A Call for Fertility Preservation Coverage for Breast Cancer Patients: The Cost of Consistency

Let's TOC Fertility: A stepped wedge cluster randomized controlled trial of the Telehealth Oncofertility Care (TOC) intervention in children, adolescent and young adult cancer survivors

INTRODUCTION

Children, adolescent, and young adult cancer survivors experience overall increased risks of infertility that are preventable through effective fertility preservation services prior to starting cancer treatment. Oncofertility care is the evidence-based practice of informing newly diagnosed cancer patients about their reproductive risks and supporting shared decision-making on fertility preservation services. Despite longstanding clinical guidelines, oncofertility care delivery continues to be limited and highly variable across adult and pediatric oncology settings.

MATERIALS AND METHODS

We describe the design of a stepped wedge cluster randomized clinical trial to evaluate the effectiveness of the multi-component Telehealth Oncofertility Care (TOC) intervention conducted in 20 adult and pediatric oncology clinics across three health systems in Southern California. Intervention components are: 1) electronic health record-based oncofertility needs screen and referral pathway to a virtual oncofertility hub; 2) telehealth oncofertility counseling through the hub; and 3) telehealth oncofertility financial navigation through the hub. We hypothesize the intervention condition will be associated with increased proportions of patients who engage in goal-concordant oncofertility care (i.e., engagement in reproductive risk counseling and fertility preservation services that meet the patient's fertility goals) and improved patient-reported outcomes, compared to the usual care control condition. We will also evaluate intervention implementation in a mixed-methods study guided by implementation science frameworks.

DISCUSSION

Our overall goal is to speed implementation of a scalable oncofertility care intervention at cancer diagnosis for children, adolescent and young adult cancer patients to improve their future fertility and quality of life.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT05443737.

Gynecologic Care of Black Breast Cancer Survivors

Purpose of Review

Black patients suffer from breast cancer-related racial health disparities, which could have implications on their gynecologic care. This review explores considerations in the gynecologic care of Black breast cancer survivors.

Recent Findings

Black people have a higher risk of leiomyoma and endometrial cancer, which could confound bleeding patterns such as in the setting of tamoxifen use. As Black people are more likely to have early-onset breast cancer, this may have implications on long-term bone and heart health. Black patients may be more likely to have menopausal symptoms at baseline and as a result of breast cancer treatment. Furthermore, Black patients are less likely to utilize assisted reproductive technology and genetic testing services.

Summary

It is important for healthcare providers to be well-versed in the intersections of breast cancer and gynecologic care. Black breast cancer survivors may have unique considerations for which practitioners should be knowledgeable.

The Status of Fertility Preservation (FP) Insurance Mandates and Their Impact on Utilization and Access to Care

Fertility preservation (FP) is the use of a specific medical intervention to protect the fertility of individuals whose disease or disease treatment may lead to infertility. These medical interventions include the cryopreservation of oocytes, embryos, ovarian tissue, sperm, and testicular tissue; oocyte and embryo cryopreservation are the most widely used interventions in the United States. Although guidelines recommend FP prior to undergoing gonadotoxic treatments, cost barriers are high. For example, the average cost of an oocyte cryopreservation cycle in the United States exceeds $10,000. High cost and lack of insurance coverage are two of the most cited reasons explaining the low Reproductive Endocrinology and Infertility (REI) referral rates and limited FP utilization. Broadening insurance mandates for FP prior to gonadotoxic treatments could improve utilization and provide cancer survivors with improved quality of life post treatment.

Disparities in fertility preservation among patients diagnosed with female breast cancer

PURPOSE

To investigate the association of specific patient factors with disparities in fertility preservation counseling and utilization of fertility preservation among patients ≤ 40 years old diagnosed with female breast cancer.

METHODS

A retrospective chart review was conducted investigating patients diagnosed with breast cancer between January 2012 and December 2020 in a multi-site health system. Rates of fertility counseling and utilization of preservation services were compared based on age, race/ethnicity, parity, insurance type, and treatment site.

