Fertility-Sparing Management in Ovarian Cancer: A Systematic Review

Ovarian cancer is the eighth most common malignancy in women and remains the leading cause of gynecologic cancer-related mortality worldwide. 1 Prognosis largely depends on the stage at diagnosis, with early detection associated with significantly improved survival outcomes. 2 Approximately 12–15% of ovarian cancer cases occur in women younger than 40 years, many of whom have not yet completed childbearing. 3 A SEER registry–based study reported that 5-year survival was approximately 89% for FIGO Stage I, 71% for Stage II, but dropped substantially to 41% and 20% for Stage III and IV, respectively, underscoring the dramatic decline in prognosis with advancing stage. 4 This epidemiological trend highlights the need to consider fertility preservation as an integral component of treatment planning for young patients. Conventional management of ovarian cancer has traditionally involved radical surgery, including bilateral salpingo-oophorectomy and hysterectomy, which effectively eliminates reproductive potential. 5 However, with improvements in surgical techniques and adjuvant therapies, survival in early-stage ovarian cancer has markedly improved. 6 , 7 Consequently, quality-of-life concerns, particularly regarding fertility preservation, have gained importance in oncologic care. 8 Fertility-sparing management (FSM), encompassing conservative surgery and adjunctive oncofertility strategies, has emerged as a promising approach for selected patients with borderline ovarian tumors (BOT), early-stage epithelial ovarian cancer (EOC), and non-epithelial malignancies. 9 , 10 Several retrospective studies, multicenter trials, and meta-analyses suggest that FSM can provide oncologic outcomes comparable to radical surgery in appropriately selected early-stage disease while allowing subsequent pregnancies. 11–13 Advances in assisted reproductive technologies (ART), including in vitro fertilization (IVF), oocyte or embryo cryopreservation, ovarian tissue banking, and the use of gonadotropin-releasing hormone agonists during chemotherapy, have further expanded reproductive options for survivors. 14–16 Nonetheless, important concerns persist regarding recurrence risks in high-grade histologies, incomplete staging procedures, and the long-term gonadotoxic effects of chemotherapy. 17 , 18 Although fertility-sparing management is widely accepted for carefully selected patients with FIGO stage IA grade 1–2 epithelial ovarian cancer, its role in patients with stage IC or grade 3 disease remains controversial because of concerns regarding recurrence risk and long-term oncologic safety. In addition, the oncologic implications of incomplete surgical staging continue to be debated. 2 , 19 Heterogeneity of reported outcomes and lack of consensus across guidelines further complicate patient selection and clinical decision-making. 20 Given these uncertainties, a comprehensive synthesis of available evidence is warranted to clarify the oncologic safety and reproductive efficacy of FSM in ovarian cancer. Therefore, this systematic review aims to synthesize current evidence regarding the oncologic safety and reproductive efficacy of FSM by evaluating oncologic and reproductive outcomes, identifying prognostic factors influencing these outcomes, and highlighting current evidence gaps to inform clinical practice and future research in oncofertility.

A total of 464 records were identified through database searches. After removing 37 duplicates, 427 records were screened by title and abstract, of which 229 were excluded due to irrelevance. A total of 198 full-text articles were assessed for eligibility. Of these, 142 studies were excluded for the following reasons: case reports or small case series (n = 26), review articles and meta-analyses (n = 22), non-relevant population (n = 27), non-fertility-sparing management interventions (n = 22), non-English full-text articles (n = 8), and insufficient data for analysis (n = 6). Finally, 56 studies were included in the qualitative and quantitative synthesis. A total of 56 studies involving approximately 7,000 patients were included, with sample sizes ranging from 13 to 660 participants. The majority of studies were retrospective cohort designs, with a smaller proportion of prospective and multicenter cohorts. Study populations consisted of women of reproductive age with ovarian tumors undergoing fertility-sparing