Oncologists: The Gatekeepers to Fertility Preservation

Last Thursday, members of the Oncofertility Consortium had the pleasure of attending a presentation by Karrie Ann Snyder, PhD, a lead research scientist in the Oncofertility Consortium who studies the way patients communicate information with their providers and what they perceive the provider is telling them.

In a recent study, Dr. Snyder asked what young female breast cancer survivors recalled about fertility preservation discussions and decisions. The patient group was collected from across the United States and were not a part of the Oncofertility Consortium.

Dr. Snyder used two different analyses to trace women’s experience from diagnosis to the beginning of treatment and examined how they learned about, or if they did, fertility preservation and how they made fertility preservation decisions. She wanted to see who was or wasn’t learning about fertility preservation options and what factors seem to shape that process.  She found that there are many ways that the patient-physician dialogue can be improved to provide better fertility preservation information.  Importantly, and perhaps not surprisingly, her work highlighted the central role that the oncologists played in decisions about all health matters during the time of her cancer treatment.  In her talk, Dr. Snyder stated that, “Oncologists are the gatekeepers to fertility preservation,” for young cancer patients. So oncologists are a critical part of the equation in providing accurate and timely information about the fertility threat of cancer treatment and referring their patients to an oncofertility specialist.  The National Fertility Hotline at 866-708-FERT (3378) is a good way for oncologists to get the help they need for their patients in a rapid and timely manner.

Dr. Snyder’s work will continue to explore how patient-provider interactions can be improved.  We will highlight forthcoming papers from her work to keep the community up to date on this important topic.

The Need for Cancer Care in Developing Countries

The past four decades has seen significant leaps in cancer survival rates…in the United States. However, what are the cancer diagnoses and survival chances for someone born in a developing country? Dr. Mark Agulnik, an assistant professor in Medicine-Hematology/Oncology at Northwestern University’s Feinberg School of Medicine recently talked about the cancer patients he saw while working in Haiti after a devastating earthquake hit the country in January 2010.

Even before the earthquake, people on Haiti had different economic and medical challenges than those in the US. While it shares an island with the Dominican Republic, a relatively stable and prosperous country, the Haitian side of the island has been deforested and has little industry to maintain the economy. The Human Development Index designates it as the poorest country in the Americas where half of the population is illiterate and life expectancy is 53 years old, more than 20 years shorter than in the United States. When the 7.0 magnitude earthquake hit, it killed 316,000 people and instantaneously made 1.5 million people homeless. When Dr. Agulnik first visited the country in the weeks after the quake, there was no commerce, tent villages housed the homeless, and a cholera epidemic was emerging due to a lack of sanitation.

Less than 1 year after the quake, medical care has improved and specialized cholera hospitals are limiting the spread of outbreaks. Dr. Agulnik, who most recently visited the country in December of 2010, described how he used his expertise as a hematologist and oncologist, who specializes in blood diseases and cancers, to treat Haitian people. He discussed a variety of patients who came into his small hospital in Port-au-Prince with advanced neck, gynecological, and thoracic cancers. In contrast to treatment within the United States, the team in Haiti worked to decrease the symptoms of these patients and ease their suffering but they did not have the tools and drugs to cure the cancers.

In addition to lacking the resources to treat these advanced cancers, many developing countries, such as Haiti, have not established screening programs that could catch cancers early and increase survival rates. Such programs are the next front in cancer care as, “More people die from cancer in the developing world than tuberculosis, HIV, and malaria,” stated Agulnik. Fortunately, organizations such as Project Medishare, the American Red Cross, and ASCO International Cancer Corps work to provide medicine and medical education in resource-limited settings. With this effort, cancer survival rates will increase in developing nations, making survivorship issues more important for these populations. Work at the Oncofertility Consortium examines the potential oncofertility needs, such as fertility preservation, of cancer patients in developing countries.

MyOncofertility.org: Fertility Preservation Made Accessible

Cancer patients and their loved ones must make an incredible number of important decisions upon diagnosis. It’s a time of extreme stress and emotions run high. Not only do they have to absorb the shock of a cancer diagnosis, they also have to navigate through the world of treatment options. Since many treatment options can harm a cancer patient’s fertility, it is essential to inform them of such risks to provide them with the greatest number of options for later fertility.

