Cryopreservation of Ovarian Tissue in Pediatrics:

What is the Child’s Best Interest?

Maria Luisa Di Pietro, MD(*); Andrea Virdis, Ph (*), Fermín J. Gonzalez-Melado, Th (**)1

(*) School of Medicine, Catholic University of Sacred Hearth, Rome

(**) Pontifical Institute “John Paul II” for Studies on Marriage and Family, Rome

Adress correspondence to Fermin J. González Melado,

Pontificio Istituto Giovanni Paolo II per studi su Matrimonio e Famiglia, Piazza San Giovanni in Laterano, 4, 00120
Città del Vaticano. Tel.: 0039-06-6988611; Fax : 0039-06-69886103; email: ferminjgm@hotmail.com

ABSTRACT. In paediatric female patients the only option for restoring fertility after chemotherapy
and radiotherapy is ovarian tissue banking. Even if this procedure is considered the most promising
available, anyway it is still an experimental option due to the paucity of data. The possibility to
offer an experimental preventive technique with potential benefits but with known risks arises a
dilemma: what is the best interest for suffering child? Is it most important to minimize risk of the
disease or to preserve the future fertility? However, if it is right to propose fertility preservation
when physical and psychic risks are acceptable, we think it is not in the child’s best interest to
retrieve ovarian tissue from very young patients whose ovaries are small and for whom surgery is a
high risk procedure. Moreover fertility preservation should not be offered if this could increase the
risk of disease worsening.

Key words: fertility preservation; paediatric cancer; child’s interest

1. CANCER TREATMENTS AND FERTILITY

Childhood cancer represents 1% of all malignancies. As a result of early detection and
improved cancer treatment, almost 80% of children and adolescent who receive diagnosis of cancer
will become long-term survivors (Sauvat 2009). Therefore quality-of-life issues, such as fertility
preservation and parenthood, have become an essential component of treatment. Unfortunately,
many treatments to eradicate malignant processes can also compromise female reproductive
function (Serebrovska 2006). So physicians and family, often, have to deal not only with the
uncertainty of long term survival, but also with the partial or total loss of fertility function.
Risk factors for female infertility include the start of therapy after the onset of puberty,
administration of alkylating agents such as procarbazine and cyclophosphamide and the delivery of
high radiation therapy to the region of the uterus and ovaries (Minton 2002). Moreover, pelvic
chemotherapy and radiotherapy can cause profound and permanent lesions on the ovary, even in
smaller female babies. Since the follicle pool (nearly one million primordial follicles) decreases
overtime, the risk of partial or total acute ovarian failure induced by chemotherapy or radiotherapy
increases as the patient’s age raises. Even when paediatric cancer survivors retain ovarian function
after completing cancer treatment, the risk of developing premature ovarian failure - defined as
cessation of menses before age 40 year - is increased. Cranial radiotherapy greater than 35 to 40 Gy

1
can impair the hypothalamic pituitary function and cause hypogonadism through gonadotropin-
releasing hormone (GnRH) deficiency (Chemaitilly 2006).
In a large study Green et al. have confirmed that women age 15 to 44 years who received a
hypothalamic/pituitary radiation dose greater 30 Gy, an ovarian/uterine radiation dose greater 5 Gy,
or CCNU, cyclophosphamide, or any AAD summed score of three or four were less likely to ever
become pregnant (Green 2009).
According to American Society of Clinical Oncology oncologists should address the
possibility of infertility as potential risk of therapy with patient treated during their reproductive
years and be prepared to discuss fertility preservation options (Lee 2006). The goal is to protect
gonadal tissue from the adverse effect of chemotherapy, radiotherapy and surgery.

