• cancer;
  • leukemia;
  • Hodgkin disease;
  • non-Hodgkin lymphoma;
  • breast cancer;
  • disparities;
  • access;
  • fertility preservation;
  • infertility;
  • fertility


  1. Top of page
  2. Abstract


This study seeks to examine the relation between sociodemographic characteristics and the utilization of fertility preservation services in reproductive age women diagnosed with cancer.


A total of 1041 women diagnosed with cancer between the ages of 18 and 40 years responded to a retrospective survey on demographic information and reproductive health history. Five cancer types were included: leukemia, Hodgkin disease, non-Hodgkin lymphoma, breast cancer, and gastrointestinal cancer. Nine hundred eighteen women reported treatment with potential to affect fertility (chemotherapy, pelvic radiation, pelvic surgery, or bone marrow transplant). Student t test, linear regression, and multivariate logistic regression were used where appropriate to determine the relation between sociodemographic characteristics and the odds of using fertility preservation services.


Sixty-one percent of women were counseled on the risk of cancer treatment to fertility by the oncology team. Overall, 4% of women pursued fertility preservation. In multivariate analysis, women who had not attained a bachelor's degree (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.5-0.9) were less likely to be counseled. Trends also suggested possible disparities in access to fertility preservation with age older than 35 years (OR, 0.1; 95% CI, 0.0-1.4) or previous children (OR, 0.3; 95% CI, 0.1-1.1) at diagnosis. Disparities in access to fertility preservation based on ethnicity and sexual orientation were also observed.


Sociodemographic health disparities likely affect access to fertility preservation services. Although awareness of fertility preservation has improved in the past decade, an unmet need remains for reproductive health counseling and fertility preservation in reproductive age women diagnosed with cancer. Cancer 2012. © 2012 American Cancer Society.


  1. Top of page
  2. Abstract

According to 2006 Surveillance, Epidemiology, and End Results (SEER) statistics, approximately 120,000 women younger than 50 years develop cancer each year in the United States.1 Early screening techniques and cancer therapies have improved cancer survival significantly over the past 20 years; the medical community is now turning to issues related to life after cancer treatment.2 Young women face post-treatment reproductive concerns relating to infertility and premature menopause.3 Fertility preservation, saving eggs and/or embryos before treatment, appears to positively affect survivors' quality of life.4, 5 The American Society of Clinical Oncology recommends that all women be offered counseling and the opportunity to take action to protect or preserve their fertility before cancer therapy.6

Advances in reproductive technology may have outpaced access. A 2008 study from the Netherlands showed that as few as 2% of women preserved their fertility before cancer treatment.7 As recently as 2009, a survey of 249 oncologists at major academic centers in the United States reported that 82% of physicians had referred a patient to a reproductive endocrinologist at some point, but more than half rarely refer.8 The reasons given for lack of referral were: lack of knowledge about reproductive options, insufficient time to discuss the issue, perception that patients could not delay treatment, and perception that if patients did not raise the issue themselves they were not interested.9

A focus on patients' access to education and resources is paramount in the discussion of postcancer treatment fertility issues. Using a statewide cancer registry of reproductive aged women, we sought to determine whether barriers to access exist within various sociodemographic groups, and whether such barriers contribute to a low utilization of fertility preservation counseling and services before cancer therapy.


  1. Top of page
  2. Abstract

We performed an analytical cross-sectional study, using the California Cancer Registry to sample women across the state. All study procedures were approved by the University of California at San Francisco Committee on Human Research.


A computer-generated randomizer was used to sample reproductive age women from the cancer registry that had a history of leukemia, Hodgkin disease, non-Hodgkin lymphoma, breast cancer, or gastrointestinal cancer. These cancers were chosen for study because they are common, nongynecologic cancer groups that can be treated with systemic chemotherapy. Patients were included in the sample if they were 18 to 40 years of age at diagnosis and were diagnosed between 1993 and 2007. Among 6709 patients initially selected for the study, 4147 patients were excluded because their contact information in the cancer registry was outdated. Letters were sent to the primary physicians of each of the remaining women before we attempted to reach the patients. Additional women were excluded if their physician thought participation in the study would cause undue psychological burden (because of severe comorbid mental illness, n = 30 patients). After exclusions, 2532 patients were contacted for participation in the study. Analyses of access included only women who reported treatment with potential to compromise fertility (ie, systemic chemotherapy, pelvic radiation, pelvic surgery, or bone marrow transplant).


The survey was created at University of California at San Francisco and assessed for readability and content validity (the extent to which our survey accurately assessed reproductive health history and quality of life) by 2 independent experts in survey methodology. It was then tested on 20 patients from the University of California at San Francisco Center for Reproductive Health for content and readability. Additional changes were made in response to this pilot study.

