The significance of fertility preservation for pediatric cancer patients has been increasingly recognized, not only globally but also within the Nordic regions, particularly given the growing population of childhood and adolescent cancer survivors [13, 14]. This surge in awareness is largely due to the potential adverse effects of gonadotoxic treatments on fertility [5]. In the Nordic countries, fertility preservation is considered an essential component of cancer care, with comprehensive healthcare systems, public funding, and strong support networks ensuring that individuals facing cancer treatment have access to fertility preservation options and support services [15].

Counseling on fertility preservation options

This study’s findings highlight changes in counseling practices. In the last 12 years, counseling has become more specialized, focusing on those patients who fulfill specific indications for fertility preservation, pointing to a more tailored and effective approach. This shows a progression in the clinical practice routine for offering counseling on fertility preservation options. The finding indicates improved fertility preservation care and strategies among pediatric oncologists, gynecologists, oncology nurses, and fertility treatment providers [16]. Fertility counseling may also increase awareness of fertility preservation options among pediatric cancer patients and parents [16]. However, there are still some centers that do not offer counseling on fertility preservation options to relevant patients, potentially affecting the quality of fertility care among pediatric cancer patients.

Clinical practices and guidelines for fertility preservation

By assessing the fertility preservation practices within Nordic oncology centers over a period of 12 years, the study illuminates significant advancements in this vital area of patient care and highlights the challenges faced in harmonizing cancer treatment plans across the Nordic pediatric oncology centers.

The data reveal a clear progression in the fertility preservation methods and guidelines within this period. By 2022, substantial progress in the establishment of national guidelines for fertility preservation was observed, aligning with the global attention on fertility care for pediatric cancer survivors. This is a clear indication of the role that Nordic recommendations and practices have had on fertility preservation protocols, as well as their subsequent incorporation into clinical routines for pediatric cancer patients in the Nordic countries. However, disparities in the implementation of and adherence to these guidelines among Nordic oncology centers point to potential barriers, such as the lack of structured and coordinated fertility preservation, limited guideline knowledge, and inconsistent adherence by oncologists and other healthcare providers [17,18,19]. Research also shows that existing clinical practice guidelines for fertility preservation that were developed by different institutions vary substantially, and only about one-third of the identified guidelines were found to be of sufficient quality [7]. This may reduce the ability of oncologists and other healthcare providers to deliver high-quality fertility care to pediatric cancer patients.

One of the most significant insights from the study is the increase in the offering of fertility preservation options across different diagnoses, especially for patients diagnosed with non-Hodgkin’s lymphoma and Wilms tumor. This serves to emphasize the role of effective collaboration between oncologists and fertility providers, together with common guidelines, in enhancing the identification of children at increased risk of subfertility caused by various cancers and their treatments.

Male fertility preservation

For boys, there is a growing emphasis in the Nordic oncology centers on evaluating sexual maturity before opting for sperm cryopreservation. Over the past decade, fertility preservation methods for postpubertal boys have already become a part of clinical practice and offered routinely to all patients who fulfill indications for fertility preservation [6, 20]. The responses to the questionnaire indicate that electroejaculation has been selected more than the other options by specialists in the Nordic countries. This is consistent with current studies that recommend considering electroejaculation as a useful option for sperm cryopreservation [20]. However, current studies have not shown any evidence regarding pregnancies or live births after sperm cryopreservation via electroejaculation in pediatric cancer patients [20].

Many countries—including the Nordics—offer testicular tissue cryopreservation for fertility preservation in prepubertal boys undergoing gonadotoxic treatments [21]. Thus far, this procedure is experimental, and there are no reports on pregnancy or live births after using frozen human testicular tissue [21]. The international guidelines recommend testicular tissue cryopreservation for prepubertal boys only within the context of an approved research protocol [20]. Despite the experimental aspect of the procedure, families and patients have shown willingness to preserve testicular tissue for the future [22]. In 2022, more centers reported that they offer male fertility preservation following cancer treatment. This practice aligns with Nordic guidelines, which do not mandate testicular biopsy prior to initiating gonadotoxic treatment. Correspondingly, a recent comprehensive international report revealed that approximately 30% of patients underwent biopsies after receiving treatments with low to medium gonadotoxic risk [23]. While male fertility preservation practice is broadly similar across the Nordic centers, there remain variations. International collaboration between the centers offering this experimental procedure will be important for ensuring good outcomes for young males at risk of future infertility.

Female fertility preservation

In terms of gender-specific findings, female fertility preservation witnessed a dramatic rise in the cryopreservation of ovarian tissue, both for prepubertal and postpubertal girls, mirroring global advancements in female fertility preservation techniques [24, 25]. The increasing reliance on techniques such as ovarian tissue cryopreservation, especially for prepubertal cancer patients, reinforces the progress in this domain [25]. This is in line with the female fertility preservation options offered in the Nordic countries over the last decade. The evidence regarding the success of this intervention is largely based on case reports and case series and may still be deemed experimental by some centers [26]. However, with increasing evidence of live births and the return of endocrine function, the international guidelines recommend considering ovarian tissue cryopreservation for prepubertal girls [6, 27, 28].

Oocyte cryopreservation stands as a clinically established method for pubertal girls [26]. This method has undergone significant global refinement and is now routinely in use [26, 27]. In the Nordic countries, the provision of oocyte cryopreservation has increased over the last 12 years. However, this option is currently only extended to postmenarcheal cancer patients if their prognosis would not be compromised by a delay in treatment initiation [27].

Over the past decade, there has been a heightened emphasis on preserving the fertility of pediatric female cancer patients after cancer therapy in the Nordic countries. Consequently, there is a need for endocrinologists and gynecologists to continue monitoring girls who are at risk of ovarian failure following cancer treatment [29]. The findings from this study indicate that several Nordic oncology centers have implemented protocols for managing girls at risk of ovarian failure after cancer treatment. This monitoring should encompass reproductive health assessments, including evaluations of ovarian function, planning for future pregnancies, and the initiation of hormone replacement therapy as necessary [30, 31]. Such measures are poised to enhance the quality of life for female cancer survivors.

Collaboration with services for fertility preservation

In the Nordic countries, fertility preservation is limited to fertility preservation programs at academic reproductive centers that belong to major university hospitals [29]. Consequently, there has been a growing need for collaboration among oncology centers to establish centralized biobanks in each country. This initiative has provided the opportunity to safeguard fertility potential, thereby potentially enhancing pediatric cancer survivors’ quality of life.

Furthermore, collaboration between the Nordic centers and fertility preservation services has grown substantially, emphasizing the integrated approach that Nordic centers have adopted over the years. This collaboration remains important, to develop transparent and rigorous clinical practice guidelines that can optimize fertility preservation for pediatric cancer patients in all centers. This might balance the harms and benefits of methods for fertility preservation in different risk groups.

The present study possesses certain limitations. Firstly, there is a difference between some of the oncology centers that responded in 2010 and those that responded in 2022. Additionally, respondents failed to address all open-ended questions. The lack of response implies limitations on information from all centers. Moreover, since the questionnaire was in English and not in the respondents’ native languages, language barriers may have led to variations in understanding the questions across different countries and time periods. Furthermore, it is also not feasible to estimate the percentage of all pediatric cancer patients treated at the responding centers.

Despite these limitations, the study’s findings demonstrate that collaboration among Nordic oncology centers has facilitated the establishment of national guidelines in each country. This collaboration has notably enhanced the provision of fertility preservation counseling and services, thereby promoting the integration of oncology and fertility care.