Improving Future Care: The Role of Oncofertility Education in Medical Curricula in Germany. Results of a nationwide survey of 346 medical students

Improving Future Care: The Role of Oncofertility Education in Medical Curricula in Germany. 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Results of a nationwide survey of 346 medical students Judith Altmann, Desislava Dimitrova, Elena Stark, Nadine Einsiedel, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8809165/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 29 Apr, 2026 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted 7 You are reading this latest preprint version Abstract Objective: To study the existing knowledge, interest and attitudes of medical students regarding fertility preservation measures. Design : A multi-center nationwide survey was conducted among medical students across Germany. The survey consisted of 15 multiple-choice questions and six questions asking participants their level of agreement of a statement. Subjects: 346 medical students in Germany. Main Outcome Measures: A multi-choice questionnaire was used to evaluate the existing knowledge, interest and attitudes of medical students regarding fertility preservation measures. Results: Regarding the assessment of ovarian reserve, Anti-Müllerian hormone testing was known by 38.8% of students, while only 15.9% were familiar with the antral follicle count method. The most widely recognized fertility preservation (FP) method was oocyte cryopreservation (91.0%), followed by ovarian tissue cryopreservation (45.1%), ovarian transposition surgery prior to pelvic radiation (38.2%), and the use of gonadotropin-releasing hormone analogues for ovarian protection during chemotherapy (28.6%). Regarding reproductive technologies such as IVF, ICSI, or hormonal stimulation 87.5% of students expressed a positive opinion. Oocyte donation was perceived positively by 77.6%. The acceptance for uterus transplantation was high among participants with 61.4%. The acceptance for surrogacy was lower with 53.2% of respondents. Social freezing was positively received by most respondents (72.7%). 80.0% of respondents expressed interest in expanding their knowledge of fertility and cancer, and 65.9% desired additional training. Conclusions: To ensure high-quality fertility preservation counseling and the implementation of necessary FP measures for all cancer patients of childbearing age, it is crucial that future physicians are familiar with methods for assessing ovarian reserve and fertility preservation techniques. Strengthening oncofertility training in medical education will enhance future physicians' ability to provide informed counseling and timely referrals, ultimately improving patient care and quality of life. This study highlights the urgent need to systematically integrate fertility preservation and oncofertility into the curriculum of medical school in Germany. Figures Figure 1 Figure 2 Introduction Infertility and premature ovarian insufficiency as a result of cancer treatment significantly increase the burden that young cancer patients must carry 1 , 2 , leading to unintended childlessness, menopausal symptoms, osteoporosis, sarcopenia, and an increased cardiovascular risk. All cancer patients of reproductive age, regardless of the type and stage of the disease, should receive comprehensive oncofertility counseling as early as possible in the treatment planning process, as stated in the ESMO guideline 3 . In Germany, as of July 2021, female cancer patients are even entitled to statutory health insurance coverage for fertility-preserving treatments 4 . Despite the existence of this and several other European guidelines 3 , 5 , 6 , studies highlight that many patients still do not receive adequate counseling or referrals to reproductive medicine specialists 1 , 7 . When asked about the reasons for not offering fertility preservation counseling to gynecological cancer patients, doctors cite a lack of knowledge, insufficient prioritization, and time constraints 7 . Medical students, as tomorrow's healthcare providers, are the key to improving fertility preservation counseling in the future, making their education on the topic critical for enhancing care quality. This study aims to examine the current knowledge, attitudes, and interest of medical students in providing fertility preservation counseling for cancer patients. Methods Prior to commencing the study, approval was obtained from the Ethics Committee of Charité. A multi-center nationwide survey was conducted among medical students across Germany. The survey consisted of 15 multiple-choice questions and six questions asking participants their level of agreement of the statement on a scale from 0 (= completely disagree) to 10 (completely agree). In our analysis we considered values under five as disagreement, five as neutral and above five as agreement. Knowledge questions were multiple choice. The questionnaire gathered information on respondents' demographics such as gender, personal expertise and knowledge related to fertility preservation counseling and whether this topic had already been covered in university classes. Knowledge of different techniques and measures of fertility preservation was tested. The last section asked participants about their personal opinions regarding fertility preservation measures, including procedures not yet legalized or established in Germany. A pilot phase involving interviews with 10 medical students was conducted to confirm the comprehensibility and feasibility of the questionnaire. The survey was administered online from 03/2024 to 08/2024. Categorical data were presented as percentages. Percentages were calculated on the basis of the total number of responses for each question individually and rounded to one decimal place. For conducting the online survey, we used the software REDCap. Figures were created using the R package ggplot2 8 . Exploratory statistical analysis was performed using IBM SPSS Statistics (version 29.0.2.0.(20)). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to quantify associations. To evaluate potential associations between the students’ academic progress and the extent of their knowledge, a bivariate analysis was performed between the knowledge of AMH as a marker of fertility and the study progress (grouped into 1st to 4th semester, 5th to 8th semester and 9th to 13th semester). To assess the influence of practical experience in the field of gynecology on students’ knowledge, a bivariate analysis was conducted between knowledge of any method used to assess ovarian reserve and the variable of having practical experience in the field of gynecology. Knowing any measurement of assessing ovarian reserve included the knowledge of AMH levels, antral follicle count (AFC) and measuring luteinizing hormone (LH), follicle-stimulating hormone (FSH) and estrogen. Results Demographic characteristics of respondents A total of 346 medical students answered the online survey. Students were distributed as follows across their medical studies: 20.8% in the 1st to 4th semester, 47.7% in the 5th to 8th semester, and 31.5% in the 9th to 13th semester of their studies. 43.4% of students had already studied gynecology as part of their curriculum, and 43.6% had acquired practical experience in this field. 36.1% of students stated that they had attended a seminar on “fertility preservation in cancer patients” in university. 80.3% of the respondents identified as female, 18.2% as male, 1.2% as non-binary, and 0.3% chose not to respond to this question. In terms of parental status, a significant majority of participants, specifically 92.5%, reported not having children of their own. Furthermore, 3.5% of the participants indicated that they had utilized the services of a reproductive medicine specialist at some point. When asked to rate the importance of having biological children on a scale from 0 to 10, 74.4% of participants considered it to be somewhat to very important to them personally. For a detailed breakdown of demographic characteristics, refer to table 1. Need for Training When asked about their interest in “fertility and cancer,” 80.0% of participants expressed a desire to gain more knowledge in reproductive medicine, while 15.9% responded with “no interest,” and 4.1% did not provide an answer. 65.9% of participants expressed interest in further classes and training on “fertility and cancer,” while 17.1% responded with “no,” and 17.1% did not provide an answer. 