Clinical aspects of fertility preservation in female patients

A bioengineered in situ ovary (ISO) supports follicle engraftment and live-births post-chemotherapy

Female cancer patients who have undergone chemotherapy have an elevated risk of developing ovarian dysfunction and failure. Experimental approaches to treat iatrogenic infertility are evolving rapidly; however, challenges and risks remain that hinder clinical translation. Biomaterials have improved in vitro follicle maturation and in vivo transplantation in mice, but there has only been marginal success for early-stage human follicles. Here, we developed methods to obtain an ovarian-specific extracellular matrix hydrogel to facilitate follicle delivery and establish an in situ ovary (ISO), which offers a permissive environment to enhance follicle survival. We demonstrate sustainable follicle engraftment, natural pregnancy, and the birth of healthy pups after intraovarian microinjection of isolated exogenous follicles into chemotherapy-treated (CTx) mice. Our results confirm that hydrogel-based follicle microinjection could offer a minimally invasive delivery platform to enhance follicle integration for patients post-chemotherapy.

A Prospective Study on Fertility Preservation in Prepubertal and Adolescent Girls Undergoing Hematological Stem Cell Transplantation

Background

Hematological stem cell transplantation (HSCT) is an established method which has markedly increased the survival rate of hematologic malignancies since its introduction in the 1980’s. The conditioning for HSCT has known gonadotoxic effects and often leads to premature loss of fertility. In this study we have prospectively followed a cohort of girls undergoing HSCT and studied the outcomes of fertility preservation treatments performed before or after HSCT, as well as the long-term reproductive outcome.

Methods

In this one-center prospective study, 39 girls counselled for fertility preservation prior to or after conditioning for HSCT for malignant or benign diseases at childhood or adolescence between 1990 and 2017 were included. The patients were presented with the option to undergo cryopreservation of ovarian tissue or oocytes depending on their age and the time available. Follicle counts of the ovarian tissue and number of oocytes collected before or after HSCT were compared between patients treated for benign and malignant diseases. Hormone measurements post HSCT treatment, including FSH and AMH, reproductive outcomes and overall survival until January 2021 were investigated.

Results

In total, 34 girls and adolescents underwent fertility preservation before or after HSCT. Before HSCT, ovarian tissue was cryopreserved in 15 patients and two patients had oocytes preserved. Thirteen patients cryopreserved ovarian tissue after HSCT and seven patients returned to cryopreserve oocytes. Follicles were present in all tissue samples collected prior to HSCT, and in more than half of the samples collected post-HSCT. Half of the patients had spontaneous menarche or resumed menstruation post HSCT. Overall, 35 patients had survived at end of follow up and 7 patients had achieved parenthood.

Conclusions

Since fertility loss is common following HSCT, fertility preservation should be offered to all patients. Fertility preservation treatments can be performed both before and after HSCT.

Clinical Trial Registration

https://clinicaltrials.gov/show/NCT04602962, identifier NTC04602962

Ovarian stimulation is a safe and effective fertility preservation option in the adolescent and young adult population

PURPOSE

The aim of this study is to describe the multidisciplinary approach and controlled ovarian hyperstimulation (COH) outcomes in adolescent and young adult (AYA) patients (ages 13-21) who underwent oocyte cryopreservation for fertility preservation (FP).

METHODS

Multi-site retrospective cohort was performed from 2007 to 2018 at Northwestern University and Michigan University. Data were analyzed by chi-square test, t-test, and logistic regression.

RESULTS

Forty-one patients began COH of which 38 patients successfully underwent oocyte retrieval, with mature oocytes obtained and cryopreserved without any adverse outcomes. To treat this group of patients, we use a multidisciplinary approach with a patient navigator. When dividing patients by ages 13-17 vs. 18-21, the median doses of FSH used were 2325 and 2038 IU, the median number of mature oocytes retrieved were 10 and 10, and median number frozen oocytes were 11 and 13, respectively. Median days of stimulation were 10 for both groups. There was no statistical difference in BMI, AMH, peak E₂, FSH dosage, days stimulated, total oocytes retrieved, mature oocytes retrieved, and oocytes frozen between the two groups. Three patients were canceled for poor response.

CONCLUSION

COH with oocyte cryopreservation is a feasible FP option for AYAs who may not have other alternatives when appropriate precautions are taken, such as proper counseling and having a support team. These promising outcomes correspond to similar findings of recent small case series, providing hope for these patients to have genetically related offspring in the future.

