This chapter provides insight into the fertility management of cancer survivors with compromised or absent ovarian function and without cryopreserved material. It begins with the evaluation of the cancer survivor for pregnancy. A flow-chart of cancer survivor screening is shown. Standard ovarian stimulation for assisted reproductive technology (ART) results in high levels of circulating estrogen, potentially 10 times the peak levels of spontaneous cycles. The mechanics of oocyte donation involves a number of steps: the recruitment of suitable donors, informed consent of donors and recipients, matching of donors to recipients, ovarian stimulation of the donor and the retrieval of her oocytes. Third-party reproduction is one of the most ethically complex aspects of reproductive health care. The chapter addresses, among other things, issues that occur when preservation of fertility has not been possible or has not been the best choice for a given individual.

Women are delaying childbirth and trying to conceive when they are over 35 years old and at this age their chances of achieving a pregnancy with their own oocytes suffer a progressive and dramatic drop. The main indications for which a woman undergoes oocyte donation are usually occult ovarian failure, advanced age and repeated failure of in vitro fertilization (IVF). The women who donate oocytes are young, with no previous pathology and with a high reproductive potential. This explains the high clinical pregnancy rates that are usually achieved with this treatment. Patients with ovarian failure due to Turner syndrome attend hospitals asking to be included in the oocyte-donation programs. It is very important to remember that in women with Turner syndrome, the risk of aortic dissection or rupture during pregnancy may be 2% and the risk of death during pregnancy is increased as much as 100-fold.

This chapter reviews the literature on the effects of age on fertility in the perimenopausal woman. The effect of age on female fertility is difficult to assess because of confounding variables such as coital frequency and other biological causes associated with infertility, the use of contraception and the social and economical constraints that limit family size. The most effective assisted reproductive technology (ART) treatment for perimenopausal women is oocyte donation. Infertility treatment in the perimenopausal woman raises many ethical questions. All fertility centers should establish guidelines based on the literature and their success rates to appropriately counsel patients about the likelihood of live birth based on age. These guidelines would also allow both the physician and the patient to justify treatment in those cases when the odds of success are low but are not nonexistent.

Pregnancy rates obtained with oocyte donation (OD) are the highest when compared to any other assisted reproduction technique (ART). OD is not only the solution for many infertile couples but also a reference model for obtaining useful knowledge of the physiology of reproduction and consequently to be applied in other ART. One of the controversies regarding ovarian stimulation for in vitro fertilization (IVF) regards the impact that successive cycles could have on oocyte recovery in terms of quality and quantity of the obtained oocytes. Age of the recipient, smoking, body mass index (BMI), and endometriosis are the various factors influencing embryo implantation. Endometriosis could affect uterine receptivity through alteration of the local environment by means of endocrine and paracrine mechanisms or due to changes in immune response. Gonadotropin-releasing hormone (GnRH) analogs could have a positive effect on the physiology of endometrial cells of patients with endometriosis.

Most of the available evidence supports the hypothesis that endometriosis compromises fertility. According to ESHRE 2005 guidelines for the diagnosis and treatment of endometriosis, treatment with intrauterine insemination (IUI) improves fertility in minimal-mild endometriosis: IUI with ovarian stimulation is effective but the role of unstimulated IUI is uncertain. Lower pregnancy and implantation rates have been documented in women with severe (stage III or IV) endometriosis when compared to mild (stage I or II) endometriosis. Assisted Reproductive Technology (ART) may bypass some of the mechanisms of endometriosis-associated infertility, but the disease may have an impact on cycle outcome. Oocyte donation appears as an alternative in patients with endometriosis with low response, poor embryo quality, or repeated ART failures. Surgery for endometriomas in women undergoing ART is indicated in symptomatic women; otherwise, it does not add any benefit to cycle outcome. However, careful surgery does not compromise ovarian reserve.

To women traditionally considered irreversibly sterile due to ovarian failure, oocyte donation and exogenous steroid replacement offers the prospect of achieving a successful pregnancy. Women requiring oocyte donation comprise two main groups: women with primary or secondary ovarian failure, and women with normal menstrual cycles. There will always be an imbalance between supply of and demand for donated oocytes due to ethical considerations. Women of ethnic origin groups must be screened for haemoglobin electrophoresis, sickle cell and Tay-Sachs disease. Adequate and sustained steroid hormone secretion by the corpus luteum of the ovulatory cycle is required for establishing and maintaining pregnancy in humans for the first seven to nine weeks. This chapter discusses oestrogen replacement, progesterone replacement, replacement protocols, oocyte donation in menstrually cyclic recipients, and implantation window. As average life expectancy and quality of life increase, pregnancy from oocyte donation to post-menopausal women becomes more possible.