RESULTS

Of the 6,783 patients diagnosed with female breast cancer, 306 (4.5%) were ≤ 40 years old at the time of diagnosis. There was no significant difference between Black or African American and White patients in rates of fertility counseling (12.1% vs 17.4%; p = 0.285) or pursuit of fertility preservation (3.3% vs 4.2%; p = 0.508), nor was a difference observed when compared by insurance type. However, younger patients (< 30 years of age), patients with 1 or no children, and patients treated in the more affluent county were more likely to undergo counseling and pursue fertility preservation than their matched counterparts.

CONCLUSION

Age, parity, and location of breast cancer care may impact rates of fertility counseling and preservation among reproductive age women diagnosed with breast cancer. Thus, further attention to age discrimination, a patient's desire for future fertility, need for standardization in fertility preservation counseling, and perhaps implementation of comprehensive fertility coverage mandates across all states could help to improve gaps in fertility counseling and fertility preservation.

Current Issues in Fertility Preservation Among Pediatric and Adolescent Cancer Patients

PURPOSE OF REVIEW

Although fertility preservation is not yet fully integrated into the comprehensive cancer care of pediatric and adolescent patients, advances continue to take place. This review summarizes recent updates and trends for health care professionals caring for these patients.

RECENT FINDINGS

The creation of standardized infertility risk assessment guidelines offers the opportunity to provide greater consistency in clinical care and to provide a current baseline for future research studies seeking to refine risk stratification for individual patients. New agents are being introduced into cancer care; as their use increases, information about their impact on fertility is being studied. Ovarian tissue cryopreservation offers a new standard of care option for fertility preservation, but additional studies are needed to further assess efficacy and impact on ovarian reserve among pediatric and adolescent patients. Standardization of fertility preservation recommendations among certain sub-populations may also make it easier to provide greater consistency in clinical care. Advances continue to be made in the field of fertility preservation, but dissemination of this information is critical to moving toward fertility preservation truly being a part of comprehensive cancer care.

Survey of young women with breast cancer to identify rates of fertility preservation (FP) discussion and barriers to FP care

PURPOSE

To identify the proportion of reproductive age women with breast cancer that engaged in a fertility preservation discussion and reproductive endocrinology and infertility (REI) consultation.

METHODS

This cross-sectional survey recruited women 18-42 years who were diagnosed with breast cancer from 2006 to 2016 by phone or email and asked them to complete an online survey. Demographic characteristics, barriers to FP, utilization of FP consultation, and FP procedures (oocyte and embryo cryopreservation) were analyzed.

RESULTS

A majority of women (64%) did not have FP discussed by any provider. Older women and those who were parents at the time of diagnosis were less likely to engage in a FP discussion. However, there were no significant differences in partner status or cancer stage between women with or without FP discussions. Of the women who desired future children prior to the cancer diagnosis, 93% received chemotherapy; however, only 34% of these women had a consultation with an REI. The most common reasons for declining FP consultation were already having their desired number of children (41%), financial barriers (14%), and concern about delaying cancer treatment and cancer recurrence (12%). Forty percent of women who desired future children and met with an REI pursued FP procedures.

CONCLUSION

Younger women were more likely to receive FP counseling. FP consultations and procedures were low even in women who desired future fertility, with the predominant barriers being cost, fears concerning a delay in cancer treatment, and future cancer recurrence.

Disparities in the use of assisted reproductive technologies after breast cancer: a population-based study

PURPOSE

Equitable access to oncofertility services is a key component of cancer survivorship care, but factors affecting access and use remain understudied.

METHODS

To describe disparities in assisted reproductive technology (ART) use among women with breast cancer in California, we conducted a population-based cohort study using linked oncology, ART, and demographic data. We identified women age 18-45 years diagnosed with invasive breast cancer between 2000 and 2015. The primary outcome was ART use-including oocyte/embryo cryopreservation or embryo transfer-after cancer diagnosis. We used log-binomial regression to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) to identify factors associated with ART use.

