A laparoscopic technique for obtaining ovarian cortical biopsy specimens for fertility conservation in patients with cancer

Prior exposure to chemotherapy does not reduce the in vitro maturation potential of oocytes obtained from ovarian cortex in cancer patients

STUDY QUESTION

Does chemotherapy exposure affect IVM potential of immature oocytes retrieved from the ovarian cortex following ovarian tissue cryopreservation (OTC) for fertility preservation?

SUMMARY ANSWER

The IVM potential of oocyte retrieved from ovarian cortex following OTC is not affected by prior exposure to chemotherapy but primarily dependent on patient's age, while successful retrieval of immature oocytes from the ovarian tissue is negatively affected by chemotherapy and its timing.

WHAT IS KNOWN ALREADY

The potential and feasibility of IVM in premenarche patients was previously demonstrated, in smaller studies. The scarce data that exist on the IVM potential of oocytes retrieved during OTC following chemotherapy support the feasibility of this process, however, this was not previously shown in the premenarche cancer patients population or in larger cohorts.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study evaluating 229 cancer patients aged 1-39 years with attempted retrieval of oocytes from the ovarian tissue and the medium following OTC in a university affiliated fertility preservation unit between 2002 and 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 172 chemotherapy naïve and 57 chemotherapy exposed patients aged 1-39 years underwent OTC in university affiliated tertiary infertility and IVF center. OTC and IVM outcomes were compared between the chemotherapy naïve and exposed groups. The main outcome measure was mean IVM rate per patient in the chemotherapy naïve and exposed groups, with subgroup analysis of a 1:1 chemotherapy exposed group matched for age at OTC and type of malignancy. We additionally analyzed premenarche and postmenarche patients' outcomes separately and investigated the effect of time from chemotherapy to IVM, malignancy type and chemotherapy regimen on oocyte number and IVM outcomes in the chemotherapy exposed group.

MAIN RESULTS AND THE ROLE OF CHANCE

While the number of retrieved oocytes and percentage of patients with at least one oocyte retrieved was higher in the chemotherapy naïve group (8.7 ± 7.9 versus 4.9 ± 5.6 oocytes and 87.2% versus 73.7%, P < 0.001 and P = 0.016, respectively), IVM rate and number of mature oocytes were comparable between the groups (29.0 ± 25.0% versus 28. 9 ± 29.2% and 2.8 ± 3.1 versus 2.2 ± 2.8, P = 0.979 and P = 0.203, respectively). Similar findings were shown in subgroup analyses for premenarche and postmenarche groups. The only parameter found to be independently associated with IVM rate in a multivariable model was menarche status (F = 8.91, P = 0.004). Logistic regression models similarly showed that past chemotherapy exposure is negatively associated with successful retrieval of oocytes while older age and menarche are predictive of successful IVM. An age and the type of malignancy matched (1:1) chemotherapy naïve and exposed groups were created (25 patients in each group). This comparison demonstrated similar IVM rate (35.4 ± 30.1% versus 31.0 ± 25.2%, P = 0.533) and number of matured oocytes (2.7 ± 3.0. versus 3.0 ± 3.9 oocytes, P = 0.772). Type of malignancy and chemotherapy regimen including alkylating agents were not associated with IVM rate.

LIMITATIONS, REASONS FOR CAUTION

This study's inherited retrospective design and the long study period carries the possible technological advancement and differences. The chemotherapy exposed group was relatively small and included different age groups. We could only evaluate the potential of the oocytes to reach metaphase II in vitro but not their fertilization potential or clinical outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

IVM is feasible even after chemotherapy broadening the fertility preservation options of cancer patients. The use of IVM for fertility preservation, even after exposure to chemotherapy, should be further studied for optimal postchemotherapy timing safety and for the in vitro matured oocytes potential for fertilization.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was received for this study by any of the authors. The authors report that no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Ovarian Stem Cells (OSCs) from the Cryopreserved Ovarian Cortex: A Potential for Neo-Oogenesis in Women with Cancer-Treatment Related Infertility: A Case Report and a Review of Literature

Cancer treatment related infertility (CTRI) affects more than one third of young women undergoing anti-cancer protocols, inducing a premature exhaustion of the ovarian reserve. In addition to ovarian suppression by GnRHa, oocyte and cortex cryopreservation has gained interest in patients with estrogen-sensitive tumors for whom the hormonal burst to prompt the multiple follicular growth could provide a further pro-life tumor pulsing. On the other hand, cortex reimplantation implies a few drawbacks due to the unknown consistency of the follicles to be reimplanted or the risk of reintroducing malignant cells. The capability of ovarian stem cells (OCSs) from fresh ovarian cortex fragments to differentiate in vitro to mature oocytes provides a tool to overcome these drawbacks. In fact, since ovarian cortex sampling and cryopreservation is practicable before gonadotoxic treatments, the recruitment of OSCs from defrosted fragments could provide a novel opportunity to verify their suitability to be expanded in vitro as oocyte like cells (OLCs). Here, we describe in very preliminary experiments the consistency of an OSC population from a single cryopreserved ovarian cortex after thawing as well as both their viability and their suitability to be further explored in their property to differentiate in OLCs, thus reinforcing interest in stemness studies in the treatment of female CTRI.

Age-Dependent in vitro Maturation Efficacy of Human Oocytes - Is There an Optimal Age?