35.1% preferred further training on “fertility and cancer” through a clinical rotation at a specialized center, 29.4% favored in-person training, and 22.4% preferred an online course. Even among medical students who had already encountered fertility-related topics in their curriculum, there was a strong demand for additional education and training opportunities. Only 14.5% of students stated that “fertility and cancer” was adequately covered during their studies, while 44.1% felt the topic was not sufficiently addressed, and 41.4% did not provide an answer (see table 2). Knowledge regarding fertility preservation When asked about their knowledge of methods to assess ovarian reserve in women, 29% of students were unaware of any (Fig. 1 ). The most recognized approach was hormonal measurement, including luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estrogen (56.2%). Anti-Müllerian hormone (AMH) testing was known by 38.8% of students (see Fig. 2 ), while only 15.9% were familiar with the antral follicle count (AFC) method. Students with practical experience in the field of gynecology (e.g. through internships) were significantly more likely to know any measurement of ovarian reserve than those without (OR = 1.960; CI = 1.261–3.046) (Fig. 1 ). Furthermore, while in the first four semesters only 6.9% of students knew AMH as a measurement of fertility, this proportion increased to 42.1% among students in the fifth to eighth semester and to 54.1% among students in the ninth to thirteenth semester (Fig. 2 ). This increase throughout the semesters was statistically significant with students in the intermediate stage of their studies being nearly ten times more likely (OR = 9.733; CI = 3.726–25.420) and in the final stage more than fifteen times more likely (OR = 15.812; CI = 5.913–42.284) to know AMH as a marker of fertility compared to students in the initial stage. The most widely recognized fertility preservation (FP) method was oocyte cryopreservation, acknowledged by 91.0% of participants, followed by ovarian tissue cryopreservation (45.1%), ovarian transposition surgery prior to pelvic radiation (38.2%), and the use of gonadotropin-releasing hormone (GnRH) analogues for ovarian protection during chemotherapy (28.6%). A small percentage (3.8%) of students were unaware of any of these methods. Regarding age limits for offering fertility preservation, 1.4% of participants believed FP should be available to women only up to the age of 30, 15.9% up to 35, 38.7% up to 40, and 38.4% up to 45. Meanwhile, 5.5% did not provide an answer. Most respondents somewhat to fully agreed that fertility-preserving measures should be offered to patients with a very good disease prognosis (89.0%). Additionally, 94.5% somewhat to fully supported offering these measures to patients with a risk of amenorrhea greater than 20%, and 83.8% to those who had not yet had children. Furthermore, 86.1% and 78.9% endorsed fertility preservation only when the efficacy of oncological therapy was not compromised or delayed, respectively. When asked to assess the safety of assisted reproductive technologies, such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), or hormonal stimulation in patients with a history of hormone-receptor-positive tumors, respondents rated these methods as very to somewhat unsafe (51.2%), neutral (19.8%), and somewhat to very safe (29.1%). Similarly, 48.4% of participants viewed the prospect of a future pregnancy in a patient with a history of a hormone-receptor-positive tumor as very to somewhat unsafe for the oncological course of the disease, while 19.0% remained neutral and 32.7% considered it somewhat to very safe. Lastly, 97.7% of participants believed that a patient's wish to preserve fertility was somewhat to very important. Attitudes of medical students concerning fertility preservation Only 6.4% of respondents viewed reproductive technologies such as IVF, ICSI, or hormonal stimulation negatively, while 6.1% remained neutral and 87.5% expressed a positive opinion. Regarding the cryopreservation of ovarian tissue, 5.2% regarded this method negatively, 9.3% remained neutral, and 85.5% viewed it positively. Oocyte donation was perceived negatively by 12.8% of respondents, neutrally by 9.6%, and positively by the remaining 77.6%. The acceptance for uterus transplantation was high among the participants with 61.4% responding positively (21.2% responding negatively, 17.4% neutrally). The acceptance for surrogacy was lower but more than half of students had a positive attitude (negative: 31.7%, neutral by 15.1%, and positive by 53.2% of respondents). Social freezing was positively received by most respondents (72.7%), while 9.0% remained neutral and 18.3% viewed it negatively. When asked about the legalization of these procedures, 67.5% supported the legalization of oocyte donation, 24.6% were unsure, and 7.8% opposed it. Regarding uterus transplantation, 45.2% approved, 46.4% were uncertain, and 8.4% disapproved. Surrogacy legalization was opposed by 22.6% of respondents, while 42.3% were undecided and 35.1% supported it. Discussion This is the first study aimed at investigating the awareness, knowledge, and attitudes of German medical students regarding fertility preservation and fertility preservation counseling, as well as identifying potential gaps in their academic training. The findings from our survey suggest that knowledge in the area of fertility preservation remains basic. While 91.0% of participants were familiar with oocyte cryopreservation, fewer than half were aware of ovarian tissue cryopreservation, ovarian transposition surgery before pelvic radiation, or the use of GnRH analogues for ovarian protection during chemotherapy. AMH measurement as a method for assessing ovarian reserve was also known by not even half of the participants. Additionally, 29.0% of participants were unaware of any methods for measuring ovarian reserve. The most commonly given answer was luteinizing hormone (LH), follicle-stimulating hormone (FSH) and estrogen measurement, which, however, does not directly indicate ovarian reserve. As their academic training progressed, students became noticeably more knowledgeable about fertility preservation topics, likely reflecting both academic coursework and practical experience within the field of gynecology. Regarding age limits, more than a third of respondents would offer fertility preservation measures to patients up to 45 years of age. This could be attributed to an overestimation of female fertility at that age, but it may also reflect a changing demographic trend, with women becoming mothers at increasingly older ages and social freezing emerging as an option for delayed childbearing. However, several studies show that even medical students tend to overestimate female fertility and underestimate age-related fertility decline 9 , 10 . On a broader societal level, this is concerning, as education at both school and university levels primarily focuses on preventing unwanted pregnancies while rarely addressing the age-related risks of infertility, despite the fact that childbearing age continues to rise in Western countries 11 . Knowledge of age-related infertility should ideally be integrated early into the medical curriculum and also included in high school education to enhance public awareness of this issue. Another important aspect is the safety of reproductive measures and pregnancies in patients who have undergone treatment for hormone receptor-positive tumors. Within our cohort, a significant level of uncertainty was observed on this matter. While studies in breast cancer suggest that reproductive measures and pregnancies are safe and do not negatively affect tumor prognosis 12 , uncertainty still persists within the medical community. Further research into other tumor types is urgently needed. Understanding gonadotoxic effects and fertility preservation options are essential for all physicians, regardless of their medical subspecialty, and therefore should be an integral part of the medical curriculum. Almost all medical subspecialties, not only gynecologic oncology, urological oncology, hematology/oncology, radiology, and radiation oncology, frequently encounter gonadotoxic treatments and fertility-related decisions. Hence, specialists should ensure timely referral of patients to reproductive medicine experts and facilitate multidisciplinary discussions of treatment strategies, taking into account the gonadotoxic potential of therapies. Our survey demonstrated an overwhelmingly positive attitude toward reproductive measures such as IVF, ICSI, and social freezing. This may be related to the fact that female medical students often face the challenge of balancing family planning with career advancement, given that medical education and specialist training in Germany take an average of 11 years to complete – and most of this survey’s respondents were female. As a result, medical students and doctors tend to delay childbearing in order to meet the demands of this time-intensive medical training and the working conditions in hospitals. This is a global trend 13 , to the extent that infertility is more common among U.S. doctors than in the general population 13 . Studies conducted among U.S. medical students revealed that the majority would consider freezing their oocytes if their employer covered the costs 14 . Non-legal options in Germany Until today, Germany’s legislation remains more conservative than that of many other European and Western countries regarding reproductive technologies 15 . Oocyte donation is still prohibited under German Law, while it is legal in countries such as France, Spain, Italy, Denmark, and the Czech Republic 16 . Similarly, surrogacy, which is legal under certain conditions in Denmark and the United Kingdom and fully permitted in Ukraine, remains illegal in Germany 16 . For women unable to carry a pregnancy due to anatomical anomalies, cancer surgery, or other factors, uterus