Setting Up a Pediatric Oncofertility Practice


Primary medical team

Address diagnosis and treatment plan with patient and family

Introduce the concept of impaired fertility from necessary treatment

Pediatric oncology

Specific oncologist(s) with interest in oncofertility. Works with oncofertility team and primary medical team to determine risk of impaired fertility with proposed treatment plan. Works with primary medical team to form timeline

Pediatric and adolescent gynecology

Addresses risk of impaired fertility with patient and family. Discusses available fertility preservation options

Performs surgery for ovarian tissue cryopreservation

Pediatric urology

Addresses risk of impaired fertility with patient and family. Discusses available fertility preservation options

Performs surgery for testicular tissue cryopreservation

Oncofertility navigator

Orchestrates communication between multiple disciplines involved in consultation process

Maintains timeline for fertility preservation procedures/treatment start date

Participates in consultations with patient/family

Helps navigate research process when applicable

Research coordinator

Ensures proper research protocols are followed and informed consent obtained for all research based fertility preservation options

Reproductive endocrinology

Provides services for oocyte harvesting and oocyte/embryo cryopreservation. Provides laboratory for semen collection/storage for sperm cryopreservation






Oncofertility Consultation Process


The oncofertility process begins when a patient initially presents to the oncology or bone marrow transplant (BMT) program for diagnosis and treatment of their underlying disease. The primary oncology/BMT team contacts the fertility navigator to initiate the fertility consult and risk assessment. Initial consultation can occur by phone and communication via the electronic medical record or by e-mail. By creating a separate specific e-mail address, the consulting team has an additional streamlined way to reach our team.

The goal of our oncofertility program is to see all patients new to the oncology and BMT division. However, we recognize that not every patient will be an appropriate candidate for a discussion on fertility preservation. A patient may be deemed ineligible for the following reasons:



  • Diagnosed with malignancy but planned therapy consists of surgery/observation only


  • Presents for phase I therapy or palliative therapy only


  • Presented to CCHMC for second opinion/consult only (Table 15.2)


    Table 15.2
    Exclusion criteria





















    Exclusion criteria at time of presentation

     Presented for second opinion/consult only

     Presented for phase I/palliative therapy only

     Diagnosed with malignancy however:

      Surgery only

      Observation only

    Consult deferred at time of presentation

     Acutely ill/urgent need to start cancer-directed therapy

If a new patient meets one or more of these criteria, we will meet with the primary medical team to discuss whether or not it is appropriate to approach the family about fertility preservation options. Certainly some families who seem ineligible by criteria alone have many questions regarding future fertility. Patients who are acutely ill at the time of presentation and require immediate oncologic treatment will have the fertility consult delayed until the patient’s medical condition is stable and timing is appropriate. This decision is always made in conjunction with the treating medical team. Patients who have previously had a fertility consult (relapse, transfer of care) may have an abbreviated consult to ensure all fertility preservation needs have been met.

Once a patient is classified as eligible, the fertility navigator contacts the oncofertility pediatric oncologist to perform the risk assessment. This physician will discuss the proposed treatment plan (surgery, radiation, chemotherapy) and timeline with the primary medical team. He or she calculates a patient-specific infertility risk assessment (low, intermediate, high). This is done using a cyclophosphamide equivalent dosing (CED) calculation and radiation/surgical risk assessment with published dose guidelines [1].

The risk assessment is then communicated back to the fertility navigator and documented in the electronic medical record. She advises the gynecology/urology team of the consultation. The fertility navigator facilitates timing of evaluation and testing for the patient to ensure all parameters are met in accordance with the fertility preservation and cancer treatment plan. In addition to the consultation with the provider and fertility navigator, the patient and family receive written information on the fertility preservation options available to them. Many families would like time to think about their decision prior to making a final choice. Thus, the fertility navigator reconnects with the family after 24–48 h and then begins to coordinate any necessary procedures or referrals. The consult is completed and documented in the electronic medical record using a standardized format. The primary medical team is updated regularly throughout the process to maintain good communication and best care for the patient (Fig. 15.1).

A336217_1_En_15_Fig1_HTML.jpg


Fig. 15.1
Flow diagram of process


Laboratory Management


Assessment of fertility at the time of evaluation informs patients/parents and the team about current fertility potential and allows informed decision making regarding possible next steps. Our oncofertility team requests baseline laboratory studies on all patients who receive a consult. We request that these be drawn prior to starting chemotherapy. It allows a frame of reference for post-therapy values, as there can be some interpersonal variability in normal levels. For females, this includes baseline AMH, FSH, and LH. For males, we request baseline testosterone. Anyone who elects to have a cryopreservation technique is required to have infectious disease testing for HIV, hepatitis B, and hepatitis C drawn before the sample is frozen. It is important to use an FDA-approved lab (Table 15.3).
Sep 24, 2017 | Posted by in GYNECOLOGY | Comments Off on Setting Up a Pediatric Oncofertility Practice
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