility preservation procedures are expensive and financial constraints might be the major cause why some patients do not pursue them. While in Western countries there are a variety of funding sources available, in developing countries these procedures might be available only for wealthy individuals. However, it is argued that expensive drugs could be replaced with cheaper ones. Low Cost IVF Foundation is currently running clinics in Tanzania, South Africa and Sudan and this is a good example on how IVF costs can be reduced below €200 euro per cycle 38 . Geographic obstacles and lack of trained specialists: Medical centres providing fertility preservation services have scarce geographical distribution in developed countries and there are even fewer of them in developing countries. Long travelling distance, and the related expenses, could be one of main restrictions for patients in developing countries to use fertility preservation services. It might also be difficult to find fertility specialist and even be referred to one. Very few studies from non Western countries report that more than half oncologists do not have enough knowledge about fertility preservation to feel comfortable in discussing it with their patients 40,41,42 . Lack of regulation or legal restrictions on fertility preservation methods: Not all countries have legal base which allows fertility preservation methods to be used by everyone. For instance some countries in Latin America only allow artificial reproduction technologies to be used by married couples or only homologous insemination to be used for IVF 38 . Such practices deny reproductive autonomy for individuals who do not qualify for procreation assistance under restrictive laws. Patient Centred Counselling: Providing high quality decisional support services for patients require trained counsellors who master a number of skills. These include helping patient to understand his or her medical condition and reflecting on personal philosophy and view of life which usually shape patient’s goals, wishes and expectations 25 . Involving patient’s partner is sometimes also encouraged 33 as well as some cultures might see acceptable to have other family members participating in fertility counselling, especially where patients are children. Training of counsellors will take time and require resources but this should be in the agenda of every oncology hospital. Counsellors should primarily inform patients both on medical conditions and their implications on future life, and also provide information about fertility preservation options. Moreover, they should be able to identify patient’s wishes and expectations. Counsellors should also be knowledgeable of local legislation, be prepared to handle patient’s emotions, have sensitivity to patients spiritual or religious needs, and be ready to evaluate which fertility preservation options can be affordable, when resources are limited. Resources for Ethical Practice: These are offered by a number of organisations worldwide. The Oncofertility Consortium based at Northwestern University in Chicago (USA) pioneered fertility preservation in Oncology and provides online tools for oncofertility communication. They developed Oncofertility Consortium Web site (http://oncofertility.northwestern.edu) for communication among http://oncofertility.northwestern.edu/ Bangladesh Journal of Bioethics 2014; 5(3):6-17 12 professional including Biomedical Humanities and the Web site for general public MyOncofertility (http://myoncofertility.org). The American Society for Bioethics and Humanities (http://www.asbh.org) have numerous publications on core competences and skills required to qualify as health care ethics consultant and also code of ethics and professional responsibilities for ethics consultants. The European School of Oncology (ESO) and the European School of Molecular Medicine (SEMM) at European Institute of Oncology (IEO) in Milan, Italy are also developing conceptual tools and providing training for oncologists in ethical counselling (http://www.semm.it/master.php). Conclusions: Cancer survival rates are improving and treatment outcomes are promising that there could also be life after cancer. This brings up a new challenge for healthcare professionals who have to address patient’s quality of life issues after cancer is cured. Assuring the best quality of life to cancer survivors some issues like fertility preservation have to addressed before starting the treatment. Professional guidelines from the USA and Europe suggest that all cancer patients should be informed about treatment