Preserving Fertility During Cancer Treatment: Options, Costs and Success Rates

Dr. Diane Reidy-Lagunes:

Today we're talking about cancer and fertility.

Amanda:

I couldn't believe that not only did this cancer diagnosis land in my lap, but it also sort of felt like a sucker punch of: “I don't have children yet. Do I want them? Are we going to have them together?” It was just all these complicated things on top of: “Are you going to survive?”

Dr. Diane Reidy-Lagunes:

While cancer treatments can be lifesaving, they can also impact the ability to have kids, adding yet another layer of challenge to what's already an incredibly difficult time.

Francesca:

Having to decide between paying for chemo bills or my fertility was not something I would think I would need to be deciding at 24.

Sebastian:

The question was brought up: Do we ask our doctors to move the surgery back so I can make more sperm deposits? It's something that weighs on you 'cause this is a choice that I have to make in this moment that's going to affect not only myself, but also future me and a potential family that I have.

Dr. Diane Reidy-Lagunes:

Today on the pod: fertility preservation before cancer treatment; understanding what the options are, how the timeline impacts cancer treatment, and the emotional and financial impact of it all. Let's talk about it.

Hello, I'm Dr. Diane Reidy-Lagunes from Memorial Sloan Kettering Cancer Center, and welcome to Cancer Straight Talk. We're bringing together national experts and patients fighting these diseases to have evidence-based conversations. Our mission is to educate and empower you and your family members to make the right decisions and live happier and healthier lives. For more information on the topics discussed here, or to send us your questions, please visit us at mskcc.org/podcast.

Today we're welcoming an outstanding panel of experts to share their insights on this important topic. Joining us is Lauren Martino, a fertility nurse practitioner here at MSK, who provides essential resources about fertility preservation to newly diagnosed patients. We'll also hear from MSK’s Dr. Julia Brockway-Marcello, a breast oncologist, and Dr. José Flores, a urologic surgeon. Additionally, we're pleased to have Dr. Lucky Sekhon join us. She's a reproductive endocrinologist and fertility specialist and OB-GYN who treats patients at the fertility clinic RMA of New York, which is part of the Mount Sinai Health System. Thank you all for being here today.

Lauren, can you walk us through the timeline? A patient comes to MSK and is diagnosed with cancer, and fertility preservation is advised by the doctor. What happens next?

Lauren Martino:

I'm 1 of 2 nurse practitioners in our fertility preservation program. So after a patient is seen, the surgeon or a medical oncologist can enter a referral to our program, and either me or my colleague will then meet with the patient and review their specific risks of infertility and go through options that they could consider. That could be egg freezing or embryo freezing if it's a female, or sperm freezing if it's a male. Then, if they want to move forward, we make a referral to one of our outside centers – our coordinating partners – that can help them with these services. So we sort of bridge two specialties, oncology and fertility, to help this go smoothly for our patients.

Dr. Diane Reidy-Lagunes:

Julia, as an oncologist specializing in breast cancer treatment, we know that many of your patients really have to think about this. Can you explain to us why fertility preservation is recommended for women before treatment is started?

Dr. Julia Brockway-Marcello:

Our treatments that we use to treat breast cancer, particularly chemotherapy, can be toxic to the ovaries, to the testes. So patients can be cured of their cancer but then have a long-term effect of infertility because of the toxicity of our treatments.

Dr. Diane Reidy-Lagunes:

And for males, cryo-preservation – which is the freezing of the sperm for future use – may also be recommended before treatment. We will get into cancer and male fertility a bit later in the episode. Dr. Flores, why is it recommended that you get this freezing of the sperm before treatment? Can you talk to us about that?

Dr. José Flores:

All the cancer treatment – chemotherapy, radiation, surgery – can impact sperm production. And because it's not guaranteed that sperm production is going to be preserved or sperm production is going to be recovered after treatment, that's the reason we always advise to go ahead and freeze the sperm.

Dr. Diane Reidy-Lagunes:

So you've been diagnosed with cancer and your doctor tells you that you need to see someone for fertility preservation. Now what? If you're a woman, that means going to see a reproductive endocrinologist at a fertility clinic. Dr. Lucky Sekhon, that's your world. Can you walk us through the options of fertility preservation for women?

Dr. Lucky Sekhon:

Yes. I see women who have been diagnosed and have a 2-week window before they have been recommended to start their chemotherapy. And that is enough time, I tell them, to freeze eggs or to freeze embryos.