The survey was made available in both English and Spanish. A professional translation company (American Language Services, Los Angeles, Calif) translated the study materials into Spanish using 2 independent translators. A third bilingual person checked translations. Paper surveys were created using Cardiff Teleform (Vista, Calif). Patients could also complete the survey online through (Palo Alto, Calif).


Women were contacted between January 2010 and September 2010. A contact letter was sent to potential participants, explaining the purpose of the survey; the source of the individual's personal contact information was the California Cancer Registry. Women were able to opt out of further contact by reaching the University of California at San Francisco study coordinator. After 1 week, a second mailing was sent that included the written survey, a link to the online survey, a written consent form, a postage-paid return envelope, and an optional refusal postcard. Women were asked to complete and return a written consent form by mail and to return the survey by mail or complete it online. Women who did not reply within 3 weeks received a reminder follow-up phone call. Those who did not reply within 2 weeks of the reminder call were sent a reminder postcard with a link to the electronic survey.

Primary Outcomes

Two binary outcomes were examined with respect to several sociodemographic predictor variables. The first outcome, counseling, refers to whether women were counseled (yes/no) about the risk of their treatment to fertility by a member of the oncology team. The second, fertility preservation, refers to whether respondents pursued fertility preservation (yes/no) under the care of a reproductive endocrinologist.

We then sought to determine the yearly prevalence of each of our 2 primary outcomes. Prevalence was calculated as affirmative responses (eg, counseled [yes]/all participants) for a given year of diagnosis (eg, in 1993, 14 of 32 patients [44%] were counseled).

Mediating Variables

Disease type, stage, and treatment type were considered as potential confounders of our primary sociodemographic exposure variables.8, 9 To define stage, summary staging was used. Summary staging is a California Cancer Registry index used for epidemiologic assessment of cancers (1 = in situ; 2 = localized; 3 = regional by direct extension; 4 = regional by lymph nodes; 5 = regional by direct extension and lymph nodes; 6 = metastatic). Treatment types included having received the following categories of treatment: chemotherapy, radiotherapy, and/or bone marrow transplant.

Predictor Variables

Several sociodemographic characteristics were assessed by survey. Some of these characteristics, such as ethnicity, gender, income, attainment of college education, population density, and age at diagnosis, were chosen based on previously observed disparities in general oncology and fertility care.10-14 Although parity and marital status have been previously associated with oncologists' perceptions of their patients' fertility concerns, their association with fertility counseling by oncologists or access to fertility preservation has not been determined.15

Parity at diagnosis was defined as whether respondents reported previously having at least 1 child. Marital status was defined as having a partner (spouse or significant other) versus being single at the time of diagnosis. Sexual orientation was defined as heterosexual, homosexual, bisexual, or other (the later 3 groups were combined at analysis for the purpose of forming dichotomous variables as “other than heterosexual”).

Annual income at the time of survey was divided into 3 groups: <$30,000; $30,001-$100,000; >$100,000. Incomes of less than approximately $30,000 per year are believed to be insufficient to adequately meet the basic needs of an average American family.16 Those who have household incomes near and above $100,000 are less likely to report difficulties in establishing medical care than women in lower income groups.17 Age groups at diagnosis were divided into mostly 5-year segments to achieve sufficient sample sizes for logistic regression (ages 18-25, 26-30, 31-35, and 36-40 years). Ethnicity was defined by the following: Caucasian, Asian/Pacific Islander, African American, Hispanic American or Latina, and Native American.

Several variables, including year of diagnosis and age at diagnosis, were derived from the cancer registry. Time since diagnosis was derived as the difference between date of diagnosis and date of recruitment. Population density was defined in the California Cancer Registry as urban or rural. Urban areas were defined in the cancer registry as those with urban cores of 50,000 or more people, or areas involved in direct regional commerce with these urban cores. Socioeconomic status (SES) is a California Cancer Registry socioeconomic index based on income and education of the patient and education for the census block group of residence at diagnosis.

Data Analysis

Survey data were merged with California Cancer Registry data with a unique, anonymous identifier code. Statistical analyses were performed using Stata version 11 (StataCorp, College Station, Tex). Statistical significance was defined by 2-sided P values <.05.

Initially, Student t tests were used to compare the characteristics of responders and nonresponders. Several variables from the California Cancer Registry were available for all patients recruited for the study. Age at diagnosis, time since diagnosis, summary staging, and SES were used to assess potential differences between those women who completed the survey and those who did not.

