{"entity":{"id":"rejuv-paed-fertility-female","kind":"technology","name":"Fertility in girls and young women treated for cancer, including ovarian tissue freezing","aka":[],"tldr":"Most female survivors treated with chemotherapy and no radiotherapy to the pelvis or brain can become pregnant: the large cohort that asked found chemotherapy-specific effects were few. The exceptions are busulfan, high-dose lomustine, pelvic and cranial radiotherapy and transplant conditioning. Before puberty, freezing ovarian tissue is the only option.","summary":"The reassuring finding first, because it is the one least often passed on. In 10,938 childhood cancer survivors and 3,949 siblings followed in the Childhood Cancer Survivor Study, 38 per cent of survivors reported having or siring a pregnancy against 62 per cent of siblings. Female survivors had a hazard ratio of 0.87 (95 per cent confidence interval 0.81 to 0.94) for pregnancy and 0.82 (0.76 to 0.89) for a livebirth, a smaller reduction than in male survivors. Among women treated with chemotherapy and no pelvic or cranial radiotherapy, only busulfan (below 450 mg/m2, hazard ratio 0.22; 450 mg/m2 or more, 0.14) and lomustine at 411 mg/m2 or more (0.41) were significantly associated with reduced pregnancy, and the cyclophosphamide equivalent dose mattered only in the highest quartile (0.85, 0.74 to 0.98). The authors wrote that the findings \"should provide reassurance to most female survivors treated with chemotherapy without radiotherapy to the pelvis or brain, given that chemotherapy-specific effects on pregnancy were generally few\". They add, in the same sentence, that fertility preservation before treatment \"remains important to maximise the reproductive potential of all adolescents newly diagnosed with cancer\".\n\nWho is actually at risk. Premature ovarian insufficiency follows alkylating agents at high cumulative dose, radiotherapy that includes the ovaries, and conditioning for haematopoietic transplant. In the St Jude Lifetime Cohort the estimated cumulative prevalence of primary ovarian failure at age 50 among women at risk after such treatment was 31.9 per cent (28.0 to 35.8). The International Guideline Harmonization Group, with PanCareSurFup, published harmonised premature ovarian insufficiency surveillance recommendations for women diagnosed under 25, because the national guidelines disagreed about who to screen. Cranial radiotherapy damages the gonadotrophin supply rather than the ovary, which is a different problem with a different treatment.\n\nWhat can be done before treatment. Oocyte or embryo freezing is standard in a post-pubertal young woman who has time for ovarian stimulation. Ovarian tissue cryopreservation needs no stimulation and no delay and is the only option for a girl before puberty. The largest pooled European experience, 285 women across five leading centres, reports that \"Recovery of endocrine function is seen in almost all women undergoing transplantation of ovarian tissue, and about one in four gives birth to a healthy child\", that \"The risk of relapse due to reimplantation of ovarian tissue appears to be very low according to current data\", and that chemotherapy given before the tissue was taken did not impair the chances of success depending on the dose and type. The same review states that \"Radiation to the pelvis, especially with relatively high doses, appears to considerably decrease the likelihood of a successful pregnancy and may be contraindicated\", because the problem then is the uterus and not the ovary. The American Society for Reproductive Medicine's 2019 committee opinion, which replaced the 2013 document, sets out the counselling standard. The 2021 PanCareLIFE and International Guideline Harmonization Group recommendations cover female patients diagnosed at 25 or younger and grade each option.\n\nWhere the honest gap is. For a prepubertal girl, the tissue is frozen without knowing whether it will ever be used, because the technique is young and the follow-up short. The European series is observational, from leading centres, and does not tell a family the chance of a live birth from tissue frozen before puberty specifically. OnCo has not found a figure for that which it is willing to print.