RESULTS

Among 36,468 women with invasive breast cancer, 206 (0.56%) used ART. Women significantly less likely to use ART were age 36-45 years at diagnosis (vs. 18-35 years: PR = 0.17, 95% CI 0.13-0.22); non-Hispanic Black or Hispanic (vs. non-Hispanic White: PR = 0.31, 95% CI 0.21-0.46); had at least one child (vs. no children: adjusted PR [aPR] = 0.39, 95% CI 0.25-0.60); or lived in non-urban areas (vs. urban: aPR = 0.28, 95% CI 0.10-0.75), whereas women more likely to use ART lived in high-SES areas (vs. low-/middle-SES areas: aPR = 2.93, 95% CI 2.04-4.20) or had private insurance (vs. public/other insurance: aPR = 2.95, 95% CI 1.59-5.49).

CONCLUSION

Women with breast cancer who are socially or economically disadvantaged, or who already had a child, are substantially less likely to use ART after diagnosis. The implementation of policies or programs targeting more equitable access to fertility services for women with cancer is warranted.

Fertility Preservation and Financial Hardship among Adolescent and Young Adult Women with Cancer

BACKGROUND

Financial hardship among adolescents and young adults (AYA) with cancer who receive gonadotoxic treatments may be exacerbated by the use of fertility services. This study examined whether AYA women with cancer who used fertility preservation had increased financial hardship.

METHODS

AYA women with cancer in North Carolina and California completed a survey in 2018-2019. Cancer-related financial hardship was compared between women who cryopreserved oocytes or embryos for fertility preservation after cancer diagnosis (n = 65) and women who received gonadotoxic treatment and reported discussing fertility with their provider, but did not use fertility preservation (n = 491). Multivariable log-binomial regression was used to estimate prevalence ratios and 95% confidence intervals (CI).

RESULTS

Women were a median age of 33 years at diagnosis and 7 years from diagnosis at the time of survey. Women who used fertility preservation were primarily ages 25 to 34 years at diagnosis (65%), non-Hispanic White (72%), and had at least a Bachelor's degree (85%). In adjusted analysis, use of fertility preservation was associated with 1.50 times the prevalence of material financial hardship (95% CI: 1.08-2.09). The magnitude of hardship was also substantially higher among women who used fertility preservation: 12% reported debt of ≥$25,000 versus 5% in the referent group.

CONCLUSIONS

This study provides new evidence that cryopreserving oocytes or embryos after cancer diagnosis for future family building is associated with increased financial vulnerability.

IMPACT

More legislation that mandates insurance coverage to mitigate hardships stemming from iatrogenic infertility could improve access to fertility preservation for young women with cancer.

Fertility preservation for pediatric patients with hemoglobinopathies: Multidisciplinary counseling needed to optimize outcomes

Hemoglobinopathies are autosomal recessive disorders that occur when genetic mutations negatively impact the function of hemoglobin. Common hemoglobinopathies that are clinically significant include sickle cell disease, alpha thalassemia, and beta thalassemia. Advancements in disease-modifying and curative treatments for the common hemoglobinopathies over the past thirty years have led to improvements in patient quality of life and longevity for those who are affected. However, the diseases, their treatments and cures pose infertility risks, making fertility preservation counseling and treatment an important part of the contemporary comprehensive patient care. Sickle cell disease negatively impacts both male and female infertility, primarily by testicular failure and decreased ovarian reserve, respectively. Fertility in both males and females with beta thalassemia major are negatively impacted by iron deposition due to chronic blood transfusions. Hematopoietic stem cell transplant (HSCT) is currently the only curative treatment for SCD and transfusion dependent beta thalassemia. Many of the conditioning regimens for HSCT contain chemotherapeutic agents with known gonadotoxicity and whole-body radiation. Although most clinical studies on toxicity and impact of HSCT on long-term health do not evaluate fertility, gonadal failure is common. Male fertility preservation modalities that exist prior to gonadotoxic treatment include sperm banking for pubertal males and testicular cryopreservation for pre-pubertal boys. For female patients, fertility preservation options include oocyte cryopreservation and ovarian tissue cryopreservation. Oocyte cryopreservation requires controlled ovarian hyperstimulation (COH) with ten to fourteen days of intensive monitoring and medication administration. This is feasible once the patient has undergone menarche. Follicular growth is monitored via transvaginal or transabdominal ultrasound, and hormone levels are monitored through frequent blood work. Oocytes are then harvested via a minimally invasive approach under anesthesia. Complications of COH are more common in patients with hemoglobinopathies. Ovarian hyperstimulation syndrome creates a greater risk to patients with underlying vascular, pulmonary, and renal injury, as they may be less able to tolerate fluids shifts. Thus, it is critical to monitor patients undergoing COH closely with close collaboration between the hematology team and the reproductive endocrinology team. Counseling patients and families about future fertility must take into consideration the patient's disease, treatment history, and planned treatment, acknowledging current knowledge gaps.

