REI Referral for Fertility Preservation in Patients Undergoing Gonadotoxic Therapy

April 20, 2022

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Yale Cancer Center Grand Rounds | April 19, 2022

Presentations by: Tanya Glenn, MD and Gabriela Beroukhim, MD

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00:00See we are talking.
00:03Generally about the topic of uncle fertility,
00:07and more specifically about reproductive
00:11endocrinology and infertility.
00:14Referral for fertility preservation and
00:17patients undergoing chemotherapy or Granada.
00:21Toxic therapy as as the the the poster said.
00:27And we're joined by two members of
00:30the OB GYN department, both who are
00:33relatively young in their careers.
00:36I don't actually know who's going first,
00:39and I'm going to introduce both
00:41of them together as we start,
00:43and they can decide that.
00:44So we have two speakers.
00:46We have Tanya Glenn,
00:48who's originally from Rochester,
00:51MN and went to college at Truman
00:54State University in Missouri and then.
00:58Went on to attend medical school at Saint
01:01Louis University School of Medicine.
01:04And took the what is not such a common
01:07path of of joining the military and
01:11did a combined military and civilian
01:13residency at at Wright Patterson Air Force
01:16Base and Wright University in Dayton, OH.
01:19She's in her final year of REI training
01:22at Yale and is going to be taking a
01:25position at Brooks Army Medical Center.
01:29After completing her her
01:32fellowship this year.
01:35And she is joined by Gabriella Barouch Kim,
01:40who is from Los Angeles,
01:42originally received her
01:44undergraduate degree at UCLA,
01:46where she received a number of honors
01:50and went on to medical school at UCSF.
01:54She is a third year resident in
01:58OBGYN and is also interested in REI.
02:03And is in the process of applying
02:06for reproductive endocrinology
02:08and infertility fellowships as the
02:10parent of a child who went through
02:13the Yale OBGYN Residency.
02:14It's always nice to interact with the
02:17with with Yale OBGYN and residents,
02:20so they're they're here today and I'm
02:23I'm not entirely sure what order.
02:26I'm not entirely sure who's talking
02:28about what,
02:28but I'm going to leave it to the two of you.
02:30You're both on one screen and
02:31I think you can figure it out.
02:33Welcome, thank you for joining us.
02:37Thank you, thank you for having us.
02:40So I'm Gabriella.
02:41I'm here with Doctor Glenn.
02:43We're actually going to be
02:46Co presenting and Doctor
02:47Glenn is going to help answer
02:49questions at the end as well.
03:02OK, your slides. They look perfect.
03:06Perfect thank you so much.
03:09So today as you already mentioned,
03:11we're going to be talking about
03:14fertility preservation for patients
03:15undergoing gonadal toxic therapy.
03:20Neither Doctor Glenn nor
03:22I have any disclosures.
03:26So our objective with this talk is to try to
03:29raise awareness for fertility preservation.
03:32Encourage patient and provider discussions
03:34surrounding the implications of cancer
03:37treatment on future reproductive capacity,
03:40improve multidisciplinary collaboration
03:41between providers caring for these
03:44patients and reproductive specialists,
03:47and discuss options for fertility
03:50preservation for patients who hope to
03:53preserve their reproductive capacity.
03:55So first I'd like to start with a
03:58little bit of background on this topic.
04:00The term oncofertility was coined by
04:02Doctor Woodruff and it refers to a field
04:06of medicine concerned with minimizing the
04:08negative effects of cancer treatment on
04:11the reproductive system and fertility,
04:14with assisting individuals with reproductive
04:16impairments resulting from cancer therapy.
04:22So what population are we referring to
04:25when we discuss fertility preservation
04:27for patients undergoing cancer therapy?
04:31So over 200,000 people under the age of
04:3549 are diagnosed with cancer annually
04:38and 85% of patients less than 39 years
04:41old will survive for five years.
04:4670,000 new cases a year of cancer
04:50are diagnosed in adolescence and
04:53young adults of these patients,
04:56more than 90% of them,
04:58will survive for at least five years,
05:00and these patients tend to be healthier
05:03and tolerate more intense therapies,
05:05which is relevant because more
05:07intense therapies can drastically
05:09reduce the reproductive lifespan.