In vitro maturation of oocytes from antral follicles seen during tissue harvesting is a fertility preservation technique with potential advantages over ovarian tissue cryopreservation (OTC), as mature frozen and later thawed oocyte used for fertilization poses decreased risk of malignant cells re-seeding, as compared to ovarian tissue implantation. We previously demonstrated that in vitro maturation (IVM) performed following OTC in fertility preservation patients, even in pre-menarche girls, yields a fair amount of oocytes available for IVM and freezing for future use. We conducted a retrospective cohort study, evaluating IVM outcomes in chemotherapy naïve patients referred for fertility preservation by OTC that had oocyte collected from the medium with attempted IVM. A total of 133 chemotherapy naïve patients aged 1-35 years were included in the study. The primary outcome was IVM rate in the different age groups - pre-menarche (1-5 and ≥6 years), post-menarche (menarche-17 years), young adults (18-24 years) and adults (25-29 and 30-35 years). We demonstrate a gradual increase in mean IVM rate in the age groups from 1 to 25 years [4.6% (1-5 years), 23.8% (6 years to menarche), and 28.4% (menarche to 17 years)], with a peak of 38.3% in the 18-24 years group, followed by a decrease in the 25-29 years group (19.3%), down to a very low IVM rate (8.9%) in the 30-35 years group. A significant difference in IVM rates was noted between the age extremes - the very young (1-5 years) and the oldest (30-35 years) groups, as compared with the 18-24-year group (p < 0.001). Importantly, number of oocytes matured, percent of patients with matured oocytes, and overall maturation rate differed significantly (p < 0.001). Our finding of extremely low success rates in those very young (under 6 years) and older (≥30 years) patients suggests that oocytes retrieved during OTC prior to chemotherapy have an optimal window of age that shows higher success rates, suggesting that oocytes may have an inherent tendency toward better maturation in those age groups.

Harvesting, processing, and evaluation of in vitro-manipulated equine preantral follicles: A review

The mammalian ovary is responsible for essential stages of folliculogenesis and hormonal production, regulating the female physiological functions during the menstrual/estrous cycles. The mare has been considered an attractive model for comparative studies due to the striking similarities shared with women regarding in vivo and in vitro folliculogenesis. The ovarian follicular population in horses contains a large number of oocytes enclosed in preantral follicles that are yet to be explored. Therefore, the in vitro manipulation of equine preantral follicles aims to avoid the process of atresia and promote the development of follicles with competent oocytes. In this regard, after ovarian tissue harvesting, the use of appropriate processing techniques, as well as suitable approaches to evaluating equine preantral follicles and ovarian tissue, are necessary. Although high-quality equine ovarian tissue can be obtained from several sources, some critical aspects, such as the age of the animals, ovarian cyclicity, reproductive phase, and the types of ovarian structures, should be considered. Therefore, this review will focus on providing an update on the most current advances concerning the critical factors able to influence equine preantral follicle quality and quantity. Also, the in vivo strategies used to harvest equine ovarian tissue, the approaches to manipulating ovarian tissue post-harvesting, the techniques for processing ovarian tissue, and the classical approaches used to evaluate preantral follicles will be discussed.

Fertility Preservation for Pediatric and Adolescent Patients With Cancer: Medical and Ethical Considerations

Many cancers presenting in children and adolescents are curable with surgery, chemotherapy, and/or radiotherapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of gonad removal, damage to germ cells as a result of adjuvant therapy, or damage to the pituitary and hypothalamus or uterus as a result of irradiation. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonadal axis. Simultaneously, advances in assisted reproductive technology have led to new possibilities for the prevention and treatment of infertility. This clinical report reviews the medical aspects and ethical considerations that arise when considering fertility preservation in pediatric and adolescent patients with cancer.

In vitro maturation rates in young premenarche patients

OBJECTIVE

To evaluate in vitro maturation (IVM) efficacy and oocyte retrieval rates after ovarian tissue cryopreservation in young premenarche girls facing chemo- and radiotherapy.

DESIGN

A retrospective cohort study.

SETTING

University-affiliated tertiary medical center.

PATIENT(S)

A total of 84 chemotherapy-naïve patients ages 0-18 years referred for fertility preservation between 2004 and 2017: 33 premenarche and 51 postmenarche patients.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

IVM in the pre- and postmenarche groups and in the subgroups of very young (up to age 5 years) and older (5-10 years) premenarche girls.

RESULTS

The number of oocytes retrieved did not significantly differ between the postmenarche and premenarche groups (10.8 ± 8.5 and 8.1 ± 6.8, respectively). However, the overall IVM rate was significantly higher in the postmenarche group (28.2% vs. 15.5%, respectively; odds ratio = 0.47). A separate analysis for patients up to 5 years of age demonstrated significantly lower oocyte yield compared with the older (5-10 years) premenarche girls (4.7 ± 5.2 vs.10.3 ± 7.0 oocytes, respectively) and much lower IVM rates (4.9% and 18.2%, respectively). Correlation of age with number of retrieved and matured oocytes showed a positive significant correlation (r = 0.45 and r = 0.64, respectively).

CONCLUSIONS

IVM performed after ovarian tissue cryopreservation in premenarche girls and specifically in very young girls (4 years and younger) yields substantially decreased maturation rates compared with postmenarche patients, raising a question as to the utility of current IVM technique in this age group. Further studies are required to assess modification of the IVM technique for young girls.

A review of reported surgical techniques in fertility preservation for prepubertal and adolescent females facing a fertility threatening diagnosis or treatment

BACKGROUND

Ovarian tissue cryopreservation is increasing as a preferred option for fertility preservation for prepubertal and young adolescent females facing a fertility threatening diagnosis or treatment.

DATA SOURCES

Ovid MEDLINE and PubMed searches for terms related to ovarian tissue removal for fertility preservation revealed there is no current consensus on operative technique for surgical ovarian cortical tissue removal in adult females. Additionally, there are limited published reports of surgical approach and outcomes in the pediatric population. In total, 22 publications were reviewed for their operative approach, ovarian tissue harvesting techniques, complications and outcomes.

CONCLUSIONS

Reported operative approaches and techniques for ovarian tissue cryopreservation for pediatric and adolescent patients are variable. Further investigations into operative technique and tissue harvesting that maintains healthy ovarian follicles for transplant will help establish standard technical principles for surgery in pediatric and adolescent females undergoing fertility preservation.

