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Dawn Ritzwoller was diagnosed with ovarian germ cell cancer when she was 13 years old. Her treatment was extensive, involving several rounds of chemotherapy and the removal of the right side of her reproductive system.
鈥淭hrough that whole process, nobody told me that this may impact my fertility at some point,鈥 says Dawn.
It was only after transferring to adult care鈥攜ears after initial diagnosis and treatment鈥攖hat Dawn learned she was at risk for primary ovarian insufficiency as a side effect from chemotherapy and surgery. At any point, her remaining ovary could stop working鈥攚hich would mean she could no longer have children.
Dawn was devastated to learn this.
鈥淚 really want kids. I鈥檝e always known I鈥檝e really wanted kids,鈥 says Dawn. 鈥淎nd I wanted to make sure that I was able to have children when the time came. That鈥檚 why I decided to pursue oncofertility services.鈥
鈥淐ancer, to me, was a loss of choice and a loss of control. I lost my hair. I lost the majority of my body weight. I lost my ovary. I lost my autonomy.
Fertility preservation is hard, but it brings back the choice to potentially be a parent if my body does not allow me to be. And I want everyone to have that option.鈥
鈥擠awn Ritzwoller
Dawn is one of thousands of adolescent and young adult (AYA) patients with cancer finding a path to parenthood in survivorship through fertility preservation. 鈥淐ancer, to me, was a loss of choice and a loss of control,鈥 says Dawn. 鈥淚 lost my hair. I lost the majority of my body weight. I lost my ovary. I lost my autonomy. Fertility preservation is hard, but it brings back the choice to potentially be a parent if my body does not allow me to be. And I want everyone to have that option.鈥
Now in her role as an AYA patient navigator at Huntsman Cancer Institute at the (the U), Dawn hopes to help others find their way through a complicated process.
Preserving Fertility and Hope
Two nationally recognized experts in oncofertility co-founded Huntsman Cancer Institute鈥檚 oncofertility program. Doug Fair, MD, is a pediatric and young adult oncologist, director of Huntsman Cancer Institute鈥檚 Adolescent and Young Adult Program, and associate professor of pediatrics at the U. Joseph Letourneau, MD, is a fertility specialist and assistant professor of obstetrics and gynecology at the U.
鈥淲e鈥檙e excited that in kids, adolescents, and young adults, our cancer survival rates are north of 85%,鈥 says Fair. 鈥淪o, we have cured cancer for a lot of patients, but what do their lives look like afterwards? I realized there was a real gap in how we thought about and talked to patients about their diagnosis and providing opportunities for them to build a family afterwards. This is a huge need, not just locally but nationally.鈥
鈥淚 realized there was a real gap in how we thought about and talked to patients about their diagnosis and providing opportunities for them to build a family afterwards. This is a huge need, not just locally but nationally.鈥
鈥擠oug Fair, MD
Almost 90,000 AYAs (aged 15-39 years old) are diagnosed with cancer every year in the United States, and that number is rising. Many of these will be at risk for infertility due to their cancer or cancer therapy. Risk factors depend on patient age and type of treatment, which can include chemotherapy, radiation, or surgery to vital structures such as the ovaries, testes, and certain parts of the brain.
Huntsman Cancer Institute, the only National Cancer Institute-designated Comprehensive Cancer Center in the Mountain West, partners with the Utah Center for Reproductive Medicine at U of U Health and Intermountain Primary Children鈥檚 Hospital to offer the latest oncofertility services. Together, this multidisciplinary team bridges oncology and reproductive medicine, delivering innovative and patient-centered care.
Options for Preservation
Options for people with testicles include sperm banking, testicular sperm extraction, and testicular tissue cryopreservation. The surgical procedures allow patients who cannot ejaculate, have a low amount of sperm, or are prepubescent to have the possibility of building a biological family later in life.
For people with ovaries, the preservation options are more complicated and costly. The most common procedure used is egg freezing, which entails stimulating the ovaries with hormones, then harvesting and freezing the eggs. Due to a process called vitrification鈥攊n which the egg is temporarily dehydrated for freezing to protect the egg from ice damage鈥攖he survival rate for frozen eggs has risen from 1-2% to 80-90% in the last 20 years.
Another option is ovarian tissue cryopreservation, which involves removing part or all of the ovary and cryopreserving the tissue. For those patients where an ovary might be in the field of radiation, the cancer team may also recommend ovarian transposition, a surgical procedure that moves the ovaries out of the radiation field.
鈥淲e provide all of the current gold standards of care for oncofertility treatment, but we also do things more on the cutting edge of the field
...The more challenging part is making patients aware of this option, along with finding ways to pay for it.鈥
鈥擩oseph Letourneau, MD
鈥淲e provide all of the current gold standards of care for oncofertility treatment,鈥 says Letourneau. 鈥淏ut we also do things more on the cutting edge of the field, like freezing pieces of ovarian or testicular tissue from prepubertal kids so that we can hopefully use that tissue when they鈥檙e older and decide if they want to have children.鈥
This specialized treatment makes the U a magnet for oncofertility services in the region.
鈥淭he ability to freeze a piece of an ovary, for example, is very technical, so there are relatively few places that can do these procedures within any region,鈥 says Letourneau. 鈥淚f people in this area need fertility preservation care, they鈥檙e generally coming here.鈥
Advocating for Access
The clinic works with 200-400 individuals who have cancer each year. But, Letourneau says, accessibility issues remain.
鈥淭he updates in preservation technology are making things easier,鈥 says Letourneau. 鈥淭he more challenging part is making patients aware of this option, along with finding ways to pay for it since many insurance plans do not cover it as part of cancer care.鈥
Fertility treatments are often cost-prohibitive, reaching a minimum of $10,000鈥$12,000 to freeze eggs, for example. Fair, Letourneau, and their colleagues co-authored and lobbied the state legislature to increase access for their patients in Utah. Their efforts resulted in the passage of HB192, which grants fertility preservation coverage to Utah Medicaid patients with cancer, and HJR8, which grants fertility preservation access to state employees who have cancer.
鈥淗B192 and HJR8 are great steps forward,鈥 says Letourneau.
鈥淭he data on this is clear. Patients want to have these conversations, and they want to be thought of as survivors right from the get-go.鈥
鈥擠oug Fair, MD
Fair says it鈥檚 best to start discussions about oncofertility at the time of diagnosis, either with patients themselves or alongside their parents for those who are underage.
鈥淒octors can still feel uncomfortable talking to their patients about oncofertility,鈥 says Fair. 鈥淚 think there鈥檚 a bias of, 鈥極h, their prognosis is not great; they may not want to talk about long-term options.鈥 Or there鈥檚 a lack of knowledge as to how to make fertility preservation consultations happen, or they worry the patient can鈥檛 afford it. But I would say to other physicians that the data on this is clear. Patients want to have these conversations, and they want to be thought of as survivors right from the get-go.鈥