Speaker- Richard A Anderson

The focus on fertility preservation in cancer patients, as outlined by the European Society of Human Reproduction and Embryology (ESHRE) guidelines, categorizes patients into four groups for tailored fertility preservation strategies: those with normal ovarian function, individuals with intrinsic fertility problems, transgender men, and women of advanced reproductive age. 

The potential ovarian damage caused by chemotoxic agents in cancer patients focuses on the impact on fertility and induction of menopause, both critical to female health during reproductive years. The guidelines underscore comprehensive care, from pathology discussion to ensuring a healthy pregnancy. Uncertainty remains about the success of fertility preservation treatments, with limited data. Anacobo's group in Spain reports lower success rates in cancer patients than elective egg freezing.

In the concept of ovarian transplantation, particularly in cases of Turner's syndrome, the hope is to salvage healthy follicles that can be replaced later, helping the patient achieve pregnancy. However, uncertainties arise regarding the success of this procedure. The surgical incision requires removing a finite amount of viable abnormal ovarian tissue, which may cause an acute toxic insult to the ovary. Removing ovarian tissue could accelerate the ovaries' downward trajectory in these women. The question also arises about the effectiveness of reintroducing ovarian tissue, as it may lose over 50% of the follicles from a normal ovarian sample. The ongoing pathology in the ovary will remain, even in depleted tissue. These questions are difficult to consider in cancer patients and differ from standard thought processes. 

The process of ovarian tissue cryopreservation is an established procedure. Still, it remains experimental in girls due to the limited number of successful pregnancies in prepubertal girls and none in women with pathological ovaries. Selection criteria established by Jacque Dene and Mary Madeline Dullman remain valid and important in this context. Isabelle de Mistera's study, published nearly a decade ago, shows that ovarian tissue cryopreservation can work in potentially normal ovaries, highlighting the potential of this procedure in the field. However, the caveats remain in adult women and the context of acute insults. The concept of ovarian tissue cryopreservation remains relevant in this context. 

Turner syndrome suggests storing ovarian tissue if the anti-müllerian hormone (AMH) is low or falling. In post-pubertal women, ovarian cryopreservation might be valid but requires careful care. A study in Melbourne and Copenhagen found ovarian follicles in mosaic ovaries, but success in egg maturation and cryopreservation was modest. Endocrinology should be considered for these patients, excluding menopausal individuals. Some patients with normal endocrinology and AMH had follicles, oocytes, and stroma abnormalities, highlighting the potential for unexpected findings in ovarian tissue. 

A new clinical guideline in the European Journal of Endocrinology recommends controlled ovarian stimulation and egg freezing as primary fertility preservation methods for Turner's syndrome patients. It emphasizes psychological support and assessment during difficult times. Variant tissue cryopreservation should be offered with ethical approval in research contexts. Shared decision-making is crucial, and pre-implantation genetic testing should be provided for those with Turner's syndrome. 

The transgender population faces challenges in fertility preservation, with the debate in the UK being politicized and weaponized. Gender professionals should consider fertility preservation early in patients' journeys, focusing on attention to detail and providing a supportive environment. Simple things like toilet signs can make a difference. Misgendering is upsetting for these individuals, and there is a question about when gynecological surgery is necessary. Some transgender men may stop their testosterone and conceive naturally early. Testosterone-free treatment for pregnancies can reduce fertility function, but it is not sterilizing. It may lead to horse-starved stomach treatment but may take years to recover. Long-term stimulation of the ovary may be necessary for fertility. Hypertriglyceridemia (HTG) is becoming more used in gender negotiation, but it is important to consider if it is needed and not making patient lives more difficult. Some groups have found success with less testosterone but question the need to test-stop testosterone.

A branch trial with a stimulation magnetic technique was conducted, resulting in a successful recovery of eggs from a healthy AMH. However, two individuals experienced negative recovery from an agonist trigger and an inadequate response to an agonist trigger. The key point is that the egg is exposed to a vast amount of testosterone in every ovary, with follicular fluid containing significantly more than the testes. The amount of testosterone administered to transmen is irrelevant to the egg's effects other than through gonadotropin suppression. Therefore, the focus should be on gonadotropin suppression rather than the effect of testosterone on the egg. 

In conclusion, the growing area of broader groups outside the cancer field emphasizes the importance of considering individual patient needs, effectiveness, and the impact of ovarian pathology in these cases.

European Society of Human Reproduction and Embryology, July 7-10, Amsterdam, The Netherlands