 

MyOncoferility.org was conceived to meet the needs of young cancer patients and their loved ones through patient education. Since fertility preservation may be neglected in the initial discussions following a cancer diagnosis, it was important to create a tool that patients could utilize to learn more about their fertility options.  It’s also a resource that can be used in conjunction with the information they receive from their health care provider. At the time of diagnosis, patients must absorb a great deal of information on oncology and may feel overwhelmed by the thought of tackling yet another major life decision, such as fertility, when it’s presented to them. In those situations, MyOncofertility.org provides a resource for these patients to learn about their fertility options in a easy-to-understand way.

 

MyOncofertility.org was designed with the knowledge that patients may be operating on information overload after a cancer diagnosis. As individuals navigate through the site, information progresses from simple to complex per the users request –allowing them to control the browsing experience.  MyOncofertility.org also features the testimonials of survivors and relatives of cancer patients in an attempt to foster solidarity through shared experience. One of the motivations for the website was to help users identify with others under similar circumstances to alleviate the feeling of isolation that often comes with a cancer diagnosis. Testimonials can be particularly useful for children, individuals with poor literacy and those with impaired vision, reaching a broader audience. Finally, Myoncoferitlity.org employs a Q & A model to create an interactive learning experience that mimics the face-to-face dialogue, which might occur between a provider and patient. A follow-up question and answer process is then initiated and users are presented with additional resources to look into if they desire more information.

 

MyOncofertility.org is a fluid project that is constantly evolving to keep in step with technology and meet the needs of users. In September 2011, MyOncofertility.org also introduced a Spanish language version to make the website more accessible to a larger constituency. To learn more about MyOncofertility.org please click here. You can also learn about how the project got started in “MyOncofertility.org: A Web-Based Patient Education Resource Supporting Decision Making Under Severe Emotional and Cognitive Overload,” authored by Kemi Jona and Adam Gerber and found in Oncofertility: Ethical, Legal, Social and Medical Perspectives.

Oncofertility Saturday Academy: Two Graduations in Two Weeks

The last two weekends saw graduation events from Oncofertility Saturday Academies more than 2,000 miles apart. On February 26, the academy based out of Oregon Health & Science University graduated 10 freshmen through senior high school students. The young men and women in the program spent multiple Saturday mornings this winter with Mary Zelinski, PhD, learning about fertility and cancer, practicing surgical techniques on fruit, and discussing ethical issues in oncofertility. The students also met with a 24 year-old leukemia survivor who preserved her fertility with egg banking.  Though her fertility had been preserved, the survivor shared the continuing dilemmas she faces as a cancer survivor, including what to tell potential boyfriends about her fertility.

 

As Oregon Health & Science University is a worldwide center for research on non-human primates, Dr. Zelinski provided the 2011 Oncofertility Saturday Academy students with the opportunity to perform an ultrasound on a pregnant female monkey, an opportunity that very few scientists ever get to experience. In the last week of their academy, the Oregon students had a busy day that included making alginate beads, acting as a physician on oncofertility case studies, and presenting a final poster on a topic in oncofertility.

 

Just one week later, the Chicago Oncofertility Saturday Academy held it’s final events for students and their families, called Family Oncofertility Saturday Academy. The day this past weekend included rotations through laboratory activities and provided the junior and senior high school girls with an opportunity to share their knowledge with family members. A ceremony later that evening included the graduation of thirty-two high school girls and a keynote speech by Andresse St. Rose, PhD, from the American Association of University Women, who studies barriers for women in the sciences and develops recommendations to increase these numbers. The standing-room only event provided students and their parents with the opportunity to celebrate their experiences.

 

The Oncofertility Saturday Academy has provided the students in Oregon and Chicago with exciting experiences they can look back on for years to come. While these programs have finished and the coordinators are (hopefully) taking a much-deserved break, the University of Pennsylvania oncofertility education program has just begun its own 6-week program.  We will continue to update you on the progress of these 10 girls throughout its session.

Miriam Menkin: One Woman’s Contribution to Fertility Research

Miriam Menkin with her husband and son

Last month I attended a lecture presented by Sarah Rodriguez, PhD addressing Miriam Menkin’s role in early in vitro fertilization (IVF) research.  Many people outside the world of reproductive endocrinology know very little about Menkin, if anything at all. Often when her name is mentioned, it is in regard to her relationship with John Rock and not as a scientist in her own right. In her lecture, Dr. Rodriguez gave Menkin her own story and in doing so, argued that we should rethink her contribution to IVF as well as how gender limited women’s opportunities in the scientific community.

