Future fertility for individuals with differences of sex development: Parent attitudes and perspectives about decision-making

SummaryBackgroundChildren, adolescents, and young adults (children/youth) with differences/disorders of sex development (DSD) face challenges related to future fertility; this may be due to variations in gonadal development, and, for some, gonadectomy performed to reduce the risk of malignancy. Childhood may be the only time for preservation of biological fertility potential for children/youth who undergo gonadectomy or have early gonadal failure. Fertility-related decision-making for these patients is particularly complicated, due to the need for parental proxy decision-making, potential discordance between gender identity and gonadal type, and uncertain future assisted reproductive technologies.ObjectiveThis study aimed to assess: (1) attitudes regarding future fertility, and (2) healthcare needs for fertility-related decision-making among parents of children/youth with DSD.Study designSemi-structured qualitative interviews about future fertility were conducted with parents of children/youth with DSD. Parents who had never discussed fertility with a healthcare provider were excluded. Grounded theory methodology was used to identify emergent themes and patterns. Demographics and clinical characteristics were assessed via survey and medical chart review.ResultsNineteen parents were interviewed (participation rate: 60%, 14 mothers/5 fathers, median patient age at diagnosis 6 months (range 0-192), eight DSD diagnoses). The most common emergent themes are summarized in the Summary Table. Most parents identified fertility as a key concern, both at time of diagnosis and throughout development. Parents expressed difficulty with timing of disclosure about potential infertility to their children. Multiple preferences related to medical decision-making about future fertility and fertility preservation were expressed, including: a desire for step-by-step decision-making, and use of medically vetted information and research to guide decisions.DiscussionThis qualitative study provided new information about the perspectives of parents of children/youth with DSD regarding future fertility. Previous studies have suggested that the possibility of biological parenthood is important to many individuals with DSD. This study provided an in-depth parental perspective. This is important because many decisions that affect future fertility are made in childhood, and require parents to make decisions on behalf of their children. The study sample was limited in its geographic diversity. Strengths of the study included diversity in age of the child/youth, ethnic backgrounds, and the DSD diagnoses that were represented.ConclusionsFuture fertility was a concern for many parents of children/youth with DSD. Parents expressed multiple priorities and preferences related to making difficult fertility-related medical decisions for their children. Many of the study findings could be incorporated into future best practices for discussions about fertility with families of children/youth with DSD.Summary Table. Parent attitudes toward fertility, disclosure, and decision-making: common themes.ThemeFrequencyTopic 1: Attitudes toward fertility/infertilityFertility status of child/youth 'unknown'12Importance of child/youth being able to have their own child12Fertility as a main concern10Concern about child dealing with fertility status in the future10Topic 2: Attitudes toward disclosureStruggle with timing of diagnosis/fertility discussion with child9Openness with family/friends8Selective disclosure to family/friends8Topic 3: Decision-making about child's future fertility and fertility preservationDesire for research, medically vetted information and statistics to guide decisions about fertility preservation/gonadectomy17Parents desire to take things step by step16Desire to discuss child's condition with other families16Alternate ways to have a child12