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A discussion of the reproductive risks associated with oncologic treatment should be an integral part of the care of all people with cancer.
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Ovarian tissue cryopreservation is the only fertility preservation option for people who cannot have ovarian stimulation, including children, people requiring emergency treatment, and those who live far from a fertility center.
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Transport of ovarian tissues, centralized processing and cryopreservation remove barriers and promote access to care.
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This case demonstrates the feasibility of implementing ovarian tissue transport and centralized cryopreservation in Canada.
A 20-year-old female pediatric cancer survivor presented to her oncology center in southwestern Ontario with right-sided supraclavicular lymphadenopathy. At the age of 15, she was diagnosed with stage IIA Hodgkin lymphoma, for which she received treatment with 2 cycles of chemotherapy with OEPA (vincristine, etoposide, prednisone and doxorubicin), leading to a complete response. Positron emission tomography scan revealed multiple lymphadenopathies in the neck and chest, above the diaphragm; the biopsy confirmed the diagnosis of stage IIA relapsed Hodgkin lymphoma. The patient was 8 weeks pregnant at the time of consultation and underwent surgical termination of pregnancy. This was her third pregnancy, which had been preceded by 2 live births. The patient expressed her desire to preserve her fertility and was referred to an oncofertility center offering fertility preservation care for an emergency virtual consultation. We informed the patient about the effects of repeated exposure to chemotherapy with alkylating agents, the high risk of future infertility and premature ovarian failure, and possible fertility preservation strategies. Given the need to begin salvage chemotherapy immediately and the distance (380 km from Toronto), the patient opted for cryopreservation of ovarian tissue after taking into account the surgical risks, transport of the tissue, its treatment, its conservation and its future transplantation. We coordinated care remotely, in close collaboration with the oncology and gynecology teams in his region. The patient underwent the pre-intervention examinations in her region; these included a serological screening test to ensure safe handling and storage of the tissue, as well as a serum anti-Müllerian hormone assay to assess initial ovarian reserve. The gynecologist in his region, trained in oophorectomy techniques specific to cryopreservation of ovarian tissue, performed a unilateral oophorectomy by laparoscopy with minimal coagulation and delicate manipulation of the tissue in order to preserve follicular viability. The contralateral ovary and the 2 fallopian tubes remained in place. We have retained professional services for the transport of the ovarian tissue under continuous temperature monitoring, maintained between 4°C and 8°C throughout the 380 km journey to our specialized embryology laboratory. Upon arrival, we stored the tissue overnight at a temperature of 4°C until it was processed by an embryologist the next day. Tissue processing was completed within 23 hours of collection and produced over 60 tissue fragments. During the treatment, we isolated 10 cumulo-oocyte complexes which were subjected to in vitro maturation, and we cryopreserved 8 oocytes in order to increase the reproductive potential. The patient was discharged on the day of surgery and began salvage chemotherapy with GDP (gemcitabine, dexamethasone, cisplatin) within 6 days, followed by autologous stem cell transplantation with conditioning chemotherapy with BEAM (carmustine, etoposide, cytarabine, melphalan) within the next 3 months. Four months after the procedure, the patient remained in good health and no immediate complications related to the fertility preservation procedure or bone marrow transplant were reported.
Discussion
In people of childbearing age with cancer, future fertility prospects often become a big concern, in addition to survival1. This case illustrates the complex challenges faced by young people with cancer who desire biological children but must undergo emergency treatment that threatens their reproductive potential. Unfortunately, many life-sustaining interventions, including surgery of the reproductive organs, chemotherapy, and abdominopelvic radiation therapy, increase the risk of infertility and dysfunction of the reproductive endocrine system.2. Advances in cancer treatment and survival have led to the emergence of oncofertility, a discipline that integrates oncology and fertility care aimed at preserving reproductive potential. For people with ovaries, the choice of fertility preservation strategy is personalized based on factors such as age, pubertal status and menarche, underlying diagnosis, urgency for oncological treatment, initial ovarian reserve, relationship status, physical and financial access to fertility care, and the person’s preferences (tableau 1)3. The success of fertility preservation interventions to achieve a live birth is closely related to the quantity of samples stored and the age of the person at the time of the intervention.