transplantation offers a potential solution. Since the first successful deceased donor transplantation in 2011 and the first live donor birth in 2014, over 30 procedures have been performed worldwide. However, this remains an experimental approach unavailable to most patients 17 . As a result, reproductive options for young cancer survivors facing infertility due to cancer treatment are significantly limited. Our study indicates a more progressive stance on these issues among medical students compared to the general German population. While a clear majority of our cohort supported oocyte donation, a 2009 survey among the German population found that only ~ 51% approved of oocyte donation, with ~ 36% supporting it for medical reasons and just ~ 13% favoring general approval 18 . However, given that this survey was conducted almost 20 years ago, public attitudes may have shifted, although the issue remains controversial. This societal trend is also reflected in a statement by the German National Academy of Sciences Leopoldina, advocating for the legalization of oocyte donation, as the Embryo Protection Law “no longer reflects societal changes and the diversity of modern family structures” 19 . Meanwhile, opinions on surrogacy remained divided within our cohort, with only a third supporting its legalization. Similarly, approval rates for uterus transplantation were only around 45%. For comparison, 45% of healthcare providers and 78% of the general population in the USA approve of uterus transplantation 20 , 21 . When asked whether oocyte donation, surrogacy and uterus transplantation should be legalized, a significant proportion of students remained undecided: ~25%, ~ 42% and ~ 46% respectively. While our survey did not explore whether this uncertainty stemmed from ethical conflicts, professional or scientific considerations or a lack of engagement with the topic, providing education on these matters could help medical students develop informed opinions. Interest in further courses and training The vast majority of students expressed a high interest in expanding their knowledge. Students believed that there is a gap in their academic education on “fertility and cancer” and demanded further courses and trainings preferably in form of clinical rotation, in-person teaching or an online course, in this order. 80.0% of respondents expressed interest in expanding their knowledge of fertility and cancer, and 65.9% desired additional training. While students show interest in the topic throughout all semesters of medical school and knowledge rises significantly with the course of medical school, even in higher semesters general knowledge of fertility preservation techniques and assessment of ovarian reserve remains basic. A strong desire for expanding their knowledge in fertility preservation has also been shown by studies in Hong Kong 10 and in the USA 22 . The emphasis on education is crucial, as the decision to offer counseling on FP significantly impacts not only tumor prognosis, but also the incidence of premature ovarian insufficiency, menopausal symptoms, osteoporosis, sarcopenia, and cardiovascular risk profiles. Moreover, it contributes to lower levels of psychological distress among patients 23 , 24 . Even if patients ultimately decide against fertility preservation after receiving counseling, their satisfaction with and adherence to oncological treatment tends to improve 23 , 24 . Active involvement in decision-making and feeling well-informed about their options also contribute to an enhanced quality of life for patients 23 , 24 . Limitations of the study: The survey only represents the situation in Germany, limiting the generalizability of our findings. Moreover, the variability in medical curricula across Germany may have influenced participants' knowledge and exposure to fertility preservation. Noting the high number of female respondents and the differences in demographics of our participants and medical students in Germany, we acknowledge that our participants may not fully represent medical students overall. The survey relied on self-reported data, which may introduce response bias. These contextual factors should be considered when interpreting our findings. Conclusion In conclusion, this study highlights the urgent need to systematically integrate fertility preservation and oncofertility into the curriculum of medical school in Germany, taking into consideration the limited knowledge but stark interest medical students displayed. To ensure high-quality fertility preservation counseling and the implementation of necessary FP measures for all cancer patients of childbearing age, it is crucial that future physicians are familiar with methods for assessing ovarian reserve and fertility preservation techniques. Strengthening oncofertility training in medical education will enhance future physicians' ability to provide informed counseling and timely referrals, ultimately improving patient care and quality of life. Declarations Funding statement: no funding CRediT Authorship Contribution Statement: J Altmann: conceptualization, project development, data collection, formal analysis, and manuscript composition D Dimitrova: project development, manuscript editing E Stark: formal analysis, manuscript editing N Einsiedel: formal analysis, manuscript editing L Heistermann: survey distribution, data collection J Sehouli: project development, survey distribution, manuscript editing, oversight Attestation statements: Data regarding any of the subjects in the study has not been previously published unless specified. Data will be made available to the editors of the journal pre and/or post publication for review or query upon request. The appropriate checklist for this study design was followed: Checklist for Reporting Of Survey Studies (CROSS). Data sharing statement: Data will be shared upon request. Trial Registration: not applicable Capsule : The present survey underscores the imperative for enhanced training, as participants exhibit limited knowledge but a significant interest in improving their understanding of fertility preservation techniques. Declaration of generative AI and AI-assisted technologies in the manuscript preparation process During the preparation of this work the authors used ChatGPT for some translations from the German language into English. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article. References Letourneau JM, Ebbel EE, Katz PP, Katz A, Ai WZ, Chien AJ, Melisko ME, Cedars MI, Rosen MP. Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer. Cancer. 2012;118(6):1710–7. doi: 10.1002/cncr.26459 . Epub 2011 Sep 1. PMID: 21887678; PMCID: PMC3235264. Benedict C, Thom B, N Friedman D, Diotallevi D, M Pottenger E, J Raghunathan N, Kelvin JF. Young adult female cancer survivors' unmet information needs and reproductive concerns contribute to decisional conflict regarding posttreatment fertility preservation. Cancer. 2016;122(13):2101–9. doi: 10.1002/cncr.29917 . Epub 2016 May 23. PMID: 27213483; PMCID: PMC4911318. Lambertini M, Peccatori F A, Demeestere I, Amant F, Wyns C, Stukenborg J-B et al. Fertility preservation and post-treatment pregnancies in post-pubertal cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2020;31(12):1664–1678. doi: 10.1016/j.annonc.2020.09.006 . Richtlinie zur Kryokonservierung des Gemeinsamen Bundesausschusses (G-BA) ESHRE Guideline Group on Female Fertility Preservation; Anderson R A, Amant F, Braat D, D'Angelo A, Chuva de Sousa Lopes S M, Demeestere I et al. ESHRE guideline: female fertility preservation. Hum Reprod Open. 2020;2020(4):hoaa052. doi: 10.1093/hropen/hoaa052 German Guideline: S2k-Leitlinie „Fertilitätserhalt bei onkologischen Erkrankungen“, 2017 Altmann J, Dimitrova D, Boer J, Sehouli J. MONITOR 25: A Pilot Survey among Health Care Professionals Regarding Fertility Preservation Counseling in Gynecological Cancer Patients. Ann Obstet Gynecol. 2024; 7(2): 1065. Wickham H (2016). ggplot2: Elegant Graphics for Data Analysis . Springer-Verlag New York. Osaah M, Damalie FJMK, Amoah VMK, Senaya CM, Dankluvi HE, Yeboah B, Damalie EA, Kolbilla DZ. Fertility knowledge, childbearing intentions and attitudes towards social egg freezing: A study of female students of a private university in Kumasi, Ghana. BMC Womens Health. 2024;24(1):553. doi: 10.1186/s12905-024-03387-3 . PMID: 39379906; PMCID: PMC11459717. Ng EYL, Ip JKH, Mak DR, Chan AYW, Chung JPW. Awareness of fertility preservation among Chinese medical students. Hong Kong Med J. 2020;26(3):184–191. doi: 10.12809/hkmj208390 . Epub 2020 May 28. PMID: 32482910. Esposito G, Parazzini F, Chatenoud L, Santucci C, La Vecchia C, Negri E. Parents' age and total fertility rate in selected high-income countries from Europe and North America, 1990–2020. Eur J Obstet Gynecol Reprod Biol. 2024;299:32–36. doi: 10.1016/j.ejogrb.2024.05.031. Epub 2024 May 26. PMID: 38824811. Azim AA, Costantini-Ferrando M, Oktay K. Safety of fertility preservation by ovarian stimulation with letrozole and gonadotropins in patients with breast cancer: a prospective controlled study. J Clin Oncol. 2008;26(16):2630-5. doi: 10.1200/JCO.2007.14.8700 . PMID: 18509175. Armstrong AG, Woods M, Keomany J, Grainger D, Shah S, Pavone M. What do female medical students know about planned oocyte cryopreservation and what are their personal attitudes? J Assist Reprod Genet. 