Fertility Preservation in Women with Turner Syndrome: A Comprehensive Review and Practical Guidelines

Abstract

In this article we review the existing fertility preservation options for women diagnosed with Turner syndrome and provide practical guidelines for the practitioner. Turner syndrome is the most common sex chromosome abnormality in women, occurring in approximately 1 in 2500 live births. Women with Turner syndrome are at extremely high risk for primary ovarian insufficiency and infertility. Although approximately 70%-80% have no spontaneous pubertal development and 90% experience primary amenorrhea, the remainder might possess a small residual of ovarian follicles at birth or early childhood. The present challenge is to identify these women as early in life as is possible, to allow them to benefit from a variety of existing fertility preservation options. To maximize the benefits of fertility preservation, all women with Turner syndrome should be evaluated by an expert as soon as possible in childhood because the vast majority will have their ovarian reserve depleted before adulthood. Cryopreservation of mature oocytes and embryos is a proven fertility preservation approach, and cryopreservation of ovarian tissue is a promising technique with a growing number of live births, but remains investigational. Oocyte cryopreservation has been performed in children with Turner syndrome as young as 13 years of age and ovarian tissue cryopreservation in affected prepubertal children. However, current efficacy of these approaches is unknown in this cohort. For those who have already lost their ovarian reserve, oocyte or embryo donation and adoption are strategies that allow fulfillment of the desire for parenting. For those with Turner syndrome-related cardiac contraindications to pregnancy, use of gestational surrogacy allows the possibility of biological parenting using their own oocytes. Alternatively, gestational surrogacy can serve to carry pregnancy resulting from the use of donor oocytes or embryos, if needed.

Keywords: Adoption; Embryo cryopreservation; Fertility preservation; Oocyte cryopreservation; Ovarian tissue cryopreservation; Turner syndrome.

Figure 1

A proposed algorhythmic approach to decision making for fertility preservation in females diagnosed with Turner Syndrome. For prepubertal girls with sufficient ovarian reserve, expert experience dictates utility of serial serum AMH assessments to delay intervention to a postpubertal age so that oocyte cryopreservation can be considered. Serum AMH level of <2 ng/mL corresponds to levels in the lower quartile for girls aged 5–13. In postpubertal girls, since the risk of follicle loss is extremely high and can proceed at a fast pace, we recommend fertility preservation regardless of the initial AMH.