Fertility preservation — structured oral station (12 minutes)

Opening prompt — "Tell me how you approach this referral."

Model response — say it in this order: ^[2]

• "This is an urgent oncofertility referral. ASCO requires that the fertility discussion be initiated and documented as early as possible, in parallel with staging, so I would see her today, confirm the oncology timeline, and run a multidisciplinary discussion with oncology, reproductive medicine and psychology."
• "With two weeks available and a reasonable AMH and antral follicle count, she is a candidate for oocyte cryopreservation — she has no partner, so embryo cryopreservation would require a donor-sperm decision that she has not made."
• "Because her cancer is oestrogen-receptor-positive, I would use a GnRH antagonist backbone with letrozole 5 mg daily co-stimulation and a GnRH agonist trigger, and complete the cycle so chemotherapy proceeds on schedule."^[2][4]

Examiner is listening for: the documented-discussion requirement, parallel multidisciplinary work, strategy choice driven by partner status and receptor status, and the named protocol. ^[2]

Probe 1 — "Why letrozole, and is it safe?"

• "In ER-positive disease, standard stimulation drives a supraphysiological oestradiol that is a concern. Oktay's 2005 prospective study established letrozole 5 mg daily with FSH, which lowered peak oestradiol while maintaining embryo yield."^[4]
• "The Kim, Turan and Oktay long-term safety study, with a mean five-year follow-up, found a recurrence hazard ratio of 0.77, 95 per cent confidence interval 0.28 to 2.13, with survival not compromised. They concluded the protocol is unlikely to cause a substantially increased recurrence risk."^[3]

Probe 2 — "Can you start stimulation today, regardless of her cycle day?"

• "Yes. The von Wolff analysis of 684 stimulations across the FertiPROTEKT network showed the outcome of stimulation is similar after initiation during any phase of the menstrual cycle, supporting random-start before gonadotoxic therapy. The luteal start did not compromise oocyte yield."^[6]

Probe 3 — "Her oncologist asks whether a GnRH agonist injection would be enough on its own. What do you say?"

• "No. ASCO is explicit that a GnRH agonist must not be used in place of proven fertility preservation methods — it does not store gametes. It can be offered as an adjunct to reduce chemotherapy-induced ovarian insufficiency."
• "The Lambertini 2018 individual patient-data meta-analysis of 873 patients found premature ovarian insufficiency of 14.1 per cent with the agonist versus 30.9 per cent control, adjusted odds ratio 0.38, with a higher post-treatment pregnancy rate and no difference in disease-free or overall survival."^[5]

Probe 4 — "The patient is in tears. She asks whether she will ever have a child."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[1]

• Move to her eye level, use her name, acknowledge the fear before the facts: "This is a lot to take in, and it is completely understandable that you are frightened. I am sorry you are going through this."
• Then commit honestly and specifically: "We have a good plan to freeze your eggs now, before chemotherapy, so that you have the option of a genetic child later. I cannot promise a baby, but we are giving you the best possible chance. I will be here with you through it."
• Avoid false reassurance and avoid jargon; offer a follow-up with the psychologist and written information.^[1]

Probe 5 — "What happens after she completes cancer treatment?"

• Re-test ovarian reserve; if she has premature ovarian insufficiency, start hormone replacement and counsel on bone, cardiovascular and fertility implications.
• When she is disease-free at the agreed interval, plan return to frozen oocytes with IVF/ICSI, or attempt natural conception if ovarian function returns; donor oocytes remain an option if her own material does not succeed.
• Document the post-treatment review and offer ongoing psychological support.^[1]