WEBVTT 00:00:00.000 --> 00:00:04.990 align:middle line:90% 00:00:04.990 --> 00:00:06.490 align:middle line:84% JANI JENSEN: My name is Jani Jensen, 00:00:06.490 --> 00:00:08.660 align:middle line:84% and I'm an assistant professor in the Department 00:00:08.660 --> 00:00:11.090 align:middle line:84% of Reproductive Endocrinology and Infertility 00:00:11.090 --> 00:00:13.680 align:middle line:84% at Mayo Clinic in Rochester, Minnesota. 00:00:13.680 --> 00:00:16.190 align:middle line:84% And I'm the author of "Fertility Preservation" which 00:00:16.190 --> 00:00:19.920 align:middle line:84% is appearing in the January 2011 issue of Mayo Clinic 00:00:19.920 --> 00:00:21.130 align:middle line:90% Proceedings. 00:00:21.130 --> 00:00:23.900 align:middle line:84% Fertility preservation is a new discipline, 00:00:23.900 --> 00:00:28.750 align:middle line:84% and it refers to strategies used to promote or retain 00:00:28.750 --> 00:00:31.520 align:middle line:84% fertility for patients that are undergoing treatment 00:00:31.520 --> 00:00:33.580 align:middle line:90% for life-threatening illnesses. 00:00:33.580 --> 00:00:37.640 align:middle line:84% Now, we usually think of this in context of cancer therapy, 00:00:37.640 --> 00:00:40.710 align:middle line:84% but it can apply to other serious illnesses, 00:00:40.710 --> 00:00:43.140 align:middle line:84% including things like lupus, or treatment 00:00:43.140 --> 00:00:46.120 align:middle line:84% of other myeloproliferative disorders. 00:00:46.120 --> 00:00:49.520 align:middle line:84% In this year alone, nearly 1.5 million Americans 00:00:49.520 --> 00:00:51.480 align:middle line:84% are going to be diagnosed with cancer. 00:00:51.480 --> 00:00:54.170 align:middle line:84% Now, of this group, approximately 10% of them 00:00:54.170 --> 00:00:56.120 align:middle line:90% are in the reproductive age. 00:00:56.120 --> 00:00:58.760 align:middle line:84% When you speak to reproductive age patients who 00:00:58.760 --> 00:01:00.830 align:middle line:84% have a new diagnosis of cancer, you'll 00:01:00.830 --> 00:01:03.200 align:middle line:84% find that a high number of them are 00:01:03.200 --> 00:01:05.360 align:middle line:84% very concerned about their ability 00:01:05.360 --> 00:01:08.000 align:middle line:90% to have children in the future. 00:01:08.000 --> 00:01:11.120 align:middle line:84% If you ask adolescent females, for example, 00:01:11.120 --> 00:01:15.320 align:middle line:84% about their desire for fertility, over 80% of them 00:01:15.320 --> 00:01:17.720 align:middle line:84% will say that they want to try any strategy 00:01:17.720 --> 00:01:20.679 align:middle line:84% to preserve fertility, and 93% of them 00:01:20.679 --> 00:01:22.220 align:middle line:84% said they would do it even if they're 00:01:22.220 --> 00:01:25.170 align:middle line:90% told that it's experimental. 00:01:25.170 --> 00:01:28.850 align:middle line:84% Recognizing this, in 2006, the American Society 00:01:28.850 --> 00:01:31.190 align:middle line:84% for Clinical Oncology issued guidelines 00:01:31.190 --> 00:01:33.590 align:middle line:84% recommending that all oncologists 00:01:33.590 --> 00:01:37.010 align:middle line:84% tell reproductive age cancer patients of risks 00:01:37.010 --> 00:01:40.766 align:middle line:84% to their future fertility of cancer treatment 00:01:40.766 --> 00:01:44.270 align:middle line:84% and refer patients who are interested in fertility 00:01:44.270 --> 00:01:48.350 align:middle line:84% preservation to a reproductive endocrinologist for fertility 00:01:48.350 --> 00:01:50.520 align:middle line:90% preservation counseling. 