Fertility Preservation | A Promising Future for Young Cancer Survivors

Listen Now

As more young people survive cancer, the issue of fertility preservation is front and center. Dr. Karen Albritton and her team explore the challenges of preserving fertility in children, teens and young adults undergoing cancer treatment and the latest breakthroughs in oncofertility that are delivering promise for the future.

Dr. Karen Albritton

Related Informtation

Oncofertility
Adolescent/Young Adult (AYA) Program
Life After Cancer
Oncology
Hematology and Oncology
Hematology and Oncology Research
Fort Worth Adolescent and Young Adult Onoclogy Coalition

Transcript

00:00:02

Host: Hello and welcome to Cook Children's Doc Talk. A while back we talked with Dr. Karen Albritton the medical director of Cook Children’s adolescent and young adult program in the Hematology and Oncology Center, and she oversees the Oncofertility Program. We also spoke with Olivia Prebus who was instrumental in developing the role of fertility navigator for the program. More recently, we talked with Toni Leavitt who we’ll be introducing later in the program. Toni is the current fertility navigator and we'll be sharing updates about the Oncofertility Program.

Dr. Albritton is trained in both pediatric and medical oncology and specializes in the care of adolescents and young adults with cancer. She recognizes the unique needs of these young patients and the challenging decisions they face about day to day living that most people take for granted. One of the biggest and often overlooked as how fertility is impacted by the cancer treatment they receive. As an active advocate for AYA cancer patients, doctor Albritton was instrumental in founding the AYA program here at Cook Children’s as well as the Fort Worth AYA Oncology Coalition, which provides resources for cancer patients and survivors, health professionals and community members. The Fort Worth AYA Oncology Coalition launched the first community supported AYA oncology inpatient unit in the nation and offers young adults diagnosed with cancer age relevant resources and specialized care designed to improve their lives before, during, and after cancer.

It is through her experience with AYAs that doctor Albritton has seen a need to consider fertility as part of all pediatric cancer care and establishing the oncofertility program here at Cook Children’s. Welcome.

00:01:48

Dr. Albritton: Thanks for having us.

00:01:51

Host: So let me start by asking what oncofertility is and why it's important?

00:01:55

Dr. Albritton:  Oncofertility is a relatively new term in the cancer world and it is a combination of 2 fields, reproductive endocrinology which deals with fertility for people with and without cancer for many different reasons who are seeking to either preserve their fertility or attempt to have children to use fertility methods to have biologic children, and many years ago it was realized that cancer patients have their fertility affected by the cancer treatments and that these 2 fields came together in a way to try to preserve fertility, monitor fertility. enhance fertility. All the crossovers of those 2 fields. And it became relevant that we were having conversations together and use each other's knowledge and science to have the best outcomes for our cancer patients.

It's important to mention that there are other disease processes, other conditions, in which fertility is affected and a lot of the things that we’ll be talking about today are offerings or conversations that we also will have the ability to have with patients in other departments. For example a patient undergoing a bone marrow transplant for sickle cell disease would have their fertility affected because of the transplant and they would be included in the offerings that we'll be talking about in our Oncofertiltiy Program.

00:03:15

Host: So tell us more about the Oncofertility Program here at Cook Children’s, your roles and how this program got started. 

00:03:22

Host: Just like I've said about the burgeoning of this field, I think the cancer world and especially the pediatric cancer world realized in the last 10 to 20 years that we had a good problem and that was that we had long-term survivors that wanted to have a very normal life. And that included having biologic children. And so we started having to answer up front even before cancer started the question of, will this affect my fertility, will I be able to have children, is there anything I need to be doing to enhance or protect my ability to have children? And so about 10 years ago we instigated a policy that all children after the age of puberty we would have a discussion right after diagnosis about how our proposed therapy would affect their fertility and whether there was anything that we could do to preserve their fertility. And that's a policy that we've had here at Cook Children’s.

We started using our AYA navigator, Olivia, as an additional resource to answer some of those questions. She's often the point person who is describing a lot of the programs and offerings and risks and education to the patient and the family. But there are a wealth of people throughout the hospital and throughout town who help make all that happen. Within the hospital the oncologist is the first person who will bring up to the patient and family that the treatments that we're proposing may impact their fertility and tell them that we'll have more information given to them by our Oncofertility Program. We then work often with surgeons and increasingly we are going to be using surgeons to do some of the procedures that will be involved in fertility preservation. Our urologists will also be involved in doing some of testicular procedures. We thankfully have great partnerships in town with our reproductive endocrinologists. Because we’re a children's hospital, we don't have on-staff reproductive endocrinologists but they're an important part of our program in the tissue preservation and also in some of the counseling for some of the elaborate procedures that may go on for future fertility.