It's about stimulating the ovaries and extracting eggs. This is a process that involves taking 8 to 10 days of injectable medications to try to get as many of the eggs that are available in that given cycle to grow and mature. You are expected to come in maybe 5 or 6 visits where we're doing check-ins in the form of blood work and ultrasound to see how you're responding to the treatment. And at one of those visits, we'll determine that we've gotten as many of the eggs that are present to grow as best as we possibly can, and you're ready for the egg retrieval.

The egg retrieval happens around 2 days after that last scan, when you take your last dose of medication. They are very quick, simple procedures. They take about 15 minutes and it's done under light sedation. The procedure itself is not a major surgery. Once it's over, you wake up in the recovery room. You go home probably an hour after it's over.

Dr. Diane Reidy-Lagunes:

And what are the chances that it actually takes?

Dr. Lucky Sekhon:

Either we are freezing the eggs that are mature and we're giving you an update the next day. Not every egg that's extracted is guaranteed to be mature and able to be one day fertilized by sperm, and so we only really freeze the mature ones.

Now for onco-fertility cases, we may also freeze even the immature eggs in the hopes that over time we're going to have lots of advancements in our field. Right now, maturing eggs outside of the body is still an active area of research, so we try to freeze whatever we can.

Not every egg is capable of turning into a pregnancy. Human reproduction is very inefficient. If people are freezing embryos, they'll see that happen in real time. They'll see that not every egg we extract on the day of the egg retrieval will successfully fertilize when they check the next day. It's typically like 70 to 80%. Then about 60% of fertilized eggs on average are able to turn into embryos, which takes about a week.

At that point – if you have a partner or if you're willing to use donor sperm – when it becomes an embryo, you can actually test the embryos and freeze them. That is very important because a lot of our embryos – even in our 20s, which is considered as good as it can possibly get when it comes to fertility – will have abnormalities or imbalances that limit the reproductive potential. So if you're creating embryos, you can test them to understand their quality, and then we freeze them and wait for the results to come back. So either way, what's expected of you as a patient – those 8 to 10 days of shots and the procedure – look the same.

Dr. Diane Reidy-Lagunes:

Got it. I think for some of our patients that have cancer, they may have an inherited gene mutation that was passed down from mom or dad. So I think this process that you described is so incredible in that medical advancements can actually help us identify a gene mutation that could be lifesaving for those embryos if they did get impregnated, right?

Dr. Lucky Sekhon:

I see so many people that know they carry a cancer-predisposing mutation, and they often are called “previvors” because of their family history. Someone else in their family who may have been affected had this testing done and that prompted them to be tested, and what it leads to is many different paths.

One is increased surveillance and just being aware of this risk and hopefully catching anything that could develop, at an earlier stage. But also there's this idea of reproductive risk: knowing that most of these genes are such that you would have about a 50% chance of passing it on to future children. Now, passing that gene on doesn't guarantee that your child is going to get cancer one day. But it obviously can predispose them.

If that's something that you feel strongly about trying to stop from propagating in your lineage, then this is something that you can do. You have to know that you carry the gene in order to be able to actually test embryos for it. It can take a few weeks, sometimes a few months, to make the specific test. But in cases where someone is rushing to get this done because they have a chemotherapy planned 2 to 3 weeks out, we talk to the lab and we say, “Can we create the embryos? And you'll freeze the samples and hold onto them as you're working towards making that specialized test to look for the gene mutation?” And they'll agree.

Dr. Diane Reidy-Lagunes:

Great. Let's hear from Meagan. Meagan was diagnosed with triple-negative breast cancer at age 29. Prior to starting chemotherapy, she did go to a fertility clinic for treatment. Let's hear her experience.

Meagan:

It was very scary and overwhelming to know that I had to do the fertility piece before starting treatment. A big factor for me was that my now-husband and I hadn't even been together for a year at that point. So when the doctors were asking me to choose between eggs or embryos with him, it felt like a very hard decision to make that really had major impacts potentially on my future.

The doctors were also transparent with me that you have a higher chance of success with embryos. It felt like a very complicated decision to have to make while I'm still processing this fact that I was just diagnosed with breast cancer. So I ended up deciding to do half eggs and half embryos with him so that I had a little bit of a safety net for myself, in case things did not end up working out. Thankfully they did, and we're happy with our own baby now.