00:01:50.520 --> 00:01:53.900 align:middle line:84% Now, despite the fact that these guidelines have been in place 00:01:53.900 --> 00:01:59.060 align:middle line:84% for over four years, nearly half of all oncologists 00:01:59.060 --> 00:02:01.880 align:middle line:84% at one large academic medical center reported 00:02:01.880 --> 00:02:04.610 align:middle line:84% that they had never referred a patient to a reproductive 00:02:04.610 --> 00:02:08.360 align:middle line:84% endocrinologist for a fertility preservation consult. Risks 00:02:08.360 --> 00:02:12.950 align:middle line:84% to future fertility vary depending on cancer treatment. 00:02:12.950 --> 00:02:16.100 align:middle line:84% One of the particular concerns we have is 00:02:16.100 --> 00:02:18.200 align:middle line:90% the use of alkylating agents-- 00:02:18.200 --> 00:02:20.990 align:middle line:84% for example, Cyclophosphamide-- for cancer treatment. 00:02:20.990 --> 00:02:23.900 align:middle line:84% Now, alkylating agents aren't cell-cycle specific, 00:02:23.900 --> 00:02:28.570 align:middle line:84% so they can affect the very primitive sperm and egg cells. 00:02:28.570 --> 00:02:33.140 align:middle line:84% And in the case of primordial stem cells-- for sperm-- 00:02:33.140 --> 00:02:36.440 align:middle line:84% once they're gone, they can't be regenerated. 00:02:36.440 --> 00:02:40.850 align:middle line:84% Women are born with a finite number of eggs. 00:02:40.850 --> 00:02:42.760 align:middle line:84% And once all the eggs are depleted, 00:02:42.760 --> 00:02:45.740 align:middle line:84% we never have an opportunity to make any more. 00:02:45.740 --> 00:02:49.220 align:middle line:84% So protecting the ovarian reserve and oocytes we already 00:02:49.220 --> 00:02:50.790 align:middle line:90% have is of critical importance. 00:02:50.790 --> 00:02:54.080 align:middle line:84% For post-pubertal men, the most successful strategy 00:02:54.080 --> 00:02:55.070 align:middle line:90% is sperm banking. 00:02:55.070 --> 00:02:58.860 align:middle line:84% Now, sperm banking has a long history in both human use, 00:02:58.860 --> 00:03:00.600 align:middle line:90% as well as in agriculture. 00:03:00.600 --> 00:03:05.710 align:middle line:84% And the samples are relatively simple to collect and store. 00:03:05.710 --> 00:03:09.370 align:middle line:84% Frozen sperm can subsequently be thawed and used 00:03:09.370 --> 00:03:12.875 align:middle line:84% either for insemination into a female partner's uterus 00:03:12.875 --> 00:03:16.170 align:middle line:84% or with a high-tech procedure, such as in vitro fertilization, 00:03:16.170 --> 00:03:19.510 align:middle line:84% where sperm are thawed and then directly injected in an egg 00:03:19.510 --> 00:03:22.240 align:middle line:84% to make an embryo that's placed in a woman's uterus. 00:03:22.240 --> 00:03:25.830 align:middle line:84% So for post-pubertal women, there are also a few options. 00:03:25.830 --> 00:03:30.560 align:middle line:84% The most mature technology is embryo cryopreservation. 00:03:30.560 --> 00:03:33.430 align:middle line:84% Now, embryo cryopreservation relies heavily 00:03:33.430 --> 00:03:36.680 align:middle line:84% on strategies from in vitro fertilization, which has been 00:03:36.680 --> 00:03:39.240 align:middle line:90% around, now, for over 30 years. 00:03:39.240 --> 00:03:40.990 align:middle line:84% One of the concerns that women have 00:03:40.990 --> 00:03:44.900 align:middle line:84% is the length of time that's required to either undergo 00:03:44.900 --> 00:03:48.350 align:middle line:90% embryo or egg freezing. 00:03:48.350 --> 00:03:51.920 align:middle line:84% Typically, we recommend that women undergo treatments 00:03:51.920 --> 00:03:53.840 align:middle line:84% between the time they maybe have surgery 00:03:53.840 --> 00:03:55.490 align:middle line:90% and then begin chemotherapy. 