Table 2.

A Comprehensive Guide to Oncofertility Options for Young Adult Female Cancer Patients

Oncofertilty Option	Procedure	^1*	^2*	^3*	^4*	^5*	^5*	Additional Considerations
Standard
Ovarian transposition/oophoropexy^102,103	Surgery is performed to move the ovaries and fallopian tubes out of the radiation field		•			•		Only protects against pelvic irradiation Will not prevent natural ovarian aging from occurring Does not protect the uterus
Gonadal shielding¹⁰⁴	Shielding is used to minimize the exposure of reproductive organs to radiation		•			•		Only protects against irradiation
Embryo cryopreservation⁴⁶	Hyperstimulation protocols are used to recruit multiple follicles to enter the growth phase Ovulation is triggered and mature eggs are aspirated Eggs are fertilized by IVF or ICSI – Embryos are cryopreserved	•		•	•			Will delay cancer treatment up to 2–5 weeks Results in the generation of embryos which are shared with the sperm donor and must be cryopreserved
Investigational
Egg cryopreservation^46,55	Hyperstimulation protocols are used to recruit multiple follicles to enter the growth phase Once multiple antral follicles are obtained, ovulation is triggered and mature eggs are aspirated Eggs are cryopreserved	•		•			•	Will delay cancer treatment up to 2–5 weeks Is becoming a viable reproductive technology Maintains the reproductive autonomy of the patient Requires ICSI/IVF post-thaw
Oocyte cryopreservation¹⁰⁵	Hyperstimulation protocols are used to recruit multiple follicles to enter the growth phase Oocytes are aspirated and cryopreserved	•		•			•	Will delay cancer treatment up to 2–5 weeks Is less effective than egg cryopreservation Requires IVM post-thaw Requires ICSI/IVF post-thaw
Isolation of an oocyte or an egg from a natural cycle¹⁰⁶	An oocyte or egg is retrieved from an unstimulated menstrual cycle The oocyte or egg is aspirated		•				•	Only results in one oocyte or egg from a natural cycle and takes approximately 2–10 days Is risky for cancer patients who only have one chance Requires cryopreservation Requires IVM if an oocyte is aspirated pre-cryopreservation or post-thaw Requires ICSI/IVF pre-cryopreservation or post-thaw
Isolation of oocytes from an ovarian biopsy¹⁰⁷	Oocytes are harvested from an ovarian biopsy		•				•	Can be performed at any stage of the menstrual cycle Requires cryopreservation Requires IVM pre-cryopreservation or Requires ICSI/IVF pre-cryopreservation or post-thaw
Ovarian tissue cryopreservation followed by transplantation^60,61,108	Ovarian tissue is removed and cryopreserved Following cancer treatment, thawed tissue can be autografted (orthotopic or heterotopic)		•			•		Can be performed at any stage of the menstrual cycle Can be done with whole ovaries or cortical strips Has the potential to reintroduce cancerous cells Has a limited lifetime
Ovarian hormonal suppression¹⁰⁹	Patients are treated with gonadotrophin- releasing hormone analogs (GnRH) or oral contraceptives to keep the ovary in a hypogonadotropic environment		•			•		Is controversial in terms of mechanism of action and efficacy
In Development
Ovarian tissue cryopreservation followed by in vitro follicle growth^{70–72,108,110}	Ovarian tissue is removed and cryopreserved Following cancer treatment, follicles can be isolated from thawed ovarian tissue and grown in vitro		•				•	Can be performed at any stage of the menstrual cycle Avoids the risk for reintroducing cancerous cells Requires IVM Requires ICS/IVF Is still being optimized for in vitro growth of primordial and primary follicles
Follicle isolation and cryopreservation^72,111	Ovarian tissue is removed Individual follicles are isolated from ovarian tissue and cryopreserved		•				•	Can be performed at any stage of the menstrual cycle Avoids the risk for reintroducing cancerous cells Requires in vitro follicle growth post-thaw Requires IVM post-thaw Requires ICSI/IVF post-thaw Could be used for transplant
Transplantation of isolated follicles¹¹²	Follicles are isolated from fresh or thawed ovarian tissue Following cancer treatment, follicles can be transplanted into the patient		•			•		Can be performed at any stage of the menstrual cycle Avoids the risk for reintroducing cancerous cells
Xenotransplantation of ovarian tissue or follicles^113–116	Ovarian tissue is removed and either cryopreserved or used to isolate follicles that are cryopreserved. Following cancer treatment, thawed tissue or follicles can be transplanted into a host that supports follicular growth and development		•				•	Can be performed at any stage of the menstrual cycle Avoids the risk for reintroducing cancerous cells
Use of fertoprotective drugs^117,118	Novel chemotherapeutics whose delivery mode is less gonadotoxic (ex. nanobins; our unpublished results)					•
Non-biological/Third Party
Egg or embryo donor	Following cancer treatment, a patient can obtain donor eggs or embryos Following relevant ART procedures, embryos can be transferred back to the patient’s own uterus or to a surrogate uterus							Can be a very high cost for the patient Will require a surrogate if the patient’s uterus has been compromised by cancer treatment
Surrogate	Following cancer treatment, patient embryos are thawed and transferred to a surrogate Following cancer treatment, patient oocytes or eggs are thawed and ART procedures are performed (IVM/IVF/ICSI); embryos are transferred to a surrogate							Bypasses pregnancy complications due to uterine dysfunction Assumes that cryopreserved material is developmentally competent Can also be used if patient’s fertility was not compromised by cancer treatment Can be a very high cost for the patient
Adoption¹¹⁹	Patients can adopt a non-biological child (children)							Does not rely on patient’s natural fertility Is not guaranteed since many adoption agencies discriminate against cancer survivors

ART = assisted reproductive technology; ICSI = intracytoplasmic sperm injection; IVF = in vitro fertilisation; IVM = in vitro maturation.

^1*

Potentially delays cancer treatment >2 weeks

^2*

Potentially delays cancer treatment <2 weeks

^3*

Requires hyperstimulation

^4*

Requires sperm donor at time of procedure

^5*

Potentially preserves or restores natural reproductive function hormonal

^6*

Requires additional ART procedures to attempt pregnancy