Fertility Preservation for Pediatric Oncology and Hematology Patients: Looking Beyond the Disease to the Future

Erika Friehling, MD, Assistant Professor and Fellowship Director in the Division of Pediatric Hematology/Oncology at UPMC Children’s Hospital of Pittsburgh, is passionate about her work and that of the Hospital in helping young cancer patients preserve their potential for future fertility after being cured of their disease.

Pediatric patients survive cancer more frequently now than in decades past, a testament to the steady advance in research and treatments that continue to provide cures and allow these young individuals to live full, normal lives. Unfortunately, the efforts to cure an individual’s cancer are not without side-effects, some long term. The impact on fertility is one such side-effect for many individuals; various forms of chemotherapy and radiation, and some surgeries are detrimental to the reproductive organs, impairing fertility.

“There is data in the literature indicating that the vast majority of patients and families want fertility-related education ahead of time before they start treatment for cancer. The data also suggest that as oncologists, we need to do a better job of dealing with this aspect of patient care at the time of the initial diagnosis,” says Dr. Friehling.

It is a very emotional time for patients and families. Many serious conversations take place rapidly upon diagnosis. Patients, families, and caregivers alike must deal with many competing priorities. Discussion of future fertility often takes a back seat to other pressing concerns.

“Our goal with the Oncofertility Preservation Program at UPMC Children’s is to improve this dynamic. Two years ago, we instituted a fertility consultation service at UPMC Children’s. Our group of experts in the field of oncofertility can bring a clear understanding of the options available to patients, and at the same time, be a resource for our oncology colleagues,” says Dr. Friehling.
A treating physician, caring for a newly diagnosed patient with Hodgkin’s lymphoma, does not need to focus on discussing fertility preservation options. Dr. Friehling’s team takes on this responsibility to meet and educate the patient and family about infertility risks of the treatment and to explore fertility preservation options.

“The oncofertility group also keeps up to date on the current literature surrounding fertility preservation and how to best counsel and educate both patients and families, guiding them through the process so that the primary oncologist can focus on the cancer care at that moment. Our consultation service removes the barriers to getting this information and increases access for patients and families.,” says Dr. Friehling.

Multidisciplinary By Design

The oncofertility team at UPMC Children’s consists of a multidisciplinary team of pediatric oncologists, neuro-oncologists, bone marrow transplant physicians, endocrinologists, adolescent gynecologists, the experts in fertility preservation at UPMC Magee-Women’s Hospital, and the Fertility Preservation Program in Pittsburgh run by UPMC Magee researcher and fertility expert Kyle Orwig, PhD.

“From a technology standpoint, we have implemented a consultation process in the electronic medical record such that for any newly diagnosed cancer patient, the treating clinicians can order the consult, and a request then goes directly to our team for follow-up.  Again, this takes the burden off of the primary oncologist and improves patient access to this information,” says Dr. Friehling.

The Consult Service: How it Works

Oncofertility specialists will first review the patient’s treatment plan. Is the patient going to receive chemotherapy? If so, which medications and how much? The same questions are asked for radiation therapy and surgery. The team also assesses how ill the patient is currently and how much time can be spent on efforts to preserve fertility before anti-cancer treatment begins.
“Our goal is to provide every family with fertility education and to discuss the risks of infertility based on the specific treatment plan,” says Dr. Friehling.

Dr. Friehling’s team will discuss the applicable fertility preservation options available to both boys and girls. Sperm banking is one option for post-pubescent males, and the oncofertility program will help coordinate the logistics for this process. There also exist potential options for egg freezing for post-pubescent females. There are also two experimental protocols available to patients at UPMC Children’s for pre-pubertal and even post-pubertal children. One option is ovarian tissue cryopreservation where either a piece of an ovary or a full ovary will be removed and frozen for potential use in the future.

The other research protocol involves testicular cryopreservation, utilizing either tissue from a biopsy or an entire testicle. While these are experimental protocols, work is progressing to bring the technologies to the clinic that will make these frozen tissues viable in the future for reimplantation, hopefully restoring fertility potential to the child after they have been cured of their cancer.

“We have patients come to Pittsburgh from around the country and the world to take part in these experimental protocols being run by Dr. Orwig, and that so far are showing great promise for the future. It is inspiring and rewarding to be able to offer the potential to preserve these young patients’ fertility for the future when they are ready to start a family. Time will tell if we are successful, but again the work done so far is incredibly promising,” says Dr. Friehling.

More Than Just Cancer

While pediatric cancers account for the majority of consults that the oncofertility program performs, fertility preservation is also of concern for patients diagnosed with other conditions. Hematologic diseases, such as sickle cell disease, can, in some cases, be treated with bone marrow transplantation, a therapy that can render patients infertile. Several metabolic disorders and immune deficiencies also can require treatment with bone marrow transplantation, which can lead to loss of fertility. Dr. Friehling’s group can consult on these cases, as well.

Program Growth and Success

UPMC Children’s sees approximately 180 new cases of pediatric cancer per year. Not all of these patients will receive treatments that put into jeopardy a patient’s future fertility.  However, Dr. Friehling’s group can consult on all oncology cases in order to educate the patient and family regardless of the type of disease, prognosis, or potential risk to fertility that treatments pose.
“Our program is unique in that we have the capabilities for multiple fertility preservation options for patients, as well as the dedicated consultation process that is key to providing access to all the options available. We are a national leader on this front and routinely consult with other institutions about our experiences with the programs that we have implemented,” says Dr. Friehling.

We have seen the growth of not only the number of consultations but also the number of fertility preservation procedures performed for patients at UPMC Children’s. In 2016 there were 11 sperm banking/freezing procedures performed. In 2017, 22 individuals pursued one of the options available (sperm cryopreservation, testicular cryopreservation, oocyte freezing, ovarian cryopreservation). So far, in 2019, there have been 26 cases of fertility preservation services, with projections to reach 30 or more cases before the end of the year. 

It is not yet known if the experimental preservation options will one day prove successful in restoring fertility. We value the opportunity to preserve reproductive tissue for a future time when the technologies prove themselves successful. We are hopeful that the potential for fertility can be preserved for survivors of childhood cancer.