Paediatric patients are at risk for future infertility due to medical conditions and treatments. As the most well-known example, many patients undergoing oncological therapy are at risk of future infertility. In addition, those receiving immunosuppressive or stem cell transplant therapy for non-malignant disorders can also face challenges. Finally, those with disorders of sexual development (DSD) or those who are transgender may have reduced fertility potential. This review provides a good overview of patient populations with future fertility concerns, and current and future options for paediatric fertility preservation. The authors cover techniques to preserve native gonadal tissue during treatment such as oophoropexy, gonadal shielding and gonadotrophin releasing hormone agonists. Current pre-treatment options are discussed. For girls: ovarian stimulation with oocyte retrieval and cryopreservation and ovarian tissue cryopreservation (through biopsy or unilateral oophorectomy). For boys: cryopreservation of semen, testicular sperm extraction and electroejaculation. Future possibilities are examined and include isolated ovarian follicular tissue grown on biomaterial artificial supports, artificial ovaries (using decellularised tissue constructs or three-dimensional printed tissues that are recellularised with native cells), prepubertal testicular tissue cryopreservation, spermatogonial stem cell (SSC) transplantation, autologous grafting and xenografting of intact testicular tissue, SSC culture and the introduction of SSCs and other essential cell types into decellularised testes in order to achieve de novo morphogenesis of the testicle. Some discussion of the ethics and the challenges facing those building a paediatric fertility preservation programme are considered. The review is useful to the paediatric urologist to aid discussion with parents when faced with boys or girls who may in the future have impaired fertility through their underlying medical condition or necessary surgical interventions.