00:03:55.490 --> 00:03:59.000 align:middle line:84% For women who do not have two to three weeks needed 00:03:59.000 --> 00:04:01.740 align:middle line:84% to undergo these procedures, we have other options. 00:04:01.740 --> 00:04:04.220 align:middle line:84% One of them is ovarian tissue cryopreservation. 00:04:04.220 --> 00:04:05.990 align:middle line:84% Ovarian tissue cryopreservation, though, 00:04:05.990 --> 00:04:07.900 align:middle line:84% is still considered more experimental 00:04:07.900 --> 00:04:11.870 align:middle line:84% than the mature technologies of embryo or egg cryopreservation, 00:04:11.870 --> 00:04:14.380 align:middle line:84% and so patients need to be cautioned about this. 00:04:14.380 --> 00:04:17.180 align:middle line:84% But for women who don't have sufficient time 00:04:17.180 --> 00:04:19.040 align:middle line:84% to undergo the other two procedures, 00:04:19.040 --> 00:04:20.720 align:middle line:84% this can be a very valuable option. 00:04:20.720 --> 00:04:24.770 align:middle line:84% The last option that we have for reproductive age women 00:04:24.770 --> 00:04:27.180 align:middle line:84% is to try to suppress the ovaries. 00:04:27.180 --> 00:04:29.720 align:middle line:84% Now, the data on ovarian suppression and return 00:04:29.720 --> 00:04:32.330 align:middle line:84% to fertility are mixed, but the theory 00:04:32.330 --> 00:04:35.090 align:middle line:84% is that shutting down communication 00:04:35.090 --> 00:04:38.390 align:middle line:84% between the hypothalamus, pituitary, and ovaries-- 00:04:38.390 --> 00:04:42.230 align:middle line:84% even temporarily-- can put the eggs in a state of quiescence, 00:04:42.230 --> 00:04:45.680 align:middle line:84% and thereby protect them from chemotherapeutic agents, 00:04:45.680 --> 00:04:49.170 align:middle line:84% which are designed to attack dividing cells. 00:04:49.170 --> 00:04:51.680 align:middle line:84% Patients can have some side effects 00:04:51.680 --> 00:04:55.220 align:middle line:84% that are menopausal from them from getting these agents. 00:04:55.220 --> 00:04:57.620 align:middle line:84% But in general, they're tolerated very well. 00:04:57.620 --> 00:04:59.720 align:middle line:84% Since this is a new discipline, there 00:04:59.720 --> 00:05:02.030 align:middle line:84% are many unanswered questions and a lot 00:05:02.030 --> 00:05:04.070 align:middle line:90% of areas of controversy. 00:05:04.070 --> 00:05:05.735 align:middle line:84% One of them, for example, is that-- 00:05:05.735 --> 00:05:08.890 align:middle line:84% are there some patients who are just to ill to even offer 00:05:08.890 --> 00:05:11.510 align:middle line:90% fertility preservation? 00:05:11.510 --> 00:05:13.330 align:middle line:84% In my experience, sometimes I find 00:05:13.330 --> 00:05:15.660 align:middle line:84% that patients who have the worst prognosis 00:05:15.660 --> 00:05:18.340 align:middle line:84% are often those who desire fertility 00:05:18.340 --> 00:05:20.280 align:middle line:90% preservation the most. 00:05:20.280 --> 00:05:24.530 align:middle line:84% Another are of controversy is in care of adolescents. 00:05:24.530 --> 00:05:28.480 align:middle line:84% So parents need to authorize or give consent 00:05:28.480 --> 00:05:30.580 align:middle line:84% to fertility preservation treatments 00:05:30.580 --> 00:05:33.060 align:middle line:84% to patients who are less than 18 years old. 00:05:33.060 --> 00:05:35.702 align:middle line:84% Another area of controversy is who should pay? 00:05:35.702 --> 00:05:39.760 align:middle line:84% So not all insurance companies will cover fertility 00:05:39.760 --> 00:05:41.280 align:middle line:90% preservation procedures. 