Optimizing the process of fertility preservation in pediatric female cancer patients - a multidisciplinary program

Background

Current evidence indicates sub-optimal incidence of fertility preservation (FP) in eligible patients. We present herein our designated multidisciplinary program for FP in pediatric and adolescent population and present our data on FP in female patients.

Methods

Pediatric patients (age 0–18) who were candidate for highly gonadotoxic treatments were referred to FP program for a multidisciplinary discussion and gonadal risk-assessment followed by either oocyte cryopreservation or ovarian cryopreservation (OCP) for female patients, and sperm banking for male patients. The OCP protocol consists of aspiration of oocytes from small antral follicles and in-vitro maturation followed by cryopreservation, as well as ovarian tissue cryopreservation.

Results

The establishment of a designated FP program resulted in a significant increase in referral and subsequent FP procedures of all eligible patients. Sixty-two female patients were referred for FP discussion during a period of 36 months; 41 underwent OCP; 11 underwent oocyte cryopreservation and six were declined due to parental decision. The median age was 13.2y (range 18 months-18y). Thirty-two (51.6 %) were chemotherapy-naïve. Seventeen patients (27 %) had sarcoma, 16 patients (26 %) had acute leukemia. The mean number of mature oocytes that were eventually vitrified was significantly higher in chemotherapy-naïve patients compared with chemotherapy-exposed patients (mean 12 oocytes (1–42) versus 2 (0–7)).

Conclusion

Multidisciplinary programs that encompass experts of all relevant fields, skilled laboratory resources and a facilitated path appear to maximize the yield. We observed a considerable higher referral rates following launching a designated program and earlier OCP in chemo-naïve patients that culminated in a better fertility preservation procedure.

Fertility preservation in women with cervical, endometrial or ovarian cancers

Background

Although cancer in general affects an aged population, a significant number of women develop cancer at childbearing age. Long-term survival rates after gynecological cancer, especially in young patients are increasing and all quality-of-life aspects, including preservation of fertility have become of major relevance.

Outcomes

Surgical techniques aimed at sparing reproductive organs and preserving fertility have been developed for women presenting with gynecological cancer found at early stages. Indications for fertility-sparing surgery are in general restricted to women presenting with a well-differentiated low-grade tumor in its early stages or with low malignant potential. Up to now, use of fertility-sparing techniques in well-selected patients has not been shown to affect overall survival negatively and fertility outcomes reported have been favorable. Still larger amounts of data and longer follow-up periods are needed. Several current fertility-sparing cancer treatments may result in sub-fertility and in those cases assisted reproductive techniques are indicated. Overall quality of life has been satisfactory in cancer patients after fertility-sparing surgery.

Conclusions

Fertility-sparing surgery is a viable tool to enable gynecological cancer patients of young age to fulfill their family building without impairment of oncological outcome. Cancer patients of reproductive age should undergo fertility counseling to analyze this sensitive subject. Further studies are needed to investigate the role of fertility-sparing treatment and combined adjuvant therapy in higher-grade cancers.

[Cryoconservation of ovarian tissue: indications and outcome of the patients]

OBJECTIVES

Ovarian Tissue Cryopreservation (OTC) is a very promising approach of fertility preservation for women and young patients who have to follow gonadotoxic treatments (chemotherapy, radiotherapy…). The aim of this study was to analyse the indications and the outcomes of the patients who had OTC in our center during the last 17 years.

PATIENTS AND METHODS

The study is retrospective. Forty-six patients, who underwent OTC in the Laboratory of Reproductive Biology of the University Hospital of Clermont-Ferrand, between January 1997 and December 2009, were included.

RESULTS

The average age on the day of ovarian tissue harvesting was 19.5 years. Fifty-two percent of the patients were minor. In order of decreasing frequency, the diseases for which OTC has been proposed were hematologic, ovarian tumors, sarcoma ou PNET and breast neoplasia. In 93.5 %, the harvesting of ovarian cortex was performed by laparoscopy. After OTC, 82.6 % of the patients were treated by chemotherapy. A bone marrow transplant was performed for 48 % of the study patients. At the time of data collection, 57 % of the patients who had evaluation of their ovarian function presented premature ovarian failure. Eight patients had one or more pregnancies after treatment. It was a natural pregnancy for five of them. The three others were obtained by medically assisted procreation (in vitro fertilization and oocyte donation).

