Approximately 10% of women diagnosed with cancer are of reproductive age. As survival rates improve, there is an increased focus on the complex issues surrounding cancer survivorship, particularly for younger women of reproductive age. Among young women diagnosed with cancer, concerns regarding future fertility are secondary only to concerns regarding survival. Guidelines from the American Society of Clinical Oncology (ASCO) and American Society for Reproductive Medicine (ASRM) state that healthcare providers should discuss the risk of infertility and fertility preservation options with all reproductive age patients diagnosed with cancer. This chapter reviews the proposed mechanisms of chemotherapy induced ovarian toxicity and how to assess baseline ovarian reserve. Fertility preservation options are discussed, including medical and conservative surgical management for select patients with gynecologic malignancies, oocyte and embryo cryopreservation, ovarian tissue cryopreservation and ovarian suppression. Data regarding the safety of ovarian stimulation and subsequent pregnancy are included.

Egg freezing was initially introduced as a fertility preservation measure in women without a male partner who were about to undergo gonadotoxic treatments. The use of oocyte cryopreservation for social reasons has been an increasingly popular strategy for women to preserve their fertility potential, a term most referred to as ‘social egg freezing’ (SEF). As well as for career progression or waiting until they are financially more secure, some women may be single, or may decide to egg freeze to relieve pressure on a relationship, until they decide they are ready to have children with their partner. Upon introduction, success rates with SEF were low due to poor oocyte survival rates. With the advent of oocyte vitrification techniques, assisted reproductive technology (ART) procedures using frozen oocytes have shown a similar live birth rate (LBR) to those using fresh oocytes. Due to this growing evidence for the efficacy of egg freezing, both the European Society for Human Reproduction and Embryology (ESHRE) and the American Society for Reproductive Medicine (ASRM) changed their stances and no longer consider oocyte freezing to be an experimental technique.

As women age, their response to ovulation induction is progressively diminished due to the continuous depletion of primordial follicles and to changes in the ovarian endocrine/paracrine microenvironment. While many couples faced with the reality of a diagnosis of low functional ovarian reserve may turn to the use of donor gametes to achieve a pregnancy, some still feel the need to try on their own, despite a poor prognosis. For such women careful preparation and hormonal priming in the months prior to beginning an IVF cycle can increase their chance of a successful outcome. Optimal treatment of these patients differs from the usual treatment of women with normal ovarian reserve in every aspect and needs to be highly individualized.

Recently there has been an increase in age-related infertility, termed ‘reproductive aging’, in which both quantity and quality of oocytes decline. Various established ways to analyze oocyte quantity include assessing age, follicle stimulating hormone, antral follicle count, and anti-Mullerian hormone. Each test has strengths and weaknesses inherent to the test itself and there can be concern when the tests are discordant. Additionally, several algorithms have been proposed that assess multiple elements to predict live birth rates per transfer and most recently cumulative live birth rates per retrieval. Knowledge about fertility has been assessed in several survey-based studies. These surveys illustrate a limited understanding of the participants regarding the impact of age-related fertility decline and a lack of realistic expectations regarding the limitations of IVF or egg cryopreservation to preserve the age-related decline in fertility. Additionally, there are inconsistencies in whether women would choose to have ovarian reserve testing and whether this would alter management. Lastly, emotional response after receiving ovarian reserve testing is also highly variable. This encourages providers to have a conversation about potential ramifications of testing.

Anti-Müllerian hormone (AMH) has recently been proposed as a diagnostic marker for polycystic ovary syndrome (PCOS) instead of polycystic ovarian morphology (PCOM) seen on ultrasound. As serum AMH level reflects excess small follicles not visible on ultrasonography, AMH level would theoretically be more accurate than PCOM as a diagnostic marker. Its value is significantly higher in PCOS patients than in normal women; its high levels are also considered to play an important role in the pathogenesis of the disorder, accounting for anovulation in PCOS patients. Nevertheless, its use is still not recommended by the international guidelines as an alternative for detecting PCOM or as a single test result for the diagnosis of PCOS. Its potential clinical applications in PCOS patients are currently the characterization of the severity of the syndrome and in deciding hormone doses for ovarian stimulation treatments. An international standard is needed to standardize the existing assays for AMH calibration before diagnostic cutoffs can be determined and before AMH use as a diagnostic marker can be considered meaningful.

Infertility is classified as a disease by the WHO and is recognized to have significant impact on the lives of the couples it affects. It is defined by the WHO as the failure of a couple to conceive after 12 months of regular, unprotected intercourse and is estimated to affect 1:7 couples. To determine the underlying cause of infertility, both the female and male should be investigated in parallel. In approximately 40% of couples there is a coexisting male and female factor contributing towards infertility. Assessments should begin after 12 months unless the female age is over 35 years or there are known risk factors, when investigations should be implemented sooner. There is a responsibility of the clinician to explore other avenues of parenthood for couples from the outset, as it is important to manage patient expectations and acceptance of childlessness if treatments fail.