title: Infertility, infertility treatment, and achievement of pregnancy in female survivors of childhood cancer: a report from the Childhood Cancer Survivor Study cohort.
abstract: BACKGROUND
  Previous studies have shown decreased pregnancy rates and early menopause in female cancer survivors; however, infertility rates and reproductive interventions have not been studied. We investigated infertility and time to pregnancy in female childhood cancer survivors, and analysed treatment characteristics associated with infertility and subsequent pregnancy.
  
  
  METHODS
  The Childhood Cancer Survivor Study (CCSS) is a cohort study including 5 year cancer survivors from 26 Canadian and US institutions who were younger than 21 years at the time of diagnosis between Jan 1, 1970, and Dec 31, 1986, and a sibling control group. We included women aged 18-39 years who had ever been sexually active. We gathered demographic, medical, and reproductive data via a baseline questionnaire, and quantified exposure to alkylating agents and radiation therapy. Self-reported infertility, medical treatment for infertility, time to first pregnancy in survivors and siblings, and the risk of infertility in survivors by demographic, disease, and treatment variables were analysed.
  
  
  RESULTS
  3531 survivors and 1366 female sibling controls who enrolled between Nov 3, 1992, and April 4, 2004, were included. Compared with their siblings, survivors had an increased risk (relative risk [RR] 1·48 [95% CI 1·23-1·78]; p<0·0001) of clinical infertility (ie, >1 year of attempts at conception without success), which was most pronounced at early reproductive ages (RR 2·92 [95% CI 1·18-7·20], p=0·020, in participants ≤24 years; 1·61 [1·05-2·48], p=0·029, in those aged 25-29 years; and 1·37 [1·11-1·69], p=0·0035, in those aged 30-40 years). Despite being equally likely to seek treatment for infertility, survivors were less likely than were their siblings to be prescribed drugs for treatment of infertility (0·57 [95% CI 0·46-0·70], p<0·0001). Increasing doses of uterine radiation and alkylating agent chemotherapy were strongly associated with infertility. Although survivors had an increased time to pregnancy compared with their siblings (p=0·032), 292 (64%) of 455 participants with self-reported clinical infertility achieved a pregnancy.
  
  
  CONCLUSIONS
  A more comprehensive understanding of infertility after cancer is crucial for counselling and decision making about future conception attempts and fertility preservation.
  
  
  BACKGROUND
  National Cancer Institute, American Lebanese Syrian Associated Charities, Swim Across America.
authors.affiliation: Department of Obstetrics and Gynecology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA. sarabarton5@gmail.com
authors.forename: Sara E
authors.initials: SE
authors.lastname: Barton
authors.forename: Julie S
authors.initials: JS
authors.lastname: Najita
authors.forename: Elizabeth S
authors.initials: ES
authors.lastname: Ginsburg
authors.forename: Wendy M
authors.initials: WM
authors.lastname: Leisenring
authors.forename: Marilyn
authors.initials: M
authors.lastname: Stovall
authors.forename: Rita E
authors.initials: RE
authors.lastname: Weathers
authors.forename: Charles A
authors.initials: CA
authors.lastname: Sklar
authors.forename: Leslie L
authors.initials: LL
authors.lastname: Robison
authors.forename: Lisa
authors.initials: L
authors.lastname: Diller
mesh_terms: D000124:Achievement; D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007246:Infertility / Q000517:prevention & control*; D009369:Neoplasms / Q000401:mortality / Q000523:psychology*; D011247:Pregnancy; D018873:Pregnancy Rate; D011379:Prognosis; D012307:Risk Factors; D057566:Self Report; D035781:Siblings; D011795:Surveys and Questionnaires; D015996:Survival Rate; D017741:Survivors / Q000523:psychology*; D055815:Young Adult