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    Interventional procedure overview of removal, preservation and reimplantation of ovarian tissue to restore fertility after gonadotoxic treatment

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    Existing assessments of this procedure

    The European Society of Human Reproduction and Embryology published a guideline on female fertility preservation in 2020 (Anderson 2020). It includes 78 recommendations on organisation of care, information provision and support, pre-fertility preservation assessment, fertility preservation interventions and after treatment care. The following recommendations relevant to OTC were described as 'strong':

    • 'To estimate the individual risk of gonadotoxicity, the characteristics of the proposed treatment, the patient and the disease should be considered.' (strength of supporting evidence=low)

    • 'It is recommended to offer OTC in patients undergoing moderate/high-risk gonadotoxic treatment where oocyte/embryo cryopreservation is not feasible, or at patient preference.' (strength of supporting evidence=low)

    • 'The slow-freezing protocol should be used for OTC as it is well established and considered as standard.' (strength of supporting evidence=very low)

    • 'For OTT, a one-step laparoscopy procedure should be performed as it is considered safe without causing additional surgical risk.' (strength of supporting evidence=low)

    • 'OTT at the orthotopic site is recommended to restore fertility.' (strength of supporting evidence=low)

    • 'OTT is not recommended in cases where the ovary is involved in the malignancy.' (strength of supporting evidence=very low)

    • 'OTT and pregnancy can be considered in hormone-sensitive tumours such as endometrial cancer treated by fertility-sparing strategy or breast cancer, after complete remission of the disease.' (strength of supporting evidence=low)

    The American Society of Clinical Oncology published a guideline update on fertility preservation in patients with cancer in 2018 (Oktay 2018). It includes the following recommendation:

    'Ovarian tissue cryopreservation for the purpose of future transplantation does not require ovarian stimulation and can be performed immediately. In addition, it does not require sexual maturity and hence may be the only method available in children. Finally, this method may also restore global ovarian function. However, it should be noted further investigation is needed to confirm whether it is safe in patients with leukemias.'

    Selection criteria for OTC have been published (Wallace 2014). These are known as the Edinburgh selection criteria:

    • Age younger than 35 years

    • No previous chemotherapy or radiotherapy if aged 15 years or older at diagnosis, but mild, non-gonadotoxic chemotherapy acceptable if younger than 15 years

    • A realistic chance of surviving for 5 years

    • A high risk of premature ovarian insufficiency (>50%)

    • Informed consent (from parents and, where possible, patient)

    • Negative serology results for HIV, syphilis, and hepatitis B

    • Not pregnant and no existing children