R E V I E W A R T I C L E
Fertility preservation in girls and youngwomen
Richard A. Anderson* andW. Hamish B.Wallace†
*Division of Reproductive and Developmental Science, MRC Centre for Reproductive Health, Queens Medical Research Institute,
University of Edinburgh and †Department of Paediatric Oncology, Royal Hospital for Sick Children, Edinburgh, UK
Summary
There is increasing interest and experience in the options available
to preserve fertility in those about to undergo potentially gonado-
toxic chemotherapy or radiation therapy, usually related to treat-
ment for cancer. Recent years have seen the development of
methods for prepubertal girls, female adolescents and adult
women, although these remain less established than sperm cryo-
preservation for men. At present, the options for prepubertal boys
remain experimental. Embryo cryopreservation following ovarian
stimulation and IVF is a routine procedure technically and its suc-
cess in the management of infertility is established. However, there
are no data on uptake or success rates in the context of fertility
preservation in women with cancer. Oocyte cryopreservation is
technically challenging and requires ovarian stimulation, thus
potentially resulting in a delay in cancer treatment. Oocyte vitrifi-
cation offers increased success rates in comparison with slow freez-
ing; however, this approach is also limited by the number of
oocytes that can be obtained. The third possibility, ovarian tissue
cryopreservation, can be performed without significant delay and
is the only option for prepubertal girls. Worldwide, a small number
of children have been born following reimplantation of frozen/
thawed ovarian tissue. It is clear that fertility preservation is impor-
tant for some girls and young women facing treatments that will
compromise their fertility, but the availability of all approaches
varies widely. Effective approaches for prepubertal boys are also
required.
(Received 22 February 2011; returned for revision 15 April 2011;
finally revised 5 May 2011; accepted 5 May 2011)
Introduction
Recent years have seen a dramatic increase in clinical activity in the
field of fertility preservation for women. Fertility preservation for
men in the form of sperm cryopreservation has been available for
many years but no analogous noninvasive technique is available for
women. The techniques that are available to women and adolescent
and prepubertal girls are all invasive and often require significant
hormone administration: they may also involve some delay in initi-
ating treatment for the underlying disease. Appropriate patient
selection and the safety and efficacy of proposed fertility-sparing
techniques are therefore all-important considerations.1 This review
will discuss current approaches in this rapidly changing field.
The emerging enthusiasm for fertility preservation can be traced
to the work of Roger Gosden and colleagues in Edinburgh who
demonstrated that ovarian tissue could be removed from a large
mammal (the ewe), cryopreserved and that following reimplanta-
tion of the tissue, ovarian activity could be restored with cyclical
ovulation and indeed spontaneous fertility.2 This work built on a
long history of investigation into the potential of ovarian trans-
plantation (reviewed in Gosden3). A key finding of those studies
and of other investigators was that cryopreservation and, in fact
more importantly the revascularization following reimplantation,
was associated with the loss of the majority of follicles within the
ovary4: the underlying concept of the nonrenewable nature of
female reproductive potential is the cornerstone on which the field
is based (Fig. 1).
A second spur to the development of this field is the growing rec-
ognition of the importance of future fertility and quality of life fol-
lowing cancer treatment. This is relevant to survivors at all ages,
but is of particular concern for survivors of childhood cancers
where long-term survival now approaches 80%,5,6 and the majority
(60%) have a least one long-term adverse consequence of their
treatment.7 The increasing number of young adults who have been
successfully treated for cancer, for whom future fertility is of major
importance,8,9 may require long-term follow-up and transition to
adult services.10
The adverse effect of chemo-radiotherapy on female reproduc-
tive function has long been recognized. Early studies demonstrated
both the acute loss of growing follicles within the ovary following
chemotherapy and the longer term effect of premature menopause,
with its consequences of shortened reproductive lifespan and hor-
mone deficiency.11–15 These studies also recognized the importance
of the chemotherapy regimen used, with alkylating agents being
highlighted as particularly gonadotoxic. Radiation therapy with a
field that includes the pelvis also has significant consequences for
future female fertility, with both ovarian and uterine effects.16,17
Correspondence: Richard A. Anderson, Division of Reproductive and
Developmental Science, MRC Centre for Reproductive Health, Queens
Medical Research Institute, University of Edinburgh, Little France Crescent,
Edinburgh EH16 4TJ, UK. Tel.: +0131 242638;
E-mail: richard.anderson@ed.ac.uk
Clinical Endocrinology (2011) 75, 409–419 doi: 10.1111/j.1365-2265.2011.04100.x
 2011 Blackwell Publishing Ltd 409

The need for fertility preservation
Female fertility is based on a pool of nongrowing primordial
follicles in the ovary, some of which enter the growth phase
each day. Follicle growth takes several months in vivo, with the
follicle becoming increasingly gonadotrophin-dependent as it
grows. Follicle growth involves proliferation of the steroido-
genic theca and granulosa cells around the oocyte, which itself
also grows. The oocyte has been in an arrested stage of meiosis
since before birth, and this does not advance until ovulation.