05:14Certain cancer treatments such as radiation,
05:17chemotherapy, and surgery,
05:18can lead to sterility and subfertility.
05:21So next I'd like to briefly discuss
05:24what some of the morbidities
05:26of are of these therapies.
05:29So specifically regarding radiation therapy,
05:32there are acute morbidities,
05:35including primary hypogonadism,
05:37premature ovarian insufficiency,
05:38which was previously referred
05:41to as premature ovarian failure,
05:44central hypogonadism,
05:45specifically for patients who are
05:47undergoing radiation to the brain,
05:50and then there are late morbidities,
05:52including secondary cancers that can
05:54result from radiation therapies,
05:56hypothalamic pituitary ovarian
05:58access deficiencies.
06:00Spinal cord dysfunction,
06:01which can potentially lead
06:03to impotence among males and
06:06infertility or ovarian insufficiency.
06:11Regarding the effects of chemotherapy,
06:14there are the effects of late morbidity,
06:16including infertility,
06:18premature ovarian insufficiency
06:20and primary hypogonadism,
06:23and there are increased risks
06:25specifically with people who are
06:27receiving alkylating agents or
06:29patients with Hodgkin's lymphoma or
06:31breast cancer with undergoing adjuvant
06:34therapy where at increased risk of
06:36premature ovarian insufficiency.
06:42Regarding stem cell therapies
06:44and the effects of those,
06:46those can lead to gonadal dysfunction
06:48and the late morbidity associated
06:51with those include secondary
06:53cancers and endocrine dysfunction.
06:57Lastly, there are the surgical effects
07:00of cancer therapies and the acute and
07:02long term effects of those include
07:04early menopause and sterilization.
07:07For example, if somebody would
07:09need to undergo removal of their
07:11ovaries or fallopian tubes.
07:15So different therapies have
07:18different reproductive reproductive
07:19risks associated with them,
07:22so high risk therapies include
07:24high dose pelvic radiation,
07:26radiation to the brain,
07:29hematopoietic stem cell transplantation,
07:32total body radiation or chemotherapy
07:35with high dose alkylating agents,
07:38whereas low risk therapies include
07:40low dose radiation to the pelvis,
07:43non alkylating chemotherapeutic drugs.
07:46Or antimetabolites.
07:51So now I'd like to transition a
07:52bit to discuss the importance
07:54of counseling these patients.
07:59So all patients of reproductive
08:02age who will undergo potentially
08:04gonadal toxic therapies should be
08:07receiving fertility counseling.
08:09This is in line with guidelines from the
08:12American Society of Clinical Oncology,
08:15which reports that all oncologic
08:18healthcare providers should be
08:20prepared to discuss infertility
08:22as a potential risk of therapy.
08:25The NCCN practice guideline also says
08:27that fertility preservation is an
08:29essential element of management of
08:32adolescents and young adults with cancer.
08:37That being said, less than half of US doctors
08:40inform cancer patients of childbearing
08:43age about fertility preservation,
08:46and only 47% of US doctors routinely
08:49refer cancer patients of childbearing
08:51age to reproductive endocrinologist.
08:5654% of oncologists do not discuss
08:59fertility, according to the JNC
09:01CN that was published in 2013,
09:05whereas specifically pediatric
09:06oncologists tend to do a bit
09:10better and 94% of pediatric
09:12oncologists discuss fertility.
09:16And what basically this highlights
09:18is that there is a discrepancy
09:21between the current guidelines and
09:23the reality regarding counseling,
09:26and this is something for all of us to
09:28work on and an area for improvement to
09:31increase access to fertility preservation.
09:36So what about Yale? What is going on?
09:40How are you doing with counseling at Yale
09:44regarding fertility preservation for patients
09:47undergoing therapy for their cancer?
09:51So we do have one study that looks into
09:54how what percentage of patients are being
09:58counselled specifically for patients
10:00who are prescribed cyclophosphamide.
10:03The study included 236 reproductive age women
10:08between December of 2019 and October of 2021.
10:14And of these 236 patients,
10:1833% received family planning
10:20counseling and 9% were offered
10:24ovarian tissue cryopreservation.
