Advances in cancer diagnosis and treatment have led to the increase of patients’ survival rates, consequently bringing more attention to the long-term side effects of cancer treatments and their impact on quality of life. Among these, gonadotoxicity is considered the principal cause of infertility in young women with cancer (Rodriguez-Wallberg and Oktay, 2014; Anderson et al., 2015).

More than 9.2 million women have been diagnosed with cancer in 2020 (GLOBOCAN, 2020), with about 10% diagnosed during reproductive age (Ward et al., 2014; Siegel et al., 2016). About 75% of women aged 18–45 years with a cancer diagnosis are interested in the possibility of having children (Letourneau et al., 2012a; Deshpande et al., 2015), but this desire could be unfulfilled. The risk of infertility, due to the disease itself or to gonadotoxic treatments, depends on different factors such as the age of the patient, the type of therapy, as well as the tumor site, stage, and grade (Lee et al., 2006). Fertility loss due to cancer treatment can be a devastating experience for young women who may not have satisfied their need for parenthood. Infertility is a significant concern for cancer patients at diagnosis (Partridge et al., 2004), who may experience higher levels of anxiety and depressive symptoms than non-cancer-related infertile women (Lawson et al., 2014, 2015). Furthermore, many cancer patients continue to report heightened reproductive concerns during survivorship, which has been linked to poorer mental and emotional health outcomes (Gorman et al., 2010, 2015; Armuand et al., 2014; Ussher and Perz, 2018, 2019). In fact, for some women, the failure of the motherhood project is far more painful than the cancer itself (La Rosa et al., 2020). Moreover, both female and male cancer patients seem to experience fertility-related psychological distress from diagnosis to survival (Logan and Anazodo, 2019; Logan et al., 2019). Furthermore, fertility loss does not only affect the individual, but may have a dyadic impact. In fact, the literature on cancer survivors shows that potential infertility is associated with feelings of pressure on the relationship, fights, frustration, concerns, or breakups (Lehmann et al., 2018, 2019). In addition, for some of them, not being able to have children was experienced as not being able to “provide” within a relationship (Lehmann et al., 2018, 2019). Moreover, a study on the reaction of female cancer patients to the risk of fertility loss reported the presence of doubts about the possibility of remarrying and feelings of regret about what the husband was also witnessing in their couple. A combination of emotional reactions of fear, anxiety, worry, loneliness, guilt, sorrow, depression, and regret also emerged (Hasanpoor-Azghdy et al., 2014).

Currently, new procedures that allow fertility preservation before cancer treatments are available, such as oocyte or ovarian tissue cryopreservation. In order to better address fertility-related concerns, professional societies such as the American Society of Clinical Oncology have published international guidelines indicating that all young adults and children with cancer should receive timely fertility counseling before treatment to safeguard their reproductive potential (Oktay et al., 2018).

Oncofertility (fertility and oncological care) thus rose as a new interdisciplinary field, which includes fertility preservation discussion and management, the management of sexual dysfunction, hormonal dysfunction, complex contraception, and psychosocial support (Anazodo et al., 2018). It involves the cooperation of different health professionals, such as gynecologic oncologists, reproductive medicine gynecologists, biologists, general oncologists, endocrinologists and psychologists, with the common objective to provide counseling about fertility preservation options for cancer patients (Lange et al., 2013; Sigismondi et al., 2015).

Despite best practice recommendations, there are many barriers in providing oncofertility services (Quinn et al., 2008). A systematic review indicates that most cancer patients in reproductive age (i.e., 14–45 years) do not receive adequate information about fertility risks and preservation strategies before initiating cancer treatment (Logan et al., 2018). The barriers to fertility preservation are multifactorial: limited time for clinical encounters, focus on treatment planning, reluctance to discuss sensitive subjects such as sexuality and fertility, poor knowledge about fertility preservation techniques (Quinn et al., 2009), distress and anxiety of the patient, and financial problems (Quinn et al., 2008).

However, several studies have underlined that receiving specialized counseling about cancer-related infertility and fertility preservation is associated with less regret and greater quality of life in cancer survivors (Letourneau et al., 2012a; Laganà et al., 2017). In fact, the decision to undergo fertility preservation before cancer treatments is not an easy one to make: patients may feel overwhelmed, adding further concerns to the understandable worry about their lives and their future as a result of the recent diagnosis. Moreover, because these techniques can be undertaken only before starting cancer treatment, these decisions usually have to be taken rapidly (Mangili et al., 2017). The literature shows that fertility preservation counseling is associated with better decision-making outcomes in the long term, specifically less regret and conflict about the decision, better coping with the burden of cancer treatment (Letourneau et al., 2012a; Mersereau et al., 2013; Benedict et al., 2015; Deshpande et al., 2015), and improved social well-being (Skaczkowski et al., 2018). For these reasons, oncofertility care should always be an integral part of cancer care, allowing for informed patient counseling and decision-making and reducing long-term impact on mental health and quality of life.

