Fertility and POI

1. Fertility Preservation — Key Recommendation

•           The 2024 ESHRE Guideline strongly recommends that fertility preservation be discussed with women at risk of POI, such as those with known genetic predispositions or undergoing gonadotoxic treatments.

•           For female relatives of individuals with POI, fertility preservation should also be offered if they are in reproductive age, as they may carry increased risk.

2. Spontaneous Pregnancy — Limited but Possible

•           Spontaneous ovulation and conception are possible in about 5–10% of women with POI, though this is unpredictable and should not be relied upon for family planning purposes.

3. Assisted Reproductive Technologies (ART)

A. Oocyte or Embryo Donation

•           The most consistently effective route to achieving pregnancy in women with established POI is via egg donation combined with in vitro fertilization (IVF).

•           While not new in the guideline, such an approach remains standard of care for women unable to utilize their own gametes (reproductive eggs) .

B. Fertility Preservation Before Onset of POI

•           Oocyte cryopreservation is a validated method for preserving fertility, especially in high-risk individuals before ovarian failure.

•           Embryo cryopreservation is another option when a partner or donor sperm is available, though its applicability is subject to ethical and regulatory considerations.

4. Emerging & Experimental Techniques

A. Ovarian Tissue Cryopreservation and Transplantation

•           Women (and prepubertal girls) at risk of POI can opt for ovarian tissue cryopreservation. After thawing, such tissue can be transplanted back, with a reported ~64% success in restoring ovarian activity and endocrine function, and over 130 live births documented.

B. In Vitro Activation (IVA) and Drug-Free IVA

•           IVA involves activating dormant follicles in ovarian cortex tissue using pharmacological agents, followed by re-implantation. This has enabled follicular growth and led to live births in some POI patients.

•           A less invasive variant — drug-free IVA — has also led to successful pregnancies and represents a promising innovation in fertility restoration for POI.

C. In Vitro Maturation (IVM)

•           In women undergoing fertility preservation, immature oocytes harvested can be matured in vitro (IVM) and subsequently fertilized via IVF. Though not POI specific, this can be relevant for related scenarios.

5. Clinical Implications & Counselling

•           Early proactive counselling is essential for women at risk of POI, to explore fertility preservation well before ovarian function declines.

•           Fertility preservation decisions must consider the patient’s age, ovarian reserve metrics, personal values, and likelihood of POI progression.

•           Use of experimental techniques like IVA or ovarian tissue re-implantation should ideally occur within robust clinical trial frameworks, with informed consent outlining uncertain outcomes and risks.

•           For women with confirmed POI and limited fertility potential, timely referral to reproductive specialists is advised to discuss donor options, adoption, or choosing to remain childfree with adequate emotional support.

In Summary:

The 2024 ESHRE Guideline underscores the importance of individualized fertility planning for women with or at risk of POI. While spontaneous conception is rare, a spectrum of clinical and experimental options—from egg donation to tissue-based activation protocols—provides avenues for reproductive autonomy. Early, well-informed conversations are essential to optimize outcomes.