Dilpreet Banwait: Fertility Preservation in Pediatric Cancer – Thinking Beyond Survival

“When a 12-year-old survives cancer, no one is thinking about the children they might have at 30. But someone has to.

When a child is diagnosed with cancer, survival is understandably the first priority. Treatment begins, families adjust to a reality they never expected, and clinicians focus on controlling the disease. Yet some of the treatments that make survival possible can also affect reproductive function, sometimes decades before a patient is ready to think about having children.

This is where fertility preservation enters the conversation.

I first encountered this idea during my undergraduate years. When the COVID-19 pandemic moved my classes online, I decided to make the most of the time and had the opportunity to intern at Max Super Specialty Hospital, Saket, under Dr. Ramandeep Arora in the Pediatric Oncology Department.

I remember seeing parents in the OPD with children who were four or five years old. Their immediate concern was, understandably, getting their child through treatment. But I kept thinking about how much life these children had ahead of them.

What happens after the cancer is treated? That question changed the way I looked at cancer care.

Conversations with Dr. Hiba Siddiqui, a senior onco-psychologist, gave me another perspective on the same issue. Her work in psycho-oncology and survivorship focuses on the psychological and social dimensions of cancer care, including the needs of children and families. Those conversations reinforced something I was beginning to understand: cancer does not simply have a treatment phase and then disappear. Its effects can extend into the life that follows. Fertility is one part of that future.

Why does fertility preservation matter in pediatric cancer?

Many cancer treatments are gonadotoxic, meaning they can damage the ovaries or testes and reduce reproductive potential. The degree of risk depends on the cancer diagnosis, treatment regimen, cumulative exposure to chemotherapy, radiation dose and field, sex, age, pubertal status, and whether hematopoietic stem-cell transplantation is involved.

The risk is substantial. A 2024 Children’s Oncology Group analysis examined 32 frontline phase III solid-tumor protocols used between 2000 and 2022. Twenty-one of the 32 protocols, or 65.6%, contained at least one treatment arm associated with a high risk of gonadal dysfunction or infertility (Bjornard et al., 2024). The authors emphasized that fertility risk should be assessed at diagnosis, when treatment changes, and during survivorship. (Children’s Oncology Group)

Yet infertility is rarely the problem that brings a child to an oncology clinic. A five-year-old is not thinking about parenthood. Their parents are thinking about treatment. Their oncologist is thinking about disease control, and the patient may be thinking about going home. That is precisely why fertility preservation needs to be considered by the healthcare team before gonadotoxic treatment begins.

The 2025 American Society of Clinical Oncology (ASCO) guideline recommends that clinicians discuss the possibility of infertility with pediatric and adult patients as early as possible before treatment begins. Patients who are interested in fertility preservation, or who are uncertain about it, should be referred to reproductive specialists. (ASCO Publications)

The timing matters because once treatment begins, some opportunities for preservation can be lost.

What does fertility preservation look like in children and adolescents?

Fertility preservation is not a single procedure. The appropriate approach depends on the patient’s age, pubertal status, diagnosis, treatment plan, urgency of therapy, and reproductive goals.

For children and adolescents who have initiated puberty, established options include:

• Sperm cryopreservation
• Oocyte cryopreservation
• Ovarian tissue cryopreservation
• Selected fertility-sparing surgical approaches, depending on the cancer and treatment plan

For prepubertal children, the options are more limited. The 2025 ASCO guideline recognizes ovarian tissue cryopreservation as an established fertility-preservation method for prepubertal patients. Testicular tissue cryopreservation remains investigational in prepubertal boys. (ASCO Publications)

This distinction is important. Pediatric fertility preservation cannot simply follow an adult model. A four-year-old, a 12-year-old who has entered puberty, and a 20-year-old young adult can all have cancer, but their reproductive biology and preservation options are fundamentally different.

Ovarian tissue cryopreservation is particularly relevant when ovarian stimulation is not possible or when chemotherapy cannot be delayed. Because it does not require sexual maturity or ovarian stimulation, it can also be considered in prepubertal patients. The 2025 ASCO guideline now classifies ovarian tissue cryopreservation as an established method of fertility preservation. (ASCO Publications)

When I first heard about this during my time in pediatric oncology, I remember being stunned by how far the field had come. Cancer treatment was being planned for the present, while reproductive medicine was already thinking about decades into the future.

What happens when fertility preservation is not discussed in time?

Having a fertility-preservation technique available does not automatically mean that a patient will receive it. The discussion has to happen, the risks have to be recognized, and the action plan has to happen quickly. The patient and family need access to the appropriate reproductive specialists and laboratory services.

This became particularly relevant to me when I later visited Dr. Puneet Rana Arora’s clinic in Gurugram. I had the opportunity to learn more about fertility preservation in pediatric oncology and contribute to research in this area.

