Table 3.

Demnographic and clinical characteristics of included studies

First author	Gouy, S et al. 2017	Nitecki, R. et al. 2021	Jiang, X et al. 2017	Johansen, G. et, 2019
Country	France	United States	China	Sweden
Study design	Case report	Retrospective cohort	Retrospective Cohort	Prospective nationwide cohort
Number of patients	6	153	108	73
Mean age years)	28.2 (range: 16–35)	N/A	30 (range: 16–40)	29 (range: 19–40)
Age of menarche (years)	N/A	N/A	N/A	N/A
Tumor size (mm)	60–150	N/A	Median 120 (range: 30–400)	N/A
Gynecological Cancer History	N/A	N/A	N/A	N/A
FIGO staging FSS	Stage IA: 2 patients	IA and IC cases only0	IA–B: 36 (33.3%)	IA: 41 out of 57 (72%)
	Stage IC1: 1 patient		IC1: 55 (50.9%)	IC: 16 out of 57 (28%)
	Stage IC2: 2 patients		IC2–3: 17 (15.7%)
	Stage IC3: 1 patient
Histology & grading	All cases were infiltrative mucinous ovarian carcinoma	Tumor histology:  Epithelial: 54.9%  Germ-cell: 37.3%  Sex-cord stromal: 7% Tumor grade:  Grade 1: 19.6%  Unknown grade: 55.6%	Tumor histology:  Mucinous: 52 (48.2%)  Serous: 9 (8.3%)  Endometrioid: 27 (25%)  Clear cell carcinoma (CCC): 20 (18.5%) Tumor grade:  Grade 1: 72 (66.7%)  Grade 2: 12 (11.1%)  Grade 3: 4 (3.7%) Clear cell carcinoma: 20 (18.5%)	Tumor histology:  Immature Teratoma: 16 (28%)  Dysgerminoma: 7 (12%)  Granulosa Cell Tumor: 19 (33%)  Yolk Sac Tumor: 3 (5%)  Sertoli–Leydig tumor: 7 (12%)  Carcinoma Struma Ovarii: 3 (5%)  Other rare types: 2 (4%) Tumor grade:  Grade 1: 8 patients  Grade 2: 7 patients  Grade 3: 3 patients
Reproductive outcomes	Patients who conceived after surgery: 2 out of 6 (33.3%) Total pregnancies: 2 Live birth rate: 2 out of 2 (100%) Pregnancy method: Oocyte donation (both cases) Pregnancy complications: Not reported	Patients who conceived after surgery: 153 out of 1,618 patients diagnosed with stage IA or IC ovarian cancer (9.5%) Total pregnancies: 153 (only first pregnancy after cancer was analyzed) Live birth rate: Not explicitly mentioned, but most pregnancies resulted in live births Preterm birth rate (< 37 weeks): 13.7% in ovarian cancer patients vs. 11.4% in controls (not statistically significant, OR 1.23, 95% CI 0.69–2.20) Small for gestational age births (< 10th percentile): 11.8% vs. 12.7% (not statistically significant, OR 0.91, 95% CI 0.50–1.66) Neonatal morbidity: 5.9% (no significant difference compared to controls, OR 1.00, 95% CI 0.44–2.28) Severe maternal morbidity: 2.6% in ovarian cancer patients vs. 1.3% in controls (not statistically significant, OR 2.03, 95% CI 0.50–8.25)	Patients who attempted pregnancy: 34 out of 52 (65.4%) Patients who conceived: 28 out of 52 (53.8%) Total pregnancies: 32 Live birth rate: 28 out of 32 (87.5%) Spontaneous abortions: 2 out of 32 (6.25%) Induced abortion: 1 case Intrauterine fetal death: 1 case Pregnancy complications: Not specified	Patients who gave birth after surgery: 11 out of 57 (19%) Total children born: 13 Live birth rate: 100% (all pregnancies resulted in full-term births) Pregnancy method: All natural conceptions Patients who required ART (IVF): 7 out of 57 (12%) Pregnancy complications: None reported
Surgical approach	Bilateral salpingo-oophorectomy with uterine preservation Peritoneal staging performed in 5 out of 6 cases Lymph node staging performed in 4 out of 6 cases	Fertility-sparing surgery (uterus and at least one ovary preserved) Peritoneal staging: Not explicitly mentioned	Fertility-sparing surgery (FSS): 52 (48.1%) Radical Surgery (RS): 56 (51.9%) Laparoscopy (LPS): 5 (4.6%) Laparotomy (LPT): 103 (95.4%) Peritoneal staging: Performed in all cases	Surgical approach: Fertility-Sparing Surgery (FSS): 57 (78%) Radical Surgery (RS): 16 (22%) Laparoscopic approach: 33% Open surgery: 67% Peritoneal staging: Performed in all cases