Reproductive issues in patients undergoing Hematopoietic Stem Cell Transplantation: an update

In 1963 George Mathé announced to the world that he had cured a patient of leukaemia by means of a bone-marrow transplant. Since than much progress has been made and nowadays Hematopoietic Stem Cell Transplantation (HSCT) is considered the most effective treatment of numerous severe haematological diseases. Gynaecological complications in HSCT women represent a serious concern for these patients, but often underestimated by clinicians in the view of Overall Survival. The main gynaecological complications of HSCT are represented by: premature ovarian failure (POF), thrombocytopenia-associated menorrhagia, genital symptoms or sexual problems in course of chronic GVHD (cGVHD), osteoporosis, secondary solid tumours due to immunosuppressive drugs to treat cGVHD and severity of cGVHD, and fertility and pregnancy issues. In particular fertility-related issues are always more relevant for patients, whose life expectation is constantly growing up after HSCT.

Thus, taking care of a patient undergoing HSCT should primarily include gynaecological evaluation, even before conditioning regimen or chemotherapy for the underlying malignancy, as, in our opinion, it is of great importance to ensure a complete diagnostic work-up and intervention options to guarantee maximum reproductive health and a better quality of life in HSCT women.

The present review aims at describing principal features of the aforementioned gynaecological complications of HSCT, and to define, on the basis of current international literature, a specific protocol for the prevention, diagnosis, management and follow-up of gynaecological complications of both autologous and heterologous transplantation, before and after the procedure.

Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients

Cancer represents the second cause of death in prepubertal children and adolescents, although it is currently associated with an overall survival rate of 80%–85%. The annual incidence rate is 186.6 per 1 million children and adolescents aged up to 19 years. Both disease and treatment options are associated with life-altering, long-term effects that require monitoring. Infertility is a common issue, and as such, fertility preservation represents an essential part in the management of young patients with cancer who are at risk of premature gonadal failure. This review deals with the up-to-date available data on fertility risk assessment and preservation strategies that should be addressed prior to antineoplastic therapy in this vulnerable subgroup of cancer patients.

Female fertility preservation strategies: cryopreservation and ovarian tissue in vitro culture, current state of the art and future perspectives

In the present review, the main strategies of female fertility preservation are covered. Procedures of fertility preservation are necessary for women who suffer from diseases whose treatment requires the use of aggressive therapies, such as chemotherapy and radiotherapy. These kinds of therapy negatively influence the health of gametes and their progenitors. The most commonly used method of female fertility preservation is ovarian tissue cryopreservation, followed by the retransplantation of thawed tissue. Another approach to female fertility preservation that has been actively developed lately is the ovarian tissue in vitro culture. The principal methods, advantages and drawbacks of these two strategies are discussed in this article.

An approach to fertility preservation in prepubertal and postpubertal females: a critical review of current literature

Advancements in childhood cancer treatment have led to increasing survivorship, creating a greater emphasis on long-term management of patients, including quality of life and side effects from therapy; foremost of which is preserving fertility. The American Society of Clinical Oncology (ASCO) recently revised their guidelines and recommend fertility preservation options be discussed at the earliest possible opportunity for newly diagnosed patients, including methods available for children that remain investigational. Herein, we discuss the current barriers to and the impact of these guidelines for pediatric oncologists caring for young female patients, and provide some suggestions on how to approach this complicated topic.

Ovarian tissue cryopreservation in girls undergoing haematopoietic stem cell transplant: experience of a single centre

Fertility after childhood haemopoietic stem cell transplant (HSCT) is a major concern. Conditioning regimens before HSCT present a high risk (>80%) of ovarian failure. Since 2000, we have proposed cryopreservation of ovarian tissue to female patients undergoing HSCT at our centre, to preserve future fertility. After clinical and haematological evaluation, the patients underwent ovarian tissue collection by laparoscopy. The tissue was analysed by histologic examination to detect any tumour contamination and then frozen following the slow freezing procedure and cryopreserved in liquid nitrogen. From August 2000 to September 2013, 47 patients planned to receive HSCT, underwent ovarian tissue cryopreservation. The median age at diagnosis was 11.1 years and at the time of procedure it was 13 years, respectively. Twenty-four patients were not pubertal at the time of storage, whereas 23 patients had already experienced menarche. The median time between laparoscopy and HSCT was 25 days. Twenty-six out of 28 evaluable patients (93%) developed hypergonadotropic hypogonadism at a median time of 23.3 months after HSCT. One patient required autologous orthotopic transplantation that resulted in one live birth. Results show a very high rate of iatrogenic hypergonadotropic hypogonadism, highlighting the need for fertility preservation in these patients.

Alginate encapsulation supports the growth and differentiation of human primordial follicles within ovarian cortical tissue

PURPOSE

In vitro follicle growth (IVFG) is an investigational fertility preservation technique in which immature follicles are grown in culture to produce mature eggs that can ultimately be fertilized. Although progress has been made in growing primate primary and secondary follicles in vitro, it has been a relatively greater challenge to isolate and culture primordial follicles. The purpose of this study was to develop methods to grow human primordial follicles in vitro using alginate hydrogels.

METHODS

We obtained human ovarian tissue for research purposes through the National Physicians Cooperative from nationwide sites and used it to test two methods for culturing primordial follicles. First, primordial follicles were isolated from the ovarian cortex and encapsulated in alginate hydrogels. Second, 1 mm × 1 mm pieces of 500 μm-thick human ovarian cortex containing primordial follicles were encapsulated in alginate hydrogels, and survival and follicle development within the tissue was assessed for up to 6 weeks.

RESULTS

We found that human ovarian tissue could be kept at 4 °C for up to 24 h while still maintaining follicle viability. Primordial follicles isolated from ovarian tissue did not survive culture. However, encapsulation and culture of ovarian cortical pieces supported the survival, differentiation, and growth of primordial and primary follicles. Within several weeks of culture, many of the ovarian tissue pieces had formed a defined surface epithelium and contained growing preantral and antral follicles.

