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Oncofertility in Women: Principles, Referral Pathways, and Clinical Decision-Making

Dr Françoise Dupont

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Pr Pierre Durand

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OVERVIEW

Advances in cancer diagnosis and treatment have substantially improved survival among women of reproductive age. As a result, preserving fertility and long-term ovarian function has become an essential component of comprehensive cancer care. Oncofertility is an interdisciplinary field that integrates oncology, reproductive medicine, gynecology, and psychosocial care to address the reproductive consequences of cancer and its treatment. Rather than being a secondary concern, fertility preservation is increasingly recognized as a determinant of quality of life, psychological well-being, and long-term health outcomes for cancer survivors.

Cancer therapies such as chemotherapy, radiotherapy, and surgery can profoundly affect ovarian reserve, endocrine function, and uterine integrity. Despite well-established guidelines recommending early counseling and referral, fertility preservation remains underutilized in clinical practice. Understanding the biological basis of gonadotoxicity, available preservation strategies, and optimal referral pathways is therefore critical for clinicians caring for women with cancer.

Female fertility is uniquely vulnerable to cancer therapy because the ovarian reserve is finite and non-renewable. Chemotherapy induces gonadal toxicity primarily through depletion of primordial follicles and disruption of folliculogenesis. Alkylating agents are particularly gonadotoxic, but many commonly used regimens carry a significant risk of treatment-induced amenorrhea and premature ovarian insufficiency (POI). Importantly, the risk of ovarian failure increases with patient age, as baseline ovarian reserve declines physiologically over time.

Radiation therapy, especially pelvic irradiation, is even more deleterious to ovarian function. Oocytes are highly radiosensitive, and relatively low doses can result in irreversible ovarian damage. In women under 40 years of age, limiting ovarian exposure to less than approximately 500 cGy is associated with a substantially lower risk of POI, whereas standard pelvic radiation doses almost invariably cause acute ovarian failure. Beyond the ovaries, radiation can damage the uterus by affecting the endometrium, myometrium, and uterine vasculature, leading to infertility and adverse obstetric outcomes such as miscarriage, preterm birth, and placental abnormalities.

Surgical cancer treatments may also compromise fertility through direct removal of reproductive organs, disruption of blood supply, or postoperative adhesions. These risks underscore the need for proactive fertility counseling before treatment initiation.

Oncofertility counseling should be patient-centered, timely, and inclusive. Professional societies recommend that all patients of reproductive age be informed about the potential reproductive effects of cancer treatment and offered fertility preservation counseling, regardless of prognosis, parity, marital status, or socioeconomic background. Even patients who are uncertain about future childbearing benefit from counseling, as it reduces decisional regret and improves quality of life.

Key principles of counseling include individualized risk assessment, clear explanation of available options, and realistic discussion of success rates. Patient age, baseline ovarian reserve, cancer type, urgency of treatment, and overall medical stability must all be considered. Counseling should also address endocrine consequences, as preservation of ovarian function is important not only for fertility but also for long-term cardiovascular, skeletal, and metabolic health.

Early referral to a reproductive endocrinology and infertility specialist is central to effective oncofertility care. Ideally, fertility preservation interventions occur before the initiation of gonadotoxic therapy. Controlled ovarian stimulation for oocyte or embryo cryopreservation typically requires approximately two weeks, a timeframe that is often compatible with oncologic treatment planning.

However, treatment urgency may limit available options. In such cases, alternatives that require minimal delay—such as ovarian tissue cryopreservation or surgical ovarian transposition—may be considered. Importantly, referral remains valuable even when fertility preservation cannot be performed immediately, as post-treatment reproductive planning and counseling may still be needed.

Barriers to timely referral include lack of provider awareness, limited institutional pathways, financial constraints, and misconceptions about patient eligibility. Addressing these barriers requires systematic integration of oncofertility into oncology workflows and improved interdisciplinary communication.

Established fertility preservation techniques include oocyte and embryo cryopreservation, which are considered the gold standard for postpubertal women. Oocyte cryopreservation offers autonomy for patients without a partner or those who prefer not to create embryos. Ovarian tissue cryopreservation is particularly valuable for prepubertal patients or those who cannot delay treatment, though it remains less widely available.

Surgical strategies play a crucial role in patients receiving pelvic radiation. Ovarian transposition (oophoropexy) relocates the ovaries outside the radiation field, significantly reducing radiation exposure and the risk of POI. When combined with uterine fixation, this approach may also decrease uterine radiation dose, thereby improving future pregnancy potential. Medical ovarian suppression with gonadotropin-releasing hormone agonists may offer additional protection during chemotherapy, though its efficacy is variable and should be viewed as an adjunct rather than a standalone strategy.

Effective oncofertility care relies on close collaboration among oncologists, reproductive specialists, gynecologists, radiation oncologists, and surgeons. Multidisciplinary planning allows fertility preservation procedures to be coordinated with diagnostic workup and cancer treatment, minimizing delays and complications. Complex cases—such as patients with pelvic malignancies or significant comorbidities—particularly benefit from centralized, coordinated care.

Clinical decision-making must balance oncologic safety with reproductive goals. Fertility preservation should never compromise cancer outcomes, but when evidence supports safety, preserving reproductive potential should be prioritized as part of holistic patient care.

Oncofertility represents a paradigm shift in the care of women with cancer, reframing fertility and ovarian function as integral components of survivorship. Understanding the mechanisms of gonadotoxicity, principles of counseling, referral pathways, and available preservation strategies is essential for modern medical practice. Early, informed, and multidisciplinary intervention can significantly reduce the burden of treatment-induced infertility and improve long-term quality of life for cancer survivors.

FAQ

Oncofertility is a multidisciplinary field that addresses the impact of cancer and its treatments on reproductive potential, integrating oncology, reproductive medicine, gynecology, and supportive care to preserve fertility and hormonal function.

Beyond childbearing, preserved ovarian function reduces risks of premature menopause, cardiovascular disease, osteoporosis, and psychological distress, contributing significantly to long-term quality of life.

Chemotherapy—especially alkylating agents—and pelvic radiotherapy are the most gonadotoxic. Pelvic radiation is particularly damaging, often causing irreversible ovarian failure without protective measures.

Age strongly affects ovarian reserve. Older reproductive-age women have fewer primordial follicles, making them more susceptible to treatment-induced premature ovarian insufficiency and reducing success rates of cryopreservation.

Ideally, counseling should occur immediately after cancer diagnosis and before treatment initiation, allowing time-sensitive interventions such as oocyte or embryo cryopreservation.

All reproductive-age patients with cancer should be offered counseling, regardless of parity, prognosis, relationship status, or perceived fertility risk.

Options include oocyte cryopreservation, embryo cryopreservation, ovarian tissue cryopreservation, ovarian transposition, and medical ovarian suppression during chemotherapy.

It is a surgical procedure that repositions the ovaries outside the pelvic radiation field to reduce radiation exposure and preserve ovarian function.

It significantly reduces the risk of ovarian failure from radiation but does not guarantee fertility preservation, as scatter radiation and vascular compromise may still occur.

Radiation can damage the uterus, leading to infertility and obstetric complications. Uterine preservation strategies aim to maintain endometrial and myometrial function for future pregnancy.

It is the gold-standard fertility preservation method for postpubertal women, allowing future use without the need for a partner at the time of preservation.

It is particularly useful for prepubertal girls or patients who cannot delay cancer treatment, as it does not require ovarian stimulation.

Gonadotropin-releasing hormone agonists may reduce chemotherapy-induced ovarian damage, but they should be considered adjunctive rather than definitive fertility preservation methods.

Barriers include lack of provider awareness, time constraints, financial limitations, limited access to specialists, and assumptions about patient priorities.

Most fertility preservation procedures can be coordinated within a short timeframe and usually do not compromise oncologic outcomes when planned early.

When appropriately selected and coordinated, fertility preservation strategies do not compromise cancer control and are considered oncologically safe.

Multidisciplinary coordination ensures timely counseling, safe procedural planning, and integration of fertility preservation into cancer treatment without delays.

Yes. Counseling reduces future regret and allows informed decision-making, even if patients ultimately decline fertility preservation.

It shapes reproductive planning, hormonal management, and long-term monitoring for complications of premature ovarian insufficiency.

Clinicians must initiate fertility discussions, ensure timely referral, and advocate for fertility preservation as a standard component of comprehensive cancer care.

DO'S AND DONTS

Early discussion maximizes available options and minimizes treatment delays. Fertility counseling should occur before gonadotoxic therapy whenever possible.

Referral should not depend on age, parity, prognosis, or relationship status. Counseling itself improves patient satisfaction and reduces long-term regret.

Optimal oncofertility care requires coordination between oncology, reproductive endocrinology, gynecology, surgery, and radiation oncology.

Patient age, ovarian reserve, cancer type, treatment urgency, and personal priorities must all be integrated into decision-making.

Preserving ovarian function is important not only for fertility but also for long-term cardiovascular, skeletal, and metabolic health.

Oocyte and embryo cryopreservation remain the gold standard; ovarian tissue cryopreservation and ovarian transposition are valuable in selected cases.

Fertility preservation must never compromise cancer outcomes. Proper staging and risk stratification are mandatory.

Patients must receive realistic, balanced information about success rates, risks, and uncertainties to make informed choices.

Clear documentation ensures accountability, continuity of care, and medico-legal protection.

Fertility preservation does not end with cancer treatment; survivorship care must include reproductive and hormonal monitoring.

Clinician assumptions based on age or social circumstances are a major cause of missed opportunities for fertility preservation.

Post-treatment counseling often occurs when preservation options are no longer feasible.

Time pressure should not justify omitting fertility counseling, especially when referral can be rapid and coordinated.