surgery, including BOT, EOC, MOGCT, and SCST. Most patients presented with early-stage disease, although several studies included advanced-stage cohorts. Fertility-sparing approaches varied across studies and included cystectomy, unilateral salpingo-oophorectomy, bilateral cystectomy, and combinations with surgical staging procedures. Follow-up duration ranged widely from approximately 26 months to over 15 years. Detailed study characteristics are summarized in Table 2 , while reproductive and oncologic outcomes are presented in Table 3 . Table 2 Study Characteristics of Included Studies Author (Year) Country Study Design Population (n) Histology/Stage Intervention (FSS) Comparison Outcomes Reported Follow-Up Yan et al (2025) 26 China Retrospective cohort BOT (n=660) FIGO I–III; serous/mucinous FSS Radical Recurrence, RFS model 78 mo Zheng et al (2025) 27 China Retrospective single-center Advanced BOT (n=144) FIGO II–IV FSS Radical DFS, OS, pregnancy 67 mo Marino et al (2025) 28 Italy Retrospective single-center JGCT (n=30) FIGO I–III FSS Radical Recurrence, OS, fertility 210 mo Jiang et al (2025) 29 China Retrospective single-center BOT (n=85) Serous/mucinous Cystectomy-based FSS None DFS, pregnancy 60 mo Bianchi et al (2025) 30 Italy Retrospective single-center cohort Advanced BOT (n=86) FIGO II–III FSS None RFS, OS 182 mo Fong et al (2025) 31 Singapore Retrospective single-center Ovarian malignancy (n=19) Mixed FSS (vNOTES) None Recurrence 26 mo Li et al (2025) 32 China Retrospective cohort with matched controls BOT + IVF (n=65) FIGO I–III FSS Control Recurrence, live birth 64 mo Ayhan et al (2023) 33 Türkiye Retrospective cohort EOC (n=68) FIGO I–III FSS None DFS, OS, fertility 60 mo Chu et al (2023) 34 China Multicenter retrospective study MOGCT (n=213) FIGO I–III FSS + chemo BEP vs PC DFS, OS, fertility 63 mo Sobiczewski et al (2022) 35 Poland Retrospective cohort BOT (n=110) FIGO I–III FSS None PFS, OS, fertility 38 mo Falcone et al (2022) 36 Italy Multicenter retrospective study Advanced BOT (n=13) FIGO II–III FSS None DFS, fertility 146 mo Birge et al (2022) 37 Sudan Retrospective cohort EOC (n=66) FIGO I FSS Radical DFS, OS, fertility 94 mo Kuji et al (2022) 38 Japan Nationwide retrospective study BOT (n=531) FIGO I–IV FSS None PFS, OS 70 mo Johansen et al (2021) 39 Sweden Nationwide prospective cohort BOT (n=277) FIGO I FSS Radical OS, fertility 62 mo Falcone et al (2021) 40 Italy Multicenter retrospective Advanced BOT (n=91) FIGO II–III FSS None DFS, OS, fertility 127 mo Chevrot et al (2020) 41 France Multicenter longitudinal cohort BOT (n=52) FIGO I FSS None DFS, fertility 57 mo Candotti et al (2020) 42 Italy Retrospective cohort BOT (n=85) FIGO I–III FSS None Recurrence, fertility 63 mo Li et al (2020) 43 China Retrospective cohort BOT (n=448) FIGO I–IV FSS Various DFS, OS, fertility 113 mo Jia et al (2020) 44 China Retrospective observational SBOT (n=94) FIGO I–III FSS Radical DFS, OS, fertility 64 mo Chen et al (2020) 45 China Multicenter retrospective EOC (n=87) FIGO I FSS Radical DFS, OS, fertility 47 mo Chen et al (2020b) 46 China Retrospective study MBOT (n=52) FIGO I FSS Non-FSS Recurrence, fertility 60 mo Wang et al (2020) 47 China Retrospective cohort IMT (n=175) FIGO I–III FSS Radical Recurrence, OS, fertility 73 mo Johansen et al (2019) 48 Sweden Prospective nationwide cohort NEOC (n=73) FIGO I FSS Radical PFS, OS, fertility 70 mo Lu et al (2019) 49 China Retrospective cohort Advanced BOT (n=19) FIGO II–III FSS None Recurrence, fertility 74 mo Delle Marchette et al (2019) 50 Italy Retrospective cohort BOT (n=535) FIGO I–III FSS SO vs Cy Recurrence, fertility 12 yr Jia et al (2018) 51 China Retrospective cohort EBOT (n=59) FIGO I–III FSS Radical Recurrence, fertility 30 mo Jia et al (2018b) 52 China Retrospective cohort EBOT (n=33) FIGO I FSS Radical Recurrence 54 mo Zhao et al (2018) 53 China Retrospective single-center MOGCT (n=148) FIGO I–IV FSS None PFS, OS, fertility 72 mo Yang et al (2017) 54 China Multicenter retrospective BOT (n=74) Early stage FSS Lap vs open Recurrence, fertility 21 mo Jiang et al (2017) 55 China Retrospective cohort EOC (n=108) FIGO I FSS Radical DFS, OS, fertility 83 mo Falcone et al (2017) 56 Italy Prospective institutional study Endometrial CA (n=28) Stage IA Hormonal FSS None Response, fertility 92 mo Park et al (2017) 57 Korea Retrospective cohort MOGCT (n=171) FIGO I–IV FSS None DFS, OS, fertility 86 mo Ghezzi et al (2016) 58 