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Women have a loose time frame for making babies.…
Date Recorded
September 12, 2019 Health Topics (The Scope Radio)
Womens Health Transcription
Dr. Jones: So you're 34 and the clock is ticking and you haven't met Mr. or Mrs. Right yet and you want a baby someday but not now. What are your options to protect your eggs because you can hear them getting older in your body?
So women around the world have been told they can have it all, and although I may not get agree with that completely, there is a time when you make babies and there's a time when you build your career. But, in fact, the making babies and chief career building tends to overlap, and sometimes we put something off and what gets put off, as we're learning about the increasing age of women having their first child in this country, is the baby making. But your eggs are getting older and what are you going to do to save them?
In the studio today with us is Dr. Joe Letourneau, who is a fertility preservation specialist and reproductive endocrinologist at the Utah Center for Reproductive Medicine. Thanks for joining us, Joe.
Dr. Letourneau: Thank you for having me.
Dr. Jones: So a 34-year-old is really looking for her next big job and she hasn't found the honey yet, but she wants to have kids someday. She's got your name. She knows you're the fertility preservation guy. What are you going to tell her?
Dr. Letourneau: That's a very common presentation that we see in our clinic now, and it's becoming more common. We've certainly become more sensitive over the years to the idea that women are building their families later. There is an intersection with, you know, family timing and ovarian and an egg physiology that that can be important. And the way it can manifest is that, you know, achieving a pregnancy becomes incrementally slightly more, you know, difficult with time.
One thing that I like to tell patients is that there's not really a fertility cliff. I think there must be many websites on the internet to suggest there is a fertility cliff where you're fertile one day and then not the next, and it's really a gradual change with time. But for some people if they anticipate many years elapsing before they plan to build their family, it may make sense to consider freezing their eggs. Essentially freezing them in time with a higher reproductive potential that they may have at their current age and that they may have in the future.
Dr. Jones: So is there a time when you're too old to save your eggs?
Dr. Letourneau: Age is quite predictive of a quality for women in one way in particular and that's having a normal number of chromosomes. The way that I like to frame this for patients is to, one, give them an understanding of how many eggs there are in the body at a given time and, two, what percentage of those eggs are normal.
So at birth, average women are born with about 1 million eggs, and by puberty there are around 300,000. It turns out that the egg comes in a unit with something called the follicle, and the follicle is what provides support to the eggs so that it can become fertilized. It also helps to regulate the menstrual cycle and provides estrogen. So the absence of follicles is what defines menopause, which is typically around age 50 or 51. So there is a decline from the start of puberty in the early teens until age 50 of about 300,000 eggs down to the end of the egg supply.
Interestingly, in this time, only 400 or 500 eggs will be ovulated or released from the ovary because, as humans, we release one egg per month because it's difficult to raise a human baby. So most eggs in the ovary are actually not released. Most of them are sort of selected for or against in a way that we don't understand well and many of them die off.
Each month, the egg that is released has a certain probability of being normal or being abnormal. And the normality of it I'm really talking about the chromosome number. If the chromosomes that come out are abnormal, the embryo that may be created will be missing some of the instructions for it to grow.
Most typically that manifests in the absence of a pregnancy. Occasionally it manifests in an early miscarriage, and more rarely it manifests as chromosomal abnormalities that the baby may have at birth. But really most commonly these chromosomal abnormalities make it hard to become pregnant. These go up with time raising pretty steadily, but rather rapidly in the late 30s and early 40s, and that's really what drives age-related fertility concerns. So freezing eggs earlier results in more normal eggs.
Dr. Jones: So ladies, as you're thinking about planning your life, understanding that women plan and God laughs. But if you're thinking about planning your life, there are some options about freezing your eggs, but you should know what's available and decide what's right for you. And thanks for joining us on The Scope. MetaDescription
The options available for freezing your eggs in time.