CONCLUSIONS

The early stages of in vitro human follicle development require the support of the native ovarian cortex.

Ovarian tissue cryopreservation and transplantation: a realistic, effective technology for fertility preservation

It is clear that ovarian tissue cryopreservation can serve a very important role in providing fertility preservation. To date, more than 30 live human births have resulted from the transplantation of cryopreserved ovarian tissue, proving the successful implementation of this technique. The ideal conditions for ovarian tissue cryopreservation have yet to be determined, indicating the crucial need for more research in this field. Nonetheless, it is recommended that ovarian tissue cryopreservation be offered as an option to women before undergoing chemotherapy treatment in instances where there is no time to delay for hormonal stimulation and oocyte retrieval.

Protection of organs other than the heart by remote ischemic conditioning

Organ or tissue dysfunction due to acute ischemia-reperfusion injury (IRI) is the leading cause of death and disability worldwide. Acute IRI induces cell injury and death in a wide variety of organs and tissues in a large number of different clinical settings. One novel therapeutic noninvasive intervention, capable of conferring multiorgan protection against acute IRI, is 'remote ischemic conditioning' (RIC). This describes an endogenous protective response to acute IRI, which is triggered by the application of one or more brief cycles of nonlethal ischemia and reperfusion to one particular organ or tissue. Originally discovered as a therapeutic strategy for protecting the myocardium against acute IRI, it has been subsequently demonstrated that RIC may confer protection against acute IRI in a number of different noncardiac organs and tissues including the kidneys, lungs, liver, skin flaps, ovaries, intestine, stomach and pancreas. The discovery that RIC can be induced noninvasively by applying the RIC stimulus to the skeletal tissue of the upper or lower limb has facilitated its application to a number of clinical settings in which organs and tissues are at high risk of acute IRI. In this article, we review the experimental studies that have investigated RIC in organs and tissues other than the heart, and we explore the therapeutic potential of RIC in preventing organ and tissue dysfunction induced by acute IRI.

Emergency IVF versus ovarian tissue cryopreservation: decision making in fertility preservation for female cancer patients

Hundreds of thousands of women in their reproductive years are diagnosed with cancer each year. As the number of female patients who survive cancer increases, the demand for effective and individualized fertility preservation options grows. Currently there are limited clinical options for fertility preservation, and the paucity of publications describing clinical experience and outcomes data has limited accessibility to these options. Decision making for patients diagnosed with cancer requires up-to-date knowledge of the efficacy and safety of available techniques. This article describes a step-by-step approach to evaluation of the cancer patient and presents an accumulation of clinical experience with challenges unique to patients with breast cancer and leukemia. Current data on reproductive outcomes of fertility preservation techniques are examined, demonstrating increasing evidence that these techniques are becoming effective enough to offer routinely to patients facing gonadotoxic cancer therapies, including those still considered to be "experimental."

Ovarian function is restored after grafting of cryopreserved immature ovary in ewes

As a result of advances in medical treatment, almost 80% of children who are diagnosed with cancer survive long-term. The adverse consequences of cancer treatments include impaired puberty and fertility. In prepubertal girls, the only therapeutic option is the cryopreservation of an ovary. To date, a dozen births have been reported after reimplantation of cryopreserved mature ovaries. To analyze ovarian function after immature grafts, we performed ovarian grafting in a ewe model. Fresh or cryopreserved ovaries from immature ewes were autografted in prepubertal or adult ewes. Cyclic hormonal activity was recovered 3 mo after grafting. Histological analysis demonstrated the presence of all follicle populations and corpora lutea not affected by cryopreservation. After 3 reproductive seasons, births had been observed in all groups, and the follicle-stimulating hormone status was under the limit, which indicated an exhausted ovary. As an indicator of potential imprinting default, the methylation status of the Igf2r gene was analyzed and did not show significant alteration compared with that of nonmanipulated animals. Taken together, these results demonstrate that immature ovarian grafting is able to restore spontaneous puberty and fertility and could guide the reimplantation of immature cortex in women.

Fertility Preservation Methods in Breast Cancer

Thanks to the recent advances in reproductive medicine, more and more young women with breast cancer may be offered the possibility of preserving their fertility. Fertility can be endangered by chemotherapy, by treatment duration and by patient's age at diagnosis. The currently available means to preserve a young woman's fertility are pharmacological protection with gonadotrophin-releasing hormone analogues during chemotherapy, and ovarian tissue or oocyte/embryo freezing before treatment. New future venues, including in vitro maturation, will improve the feasibility and efficacy of the fertility preservation methods in breast cancer patients.

Adaptation of a trap door technique for the recovery of ovarian cortical biopsies from Cebus apella (capuchin monkey)

There is a paucity of efficient cryopreservation protocols for primordial follicles enclosed in the ovarian tissue from non-human primates (NHP), in special New World primates. Our objective was to establish an optimal procedure for the recovery of ovarian biopsies from capuchin monkeys. To this end, we adapted a trap door biopsy method. Follicular density and quality of the biopsies were evaluated and ultrasound analysis was performed before and continuously after surgery to assess ovarian structure. Ovarian tissue biopsies recovered by the trap door technique allowed the successful harvesting of primordial follicles from capuchin monkeys, and no complication was recorded. The female cycle was not affected by surgery and no adherence was found thereafter. In conclusion, the adaptation of a trap door biopsy method is a safe procedure and allows recovery of healthy primordial follicles.

Multiple approaches for individualized fertility protective therapy in cancer patients

In the last decade, fertility preservation has risen as a major field of interest, creating new interactions between oncologists and gynecologists. Various options, such as cryopreservation of ovarian tissue, have been developed and are currently routinely proposed in many centers. However, many of the options remain experimental and should be offered to patients only after adequate counseling. This paper addresses the efficiency and the potential of the different fertility preservation approaches.

