Update Course Rewind: Fertility Preservation 2023

GlobalCastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello Pediatric surgery family. I'm M Goti, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held past August. In this video series, we'll recap the sessions and share the main highlights with you. Today we'll delve into the topic of fertility preservation. Joining the discussion are doctors Aaron Rowell and Dan Walman, both pediatric surgeons, and Dr. Leslie Breach, a pediatric gynecologist. I'm actually really excited about this session because we all spend a lot of time figuring out how to get the very best outcomes for the patients that are sitting right in front of us. And what continues to evolve is how we think about the impact of that care in the long term. And obviously one of the things that's very, very important to patients and their families is fertility. We're going to see a couple of cases about fertility preservation. Let's hear the first one from Dr. Rowell. You have a six-year-old female with hemophagocytic lymphohistiocytosis or HLH. You could substitute a sarcoma or some other tumor that would place this patient in a category of needing chemotherapy and or radiation that would put this child at a high level of significant risk for infertility. In this case, the child will need a stem cell transplant and the parents were then canceled about infertility and decided to proceed with fertility preservation at the same time as their anesthesia for a central line insertion. How would you perform fertility preservation in this six-year-old female? I think one of the sort of standards now is that all patients and families should be receiving counseling. Families have definitely shown us is extremely important to them. We should know that around 20 to 30% of the families will intervene and ask to do something to preserve fertility. They want to know their options, that they were informed and counseled, and they made the best decision possible for them. That our major societies including ASCO, AAP, ASRM, have guidelines that families should receive this counseling. Even if they don't do any surgery at all, that the counseling should occur and be documented prior to the start of their high-risk chemotherapy. Since you two are experts in this, just to explain the mechanics of how it works in your different institutions. When we have a patient who's got a new diagnosis of cancer or is going to come up to stem cell transplant, they activate our counseling service through an order set in Epic. It's easily available to anyone and then that triggers a consult by, we have an advanced practice nurse practitioner. Dr. Rowell mentioned that she does some of the counseling herself, and they also have staff from oncology. So we have multiple different people who could be available to talk to the family about that risk assessment and understand based on the treatment that child's getting, which is usually their cyclophosphamide equivalent dose or the CED level of the chemo that they get that places them at a high level of risk. And there's a very good risk stratification where you can look at a table and understand where your patients fall in that. Patient is really at a high level, which for a pre-pubertal girl would be a CED of 8 to 12 or more, or a post-pubertal patient 4 grams per meter squared, they would really be a candidate for an oophorectomy because their level of POI or premature ovarian insufficiency would be sufficiently high. Also, there's a similar risk stratification for males, that's in this reference as well. In many centers, what we would use is your oncologist to jump in and do your risk assessment for you, and then you as a surgeon would say, this is a family that's at high risk. They've made a decision to move forward. So luckily none of you will have to sift through and figure out their risk that usually you would integrate with your oncology team. And here's our poll. Our audience from all around the world are saying they would do a laparoscopic biopsy or partial oophorectomy of one ovary. It's really important to recognize this as a pre-pubertal child. The size of this child's ovary is about 2 centimeters. It's about the size of a grape and that really what you ought to do is a laparoscopic oophorectomy. And that was their best recommendation. And the reason is that you can damage the ovary by taking a biopsy and put the child at a high level of risk for hemorrhage, which would then impact the child's being able to start their stem cell transplant or their chemotherapy. Re-implanted ovarian strips can restore ovarian function for about two to five years and it can result in a live birth. And that has happened in two children who were nine years old. No one younger than that has not yet happened in the United States, but it's possible and you don't want to do a biopsy and then not have enough tissue because a small biopsy of one ovary really wouldn't necessarily give you enough to sustain that child's entire reproductive future. So, that's why they recommend unilateral oophorectomy and really pay attention to the technique so that you don't damage that ovary at all. This is the size of a six-year-old ovary. You can see it's about 2 centimeters and if you tried to do a biopsy of it, you really would not be left with very much tissue and you would then damage by default coming across the ovarian cortical surface, some of the follicles that are there. And so you'd sort of have that um risk of damaging tissue that you're trying to save and not having enough in the future to restore fertility. I just would say having a fertility navigator of some sort, and in many institutions that's a nurse, integrates between oncology, surgery, urology, gynecology, and that role has been advocated strongly in the literature. And so I would say a navigator that can run interference and tea up these procedures for you. And we can move on to another question about what technique would you use to remove ovarian tissue? In general, you want to stay away from the ovarian capsule because that's where all the follicle pool is and we do have an animal model. It's the best we have at this point. A piglet model that mimics a pre-pubertal child. In this model, if surgeons can stay at least a centimeter away from the ovarian capsule, there were healthier tissue parameters of production of glucose, decrease lactose, and increase estradiol from ovarian follicles in culture. So the surgical technique really matters in addition to how it's frozen and then the long-term thawing. Do you have to worry about damage to the fallopian tube that you're leaving in? The issue I would say is just being far enough away from the fimbria. The fimbria are very fragile and you can get some scarring and you'll find a hydrosalpinx later. So yes, protecting the fallopian tube is extremely important. I think anything that could keep you a centimeter away and not have extensive spread, the cool seal is something that we've used recently as well. That's a great instrument and has a 3 mm option for a really small child. The biggest thing is avoiding spread that's within a centimeter of capsule. If you stretch it with a Maryland dissector and pull out on that tissue and go from medial to lateral right along the fallopian tube with your left hand, you really can get a centimeter away. And Dr. Breach has another technique that would help surgeons to protect the fallopian tube. Let's hear it from her. Start on the side of the uterus, do the uter ovarian ligament and obviously using your energy device, coming up the mesosalpinx, trying to stay away from the fallopian tube, and then also coming even with an endo loop. When we're getting to the IP might be a way to keep some of that damage away from the distal fimbria as well as protecting the ovaries. So another innovative technique that one could use. And then our last question, if you had a child who had a recurrent abdominal pelvic tumor and in this case, it's a wills tumor. The child's chemotherapy regimen and their diagnosis was going to place them at a high level of significant risk and you were expected to do a fertility preservation. This child had just completed a major abdominal surgery several weeks ago. Would you go back in and remove an ovary if the family wanted that and if you were going to do that, how would you do it? Here Dr. Rowell shares her experience. About 140 patients and of those, 17 had had an abdominal pelvic tumor surgery within a month of their laparoscopic oophorectomy. It was a median of 29 days after open surgery, so 16 of the 17 patients were done laparoscopically with no trouble. One of them was done open by choice because they needed another tumor biopsy. These numbers are small because the field of fertility preservation, especially for pre-pubertal patients is continuing to evolve, but we do have an ability to make an impact right now on small children that have 10, 15, 20 years to see the results of this work and hopefully have their fertility restored. In summary, fertility counseling and preservation are essential for patients undergoing chemotherapy or radiation as recommended by major medical societies like ASCO, AAP, and ASRM. Risk stratification, such as CED levels, helps determine appropriate fertility preservation techniques. For pre-pubertal females, a laparoscopic oophorectomy is usually more favored than a biopsy because it poses fewer risks and has better results in preserving fertility. Surgical precision is the key with techniques designed to protect the ovarian capsule and fallopian tube. Even though there's limited research in this domain, early studies suggest that maintaining fertility is still possible after major surgeries. This underlies the progressive and significant nature of this medical specialty. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. GlobalCastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.