[How I manage chronic myeloid leukemia patients' fertility]

Tyrosine kinase inhibitors (TKIs) have dramatically improved the prognosis of chronic myeloid leukemia (CML), bringing the CML patients' fertility to the forefront of survivorship care. This review outlines current evidence and pragmatic guidance for patients with CML who desire pregnancy. Ideally, patients should achieve and sustain a deep molecular response (MR4.5), fulfill eligibility criteria for treatment-free remission (TFR), discontinue TKIs, and pursue planned conception under close molecular monitoring. When pregnancy occurs during therapy, TKI exposure should be avoided in the first trimester; interferon-alpha (IFN-α) is the preferred option for disease control. In the event of molecular relapse, carefully considered use of imatinib or nilotinib at the lowest effective dose may be employed exclusively in the second or third trimester following multidisciplinary counseling, whereas dasatinib should be avoided throughout gestation. Available data suggest there is minimal impact of TKIs on male fertility; treatment interruption is generally unnecessary. We emphasize structured algorithms, explicit intervention thresholds, and monthly BCR-ABL1 (IS) testing, as well as collaboration with obstetrics, neonatology, and reproductive medicine, including assisted reproductive technologies. Finally, we discuss practical pathways applicable to resource-limited settings to balance maternal-fetal safety with patient values and to support informed, preference-concordant decision-making.