Increasing Fertility Referrals in Hematopoietic Cell Transplant and Cellular Therapy Patients- a Single Institution Experience

Introduction Pediatric, adolescent, and young adult patients undergoing a hematopoietic cell transplant (HCT) and cellular therapies (CT) are at risk for significant gonadal dysfunction secondary to preconditioning with alkylating agents and total body irradiation. Guidelines recommend that patients receiving gonadotoxic therapies be offered a fertility preservation consultation. Patients also report improved satisfaction with fertility counseling when performed by a reproductive specialist. Children's Hospital Colorado established the Fertility Preservation (FP) and Reproductive Late Effects Program in January 2020. However, referrals to the FP team continue to be underutilized in HCT patients, and the type of counseling provided by HCT providers is variable. Objectives We aim to increase the number of patients who receive counseling from the FP team prior to HCT or CT by incorporating a fertility bundle into the existing workflow. Methods All patients 0-30 years who received an HCT, CT, and/or gene therapy between January 2020 and September 2023 were identified using electronic medical records. A retrospective chart review identified those who had a documented FP team consult prior to implementation of the intervention. A fertility bundle, consisting of a pre-selected fertility referral order and a fertility counseling reminder in the pre-transplant workup checklist, was included in the transplant workflow in August 2023. Prospective data are being collected. Descriptive statistics were used for analysis. Results 216 patients were evaluated pre-implementation and met inclusion criteria. A total of 31.5% [N=68] (autologous=25.8% [N=22], allogeneic=37.7% [N=40], CART=25% [N=6]) patients received a fertility consult prior to HCT or CT. Of those who received a consultation, 57.4% [N=39] (autologous=54.5% [N=12], allogeneic=62.5% [N=25], CART=33% [N=2]) pursued fertility preservation prior to therapy. Following implementation of the fertility bundle, 10 patients have thus far met inclusion criteria. 70% [N=7] had a documented fertility consultation prior to receiving HCT or CT [Risk Ratio 2.22; 95% Confidence Interval 1.42-3.49; p=0.011]. Of those who did receive a consultation, 71.4% [N=5] pursued fertility preservation. Conclusions Despite the known significant risks to fertility associated with HCT and CT, we found that at our institution, a minority of patients were being referred for formal fertility consultation, highlighting the need for improvement. The implementation of a fertility bundle is showing early benefit with an increase in patients who receive formal consultation. We also hope to implement a best practice alert to aid in identifying patients who warrant a FP consultation. While the number of individuals who pursue FP also appears to be increasing, further data are being collected to better understand barriers to pursuing FP.