Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And today, we're highlighting the American Society for Reproductive Medicine's new guidance on fertility preservation, what urologists should know. Joining me is Dr. Robert Brannigan. He's the Janice Binstein Professor of Urology, the vice chair of Clinical Urology and chief of Male Reproductive Medicine at Northwestern Medicine, as well as the president of the American Society for Reproductive Medicine.

Dr. Brannigan, it's always a pleasure. Thank you so much for being with us today. As president of the ASRM, what was your role in this committee opinion? How involved are you in shaping guidance like the one we're going to talk about today?

Robert Brannigan, MD: Yeah. Well, first of all, Melanie, thank you so much for the chance to join you and your audience. I always look forward to spending the time with you and covering these new topics. So, certainly my role as president of ASRM, I'm very involved with not only the review of this manuscript, but this area of fertility preservation is one that I'm very invested in personally. And so, I had the chance to help out with some of the direction of this on the front end and the editing of it as we were developing the statements.

Melanie Cole, MS: That's great. That's really cool that, you know, you get to shape this kind of guidance. So, what's new in this 2026 committee opinion compared with prior guidance it replaces? And what should urologists change in their practice as soon as they can?

Robert Brannigan, MD: I think that it's important for physicians and urologists in particular to realize that fertility preservation is a concern or issue not only for those facing a cancer diagnosis and cancer treatments, but also other medical therapies that might be treating specific medical conditions that might not be cancer-related, but that nonetheless can permanently and irreversibly affect fertility.

Melanie Cole, MS: So Dr. Brannigan, then the opinion highlights rapid referral and timely intervention, which we all know is really important. So, what does an ideal urology workflow look like for same week fertility preservation? And where do those delays most commonly happen? Walk us through the process.

Robert Brannigan, MD: Yeah. So very often, you know, especially in the setting of cancer, this is an urgent clinical matter. And we need to firm up a diagnosis, then also very often stage a cancer. And there can be ancillary tests including CT scan imaging, procedures such as bone marrow biopsies, a whole host of things that a patient may need to get done in a very timely fashion.

And the problem is that the clock is running for these patients very often. They need to get treatment in an expedited way. And nonetheless, part of comprehensive care of these patients is to provide fertility preservation. So, the challenge is on the front end to find a window of time where fertility preservation measures can be enacted without upsetting the apple cart or upsetting the flow of this other ongoing care.

Melanie Cole, MS: When we think of a male factor standpoint, from that view, how should clinicians think about the menu of preservation options? I mean, there are so many in your toolbox these days, and speak a little bit about patient scenarios, how they push you towards one path versus another. Is this a shared decision-making clinical situation with the patient? Are you basing it on guidance and what you feel is best for the patient? Speak about that a little bit.

Robert Brannigan, MD: This is great, Melanie. I think this really gets to the heart of what I really like to talk about with clinicians who are either taking care of patients who may be receiving fertility-impairing therapies or those who are providing the fertility preservation. So, I think it's important to think of patients along the continuum of the adult, the adolescent and the prepubertal patient.

So, I would say how should clinicians think about the adult patient? I think, first and foremost, we need to not make assumptions about what a particular adult might or might not want in their reproductive future. We're seeing lots of folks waiting until later in life to begin their families. And so, even though someone may be older or say someone may already have children, we really don't know what they may want after their therapy unless we ask them. So, we need to not have assumptions about the adult, and we need to ask them what do they want? Do they want to have their fertility preserved?

For the adolescent, it's challenging because those patients are typically treated at children's hospitals and people like me, reproductive specialists, are not typically seated in children's hospitals. We don't spend time there because these are minors. Nonetheless, these adolescents are every bit of susceptible to the effects of these potential reproduction-inhibiting therapies as an adult. So, what do we need to do? We need to make ourselves available to our colleagues in pediatrics and be able to provide these fertility-preserving services in that pediatric environment.

And then, the third group, prepubertal patients are those young males that are not yet making sperm. And unfortunately, there's no way to preserve the fertility of these folks. There's no way to freeze sperm. Nonetheless, for those patients, we do have certain protocols, investigational protocols, where testicular tissue from these patients can be retrieved through a simple outpatient procedure and sent off to a site that is actively freezing this tissue on a protocol with the hope that one day the science will catch up to the clinical need and that tissue may be usable to help preserve their fertility.

Melanie Cole, MS: So where are you in the point of the pediatric, not prepubescent, but ones that have already gone through puberty? Where are urologists, such as you, showing up in that space at these pediatric children's hospitals?

Robert Brannigan, MD: Yeah, Melanie. So, we rely a lot on colleagues embedded within the oncology treatment teams to have an awareness of patients as they're coming through and to tip us off and to get the patients to us, and sometimes we'll go to the patients. So, we're very fortunate here in our hospital setup. We have Lurie Children's Hospital that is literally a sky bridge away from our adult hospital. And so, we're able to go back and forth. Patients can come to us, we can go to the patients to help deliver this care. It's really wonderful.