The approach to ovarian dermoids in adolescents and young women

BACKGROUND

Mature cystic teratomas (MCTs) are the most common ovarian neoplastic lesions found in adolescents. MCTs are usually asymptomatic and are often discovered incidentally on exam or imaging. The recurrence rate of MCTs following cystectomy is 3-4% and incidence of malignant transformation is estimated to be 0.17-2%. Given the accuracy with which MCTs can be diagnosed preoperatively studies suggest that these lesions can be treated surgically using laparoscopic techniques. The management of MCTs in the adolescent population poses unique challenges given the potential impact on sexual development and fertility.

CASE

A 17-year-old female was found to have bilateral adnexal masses consistent in appearance with MCTs on computed tomography after a motor vehicle accident. She underwent exploratory laparotomy with pathology confirming the presence of bilateral ovarian MCTs. Three years later she returned to the office with occasional abdominopelvic pain. Ultrasound revealed bilateral complex cysts suggestive of recurrent MCTs. She was expectantly managed with serial ultrasounds and after 24 months, slow but visible growth of the MCTs was confirmed. The patient is now 22 years old and asymptomatic. What is the most appropriate management?

SUMMARY AND CONCLUSION

The risks of expectant management in women like the one presented are small. This suggests that although the traditional treatment for MCTs is laparoscopic ovarian cystectomy, in children and adolescents with MCTs we should consider close follow-up without intervention to preserve ovarian function and future fertility.

Ovarian cryopreservation after laparoscopic ovariectomy using the Endo-GIA stapling device and LAPRO-clip absorbable ligating clip in a woman: a case report

INTRODUCTION

Several options are available for preserving fertility before cytotoxic treatment, including ovarian tissue cryopreservation. Most reported surgical techniques include electrocoagulation. Our hypothesis is that avoidance of electrocoagulation may decrease ovarian cortex injury during cryopreservation procedures.

CASE PRESENTATION

We report a laparoscopic technique of whole-ovary removal without coagulation using Endo-GIA forceps and clips. Laparoscopic ovariectomy was performed for cryopreservation in a 37-year-old Caucasian woman with breast cancer and for whom chemotherapy was planned. The procedure was completed quickly and without complication. This Endo-GIA procedure was of short duration with a short period of ischemia before freezing.

CONCLUSION

Laparoscopic ovariectomy using the Endo-GIA stapling device procedure without coagulation may diminish ovary injury before ovarian cryopreservation.

Ovarian tissue cryopreservation in hematologic malignancy: Ten years' experience

Cryopreservation of ovarian tissue is currently practiced in an attempt to preserve fertility before commencing potentially sterilizing chemotherapy. Clinical and laboratory guidelines are needed to standardize the procedure. Over the last 10 years ovarian tissue was stored in female patients with hematologic malignancies. Patients' records and consultation charts were evaluated, surgical and laboratory reports were revised and ovarian histology was investigated. Fifty-six patients with hematologic malignancies (age 24 +/- 5.5) had cryopreserved ovarian tissue. Thirty-three patients had Hodgkin's disease, 14 non-Hodgkin's lymphoma, 6 acute leukemia, and 3 chronic myelocytic leukemia. Harvesting of ovarian tissue was also performed following previous exposure to chemotherapy (33 patients), 13 of them shortly after the chemotherapy. Partial oophorectomy was the preferred surgical procedure. Fertility was restored with ovarian tissue transplantation in a sterilized patient and following fertility treatment in a patient with very low ovarian reserve. We recommend that indications and timing of ovarian tissue banking should be individualized. Patients previously exposed to chemotherapy can consider ovarian tissue freezing. The extent of tissue removed should take into account the large number of follicles lost and the risk of future sterilization. Tissue handling should enable further investigation of primordial follicles and identification of cancer cells.

Fertility preservation in cancer patients using stored ovarian tissue: clinical aspects

PURPOSE OF REVIEW

This review covers the medical approach and laboratory guidelines needed for fertility preservation using stored ovarian tissue in cancer patients. Indications, careful patient selection and timing are essential. Techniques for tissue harvesting and storage are evaluated. Up-to-date information on publications reporting on transplantation, recovery of endocrine function, pregnancy and delivery of healthy babies is reviewed as well as relevant data on safety measures to detect cancer cells in stored ovarian tissue.

RECENT FINDINGS

Recent literature review indicates 12 pregnancies, five deliveries of healthy babies and two ongoing pregnancies after transplantation of ovarian tissue using different methods. To increase the safety of ovarian tissue cryopreservation-reimplantation procedures, algorithm and methods to identify tumor involvement in the ovaries and detection of small numbers of cancer cells in ovarian tissue were recently reported.

SUMMARY

Cryopreservation of ovarian tissue has been practiced for over a decade in an attempt to preserve fertility before the commencement of potentially sterilizing chemotherapy. With more than a few recent reports on pregnancies and deliveries after transplantation of ovarian tissue, there will be more patients requesting the storage of ovarian tissue in order to preserve fertility prior to cancer treatments.

Human oocyte and ovarian tissue cryopreservation and its application

PURPOSE

To review the recent progress in human oocyte and ovarian tissue cryopreservation, and in the application of these two technologies for preserving female fertility of patients who are undergoing cancer treatment.

DESIGN

The literature on human oocyte and ovarian tissue freezing was searched with PubMed. The scientific background, current developments and potential future applications of these two methods were reviewed.

RESULTS

Chemotherapy and/or radiotherapy can induce premature ovarian failure in most of female cancer patients. Consequently, there has been a greater need for options to preserve the reproductive potential of these individuals. However, options are somewhat limited currently, particularly following aggressive chemotherapy and/or radiotherapy treatment protocols. In recent years, there have been considerable advances in the cryopreservation of human oocytes and ovarian tissue. For women facing upcoming cancer therapies, cryopreservation of ovarian tissue and oocytes is a technology that holds promise for banking reproductive potential for the future. Recent laboratory modifications have resulted in improved oocyte survival, oocyte fertilization, and pregnancy rates from frozen-thawed oocytes in IVF. This suggests potential for clinical application.

