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Young Adult Oncology Program Oncology Adult Young Inpatient Outpatient

Patient handouts for females for handouts Patient OHSU fertility preservation policy CONTENTS: and Adolescent the of director the from message A patients about fertility to risk Talking Male fertility preservation procedures: procedures preservation fertility Female males for handouts Patient

Procedures for healthcare professionals to help oncology patients help oncology to professionals healthcare for Procedures Fertility Preservation Kit Fertility Preservation 2 ONCOLOGY Young Adult Program Director, Cancer OHSUKnight InstituteAdolescent and Brandon Hayes-Lattin, M.D. Sincerely, to [email protected] Ph .D Block, callRebecca risk, about cancerandfertility information you onincreasing have awarenessIf questionsorneedfurther cancer and these available materials, and ensure they are accessible for use Please inform all providers in your clinic or unit about the issue of fertility risk and thatcontains: Preservation Kit Fertility Additionally, eachOHSUunitandclinicthatseespatientswithcancer hasa awareness andeducation. well asavenues for movement becominginvolved to increase inthisimportant are available as preservation Professional onfertility educationopportunities age patients ofchildbearing educationof thefertility andsupporting to upholdingthesepatientrights isaFertile Cancer HopeCenter Institute OHSU Knight ofExcellence, committed there are anumberofoptionsavailable, bothbefore treatment andafter . that Patients shouldknow withcancerwhoare abouttheirfertility concerned patients’ (seebackpage). rights fertility cancer treatment .OHSUHealthcare isproud tothatsupports have apolicy before isatrisk initiating ifhisorherfertility to know patienthastheright Every HealthcareDear Professional, Oncology Program Adolescent and Young Adult CANCER PATIENTS BETWEEN THE AGES OF 15 AND 40. AND 15 OF AGES THE FOR BETWEEN SUPPORT PATIENTS CANCER PROVIDES THAT PROGRAM UNIQUE A • • • www.ohsu.edu/ayafertility. Supplies for specimenswhileinthehospital patientsto collect Supplies for referring consultations patientsfor fertility Educational for materials patientsandhealthcare professionals .For more materials, informationgo Kit oradditionalFertility .

.at 503 494-6047 . or Young Adult Program Institute Adolescent and Director, Cancer OHSUKnight Brandon Hayes-Lattin, M.D. ONCOLOGY 3 . . . . . www.ohsu.edu/ayafertility . . Describe the options available here at . Describe here available the options . The points below will help you prepare for for prepare will help you points below The . parents, friends or a significant other friends or a significant . parents, .g . . Be sure to ask your patients who they would like patients who they would ask your to . Be sure . booklet uncomfortable about discussing . If are or unsure you There is no time to do anything about it about anything do to time no is There done be can that nothing is There preservation fertility afford to able unlikely is patient The single is patient The poor is Prognosis young is patient The fertility preserve to necessary or idea good a is it think not do We

The decision is always the patient’s the always is decision The Supply appropriate materials to patients and patient families for review patients and patient families for materials to Supply appropriate more for OHSU Fertility Consultants for information referral Provide if: even risk, at is fertility their if know to right a have patients All . for initiating treatment Discuss flexibility of timing of riskExplain what that level means if no action is taken . preservingNotify patient and family of options for fertility based on building a family based on fertilityNotify patient of options for State patient’s level of risk based on your assessment of the patient’s assessment of the patient’s of risk level based on your patient’s State information and/or fertilityinformation preservation . cancer, treatment plan and timing treatment cancer, family the patient and OHSU to preservation adoption, donor eggs and options including , donor sperm . cancer and treatment plan . cancer and treatment

Fertile Hope Fertile • • • • • • Options • • Risk • What to remember to What Provide handouts handouts Provide Prepare talking points described and in below “Options” and “Risk” Start the reviewing by the who can consult with clinic another individual in your identify this topic, ready feel patients until you e in this conversation, involved Discuss with patient Talking to patients about fertility patients to risks Talking It is important about if/how patients and their families with your talk that you they can preserve their fertility . Relevant during age ranges are cancer treatment in the policylisted on the back page a discussion . .

or need need or or For more more For . 503 494-6047 494-6047 503 at at . D . Fertility Kit materials, go to to go materials, Kit Fertility www.ohsu.edu/ayafertility awareness about cancer and and cancer about awareness Block, Rebecca call risk, fertility Ph [email protected] additional or information If you have questions questions have you If increasing on information further TALKING POINTS 4 ONCOLOGY 2 1 received between 8-9 am. Weekend or holiday freezes are not not typically done but may be possible Weekend or holiday collection Pediatric inpatients may be eligible for a pass to go to the Andrology Lab. If interested, ask the charge nurse about this option. Please note: 6 5 4 3 2 1 Weekday collection If you have a patient who would like to preserve his fertility by banking sperm, take the following steps: TION: INPTIENT N E I PAT N I : N O I AT V R E S E R P M R E P S R O F E R U D E C O R P ......