effect on their future fertility and available fertility preservation options should also be discussed. However, there are still communication problems induced by lack of time and expertise followed by personal biases held by physicians when initiating discussion on fertility preservation with a patient. Next to the information provided to all cancer patients about treatment effect on fertility and fertility preservation options other core principles allow parents to act in order to preserve fertility for their children, accept the use of PDG to avoid serious inherited conditions in the offspring, do not justify the denial of reproductive services based on the concerns about the welfare of the future child. Moreover, patients should be referred to other relevant specialists and support services when needed and given time to reflect on fertility preservation discussion and possible choices before making decisions. There is very little data on fertility preservation services and how often cancer patients use them in developing countries. Cultural and religious constraints, financial restrains, long distance to the facilities and lack of trained specialists as well as lack of regulation and legal restrictions on fertility preservation methods are often met in developed countries and can be relevant globally. Our proposal is that despite of limited resources fertility preservation issues in cancer patients should be addressed regardless the individual income and the level of development of the country of origin. A set up of ethical oncofertility practice can be started though oncofertility counselling where providing quality decision support services for all cancer patients. Such service would help patient to understand his or her medical condition and possible solutions while reflecting on personal philosophy and view of life which usually shape patient’s goals, wishes and expectations. Counsellors will play an important role and in addition to medical knowledge and communication skills will need to be knowledgeable of local legislation, have sensitivity to patient’s religious and spiritual needs, be ready http://myoncofertility.org/ http://www.asbh.org/ http://www.semm.it/master.php Bangladesh Journal of Bioethics 2014; 5(3):6-17 13 to handle patient’s emotions and also help patient to evaluate which fertility preservation options could be affordable when resources are limited. References: 1. Snyder KA. Oncofertility and the Social Sciences. In: Woodruff TK, Snyder KA, editors. Oncofertility: Fertility Preservation for Cancer Survivors. Boston, MA: Springer US; 2007: p. 137– 48. Available from: http://link.springer.com/10.1007/978-0-387-72293-1 2. Patrizio P, Caplan AL. Ethical issues surrounding fertility preservation in cancer patients. Clin Obstet Gynecol. 2010;53(4):717–26. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21048439 3. Lambertini M, Anserini P, Levaggi A, Poggio F, Del Mastro L. Fertility counseling of young breast cancer patients. J Thorac Dis. 2013;5(Suppl 1):S68–80. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3695540&tool=pmcentrez&rendertype= abstract 4. De Angelis R, Sant M, Coleman MP, Francisci S, Baili P, Pierannunzio D, et al. Cancer survival in Europe 1999-2007 by country and age: results of EUROCARE-5-a population-based study. Lancet Oncol. 2014;15(1):23–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24314615 5. Gatta G, Botta L, Rossi S, Aareleid T, Bielska-Lasota M, Clavel J, et al. Childhood cancer survival in Europe 1999-2007: results of EUROCARE-5-a population-based study. Lancet Oncol. 2014;15(1):35–47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24314616 6. Armenian SH, Landier W, Hudson MM, Robison LL, Bhatia S. Children’s Oncology Group's 2013 blueprint for research: survivorship and outcomes. Pediatr Blood Cancer. 2013;60(6):1063–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23255494 7. Coleman MP, Quaresma M, Berrino F, Lutz J-M, De Angelis R, Capocaccia R, et al. Cancer survival in five continents: a worldwide population-based study (CONCORD). Lancet Oncol. 2008;9(8):730–56. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18639491 8. Haggar FA, Pereira G, Preen DD, Holman CDJ, Einarsdottir K. Cancer survival and excess mortality estimates among adolescents and young adults in Western Australia, 1982-2004: a population-based study. PLoS One. 2013;8(2):e55630. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3566059&tool=pmcentrez&rendertype= abstract Bangladesh Journal of Bioethics 2014; 5(3):6-17 14 9. Ward E, Desantis C, Robbins A, Kohler B, Jemal A. Childhood and adolescent cancer statistics, 2014. CA Cancer J Clin. 2014;64(2):83-103. