距离是否会阻碍男性生育能力的保存?

IF 503.1 1区 医学 Q1 ONCOLOGY CA: A Cancer Journal for Clinicians Pub Date : 2023-07-03 DOI:10.3322/caac.21804
Mike Fillon
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Lead author Daniel Pelzman, MD, resident physician at UPMC’s Department of Urology in Pittsburgh, Pennsylvania, says that this was a key reason prompting the study. “There has been so little research done about geography as a potential barrier to fertility preservation in men. We believe this is the first study to investigate whether the distances from fertility centers decreased the odds of males taking advantage of FP after referral.”</p><p>For the study, the researchers investigated male patients who were referred to the UPMC fertility clinic for FP between 2013 and 2021. Each subject had at least reached puberty, and all had FP recommended by a reproductive specialist. Semen was collected at a time chosen by the patients. 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Still, the researchers noted that the proportion of patients undergoing FP was consistently high (i.e., &gt;50%). “This finding confirms that men <i>want</i> to pursue fertility preservation after referral, even if it is difficult logistically,” Dr Pelzman concluded.</p><p>Timothy D. Gilligan, MD, vice-chair for education and associate professor of medicine at the Cleveland Clinic’s Taussig Cancer Institute in Cleveland, Ohio, agrees that men would be more likely to complete sperm banking if there were a facility for doing so closer to where they live. “The study was not able to determine whether the men who lived farther away simply went somewhere else closer to do sperm banking, however,” he adds. “In other words, it’s possible that the men who did not complete sperm banking in Pittsburgh did complete it somewhere else.”</p><p>Dr Gilligan says that a more robust study design would have entailed contacting the subjects of the study to determine whether they had completed sperm banking at a different facility. He adds that one limitation of the study is the denominator: The researchers looked at men who were referred, but it is not known how many men should have been referred but were not.</p><p>The ultimate question is what percent of men who are appropriate candidates for sperm banking and who want to have their fertility preserved end up being referred for sperm banking and then complete sperm banking,” says Dr Gilligan. “There can be failures to offer fertility preservation, to make fertility preservation feasible, and by the patient to follow through with sperm banking even if it is feasible. 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引用次数: 0