2. FEMALE FERTILITY PRESERVATION

Many methods are currently under investigation to preserve fertility in women: embryo and
oocyte cryopreservation and ovarian tissue banking before beginning chemotherapy or radiotherapy
(Marhhom 2007). Embryo cryopreservation is currently the most used method in adult females. It
requires ovarian stimulation and a sperm donor, so is not useful in the case of paediatric age.
Oocyte cryopreservation is therefore under development and requires hormonal stimulation as well:
thus, neither this technique is a practical chance for child patients. Some authors hold ovarian tissue
banking and subsequent auto-transplantation as the only option to restore fertility after successful
chemotherapy and radiotherapy in young women (Anderson 2008). In this technique, ovarian tissue
is surgically excised and processed into cortical strips for cryopreservation. The ovarian cortex in
prepuberal girls mainly consists of immature oocytes in primordial follicles. Primordial follicles
seem to be less vulnerable to damage from freezing and thawing than mature oocytes due to high
surface-to-volume ratio, low-metabolic rate and absence of zona pellucida (Sonmezer 2004). So the
chance of later restoring fertility could be higher, theoretically, using this technique in spite of low
survival rate and low developmental potential of oocytes from frozen-thawed ovarian tissue cannot
be ignored.
Two different surgical approaches have been used for autotransplantation in human:
orthotopic or heterotopic (West 2009). Orthotopic transplantation places ovarian tissue at close
proximity to the infundibulo-pelvic ligament with the hope that natural pregnancy may occur. Seven
live births following orthotopic transplantation of cryopreserved ovarian tissue and natural or
artificial fertilization have been described (Levine 2010). Heterotopic transplantation is an
alternative approach. Cryopreserved ovarian tissue is transplanted outside of the pelvis such as the
forearm or abdomen. It is technically easier and less risky than orthotopic transplantation; moreover

2
monitoring follicle growth is quite simple. Anyway, current literature do not report any pregnancy
after heterotopic ovarian tissue transplantation in human. Oktay et al. (Oktay 2004) described
ovarian endocrine function restoring, development of a dominant follicle and resumption of
menstrual cycles in two women after heterotopic transplantation. In a patient pituitary function was
interrupted using a GnRh antagonist; for 11 days the patient was treated with hCG then was
performed percutaneous oocyte retrieval form the forearm, but the fertilization could not be
achieved with ICSI.
As implanted ovarian tissue does not survive longer than 2 to 3 years, it cannot be re-
implanted again whenever the patient desires a pregnancy. The reason is follicular loss that takes
place after tissue grafting (Tao 2008). To minimize this, the cryopreservation of the whole ovary
along with its vessels has been evaluated. Unfortunately, in the fertility preservation approach,
removal of whole ovary is not the suitable choice as one can never completely exclude ovarian
function recovery after chemotherapy and radiotherapy. Moreover, the risk of metastatic disease
remains an important concern.

3. FERTILITY PRESERVATION RESEARCH IN PAEDIATRIC POPULATION

Even if some authors consider ovarian tissue preservation procedure to be the most
promising available for the protection of fertility in girls (Fallat 2008), it is still an experimental
option due to the paucity of data. Undoubtedly the autotransplantation of frozen/thawed ovarian
tissue is potentially an useful method, but it is too early to determine the true benefits, since there
are only few case reports of life birth after transplantation of cryopreserved human ovarian tissue.
Moreover treatment regimens are constantly evolving, and there is a need for many years of follow-
up for children treated in pre-pubertal age before the effect on fertility can reliably be assessed. So
fertility-preserving strategies should be offered only in the context of a well-designed research
study. Since a dilemma arises whether we should even offer an experimental technique with
potential benefits but with known risks, we can analyze the issue referring to the ethical principles
of biomedical research: the proportionality of the experimental technique, the minimization of the
risks, the respect of autonomy.
According to the principle of proportionality the risk of an experimental technique should be
in proportion to expected benefits. Cryopreservation of ovaric tissue is not immediately essential to
the health and well-being of the child, moreover it provides unrealistic expectations because of the
hope of survival and subsequent procreation. Potential risks related to this technique are: 1. the risk
of delaying anti-cancer therapy; 2. the surgical risk of laparoscopy or laparotomy for collecting
ovarian tissue; 3. the risk of transferring cancer cells. Moreover, ovarian tissue surgery requires