In addition our support staff is important, the psychologists, the ethics committee here, our social workers are all involved because of the complexities of this program and the procedures that we're talking about. They can be expensive, they can be emotionally draining, there can be ethical issues involved, and so it really takes a whole team here at Cook Children's to make this Oncofertility Program work.

00:05:44

Host: So what additional disciplines make up the oncofertility team and what roles do they play?

00:05:44

Dr. Albritton: Because we're a children's hospital we don't have some of the reproductive endocrinologists right on staff that we would need to fully flesh out as some of the options that we would want and so we have partnered with some of the reproductive endocrinologists in town who have been wonderful at really working closely with us, being available nights and weekends and just bending over backwards to really make sure that our cancer patients have all of their options at their fingertips. Especially before they start cancer therapy but then after cancer treatment as well and they continue to follow them monitor their fertility help them with any IVF procedures etc.

Within the hospital we partner with our surgical team and our urology team if there any procedures that need to be done and we'll talk about some exciting ones that we have increased the partnership with because of some exciting opportunities.

00:06:44

Host: Olivia, are all pediatric cancer patients at risk of infertility due to treatment?

00:06:49

Olivia Prebus: Not all children with cancer are at an increased risk for future fertility problems. The risk to future fertility really hinges upon certain elements in a person's treatment plan. So what we're looking at is the type and dose of chemotherapy that the patient will receive, whether or not they'll have radiation, where that radiation will target, and what doses that radiation will be, and what if any surgical procedures might directly impact reproductive organs. So what we know is when we look at this treatment plan we can very quickly assess whether or not a particular patient is at risk. What we do know though is that just because a patient has not reached puberty does not mean that they do not suffer any long term impact of fertility if their treatment plan includes any elements that might impact it negatively in the future 

00:07:41

Host: So how is the level of risk determined?

00:07:45

Olivia Prebus: So the process to establish the risk to a patient’s fertility is a multiple step process. The first part really consists of sitting down with the oncologist who will be treating the child and really learning what the treatment plan is going to look like. So by that we mean what chemotherapy, radiation, or surgery might feed into treating this patient's cancer. Once we have a sense of the treatment plan we then go and pull out those high-risk elements that we talked about before. So the certain chemotherapies that we know have long term negative impact on fertility, we pull those medicines out and then we calculate the doses. Similarly, if we see that radiation may impact reproductive organs, we will then again calculate a dose. So once we know doses of high-risk medications or high-risk radiation we then will go to risk assessment tables. And these tables are really a way of bringing together the best available evidence that we currently have for assessing the risk to future fertility. And they are changing all the time as new information comes to light. And a large portion of what these tables are based on are population-based studies of long term survivors, so looking at patients who were treated for cancer and what are their long term outcomes around fertility.

So in order to make sure that we're keeping ourselves up to date with this best available evidence we really continue to make sure that we're in close contact with the different organizations around the country that are continuing to refine these risk tables.

00:09:12

Host:  And is there a difference in how males and females are affected? Is one gender at higher risk of fertility challenges than the other?

00:09:22

Olivia Prebus: That's a really difficult question to answer with a yes or no, but absolutely there are different factors at play when you're thinking about risk to fertility for a male or female patient. For male patients the damage really occurs to the cells that help the body produce sperm. That damage can occur even before puberty. So what we're really talking about in terms of risk is sort of a a range from an complete inability to produce sperm, to a completely normal sperm count after treatment or somewhere in the middle. so lower than normal sperm count. And so really what that looks like if you're talking about fertility or infertility is it is a spectrum that were counseling patients on.

With female patients, the damage is occurring to cells that are already present in the body. So female patients, the risk is a bit different because biologically they are born already with their full ovarian reserve. So the damage that is caused to oocytes, whether they're mature or immature, by chemotherapy or radiation, diminishes that ovarian reserve. So again, I guess it's fairly similar to men and that there is a spectrum but what we're talking about really with women tends to be if you're not going to be completely infertile due to your treatment we're talking about a reduced window of fertility, so you have fewer eggs, which means that the time at which she will menopause may be sooner than somebody who hasn't received treatment. 