Italy Multi-institutional cohort EOC (n=65) FIGO I–III FSS None RFS, OS, fertility 38 mo Ouldamer et al (2016) 59 France Retrospective multi-centre BOT (n=187) FIGO I–III FSS None Fertility 42 mo Chen et al (2016) 60 China Retrospective single-centre BOT (n=122) FIGO I FSS Subtype compare Recurrence, fertility 58 mo Helpman et al (2015) 61 Israel Historic cohort (1981–2011) Advanced BOT (n=59) FIGO IC–III FSS Non-FSS Recurrence, OS, fertility 55 mo Park et al (2015) 62 Korea Retrospective cohort MOGCT (n=42) FIGO I–IV FSS None DFS, OS 93 mo Ditto et al (2015) 63 Italy Retrospective multi-institutional EOC (n=307) FIGO I–III FSS Radical DFS, OS 80 mo Yuan et al (2014) 64 China Retrospective cohort Endometrioma (n=375) rAFS III–IV Conservative Semi-radical Recurrence, pregnancy 28 mo Al Husaini et al (2012) 65 Saudi Arabia Retrospective cohort Dysgerminoma (n=65) FIGO I–IV FSS Radical DFS, OS, fertility 54 mo Tsai et al (2011) 66 Taiwan Retrospective cohort BOT (n=61) FIGO I–III FSS Radical Recurrence, OS 56 mo Hu et al (2011) 67 China Multicenter retrospective EOC (n=94) FIGO I–III FSS None DFS, OS, fertility 58 mo Song et al (2011) 68 Korea Retrospective cohort Advanced BOT (n=25) FIGO II–III FSS Radical DFS, OS, fertility 71 mo Koskas et al (2011) 69 France Retrospective cohort MBOT (n=31) FIGO I–II FSS USO vs cyst RFS, fertility 59 mo Satoh et al (2010) 70 Japan Multicenter retrospective EOC (n=211) FIGO I FSS None RFS, OS, fertility 78 mo Palomba et al (2010) 71 Italy RCT + 11-year follow-up BOT (n=32) Stage I FSS Comparison Recurrence, fertility 130 mo Hannemann et al (2008) 72 UK Registry-based retrospective Gynecologic cancers (n=63) Mixed FSS None OS ≥2 yr De La Motte Rouge et al (2008) 73 France Prospective cohort YST (n=52) FIGO I–IV FSS Radical EFS, OS, fertility 68 mo Laurent et al (2008) 74 France Retrospective cohort SBOT-MP (n=15) FIGO I–III FSS None Recurrence, OS 63 mo Zhang et al (2007) 75 China Retrospective cohort SCST (n=376) FIGO I–IV FSS Radical OS 10 yr Tinelli et al (2007) 76 Italy Retrospective single-center BOT (n=43) FIGO I FSS None Recurrence, fertility 44 mo Rao et al (2005) 77 USA Retrospective cohort LMP (n=38) FIGO I–III FSS Radical Recurrence, fertility 26 mo Donnez et al (2003) 78 Belgium Retrospective cohort BOT (n=16) FIGO I–II FSS Radical Recurrence, fertility 42 mo Seracchioli et al (2001) 79 Italy Retrospective cohort BOT (n=19) FIGO I FSS None Recurrence, fertility 42 mo Gonzalez-Lira et al (1997) 80 Mexico Retrospective cohort Ovarian cancer (n=72) Mixed FSS Radical PFS, fertility 10 yr Piura et al (1995) 81 Israel Retrospective cohort MOGCT (n=20) FIGO I–III FSS Radical OS, fertility 388 mo Abbreviations : BOT, borderline ovarian tumors; EOC, epithelial ovarian cancer; MOGCT, malignant ovarian germ cell tumors; SCST, sex cord-stromal tumors; EBOT, endometrioid borderline ovarian tumors; MBOT, mucinous borderline ovarian tumors; SBOT, serous borderline ovarian tumors; FSS, fertility-sparing surgery; USO, unilateral salpingo-oophorectomy; SO, salpingo-oophorectomy; DFS, disease-free survival; RFS, recurrence-free survival; PFS, progression-free survival; OS, overall survival; Cy, cystectomy. Table 3 Outcome Findings of the Study Outcome Category Summary Findings Across Included Studies (n = 56) Recurrence (%) Borderline ovarian tumors (BOT): 5–76%, highest in cases managed with cystectomy, bilateral disease, advanced stage, or serous micropapillary subtype. 26–29 , 35 , 36 , 40–42 , 44 , 48–54 , 59–61 , 68 , 69 , 75 , 77–79 Early-stage epithelial ovarian cancer (EOC): generally 5–20%. 33 , 37 , 45 , 55 , 58 , 63 , 67 , 70 Malignant ovarian germ cell tumors (MOGCT) / sex cord-stromal tumors (SCST), mostly <10. 13 , 28 , 34 , 47 , 48 , 54 , 57 , 73 , 81 Disease-Free Survival (DFS/ RFS) 5-year DFS commonly 80–95% in BOT and early-stage EOC. 26 , 29 , 30 , 33 , 37 , 43–45 MOGCT/SCST consistently report DFS >85–90%. 28 , 34 , 48 , 54 , 57 , 62 , 65 , 73   Overall survival BOT: OS exceeding 90–95% across studies. 26 , 30 , 39 , 40 , 50 , 59 , 60 , 68 , 75 Early-stage EOC: OS 85–95%, depending on grade and histology. 26 , 37 , 41 , 49 , 54 , 55 , 58 , 59 MOGCT/SCST: OS typically >90–97%. 34 , 40 , 48 , 57 , 60 , 67 , 73 , 81 Pregnancy Rate (%) Ranges from 25–88% overall. 26–30 , 32–36 , 41 , 43 , 44 , 56 , 59–61 , 63 , 67 , 74–76 , 78 , 82 Highest in: BOT (up to 88%), MOGCT (75–80%), early-stage EOC stage I (40–60%). 