00:05:41.280 --> 00:05:45.580 align:middle line:84% Recognizing this, many large academic medical centers 00:05:45.580 --> 00:05:49.270 align:middle line:84% have developed programs to give discounted prices 00:05:49.270 --> 00:05:51.130 align:middle line:84% to cancer patients who are undergoing 00:05:51.130 --> 00:05:53.350 align:middle line:84% this type of treatment, and there are also 00:05:53.350 --> 00:05:56.350 align:middle line:84% several good programs that offer discounted or even free 00:05:56.350 --> 00:05:58.120 align:middle line:84% medications for the patients, which 00:05:58.120 --> 00:05:59.340 align:middle line:90% can be a significant cost. 00:05:59.340 --> 00:06:03.110 align:middle line:84% Another area of concern is whether or not 00:06:03.110 --> 00:06:07.070 align:middle line:84% the treatments may worsen outcomes for patients. 00:06:07.070 --> 00:06:09.880 align:middle line:84% And this is particularly true for cancers 00:06:09.880 --> 00:06:13.303 align:middle line:84% like breast cancer, which can be hormonally responsive. 00:06:13.303 --> 00:06:17.190 align:middle line:84% Data that have been published to this point 00:06:17.190 --> 00:06:19.910 align:middle line:84% are relatively short-time, with outcomes ranging 00:06:19.910 --> 00:06:21.760 align:middle line:90% between two and five years. 00:06:21.760 --> 00:06:24.760 align:middle line:84% But what some of the larger studies of women with breast 00:06:24.760 --> 00:06:27.340 align:middle line:84% cancer who have undergone fertility preservation 00:06:27.340 --> 00:06:30.000 align:middle line:84% have shown is that women who have done this 00:06:30.000 --> 00:06:33.080 align:middle line:84% seem to be at no increased risk of cancer recurrence 00:06:33.080 --> 00:06:34.630 align:middle line:90% or mortality. 00:06:34.630 --> 00:06:38.080 align:middle line:84% Women often ask when the best time to attempt pregnancy 00:06:38.080 --> 00:06:41.000 align:middle line:90% would be after cancer treatment. 00:06:41.000 --> 00:06:43.420 align:middle line:84% Now, there's not a consensus opinion, 00:06:43.420 --> 00:06:45.790 align:middle line:84% but most experts recommend that women 00:06:45.790 --> 00:06:50.170 align:middle line:84% delay trying to conceive for at least one, 00:06:50.170 --> 00:06:53.900 align:middle line:84% and ideally two or more years after cancer treatment is 00:06:53.900 --> 00:06:55.990 align:middle line:84% completed, because the risk of recurrence 00:06:55.990 --> 00:06:59.140 align:middle line:90% is highest in that window. 00:06:59.140 --> 00:07:01.720 align:middle line:84% One question that patients always ask 00:07:01.720 --> 00:07:05.740 align:middle line:84% is if there is a risk to the offspring that 00:07:05.740 --> 00:07:07.480 align:middle line:90% are born from cancer survivors. 00:07:07.480 --> 00:07:10.170 align:middle line:84% We now have reassuring data from large studies 00:07:10.170 --> 00:07:12.940 align:middle line:84% that have looked at several thousand children born 00:07:12.940 --> 00:07:16.060 align:middle line:84% to cancer survivors that have shown that there's no increased 00:07:16.060 --> 00:07:19.510 align:middle line:84% risk of having birth defects or any type of childhood 00:07:19.510 --> 00:07:20.500 align:middle line:90% malignancies. 00:07:20.500 --> 00:07:23.560 align:middle line:84% Patients are often very reassured to hear this. 00:07:23.560 --> 00:07:25.900 align:middle line:84% SPEAKER: We hope you benefited from this presentation, 00:07:25.900 --> 00:07:29.180 align:middle line:84% based on the content of Mayo Clinic Proceedings. 00:07:29.180 --> 00:07:31.600 align:middle line:84% Our journal's mission is to promote the best interests 00:07:31.600 --> 00:07:34.360 align:middle line:84% of patients by advancing the knowledge and professionalism 00:07:34.360 --> 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