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Sep 16, 2026, 17:14

When the Body Peaks Before the Eggs: Understanding Fertility in Elite Female Athletes

“Does elite sport itself reduce fertility?

Current evidence does not support the simple conclusion that elite sport itself causes infertility. A more clinically relevant concern is low energy availability (LEA), where energy intake is insufficient for both exercise demands and normal physiological function. When sufficiently severe or prolonged, LEA can contribute to Relative Energy Deficiency in Sport (RED-S), which can affect reproductive and other physiological systems (Mountjoy et al., 2023).

One reproductive manifestation is functional hypothalamic amenorrhoea (FHA). Reduced hypothalamic gonadotrophin-releasing hormone signalling can suppress pituitary FSH and LH secretion, resulting in menstrual disruption and hypoestrogenism.

This is fundamentally different from diminished ovarian reserve (DOR). FHA/RED-S represents functional suppression of the reproductive axis; DOR concerns the quantity of the remaining follicular pool. Menstrual dysfunction therefore should not automatically be interpreted as ovarian depletion or infertility.

AMH and antral follicle count (AFC) are useful indicators of ovarian reserve and expected response to ovarian stimulation, but neither directly measures oocyte competence or independently predicts live birth with precision. Energy deficiency and endocrine disruption can also complicate interpretation of reproductive biomarkers.

Clinical assessment should therefore consider menstrual history, nutrition, training load, endocrine findings, and ovarian reserve together rather than relying on a single AMH result.

A 2026 narrative review similarly concluded that elite-level exercise can adversely affect menstrual function, while the direct effect on fertility remains less clearly established (L’Heveder et al., 2026).

The clinical priority is therefore broader than egg freezing: identify RED-S or FHA, correct energy imbalance, protect bone and reproductive health, and provide fertility counselling when clinically appropriate.

Why can an athlete reach peak performance while reproductive ageing continues?

Athletic performance and reproductive ageing are governed by different biological processes.

An athlete can reach exceptional cardiovascular fitness, muscular strength and competitive performance while age-related changes in oocyte competence continue independently. Elite training does not stop reproductive ageing, nor does physical fitness prevent the age-related increase in oocyte chromosomal abnormalities.

This distinction is important because ovarian reserve and oocyte competence are different endpoints. Reserve reflects aspects of the remaining follicular pool, whereas competence concerns the ability of an oocyte to fertilise normally, support embryo development and ultimately contribute to a healthy pregnancy.

For athletes planning pregnancy after retirement, reproductive ageing can therefore become relevant even when menstrual cycles remain normal. The issue is not that sport necessarily accelerates ovarian ageing; rather, the sporting career and reproductive timeline may not coincide.

This makes reproductive counselling more informative than routine menstrual monitoring alone. A regular cycle does not provide a complete assessment of future reproductive potential.

What does oocyte cryopreservation actually preserve?

Oocyte cryopreservation is an established fertility-preservation option. ESHRE guidelines address fertility preservation for women concerned about age-related reproductive decline, while ASRM considers planned oocyte cryopreservation ethically permissible when appropriate counselling covers efficacy, risks, costs and uncertainties (ESHRE, 2020; ASRM Ethics Committee, 2024).

Modern oocyte cryopreservation primarily uses vitrification, an ultra-rapid cooling technique that greatly reduces damaging ice-crystal formation compared with traditional slow freezing. The quality of vitrification and warming is therefore an important laboratory determinant of outcome.

But freezing an oocyte does not freeze the entire reproductive outcome.

The biological pathway is:

Mature oocyte – vitrification – warming – survival – fertilisation – embryo development – blastocyst formation – implantation – pregnancy – live birth.

Attrition can occur at every stage. Not every vitrified oocyte survives warming; not every surviving oocyte fertilises normally; not every fertilised oocyte develops into a blastocyst; and not every blastocyst implants or results in live birth.

