Existing and emerging strategies for fertility preservation in female patients with leukemia

Leukemia, the most common malignancy in childhood, affects individuals from prepubertal girl to women of reproductive age. It originates from immature hematopoietic cells in the bone marrow and disseminates systemically via the blood and lymphatic circulations. Although survival rates have improved substantially, standard treatments, including intensive chemotherapy and hematopoietic stem cell transplantation, often combined with total body irradiation, are highly gonadotoxic. Consequently, a significant proportion of survivors experience long-term endocrine dysfunction and infertility, with females at particular risk of primary ovarian insufficiency. Fertility preservation in leukemia patients presents significant challenges. In females, oocyte or embryo cryopreservation requires sexual maturity and ovarian stimulation, limiting its use in prepubertal girls. Ovarian tissue cryopreservation is therefore the primary option in this population. However, its application remains controversial due to the risk of leukemic cell contamination and potential disease reintroduction following transplantation. Experimental evidence indicates that leukemic cells can infiltrate reproductive tissues, potentially compromising tissue integrity and function. These findings underscore the need for careful evaluation of current approaches. This review synthesizes current clinical and experimental evidence, highlights key knowledge gaps, and discusses emerging strategies to improve the safety and efficacy of fertility preservation in female patients with leukemia.