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REI Referral for Fertility Preservation in Patients Undergoing Gonadotoxic Therapy

April 20, 2022

Yale Cancer Center Grand Rounds | April 19, 2022

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

ID
7739

Transcript

  • 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.