Selected Podcast
Fertility Preservation: Understanding Your Options
There are many reasons why people may choose to explore fertility services that would preserve their ability to have children in the future. Some women may choose to do so for personal reasons such as career advancement. Other individuals may deal with medical conditions such as cancer diagnosed during reproductive age, before they completed or even started to build their families. It is known that certain treatments like chemotherapy or radiation to the pelvis may result in the loss of ability to have biological children in the future. It is very important for everyone who wishes to have a family in the future to understand what fertility preservation options are available to them in the present to help them make the best decision for their unique situation. The Stanford Medicine Fertility and Reproductive Health Services experts are addressing in this podcast the most common questions about fertility preservation to help you choose what is best for you.
Featuring:
Anna Sokalska, MD, PhD, is the director of the Fertility Preservation Program at Stanford Children’s Health. She offers a unique perspective on fertility as both a PhD and a doctor of obstetrics and gynecology. Dr. Sokalska’s research efforts focused on the implantation window, reproductive aging, endometriosis, chronic pelvic pain, polycystic ovarian syndrome (PCOS), the uterine microbiome, and more, bringing full meaning to the moniker “physician-scientist.” Dr. Sokalska is a board-certified OB/GYN and specialist in reproductive endocrinology and infertility (REI). She completed a fellowship program at the University of Pennsylvania, where she also completed her Obstetrics and Gynecology residency. She joined the Stanford obstetrics and gynecology team in 2019. Dr. Sokalska was awarded first scholar in her medical school class at the Poznan University of Medical Sciences in Poland. She completed a research fellowship at Malmö University in Sweden and postdoctorate work at UC Davis, concentrating her studies on endometriosis and polycystic ovary syndrome. Dr. Sokalska’s passion is solving her patients’ infertility issues and preserving their fertility so they can fulfill their dreams of bringing a child into the world.
Learn more about Anna, Sokalska, MD, PhD
Brandie Plasencia, RN, BSN, is the nurse coordinator for the Fertility Preservation Program at Stanford Children’s Health. Plasencia graduated from Saint Mary’s College, in California, with a BS in psychology and went on to pursue her MA in psychology at Argosy University. Her first career was as a social worker for foster children and families, where she spent her time assisting them on their new journeys. After four years, Plasencia decided that she wanted to pursue her love of science and caring for people and therefore attended Samuel Merritt University and graduated with a BS in nursing. She spent the first six years of her nursing career caring for patients who were hospitalized for various conditions, including those requiring chemotherapy infusions. During her time caring for these oncology patients, she learned that some of her patients reported not having had a discussion with their provider about freezing their eggs prior to chemotherapy or radiation. Plasencia felt a desire to educate and walk with these patients as they journey to preserve their fertility prior to cancer treatment. She is now pursuing her passion at Stanford Fertility and Reproductive Health and guides her patients through every step of the process.
Learn more about Brandie Plasencia, RN, BSN
Anna Sokalska, MD, PhD | Brandie Plasencia, RN, BSN
Anna Sokalska, MD, PhD, is the director of the Fertility Preservation Program at Stanford Children’s Health. She offers a unique perspective on fertility as both a PhD and a doctor of obstetrics and gynecology. Dr. Sokalska’s research efforts focused on the implantation window, reproductive aging, endometriosis, chronic pelvic pain, polycystic ovarian syndrome (PCOS), the uterine microbiome, and more, bringing full meaning to the moniker “physician-scientist.” Dr. Sokalska is a board-certified OB/GYN and specialist in reproductive endocrinology and infertility (REI). She completed a fellowship program at the University of Pennsylvania, where she also completed her Obstetrics and Gynecology residency. She joined the Stanford obstetrics and gynecology team in 2019. Dr. Sokalska was awarded first scholar in her medical school class at the Poznan University of Medical Sciences in Poland. She completed a research fellowship at Malmö University in Sweden and postdoctorate work at UC Davis, concentrating her studies on endometriosis and polycystic ovary syndrome. Dr. Sokalska’s passion is solving her patients’ infertility issues and preserving their fertility so they can fulfill their dreams of bringing a child into the world. Learn more about Anna, Sokalska, MD, PhD
Brandie Plasencia, RN, BSN, is the nurse coordinator for the Fertility Preservation Program at Stanford Children’s Health. Plasencia graduated from Saint Mary’s College, in California, with a BS in psychology and went on to pursue her MA in psychology at Argosy University. Her first career was as a social worker for foster children and families, where she spent her time assisting them on their new journeys. After four years, Plasencia decided that she wanted to pursue her love of science and caring for people and therefore attended Samuel Merritt University and graduated with a BS in nursing. She spent the first six years of her nursing career caring for patients who were hospitalized for various conditions, including those requiring chemotherapy infusions. During her time caring for these oncology patients, she learned that some of her patients reported not having had a discussion with their provider about freezing their eggs prior to chemotherapy or radiation. Plasencia felt a desire to educate and walk with these patients as they journey to preserve their fertility prior to cancer treatment. She is now pursuing her passion at Stanford Fertility and Reproductive Health and guides her patients through every step of the process. Learn more about Brandie Plasencia, RN, BSN
Transcription:
Caitlin Whyte: There are many reasons why people may choose to explore fertility services that would preserve their ability to have children in the future. Some women may choose to do so for personal reasons such as career advancement. Other individuals may deal with medical conditions such as cancer diagnosed during reproductive age, before they completed or even started to build their families. It is known that certain treatments like chemotherapy or radiation to the pelvis may result in the loss of ability to have biological children in the future. It is very important for everyone who wishes to have a family in the future to understand what fertility preservation options are available to them in the present to help them make the best decision for their unique situation. The Stanford Medicine Fertility and Reproductive Health Services experts are addressing in this podcast the most common questions about fertility preservation to help you choose what is best for you.