DISCUSSION AND CONCLUSION

We report a long-term follow-up of patients treated in our center for OTC. The originality of our study is to evaluate all aspects of OTC from the decision to propose the patients an OTC to their outcomes several years after the ovarian tissue harvesting. It is therefore a multidisciplinary approach both oncology, gynecological and pediatric whereas OTC is often considered restrictively in the literature. Finally, it seems to be essential to establish a specific medical care for these patients. This monitoring will allow an adequate assessment of pubertal development and ovarian function, management of estrogen deficiency and secondary infertility, supporting patients in their desire for motherhood.

Fertility preservation during cancer treatment: clinical guidelines

The majority of children, adolescents, and young adults diagnosed with cancer today will become long-term survivors. The threat to fertility that cancer treatments pose to young patients cannot be prevented in many cases, and thus research into methods for fertility preservation is developing, aiming at offering cancer patients the ability to have biologically related children in the future. This paper discusses the current status of fertility preservation methods when infertility risks are related to surgical oncologic treatments, radiation therapy, or chemotherapy. Several scientific groups and societies have developed consensus documents and guidelines for fertility preservation. Decisions about fertility and imminent potentially gonadotoxic therapies must be made rapidly. Timely and complete information on the impact of cancer treatment on fertility and fertility preservation options should be presented to all patients when a cancer treatment is planned.

Fertility preservation in young breast cancer patients: addressing individual patient needs

SUMMARY In female patients, infertility may be regarded as an essential loss of femininity and infertility after cancer, and is known to be associated with psychosocial distress. Fertility preservation is thus an important issue for young women diagnosed with breast cancer. Nevertheless, breast cancer patients have traditionally not been offered the most well-established methods for fertility preservation, such as embryo and oocyte freezing, as a rise in estradiol during standard stimulation protocols has been regarded as potentially deleterious in these patients. Alternative protocols for stimulation, such as those using tamoxifen and aromatase inhibitors, have therefore been developed. Protocols including aromatase inhibitors have been demonstrated to be more effective than those using tamoxifen in terms of the number of oocytes and embryos obtained, while maintaining estradiol levels within the normal range of a menstrual cycle. Cryopreservation of immature oocytes and ovarian cortical tissue are methods that are still under development. Reports of children born after application of these experimental methods are currently increasing and these methods are thus gaining a place within the options for fertility preservation in breast cancer patients.

Female reproductive health after childhood, adolescent, and young adult cancers: guidelines for the assessment and management of female reproductive complications

PURPOSE

As more young female patients with cancer survive their primary disease, concerns about reproductive health related to primary therapy gain relevance. Cancer therapy can often affect reproductive organs, leading to impaired pubertal development, hormonal regulation, fertility, and sexual function, affecting quality of life.

METHODS

The Children's Oncology Group Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancer (COG-LTFU Guidelines) are evidence-based recommendations for screening and management of late effects of therapeutic exposures. The guidelines are updated every 2 years by a multidisciplinary panel based on current literature review and expert consensus.

RESULTS

This review summarizes the current task force recommendations for the assessment and management of female reproductive complications after treatment for childhood, adolescent, and young adult cancers. Experimental pretreatment as well as post-treatment fertility preservation strategies, including barriers and ethical considerations, which are not included in the COG-LTFU Guidelines, are also discussed.

CONCLUSION

Ongoing research will continue to inform COG-LTFU Guideline recommendations for follow-up care of female survivors of childhood cancer to improve their health and quality of life.

Ovarian tissue and follicle transplantation as an option for fertility preservation

OBJECTIVE

To review and summarize data from the scientific literature on ovarian tissue and follicle transplantation as an option for fertility preservation.

DESIGN

Review of pertinent literature.

SETTING

University hospital.

PATIENT(S)

Women having undergone ovarian tissue transplantation.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Review of the literature.

RESULT(S)

Over the last decade, the field of ovarian transplantation and cryopreservation has significantly progressed, becoming applicable in humans. Indeed, fresh and frozen cortical ovarian tissue transplantations have been successfully reported worldwide, resulting in around 28 healthy babies. Although ovarian-tissue harvesting seems to be safe, the risk of reimplantation of cancer from ovarian cortical transplants cannot be estimated at this time. As a consequence, auto-transplantation of ovarian tissue in women having suffered from systemic hematological malignancies is not recommended. In these situations, reimplantation of isolated ovarian follicles might represent an interesting option in the future.

CONCLUSION(S)

Although the clinical experience is limited, the robust results obtained open new perspectives for the management of premature ovarian failure resulting or not from gonadotoxic treatments.