10:27There were certain factors which
10:29modified a patient's likelihood
10:31for receiving counseling and those
10:33included Caucasian race age,
10:35less than 40,
10:36and those who had living children were
10:39less likely to receive this counseling.
10:46So how can we improve access
10:49for fertility preservation?
10:54There are several things that need to
10:56happen for us to achieve that goal.
10:58One is to increase awareness.
11:02Next would be to assess patient's
11:05interest in receiving fertility,
11:07preservation treatment,
11:10as well as the provider
11:13providing basic counseling
11:15regarding fertility preservation.
11:17Placing a referral when indicated,
11:19and then ensuring that a patient
11:21is able to access this care.
11:27So how do we increase awareness?
11:31Well, patients are often overwhelmed
11:33by a cancer diagnosis, especially when
11:36they first receive that diagnosis.
11:38They can be worried about
11:39delays in cancer treatment,
11:41or they could just be unaware of the
11:45potential effects of their therapy
11:48on their reproductive capacity.
11:50The medical team already has a
11:53considerable amount of counseling to do
11:55when a patient receives this diagnosis,
11:58and oftentimes that the discussion of
12:01fertility preservation cannot be prioritized.
12:04However, the onus really falls on the
12:07medical team to be able to identify
12:10these patients who are at risk and to
12:13be able to provide basic counseling
12:15and place the referral to reproductive
12:17endocrinology when indicated.
12:21So what are some ways that we propose we
12:25optimize this awareness so one is just
12:28through education and collaboration,
12:30which is why doctor Glenn and I
12:33are here is to try to promote that
12:36and something else that we that
12:38we proposed was epic optimization,
12:42which we'll talk about a little
12:43bit more in the next slide.
12:47So something that Doctor Glenn and I
12:49had proposed to the Epic optimization
12:52team is to potentially have a hard
12:55stop when a new diagnosis of cancer is
12:58entered into a patients problem list.
13:01A provider could could encounter this alert
13:05that would require that they acknowledge
13:09a reason for either referring a patient
13:13to reproductive endocrinology or not.
13:16Facing a referral or acknowledging that
13:19this is not applicable for this patient.
13:24After a after a provider is met with
13:27this alert they would then when
13:30indicated either place a consult to
13:33gynecology when a patient is in the
13:36inpatient setting or if they are in
13:39the outpatient setting they would
13:41simply just place an REI referral.
13:43I just want to highlight here that when
13:47patients are in the inpatient setting,
13:50that console is a general consult to
13:53gynecology. Once that console is placed,
13:56the guide, the inpatient gynecology
13:59resident team will contact
14:01reproductive endocrinology.
14:05This can also be done for for preservation.
14:10For male patients, it would still be a
14:13gynecology consult in that case as well.
14:18So now regarding education,
14:21the Oncofertility Conservatorium was
14:23developed in 2007 to address the lack
14:26of knowledge concerning fertility,
14:28preservation and the National physicians
14:32cooperative includes 83 institutions,
14:35including oncologists,
14:36surgeons, endocrinologists,
14:38reproductive endocrinologist,
14:40urologist, rheumatologist, geneticist,
14:41and mental health providers,
14:44and below are also different links.
14:48That can be used by both providers and
14:52patients to promote education on this topic.
15:01And then regarding counseling.
15:02So there are several steps
15:04involved in counseling patients,
15:06including informing patients of
15:09the potential risks to fertility.
15:12Of their therapy,
15:14as well as just inquiring whether they
15:17desire to preserve their fertility.
15:19Referring patients to REI if
15:21they are interested as well as
15:23following up on those patients.
15:28At this point I want to just
15:30transition a bit to discuss to
15:33discuss patient perspectives and
15:34hopefully this will help highlight
15:37again the importance of this topic.
15:43So in a study that looked at
15:46female cancer survivors. Umm?
15:50There was an increased rate of
15:53pregnancy termination among female
15:55cancer providers due to a fear of the
15:57effect of their therapies on their
16:00future on their future children,
16:02and what this really highlights
16:04is a gap in education.
16:08This study also showed that 91%
16:11of female cancer survivors felt
16:13that their quality of life was
16:15improved after receiving counseling
16:17and treatment about fertility.