Oncologic outcomes	Mean follow-up duration: 97 months (range: 27–262 months) Recurrence rate: 2 out of 6 (33.3%) Survival rate: 5 out of 6 patients survived (one patient died from recurrence) Recurrence location: -Pelvic peritoneum (1 case) -Uterine serosa with nodal involvement (1 case, fatal) Patients who received chemotherapy: 1 out of 6 (16.7%)	Recurrence rate: Not reported Survival rate: Not explicitly mentioned Patients who received chemotherapy: 26.1% (majority did not receive chemotherapy)	Mean follow-up duration: 83 months (range: 9–216 months) Recurrence rate: 14 out of 108 (13%) Survival rate: 92.6% Patients who received chemotherapy: 83 out of 108 (76.9%)	Mean follow-up duration: 65 months (range: 20–111 months) Recurrence rate: 4 out of 73 (5%) FSS group: 2 out of 57 (3.5%) Radical surgery (RS) group: 2 out of 16 (12.5%) Survival rate: 98% (5-year OS rate) Patients who received chemotherapy: 18 out of 57 (32%)
Main outcome	Uterine preservation with bilateral salpingo-oophorectomy allowed pregnancy through oocyte donation but carried a high recurrence risk (33.3%), with one recurrence proving fatal. This raises concerns about the oncologic safety of this approach in infiltrative mucinous ovarian cancer	Pregnancy after fertility-sparing surgery in stage IA or IC ovarian cancer does not increase the risk of adverse obstetric outcomes, including preterm birth, neonatal morbidity, or severe maternal morbidity, compared to matched controls. These findings provide reassurance that pregnancy is safe following fertility preserving treatment	Fertility-sparing surgery (FSS) is a safe option for young patients with early-stage epithelial ovarian cancer (EOC), providing similar survival rates (92.6%) to radical surgery. Over half (53.8%) of FSS patients conceived, and 87.5% of pregnancies resulted in live births, indicating strong reproductive potential after treatment. However, the 13% recurrence rate highlights the need for cautious patient selection	Fertility-sparing surgery (FSS) provides excellent survival outcomes (98%) and a low recurrence rate (3.5%), making it a safe and viable option for young women with early-stage non-epithelial ovarian cancer. Natural fertility was preserved, with 19% of patients successfully giving birth, and only 12% required ART

First author	Park, J. et al. 2016	Watanabe, T. et al. 2020	Ko, Mu-En et al. 2023	Abdelsalam, M et al. 022
Country	Korea	Japan	Taiwan	Egypt
Study design	Retrospective cohort	Retrospective cohort	Retrospective cohort	Prospective cohort
Number of patients	18	29	33 (EOC group only)	60
Mean Age years)	33.5 (range: 14–40)	27.2 (range: 12–39)	EOC group: 34 (range: 22–42) years	30 ± 4 (Fertility-Sparing Surgery group) vs. 35 ± 5 (Radical Surgery group)
Age of menarche (years)	N/A	N/A	N/A	N/A
Tumor size (mm)	N/A	N/A	EOC group: Median 160 (range: 30–400)	Mean 34 ± 13 cm (FSS group) vs. 60 ± 26 (Radical Surgery group)
Gynecological cancer history	N/A	N/A	N/A	N/A
FIGO staging FSS	IA: 6 patients (33.3%) IC: 12 patients (66.7%) Upstaged to IIIA1: 2 patients after complete staging	IA: 14 (48.3%) IC1: 6 (20.7%) IC3: 9 (31.0%)	Stage IA: 15 (45.5%) Stage IC: 18 (54.5%)	FSS group: Stage IA: 10 (40%) Stage IB: 9 (36%) Stage IC: 2 (8%) Other stage I subtypes: 4 (16%)
Histology & grading	Tumor histology:  Mucinous: 7 (38.9%)  Endometrioid: 5 (27.8%)  Clear cell: 3 (16.7%)  Serous: 3 (16.7%) Tumor grade:  Grade 1: 9 (50%)  Grade 2: 4 (22.2%)  Grade 3: 5 (27.8%)	Tumor histology:  Mucinous: 16 (55.2%)  Serous: 5 (17.2%)  Endometrioid: 5 (17.2%)  Clear cell: 3 (10.4%) Tumor grade:  Grade 1: 13 (44.8%)  Grade 2: 10 (34.5%)  Grade 3: 6 (20.7%)	Tumor histology (EOC group):  Mucinous: 45.5%  Serous: 3%  Clear cell: 30.3%  Endometrioid: 21.2% Tumor grade (EOC group):  Grade 1: 9 (27.3%)  Grade 2: 13 (39.4%)  Grade 3: 11 (33.3%)	Tumor histology (FSS group):  Serous: 15 (60%)  Mucinous: 7 (28%)  Endometrioid: 3 (12%) Tumor grade (FSS group):  Low Grade: 19 (76%)  High Grade: 6 (24%)