In this podcast, Stanford Medicine Fertility and Reproductive Health Services experts address the most common questions about fertility preservation to help you choose what is best for you.
Joining us today are Dr. Anna Sokalska, Director of the Fertility Preservation Program at Stanford Children's Health and Assistant Professor at the Stanford University School of Medicine, as well as Brandie Plasencia, nurse coordinator in the Fertility Preservation Program at Stanford Children's Health.
This is Health Talks from Stanford Children's Health. I'm your host, Caitlin Whyte. We'll start with you, doctor. What types of patients seek the fertility and reproductive health program services at Stanford Children's Health?
Anna Sokalska, MD, PhD: The clinic is helping couples unable to conceive, patients with recurrent pregnancy loss, single men and women, same sex couples and transgender individuals. So we also see patients who are not actually dealing with infertility or pregnancy loss but would like to preserve their fertility for the future for both reasons, social reasons, or also facing the gonadotoxic treatment. It means the treatment is harmful to oocytes or also called eggs or harmful to sperm.
Another group of the patients seeking our help are patients with different hormonal abnormalities, like for example, polycystic ovary syndrome. That is one of the most common conditions seen. And we are seeing a lot of patients with this disease also.
Caitlin Whyte: Now, with so many fertility clinics in the Bay Area and California in general, what makes the program at Stanford Children's Health unique? And why are couples or individuals coming to you to build a family?
Anna Sokalska, MD, PhD: We offer one of the nation's most comprehensive and progressive treatment program. Our team includes some of the country's top embryologists, reproductive endocrinologists, nurses, and technicians. Our team of physicians includes American Board of Obstetrics and Gynecology certified specialists and sub-specialists, research leaders in the field and faculty members at Stanford School of Medicine, all of whom have very extensive clinical experience treating infertility.
We also work closely with the other specialists from Stanford Health System, giving us the possibility for multidisciplinary approach to the patient's care. Since as, you know, Stanford is a premier research university, we have many collaborations with the best scientists in many disciplines, which allows us to push the envelope with the innovative treatments. Patients of our clinic have also unique opportunity to participate in various clinical trials conducted at our institution.
Caitlin Whyte: So just how many couples are impacted by infertility in the US?
Anna Sokalska, MD, PhD: Infertility is a common problem. And according to Centers for Disease Control and Prevention report, it is estimated that about 6% of married women aged 15 to 44 years in the United States are unable to get pregnant after one year of trying, which is actually the definition of infertility. And about 12% of women aged 15 to 44 years in the United States have difficulty getting pregnant or carrying the pregnancy to term.
Caitlin Whyte: So let's talk about your team. How can your fertility program experts at Stanford help these couples build a family?
Anna Sokalska, MD, PhD: Our clinic offers all available methods of treatment from the least complicated like ovarian stimulation, ovulation induction, intrauterine insemination through the most advanced, assisted reproductive techniques, including in-vitro fertilization, intracytoplasmic sperm injection, testicular sperm extraction, rapidly growing area of care is genetic counseling and pre-implantation genetic testing, which is also offered by our clinic.
Caitlin Whyte: Now you and your team do so much good work at Stanford, but are there situations in which you can not help these individuals? When does that ever happen?