Recent advances in oocyte and ovarian tissue cryopreservation and transplantation

Options for preserving fertility in women include well-established methods such as fertility-sparing surgery, shielding to reduce radiation damage to reproductive organs, and emergency in-vitro fertilisation after controlled ovarian stimulation, with the aim of freezing embryos. The practice of transfering frozen or thawed embryos has been in place for over 25 years, and today is a routine clinical treatment in fertility clinics. Oocytes may also be frozen unfertilised for later thawing and fertilisation by intracytoplasmic sperm injection in vitro. In recent years, oocyte cryopreservation methods have further developed, reaching promising standards. More than 1000 children are born worldwide after fertilisation of frozen and thawed oocytes. Nevertheless, this technique is still considered experimental. In this chapter, we focus on options for fertility preservation still in development that can be offered to women. These include freezing of oocytes and ovarian cortex and the transplantation of ovarian tissue.

Sex differences in fertility-related information received by young adult cancer survivors

PURPOSE

The aim was to investigate male and female cancer survivors' perception of fertility-related information and use of fertility preservation (FP) in connection with cancer treatment during reproductive age.

METHODS

The study sample consisted of cancer survivors diagnosed from 2003 to 2007 identified in population-based registers in Sweden. Inclusion criteria included survivors who were age 18 to 45 years at diagnosis and had lymphoma, acute leukemia, testicular cancer, ovarian cancer, or female breast cancer treated with chemotherapy. Of 810 eligible participants, 484 survivors (60% response rate) completed a postal questionnaire.

RESULTS

The majority of male participants reported having received information about treatment impact on fertility (80%) and FP (68%), and more than half of the men banked frozen sperm (54%). Among women, less than half (48%) reported that they received information about treatment impact on fertility, and 14% reported that they received information about FP. Only seven women (2%) underwent FP. Predictors for receiving information about treatment impact on fertility were a pretreatment desire to have children (odds ratio [OR], 3.5), male sex (OR, 3.2), and being ≤ 35 years of age at diagnosis (OR, 2.0). Predictors for receiving information about FP included male sex (OR, 14.4), age ≤ 35 at diagnosis (OR, 5.1), and having no children at diagnosis (OR, 2.5).

CONCLUSION

Our results show marked sex differences regarding the receipt of fertility-related information and use of FP. There is an urgent need to develop fertility-related information adapted to female patients with cancer to improve their opportunities to participate in informed decisions regarding their treatment and future reproductive ability.

Fertility preservation in female cancer patients

With improved survival rates among cancer patients, fertility preservation is now being recognized as an issue of great importance. There are currently several methods of fertility preservation available in female cancer patients and the options and techniques via assisted reproduction and cryopreservation are increasing, but some are still experimental and continues to be evaluated. The established means of preserving fertility include embryo cryopreservation, gonadal shielding during radiation therapy, ovarian transposition, conservative gynecologic surgery such as radical trachelectomy, donor embryos/oocytes, gestational surrogacy, and adoption. The experimental methods include oocyte cryopreservation, ovarian cryopreservation and transplantation, in vitro maturation, and ovarian suppression. With advances in methods for the preservation of fertility, providing information about risk of infertility and possible options of fertility preservation to all young patients with cancer, and discussing future fertility with them should be also considered as one of the important parts of consultation at the time of cancer diagnosis.

Options on fertility preservation in female cancer patients

Infertility following treatment of cancer is a quality of survival's recognized issue and efforts should be made to help young cancer patients retaining their fertility potential. Options to preserve fertility in female patients include well established methods such as shielding to reduce radiation damage to reproductive organs, fertility-sparing surgery and emergency in vitro fertilization after controlled ovarian stimulation, aiming at freezing embryos. Transfer of frozen/thawed embryos today is a clinical routine in fertility clinics worldwide and it has been used for over 25 years. Mature oocytes after ovarian stimulation can also be frozen unfertilized, nevertheless overall pregnancy rates after fertilization of frozen-thawn oocytes are still relatively lower than those with embryo freezing. Remaining fertility preservation options are still in development and include the freezing of immature oocytes aiming at later in vitro maturing and fertilizing them and the cryopreservation of ovarian tissue for future retransplantation or for in vitro growth and maturation of follicles, both still experimental.

