Fertility and future pregnancy potential are of concern to survivors of childhood cancer. Radiotherapy causes both ovarian and uterine damage. There are no reports of uterine damage after chemotherapy. The magnitude of risk is related to age at treatment, dose, and schedule. The dose of radiation required to destroy fifty percent of immature oocytes is <2 Gy. Reduced ovarian volume and low inhibin B and anti-Mullerian hormone concentrations in survivors with regular menses may be markers of incipient ovarian failure. Uterine damage, manifest by impaired growth and blood flow, is a likely consequence of pelvic irradiation. Uterine volume correlates with age at irradiation. Exposure of the pelvis to radiation is associated with an increased risk of miscarriage, midtrimester pregnancy loss, preterm birth, and low birthweight. The optimal dose and delivery route of estrogen replacement required to facilitate uterine growth in adolescent women treated with total body irradiation in childhood needs to be established. If female survivors of childhood cancer do achieve a pregnancy, then these pregnancies are high risk, pose a challenge for optimal mode of delivery, and require a multidisciplinary approach to management.