Dr. Diane Reidy-Lagunes:

Lucky, any advice that you have for partners that are trying to decide between embryo versus eggs, and what risks or benefits may be there?

Dr. Lucky Sekhon:

There is this very strong narrative that I always hear: “embryos are better.” It's not that they're better, it's that you are closer to your end goal.

When I was talking about coming back to use frozen eggs, I didn't mention that you thaw them out before you fertilize them. We are pretty good with egg freezing now, to the point where thaw survival rate can be as high as 90 to 95%. But eggs are a single cell, so they're a little bit more fragile than an embryo that has grown and divided into 100 to 200 cells. So embryos typically have a very high thaw survival, and it's very reliable. You expect not every egg to survive the thaw. You already know there's going to be drop-off with fertilization and growing them into embryos. So you might be working with a few less eggs than you otherwise would have if you had just collected them fresh without freezing them. So that's one.

The other is, you know where you stand within a week. You'll know how many actually fertilized, if you're creating embryos. You're going to know in a week how many turned into embryos, and you can do genetic testing on an embryo because you're removing just a few cells of something that has 100 to 200 cells. You cannot break apart a single-celled egg without damaging it to try to get information on it.

So I think you are more confident if you freeze embryos because you know where you stand. It's still not 100%, not every embryo will implant, but if it has a good grade – which we determine by looking at it under the microscope and it's genetically tested and it has all of the chromosomes it's supposed to have, 46 – it's a pretty high rate of success, about 60 to 70% chance of live birth in most cases.

So even when we freeze embryos, it's not like you freeze 1 embryo and it guarantees anything. But you're ideally trying to calculate: if it's a 60 to 70% chance, potentially two embryos per desired child in the future is kind of a good goal. It's harder to know how many eggs you truly need to be successful. It’s a big guessing game and therefore that's where it gets harder to know where you stand. So I wouldn't say it's better. I would say it's more confident to freeze embryos and maybe slightly more efficient.

Dr. Diane Reidy-Lagunes:

That's super helpful. I'm going to come back to Dr. Flores to talk about the next steps for a male, but let's hear from a patient, Sebastian.

Sebastian:

Hi, I'm Sebastian. I am 31 years old. I have been diagnosed with testicular cancer two times, and it wasn't until the second diagnosis that I started to talk about future family planning, fertility preservation, specifically sperm banking. And that's led to a lot. It's not only dealing with the second diagnosis and what that means in a sort of existential way and what it means for you and your future family, but also there's financial stressors that are added on top of that: keeping the sperm frozen or actually going to the facility and doing the sperm banking. And then after that it's going to be IVF. It's kind of mentally colossal, even just the thought of family planning right now.

Dr. Diane Reidy-Lagunes:

José, we'll talk about the financial burden that Sebastian describes later on in the episode, but can you walk us through the steps that a man actually goes through, in terms of the timeline and the steps in order to preserve fertility when they see you?

Dr. José Flores:

Our fertility nurses are going to talk to the patient. They're going to explain all the details about semen analysis, about banking sperm, the cost associated, where to go, how this is done. They're going to do that here at MSK.

Dr. Diane Reidy-Lagunes:

Got it. And I think this is so interesting, which you've taught me: the cancer itself can cause a low amount of sperm for an individual patient. So even before the treatment, you may have some problems with low sperm, which is why it's so critically important to try to preserve. And then if you have low amounts of sperm, then there are alternative therapies and surgeries and/or procedures that you can do to try to increase the chances of getting that sperm.

Dr. José Flores:

And unfortunately, like you said, cancer by itself can impact the sperm production. And so many times, we don't know why. There are so many factors, and we are here to offer the patients options.

Dr. Diane Reidy-Lagunes:

That’s right. I think it is incredibly important to remember even if you've had the chemo, the radiation, or the surgery, and you're having a problem, you can still come to us and there are potential opportunities, which is important to know.

Dr. José Flores:

That’s correct.

Dr. Diane Reidy-Lagunes:

Julia, many patients have a fear of delaying the cancer treatment. They want to start it yesterday, which is so understandable. What are your thoughts on that?