Chemotherapy, radiotherapy and surgery can all have adverse
affects on reproduction. The dynamic nature of folliculogenesis
based on granulosa and theca cell proliferation makes it a
prime target for chemotherapeutic agents but it is the effects
on the nongrowing stockpile of primordial follicles (Fig. 1) that
is of particular importance for future reproductive potential.
The mechanism by which chemotherapy causes loss of primor-
dial follicles is, however, poorly understood. There are likely to
be differences between different agents in, for example, whether
the oocyte itself or the surrounding granulosa cells are the pri-
mary targets and there may also be secondary effects relating to
the loss of the growing follicle pool. This is because the pri-
mordial population is primarily held in a growth-inhibitory
environment and loss of this results in increased follicle activa-
tion. A full understanding of how this is organized is lacking,
but insights have been generated following analysis of knockout
of a number of oocyte-specific and granulosa cell genes.18 A
clear example of this is the anti-Mu¨llerian hormone (AMH)
knockout mouse. These animals show a greatly increased num-
ber of growing follicles in young adulthood, but in time this
becomes unsustainable and follicle depletion ensues.19 The
importance of this, in the context of chemotherapy, is that loss
of the growing follicle pool population will result in increased
activation of primordial follicles which may then themselves be
subject to damage during further cycles of treatment.20 It is
clear, however, that direct effects of both chemotherapy and
radiotherapy on the primordial population occur and are of
primary importance. A further mechanism is damage to the
ovarian vasculature: angiogenesis is essential for successful folli-
cle growth21 but loss of primordial follicles is also suggested by
the identification of triangular areas of fibrosis with depletion
of primordial follicles following chemotherapy, reflecting a vas-
cular distribution.22
It is important to emphasize that there is no evidence to suggest
that the prepubertal female (or male) reproductive tract is pro-
tected from the adverse effects of cancer therapies. A series of publi-
cations have recently emerged from the large United States
Childhood Cancer Survivor Study (CCSS) documenting, in a large
series of 5-year childhood cancer survivors, the increased risks of
acute ovarian failure, premature menopause and reduced fertility
in female survivors. These studies confirmed an increased risk fol-
lowing alkylating agent-based chemotherapy and abdominal pelvic
irradiation.23–25 Intriguingly, these studies also suggest a specific
adverse effect associated with the diagnosis of Hodgkin’s lym-
phoma, the basis of which is as yet unknown but may relate to the
well-characterized immunoregulatory nature of this cancer that
predominantly affects young adults. The susceptibility of the pre-
pubertal uterus to radiotherapy is also clearly demonstrated in
these studies, as its size in adult survivors is related to the age at
which pelvic radiotherapy was administered.26,27 Uterine irradia-
tion at any age results in increased risks of miscarriage, premature
delivery, low birth weight and maternal haemorrhage,28–30 and a
(a) (b)
Fig. 1 Illustration of the decline in primordial follicle number with age. Photomicrographs of ovarian tissue in two patients requesting ovarian tissue
cryopreservation, aged 8 (a) and 22 years (b). Arrows indicate primordial follicles.
410 R. A. Anderson and W. H. B. Wallace
 2011 Blackwell Publishing Ltd, Clinical Endocrinology, 75, 409–419