How To Approach Fertility Conversations With AYA Patients as an Oncology Nurse

Donna Herrera Bell, MSN, RN, NP-C

The level of invasiveness surrounding fertility preservation can differ greatly between young men and women with cancer and so oncology nurses should be conscience of this when crafting conversations about family planning with adolescent or young adult patients, according to Donna Herrera Bell, MSN, APRN, FNP-C.

Bell is a nurse practitioner with The University of Texas MD Anderson Cancer Center who spent 14 years working at Children’s Cancer Hospital with children and adolescents with leukemia and lymphoma. Recently, she helped develop a Pediatric Onco-Fertility consult service with MD Anderson.

Following her presentation at the 47th Annual Oncology Nursing Society Congress about eliminating barriers to conversations around fertility preservation in AYA patients with cancer, Bell met with Oncology Nursing News® to discuss how nurses can help improve fertility conversations with these populations.

Conversations With Young Men Center on Family Building

“With men, we conduct fertility-risk counseling, we look at what the risks are—according to the type of treatment that they have either received or plan to receive—and then make recommendations about fertility preservation,” Bell explained.

With men, Bell said, fertility preservation is much less invasive and, therefore, fertility conversations should revolve around a young man’s desire for family building in the future. Men who have undergone puberty can bank sperm prior to receiving any type of chemotherapy, radiation, surgery, etc., which may pose a risk to their fertility. However, providers should understand that patients with low-fertility risk and low desire for biological children may choose to forego additional appointments and clinical visits.

“Some young men have never considered [family building, while] some young men have very clear goals about what their desires are for future family building,” Bell said in the interview. “They say, ‘Yes. I want to have biologic children in the future.’”

In contrast, some young men may be open to the idea of adoption or non-biological children in the future and may feel that navigating a sperm bank is too much of a burden while also undergoing a cancer diagnosis. The important thing for an oncology nurse to emphasize to these patients is that once treatment has begun, the window for fertility preservation has closed.

“A great example is for young men with acute myeloid leukemia,” said Bell. “Their initial chemotherapy is going to be low risk in terms of fertility. However, if they do not respond [to frontline chemotherapy,] their treatment will change, and will usually require more aggressive treatment, which will change that risk of fertility for them, but the window to preserve fertility will have already closed since they’ve started chemotherapy.”

Therefore, it is important for nurses to have those candid conversations with young men, she emphasized, and to make it clear that those risks may change.

Young Women Must Consider Timeliness and Invasiveness of Procedures

Fertility preservation for women is both more invasive and more time consuming than that for men—meaning that the decision can become a bit more complex for females.

“Fertility preservation for women is invasive,” said Bell. “It involves oocyte retrieval, where medications are given so the ovary will mature an oocyte for retrieval.”

Unfortunately, this process takes at least 14 days to complete which, in turn, can mean that women must delay their cancer treatment by at least a couple weeks to undergo the oocyte retrieval process. This delay can represent a significant barrier to women considering fertility preservation, especially if their cancer is advanced and their oncologists feels that that it’s not safe to delay treatment by 2 weeks. Therefore, cancer stage and fertility risk are important conversations to have with young women during this process.

Similar to men, different treatment types pose different fertility risks: if the ovary will be undergoing radiation, this may pose a risk as different chemotherapies represent different degrees of potential harm. However, unlike men, age may also play a role in determining risk in adolescent or young adult women.

“Girls are born with all the eggs we are going to have, and we don't ever make any more,” explained Bell. “Our window of fertility opens at puberty, and it closes at menopause. Usually around age 50.”

For older women, in their late 20s or early 30s, for example, the ovarian reserve is already lower than that of a 16-year-old woman. Thus, the older a woman is means she is more sensitive to fertility risk than one who is younger. Age is also an important factor to consider as well, she explained.

Once again, Bell suggests asking patients the following questions: “What are your family building goals? Have you thought about what you want your family to look like? What are options that you are open to pursuing?”

“Having those individual discussions with patients, partners, and families, is really key to helping that adolescent or young adult feel like this is not something that's being taken from them,” she said.

Other Potential Barriers to Consider

Many young adults that Bell meets feel as though fertility is 1 more thing that cancer has jeopardized for them. Therefore, it is vital that providers take the time to ensure that patients understand their potential risks, and options available to them, to decrease any potential decisional regret they may feel as survivors.

Unfortunately, fertility preservation for young patients is not covered by most insurances. Some organizations help to cover some of these costs; however, even with these resources, a procedure such as oocyte cryopreservation may still be close to $7000 out of pocket for a patient—a patient who only recently received a cancer diagnosis.

Although not everyone may be able to afford fertility preservation procedures, every provider can afford to take the time to have a meaningful conversation about these options with newly diagnosed patients, according to Bell.

“Everyone can have this discussion, and every patient should feel empowered about making these decisions and having this choice,” she said.