3
general anaesthesia and laparoscopical or laparotomic surgery. Furthermore risks related to surgical
procedures, such as bleeding, thrombosis or infection (Cohen 2009), are higher in children,
especially in cancer patients.
Anyway we should take into account two possible situation: the cancer site is the pelvis; the
cancer site is outside the pelvis. The former might require an abdominal surgical approach, so a
lararoscopical or laparotomy surgery is necessary and in the best interest of the child; the latter does
not require any surgery on abdomen. In this case the best interest of the child is treatment of cancer
and any surgical procedure to fertility preservation might dangerously delaying cancer treatments.
Moreover, in the first case the surgical procedure to obtain ovarian tissue may be coupled with the
surgical therapy needed for the cancer. This may reduce the risks related to a surgical intervention
only aimed to the ovarian tissue, even if we cannot exclude the risk of bleeding at all. In any case
patient’s primary disease and the rate risk/benefit should be carefully evaluated.
The risk of transferring cancer cells depends on the disease type, activity, stage, and mass of
malignant cells transferred. Ideally, ovarian tissue cryopreservation for the purposes of future
transplantation should be performed on patient with a low risk for cancer metastasis to the ovary.
Fortunately, most of the malignant diseases encountered during the reproductive years do not
metastasize to the ovaries (Yada-Hashimoto 2003). Exceptions include blood malignances such as
leukemia, neuroblastoma and Burkitt’s lymphoma. Cancers with a low risk of ovarian involvement
include Wilms’ tumor, Ewing’s sarcoma, non Hodgkin’s and Hodgkin’s lymphomas. In a child or
adolescent with one of these tumours, there is not a specific contraindication to ovarian-tissue
cryopreservation if it is available, but the potential risk of development of a metastatic tumour in the
reproductive tract must be considered and fully disclosed to the patient and family before
proceeding. Cancers with moderate risk include adenocarcinoma of the colon, rectum, and
appendix, upper gastrointestinal system malignancies, and cervical carcinoma with adenosquamous
differentiation. Histological evaluation of ovarian samples has been suggested in order to prevent
cancer transmission, although it is not possible to completely eliminate the risk of transmission in
haematological or disseminated malignancies (Dolmans 2010). It has been proposed to avoid the
option of ovarian autotransplantation for patients with high risk cancers as leukemia and
neuroblastoma. Alternatively, ovarian tissue harvest should be performed after the first cycle of
chemotherapy in order to ablate any neoplastic cells residing within the ovary. However, in doing
this, it is also wise to remember that the ovarian reserve may be compromised with each cycle of
chemotherapy, which will diminish the longevity and survival of the grafts.
The respect of autonomy requires a well informed patient, who give her consent voluntarily.
The standard elements of informed consent include: disclosure, comprehension, voluntariness,

4
competence and consent. With children and adolescents a complicating factor can be uncertainty
about decisional capacity. Deciding about the cryopreservation of ovarian tissue requires a high
level of decisional capacity, because this decision involves future fertility and because it is difficult
to estimate the desire of a future pregnancy. Moreover awareness of the potential premature
menopause is important for those young women who have survived cancer therapy in childhood. In
fact, a survey of teenaged cancer patients and their parents showed that 81% of the girls and 93% of
parents were interested in trying research-based methods of fertility preservation (Burns 2006).
Young people are not legally considered to be able to give valid consent to medical
treatment. In Italy, the age of consent is eighteen years but it is possible an evaluation of individual
capacity for all young patients. When patients younger than eighteen are capable to achieve a
developmentally appropriate awareness of their condition and the risks/benefits of the available
treatment alternatives, they should be involved in the decision making about fertility preservation
above all if invasive procedure is necessary. In other cases the presumption is that parents have the
authority to make treatment decision for a child when the child does not have the capacity to do so.
While this is true, the treatment choices of the parents on behalf of the child must be in the child’s
best interest. But how does one decide what is in the child’s or adolescent’s best interest?
In this case the best interest includes both the present interest in minimizing risk and the
future interest in fertility preservation. For an appropriate decision a full explanation including
risks, discomforts, benefits, and alternatives is needed. In fact, in additional to decisional capacity,
informed choice requires disclosure and understanding. Knowing that there are options for fertility
preservation can be a relief for adolescents and their parents, but they should be well informed to
prevent false expectations as well as the possibility of being exploited by the commercial interests.
Parents and patient should be informed that the refuse of preserving fertility does not condemn one
to a life without reproduction and that, on the other side the participation to the procedure may not
ensure future reproduction.
There are two steps of information: 1. the information before the cryopreservation of ovarian
tissue; 2. the information about the use of stored tissue. In the first step, parents of minors and age-
appropriate children are informed of the possibility of preserving fertility and about their physical
and psychological harms in realistic terms. Physical harms include those associated with the surgery
to retrieve ovarian tissue and the risk of implanting malignant cells cryopreserved with the ovarian
tissue. A relevant consideration here is whether the surgery will be performed at the same time of
any required cancer surgery or whether an additional laparoscopy or laparotomy, and anaesthesia
will be required. Psychological harms may include the potential false hope not only in regard to
fertility preservation, but also in regard to the cancer treatment. Parents and patients are

