In a scenario where cancer mortality falls more dramatically than its incidence, another picture is built up where women at the height of their careers, or without a stable relationship, increasingly choose to postpone motherhood. In the United States of America, statistics on births point to the downward trend of 1–2 % per year among women aged 20–29 and an upward trend to 3 % in their 30s, with births among women aged 35–39 reaching nearly 50 births/1,000 individuals in 2013 (the highest rate in the country since 1963) [19]. Similarly, in Brazil, higher live births rates are observed among women aged 30–39 years, and there is a clear fall of the numbers among younger women [24].

Looking at the two situations and understanding that the incidence of many cancers increases with increasing age, it is assumed that there will be more cancer diagnoses in women who did not have children or finished their offsprings, and consequently there will be more cancer survivors interested in future procreation.

Although still few cases, there is an observed increase in cases over time. The number of referrals has increased, already very close number of referrals to the sum of all referrals made in previous years in some of the big centers of Reproductive Medicine in Brazil. This is likely due to women’s increased access to information on the possibility of preserving their gametes before the antineoplastic treatment, as well as repeat diffusion actions of oncofertility among clinical oncologists, oncology surgeons, gynecologists, urologists, mastologists, and other health professionals.

The best way to raise oncologist’s awareness about the importance of discussing oncofertility should begin with the identification of those patients who would potentially benefit fertility preservation strategies before chemotherapy or radiation therapy. Considering an estimated 10 % of female cancer cases occur before the age of 45, with a survival rate of about 85 % [21], and passing the yearly statistics of cancer around the world [4, 12, 13, 21], we could share with the oncologists the deduction that oncofertility strategies could benefit more than 15,000 women in Brazil, 66,000 women in the United States of America, 160,000 women in Europe, and 830,000 women worldwide every year.

As recently suggested by the founder of the Global Oncofertility Consortium, Teresa Woodruff [37], there is a great expectation that, in a near future, oncofertility assumes the role of modifying culture on cancer treatment, bringing innovation while opening the world’s eyes to procreation perspective as a quality of life factor for cancer survivors.

In Brazil, cancer is already the leading cause of death (7% of total) due to illness among children and adolescents from 1 to 19 years old, for all regions. It is estimated that approximately 12,600 new cases of cancer occur in children and adolescents in Brazil each year in 2016 and 2017. The Southeast and Northeast regions will present the highest number of new cases, 6,050 and 2,750, respectively, followed by the South 1,320), Midwest (1,270) and North (1,210) [4].

In Brazil, the most common types of cancer in children are carcinomas and other epithelial malignancies (28 %), leukemia (15 %), bone tumors (14 %), lymphoma and other reticuloendothelial tumors (10 %), soft tissue sarcomas (7 %), renal tumors (6 %), central nervous system and miscellaneous intracranial tumors, and intraspinal neoplasms (6 %) [3].

Between 2005 and 2009, the overall incidence of cancer in children aged under 14 increased about 0.5 % per year, a consistent trend in the country since mid 1970s. However, the mortality rate for childhood cancer has decreased by more than a half over the past three decades, from 4.9 per 100,000 in 1975 to 2.1 per 100,000 individuals in 2009 [35]. The good results of anticancer treatments in children can also be translated by mean cumulative survival rate in 5 years, which now exceeds 80 % [3, 21]. Thousands of girls and adolescents with cancer receive successful anticancer treatments annually, and then we may already have at least one childhood or adolescence cancer survivor in each group of 570 adults in reproductive age [20].

Ovarian cortex cryopreservation is the fertility preservation strategy of greater relevance in oncological patients in childhood. Sixty births have already been well documented in literature [11], at orthotopic or heterotopic sites, reinforcing the near inclusion of this strategy in the routine of specialized services in reproductive medicine around the world. Although it is still considered experimental [23], the advantage of allowing the preservation of thousands of viable primordial follicles could be held in the absence of the hypothalamic-pituitary-ovarian axis activation [6, 27], and it should be applied to specific groups of patients, such as prepubertal girls [7, 28].

The major restriction to the use of ovarian cryopreservation is the presumed risk of recurrence of cancer, originated from metastasis in ovarian tissue reused. Although there are no reports in humans, this hypothesis should be highlighted for the patient and their caregivers and is fundamental to clarify that the risks may vary according to the type of tumor, as not all tumors are likely to develop metastatic foci in the ovaries [29, 36]. The literature reports efforts to develop efficient techniques for isolation of primordial, primary and secondary follicles, and their maturation in vitro. There are only reports of births after cultivation of secondary follicles in mice [40], but studies with primate and human follicles have shown promising results [2, 30, 38, 39, 41].