Logistic regression was used to determine the relation between sociodemographic predictors and the odds of receiving counseling for fertility preservation or pursuing fertility preservation. Univariate analyses were initially performed for each sociodemographic predictor to evaluate the magnitude of effect on counseling as well as fertility preservation. Multivariate analyses were then performed to adjust for the effect of potential confounding variables (disease type, stage, and treatment) and the effects of other sociodemographic variables whose univariate P value was <.2.

Finally, linear regression was used to determine the rate of increase in the prevalence of counseling and fertility preservation over time, while adjusting for the effects of sociodemographic, disease, and treatment characteristics.


  1. Top of page
  2. Abstract

Patient Sample

Of the 2532 women who were contacted, 1378 women replied to our initial contact letter or survey. Of these, 337 refused and 1041 (41%) completed our survey. Forty-seven percent of participants completed it online and 53% on paper. Reasons for declining included: a request to be removed from all cancer registry studies (57%), no interest in further childbearing (10%), the topic of infertility was too emotionally difficult to discuss (2%), the survey was too long (3%), or no reason given (28%). The average time to complete the survey was 26 minutes. Of the 1041 women who completed the survey, 918 reported treatment with the potential to compromise their fertility and were included in our analyses of fertility counseling and preservation.

Table 1 shows comparisons of the 1041 responders and 1491 nonresponders, based on disease and demographic data in the cancer registry. Patients who completed the survey were 1.4 years younger at diagnosis than those who did not (P < .0001), and were diagnosed with more aggressive cancers, as indicated by a SEER summary stage index (range of 0 [in situ] to 7 [metastatic]) of 3.7 versus 3.4 (P = .0008). There were no differences between responders and nonresponders in SES (calculated from median income and education for the census block group of residence at diagnosis, P = .8) or years since diagnosis (P = .2).

Table 1. Comparison of Survey Responders Versus Nonresponders
CharacteristicCompleted Survey, n=1041, Mean (SD)Nonresponders, n=1491, Mean (SD)P, t Test
  • Abbreviation: SD, standard deviation.

  • a

    Summary stage index = Surveillance, Epidemiology, and End Results staging index. Scores range from 0 (in situ) to 7 (metastatic).

  • b

    Socioeconomic index was calculated from income, education, and education for the census block group of residence at diagnosis.

Age at diagnosis, y31.8 (6.7)33.2 (6.2)<.0001
Age at survey, y41.3 (8.4)42.5 (8.0).0002
Summary stage indexa3.7 (2.1)3.4 (2.1).0008
Socioeconomic indexb2.5 (1.4)2.5 (1.3).8
Time since diagnosis, y9.5 (4.4)9.3 (4.4).2

The age and childbearing desires of the 918 participants who reported treatment with potential to affect fertility are listed in Table 2. Patients with a history of breast and gastrointestinal cancers tended to be oldest at diagnosis and most likely to have had children before treatment. Depending on the type of cancer, between 47% and 63% of respondents reported desiring to have children after treatment, with the highest rates among women with leukemia (59%) and Hodgkin disease (63%). These latter 2 groups were also composed of women with the lowest mean ages.

Table 2. Characteristics of Women Reporting Treatment With Potential to Impact Fertility
CharacteristicTotal Sample, n=918Type of Cancer
Leukemia, n=121Hodgkin Disease, n=286aNon-Hodgkin Lymphoma, n=169aBreast Cancer, n=223Gastrointestinal Cancer, n=108
  • Abbreviation: SD, standard deviation.

  • a

    Data are missing from 11 patients with Hodgkin disease or non-Hodgkin lymphoma.

Age at diagnosis, y, mean (SD)31.5 (6.7)28.3 (7.2)27.9 (6.2)31.6 (6.0)36.3 (4.0)34.9 (4.6)
Age at survey, y, mean (SD)40.9 (8.4)37.0 (8.3)36.5 (8.0)40.5 (7.1)47.1 (5.9)44.6 (6.2)
Years since diagnosis, mean (SD)9.6 (4.4)8.7 (4.3)8.6 (4.4)8.9 (3.9)10.8 (4.5)9.7 (4.0)
Children before treatment, No. (%)476 (52%)46 (38%)105 (37%)88 (52%)163 (73%)76 (70%)
Desiring children after treatment, No. (%)504 (54%)71 (59%)181 (63%)82 (49%)104 (47%)61 (56%)

Access to Counseling by the Oncology Team

Overall, 61% of women were counseled on the risk of cancer treatment to fertility by the oncology team (Table 3). Age at diagnosis, the desire for future children at diagnosis, and education level were significantly associated with an increased odds of receiving fertility preservation counseling. No significant differences in access to counseling were noted with regard to: parity, marital status, household income, sexual orientation, population density, or ethnicity.