2023;40(6):1305–1311. doi: 10.1007/s10815-023-02845-5 . Epub 2023 Jun 22. PMID: 37347348; PMCID: PMC10310635. Mahesan AM, Sadek S, Ramadan H, Bocca S, Paul ABM, Stadtmauer L. Knowledge and attitudes regarding elective oocyte cryopreservation in undergraduate and medical students. Fertil Res Pract. 2019;5:5. doi: 10.1186/s40738-019-0057-9 . PMID: 31007938; PMCID: PMC6458751. German Embryo Protection Law: "Embryonenschutzgesetz vom 13. Dezember 1990 (BGBl. I S. 2746), das zuletzt durch Artikel 1 des Gesetzes vom 21. November 2011 (BGBl. I S. 2228) geändert worden ist" Piersanti V, Consalvo F, Signore F, Del Rio A, Zaami S. Surrogacy and "Procreative Tourism". What Does the Future Hold from the Ethical and Legal Perspectives? Medicina (Kaunas). 2021;57(1):47. doi: 10.3390/medicina57010047 . PMID: 33429930; PMCID: PMC7827900. Practice Committee of the American Society for Reproductive Medicine. American Society for Reproductive Medicine position statement on uterus transplantation: a committee opinion. Fertil Steril. 2018;110(4):605–610. doi: 10.1016/j.fertnstert.2018.06.017 . PMID: 30196945. Stöbel-Richter Y, Goldschmidt S, Brähler E, Weidner K, Beutel M. Egg donation, surrogate mothering, and cloning: attitudes of men and women in Germany based on a representative survey. Fertil Steril. 2009;92(1):124–30. Stellungnahme der Leopoldina Nationale Akademie der Wissenschaften „Fortpflanzungsmedizin in Deutschland –für eine zeitgemäße Gesetzgebung“ 2019 Hariton E, Bortoletto P, Goldman RH, Farland LV, Ginsburg ES, Gargiulo AR. A Survey of Public Opinion in the United States Regarding Uterine Transplantation. J Minim Invasive Gynecol. 2018 Sep-Oct;25(6):980–985. doi: 10.1016/j.jmig.2018.03.001. Epub 2018 Mar 7. Riggan KA, Khan Z, Langstraat CL, Allyse MA. Provider Knowledge and Support of Uterus Transplantation: Surveying Multidisciplinary Team Members. Mayo Clin Proc Innov Qual Outcomes. 2020;4(2):150–158. doi: 10.1016/j.mayocpiqo.2019.11.001. eCollection 2020 Apr. Hunt KN, Kelly AG, Faubion L, Melikian R, Pearson C, Plowden TC, Files JA, Chamorro Dauer LV, Marshall AL, Blakemore JK. Fertility Knowledge and Educational Experiences of Graduating Medical Students: A Multi-Institution Survey. J Womens Health (Larchmt). 2024;33(8):1095–1101. doi: 10.1089/jwh.2023.1016. Epub 2024 Apr 5. PMID: 38578025. Armuand GM, Wettergren L, Rodriguez-Wallberg KA, Lampic C. Desire for children, difficulties achieving a pregnancy, and infertility distress 3 to 7 years after cancer diagnosis. Support Care Cancer 22(10):2805–2812. Logan S, Perz J, Ussher JM, Peate M, Anazodo A. Systematic review of fertility-related psychological distress in cancer patients: informing on an improved model of care. Psychooncology. 28(1):22–30. Tables Table 1 to 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1.docx Table2.docx Cite Share Download PDF Status: Published Journal Publication published 29 Apr, 2026 Read the published version in Archives of Gynecology and Obstetrics → Version 1 posted Editorial decision: Revision requested 01 Mar, 2026 Reviews received at journal 21 Feb, 2026 Reviewers agreed at journal 09 Feb, 2026 Reviewers invited by journal 09 Feb, 2026 Editor assigned by journal 09 Feb, 2026 Submission checks completed at journal 08 Feb, 2026 First submitted to journal 06 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8809165","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":588380294,"identity":"07be31e8-c113-4541-9bd3-a7c77f52e904","order_by":0,"name":"Judith Altmann","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABEElEQVRIie2PMUvDQBTHXwic0zkHSrmvcKGDg1G/SkIgLgp1q+DQ6Tq0kDX9FpFAqZOvBJwSsxYyuXSOOArFl4aCUC6uDvcbHtz78+N/D8Bg+IdYU5BIA867tweSJnZJj7KhlLHDO+oU7FEICb+U/KBAn2In4XP+uQbBxDz4elhX4uKs/MibCQxj3ceSaIybAlzFeDZYFrX7sriViAWMlpoaK7mjWxRYpKQDrmpfYgTtJkixX7lpW765evdltSNlD8HrH0pAyopa0JfbtmVKLbpbFrsxlsoJFbtfXXIVuumWWoo3Z5RoWtxZmDWPyruK7TKruboWsorsZvLkDWPN+W63d06C080RoU0MBoPBcOQHd/lnT8z3YWQAAAAASUVORK5CYII=","orcid":"","institution":"Charité - University Hospital Berlin","correspondingAuthor":true,"prefix":"","firstName":"Judith","middleName":"","lastName":"Altmann","suffix":""},{"id":588380295,"identity":"0ee2bd62-e030-4496-a055-309d4063c91a","order_by":1,"name":"Desislava Dimitrova","email":"","orcid":"","institution":"Charité - University Hospital Berlin","correspondingAuthor":false,"prefix":"","firstName":"Desislava","middleName":"","lastName":"Dimitrova","suffix":""},{"id":588380296,"identity":"9e90e653-3c6c-4874-aea0-4b0650f59f01","order_by":2,"name":"Elena Stark","email":"","orcid":"","institution":"Charité - University Hospital Berlin","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Stark","suffix":""},{"id":588380297,"identity":"0ac8665e-9cff-4812-9a4b-f5a9a60bffaa","order_by":3,"name":"Nadine Einsiedel","email":"","orcid":"","institution":"Charité - University Hospital Berlin","correspondingAuthor":false,"prefix":"","firstName":"Nadine","middleName":"","lastName":"Einsiedel","suffix":""},{"id":588380298,"identity":"94f17743-9724-4c66-a96e-e620901dfc7b","order_by":4,"name":"Lea Heistermann","email":"","orcid":"","institution":"Charité - University Hospital Berlin","correspondingAuthor":false,"prefix":"","firstName":"Lea","middleName":"","lastName":"Heistermann","suffix":""},{"id":588380299,"identity":"d1b473a1-8023-4860-a97e-405776b10e55","order_by":5,"name":"Jalid Sehouli","email":"","orcid":"","institution":"Charité - University Hospital Berlin","correspondingAuthor":false,"prefix":"","firstName":"Jalid","middleName":"","lastName":"Sehouli","suffix":""}],"badges":[],"createdAt":"2026-02-06 16:12:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8809165/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8809165/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00404-026-08425-z","type":"published","date":"2026-04-29T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":102745838,"identity":"b8926d42-2a01-4ff7-adde-abfbdb3fe5af","added_by":"auto","created_at":"2026-02-16 08:54:17","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":173484,"visible":true,"origin":"","legend":"\u003cp\u003eknowledge of any methods of assessing ovarian reserve in relation to study progress\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8809165/v1/012dd310d5ec9388d9f3da53.png"},{"id":102442230,"identity":"acf4893b-0a68-4905-927a-609502e882fe","added_by":"auto","created_at":"2026-02-11 17:03:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":180143,"visible":true,"origin":"","legend":"\u003cp\u003eknowledge of AMH (Anti-Muellerian Hormone) as a measurement of ovarian reserve in relation to study progress\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8809165/v1/9db61ee5e4e103207605f57e.png"},{"id":108438800,"identity":"c76dda43-6b62-4f0b-8fbf-e793a7b7bb2d","added_by":"auto","created_at":"2026-05-04 16:10:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":522003,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8809165/v1/e2f6abc2-1e3d-4cb6-a13d-24428eed77c1.pdf"},{"id":102745832,"identity":"7934dbcd-72de-4e7b-92d9-01fb224d205f","added_by":"auto","created_at":"2026-02-16 08:54:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":22196,"visible":true,"origin":"","legend":"","description":"","filename":"Table1.docx","url":"https://assets-eu.researchsquare.com/files/rs-8809165/v1/fd54d48a957ebb290ab7c80f.docx"},{"id":102745461,"identity":"d4a35ab7-3106-4b6e-a55f-dc50da2feb93","added_by":"auto","created_at":"2026-02-16 08:50:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":3764735,"visible":true,"origin":"","legend":"","description":"","filename":"Table2.docx","url":"https://assets-eu.researchsquare.com/files/rs-8809165/v1/0ee65a5c40efa985f8caa204.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eImproving Future Care: The Role of Oncofertility Education in Medical Curricula in Germany. Results of a nationwide survey of 346 medical students\u003c/p\u003e","fulltext":[{"header":"Introduction","content":" \u003cp\u003eInfertility and premature ovarian insufficiency as a result of cancer treatment significantly increase the burden that young cancer patients must carry\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e, leading to unintended childlessness, menopausal symptoms, osteoporosis, sarcopenia, and an increased cardiovascular risk.\u003c/p\u003e \u003cp\u003eAll cancer patients of reproductive age, regardless of the type and stage of the disease, should receive comprehensive oncofertility counseling as early as possible in the treatment planning process, as stated in the ESMO guideline\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In Germany, as of July 2021, female cancer patients are even entitled to statutory health insurance coverage for fertility-preserving treatments\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Despite the existence of this and several other European guidelines\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, studies highlight that many patients still do not receive adequate counseling or referrals to reproductive medicine specialists\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhen asked about the reasons for not offering fertility preservation counseling to gynecological cancer patients, doctors cite a lack of knowledge, insufficient prioritization, and time constraints\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Medical students, as tomorrow's healthcare providers, are the key to improving fertility preservation counseling in the future, making their education on the topic critical for enhancing care quality.