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24488779 10. Sankaranarayanan R, Swaminathan R, Brenner H, Chen K, Chia KS, Chen JG, et al. Cancer survival in Africa, Asia, and Central America: a population-based study. Lancet Oncol. 2010;11(2):165–73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20005175 11. Stefan DC. Childhood Cancer in Africa: An Overview of Resources. J Pediatr Hematol Oncol. 2014 Jan 30 [in press]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24487917 12. Parkin DM, Bray F, Ferlay J, Jemal A. Cancer in Africa 2012. Cancer Epidemiol Biomarkers Prev. 2014 Apr 3 [in press];953–66. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24700176 13. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin. 2011;61(2):69–90. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21296855 14. Resetkova N, Hayashi M, Kolp LA, Christianson MS. Fertility Preservation for Prepubertal Girls: Update and Current Challenges. Curr Obstet Gynecol Rep. 2013;2(4):218–25. Available from: http://link.springer.com/10.1007/s13669-013-0060-9 15. Kaatsch P, Steliarova-Foucher E, Crocetti E, Magnani C, Spix C, Zambon P. Time trends of cancer incidence in European children (1978-1997): report from the Automated Childhood Cancer Information System project. Eur J Cancer. 2006;42(13):1961–71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16919764 16. Smith M a, Seibel NL, Altekruse SF, Ries L a G, Melbert DL, O’Leary M, et al. Outcomes for children and adolescents with cancer: challenges for the twenty-first century. J Clin Oncol. 2010;28(15):2625–34. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2881732&tool=pmcentrez&rendertype= abstract 17. Kaatsch P. Epidemiology of childhood cancer. Cancer Treat Rev. 2010;36(4):277–85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20231056 18. Jeruss JS, Woodruff TK. Preservation of fertility in patients with cancer. N Engl J Med. 2009;360(9):902–11. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2927217&tool=pmcentrez&rendertype= abstract Bangladesh Journal of Bioethics 2014; 5(3):6-17 15 19. Klock SC, Zhang JX, Kazer RR. Fertility preservation for female cancer patients: early clinical experience. Fertil Steril. 2010;94(1):149–55. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19406395 20. Trost L, Brannigan R. Fertility Preservation in Males. In: Gracia C, Woodruff TK, editors. Oncofertility Medical Practice: Clinical Issues and Implementation. New York, NY: Springer New York; 2012. p. 27–50. Available from: http://link.springer.com/10.1007/978-1-4419-9425-7 21. Loren AW, Mangu PB, Beck LN, Brennan L, Magdalinski AJ, Partridge AH, et al. Fertility preservation for patients with cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2013;31(19):2500–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23715580 22. American Society for Reproductive Medicine. Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion. Fertil Steril. American Society for Reproductive Medicine; 2013;100(5):1214–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24011612 23. Peccatori FA, Azim HA, Orecchia R, Hoekstra HJ, Pavlidis N, Kesic V, et al. Cancer, pregnancy and fertility: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2013;24 Suppl 6(May):vi160–70. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23813932 24. Dolmans M-M, Jadoul P, Gilliaux S, Amorim C a, Luyckx V, Squifflet J, et al. A review of 15 years of ovarian tissue bank activities. J Assist Reprod Genet. 2013;30(3):305–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23417329 25. Linkeviciute A, Boniolo G, Chiavari L, Peccatori FA. Fertility Preservation in Cancer Patients: The Global Framework. Cancer Treat Rev. 2014 Jun 11[in press]; Available from: http://linkinghub.elsevier.com/retrieve/pii/S030573721400111X 26. Légaré F, Stacey D. An Interprofessional Approach to Shared Decision Making: What it Means and Where Next. In: Woodruff TK, Clayman ML, Waimey KE, editors. Oncofertility Communication: Sharing Information and Building Relationships across Disciplines. New York, NY: Springer New York; 2014. p. 131–9. Available from: http://link.springer.com/10.1007/978-1- 4614-8235-2 27. Balthazar U, Deal AM, Fritz M a, Kondapalli L a, Kim JY, Mersereau JE. The current fertility preservation consultation model: are we adequately informing cancer patients of their options? Hum Reprod. 