Pregnancy after haematopoietic stem cell transplantation: likelihood, risks, and management

PURPOSE OF REVIEW: Advances in haematopoietic stem cell transplantation (HSCT) have improved long-term survival, making fertility and reproductive health increasingly important aspects of survivorship. This review summarizes current evidence regarding fertility after HSCT, fertility preservation, and pregnancy outcomes. RECENT FINDINGS: Infertility remains common after HSCT, particularly following total body irradiation and myeloablative conditioning, with reproductive outcomes influenced by age at transplantation, conditioning intensity, pretransplant therapy and other related factors. Although fertility remains substantially reduced after HSCT, spontaneous conception and successful pregnancies have been reported. As posttransplant fertility cannot be reliably predicted, early fertility counselling and discussion of fertility-preservation options should be standard components of care before gonadotoxic therapy and HSCT. Most pregnancies following HSCT result in live births but carry increased risks of preterm birth, low birth weight, and placental insufficiency, particularly after total body irradiation. For survivors who conceive, multidisciplinary management is essential to optimize maternal and neonatal outcomes. SUMMARY: Fertility preservation should be routinely discussed before gonadotoxic therapy and HSCT, as posttransplant reproductive recovery cannot be reliably predicted. Multidisciplinary pregnancy care and prospective studies defining regimen-specific reproductive risks are needed to optimize reproductive outcomes.