Data sharing in the modern era involves the use of digital social networks. We evaluated a WhatsApp platform used by Israeli REI physicians for fertility preservation challenges. Content analysis of the dedicated WhatsApp discussion group revealed that this group was rapidly growing and active in aiding physicians to discuss and plan treatment in a wide range of FP cases, for which, published, evidence-based data, is absent. Common issues of concern for FP clinicians included management of oncofertility cases, queries about potential gonadotoxic damage by targeted anti-cancer therapies, and fertility preservation in female patients with premature ovarian insufficiency. We also demonstrated that clinicians found participation in this group useful, including expansion of knowledge and assistance in clinical decision making. This provided an opportunity for a genuine, quantifiable glimpse of real-life concerns of clinicians involved in fertility preservation.
Management of clinical cases of oncofertility were the most frequently discussed issue, prompting a wide range of opinions and clinical options offered by group members. While guidelines offer a general framework for fertility preservation, clinical scenarios often present specific dilemmas requiring prompt solutions. One example is the management of FP immediately after pregnancy, which was discussed in our group during time of analysis. While the first description of a similar case was first published in 2019 [9], actual experience in this situation was shared in the discussion group by clinicians from three centers. This demonstrates how online communication can efficiently summarize clinical approaches and experience of many clinicians when information in standard medical literature is limited.
Interestingly, management of breast cancer, the most common malignancy in women, was raised in only two discussions. We cautiously interpret this finding as reflecting the fact that FP in women with breast cancer has become a mainstream and routinely performed FP service, and therefore raises relatively fewer controversies.
The second most common issue raised was whether FP is indicated before treatment with targeted anti-cancer therapies. Introduction of such agents aims to exclusively affect cancer cells and therefore may have better efficacy and less adverse side effects than classical chemotherapy [4]. However, there is limited data on their potential gonadotoxic effect on humans. Our findings reflect the need for clinicians to make decisions despite uncertainty and lack of knowledge. This reinforces the urgent need for more research in this area [10].
Members also posed queries about management of women and girls with POI. Here, the main issue discussed was the viability of FP given diminished ovarian reserve. This is even more vague and elusive regarding girls, for example with Turner syndrome [11]. Efficacy of OTC in girls with normal ovarian reserve is currently unknown, but will probably be low in girls with ovarian insufficiency, therefore offering OTC in this situation is debatable [12]. On the other hand, women and girls with POI are at high risk to lose their chances for genetic motherhood in the near future, and therefore may prefer OTC even when chances for success are unknown.
The internet has enhanced communication in medicine significantly, for both professional-patient and intra-professional communication. Traditionally, physicians relied on personal communication, local staff meetings or occasional conferences. These are all limited in extent and availability and are time consuming. Asynchronous digital communication offers a platform for timely knowledge sharing and clinical discussion with a community of practice made up of a large number of colleagues who are geographically dispersed. This is especially useful in a relatively new field where the number of specialists practicing in a single center is small. According to our survey, clinicians involved in FP management reported gaining significant knowledge from participating in a dedicated professional WhatsApp group. Moreover, the majority of group members found participation in the group useful for making clinical decisions.
More than half of the participants actively initiated discussions in the WhatsApp group. Members of this group had considerable experience as specialists in obstetrics and gynecology (average 15 years post completion of residency). However, experienced clinicians were not less likely to raise queries, gain knowledge or assistance in clinical decision making than less experienced participants. This highlights the fact that dilemmas in FP are challenging for both highly and less experienced clinicians.
The approach we are describing had several limitations. Ideally, medical decisions should be based upon best available research data rather than on expert opinion. We do not suggest replacing scientific and clinical research with personal opinions and experience. However, in situations where good quality evidence is absent, shared knowledge and opinions via intra-professional consultation can assist physicians and their patients.
Further, participants differ in extent of participation in discussion groups. Differences in knowledge, experience and overconfidence or lack of it may all play a role in participation in such professional group. Perhaps some clinicians may feel uncomfortable in raising queries and possibly exposing lack of professional knowledge and experience to their colleagues. Others may be overconfident and present firm opinions which are not necessarily correct. Therefore, opinions and clinical suggestions presented on such a group should be judged cautiously.
In conclusion, we describe a useful internet platform that aids clinicians involved in fertility preservation to deal with common controversial issues. These findings may direct future research and educational endeavors, including creation of guidelines focusing on key, essential issues relevant to FP clinicians. Intra-professional collaboration by whatsapp group adds knowledge and assists in clinical decision making.