Reproductive outcomes	Patients who conceived after surgery: 4 out of 18 (22.2%) Total pregnancies: 4 Live birth rate: 3 out of 4 (75%) Ongoing pregnancy at time of study: 1 patient Pregnancy method: 2 spontaneous, 2 IVF Pregnancy complications: Not detailed	Patients who conceived after surgery: 5 out of 29 (17.2%) Total pregnancies: 7 Live birth rate: 6 out of 7 (85.7%) Pregnancy complications: None reported Patients who received chemotherapy and later conceived: 4 out of 5 (80%) Healthy children born: 6	Patients who conceived after surgery: EOC group: 12 out of 14 married patients (85.7%) Total pregnancies: EOC group: 15 Live birth rate: EOC group: 93.3% (14 out of 15 pregnancies resulted in live births) Spontaneous abortions: EOC group: 1 case Preterm births: EOC group: 2 cases (both twin pregnancies, delivered at 31 and 34 weeks) ART use (IVF): EOC group: 3 patients required ART	Patients who attempted pregnancy: 18 out of 25 (72%) Patients who conceived: 15 out of 18 (83%) Total pregnancies: 15 Live birth rate: 13 out of 15 (86.7%) Spontaneous abortions: 1 (6.7%) Intrauterine fetal death: 1 (6.7%) Pregnancy complications: Not reported Infertility after surgery: 3 out of 18 (17%) Patients unable to conceive due to recurrence: 5 out of 25 (20%)
Surgical approach	All patients underwent laparoscopic fertility-sparing surgery Complete surgical staging performed in 4 patients (22.2%) Procedures included salpingo-oophorectomy, omentectomy, lymphadenectomy, and peritoneal biopsy Peritoneal staging: Performed in all cases	Unilateral Salpingo-Oophorectomy (USO): 10 (34.5%)USO + Omentectomy (OMT): 3 (10.3%) USO + OMT + Lymphadenectomy (LA): 15 (51.7%) Cystectomy: 1 (3.5%) Peritoneal staging: Performed in all cases	EOC group:  Laparoscopy: 5 (15.2%)  Laparotomy: 28 (84.8%)  Peritoneal staging: Performed in all cases	Unilateral Salpingo-Oophorectomy (USO): All FSS patients Complete surgical staging performed in all cases Peritoneal staging: Performed in all cases
Oncologic outcomes	Mean follow-up duration: 47.3 months (range: 11.5–195.3 months) Recurrence rate: 1 out of 18 (5.6%) Survival rate: 100% (no deaths reported) Patients who received chemotherapy: 17 out of 18 (94.4%)	Mean follow-up duration: 60.6 months (range: 6–135 months) Recurrence rate: 5 out of 29 (17.2%) Survival rate: 5-year OS: 95.7%, 10-year OS: 89.3% Patients who received chemotherapy: 19 out of 29 (65.5%)	Mean follow-up duration:  EOC group: 97 months (range: 3–180 months) Recurrence rate:  EOC group: 1 out of 33 (3%) Survival rate: Not explicitly mentioned, but no cancer-related deaths in the EOC group Patients who received chemotherapy: EOC group: 20 out of 33 (60.6%)	Mean follow-up duration: 56 months (range: 25–60 months) Recurrence rate: 5 out of 25 (20%) in FSS group vs. 8 out of 35 (22.9%) in radical surgery group Survival rate: 88% (FSS) vs. 85.7% (Radical Surgery), no significant difference Patients who received chemotherapy: Higher in radical surgery group than FSS group (exact numbers not provided)
Main outcome	Laparoscopic fertility-sparing surgery (FSS) in young women with early-stage epithelial ovarian cancer is feasible and safe, with a low recurrence rate (5.6%) and no cancer-related deaths. Pregnancy was achieved in 22.2% of patients, with a 75% live birth rate, supporting the reproductive benefits of FSS. However, careful patient selection is crucial, particularly for cases with high-risk features	Fertility-sparing surgery (FSS) is a viable option for early-stage epithelial ovarian cancer (EOC) with good survival outcomes (95.7% at 5 years). 