Surgical approaches to fertility preservation in the cancer patient: current and future directions

Advances in oncologic therapies have markedly improved survival among reproductive-age female patients, making fertility preservation an essential component of comprehensive cancer care. Gonadotoxic treatments, including chemotherapy, radiotherapy, and surgery, can disrupt ovarian and uterine endocrine function, resulting in premature ovarian insufficiency and infertility. This narrative review summarizes current and emerging surgical approaches to fertility preservation, organized by anatomic focus on the ovary, uterus, and cervix. Ovarian transposition preserves ovarian endocrine function by relocating the ovaries outside the pelvic radiation field, while ovarian tissue cryopreservation preserves primordial follicles through surgical harvesting, cryostorage, and reimplantation to restore ovarian function and fertility. Emerging uterine-preserving strategies, such as uterine transposition and uterine transplantation, demonstrate growing feasibility for restoring reproductive and endocrine uterine function. Fertility-sparing cervical procedures, including radical and simple trachelectomy, maintain favorable oncologic outcomes while preserving reproductive potential in appropriately selected patients. Across all modalities, multidisciplinary collaboration and individualized counseling are critical to optimize both oncologic and reproductive outcomes. Continued research aimed at refining surgical techniques, improve graft viability, and expanding equitable access will be key to advancing fertility preservation as a standard component of comprehensive cancer care.