Anna Sokalska, MD, PhD: Yes. Unfortunately, autologous cycles. It means using the couple's own gametes is not always feasible. For example, in the cases of so-called non-obstructive azoospermia, where there is a failure of sperm production or ovarian failure, where the ovary has a very few viable eggs left, we unfortunately cannot help with the procreation. In this situation, so called third-party reproduction where sperm or eggs from the donors is offered.
Caitlin Whyte: Well, let's talk about your patients as well. When it comes to the fertility preservation program services at Stanford Children's Health, who are the majority of your patients and how old are these patients?
Anna Sokalska, MD, PhD: The main group of patients are the ones diagnosed with the different types of cancers requiring chemotherapy, radiation, or surgery potentially affecting their ability of having their own biological children in the future.
I would like to stress that cancer survivors are also welcome in our clinic. They may not always realize that cancer treatment may not lead to infertility immediately, but may make their window of fertility much narrower and they may reach the menopause sooner. In that situation, they may consider fertility preservation after chemotherapy if they are not ready at that moment to start a family.
We also offer fertility preservation to transgender patients before gender-affirming hormonal therapy. Also patients with a genetic susceptibility to cancers, like for example, BRCA mutation or Lynch syndrome are encouraged to see us. And also more and more young females are considering social or so-called elective fertility preservation to be able to focus on professional career and delay childbearing. We are seeing patients as young as few months old and up to late in the reproductive years.
Caitlin Whyte: You touched on my next question already. You know, I have a friend who her husband had testicular cancer. And while he's fine, now they are looking into alternative methods of reproduction and preservation. Can you focus on how cancer treatment impacts one's ability to build a family? And why does this happen?
Anna Sokalska, MD, PhD: That is actually a very good question. Why do we even talk about fertility preservation? So as, you know, each woman is born with a certain number of eggs. At the time we are born, the number of oocytes in our ovaries is about half a million to two millions. Around the time of the first menstruation, it's about 300,000 to 500,000 and this number only goes down with age. Unfortunately, there is no way to stop it. No way to reverse it or slow it down. Simply, we cannot produce new eggs.
Treatment like chemotherapy and especially the one containing the type of chemotherapeutics called alkylating agents or, for example, pelvic radiation may significantly accelerate the decline of the number of available oocytes leading to decreased fertility potential or infertility after treatment.
Caitlin Whyte: So in general, what other factors can increase an individual's personal risk for infertiliy?
Anna Sokalska, MD, PhD: Yes. The main risk factor limiting fertility is obviously age. But there are many different other including some chronic diseases or specific type of the treatment. The best way actually to evaluate the personal risk is to seek the consultation with the reproductive endocrinologist.
Caitlin Whyte: Now, we've mentioned fertility preservation a couple of times today in this conversation. So doctor, would you tell us more about what fertility preservation means?
Anna Sokalska, MD, PhD: Fertility preservation is the process of saving or protecting oocytes, sperm, ovarian, or testicular tissue with a goal that the person undergoing fertility preservation can use them to have biological children in the future.
Caitlin Whyte: When would you say is the best moment to look into these fertility preservation services?
Anna Sokalska, MD, PhD: I would say as soon as possible. Especially in the settings of the new diagnosis of cancer, time is of the essence. And the sooner the patient is referred to the reproductive endocrinologist, the sooner the fertility preservation process can be initiated without clinically significant delay in cancer treatment.
Caitlin Whyte: Now, what fertility preservation options or treatments are available for individuals who can not start a family now, but like you were saying, would like to delay building a family?
Anna Sokalska, MD, PhD: There are several options and two of them are considered gold standard. One of them is oocyte cryopreservation, which is offered to the women without the partner or not interested in using donor sperm or not interested in cryopreservation of the embryos. And the second method is actually embryo cryopreservation offered to women with partner or willing to use the donor sperm. These two methods require about two weeks of ovarian stimulation followed by egg retrieval or so-called collection of eggs. This means that that may potentially delay the start of the chemotherapy by about two weeks. However, in the majority of the cases, this is acceptable and actually does not affect long-term cancer treatment outcomes.
The third method is ovarian tissue cryopreservation, which requires surgery, usually minimally invasive, to remove the entire ovary or portions of each ovary, freezing the eggs-containing parts of the ovary, and then subsequent surgery or surgeries to transplant the tissue back whenever a patient is done with the cancer treatment and ready to start family. This method is offered to pre-pubertal girls and women who do not have enough time for ovarian stimulation for egg or embryo banking.