31 , 41 , 43 , 58 , 60 , 78 Live Birth Rate (%) Generally 20–80% among women attempting conception. 27–29 , 32–37 , 40 , 42 , 48 , 56–59 , 65 , 69 , 71 , 73 , 80 Some BOT cohorts report live birth rates >70%. 68 , 69 , 76 , 79 ART Use ART utilized in a minority of patients (5–30%), more frequently in older women or after more extensive surgery. 29 , 32–34 , 39–42 , 44 , 48 , 70 Studies involving IVF/ICSI show live birth rates comparable to infertile controls and no increase in tumor recurrence. 34 , 39 , 51 Key Findings (Overall) Fertility-sparing surgery (FSS) is oncologically safe for selected patients with BOT and early-stage EOC. Recurrence is higher after cystectomy compared with USO in BOT. MOGCT shows the highest oncologic and fertility outcomes. Most pregnancies occur spontaneously; ART is effective without compromising oncologic safety. Adequate staging and appropriate patient selection are essential for optimal outcomes. Abbreviations : BOT, borderline ovarian tumors; EOC, epithelial ovarian cancer; MOGCT, malignant ovarian germ cell tumors; SCST, sex cord-stromal tumors; DFS, disease-free survival; RFS, recurrence-free survival; OS, overall survival; DSS, disease-specific survival; ART, assisted reproductive technology; IVF, in vitro fertilization; ICSI, intracytoplasmic sperm injection; FSS, fertility-sparing surgery; USO, unilateral salpingo-oophorectomy. Study Characteristics of Included Studies Abbreviations : BOT, borderline ovarian tumors; EOC, epithelial ovarian cancer; MOGCT, malignant ovarian germ cell tumors; SCST, sex cord-stromal tumors; EBOT, endometrioid borderline ovarian tumors; MBOT, mucinous borderline ovarian tumors; SBOT, serous borderline ovarian tumors; FSS, fertility-sparing surgery; USO, unilateral salpingo-oophorectomy; SO, salpingo-oophorectomy; DFS, disease-free survival; RFS, recurrence-free survival; PFS, progression-free survival; OS, overall survival; Cy, cystectomy. Outcome Findings of the Study Borderline ovarian tumors (BOT): 5–76%, highest in cases managed with cystectomy, bilateral disease, advanced stage, or serous micropapillary subtype. 26–29 , 35 , 36 , 40–42 , 44 , 48–54 , 59–61 , 68 , 69 , 75 , 77–79 Early-stage epithelial ovarian cancer (EOC): generally 5–20%. 33 , 37 , 45 , 55 , 58 , 63 , 67 , 70 Malignant ovarian germ cell tumors (MOGCT) / sex cord-stromal tumors (SCST), mostly 85–90%. 28 , 34 , 48 , 54 , 57 , 62 , 65 , 73 BOT: OS exceeding 90–95% across studies. 26 , 30 , 39 , 40 , 50 , 59 , 60 , 68 , 75 Early-stage EOC: OS 85–95%, depending on grade and histology. 26 , 37 , 41 , 49 , 54 , 55 , 58 , 59 MOGCT/SCST: OS typically >90–97%. 34 , 40 , 48 , 57 , 60 , 67 , 73 , 81 Ranges from 25–88% overall. 26–30 , 32–36 , 41 , 43 , 44 , 56 , 59–61 , 63 , 67 , 74–76 , 78 , 82 Highest in: BOT (up to 88%), MOGCT (75–80%), early-stage EOC stage I (40–60%). 31 , 41 , 43 , 58 , 60 , 78 Generally 20–80% among women attempting conception. 27–29 , 32–37 , 40 , 42 , 48 , 56–59 , 65 , 69 , 71 , 73 , 80 Some BOT cohorts report live birth rates >70%. 68 , 69 , 76 , 79 ART utilized in a minority of patients (5–30%), more frequently in older women or after more extensive surgery. 29 , 32–34 , 39–42 , 44 , 48 , 70 Studies involving IVF/ICSI show live birth rates comparable to infertile controls and no increase in tumor recurrence. 34 , 39 , 51 Fertility-sparing surgery (FSS) is oncologically safe for selected patients with BOT and early-stage EOC. Recurrence is higher after cystectomy compared with USO in BOT. MOGCT shows the highest oncologic and fertility outcomes. Most pregnancies occur spontaneously; ART is effective without compromising oncologic safety. Adequate staging and appropriate patient selection are essential for optimal outcomes. Abbreviations : BOT, borderline ovarian tumors; EOC, epithelial ovarian cancer; MOGCT, malignant ovarian germ cell tumors; SCST, sex cord-stromal tumors; DFS, disease-free survival; RFS, recurrence-free survival; OS, overall survival; DSS, disease-specific survival; ART, assisted reproductive technology; IVF, in vitro fertilization; ICSI, intracytoplasmic sperm injection; FSS, fertility-sparing surgery; USO, unilateral salpingo-oophorectomy. Reproductive outcomes following FSS were consistently favorable across studies, with pregnancy rates ranging from approximately 25% to over 80% among women attempting conception. 26–30 , 32–36 , 41 , 43 , 44 , 56 , 59–61 , 63 , 67 , 74–76 , 78 , 82 High pregnancy rates were reported in several cohorts, particularly when analysis was restricted to patients actively attempting pregnancy, where success rates frequently exceeded 70–80%. 