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Challenge: Female fertility after chemotherapy.

Background:

 Chemotherapy will often result in infertility and premature ovarian failure.

 The risk of loss of fertility is difficult to predict as comprehensive information about the gonadotoxicity of current cancer drug regimens do not exist.

 The loss of fertility is influenced by the age of the patient, pretreatment ovarian reserve, and the type and duration of chemotherapy administered.

 Return of menstrual function after chemotherapy does not always imply the return of fertility, nor does oligomenorrhea always indicate ovarian insufficiency.

 When there is a return of ovarian function, the reduced ovarian reserve that occurs after chemotherapy may limit the window of reproductive opportunity.

Management options:

 Onco‐fertility counseling and management requires a multidisciplinary service.

 Management is influenced by the age of the patient, her ovarian reserve after chemotherapy and whether she had fertility preservation before cancer treatment.

 Early referral for fertility discussion and assessment of ovarian reserve.

 There should be a low threshold to move to assisted reproduction techniques.

 Oocyte donation, surrogacy and adoption could be relevant management options.

 Appropriate prepregnancy counseling depending upon type of chemotherapy administered.

Prevention:

 Early referral for consideration of fertility preservation options prior to treatment.

 The concomitant use of GnRH is suggested, but not proven yet, to reduce gonadotoxicity of chemotherapy.