00:10:48

Host: Dr. Albritton, what are the different preservation options for boys and girls. 

00:10:54

Dr. Albritton: Currently we have the option of sperm banking. That is only an option for boys who have mature sperm which happens at puberty. The sperm banking is done through masturbation and that is something that we have to assess whether the patient is psychologically and emotionally and physically mature enough to produce a specimen for. That specimen can be saved for an indefinite amount of time, there are children who have been born out of specimens that have been stored for 20 years, so any post pubertal male is offered the option of sperm banking.

For females the options are much more limited. The only approved option right now in the United States is to collect an egg and either to freeze the egg itself unfertilized or to fertilize it with a sperm and freeze that embryo. This is a complicated option for our patients for several reasons. Most of our patients in the pediatric hospital do not have a sperm donor either they’re and married or do not have a partner that they would want to fertilize and create an embryo with, but thankfully we do have the option now in the last few years of freezing oocytes. Those oocytes, like frozen sperm, can be stored an indefinite amount of time and then be fertilized later when the patient is ready to have a family.

There are problems with oocyte collection. It is a complicated process that involves hormonal stimulation that takes about 2 weeks of time and often we do not have that length of time available to us before we want to start aggressive chemotherapy. In those patients we do offer ovarian supression with hormonal therapy. It's somewhat controversial as to how much that protects the patient from infertility from their cancer treatment and that it is something that both will at least keep them from having menstrual cycles and anemia during their cancer treatment and it may actually protect their ovaries somewhat long term from some of the damages of chemotherapy.

That has been a rather unsatisfactory menu of options for cancer patients and for a long time we've been hoping to have more options for a couple reasons. One is because all of those options I just mentioned are all for post pubertal patients. The other is the issue of time for the females. We are excited now to have several options on the horizon that will overcome some of those problems. For females we are excited to start offering ovarian tissue cryopreservation. This is a procedure in which an ovary is removed at the time of another surgical procedure before chemotherapy starts. That tissue is sectioned and parts of it are frozen just like we talked about freezing sperm or oocytes. It is stored away for future use.

The technology is rapidly advancing and there is incredible work being done as to how those samples then will be used and reimplanted in the body. This is different than how we talked about using oocytes and sperm in terms of using in vitro fertilization outside of the body and creating an embryo that then is implanted in the uterus. This is actually reimplanting the tissue that we have surgically resected into the now cancer survivor, and having it revascularized, start to become healthy again, and start making healthy eggs again within the body. What is unclear yet is whether those then are harvested and again in vitro fertilization is done. There are exciting opportunities potentially to reimplant the tissue even in the pelvic and have normal pregnancies. In any case, now that we know that it is safe and efficacious to do ovarian tissue cryopreservation, we feel it's an important offering for our young children even if we don't know how exactly it's going to be used in the future. This would be an offering available to patients of any age so now our prepubertal females will also have an option to preserve their fertility.

In males we also are looking forward to the opportunity to offer our prepubertal males testicular tissue cryopreservation. This is still experimental and we will be participating in a multisite clinical trial looking at the safety and efficacy of this. But it is something that we would offer families whose sons are at very high risk of infertility, as an opportunity to possibly preserve their fertility and certainly contribute to the field of research of oncofertility.

00:15:28

Host: So that said, Olivia, what are the challenges for kids and parents in making the decisions?

00:15:34

Olivia Prebus: There can be many challenges. We like to think of offering fertility preservation as offering a ray of hope in a really dark time in a patient and family's life. And I think that many patients look back on the conversations with that but in the moment it can be a lot of information to process on the heels of just being told that their child has cancer. And so there's a whole lot of emotional processing and then we're layering quite complicated information on top of that. So I think that is one of the biggest challenges that we see. The second, and probably it goes hand in hand but the first, is the timing. So in pediatric oncology the time from diagnosis to the start of aggressive treatment is very short for the most part. So when we're talking about decisions that need to be made and executed before starting chemotherapy or treatment there is a lot of pressure to make a big decision like this, so we try our best to get in there and start the conversation in order to leave as much time as possible for the family to sit with the information, ask those clarifying questions, and make the decision that's right for them.

