Removal, preservation and subsequent reimplantation of ovarian tissue to prevent symptoms from the menopause

Evidence-based recommendations on removal, preservation and subsequent reimplantation of ovarian tissue to prevent symptoms from the menopause. This involves removing a small piece of ovarian tissue using keyhole surgery, freezing and storing it. After menopause starts, the tissue is thawed and transplanted under the skin of the armpit, abdomen or forearm, with the aim of producing oestrogen.

# Recommendations
Evidence on the safety and efficacy of removal, preservation and subsequent reimplantation of ovarian tissue to prevent symptoms from the menopause is inadequate in quality and quantity. Therefore, this procedure should not be done unless it is part of a formal research study, with appropriate governance and ethics approval. Find out what only in research means on the NICE interventional procedures guidance page.
Research should include randomised controlled trials and should report details of:
patient selection, including the age at which ovarian tissue is removed
the procedure, including the techniques used for harvesting tissue and cryopreservation, the timing and the frequency of reimplantation of ovarian tissue, and the association between the amount of tissue removed and reimplanted and subsequent endocrine function
endocrine function in the period between removing and reimplanting ovarian tissue
a comparator group who have pharmacological hormone replacement therapy (HRT).
Patient selection should be done by a multidisciplinary team including clinicians with specialist expertise in managing menopause.
The procedure should only be done by surgeons with specialist expertise in the procedure.# The condition, current treatments and procedure

# The condition
Menopause occurs with the final menstrual period and is usually diagnosed clinically after 12 months of amenorrhoea. It usually happens when someone is between 45 and 55, although around 1% of women have early (premature) menopause before 40.
As oestrogen levels reduce, most people have some symptoms, which can affect quality of life. Most commonly, these are hot flushes and night sweats. Other symptoms are mood changes, memory and concentration loss, vaginal dryness, a lack of interest in sex, headaches, and joint and muscle stiffness. Menopause can also increase the risk of osteoporosis and cardiovascular disease.

# Current treatments
Symptoms can be treated with pharmacological hormone replacement therapy (HRT). For someone with a uterus, HRT usually consists of an oestrogen and a progestogen. For someone who has had their uterus removed, it is usually oestrogen only. HRT aims to replace the hormones that are no longer produced by the ovaries because of menopause. Non-hormonal treatments can also be used.

# The procedure
The level of reproductive hormones and ovarian reserve is assessed first. If this is adequate, one-third to one-half of the outer cortex of 1 ovary is removed laparoscopically under general anaesthesia and cryopreserved in thin slices. When menopause starts, a slice of the ovarian tissue is thawed and regrafted under the skin in a heterotopic site (for example, the forearm or axilla) with the aim of restoring normal ovarian endocrine function. The transplantation process is reversible and may be repeated to maintain endocrine function. The aim is to prevent the symptoms associated with the menopause.