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Welcome to UAB Med Cast, a continuing education podcast for medical professionals. Bringing knowledge to your world, here's Melanie Cole.

Melanie: Welcome to UAB Med Cast. I'm Melanie Cole. And today, we're discussing Hope For the Future: Fertility Preservation For Life After Cancer: The Importance of Fertility Preservation Discussions. Joining me is Dr. Sukhkamal Campbell. She's the Director of Fertility Preservation Services at UAB Medicine. Dr. Campbell, it's a pleasure to have you with us today. And this is a really great topic and a very burgeoning field. So tell us a little bit about some of the reasons patients may decide to explore fertility preservation options. And while you're doing that, give us a little history on how these options have changed and evolved over the years.

Dr Sukhkamal Campbell: Sure. Thank you so much for having me and for letting me talk about this important topic. So I guess there are a few different options that we discuss with our patients. The kind of gold standard option would be to freeze eggs or oocyte cryopreservation or embryo cryopreservation if they have access to sperm or have a partner. That would be the gold standard to be completed prior to therapy initiation for patients who are undergoing chemotherapies or radiation or a combination of those things that may affect their future fertility.

Other options that we have available would also include ovarian tissue cryopreservation, which is a newer technique that the experimental label has just been released. So it's no longer considered experimental and is considered a viable option for all patients. So it should be offered to women, both prepubescent girls as well as women in the reproductive age range. And that change happened in the last couple of years after the American Society for Reproductive Medicine labeled that technique as no longer experimental.

And so that is something that is up and coming that is new in the field of fertility preservation as a viable option. We do not yet offer that at UAB, but are working towards that goal. And basically, it would be the removal of ovarian tissue cortical strips during surgery that can be frozen and, at a later point after treatment completion, can be retransplanted back into the patient for use for fertility or ovulation.

But some patients, as we know, don't have the time or it may not have the resources to undergo fertility preservation options such as egg freezing. And for those patients, we would recommend the use of a GnRH agonist, such as Lupron, which we would basically give them as an injection to put them into temporary menopause and make the ovaries more quiescent during their treatment phase with the hopes that maybe the ovaries would not be as visible to the chemotherapeutic or gonadotoxic agents that patients are receiving. Those are kind of our main options that we have available right now.

We also offer sperm banking. And so that's been kind of the standard of care for male patients undergoing treatments that may harm their fertility in addition to the other treatments I mentioned previously,

Melanie: So tell us what's the role of the oncologist in advising patients about their fertility preservation options. And at what point should preservation be considered? What age for a child that may have cancer? Tell us a little bit about the process.

Dr Sukhkamal Campbell: Sure. As far as oncologists and how they should be involved, they're integral in this process and take such great care of our patients, the patients that we share, talking about their treatment and their timeline and their diagnosis. I know that their initial visits with patients are just so overwhelming at times, probably because they cover so much ground, they cover so many things with the patients.

But it would be ideal if within the first or second visit, they discuss fertility preservation or fertility desires with our patients. I know that this can be overwhelming and taxing due to time constraints in clinic or maybe another barrier could be fear of not knowing how to bring this topic up or how to discuss options thoroughly. But I would hope that if the oncologist can at least bring up the topic in this initial visits, that can allow for patients who are may be ambivalent about fertility preservation or those who desire fertility preservation to reach out and say, “I want to discuss this further" or "I have questions about fertility and my future fertility goals," to allow the oncologists to then refer them to see one of us in the reproductive field.

I don't think that the whole burden of this discussion should be on the oncologist, but I do think it would be ideal for them to bring up the topic with patients. Even those who have children or maybe those who they think have completed family building, it's important to bring up the topic and allow the patient to make that decision for themselves, to have an appointment with their reproductive specialist and talk through the options more thoroughly and, therefore, allow the patient to make an informed decision about their future fertility and reduce their regret about future potential for infertility related to their treatment.

Melanie: Well, thank you for that. So, Dr. Campbell, are there options if the person didn't do fertility preservation before their treatments? Is it too late? And while you're speaking of that, and you've been telling us about some of the options available, does a patient's age play a role in which option might be more successful? For example, are certain techniques more effective in women at a higher reproductive age?