Dr. Julia Brockway-Marcello:

Absolutely. We talk about how timing is everything and a workup for a cancer diagnosis can take several weeks. When the surgeon refers the patient to us in medical oncology for the discussion of these cell-killing chemotherapies that can render a patient infertile, they're concurrently referring the patients to fertility preservation. So I often see patients that have already been referred to fertility preservation, to talk about those options. Occasionally they've even started it before even seeing me.

While we don't have data that says that delaying our treatment for breast cancer by another 2 weeks will have a longer-term impact, the longer-term impact on missing out on the opportunity to preserve fertility is, in my opinion, in my regard when I counsel my patients, I want them to have every possible option in the future.

Dr. Diane Reidy-Lagunes:

I think that’s so important to emphasize. Lauren, anything you want to add there?

Lauren Martino:

When I'm speaking to patients with breast cancer, we are the second person in the hospital to speak with them. First, it's the surgeon and then it's me. We really get in there soon and we try to explain that a lot of fertility preservation can be done concurrently. This really does help to alleviate fears, to know that they're not necessarily delaying treatment. Some of our patients can't delay, but for the ones that are, it can make a huge, huge difference to start early.

Dr. Diane Reidy-Lagunes:

I've heard patients say, “What if the injections actually drive the cancer, or somehow feed the cancer and make it become more aggressive?” Any concerns there?

Dr. Lucky Sekhon:

We have a lot of data now, and there are a lot of studies that are very reassuring that don't show that this process of stimulating the ovaries to extract eggs increases your risk of ovarian or even breast cancer. This is confusing for people because a lot of these types of cancers are driven by hormones. So I always explain it this way:

When you're going through this 2-week process, your hormone levels don't start rising right away. Your estrogen levels are probably elevated beyond what normally would happen with ovulating 1 egg naturally on your own every month. They're probably elevated far above that level for a very transient period of time, only about a week. And so yes, it can feel like a lot that you're going through this cycle, but at the end of the day, the actual absolute amount of exposure to elevated estrogen is not that much. This is very different than taking long-term hormone replacement therapy and other types of long-term estrogen exposure.

Dr. Diane Reidy-Lagunes:

That's super helpful. Clearly there are certain diseases that we care for where time just is not on our side and we have to start the treatment right away, so we're not able to do this process. What are their alternatives in that situation?

Lauren Martino:

Depending on the situation, there could be other options. For females who are at really significantly high risk for impaired fertility, they could consider ovarian tissue cryo-preservation. This is the surgical removal of an ovary where the outer tissue, where the eggs are held, are divided into strips and stored. And these are immature eggs. It's a different technology than mature egg freezing, but it can actually be done after treatment starts. But it's something we want to be very judicial about because it's the removal of an ovary. So again, this would be more appropriate for patients who are really, really high risk.

Alternatively, sometimes the best answer is to not do anything right now and wait it out. In those cases, females could have ovarian-reserve testing after treatment is done. The time period is anywhere from 6 months to a year after. They can have this done to reassess things and see where they are. Egg retrieval might even be a good option at that point because the risk is premature infertility and menopause. So they may still have a window, it just may not last as long as they want.

And our male patients can have a semen analysis just to check and see where their sperm production is.

Dr. Diane Reidy-Lagunes:

Any additional thoughts, Lucky?

Dr. Lucky Sekhon:

Another thing that we'll often offer to patients is kind of shutting down the ovaries and inducing this temporary menopause with a medication called Lupron. By making the ovary less metabolically active, the idea is it may theoretically expose the ovary less to these cytotoxic medications that can sometimes deplete the ovarian reserve. There's some interesting data on this that suggests women are more likely to get their periods back after undergoing chemotherapy if their ovaries were protected with this Lupron treatment.

Dr. Diane Reidy-Lagunes:

Great. Lucky, how successful are we overall with these procedures?

Dr. Lucky Sekhon:

I think sperm cryopreservation, we're really good at that. In my experience, men who come back with their partners to build their family and they froze multiple vials of sperm, their partners don't have to resort to IVF as a first step. Depending on how many vials of sperm were able to be frozen and the quality, doing something called intrauterine insemination is a viable option. It's basically exposing the female partner to sperm at the right part of their cycle and just seeing if it turns into a pregnancy. It's not the most efficient because human reproduction is inefficient (if someone's trying with timed intercourse and has a normal semen analysis, we normally say even in your 20s, it's like a 20% chance each month).