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When parents are faced with a child's cancer…
Date Recorded
August 22, 2019 Health Topics (The Scope Radio)
Family Health and Wellness
Womens Health Transcription
Dr. Jones: When parents are faced with the diagnosis of cancer in a child, they are overwhelmed with the fear of losing their child. Overwhelmed by the medications and the surgery and the testing and the last thing on their mind is thinking about their child as a future adult with hopes and dreams and children of their own. But what are the options for fertility preservation?
Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.
Dr. Jones: Over the last 40 years the survival rate of childhood cancer has gone from 10 percent to almost 90 percent. In years past, our goals in the treatment of childhood cancers were just to get kids past the crisis of diagnosis to survival for five years and now we're thinking about long-term survivorship to adulthood with what a full life means for these children. This means thinking about these kids having kids. These are decisions made often by the parents because the kids are often clueless about having kids.
So, today in The Scope studio we are joined by Dr. Douglas Fair and Dr. Joe Letourneau. Dr. Fair is an oncologist at Primary Children's Hospital and co-director of the Huntsman-Intermountain Adolescent and Young Adult cancer care program. And Dr. Letourneau is a fertility preservation specialist at the University Center for Reproductive Medicine at the University of Utah. And thanks for joining us.
Dr. Fair, how do we approach parents and children about fertility preservation? They got a really sick kid, and they just want their kid to live to Christmas, but we want them to have a whole life.
Dr. Fair: I think you said it well in that. Unfortunately, at the time of diagnosis because of the intensity of a new diagnosis, the workup, the planning, the discussion in referral for fertility preservation can be forgotten or minimized. And I think additionally, fertility preservation counseling is complicated, it's nuanced, it's consequential. And particularly, for women, it can involve an additional procedure, and it can delay the initiation of cancer therapy and, in some cases, particularly for women can be costly.
So, it's a lot to know and it's a lot to talk about. And really it was with my own ignorance that I realized that I in my training, which is not different from other pediatric or adult oncology training, didn't get a lot of understanding about what the fertility preservation process is, not to mention, all of the different nuances of having that conversation with a child, with a teenager or with a parent. So, it really is a really difficult conversation.
And what we are finding out from data and what we can also say by intuition it's a super important conversation that parents really care about and they just sometimes don't know where fertility lies in importance when their child is diagnosed with cancer and it's our job as oncologists to bring that up and to describe that.
Dr. Jones: Right. Well, I remember in my own clinic when I'd see adolescents and I'd be approaching them and when the mother's in the room, the adolescence got her arms crossed and her eyes are rolling even though she's pretty sick. When her mother is out of the room, then I can actually have a conversation with her but it's complicated on this issue even talking about fertility or sex. Are the approaches different depending on the ages? Can you actually do this conversation and have technology for four-year-olds or is it mostly for teenagers?
Dr. Fair: It's a great question. I'll take the conversation piece first and I would just echo your hint that it is tailored to the patient. And that certainly includes age, maturity, but also the family dynamics and where the patient is and how well the patient feels.
And that's where it's just really important to be nimble and to be flexible but knowing that it's a super important topic that even if the parents or the child don't really want to talk about anything, certainly not cancer and not fertility or sometimes awkward things like eggs, testes, ejaculation, fertility preservation. These are really important topics that they will care about in their survivorship. And so I think that's a really important thing to state.
And to your other question about just the technology and what can we do now for patients, we typically break patients down into prepubescent or pubescent. So, meaning patients who have gone through puberty which is usually somewhere between the ages of 12 to 14 when patients go through puberty and then so older or past puberty or before puberty. And I'll let Joe talk a little bit about the options that we have for prepubescent patients.
Dr. Jones: Yeah. Joe, let's talk a little bit about let's say a 12-year-old or 10-year-old boy. So, he hasn't really developed or matured yet. Is there much we can do in that particular situation?
Dr. Letourneau: Well, one of the hallmarks of puberty is the maturation of the sperm and the eggs and the ability for them to eventually create a pregnancy. So, with young children, it can be difficult because we hope in the future that we can mature sperm and eggs from very young gonads but at this point, that remains an experimental process. It seems achievable but at this point, the gametes or the sperms and eggs that we can get from prepubescent children would not be likely to make a pregnancy so it would require a technology that can achieve that maturation outside of the body.