Dr Sukhkamal Campbell: That's a really good question. So we can talk about age first. Age is a very important factor in reproduction for women. The reproductive age range would be, you know, I guess, 18 to 45, but it could also include younger women, girls, prepubescent girls that may have chemotherapies or radiation that affects their fertility. And in those patients, we would recommend ovarian tissue cryopreservation because we would not be able to stimulate their ovaries using gonadotropins like we do for traditional oocyte harvesting or oocyte cryopreservation.

So for younger women and girls under that 18-year-old age range, typically we talk about oocyte cryopreservation, if they've started having their menstrual cycle. Otherwise, they're prepubescent, then we would talk about ovarian tissue cryopreservation. For men, basically, it's sperm banking throughout that same timeframe, but can last even longer. For men, there's not that much of an age constraint as there is for women.

And it's important to talk with patients. Those who may not have met with us prior to their treatment initiation, it's still valuable for them to meet with us post-treatment because we can assess their ovarian reserve by measuring serum markers, such as the anti-Mullerian hormone level or AMH level that tells us about their ovarian reserve. We can assess if they have had resumption of their menstrual cycles, which is important to note that the menstrual cycle resumption does not always serve as a surrogate for ovarian function resumption of fertility and return to fertility. So they may have menstrual cycles, but they may be infertile.

And it's important to assess that with them post-treatment even if they have not had a pre-treatment fertility preservation consultation. We could get an ultrasound. We can assess their hormonal levels and see if they need hormone replacement therapy to return them back to physiologic hormone level.

So I would say it's important for patients who are both pre-treatment and also those who are post-treatment to meet with us to help and kind of assess their fertility, but also assess their overall health and make sure that their hormonal levels are where they need to be physiologically.

Melanie: I'm so glad you brought that up because that was going to be my question about post-treatment evaluation for the gynecologic late effects. So that was great. Thank you so much. And in many cases, Dr. Campbell, treatment can be time sensitive obviously with this and requires that coordination as we talked about oncologists by several teams. Can you share the multidisciplinary approach and how your team collaborates with other specialties?

Dr Sukhkamal Campbell: Definitely. I think that's a huge part of this process. And I think that in places that fertility preservation works well, it's because of that collaborative, collegial kind of team approach, having input from oncology, from the maybe navigator or social worker that's working with the patient as well as the reproductive specialist and maybe other teams outside of that area as well.

There are many different barriers that come up. Probably the most common is a financial barrier because in many States there is not insurance-mandated coverage for fertility preservation, even the cases of iatrogenic infertility, infertility due to chemotherapies and other treatments. There's not insurance coverage that is mandated and that can serve as a major barrier for our patients.

But I think that it's important to have that open line of communication to make sure that the oncology team knows that we're here for them, to support those discussions. I would like for the UAB oncologist to know and other providers know that I'm happy to see these patients within 48 hours of their initial diagnosis within their timeframe of consultation. We will work them into clinic within 48 hours of that consult. So please feel free to send these patients. Don't feel the burden of having to talk about the entire detail of fertility preservation with them. It's just enough to bring up the topic and, if the patient desires more discussion, I'm happy to see them basically urgently immediately within the next 48 hours.

And so I think that's why it's so important to have that communication open between the two fields so that we know each other, who's out there and we know how to contact each other either through the medical record or otherwise through email or phone call so that we can get these patients taken care of.

And then afterwards, let's say I see a patient, I will communicate with the oncologist the patient's fertility desires. If they desire to move forward with oocyte cryopreservation, that takes two to three weeks to get through that entire process of stimulation, of getting their medications through companies like Livestrong and Walgreens, which can provide some support for medication coverage. So that takes time. It takes two to three weeks. And I want to communicate that back to the oncologist and confirm that they are okay with that time delay, because sometimes that will cause a delay in treatment initiation.

And then for patients who maybe see us and don't desire to follow up with oocyte cryopreservation, then we can relay lab work or relay other issues back to their oncologist. And I would hope that we can keep that line of communication open to discuss those patient-centered issues.

Melanie: That's great information. And thank you so much, Dr. Campbell, for sharing your expertise with us today. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST.

And that concludes this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please visit our website at UABMedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.