27 , 29 , 57 Long-term data demonstrated cumulative pregnancy rates approaching 85% in selected populations. 50 Live birth rates were similarly high, generally exceeding 40–80% of pregnancies, with some studies reporting near-universal term delivery among those who conceived. 33 , 35 , 45 , 50 , 58 , 68 , 76 , 77 , 79 Obstetric outcomes were favorable, with the majority resulting in term deliveries and low rates of obstetric complications. 35 , 42 , 69 Most pregnancies occurred spontaneously, indicating preserved ovarian function after FSS. The use of assisted reproductive technologies (ART), including IVF and ovulation induction, was reported in a minority of patients, generally ranging from 5% to 30% depending on the cohort. 34 , 39 , 41 Importantly, ART use was not associated with increased recurrence risk or worse oncologic outcomes. 32 Additionally, pregnancy after FSS did not negatively impact survival and may even be associated with reduced recurrence risk in some studies. 64 Several factors were identified as influencing reproductive success. Younger age, particularly ≤35 years, was consistently associated with higher pregnancy and live birth rates, whereas increasing age significantly reduced fertility potential 35 , 38 , 59 The number of surgical interventions also played a critical role, with repeated surgeries negatively impacting fertility outcomes. 50 Additionally, underlying gynecological conditions, such as endometrial pathology and endometriosis, were associated with poorer reproductive outcomes despite ovarian preservation. 51 Surgical technique also influenced fertility outcomes. While more conservative procedures such as cystectomy preserved more ovarian tissue and were associated with higher pregnancy rates, they carried a higher recurrence risk, highlighting a trade-off between oncologic safety and fertility preservation. 69 , 82 Overall, FSS enables meaningful preservation of reproductive potential, particularly in early-stage disease, with a high likelihood of spontaneous conception and favorable obstetric outcomes. Across the included studies, recurrence rates following FSS showed wide variability, ranging from approximately 3–10% in early-stage disease to over 70% in selected high-risk or advanced-stage cohorts. 30 , 36 , 38 , 45 Comparative studies consistently demonstrated higher recurrence rates in patients undergoing FSS compared with radical surgery, particularly in advanced-stage BOT and bilateral disease. 27 , 44 , 66 However, most recurrences were borderline, non-invasive, and predominantly confined to the remaining ovary, allowing for effective salvage surgery and repeat fertility-preserving procedures. 35 , 41 , 49 In malignant ovarian germ cell tumors, oncologic outcomes were particularly favorable, with 5-year OS exceeding 90–95% across studies. 57 , 65 , 81 Recurrence rates were generally low (approximately 5–15%) and, when present, were often highly responsive to chemotherapy or salvage surgery. 55 , 65 Similarly, in early-stage epithelial ovarian cancer, studies consistently reported excellent survival outcomes, with no significant survival disadvantage associated with FSS compared with radical surgery. 43 , 45 , 63 Key prognostic factors associated with recurrence and worse DFS included advanced FIGO stage, invasive peritoneal implants, micropapillary patterns, tumor grade, bilateral ovarian involvement, elevated CA-125 levels, and incomplete cytoreduction. 33 , 34 , 43 , 44 , 57 Histology-specific differences were also observed, with mucinous and clear-cell subtypes demonstrating distinct recurrence patterns and prognosis. 69 , 70 Importantly, surgical approach influenced recurrence risk, with cystectomy-based procedures consistently associated with higher recurrence compared to unilateral salpingo-oophorectomy. 60 , 66 , 69

Overall, FSM in young women with early-stage ovarian cancer demonstrated oncologic safety comparable to radical surgery in low-risk disease, while preserving meaningful chances of pregnancy and live birth. Recurrence risks remain higher in high-grade tumors and incomplete staging cases, underscoring the importance of strict patient selection. Integration of ART and fertility preservation techniques further enhances reproductive outcomes, providing a balanced approach between survival and quality of life.