Another thing that we encounter that's a challenge for more for the patient perspective is developmentally young teens have a very difficult time projecting into the future, So they often are very hard wired to think only about what is right in front of their face. And so when you're talking to a 14, 15 year old boy about masturbating, they can often get very caught up in, that's extremely embarrassing, this is a private thing that I'm not used to having anybody else know about and now you're talking about this and my parents know what's going on.  And sometimes I can be a real barrier for these patients to get past. And not all patients do. For some patients that's the reason they decide they don't want to pursue sperm banking.

Um, similarly for female patients, we’re talking about surgical intervention and shots for 2 weeks straight every day, I mean, these are not easy things to ask of of young people and so sometimes that can be another challenge. Often times parents can be very helpful at reframing the conversation but were always very mindful of discussing there is no wrong option. And really and truly very rarely is there tension between the decision the patient makes some of the parents want but sometimes that does happen, but we're really trying to create a nurturing environment so that this patient feels like they have some choice to make at a time when they don't feel they have a lot of options or choices.

Another challenge that's very real in the current environment is financial. Oocyte cryopreservation is extremely expensive. There are programs that can help defray the costs of the hormonal stimulation medications but when you're talking about a surgical procedure under anesthesia you know 4 to 10 thousand dollars up front is an awful lot of money when you've just found out that your child has cancer and you're anticipating additional health care costs to your family. Then we have to think about long-term storage costs, especially for younger patients. If you're talking about an annual storage fee of 4 or 5 hundred dollars a year, adding up over many years until a child is ready to start a family, that can also add up. Sperm banking, while not as expensive on the front end because that does not involve surgical procedures, is also costly when you think about long-term storage. So as best we can, we try to identify ways to defray the cost so that that doesn't become the reason, or the sole reason, that somebody chooses not to pursue if they would otherwise wish to do so.

So given these really difficult choices and really difficult um things that we're asking patients to do, um we always also like to make sure that we are saying there is no wrong answer and if you decide today and now that sperm banking or oocyte banking is not the best decision for you, we always talk about other methods of building a family in the future in the event that their current treatment does render them infertile. Really, our biggest role is to provide information and in no way would we ever want to feel like we're pressuring a family or a patient to make any decision. We really do just provide the information and some context so that they can make the best decision for them.

00:19:52

Host: So from what I've read, there are also ethical concerns with regard to oncofertility. What are those and how can they be overcome?

00:20:00

Olivia Prebus: This is a really rich area of study within the oncofertility community, and I really commend the discipline for really taking this ethical approach from the very beginning. There are many ethicists who write articles and books about the ethics of oncofertility. So with that as a backdrop, we’re really just focusing on 2 or 3 of sort of the top issues that seem to come to mind. The first really does play into some families decision making. There is a very real use of IVF and other assisted reproductive techniques involved in the future use of stored reproductive tissue, stored sperm, all of this. And so for some people it is ethically a difficult area when you're talking about embryos and IVF and things like that. The way that we mitigate this is, as we've talked about before our job is really to lay all the information on the table. Our job is not to pressure anybody into making a choice that does not sync with their values.

Another question has to do with for those patients that elect to pursue fertility preservation, if that patient then dies what happens to the tissue? So this is an area that's particularly difficult for minor patients. A patient over the age of 18 can very clearly and legally write out their intention as to what happens to their reproductive tissue in the event of their death. For a minor patient there have been some cases of parents wishing to use the reproductive tissue of a deceased child in order to have grandchildren. The way that this is circumvented here, and increasingly at many practices around the country, is to put very plain clear language in all consents and all conversations about the use of tissue in the event of the patient's death. We really feel that that tissue is part of the patient and the purpose of fertility preservation is to preserve the patient's ability to be a parent. And if the patient is no longer living they can no longer be a parent so we really very clearly state that in the event of a child's death or patients death at any point before they turn 18 that issue needs to be destroyed and not be available for use by other individuals.

A final, and very overarching, ethical question that really informs the presence of oncofertility as a discipline has to do with the real informed consent of patients and really understanding the impacts that their treatment will have. All of the major oncological and reproductive medicine societies have come together and said you know it is extremely important that patients are fully and transparently educated about the risks that their treatment, which is lifesaving, may have on their future fertility, and to withhold that information is ethically inappropriate. So even just the act of having the conversation and presenting the options really does overcome what is a very serious ethical obstacle that is, quite frankly, still a problem within oncology at large. This continues to be a problem despite all of these recommendations from professional societies.

00:23:11

Host: Dr. Albritton, as cancer treatment improves so does survivorship. How does that drive the need for fertility preservation?