The sperm stem cells and the eggs that we are born with are not necessarily able to create a pregnancy, they don't have a fertilized ability in a sense. And that's a gap in our technology and research that we hope to close particularly for young patients who are prepubescent.
A lot of our focus in counseling is on education. We want people to know that even if there's not a proven treatment now, the door is not closed on family building in many ways. We don't want people to grow up and wonder if they can ever have a partner, wonder if they're good enough, wonder if they'll live a normal life. We want them to know that they have a lot of options, a lot of normal options to build a family. And sometimes that includes considering fertility treatment in the future, sometimes that includes considering donated eggs or sperm in the future, and sometimes it may include considering adoption as a very normal way to build a family.
Dr. Jones: Well, there are somewhere close to 400,000 survivors of childhood cancer living in the U.S. now, and they're trying to live their lives in ways that they now are survivors, hopefully, putting that thing in the past, "Oh, that happened to me in the past." So, that's really encouraging that we're doing so well these days.
The other encouraging bit is that really young kids, their ovaries and their testes are a little bit more resistant to chemotherapy. So, the younger the kids are the more likely they are to actually make it through with some eggs and sperm left. Do I have that right?
Dr. Letourneau: That's correct. A lot of what makes the sperm and egg cells susceptible to chemotherapy is the fact that later in life they, or the supporting cells around them, are rapidly dividing making them susceptible to chemotherapy, which targets rapidly dividing cells. Early in life when they're quiescent or sleeping, chemotherapy is a bit less likely to see them in a way.
Dr. Jones: So, I have some questions, of course, on the larger issues. But what have I not asked you about kids in the program, the oncofertility program for younger patients? Is there often a debate between the mom and the parents or are the kids mostly going along or the kids have questions too?
Dr. Fair: I think what is surprising, at least that I've found anecdotally, is that, well, once you break the barrier of talking about an awkward or difficult topic, families are super happy that you brought up that topic even if we are talking about a patient that doesn't have good fertility preservation options like we're talking about prepubescent males and females. And I think there's a couple of reasons for that and data support that. So, patients have told us in studies, in surveys that after they have been done with their treatment even if they haven't preserved their eggs or sperm, they feel that they were taken much better care by their cancer team if fertility preservation was brought up.
And to emphasize a point that Joe mentioned, just because we can't preserve eggs or sperm before cancer therapy doesn't mean that fertility preservation or oncofertility or thinking about family building is not an important part of their care and in survivorship. And that's again on oncologists to really realize that this is a really important feature of patient survivorship. And so as Joe said, there can be important timing considerations and different physiologic considerations to seeing a fertility specialist like Joe after they've completed therapy to see where exactly where are their fertility preservation options and having that conversation again even if at the beginning before therapy they couldn't preserve.
Dr. Jones: And I think that's been one of the unique things about the Huntsman Cancer Center is trying to look at the patient and the family in a really big way rather than just, "Oh, you have this cancer and you are your cancer." It's "You are this person, you have potentially this future, you are this family." And the Huntsman has done a really great job and the oncofertility consortium and the oncofertility program here has been trying to think big.
Dr. Fair: They really have. They've been incredibly supportive in adolescent and young adult cancer medicine which this falls is a big part of that with survivorship, which fertility preservation and oncofertility is a big part of that and then directly oncofertility. The University of Utah and the Huntsman have really just been super supportive since Joe and I started this program and it's really just been a series of yes, yes, yes that sounds like something that patients would really benefit from. How can we be supportive?
Dr. Jones: I think helping parents and their kids think about these options and providing access to fertility preservation technology is part of our mission. And I thank you both for being here and I thank everyone for listening to The Scope.
Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com. MetaDescription
Learn about fertility preservation in children going through cancer treatments so they have the option to have a family later in life.
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