Incomplete staging or ignoring high-risk features may expose patients to unacceptable recurrence risk.

Patients must be counseled about surgical, anesthetic, and treatment-related risks, including possible complications.

GnRH agonists are adjunctive measures and should not replace established fertility preservation techniques.

Radiation-induced uterine damage can compromise pregnancy even when ovarian function is preserved.

Cost, access, and emotional distress significantly influence patient decisions and must be acknowledged.

Oncofertility should be integrated into standard cancer care pathways, not offered selectively.

Patients require ongoing guidance regarding reproduction, pregnancy timing, and long-term survivorship planning.

BIBLIOGRAPHY

  • Dillard V, Bindra A, Torres-Rodriguez J, Vallerie AM, Fields M, Gilbert SAB, Zaritsky E.
    Laparoscopic uterine fixation and ovarian pexy for fertility and ovarian preservation in a 40-year-old with anal cancer. Fertility and Sterility Reports. 2025;6(2):218–224.

  • Kalluru S, Vu M, Brady PC.
    Fertility preservation for cancer: referral guidelines, treatment options, and specific considerations. Fertility and Sterility. 2025;124(4):585–592.

  • Habib N, Idoubba S, Futcher F, Pieri E, Schettini G, Giorgi M, Rovira Negre R, Gabriele C.
    Cervical cancer treatment and fertility: what we know and what we do. Cancers. 2025;17:3057.

  • Chatziioannou SS, Papasideri V, Sofoudis C.
    Fertility-sparing surgery upon reproductive and oncologic results in ovarian cancer patients stage I (FIGO): a systematic review. Archives of Gynecology and Obstetrics. 2025;312:671–689.

Dillard V, Bindra A, Torres-Rodriguez J, Vallerie AM, Fields M, Gilbert SAB, Zaritsky E.
Laparoscopic uterine fixation and ovarian pexy for fertility and ovarian preservation in a 40-year-old with anal cancer. Fertility and Sterility Reports. 2025;6(2):218–224.

1. Scientific and Clinical Context

Anal cancer treatment protocols typically involve combined chemotherapy and high-dose pelvic radiation, which almost invariably results in premature ovarian insufficiency (POI) if protective measures are not undertaken. In addition, uterine irradiation compromises future pregnancy potential even if ovarian function is preserved. The novelty of this report lies in its combined surgical strategy: ovarian transposition (oophoropexy) and uterine fixation, performed in coordination with oocyte cryopreservation.

Importantly, the patient described is 40 years old, an age at which fertility preservation is often overlooked or deprioritized. The authors explicitly challenge the age-based bias frequently encountered in clinical practice and reframe fertility preservation as not only a reproductive issue, but also an endocrine and quality-of-life issue.

2. Objectives of the Article

The article has three clearly identifiable objectives:

  1. To describe a novel multidisciplinary fertility and ovarian preservation strategy combining assisted reproduction, laparoscopic surgery, and radiation oncology planning.
  2. To quantify radiation dose reduction to the ovaries (and secondarily the uterus) achieved through ovarian transposition and uterine fixation.
  3. To illustrate the feasibility and clinical relevance of fertility preservation in older reproductive-age women undergoing pelvic chemoradiation.

Unlike randomized trials or cohort studies, this case report aims primarily at conceptual demonstration and educational value, rather than long-term outcome assessment.

3. Patient Characteristics and Initial Evaluation

The patient is a 40-year-old nulliparous woman with a history of cervical intraepithelial neoplasia grade 3 previously treated with LEEP. She presented with rectal bleeding and was diagnosed with stage IIA squamous cell carcinoma of the anal canal, with no lymph node or distant metastases.

Several aspects of the patient profile are educationally important:

  • She is nulliparous, increasing the psychological and reproductive significance of fertility preservation.
  • She has no prior pelvic surgeries, making laparoscopic transposition technically feasible.
  • She explicitly stated that fertility and hormonal preservation were priorities, emphasizing the importance of patient-driven decision-making.

Baseline ovarian reserve testing revealed a low AMH (0.5 ng/mL) and a reduced antral follicle count, consistent with age-related ovarian decline. This finding underscores a critical teaching point: low ovarian reserve does not negate the value of fertility preservation, especially when endocrine preservation is also a goal.

4. Fertility Preservation Strategy: Assisted Reproduction

The first step in the preservation strategy was controlled ovarian stimulation and oocyte cryopreservation.

The patient underwent:

  • An antagonist stimulation protocol
  • High-dose gonadotropin stimulation (450 IU daily for 10 days)
  • Retrieval of 6 oocytes, of which 4 were mature and successfully cryopreserved

From an educational standpoint, this section illustrates several key principles:

  • Even at age 40 with diminished ovarian reserve, retrieval of usable oocytes is feasible
  • The goal of cryopreservation is not necessarily high oocyte yield, but preserving reproductive options
  • Oocyte cryopreservation avoids the ethical and legal complexities of embryo cryopreservation

The authors appropriately frame this step as complementary, not exclusive, to surgical ovarian preservation.

5. Surgical Technique: Ovarian Transposition and Uterine Fixation

The core innovation of the article lies in the combined laparoscopic procedure.

Ovarian Transposition

The ovaries were mobilized by:

  • Transection of the utero-ovarian ligament
  • Dissection of the mesosalpinx
  • Preservation of the infundibulopelvic ligament to maintain vascular supply

Each ovary was then:

  • Transposed above the iliac crest
  • Fixed to the anterior abdominal wall
  • Marked with surgical clips for radiation planning

This technique is well established for ovarian protection but is rarely described in such detail in non-gynecologic cancers.

Uterine Fixation

In addition, the uterus was:

  • Elevated 4–5 cm above the pubic symphysis
  • Fixed to the anterior abdominal wall using barbed delayed-absorbable sutures

This step is particularly innovative. While ovarian transposition is widely described, uterine pexy is rarely performed, despite increasing evidence that uterine radiation damage severely compromises pregnancy outcomes.

6. Radiation Therapy and Dosimetric Outcomes

The patient subsequently underwent external beam radiation therapy using volumetric modulated arc therapy (VMAT), combined with mitomycin and capecitabine.

Dosimetric analysis revealed:

  • Mean dose to right ovary: 473 cGy
  • Mean dose to left ovary: 258 cGy

These values are critical because ovarian exposure below 500 cGy is associated with a significantly lower risk of POI in women under 40. Without transposition, estimated ovarian exposure would have exceeded 4,200 cGy, almost certainly causing immediate ovarian failure.

The uterus also received a modestly reduced dose, though exact fertility thresholds for uterine radiation remain less clearly defined.

7. Complications and Safety Considerations

The patient experienced a partial small bowel obstruction two weeks postoperatively, managed conservatively. This complication highlights an important teaching point: fertility-preserving surgery is not without risk, and patients must be counseled accordingly.

However, the complication resolved without surgical intervention, and oncologic treatment was not delayed, supporting the overall feasibility of the approach.

8. Interpretation and Educational Value

This case report provides several high-yield teaching messages:

  • Fertility preservation should not be restricted by age alone
  • Ovarian transposition is highly effective when combined with modern radiation techniques
  • Uterine preservation deserves greater attention in oncofertility
  • Multidisciplinary coordination is essential and achievable
  • Endocrine preservation is as important as reproductive preservation

The article successfully reframes fertility preservation as a core survivorship issue, not a luxury.

9. Limitations

As a single case report:

  • Long-term ovarian function and pregnancy outcomes are unknown
  • Generalizability is limited
  • No comparative control exists

Nevertheless, the mechanistic rationale and dosimetric data strongly support the strategy.

Conclusion

This article is an exemplary teaching case in modern oncofertility. It expands the scope of fertility preservation beyond gynecologic cancers, challenges age-based biases, and introduces uterine fixation as an underutilized but promising adjunct. For medical education, it serves as a model for patient-centered, multidisciplinary, evidence-informed care.

Kalluru S, Vu M, Brady PC.
Fertility preservation for cancer: referral guidelines, treatment options, and specific considerations. Fertility and Sterility. 2025;124(4):585–592.

1. Positioning of the Article in the Field of Oncofertility

The authors explicitly frame fertility preservation as a standard component of comprehensive cancer care, rather than an optional or ancillary service. This positioning aligns with the evolution of survivorship medicine, where long-term quality of life—including reproductive potential—is increasingly prioritized alongside oncologic outcomes.

Crucially, this review highlights a persistent and well-documented paradox: despite clear professional guidelines, fertility preservation remains underutilized, under-discussed, and inconsistently implemented in routine oncology practice.

2. Objectives and Scope

The article has four primary objectives:

  1. To summarize current fertility preservation options available for cancer patients
  2. To outline referral guidelines recommended by professional societies
  3. To analyze timing and feasibility considerations in real-world oncology settings
  4. To identify systemic, provider-level, and patient-level barriers to fertility preservation

The scope is deliberately broad, encompassing:

  • Pediatric, adolescent, and adult patients
  • Medical, surgical, and radiation oncology contexts
  • Both female and male fertility preservation (with emphasis on female patients)

This breadth makes the article particularly valuable for teaching systems-based practice and multidisciplinary care.

3. Methodological Approach

The authors conducted a structured narrative review based on systematic literature searches in PubMed, ScienceDirect, and Embase through February 2025. Included studies comprised original research, observational studies, and qualitative analyses related to fertility preservation in oncology.

While not a formal meta-analysis, the review is methodologically rigorous and transparent in its selection criteria. The absence of quantitative synthesis is appropriate given the heterogeneity of cancer types, patient populations, and fertility preservation strategies.

From an educational standpoint, this methodology supports the article’s role as a clinical practice guide rather than a statistical comparison of outcomes.