Fertility preservation strategies for people with ovaries*
In prepubertal or adolescent individuals who cannot undergo ovarian stimulation and who are at high risk of infertility according to the internationally recognized standardized model during oncological treatment4as well as for people under the age of 35 who need to start emergency chemotherapy and those who have limited access to a fertility clinic, cryopreservation of ovarian tissue has been considered best clinical practice by international fertility and oncology societies since it was declared, in 2019, no longer an experimental intervention5,6. This multi-step procedure includes laparoscopic removal of an entire ovary or part of an ovary, transport to a specialized embryology laboratory, and processing, cryopreservation and storage (figure 1). Processing ovarian tissue for cryopreservation also produces mature oocytes, which can increase reproductive potential. Ovarian tissue can be stored for more than 10 years. When a pregnancy is desired, the tissue is thawed, prepared for transplantation, and autografted into the person’s pelvis to restore fertility and endocrine function.
The hub-and-spoke model of ovarian tissue cryopreservation in Canada. This model provides access to expert fertility counseling and preservation services, while overcoming geographic and systemic barriers to promote patient comfort, ensure timely oncology treatment and provide a safe and cost-effective solution. See the Related Content tab for an accessible version.
Despite clinical guidelines from the Canadian Obstetrics and Gynecology and Fertility Societies that have endorsed fertility preservation in people with cancer7–9there are several barriers to providing oncofertility care10. Patient barriers include lack of awareness and high survivorship distress, and health care provider barriers include knowledge gaps and unease with discussing infertility risks, leading to low referral rates for counseling and intervention. Barriers at the health care system level include a lack of well-structured and accessible resources to provide timely oncofertility counseling, and a lack of care pathways to coordinate interventions. Funding for fertility preservation interventions also varies from province to province and can constitute a significant barrier to access in provinces where patients must pay out-of-pocket costs for this service.
Although laparoscopic oophorectomies are readily available in primary care centers that have an operating room and a gynecologist on duty, the main practical barrier to equitable access to oncofertility care is that the processing and storage of ovarian tissue requires expertise and specialized equipment that is rarely present in most fertility clinics that perform oocyte or embryo cryopreservation. Centralizing the processing and storage of ovarian tissue in a specialized cryopreservation facility offers several advantages, particularly for patients living in remote areas. Access to care made possible by local tissue collection, followed by safe transport of tissue to a central facility, has been shown to be feasible and safe11. As cryopreservation of ovarian tissue is relatively rare, centralization of services is also very cost-effective, as it avoids the need to maintain multiple treatment facilities. Additionally, a centralized cryobank in a high-volume environment promotes quality control and assurance because expertise can be concentrated and standardized procedures applied consistently.
This approach is common in many European countries that have established centralized ovarian tissue cryopreservation programs and transported tissue between regions successfully, leading to live births. Launched by the Danish Network, founded in 1999 and whose slogan is “the patient stays, the tissue moves”, the centralization of ovarian tissue cryopreservation in Denmark and southern Sweden has made it possible to collect ovarian tissue locally and transport it for processing and storage12. A network comprising 125 establishments in Germany, Austria and Switzerland groups the processing of ovarian tissues into 3 main cryobanks with the aim of optimizing the logistics of their transport13. To optimize resources and results, the Netherlands merged 7 fertility preservation facilities into 1 centralized national program in 201814. The UK’s centralized cryobank in Oxford follows a hub-and-spoke model and provides cryopreservation services for England, Wales and Northern Ireland15. Similar centralized models exist in Japan and the United States.
Our case demonstrates the feasibility of implementing a centralized hub-and-spoke model for the purposes of cryopreservation of ovarian tissues in Canada. We have succeeded in providing specialized oncofertility services thanks to coordinated care pathways that have overcome geographic barriers, which validates this principle. The Toronto Oncofertility Center serves as a central point to provide specialized oncofertility expertise, while collaborating with local health care teams using a multidisciplinary strategy to provide emergency virtual consultations, coordinate local surgical procedures, retain professional ovarian tissue transport services, and provide centralized expert processing and storage. The model described aims to reduce the rate of infertility and dysfunction of the reproductive endocrine system, to reduce as much as possible the psychosocial repercussions of infertility and to improve the quality of life of the people concerned and their families by promoting access to care and the coordination of it.
Footnotes
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Competing interests: Madison Erb says she received travel support from Ferring, and she serves on the board of directors of the Canadian Fertility and Andrology Society’s Fertility Preservation Special Interest Group. No other competing interests have been declared.
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This article has been peer-reviewed.
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The authors obtained consent from the patient.
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Collaborations : All authors contributed to the development and design of the work. Jennia Michaeli wrote the draft of the manuscript. All authors participated in critical revision of its important intellectual content, gave final approval for the version intended for publication, and take full responsibility for all aspects of the work.
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Financing: Mount Sinai Fertility covered the costs associated with processing and cryopreservation of the tissue. First International Courier covered the costs associated with transporting the fabric.
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Translation and revision: Francophonie Team of the Canadian Medical Association
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date: 2026-02-09 19:56:00