16:22There was also a cross sectional study
16:26concerning fertility after cancer,
16:28where the primary outcome was use of
16:32fertility treatment and in this study,
16:3575% of participants reported that having
16:38a biological child was important to them.
16:4215% of these participants
16:44actually used fertility services.
16:46And survivors were less likely to pursue
16:50infertility treatment due to a fear of
16:53adverse effects on their personal health,
16:56which again highlights a
16:57gap in their education.
17:02Other patient perspectives include a survey
17:04from the Journal of Clinical Oncology.
17:07In this survey, 81% of teen girls and
17:1193% of their parents would be interested
17:15in fertility preservation, even if that,
17:17even if that method were to be experimental.
17:24In a survey from the Journal of
17:27Assisted Reproduction and Genetics.
17:3012.5% of patients reported that they were.
17:33They would regret if they were unable
17:35to use the tissue that they preserved
17:39for ovarian tissue preservation.
17:41In these patients and parents felt
17:44more in control of their decision
17:46with receiving this counseling.
17:52Other patient perspectives.
17:54There are studies and surveys that
17:56indicate that 26 to 80% of individuals
18:00remember discussing fertility.
18:02This range really highlights the
18:04variability in each practice.
18:0868% of males and 14% of females
18:11remembered being offered a referral
18:13for fertility preservation.
18:17And then this last statistic reports
18:20that female survivors were less
18:22likely to be prescribed infertility
18:25medications after seeking help,
18:28and that relative risk was 0.57.
18:31And what this shows us is that there's
18:34also a lack of education among providers.
18:39So next, I'd like to speak about the
18:41different methods that can be offered
18:43to patients for fertility preservation.
18:48So there are many proven as
18:50well as experimental methods
18:52for preserving fertility.
18:53These include gamete or embryo
18:57cryopreservation, ovarian tissue,
18:59or whole ovary preservation,
19:01suppression of damage which
19:03can include decreasing the
19:05dose of a certain therapy or
19:07using an alternative therapy.
19:09Decreasing the dose to the gonads,
19:12or steel or shielding the gonads
19:15or avoidance of damage entirely,
19:17which could entail.
19:18Removing the gonads or using
19:20an alternative therapy.
19:24So to discuss some of the proven methods,
19:27the gold standard is considered
19:30embryo cryopreservation.
19:31This process includes stimulating
19:33the ovaries with gonadotropins,
19:36surgically retrieving oocytes,
19:38inseminating the O sites,
19:40culturing them for three to five days,
19:43and then cryo preserving them.
19:46This tends to have a high success
19:48with 90% survival of embryos and
19:51live birth rates between 22 to 35.
19:54Percent, this whole process
19:56takes about two to three weeks,
19:58and some of the cons include
20:00exposure to high dose hormones,
20:02the time involved,
20:03and the fact that the that the patient
20:07would need either partner or donor sperm.
20:11Another option is mature
20:14O site cryopreservation.
20:15This tends to have slightly lower success
20:18rates between 50 and 90% survival.
20:21That's likely due to attrition of the
20:24O sites, as they need to be frozen,
20:27thawed, then inseminated.
20:29And sorry it fertilized and
20:34after fertilization matured.
20:36This process takes essentially the
20:38amount the same amount of time as.
20:40Embryo choir preservation.
20:42There are fewer ethical objection
20:45objections and no partner is required
20:49for oversight chair preservation.
20:51Another proven method includes O for praxy.
20:55This has a success rate between 16 and
20:5890% and involves fixing the ovary to
21:01the pelvic brim with a surgical clip.
21:04This is typically used for
21:06patients who will be exposed to,
21:08for example,
21:09radiation therapy to the pelvis and
21:11what it's essentially doing is moving
21:14the gonads away from that site.
21:17There are no ethical obligations,
21:20I'm sorry there's no ethical objections
21:23to over prexy and enables a patient
21:26to be able to use their own O sites
21:30and there's no stimulation required.
21:32Some of the cons include that.
21:39It really depends on a
21:41patient's vascular system.
21:42It depends on their age.
21:44It depends on the dose of
21:47radiation that they're receiving,
21:49and it can also be affected if
21:52the area is not shielded. The.
21:59Other methods for.