4. Importance of Fertility Preservation from the Patient Perspective

One of the article’s strengths is its emphasis on patient-centered motivations. The authors draw on multiple studies demonstrating that reproductive-aged cancer patients consistently rank future fertility and parenthood among their top concerns—even at the time of diagnosis.

Key teaching points include:

  • Fertility concerns are present even when survival is the primary focus
  • Counseling is associated with reduced decisional regret, regardless of whether fertility preservation is pursued
  • Psychological well-being and perceived autonomy are significantly improved when fertility is addressed proactively

Importantly, the authors dismantle the misconception that fertility preservation is only relevant for patients who actively plan pregnancy. Instead, they frame it as a means of keeping options open, which has intrinsic value.

5. Who Should Be Referred for Fertility Preservation?

A cornerstone of the article is its discussion of eligibility and referral criteria.

The authors strongly endorse existing recommendations from major professional societies, which state that:

  • All reproductive-age cancer patients should be offered fertility preservation counseling
  • Referral should occur regardless of cancer prognosis, parity, marital status, sexual orientation, or socioeconomic background

This inclusive approach is pedagogically important because it counters implicit biases frequently encountered in clinical practice, such as:

  • Assuming older patients are not interested in fertility
  • Assuming patients with children do not value future fertility
  • Withholding referral due to perceived poor prognosis

The article also highlights special populations:

  • Prepubertal patients, for whom ovarian tissue cryopreservation may be the only option
  • Patients over 40, who may have lower success rates but still benefit from counseling and endocrine preservation
  • Patients with novel cancer therapies, where gonadotoxic risk is uncertain but potentially significant

6. Timing of Fertility Preservation

Timing is presented as one of the most critical—and misunderstood—elements of oncofertility care.

The authors emphasize that:

  • Most oocyte or embryo cryopreservation cycles require approximately two weeks
  • This period can often overlap with diagnostic workup, imaging, and port placement
  • Fertility preservation rarely causes clinically meaningful delays when planned early

They also discuss scenarios where timing is constrained:

  • Aggressive malignancies requiring immediate treatment
  • Medically unstable patients

In such cases, the article underscores the value of:

  • Ovarian tissue cryopreservation
  • Surgical strategies such as ovarian transposition
  • Post-treatment fertility counseling when pre-treatment preservation is not feasible

This nuanced discussion is highly valuable for trainees learning to balance oncologic urgency with survivorship goals.

7. Fertility Preservation Techniques

The article provides a clear, structured overview of available techniques:

Oocyte and Embryo Cryopreservation

  • Considered the gold standard for postpubertal women
  • Embryo cryopreservation requires sperm and involves legal/ethical considerations
  • Oocyte cryopreservation preserves autonomy and flexibility

Ovarian Tissue Cryopreservation

  • Particularly useful for prepubertal patients or urgent cases
  • Requires laparoscopic surgery
  • Still considered emerging, but increasingly accepted

Ovarian Transposition

  • Highly effective for patients receiving pelvic radiation
  • Requires close coordination with radiation oncology

Medical Ovarian Suppression

  • GnRH agonists may reduce chemotherapy-induced ovarian damage
  • Should be considered adjunctive, not definitive

The authors consistently emphasize individualized decision-making, rather than a one-size-fits-all approach.

8. Medical Eligibility and Safety Considerations

An important educational contribution of this article is its detailed discussion of medical eligibility, which is often underrepresented in oncofertility literature.

The authors address:

  • Cardiopulmonary stability for anesthesia
  • Hematologic considerations (thrombocytopenia, anticoagulation)
  • Risk of thromboembolism
  • Tumor location and risk of tumor seeding during oocyte retrieval

This section reinforces that fertility preservation is not merely a reproductive issue, but a complex medical intervention requiring careful risk stratification and interdisciplinary planning.

9. Barriers to Fertility Preservation

The article identifies four major categories of barriers:

  1. Provider-level barriers
    Lack of awareness, discomfort initiating fertility discussions, and time constraints.
  2. Institutional barriers
    Absence of standardized referral pathways and multidisciplinary coordination.
  3. Patient-level barriers
    Emotional overload at diagnosis, financial concerns, and lack of information.
  4. Systemic barriers
    Insurance coverage limitations and disparities in access to care.

From a teaching perspective, this section is essential for understanding why evidence-based recommendations fail to translate into practice.

10. Educational and Clinical Implications

This article is foundational for:

  • Teaching ethical responsibility in oncology
  • Understanding systems-based practice
  • Developing institutional oncofertility programs
  • Training clinicians to initiate fertility discussions proactively

It reframes fertility preservation as a standard of care, not an exception.

Conclusion

Kalluru et al. provide a comprehensive, practice-defining review that bridges evidence, ethics, and implementation. The article is indispensable for teaching oncofertility because it moves beyond techniques to address when, why, and how fertility preservation should be integrated into cancer care. Its greatest contribution lies in exposing the gap between guidelines and practice—and offering a roadmap to close it.

Habib N, Idoubba S, Futcher F, Pieri E, Schettini G, Giorgi M, Rovira Negre R, Gabriele C.
Cervical cancer treatment and fertility: what we know and what we do. Cancers. 2025;17:3057.

1. Scientific Context and Rationale

This article addresses that evolution by providing a comprehensive, evidence-based synthesis of fertility-preserving strategies in cervical cancer. Unlike narrow procedural papers, it integrates oncologic safety, surgical techniques, reproductive outcomes, and patient selection, making it particularly valuable for advanced medical education and gynecologic oncology training.

The authors explicitly focus on early-stage cervical cancer (FIGO IA1–IB1), where fertility-sparing approaches are most relevant and ethically justifiable. The review responds to a critical clinical question: how can clinicians safely treat cervical cancer while preserving a woman’s reproductive potential?

2. Objectives and Scope of the Review

The primary objective of the article is to summarize and critically evaluate fertility-preserving treatment options for women with early-stage cervical cancer. Specifically, the authors aim to:

  1. Describe standard and conservative surgical approaches to cervical cancer
  2. Analyze oncologic safety of fertility-sparing strategies
  3. Review reproductive outcomes following conservative treatment
  4. Identify selection criteria and contraindications
  5. Discuss adjunctive fertility preservation techniques (e.g., ovarian transposition, cryopreservation)

The scope is deliberately broad, covering surgical, medical, and radiation-related considerations. This breadth allows the article to function as both a clinical reference and a teaching review.

3. Epidemiologic and Biological Foundations

The review begins by contextualizing cervical cancer epidemiology. Cervical cancer remains one of the most common malignancies in women worldwide, with a mean age at diagnosis of approximately 47 years, placing many patients within their reproductive years. Persistent infection with high-risk human papillomavirus (HPV), particularly types 16 and 18, is responsible for nearly all cases.

A key teaching point emphasized by the authors is that early-stage cervical cancer rarely involves the uterine corpus, a biologic characteristic that underpins the feasibility of uterine-sparing surgery. Additionally, parametrial involvement and nodal metastases are uncommon in small, low-risk tumors, further supporting conservative approaches in selected patients.

This biological rationale is essential for understanding why fertility preservation is oncologically acceptable in early disease—but unsafe in more advanced stages.

4. Staging and Patient Selection

The authors rely on the FIGO staging system, focusing on:

  • Stage IA1–IA2: Microinvasive disease
  • Stage IB1: Tumors ≤ 2 cm confined to the cervix

They emphasize that patient selection is the cornerstone of fertility preservation. Ideal candidates share the following features:

  • Tumor ≤ 2 cm
  • Limited stromal invasion
  • Absence of high-risk histologic subtypes
  • No radiologic or surgical evidence of lymph node metastasis
  • Strong desire to preserve fertility

Importantly, the review stresses that fertility-sparing approaches are contraindicated in aggressive histologies (e.g., small-cell neuroendocrine carcinoma) and in patients with nodal involvement, where chemoradiation would be required.

This section is particularly valuable pedagogically, as it reinforces the principle that fertility preservation is a privilege of low-risk biology, not a universal right.

5. Fertility-Sparing Surgical Techniques

The core of the article is a detailed analysis of conservative surgical options.

Conization

For stage IA1 disease without lymphovascular space invasion (LVSI), conization alone may be curative. The authors highlight that cold-knife conization allows precise histologic assessment of margins and invasion depth.

Pregnancy rates after conization range from 36% to 55%, but the risk of cervical insufficiency and preterm birth is increased, necessitating careful obstetric surveillance.

Simple Trachelectomy

In selected cases with minimal invasion, simple trachelectomy (removal of the cervix without extensive parametrial resection) may be performed. This approach preserves uterine anatomy while offering greater oncologic security than conization in borderline cases.

Radical Trachelectomy

Radical trachelectomy represents the most widely used fertility-sparing surgery for stage IB1 disease. It involves removal of the cervix, upper vagina, and surrounding parametrial tissue, with preservation of the uterine body.

Pregnancy rates after radical trachelectomy range from 10% to 38%, reflecting both surgical complexity and obstetric risks. Nonetheless, oncologic outcomes are comparable to radical hysterectomy in appropriately selected patients.

The authors emphasize that surgical radicality must be minimized without compromising oncologic safety, a recurring theme throughout the review.

6. Lymph Node Assessment

A critical component of fertility-sparing management is nodal evaluation. The presence of lymph node metastases effectively contraindicates uterine preservation.

The review discusses:

  • Sentinel lymph node (SLN) mapping
  • Selective pelvic lymphadenectomy

SLN biopsy is increasingly favored to reduce surgical morbidity while maintaining diagnostic accuracy. The authors highlight that a positive sentinel node mandates abandonment of fertility-sparing surgery, reinforcing the primacy of oncologic safety.

