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<b><i>Introduction:</i></b> Ovarian tissue cryopreservation (OTC) has proven to be effective in other patient groups, but the effectiveness in girls with Turner syndrome (TS) is still unclear. Guidelines for counselling about OTC in TS are lacking. The aim of this study was to gain insight into the experiences of patients, parents, and healthcare providers with the decision-making process regarding OTC in girls with TS. <b><i>Methods:</i></b> Within a year after counselling, a survey was sent to 132 girls with TS and their parents. Furthermore, focus groups were conducted with (1) gynaecologists with subspeciality reproductive medicine, (2) paediatric endocrinologists, (3) parents of girls aged 2–12, and (4) parents of girls aged 13–18. Transcripts were analysed using a thematic analysis approach. <b><i>Results:</i></b> The response rate of the survey was 45%. Of the survey respondents, 90% appreciated counselling regarding their future parenting options and considered it an addition to existing healthcare. Girls with TS and their parents indicated that the option of OTC raised hope for future genetic offspring and instantly made them feel that their only option was to seize this opportunity. Gynaecologists and paediatricians found it challenging to truly make families grasp a realistic perspective of OTC in girls with TS. <b><i>Discussion and Conclusion:</i></b> Offering young girls with TS the possibility of fertility preservation in an experimental setting raised high hopes and led to challenges for healthcare providers in ensuring a considered decision. The appropriate moment for counselling should be tailored to the individual and discussed with patient, parents, and paediatrician.

Study question Which girls with TS could benefit from FP by OTC, based on the presence of follicles in relation to karyotype, clinical and hormonal data? Summary answer Girls with TS who have favourable predictive parameters (e.g 46,XX cell line, a measurable AMH or spontaneous puberty) could benefit from FP by OTC. What is known already Infertility due to premature ovarian insufficiency is a major concern for girls with TS and their parents. Physicians are often asked about possible options to preserve their fertility. However, evidence for successful FP by OTC in these girls is lacking. Without evidence on the effectiveness of OTC in TS girls, it should only be offered in a research setting. Study design, size, duration A national prospective exploratory intervention study. Ovarian cortex will be obtained after unilateral ovariectomy from 106 girls with TS aged 2-18 years. Patients will be included between 2017 and 2022. Participants/materials, setting, methods All girls with TS who have completed the diagnostic work up of TS were included. After unilateral ovariectomy, one fragment of the ovarian cortex was used to determine the number of follicles by serial sectioning and staining. Karyotyping of ovarian cells, lymphocytes, buccal cells and urine cells was performed by Fluorescence in situ hybridization (FISH). Blood samples obtained before oophorectomy and during the yearly clinical visit after oophorectomy will provide information on hormonal parameters. Main results and the role of chance Currently, we have received 106 informed consent forms and 86 TS patients (age 3-19) had a unilateral ovariectomy. Oocytes were found in 32,6% (n = 28; age 5-19) of which 11 were prepubertal, 16 had a spontaneous puberty, 22 had numerical chromosome X aberrations, of whom one 45,X monosomy and 6 had structural chromosome X aberrations. In 6 patients with structural aberrations we found a low follicle density. In 24/28 patients AMH was measurable (0.1 - 4.79µg/L) and 25/28 patients had a FSH below 15 E/L. FISH was used to karyotype the ovarian cortex cells of 12 patients with a numerical aberration and revealed that 112 of the 119 oocytes (94,1%) had a normal X-chromosomal content. Granulosa cells were largely 45,X, but showed different levels of X chromosome mosaicism, not only between patients but also between individual follicles of the same patient. Despite the level of aneuploidy (0–80%) of ovarian stromal cells, no obvious morphological/histological abnormalities were observed in the ovarian cortex tissue. Hormone values and the chromosome pattern were found to be predictive parameters for the presence of follicles. The chance of finding follicles in girls with a 46,XX cell line was three times higher than in girls without a 46,XX cell line. Limitations, reasons for caution The final analysis will be performed when the dataset of 106 TS girls is completed. Further research is necessary to determine the effects of ovarian mosaicism on folliculogenesis, i.e. are follicles capable to grow to antral stages, and to elucidate if OTC is an effective method for FP in TS. Wider implications of the findings A combination of clinical, hormonal and karyotypic data could provide predictive parameters to define which girls with TS might benefit from fertility preservation. These parameters could help physicians during FP counselling to determine if OTC is an option for a certain girl with TS. Trial registration number NCT03381300