00:23:20

Dr. Albritton: As I said before it's a good problem to have that we have so many children surviving their cancer treatment and hoping to be parents themselves. Many survivors when interviewed about the impact of cancer on their lives, cite fertility or infertility as a major grief in their life. Many of them say finding out they were infertile was almost worse than the cancer itself. Many of them are very bitter that they were never told about the risks to their fertility before their treatment. This is one of the reasons we feel so strongly that patients and families should be educated before treatment, they need to know the risks going into treatment and what we can potentially do about it. So it's a good problem to have that we have so many survivors, that the survivorship community is calling for us to at least educate them and hopefully to mitigate the risks. One of the things that the survivorship community has started to advocate around is not only education but the payment of fertility preservation options by insurance companies. Currently, insurance companies do not pay for fertility preservation options standardly, and as Olivia mentioned these can be very very expensive procedures. And it is heartbreaking when a family actually decides not to pursue an option solely because of a financial reason because their insurance company wouldn't cover their fertility preservation. Thankfully, at Cook Children’s we have some philanthropic donors who help mitigate that but the advocacy community at large is really rallying around the idea that this should be a right of cancer patients to have their fertility preserved prior to starting treatment.

There's now legislation in several states and it is pending in Texas it is being considered whether we can redefine the definition of infertility in a way that includes iatrogenic, meaning caused by physicians caused by medical care, and that would then allow coverage of these procedures prior to the start of cancer treatment. That would be a wonderful, wonderful change created by the cancer survivor advocacy community as a way to expand the options for cancer survivors to have as normal a life as possible.

00:25:35

Host: So Olivia, let's talk about fertility post treatment. Is there a longer term need for fertility discussions among survivors, meaning how long after treatment might a person be affected by a decline in fertility?

00:25:48

Olivia Prebus: The fertility discussion only begins at diagnosis, it really is something that threads through the rest of the patients oncology care into their survivorship care and really impacts them for the rest of their life. We have made it a priority to include conversations about reproductive health and fertility throughout this treatment continuum, into survivorship. So I will meet the family at the beginning of their treatment to discuss the risks. Sometimes treatment plans will change, depending on how well or poorly a patient responds to treatment. So if there are ever changes in their risk assessment we also go back and have that conversation. Looking into survivorship care, we like to make sure that we again revisit the education that was provided in context of their treatment plan because we know that patients may not remember or remember very clearly the conversations that they had with you when they were in great distress at time of diagnosis or during treatment. So this can sometimes be a great opportunity to clarify not just risk but what then this means for them and their survivorship care.

When you're talking about male patients, to answer your question about how long is the impact, studies show a wide variability as to when sperm counts normalize, if they will normalize, anywhere ranging from 2 to 10 years. So it's very important to counsel patients on a number of things. One is to make sure that they're engaging in safe sex practices if they are sexually active, not assuming that they're infertile. The other is helping them to understand what options exist for them to reassess what their sperm count is, and their sperm health, and when they might do it. Being that there are costs associated with semen analysis, our general guideline is for patients, if they're dying to know and they want to know, wait 3 or 4 years and if you feel like you'd like to have a semen analysis absolutely we can refer for that. Otherwise, we often say when the patient is ready to start a family that might be a good time to get a semen analysis before sort of starting that process with their partner.

For female patients the conversation is a bit different. So we're talking about potentially a smaller window for reproductive ability, or a smaller window to start a family. Many patients will still have ovarian reserve at the end of treatment so they will still have the ability to have children. But they may, as we said earlier, have an early menopause. And with women, as the ovarian reserve decreases there are other more systemic health issues that they need to be mindful of such as cardiac health, bone health. So really it is a much more global wellness picture that we're talking about even as we're talking about fertility. Female patients who maybe did not have the opportunity or chose not to egg bank prior to treatment may have that opportunity in this window after treatment.

So a large part of the survivorship care is monitoring lab work and then making appropriate referrals to reproductive endocrinology clinics for those patients that we identified as being at a higher risk in survivorship.

00:29:05

Host: So who follows up with these patients after treatment is complete? Is it the oncology team, primary care physician?