7. Reproductive Outcomes and Obstetric Risks

The article provides a nuanced discussion of reproductive outcomes. While fertility preservation allows the possibility of pregnancy, it does not guarantee it.

Key points include:

  • Increased risk of miscarriage and preterm birth after trachelectomy
  • Frequent need for cervical cerclage
  • Higher reliance on assisted reproductive technologies in some patients

Despite these challenges, the authors emphasize that successful pregnancy is achievable, and reproductive outcomes must be balanced against the patient’s informed preferences.

8. Adjunctive Fertility Preservation Strategies

Beyond surgery, the authors discuss complementary strategies:

  • Ovarian transposition to protect ovarian function when radiation is anticipated
  • Oocyte and embryo cryopreservation as backup options
  • Ovarian tissue cryopreservation in select scenarios

They caution that ovarian transposition preserves endocrine function more reliably than natural fertility, highlighting the complexity of reproductive counseling.

9. Strengths and Limitations

Strengths

  • Comprehensive, well-structured synthesis
  • Clear emphasis on patient selection
  • Integration of oncologic and reproductive outcomes

Limitations

  • Predominantly observational data
  • Limited randomized evidence
  • Heterogeneity in reported outcomes

Nevertheless, the review reflects current best practice and guideline-concordant care.

10. Educational and Clinical Implications

This article is essential for teaching:

  • Fertility-sparing gynecologic oncology
  • Risk stratification and staging
  • Shared decision-making
  • Integration of reproductive goals into cancer care

It reinforces the principle that fertility preservation must never compromise survival, but when safe, should be actively pursued.

Conclusion

Habib et al. provide a definitive and pedagogically rich review of fertility preservation in early-stage cervical cancer. The article elegantly balances oncologic rigor with reproductive compassion, offering clinicians a clear framework for identifying candidates, selecting appropriate surgical strategies, and counseling patients realistically. It stands as a cornerstone reference in modern gynecologic oncofertility.

Chatziioannou SS, Papasideri V, Sofoudis C.
Fertility-sparing surgery upon reproductive and oncologic results in ovarian cancer patients stage I (FIGO): a systematic review. Archives of Gynecology and Obstetrics. 2025;312:671–689.

  1. Clinical and Scientific Background

This systematic review directly addresses that debate by evaluating both oncologic safety and reproductive outcomes of fertility-sparing surgery in women with FIGO stage I ovarian cancer. The article is particularly important because ovarian cancer differs fundamentally from cervical cancer: it often lacks early symptoms, carries a higher intrinsic recurrence risk, and exhibits marked heterogeneity in histology and biological behavior. Consequently, fertility preservation in ovarian cancer requires an especially cautious, evidence-driven approach.

  1. Objectives of the Review

The authors define a clear and clinically relevant primary objective:
to assess whether fertility-sparing surgery in FIGO stage I ovarian cancer can preserve reproductive potential without compromising oncologic outcomes.

Secondary objectives include:

  • Evaluating pregnancy and live birth rates after FSS
  • Assessing recurrence patterns and survival outcomes
  • Identifying histologic subtypes and FIGO substages associated with higher risk
  • Highlighting the need for multidisciplinary counseling and long-term follow-up

Unlike narrative reviews, this article adopts a systematic methodology, lending greater robustness to its conclusions and making it particularly valuable for advanced teaching and guideline-oriented discussions.

  1. Methodology and Study Selection

The authors conducted a systematic search of MEDLINE, SCOPUS, and Google Scholar for studies published from 2014 onward. Inclusion criteria were strict and clinically appropriate:

  • Women under 50 years of age
  • Diagnosed with FIGO stage I ovarian cancer
  • Undergoing fertility-sparing surgery
  • Reporting oncologic and/or reproductive outcomes

Seventeen studies comprising 1,030 patients met inclusion criteria. These included cohort studies, case–control studies, and case series. Meta-analysis was deliberately not performed due to substantial heterogeneity in study design, histologic subtypes, staging definitions, and outcome reporting.

From a pedagogical standpoint, this methodological choice is important: it teaches learners that qualitative synthesis may be more appropriate than forced quantitative pooling when data heterogeneity is high.

  1. Definition and Scope of Fertility-Sparing Surgery

In the context of ovarian cancer, fertility-sparing surgery is defined as:

  • Preservation of the uterus
  • Preservation of at least part of one ovary
  • Complete surgical staging (including peritoneal washings, biopsies, and lymph node assessment when indicated)

Typically, this involves unilateral salpingo-oophorectomy with full staging, leaving the contralateral ovary and uterus intact.

The review emphasizes that FSS is not incomplete surgery, but rather oncologically principled surgery adapted to reproductive goals. This distinction is crucial for trainee education, as fertility preservation must never be equated with oncologic compromise.

  1. Reproductive Outcomes After Fertility-Sparing Surgery

One of the most valuable contributions of this review is its detailed analysis of reproductive outcomes.

Across included studies:

  • Pregnancy rates ranged from 25% to 91.3%
  • Live birth rates exceeded 80% in most series
  • Spontaneous conception was common
  • Use of assisted reproductive technologies (ART) ranged from 3.7% to 28%

However, a critical and often overlooked finding is that only 13% of patients actively attempted pregnancy, despite 58% expressing a desire for future fertility. This discrepancy highlights the psychological, social, and medical barriers that persist even after fertility-preserving surgery.

Educationally, this finding reinforces that fertility preservation is about maintaining possibility, not guaranteeing outcome.

  1. Oncologic Outcomes and Recurrence Risk

Oncologic safety is the central concern in ovarian cancer, and the review addresses this with appropriate rigor.

Key findings include:

  • Recurrence rates ranged from 3% to 33.3%
  • Most studies reported recurrence rates between 8% and 15%
  • Overall survival ranged from 88% to 100%
  • Disease-free survival exceeded 90% in most cohorts

Importantly, recurrence risk was not uniform. Higher recurrence rates were observed in:

  • Mucinous ovarian carcinoma
  • FIGO stage IC2 and IC3
  • Certain high-grade histologies

These findings underscore a fundamental teaching point: histology and substage matter more than fertility intent when determining eligibility for FSS.

  1. Histologic Subtypes and Risk Stratification

The review highlights the heterogeneity of ovarian cancer and its implications for fertility preservation.

  • Low-grade serous, endometrioid, and some mucinous tumors demonstrated favorable outcomes with FSS
  • High-grade serous carcinoma and advanced substages were associated with higher recurrence risk
  • Borderline tumors were excluded, emphasizing the focus on invasive disease

This stratification is critical for clinical decision-making. The authors repeatedly stress that FSS should be limited to carefully selected patients with favorable tumor biology, reinforcing a core principle of gynecologic oncology.

  1. Multidisciplinary Counseling and Surveillance

The authors emphasize that fertility-sparing surgery in ovarian cancer requires more than surgical expertise. Patients must receive:

  • Detailed counseling on recurrence risk
  • Realistic discussion of fertility prospects
  • Long-term oncologic surveillance
  • Access to reproductive endocrinology services

Surveillance after FSS is particularly important because recurrence may necessitate completion surgery or chemotherapy, potentially eliminating fertility potential at a later stage.

This section is highly relevant for teaching shared decision-making, informed consent, and survivorship planning.

  1. Strengths and Limitations of the Review

Strengths

  • Systematic methodology
  • Large cumulative patient population
  • Balanced assessment of oncologic and reproductive outcomes
  • Clear identification of risk factors

Limitations

  • Predominantly retrospective data
  • Heterogeneous study designs
  • Lack of randomized controlled trials
  • Variable follow-up durations

The authors appropriately caution against overgeneralization and call for further prospective studies.

  1. Educational and Clinical Implications

This review is foundational for teaching advanced oncofertility concepts because it demonstrates that:

  • Fertility preservation in ovarian cancer is possible but conditional
  • Oncologic safety must always take precedence
  • Patient selection is the single most important determinant of success
  • Fertility preservation does not end at surgery—it requires long-term planning

It also reinforces the need for institutional expertise and centralized care when offering fertility-sparing options in ovarian cancer.

Conclusion

Chatziioannou et al. provide a rigorous, clinically nuanced, and educationally rich systematic review of fertility-sparing surgery in stage I ovarian cancer. Their analysis confirms that, in carefully selected patients, fertility preservation can be achieved with acceptable oncologic outcomes and meaningful reproductive potential. However, the review also clearly delineates the limits of this approach, emphasizing that fertility preservation in ovarian cancer must be selective, individualized, and multidisciplinary.