You have to keep in mind how many vials does the male partner has stored, especially if they can't make new sperm now. Often in these cases, you might try a few rounds of insemination, but once you get down to a certain number, you want to be really conservative with what you have stored, and it may make sense to do IVF. The difference is: inseminations, which have a lower chance of success per cycle, use up an entire vial. So it is 1 round of IVF. But with IVF, you have a lot more efficiency where you take 1 vial that has millions of sperm in it hopefully, and you're putting 1 sperm with each egg that is possible. And so you can create multiple embryos from just 1 vial of sperm. So even in patients who have testicular cancer and the quality of the samples or the amount that's frozen isn't that plentiful, there's a lot of hope there and our success rates tend to be very high in most cases.

When it comes to the female side, coming back to using frozen eggs, it really depends on how many eggs were frozen and the age at which they were frozen, because those are the two main factors that dictate chance of success. I'll throw out some rough numbers, but don't hold me to it because everyone's biology is different. The younger you are, the less eggs you need. The older you tend to be, the more eggs you need to make up for egg quality issues that we anticipate with age.

If you're in your 20s, 10 eggs could be enough. It might be enough to get multiple embryos because you tend to have a very high conversion rate from egg to embryo, and a lower proportion of the embryos resulting from your eggs at that age are going to be abnormal or have imbalances. As we get to 38 and older, it's harder to know how many you need to be successful, but I would feel more confident if I had 20, 25. At the end of the day, whatever number you have is better than having nothing frozen, and it gives you hope and it's a chance. Eventually, if you come back to use them, you're going to turn them into embryos and know what you have to work with.

If you have tested embryos and they have good grades and they have all the chromosomes they're supposed to have, across the board – no matter how long they're frozen, no matter what the age of your uterus is or the age of a surrogate is, if someone else is carrying the pregnancy for you, which sometimes people will need to do, it doesn't matter across the board – it's like 60 to 70% chance of live birth per embryo if it's a high quality embryo. So if you have 3 or 4 embryos frozen, that's a very high chance of success. You have a high degree of confidence that you're going to be able to come back and successfully thaw it 98% of the time to try to get pregnant with that embryo.

Dr. Diane Reidy-Lagunes:

Got it. Good numbers. So let's talk about the cost because this is a big potential problem for our patients, on top of the cancer treatment cost. Dr. Flores, what is the cost for banking sperm?

Dr. José Flores:

It can cost around $1,000. But then you have an annual fee to maintain the samples frozen. That can cost around $700. I know it sounds expensive so here at MSK, we have social workers, fertility nurses that know about that, and they can help with financial support. But each case is going to be evaluated case by case.

Dr. Diane Reidy-Lagunes:

Dr. Sekhon, what is the cost of freezing the eggs or the embryos?

Dr. Lucky Sekhon:

Assuming no insurance coverage, assuming no grant, if you're paying out of pocket for egg freezing, typically it's about $10,000 for a cycle. That's covering all of the lab procedures and all of the monitoring and everything in the lead up to the egg retrieval and the egg retrieval procedure itself.

That doesn't necessarily include the cost of medications. Depending on the pharmacy that you're getting them from and how much medication will be required for your protocol to induce an appropriate response from the ovaries, it could be anywhere from $2,500 to $5,000. Medications are also expensive. So this is why it's imperative to have people to help, and organizations to help, where insurance coverage does not exist.

Dr. Diane Reidy-Lagunes:

And I imagine the cost estimate can vary depending on where you are in the country, perhaps even lower. And there a cost for storage as well, correct?

Dr. Lucky Sekhon:

Yes. Every clinic is different. At ours, the first year there has no cost of storage. It's included as part of the cycle. Thereafter, it's usually around $1,000 per year to maintain. A lot of people don't realize what goes into the storage of eggs and embryos, but it's an active process where there's active monitoring, a backup alarm, generator, because the eggs and embryos have to be maintained at a specific temperature in order for their viability to be maintained.

Lauren Martino:

Insurance is not quite where it needs to be, for sure, but it is coming along. There have been some laws passed in New York, New Jersey, Connecticut, and throughout the rest of the United States, that are trying to mandate coverage for fertility preservation for iatrogenic infertility. The current laws are not perfect – there is a long way to go – but it is improving, and we are still actively working to try to get more coverage for our patients. My hope is that, if we were to have this podcast in 5 or 10 years, this wouldn't be an issue anymore. Hopefully, advocacy groups like Chick Mission, in addition to giving grants, are successful with all of their advocacy and getting some laws passed.