Give the patient the following materials:

• • • • •

paged, ask them to alert the lab technician immediately to notify them patient’s room • • • • • • When the door hanger is removed, check with the patient to ensure the following: If If you have a Friday evening or weekend admission, call If you know in advance that a patient will need to bank on the weekend, call the Andrology Lab Call the Andrology Lab at Escort family and friends out of the patient’s room Give the patient a specimen cup and a paper bag Complete the

Floor) and can drop off the bag and forms immediately A family member or friend knows where the Andrology Lab is located (Center for Health & Healing, 10th Payment method has been determined The The cup is in the bag The specimen is in the cup and closed tightly If If no one is available to assist with transport, call the Andrology Lab for help A friend or family member may bring the specimen with the consent form and Samples must be received The specimen must be received by the Andrology Lab within 30 – 45 minutes of collection The Andrology Lab will provide tram passes to get back to Marquam Hill Andrology Lab, Center for Health & Healing, 10th Floor Fertility reception desk Sperm Preservation if You Are in the Hospital: Hospital: the in Are You if Preservation Sperm Cancer and Fertility: For Patients OHSU Adolescent and Young Adult Oncology Program brochure Sperm Banking Consent: Collection & Delivery Information: Male Fertility Preservation: sample is taken to the lab Sperm Banking Consent Forms Andrology Laboratory Requisition . Ask the patient to remove the door hanger when he is finished . 503 418-3700 . . Payment may be made via cash, check or credit card before noon These consent forms are submitted to the Andrology Lab with the specimen This includes the cost of are completed to let them know that the order is on its way . . . Also, call . Details the collection process . The full specimen cup goes into the paper bag . Hang the “Stop Sign” door hanger on the door of the and fax the order to 503 418-3761 . This provides step-by-step directions for patients for directions step-by-step provides This 503 418-3700 . and leave a message and have the on-call fertility doctor .

In these cases, samples must be 503 418-3708 . Payment is expected when the ...... payment . . . to the . . . . ONCOLOGY 5 . . . Payment may be be may Payment . . . Details the collection process collection the Details m m www.ohsu.edu/ayafertility . . . The specimen must be received received be must specimen The . . - 4:30 p 4:30 - - 4:30 p 4:30 - . . . . m m . . This includes the cost of cryopreservation of cost the includes This These consent forms are submitted to the the to submitted are forms consent These . This provides step by step directions for patients for directions step by step provides This . . Bond Ave Bond . W . Payment is expected when the sample is taken to the lab the to taken is sample the when expected is Payment card credit or check cash, via made specimen the with Lab Andrology Male Fertility Preservation: Preservation: Fertility Male Information: Delivery & Collection Semen Consent: Banking Sperm brochure Program Oncology Adult Young and Adolescent OHSU Patients For Fertility: and Cancer Sperm Preservation: Sperm

If a patient is unable to collect a specimen, a referral to Urology can be made to to made be can Urology to referral a specimen, a collect to unable is patient a If collection specimen in options other explore Urology Floor 10th Healing, & Health for Center 346-1500 503 a 8 Friday, through Monday Hours: Andrology Lab Andrology Floor 10th Healing, & Health for Center desk reception Fertility S 3303 97239 OR Portland, 418-3700 503 a 8 Friday, through Monday Hours: • • • • • • Same-day appointments are often available often are appointments Same-day Give the patient the following materials: following the patient the Give EPIC in order the Complete submit the specimen and the consent form consent the and specimen the submit noon before Direct the patient to call the Andrology Lab for an appointment to collect and and collect to appointment an for Lab Andrology the call to patient the Direct . . . 3 2 If you have a patient who would like to preserve his fertility by banking sperm, sperm, banking by fertility his preserve to like would who patient a have you If steps: following the take 1

