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Radiotherapy to the pelvis can stop the ovaries working and end fertility, and can damage sperm production. Before treatment starts, your team should talk with you about fertility and refer you quickly if you want to protect it: sperm, eggs or embryos can be frozen, and for some women a surgeon can move the ovaries up out of the radiation field.
Ovaries are very sensitive to radiation: in women under 40, under 2 Gy is estimated to destroy half the oocytes and 14 Gy may cause complete ovarian failure (review of Wallace et al.), far below pelvic doses for cervical, rectal or anal cancer. NICE NG257 (March 2026) says to discuss fertility preservation with everyone preparing for treatment likely to impair fertility, at the earliest opportunity if treatment is urgent; to offer sperm cryopreservation, and oocyte or embryo cryopreservation, to those of reproductive age; to consider ovarian tissue cryopreservation when those are not feasible; and not to apply the usual NHS fertility eligibility criteria. ASCO (2025) lists ovarian transposition among established methods for females, with embryo, oocyte and ovarian tissue cryopreservation.
ESHRE (2020) says women having pelvic radiotherapy without chemotherapy may be offered ovarian transposition to prevent premature ovarian insufficiency (WEAK, low certainty), that women with reduced ovarian reserve or at risk of ovarian metastases are not candidates (good practice point), and that transposition can be done at the same time as ovarian tissue cryopreservation. A 2026 review: transposition is for premenopausal women, generally 40 or younger, whose ovaries need not be removed; ovaries are moved at least 4 cm from the field or 1.5 cm above the iliac crest and marked with clips; reported success ranges from 15% to 100%, about 50% to 65% in cervical cancer after external beam radiotherapy, lower with chemotherapy; ovarian metastasis is rare (0.36% in cervical cancer). A 2022 meta-analysis of 1,160 women with cervical cancer found preserved ovarian function in 61% after external beam radiotherapy. Pregnancies after transposition and pelvic radiotherapy are few; a gestational carrier may be an option when the uterus has been affected by radiation (review).
Why: Once radiotherapy starts, some options are lost; the conversation has to happen first.
“Discuss fertility preservation as an option with people who are preparing for medical treatment, or who have a medical condition, that is likely to impair their fertility. For people who need urgent treatment, this discussion should take place at the earliest possible opportunity.”
NICE 2026 · [2026]
Why: Specialists can say quickly which options are realistic before treatment begins.
“Patients interested in or uncertain about FP should be referred to reproductive specialists.”
American Society of Clinical Oncology (Journal of Clinical Oncology) 2025 · as printed in the abstract (full grade not read)
Why: Stored sperm keeps the option of biological children open even if production stops.
“Offer sperm cryopreservation to men (and boys), and trans women and non-binary people with male reproductive organs who are of reproductive age, and who are preparing for medical treatment, or who have a medical condition, that is likely to make them infertile.”
NICE 2026 · [2026]
Why: Eggs or embryos frozen before radiotherapy are not exposed to it.
“Offer oocyte or embryo cryopreservation (as appropriate) to women (and girls), and trans men and non-binary people with female reproductive organs who are of reproductive age, and who are preparing for medical treatment, or who have a medical condition, that is likely to make them infertile.”
NICE 2026 · [2026]
Why: Ovarian tissue can be removed quickly and stored without hormone treatment.
“Consider ovarian tissue cryopreservation when oocyte or embryo cryopreservation is not feasible, for example, in girls before puberty.”
NICE 2026 · [2026]
Why: Moving the ovaries out of the beam can keep them making hormones and avoid early menopause.
“Where pelvic radiotherapy without chemotherapy is planned, women may be offered ovarian transposition with the aim to prevent POI (Gubbala et al., 2014; Hoekman et al., 2019).”
European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 · WEAK ⊕⊕◯◯
Why: Moving ovaries that have few eggs left gains little, and moving ovaries that may hold cancer can spread it.
“Women with reduced ovarian reserve and women at risk of having ovarian metastases are inappropriate candidates for ovarian transposition.”
European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 · GPP
Why: One operation can both protect the remaining ovary and store tissue as a back-up.
“Ovarian transposition can be performed at the same time as OTC in patients who will receive pelvic irradiation.”
European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 · GPP
Why: The further the ovaries are from the field, the more likely they are to keep working.
“The location of transposed ovaries should be at least 4 cm from the radiation field or 1.5 cm above the iliac crest to avoid gonadotoxic radiation doses.”