5
psychologically vulnerable, when they recognize the disease as well as a possibility of infertility
after cancer therapy. In this situation, it is important that physicians should be cautious when
delivering information at the time of cryopreservation and carefully balance the possible benefits
with the potential risks. Treatment options with appropriate-age children should be discussed with
the patient and the discussion should take place apart from parents, so that these young persons do
not feel under pressure to proceed with a treatment preferred by parents.
In the second step, parents and patients are informed of the possibility that children might
not be ready to use stored tissue for several years and deterioration of the germ cells may occur over
time. Consideration must be given to disposition of ovarian tissue regardless of whether the child
lives or dies. If the child survives, a decision must be made relative to when she will have the
necessary maturity and moral development to make a personal decision about what to do with the
cryopreserved biological material. If the child dies, the parents or other persons should not have
discretion over the biological material and it should be destroyed.

CONCLUSION: WHAT IS THE CHILD’S BEST INTEREST?

In front of this situation, parents and physician have to pay attention t the best interest of
child: “parents or guardian have the moral and legal responsibility to act in the child’s best interest”
(Jonsen 2006). What is the best interest for suffering child? Is it most important to minimize risk of
the disease or to preserve the future fertility? Do parental preferences override the right of a child to
receive appropriate care?
According to some authors paediatric fertility preservation is not justified because there is
not expectation of direct benefit to the child in the immediate future and may cause unwanted risks
(Cohen 2008); according to other authors there is a physicians’ ethical responsibility suggesting
ovarian tissue cryopreservation to all young cancer patients (Donnez 2006). And if a study by
Anderson et al. demonstrates a high awareness among UK paediatric oncologists concerning the
potential adverse effect of cancer treatment on fertility so they use to discuss this with patients and
their families (Anderson 2008), another study demonstrates a number of barriers to physician
communication about fertility preservation (Vadaparampil 2008). The missing information is a
consequence of physicians’ lack of knowledge about fertility preservation techniques,
overestimation of economic costs and lack of time to discuss the issue.
However, if it is right to propose fertility preservation when physical and psychic risks are
acceptable, we think it is not in the best interest of the child to retrieve ovarian tissue from very
young patients whose ovaries are small and for whom surgery is a high risk procedure. Moreover
fertility preservation should not be offered if this could increase the risk of disease worsening.

6
 NOTES
1. - Maria Luisa Di Pietro, MD, Specialization in Endocrinology and Forensic Medicine, Associate
Professor, School of Medicine “A. Gemelli”, Catholic University of the Sacred Heart (Rome) and
Charged Professor of Bioethics and Family, Pontifical John Paul II Institute for Studies on Marriage
and Family (Rome); Member of the National Bioethics Committee (Italy); Chief of Ethic
Committee of Pediatrics Hospital “Bambino Gesù”- Rome.

- Andrea Virdis, MA Phil, PhD. Degree in Philosophy at the University of Cagliari (2003); PhD in
Bioethics at the Catholic University of the Sacred Heart in Rome (2007); Post-doc Fellowship and
Professor (indentured) at School of Medicine "A. Gemelli" of the Catholic University of the Sacred
Heart, (Rome).

-Fermín Jesús González Melado, MA Th. Degree in Biology at the University of Extremadura
(2000); Master in Bioethics at the University of Navarra (2007) and Degree in Theology at the
Pontifical Institute John Paul II for studies on marriage and family (Rome-Washington 2010). He is
doing his PhD in Moral Theology and Bioethics at Lateran University (Rome).

REFERENCES
Anderson, Richard; Wallace, Hamish; and Baird, David. Ovarian Cryopreservation for Fertility
Preservation: Indications and Outcomes. Reproduction 2008; 136: 681-689.

———; Weddell, Annette; Spoudeas, Helen; et al. Do Doctors Discuss Fertility Issues Before they
Treat Young Patients with Cancer?. Human Reproduction 2008; 23: 2246-2251.

Burns, Karen; Boudreau, Christian; and Panepinto, Julie. Attitudes Regarding Fertility Preservation
in Female Adolescent Cancer Patients. J Pediatr Hematol Oncol 2006; 28: 350-354.

