Fertility Preservation in the Age of Assisted Reproductive Technologies

Oncofertility and Reproductive Counseling in Patients with Breast Cancer: A Retrospective Study

Introduction. Improving the prognosis of breast cancer patients is of utmost importance in terms of increasing survival rates. Modern medicine has therefore prioritized better quality of life for patients, even after the disease, through a better management of the potential long-term side effects induced by anticancer treatments. Fertility preservation and family planning are therefore crucial issues to be addressed in all cancer patients of reproductive age. Along those lines, a new branch of medicine with distinct multidisciplinary characteristics has developed over the years: oncofertility. Although both national and international guidelines value reproductive counseling as an essential aspect of the diagnostic-therapeutic pathway, part and parcel of the informed consent process, it is not included within the protocols adopted by the operating units for the care and management of neoplastic diseases. Objective. This study aimed to evaluate the activity of the Breast Unit of the Policlinico Umberto I Hospital, Rome, Italy, and the degree of compliance with guidelines. By knowing the strengths and weaknesses of such approaches, the standards of care offered to breast cancer patients can be improved. Materials and methods. A retrospective study based on a review of medical records was conducted between 2014 and 2021. Patients under 40 years of age diagnosed with non-metastatic malignancies were included who received chemotherapy treatment, namely neoadjuvant, adjuvant or adjuvant hormone therapy. Results. The data were extracted from the medical records of 51 patients who met the inclusion criteria, 41% of whom received reproductive counseling, and of these, 43% decided to undertake a path of fertility preservation. Factors such as the absence of children and young age reportedly favored both the interest in counseling proposals by the medical staff and the decision to undertake a path of fertility preservation. Conclusions. The study shows that there has been growing interest in the topic of oncofertility, especially in light of law 219/2017. Therefore, since 2018, multiple proposals for reproductive counseling have been set forth, but there was not an equally growing demand for fertility preservation practices, which can be explained by the invasive nature of such practices, the patients’ concern about their own state of health, and poor or inadequate information. Such impediments highlight the importance of standardized counseling and the need for a multidisciplinary medical team to support the patient in the decision-making process. The study also revealed a drop in the number of patients receiving counseling due to the COVID-19 pandemic, contrary to the positive trend that was recorded prior to the pandemic.

And When I Die: Theory of Planned Behavior as Applied to Sperm Cryopreservation

The present study investigates fertility intentions of men, aged 18-59, as expressed in willingness to cryopreserve sperm for future use in procreation. An economic stated-preference framework is combined with the Theory of Planned Behavior (TPB) to investigate which attributes are important in the decision to cryopreserve sperm, what is the Willingness to Pay (WTP) for cryopreservation, and which attributes influence it. A structured, two-part questionnaire was used, based on WTP and Conjoint analysis (CA) applied in tandem to elicit respondents' preferences in evaluating utility. Findings show which attributes are important in the decision to cryopreserve sperm among them Risk of Infertility, Personal monthly income, Chance of pregnancy from frozen semen, Age and what are significant predictor variables for the WTP which are Personal monthly income, Importance of the risk of infertility, Initial registration fee to sperm bank and cryopreservation, and Degree of religious observance. The findings further demonstrate that respondents value sperm cryopreservation and have a positive WTP for it as it seems to contribute to improving well-being. As a result of these findings, governments should consider state funding for cryopreservation as part of national health policy.

Cryo-banking of human spermatozoa by aseptic cryoprotectants-free vitrification in liquid air: Positive effect of elevated warming temperature