17.2% of patients conceived, and 85.7% of pregnancies resulted in live births, even after chemotherapy. However, the recurrence rate (17.2%) suggests careful patient selection is necessary	Fertility-sparing surgery (FSS) is a viable option for early-stage EOC and BOT, with high pregnancy success rates (85.7% for EOC and 57.1% for BOT). Live birth rates were excellent (93.3% for EOC and 88.5% for BOT), and recurrence rates remained low (3% for EOC and 11.3% for BOT). Careful patient selection is essential, especially for high-risk cases	Fertility-sparing surgery (FSS) provides similar oncologic outcomes to radical surgery, with no significant difference in recurrence (20% vs. 22.9%) or survival (88% vs. 85.7%). 83% of FSS patients who attempted pregnancy conceived, with an 86.7% live birth rate. Careful selection is essential, particularly for high-risk cases

First author	Johansen et 2020	Khatun et al. 020	Swift et al. 2022	Lin et al. 2022
Country	Sweden	Bangladesh	Canada	China
Study design	Nationwide prospective	Case report	Retrospective cohort	Retrospective cohort
Number of patients	83	31	31	159
Mean age years)	29 (range: 19–39) for FSS group, 37 (range: 26–40) for RS group	31	36 (range: 26–42) for FSS group, 42 (range: 35–45) for RS group	31 (range: 12–76) for all patients, 24 (range: 12–40) for FSS group
Age of menarche (years)	N/A	N/A	N/A	N/A
Tumor size (mm)	Mean 34 ± 13 (FSS group) vs. 60 ± 26 (Radical Surgery group)	100	N/A	Median 150 (range: 39–400)
Gynecological cancer history	N/A	N/A	N/A	N/A
FIGO staging FSS	Stage IA: 27 (75%) Stage IC: 9 (25%)	IA	FSS group: Stage IA: 9 (81.8%) Stage IC: 2 (18.2%)	Stage IA: 55 (34.6%) Stage IC: 104 (65.4%) IC1: 63 (39.6%) IC2: 33 (20.8%) IC3: 4 (2.5%)
Histology & grading	Tumor histology (FSS group): Mucinous: 18 (50%) Endometrioid: 10 (28%) Serous (high-grade and low-grade): 3 (8%) Clear cell: 3 (8%) Other rare types: 2 (6%) Tumor grade (FSS group): Grade 1: 6 Grade 2: 2 Grade 3: 1	Tumor histology: Mucinous Cystadenocarcinoma Tumor grade: Not explicitly mentioned	Tumor histology (FSS group): Endometrioid only Tumor grade (FSS group): Grade 1: 7 (63.6%) Grade 2: 4 (36.4%)	Tumor histology: Mucinous Ovarian Carcinoma Tumor grade: Not explicitly reported
Reproductive outcomes	Patients who conceived after surgery: 9 out of 36 (25%) Total pregnancies: 12 Live birth rate: 100% (all pregnancies resulted in live births) Pregnancy method: All natural conceptions Patients who required ART (IVF/ET): 1 out of 36 (3%) Pregnancy complications: Not reported	Patients who conceived after surgery: 1 (100%) Total pregnancies: 1 Live birth rate: 100% (full-term) Pregnancy method: Natural conception Mode of delivery: Cesarean section Pregnancy complications: Not reported	Patients who attempted pregnancy: 7 out of 11 (63.6%) Patients who conceived: 5 out of 7 (71.4%) Total pregnancies: 5 Live birth rate: 5 out of 5 (100%) Spontaneous abortions: 3 Pregnancy method: 4 required IVF, 1 conceived naturally	Patients who attempted pregnancy: 23 out of 57 (40.4%) Patients who conceived: 21 out of 23 (91.3%) Total pregnancies: 27 Live birth rate: 88.9% (24 out of 27 pregnancies resulted in live births) Spontaneous pregnancies: 26 out of 27 (96.3%) ART use (IVF): 1 patient (3.7%) Preterm births: 3 cases (all via cesarean section) Cesarean section rate: 91.7% Pregnancy complications: Not detailed
Surgical approach	Unilateral Salpingo-Oophorectomy (USO): All FSS patients Complete surgical staging performed in 92% of FSS patients Peritoneal staging: Performed in all cases	Right Adnexectomy Omentectomy Peritoneal biopsy Contralateral ovary biopsy Peritoneal staging: Performed	Unilateral Salpingo-Oophorectomy (USO): All FSS patients Complete surgical staging performed in 32.3% of all patients	FSS group: Unilateral Salpingo-Oophorectomy (USO): All patients Complete surgical staging performed in 88.5% of cases