\u003c/p\u003e \u003cp\u003eThis study aims to examine the current knowledge, attitudes, and interest of medical students in providing fertility preservation counseling for cancer patients.\u003c/p\u003e "},{"header":"Methods","content":"\u003cp\u003e Prior to commencing the study, approval was obtained from the Ethics Committee of Charit\u0026eacute;. A multi-center nationwide survey was conducted among medical students across Germany.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe survey consisted of 15 multiple-choice questions and six questions asking participants their level of agreement of the statement on a scale from 0 (=\u0026thinsp;completely disagree) to 10 (completely agree). In our analysis we considered values under five as disagreement, five as neutral and above five as agreement. Knowledge questions were multiple choice.\u003c/p\u003e \u003cp\u003eThe questionnaire gathered information on respondents' demographics such as gender, personal expertise and knowledge related to fertility preservation counseling and whether this topic had already been covered in university classes. Knowledge of different techniques and measures of fertility preservation was tested. The last section asked participants about their personal opinions regarding fertility preservation measures, including procedures not yet legalized or established in Germany.\u003c/p\u003e \u003cp\u003eA pilot phase involving interviews with 10 medical students was conducted to confirm the comprehensibility and feasibility of the questionnaire. The survey was administered online from 03/2024 to 08/2024.\u003c/p\u003e \u003cp\u003eCategorical data were presented as percentages. Percentages were calculated on the basis of the total number of responses for each question individually and rounded to one decimal place.\u003c/p\u003e \u003cp\u003eFor conducting the online survey, we used the software REDCap. Figures were created using the R package ggplot2\u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eExploratory statistical analysis was performed using IBM SPSS Statistics (version 29.0.2.0.(20)). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to quantify associations.\u003c/p\u003e \u003cp\u003eTo evaluate potential associations between the students\u0026rsquo; academic progress and the extent of their knowledge, a bivariate analysis was performed between the knowledge of AMH as a marker of fertility and the study progress (grouped into 1st to 4th semester, 5th to 8th semester and 9th to 13th semester).\u003c/p\u003e \u003cp\u003eTo assess the influence of practical experience in the field of gynecology on students\u0026rsquo; knowledge, a bivariate analysis was conducted between knowledge of any method used to assess ovarian reserve and the variable of having practical experience in the field of gynecology. Knowing any measurement of assessing ovarian reserve included the knowledge of AMH levels, antral follicle count (AFC) and measuring luteinizing hormone (LH), follicle-stimulating hormone (FSH) and estrogen.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDemographic characteristics of respondents\u003c/h2\u003e \u003cp\u003eA total of 346 medical students answered the online survey. Students were distributed as follows across their medical studies: 20.8% in the 1st to 4th semester, 47.7% in the 5th to 8th semester, and 31.5% in the 9th to 13th semester of their studies. 43.4% of students had already studied gynecology as part of their curriculum, and 43.6% had acquired practical experience in this field. 36.1% of students stated that they had attended a seminar on \u0026ldquo;fertility preservation in cancer patients\u0026rdquo; in university.\u003c/p\u003e \u003cp\u003e80.3% of the respondents identified as female, 18.2% as male, 1.2% as non-binary, and 0.3% chose not to respond to this question. In terms of parental status, a significant majority of participants, specifically 92.5%, reported not having children of their own. Furthermore, 3.5% of the participants indicated that they had utilized the services of a reproductive medicine specialist at some point.\u003c/p\u003e \u003cp\u003eWhen asked to rate the importance of having biological children on a scale from 0 to 10, 74.4% of participants considered it to be somewhat to very important to them personally.\u003c/p\u003e \u003cp\u003eFor a detailed breakdown of demographic characteristics, refer to table 1.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eNeed for Training\u003c/h3\u003e\n\u003cp\u003eWhen asked about their interest in \u0026ldquo;fertility and cancer,\u0026rdquo; 80.0% of participants expressed a desire to gain more knowledge in reproductive medicine, while 15.9% responded with \u0026ldquo;no interest,\u0026rdquo; and 4.1% did not provide an answer. 65.9% of participants expressed interest in further classes and training on \u0026ldquo;fertility and cancer,\u0026rdquo; while 17.1% responded with \u0026ldquo;no,\u0026rdquo; and 17.1% did not provide an answer. 35.1% preferred further training on \u0026ldquo;fertility and cancer\u0026rdquo; through a clinical rotation at a specialized center, 29.4% favored in-person training, and 22.4% preferred an online course. Even among medical students who had already encountered fertility-related topics in their curriculum, there was a strong demand for additional education and training opportunities.\u003c/p\u003e \u003cp\u003eOnly 14.5% of students stated that \u0026ldquo;fertility and cancer\u0026rdquo; was adequately covered during their studies, while 44.1% felt the topic was not sufficiently addressed, and 41.4% did not provide an answer (see table 2).\u003c/p\u003e\n\u003ch3\u003eKnowledge regarding fertility preservation\u003c/h3\u003e\n\u003cp\u003eWhen asked about their knowledge of methods to assess ovarian reserve in women, 29% of students were unaware of any (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The most recognized approach was hormonal measurement, including luteinizing hormone (LH), follicle-stimulating hormone (FSH), and estrogen (56.2%). Anti-M\u0026uuml;llerian hormone (AMH) testing was known by 38.8% of students (see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), while only 15.9% were familiar with the antral follicle count (AFC) method.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eStudents with practical experience in the field of gynecology (e.g. through internships) were significantly more likely to know any measurement of ovarian reserve than those without (OR\u0026thinsp;=\u0026thinsp;1.960; CI\u0026thinsp;=\u0026thinsp;1.261\u0026ndash;3.046) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, while in the first four semesters only 6.9% of students knew AMH as a measurement of fertility, this proportion increased to 42.1% among students in the fifth to eighth semester and to 54.1% among students in the ninth to thirteenth semester (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This increase throughout the semesters was statistically significant with students in the intermediate stage of their studies being nearly ten times more likely (OR\u0026thinsp;=\u0026thinsp;9.733; CI\u0026thinsp;=\u0026thinsp;3.726\u0026ndash;25.420) and in the final stage more than fifteen times more likely (OR\u0026thinsp;=\u0026thinsp;15.812; CI\u0026thinsp;=\u0026thinsp;5.913\u0026ndash;42.284) to know AMH as a marker of fertility compared to students in the initial stage.\u003c/p\u003e \u003cp\u003eThe most widely recognized fertility preservation (FP) method was oocyte cryopreservation, acknowledged by 91.0% of participants, followed by ovarian tissue cryopreservation (45.1%), ovarian transposition surgery prior to pelvic radiation (38.2%), and the use of gonadotropin-releasing hormone (GnRH) analogues for ovarian protection during chemotherapy (28.6%). A small percentage (3.8%) of students were unaware of any of these methods.\u003c/p\u003e \u003cp\u003eRegarding age limits for offering fertility preservation, 1.4% of participants believed FP should be available to women only up to the age of 30, 15.9% up to 35, 38.7% up to 40, and 38.4% up to 45. Meanwhile, 5.5% did not provide an answer.\u003c/p\u003e \u003cp\u003eMost respondents somewhat to fully agreed that fertility-preserving measures should be offered to patients with a very good disease prognosis (89.0%). Additionally, 94.5% somewhat to fully supported offering these measures to patients with a risk of amenorrhea greater than 20%, and 83.8% to those who had not yet had children. Furthermore, 86.1% and 78.9% endorsed fertility preservation only when the efficacy of oncological therapy was not compromised or delayed, respectively.