Families at pediatric centers across the country expect fertility preservation options for young children undergoing aggressive chemotherapy. But the decision to preserve is so complex that families need expert, proactive guidance from providers.
Children’s Health℠ has offered comprehensive fertility preservation counseling and care for years, including the latest procedures for pediatric ovarian and testicular tissue freezing. Its providers have developed valuable insights about when to discuss options with families, how to make this difficult decision easier for them and the best ways to perform procedures.
The program brings together specialties from oncology, urology and gynecology, with the goal of providing a standardized, proactive continuum of care for fertility preservation and survivorship from pre-treatment risk assessment to long-term monitoring and transition to adult care.
First step: Counseling families on their options
For parents of prepubescent children, reaching a decision about fertility preservation means factoring multiple unknowns. First is the risk that chemotherapy might affect reproductive organs.
Secondly, the technology to develop mature sperm from tissue preserved before puberty doesn’t yet exist – and getting eggs from prepubertal ovaries have not been as successful as with older ovaries. Families who choose to freeze tissue are chancing that the needed technology will advance by the time their child grows up.
But mixed with this uncertainty is hope. “The child may have life-threatening cancer, but we’re talking about years into their future. Many parents feel uplifted by that,” says Ksenya Shliakhtsitsava, M.D., Pediatric Hematologist/Oncologist at Children’s Health and Assistant Professor of Pediatrics at UT Southwestern.
Whether they choose preservation or not, research shows that families appreciate having the option. The diagnosis was out of their control. This decision, at least, was not.
Second step: Multidisciplinary care and fertility coordination
Typically, a dedicated fertility coordinator will lead the conversation with families and serve as their main point of contact. “We aim for a consistent, standardized approach while still personalizing conversations so every patient receives the same level of support and attention,” Dr. Shliakhtsitsava says.
With the coordinator running point, the team’s specialists can focus on individual aspects of the child’s care. Dr. Shliakhtsitsava discusses treatment and risks to fertility, while the team’s gynecologist and urologist focus on preservation options and procedures.
Gynecology: Giving girls the best chance possible
Jason Jarin, M.D., Pediatric Gynecologist at Children’s Health and Associate Professor at UT Southwestern, says families often have three questions about ovarian tissue freezing.
How is the tissue acquired?
Dr. Jarin removes the entire right ovary, since it’s the one more likely to develop ovarian torsion and other problems in the future. The procedure is usually laparoscopic and scheduled to coincide with the placement of a port or central line so the child doesn’t need additional anesthesia. And Dr. Jarin prioritizes these procedures so they don’t delay treatment. “Patients usually proceed to chemotherapy within 24 to 48 hours,” Dr. Jarin says.
What happens to the tissue?
Dr. Jarin divides it into pieces and sends them to the nation’s leading preservation center in Pittsburgh. The pieces are frozen separately, so in the future each one can be used and the patient has multiple chances to get viable eggs.
What can the tissue do?
One day, experts expect the tissue can be reimplanted so it can mature and produce eggs. But they know that it won’t produce enough estrogen. “The child will need hormone replacement therapy once they reach puberty,” says Dr. Jarin.
Urology: Surgical procedures to preserve fertility
While no human children have been produced from frozen testicular tissue at this time, researchers have had success in other mammals. And the science is advancing rapidly.
“I expect a high potential for success in the future, and acquiring the tissue is very low risk. That’s why I’m confident in offering this to patients,” says Irina Stanasel, M.D., Pediatric Urologist at Children’s Health and Associate Professor at UT Southwestern.
Dr. Stanasel removes about a quarter of one testicle. It’s a small organ, and the child will be immunocompromised soon, so she takes time to establish hemostasis and perform every step cleanly and carefully. “For hemostasis I use a bipolar device, which seals the vessels without damaging nearby tissue,” she says.
Similar to ovary removal, Dr. Stanasel makes use of an existing anesthesia appointment. And she lets patients cancel or reschedule anytime so they have the time they need to make these big decisions. “Families should be utterly free to figure out what they want, without pressure,” she says.
Guiding families with personalized care and expertise
It’s easy to overlook fertility preservation when families are facing a fresh diagnosis and imminent treatment. But it’s important to provide the option as soon as possible. “Even one or two days is an invaluable window for families to think it over and let their emotions settle,” says Dr. Shliakhtsitsava.
She recalls one young patient with a life-threatening diagnosis and high risk of infertility. The father wanted to start treatment immediately, but the mother felt strongly they should pursue ovarian freezing. She had struggled to get pregnant, so she knew that pain and couldn’t bear to leave her daughter with no chance of having her own children.
“They took one day to discuss. Dr. Jarin removed the ovary the next day, and the child was in treatment a day after that,” Dr. Shliakhtsitsava says.
Not everyone opts for preservation, and only the family can determine what’s right for them. But providers can help take some of the pressure off. “There’s no right or wrong answer. That’s what we tell everyone. Whatever a family decides: That’s the right thing. And we will support them,” she says.
Learn more about the fertility preservation and cancer care at Children’s Health.