Childbearing vs. clinical trial participation: is it one or the other?

Recent advances have shed light on the importance of early therapeutic intervention for neurodegenerative diseases. Primary prevention trials present a potential disease-modifying strategy for pre-symptomatic patients of autosomal dominant neurodegenerative diseases (ADND), such as early onset familial Alzheimer's disease (AD) and Huntington's disease (HD). As trials target earlier disease stages, however, prospective participants face new ethical and logistical challenges, namely childbearing and reproductive health decisions. Since pregnancy is an exclusion criteria for such trials, participants of reproductive age must choose between participating in research and having a family. Such decisions carry significant burdens for ADND patients that if left unaddressed could impact patient well-being and the field as whole. We use our perspective as scientists, advocates, and ADND family members to highlight current shortcomings in the field regarding trial participation and family planning issues for ADND patients and call for the establishment of a normative standard to address these concerns.

Fertility-a human right worthy of mandated insurance coverage: the evolution, limitations, and future of access to care

We review the history, current status, and potential future of state infertility mandates and focus on the business implications of mandates and on the inadequacies and reproductive injustice resulting from gaps between legislative intent and practical implementation. Nineteen states have passed laws that require insurers to either cover or offer coverage for infertility diagnoses and treatment. The qualifications for coverage, extent of coverage, and exemptions vary drastically from one state to another, resulting in deficiencies in access to care even within mandated states for certain groups, such as single individuals, patients in same-sex relationships, and patients pursuing fertility preservation. Although insurance coverage of fertility services in the United States has expanded as an increasing number of states have enacted infertility mandates, significant gaps in implementation and access remain even among states with existing mandates. Provider, patient, and legislative advocacy is warranted in the name of reproductive justice to expand insurance coverage and, in turn, maximize reproductive outcomes, which have been shown to improve as financial barriers are lifted.

Burning Questions in the Oncofertility Counseling of Young Breast Cancer Patients

The improved prognosis of breast cancer patients makes survivorship issues an area of crucial importance. In this regard, an increased attention is needed toward the development of potential anticancer treatment-related long-term side-effects, including gonadal failure and infertility in young women. Therefore, fertility preservation and family planning are crucial issues to be addressed in all young women of reproductive age with newly diagnosed cancer. Despite a growing availability of data on the efficacy and safety of fertility preservation options and the fact that conceiving after prior history of breast cancer has become more accepted over time, there are still several gray zones in this field so that many physicians remain uncomfortable to deal with these topics. The purpose of this review is to answer some of the most controversial questions frequently asked by patients during their oncofertility counseling, in order to provide a detailed and up-to-date overview on the evidence available in this field to physicians involved in the care of young women with breast cancer.

Factors Affecting Fertility Decision-Making Among Transgender Adolescents and Young Adults

PURPOSE

This study aimed to identify factors affecting transgender adolescents' and young adults' (AYA) decisions to pursue fertility preservation (FP).

METHODS

Participants completed a semistructured interview between December 2016 and June 2017 to inform improvements in fertility counseling and the development of a fertility decision aid targeted to transgender youth. Interviews included open-ended questions within the following domains: (1) gender-affirming medical care received, (2) knowledge of gender-affirming hormone effects on fertility and FP options, (3) FP decision-making, and (4) how, when, and what information AYA prefer to receive regarding FP. The interviews were analyzed thematically.

RESULTS

Eighteen transgender AYA (ages 15-24) participated (60% participation rate). The majority was White (61%) and assigned female at birth (67%). Half received specialized FP counseling (50%). Few of the transgender AYA pursued FP (33%). Five key themes reflecting factors affecting transgender AYA's FP decision-making were identified: (1) future parenthood desires, (2) individual experiences of gender dysphoria, (3) family values around biological parenthood, (4) financial considerations, and (5) fertility information provision.