COURSE OUTLINE (90 mn)
  • Welcome and brief contextualization of oncofertility as a modern medical discipline
  • Definition of oncofertility: integration of oncology, reproductive medicine, gynecology, surgery, and survivorship care
  • Explanation of why fertility preservation is no longer optional but a component of standard cancer care
  • Presentation of learning objectives:
    • Understand mechanisms of gonadotoxicity
    • Identify patients requiring fertility counseling
    • Know available fertility preservation strategies
    • Integrate fertility preservation into real-world oncology workflows
  • Rising incidence of cancer in women of reproductive age
  • Improved cancer survival and shift toward long-term quality-of-life outcomes
  • Definition of cancer survivorship and its reproductive dimension
  • Psychological impact of infertility and premature menopause
  • Fertility as a determinant of identity, mental health, and life planning
  • Introduction of fertility preservation as a survivorship intervention, not a luxury

15–22 min: Ovarian physiology and vulnerability

  • Finite ovarian reserve and lack of follicular regeneration
  • Age-related decline in ovarian reserve
  • Concept of primordial follicle pool depletion

22–26 min: Chemotherapy-induced ovarian damage

  • Mechanisms: DNA damage, follicular apoptosis, vascular injury
  • Differential gonadotoxicity by drug class (conceptual, not exhaustive)
  • Interaction between age and chemotherapy risk
  • Clinical outcomes: amenorrhea vs premature ovarian insufficiency

26–30 min: Radiation-induced ovarian and uterine damage

  • Extreme radiosensitivity of oocytes
  • Dose–response relationship for ovarian failure
  • Threshold concept (<500 cGy vs pelvic doses >4000 cGy)
  • Uterine effects: endometrium, myometrium, vasculature
  • Obstetric consequences even with preserved ovarian function

30–35 min: Ethical and professional responsibility

  • Fertility counseling as a duty of care
  • Counseling independent of prognosis, age, or parity
  • Difference between counseling and intervention

35–40 min: Patient-centered counseling

  • Addressing uncertainty and emotional overload at diagnosis
  • Explaining risks in understandable terms
  • Managing unrealistic expectations without discouragement
  • Importance of documenting fertility discussions

40–45 min: Counseling special situations

  • Older reproductive-age women
  • Patients unsure about future childbearing
  • Patients with poor prognosis
  • Emphasis on reduced decisional regret even when preservation is declined

45–50 min: When to refer

  • Ideal timing: immediately after diagnosis, before treatment
  • Why late referral limits options
  • Fertility counseling even when preservation is not feasible

50–55 min: Practical timing constraints

  • Typical duration of ovarian stimulation
  • Coordination with imaging, staging, and port placement
  • Urgent cancers and alternative strategies

55–60 min: System-level barriers

  • Lack of standardized referral pathways
  • Provider discomfort or lack of knowledge
  • Financial and access barriers
  • Importance of institutional oncofertility programs

60–65 min: Cryopreservation techniques

  • Oocyte cryopreservation: indications, advantages, limitations
  • Embryo cryopreservation: requirements and legal considerations
  • Ovarian tissue cryopreservation: indications and emerging role

65–70 min: Surgical preservation strategies

  • Ovarian transposition: principles, indications, limitations
  • Importance of coordination with radiation oncology
  • Endocrine vs reproductive preservation

70–75 min: Medical strategies

  • GnRH agonists during chemotherapy
  • Evidence-based role as adjunctive therapy
  • Why medical suppression alone is insufficient

75–80 min: Multidisciplinary coordination

  • Roles of oncologist, reproductive endocrinologist, surgeon, radiation oncologist
  • Importance of shared planning
  • Avoiding treatment delays

80–85 min: Integrated clinical case discussion

  • Example: reproductive-age woman with pelvic cancer requiring chemoradiation
  • Step-by-step decision-making:
    • Counseling
    • Referral
    • Choice of fertility preservation strategy
    • Oncologic safety validation
  • Key clinical reasoning points and pitfalls
  • Fertility preservation is part of standard cancer care
  • Counseling should be universal, early, and documented
  • Oncologic safety always takes priority
  • Multidisciplinary coordination is essential
  • Survivorship planning extends beyond cancer treatment
Simulated Clinical Cases

Clinical scenario
A 32-year-old nulliparous woman is diagnosed with stage II hormone receptor–positive breast cancer. Neoadjuvant chemotherapy is planned to begin in 3 weeks. She is distressed and states she “might want children later but is not sure.” AMH is 2.1 ng/mL.

Questions
Should fertility preservation be discussed and offered? What strategy is appropriate?

Detailed answer
Yes, fertility preservation counseling is mandatory despite the patient’s uncertainty. Counseling itself reduces decisional regret and preserves autonomy. With a 3-week window, controlled ovarian stimulation followed by oocyte cryopreservation is feasible. Embryo cryopreservation could be discussed but requires sperm and raises legal considerations. Chemotherapy carries a significant risk of ovarian insufficiency, amplified by age over time. A multidisciplinary discussion should reassure the oncology team that fertility preservation can usually be completed without delaying treatment. GnRH agonist co-treatment may be considered as an adjunct but should not replace cryopreservation.

Key learning points

  • Uncertainty about childbearing is not a reason to withhold counseling
  • Early referral enables parallel planning
  • Oocyte cryopreservation preserves future choice

Clinical scenario
A 24-year-old woman presents with newly diagnosed aggressive non-Hodgkin lymphoma. Chemotherapy must start within 7 days. She has no prior pregnancies and expresses strong desire for future fertility.

Questions
What fertility preservation options are realistic?

Detailed answer
Time constraints make ovarian stimulation impractical. However, fertility counseling remains essential. Ovarian tissue cryopreservation is a viable option because it requires only a single laparoscopic procedure and no stimulation. The patient should also be counseled about the role of GnRH agonists during chemotherapy as an adjunctive measure. Even if no preservation procedure is ultimately feasible, counseling should still occur to reduce regret and prepare for post-treatment reproductive planning.

Key learning points

  • Urgency does not negate the need for counseling
  • Ovarian tissue cryopreservation is valuable in time-limited settings
  • Adjunctive strategies may be used but are not definitive

Clinical scenario
A 38-year-old nulliparous woman is diagnosed with stage IIA anal squamous cell carcinoma. Pelvic chemoradiation is planned. She prioritizes hormonal preservation and would like the option of pregnancy if possible.

Questions
What fertility and endocrine preservation strategy should be proposed?

Detailed answer
This patient is at very high risk of radiation-induced ovarian failure. A combined strategy is appropriate:

  1. Oocyte cryopreservation before treatment, acknowledging potentially limited yield due to age.
  2. Laparoscopic ovarian transposition to move ovaries out of the radiation field.
  3. Consideration of uterine fixation to reduce uterine dose if technically feasible.
    Close collaboration with radiation oncology is critical to optimize dosimetry. Counseling should emphasize that ovarian transposition improves endocrine preservation and may allow fertility, but pregnancy outcomes may still be limited by uterine radiation.

Key learning points

  • Pelvic radiation is highly gonadotoxic
  • Combined strategies maximize preservation
  • Endocrine preservation is a legitimate goal

Clinical scenario
A 29-year-old woman is diagnosed with FIGO stage IB1 cervical cancer (tumor 1.8 cm). Imaging shows no nodal disease. She wishes to preserve fertility.

Questions
Is fertility-sparing surgery appropriate?

Detailed answer
Yes. The patient meets key eligibility criteria: tumor ≤2 cm, early stage, no nodal involvement, and strong fertility desire. Radical trachelectomy with sentinel lymph node assessment is an appropriate fertility-sparing option. She should be counseled regarding oncologic safety, obstetric risks (miscarriage, preterm birth), and the potential need for assisted reproductive technologies. If sentinel nodes are positive intraoperatively, fertility preservation must be abandoned in favor of definitive treatment.

Key learning points

  • Patient selection is critical
  • Oncologic safety overrides fertility goals
  • Fertility-sparing surgery carries obstetric risks

Clinical scenario
During radical trachelectomy for early-stage cervical cancer, frozen section reveals a positive sentinel lymph node.

Questions
How should management change?

Detailed answer
Fertility-sparing surgery must be aborted. Nodal involvement indicates higher recurrence risk and necessitates chemoradiation, which is incompatible with uterine preservation. The patient should be counseled compassionately but clearly that oncologic safety requires definitive treatment. If not already performed, fertility preservation options such as oocyte or embryo cryopreservation may be considered urgently before adjuvant therapy if time allows.

Key learning points

  • Lymph node status is a decisive factor
  • Fertility preservation cannot compromise survival
  • Counseling should be ongoing and adaptive

Clinical scenario
A 27-year-old woman undergoes surgery for an adnexal mass. Final pathology shows FIGO stage IA low-grade endometrioid ovarian carcinoma. She desires future fertility.

Questions
Is fertility-sparing surgery acceptable?

Detailed answer
Yes. In carefully selected patients with stage IA disease and favorable histology, unilateral salpingo-oophorectomy with comprehensive staging is oncologically acceptable. The uterus and contralateral ovary may be preserved. She should be counseled regarding recurrence risk, the need for long-term surveillance, and realistic fertility expectations. Referral to reproductive endocrinology for future planning is appropriate.

Key learning points

  • Fertility-sparing surgery is possible in selected ovarian cancers
  • Histology and stage determine eligibility
  • Long-term follow-up is essential

Clinical scenario
A 31-year-old woman is found to have FIGO stage IC3 ovarian cancer after cyst rupture. She strongly wishes to preserve fertility.

Questions
Should fertility-sparing surgery be offered?

Detailed answer
Extreme caution is required. FIGO IC3 disease carries a higher recurrence risk. Fertility-sparing surgery is controversial and often discouraged in this context. The patient must receive detailed counseling about significantly increased oncologic risk. In many cases, completion surgery is recommended. Fertility preservation through oocyte or embryo cryopreservation before definitive treatment may be more appropriate than uterine preservation.

Key learning points

  • Not all early-stage ovarian cancers are suitable for FSS
  • Recurrence risk must be explicitly discussed
  • Fertility preservation ≠ fertility-sparing surgery

Clinical scenario
A 41-year-old woman with newly diagnosed rectal cancer will receive pelvic radiation. AMH is 0.3 ng/mL. She does not plan pregnancy but fears early menopause.

Questions
Is fertility preservation still relevant?

Detailed answer
Yes. Even if pregnancy is unlikely, endocrine preservation is clinically important. Ovarian transposition may reduce the risk of premature menopause. Oocyte cryopreservation may be discussed but with realistic expectations regarding yield and success. Counseling should focus on hormonal health, quality of life, and patient priorities rather than age-based exclusion.

Key learning points

  • Age alone is not a contraindication to counseling
  • Endocrine outcomes matter independently of fertility
  • Patient goals should guide decision-making

Clinical scenario
A 26-year-old woman with Hodgkin lymphoma receives fertility counseling but declines all preservation procedures due to emotional overload.

