Laparoscopic medulla-sparing ovarian tissue biopsy for cryopreservation: step-by-step surgical technique

Abstract

In the last years the demand for fertility preservation has grown due to the increasing survival rates among cancer patients and the rising awareness of the importance of quality of life after gonadotoxic therapy. Among fertility sparing approaches, ovarian tissue cryopreservation (OTC) is a valid strategy to preserve ovarian endocrine and reproductive function in pre and post-puberal women that will undergo gonadotoxic cancer treatments. Currently, there is no universal consensus regarding ovarian tissue retrieval technique for fertility preservation. Aim of this video is to describe a laparoscopic technique for ovarian tissue biopsy (OTB) for fertility preservation. Step by step description of the surgical technique with narrated video footage. Academic tertiary hospital. Patients with a high risk of premature ovarian insufficiency (POI) usually due to gonadotoxic treatments who undergo ovarian tissue biopsy for fertility preservation. In this video we present the clinical case of a 28-year-old patient affected by Hodgkin lymphoma who underwent laparoscopy for OTB before chemotherapy. After exposing the chosen ovary, an incision at the tubal pole of the ovary is made with scissors. Through section and dissection, a large cortical biopsy of the ovary is performed without removing and avoiding any damage to the medulla. At the end of the procedure haemostasis was obtained with selective coagulation using bipolar coagulation. Standardization of a step-by-step laparoscopic technique can provide an effective method to optimize ovarian tissue removal minimizing tissue injury. Medulla sparing ovarian biopsy allows retrieval of only the cortical part of the ovary maximizing the number of primordial follicles obtained without damaging the vascular supply of the ovary contained within the medulla. Primordial follicles are resistant to cryoinjury due to their relatively inactive metabolism, and they are usually found at approximately 0.8 mm below the surface of the cortex. This technique could also reduce the back-table processing time of the ovarian tissue before the cryopreservation. One disadvantage could be the difficulty of the technique compared to an oophorectomy because it requires a skilled surgeon that can easily find the cleavage plane between the medulla and the cortex, even in patients submitted to previous chemoradiotherapy or during GnRh analogue therapy.