00:29:14

Olivia Prebus: Primarily it is the oncology team that does the closest monitoring of patients and their survivorship care. So the first 2 years after a patient completes active therapy, we call this the surveillance period where they're still coming very regularly to their primary oncologist for care. And really, during this period it's about starting to monitor for long term effects but it's also about being very vigilant about the possibility of a relapse. At Cook Children’s, we then transfer our patients to our Life After Cancer program for more long term survivorship care. The ultimate goal is that at some point the patient will then return to a more primary care model, but then continue to have a very clearly defined plan to monitor for long term side effects of their care.

00:29:59

Host: Dr. Albritton, is there a lack of training or knowledge among physicians when it comes to pediatric oncofertility?

00:30:07

Dr. Albritton: Absolutely. And for good reason. This is a rapidly, rapidly changing field. There is a lack of knowledge even among the experts in the field. Ironically, this morning there was a flurry of emails in my inbox among a group of highly trained specialists in oncofertility having an exchange of ideas about the best way to offer contraception to cancer patients. So if this group of specialists still can't answer all the questions there is absolutely a lack of knowledge in both oncologists and certainly in primary care providers.

So much has evolved in our understanding of what groups of patients are at risk after what amount of treatments, that the average oncologist really needs to be able to turn to a group that is keeping up with that information and has the latest information and is giving the appropriate risk information to the patient. In the past, we've had so few options to offer in oncofertiltiy that I think it was sadly common for treating physicians to skirt the topic. It is very hard to know that you will name a problem and not have a solution for it. So to tell a patient and a family, the treatment I have just described will make you infertile and I can't do anything about it. is heartbreaking. And I think that many physicians try maybe to even avoid having any discussion to avoid that second grief at the start. Or they wouldn't know they didn't know what the risk was. As we gain information and we're able to more clearly define risks, and wonderfully have increasing options to offer, it's our duty to access the information from the specialists and pass that information on to our patients at Cook Children’s. The important thing for primary care doctors to know is that there’s hope. And to tell their patients and families to make sure that they ask about the risks of infertility based on their cancer treatment and ask if there are any options available including experimental options because there may be clinical trials available to them to preserve fertility.

00:32:18

Host: Are there steps that the medical profession can take then to assure that more primary care physicians receive training in the importance of oncofertility?

00:32:26

Dr. Albritton: As I said, I think the field is so specialized, I'm not sure there will ever be widespread knowledge to the primary care physicians about all these details of treatment options. What I really want them to know is that we are a resource. At Cook Children’s, we will always be keeping up with the latest available options, the state-of-the-art clinical trials that we can offer our patients to make sure that they are getting the best options offered to them. We are always available as a resource. We know that as a team we are not only helping the patient and the family navigate cancer, but we consider the primary care physician part of our team and want them to have all of their questions answered and we will always be a resource and they're welcome to call us.

00:33:08

Host: Now I'd like to introduce Toni Levitt who, as mentioned earlier, has taken over the role of fertility navigator. Toni a lot of really exciting things have happened since the Oncofertility Program was first launched, can I just say welcome, and before we dive into that can you tell us just a little bit about you and when you joined the program?

00:33:30

Toni Leavitt: Hi and thank you for having me. I'm actually a nurse practitioner by training and I'm dually certified in both adult oncology in family practice. I've been in the nursing field for about 10 years and became an oncology nurse because I just love taking care of patients and oncology patients specifically because it's a particularly vulnerable time for them and their families and I love having the ability to support them. When this position came up to manage both the Adolescent Young Adult, or AYA, and oncofertility programs here at Cook Children’s, it seemed like a really perfect fit, based on my interests. I really enjoy the direct patient care and program managereal responsibilities such as data collection and project strategy.

00:34:12

Host: And how long have you been with the program now?

00:34:15

Toni Leavitt: I joined Cook Children’s at the height of the pandemic in July of 2020 and it's been a really exciting few months.

00:34:23

Host: I bet. And what are some of the latest updates in oncofertility here at Cook Children’s since you've come on board?

00:34:29

Toni Leavitt: It's been an exciting time since I joined. As mentioned, Olivia and Dr. Albritton had worked hard exploring how to bring prepubertal fertility preservation options to Cook Children’s, including both ovarian and testicular tissue cryopreservation. Since arriving at Cook Children’s we've actually expanded our offerings. First, we now have a research study for testicular tissue cryopreservation, which is an opportunity for post pubertal males to preserve a portion of the testis to use for future fertility. This is only an option for our male patients who are at very high risk for infertility. For our female patients who are prepubertal, we now offer ovarian tissue cryopreservation. Like testicular, we only offer it when that individual is at very high risk for infertility due to their treatment, which can be surgical, radiation, or chemotherapy related. Ovarian tissue cryopreservation is when an ovary is removed and cryopreserved for future fertility. This is no longer considered experimental.