Table 3. Univariate and Multivariate Logistic Regression Analysis to Evaluate the Independent Effects of Each Predictor on Access to Fertility Counseling by an Oncologist
CharacteristicNo.Fertility Addressed by an Oncologist
%Univariate OR (95% CI)PAdjusted OR (95% CI)P
  • Abbreviations: CI, confidence interval; OR, odds ratio.

  • a

    Only 1 respondent in multivariate model.

All women with treatment with potential to affect fertility91861    
Age at diagnosis      
 18-25 years207651.0 1.0 
 26-30 years160681.1 (0.7-1.8).581.1 (0.6,2.1).81
 31-35 years191671.1 (0.7-1.8).631.0 (0.5-2.0).91
 36-40 years360520.6 (0.4-0.8).0030.6 (0.3-1.3).21
Desired future children      
 No414541.0 1.0 
 Yes504661.7 (1.3-2.2)<.0011.2 (0.8-1.8).45
Prior children at diagnosis      
 No442631.0 1.0 
 Yes476580.8 (0.6-1.1).130.8 (0.5-1.2).32
Partnered at diagnosis      
 No178631.0 1.0 
 Yes677641.0 (0.7-1.4).881.0 (0.6-1.7).91
Sexual orientation      
 Heterosexual813641.0 1.0 
 Lesbian, bisexual, transgender29550.7 (0.3-1.4).330.8 (0.3-2.3).63
 Less than bachelor's392581.0 1.0 
 Bachelor's or higher457681.5 (1.1-2.0).0051.4 (1.0-2.1).09
Annual income      
 $30,000-$100,000370631.0 1.0 
 <$30,000101570.8 (0.5-1.3).330.7 (0.4-1.2).18
 >$100,000447671.2 (0.9-1.6).231.1 (0.7-1.7).6
Population density      
 Urban555631.0 1.0 
 Rural100661.2 (0.7-1.8).550.9 (0.5-1.6).7
 Caucasian575651.0 1.0 
 Asian American50641.0 (0.5-1.6).880.7 (0.3-1.4).3
 African American31711.3 (0.6-2.9).51.7 (0.7-4.2).28
 Latina or Hispanic American117580.8 (0.5-1.1).160.9 (0.5-1.5).59
 Native American3661.1 (0.1-11.9).95a 

After adjustment for age, desire for future children, parity at diagnosis, household income, ethnicity, disease type, disease stage, and treatment type, achieving a higher education level remained associated with increased counseling (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.0-2.1; Table 3). Women who had attained at least a bachelor's degree were 20% more likely to be counseled than those who had not. Age at diagnosis and desire for future children at diagnosis were not associated with having received counseling. However, women whose household income was <$30,000 per year may have been less likely to be counseled than those whose income was between $30,000 and $100,000 per year (OR, 0.7; 95% CI, 0.4-1.2), although this relation did not reach statistical significance (P = .18). No significant differences in counseling were noted for women whose household income exceeded $100,000 per year versus those with incomes between $30,000 and $100,000 per year.

Access to Fertility Preservation

Overall, 4% of women underwent fertility preservation (Table 4). Age at diagnosis, the desire for future children at diagnosis, parity at diagnosis, and education level were significantly associated with increased odds of pursuing fertility preservation. There was a trend toward decreased access for Latina women versus Caucasian women. No significant differences in access to fertility preservation were noted with regard to: marital status, household income, or population density.

Table 4. Univariate and Multivariate Logistic Regression Analysis to Evaluate the Independent Effects of Each Predictor on Access to Fertility Preservation Services
CharacteristicNo.Preserved Fertility
%Univariate OR (95% CI)PAdjusted OR (95% CI)P
  • Abbreviations: CI, confidence interval; OR, odds ratio.

  • a

    No one in these groups underwent fertility preservation.

All women with treatment with potential to affect fertility9184    
Age at diagnosis      
 18-25 years20771.0 1.0 
 26-30 years16040.6 (0.2-1.5).260.9 (0.3-2.7).79
 31-35 years19150.7 (0.3-1.6).411.0 (0.3-3.3).97
 36-40 years360<10.0 (0.0-0.3).0010.1 (0.0-1.4).09
Desired future children      
 No41411.0 1.0 
 Yes50466.2 (2.2-17.9).0012.1 (0.6-7.1).26
Prior children at diagnosis      
 No44271.0 1.0 
 Yes476<10.1 (0.0-0.4)<.0010.3 (0.1-1.1).07
Partnered at diagnosis      
 No17851.0 1.0 
 Yes67740.7 (0.3-1.5).350.9 (0.3-2.4).84
Sexual orientation      
 Heterosexual81341.0 1.0 
 Lesbian, bisexual, transgender290a a 
 Less than Bachelor's39221.0 1.0 
 Bachelor's or higher45763.9 (1.6-9.6).0031.6 (0.5-4.8).4
Annual income      
 $30,000-$100,00037041.0 1.0 
 <$30,00010131.0 (0.3-3.2).941.7 (0.4-6.2).45
 >$100,00044741.1 (0.5-2.3).861.2 (0.4-3.4).76
Population density      
 Urban55551.0 1.0 
 Rural10020.4 (0.1-1.6).20.5 (0.1-2.5).39
 Caucasian57551.0 1.0 
 Asian American5020.4 (0.1-3.0).370.3 (0.0-2.9).32
 African American310a a 
 Latina or Hispanic American117<10.2 (0.0-1.3).080.2 (0.0-1.3).09
 Native American30a a 