CONCLUSIONS

Transgender AYA consider numerous factors in deciding whether to pursue FP. Although individual desires for and family values around biological parenthood influenced whether AYA pursued specialized FP counseling, individual experiences of gender dysphoria and costs of FP were barriers. AYA also identified shortcomings in fertility counseling with providers, highlighting the need to establish standardized counseling protocols and develop patient decision aids.

Fertility preservation in breast cancer with case-based examples for guidance

With more young breast cancer survivors, a trend toward having children later in life, and improvements in assisted reproductive technology (ART), fertility preserving techniques are of growing importance prior to initiation of gonadotoxic treatments. The American Society for Clinical Oncology (ASCO) updated their Fertility Preservation in Patients with Cancer guidelines in April of 2018. ASCO continues to recognize oocyte and embryo cryopreservation as standard practice for women interested in preserving fertility and sperm cryopreservation as standard practice for men. ASCO has clarified their statement on ovarian suppression during chemotherapy as an option when standard methods are unavailable but should not be used as the sole method of fertility preservation (FP) due to conflicting evidence. ASCO also updated their statement on ovarian tissue cryopreservation, which is still labeled experimental but ASCO acknowledges that it can restore global ovarian function and could be of use in specific patients. The NCCN's Version 1.2018 Clinical Practice Guidelines® for treatment of breast cancer include fertility counseling as part of their work-up in all types of breast cancer for premenopausal women.The purpose of this review is to explain the indications and evidence for the different methods of FP for young breast cancer patients in accordance with ASCO and NCCN guidelines. The guidance will then be applied to three theoretical clinical cases in order to highlight actual use in clinical practice.

Fertility preservation in patients with hematologic malignancies and recipients of hematopoietic cell transplants

Patients with hematologic malignancies and those undergoing hematopoietic cell transplantation (HCT) face a complex set of challenges when considering options for fertility preservation (FP). There are no standard options for prepubertal children, and women with hematologic malignancies may not be eligible for standard FP options. Fortunately, initial therapies for most blood cancers are not highly gonadotoxic, affording an important opportunity for postremission counseling and referrals to fertility specialists. These patients face a high risk of relapse, and many will be referred for autologous or allogeneic HCT, which carries an extremely high risk of infertility. The expanding indications for HCT to include benign hematologic disorders as well as autoimmune diseases mandate that all hematologists are familiar with these risks. Oncofertility researchers are continually pushing the boundaries of what may be possible for our patients; in the meantime, communication and shared decision-making between hematologists and patients, as well as program-building, education, and outreach are essential to ensure that these patients, many of whom will be cured, maintain all of their options for a fulfilling life after intensive therapy.

Looking Through the Lens of a Family Planner to Prioritize Reproductive Health Among Women With Cancer

PURPOSE

Prioritization of cancer treatment initiation in women of reproductive age may underscore potential implications on reproductive health. This study describes a family planning quotient (FPQ) and reproductive life index (RepLI) tool designed to help providers to discuss effectively reproductive health with women with cancer.

METHODS

We tailored the FPQ/RepLI tool for patients with cancer after development in the family planning setting and piloted it with 36 oncology patients referred to our family planning clinic. Each patient completed the FPQ/RepLI with a health educator or medical student and then met with a physician to create a reproductive life plan. A subsample evaluated the tool by rating satisfaction using a Likert scale. Summary statistics were calculated overall and by childbearing status.

RESULTS

Of the 36 women, 22 did not desire additional children and received contraception. One third (n = 14) had not completed childbearing, four of whom continued with fertility preservation counseling. Women who desired childbearing were less likely to already have children ( P = .02), and more than one half were using long-term contraception. All agreed that the FPQ/RepLI helped them to talk to their provider about their reproductive goals. Only 44.4% agreed that their oncologist knew how many children they desired, and 88.9% found the tool helpful and would use it for future tracking of their reproductive goals.

CONCLUSION

The FPQ/RepLI is useful for assessing the reproductive health of young women with a new cancer diagnosis, understanding desires of future childbearing, and providing effective contraception. We recommend the incorporation of this tool into practice to better understand patients' reproductive needs.

