Building a Comprehensive Fertility Preservation Program: A Single Institution Experience

Infertility is a well-documented late effect of cancer survivors and patients with non-malignant hematological conditions treated with hematopoietic stem cell transplants (HSCT) or gene therapy. Major clinical practice guidelines emphasize importance of addressing the possibility of infertility and fertility preservation options as early as possible before treatment starts and referring patients, who express an interest in fertility preservation to reproductive specialists. However, significant heterogeneity exists across different institutions how these discussions approached and documented, what fertility preservation options if any available to patients and if these are covered by insurance. The purpose of this presentation is to describe steps towards building a comprehensive fertility preservation program at Children's Medical Center (CMC) in Dallas, Texas. Proceeding a comprehensive program inception from 09/2018 to 08/2022 several quality improvement Plan-Do-Study-Act (PDSA) cycles focused on improving infertility risk discussions at the time of diagnosis and documentation of these discussion conducted. A collaborative multidisciplinary team comprised of pediatric hematology/oncology, adolescent gynecology, pediatric urology and reproductive endocrinology physicians and nurse practitioners, a pediatric psychologist and a social worker was established in August of 2022. Monthly meetings were conducted to determine the objectives, required resources, and organization of the program. A protocol was developed and refined to guide referral, screening and monitoring. Patient eligibility was determined by patient cancer or hematological disorder history and anticipated gonadotoxic therapy exposure. Collaboration was established with University of Pittsburg Medical Center (UPMC) to allow access to ovarian tissue cryopreservation and experimental protocol for testicular tissue freezing. Business plan was generated and presented to hospital administration to allow for additional resources devoted to program growth and development. PDSA Cycle 1: N = 206 patients. 170 (82%) had fertility discussion documented in the Electronic Health Records (HER) at the time of diagnosis. PDSA Cycle 2: N=161 (68 hematologic, 93 solid; 94 males, 67 females). One hundred forty (86%) had infertility discussion documented utilizing smart phrase in the EHR. Patients with hematologic malignancies were less likely to have infertility risk discussions documented compared to patients with solid tumors (11% vs 16%). In June of 2021 IRB approved testicular tissue cryopreservation protocol and in August of 2021 ovarian tissue cryopreservation became available at CMC in collaboration with UPMC. Currently patients at CMC have access to all standard of care and experimental fertility preservation options. Fertility navigator was hired in December of 2023 and serves as a liaison between patients, multiple specialists and institutions. Patient facing educational materials developed on fertility preservation options to assist with counseling and decision-making process at the time of diagnosis. We are currently working on ensuring every patient prior to gonadotoxic therapy has infertility risk assessment and discussion and an opportunity to consider a fertility preservation procedure if indicated and desired. An institutional, multi-disciplinary pediatric fertility preservation program for patients with oncological diagnosis and hematological conditions requiring chemotherapy exposure as part of their therapy has been successfully established to address the reproductive health needs of this growing population.