After adjustment for age, desire for future children, parity at diagnosis, education level, ethnicity, disease type, disease stage, and treatment type, several differences persisted. For instance, women older than 35 years at diagnosis were approximately 90% less likely to preserve their fertility than their 18- to 25-year-old counterparts (OR, 0.1; 95% CI, 0.0-1.4; Table 4); however, this difference did not achieve statistical significance. A trend was seen with regard to pretreatment parity, where women who had already had at least 1 child at diagnosis had 70% lower odds of pursuing fertility preservation than women without children (OR, 0.3; 95% CI, 0.1-1.1); however, this difference also did not achieve statistical significance. Latina women were 80% less likely to preserve fertility than Caucasian women (OR, 0.2; 95% CI, 0.0-1.3), although this difference did not achieve statistical significance.

Furthermore, no fertility preservation was noted among the 31 women identifying as African American, despite having no significant differences in childbearing from Caucasian women in our study. A similar pattern was seen among the 29 women who identified with a sexual orientation other than heterosexual, despite having no differences in childbearing desires compared with women identifying as heterosexual.

Counseling and Fertility Preservation Rates Over Time

The prevalence of counseling by subjects' oncology teams was 44% in 1993. After adjustment for age, desire for future children, parity at diagnosis, education, ethnicity, disease type, disease stage, and treatment type, the prevalence of counseling increased significantly at a rate of approximately 0.9% per year from 1993 to 2007 (R2 = 0.1; P < .05). The prevalence of fertility preservation was 0% in 1993. By 2000, the prevalence of fertility preservation was 2%. After controlling for age, desire for future children, parity at diagnosis, education level, ethnicity, disease type, disease stage, and treatment type, the prevalence of fertility preservation increased significantly at approximately 1.3% per year from 2000 to 2007 (R2 = .11; P = .03; Fig. 1).

thumbnail image

Figure 1. Prevalence of counseling for fertility preservation and utilization of fertility preservation from 1993 to 2007 among young female cancer survivors is shown.

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  2. Abstract

Although the prevalence of both counseling and fertility preservation utilization has increased over time, there remains a large unmet need for fertility preservation. Across the state of California, it appears that certain groups of women are more likely to receive important information about reproductive health at the time of diagnosis, and are also more likely to preserve their fertility than others.

The prevalence of counseling and access to fertility preservation observed in this study is consistent with that previously reported by others. The 61% rate of counseling observed in our study is similar to previously reported rates of 34% to 72%.18 We observed that 4% of women underwent fertility preservation, which is consistent with the work of Jenninga and colleagues, whose data demonstrate a 2% rate of fertility preservation in the Netherlands between 2002 and 2008 as well as low utilization rates at academic medical centers in the United States.7, 19, 20 The observed 4% rate of utilization is also similar to the low utilization of infertility services in general.21 Consistent with our observed rise in preservation rates starting in the year 2000, Lee and colleagues found that over the past decade women have become more likely to see fertility physicians before cancer treatment to preserve fertility as opposed to seeing them afterward to treat infertility.22

Certain aspects of SES appear to be associated with access to counseling about fertility loss and access to fertility preservation. For instance, women who graduate with a bachelor's degree are more likely to discuss the risks of cancer treatment to fertility than women who do not. This may reflect an assertiveness and proactive attitude on the part of patients with higher health literacy that may have been associated with patients being more likely to bring up the topic themselves. This is consistent with disparities seen in delivery of timely cancer care, where young women with lower levels of education are more likely to experience delays in diagnosis and treatment of cervical and breast cancers.11 Medical providers report their lack of awareness and comfort in discussing fertility, and their lack of knowledge of available resources, as barriers to fertility discussions.23 A recent telephone survey of 282 French women, aged 20 to 44 years, who survived unspecified cancers indicated that, of the 37% of women who reported treatment-induced infertility, 30% of those women reported that they had not been informed of the risk of infertility before their treatment.24 Because oncologists often do not discuss fertility unless the patient raises the issue, patients may benefit from a certain education background in their ability to pursue further information independently.23