Currently, the concept of a shared decision-making process, which allows for the provision of all necessary information to the patient in order to guarantee an optimal quality of life, is gaining support. Including patients’ psychological point of view allows them to consider future projects that may occur after the disease and thus endure long-term planning. Since patients are generally referred to oncofertility specialists on an emergency basis, they frequently have limited information, many fears and questions, and varying expectations about the therapeutic process. Consistently, the psychological management of this path is critical, as the psychologist can welcome and support patients before their oncofertility visit.

Few studies in the available literature have investigated which variables could intervene in the decision-making process about undergoing fertility preservation techniques in cancer patients. Some of these studies have shown that this decision may be influenced by personal factors (i.e., age, gender, relationship status, having children, and personal beliefs), illness factors (i.e., prognosis, stage of cancer, and time to commence oncological treatment) and fertility preservation-related factors (i.e., expected burden, duration, and costs of treatments) (Logan and Anazodo, 2019; Melo et al., 2019). However, very few studies have investigated which psychological factors may influence the choice to undergo fertility preservation techniques in cancer patients (Hershberger et al., 2016; Melo et al., 2019), highlighting the role of a high desire for motherhood and a strong individual value for the possibility of guaranteeing a future pregnancy (Hershberger et al., 2016; Melo et al., 2019).

The aim of the present study is thus to investigate which sociodemographic and psychological variables predict a high motivation to undergo fertility preservation, first of all, evaluating the sociodemographic and psychological characteristics of female cancer patients that are referred to the Oncofertility Unit of the San Raffaele Hospital before gonadotoxic treatment. Considering that the San Raffaele Hospital is an Italian reference center for fertility preservation, we are not able to intercept female cancer patients who decline such possibility and all the patients who come to the oncofertility examination have usually already been informed by their oncologists about the effects of therapies on fertility and about fertility preservation opportunities. Therefore, they are usually already motivated to undergo fertility preservation techniques. As such, the hypothesis that the present study addressed is that women who decide to undergo fertility preservation may have specific adaptive psychological characteristics that allow them to cope with the disease in the short-term and to preserve the mental space for future planning and thus for possible parenthood.

Descriptive statistics for sociodemographic variables are reported in Table 1. The sample consisted of 58 women recently diagnosed with cancer, aged between 20 and 42 years (median = 33; IQR = 28, 75–37); the majority of them had a partner (82.8%, n = 48) and had no children (86.2%, n = 50). In addition, the majority of the sample had never had an abortion in the past (82.8%, n = 48) and 53.4% (n = 31) had at least a bachelor’s degree.

Table 2 shows descriptive statistics for the psychometric variables, together with the results of the comparisons with reference values from the general population and the population of infertile women. The level of depression in our sample resulted to be significantly higher than that of the general population (adj. p = 0.018), with a distribution of the scores (median = 9; IQR = 6.00–14.25) that indicates mainly a minimum level of depression. Trait anxiety was lower than that of the general population (adj. p = 0.007), with a distribution (median = 38; IQR = 31.00–44.00) indicating low anxiety for most of the patients, and state anxiety was lower than that of the population of infertile women (p = 0.003), with a median value (median = 43; IQR = 35.00–55.00) indicating medium anxiety. There was no significant difference in state anxiety levels when compared to the general population (adj. p = 0.124). As regards the FPI, we observed a significant difference between our sample and the population of infertile women only for the subscale “Rejection of childfree lifestyle” (adj. p < 0.001): our sample reported significantly lower scores than that of the population of infertile women.

As expected from the design of the study, the patients in the sample declared mostly high levels of motivation to undergo fertility preservation treatments (median = 9, IQR = 8–10, min = 3, max = 10). Thus, in the study, a high motivation was defined as equal to 10. Almost half of the sample (44.8%; n = 26) declared a high motivation. Multiple logistic regression analysis was performed in order to identify which factors predicted a high motivation to undergo fertility preservation techniques. In the analysis, all collected variables were considered except for the FPI subscales “Social concern,” “Sexual concern,” and “Relational concern.” For the FPI subscales, we only included the “Need for parenthood” and “Rejection of childfree lifestyle” subscales because they reflect the individual investment in parenthood. After backward variable selection, only the “Need for parenthood” subscale of the FPI was retained in the model; the higher the values of the subscale, the higher the probability to have a high motivation (OR = 1,114 [1.040–1.194], p = 0,002). In the literature a moderate correlation was observed between the “Need for parenthood” and the “Rejection of childfree lifestyle” subscales (Moura-Ramos et al., 2012; Donarelli et al., 2015), which was confirmed also in our sample (rho = 0.682; p < 0.001), suggesting the possibility of a partial overlap between the meanings of the two subscales. Thus, we alternatively evaluated as possible predictor the construct “Representations about the importance of parenthood” (defined as the sum of the two subscales by Moura-Ramos et al., 2012) in place of the two separate subscales. At multiple logistic regression analysis, only this variable was retained in the final model with a similar role (OR = 1.061 [1.021–1.104], p = 0.003).

The choice to preserve fertility before antineoplastic treatments can be a complex process both from a medical and emotional point of view; consequently, not all cancer patients may have the mental space to evaluate this possibility (Di Mattei et al., 2020).