Chemaitilly, Wassim; Mertens, Ann ; Mitby, Pauline ; et al. Acute Ovarian Failure in the
Childhood Cancer Survivor Study. J Clin Endocrinol Metab 2006; 91: 1723-1728.

Cohen, Cynthia. Some Perils of ‘‘Waiting to Be Born’’: Fertility Preservation in Girls Facing
Certain Treatments for Cancer. Am J Bioeth 2008; 8: 30-32.

———. Ethical Issues Regarding Fertility Preservation in Adolescents and Children. Pediatr Blood
Cancer 2009; 53: 249-253.

Dolmans, Marie-Madeleine ; Marinescu, Cristina ; Saussoy, Pascale ; et al. Reimplantation of

Cryopreserved Ovarian Tissue from Patients with Acute Lymphoblastic Leukemia is
Potentially Unsafe. Blood 2010; 116: 2908-2914.

Donnez, Jacques; Martinez-Madrid, Belen; Jadoul Pascale; et al. Ovarian Tissue Cryopreservation
and Transplantation: A Review. Human Reproduction Update 2006; 12: 519-535.

7
Fallat, Mary; Hutter, John; and the Committee on Bioethics, Section on Hematology/Oncology and
Section on Surgey. Preservation of Fertility in Pediatric and Adolescent Patients with Cancer.
Pediatrics 2008; 121: e1461-e1469.

Green, Daniel; Kowashma, Toana: Stovall, Marilyn; et al. Fertility of Female Survivors of
Childhood Cancer: A Report from the Childhood Cancer Survivor Study. J Clin Oncol 2009;
27: 2677-2685.

Jonsen, Albert; Siegler, Mark; and Winslade, William. Clinical ethics: A Practical Approach to
Ethical Decision in Clinical Medicine. 6th ed. New York: McGraw-Hill, 2006.

Lee, Stephanie; Schover, Leslie; Partridge, Ann; et al. American Society of Clinical Oncology
recommendations on fertility preservation in cancer patients. J Clin Oncol 2006; 24: 2917-
2931.

Levine, Jennifer; Canada, Andrea; and Stern, Catharyn. Fertility Preservation in Adolescent and
Young Adults with Cancer. J Clin Oncol 2010 May 10 (Epub ahead of print).

Marhhom, Enbal; Cohen, Ilan. Fertility Preservation Options for Women with Malignancies. Obstet
Gynecol Surv 2007; 62:58-72.

Minton, Sussan; and Munster, Pamela. Chemotherapy-Induced Amenorrhea and Fertility in Women
Undergoing Adjuvant Treatment for Breast Cancer. Cancer Control. 2002; 9: 466-472.

Oktay, Kutuk; Buyuk, Erkan; Veeck, Lucinda; et al. Embryo Development After Heterotopic
Transplantation of Cryopreserved Ovarian Tissue. Lancet 2004; 363: 838-840.

Sauvat, Frederique; Binart, Nadine; Poirot, Caherine; et al. Preserving Fertility in Prepubertal
Children. Horm Res. 2009; 7 (suppl 1): 82-86.

Serebrovska, Zoya; Serebrovskaya, Tatiana; Di Pietro, Maria Luisa; and Pyle Rose. Fertility
Restoration by Cryopreservation of Oocytes and Ovarian Tissue from the Position of
Biomedical Ethics: A review. Fisiol Zh. 2006; 52: 101-108.

Sonmezer, Murat; and Oktay, Kutluk. Fertility Preservation in Female Patients. Hum Reprod
Update 2004; 10: 251-266.

Tao, Tao; and Del Valle, Alfonso. Human Oocyte and Ovarian Tissue Cryopreservation and Its
Application. J Assist Reprod Genet 2008; 25: 287-296.

Vadaparampila, Sussan ; Quinna, Gwendolyn ; King, Lindsey, et al. Barriers to Fertility

Preservation Among Pediatric. Patient Educ Couns. 2008; 72: 402-410.

8
West, Erin; Zelinski, Mary; Kondapalli, Laxmi; et al. Preserving Female Fertility Following Cancer
Treatment: Current Options and Future Possibilities. Pediatr Blood Cancer 2009; 53: 289-
295.

Yada-Hashimoto, Namiko; Yamamoto, Toshiya; Karniura, Shoji; et al. Metastatic Ovarian

Tumors: A Review of 64 cases. Gynecol Oncol 2003; 89: 314-317.