Household income may affect access. Although we did not find a significant relation between income and access, our relatively uneven distribution, with low sampling of women with incomes <$30,000, may have limited our ability to detect true differences. Women whose household incomes are insufficient to adequately meet the basic needs of an average American family may be less likely to receive infertility counseling by their oncologists than women with higher incomes. Other studies including young women with cancer have showed that lower income is associated with poorer outcomes, including increased probability of delay in diagnosis.11 In a study of 314 cancer patients who were referred to a reproductive endocrinologist for fertility services, Lee and colleagues found no association between income and whether women were able to present in a timely fashion and preserve fertility versus whether they presented after cancer treatment with diagnosed infertility.22 Duffy and colleagues also showed in a study of 166 breast cancer survivors that income did not predict whether women were counseled about fertility issues by their oncologist.23 The possibility that income does impact one's ability to access fertility preservation would not be surprising, given that fertility preservation is not routinely covered by insurance and that the costs of fertility preservation are significant.25 The average total cost of clinical services, consultations, procedures necessary to retrieve eggs and/or produce embryos, and freezing services is between $8000 and $24,000.26, 27

Women who understand the potential benefits of fertility preservation may be willing to make an extra effort to seek out additional resources. Despite the cost, it may be the case that women from lower income groups receive financial assistance from nonprofit organizations or from family members. We also observed no difference in fertility preservation utilization between women who live in urban areas and those in rural areas, despite the need for women in rural regions to expend greater resources to travel further distances to specialized fertility centers.

We found no differences in counseling or fertility preservation with regard to partner status, but did show a trend toward decreased rates of fertility preservation for women who had previous children at the time of diagnosis. The finding that partner status does not predict counseling was also reported by Duffy and colleagues.23 Our study, like Duffy et al's, also showed no difference with regard to counseling in women with previous children. However, there was a decrease in utilization of fertility preservation among women who were already parents at diagnosis, despite controlling for age and parenting desires. The emotional impact of not preserving fertility could be higher in women without previous children. In prior studies, women who experienced primary infertility (desired a child at diagnosis but were never able to have a child) experience greater distress than women with secondary infertility (had at least 1 child at diagnosis but were unable to have another).28, 29

This study showed that women who are older than 35 years at diagnosis could be less likely to be counseled than women in their early 20s, regardless of parenting desires or parity at diagnosis. This is consistent with the findings of Duffy and colleagues in young breast cancer patients.23 Age also predicted lower rates of fertility preservation in our study by univariate analysis, but the relation did not retain significance in our multivariate model. Age at diagnosis has been associated with increased risk of cancer recurrence, with difficulty in obtaining insurance, and with employment-base discrimination of young women with cancer.30, 31 Taken together with our findings, age could remain a focus of future study as a predictor of access to fertility preservation.

This is the first study to examine the association of sexual orientation and utilization. In a study of 249 oncologists across the United States, Forman et al found that when oncologists did not refer a patient to a reproductive endocrinologist, in 1% of cases it was because the patient identified as a lesbian.8 The study by Forman and colleagues did not comment on childbearing desires, so it is difficult to determine whether these women requested or declined referral based on parenting plans. This study demonstrates that there is no significant association between sexual orientation and oncologists counseling women about potential reproductive compromise after treatment. However, this study does show that, despite there being no significant differences in parenting desires based on sexual orientation, none of the women who identified with an orientation other than heterosexual preserved her fertility. Given the low overall utilization rates, our study may be underpowered, and possibly subject to sampling bias, with 31 women not identifying as heterosexual. Assessing the impact of sexual orientation on seeking fertility preservation should also be a focus of future research.

Caucasian women in our study appeared more likely to seek fertility preservation services than Latina or African American women, although our observation did not achieve statistical significance. This is in contrast to Lee and colleagues, who found that neither race nor ethnicity predicts whether women will present to fertility centers for fertility preservation before cancer treatment or for fertility care after cancer treatment.22 The data in our study are consistent with patterns seen with regard to health disparities in general infertility care, as women from many ethnic backgrounds are less likely to have access to any specialized fertility treatment, regardless of whether it is before or after a cancer diagnosis. African American women often seek fertility treatment after waiting a longer time with untreated infertility than Caucasian women.32, 33 Low-income Latino immigrant patients, as well as African Americans and Arab Americans, face challenges in linguistic and cultural barriers as well as accessibility and affordability of treatment.34, 35 Our findings are consistent with patterns seen in general infertility treatment in Massachusetts, a state with mandated insurance coverage for infertility services, where such services are disproportionately accessed by Caucasians, by the highly educated, and by the wealthy.33