5'-(N-ethylcarboxamido) adenosine improves angiogenesis in transplanted human ovarian tissue

To investigate the effect of 5'-(N-ethylcarboxamido) adenosine (NECA), an adenosine agonist, on triggering angiogenesis in transplanted human ovarian tissue, the expression of angiopoietin-1 (Ang1), Ang2, vascular endothelial growth factor 121 (VEGF-121) and VEGF-189 at both gene and protein levels as well as the density of vasculature were studied in tissue fragments grafted to NECA-treated and control groups of nude mice. The results showed that NECA treatment triggered down-regulation of Ang1, induced VEGF-189 expression, and stimulated neovascularization, highlighting the beneficial effect of NECA on the process of angiogenesis.

Fertility preservation in women with breast cancer

Fertility preservation is an important issue for young women diagnosed with breast cancer. The most well-established options for fertility preservation in cancer patients, embryo and oocyte cryopreservation, have not been traditionally offered to breast cancer patients as estradiol rise during standard stimulation protocols may not be safe for those patients. Potentially safer stimulation protocols using tamoxifen and aromatase inhibitors induce lower levels of estradiol whereas similar results in terms of number of oocyte and embryo obtained to standard protocols. Cryopreservation of immature oocytes and ovarian cortical tissue, both still experimental methods, are also fertility preservation options for breast cancer patients.

Fertility preservation medicine: options for young adults and children with cancer

As cancer survival rates continue to improve, many young adults and children will face infertility after successful treatment of their malignant diseases. Fertility is now recognized as a critical component of quality-of-life for cancer survivors and fertility preservation is an emerging discipline that addresses the need for improving cancer survivors' options to have children later in life. Fertility preservation by established methods is often possible in adult female and male cancer patients before starting their gonadotoxic treatments. In prepubertal children, options are still experimental and most challenging. Embryos, oocytes, sperm, or gonadal tissue (ovarian and testicular) can be cryopreserved and stored at subzero temperatures until the time when the patients are disease-free and wish to start a family. As fertility preservation choices include both established and experimental techniques, a highly individualized approach is required in the management of those patients looking for fertility preservation options.

Fertility preservation in girls during childhood: is it feasible, efficient and safe and to whom should it be proposed?

BACKGROUND

In prepubertal and adolescent girls, fertility may be impaired by gonadotoxic treatments, repeat ovarian surgery or genetic disorders. Cryopreservation of ovarian cortex is an existing option to preserve fertility in these young girls at risk of premature ovarian failure (POF). The efficacy, feasibility and risks of ovarian cryopreservation in children must be assessed in order to validate the technique.

METHODS

Here, we conducted a review of ovarian cryopreservation in adults and, more specifically, in children using the PubMed databases. In addition, our own experience with ovarian cryopreservation in children was evaluated and compared with the literature.

RESULTS

Analysis of the literature and six published series on ovarian cryopreservation in children, as well as our own series of 58 cases, show that there is no reason to doubt its efficacy in this young population. However, no consensus has yet been reached on the indications for the technique. Indeed, with existing models, the real risk of POF may be over- or underestimated.

CONCLUSION

Our review suggests that ovarian cortex cryopreservation is feasible and as safe as comparable operative procedures in children. Although no births have yet resulted from freeze-thawing of prepubertal ovarian cortex, the results of this approach in adults are encouraging. However, the absence of consensus on the indications for fertility preservation, as well as the optimal timing and quantity of ovarian cortex for cryopreservation, should be taken into consideration when discussing fertility issues with girls at risk of POF and their parents.

Fertility preservation by ovarian stimulation and oocyte cryopreservation in a 14-year-old adolescent with Turner syndrome mosaicism and impending premature ovarian failure

OBJECTIVE

To report a novel approach to fertility preservation in adolescents with Turner syndrome mosaicism by repeated controlled ovarian stimulation and oocyte cryopreservation.

DESIGN

Case report.

SETTING

Academic reproductive medicine center.

PATIENT(S)

Fourteen-year-old adolescent diagnosed with Turner syndrome mosaicism.

INTERVENTION(S)

Two cyles of controlled ovarian stimulation and oocyte cryopreservation within 1 year.

MAIN OUTCOME MEASURE(S)

Recovery of oocytes after controlled ovarian stimulation and oocyte cryopreservation.

RESULT(S)

Eleven oocytes were retrieved, of which eight were mature and three were immature during the first cycle. One year later, four mature and three immature oocytes were retrieved after a treatment cycle with even higher gonadotropin doses. All oocytes were cryopreserved by vitrification.

CONCLUSION(S)

Controlled ovarian stimulation and oocyte cryopreservation may be an option for fertility preservation in selected adolescents with Turner syndrome mosaicism and impending ovarian failure.