The . If there is . Let the social worker . . this call know to bill the fund social worker will also email the manager fund’s with the patient’s name no social worker available, a physician or nurse can make The NickWilson Charitable is Fund available to pay for collection and the firstyear of storage know; he or she will call the Andrology lab and let them Patients under 21 years old: years 21 under Patients PROCEDURE FOR SPERM PRESERVATION: OUTPATIENT 6 ONCOLOGY F E M A L E F E R T I L I T Y P R E S E R V AT I O N P R O C E D U R E S S E R U D E C O R P N O I AT V R E S E R P Y T I L I T R E F E L A M E F the fullest extent possible Please note: The OHSU Fertility Consultants work to accommodate tight timelines to 503 418-3700 Phillip E David M Paula Amato, M OHSU Fertility Consultants Contacts: her fertility, take the following steps: If you have a patient who would like more information about options to preserve 2 1 next steps These materials provide an overview of the fertility preservation process and . . to set up their own consultation appointment appointment If inpatient, call Ask the patient if she would like a referral to OHSU Fertility Consultants Give the patient the following materials: • • • •

. Patton, M . Cancer and Fertility: For Patients OHSU Adolescent and Young Adult Oncology Program brochure Treatment Options to Preserve Fertility in Women Fertility Preservation for Women Lee, M . . . D D . . . D . For an outpatient referral, have the patient call . 503 418-3700 . and request an inpatient consultation . 503 418-3700 .

ONCOLOGY 7 www.ohsu.edu/ayafertility Brown paper bags Brown paper bag) lab stickerAndrology (place on brown Sterile cup Sperm Preservation if You Are in the Hospital Are You if Sperm Preservation Reading material privacy for sign Stop

Additional items for inpatient males items Additional Patient handouts for females Patient Women for Fertility Preservation Fertility Preserve Options to Treatment Patients and Fertility: For Cancer Brochure Oncology Adult Young and OHSU Adolescent Cancer and Fertility: For Patients Patients For Fertility: and Cancer Forms Consent (Cryopreservation) Banking Sperm (outpatient) Preservation Sperm Brochure Oncology Adult Young and Adolescent OHSU Patient handouts for males males for handouts Patient Preservation Fertility Male Information Delivery & Collection Semen .

or need need or or For more more For . 503 494-6047 494-6047 503 at at . D . MATERIALS TO GIVE TO PATIENTS Fertility Kit materials, go to to go materials, Kit Fertility www.ohsu.edu/ayafertility awareness about cancer and and cancer about awareness Block, Rebecca call risk, fertility Ph [email protected] additional or information If you have questions questions have you If increasing on information further OHSU Healthcare System Fertility preservation in patients with cancer

Effective:April 2, 2009 No: HC-CLN-GPC-P018 Policy: (clin 01 .56)

All Oregon Health & Science University (OHSU) patients of childbearing ability who are diagnosed with cancer and may have their fertility compro- mised secondary to treatment will be notified of such risk, and standard fertility preservation options will be discussed as appropriate .

The purpose of this policy is to ensure a consistent approach to addressing fertility preservation across all OHSU settings, disciplines and patient populations . This document provides minimum standards for addressing risk in cancer patients .

Procedure For physicians diagnosing and treating cancer patients: 1 . Females between 8 and 50 years of age and males >11 years of age will be assessed for childbearing ability and the desire to preserve fertility . 2 . Before treatment begins, infertility risk will be discussed with patients of childbearing ability with the desire to preserve fertility . 3 . Basic questions about whether fertility preservation options decrease the chance of successful cancer treatment, increase the risk of compli- cations or compromise the health of offspring will be addressed as appropriate . 4 . Appropriate standard fertility-sparing interventions will be discussed and referrals will be made to fertility specialists as indicated . 5 . Parents are informed that they may make decisions related to fertility on behalf of a minor child as long as the minor assents, the intervention does not pose undue risk and has a reasonable chance to benefit the child . A referral for psychosocial support will be provided as appropriate .

Definitions • Cancer Treatment: any chemotherapy, biotherapy, surgery or radiation therapy with the potential to compromise fertility . • Standard fertility preservation options: sperm cryopreservation, , gonadal shielding, oophoropexy, or conservative surgical approaches . Investigational options are not addressed by this policy, but may be offered as deemed appropriate .

Bibliography • American Society of Clinical Oncology Recommendations on Fertility Preservation in Cancer Patients . (2006) . Journal of Clinical Oncology 24(18): 2917-31 . • Fertility Preservation and reproduction in cancer patients . (2005) . The ethics committee of the American Society for Reproductive Medicine . Fertility and Sterility 83(6):1622-8 .

Related forms: None Supercedes: None Reviewed: 36 Months Author: Adolescent/Young Adult Oncology Program (Reviewed October 2008) Review Committee: OHSU Professional Board Approved: Professional Board (clin - adm)

OHSU Knight Cancer Institute Mail Code: BTE355 3181 S .W . Sam Jackson Park Road Portland, OR 97239-3098 www.ohsu.edu/ayafertility

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