22:01For fertility preservation,
22:04include ovarian tissue cryopreservation.
22:07This was previously thought to be
22:11experimental and is now a proven method
22:13and involves obtaining ovarian cortical
22:16tissue prior to ovarian failure.
22:19The tissue is obtained via
22:22laparoscopy or laparotomy.
22:23The tissue is dissected into into
22:26small fragments, cryopreserved,
22:27and then can later be transplanted.
22:30Most typically,
22:31that's done as an orthotopic.
22:33Transplant and not a heterotopic transplant.
22:37Live birth rates are between 23
22:40to 25% and this is particularly
22:44useful for prepubescent girls,
22:47and it can also be used as a
22:49form of endogenous hormones.
22:51Once this tissue is retransplantation.
22:55Some of the cons include.
22:58That reimplantation of potential
23:03cancer potential cancer.
23:06Once the tissue is removed and
23:08then reimplanted the uncertain
23:10life span of this tissue.
23:12The fact that it requires surgery
23:14and may require IVF down the line
23:18and the age limit such that patients
23:20who are typically over the age of 40
23:22will have less benefit in this case.
23:29Next, I'd like to go over just
23:32a few experimental methods
23:33which include whole ovary,
23:35including pedicle cryopreservation.
23:36This is typically reserved for very young
23:40patients whose ovaries are very small,
23:43for which ovarian tissue, cryo.
23:46Location would be very difficult.
23:49Another experimental method
23:50includes GNRH agonist therapies.
23:53The thought process with this is that we
23:56shut down the ovaries while a patient
24:00is receiving their cancer therapy,
24:02and the thought is that when
24:04these ovaries are less active,
24:06they'll be less susceptible to the
24:08harmful effects of the therapies.
24:13Some alternative options for patients
24:15include the use of donor eggs,
24:17the use of donor ombria embryos,
24:20surrogates or adoption.
24:27Lastly, to go over what happens
24:29post treatment for these patients.
24:31So regarding evaluation of
24:33their fertility down the line,
24:35most reproductive endocrinologists
24:37or gynecologists would look for
24:39patients to resume their menstrual
24:41cycle as well as test their anti
24:44mullerian hormone level to get a
24:46proxy of their ovarian reserve.
24:51Regarding the use of medications
24:53and outcomes for these patients,
24:56generally we use the same medications.
24:59However, as already mentioned,
25:00if a patient has an
25:03estrogen sensitive cancer,
25:04we can consider adding letrozole
25:07and aroma taste inhibitor or
25:10tamoxifen to reduce the exposure
25:13to high levels of estradiol.
25:18There are lower pregnancy rates in
25:21the first five years with autologous
25:24with use of autologous O sites and
25:27that lower pregnancy rate is 60%.
25:29However, notably,
25:30if someone were to use donor O sites,
25:33pregnancy rates tend to be fairly comparable.
25:39Regarding pregnancy complications,
25:41pregnancy does not affect recurrence
25:44of any cancer and generally pregnancy
25:47complications tend to be very low.
25:50The one exception to this is that
25:53some patients who receive very high
25:55dose of radiation to the uterus,
25:57especially at a young age,
25:59can potentially have a bit higher risk.
26:04Pregnancy outcomes and
26:06pregnancy complications.
26:09Regarding risk to offspring,
26:11there is no increased risk of anomalies.
26:14However, a provider may consider
26:15referring a patient to a genetic
26:18counselor specifically, if there is
26:20a genetic predisposition to cancer.
26:25Some other concerns that I'd
26:27like to briefly discuss include
26:30some safety concerns so.
26:32It should be determined by
26:35a multidisciplinary team,
26:36including the medical oncologist
26:39and reproductive endocrinologist.
26:41As to a discussion of the risks,
26:44benefits, preferences,
26:45and prognosis of this patient
26:49to discuss whether pursuing
26:51fertility preservation would
26:52be safe for the patient.
26:58There should also be consideration
27:02paid to trying to prevent any
27:06delays in in oncologic treatment.
27:09Regarding the legal implications,
27:11we should acknowledge the legal
27:14implications of not following the
27:15standard of care as well as the medical
27:19liability and potential malpractice with
27:21omission of information specifically
27:23regarding the the risks of cancer
27:27therapies on reproductive capacity.