Although she was a brilliant woman who aspired to become a doctor, Menkin like so many other women during the early 20th century, was unable to get an advanced degree preventing her from fully pursuing her own scientific interests. Her lack of sufficient academic credentials, gender and familial obligations prevented her from doing research in her own laboratory so she spent most of her career as a lab assistant helping other scientists with theirs. In 1937, she began working as a lab tech for John Rock to help him with, “the hunt for eggs,” and in 1944, she presumably discovered the first instance of IVF in Rock’s laboratory.  In a cruel twist of fate, Menkin was forced to move out of state shortly after this discovery when her husband’s position at Harvard was not renewed.  She spent six years away from Rock’s laboratory and returned only after she divorced her husband, but by that time Rock had moved onto birth control research. Menkin was never able to return to IVF research; however, it always remained her desire to.

As Menkin demonstrates, women have not been absent from scientific research in the early 20th century, many simply haven’t shared in the spotlight with their male counterparts. Who knows what Menkin might have achieved, had she been afforded the resources to continue exploring IVF. Although none of the 5 embryos produced in Rock’s laboratory with Menkin’s assistance resulted in a live birth, she was still an integral player in establishing that embryos could in fact, be created outside of the human body. To listen to Dr. Rodriguez’s lecture on Miriam Menkin, please click *here.

*An audio recording of this lecture will be made available within the next week.

Youngest Oncofertility Patient Receives Fertility Preservation

FAMILY TRAVELS TO RHODE ISLAND FROM OHIO FOR FERTILITY PRESERVATION FOR TWO-YEAR-OLD GIRL

Having a child diagnosed with cancer is a parent’s worst nightmare.  But juxtaposing the knowledge that your child may survive, and then may never be able to naturally have children of her own, can be heart-wrenching.  On Tuesday, March 1, 2011, Jared Robins, MD, a reproductive endocrinologist and leader of the Program for Fertility Preservation at Women & Infants Hospital, cryopreserved an ovary of a two-year-old girl from Ohio who is battling a stage four neuroblastoma.  This surgical procedure, which was performed at Hasbro Children’s Hospital, offers the hope of fertility when this patient survives her treatment.

Once their daughter was diagnosed, the Ohio family met with oncologists from the Cleveland area and were told there was nothing that could be done to preserve their daughter’s fertility throughout her cancer treatment.  Their own research led them to Dr. Robins.

While the family is choosing to remain anonymous, the father said, “Time was of the essence, as we only have a three- to four-week window before our daughter will have her stem cell transplant, destroying her fertility.  Dr. Robins called us back within 45 minutes of our initial call.”

Dr. Robins then contacted Jennifer Welch, MD, pediatric oncologist at Hasbro Children’s Hospital and co-principal investigator with Dr. Robins of a unique program that offers ovarian preservation to children who undergo cancer treatment.  From there, a multidisciplinary team that also includes the Division of Pediatric Surgery at Hasbro Children’s Hospital set out to organize the family’s travel to Rhode Island and to coordinate a laparoscopic procedure to harvest the girl’s ovarian tissue.  With the help of the Hasbro operating room staff and in close collaboration with the Providence Ronald McDonald House, the child underwent the surgical procedure the morning after her arrival, and the family could travel back to Cleveland the next morning.

The father commented, “We have been so impressed by the entire team.  We wanted the experts, but we also wanted someone who would make us feel comfortable.  We have felt that here.”

It is estimated that 1 in 500 children will be diagnosed with a form of childhood cancer.  With the use of aggressive treatment modalities, more than 80 percent of these children will be cured. Therefore, many of these children and their parents are looking beyond the cancer at important quality of life issues including future children.

Unfortunately, some aggressive treatments for cancer can render a child infertile.  The likelihood that this will occur depends on the child’s age, type of cancer and treatment plan.  The Program for Fertility Preservation at Women & Infants offers options for fertility preservation in children, in coordination with the Division of Pediatric Hematology/Oncology at Hasbro Children’s Hospital.

This program offers an experimental procedure that enables physicians to freeze tissue from the ovaries before they are damaged.  Once the child is cured of her cancer and ready to have children this tissue may be transplanted back into her body or eggs may be extracted from the tissue for in vitro fertilization.