\n\nWhat comes back, and when: ovarian function may recover in the months to years after chemotherapy, and a woman who resumes periods is not thereby safe, because the ovarian reserve can be reduced without being exhausted and menopause may come a decade early. That is the reason for surveillance rather than reassurance, and the reason to discuss family planning earlier than a peer would.","status":"standard-of-care","asOf":"2026-10-02","wikipedia":"https://en.wikipedia.org/wiki/Ovarian_tissue_cryopreservation","links":[{"label":"Pregnancy after chemotherapy in male and female survivors of childhood cancer treated between 1970 and 1999 (CCSS) (Lancet Oncol 2016)","url":"https://doi.org/10.1016/S1470-2045(16)00086-3"},{"label":"Transplantation of cryopreserved ovarian tissue in a series of 285 women: a review of five leading European centers (Fertil Steril 2021)","url":"https://doi.org/10.1016/j.fertnstert.2021.03.008"},{"label":"Recommendations for premature ovarian insufficiency surveillance for female survivors of childhood, adolescent and young adult cancer (IGHG with PanCareSurFup) (JCO 2016)","url":"https://doi.org/10.1200/JCO.2015.64.3288"},{"label":"Fertility preservation for female patients with childhood, adolescent and young adult cancer: PanCareLIFE and IGHG recommendations (Lancet Oncol 2021)","url":"https://doi.org/10.1016/S1470-2045(20)30594-5"},{"label":"Fertility preservation in patients undergoing gonadotoxic therapy or gonadectomy: a committee opinion (ASRM) (Fertil Steril 2019)","url":"https://doi.org/10.1016/j.fertnstert.2019.09.013"},{"label":"Clinical ascertainment of health outcomes among adults treated for childhood cancer (SJLIFE) (JAMA 2013)","url":"https://doi.org/10.1001/jama.2013.6296"}],"tags":["rejuvenation","survivorship","paediatric","late-effects","evidence:moderate"],"related":["ighg","pancaresurfup","sjlife","idea-acc-default-fertility-preservation-referral","idea-moon-fertility-preservation-default"],"cancers":["childhood-cancers","all-leukemia","hodgkin-lymphoma","ewing-sarcoma","osteosarcoma","paediatric-germ-cell-tumours"],"sections":["rejuvenation","supportive-care","hormonal"],"technologies":["fertility-preservation","rejuv-paed-pituitary-and-puberty","ovarian-function-after-chemotherapy","menopause-after-cancer-treatment","total-body-irradiation","allogeneic-transplant","rejuv-paed-cog-ltfu-guidelines"],"targets":[],"drugs":["busulfan","lomustine","cyclophosphamide","ifosfamide","procarbazine"],"companies":[],"institutions":[],"pathways":[],"terms":["late-effects","lymphoma-decision-fertility-timing"],"trials":[],"people":[],"bottlenecks":["b-survivorship","b-toxicity-qol"],"keyPapers":[],"journals":[],"dependsOn":[],"notes":[],"principle":"A girl is born with every oocyte she will have. Alkylating agents and ionising radiation destroy primordial follicles without replacement, so the injury shows as a reduced reserve that is consumed at the normal rate from a lower starting point, producing early menopause rather than immediate infertility. Pelvic radiotherapy additionally damages the uterine myometrium and vasculature, which impairs carrying a pregnancy independently of whether eggs are available. Ovarian tissue cryopreservation banks cortical follicles before the exposure and restores both hormone production and, in a minority, fertility when grafted back.","strengths":["Most women treated with chemotherapy alone can conceive, which is worth saying plainly","Ovarian tissue freezing requires no delay and is the only option before puberty","Harmonised international surveillance and fertility preservation guidelines exist for this age group"],"limitations":["No reliable live-birth figure for tissue frozen before puberty specifically","Pelvic radiotherapy damages the uterus, which fertility preservation does not address","Access, funding and referral are inconsistent and the decision has a deadline measured in days"]},"route":"/technologies/rejuv-paed-fertility-female/","neighbours":{"collection":[{"id":"ighg","kind":"collection","name":"International Guideline Harmonization Group for late effects of childhood cancer","route":"/collections/ighg/"},{"id":"pancaresurfup","kind":"collection","name":"PanCareSurFup and the European survivor cohorts","route":"/collections/pancaresurfup/"},{"id":"sjlife","kind":"collection","name":"St