Cryoprotectant-free vitrification is a common method for spermatozoa cryopreservation by direct plunging into liquid nitrogen. However, the commercial liquid nitrogen could be potentially contaminated by microorganisms. Warming temperature plays an essential role for quality of human spermatozoa after vitrification. This study aimed to evaluate comparatively a quality spermatozoa after vitrification in liquid nitrogen and clean liquid air as well as with two warming rates: at 42 °C and 45 °C. After performing of routine swim-up of normozoospermia samples, spermatozoa from the same ejaculate were divided into two groups: vitrified in liquid nitrogen (LN) and sterile liquid air (LA). Spermatozoa of LN group were warmed at 42 °C, and spermatozoa of LA groups were divided and warmed at 42 °C (LA42) and 45 °C (LA45). Then spermatozoa motility, reactive oxygen species (ROS), mitochondrial membrane potential (MMP), reactive nitrogen species (RNS), and viability were assessed. It was no found significant differences in quality of spermatozoa from LN and LA groups in the motility, ROS, MMP, RNS rates after warming at 42 °C. A tendency to obtain better spermatozoa quality was found with using of warming by 42 °C in comparison with 45 °C. It was concluded that cryoprotectant-free vitrification by direct dropping of human spermatozoa into clean liquid air can be used as an alternative to cooling in liquid nitrogen. Warming of spermatozoa at 42 °C allows to preserve the spermatozoa physiological parameters.

MALDI MS Analysis to Investigate the Lipid Composition of Sperm

Background:

The sperm plasma membrane meets the requirements of sperm transit through the female genital tract and subsequent fertilization. Commonly, the (phospho)lipid composition of sperm is characterized by tremendous amounts of highly unsaturated fatty acyl residues such as docosahexaenoic and docosapentaenoic acid. While human sperm contain almost exclusively diacyl lipids, many animal sperm additionally contain significant amounts of ether lipids such as alkylacyl- and alkenyl-acyl lipids (plasmalogens).

Hypothesis/Objective:

It is suggested that deviations from the typical lipid composition are indicative of pathological changes. Therefore, simple methods to elucidate the sperm lipid composition are essential.

Method:

Matrix-assisted laser desorption and ionization (MALDI) mass spectrometry (MS) is a fast and simple method. Since the selection of the most suitable matrix is a crucial step in MALDI MS, this topic will be highlighted. It will also be shown that MALDI MS can be easily combined with thin-layer chromatography to overcome ion suppression effects.

Results:

The lipid composition of sperm from different species can be elucidated by MALDI MS. However, different matrix compounds have to be used to record positive and negative ion mass spectra. Since some sperm (glyco)lipids are characterized by the presence of sulfate residues which suppress the detection of less acidic lipids in the negative ion mode, previous separation is often necessary. It will be also emphasized that plasmalogens can be easily identified by either enzymatic digestion or treatment with acids.

Conclusion:

MALDI MS is a reliable method to obtain sperm lipid fingerprints in a simple and convenient way.

Knowledge and decision making about future fertility and oocyte cryopreservation among young women

The objective was to examine what young graduate student women know about preserving fertility/oocyte cryopreservation, and which reproductive resources they use. A prospective, cross-sectional design was used and the study was conducted at a University on the East Coast of the United States. The participants were 278 female graduate students. Participants completed a survey with questions about demographics, fertility knowledge, oocyte cryopreservation, and sources of fertility information. Descriptive statistics were calculated for all variables. Participants had average knowledge about fertility (64% items correct). The most used fertility information source was formal education (87.1%), information to help make fertility decisions was gynaecologists (85.3%), and oocyte cryopreservation was media (63.4%). Only 26.6% reported being well informed about fertility. Although 93.9% had heard of oocyte cryopreservation, only 7.2% had considered its use. Most (74.9%) ranked fertility as important, though 83% would consider postponing family until career (85.2%) and relationship (85.2%) were established. Half felt that there was a social stigma surrounding oocyte cryopreservation, and 70.1% believed that the media gives the impression that motherhood is viable after 40 years old. Professionally motivated women receive the most information about fertility from formal, accuracy-driven sources (i.e. education, healthcare providers), but information about fertility preservation from media. They lack knowledge about fertility planning.

Social Freezing in Medical Practice. Experiences and Attitudes of Gynecologists in Germany

Surveys of the German public have revealed a high acceptance of social freezing, i.e. oocyte conservation without medical indication. Up to now, there are no investigations available on the experiences and attitudes of health professionals towards social freezing. Between August 2015 and January 2016, we surveyed gynecologists Germany-wide on the topic social freezing. Five gynecologists specialized in reproductive medicine and five office-based gynecologists in standard care were chosen for the survey. The survey was conducted with an explorative, qualitative research design. The demand for social freezing in Germany is low. With regard to their fertility age, most women attend consultations too late, they have only little previous knowledge and false expectations. The gynecologists consider it the duty of society and politics to provide for the compatibility of family and work. They relate late parenthood to disadvantages primarily for the children. A majority of the gynecologists interviewed tend to advise natural reproduction. Social freezing is often mistaken as a kind of fertility insurance. Thus, it is necessary that physicians inform women early about the possibilities and limitations of social freezing. In the first place, social freezing is not a medical or medical-ethical topic. Women consider the method as a possibility to ensure the compatibility of family and work. This compatibility should be mostly perceived as a political topic. It cannot be a medical task to solve this issue. In fact, a debate in society as a whole is necessary that includes all relevant actors.

