Fertility Preservation in Adolescents with Diminished Ovarian Reserve

Introduction to Fertility Preservation

The American Society of Clinical Oncology recommends that adolescents with diminished ovarian reserve be immediately referred to reproductive endocrinology for fertility preservation, with oocyte cryopreservation as the primary option for postpubertal patients and ovarian tissue cryopreservation for prepubertal patients, while simultaneously initiating sex steroid replacement therapy to prevent long-term health consequences of estrogen deprivation 1, 2

All adolescents with confirmed or suspected diminished ovarian reserve require urgent referral to gynecology, endocrinology, and/or reproductive endocrinology consultation, as recommended by the American College of Obstetricians and Gynecologists 1, 3, 4
Prepubertal females with no signs of puberty by age 13 years, primary amenorrhea by age 16 years, or failure to initiate/progress through puberty should be referred for specialist consultation 1, 5, 6
Postpubertal females with menstrual cycle dysfunction suggestive of premature ovarian insufficiency (POI) should also be referred, even if they have regular cycles but were exposed to gonadotoxic treatments 1, 3, 4

Oocyte cryopreservation (vitrification) is the first-line fertility preservation method for postpubertal adolescents with diminished ovarian reserve, as endorsed by the American Society for Reproductive Medicine 2, 7, 8
Ovarian tissue cryopreservation is the only viable option for prepubertal patients with diminished ovarian reserve, and is recommended by the American Society for Reproductive Medicine 2, 7
Embryo cryopreservation after IVF is an alternative for adolescents with partners or willing to use donor sperm, with live birth rates of 45% in young women, comparable to infertile couples without cancer history 2

All adolescents diagnosed with diminished ovarian reserve or POI require sex steroid replacement therapy to prevent serious health consequences, including bone health preservation, cardiovascular health protection, and sexual function maintenance, as recommended by the Endocrine Society 1, 4, 5, 6

AMH testing should be performed in adolescents ≥25 years old to assess ovarian reserve and guide fertility counseling, but interpretation requires caution in adolescents under 25 years due to normal fluctuations throughout the menstrual cycle, as noted by the American College of Obstetricians and Gynecologists 1, 3, 10

Fertility preservation should ideally be initiated before any gonadotoxic treatment begins, but when impractical or impossible before treatment, it should be readdressed later in the treatment course, as recommended by the National Comprehensive Cancer Network 11, 2

Adolescents with mosaic Turner syndrome may be candidates for fertility preservation if diagnosed early, before complete follicle depletion, as noted by the American Society for Reproductive Medicine 7
Adolescents with endometriosis requiring bilateral surgery or recurrent procedures should be counseled about fertility preservation before additional ovarian damage occurs, as recommended by the American College of Obstetricians and Gynecologists 7, 8