AbstractSTUDY QUESTIONDoes cancer itself, before any gonadotoxic treatment, affect ovarian function in reproductive-aged patients?SUMMARY ANSWEROur study revealed that women with cancer may have decreased ovarian reserve markers even before cancer therapy.WHAT IS KNOWN ALREADYWith the field ‘oncofertility’ improving rapidly, cancer therapy-mediated ovarian damage is well characterized. However, there is a controversy about whether cancer itself affects ovarian function before gonadotoxic treatment.STUDY DESIGN, SIZE, DURATIONWe conducted a systematic meta-analysis investigating the association between cancer and ovarian function prior to gonadotoxic treatment. Titles or abstracts related to ovarian reserve (e.g. anti-Müllerian hormone (AMH), antral follicle count (AFC), or basal follicle-stimulating hormone (FSH)) combined with titles or abstracts related to the exposure (e.g. cancer*, oncolog*, or malignan*) were searched in PubMed, Embase, and Web of Science databases from inception to 1 February 2022.PARTICIPANTS/MATERIALS, SETTING, METHODSWe included cohort, case-control, and cross-sectional studies in English that examined ovarian reserve in reproductive-aged patients (18–45 years) with cancer compared to age-matched controls before cancer treatment. The quality of the included studies was assessed by ROBINS-I. Fixed or random effects were conducted to estimate standard or weighted mean difference (SMD or WMD, respectively) and CI. Heterogeneity was assessed by theQtest andI2statistics, and publication bias was evaluated by Egger’s and Begg’s tests.MAIN RESULTS AND THE ROLE OF CHANCEThe review identified 17 eligible studies for inclusion. The results showed that cancer patients had lower serum AMH levels compared to healthy controls (SMD = −0.19, 95% CI = −0.34 to −0.03,P=0.001), especially women with hematological malignancies (SMD = −0.62, 95% CI = −0.99 to −0.24,P=0.001). The AFC was also decreased in patients with cancer (WMD = −0.93, 95% CI = −1.79 to −0.07,P= 0.033) compared to controls, while inhibin B and basal FSH levels showed no statistically significant differences.LIMITATIONS, REASONS FOR CAUTIONSerum AMH and basal FSH levels in this meta-analysis showed high heterogeneity, and the small number of studies contributing to most subgroup analyses limited the heterogeneity analysis. Moreover, the studies for specific cancer subtypes may be too small to draw conclusions; more studies are needed to investigate the possible impact of cancer type and stage on ovarian function.WIDER IMPLICATIONS OF THE FINDINGSOur study confirmed the findings that cancer per se, especially hematological malignancies, negatively affects serum AMH level, and AFC values of reproductive-aged women. However, the lower AMH levels and AFC values may also be due to the changes in ovarian physiology under oncological conditions, rather than actual lower ovarian reserves. Based on the meta-analysis, clinicians should raise awareness about the possible need for personalized approaches for young women with cancer who are interested in pursuing fertility preservation strategies before anticancer treatments.STUDY FUNDING/COMPETING INTEREST(S)This work was financially supported by the National Natural Science Foundation of China (nos 81873824, 82001514, and 81902669) and the Applied Basic Research Program of Wuhan Municipal Bureau of Science and Technology (2019020701011436). The authors declare that they have no conflicts of interest.REGISTRATION NUMBERPROSPERO (CRD42021235954).