In 2023, I co-authored Barriers to Accessing Fertility Preservation in Adolescents with Hodgkin Lymphoma in India with Dr. Ramandeep Arora. Published in Pediatric Hematology and Oncology, the study explored the perspectives of healthcare professionals involved in the care of adolescents with Hodgkin lymphoma and identified a constellation of interconnected barriers to accessing fertility preservation in India (Banwait et al., 2023). (PubMed)

The barriers identified included:

• Insufficient infrastructure and supportive care
• Limited patient knowledge and awareness
• Sociocultural beliefs
• Weak referral pathways
• Patient-navigation difficulties
• An inadequate healthcare workforce
• Concerns about delaying cancer treatment
• Unclear accountability and governance across stakeholders

The study also showed that these barriers were not experienced uniformly. Public hospitals faced greater challenges related to patient navigation and workforce capacity, while charitable and private hospitals were comparatively better equipped to provide fertility-preservation services. Perspectives also differed between professional groups, with social workers describing some of the practical difficulties faced by families in greater depth than oncologists encountered in their clinical roles. (ResearchGate)

This distinction matters. The existence of a fertility-preservation technique is only one part of access. A patient and family need to know that infertility is a possible consequence of treatment; a clinician needs to raise the issue, a referral needs to happen quickly, and a reproductive specialist needs to be available. Along with this, all the necessary laboratory and clinical infrastructure needs to exist.

In pediatric oncology, all of this happens against the pressure of a cancer diagnosis, where delaying treatment is often a major concern.

The challenge, therefore, is not simply developing better fertility-preservation techniques. It is building a system in which those techniques can reach the patients who need them, at the time when they can still make a difference.

I understood this differently when I met a young adult who was about to undergo chemotherapy and had chosen to pursue fertility preservation. He was around my age, and I remember thinking that he was completely normal. I don’t know what I had expected. Perhaps I had unconsciously separated the idea of a cancer patient from the idea of someone at exactly the same stage of life as me.

But there he was, a young person with plans, a future and an entire life ahead of him, preparing to begin cancer treatment. I found myself thinking: I have my whole life ahead of me and so does he. And suddenly, fertility preservation was no longer an abstract clinical concept.

It was about protecting an option for a future that cancer had suddenly made uncertain.

How should fertility preservation become part of cancer care?

Fertility preservation needs to be considered before cancer-directed therapy whenever possible. The 2025 ASCO guideline recommends discussing infertility risk early and referring patients to reproductive specialists, with established fertility-preservation methods offered to children and adolescents who have initiated puberty when appropriate. For prepubertal children, ovarian and testicular tissue cryopreservation are the available tissue-based approaches, with testicular tissue cryopreservation remaining investigational. (ASCO Publications)

This requires collaboration across disciplines. Pediatric oncologists identify the potential gonadotoxicity of treatment, reproductive medicine specialists assess preservation options, while embryologists and laboratory teams provide the technical expertise required to preserve reproductive material. In addition to this, psycho-oncology professionals help patients and families navigate the emotional and psychological consequences of these decisions.

But the conversation also changes with age. For a young child, parents or guardians are making decisions about a future the child cannot yet understand. For an adolescent, the patient’s own voice and developing autonomy become increasingly important. For a young adult, fertility can already be closely connected to relationships, family planning and identity. That is why fertility preservation belongs within cancer care rather than somewhere after it.

My first exposure to pediatric oncology eventually became one of the experiences that led me towards reproductive medicine. Today, as a trainee embryologist, I understand more of the science behind fertility preservation and the work that goes into preserving reproductive potential.

But I still think about those children in the OPD; I still think about that boy my age who was preparing for chemotherapy, and I still think about the conversations that helped me understand that cancer is not only about survival.

For a child with cancer, parenthood can feel like a lifetime away. For medicine, it cannot be an afterthought.”

Written by Dilpreet Banwait

Trainee Embryologist, Cloudnine Group of Hospitals

References

Title: Fertility Preservation in People With Cancer: ASCO Guideline Update

Authors: H Irene Su, Christina Lacchetti, Joseph Letourneau, Ann H Partridge, Rubina Qamar, Gwendolyn P Quinn, Joyce Reinecke, James F Smith, Megan Tesch, W Hamish Wallace, Erica T Wang, Alison W Loren

You can read the Full Article in the Journal of Clinical Oncology.

Title: Barriers to Accessing Fertility Preservation in Adolescents with Hodgkin Lymphoma in India

Authors: Dilpreet Kaur Banwait, Puneet Rana Arora, Amita Mahajan, Veronique Dinand, Sandeep Jain, Manas Kalra, Jagdish Chandra, Ramandeep Singh Arora

You can read the Full Article in Pediatric Hematology and Oncology.

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