CONCLUSIONS

In the case of patients who are facing infertility due to cancer therapy, oocyte cryopreservation may be one of the few options available. Ovarian tissue cryopreservation can only be recommended as an experimental protocol in carefully selected patients. In ovarian tissue transplantation, more research is needed in order to enhance the revascularization process with the goal of reducing the follicular loss that takes place after tissue grafting. These technologies are still investigational, although tremendous progress has been made. The availability of such treatment will potentially lead to its demand not only from patients with cancer but also from healthy women who chose to postpone childbearing until later in life and therefore wish to retain their fertility.

Preservation of fertility in pediatric and adolescent patients with cancer

Many cancers that present in children and adolescents are curable with surgery, chemotherapy, and/or radiation therapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of either gonad removal or damage to germ cells from adjuvant therapy. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonads. Simultaneously, advances in assisted reproductive techniques have led to new possibilities for the prevention and treatment of infertility. This technical report reviews the topic of fertility preservation in pediatric and adolescent patients with cancer, including ethical considerations.

Immature cryopreserved ovary restores puberty and fertility in mice without alteration of epigenetic marks

BACKGROUND

Progress in oncology could improve survival rate in children, but would probably lead to impaired fertility and puberty. In pre-pubertal girls, the only therapeutic option is the cryopreservation of one ovary. Three births have been reported after reimplantation of cryopreserved mature ovary. Conversely, reimplantation of ovary preserved before puberty (defined as immature ovary) has never been performed in humans.

METHODOLOGY/PRINCIPAL FINDINGS

In order to analyze ovarian function, we performed transplantation using fresh or cryopreserved immature grafts in pre-pubertal or adult mice. Puberty as well as cyclic hormonal activity was restored. All follicle populations were present although a significant reduction in follicle density was observed with or without cryopreservation. Although fertility was restored, the graft is of limited life span. Because ex vivo ovary manipulation and cryopreservation procedure, the status of genomic imprinting was investigated. Methylation status of the H19 and Lit1 Imprinting Control Regions in kidney, muscle and tongue of offsprings from grafted mice does not show significant alteration when compared to those of unoperated mice.

CONCLUSIONS/SIGNIFICANCE

These results demonstrate that immature ovarian grafting can restore spontaneous puberty and fertility. However, these data suggest that follicle depletion leads to premature ovarian failure. This study addresses the very important epigenetics issue, and provides valuable information to the study of ovarian transplantation suggesting that these procedures do not perturb normal epigenetics marks. These results are highly relevant to the reimplantation question of immature cortex in women.

Ovarian tissue preservation, present and clinical perspectives

Ovarian tissue preservation and transplantation are intended for women undergoing aggressive regimens of chemical and/or radiological therapy, bone marrow transplantation or stem cell transplantation. Main indications for the procedure are neoplastic diseases and autoimmune disorders. The first live human birth after ovarian tissue autotransplantation was successfully done in 2002. Cryopreserved ovarian tissue can be autografted either orthotopically or heterotopically. Neovascularization of the implanted tissue is essential for the procedure. Vascular transplantation seems to be the best approach for avoiding follicular loss and extending the lifespan of the ovarian grafts. The procedure, regardless of whether ortho- or heterotopic, is connected with a risk of reimplantation of neoplastic cells. This can be minimized by multiple ovary biopsies, thorough histological examination and molecular genetic techniques. Introducing ovarian tissue transplantation into clinical practice requires many problems to be solved. Standardization of the freeze-thaw protocol is one of the most important issues. Solving the problem of transient graft ischemia is also essential. Eventually, the future safety of the method requires the development of efficient tests to detect the presence of neoplastic cells in the transplanted tissue.

Ovarian tissue cryostorage and grafting: an option to preserve fertility in pediatric patients with malignancies

Fertility preservation in childhood cancer has become an important area of investigation due to increasing survival rates after cancer therapy. For these patients with an increased risk of infertility and premature ovarian failure, cryopreservation of ovarian tissue is a promising tool to preserve at least part of the reproductive potential. In recent years significant improvements have been achieved in this area, and 2 live births after autografting of frozen-thawed ovarian tissue have been reported. However, further research is needed to assess the clinical effectiveness of ovarian cryopreservation, to optimize the technique, and to limit the risk of reintroducing cancer cells in the patient with the graft.

Biochemical pregnancy after fertilization of an oocyte aspirated from a heterotopic autotransplant of cryopreserved ovarian tissue: Case Report

Autotransplantation of frozen/thawed ovarian tissue in women undergoing cancer therapy has so far led to the birth of two healthy babies. In both cases, it can be discussed whether the fertilized oocyte originated from the transplant or from the native ovary. We now present a biochemical pregnancy achieved after heterotopical autotransplantation of cryopreserved ovarian cortical tissue and hence the unquestionable proof that pregnancy can occur after transplantation of cryopreserved ovarian tissue. A woman diagnosed with Hodgkin's lymphoma had ovarian tissue cryopreserved at the age of 28, before receiving chemotherapy and radiation therapy that rendered her amenorrhoeic. After complete remission, she had autotransplantation of ovarian tissue to the remaining ovary, to the right pelvic wall and to a midline subperitoneal pocket on the lower abdominal wall. The transplanted tissue resumed hormone secretion and follicles developed in all three locations. Three times during 8 months, when follicles could not be visualized in other locations, oocytes were aspirated from the subperitoneal autotransplanted tissue on the lower abdominal wall. Twice, an oocyte was retrieved, fertilized by intracytoplasmatic sperm injection (ICSI) and transferred to the woman's uterus. One of the treatments resulted in a positive pregnancy test 14 days after transfer. Clinical pregnancy, however, was not achieved. In conclusion, heterotopic autotransplantation of cryopreserved ovarian tissue can sustain follicle development. The oocytes of aspirated mature follicles are capable of fertilization after ICSI, and the resulting embryo is competent of producing hCG at detectable levels.