Lim et al., Gynecologic Oncology Reports 2026 · narrative review (no grade)
Why: The radiotherapy planners need to find the ovaries on the planning scan to keep dose off them.
“The inferior margin of the ovaries should be tagged with radiopaque surgical clips for future identification on CT imaging (Buonomo et al., 2021).”
Lim et al., Gynecologic Oncology Reports 2026 · narrative review (no grade)
Why: Realistic expectations matter: keeping the ovaries working is not the same as being able to carry a pregnancy after radiation to the uterus.
“Approximately 50–65% of patients with cervical cancer who undergo OT followed by external beam radiation therapy with or without brachytherapy maintain ovarian function; adjuvant chemotherapy further reduces ovarian function preservation.”
Lim et al., Gynecologic Oncology Reports 2026 · narrative review (no grade)
Why: Preservation before cancer treatment is a different situation from treating infertility.
“For NHS-funded fertility preservation, do not apply the eligibility criteria used for conventional fertility treatment, including the lower age limit.”
NICE 2026 · [2013, amended 2026]
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
Discuss fertility before treatment with everyone at risk and refer promptly (NICE NG257 2026; ASCO 2025); offer sperm, egg or embryo cryopreservation, and consider ovarian tissue cryopreservation when those are not feasible (NICE [2026]). For premenopausal women having pelvic radiotherapy, ovarian transposition is an established option (ASCO 2025) that ESHRE (2020) supports weakly and only without chemotherapy (WEAK, low certainty), excluding women with reduced ovarian reserve or a risk of ovarian metastases. Where done, the ovaries go at least 4 cm from the field or 1.5 cm above the iliac crest, marked with clips (2026 review). NICE NG257 does not mention ovarian transposition; the guidelines differ on whether chemotherapy alongside radiotherapy rules it out (ESHRE limits it to radiotherapy without chemotherapy; ASCO's abstract sets no such limit).
NICE 2026 · American Society of Clinical Oncology (Journal of Clinical Oncology) 2025 · European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 · Lim et al., Gynecologic Oncology Reports 2026
Where it differs: Many women with cervical, rectal or anal cancer have chemotherapy with their radiotherapy. ESHRE's recommendation covers radiotherapy without chemotherapy; the 2026 review reports transposition in these settings with lower success when chemotherapy is added.
Evidence: Observational series; ovarian function preserved in about 50% to 65% after external beam radiotherapy for cervical cancer, lower with adjuvant chemotherapy (review); 61% after external beam radiotherapy in a 2022 meta-analysis of 29 studies.
European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 · Lim et al., Gynecologic Oncology Reports 2026 · BMC Women's Health 2022
Where it differs: Higher baseline risk of ovarian metastasis than in cervical cancer (about 1% to 8%, around 5% in premenopausal women), so the 2026 review judges the risks may outweigh the benefits in locally advanced disease.
Evidence: Review of retrospective data; no ovarian metastases after transposition reported in this subgroup.
Where it differs: Older technique for lymphoma fields in which the uterus shields the ovaries; most successful pregnancies after transposition and pelvic radiotherapy were in Hodgkin lymphoma with an inverted Y field and a lead shield to the uterus.
Evidence: Historical case series, cited in the 2026 review.
Where it differs: Removing the fallopian tubes at the same operation to lower the later risk of ovarian cancer, which the review says should be considered.
Evidence: Review citing data that salpingectomy can reduce ovarian cancer risk by up to 65%; not specific to transposition.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Ovarian transposition before pelvic radiotherapy without chemotherapy | WEAK ⊕⊕◯◯ | European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 |
| Not for women with reduced ovarian reserve or at risk of ovarian metastases | GPP | European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 |
| Provide decision aids to patients considering fertility preservation “It is recommended to provide decision aids to patients who are considering FP (Peate et al., 2009; Anazodo et al., 2019; Wang et al., 2019).” | STRONG ⊕⊕◯◯ | European Society of Human Reproduction and Embryology (Human Reproduction Open) 2020 |
| Ovarian transposition is an established fertility preservation method for females “For females, established FP methods should be offered, including embryo, oocyte, and ovarian tissue cryopreservation (OTC), ovarian transposition, and conservative gynecologic surgery.” | as printed in the abstract (grade not read) | American Society of Clinical Oncology (Journal of Clinical Oncology) 2025 |
| Offer sperm cryopreservation before treatment likely to cause infertility | [2026] | NICE 2026 |
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