These experimental studies are being conducted with the support of the National Institute of Health’s Oncofertility Consortium, with the hope of determining how best to freeze the ovarian tissue of young girls.  The Women & Infants /Hasbro site is one of only a few in the country and the only one in New England to be enrolling children.

Last year, the pediatric oncofertility team at Women & Infants and Hasbro Children’s hospitals completed a surgical procedure on a 17-month-old Rhode Island girl who is battling cancer.  This is the youngest known patient to undergo pediatric fertility preservation under the Oncofertility Consortium.

Dr. Robins said, “Freezing part of a child’s ovary to preserve her fertility 20 or 30 years down the line is a research procedure.  Although we are far from knowing all of the facts about its efficacy, we do believe that we can give a hope of fertility to these young cancer survivors.”

Each year, the pediatric oncology program at Hasbro Children’s Hospital sees approximately 60 new patients diagnosed with cancer. As a treatment plan is developed, sometimes it may likely lead to loss of ovarian function in young female patients. Dr. Welch discusses the possibility of harvesting ovarian tissue with patients and coordinates with the pediatric surgeon and Dr. Robins’ team. Ideally, harvesting can be done at the same time as another oncology-related operation on the child at Hasbro Children’s Hospital. Both teams are present in the operating room, and Dr. Robins continues fertility preservation procedures from there on.

For information about fertility preservation services for adults or children, call the National Fertility Preservation FERTLINE at (866) 708-3378 or Women & Infants Program for Fertility Preservation at (401) 453-7500 in Rhode Island.

About Women & Infants Hospital

Women & Infants Hospital of Rhode Island (womenandinfants.org), a Care New England hospital, is one of the nation’s leading specialty hospitals for women and newborns and a U.S.News Best Hospital in Gynecology.  The primary teaching affiliate of The Warren Alpert Medical School of Brown University for obstetrics, gynecology and newborn pediatrics, as well as a number of specialized programs in women’s medicine, Women & Infants is the seventh largest obstetrical service in the country with more than 8,500 deliveries per year. In 2009, Women & Infants opened the country’s largest, single-family room neonatal intensive care unit. The hospital is also a member of the Oncofertility Consortium‘s National Physician’s Cooperative, a network of clinical sites dedicated to preserving the fertility of young cancer patients.

New England’s premier hospital for women and newborns, Women & Infants and Brown offer fellowship programs in gynecologic oncology, maternal-fetal medicine, urogynecology and reconstructive pelvic surgery, neonatal-perinatal medicine, pediatric and perinatal pathology, gynecologic pathology and cytopathology, and reproductive endocrinology and infertility, as well as the nation’s only fellowship program in obstetric medicine.

Women & Infants has been designated as a Breast Center of Excellence from the American College of Radiography; a Center for In Vitro Maturation Excellence by SAGE In Vitro Fertilization; a Center of Biomedical Research Excellence by the National Institutes of Health; and a Neonatal Resource Services Center of Excellence.  It is one of the largest and most prestigious research facilities in high risk and normal obstetrics, gynecology and newborn pediatrics in the nation, and is a member of the National Cancer Institute’s Gynecologic Oncology Group.

About Hasbro Children’s Hospital

Hasbro Children’s Hospital (www.hasbrochildrenshospital.org) in Providence, RI, is the premier pediatric facility for clinical care, research and education for Rhode Island and surrounding southeastern New England.  A private, not-for-profit institution, it is the pediatric division of Rhode Island Hospital.  Rhode Island Hospital is the principal teaching hospital of The Warren Alpert Medical School of Brown University.  It was ranked among the top 30 children’s hospitals in the country by Parents magazine in 2009.

Gina Shaw: Survivor, Mom, and Book Author About Having Kids After Cancer

When Gina Shaw was undergoing cancer treatment, she tried to find a book that could clearly and simply provide her with information about having children after cancer. Shaw, who started chemotherapy on her 37th birthday and did not have any children at the time, could not find any such resource.  As a freelance writer, Shaw decided to write her own book to discuss the family-building options that cancer patients have before, during, and after completing treatment. She talked with the Oncofertility Consortium about the making of her book, which was published last week.