This study has several important strengths and limitations. A significant proportion of the eligible participants in our study were not reached. However, the response was similar to that seen in several other registry-based studies of young female cancer survivors, with rates of 26% to 51%,3, 15, 36, 37 Given the importance of survivorship issues, the National Cancer Institute recently recommended the use of cancer registries as a means of conducting studies that could rapidly yield information about life after treatment.38, 39 Despite the benefits of registry-based studies, the possibility of sampling bias remains a concern in this study. Whereas women who responded were slightly younger at diagnosis than those who did not, there were no differences with regard to SES. It is also likely, given the consistency of our counseling and preservation rates with those of other studies, that we achieved a relatively accurate sampling of the population, with regard to previous exposure to fertility preservation. However, other important confounding factors that were not controlled for in our study include the absence of information regarding current disease state (ie, recurrence or not) and residual side effects.

We have observed that women who are childless, younger, Caucasian, heterosexual, and who graduated from college may be more likely than women of different backgrounds to be counseled about the risks of cancer treatment to fertility or to preserve fertility before cancer treatment. A focus on the quality of counseling and the quantity of patients seeing a fertility specialist has likely led to improved rates of access over the past decade. However, failing to focus on equity will likely result in continued unequal distribution of reproductive health counseling and fertility preservation. An opportunity lies ahead to explore educational and policy interventions to ameliorate health disparities that may exist in the growing field of fertility preservation.


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  2. Abstract

This project was supported by National Institutes of Health grant number TL1 RR024129. The National Institutes of Health had no role in study design; in collection, analysis, and interpretation of data; in the writing of this report; or in the decision to submit this paper for publication.


The authors made no disclosures.