Depending on the age and on the stage of pubertal development, different fertility preservation options can be offered; ovarian tissue cryopreservation is always an option, especially if ovarian failure is highly probable. For those patients in a postpubertal stage oocyte cryopreservation, applying a random start ovulation induction can also be offered. In general, postpubertal girls and their parents are more likely to agree with fertility preservation procedures; younger kids and their parents are not usually receptive to fertility matters and frequently refuse to accept, especially when laparoscopy is indicated for ovarian biopsy.

The precocity of referral also influences the procedures that are offered. For ovulation induction, the patients need nearly 9–12 days until retrieval of mature oocytes, and sometimes, depending on ovarian response, more than one retrieval is necessary. In case ovarian tissue cryopreservation is indicated in combination with oocyte cryopreservation, the ideal is to proceed ovarian biopsy and then ovulation induction and oocyte pick up, because the punctures and the hematomas make the tissue unfeasible for storage. In cases of precondition chemotherapy before bone marrow transplantation (BMT) in none oncological patients, when we have 2 months or more available, oocyte pickup may be done before ovarian biopsy without prejudice of the tissue.

An important and delicate issue is the process of obtaining informed consent for fertility preservation in children and incapable. That is because the subject is a difficult context in the age group or the lack of awareness for such a decision. Still, because the techniques considered most appropriate for sexually immature individuals, they are considered experimental in younger populations [26], as discussed in the previous paragraphs.

In such cases, parents or legal guardians often make the decision on behalf of the patient, assisted by a multidisciplinary team. It is observed commonly the exclusion of patient of decisions to be made around the antineoplastic treatment. The reasons for that are exclusive focus on healing, without valuing the quality of life after survival; the discomfort of parents in dealing with issues related to sexual life of the child as an adult; and the desire to protect children and adolescents against anxiety generated by sensitive issues such as sexuality and procreation [18]. However, it should be noted that the American Academy of Pediatrics recommends assistants to give the child over the age of 7 the opportunity to discuss the issue and even refuse to preserve fertility, even if it is a desire of parents [1, 32].

Brazil is a country of an emerging economy that has a Public Health System which, although still needs improvements in many ways, offers a comprehensive care to any patient with cancer. At the present, there are 276 hospitals enabled in cancer treatment. All states have at least one hospital enabled in oncology, where the cancer patient can find medical access to more complex surgeries and treatments.

However, in fertility preservation in Brazil, the procedure’s cost is an important obstacle. In the Brazilian Public Health System, infertility, in general, is not considered as a disease; thus, the patient has to pay for the ovulation induction drugs and for the procedure itself. There are few centers that offer assisted reproduction techniques for free.

The practice of fertility preservation for cancer patients it is still being built even in the private clinics. Not many doctors are aware of the options for gametes preservation, and few know that the procedure should be done before the start of the treatment. Fertility preservation is generally more discussed in more developed regions where the hospitals and universities are aware of the concept of oncofertility.

Oncofertility has been increasingly discussed in Brazil through meeting events related to cancer and fertility, and information has been widespread also through the Internet. The eight current center members of the Brazilian Oncofertility Consortium have contributed to many discussions, participation, and promotion of events on the topic of oncofertility and fertility preservation.

At Pró-Criar Medicina Reprodutiva, located in Belo Horizonte, State of Minas Gerais, they have received an increasing number of young men and women with cancer diagnosis for discussion of fertility preservation. Most of them choose to cryopreserve oocytes and sperm, and a reduced number makes the choice to cryopreserve ovarian tissue. The clinic have provided this technique as an experimental treatment, including children and adolescents, with no cost, as a research project, in partnership with the Faculty of Medical Sciences of Minas Gerais, approved by a Research Ethics Committee. This increase in number of patients looking for gamete preservation has not happened with children or adolescents in pre- or peripubertal periods. The clinic has seen patients who have undergone treatment for cancer, chemo- and radiation therapy, and even marrow transplant, whose parents did not have the opportunity to discuss alternatives to preserve fertility before the start of treatment. Rare cases received information before the cancer treatment. In only one peripubertal case was held freezing of ovarian tissue samples. In a few other cases, the clinic was approached by oncologists, but the children had no medical condition for a laparoscopy. The clinic aims to assist the cancer patient in up to 24 h for a consultation and, in case of male, for also a sperm banking.