Clinical Consensus Statement No. 459: Oncofertility – Bridging the Geographical Gap in Pediatric and Adolescent Gynaecology in Canada

Abstract

Objective

To review the options for fertility preservation in Canada for paediatric and adolescent gynaecology patients who are receiving fertotoxic therapy.

Target Population

Adolescent and pediatric individuals with ovaries and a treatment plan that affects future reproductive options.

Options

Depending on the individual’s pubertal status and in accordance with ethical guidelines, appropriate fertility preservation methods such as oocyte preservation, ovarian tissue preservation, and ovarian transposition should be considered alongside their treatment. Modification of treatment protocols may also be necessary.

Outcomes

Canada currently lacks provincial and national initiatives to offer fertility preservation for pediatric and adolescent individuals. Many barriers contribute to this, including knowledge gaps among providers, lack of assent processes, and limited access to urgent consultation and specialized procedures. In addition to this, patients and providers may experience barriers in accessing funding.

Benefits, Harms, and Costs

The recommendations outlined in this committee opinion will benefit both providers and families by providing them with knowledge of treatment options. While consultations with specialist providers and in hospital procedures are covered, patients are responsible to pay for medications, procedures performed in private surgical centres, and tissue storage, which can put a large financial burden on families. There may be inter-province and inter-hospital differences in coverage for treatment. Additionally, there is considerable gender inequity in the higher cost of cryopreservation of eggs compared with sperm.

Evidence

A literature review of systematic reviews and original research (cohort studies, case series/studies were included; there were no randomized Controlled trials published) was conducted in PubMed from January 1990 to January 2025 using the MeSH search terms fertility preservation, paediatric/pediatric, adolescent, and female. Articles were included if they focused on individuals assigned female at birth, were related to the field of oncofertility, were available through the University of Calgary’s library system, and were written in English.

Validation Methods

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

Intended Audience

Family physicians and nurse practitioners providing primary care, obstetricians and Gynaecologists, Reproductive Endocrinologist and Infertility Specialists, and Paediatric Oncologists

Tweetable Abstract

Oncofertility – It takes a village. Building a network to improve access to oncofertility in Canada.

SUMMARY STATEMENTS

• 1.
  Fertotoxic therapy can have detrimental effects on the future fertility of paediatric and adolescent patients (high).
• 2.
  If natural conception occurs in a childhood cancer survivor, there is no increased risk of chromosomal anomalies, genetic anomalies, or cancers (high).
• 3.
  Ovarian tissue cryopreservation is no longer experimental and is the only option for fertility preservation in prepubertal patients (moderate).
• 4.
  In pubertal patients, ovarian tissue cryopreservation can be combined with additional procedures under one general anesthetic to minimize morbidity (moderate).
• 5.
  In pubertal patients, oocyte cryopreservation, where available, and where a delay in treatment is acceptable, should be first choice for fertility preservation (moderate).
• 6.
  Starting chemotherapy is not a contraindication to ovarian tissue cryopreservation (low).

RECOMMENDATIONS

• 1.
  All pre- and post-pubertal individuals who have ovaries should be counselled with accurate information on the risks of infertility/subfertility with the use of fertotoxic therapy and be offered a referral to a specialist in fertility preservation (strong, high).
• 2.
  Initial consultation with a specialist in fertility preservation can be offered through telehealth to facilitate access in remote areas (strong, high).
• 3.
  If natural conception occurs in a childhood cancer survivor, they should be counselled that there is no increased risk of chromosomal anomalies, genetic anomalies, or cancer (unless the patient’s cancer was genetically related) (strong, high).
• 4.
  All individuals who are undergoing fertility preservation should have the option of providing assent to their care in addition to parental/guardian consent (strong, high).
• 5.
  All paediatric oncology programs should have oncofertility pathways for offering fertility preservation, with multidisciplinary teams composed of oncology, reproductive endocrinology and infertility, paediatric gynaecology, paediatric surgery, and ethics representation, depending on the province and hospital system (strong, high).
• 6.
  Pre-pubertal patients should be offered gonadal shielding and/or ovarian transposition or ovarian tissue cryopreservation prior to the start of targeted radiation therapy in which the ovaries will be in field of treatment (conditional, low).
• 7.
  Long-term follow-up should be the standard of care to monitor menstrual function, ovarian reserve, healthy sexual function, contraception, and review fertility goals (strong, moderate).