American Society of Clinical Oncology recommendations on fertility preservation in cancer patients

PURPOSE

To develop guidance to practicing oncologists about available fertility preservation methods and related issues in people treated for cancer.

METHODS

An expert panel and a writing committee were formed. The questions to be addressed by the guideline were determined, and a systematic review of the literature from 1987 to 2005 was performed, and included a search of online databases and consultation with content experts.

RESULTS

The literature review found many cohort studies, case series, and case reports, but relatively few randomized or definitive trials examining the success and impact of fertility preservation methods in people with cancer. Fertility preservation methods are used infrequently in people with cancer.

RECOMMENDATIONS

As part of education and informed consent before cancer therapy, oncologists should address the possibility of infertility with patients treated during their reproductive years and be prepared to discuss possible fertility preservation options or refer appropriate and interested patients to reproductive specialists. Clinician judgment should be employed in the timing of raising this issue, but discussion at the earliest possible opportunity is encouraged. Sperm and embryo cryopreservation are considered standard practice and are widely available; other available fertility preservation methods should be considered investigational and be performed in centers with the necessary expertise.

CONCLUSION

Fertility preservation is often possible in people undergoing treatment for cancer. To preserve the full range of options, fertility preservation approaches should be considered as early as possible during treatment planning.

Clinical potential and putative risks of fertility preservation in children utilizing gonadal tissue or germline stem cells

Rapid progress in the development of novel experimental strategies to generate fertile gametes from cryo-preserved ovarian and testicular tissue motivates oncologists to investigate ways in which gonadal tissue might be preserved. Childhood cancer patients remain the major pediatric group which can benefit from these techniques. Other potential candidates include patients with systemic diseases, which require gonadotoxic chemotherapy, patients undergoing gonadectomy, patients with Turner or Kleinefelter's syndrome, and boys with cryptorchid testes. This review aims to present an overview of the current state of knowledge in experimental germ stem cell transplantation in higher primates including humans, and the clinical risks and limitations related to such procedures in children. This area of research is discussed in the context of the potential future options that may become available for preserving fertility in boys and girls.

Orthotopic transplantation of LH receptor knockout and wild-type ovaries

Luteinizing hormone (LH) receptor knockout animals have an ovarian failure due to an arrest in folliculogenesis at the antral stage. As a result, the animals have an infertility phenotype. The present study was undertaken to determine whether this phenotype could be reversed by orthotopic transplantation of wild-type ovaries. The results revealed that transplanting wild-type ovaries into null animals did not result in resumption of estrus cycles. Although the number of different types of follicles increased, none progressed to ovulation. The serum hormone profiles improved, reflecting the ovarian changes. The wild-type animals with null ovaries also failed to cycle and their ovaries and serum hormone levels were more like null animals with their own ovaries. Although the lack of rescue of null ovaries placed into wild-type animals was predicted, the failure of wild-type ovaries placed in null animals was not, which could be due to chronic exposure of transplanted tissue to high circulating LH levels and also possibly due to altered internal milieu in null animals. These findings may have implications for potential future considerations of grafting normal donor ovaries into women who have an ovarian failure resulting from inactivating LH receptor mutations.

Restoration of ovarian function after orthotopic (intraovarian and periovarian) transplantation of cryopreserved ovarian tissue in a woman treated by bone marrow transplantation for sickle cell anaemia: Case report

Ovarian function after orthotopic transplantation of cryopreserved ovarian tissue has been restored in women with malignant disease. Here the techniques are adapted for a non-cancer patient. In 1999, right oophorectomy was performed in a 21 year old woman before chemotherapy, prior to bone marrow transplantation. Ovarian cortex was frozen, according to a strict protocol. After thawing, ovarian cortex was reimplanted into the ovary and in a peritoneal window close to the ovary in 2004. Four-and-a-half months after reimplantation, LH, FSH, 17beta-estradiol and progesterone levels, as well as ultrasonography, demonstrated the presence of an ovulatory cycle. After this cycle, the patient experienced two other ovulatory cycles, evidenced by FSH and 17beta-estradiol concentrations, as well as ultrasound demonstration of a follicle. Follicular development was clearly observed in both the intraovarian site (1st and 2nd cycle) and the peritoneal window (3rd cycle). Restoration of endocrine ovarian function occurred after ovarian cortical strips, biopsied and cryopreserved before chemotherapy, were reimplanted into the ovary itself and a periovarian peritoneal window.

Follow-up of ovarian function post-chemotherapy following ovarian cryopreservation and transplantation

BACKGROUND

The purpose of this study was to assess the ovarian function after treatment of a malignant disease in women who previously had cortical tissue from an entire ovary cryopreserved prior to chemotherapy, and to assess ovarian function after autotransplantation of cryopreserved ovarian tissue. All were treated with chemotherapeutic drugs with an estimated high risk of inducing ovarian failure.

METHODS

Twenty-two women with breast cancer (n = 8), Hodgkin's disease (n = 6), non-Hodgkin's (n = 2), leukaemia (n = 5) or brain tumour (n = 1) underwent a clinical examination >18 months after cryopreservation. Three patients with premature ovarian failure had ovarian tissue autotransplanted orthotopically and heterotopically. Ovarian function was assessed by ultrasonography of the remaining ovary and hormone measurements.

RESULTS

Nine of 22 women (41%) had sonographic and hormonal signs of ovarian failure with ovarian volumes <1.3 cm3, no antral follicles and high FSH levels (median 57.1 IU/l). Thirteen of the 22 women (59%) still menstruated and 10 had a seemingly normal ovarian function, with a median ovarian volume of 6.8 cm3, a median number of antral follicles of six, FSH <15 IU/l and normal estradiol levels. All three patients with autotransplanted ovarian tissue regained ovarian function as confirmed by return of menses, follicles on ultrasonography and normalized hormone levels. Two embryos were created from the crypreserved tissue after IVF.