摘要

一项新的回顾性研究表明,对于希望接受促性腺毒素治疗的癌症患者来说,距离可能会影响他们从家到诊所的长途跋涉的决定。总的来说,匹兹堡大学医学中心(UPMC)的研究人员发现,距离似乎在男性是否接受生育能力保存(FP)方面发挥了作用。该研究发表在JCO肿瘤学实践(doi:10.1200/OP.22.00789)。该研究的作者指出,尽管近90%的美国人住在离泌尿科医生不到半小时车程的地方,但住在专家和提供计划生育服务的医疗中心附近的男性的生育率急剧下降。主要作者Daniel Pelzman医学博士是宾夕法尼亚州匹兹堡UPMC泌尿科的住院医师,他说这是促使这项研究的关键原因。“关于地理是男性保持生育能力的潜在障碍的研究很少。我们相信这是第一个调查距离生育中心的距离是否会降低男性转诊后利用计划生育的几率的研究。”在这项研究中,研究人员调查了2013年至2021年间被转介到UPMC生育诊所接受计划生育治疗的男性患者。每个受试者都至少进入了青春期,并且都接受了生殖专家推荐的计划生育。精液在病人选择的时间收集。虽然并非所有患者在计划生育之前都看过生殖泌尿科医生,但他们都同意通过电话或亲自与计划生育协调员进行咨询。具体来说,该研究报告称,对于所有癌症类型,73.6%(182)居住在距离UPMC生育诊所不超过20英里的患者接受了计划生育。尽管居住在20-40英里以外的人(70名男性)接受计划生育的比例略高(76.1%),但人们离UPMC生育诊所越远,这一比例就越低;在距离诊所40-60英里的47名患者中,只有59.6%(28 / 47)和58.3%(14 / 24)的患者居住在距离诊所80-100英里的生育诊所接受了精子库。尽管如此,研究人员指出,接受FP的患者比例一直很高(即50%)。Pelzman博士总结道:“这一发现证实,男性在转诊后希望保持生育能力,即使这在后勤上很困难。”蒂莫西·d·吉利根医学博士是俄亥俄州克利夫兰克利夫兰诊所陶西格癌症研究所的教育副主席和医学副教授,他也认为,如果在他们居住的地方附近有这样的设施,男性将更有可能完成精子库。他补充说:“然而,这项研究并不能确定那些住得更远的男性是否只是去了更近的地方去做精子银行。”“换句话说,没有在匹兹堡完成精子库的男性有可能在其他地方完成了这项工作。”吉利根博士说,一个更可靠的研究设计需要联系研究对象,以确定他们是否在不同的机构完成了精子库。他补充说,这项研究的一个局限性是分母:研究人员研究的是被推荐的男性,但不知道有多少男性应该被推荐,但没有。吉利根博士说:“最终的问题是,有多少男性是精子库的合适人选,并希望保留生育能力,最终被转介到精子库,然后完成精子库。”“可能无法提供生育能力保存,无法使生育能力保存可行,即使可行,患者也无法坚持使用精子库。如果我们的目标是让那些希望保持生育能力的男性能够做到这一点,那么我们需要研究这个过程中可能出现问题的所有不同点。”吉利根博士还感叹,在美国,获得医疗服务的机会因地区而异。他说:“农村地区是出了名的服务不足。“运营这样一家诊所不仅有成本问题,而且还存在万一标本处理不当或储存不当时的责任问题。”他相信,如果精子库的服务范围扩大,会有更多的男性保存自己的精子。研究作者提出的一个解决方案是邮寄精液冷冻保存服务。尽管作者认为这可能成为一种可行的选择,但目前还没有多少数据表明这种选择有多可靠或准确。吉利根博士对此表示赞同。正如研究中提到的那样,邮寄精液冷冻保存试剂盒可能比试图在每个城镇建立生育保存诊所更经济可行。 吉利根博士的一个关键结论是,临床医生不仅要记住为合适的患者提供冷冻保存,并为那些想要这样做的人提供推荐,还需要与他们讨论完成计划生育的障碍,包括经济、文化、后勤和情感问题。他说:“癌症的诊断通常是令人恐惧和困惑的,患者往往非常担心自己的癌症存活下来,以至于生育似乎不是他们的首要任务,即使它在未来将是一个首要任务。”“我们能做的一件事就是证实许多人对生育能力的重视,并帮助他们认识到,即使他们在癌症诊断后并不担心生育能力,但当他们的治疗完成后,他们很可能会有不同的感觉。”他继续说:“保留生育能力是为了保留你未来的选择,这样你就不会从未来的自己那里拿走选择。”“在这种复杂的情况下,住在离生育保存诊所很远的地方可能会成为另一个障碍,临床医生可以通过与患者一起制定策略来帮助他们克服这种后勤挑战。”佩尔兹曼博士认为,这项研究传达的信息是双重的。“首先,医院系统和提供者应该加大努力,确保即使是远离生育中心的男性也能获得生育保护。然而,更重要的是,距离不应妨碍转诊给生殖专家,因为如果转诊,来自不同距离的男性中有很大一部分会寻求保留生育能力。”
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Does distance deter male fertility preservation?

For patients with cancer under-going gonadotoxic therapies who wish to undergo sperm banking, distance may have an impact on their decision for making the trek from their homes to the clinic according to a new retrospective study. Overall, researchers at the University of Pittsburgh Medical Center (UPMC) found that distance seemed to play a role in whether or not men underwent fertility preservation (FP).

The study appears in JCO Oncology Practice (doi:10.1200/OP.22.00789).

The study authors note that although nearly 90% of the US population lives within a half-hour’s drive to a urologist, there is a steep dropoff for males who live close to specialists and medical centers offering FP. Lead author Daniel Pelzman, MD, resident physician at UPMC’s Department of Urology in Pittsburgh, Pennsylvania, says that this was a key reason prompting the study. “There has been so little research done about geography as a potential barrier to fertility preservation in men. We believe this is the first study to investigate whether the distances from fertility centers decreased the odds of males taking advantage of FP after referral.”

For the study, the researchers investigated male patients who were referred to the UPMC fertility clinic for FP between 2013 and 2021. Each subject had at least reached puberty, and all had FP recommended by a reproductive specialist. Semen was collected at a time chosen by the patients. Although not all patients saw a reproductive urologist before FP, all of them agreed to counseling with an FP coordinator by phone or in person.

