Preserving fertility for cancer survivors ‘takes a village’ of multidisciplinary providers
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Establishing and running a successful fertility preservation program for cancer survivors requires a multidisciplinary team effort, according to a presenter at the Cancer Center Survivorship Research Forum.
“It’s not just the reproductive endocrinologists — it’s often the surgeons, the embryologists, the navigators who guide the patients through,” Ruben John Alvero, MD, professor of obstetrics and gynecology at Stanford Medical School and division director of reproductive endocrinology and infertility at Lucille Packard Children’s Hospital, told Healio. “It involves the psychologists and nurses, too. It’s a huge enterprise — it’s the kind of thing that takes a village.”
Approaches to fertility preservation
In his breakout session presentation, Alvero discussed fertility preservation methods through ovarian and testicular routes.
“The testicular side is a lot easier, because collecting sperm isn’t that difficult and there aren’t many permutations to it,” he said. “Regarding the ovary, we have to either collect eggs and freeze them, or freeze them as embryos if they’re in a partnered relationship or have identified a sperm source.”
The use of eggs provides flexibility for the future, Alvero added, because this approach does not require commitment to a specific source of sperm. Conversely, he said the use of embryos is beneficial in the sense that they freeze and thaw better, and more information can be gleaned about the quality and prognosis of the embryo.
“Obviously, it’s a tradeoff,” Alvero said. “The patient has to decide autonomously based on these various factors.”
Another major area of fertility preservation is that of ovarian tissue cryopreservation, which typically is done in prepubertal girls undergoing treatment for cancer.
“They haven’t gone through puberty, so collecting eggs would be impossible,” Alvero said. “So, we collect the ovarian tissue, and freeze it in the hope that we can use it at some point in the future.”
The need for improvement
Alvero expressed the hope that, over time, reproductive technologies will advance and be applicable to preserved eggs and embryos.
“As our technology gets better and better, there will be more promise to use these tissues for fertility,” he told Healio. “Right now, relatively few centers do the ovarian tissue reimplantation part of this process, and that’s one of the big holdups.”
Financial issues also present a barrier to the delivery of fertility preservation services, Alvero said. He noted that in California, Senate Bill 600 requires that private insurers cover fertility preservation.
Despite the legal provision, coverage can be inconsistent because many insurance companies find “clever ways [to] avoid it,” Alvero said. Additionally, the provision does not help those with public insurance.
“For many of our patients, it’s a tough decision to make in terms of how much money to spend on [fertility preservation],” he added. “We’re working on improving access to care, especially in that financing aspect.”
Alvero said oncologists can play a role in assisting with fertility preservation by referring patients for these services before the initiation of cancer treatment.
“Oncologists have increasingly participated in fertility preservation — it used to be a hard sell, because oncologists are focused on treating cancer,” he said. “However, quality survival is also important, and for many reproductive age patients, fertility is part of that.”
Alvero said oncologists ideally should refer patients for fertility preservation within a day or two, so that the fertility preservation team can begin investigating insurance coverage or other authorizations, ordering medications, and teach patients about the procedure.
“A lot of times, once treatment has started, we’re adding toxic therapies that can adversely affect the eggs and the outcomes are going to be poor,” he said. “The biggest thing the oncologist can help us with is to get the patient to us as soon as possible.”
For more information:
Ruben John Alvero, MD, can be reached at Stanford Children’s Health, 1195 W. Fremont Ave., Sunnyvale, CA 94087; email: ralvero@stanford.edu.
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Alvero RJ. Oncofertility. Presented at: Cancer Center Survivorship Research Forum; Sept. 11-12, 2023, Stanford, California.
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