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Breast Cancer Editorial Current State of Fertility Preservation in Cancer Patients—What is Established and What is Still Controversial? Kutluk Oktay, MD, PhD, FACOG, 1,2 and Giuliano Bedoschi, MD 1,2 1. Innovation Institute for Fertility Preservation and IVF, New York, New York, US; 2. Laboratory of Molecular Reproduction and Fertility Preservation, Obstetrics and Gynecology, New York Medical College, Valhalla, New York, US Abstract Fertility Preservation is an essential part of cancer care when treating young females and men. While semen cryopreservation is a straightforward approach for postpubertal men and there is the option of experimental testicular tissue freezing for prepubertal boys, the options for females are more tumultuous. The last 17 years brought us established approaches such the embryo and oocyte cryopreservation and the ovarian cryopreservation is ready to join the list. However, there still is no proven medical fertility preservation method and the controversy around the utility of GnRHa continues. Keywords Fertility preservation, cancer, quality of life, oocyte and embryo cryopreservation, ovarian tissue cryopreservation, GnRHa Disclosure: Kutluk Oktay, MD, PhD, FACOG is the Co-Chair for the American Society for Clinical Oncology Fertility Preservation Guidelines Committee. Giuliano Bedoschi has nothing to disclose in relation to this article. This article is a short opinion piece and has not been submitted to external peer reviewers. Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit. Received: February 10, 2016 Published Online: March 30, 2016 Citation: Oncology & Hematology Review, 2016;12(1):33–5 Correspondence: Kutluk Oktay, MD, PhD, FACOG, 124 E 84th Street, New York, New York 10028, US. E: firstname.lastname@example.org Support: Supported by NIH RO1 HD053112 from the NICHD and NCI. It has been estimated that approximately 1% of all females may be exposed to some form of gonadotoxic cancer treatment by the age of 45. 1 Given the quality of life consequences of cancer-treatment-induced infertility and ovarian failure, fertility preservation becomes an essential component of cancer care. The fertility preservation field has shown significant evolution within the past 17 years but it is not without its controversies. While embryo and oocyte cryopreservation are considered established techniques, various discussions continue around ovarian cryopreservation as well as the utility of Gonadotropin Releasing Hormone Agonists (GnRHa). To us, ovarian cryopreservation followed by transplantation is the easier one to address first. The question revolves around whether it should still be considered experimental. Recent reports including some of ours put the number of live births over 60, with more than a third of women having at least one child after an ovarian transplant. 2,3 Ovarian cryopreservation has several advantages over gamete freezing techniques, as after transplantation, normal ovarian endocrine function can be restored and fertility can be achieved without assisted reproduction techniques. There is no need for ovarian stimulation or a significant delay before chemotherapy as tissue is harvested via a brief outpatient laparoscopic procedure. We have shown the safety of ovarian tissue harvesting in cancer patients, 4 even in those with multiple medical issues. TOU CH MED ICA L MEDIA Why then, is ovarian tissue freezing still considered experimental? Among the several reasons that have been cited are the relative brevity of experience, lack of randomized studies-especially on the risk of reseeding cancer cells, and the unpredictable duration of ovarian function after a transplant. We performed the first case of autologous ovarian transplantation with cryopreserved tissue in 1999, 5 which successfully restored ovarian endocrine function in a surgically menopausal young woman. There is now 17 years of experience with this procedure. Animal as well cadaveric studies suggest by and large that micrometastasis to the ovaries is not a real concern especially for the cancer types for which ovarian tissue freezing is commonly performed. And finally, with the advent of new transplant techniques, like the one we recently reported, 2 ovarian function becomes more predictable after transplants. Given this profile, ovarian cryopreservation stands as a valid method of fertility preservation. This is especially true when the patient is a child and hence cannot be a candidate for egg freezing, or when there is insufficient time or contraindication for ovarian stimulation. That brings us to the controversy regarding ovarian suppression with GnRHa to protect ovaries during chemotherapy. The recent randomized trial by Moore et al. suggested that Zoladex ® (AstraZeneca, Macclesfield, UK) may preserve ovarian function during chemotherapy in women with 33