Our children's hospital used to be located in Lincoln Park. And that barrier, although it was only a few miles, it was a substantial barrier to effectively delivering care. I would point out though that even if there is a barrier of distance, now we have mail-in kits that can be used to help these adolescents or adults that are in more remote or rural areas. They can use these to mail in specimens to a centrally located laboratory for processing and freezing.

Melanie Cole, MS: I remember when it was in Lincoln Park, and I can see where that would change things. Now, along those lines, then, Dr. Brannigan, the guidance talks about fertility preservation working best through these coordinated programs, almost like you were just describing. So, what does good coordination look like? What role do you play when you're working within your institution or with referring physicians?

Robert Brannigan, MD: A good working program is one that gets the patients in quickly and seamlessly for sperm banking in a way that does not disrupt the schedule of ongoing cancer care in particular. And also, someone like me being available to go to the children's hospital in those instances where perhaps a patient may not be able to produce a semen sample. Occasionally, we'll need to do surgery to extract testicular tissue with the hope that there will be sperm there that can be frozen from that postpubertal adolescent patient.

Melanie Cole, MS: Dr. Brannigan, this is just such an important and interesting topic. And documentation and disposition planning are called out, including planning for storage and what happens in the event of death and reconsent when minors become adults, what should urologists make sure is documented before cryopreservation? Tell us a little bit about the paperwork that goes into what you're discussing today.

Robert Brannigan, MD: So, the paperwork is really important in any individual under 18 years old, they're not of legal age, so they cannot consent, but they can assent or agree. And the parent or guardian would then sign off on that document. When that patient becomes an adult, then the consent process is put into place and they then have full legal right and oversight over the disposition of those samples, which are theirs.

I think also, on the front end, talking to the patient again, whether it's a full adult or adolescent patient about their reproductive goals, I think sometimes clinicians underestimate the thought process that some patients — again, even younger patients — have put into this issue. And very often, a 14-, 15-year-old young man, young male has thought about this, and it's important to document: Do they want to have children? What's their perspective on these matters now? And part of the consenting process also does involve the uncomfortable aspect that some of these patients unfortunately may not survive their underlying condition. And so, part of that paperwork is documenting what they would want to have happen to the specimens should they not survive their condition.

Melanie Cole, MS: When you're advising other urologists about having that particular conversation, do you have any words of advice for them?

Robert Brannigan, MD: I think that for urologists having that conversation or consenting these patients, it really involves a couple of perspectives. Number one is just reminding along the way that we are that patient's advocate, we're their cheerleader, we're hoping and pulling for the best for them.

But secondly, it's being a scout and taking into account all possible outcomes. And that is certainly one of them. And so, again, that's just one facet of the conversation. Another facet is how would you plan to use these specimens? When would you plan to use them? And again, these are just patients thinking forward about what might be or what could be.

Melanie, I think one important thing that we really need to mention here is that the five-year survivor rate for young men of reproductive age who have been diagnosed with cancer is really, really high. It's about 85%. So, the vast majority of these patients are going to live beyond their cancer diagnosis and treatment and live to the point of reproduction where they may want to have the opportunity to start families of their own. So, that good news, those great stats are numbers that we share with the patients when we're having these conversations as well.

Melanie Cole, MS: It's a great way to lead the conversation with that kind of information, right? So, the opinion notes that fertility preservation is still underused and influenced by financial and access barriers. Dr. Brannigan, what are some of the biggest obstacles you see? How can urologists help patients to navigate them? Because I do think that that would be a big gap in access to care when they think that it's going to be a financial burden.

Robert Brannigan, MD: Yes. So Melanie, this is a really important point because what we find is, although there are certain states, including Illinois, that have legislation that's been passed, stating that fertility preservation is something that should be covered under insurance plans, when it comes to actual implementation of these policies, very often there's a lag in coverage or the coverage doesn't exist at all despite the existing legislation.

So, you know, I think the group here at Northwestern — I look at Kristen Smith, who is a patient navigator. And I look at the work of Teresa Woodruff who oversaw the Oncofertility Consortium here years ago. Over the years, they did a lot of work with the private insurance companies, the commercial insurers trying to shore up this facet of care, especially oncologic care for patients. And we did see an uptick in coverage. It's just not perfect though. And I think that there's still work to do to recognize or to help everyone see that this is a critical aspect of comprehensive oncologic care.

Melanie Cole, MS: Really such important information, Dr. Brannigan. As we wrap up, if there's one thing that you'd like urologists to do differently tomorrow after hearing this conversation you and I are having, what would it be? What would you like the key takeaways for them to be about the American Society for Reproductive Medicine's new guidance on fertility preservation?

Robert Brannigan, MD: I would encourage the urologists out there to not make any assumptions about who might or who might not want to preserve their future fertility. I think that's where we as clinicians sometimes get into trouble. Let's let the patients be presented the information and make the decision. And I would point out also that urologists don't need to take this upon themselves to deliver this care. There are folks that do fertility preservation work certainly here at Northwestern and other hospitals throughout the Midwest and throughout the United States that are readily available and do this every day and want to help, want to help you help your patients.

Melanie Cole, MS: Thank you so much, Dr. Brannigan. What a great guest you are as always. Thank you for sharing your incredible expertise today. And to refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.