The book, Having Children After Cancer: How to Make Informed Choices Before and After Treatment and Build the Family of Your Dreams, discusses many of the fertility issues involved in cancer treatment. In it, Shaw talks about how different treatments can affect the fertility of men, women, and children in addition to laying out the different methods for fertility preservation. The book also provides information to cancer survivors who are interested in learning about options if their fertility has been compromised by cancer or its treatment. Finally, as any other expectant parents, cancer survivors often wonder how the physical and genetic aspects of their cancer can affect their children. In her book Shaw answers these questions and discusses the emotional issues of parenthood after cancer.

Gina Shaw guides cancer patients and survivors through the book by providing the personal stories of about two-dozen survivors.  Shaw stated that she, “interviewed patients about what it felt like to undergo embryo banking, chemotherapy, and more.” She also talked with women who had received radiation for breast cancer and described their experiences breast-feeding, as radiation can impair later lactation on that breast.

In addition to talking with patients, Shaw also interviewed medical experts in the reproductive, oncology, and oncofertility fields. She said, “The members of the Oncofertility Consortium were really helpful and played a key role in the fertility preservation, financing, and insurance sections of the book.”

In discussing fertility preservation, Shaw stated that about half of the survivors she met with were not informed of their fertility preservation options and that, “Some people who were informed received that information in a very cursory way.” In addition, she described that survivors who received cancer treatment, “ in a small community-based oncology setting may be less likely to receive fertility information,” than those in large centers. With the publication of Shaw’s new book and the continued work of the Oncofertility Consortium, hopefully all young cancer patients will receive fertility information at the time of cancer diagnosis.

True North Treks Hikes Into Cancer Survivorship

First Trek in Northern Montana

Oftentimes young adult cancer survivors are referred to as being “lost in transition” when they finish treatment and enter survivorship. Important life events, milestones, and decisions such as fertility that many of us experience are either significantly interrupted or abandoned as a result of their diagnosis and treatment. Dr. David Victorson, Assistant Professor in Medical Social Sciences and Institute for Healthcare Studies here at Northwestern University had been working with young adult cancer patients and was profoundly moved by their experience. It encouraged him to create True North Treks, an organization founded to support young adult cancer survivors during the transition from patient to survivor through experiential treks in nature where mindful awareness practices and outdoor survival skills are taught.

Recently I had an opportunity to talk with Melanie, the program director for True North Treks, about the organization. If anyone can relate to the participants of True North Treks, Melanie is certainly that person.  In 2004 at the age of 24, she was diagnosed with papillary thyroid carcinoma and underwent two rounds of radioactive iodine treatment and multiple surgeries for cancerous lymph nodes.  She found Dr. Victorson through the web community of young adult cancer survivors and shortly thereafter became the program director as well as an expedition leader for True North Treks. I asked her what she thought cancer survivors could gain from this type of experience and she replied, “Cancer can be so disruptive and rock you to the core of who you think you are so being able to trust your own body again and push yourself physically is really powerful.”  Further discussion proved the treks are designed to do exactly this.

A trek is made up of 6 to 8 participants who hike out to picturesque, but relatively isolated areas that are appropriate for the participant’s physical capacity.  Many of the survivors struggle with the late effects of cancer including reduced lung capacity so it’s important that the treks are challenging, but accessible.  While on the trek, they’re taught outdoor survival skills, mindful awareness, and they get to spend time with other young survivors who can sympathize with their experience.  Frequently with a cancer diagnosis comes a fear of the unknown – not knowing what’s going to happen next, but for Melanie, this is exactly why True North Treks is a great fit for a young cancer survivor.  She says, “We want them to be confident in their skills and really embrace the experience without the fear of being in an unknown environment. A lot of what we talk about on the trek is managing the unknown and finding different ways to embrace that in positive ways rather than being thrown off by it.”

To learn more about True North Treks, including how to sign up for their next expedition to the Olympic Peninsula September 9-14th, please visit www.truenorthtreks.org.

Who Makes Fertility Decisions in Pediatric Cancer Patients?

Young women and men facing cancer treatments are forced to confront not only their cancer diagnosis, but also the potential loss of their fertility. Each individual case and treatment plan may affect fertility differently; however, healthcare providers should inform their patients about fertility preservation options. At Northwestern, the Oncofertility Patient Navigator immediately reaches out to newly diagnosed cancer patients and their families to discuss options for preserving fertility. This decision is complex enough for an adult, but what happens if the cancer patient is a child? In a perfect world, two parents who have their child’s best interests at heart can discuss the situation and come to a joint decision as to how to proceed with the child’s treatment collaboratively and amicably.