Specifically, the study reported that for all cancer types, 73.6% (182) of the patients who lived no more than 20 miles away from the UPMC fertility clinic underwent FP. Although a slightly higher proportion of those living 20–40 miles away (70 men) underwent FP (76.1%), rates consistently dropped the farther out people lived from the UPMC fertility clinic; only 59.6% (28 of 47) of the patients who lived 40–60 miles from the clinic and 58.3% (14 of 24) of the patients who lived 80–100 miles from the clinic underwent sperm banking at the UPMC fertility clinic. Still, the researchers noted that the proportion of patients undergoing FP was consistently high (i.e., >50%). “This finding confirms that men want to pursue fertility preservation after referral, even if it is difficult logistically,” Dr Pelzman concluded.

Timothy D. Gilligan, MD, vice-chair for education and associate professor of medicine at the Cleveland Clinic’s Taussig Cancer Institute in Cleveland, Ohio, agrees that men would be more likely to complete sperm banking if there were a facility for doing so closer to where they live. “The study was not able to determine whether the men who lived farther away simply went somewhere else closer to do sperm banking, however,” he adds. “In other words, it’s possible that the men who did not complete sperm banking in Pittsburgh did complete it somewhere else.”

Dr Gilligan says that a more robust study design would have entailed contacting the subjects of the study to determine whether they had completed sperm banking at a different facility. He adds that one limitation of the study is the denominator: The researchers looked at men who were referred, but it is not known how many men should have been referred but were not.

The ultimate question is what percent of men who are appropriate candidates for sperm banking and who want to have their fertility preserved end up being referred for sperm banking and then complete sperm banking,” says Dr Gilligan. “There can be failures to offer fertility preservation, to make fertility preservation feasible, and by the patient to follow through with sperm banking even if it is feasible. If our goal is for men who desire to preserve their fertility to be able to do so, then we need to look at all of the different points in the process where things may break down.”

Dr Gilligan also laments that access to care in the United States varies by region. “Rural areas are famously underserved,” he says. “There is not only the cost of running such a clinic but also the problem of liability in case the specimen is mishandled or not properly stored.” If sperm banking were offered more widely, he believes more men would preserve their sperm.

One solution proposed by the study authors is mail-in semen cryopreservation services. Although the authors believe that this could emerge as a viable option, at this time there are minimal data on how reliable or accurate this option is.

Dr Gilligan agrees. “As the study mentions, mail-in semen cryopreservation kits may be a much more economically feasible solution than trying to set up a fertility preservation clinic in every town.”

A key takeaway for Dr Gilligan is that clinicians must not only remember to offer cryopreservation to appropriate patients and to make referrals for those who want to do so but also need to talk with them about barriers to completing FP, including economic, cultural, logistical, and emotional issues. “A diagnosis of cancer is often terrifying and disorienting, and patients are often so worried about surviving their cancer that fertility does not seem like a priority, even if it will be a priority in the future,” he says. “One thing we can do is to validate the importance that many people put on fertility and to help them recognize that even if they aren’t worried about fertility in the aftermath of their cancer diagnosis, they may well feel differently in the future when their treatment has been completed.

“Fertility preservation is about preserving your future options so that you aren’t taking options away from your future self,” he continues. “In this complicated context, living a long distance from the fertility preservation clinic can become yet another barrier, and clinicians can help patients by strategizing with them about ways to overcome such logistical challenges.”

Dr Pelzman believes that the takeaway messages from the study are twofold. “First, hospital systems and providers should increase their efforts to ensure access to fertility preservation even for men living far from fertility centers. More importantly, however, distance should not preclude referral to a reproductive specialist, as a high percentage of men from all distances will pursue fertility preservation if referred.”

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来源期刊
CiteScore
873.20
自引率
0.10%
发文量
51
审稿时长
1 months
期刊介绍: CA: A Cancer Journal for Clinicians" has been published by the American Cancer Society since 1950, making it one of the oldest peer-reviewed journals in oncology. It maintains the highest impact factor among all ISI-ranked journals. The journal effectively reaches a broad and diverse audience of health professionals, offering a unique platform to disseminate information on cancer prevention, early detection, various treatment modalities, palliative care, advocacy matters, quality-of-life topics, and more. As the premier journal of the American Cancer Society, it publishes mission-driven content that significantly influences patient care.
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