Window of opportunity: rate of referral to infertility providers among reproductive age women with newly diagnosed gynecologic cancers

The goal of this study is to examine the referral rate to fertility specialists for women with newly diagnosed gynecologic cancer and the impacting factors. This Institutional Review Board approved, retrospective cohort study investigated the referral rate from gynecologic oncologists (Gyn Onc) to reproductive endocrinologist and infertility (REI) specialists at a single academic institution from 2010 to 2022 with newly diagnosed gyn cancer. Patients included were age 18-42 at time of diagnosis to encompass women eligible for fertility preservation by institution-based age criteria. Electronic medical records were used to identify demographics, referral rates, and fertility trends. Descriptive statistics were generated to describe referral rates, treatment plans, and fertility visit outcomes. Patients were excluded if they had a prior hysterectomy, received Gyn Onc care at outside institutions, or had prior cancer. Of 451 patients reviewed, 268 patients met criteria for inclusion. 85.4% of patients were nulliparous and 46.9% were age 18-34. The first step in oncologic therapy was surgery (80.5%), chemotherapy (8.8%), chemotherapy with radiation (8.4%), and radiation alone (2.3%). The median time from diagnosis to treatment was 47.6 days. Of those who were offered surgery, 41.2% were offered fertility sparing surgery management. Median time from first Gyn Onc visit to treatment was 47.6 days. 15.4% of patients with newly diagnosed gyn malignancies were referred to REI. Women who were referred to REI were 6 times more likely to be nulliparous than patients who did not receive referral. The attendance rate was 90.5% for REI referrals. Fertility options were offered at 92.1% of REI visits. 62.9% of patients elected to undergo fertility testing, and 44.1% underwent fertility preservation. With a median follow up of 57.4 months (4.7 years), 14.8% of patients who received fertility sparing surgery and REI referral achieved pregnancy. Despite advances in the expediency of reproductive options and well intentioned oncologists, the REI referral rate in our cohort was lower than expected. This study highlights referral rate as a barrier to fertility options given the high attendance rate of referrals once placed and a significant majority of patients electing to undergo fertility workup. While the majority of patients in this study were offered surgical intervention as an initial step, the majority of these patients require surgery that doesn’t preserve fertility, highlighting the need for timely preoperative referral to REI. With a median time to treatment of 47.6 days, we demonstrate that an opportunity exists for accessing fertility preservation without impacting standard oncologic care.