The fourth method offered is injection of GnRH antagonist given during the chemotherapy. And that method is putting the patient in the state of biochemical menopause. However, this method has an uncertain efficacy and should not be offered as a main fertility preservation option.
Ovarian transposition, it means moving the ovaries outside the radiation field during the surgical procedure is also worth mentioning. And that method may be offered to patients with, for example, cervical or rectal cancer, planning pelvic radiation. Obviously, the selection of the methods depends on the patient's age and preference, general health and, of course, how much time we have for fertility preservation process before the chemotherapy needs to be initiated.
Caitlin Whyte: Now with all of these options, are certain fertility preservation methods or treatments better than others? Are there any downsides for moving forward with any of these solutions?
Anna Sokalska, MD, PhD: Yes. As mentioned before, oocyte and embryo cryopreservation are gold standards. Ovarian tissue cryopreservation was considered to be experimental method until December 2019, and there are only 200 live births reported worldwide using this method. So we can say that we are still in the process of gaining more knowledge about the true safety and efficacy of this method. We need to keep in mind that regardless of the method, fertility preservation may delay the cancer treatment and it may not be safe in every single case. That's why all fertility preservation procedures in our clinic are discussed and closely coordinated with the multidisciplinary team of oncologists to reassure the safety of potential delay in cancer treatment.
Caitlin Whyte: Now, focusing again on all of the options available, are all fertility and reproductive health programs the same? Do they offer the same services or outcomes to their fertility patients?
Anna Sokalska, MD, PhD: Unfortunately, not all the infertility clinics are able to offer all possible options. While oocyte and embryo cryopreservation are widely available, there is limited number of clinics offering ovarian tissue cryopreservation and experimental testicular tissue cryopreservation. The oncofertility program at Stanford was one of the first established in USA and we do have extensive expertise in all procedures. And we also offer comprehensive multidisciplinary care.
Caitlin Whyte: So just how many people choose to preserve their ability to build a family based on your experience at Stanford Children's health? How does this process work?
Anna Sokalska, MD, PhD: Our clinic sees a significant number of patients for both elective, as I said before, social fertility preservation and fertility preservation in the setting of the diagnosis requiring gonadotoxic treatment. Our goal is to see the second group of patients. Since I mentioned this before, the time is of the essence within 24 to 48 hours from the moment we have received the referral.
Caitlin Whyte: Now you mentioned that some patients start their fertility journey pretty early on. So just how long does fertility preservation last?
Anna Sokalska, MD, PhD: Well, actually both oocytes and embryos can be cryopreserved for many years before they are used.
Caitlin Whyte: Do most of the individuals who choose to preserve their ability to build a family manage to do so when desired? Based on your experience, what is the likelihood of this happening?
Anna Sokalska, MD, PhD: Yes. So the main obstacle is the time and the general health condition of the patient. Not in all cases, it is safe to postpone the chemotherapy and proceed with the fertility preservation process.
Caitlin Whyte: And wrapping up here, doctor, what is your success rate at Stanford Children's Health? Success rates vary and depend on many factors including the clinic performing the procedure, the infertility diagnosis and the age of the woman undergoing that procedure.
The last factor, I mean, the age is especially important. CDC and SART, which is the Society for Assisted Reproductive Technology published assisted reproductive technology's success rates for all fertility clinics in the United States and they are actually easily available online. However, I would strongly recommend to interpret these numbers with the caution and knowledge that some of the clinics are not accepting patients with a poor prognosis making their success data looking better than the others. This is called cherry picking the best prognosis patients and our clinic accepts all patients.
Well, thank you so much for joining us today, doctor. Now, moving to Brandie. For individuals interested in fertility preservation services, what is the investment they're looking at?
Brandie Plasencia, RN, BSN: You said it right. It is an investment. An investment in the future for most of these individuals. The financial commitment depends on the insurance plan that a patient has. Some employers offer fertility services as a covered benefit while others do not. So the costs can vary widely. In general, individuals may pay a few thousand dollars out of pocket for fertility preservation in case their insurance doesn't cover it. However, every case is unique. So it's best for those interested to check in with our financial coordinator and their insurance plan.
Caitlin Whyte: You mentioned this cost does vary on a case by case basis, but what is impacting this estimate?
Brandie Plasencia, RN, BSN: Yes, exactly. As mentioned earlier, every situation is unique and the cost does vary from patient to patient. It's important to have a consultation with one of our fertility experts to determine the best options for your fertility treatment as this will impact the estimate of cost.
