Ovarian Transplantation: Surgical Techniques and Anatomic Considerations for the Minimally Invasive Gynecologic Surgeon

INTRODUCTION: Ovarian tissue cryopreservation with subsequent autologous transplantation has advanced from an experimental approach to an established method of fertility preservation for patients at risk of premature ovarian insufficiency. Orthotopic transplantation, in which tissue is reimplanted into the pelvic cavity, offers both restoration of endocrine function and the potential for spontaneous conception. While outcomes are promising with endocrine recovery in ∼90% of patients and ∼30% live birth rates, there remains limited guidance on surgical technique and anatomic considerations for minimally invasive gynecologic surgeons. OBJECTIVE: Objectives include presenting a laparoscopic technique for orthotopic ovarian cortex autotransplantation and emphasizing surgical principles, anatomic considerations, and strategies to optimize graft survival and fertility outcomes. METHODS: We describe a 31-year-old patient who underwent ovarian tissue cryopreservation prior to chemotherapy for glioblastoma multiforme and later elected for autologous transplantation. Orthotopic grafts were placed onto the ovary and into a peritoneal pocket within the ovarian fossa. Sharp bed preparation was performed with a laparoscopic scalpel to improve vascularity, and thaw-to-fixation was limited to under 90 minutes. A glove-finger sleeve was used to deliver the graft atraumatically. Cortical strips were secured to the ovary with limited interrupted sutures to minimize fibrosis, and a V-loc suture was used to close the peritoneal pocket without compressing the graft. RESULTS: The procedure was completed successfully without complications. Technical priorities included minimizing graft trauma, ensuring vascular access while avoiding hematoma, and limiting suture placement. Literature demonstrates restoration of ovarian endocrine function in the majority of patients and spontaneous conception in selected cases, supporting the clinical utility of this technique. CONCLUSIONS: Laparoscopic ovarian cortex autotransplantation is feasible and effective, with reproducible outcomes when attention is given to surgical detail and interdisciplinary coordination. Minimally invasive surgeons should be familiar with anatomic landmarks, graft-handling principles, and postoperative considerations. Future refinements may incorporate angiogenic scaffolds and standardized multicenter data collection to further optimize success.