  1. Top of page
  2. Abstract
  • 1
    National Cancer Institute. Surveillance Epidemiology and End Results. Fast Stats. Statistics stratified by age. Available at: Accessed on January 7, 2010.
  • 2
    Knopman J, Papadopoulos E, Grifo J, et al. Surviving childhood and reproductive-age malignancy: effects on fertility and future parenthood. Lancet Oncol. 2010; 11: 490-498.
  • 3
    Partridge A, Gelber S, Peppercorn J, et al. Web-based survey of fertility issues in young women with breast cancer. J Clinical Oncol. 2004; 22: 4174-4183.
  • 4
    Patel A, Sreedevi M, Malapati R, et al. Reproductive health assessment for women with cancer: a pilot study. Am J Obstet Gynecol. 2009; 201: 191. e1- 4.
  • 5
    Letourneau J, Ebbel E, Katz P, et al. Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer. Cancer. 2011 Sep 1. doi: 10.1002/cncr.26459. [Epub ahead of print].
  • 6
    Lee S, Schover L, Partridge A, et al. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol. 2006; 24: 2917-2931.
  • 7
    Jenninga E, Hilders CG, Louwe LA, et al. Female fertility preservation: practical and ethical considerations of an underused procedure. Cancer J. 2008; 14: 333-339.
  • 8
    Forman E, Anders C, Behera M. A nationwide survey of oncologists regarding treatment-related infertility and fertility preservation in female cancer patients. Fertil Steril. 2010; 94: 1652-1656.
  • 9
    Quinn GP, Vadaparampil ST, Lee JH, et al. Physician referral for fertility preservation in oncology patients: a national study of practice behaviors. J Clin Oncol. 2009; 27: 5952-5957.
  • 10
    Burris J, Andrykowski M. Disparities in mental health between rural and nonrural cancer survivors: a preliminary study. Psychooncology. 2010; 19: 637-645.
  • 11
    Ashing-Giwa K, Gonzalez P, Lim JW, et al. Diagnostic and therapeutic delays among a multiethnic sample of breast and cervical cancer survivors. Cancer. 2010; 116: 3195-3204.
  • 12
    Boxwala F, Bridgemohan A, Griffith D, et al. Factors associated with breast cancer screening in Asian Indian women in metro-Detroit. J Immigr Minor Health. 2010; 12: 534-543.
  • 13
    Soliman H, Agresta S. Current issues in adolescent and young adult cancer survivorship. Cancer Control. 2008; 15: 55-62.
  • 14
    Missmer S, Seifer D, Jain T. Cultural factors contributing to health care disparities among patients with infertility in Midwestern United States. Fertil Steril. 2011; 95: 1943-1949.
  • 15
    Nakayama K, Liu P, Detry M, et al. Receiving information on fertility- and menopause-related treatment effects among women who undergo hematopoietic stem cell transplantation: changes in perceived importance over time. Biol Blood Marrow Transplant. 2009; 15: 1465-1474.
  • 16
    Pierce, D. Overlooked and Undercounted 2009: Struggle to Make Ends Meet in California. Report of the United Way of the Bay Area. Available at: Accessed on June 5, 2011.
  • 17
    Mendes E. In the United States, Health Disparities Across Incomes Are Wide-Ranging. Gallop Well-Being Index. Available at: Accessed on April 12, 2011.
  • 18
    Tschudin S, Bitzer J. Psychological aspects of fertility preservation in men and women affected by cancer and other life-threatening diseases. Hum Reprod Update. 2009; 15: 587-597.
  • 19
    Klock C, Zhang J, Kazer R. Fertility preservation for female cancer patients: early clinical experience. Fertil Steril. 2010; 94: 149-155.
  • 20
    Robertson Missmer S, Ginsburg E. Embryo yield after in vitro fertilization in women undergoing embryo banking for fertility preservation before chemotherapy. Fertil Steril. 2011; 95: 588-591.
  • 21
    Chandra A, Stephen EH. Infertility service use among U.S. women: 1995 and 2002. Fertil Steril. 2010; 93: 725-736.
  • 22
    Lee S, Heytens E, Moy F, Ozkavukcu S, Oktay K. Determinants of access to fertility preservation in women with breast cancer. Fertil Steril. 2011; 95: 1932-1936.
  • 23
    Duffy CM, Allen SM, Clark MA. Discussions regarding reproductive health for young women with breast cancer undergoing chemotherapy. J Clin Oncol. 2005; 23: 766-773.
  • 24
    Mancini J, Rey D, Preau M, et al. Infertility induced by cancer treatment: inappropriate or no information provided to majority of French survivors of cancer. Fertil Steril. 2008; 90: 1616-1625.
  • 25
    Quinn G. Vadaparampil S, McGowan Lowery K, et al. State laws and regulation addressing third-party reimbursement for infertility treatment: implications for cancer survivors. Fertil Steril. 2011; 95: 72-78.
  • 26
    Beck L, Sileo M, Copperman A. The average cost of fertility preservation for female cancer patients. Paper presented at: 66th Annual American Society of Reproductive Medicine Conference; October 26–29, 2010; Denver, Colo; P-39.
  • 27
    Katz P, Showstack J, Smith J, et al. Costs of infertility treatment: results from an 18-month prospective cohort study. Fertil Steril. 2011; 95: 915-921.
  • 28
    Wenzel L, Dogan-Ates A, Habbal R, et al. Defining and measuring reproductive concerns of female cancer survivors. J Natl Cancer Inst Monogr. 2005; 34: 94-98.
  • 29
    Canada AL, Schover LR. The psychosocial impact of interrupted childbearing in long-term female cancer survivors. Psychooncology. 2010 Dec 2. [Epub ahead of print].
  • 30
    Langeveld N, Grootenhuis M, Voute P, et al. Quality of life, self-esteem and worries in young adult survivors of childhood cancer. Psychooncology. 2004; 13: 867-881.
  • 31
    Leung W, Hudson M, Strickland D, et al. Late effects of treatment in survivors of childhood acute myeloid leukemia. J Clin Oncol. 2000; 18: 3273-3279.
  • 32
    Seifer D, Zackula R, Grainger D, et al. Trends of racial disparities in assisted reproductive technology outcomes in black women compared with white women: Society for Assisted Reproductive Technology 1999 and 2000 vs. 2004-2006. Fertil Steril. 2010; 93: 626-635.
  • 33
    Jain T. Socioeconomic and racial disparities among infertility patients seeking care. Fertil Steril. 2006; 85: 876-881.
  • 34
    Nachtigall R, Castrillo M, Shah N, et al. The challenge of providing infertility services to a low-income immigrant Latino population. Fertil Steril. 2009; 92: 116-123.
  • 35
    Inhorn M, Fakih M. Arab Americans, African Americans, and infertility: barriers to reproduction and medical care. Fertil Steril. 2006; 85: 844-852.
  • 36
    Huyghe E, Sui D, Odensky E, et al. Needs assessment survey to justify establishing a reproductive health clinic at a comprehensive cancer center. J Sex Med. 2009; 6: 149-163.
  • 37
    Schover LR, Rybicki LA, Martin BA, et al. Having children after cancer. A pilot survey of survivors' attitudes and experiences. Cancer. 1999; 86: 697-709.
  • 38
    Arora NK, Hamilton AS, Potosky AL, et al. Population-based survivorship research using cancer registries: a study of non-Hodgkin's lymphoma survivors. J Cancer Surviv. 2007; 1: 49-63.
  • 39
    National Cancer Institute. Report of the Leukemia, Lymphoma, and Myeloma Progress Review Group. Available at: Accessed on November 8, 2010.