If a woman is diagnosed with AML when she is younger, how might this affect her fertility?

If a woman is diagnosed with AML when she is younger, how might this affect her fertility? Leukemia treatments have evolved a lot over time, and there are two phases of leukemia treatment. We divide it into what we call induction, and the second one is what we call consolidation. The induction part of leukemia management is dealing with getting the leukemia into remission. So you want the leukemia to go away to as low a number as possible, preferably 0% leukemia cells in the bone marrow, and you want the normal cells to recover back to normal. And that's kind of the role of induction and the initial treatment of leukemia, as we call induction with chemotherapy. There's a phase that comes after it, which is what I call the cleanup phase, so you want to get rid of whatever little is left behind, and that is consolidation. Consolidation can take the form of either more chemotherapy or a stem cell transplant, and that's where fertility issues come in for young women. The standard induction chemotherapy usually does not cause infertility so much. The risk of infertility with the induction chemotherapy, the initial phase of chemotherapy, is low. But when these patients go into stem cell transplant, an overwhelmingly large number of younger patients are generally transplanted, because that is one of our best ways to cure AML in certain biological subgroups, a transplant is absolutely recommended after you're in remission, and the infertility risk is very high after a stem cell transplant. Where this becomes challenging is when a young patient, a female patient comes in for leukemia, you're dealing with a very aggressive disease. You want to start treatment very fast, but at the same time, you're also planning for fertility issues down the line. So there is a big discussion that usually we do, and I usually talk to the patients about the risk of fertility and infertility. We may not even know at that time when they first come in whether we're going to transplant or not, because we're still waiting for the molecular studies, chromosomes, cytogenetics, all of the stuff that we take into consideration deciding whether somebody needs to be transplanted or not. That information may not be available until a couple weeks, and we don't wait for treatment, many times for two weeks, you start the initial treatment, because that initial treatment is not going to change. So we decide somewhere middle of after a couple weeks that somebody needs to be transplanted or not, yet the question on how to prepare best for infertility has to be done in an agnostic fashion right from the beginning. You almost prepare them that they're all going to go for a stem cell transplant, because you don't want to then realize that, oh, we really want you to be transplanted, but we didn't take into account the fertility question when we first started treatment. So there's usually, at our center, we usually have a fertility team and reproductive endocrinology that meets the patients at the first day of diagnosis and treatment planning. And it's a bit tricky and challenging, because sometimes the patients are too sick and you have to start treatment, because at this point we are just trying to save their lives at that point. Any delay of treatment therapy would be dangerous. In those cases, we just start treatment. But in some patients, there is some time to wait while we're working up the leukemia and waiting for the biopsy results and doing things where there might be a chance where you could induce, so we have the fertility doctor see, and sometimes we can have kind of akin to how IVF works. You have egg donations. So if the patient is stimulated, you take the eggs and you freeze it before chemotherapy gets into the patient, because once chemotherapy gets into the patient, the chances of a healthy egg in the near term is lower. So to do it after chemotherapy, the healthy egg chances are lower. So in that case, it's better to do earlier. But if somebody is very sick and you can't do it, then there are other options of ovarian preservation where you take a part of the ovary after they are in remission and you freeze it for future use. So there's a lot of things that we can do to preserve fertility in addition to giving certain hormonal shots to sort of keep the ovaries sleeping during the phase where chemotherapy is going in. And there are several choices that we carefully lay out and discuss with the reproductive endocrinologist, the patient, and all the doctors involved, and decide how to best preserve fertility while we're trying our best to get them into remission and cure the disease. Are all those methods covered by insurance? So not everything is covered by insurance. So not all of those options for fertility preservation is covered by insurance. Usually egg donation and ovarian retrieval or ovarian tissue retrieval tends to be covered. But what part that's not covered is the freezing of the egg and freezing of the ovarian tissue. So many times patients have to pay out of pocket. But there are certain grants that are available where we apply for these in order to get some financial assistance in order to help patients pay for the tissue. So that's something we always take into account. Some of the drugs that we use in ovarian stimulation may or may not get covered because not everyone's insurance covers ovarian stimulation. Depending on what age they are, whether they have cancer or not, there might be restrictions. But there are some grants available that we apply for and help patients get through the financial costs of fertility preservation.