Another important piece of information that listeners should know is that California passed Senate Bill 600 in October 2019. And it requires most insurance carriers to cover services for fertility preservation in the setting of a diagnosis or treatment that may cause infertility. While this law is in place, not all insurance companies are aware of it. And because of this, we assist in appealing denied claims for these patients.
To help navigate these financial questions, we encourage you to talk with our knowledgeable financial counselors as they can help to address your insurance questions, provide estimates and explain benefits.
Caitlin Whyte: So how does one get started if they're interested in pursuing the fertility preservation solutions that we discussed earlier?
Brandie Plasencia, RN, BSN: Patients who are interested in seeking fertility preservation services at our clinic can get in touch with us by calling our clinic at {650} 498-7911. They can also ask their provider to submit a referral or even email our team. The email address is fertilitypreservation@stanfordchildrens.org. Our amazing team of patient navigators will educate and assist you in registering for an account and scheduling an appointment. If a patient has a new diagnosis of cancer or needs immediate fertility preservation, the team will reach out to me directly, given that I am the nurse coordinator for the fertility preservation program.
Our goal is to contact these patients and schedule a consultation within 24 to 48 hours of receiving the referral. We understand that the sooner a consultation is scheduled and options are discussed, the sooner the cancer treatment can begin
Caitlin Whyte: And Brandie, what other fertility services are available at Stanford Children's Health for your patients? Do fertility patients need to deliver at Stanford Children's Health or can they choose a local obstetrician and hospital?
Brandie Plasencia, RN, BSN: Dr. Sokalska covered really well the broad variety of services that we can offer at Stanford Children's Fertility and Reproductive Health. In addition to those mentioned, we also have a genetic counselor who can educate patients about genetic abnormalities and testing their embryos.
Regarding your second question, while it's not required to be a Stanford Children's Health patient or use our obstetricians, we have many experts available with which we are collaborating closely with. Patients may find beneficial being consulted and followed by a maternal-fetal medicine providers who have extensive expertise in managing high-risk pregnancies. And should any problems arise after birth, our Johnson Center's neonatology team can assist as needed.
The other benefit of delivering at Stanford Children's Health in the case of a high risk pregnancy is that we're in close proximity to the adult hospital and our teams collaborate very well together on highly complex cases to ensure the best outcomes for both the parent and the baby.
Caitlin Whyte: Well, thank you, ladies, both so much for your time and for joining us today. To learn more about Stanford Children's Health Fertility Preservation Services, visit fertility.stanfordchildrens.org. We hope you enjoyed this podcast. And if you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Children's Health. I'm Caitlin Whyte. Stay well.
Caitlin Whyte: There are many reasons why people may choose to explore fertility services that would preserve their ability to have children in the future. Some women may choose to do so for personal reasons such as career advancement. Other individuals may deal with medical conditions such as cancer diagnosed during reproductive age, before they completed or even started to build their families. It is known that certain treatments like chemotherapy or radiation to the pelvis may result in the loss of ability to have biological children in the future. It is very important for everyone who wishes to have a family in the future to understand what fertility preservation options are available to them in the present to help them make the best decision for their unique situation. The Stanford Medicine Fertility and Reproductive Health Services experts are addressing in this podcast the most common questions about fertility preservation to help you choose what is best for you.
In this podcast, Stanford Medicine Fertility and Reproductive Health Services experts address the most common questions about fertility preservation to help you choose what is best for you.
Joining us today are Dr. Anna Sokalska, Director of the Fertility Preservation Program at Stanford Children's Health and Assistant Professor at the Stanford University School of Medicine, as well as Brandie Plasencia, nurse coordinator in the Fertility Preservation Program at Stanford Children's Health.
This is Health Talks from Stanford Children's Health. I'm your host, Caitlin Whyte. We'll start with you, doctor. What types of patients seek the fertility and reproductive health program services at Stanford Children's Health?
Anna Sokalska, MD, PhD: The clinic is helping couples unable to conceive, patients with recurrent pregnancy loss, single men and women, same sex couples and transgender individuals. So we also see patients who are not actually dealing with infertility or pregnancy loss but would like to preserve their fertility for the future for both reasons, social reasons, or also facing the gonadotoxic treatment. It means the treatment is harmful to oocytes or also called eggs or harmful to sperm.
Another group of the patients seeking our help are patients with different hormonal abnormalities, like for example, polycystic ovary syndrome. That is one of the most common conditions seen. And we are seeing a lot of patients with this disease also.