Dr. Diane Reidy-Lagunes:

We're going to hear about that right now. I could not agree more. Let's hear from Alexandra. She was diagnosed with stage 3 sarcoma at age 36, just a few months after giving birth to her son Dylan, and in the middle of the pandemic. She talks about the burden of cost.

Alexandra:

It's important to talk about the disappointment and the anger that can come along with having a treatment save your life and simultaneously ruin parts of your life. The financial aspect was so hard to wrap my head around because I had gone on maternity leave and then gave birth and then we had the pandemic. The industry I work in, entertainment, was completely shut down. To think that I was going to have thousands and thousands of dollars out of pocket for my treatments, and then have to even consider egg freezing, was something that was off the table. It was not something we could afford to think about or do at that point in time. But Chick Mission gave me a grant and I just felt this huge relief because I could have something in the freezer for the future, God forbid I needed it. It wouldn't have been possible if I didn't have somebody like that helping me.

Dr. Diane Reidy-Lagunes:

Let's hear from the amazing Amanda Rice, a 3-time cancer survivor and the founder of the Chick Mission. Again, this organization provides need-based grants to women with cancer and helps pay for the egg freezing.

Amanda Rice:

I was originally diagnosed in 2014 with breast cancer at age 37. I had not had children, and this came out of nowhere. I knew I had great health insurance. I had fertility benefits, and so I decided to move forward with egg freezing. When I went to meet with the reproductive endocrinologist, the billing office was like, “You may want to call your insurance company because they denied you.” I picked up the phone, and they said, “Well, you're not infertile yet, so you don't qualify.” Even though I had a very high risk of becoming infertile, I didn't qualify until I became infertile, which by their definition means you're trying for 6 months without success. And that was the lowest point of my cancer journey.

So the Chick Mission is a triple threat mission, I like to say. We provide need-based grants to young women with cancer, those that were just diagnosed who need to preserve their eggs before they start their life-saving treatment. The second part of our mission is really about educating people, and then the third leg is advocacy. We band together with lots of different organizations across the country to work on legislative change. This is something that within 10 years’ time shouldn't be an issue anymore because every state passes a law that mandates insurance covers this, and ultimately a federal bill. That's the goal.

Dr. Diane Reidy-Lagunes:

A worthy and justified goal, indeed. Boy, I hope so. Any final thoughts?

Dr. Julia Brockway-Marcello:

As we are treating more and more patients who are young, these issues have to be at the forefront in that initial visit, in that initial conversation. We're not only thinking about, “How are we going to cure this person of this cancer,” but “What are we going to do to allow them to live beyond this cancer?”

Dr. Lucky Sekhon:

I totally agree. Survivorship continues to increase, and we really do need to be focusing on supporting mental and physical health and future goals in quality of life, their fertility. Something I'm passionate about in my practice is something we talked about earlier, “previvors,” because now I get to have these conversations with these women in their 20s who know they have the BRCA gene. I just think it's so amazing that now they can decide to do things like egg freezing. That if, God forbid they are diagnosed with a cancer, now they don't have to rush to go through this process. We're continuing to get ahead of this, and I think education and awareness are key.

Lauren Martino:

I can tell you, in working with our patients and our survivors, as their lives start to come together after treatment, fertility is one of the first things that they bring up and they want to talk about. It certainly takes a village: We need our oncologists to refer early, and we need our reproductive endocrinologist and neurologist and andrologist to move mountains and get our patients in. Everyone does this collective effort, and it makes a huge difference in the lives of our patients.

Dr. Diane Reidy-Lagunes:

That's right. Our patients deserve to have the opportunity to at least have the conversations and then make these decisions for themselves. So thank you all so much for all you do and for joining us today.

Thank you for listening to Cancer Straight Talk from Memorial Sloan Kettering Cancer Center. For more information or to send us your questions, please visit us at mskcc.org/podcast. Help others find this helpful resource by rating and reviewing it on Apple Podcasts or wherever you listen. Any products mentioned on the show are not official endorsements by Memorial Sloan Kettering. These episodes are for you but are not intended to be a medical substitute. Please remember to consult your doctor with any questions you have regarding medical conditions. I'm Dr. Diane Reidy-Lagunes. Onward and upward.