Questions
How should this be managed?

Detailed answer
The patient’s decision must be respected. The key responsibility of the clinician is to ensure informed choice, not to persuade. The discussion and decision should be documented. She should be reassured that counseling remains available later, including survivorship fertility assessment after treatment. This approach still improves psychological outcomes and reduces regret.

Key learning points

  • Counseling is beneficial even when preservation is declined
  • Respect for autonomy is central
  • Documentation is essential

Clinical scenario
A 30-year-old woman treated for cervical cancer presents 2 years later with permanent amenorrhea and distress. Fertility preservation was never discussed at diagnosis.

Questions
What went wrong, and what can be learned?

Detailed answer
The failure lies in omission of fertility counseling at diagnosis. This represents a systems-level and provider-level lapse, not patient failure. Even if fertility preservation had not been feasible, counseling would have reduced regret and allowed informed decision-making. This case highlights the ethical obligation to systematically address fertility in cancer care and the importance of institutional referral pathways.

Key learning points

  • Missed counseling is a preventable harm
  • Systems-based solutions are required
  • Fertility discussions are part of standard care
Powerpoint slides

Slide 1 — Why Oncofertility Matters

  • Cancer survival is improving in reproductive-age women.
    More patients live long enough to experience the downstream impact of infertility and endocrine failure, making fertility a survivorship priority.
  • Fertility loss affects identity, relationships, and mental health.
    Many patients describe fertility as central to future life plans; unmet counseling needs are linked to distress and regret.
  • Oncofertility is not “optional care.”
    It is a component of comprehensive oncology care, similar to symptom control or long-term monitoring.
  • Preservation is about options, not promises.
    The aim is to keep reproductive pathways open without compromising cancer outcomes.
  • Endocrine preservation matters beyond pregnancy.
    Avoiding early menopause reduces long-term risks such as osteoporosis and cardiovascular disease.

Slide 2 — What Is Oncofertility?

  • An interdisciplinary clinical field.
    It connects oncology, reproductive endocrinology, gynecology, surgery, radiation oncology, and survivorship care.
  • Two major goals: fertility and hormonal function.
    Some patients prioritize pregnancy; others prioritize avoiding premature menopause—often both.
  • Centered on shared decision-making.
    Choices must reflect patient values, treatment urgency, and oncologic safety.
  • Requires rapid, coordinated pathways.
    The best outcomes occur when referral and planning happen immediately after diagnosis.
  • Applies to gynecologic and non-gynecologic cancers.
    Pelvic cancers outside the reproductive tract (e.g., anal cancer) can still threaten ovaries and uterus through radiation.

Slide 3 — Learning Objectives

  • Explain mechanisms of gonadotoxicity.
    Learners should link treatment types to ovarian reserve depletion and uterine injury mechanisms.
  • Identify who needs counseling and referral.
    Emphasis on universal discussion for reproductive-age patients, regardless of parity or prognosis.
  • Compare fertility preservation strategies.
    Oocyte/embryo cryopreservation, ovarian tissue cryopreservation, ovarian transposition, and adjunctive medical methods.
  • Integrate timing into cancer workflows.
    Understand how to coordinate fertility steps without compromising oncologic timing.
  • Apply a multidisciplinary clinical approach.
    Recognize each specialty’s role and how to structure communication and documentation.

Slide 4 — The Female Ovarian Reserve: Why It’s Fragile

  • Finite, non-renewable follicle pool.
    Women are born with a limited number of primordial follicles; loss is permanent.
  • Age-related decline accelerates over time.
    Reduced baseline reserve means older patients can cross the threshold to POI with less treatment exposure.
  • Reserve is both quantity and quality.
    With age, oocyte competence decreases, influencing success rates even if oocytes are preserved.
  • Markers (AMH/AFC) estimate reserve—not destiny.
    They guide counseling on likely yield and urgency, but cannot guarantee outcomes.
  • Cancer care adds iatrogenic depletion.
    Chemotherapy and radiation can rapidly reduce reserve beyond physiologic aging.

Slide 5 — Chemotherapy and the Ovary

  • Two main injury pathways.
    Primordial follicle depletion plus disruption of follicles in growth lead to reduced reserve and endocrine instability.
  • Risk varies by agent and regimen.
    Some drug classes are more gonadotoxic; risk is cumulative and dose-dependent.
  • Age amplifies toxicity.
    At older reproductive ages, even moderate follicle loss can translate into permanent POI.
  • Clinical endpoints vary (amenorrhea vs POI).
    Amenorrhea may be temporary; POI implies sustained ovarian failure with hypoestrogenism.
  • Counseling must include uncertainty.
    Patients need realistic ranges of risk and acknowledgment of unpredictable individual response.

Slide 6 — Radiation: The Highest-Risk Modality for Ovarian Failure

  • Oocytes are extremely radiosensitive.
    Even relatively low doses can cause irreversible follicular loss.
  • Pelvic radiation doses are typically sterilizing.
    Standard pelvic fields expose ovaries to doses that almost guarantee acute ovarian failure unless protective measures are used.
  • Dose reduction is clinically meaningful.
    Strategies aiming to keep ovarian exposure around the sub-500 cGy range can reduce POI risk in younger patients.
  • Scatter radiation still matters.
    Even after transposition, planning and dosimetry are essential to minimize residual exposure.
  • Timing is critical.
    Protective surgery must be coordinated before radiation begins.

Slide 7 — Radiation and the Uterus: Often Forgotten

  • Uterine tissues are vulnerable.
    Endometrium, myometrium, and vasculature can be damaged, impacting implantation and growth.
  • Pregnancy risks persist even with preserved ovaries.
    Miscarriage, preterm birth, placental abnormalities, and low birth weight become more likely after uterine irradiation.
  • Preserving ovaries ≠ preserving fertility.
    Patients may retain hormones yet remain unable to carry a pregnancy safely.
  • Uterine dose reduction strategies exist.
    Techniques such as uterine fixation (pex y) may reduce dose in selected pelvic radiation cases.
  • Counseling must include obstetric sequelae.
    Fertility preservation discussions should cover not only conception but also pregnancy outcomes.

Slide 8 — Why Counseling Must Be Universal

  • Guideline principle: discuss fertility with all reproductive-age patients.
    Counseling should not be restricted by perceived prognosis, parity, or social assumptions.
  • Many patients won’t ask spontaneously.
    Diagnosis shock and time pressure can suppress questions; clinicians must initiate discussion.
  • Counseling reduces future regret.
    Even patients who decline preservation benefit from having understood their options early.
  • Equity requires standardization.
    Inconsistent counseling worsens disparities linked to socioeconomic status, access, and institutional resources.
  • Document the discussion.
    Documentation supports continuity of care and reinforces accountability.

Slide 9 — The Referral Pathway: What “Early” Really Means

  • Best time: immediately after diagnosis.
    Fertility planning should be part of initial cancer-care mapping.
  • Referral is not the same as delaying treatment.
    Early referral allows parallel planning and avoids last-minute decisions.
  • Coordinate with staging and logistics.
    Imaging, port placement, and surgical consults can occur during fertility workup.
  • Build institutional pathways.
    Standard triggers (e.g., diagnosis in reproductive age) reduce missed referrals.
  • Offer referral even if uncertain.
    Patients unsure about children still deserve informed choice.

Slide 10 — Time and Feasibility: The Real-World Constraint

  • Typical oocyte/embryo cryopreservation timeline.
    Controlled ovarian stimulation usually requires about ~2 weeks in many clinical settings.
  • Urgency determines what’s possible.
    Highly aggressive cancers may not allow stimulation; alternatives should be presented.
  • Laparoscopic options may be faster.
    Ovarian tissue cryopreservation or transposition may be feasible when time is limited.
  • Complications can delay treatment.
    Patients must be counseled about risks like surgical complications or stimulation-related issues.
  • Shared planning prevents bottlenecks.
    Early multidisciplinary communication reduces delays and avoids last-minute cancellations.

Slide 11 — Option 1: Oocyte Cryopreservation

  • Gold standard for postpubertal women.
    Preserves unfertilized eggs for later use; avoids need for a partner at the time of preservation.
  • Requires stimulation and retrieval.
    Patients need medical stability for anesthesia and transvaginal retrieval procedures.
  • Success is age-dependent.
    Older patients may yield fewer mature oocytes; counseling must be honest yet supportive.
  • Autonomy and future flexibility.
    Oocytes allow later decisions about partner, donor sperm, and embryo creation.
  • Not just about pregnancy—also about control.
    For many patients, preserving oocytes reduces helplessness during cancer treatment.

Slide 12 — Option 2: Embryo Cryopreservation

  • Also a gold-standard option.
    Embryos may offer strong outcomes in many contexts but require sperm at preservation.
  • Legal and ethical dimensions.
    Embryos may be considered shared assets; future use can depend on consent frameworks.
  • Potential advantage: embryo testing.
    Genetic testing may help decision-making in advanced reproductive age, but adds complexity.
  • Time and stimulation requirements are similar.
    Like oocyte cryopreservation, this usually requires a stimulation cycle.
  • Counseling must cover contingencies.
    Relationship changes, consent withdrawal, and storage planning must be discussed.

Slide 13 — Option 3: Ovarian Tissue Cryopreservation

  • Useful when time is limited.
    Requires a single surgical procedure without the delay of stimulation.
  • Key role in prepubertal patients.
    It may be the only fertility preservation strategy when ovarian stimulation is not possible.
  • Reimplantation and endocrine restoration.
    Tissue can potentially restore hormonal function and, in some contexts, fertility.
  • Requires specialized expertise and pathways.
    Not all centers offer it; referral networks and protocols matter.
  • Counseling should acknowledge evolving evidence.
    Patients should understand current benefits, limitations, and uncertainties.