2012;27(8):2413–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22674206 Bangladesh Journal of Bioethics 2014; 5(3):6-17 16 28. Armuand GM, Rodriguez-Wallberg KA, Wettergren L, Ahlgren J, Enblad G, Höglund M, et al. Sex differences in fertility-related information received by young adult cancer survivors. J Clin Oncol. 2012;30(17):2147–53. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22585695 29. Geue K, Richter D, Schmidt R, Sender A, Siedentopf F, Brähler E, et al. The Desire for Children and Fertility Issues Among Young German Cancer Survivors. J Adolesc Health. 2014;54(5):527- 35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24315429 30. Senkus E, Gomez H, Dirix L, Jerusalem G, Murray E, Van Tienhoven G, et al. Attitudes of young patients with breast cancer toward fertility loss related to adjuvant systemic therapies. EORTC study 10002 BIG 3-98. Psychooncology. 2014;23(2):173–82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24038775 31. Traina CLH. Ovarian Tissue Cryopreservation and Bioethical Discourse. In: Woodruff TK, Zoloth L, Campo-Engelstein L, Rodriguez S, editors. Oncofertility: Ethical, Legal, Social, and Medical Perspectives. Boston, MA: Springer US; 2010. p. 173–80. Available from: http://link.springer.com/10.1007/978-1-4419-6518-9 32. Stacey D, Kryworuchko J, Bennett C, Murray MA, Mullan S, Légaré F. Decision coaching to prepare patients for making health decisions: a systematic review of decision coaching in trials of patient decision AIDS. Med Decis Mak an Int J Soc Med Decis Mak. 2012;32(3):22–33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22505617 33. Cardoso F, Loibl S, Pagani O, Graziottin A, Panizza P, Martincich L, et al. The European Society of Breast Cancer Specialists recommendations for the management of young women with breast cancer. Eur J Cancer. 2012;48(18):3355–77. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23116682 34. Coccia PF, Pappo AS, Altman J, Bhatia S, Borinstein SC, Flynn J, et al. Adolescent and young adult oncology, version 2.2014. J Natl Compr Canc Netw. 2014;12(1):21–32; quiz 32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24453290 35. Shah DK, Goldman E, Fisseha S. Medical, ethical, and legal considerations in fertility preservation. Int J Gynaecol Obstet. International Federation of Gynecology and Obstetrics; 2011;115(1):11–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21767834 36. Backhus LE, Zoloth L. Today’s Research, Tomorrows Cures: The Ethical Implications of Oncofertility. In: Woodruff TK, Snyder KA, editors. Oncofertility: Fertility Preservation for Cancer Survivors. Boston, MA: Springer US; 2007. p. 163–79. Available from: http://link.springer.com/10.1007/978-0-387-72293-1 Bangladesh Journal of Bioethics 2014; 5(3):6-17 17 37. Gracia CR, Gracia JJE, Chen S. Ethical Dilemmas in Oncofertility: An Exploration of Three Clinical Scenarios. In: Woodruff TK, Zoloth L, Campo-Engelstein L, Rodriguez S, editors. Oncofertility: Ethical, Legal, Social, and Medical Perspectives. Boston, MA: Springer US; 2010. p. 195–208. Available from: http://link.springer.com/10.1007/978-1-4419-6518-9 38. Fleetwood A, Campo-Engelstein L. The Impact of Infertility: Why ART Should Be a Higher Priority for Women in the Global South. In: Woodruff TK, Zoloth L, Campo-Engelstein L, Rodriguez S, editors. Oncofertility: Ethical, Legal, Social, and Medical Perspectives. Boston, MA: Springer US; 2010. p. 237–48. Available from: http://link.springer.com/10.1007/978-1-4419-6518-9 39. Zoloth L, Henning AA. Bioethics and Oncofertility: Arguments and Insights from Religious Traditions. In: Woodruff TK, Zoloth L, Campo-Engelstein L, Rodriguez S, editors. Oncofertility: Ethical, Legal, Social, and Medical Perspectives. Boston, MA: Springer US; 2010. p. 261–78. Available from: http://link.springer.com/10.1007/978-1-4419-6518-9 40. Rabah DM, Wahdan IH, Merdawy A, Abourafe B, Arafa MA. Oncologists’ knowledge and practice towards sperm cryopreservation in Arabic communities. J Cancer Surviv Res Pract. 2010;4(3):279–83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20652434 41. Küçük M, Yavaşoğlu I, Bolaman AZ, Kadıköylü G. Knowledge, attitudes, and practices of hematologists regarding fertility preservation in Turkey. Turkish J Haematol Off J Turkish Soc Haematol. 2013;30(3):269–74. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3878530&tool=pmcentrez&rendertype= abstract 42. Ghorbani B, Madahi P, Shirazi E, Ardekani HS, Kamali K. Iranian Oncologists’ Attitude towards Fertility Preservation in a Sample Group. J Reprod Infertil. 2011;12(1):33–6. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3719279&tool=pmcentrez&rendertype= abstract Conflict of Interest: The authors have no conflict of interest.