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Early referral at the time of diagnosis gives the patient the opportunity to discuss fertility and to avail themselves of the best option for fertility preservation through cryopreservation of oocytes or embryos (see Chapter 10). For example, in Case History 2, although the ABVD regimen for HL is thought not to significantly affect fertility, the patient would have benefitted from fertility preservation prior to treatment as her ovarian reserve of 12.5 pmol/L was low for her age and will reduce her window of reproductive opportunity. Her treatment was then escalated to BEACOPP which is more gonadotoxic than ABVD, and with an already reduced pretreatment ovarian reserve, this patient would likely develop premature ovarian failure. In general, women older than 35 years undergoing treatment with ABVD would benefit from early fertility discussion as it has now been shown that they have a diminished ovarian reserve recovery when assessed a year after completion of chemotherapy [13].

Sadly, there is still no treatment that will remove the risk of ovarian compromise after chemotherapy. Both case histories had concomitant gonadotropin releasing analogue (GnRHa) during chemotherapy and despite recent studies suggesting some benefit in reducing the risk of ovarian failure, improvement in pregnancy rates is yet to be demonstrated [20,21]. However, it still has an important use in avoiding the heavy menstrual loss and irregular bleeding that occurs during chemotherapy in hematological malignancies, particularly in those with leukemia and clotting defects [22].