Slide 14 — Surgical Strategy: Ovarian Transposition (Oophoropexy)

  • Goal: reduce ovarian radiation dose.
    Ovaries are repositioned outside the planned radiation field to preserve function.
  • Planning is everything.
    Placement must be coordinated with radiation oncology to optimize field design and minimize scatter.
  • Endocrine preservation often exceeds fertility preservation.
    Many retain hormonal function; spontaneous conception may still be limited.
  • Not risk-free.
    Surgical risks and the possibility of residual dose exposure must be disclosed.
  • Best used with clear indications.
    Particularly important for pelvic radiation protocols where ovarian dose would otherwise be sterilizing.

Slide 15 — Uterine Fixation: Why It’s Emerging

  • Problem: uterus can be the limiting factor.
    Even with preserved ovaries, uterine irradiation can compromise pregnancy potential.
  • Concept: physical displacement to reduce dose.
    Elevation/fixation may shift uterine position away from higher-dose zones in selected plans.
  • Evidence is early and case-based.
    Current support includes case-level experiences showing meaningful dose reduction.
  • Requires careful patient selection.
    Not all pelvic cancers or radiation plans can benefit; requires individualized planning.
  • Counseling must be transparent.
    Present as a potentially beneficial adjunct, not a guaranteed uterine-protection solution.

Slide 16 — Medical Strategy: GnRH Agonists

  • Mechanism: ovarian suppression during chemotherapy.
    The goal is to reduce follicular activity and possibly lessen chemotherapy impact.
  • Adjunctive—not definitive.
    Should not replace cryopreservation or surgical strategies when those are feasible.
  • Useful when procedures aren’t possible.
    May be considered when time constraints or instability prevent standard preservation.
  • Explain expectations clearly.
    Patients need to understand that protection is incomplete and variable.
  • Integrate with multidisciplinary planning.
    Best used as part of a combined strategy rather than a standalone solution.

Slide 17 — Multidisciplinary Team: Who Does What?

  • Oncologist: initiates counseling and referral.
    Identifies reproductive-age patients and triggers early discussions.
  • REI specialist: evaluates options and feasibility.
    Assesses reserve, timing, stimulation candidacy, and cryopreservation logistics.
  • Surgeon/gynecologist: performs protective procedures.
    Ovarian transposition, tissue harvesting, uterine fixation, and complication management.
  • Radiation oncologist: designs dose-sparing plans.
    Integrates clip markers and altered anatomy into planning and dosimetry.
  • Survivorship support: long-term reproductive follow-up.
    Includes endocrine management, pregnancy planning, and psychosocial support.

Slide 18 — Case-Based Integration: Pelvic Cancer Requiring Chemoradiation

  • Initial step: confirm patient priorities early.
    Ask directly about fertility and endocrine goals at diagnosis, before treatment commitments.
  • Parallel planning prevents delay.
    Arrange REI consult while oncologic staging and preparation proceed.
  • Combine strategies when appropriate.
    Example pathway: oocyte cryopreservation + ovarian transposition ± uterine fixation.
  • Use dosimetry as proof-of-impact.
    Compare predicted ovarian dose with and without transposition to guide counseling.
  • Plan survivorship follow-up.
    Discuss endocrine monitoring, fertility timeline, and pregnancy considerations early.

Slide 19 — Barriers and How to Overcome Them

  • Provider barriers: discomfort, knowledge gaps.
    Use scripts, checklists, and training to normalize fertility conversations.
  • Institutional barriers: missing pathways.
    Create automatic referral triggers and standard operating procedures.
  • Financial barriers: unequal access.
    Identify support resources and provide transparent counseling about costs early.
  • Time pressure: fear of delaying care.
    Emphasize parallel workflows and rapid consult models.
  • Equity lens: reduce disparities.
    Standardizing counseling minimizes bias-driven variation in care.

Slide 20 — Take-Home Messages

  • Always ask—never assume.
    Many patients value fertility and hormonal preservation but will not raise it spontaneously.
  • Counsel early and refer early.
    Timing determines feasibility; delays convert options into regrets.
  • Oncologic safety is non-negotiable.
    Fertility preservation must fit within safe, stage-appropriate cancer treatment.
  • Preserve options, not promises.
    Communicate realistic expectations about success rates and uncertainties.
  • Multidisciplinary care is the mechanism of success.
    The best outcomes come from coordinated planning across oncology, REI, surgery, and radiation.
Revision sheet
  1. Core Definitions (Must-Know)
  • Oncofertility: An interdisciplinary field integrating oncology and reproductive medicine to preserve fertility and hormonal function in cancer patients.
  • Ovarian reserve: The quantity and quality of remaining primordial follicles; finite and non-renewable.
  • Premature ovarian insufficiency (POI): Loss of ovarian function before age 40, characterized by amenorrhea and hypoestrogenism.
  • Fertility preservation: Medical or surgical strategies used before or during cancer treatment to maintain reproductive potential.
  • Fertility-sparing surgery (FSS): Oncologic surgery adapted to preserve the uterus and/or at least one ovary without compromising cancer outcomes.
  1. Why Oncofertility Matters (High-Yield Concepts)
  • Cancer survival in reproductive-age women is increasing → fertility is a survivorship issue.
  • Infertility and premature menopause have psychological, cardiovascular, skeletal, and metabolic consequences.
  • Fertility preservation is about preserving options, not guaranteeing pregnancy.
  • Counseling alone reduces decisional regret, even if no preservation is performed.
  1. Gonadotoxicity: Mechanisms You Must Understand

Chemotherapy

  • Causes DNA damage, follicular apoptosis, and vascular injury.
  • Risk depends on:
    • Drug class and cumulative dose
    • Patient age (strongest modifier)
  • Outcomes:
    • Temporary amenorrhea vs permanent POI

Radiation

  • Oocytes are extremely radiosensitive.
  • Pelvic radiation without protection is usually sterilizing.
  • Ovarian exposure < ~500 cGy (in younger women) is associated with lower POI risk.
  • Radiation also damages the uterus, affecting pregnancy even if ovaries function.
  1. Who Must Be Counseled? (Exam Favorite)

All reproductive-age cancer patients, regardless of:

  • Age
  • Parity
  • Prognosis
  • Relationship status
  • Certainty about future childbearing

➡️ Do not wait for the patient to ask.
➡️ Counseling ≠ intervention, but counseling is mandatory.

  1. Timing Principles
  • Best time: Immediately after cancer diagnosis, before gonadotoxic treatment.
  • Early referral allows parallel planning with staging and treatment preparation.
  • Delay = loss of options.
  • Even when time is limited, counseling must still occur.
  1. Fertility Preservation Options (Know Indications)

Oocyte Cryopreservation

  • Gold standard for postpubertal women.
  • Requires ovarian stimulation (~2 weeks).
  • Preserves autonomy (no sperm required).

Embryo Cryopreservation

  • Also gold standard.
  • Requires sperm and has legal/ethical implications.

Ovarian Tissue Cryopreservation

  • No stimulation needed.
  • Useful in:
    • Prepubertal girls
    • Urgent treatment settings

Ovarian Transposition (Oophoropexy)

  • Surgical relocation of ovaries outside radiation field.
  • Preserves endocrine function more reliably than fertility.
  • Requires coordination with radiation oncology.

GnRH Agonists

  • Adjunctive only.
  • Never a substitute for established preservation methods.
  1. Gynecologic Cancer–Specific Points

Cervical Cancer

  • Fertility-sparing surgery possible in early stages (FIGO IA–IB1) with low-risk features.
  • Options:
    • Conization
    • Simple trachelectomy
    • Radical trachelectomy
  • Positive lymph nodes contraindicate uterine preservation.

Ovarian Cancer

  • FSS may be considered in FIGO stage I, carefully selected patients.
  • Typically involves unilateral salpingo-oophorectomy with full staging.
  • Higher recurrence risk in:
    • FIGO IC2/IC3
    • Certain histologies (e.g., mucinous)
  • Oncologic safety always overrides fertility goals.
  1. Multidisciplinary Care (Key Exam Principle)

Effective oncofertility care requires:

  • Oncologist → initiates counseling and referral
  • Reproductive endocrinologist → fertility assessment and cryopreservation
  • Surgeon/gynecologist → protective or fertility-sparing surgery
  • Radiation oncologist → dose planning and organ protection
  • Survivorship team → long-term reproductive and endocrine follow-up
  1. Common Pitfalls (Know These)
  • ❌ Assuming patients are “too old” or “not interested”
  • ❌ Delaying fertility discussion until after treatment
  • ❌ Relying only on GnRH agonists
  • ❌ Offering fertility-sparing surgery without adequate staging
  • ❌ Ignoring uterine radiation effects
  • ❌ Failing to document fertility counseling
  1. Key Exam Take-Home Messages
  • Always ask about fertility.
  • Counsel early, refer early.
  • Preserve options, not promises.
  • Oncologic safety is non-negotiable.
  • Fertility preservation is standard cancer care, not an extra.
Multiple-Choice Questions

Q1. Which statement best defines oncofertility?

A. A subspecialty limited to assisted reproductive technologies
B. The study of cancer genetics affecting reproduction
C. An interdisciplinary field addressing reproductive consequences of cancer and its treatment
D. A surgical discipline focused on ovarian preservation
E. A survivorship program limited to gynecologic cancers

Correct answer: C
Explanation: Oncofertility integrates oncology, reproductive medicine, gynecology, surgery, and survivorship care.

Q2. Why is female fertility particularly vulnerable to cancer treatment?