\u003c/p\u003e \u003cp\u003eWhen asked to assess the safety of assisted reproductive technologies, such as in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), or hormonal stimulation in patients with a history of hormone-receptor-positive tumors, respondents rated these methods as very to somewhat unsafe (51.2%), neutral (19.8%), and somewhat to very safe (29.1%).\u003c/p\u003e \u003cp\u003eSimilarly, 48.4% of participants viewed the prospect of a future pregnancy in a patient with a history of a hormone-receptor-positive tumor as very to somewhat unsafe for the oncological course of the disease, while 19.0% remained neutral and 32.7% considered it somewhat to very safe.\u003c/p\u003e \u003cp\u003eLastly, 97.7% of participants believed that a patient's wish to preserve fertility was somewhat to very important.\u003c/p\u003e\n\u003ch3\u003eAttitudes of medical students concerning fertility preservation\u003c/h3\u003e\n\u003cp\u003eOnly 6.4% of respondents viewed reproductive technologies such as IVF, ICSI, or hormonal stimulation negatively, while 6.1% remained neutral and 87.5% expressed a positive opinion.\u003c/p\u003e \u003cp\u003eRegarding the cryopreservation of ovarian tissue, 5.2% regarded this method negatively, 9.3% remained neutral, and 85.5% viewed it positively.\u003c/p\u003e \u003cp\u003eOocyte donation was perceived negatively by 12.8% of respondents, neutrally by 9.6%, and positively by the remaining 77.6%.\u003c/p\u003e \u003cp\u003eThe acceptance for uterus transplantation was high among the participants with 61.4% responding positively (21.2% responding negatively, 17.4% neutrally). The acceptance for surrogacy was lower but more than half of students had a positive attitude (negative: 31.7%, neutral by 15.1%, and positive by 53.2% of respondents).\u003c/p\u003e \u003cp\u003eSocial freezing was positively received by most respondents (72.7%), while 9.0% remained neutral and 18.3% viewed it negatively.\u003c/p\u003e \u003cp\u003eWhen asked about the legalization of these procedures, 67.5% supported the legalization of oocyte donation, 24.6% were unsure, and 7.8% opposed it.\u003c/p\u003e \u003cp\u003eRegarding uterus transplantation, 45.2% approved, 46.4% were uncertain, and 8.4% disapproved.\u003c/p\u003e \u003cp\u003eSurrogacy legalization was opposed by 22.6% of respondents, while 42.3% were undecided and 35.1% supported it.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis is the first study aimed at investigating the awareness, knowledge, and attitudes of German medical students regarding fertility preservation and fertility preservation counseling, as well as identifying potential gaps in their academic training.\u003c/p\u003e \u003cp\u003eThe findings from our survey suggest that knowledge in the area of fertility preservation remains basic. While 91.0% of participants were familiar with oocyte cryopreservation, fewer than half were aware of ovarian tissue cryopreservation, ovarian transposition surgery before pelvic radiation, or the use of GnRH analogues for ovarian protection during chemotherapy. AMH measurement as a method for assessing ovarian reserve was also known by not even half of the participants. Additionally, 29.0% of participants were unaware of any methods for measuring ovarian reserve. The most commonly given answer was luteinizing hormone (LH), follicle-stimulating hormone (FSH) and estrogen measurement, which, however, does not directly indicate ovarian reserve.\u003c/p\u003e \u003cp\u003eAs their academic training progressed, students became noticeably more knowledgeable about fertility preservation topics, likely reflecting both academic coursework and practical experience within the field of gynecology.\u003c/p\u003e \u003cp\u003eRegarding age limits, more than a third of respondents would offer fertility preservation measures to patients up to 45 years of age. This could be attributed to an overestimation of female fertility at that age, but it may also reflect a changing demographic trend, with women becoming mothers at increasingly older ages and social freezing emerging as an option for delayed childbearing. However, several studies show that even medical students tend to overestimate female fertility and underestimate age-related fertility decline\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOn a broader societal level, this is concerning, as education at both school and university levels primarily focuses on preventing unwanted pregnancies while rarely addressing the age-related risks of infertility, despite the fact that childbearing age continues to rise in Western countries\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Knowledge of age-related infertility should ideally be integrated early into the medical curriculum and also included in high school education to enhance public awareness of this issue.\u003c/p\u003e \u003cp\u003eAnother important aspect is the safety of reproductive measures and pregnancies in patients who have undergone treatment for hormone receptor-positive tumors. Within our cohort, a significant level of uncertainty was observed on this matter. While studies in breast cancer suggest that reproductive measures and pregnancies are safe and do not negatively affect tumor prognosis\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e, uncertainty still persists within the medical community. Further research into other tumor types is urgently needed.\u003c/p\u003e \u003cp\u003eUnderstanding gonadotoxic effects and fertility preservation options are essential for all physicians, regardless of their medical subspecialty, and therefore should be an integral part of the medical curriculum. Almost all medical subspecialties, not only gynecologic oncology, urological oncology, hematology/oncology, radiology, and radiation oncology, frequently encounter gonadotoxic treatments and fertility-related decisions. Hence, specialists should ensure timely referral of patients to reproductive medicine experts and facilitate multidisciplinary discussions of treatment strategies, taking into account the gonadotoxic potential of therapies.\u003c/p\u003e \u003cp\u003eOur survey demonstrated an overwhelmingly positive attitude toward reproductive measures such as IVF, ICSI, and social freezing. This may be related to the fact that female medical students often face the challenge of balancing family planning with career advancement, given that medical education and specialist training in Germany take an average of 11 years to complete \u0026ndash; and most of this survey\u0026rsquo;s respondents were female. As a result, medical students and doctors tend to delay childbearing in order to meet the demands of this time-intensive medical training and the working conditions in hospitals. This is a global trend\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, to the extent that infertility is more common among U.S. doctors than in the general population\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Studies conducted among U.S. medical students revealed that the majority would consider freezing their oocytes if their employer covered the costs\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eNon-legal options in Germany\u003c/h2\u003e \u003cp\u003eUntil today, Germany\u0026rsquo;s legislation remains more conservative than that of many other European and Western countries regarding reproductive technologies\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Oocyte donation is still prohibited under German Law, while it is legal in countries such as France, Spain, Italy, Denmark, and the Czech Republic\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Similarly, surrogacy, which is legal under certain conditions in Denmark and the United Kingdom and fully permitted in Ukraine, remains illegal in Germany\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. For women unable to carry a pregnancy due to anatomical anomalies, cancer surgery, or other factors, uterus transplantation offers a potential solution. Since the first successful deceased donor transplantation in 2011 and the first live donor birth in 2014, over 30 procedures have been performed worldwide. However, this remains an experimental approach unavailable to most patients\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. As a result, reproductive options for young cancer survivors facing infertility due to cancer treatment are significantly limited.\u003c/p\u003e \u003cp\u003eOur study indicates a more progressive stance on these issues among medical students compared to the general German population. While a clear majority of our cohort supported oocyte donation, a 2009 survey among the German population found that only\u0026thinsp;~\u0026thinsp;51% approved of oocyte donation, with ~\u0026thinsp;36% supporting it for medical reasons and just\u0026thinsp;~\u0026thinsp;13% favoring general approval\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. However, given that this survey was conducted almost 20 years ago, public attitudes may have shifted, although the issue remains controversial. This societal trend is also reflected in a statement by the German National Academy of Sciences Leopoldina, advocating for the legalization of oocyte donation, as the Embryo Protection Law \u0026ldquo;no longer reflects societal changes and the diversity of modern family structures\u0026rdquo;\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMeanwhile, opinions on surrogacy remained divided within our cohort, with only a third supporting its legalization. Similarly, approval rates for uterus transplantation were only around 45%. For comparison, 45% of healthcare providers and 78% of the general population in the USA approve of uterus transplantation\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. When asked whether oocyte donation, surrogacy and uterus transplantation should be legalized, a significant proportion of students remained undecided: ~25%, ~\u0026thinsp;42% and ~\u0026thinsp;46% respectively. While our survey did not explore whether this uncertainty stemmed from ethical conflicts, professional or scientific considerations or a lack of engagement with the topic, providing education on these matters could help medical students develop informed opinions.