A frozen oocyte is a preserved opportunity, not a preserved baby.

A 2024 systematic review and meta-analysis involving 27 studies and 13,724 patients reported aggregate oocyte survival of approximately 81.4%, implantation of 44.4%, clinical pregnancy of 34.2% and live birth of 28.9% among patients who returned to use their preserved oocytes (Kirubarajan et al., 2024). However, only 10.8% returned to thaw in the available studies, and outcomes varied substantially between populations, ages, oocyte numbers and laboratories. These figures therefore cannot be interpreted as an individual patient’s probability of live birth.

Laboratory quality is consequently central to fertility preservation. A robust Quality Management System (QMS), validated vitrification and warming procedures, competency assessment, traceability, equipment monitoring and defined laboratory key performance indicators (KPIs) help determine whether the technical potential of cryopreservation is translated into clinical outcomes. ASRM recommends providing clinic-specific freeze-thaw and live-birth information where available (ASRM Ethics Committee, 2024).

For an athlete with a stable partner, embryo cryopreservation is another option. A vitrified embryo has already passed fertilisation and early developmental stages, providing more biological information than an unfertilised oocyte and therefore greater developmental predictability. However, embryo cryopreservation also involves decisions regarding the sperm source and future disposition of embryos. Oocyte cryopreservation preserves greater reproductive autonomy. The choice is therefore individual rather than universally preferable.

Does age at freezing matter more than athletic status?

Age at vitrification is one of the most important factors influencing future reproductive potential because the biological age of the oocyte is preserved at the time of freezing.

ASRM reports that younger age at oocyte cryopreservation and the number of oocytes stored are important predictors of future success, while evidence remains insufficient to provide a precise individual live-birth prediction (ASRM, 2021).

For elite athletes, timing also has practical implications. Controlled ovarian stimulation requires gonadotrophin treatment, monitoring and oocyte retrieval. During stimulation, the ovaries enlarge, and ovarian torsion is a recognised potential complication. Treatment can also interfere temporarily with training, competition, travel and recovery.

Where fertility preservation is clinically appropriate, scheduling stimulation during an off-season or lower-demand recovery period can reduce disruption to athletic preparation.

Anti-doping compliance requires equally careful planning. The WADA Prohibited List is substance- and circumstance-specific; fertility medications should therefore be reviewed individually rather than assuming that all reproductive hormones are prohibited or permitted. Where a medically necessary substance falls under prohibited rules, the appropriate Therapeutic Use Exemption (TUE) process must be addressed in advance (WADA, 2026).

A comprehensive reproductive-health framework for elite sports organisations could combine menstrual-health surveillance, assessment of energy availability and RED-S risk, appropriate interpretation of AMH/AFC, access to reproductive specialists and timely fertility counselling during the early 30s, when reproductive ageing becomes increasingly relevant to future planning.

The strongest evidence-based approach to fertility support in elite sport is therefore broader than offering egg freezing. It includes education about reproductive ageing, protection of menstrual and metabolic health, appropriate fertility evaluation, discussion of oocyte or embryo cryopreservation when relevant, and meaningful support for pregnancy and maternity during an athletic career.

Fertility preservation can expand reproductive options, but it should not become an implicit expectation or a substitute for pregnancy and maternity support.

The biology is neither a warning against elite sport nor a promise from fertility technology.

It is a question of timing.

The body may reach its sporting peak while the reproductive clock continues on its own trajectory. Understanding that difference is where scientifically informed fertility care for elite athletes begins.”

Written by Saadat Hassan
Senior Clinical Embryologist/IVF and Embryology
BSc (Hons) Medical Laboratory Technology
King Edward Medical University, Lahore, Pakistan

References

Title: Planned oocyte cryopreservation to preserve future reproductive potential: an Ethics Committee opinion

Authors: Ethics Committee of the American Society for Reproductive Medicine

You can read the Full Article in Fertility and Sterility.