A. Oocytes regenerate throughout life
B. The ovarian reserve is finite and non-renewable
C. The uterus is the primary site of damage
D. Hormonal feedback prevents ovarian injury
E. Chemotherapy spares primordial follicles

Correct answer: B

Q3. Which factor most strongly modifies the risk of chemotherapy-induced ovarian insufficiency?

A. Body mass index
B. Cancer stage
C. Patient age
D. Tumor histology
E. Route of chemotherapy administration

Correct answer: C

Q4. Which cancer treatment modality is most consistently associated with irreversible ovarian failure?

A. Hormonal therapy
B. Targeted therapy
C. Immunotherapy
D. Pelvic radiation therapy
E. Surgery alone

Correct answer: D

Q5. Ovarian radiation exposure below which threshold is associated with a lower risk of POI in women under 40?

A. 100 cGy
B. 250 cGy
C. 500 cGy
D. 1000 cGy
E. 2000 cGy

Correct answer: C

Q6. Why is uterine preservation important in oncofertility?

A. The uterus is resistant to radiation
B. Uterine damage affects only implantation rates
C. Radiation can impair pregnancy even with preserved ovarian function
D. Uterine damage is reversible
E. Uterine injury does not affect obstetric outcomes

Correct answer: C

Q7. Which patients should be offered fertility preservation counseling?

A. Only nulliparous patients
B. Only patients under 35
C. Only patients with favorable prognosis
D. All reproductive-age cancer patients
E. Only patients actively planning pregnancy

Correct answer: D

Q8. What is the primary benefit of fertility counseling even when preservation is not pursued?

A. Increased pregnancy rates
B. Reduced decisional regret
C. Improved cancer survival
D. Shorter treatment delays
E. Lower treatment cost

Correct answer: B

Q9. Which fertility preservation method is considered the gold standard for postpubertal women?

A. Ovarian tissue cryopreservation
B. GnRH agonist therapy
C. Oocyte cryopreservation
D. Ovarian transposition alone
E. Expectant management

Correct answer: C

Q10. What is a major advantage of oocyte cryopreservation over embryo cryopreservation?

A. Higher success rates
B. No need for ovarian stimulation
C. Avoids need for sperm at preservation
D. Lower cost
E. Shorter procedure time

Correct answer: C

Q11. Which patients are most suitable for ovarian tissue cryopreservation?

A. Postmenopausal women
B. Prepubertal girls
C. Patients with ovarian metastases
D. Patients receiving hormonal therapy only
E. Patients refusing surgery

Correct answer: B

Q12. What is ovarian transposition primarily intended to prevent?

A. Chemotherapy-induced amenorrhea
B. Surgical menopause
C. Radiation-induced ovarian damage
D. Ovarian hyperstimulation syndrome
E. Genetic damage to oocytes

Correct answer: C

Q13. Which statement regarding ovarian transposition is TRUE?

A. It guarantees future fertility
B. It eliminates all radiation exposure
C. It is most effective when combined with radiation planning
D. It is contraindicated in pelvic radiation
E. It replaces cryopreservation

Correct answer: C

Q14. Why is ovarian endocrine preservation clinically important beyond fertility?

A. It improves cancer outcomes
B. It reduces surgical risk
C. It prevents cardiovascular and skeletal complications
D. It eliminates need for contraception
E. It shortens survivorship follow-up

Correct answer: C

Q15. Which strategy is considered adjunctive rather than definitive for fertility preservation?

A. Oocyte cryopreservation
B. Embryo cryopreservation
C. Ovarian tissue cryopreservation
D. GnRH agonist therapy
E. Ovarian transposition

Correct answer: D

Q16. What is the ideal timing for fertility preservation referral?

A. After completion of cancer treatment
B. At the onset of infertility symptoms
C. Immediately after cancer diagnosis
D. Only after staging surgery
E. During survivorship follow-up

Correct answer: C

Q17. Which factor most commonly limits fertility preservation in practice?

A. Lack of effective techniques
B. Excessive complication rates
C. System-level and referral barriers
D. Patient refusal
E. Oncologic contraindications

Correct answer: C

Q18. Which professional principle underpins universal fertility counseling?

A. Cost-effectiveness
B. Patient autonomy
C. Institutional policy
D. Research enrollment
E. Prognostic stratification

Correct answer: B

Q19. In early-stage cervical cancer, fertility-sparing surgery is appropriate when:

A. Tumor size >4 cm
B. Lymph nodes are positive
C. Disease is FIGO IA–IB1 with low-risk features
D. Histology is neuroendocrine
E. Parametrial invasion is present

Correct answer: C

Q20. Which surgical option is most commonly used for fertility preservation in FIGO IB1 cervical cancer?

A. Conization
B. Simple hysterectomy
C. Radical trachelectomy
D. Total hysterectomy
E. Oophorectomy

Correct answer: C

Q21. Why is lymph node assessment critical before fertility-sparing surgery?

A. It predicts ovarian reserve
B. It determines chemotherapy dosing
C. Positive nodes contraindicate uterine preservation
D. It improves pregnancy rates
E. It reduces surgical time

Correct answer: C

Q22. In ovarian cancer, fertility-sparing surgery typically involves:

A. Bilateral oophorectomy
B. Unilateral salpingo-oophorectomy with staging
C. Ovarian cystectomy only
D. No lymph node evaluation
E. Chemotherapy alone

Correct answer: B

Q23. Which ovarian cancer feature is associated with higher recurrence after FSS?

A. Stage IA disease
B. Endometrioid histology
C. FIGO IC2/IC3 substage
D. Low-grade tumors
E. Young patient age

Correct answer: C

Q24. Which statement about fertility outcomes after ovarian FSS is TRUE?

A. Pregnancy is impossible
B. Live birth rates are negligible
C. Many patients never attempt pregnancy
D. ART is mandatory in all cases
E. Fertility preservation guarantees conception

Correct answer: C

Q25. What is the primary oncologic principle governing fertility preservation?

A. Maximize reproductive potential
B. Minimize surgical morbidity
C. Preserve fertility whenever requested
D. Never compromise cancer outcomes
E. Favor medical over surgical approaches

Correct answer: D

Q26. Which barrier most commonly prevents clinicians from discussing fertility?

A. Patient refusal
B. Time pressure and lack of training
C. Legal restrictions
D. Lack of evidence
E. Cultural opposition

Correct answer: B

Q27. Documentation of fertility discussions is important primarily to:

A. Increase billing
B. Reduce procedure time
C. Ensure continuity and medico-legal protection
D. Improve ovarian reserve
E. Satisfy institutional audits

Correct answer: C

Q28. Which outcome is most strongly improved by fertility counseling itself?

A. Oocyte yield
B. Live birth rate
C. Psychological well-being
D. Cancer survival
E. Treatment adherence

Correct answer: C

Q29. Which statement best reflects shared decision-making in oncofertility?

A. Clinician decides based on age
B. Patient decides without guidance
C. Decisions integrate evidence and patient values
D. Fertility is prioritized over cancer care
E. Counseling is optional

Correct answer: C

Q30. Which uterine effect of radiation most impacts future pregnancy?

A. Cervical stenosis only
B. Endometrial atrophy and vascular damage
C. Tubal obstruction
D. Myometrial hypertrophy
E. Ovarian cyst formation

Correct answer: B

Q31. Which statement about older reproductive-age women is TRUE?

A. Fertility preservation is contraindicated
B. Counseling is unnecessary
C. Ovarian reserve is irrelevant
D. Endocrine preservation may still be beneficial
E. Cryopreservation is illegal

Correct answer: D

Q32. Why should fertility preservation not be delayed until survivorship?

A. It is more expensive later
B. Options may no longer be feasible
C. Survivorship care excludes fertility
D. Cancer recurrence is inevitable
E. Hormonal recovery is guaranteed

Correct answer: B

Q33. Which clinical discipline is essential in planning ovarian transposition?

A. Psychiatry
B. Radiation oncology
C. Pathology
D. Genetics
E. Endocrinology

Correct answer: B

Q34. Which factor most determines eligibility for fertility-sparing surgery in gynecologic cancers?

A. Desire for pregnancy
B. Tumor biology and stage
C. Age under 35
D. Marital status
E. Insurance coverage

Correct answer: B

Q35. What is a key limitation of fertility preservation strategies?

A. They are experimental
B. They are universally unsafe
C. They preserve options, not guarantees
D. They always delay treatment
E. They replace survivorship care

Correct answer: C

Q36. Which outcome best defines success of oncofertility care?

A. Pregnancy in all patients
B. Zero recurrence
C. Informed patient choice with oncologic safety
D. Maximal oocyte yield
E. Absence of complications

Correct answer: C

Q37. Why is long-term follow-up essential after fertility-sparing treatment?

A. To detect ovarian hyperstimulation
B. To plan contraception
C. To monitor recurrence and reproductive health
D. To reduce counseling time
E. To ensure insurance coverage

Correct answer: C

Q38. Which misconception most commonly limits fertility discussions?

A. Fertility preservation is experimental
B. Patients will ask if interested
C. Counseling is time-consuming
D. Cryopreservation always fails
E. Radiation does not affect fertility

Correct answer: B

Q39. Which statement best summarizes modern oncofertility practice?

A Fertility is secondary to survival
B. Fertility preservation is optional
C. Fertility discussions are standardized and early
D. Only gynecologic cancers are relevant
E. Fertility care ends after treatment

Correct answer: C

Q40. The most important take-home message for clinicians is:

A. Preserve fertility whenever possible
B. Avoid discussing fertility unless asked
C. Balance oncologic safety with patient values
D. Refer only low-risk patients
E. Focus on technical success

Correct answer: C

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