What are the approaches for ovarian support?

Approaches for Ovarian Support

Ovarian support strategies should be tailored based on the patient's age, fertility goals, and risk of gonadotoxicity, with oocyte or embryo cryopreservation being the most effective method when a 2-week treatment delay is feasible. 1

Fertility Preservation Options

Oocyte and Embryo Cryopreservation

• Random start ovarian stimulation protocols should be implemented to minimize delays in starting anticancer treatments while preserving fertility 1
• Close coordination with reproductive medicine centers is essential for timely referral and access to these preservation techniques 1
• Age significantly impacts success rates, with cumulative live birth rates of 61.9% for women ≤35 years with 12 cryopreserved oocytes versus 43.4% for women >35 years with 10 cryopreserved oocytes 1
• For women with estrogen-sensitive tumors, aromatase inhibitors can be administered during ovarian stimulation to prevent supraphysiological estrogen levels 1
• Double stimulation may be considered for women with low ovarian reserve without urgent need for anticancer treatment, potentially doubling the number of retrieved oocytes 1

Ovarian Tissue Cryopreservation

• This approach is recommended when oocyte or embryo cryopreservation isn't feasible due to time constraints or other factors 1
• Should not be offered to women over 36 years of age due to limited success rates 1
• Procedure involves laparoscopic biopsies of ovarian cortex or unilateral ovariectomy without requiring pretreatment 1
• Ovarian function restoration occurs in approximately 95% of cases within 4-9 months after transplantation 1
• Live birth rate is approximately 40%, with half resulting from natural conception 1
• Caution is advised for patients with acute leukemia or pelvic involvement of malignancy due to risk of reintroducing malignant cells 1

Ovarian Transposition and Gonadal Shielding

• Ovarian transposition should be considered for women ≤40 years requiring pelvic radiotherapy 1
• Should be performed by experienced laparoscopists to minimize complications and maximize preservation of ovarian function 1
• Retained ovarian function rate is approximately 65% in patients undergoing surgery and radiotherapy 1
• Gonadal shielding using lead blocks during radiotherapy can reduce radiation exposure to 4-5 Gy and serves as a non-surgical alternative 1
• Pregnancy rates after these procedures vary between 0-50%, depending on the irradiated organ 1

Temporary Ovarian Suppression

• For premenopausal breast cancer patients undergoing chemotherapy, temporary ovarian suppression with GnRH agonists is recommended for ovarian function preservation 1
• For women with non-breast malignancies, GnRH agonists during chemotherapy may be considered to reduce premature ovarian insufficiency risk, though evidence is limited 1
• Should not be considered an alternative to cryopreservation strategies but may be offered as an additional option 1

Pharmacological Approaches

Clomiphene Citrate

• Indicated for treatment of ovulatory dysfunction in women desiring pregnancy 2
• Most effective for patients with polycystic ovary syndrome, amenorrhea-galactorrhea syndrome, psychogenic amenorrhea, and post-oral-contraceptive amenorrhea 2
• Should not be used in patients with ovarian cysts (except those with polycystic ovary syndrome), abnormal vaginal bleeding, or liver dysfunction 2
• Not recommended for long-term cyclic therapy beyond approximately six cycles 2

Hormone Therapy for Primary Ovarian Insufficiency

• Systemic hormone therapy is effective for treating hypoestrogenism symptoms and mitigating long-term health risks 3
• Reduces risk of osteoporosis, cardiovascular disease, and urogenital atrophy while improving quality of life 3
• First-line approach is hormone therapy (oral or transdermal) that achieves replacement levels of estrogen 3
• Treatment should continue until the average age of natural menopause (50-51 years) 3

Special Considerations

Fertility-Sparing Surgery

• For patients with borderline ovarian tumors, fertility-sparing surgery should be offered to young women desiring pregnancy 4
• For epithelial ovarian cancer, fertility-sparing surgery should only be considered after staging for women with stage IA grade 1 serous, mucinous, or endometrioid tumors 4
• Has significant role in non-epithelial ovarian cancer, particularly for women with malignant ovarian germ cell tumors 4

Common Pitfalls and Caveats

• Failure to consider age as a critical factor in fertility preservation success rates 1
• Delaying referral to reproductive specialists, which may limit preservation options 1
• Not analyzing ovarian tissue for neoplastic cells before transplantation, risking reintroduction of malignancy 1
• Using temporary ovarian suppression as the sole fertility preservation strategy rather than as an adjunct to cryopreservation 1
• Overlooking the need for comprehensive longitudinal management, especially for adolescents and young women with primary ovarian insufficiency 3