Ovarian tissue vitrification and heterotopic autologous transplantation in prepubertal Wistar rats

OBJECTIVE

To evaluate the efficiency of ovarian tissue heterotopic autografting after vitrification in prepubertal rats.

METHODS

Fragments of excised ovaries from prepubertal rats were used after assessing post-warming cellular viability, to determine the best vitrification protocol prior to retroauricular autografting. Pre-pubertal females (N=24) were castrated and divided into three group: Group 1 - fresh ovarian tissue transplantation; Group 2 - vitrified/warmed tissue transplantation; Group 3 - bilateral oophorectomy without transplantation. The ovarian fragments were exposed to solutions from the Ingamed® commercial kit, allocated in bacteriological loops and immersed in liquid nitrogen. Sixty days after transplantation, a vaginal mucus sample was collected for cytology tests, followed by sacrificing the animal, performing a cardiac puncture for collecting a blood sample to determine luteinizing hormone and estradiol levels, and excision of the transplanted fragment for histology tests.

RESULTS

Vaginal cytology revealed that 87.5% of females from groups 1 and 2 had estrus while all females in Group 3 remained in diestrus. The mean LH value in groups 1 (0.08 mIU/mL) and 2 (0.34 mIU/mL) were statistically different from that of Group 3 (2.27 mIU/mL). E2 values did not differ between the groups. The histological analysis of Group 1 excised grafts versus those from Group 2 showed a higher percentage of primary follicles (62.5% vs. 12.5%), developing follicles (75% vs. 25%), corpus luteum (37.5% vs. 12.5%) and stromal region (100% vs. 87.5%).

CONCLUSION

This study indicated that pre-pubertal ovarian tissue vitrification can be used to preserve fertility and to restore endocrine function in castrated rats.

Utilization of cryopreserved sperm cells based on the indication for storage

Purpose

Cryopreservation of sperm from human semen has been available since the 1950s. The actual utilization of available cryopreservation technology has been infrequently reported. We set out to examine the utilization and outcomes of cryopreserved sperm cells based on the indication for storage.

Materials and Methods

A dataset was developed from retrospective review. The purposes for cryopreservation, eventual utilization, and outcomes of use for insemination were recorded. The types of utilization were accumulated as proportions for different purposes. The timing for use of samples for insemination procedures was evaluated using survival statistics. The frequency of patients arranging to destroy samples was also reported.

Results

From September 1988 through March 2015, 1442 samples were cryopreserved. Samples were cryopreserved for four primary purposes: infertility treatments focused on intrauterine insemination (IUI) or in vitro fertilization/intracellular injection (IVF/ICSI), for fertility preservation related to cancer treatment, or prior to military deployment. Total utilization rates were 19.3%. Samples cryopreserved for IUI were more likely to be used (64.3%), while samples cryopreserved as backup for IVF/ICSI were more likely to be destroyed (29.8%). Pregnancy rates varied based on the indication and ART used. Pregnancies per cycle were 35% for IVF/ICSI and were 10% for IUI.

Conclusions

Cryopreservation of sperm is a valuable and underutilized resource, particularly amongst male cancer patients. This technology can facilitate infertility treatments based on a variety of indications, including deployment-a patient cohort unique to our dataset.