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. 21 No institutional review board approval was required, as only previously published, de-identified data were analyzed. All authors contributed to the development of the search strategy and the definition of inclusion and exclusion criteria. The protocol was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO; Registration ID: CRD420261368106). The primary research question was “What are the oncologic and reproductive outcomes of FSM in women with ovarian cancer?”. Secondary research questions included “Which prognostic factors (stage, histology, grade, completeness of staging, adjuvant therapy) influence outcomes following FSM?”, “What is the role of ART in improving reproductive success after FSM?”. The conceptual framework of this review is presented in Figure 1 . Figure 1 Conceptual framework of fertility-sparing management (FSM) in ovarian cancer. Young women diagnosed with ovarian cancer face two main management pathways: standard radical surgery (hysterectomy with bilateral salpingo-oophorectomy) or fertility-sparing surgery (unilateral salpingo-oophorectomy ± staging). Radical surgery ensures oncologic control but eliminates reproductive potential. In contrast, FSM provides comparable oncologic outcomes in selected early-stage cases while maintaining fertility potential. Reproductive outcomes, including pregnancy and live birth, may be further enhanced by adjunct fertility strategies such as assisted reproductive technologies (ART), cryopreservation, and gonadotropin-releasing hormone (GnRH) agonists. Fertility-sparing options in ovarian cancer surgery for young women, with outcomes. Conceptual framework of fertility-sparing management (FSM) in ovarian cancer. Young women diagnosed with ovarian cancer face two main management pathways: standard radical surgery (hysterectomy with bilateral salpingo-oophorectomy) or fertility-sparing surgery (unilateral salpingo-oophorectomy ± staging). Radical surgery ensures oncologic control but eliminates reproductive potential. In contrast, FSM provides comparable oncologic outcomes in selected early-stage cases while maintaining fertility potential. Reproductive outcomes, including pregnancy and live birth, may be further enhanced by adjunct fertility strategies such as assisted reproductive technologies (ART), cryopreservation, and gonadotropin-releasing hormone (GnRH) agonists. A comprehensive literature search was performed in PubMed/MEDLINE, EMBASE, Scopus, and Cochrane CENTRAL databases from January 1995 to September 2025. Boolean operators were applied using the following search string: (“ovarian neoplasms” OR “ovarian cancer” OR “epithelial ovarian carcinoma” OR “borderline ovarian tumor” OR “germ cell tumor”) AND (“fertility-sparing surgery” OR “fertility preservation” OR “conservative surgery” OR “fertility-sparing management”) AND (“oncologic outcomes” OR “survival” OR “recurrence” OR “reproductive outcomes” OR “pregnancy” OR “live birth”). Reference lists of relevant articles and reviews were hand-searched to identify additional eligible studies. Studies were included according to predefined eligibility criteria based on the PICO framework, as summarized in Table 1 . Exclusion criteria: case reports, case series <10 patients, conference abstracts, reviews, animal studies, and studies not reporting both oncologic and/or reproductive outcomes. Table 1 PICO Framework The Components of PICO (Population, Intervention, Comparison, and Outcomes) Inclusion Criteria Population (P) Women diagnosed with epithelial ovarian carcinoma (EOC), borderline ovarian tumors (BOT), or non-epithelial ovarian malignancies. Intervention (I) Fertility-sparing management (FSM), defined as conservative surgery (eg, unilateral salpingo-oophorectomy, cystectomy, uterine preservation) with or without adjunctive fertility preservation strategies. Comparison (C) Standard radical surgery or non-FSM approaches when available. Outcomes (O) Primary outcomes: Reproductive outcomes (pregnancy rate, live birth rate) and oncologic outcomes (recurrence rate, disease-free survival, overall survival). Secondary outcomes: Use of ART, ovarian reserve, gonadotoxicity of chemotherapy, prognostic factors affecting outcomes. Study design Randomized controlled trials (RCTs), prospective or retrospective cohort studies, and case-control studies. Language English full-text. PICO Framework All studies retrieved from the search were independently screened by two reviewers. Full-text articles of potentially eligible studies were assessed against predefined inclusion criteria. Any disagreements were resolved through discussion or consultation with a third reviewer. Data extraction was performed independently by two reviewers using a standardized form. Extracted data included study characteristics (author, year, country, design, sample size), patient characteristics (age, histology, stage, grade), details of fertility-sparing management and completeness of staging, use of adjuvant therapy, oncologic outcomes (recurrence, disease-free survival, overall survival), reproductive outcomes (pregnancy, live birth, ART use), and duration of follow-up. The study selection process is summarized in Figure 2 . 