27:32Additionally, the ethical considerations
27:34to consider that every patient has the
27:38right to know their options concerning
27:40fertility preservation as well as the
27:43risks and costs associated with that.
27:45Post humus utilization.
27:46This typically will depend on
27:49a patient's advance directive.
27:53Minors who are diagnosed with
27:55cancer will typically require
27:56a surrogate decision maker.
27:59And of course,
28:00the cost of these therapies.
28:05Just to briefly discuss the cost.
28:09There is legislation regarding
28:11costs specifically in Connecticut.
28:14In general, in 1942,
28:15the US Supreme Court acknowledged that
28:18procreation is a basic civil right
28:21and then specifically in Connecticut.
28:23We do have the fertility preservation bill.
28:27This was an acted,
28:29and basically it ensures that patients
28:32are covered for fertility preservation.
28:35If they have a medical necessity and having
28:40prior cancer treatment is considered,
28:44makes fertility preservation
28:46a medical necessity,
28:47and so patients who have private insurance.
28:53Have have this cost covered under this bill.
28:58Unfortunately,
28:58that bill does not cover the cost
29:01for people without insurance
29:02or for people with Medicaid,
29:04and so there are other means to try to
29:07reduce that cost for those patients,
29:09and they are listed below.
29:12So for example,
29:13with repro tech,
29:15they provide discounted long
29:16term storage of ovarian tissue
29:19as well as O sites and embryos,
29:22specifically regarding the cost of
29:24ovarian tissue prior preservation
29:26that one tends to be a bit costly.
29:28And can be between 12 to 24,000.
29:30However,
29:30this can also vary based off
29:32of the patient's income.
29:36And so lastly, to summarize,
29:38some of the things that we discussed today.
29:41Certain cancer treatments
29:42such as chemotherapy,
29:43radiation and surgery can lead to
29:46sterility and subfertility all patients
29:49of reproductive age who will undergo
29:51potentially genotoxic therapies
29:53should receive appropriate counseling.
29:55Some of the methods to try to optimize
29:58access to fertility preservation
30:00and include increasing awareness,
30:02promoting education and counseling,
30:05and collaboration, and methods.
30:07To preserve fertility,
30:08include embryo 4 O site cryopreservation,
30:12O for paxi, ovarian tissue cryopreservation,
30:15or experimental methods.
30:18Thank you so much for your attention.
30:21Here are some of our references and
30:22we're happy to answer any questions.
30:26There's.
30:34OK, so we have a question
30:37here regarding oh for proxy.
30:39The range of success rates listed
30:42are quite wide, from 10 to 90%.
30:44I had heard roughly a 50% chance
30:47of damaging the ovary directly
30:49from the procedure itself,
30:50which seems a high risk since since the
30:53risk from radiation is also probabilistic.
30:56Does Yale offer this option?
30:59What do the success rates look like
31:02in modern practice and what patients?
31:04Do well versus poorly with this approach.
31:15I actually have not seen any
31:18perplexity done here at Yale,
31:19but it is actually a simple procedure.
31:21It's the same thing.
31:22If we had some with ovarian torsion,
31:24it's actually the same procedure to be done,
31:26so it's something that we can actually do.
31:28I haven't seen a whole lot of public
31:30radiation patients come through. I
31:32couldn't give you the exact
31:33statistics, mainly because
31:36the problem is is like it varies on dose.
31:41Where it's located?
31:42Are they shielding or not?
31:43And so that's why you see that wide range.
31:46So even with Uber,
31:47Paxi would probably still
31:48recommend doing an additional.
31:52Fertility preservation procedure like
31:55tissue or embryo cryopreservation.
31:57Just to make sure that if there
31:59is any scatter from the radiation
32:01that we're still protecting
32:02them as much as possible.
32:06So I have a question for you, so, UM,
32:08you know. Obviously these issues come
32:10up with a fair amount of frequency,
32:13and I'm struck that you gave a great talk,
32:18but one of you is going off to take
32:21a job in Texas and and Gabriella,
32:25you're going off to do a
32:27fellowship in another year.
32:28So who on the in in the REI?