Identification of protein changes in human spermatozoa throughout the cryopreservation process

Cryoinjury is a consequence of cryopreservation and may have a negative impact on sperm quality regarding motility, morphology, and viability. This study was designed to identify potential proteomic changes in human sperm cells throughout the cryopreservation process. Comparisons made within this study included the detection of the sperm proteomic changes induced by incubation of the sperm cells with a protein-free cryoprotectant (with and without CryoSperm), and the proteomic changes induced by freezing, thawing, and subsequent after-thawing incubation at two different temperatures (0 °C vs. 23 °C). Tandem Mass Tag (TMT) peptide labeling coupled with LC-MS/MS was used for protein quantification. LC-MS/MS resulted in the identification of 769 quantifiable proteins. The abundance of 105 proteins was altered upon CryoSperm incubation. Freezing and thawing also induced substantial protein changes. However, fewer changes were observed when semen was thawed and then maintained after-thawing at approximately 0 °C than when it was maintained after-thawing at 23 °C, with 60 and 99 differential proteins detected, respectively, as compared to unfrozen semen incubated in CryoSperm. Collectively, these differences indicate that substantial changes occur in the sperm proteome at every stage of the cryopreservation process which may ultimately impair the sperm fertilizing capability. This is the first study to compare protein levels in fresh and cryopreserved semen using the TMT technology coupled to LC-MS/MS.

Designing 3-Dimensional In Vitro Oviduct Culture Systems to Study Mammalian Fertilization and Embryo Production

The oviduct was long considered a largely passive conduit for gametes and embryos. However, an increasing number of studies into oviduct physiology have demonstrated that it specifically and significantly influences gamete interaction, fertilization and early embryo development. While oviduct epithelial cell (OEC) function has been examined during maintenance in conventional tissue culture dishes, cells seeded into these two-dimensional (2-D) conditions suffer a rapid loss of differentiated OEC characteristics, such as ciliation and secretory activity. Recently, three-dimensional (3-D) cell culture systems have been developed that make use of cell inserts to create basolateral and apical medium compartments with a confluent epithelial cell layer at the interface. Using such 3-D culture systems, OECs can be triggered to redevelop typical differentiated cell properties and levels of tissue organization can be developed that are not possible in a 2-D culture. 3-D culture systems can be further refined using new micro-engineering techniques (including microfluidics and 3-D printing) which can be used to produce ‘organs-on-chips’, i.e. live 3-D cultures that bio-mimic the oviduct. In this review, concepts for designing bio-mimic 3-D oviduct cultures are presented. The increased possibilities and concomitant challenges when trying to more closely investigate oviduct physiology, gamete activation, fertilization and embryo production are discussed.

Successful Oocyte Cryopreservation in Reproductive-Aged Cancer Survivors

OBJECTIVE

To demonstrate that oocyte cryopreservation is a feasible reproductive option for patients with cancer of childbearing age who require gonadotoxic therapies.

METHODS

This study is a university-based retrospective review of reproductive-aged cancer patient treatment cycles that included ovarian stimulation, transvaginal oocyte retrieval, oocyte cryopreservation, and, in some cases, subsequent oocyte thaw, in vitro fertilization, and embryo transfer. Outcome measures included ovarian stimulation response, number of oocytes retrieved, cryopreserved, and thawed, and pregnancy data.

RESULTS

From 2005 to 2014, 176 reproductive-aged patients with cancer (median age 31 years, interquartile range 24-36) completed 182 oocyte cryopreservation cycles. Median time between consult request and oocyte retrieval was 12 days (interquartile range 10-14). Median peak stimulation estradiol was 1,446 pg/mL (interquartile range 730-2,687); 15 (interquartile range 9-23) oocytes were retrieved and 10 (interquartile range 5-18) metaphase II oocytes were cryopreserved per cycle. Ten patients (11 cycles) have returned to attempt pregnancy with their cryopreserved oocytes. Among thawed oocytes, the cryopreservation survival rate was 86% (confidence interval [CI] 78-94%). Nine of 11 thaw cycles resulted in embryos suitable for transfer. The embryo implantation rate was 27% (CI 8-46%) and the live birth rate was 44% (CI 12-77%) per embryo transfer. Chance for live birth with embryos created from cryopreserved oocytes was similar between the patients with cancer in this study and noncancer patients who underwent the same treatment at our center (44% [CI 12-77%] compared with 33% [CI 22-44%] per embryo transfer).

CONCLUSION

Oocyte cryopreservation is now a feasible fertility preservation option for reproductive-aged patients with cancer who require gonadotoxic therapies.