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInterest in further courses and training\u003c/h3\u003e\n\u003cp\u003eThe vast majority of students expressed a high interest in expanding their knowledge. Students believed that there is a gap in their academic education on \u0026ldquo;fertility and cancer\u0026rdquo; and demanded further courses and trainings preferably in form of clinical rotation, in-person teaching or an online course, in this order.\u003c/p\u003e \u003cp\u003e80.0% of respondents expressed interest in expanding their knowledge of fertility and cancer, and 65.9% desired additional training. While students show interest in the topic throughout all semesters of medical school and knowledge rises significantly with the course of medical school, even in higher semesters general knowledge of fertility preservation techniques and assessment of ovarian reserve remains basic.\u003c/p\u003e \u003cp\u003eA strong desire for expanding their knowledge in fertility preservation has also been shown by studies in Hong Kong\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and in the USA\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe emphasis on education is crucial, as the decision to offer counseling on FP significantly impacts not only tumor prognosis, but also the incidence of premature ovarian insufficiency, menopausal symptoms, osteoporosis, sarcopenia, and cardiovascular risk profiles. Moreover, it contributes to lower levels of psychological distress among patients\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Even if patients ultimately decide against fertility preservation after receiving counseling, their satisfaction with and adherence to oncological treatment tends to improve\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Active involvement in decision-making and feeling well-informed about their options also contribute to an enhanced quality of life for patients\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\n\u003ch3\u003eLimitations of the study:\u003c/h3\u003e\n\u003cp\u003eThe survey only represents the situation in Germany, limiting the generalizability of our findings. Moreover, the variability in medical curricula across Germany may have influenced participants' knowledge and exposure to fertility preservation. Noting the high number of female respondents and the differences in demographics of our participants and medical students in Germany, we acknowledge that our participants may not fully represent medical students overall. The survey relied on self-reported data, which may introduce response bias. These contextual factors should be considered when interpreting our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study highlights the urgent need to systematically integrate fertility preservation and oncofertility into the curriculum of medical school in Germany, taking into consideration the limited knowledge but stark interest medical students displayed.\u003c/p\u003e \u003cp\u003eTo ensure high-quality fertility preservation counseling and the implementation of necessary FP measures for all cancer patients of childbearing age, it is crucial that future physicians are familiar with methods for assessing ovarian reserve and fertility preservation techniques. Strengthening oncofertility training in medical education will enhance future physicians' ability to provide informed counseling and timely referrals, ultimately improving patient care and quality of life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding statement:\u0026nbsp;\u003c/strong\u003eno funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCRediT Authorship Contribution Statement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJ Altmann: conceptualization, project development, data collection, formal analysis, and manuscript composition\u003c/p\u003e\n\u003cp\u003eD Dimitrova: \u0026nbsp; project development, manuscript editing\u003c/p\u003e\n\u003cp\u003eE Stark: formal analysis, manuscript editing\u003c/p\u003e\n\u003cp\u003eN Einsiedel: formal analysis, manuscript editing\u003c/p\u003e\n\u003cp\u003eL Heistermann: survey distribution, data collection\u003c/p\u003e\n\u003cp\u003eJ Sehouli: project development, survey distribution, manuscript editing, oversight\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttestation statements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData regarding any of the subjects in the study has not been previously published unless specified.\u003c/p\u003e\n\u003cp\u003eData will be made available to the editors of the journal pre and/or post publication for review or query upon request.\u003c/p\u003e\n\u003cp\u003eThe appropriate checklist for this study design was followed: Checklist for Reporting Of Survey Studies (CROSS).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData sharing statement:\u0026nbsp;\u003c/strong\u003eData will be shared upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration:\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCapsule\u003c/strong\u003e: The present survey underscores the imperative for enhanced training, as participants exhibit limited knowledge but a significant interest in improving their understanding of fertility preservation techniques.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of generative AI and AI-assisted technologies in the manuscript preparation process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDuring the preparation of this work the authors used ChatGPT for some translations from the German language into English. After using this tool, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLetourneau JM, Ebbel EE, Katz PP, Katz A, Ai WZ, Chien AJ, Melisko ME, Cedars MI, Rosen MP. Pretreatment fertility counseling and fertility preservation improve quality of life in reproductive age women with cancer. Cancer. 2012;118(6):1710\u0026ndash;7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cncr.26459\u003c/span\u003e\u003cspan address=\"10.1002/cncr.26459\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2011 Sep 1. PMID: 21887678; PMCID: PMC3235264.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBenedict C, Thom B, N Friedman D, Diotallevi D, M Pottenger E, J Raghunathan N, Kelvin JF. Young adult female cancer survivors' unmet information needs and reproductive concerns contribute to decisional conflict regarding posttreatment fertility preservation. Cancer. 2016;122(13):2101\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/cncr.29917\u003c/span\u003e\u003cspan address=\"10.1002/cncr.29917\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2016 May 23. PMID: 27213483; PMCID: PMC4911318.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLambertini M, Peccatori F A, Demeestere I, Amant F, Wyns C, Stukenborg J-B et al. Fertility preservation and post-treatment pregnancies in post-pubertal cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2020;31(12):1664\u0026ndash;1678. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.annonc.2020.09.006\u003c/span\u003e\u003cspan address=\"10.1016/j.annonc.2020.09.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichtlinie zur Kryokonservierung des Gemeinsamen Bundesausschusses (G-BA)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eESHRE Guideline Group on Female Fertility Preservation; Anderson R A, Amant F, Braat D, D'Angelo A, Chuva de Sousa Lopes S M, Demeestere I et al. ESHRE guideline: female fertility preservation. Hum Reprod Open. 2020;2020(4):hoaa052. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/hropen/hoaa052\u003c/span\u003e\u003cspan address=\"10.1093/hropen/hoaa052\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerman Guideline: S2k-Leitlinie \u0026bdquo;Fertilit\u0026auml;tserhalt bei onkologischen Erkrankungen\u0026ldquo;, 2017\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAltmann J, Dimitrova D, Boer J, Sehouli J. MONITOR 25: A Pilot Survey among Health Care Professionals Regarding Fertility Preservation Counseling in Gynecological Cancer Patients. Ann Obstet Gynecol. 2024; 7(2): 1065.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWickham H (2016). \u003cem\u003eggplot2: Elegant Graphics for Data Analysis\u003c/em\u003e. Springer-Verlag New York.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsaah M, Damalie FJMK, Amoah VMK, Senaya CM, Dankluvi HE, Yeboah B, Damalie EA, Kolbilla DZ. Fertility knowledge, childbearing intentions and attitudes towards social egg freezing: A study of female students of a private university in Kumasi, Ghana. BMC Womens Health. 