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Hypogonadism is common in both males and females after AHSCT. In males, cytotoxic chemotherapy and irradiation can damage the germinal epithelium of testes and Leydig cells [42], leading to hypogonadism. At 3 months post‐AHSCT, 85% of men have high follicle stimulating hormone (FSH) level and about one‐third have low testosterone levels, indicating inhibition of the reproductive axis [36]. Though testosterone level in most men normalizes at 1 year, FSH level remains elevated, along with azoospermia in around 90% [36]. Prior exposure to pelvic or abdominal radiotherapy is associated with high FSH level. A small prospective study on male sexual function in AHSCT survivors who were disease free for at least 6 months after transplant demonstrated normal patient‐reported interest in sexual activities and erectile function in more than three‐quarters of survivors, despite high FSH, high luteinizing hormone (LH), and low testosterone level in 88%, 47%, and 38% of patients respectively [43]. Notably, decreased testosterone level correlated with loss of libido and a diagnosis of Hodgkin disease. A study from the Center for International Blood and Marrow Transplant Research (CIBMTR) database identified 13 male AHSCT survivors whose female partners had successful pregnancy [44]. Notably, in these males, the median age at AHSCT was 28 years, with the most common primary diagnosis being lymphoma. Furthermore, only one out of 13 had received TBI as a part of the conditioning regimen and approximately one‐quarter had received radiation prior to transplant. Gonadal function in males should be monitored with serum FSH, LH, and testosterone levels [17]. In pre‐pubertal boys, annual FSH and LH monitoring should be considered from the age of nine. Testosterone level should also be monitored to ensure normal progression of puberty. Semen banking or cryopreservation of testicular tissue should be discussed prior to transplant.

Ovarian suppression, due to damage to follicles by gonadotoxic chemotherapy and/or radiation, is common in females. A Canadian study investigated ovarian function in 17 AHSCT survivors less than 50 years of age who were alive and disease‐free for at least 18 months after transplant [45]. Notably, the median age at transplant was 27 years in this study. All patients became menopausal immediately after AHSCT, with approximately one‐third recovering ovarian function at a median of 24 months after AHSCT [45]. The median age at transplant for patients who recovered ovarian function versus those who did not was 19 and 30 years respectively (p = 0.03). Furthermore, exposure to TBI as a part of conditioning regimen demonstrated a trend towards sustained loss of ovarian function. Another study on 21 auto‐transplant recipients aged 11–21 years showed clinical and hormonal evidence of ovarian failure in approximately 60% at a median of 7 years posttransplant [46]. Notably, exposure to high‐dose busulfan in conditioning regimen was associated with severe and persistent ovarian failure. A study from the CIBMTR database identified 20 women who reported successful pregnancy after AHSCT [44]. The median age at AHSCT was 22 years and none of these women had received TBI as a part of the conditioning regimen. Another study from the European Society for Blood and Marrow Transplantation identified 39 female patients who successfully conceived after transplant [47]. The median age at transplant of these 39 women was 24 years, with the median time from AHSCT to pregnancy being 2.5 years. Only 5% of these patients had received TBI as a part of conditioning [47]. Prepubertal girls undergoing AHSCT should be referred to endocrinology for full evaluation if there is a delay in puberty onset. Monitoring of LH and FSH level should be started at 8 years of age. In adult female survivors, fertility posttransplant depends on pretransplant ovarian reserve. Women of child‐bearing age should undergo fertility consult pretransplant. Cryopreservation of embryos or unfertilized eggs is a widely used fertility preservation strategy in females. In situations where AHSCT cannot be delayed, cryopreservation of ovarian tissue obtained laparoscopically can also be considered.