Caitlin Whyte: Now, with so many fertility clinics in the Bay Area and California in general, what makes the program at Stanford Children's Health unique? And why are couples or individuals coming to you to build a family?
Anna Sokalska, MD, PhD: We offer one of the nation's most comprehensive and progressive treatment program. Our team includes some of the country's top embryologists, reproductive endocrinologists, nurses, and technicians. Our team of physicians includes American Board of Obstetrics and Gynecology certified specialists and sub-specialists, research leaders in the field and faculty members at Stanford School of Medicine, all of whom have very extensive clinical experience treating infertility.
We also work closely with the other specialists from Stanford Health System, giving us the possibility for multidisciplinary approach to the patient's care. Since as, you know, Stanford is a premier research university, we have many collaborations with the best scientists in many disciplines, which allows us to push the envelope with the innovative treatments. Patients of our clinic have also unique opportunity to participate in various clinical trials conducted at our institution.
Caitlin Whyte: So just how many couples are impacted by infertility in the US?
Anna Sokalska, MD, PhD: Infertility is a common problem. And according to Centers for Disease Control and Prevention report, it is estimated that about 6% of married women aged 15 to 44 years in the United States are unable to get pregnant after one year of trying, which is actually the definition of infertility. And about 12% of women aged 15 to 44 years in the United States have difficulty getting pregnant or carrying the pregnancy to term.
Caitlin Whyte: So let's talk about your team. How can your fertility program experts at Stanford help these couples build a family?
Anna Sokalska, MD, PhD: Our clinic offers all available methods of treatment from the least complicated like ovarian stimulation, ovulation induction, intrauterine insemination through the most advanced, assisted reproductive techniques, including in-vitro fertilization, intracytoplasmic sperm injection, testicular sperm extraction, rapidly growing area of care is genetic counseling and pre-implantation genetic testing, which is also offered by our clinic.
Caitlin Whyte: Now you and your team do so much good work at Stanford, but are there situations in which you can not help these individuals? When does that ever happen?
Anna Sokalska, MD, PhD: Yes. Unfortunately, autologous cycles. It means using the couple's own gametes is not always feasible. For example, in the cases of so-called non-obstructive azoospermia, where there is a failure of sperm production or ovarian failure, where the ovary has a very few viable eggs left, we unfortunately cannot help with the procreation. In this situation, so called third-party reproduction where sperm or eggs from the donors is offered.
Caitlin Whyte: Well, let's talk about your patients as well. When it comes to the fertility preservation program services at Stanford Children's Health, who are the majority of your patients and how old are these patients?
Anna Sokalska, MD, PhD: The main group of patients are the ones diagnosed with the different types of cancers requiring chemotherapy, radiation, or surgery potentially affecting their ability of having their own biological children in the future.
I would like to stress that cancer survivors are also welcome in our clinic. They may not always realize that cancer treatment may not lead to infertility immediately, but may make their window of fertility much narrower and they may reach the menopause sooner. In that situation, they may consider fertility preservation after chemotherapy if they are not ready at that moment to start a family.
We also offer fertility preservation to transgender patients before gender-affirming hormonal therapy. Also patients with a genetic susceptibility to cancers, like for example, BRCA mutation or Lynch syndrome are encouraged to see us. And also more and more young females are considering social or so-called elective fertility preservation to be able to focus on professional career and delay childbearing. We are seeing patients as young as few months old and up to late in the reproductive years.
Caitlin Whyte: You touched on my next question already. You know, I have a friend who her husband had testicular cancer. And while he's fine, now they are looking into alternative methods of reproduction and preservation. Can you focus on how cancer treatment impacts one's ability to build a family? And why does this happen?
Anna Sokalska, MD, PhD: That is actually a very good question. Why do we even talk about fertility preservation? So as, you know, each woman is born with a certain number of eggs. At the time we are born, the number of oocytes in our ovaries is about half a million to two millions. Around the time of the first menstruation, it's about 300,000 to 500,000 and this number only goes down with age. Unfortunately, there is no way to stop it. No way to reverse it or slow it down. Simply, we cannot produce new eggs.
Treatment like chemotherapy and especially the one containing the type of chemotherapeutics called alkylating agents or, for example, pelvic radiation may significantly accelerate the decline of the number of available oocytes leading to decreased fertility potential or infertility after treatment.
Caitlin Whyte: So in general, what other factors can increase an individual's personal risk for infertiliy?
Anna Sokalska, MD, PhD: Yes. The main risk factor limiting fertility is obviously age. But there are many different other including some chronic diseases or specific type of the treatment. The best way actually to evaluate the personal risk is to seek the consultation with the reproductive endocrinologist.