Oncologic outcomes	Mean follow-up duration: 63 months (range: 16–111) for FSS group, 64 months (range: 21–112) for RS group Recurrence rate: 2 out of 36 (6%) in FSS group, 6 out of 47 (13%) in RS group Survival rate: 5-year OS: 97% (FSS) vs. 89% (RS), p = 0.3 (no significant difference) 5-year Disease-Free Survival (DFS): 93% (FSS) vs. 82% (RS), p = 0.5 Patients who received chemotherapy: 14 out of 36 (39%) in FSS group, 34 out of 47 (72%) in RS group	Mean follow-up duration: 3 years Recurrence rate: 0% (No relapse during follow-up) Survival rate: 100% Patients who received chemotherapy: Yes (BEP regimen: Bleomycin, Etoposide, Cisplatin, 6 cycles)	Mean follow-up duration: 6 years (range: 1.8–17.3 years) Recurrence rate: 1 out of 11 (9.1%) in FSS group, 3 out of 20 (15%) in RS group Survival rate: 100% (FSS) vs. 92.6% (RS), no significant difference Peritoneal staging: Performed in all cases Patients who received chemotherapy: 1 out of 11 (9.1%) in FSS group, 7 out of 20 (35%) in RS group	Mean follow-up duration: 69 months (range: 6–240 months) Recurrence rate: 18 out of 159 (11.3%) FSS group: 12 out of 78 (15.4%) pregnancy Surgery (RS) group: 6 out of 81 (7.4%) Survival rate: 5-year OS: 98.6% (FSS) vs. 100% (RS), no significant difference Patients who received chemotherapy: 56.4% (FSS group), 69.1% (RS group)
Main outcome	Fertility-sparing surgery (FSS) provides similar oncologic outcomes to radical surgery (97% vs. 89% 5-year OS) while preserving fertility. 25% of FSS patients conceived, all naturally, with 100% live birth rates. The low recurrence rate (6%) suggests that FSS is a viable and safe option for select early-stage EOC patients	Fertility-sparing surgery (FSS) was successful in preserving fertility, allowing a full-term pregnancy without recurrence. After 3 years of follow-up, the patient remained disease-free, reinforcing the potential feasibility of FSS in carefully selected early-stage epithelial ovarian cancer cases	Fertility-sparing surgery (FSS) provides comparable oncologic outcomes to radical surgery (100% vs. 92.6% survival) with a low recurrence rate (9.1%). 71.4% of patients attempting pregnancy conceived, and all resulted in live births. IVF was required in 80% of cases, suggesting that endometriosis-associated infertility may be a factor	Fertility-sparing surgery (FSS) is a feasible option for young women with unilateral stage I mucinous ovarian carcinoma, with high live birth rates (88.9%) and acceptable recurrence risk (15.4%). The 5-year overall survival was excellent (98.6%), comparable to radical surgery. However, complete staging is essential to optimize oncologic outcomes

First author	Letourneau et al. 2015
Country	United States
Study design	Retrospective cohort
Number of patients	82
Mean age years)	32 (± 6 years)
Age of menarche (years)	N/A
Tumor size (mm)	N/A
Gynecological cancer history	N/A
FIGO staging FSS	N/A
Histology & grading	N/A
Reproductive outcomes	Patients who attempted pregnancy: 29 out of 82 (35.4%)
	Patients who conceived: 19 out of 29 (68%)
	Women who desired children after treatment: 58%
	Women who actually attempted pregnancy: 13%
Surgical approach	Unilateral Salpingo-Oophorectomy (USO): Majority of cases
	Complete surgical staging performed in all cases
Oncologic outcomes	Mean follow-up duration: 11.5 years
	Recurrence rate: 8–10% in FSS group
	Survival rate: Not explicitly reported
	Patients who received chemotherapy: Not specified
Main outcome	Fertility-sparing surgery (FSS) maintains reproductive potential, with a 67.7% pregnancy success rate and all pregnancies resulting in live births. FSS is associated with a recurrence rate of 8–10%, emphasizing the need for careful patient selection