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Specialist & Emerging Care

Ovarian Tissue Cryopreservation: Fertility Preservation When Time and Puberty Matter

10 min readEvidence synthesis
Read the evidence

The question in focus

An evidence-based review of ovarian tissue cryopreservation, candidate selection, surgical and oncologic safety, transplantation outcomes and long-term follow-up.

Evidence at a glance

28%

pooled live-birth rate after frozen ovarian-tissue transplantation

An individual-patient-data meta-analysis estimated a 28% live-birth rate, but cohorts, denominators and follow-up differed and the evidence was observational.

Fresh and Cryopreserved Ovarian Tissue Transplantation: An Individual Patient Data Meta-Analysis

A different option from egg or embryo freezing

Ovarian tissue cryopreservation removes strips of ovarian cortex containing immature follicles and stores them for possible later transplantation. Unlike oocyte or embryo cryopreservation, it does not require ovarian stimulation and can usually be organised quickly. It may be the only fertility-preservation option for prepubertal children facing highly gonadotoxic treatment [1][2].

ASCO's 2025 guideline considers ovarian tissue cryopreservation for future transplantation an established fertility-preservation method for people with cancer, while rating parts of the evidence as low or moderate quality [1]. Established does not mean guaranteed or appropriate for everyone. Oocyte and embryo cryopreservation remain established alternatives for postpubertal patients when treatment timing, ovarian reserve and personal preferences allow.

  • Offer fertility counselling before gonadotoxic therapy whenever clinically feasible.
  • Compare tissue, oocyte and embryo options using the person's age and timeline.
  • Do not delay urgent cancer treatment without oncology agreement.

Candidate selection starts with future ovarian-failure risk

The benefit depends on the chance that planned treatment will substantially damage ovarian function, balanced against surgical risk, prognosis and likelihood of future use. Age matters because follicle density and reproductive potential decline over time. The tissue procedure cannot preserve a uterus or reverse other infertility factors.

A multidisciplinary team should include oncology or the relevant disease specialist, reproductive medicine, surgery, pathology and age-appropriate psychological support. ESHRE recommends coordinated referral pathways, standard information and clear responsibility for follow-up [2]. For children, assent should be sought when developmentally possible alongside parental permission, and future autonomy over storage and use should be protected.

  • Estimate gonadotoxic risk from the actual treatment regimen, not the diagnosis alone.
  • Discuss storage duration, costs, consent at adulthood and what happens if contact is lost.
  • Reassess fertility after treatment rather than assuming stored tissue must be used.

The central safety question is malignant contamination

Autotransplantation can theoretically reintroduce malignant cells contained in stored tissue. ESHRE advises malignancy-specific assessment because the risk of ovarian involvement and reseeding varies by cancer type and disease status [2]. Haematologic malignancies and cancers with ovarian involvement require particular caution. Histology, molecular testing or other assessment can reduce uncertainty but cannot always prove that every fragment is free of disease.

The future alternative of maturing follicles outside the body could avoid retransplantation, but in-vitro growth of human primordial follicles to routinely usable mature oocytes remains investigational. It should not be presented as an available rescue if transplantation is unsafe. The consent process needs to distinguish what can be done today from techniques that may or may not become clinically available.

  • Obtain disease-specific assessment of ovarian involvement and reseeding risk.
  • Record exactly what tissue testing was performed and its limitations.
  • Label in-vitro follicle maturation as investigational.

Outcomes are promising but denominators differ

A 2022 individual-patient-data meta-analysis of frozen-thawed ovarian tissue transplantation estimated a live-birth rate of 28% [3]. A German network analysis of 196 transplanted women reported a live-birth rate of 26.5% per transplanted woman [4]. These are not rates per person who originally stored tissue, because many never return for transplantation, remain fertile, do not wish to conceive or are not eligible.

Transplanted tissue can restore endocrine function and may allow spontaneous conception or IVF. In a 2024 pooled review of 162 childbirths after transplantation, 66.7% were conceived naturally and 33.3% using assisted reproduction [5]. Published experience is vulnerable to selection and publication bias, and centre expertise matters. Counselling should use programme-specific and age-specific data where available.

  • Ask for outcomes per tissue collection, per transplantation and per pregnancy attempt.
  • Separate restoration of ovarian function from live birth.
  • Include miscarriage, obstetric and neonatal outcomes in reporting.

A preservation programme is a decades-long service

Storage may continue for many years, a reality recognised in fertility-preservation guidance that addresses counselling, storage and later use [2][6]. Services need reliable consent renewal, identity verification, temperature monitoring, disaster recovery, relocation plans and processes for death, incapacity or changed wishes. A child who reaches adulthood must be able to make a fresh, informed decision. Data and tissue governance should be designed for long time horizons, not a single surgical episode.

Follow-up should assess spontaneous ovarian recovery, endocrine health, fertility goals and the continuing value of storage. Digital registries can prevent people from being lost, but contact preferences and cross-border movement change. Success is not the number of tissue samples banked. It is timely counselling, safe collection, transparent uncertainty and equitable access to future review and use.

  • Maintain a verifiable chain of custody and storage audit.
  • Create a transition process from paediatric to adult consent.
  • Fund counselling and follow-up, not only tissue collection.

What the evidence cannot yet answer

  • Most outcome evidence is observational and based on selected people who returned for transplantation.
  • Live-birth denominators and follow-up differ across cohorts, and publication bias is possible.
  • Safety assessment cannot always eliminate the risk of reintroducing malignant cells, and in-vitro follicle maturation remains investigational.

Questions worth taking into care

  1. How likely is this specific treatment to cause permanent ovarian insufficiency?
  2. Why is ovarian tissue preferred over oocyte or embryo cryopreservation in this case?
  3. What is the disease-specific risk of malignant contamination and how is tissue assessed?
  4. What are this centre's outcomes per transplant and per person who stored tissue?
  5. Who funds storage, long-term contact, adult re-consent and future transplantation?

Source record

Evidence used in this review

Sources were selected for clinical authority, methodological relevance and traceability. Links open the original guidance, public-health record or research publication.

  1. [1]
    Fertility Preservation in People With Cancer: ASCO Guideline Update

    American Society of Clinical Oncology · 2025

  2. [2]
    ESHRE Guideline: Female Fertility Preservation

    European Society of Human Reproduction and Embryology · 2020

  3. [3]
  4. [4]
  5. [5]
  6. [6]
    Fertility Preservation for Medical Indications

    National Institute for Health and Care Excellence · 2026

Editorial standard

This evidence synthesis is for general information. It does not diagnose a condition or replace care from a qualified health professional. Treatment choices depend on individual history, examination, local guidance and informed preference. Emergency or rapidly worsening symptoms need urgent local medical assessment.