As in many life situations, the ideal is far from a reality that it is much more complicated.  First it is important to bear in mind that families are asked to make life altering decisions on fertility shortly after their child has been diagnosed with cancer. The difference between fertility decisions with a cancer patient and an average person seeking treatment for infertility is time –cancer patients need to make decisions and begin fertility preservation procedures quickly.

Imagine you just find out that your 7 year old daughter has been diagnosed with cancer and now you are meeting with the Oncofertility Patient Navigator only hours after you’ve received this information. You are in this meeting with your husband who is not your child’s biological parent, but has been in the child’s life since she was a baby. The biological father has been involved, but not to the extent that the stepfather has. You disagree on how to proceed and your child’s young age prevents her from participating fully in the decision making process. The question then becomes, who has more authority in making the decision for the child – the mother and stepfather, the mother, the father, etc..?

Other issues may arise in the fertility preservation of legal minors, including an adolescent child disagreeing with his or her parents on whether or not to pursue fertility preservation. This could be basic adolescent rebellion or there could be some fundamental ideological or religious differences between the parents and the child that need to be addressed. A health care provider familiar with the ethical dilemmas in oncofertility may help guide the family to a resolution that is hopefully consistent with the beliefs and values of everyone involved.  It is important for the adolescent child to feel that they have some autonomy over their body and their treatment options; however, assuming that the parents have the child’s best interests in mind, they may be better equipped to make rational decisions at such an emotionally charged time.

Facing infertility is a difficult issue, but coupled with a cancer diagnosis and impending cancer treatment, it can seem overwhelming. Families face significant personal and ethical decisions when they are dealing with a minor’s fertility options.  These decisions become even more difficult when the families do not agree on how to proceed. In these instances, who has the final say? It’s a complex dynamic and one that needs to be explored more thoroughly as we examine fertility preservation in a pediatric cancer context. You can read more about this topic in “Whose Future is it? Ethical Family Decision Making About Daughters’ Treatment in the Oncofertility Context,” by Kathleen M. Galvin, PhD., and Marla L. Clayman PhD., in Oncofertility: Ethical Legal, Social, and Medical Perspectives.

Treating Infertility in Developing Countries

Recently I read a piece by Lisa Campo-Engelstein, PhD and Amanda Fleetwood, PhD arguing for the inclusion of low cost assisted reproductive technology (ART) centers in the Global South, a term used for developing countries in academic literature. They reason that ART services give women reproductive autonomy and can alleviate the stigma that infertility brings to women and their families. Specifically focusing on three low cost ART centers in sub-Saharan Africa (Sudan, South Africa and Tanzania), I wondered how these centers were accessible to the people they were meant to reach. How do we define “low cost” in areas were the average monthly take home pay is between $50-60, but the reduced treatment cost for ART is $300? How do we reach the people that need this service the most – the people that are unable to get to these centers due to a lack of infrastructure within their particular region?  How do we engage the local population to take advantage of these services and monitor them when or if they do considering the immense stigma attached to infertility? All questions that need to be addressed, but at the heart of it is, “is there a need for these services and if so, how can we make it happen so that it reaches the people it was meant to assist?”

Certainly one can argue that by creating low cost ART centers we are only treating the symptoms of a much larger problem (infertility due to sexually transmitted diseases and poor healthcare services), but regardless of this debate, it doesn’t detract from the fact that there are still couples suffering from infertility that need reproductive choices. Taking that a step further, in many countries umbrellaed into the term, “the Global South,” children are so highly valued that a woman who does not produce any children will very likely suffer a stigmatization that devalues her status in the community and can lead to more extreme conditions such as ostracism and violence in certain areas. It’s also important to note that in most cases women are blamed for infertility issues, whether or not this is actually the case, so by giving them reproductive options you are facilitating women’s autonomy in the public as well as the private sphere.

I think there are a lot of variables that come into play when we begin to think about low cost ART centers; funding, access, resource distribution, eligibility, etc… Nonetheless, after careful reflection and an admitted “change of heart,” I believe that if implemented with prevention strategies and the mission to help those most in need of this service, it will prove to be an incredible resource for women (and men) in the Global South. For more information on ART and the Global South, please read, “The Impact of Infertility: Why ART Should Be a Higher Priority for Women in the Global South,” in Oncofertility: Ethical, Legal, Social, and Medical Perspectives.

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