32:32Faculty is interested in these issues,
32:34who we should approach?
32:37Well, Gavin, be here for
32:39another year and so I
32:42understand that. But you know,
32:44again. So in training
32:47no, absolutely. And so we're
32:49working with Doctor Callan as well,
32:51and she does mainly the probably the
32:53most of the fertility preservation.
32:56But the fellows all work together too,
32:59so it's everything's just
33:00kind of passed down for.
33:02So my second year fellow,
33:03who's a rising third year now Eric Kahn,
33:06would be another good point.
33:08Of reference as well.
33:14There's another chat. The questions.
33:19Can you talk a little bit more
33:21about your outpatient services?
33:22How quickly can these patients be seen,
33:24particularly those who need to start
33:26anti cancer treatment quickly?
33:28Absolutely. So usually the third
33:30year fellow actually does all of
33:33the at least the Medicaid referrals
33:35and other referrals as well.
33:37If you just mark them urgent,
33:38we usually can see them within
33:40a week if not faster inpatient.
33:42Of course we see within 24 hours a lot
33:44of times it's just be like video chat
33:46so we can just talk about the options.
33:48And start getting things set up on our end,
33:51but usually we see people very
33:53quickly and you know we manage to
33:55squeeze them in somewhere because
33:57we know how important this is and.
34:00You know the hard part is when patients
34:03you know are not stable enough,
34:05and those are probably the hardest patients,
34:06and so usually if they have to
34:09undergo cancer treatment immediately,
34:11we want to make sure that they know how
34:12to find us afterwards so we can start
34:14planning after their treatment as well.
34:17Ohh Kurt,
34:18is there any movement to extend reproductive
34:21coverage to patients with Medicaid?
34:23I wish I've not seen any movement from.
34:26Fortunately for that,
34:27I think there's this an ongoing struggle.
34:30The hard part too is.
34:31I'm not originally from East Coast,
34:33but since all the states are so small
34:35each time you move states we see a
34:37lot of patients from Rhode Island and
34:38Massachusetts and New York and all of
34:40those states have different policies
34:42when it comes to fertility preservation,
34:44and so it makes it very difficult
34:46to keep up with. I think,
34:48but I have not seen any
34:50improvement in that area.
34:55Can you clarify if the quality
34:56of life statistic is independent
34:58of whether or not the patient
35:01used preservation strategies?
35:02I think the stress is the
35:03importance of referral,
35:04regardless of whether or
35:05not you have time. Yes,
35:08it does. Patients, even if they
35:11cannot pursue the treatment.
35:12Especially they can't pursue it immediately.
35:14Still appreciate the counseling that
35:17they receive so that they're aware of it.
35:20It's not 10 years down the road that they're.
35:22Surprised by this outcome.
35:29Something as well as that
35:30we're doing a lot more ovarian
35:32tissue crime preservation.
35:33I'm doctor ate. Who's a Yale physician,
35:36but recently has been working
35:39a little bit more with us.
35:41He does the ovarian tissue crime
35:43preservation, he kind of based out of
35:44New York when he comes down and does
35:46ovarian just require preservation,
35:48and does a lot of research on fertility,
35:50preservation, and so we're lucky to have
35:52him and that we can kind of continue.
35:54Still other areas that we're
35:56trying to improve on is, you know,
36:00testicular tissue prior preservation.
36:02Hopefully we will get more.
36:03There's only like 1 area,
36:05I think in Philadelphia or
36:07Pittsburgh around here.
36:08That does that for prepubescent boys,
36:10that is still experimental,
36:12but there's a lot of different
36:14things that we're just trying
36:16to bring more to Yale so that we
36:18can ensure that we kind of cover
36:20everyone for fertility preservation.
36:22When it comes to male fertility preservation.
36:25It's usually if they're postural,
36:27very straightforward.
36:28If there's any problem with ***********
36:30or the patients are unable to do so,
36:32we just have our colleague from Urology, Dr.
36:34Honig, help us with that,
36:37but we have our own andrology
36:39lab and store sperm here.
36:46Any other questions?
36:51Well, thank you both.
36:53It was really great and we
36:55look forward to interacting
36:57with your colleagues in the in
36:59the years ahead and good luck.