2024;24(1):553. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12905-024-03387-3\u003c/span\u003e\u003cspan address=\"10.1186/s12905-024-03387-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 39379906; PMCID: PMC11459717.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg EYL, Ip JKH, Mak DR, Chan AYW, Chung JPW. Awareness of fertility preservation among Chinese medical students. Hong Kong Med J. 2020;26(3):184\u0026ndash;191. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.12809/hkmj208390\u003c/span\u003e\u003cspan address=\"10.12809/hkmj208390\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2020 May 28. PMID: 32482910.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEsposito G, Parazzini F, Chatenoud L, Santucci C, La Vecchia C, Negri E. Parents' age and total fertility rate in selected high-income countries from Europe and North America, 1990\u0026ndash;2020. Eur J Obstet Gynecol Reprod Biol. 2024;299:32\u0026ndash;36. doi: 10.1016/j.ejogrb.2024.05.031. Epub 2024 May 26. PMID: 38824811.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAzim AA, Costantini-Ferrando M, Oktay K. Safety of fertility preservation by ovarian stimulation with letrozole and gonadotropins in patients with breast cancer: a prospective controlled study. J Clin Oncol. 2008;26(16):2630-5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/JCO.2007.14.8700\u003c/span\u003e\u003cspan address=\"10.1200/JCO.2007.14.8700\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 18509175.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmstrong AG, Woods M, Keomany J, Grainger D, Shah S, Pavone M. What do female medical students know about planned oocyte cryopreservation and what are their personal attitudes? J Assist Reprod Genet. 2023;40(6):1305\u0026ndash;1311. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s10815-023-02845-5\u003c/span\u003e\u003cspan address=\"10.1007/s10815-023-02845-5\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2023 Jun 22. PMID: 37347348; PMCID: PMC10310635.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMahesan AM, Sadek S, Ramadan H, Bocca S, Paul ABM, Stadtmauer L. Knowledge and attitudes regarding elective oocyte cryopreservation in undergraduate and medical students. Fertil Res Pract. 2019;5:5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s40738-019-0057-9\u003c/span\u003e\u003cspan address=\"10.1186/s40738-019-0057-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 31007938; PMCID: PMC6458751.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGerman Embryo Protection Law: \"Embryonenschutzgesetz vom 13. Dezember 1990 (BGBl. I S. 2746), das zuletzt durch Artikel 1 des Gesetzes vom 21. November 2011 (BGBl. I S. 2228) ge\u0026auml;ndert worden ist\"\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiersanti V, Consalvo F, Signore F, Del Rio A, Zaami S. Surrogacy and \"Procreative Tourism\". What Does the Future Hold from the Ethical and Legal Perspectives? Medicina (Kaunas). 2021;57(1):47. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/medicina57010047\u003c/span\u003e\u003cspan address=\"10.3390/medicina57010047\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 33429930; PMCID: PMC7827900.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePractice Committee of the American Society for Reproductive Medicine. American Society for Reproductive Medicine position statement on uterus transplantation: a committee opinion. Fertil Steril. 2018;110(4):605\u0026ndash;610. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.fertnstert.2018.06.017\u003c/span\u003e\u003cspan address=\"10.1016/j.fertnstert.2018.06.017\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. PMID: 30196945.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSt\u0026ouml;bel-Richter Y, Goldschmidt S, Br\u0026auml;hler E, Weidner K, Beutel M. Egg donation, surrogate mothering, and cloning: attitudes of men and women in Germany based on a representative survey. Fertil Steril. 2009;92(1):124\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStellungnahme der Leopoldina Nationale Akademie der Wissenschaften \u0026bdquo;Fortpflanzungsmedizin in Deutschland \u0026ndash;f\u0026uuml;r eine zeitgem\u0026auml;\u0026szlig;e Gesetzgebung\u0026ldquo; 2019\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHariton E, Bortoletto P, Goldman RH, Farland LV, Ginsburg ES, Gargiulo AR. A Survey of Public Opinion in the United States Regarding Uterine Transplantation. J Minim Invasive Gynecol. 2018 Sep-Oct;25(6):980\u0026ndash;985. doi: 10.1016/j.jmig.2018.03.001. Epub 2018 Mar 7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRiggan KA, Khan Z, Langstraat CL, Allyse MA. Provider Knowledge and Support of Uterus Transplantation: Surveying Multidisciplinary Team Members. Mayo Clin Proc Innov Qual Outcomes. 2020;4(2):150\u0026ndash;158. doi: 10.1016/j.mayocpiqo.2019.11.001. eCollection 2020 Apr.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHunt KN, Kelly AG, Faubion L, Melikian R, Pearson C, Plowden TC, Files JA, Chamorro Dauer LV, Marshall AL, Blakemore JK. Fertility Knowledge and Educational Experiences of Graduating Medical Students: A Multi-Institution Survey. J Womens Health (Larchmt). 2024;33(8):1095\u0026ndash;1101. doi: 10.1089/jwh.2023.1016. Epub 2024 Apr 5. PMID: 38578025.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArmuand GM, Wettergren L, Rodriguez-Wallberg KA, Lampic C. Desire for children, difficulties achieving a pregnancy, and infertility distress 3 to 7 years after cancer diagnosis. Support Care Cancer 22(10):2805\u0026ndash;2812.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLogan S, Perz J, Ussher JM, Peate M, Anazodo A. Systematic review of fertility-related psychological distress in cancer patients: informing on an improved model of care. Psychooncology. 28(1):22\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 to 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-gynecology-and-obstetrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"arch","sideBox":"Learn more about [Archives of Gynecology and Obstetrics](https://www.springer.com/journal/404)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/arch/default.aspx","title":"Archives of Gynecology and Obstetrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8809165/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8809165/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo study the existing knowledge, interest and attitudes of medical students regarding fertility preservation measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e: A multi-center nationwide survey was conducted among medical students across Germany. The survey consisted of 15 multiple-choice questions and six questions asking participants their level of agreement of a statement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubjects: \u003c/strong\u003e346 medical students in Germany.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMain Outcome Measures: \u003c/strong\u003eA multi-choice questionnaire was used to evaluate the existing knowledge, interest and attitudes of medical students regarding fertility preservation measures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eRegarding the assessment of ovarian reserve, Anti-Müllerian hormone testing was known by 38.8% of students, while only 15.9% were familiar with the antral follicle count method. The most widely recognized fertility preservation (FP) method was oocyte cryopreservation (91.0%), followed by ovarian tissue cryopreservation (45.1%), ovarian transposition surgery prior to pelvic radiation (38.2%), and the use of gonadotropin-releasing hormone analogues for ovarian protection during chemotherapy (28.6%). Regarding reproductive technologies such as IVF, ICSI, or hormonal stimulation 87.5% of students expressed a positive opinion. Oocyte donation was perceived positively by 77.6%. The acceptance for uterus transplantation was high among participants with 61.4%. The acceptance for surrogacy was lower with 53.2% of respondents. Social freezing was positively received by most respondents (72.7%). 80.0% of respondents expressed interest in expanding their knowledge of fertility and cancer, and 65.9% desired additional training.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eTo ensure high-quality fertility preservation counseling and the implementation of necessary FP measures for all cancer patients of childbearing age, it is crucial that future physicians are familiar with methods for assessing ovarian reserve and fertility preservation techniques. Strengthening oncofertility training in medical education will enhance future physicians' ability to provide informed counseling and timely referrals, ultimately improving patient care and quality of life. This study highlights the urgent need to systematically integrate fertility preservation and oncofertility into the curriculum of medical school in Germany.\u003c/p\u003e","manuscriptTitle":"Improving Future Care: The Role of Oncofertility Education in Medical Curricula in Germany. 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