Women After Bone Marrow Transplants Know Little About Their Fertility, Study Finds

For the growing population of women who have survived a hematopoietic stem cell transplantation, one of the most consequential and least discussed consequences of their treatment is the damage it inflicts on the ovaries. The conditioning chemotherapy and radiation that precede a transplant are among the most gonadotoxic interventions in modern medicine, often depleting the finite pool of ovarian follicles and pushing patients into premature ovarian insufficiency. Yet a new cross-sectional study from Iran’s largest transplant referral center suggests that many female survivors are navigating their reproductive futures with strikingly little accurate information. The research, published in the Journal of Cancer Survivorship, surveyed 209 women at least one year after transplantation and found that their fertility knowledge was, on average, poor, even as nearly half of them still hoped to have children one day.

The study was conducted by a team of nursing and hematology researchers affiliated with Tehran University of Medical Sciences, drawing participants from the Hematology-Oncology and Stem Cell Transplantation Research Center. The women, whose mean age was approximately 34.7 years with a standard deviation of about 9 years, completed a sociodemographic profile, a researcher-developed Fertility Knowledge Questionnaire scored out of 10, and the Attitude Toward Fertility and Childbearing Scale, a validated psychometric instrument. The researchers then used multivariable linear regression to identify which characteristics independently predicted knowledge and attitude scores, an approach that allowed them to separate the effects of age, education, marital status, economic circumstances, and reproductive history from one another.

The headline numbers are sobering. The mean fertility knowledge score was 4.56 out of 10, with a standard deviation of 1.92, placing the average survivor well below the midpoint of the scale. More alarming than the aggregate score was the pattern of specific deficits. When asked about the appropriate timing for pregnancy after transplantation, 92.3 percent of respondents answered incorrectly. When asked about treatment-related reproductive risks, 94.7 percent got the answer wrong. These are not obscure clinical details; the recommended interval before attempting conception after transplant, and the realistic probability of spontaneous pregnancy given gonadal damage, are precisely the facts a survivor needs in order to plan contraception, seek specialist care, or avoid an unplanned and potentially dangerous pregnancy.

Against this backdrop of ignorance, the survivors’ attitudes toward parenthood were remarkably warm. The mean attitude score was 63.25, with a standard deviation of 10.73, which the authors characterize as relatively positive. Nearly half of the participants, 47.4 percent, expressed a desire for future children. Taken together, the two findings sketch a paradox: a population that wants children but does not understand the biological constraints, risks, and timelines that govern whether and when those children might be safely conceived after a transplant.

Perhaps the most intriguing statistical result is a significant inverse correlation between knowledge and attitude scores, with a Pearson coefficient of minus 0.334 and a p-value below 0.01. In plain terms, women who knew more about their post-transplant fertility tended to hold less optimistic attitudes toward childbearing, while those with greater knowledge gaps were more hopeful. The authors interpret this cautiously, suggesting that enhanced awareness of reproductive risk might temper what they call reproductive optimism. The correlation is cross-sectional, so causality cannot be established; it is equally possible that women who have already absorbed difficult information about their fertility have emotionally adjusted their expectations downward. Either way, the finding challenges the common assumption that education alone will uniformly empower and reassure patients.

The regression models also revealed who knew more and who wanted more. For knowledge, the model accounted for a substantial 46 percent of the variance, with older age, holding a master’s degree, being divorced, and having health insurance each independently predicting higher scores. The education effect is unsurprising, but the insurance finding hints at structural inequities in how survivorship information is delivered: women with coverage may have more frequent follow-up encounters and better access to counseling. For attitudes, the model explained 31 percent of the variance, with younger age, having fewer existing children, and reporting superior economic status predicting more positive views of future childbearing. Younger women, with more reproductive years potentially ahead of them, and women who have not yet completed their families, logically attach more value to future parenthood.

The clinical context makes these gaps more dangerous than they might first appear. Pregnancy after hematopoietic cell transplantation is possible, and case series from large registries such as the Center for International Blood and Marrow Transplant Research have documented successful outcomes, but it is considered high risk for both mother and fetus. Survivors face elevated rates of ovarian failure, and those who do conceive require careful obstetric surveillance for complications including relapse, graft-versus-host disease flare, and the teratogenic potential of ongoing medications such as immunosuppressants. A survivor who does not know that pregnancy should be deferred for a specified period after transplant, or that her residual ovarian reserve may be minimal, could inadvertently conceive during a window when the risks are highest, or conversely abandon hope of biological motherhood without ever exploring options such as donor oocytes or previously cryopreserved embryos.

The timing of information delivery is a central theme of the study’s implications. The authors argue that structured, multidisciplinary, and psychologically informed fertility counseling should be incorporated into routine survivorship care, and ideally initiated before conditioning regimens begin. This aligns with a broader movement in oncofertility: fertility preservation options for women facing gonadotoxic therapy, including oocyte and embryo cryopreservation and ovarian tissue freezing, are time-sensitive and must be discussed in the narrow interval between diagnosis and treatment. Once the transplant is complete and ovarian function has been lost, the menu of options narrows dramatically. Prior research has shown that women often report greater vulnerability than men when confronting treatment-induced infertility, and that fertility-related distress among transplant survivors persists for a decade or more after the procedure.

The study’s framework draws on established health psychology models, including the Health Belief Model and Protection Motivation Theory, which posit that perceived susceptibility and perceived severity shape whether people adopt protective behaviors. In this light, the inverse knowledge-attitude correlation takes on additional meaning: survivors who perceive themselves as highly susceptible to infertility and pregnancy complications may rationally lower their childbearing aspirations, while those who underestimate the threat maintain optimism that may not match their clinical reality. Effective counseling, the authors imply, must do more than transfer facts; it must help patients integrate accurate risk information into their life plans without extinguishing legitimate hope, since spontaneous pregnancies and assisted reproduction outcomes do occur in this population.

The findings carry weight beyond Iran. Hematopoietic stem cell transplantation is performed tens of thousands of times each year worldwide, and the population of long-term survivors continues to expand as survival rates improve. Survivorship guidelines in Europe and North America increasingly call for routine assessment of reproductive concerns, but implementation remains uneven, and fertility discussions are frequently omitted from post-transplant follow-up, particularly for patients who are older, unmarried, or already parents at the time of treatment. This study suggests that such omissions leave a measurable knowledge vacuum. The authors’ call for psychologically informed counseling acknowledges a further nuance: information that arrives without emotional support can itself be distressing, and the goal of survivorship care is not simply to raise scores on a questionnaire but to equip women to make reproductive decisions that reflect both their medical reality and their personal values. For the nearly half of surveyed survivors who still hope for children, that kind of informed, compassionate guidance may determine whether their reproductive futures are chosen deliberately or left to chance.

Subject of Research: Fertility knowledge and childbearing attitudes among female hematopoietic stem cell transplantation survivors

Article Title: Fertility-related knowledge and childbearing attitudes among female survivors of hematopoietic stem cell transplantation: a cross-sectional study

Article References: Dehghan, A. H., Vafaeinezhad, F., Chekeni, A. M., Ghane, G., rozveh, A. K., & Vaezi, M. (2026). Fertility-related knowledge and childbearing attitudes among female survivors of hematopoietic stem cell transplantation: a cross-sectional study. Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02134-x

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02134-x

Keywords: hematopoietic stem cell transplantation, fertility knowledge, childbearing attitudes, cancer survivorship, fertility preservation, gonadotoxicity, premature ovarian insufficiency, reproductive counseling, women's health, oncofertility, cross-sectional study, survivorship care