22 Figure 2 PRISMA flow diagram of study selection. The flowchart outlines the study selection process starting with identification of new studies via databases and registers. Records identified through database searching include PubMed, MEDLINE, EMBASE, Scopus and Cochrane CENTRAL, totaling 464. Records removed before screening due to duplicates number 37. Screening involves 427 records, with 229 excluded for irrelevant titles and abstracts. Reports sought for retrieval total 198, with none not retrieved. Eligibility assessment includes 198 records, with 142 full-text articles excluded for reasons such as case reports or series, review articles and meta-analyses, non-relevant population, non-FSM intervention, non-English full-text and insufficient data for analysis. Finally, 56 studies are included in qualitative and quantitative synthesis. A flowchart of study selection process from identification to inclusion, detailing records screened and excluded. PRISMA flow diagram of study selection. The methodological quality of included studies was assessed using validated tools according to study design. The risk of bias in non-randomized studies was evaluated using the ROBINS-I tool. 23 Cohort studies were appraised using the Newcastle–Ottawa Scale (NOS), assessing selection, comparability, and outcome domains, and visualized using the NOS-TLPlot tool. 24 Randomized controlled trials were assessed using the Cochrane Risk of Bias 2 (RoB 2) tool. 25 The results are presented in Figures 3–5 . Due to substantial clinical and methodological heterogeneity among the included studies, a formal meta-analysis was not performed, and the findings were synthesized qualitatively. Figure 3 Risk of bias assessment using ROBINS-I. ( a ) Summary plot showing the proportion of studies at low, moderate, and serious risk of bias across each ROBINS-I domain. ( b ) Traffic light plot presenting the domain-level risk of bias for each included study. 23 A summary plot and traffic light plot assess the risk of bias in studies. The summary plot shows the proportion of studies at low, moderate and serious risk across domains: bias due to confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes and selection of reported results. The traffic light plot presents domain-level risk for each study, including Yan et al (2025) to Piura et al (1995). Domains D1 to D7 correspond to specific biases, with judgments marked as low, moderate, or serious risk. The plot visually represents the methodological quality of studies using ROBINS-I, Newcastle–Ottawa Scale and Cochrane Risk of Bias 2 tools. Risk of bias assessment summary and traffic light plot for various studies. Figure 4 Risk of bias assessment of randomized controlled trials using RoB 2 tool. 25 Risk of bias assessment for Palomba et al (2010) across five domains and overall judgment. Figure 5 Newcastle–Ottawa Scale quality assessment of included studies. ( a ) Heatmap of NOS domain scores and overall risk of bias for each included study. 24 ( b ) Stacked area chart illustrating the distribution of risk of bias across NOS domains. The Risk of Bias heatmap reviews 28 studies from Seracchioli et al (2001) to Jiang et al (2025) across four domains: Selection, Comparability, Outcome/Exposure and Overall RoB. Risk levels are categorized as High, Moderate, or Low. Selection mostly shows Low risk, with one Moderate. Comparability often rates Moderate or High. Outcome/Exposure is generally Low, except for High ratings in Fong et al (2025), Hannemann et al (2008), Laurent et al (2008) and Seracchioli et al (2001). Overall RoB is mostly Moderate or Low, with High in the same studies. Notable ratings: Jiang et al (2025) and Bianchi et al (2025) show Low, Moderate, Low, Moderate; Fong et al (2025) shows Low, High, High, High; Li et al (2025) and Ayhan et al (2023) show Low across all domains; Hannemann et al (2008) and Laurent et al (2008) show Moderate, High, High, High. The pattern indicates Low risk in Selection and Outcome/Exposure, with higher risks in Comparability and Overall RoB. Heatmap: Bias Risk by Domain/Study; rows: author/year, columns: Selection, Comparability, Outcome, Overall. Figure 5 Continued. Stacked area chart: risk by domain, x: Selection to Outcome/Exposure, y: 0-100%. Risk of bias assessment using ROBINS-I. ( a ) Summary plot showing the proportion of studies at low, moderate, and serious risk of bias across each ROBINS-I domain. ( b ) Traffic light plot presenting the domain-level risk of bias for each included study. 23 Risk of bias assessment of randomized controlled trials using RoB 2 tool. 25 Newcastle–Ottawa Scale quality assessment of included studies. ( a ) Heatmap of NOS domain scores and overall risk of bias for each included study. 24 ( b ) Stacked area chart illustrating the distribution of risk of bias across NOS domains. Continued.