Jude Lifetime Cohort Study (SJLIFE)","route":"/collections/sjlife/"}],"idea":[{"id":"idea-acc-default-fertility-preservation-referral","kind":"idea","name":"Default fertility preservation referral for every patient under 40 before treatment","route":"/ideas/idea-acc-default-fertility-preservation-referral/"},{"id":"idea-moon-fertility-preservation-default","kind":"idea","name":"Fertility preservation offered and funded by default before gonadotoxic treatment","route":"/ideas/idea-moon-fertility-preservation-default/"}],"cancer":[{"id":"all-leukemia","kind":"cancer","name":"Acute lymphoblastic leukaemia","route":"/cancers/all-leukemia/"},{"id":"childhood-cancers","kind":"cancer","name":"Childhood cancers (all types)","route":"/cancers/childhood-cancers/"},{"id":"ewing-sarcoma","kind":"cancer","name":"Ewing sarcoma","route":"/cancers/ewing-sarcoma/"},{"id":"paediatric-germ-cell-tumours","kind":"cancer","name":"Germ cell tumours of childhood and adolescence (extracranial and CNS)","route":"/cancers/paediatric-germ-cell-tumours/"},{"id":"hodgkin-lymphoma","kind":"cancer","name":"Hodgkin lymphoma","route":"/cancers/hodgkin-lymphoma/"},{"id":"osteosarcoma","kind":"cancer","name":"Osteosarcoma","route":"/cancers/osteosarcoma/"}],"section":[{"id":"hormonal","kind":"section","name":"Hormonal Therapy","route":"/fronts/hormonal/"},{"id":"rejuvenation","kind":"section","name":"Recovery & Rejuvenation","route":"/fronts/rejuvenation/"},{"id":"supportive-care","kind":"section","name":"Supportive Care & Survivorship","route":"/fronts/supportive-care/"}],"technology":[{"id":"rejuv-paed-chronic-disease-burden","kind":"technology","name":"How much illness childhood cancer survivors carry, and at what age","route":"/technologies/rejuv-paed-chronic-disease-burden/"},{"id":"menopause-after-cancer-treatment","kind":"technology","name":"Menopause brought on by cancer treatment, and the options for it","route":"/technologies/menopause-after-cancer-treatment/"},{"id":"fertility-preservation","kind":"technology","name":"Oncofertility and fertility preservation","route":"/technologies/fertility-preservation/"},{"id":"ovarian-function-after-chemotherapy","kind":"technology","name":"Ovarian function after chemotherapy: who recovers, and when","route":"/technologies/ovarian-function-after-chemotherapy/"},{"id":"rejuv-paed-cog-ltfu-guidelines","kind":"technology","name":"The Children's Oncology Group Long-Term Follow-Up Guidelines","route":"/technologies/rejuv-paed-cog-ltfu-guidelines/"},{"id":"rejuv-paed-pituitary-and-puberty","kind":"technology","name":"The pituitary, puberty and the hypothalamic axis after cranial radiotherapy in childhood","route":"/technologies/rejuv-paed-pituitary-and-puberty/"},{"id":"total-body-irradiation","kind":"technology","name":"Total body and total marrow irradiation","route":"/technologies/total-body-irradiation/"},{"id":"rejuv-access-fertility-preservation","kind":"technology","name":"Who gets told about fertility before treatment, and who does not","route":"/technologies/rejuv-access-fertility-preservation/"}],"term":[{"id":"allogeneic-transplant","kind":"term","name":"Allogeneic stem cell transplant (allo-SCT)","route":"/terms/allogeneic-transplant/"},{"id":"lymphoma-decision-fertility-timing","kind":"term","name":"Fertility preservation before lymphoma treatment: a decision with a deadline in days","route":"/terms/lymphoma-decision-fertility-timing/"},{"id":"late-effects","kind":"term","name":"Late effects and survivorship toxicity","route":"/terms/late-effects/"}],"drug":[{"id":"busulfan","kind":"drug","name":"Busulfan","route":"/drugs/busulfan/"},{"id":"cyclophosphamide","kind":"drug","name":"Cyclophosphamide","route":"/drugs/cyclophosphamide/"},{"id":"ifosfamide","kind":"drug","name":"Ifosfamide","route":"/drugs/ifosfamide/"},{"id":"lomustine","kind":"drug","name":"Lomustine (CCNU)","route":"/drugs/lomustine/"},{"id":"procarbazine","kind":"drug","name":"Procarbazine","route":"/drugs/procarbazine/"}],"bottleneck":[{"id":"b-survivorship","kind":"bottleneck","name":"Survivorship and late effects are neglected","route":"/bottlenecks/b-survivorship/"},{"id":"b-toxicity-qol","kind":"bottleneck","name":"Toxicity and quality of life are undervalued","route":"/bottlenecks/b-toxicity-qol/"}]}}