Shortly after I arrived, we identified a prepubertal female patient who would benefit from ovarian tissue cryopreservation. We offered this to the family and they seemed interested, mainly because the dad didn't want to eliminate future fertility for his daughter. On the day of the surgery I had the opportunity to go into the operating room with doctor Blake Palmer, and received this tiny ovary, sent it to Pittsburgh, where it will be preserved for future use. It was a really rewarding experience for the family, of course the patient, and all of the medical team members involved.

00:36:19

Host: So in terms of advancements in fertility preservation, some of the biggest changes are in ovarian and testicular tissue cryopreservation, also known as OTC and TTC. Can you share a little about this?

00:36:31

Toni Leavitt: OTC is a clinical offering, so it's no longer considered experimental here or anywhere else, while TTC, or testicular cryopreservation, is under an IRB or research protocol that is part of a national study. Eligibility will be carefully considered by the medical team prior to offering and while these cases will be few and far between as it's only offered to those at very high risk for infertility, I'm thrilled that we now have these options available here at Cook Children’s.

00:37:03

Host: What about other forms of fertility preservation? What alternatives are available and at what age can they be considered for an oncology patient. 

00:37:12

Toni Leavitt: For post pubertal males, it's our policy to offer sperm banking, and for our post pubertal females we can coordinate oocyte or egg cryopreservation or embryo cryopreservation for those who have a partner. We work closely with the reproductive endocrinologists in town to offer these options. For our prepubertal patients, those who have not yet gone through puberty, OTC and TTC are the only possibilities, and still it is only offered to those at significantly high risk for infertility due to the treatment they'll be receiving. We continue to hope that fertility preservation laws will be passed to make all of these options affordable for our patients and work closely with an advocacy group to support that initiative here in Texas.

00:37:56

Host: You mentioned prepubertal children who have serious types of cancer, what are the challenges? Like why do they have to be at high, high risk? And is there an age cut off for that?

00:38:07

Toni Leavitt: We define significantly high risk for infertility as those receiving a very high dose of chemotherapy, where it is unlikely that they will be fertile in the future. Or they are receiving radiation to either at the brain or the pelvis that will also affect their fertility. Ovarian tissue cryopreservation and testicular tissue cryopreservation involves removing that tissue from the patient and so our preference is to not remove that tissue unless absolutely necessary to preserve fertility.

00:38:42

Host: So when you say remove the tissue then is it like perhaps the whole ovary or testicle?

00:38:49

Toni Leavitt: Yes

00:38:52

Host: It's gotta be really, I'm sure in some cases, like a challenging choice for parents and for the patients. But it also has to be, I guess, somewhat reassuring that in the long term they can still go on and have a family and live as close to a normal life as possible, whatever a normal life might be.

00:39:12

Toni Leavitt: Absolutely. I remember talking to the parent of our first patient and he said, I don't want to make the decision for her, I want to keep this option open for her. 

00:39:25

Host: As cancer treatments improve, and childhood cancer survivors go on to live fulfilling lives as adults, the ability to help ensure that even young patients can look forward to having children some day is absolutely amazing. And as more advancements in medical breakthroughs come in both cancer and fertility care, what does the future look like. 

00:39:46

Toni Leavitt: It would be fantastic if we had less toxic treatments that did not impact fertility as significantly as the ones we currently rely on do. I hope that the future entails coverage for fertility preservation for all of our patients, making these options a possibility for everyone who would benefit from them. I would also love to consult not only with those who would benefit from a method of fertility preservation but also those at low risk for infertility to provide reassurance to them. One benefit of COVID has been the increased use of telemedicine and with time it would be great to provide fertility counseling via telemedicine, so we can expand our reach beyond the medical center. Many goals, but I think all of these would be incredibly fulfilling for our patients.

00:41:24

Host: That was really, really informative. Thank you for taking the time from your hectic schedules to talk about fertility preservation and about the important work you're doing for pediatric oncology patients at Cook Children’s as well as across North Texas and the U. S.

00:40:50

Dr. Albritton: Thank you so much and for talking about this important topic.

00:41:04

Host: We're so glad you could join us today. If you'd like to learn more about this program or any program at Cook Children’s please visit us at Cook Children’s.org.