A Reproductive Endocrinologist Discusses Need to Cover Fertility Intervention in Cancer Care

With earlier diagnosis and better treatment options that improve survival outcomes, patients being treated for cancer have a few other things to worry about. Awareness around the impact of anticancer agents on patient fertility has resulted in patients seeking fertility preservation prior to treatment. However, challenges remain around insurance coverage for fertility preservation.

The American Journal of Managed Care^® (AJMC^®) spoke with Jane L. Frederick (JLF), MD, FACOG, a reproductive endocrinologist and fertility specialist who works with HRC Fertility, California. Frederick spoke about the changing landscape of cancer treatment, partnering with oncologists, and helping patients gain financial assistance for their fertility preservation and treatment.

AJMC^®: Can you describe your practice and the patients with cancer that your practice serves?

JLF: I am a specialist in the reproductive endocrinology and fertility role, with over 27 years of experience, and in the last 15 years, we as an industry have been

able to perfect the art of freezing eggs for fertility preservation. I have been seeing an increasing number of patients who have a cancer diagnosis and are getting referred for fertility preservation. The good news is that cancer is getting diagnosed earlier, people are getting treatment earlier, and the treatment that we have is more effective—that means we are seeing more cancer survivors. As a specialist in fertility, it’s important that we offer cancer survivors the opportunity to have their own genetic offspring.

So, whereas in the past when you got the diagnosis of cancer your fertility was over because we couldn’t help you freeze your eggs, at least as a woman, now I

get those referrals to have the patient undergo an IVF [in vitro fertilization] procedure—I can successfully get [the patients] in my office, and within 2 or 3 weeks I

can have them undergo an IVF cycle, freeze their eggs, and get them back into treatment with their oncologist. I would say the fact that we’ve been able, as specialists, to perfect the art of freezing an egg and allowing it to survive, gives these patients hope to come back to have a family. For me, that’s really a great

reward as a fertility specialist, and it’s something I’m very passionate about.

AJMC^®: What has increased infertility referrals: patient awareness or oncologist awareness?

JLF: The consumer is more aware that when they get the diagnosis of cancer that there are options for them. There’s always been that option for males to come in and freeze their sperm, but I think women are more aware that this option is available and I am seeing more and more oncologists allowing the patient to have this information and come see me for an evaluation.

For a long time, we battled the philosophy from the oncologists that:

• It won’t work
• The myth was that my treatment would postpone chemotherapy
• Whatever I’m doing would contribute to the unsuccessful treatment of the oncologist

There have been many studies showing that delaying chemotherapy treatment may not be possible for every tumor or diagnosis—some patients need to be treated the day after the diagnosis if it’s that bad. But, if the oncologist feels there is time, and can get a referral and get an opportunity to freeze the egg, then I am seeing more and more oncologists understand that. There are many studies showing that my care and my procedures are not delaying the success of that patient being a cancer survivor.

AJMC^®: What is the duration of time for the patients, after they consult with you, before they can start their cancer treatment?

JLF: When I get a call from a patient with cancer, male or female, my office knows that they are given priority to see me in the next 24 hours. I’ve educated my staff [to understand] that these patients are very special and we need to get them in right away.

If the oncologist has [told the patient] that your type of tumor has a window of opportunity here, then I can start the patient on the stimulation drugs within a week or so of her seeing me, and then I can have her undergo an egg harvest at the end of the 2- or 3-week period. On the day following the egg harvest, she can go back and start her chemo.

The other factor that I’ve been a pioneer in is trying to get the industry—the fertility industry, the pharmaceutical companies, for example—to pay for the medication costs of the cancer patient because the medication for IVF can be a couple thousand dollars and usually insurance doesn’t cover it. So, I now have resources for the patient to reach out to, such as Fertile Hope and the LIVESTRONG Society. I’ve partnered with them to allow the patient to get the pharmaceutical meds that they need to get started. Then, as the center of excellence, my services are greatly reduced in cost so that we can get patients in for treatment and that helps them cost-wise. The goal is to spread the word that this is available and it’s an opportunity to preserve the fertility for the woman with cancer—we’ve already been doing that for the male patient for many, many years—but the success of egg freezing is only recent.

The key is to spread the word, not only to the consumer but also to the oncologist, because we don’t want them to feel that this procedure would be detrimental to their treatment and their survivor rate.

AJMC^®: Do you have oncologists that you actively partner with?

JLF: I often do a lunch-and-learn with the oncologists’ offices close by [our practice]. I also present at the various tumor boards of hospitals in my area. In those meetings, I discuss the prognosis with the oncologist, the nurse oncologist, the social worker—we also have representatives of the oncology navigation staff at the tumor board. I feel like those reach-outs are vital for getting information out about patients who need my help.

When the patient has completed her oncology treatment, I always tell her to wait until her doctor has said it’s okay to get pregnant. Sometimes there’s some treatment afterwards that requires a 5-year remission period to ensure that the cancer has not returned, so I always wait. I partner with the oncologists to make sure that it’s safe for the patient to come back and achieve a pregnancy.

AJMC^®: Do you see any disease-specific trends in the success of fertility? Does the patient’s cancer treatment influence the success of their fertility?

JLF: It’s age related. The 40-year old egg is not as strong as the 20-year old egg. No matter what cancer you have, your eggs are the best when you’re younger. With that in mind, I obviously have more success when the younger patient comes to freeze her eggs; however, I do freeze eggs for cancer patients in their 40s; they just know that those eggs are not the best. The success rate really depends on the patient’s age.

If the treatment causes them to be sterile—you’re in one of 2 categories: you have either become sterile or not. So, if you’re young and you undergo chemotherapy treatment, many times those patients will get their periods back and be able to conceive on their own. If you’re older, and you undergo chemotherapy treatment, then more often those patients become sterile.

A lot of our success afterwards will depend on how they responded to the chemo, whether they got their period back or not, and you can test a woman’s egg reserve by doing blood work when she is menstruating, where we can check the FSH [follicle-stimulating hormone] levels or you can do LH [luteinizing hormone] levels. So, there are target blood tests that we can run to see whether her egg reserve came back to normal.

Some patients may require a hysterectomy or the ovaries may be removed, and that would obviously prevent them from getting pregnant on their own. Some patients need to undergo radiation therapy—radiation therapy and chemotherapy together probably have the worst prognosis of fertility preservation. It’s not only the type of chemo and radiation that you got, but it’s the drug volume that you received and the type of drug given, and whether it has a more serious effect on the ovary reserve.

AJMC^®: In your experience, do your patients face reimbursement challenges with their fertility treatment?

JLF: I am a big proponent for lobbying to the insurance companies that this kind of treatment for fertility preservation should be covered. I really feel that these patients need our help the most, and some insurance companies are slowly realizing it. My hope is that we can change the focus and allow more coverage on their insurance for fertility preservation or for the treatment thereafter when they return [following their cancer treatment].

So, it is expensive and many times it is cash for patients who don’t have coverage, but as I said I am a center of excellence for the oncology referrals, so my fees are greatly reduced to help accommodate as many patients as possible. I always tell them, ‘Don’t let the financial aspect of this part prevent you from having a child. I will work with you and it’s our goal to make this a possibility for you, and not a financial burden.’

I try hard to lobby for the insurance companies, hoping that they will realize the importance [of fertility preservation and treatment] and allow those patients to have universal coverage.