CONCLUSIONS

Treatment with bone-marrow transplantation and/or high doses of alkylating agents led to ovarian failure in all patients. Autotransplantation of ovarian tissue led to return of ovarian function.

The role of cryopreservation for women prior to treatment of malignancy

PURPOSE OF REVIEW

The purpose of this review is to investigate recent advances in xenografting, as well as in orthotopic and heterotopic autotransplantation of human cryopreserved ovarian tissue.

RECENT FINDINGS

The first livebirth after orthotopic transplantation of cryopreserved ovarian tissue was reported recently. We discuss this case and other cases of reimplantation of cryopreserved ovarian tissue, bearing in mind that many questions remain.

SUMMARY

Finally, we report the latest developments in research on the transplantation of an intact ovary and the reimplantation of isolated follicles.

Livebirth after orthotopic transplantation of cryopreserved ovarian tissue

BACKGROUND

The lifesaving treatment endured by cancer patients leads, in many women, to early menopause and subsequent infertility. In clinical situations for which chemotherapy needs to be started, ovarian tissue cryopreservation looks to be a promising option to restore fertility. In 1997, biopsy samples of ovarian cortex were taken from a woman with stage IV Hodgkin's lymphoma and cryopreserved before chemotherapy was initiated. After her cancer treatment, the patient had premature ovarian failure.

METHODS

In 2003, after freeze-thawing, orthotopic autotransplantation of ovarian cortical tissue was done by laparoscopy.

FINDINGS

5 months after reimplantation, basal body temperature, menstrual cycles, vaginal ultrasonography, and hormone concentrations indicated recovery of regular ovulatory cycles. Laparoscopy at 5 months confirmed the ultrasonographic data and showed the presence of a follicle at the site of reimplantation, clearly situated outside the ovaries, both of which appeared atrophic. From 5 to 9 months, the patient had menstrual bleeding and development of a follicle or corpus luteum with every cycle. 11 months after reimplantation, human chorionic gonadotrophin concentrations and vaginal echography confirmed a viable intrauterine pregnancy, which has resulted in a livebirth.

INTERPRETATION

We have described a livebirth after orthotopic autotransplantation of cryopreserved ovarian tissue. Our findings suggest that cryopreservation of ovarian tissue should be offered to all young women diagnosed with cancer.

Significance of ovarian histology in the management of patients presenting a premature ovarian failure

BACKGROUND

Premature ovarian failure (POF) is a heterogeneous syndrome, possibly due to mutations of genes involved in the normal development of the ovary and/or follicles. Based essentially on animal models, these mutations are associated with various ovarian phenotypes, from a complete absence of follicles to a partial follicular maturation. The aim of the present study was to determine whether ovarian histology, compared to pelvic ultrasonography, would be helpful in identifying which patients display an impaired follicular reserve and/or growth, and in orientating the search for POF aetiology.

METHODS AND RESULTS

We studied a cohort of 61 patients suffering from POF with a normal karyotype. Their median age (range) at diagnosis was 26 years (15-39). The FSH plasma level was high, 67.0 IU/l (13-155). Estradiol and inhibin B plasma levels were low: 18.5 pmol/l (18.5-555) and 5 pg/ml (5-105) respectively. Both pelvic ultrasonography and ovarian biopsies were performed in each patient. The presence of follicles suggested at ultrasonography was confirmed at histology in 56% of the patients. Ovarian histology led to the distinction of two phenotypes: (i) small-sized ovaries, deprived of follicles; and (ii) normal-sized ovaries with partial follicular maturation. To confirm the value of ovarian biopsies, samples from 20 normal women were studied. These demonstrated that ovarian biopsy at random enables reliable assessment of follicular presence, especially when their size is <2 mm.

CONCLUSION

Ovarian histology appears to be a reliable tool in evaluating the follicular reserve, and helpful and complementary to clinical and hormonal phenotyping in orienting the search for the various genetic causes of POF syndrome.

Oocyte cryopreservation in oncological patients

The use of chemotherapy and radiotherapy in oncological patients may reduce their reproductive potential. Sperm cryopreservation has been already used in men affected by neoplastic disease. Oocyte cryopreservation might be an important solution for these patients at risk of losing ovarian function. A program of oocyte cryopreservation for oncological patients is also present in our center. From June 1996 to January 2000, 18 patients awaiting chemotherapy and radiotherapy for neoplastic disease were included in our oocyte cryopreservation program. Our experience documents that oocyte storage may be a concrete and pragmatic alternative for oncological patients. The duration of oocyte storage does not seem to interfere with oocyte survival as pregnancies occurred even after several years of gamete cryopreservation in liquid nitrogen.

Angiogenesis in ectopic ovarian xenotransplantation: Multiparameter characterization of the neovasculature by dynamic contrast-enhanced MRI

It has been suggested that ovarian cryopreservation and xenotransplantation can be used to preserve oocytes from damage during anticancer treatments. The main obstacle to subsequent ovarian grafting is loss of oocytes due to impaired perfusion. The aim of this study was to characterize angiogenic events following ovary xenotransplantation. Rat ovaries were transplanted into or onto the muscle of immunocompromised CD1-nude mice. Ovariectomy (OVX) of host mice prior to transplantation supported the resumption of follicular development, as manifested by the prevalence of antral follicles and corpora lutea. Two days after transplantation, the grafts were devoid of blood supply. Functional vessels within the graft were detected by MRI and histology from day 7 and on. By 2-3 weeks, both blood volume fraction and permeability in the graft, as measured with the use of albumin-based MR contrast material, were significantly elevated relative to the adjacent muscle. Extravasation of contrast material from the graft neovasculature was followed by interstitial convection in the muscle surrounding the graft, and draining toward the proximal popliteal lymph node. Development of the vasculature was monitored noninvasively, providing a time scale for revascularization and recovery of ovarian function following xenotransplantation of ovarian grafts.