Our findings show that our sample display significantly higher levels of depression as compared to the general population; this finding could be explained considering that these patients have recently received a life-threatening diagnosis. However, their scores can be classified as minimum depression (Dozois et al., 1998); it is possible that women with higher levels of depression do not come to the Oncofertility Unit, as they may consider it an additional burden.

As compared to the general population, our sample also shows lower levels of trait anxiety, which can be interpreted as low anxiety (Elliott, 1993). This personality trait may promote the possibility to undertake further procedures other than cancer treatment. Our patients also show medium state anxiety levels (Elliott, 1993), probably as a reaction to their disease. However, these do not significantly differ from the reference values of the general population. As compared to the population of infertile women, the state anxiety levels in our sample are significantly lower. These could be explained by the fact that infertile women have overt reproductive difficulties, and they are actually seeking pregnancy when their anxiety levels are measured.

As regards the subscales and the global scale of the FPI, we observed no significant difference between our sample and the population of infertile women, except for the “Rejection of childfree lifestyle” subscale, whose scores in our sample are significantly lower than those of the population of infertile women. This shows that cancer patients and infertile women both experience infertility as a stressful condition: infertility seems to represent an event of great impact for every woman on a social, relational and/or individual level. Furthermore, we can hypothesize that the significantly lower scores obtained in the “Rejection of childfree lifestyle” subscale in women with cancer could be explained considering that infertile women are usually evaluated while they are trying to have a child; therefore, it is plausible that they have a more negative view of a life without children, while cancer patients undergo fertility preservation techniques with the purpose of a future investment, and not for imminent motherhood.

As far as we know, few studies have investigated which psychological factors may influence the choice to undergo fertility preservation in cancer patients, and even fewer studies have investigated the level of motivation. The purpose of this study was therefore to evaluate which sociodemographic and psychological variables predict a high motivation to undergo fertility preservation in female cancer patients.

Our results show that sociodemographic variables such as age, relationship status, number of children, education and number of abortions do not significantly predict a high motivation to undergo fertility treatment. The literature includes mixed findings. In line with our results, Flink et al. (2017a) highlighted that age, relationship status, education and having children are not significantly associated with adherence to fertility preservation techniques. Similarly, the same authors (Flink et al., 2017b) reported no significant association between sociodemographic characteristics, such as relationship status or having children, and the complex process of decision-making about fertility preservation in cancer patients, while highlighting a small influence of factors such as cultural beliefs and social pressure. Also Hershberger et al. (2016) found no significant difference in age, relationship status, having children, and education between a group of cancer patients that decided to preserve fertility and another group that rejected this option.

However, other studies report different findings. For example, Letourneau et al. (2012a) found that women with cancer who do not have college degree, are over 35 years old, and have children are less likely to access to fertility preservation. Other studies highlight a significant association between not having children and a greater probability of proceeding with fertility preservation techniques (von Wolff et al., 2016; Melo et al., 2019). A possible interpretation is that women with certain sociodemographic characteristics are less likely to receive adequate oncofertility counseling. It can be hypothesized that women with cancer who already have children prioritize antineoplastic treatments over fertility preservation; however, another possibility is that oncologists are more likely to refer women without children to fertility preservation specialists.

The discrepancy with our findings may be related to the different objective of these studies, which focus on the actual decision rather than the level of motivation to undergo fertility preservation techniques. Although not having children can influence the decision to undergo fertility preservation, this factor may not be so decisive in affecting the level of motivation: other factors may have a greater impact on the motivation to preserve fertility. Specifically, we found that the only two factors predicting a high motivation to undergo fertility preservation were the “Need for parenthood” subscale and the “Representations about the importance of parenthood” construct. Thus, we can hypothesize that the strong desire for motherhood as an essential life value can predict a high motivation to preserve fertility. This is in line with other studies, showing that the desire for motherhood and the importance of parenthood are crucial factors influencing the choice to preserve fertility before cancer treatment (Baysal et al., 2015; Hershberger et al., 2016; Flink et al., 2017a), while women who decline this path place more emphasis on surviving cancer (Hershberger et al., 2016). Similarly, Melo et al. (2019) found that another predictor of the decision to preserve fertility is the possibility to have a child in the future.

Finally, depression and anxiety levels did not significantly predict a high motivation. Although no studies in the literature have investigated this aspect, it could be assumed that the levels found within our sample are not clinically relevant; this could allow patients to decide to access the service and preserve fertility, but could be irrelevant for a high motivation, which remains closely associated to the importance of parenthood.

The datasets presented in this article are not readily available because data cannot be shared as participants did not provide written informed consent for it. Requests should be directed to GP, g.perego23@campus.unimib.it.

The studies involving human participants were reviewed and approved by the Ethics Committee of the San Raffaele Hospital. The patients/participants provided their written informed consent to participate in this study.

VEDM, GP, and PT contributed to the conception and design of the study. PT, PR, MM, and LN organized the database. PR and LN performed the statistical analysis. GP, PT, PR, and MM wrote the first draft of the manuscript. VEDM, GM, AB, RC, EP, and MC revised the manuscript critically. All authors read and approved the final version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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