The National Physicians Cooperative: transforming fertility management in the cancer setting and beyond

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines – oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health – in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

The intersection of financial toxicity and family building in young adult cancer survivors

Financial toxicity and family building difficulties may co-occur in young adult cancer survivors. We describe this intersection and propose steps to alleviate associated distress.

Modeling of live-birth rates and cost-effectiveness of oocyte cryopreservation for cancer patients prior to high- and low-risk gonadotoxic chemotherapy

STUDY QUESTION

What is the live-birth rate (LBR) and cost-effectiveness of fertility preservation with oocyte cryopreservation (FP-OC) compared to expectant management in cancer patients age 25-40 based on estimated gonadotoxicity of treatments 5 years after cancer diagnosis?

SUMMARY ANSWER

Oocyte cryopreservation prior to cancer treatment is more costly, yet more effective (producing more live births), than not undergoing oocyte cryopreservation but it is most beneficial for patients undergoing high-risk chemotherapy (HRC).

WHAT IS KNOWN ALREADY

The decision to undergo FP prior to treatment is multifactorial and can be costly and delay treatment. Not all treatments carry the same gonadotoxicity and patients may choose to undergo FP-OC based on the probability of premature ovarian insufficiency, predicted outcomes and cost. A comprehensive model that incorporates age at diagnosis and toxicity of treatment to help guide patients in the decision to undergo FP-OC does not yet exist.

STUDY DESIGN, SIZE DURATION

This study used a Decision Analysis Model to estimate effectiveness and cost of FP for cancer patients.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Age-based estimates of LBR and cost per live birth were calculated for ages 25-40 years based on gonadotoxicity of treatment. A decision analysis model was constructed using Treeage Pro 2015 with case base probabilities derived from national registries, practice guidelines and medical records from a national network of infertility practices (IntegraMed).

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to no FP-OC, FP-OC improved LBRs for women of all ages undergoing either low-risk chemotherapy (LRC) or HRC; however, it was most cost effective for women undergoing LRC at older ages or HRC at younger ages. Although FP-OC results in higher LBRs, it was always more costly. Using donor oocyte IVF can be a successful alternative to autologous FP-OC.

LIMITATIONS REASONS FOR CAUTION

Decision tree results reflect probabilities of certain events and are compiled from multiple reputable sources but are not directly derived from a recruited cohort of patients. Outcomes are based on United States estimates and should be interpreted in the broader context of individual patient diagnoses, treatment care plans and country of origin.

WIDER IMPLICATIONS OF THE FINDINGS

The development of this analytic model will help guide practitioners in their counseling of women from age 25 to 40 years, who are considering FP-OC at the time of cancer diagnosis. It provides a realistic pathway from diagnosis to LB and accounts for the majority of costs and outcome possibilities.

STUDY FUNDING/COMPETING INTEREST(s)

This study was partially funded by a grant from National Institute of Health (NIH)/National Institute of Child Health and Human Development (NICHD) (R01 HD67683) to A.Z.S. There are no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Recent advances in fertility preservation and counseling for female cancer patients

INTRODUCTION

Ensuring quality of life for increasing numbers of women surviving cancer has become a key challenge. Patients need to be counseled on potential fertility loss resulting from gonadotoxic treatments, and referred to fertility specialists to discuss existing options and available results. Areas covered: Fertility preservation options have existed for over twenty years. The proposed fertility preservation approach depends on patient age, the urgency of required chemotherapy, and psychosocial factors such as financial concerns, especially in countries where techniques are not covered by social security. Efficacy in terms of pregnancy rates has been demonstrated with frozen-thawed embryos, oocytes and re-implanted ovarian tissue. Appropriate counseling by oncologists is on the increase, despite persistently low rates of referral to fertility specialists. Expert commentary: Access to oncofertility services is steadily improving, facilitated by the growing involvement of public healthcare systems and sustained efforts all over the world to establish specific oncofertility programs. Early referral to reproductive specialists before initiation of chemo/radiotherapy is crucial to success in the field of female fertility preservation. In the near future, efforts should focus on increasing patient referrals and establishing international registries on short- and long-term outcomes of fertility preservation strategies.