This review provides a comprehensive synthesis of current evidence on fertility-sparing management (FSM) in ovarian tumors, encompassing a large number of studies with diverse histologic subtypes and long-term follow-up. The inclusion of both oncologic and reproductive outcomes offers a clinically relevant perspective for oncofertility decision-making. However, several limitations should be acknowledged. Most included studies were retrospective and heterogeneous in design, patient selection, surgical approach, completeness of surgical staging, outcome reporting, and follow-up duration, which may introduce bias. Differences in the definitions of recurrence further limited direct comparison across studies and precluded formal quantitative meta-analysis. In addition, important confounding factors, including disease stage, treatment selection, ethnicity, family history, and genetic predisposition, were not consistently reported or controlled across the included studies. These factors may have influenced the reported oncologic and reproductive outcomes and should be considered when interpreting and generalizing the findings.

This systematic review confirms that FSM is a safe and effective strategy for carefully selected young women with early-stage ovarian cancer. Oncologic outcomes, particularly overall and disease-free survival, are comparable to radical surgery in low-risk patients, while meaningful reproductive potential can be preserved. Pregnancy and live birth rates following FSM are encouraging, and the integration of ART further enhances reproductive success. Based on the available evidence, FSM should be considered a standard treatment option for carefully selected patients with borderline ovarian tumors, malignant ovarian germ cell tumors, and FIGO stage IA grade 1–2 epithelial ovarian cancer, whereas caution is warranted in patients with high-grade histology or more advanced-stage epithelial ovarian cancer.

This systematic review demonstrates that FSM is oncologically safe in carefully selected women with early-stage ovarian cancer, particularly those with Stage IA–IC, Grade 1–2 epithelial ovarian EOC, BOT, and germ cell tumors. Across the included studies, overall survival (OS) consistently remained high, frequently exceeding 90–95%, with no significant differences between FSM and radical surgery in most comparative analyses. 27 , 45 , 63 , 77 These findings are consistent with previous reviews and meta-analyses, which report comparable survival outcomes when comprehensive staging protocols are followed. 2 , 5–7 In these cohorts, five-year overall survival frequently exceeded 90%, and recurrences, when present, were often salvageable. 1 , 8–10 , 82 These data support the notion that, in appropriately selected cases, FSM does not compromise oncologic safety. From a reproductive perspective, our synthesis confirms that FSM enables meaningful reproductive potential. Across included studies, pregnancy rates varied widely, ranging from approximately 20% to over 80% among women attempting conception, with live birth rates commonly exceeding 60% of achieved pregnancies. 29 , 42 , 50 , 54 These outcomes highlight the importance of fertility preservation strategies as integral to survivorship care. The growing role of assisted reproductive technologies (ART), including in vitro fertilization (IVF), oocyte and embryo cryopreservation, and ovarian tissue banking, has further expanded opportunities for conception among survivors. 14–16 , 83 Importantly, the use of gonadotropin-releasing hormone (GnRH) agonists during chemotherapy may mitigate gonadotoxic effects and preserve ovarian reserve. 18 Despite these encouraging outcomes, several controversies remain. FSM is associated with increased recurrence risk in patients with high-grade histologies, advanced-stage disease, or when surgical staging is incomplete. 17 , 33 , 44 , 84 This emphasizes the need for careful patient selection and adherence to staging protocols. Moreover, surgical technique influences outcomes, with cystectomy-based approaches consistently associated with higher recurrence rates compared to unilateral salpingo-oophorectomy. 60 , 66 , 69 Among the major multicenter collaborative studies, the GINECO–TMRG OPTIBOT study demonstrated favorable oncologic and reproductive outcomes following fertility-sparing surgery in patients with FIGO stage I borderline ovarian tumors. In contrast, the MITO14 study evaluated a higher-risk population with FIGO stage II–III serous borderline ovarian tumors and extra-ovarian invasive implants, reporting higher recurrence rates despite acceptable long-term survival outcomes. 36 , 41 Clinically, FSM should be considered within a multidisciplinary framework involving gynecologic oncologists, reproductive endocrinologists, and fertility counselors. Early referral to fertility specialists and integration of oncofertility services are crucial to optimize reproductive outcomes. Shared decision-making is essential to balance oncologic safety with reproductive goals, particularly given the psychosocial impact of infertility in young women with cancer. Future research should focus on prospective, multicenter studies with standardized reporting of both oncologic and reproductive endpoints. The development of risk-stratification models integrating molecular markers, tumor biology, and fertility parameters may improve patient selection. Long-term follow-up is also needed to evaluate the impact of ART and fertility preservation interventions on survival and recurrence.