Caitlin Whyte: Now, we've mentioned fertility preservation a couple of times today in this conversation. So doctor, would you tell us more about what fertility preservation means?
Anna Sokalska, MD, PhD: Fertility preservation is the process of saving or protecting oocytes, sperm, ovarian, or testicular tissue with a goal that the person undergoing fertility preservation can use them to have biological children in the future.
Caitlin Whyte: When would you say is the best moment to look into these fertility preservation services?
Anna Sokalska, MD, PhD: I would say as soon as possible. Especially in the settings of the new diagnosis of cancer, time is of the essence. And the sooner the patient is referred to the reproductive endocrinologist, the sooner the fertility preservation process can be initiated without clinically significant delay in cancer treatment.
Caitlin Whyte: Now, what fertility preservation options or treatments are available for individuals who can not start a family now, but like you were saying, would like to delay building a family?
Anna Sokalska, MD, PhD: There are several options and two of them are considered gold standard. One of them is oocyte cryopreservation, which is offered to the women without the partner or not interested in using donor sperm or not interested in cryopreservation of the embryos. And the second method is actually embryo cryopreservation offered to women with partner or willing to use the donor sperm. These two methods require about two weeks of ovarian stimulation followed by egg retrieval or so-called collection of eggs. This means that that may potentially delay the start of the chemotherapy by about two weeks. However, in the majority of the cases, this is acceptable and actually does not affect long-term cancer treatment outcomes.
The third method is ovarian tissue cryopreservation, which requires surgery, usually minimally invasive, to remove the entire ovary or portions of each ovary, freezing the eggs-containing parts of the ovary, and then subsequent surgery or surgeries to transplant the tissue back whenever a patient is done with the cancer treatment and ready to start family. This method is offered to pre-pubertal girls and women who do not have enough time for ovarian stimulation for egg or embryo banking.
The fourth method offered is injection of GnRH antagonist given during the chemotherapy. And that method is putting the patient in the state of biochemical menopause. However, this method has an uncertain efficacy and should not be offered as a main fertility preservation option.
Ovarian transposition, it means moving the ovaries outside the radiation field during the surgical procedure is also worth mentioning. And that method may be offered to patients with, for example, cervical or rectal cancer, planning pelvic radiation. Obviously, the selection of the methods depends on the patient's age and preference, general health and, of course, how much time we have for fertility preservation process before the chemotherapy needs to be initiated.
Caitlin Whyte: Now with all of these options, are certain fertility preservation methods or treatments better than others? Are there any downsides for moving forward with any of these solutions?
Anna Sokalska, MD, PhD: Yes. As mentioned before, oocyte and embryo cryopreservation are gold standards. Ovarian tissue cryopreservation was considered to be experimental method until December 2019, and there are only 200 live births reported worldwide using this method. So we can say that we are still in the process of gaining more knowledge about the true safety and efficacy of this method. We need to keep in mind that regardless of the method, fertility preservation may delay the cancer treatment and it may not be safe in every single case. That's why all fertility preservation procedures in our clinic are discussed and closely coordinated with the multidisciplinary team of oncologists to reassure the safety of potential delay in cancer treatment.
Caitlin Whyte: Now, focusing again on all of the options available, are all fertility and reproductive health programs the same? Do they offer the same services or outcomes to their fertility patients?
Anna Sokalska, MD, PhD: Unfortunately, not all the infertility clinics are able to offer all possible options. While oocyte and embryo cryopreservation are widely available, there is limited number of clinics offering ovarian tissue cryopreservation and experimental testicular tissue cryopreservation. The oncofertility program at Stanford was one of the first established in USA and we do have extensive expertise in all procedures. And we also offer comprehensive multidisciplinary care.
Caitlin Whyte: So just how many people choose to preserve their ability to build a family based on your experience at Stanford Children's health? How does this process work?
Anna Sokalska, MD, PhD: Our clinic sees a significant number of patients for both elective, as I said before, social fertility preservation and fertility preservation in the setting of the diagnosis requiring gonadotoxic treatment. Our goal is to see the second group of patients. Since I mentioned this before, the time is of the essence within 24 to 48 hours from the moment we have received the referral.
Caitlin Whyte: Now you mentioned that some patients start their fertility journey pretty early on. So just how long does fertility preservation last?
Anna Sokalska, MD, PhD: Well, actually both oocytes and embryos can be cryopreserved for many years before they are used.
