Fertility Preservation: How to Preserve Ovarian Function in Children, Adolescents and Adults

Abstract

Chemotherapy, pelvic radiotherapy and ovarian surgery have known gonadotoxic effects that can lead to endocrine dysfunction, cessation of ovarian endocrine activity and early depletion of the ovarian reserve, causing a risk for future fertility problems, even in children. Important determinants of this risk are the patient’s age and ovarian reserve, type of treatment and dose. When the risk of premature ovarian insufficiency is high, fertility preservation strategies must be offered to the patient. Furthermore, fertility preservation may sometimes be needed in conditions other than cancer, such as in non-malignant diseases or in patients seeking fertility preservation for personal reasons. Oocyte and/or embryo vitrification and ovarian tissue cryopreservation are the two methods currently endorsed by the American Society for Reproductive Medicine, yielding encouraging results in terms of pregnancy and live birth rates. The choice of one technique above the other depends mostly on the age and pubertal status of the patient, and personal and medical circumstances. This review focuses on the available fertility preservation techniques, their appropriateness according to patient age and their efficacy in terms of pregnancy and live birth rates.

Ovarian Tissue Cryopreservation in Children and Adolescents

“…Since then, multiple series conducted in patients below the age of 18 years old with various oncological and non-oncological diseases have been published [ 11 ]. As mentioned before, ovarian tissue cryopreservation is essentially the only option of fertility preservation for girls before puberty and adolescents who will be under anti-cancer and gonadotoxic treatment, given the fact that ovarian stimulation and subsequent oocyte removal are not feasible in that age, mainly due to the invasive nature of the method, virginity and immaturity issues of the patient [ 63 ].…”

“…Indications include treatment with alkylating agents, pre-allograft and autologous hematopoietic stem cell conditioning, ovarian-focused radiotherapy and gonadectomy [ 63 ]. Ovarian tissue cryopreservation is also an option even in diseases other than neoplasms, such as Turner syndrome when fertility is at risk, or in the case of allogenic transplantation of hematopoietic stem cells and incidental gonadotoxic treatment (e.g., sickle cell disease) [ 63 ].…”

“…The indications for ovarian tissue cryopreservation in children (≤18 years old) seem to include hematological malignancies (leukemia, myelodysplastic syndromes), lymphomas, bone tumors, neurological neoplasms (neuroblastoma, central nervous system cancer), sarcomas and benign hematological diseases [ 11 , 63 ]. The most frequent malignancies considered as indications are leukemias, myeloproliferative or myelodysplastic diseases, neurological neoplasms and sarcoma [ 64 ], while the most common non-malignant diseases were Turner syndrome and benign hemoglobinopathies [ 11 , 63 ]. Although there are no general guidelines, ovarian tissue cryopreservation can be a beneficial option in young girls with metabolic diseases causing ovarian degeneration, such as galactosemia.…”

A fertile future: Fertility preservation special series

“…For this group of patients, the aim is to re-implant the cryopreserved ovarian tissue once the patient has reached adulthood and wishes to start a family. Although success has recently been achieved for women whose tissue was cryopreserved in childhood, with the live birth of babies post re-implantation (Dolmans et al, 2021), there is clearly much to be done to establish this technique. However, for patients with blood cancer, the tissue is not routinely re-implanted due to the potential for reintroducing the cancer and therefore in vitro culture of the ovarian tissue to generate mature eggs is required.…”

“…For this group of patients, the aim is to re-implant the cryopreserved ovarian tissue once the patient has reached adulthood and wishes to start a family. Although success has recently been achieved for women whose tissue was cryopreserved in childhood, with the live birth of babies post-re-implantation ( Dolmans et al . 2021 ), there is clearly much to be done to establish this technique.…”