What are the options for fertility preservation in patients with ovarian cancer?

Fertility Preservation Options in Ovarian Cancer

For patients with ovarian cancer, fertility preservation options include conservative gynecologic surgery (ovarian cystectomy), embryo and oocyte cryopreservation, with ovarian tissue cryopreservation remaining experimental and requiring careful consideration due to risk of reintroducing cancer cells. 1

Initial Approach and Timing

• All healthcare providers caring for ovarian cancer patients should address fertility preservation as early as possible before treatment starts to preserve the full range of options 1
• Early referral to reproductive specialists is essential for patients who express interest in fertility preservation or are ambivalent about future fertility 1
• Discussions about fertility preservation should be documented in the medical record 1

Established Fertility Preservation Options for Ovarian Cancer

Conservative Gynecologic Surgery

• Ovarian cystectomy can be performed for early-stage ovarian cancer to preserve fertility 1
• Fertility-sparing surgery should be considered as the primary approach for eligible patients with early-stage disease 2, 3
• Patient selection is critical - this approach is generally restricted to early-stage disease with favorable histology 3

Embryo and Oocyte Cryopreservation

• Both embryo and oocyte cryopreservation are established fertility preservation methods for female patients 1
• For ovarian cancer patients specifically, these are the most suitable established options 2
• Special consideration for ovarian stimulation protocols:
  • Protocols using aromatase inhibitors (like letrozole) have been developed to minimize estrogen exposure in hormone-sensitive cancers 1, 4
  • Random start or dual stimulation protocols can be considered to avoid treatment delays 4

Experimental Options

Ovarian Tissue Cryopreservation

• This method is still considered experimental and should be performed only in centers with necessary expertise under IRB-approved protocols 1
• A major concern with this approach in ovarian cancer is the potential for reintroducing cancer cells during reimplantation 1, 2
• This option should be discussed with appropriate caution regarding its experimental nature and specific risks for ovarian cancer patients 1

Ovarian Suppression

• There is insufficient evidence regarding the effectiveness of GnRH analogs for fertility preservation 1
• GnRH analogs should not be relied upon as a primary fertility preservation method 1
• If other proven options are not available, GnRH analogs may be considered, preferably as part of a clinical trial 1

Special Considerations for Ovarian Cancer

• The risk of reintroducing malignant cells is a particular concern with ovarian tissue cryopreservation in ovarian cancer patients 2
• For hormone-sensitive ovarian cancers, there are concerns about fertility preservation interventions that increase estrogen levels 1
• Modified ovarian stimulation protocols using aromatase inhibitors can help mitigate estrogen exposure 1, 4
• In vitro maturation (IVM) of oocytes can be considered when controlled ovarian stimulation is contraindicated, though oocyte competence may be lower 4

Multidisciplinary Approach

• A multidisciplinary team including oncologists, reproductive specialists, and surgeons should discuss and propose personalized treatment and fertility preservation strategies 4, 5
• Patients should be encouraged to participate in registries and clinical studies to further define the safety and efficacy of fertility preservation interventions 1
• Psychological support should be offered, with referrals to psychosocial providers when patients experience distress about potential infertility 1

Common Pitfalls and Caveats

• Delaying the discussion about fertility preservation may limit available options 1
• Assuming all fertility preservation methods carry equal risk for all cancer types - ovarian cancer presents unique challenges, particularly regarding tissue reimplantation 2
• Relying solely on ovarian suppression with GnRH analogs, which has insufficient evidence as a fertility preservation method 1
• Failing to consider the specific stage and histology of ovarian cancer when determining fertility preservation options 3