Caitlin Whyte: Do most of the individuals who choose to preserve their ability to build a family manage to do so when desired? Based on your experience, what is the likelihood of this happening?
Anna Sokalska, MD, PhD: Yes. So the main obstacle is the time and the general health condition of the patient. Not in all cases, it is safe to postpone the chemotherapy and proceed with the fertility preservation process.
Caitlin Whyte: And wrapping up here, doctor, what is your success rate at Stanford Children's Health? Success rates vary and depend on many factors including the clinic performing the procedure, the infertility diagnosis and the age of the woman undergoing that procedure.
The last factor, I mean, the age is especially important. CDC and SART, which is the Society for Assisted Reproductive Technology published assisted reproductive technology's success rates for all fertility clinics in the United States and they are actually easily available online. However, I would strongly recommend to interpret these numbers with the caution and knowledge that some of the clinics are not accepting patients with a poor prognosis making their success data looking better than the others. This is called cherry picking the best prognosis patients and our clinic accepts all patients.
Well, thank you so much for joining us today, doctor. Now, moving to Brandie. For individuals interested in fertility preservation services, what is the investment they're looking at?
Brandie Plasencia, RN, BSN: You said it right. It is an investment. An investment in the future for most of these individuals. The financial commitment depends on the insurance plan that a patient has. Some employers offer fertility services as a covered benefit while others do not. So the costs can vary widely. In general, individuals may pay a few thousand dollars out of pocket for fertility preservation in case their insurance doesn't cover it. However, every case is unique. So it's best for those interested to check in with our financial coordinator and their insurance plan.
Caitlin Whyte: You mentioned this cost does vary on a case by case basis, but what is impacting this estimate?
Brandie Plasencia, RN, BSN: Yes, exactly. As mentioned earlier, every situation is unique and the cost does vary from patient to patient. It's important to have a consultation with one of our fertility experts to determine the best options for your fertility treatment as this will impact the estimate of cost.
Another important piece of information that listeners should know is that California passed Senate Bill 600 in October 2019. And it requires most insurance carriers to cover services for fertility preservation in the setting of a diagnosis or treatment that may cause infertility. While this law is in place, not all insurance companies are aware of it. And because of this, we assist in appealing denied claims for these patients.
To help navigate these financial questions, we encourage you to talk with our knowledgeable financial counselors as they can help to address your insurance questions, provide estimates and explain benefits.
Caitlin Whyte: So how does one get started if they're interested in pursuing the fertility preservation solutions that we discussed earlier?
Brandie Plasencia, RN, BSN: Patients who are interested in seeking fertility preservation services at our clinic can get in touch with us by calling our clinic at {650} 498-7911. They can also ask their provider to submit a referral or even email our team. The email address is fertilitypreservation@stanfordchildrens.org. Our amazing team of patient navigators will educate and assist you in registering for an account and scheduling an appointment. If a patient has a new diagnosis of cancer or needs immediate fertility preservation, the team will reach out to me directly, given that I am the nurse coordinator for the fertility preservation program.
Our goal is to contact these patients and schedule a consultation within 24 to 48 hours of receiving the referral. We understand that the sooner a consultation is scheduled and options are discussed, the sooner the cancer treatment can begin
Caitlin Whyte: And Brandie, what other fertility services are available at Stanford Children's Health for your patients? Do fertility patients need to deliver at Stanford Children's Health or can they choose a local obstetrician and hospital?
Brandie Plasencia, RN, BSN: Dr. Sokalska covered really well the broad variety of services that we can offer at Stanford Children's Fertility and Reproductive Health. In addition to those mentioned, we also have a genetic counselor who can educate patients about genetic abnormalities and testing their embryos.
Regarding your second question, while it's not required to be a Stanford Children's Health patient or use our obstetricians, we have many experts available with which we are collaborating closely with. Patients may find beneficial being consulted and followed by a maternal-fetal medicine providers who have extensive expertise in managing high-risk pregnancies. And should any problems arise after birth, our Johnson Center's neonatology team can assist as needed.
The other benefit of delivering at Stanford Children's Health in the case of a high risk pregnancy is that we're in close proximity to the adult hospital and our teams collaborate very well together on highly complex cases to ensure the best outcomes for both the parent and the baby.
Caitlin Whyte: Well, thank you, ladies, both so much for your time and for joining us today. To learn more about Stanford Children's Health Fertility Preservation Services, visit fertility.stanfordchildrens.org. We hope you enjoyed this podcast. And if you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Children's Health. I'm Caitlin Whyte. Stay well.