Préservation de la fertilité en cas de traitement stérilisant

Ethical, legal, social, and policy issues of ovarian tissue cryopreservation in prepubertal girls: a critical interpretive review

PURPOSE

Despite the increasing number of childhood cancer survivors, significant advances in ovarian tissue cryopreservation (OTC) technique and medical societies' recommendations, fertility preservation (FP) and FP discussions are not always offered as a standard of care in the pediatric context. The aim of this literature review is to understand what ethical, legal, social, and policy issues may influence the provision of FP by OTC in prepubertal girls with cancer.

METHODS

A critical interpretive review of peer-reviewed papers published between 2000 and January 2023 was conducted, guided by the McDougall's version of the critical interpretive synthesis (Dixon-Woods), to capture recurring concepts, principles, and arguments regarding FP by OTC for prepubertal girls.

RESULTS

Of 931 potentially relevant papers, 162 were included in our analysis. Data were grouped into seven thematic categories: (1) risks of the procedure, (2) unique decision-making issues in pediatric oncofertility, (3) counseling, (4) cultural and cost issues, and (5) disposition of cryopreserved reproductive tissue.

CONCLUSION

This first literature review focusing on ethical, legal, social, and policy issues surrounding OTC in prepubertal girls highlights concerns in the oncofertility debate. Although OTC is no longer experimental as of December 2019, these issues could limit its availability and the child's future reproductive autonomy. This review concludes that specific actions must be provided to enable the offer of FP, such as supporting families' decision-making in this unique and complex context, and providing pediatric patients universal and full access to free or highly subsidized OTC.

[Use of conventional assisted reproductive technologies and history of cancer: what are the results?]

Therapeutic advances in oncology have improved the prognosis for long-term survival of children and young adults. As well as other couples or because of adverse side effects of cancer treatments on reproductive function, some cancer survivors will therefore be brought to use assisted reproductive technologies (intrauterine inseminations, in vitro fertilization, intracytoplasmic sperm injection, oocyte or sperm donation…). The purpose of this review is to summarize available scientific datas regarding success rate of assisted reproductive technologies in cancer survivors.

[Ovarian cryopreservation: evaluation of two surgical procedures]

OBJECTIVES

To evaluate various surgical techniques for partial oophorectomy cryopreservation. To evaluate the consequences of prior exposure to cytotoxic therapy on the quality of the ovary removed.

PATIENTS AND METHODS

Single center retrospective observational study over 4 years of women who had ovarian cryopreservation surgery for chemotherapy or radiotherapy which were at high risk of premature ovarian failure. Several techniques have been proposed: partial oophorectomy with clamping of the vascular gonadal pedicle (indirect tissue sample) without clamping (direct tissue sample) and partial oophorectomy with an automatic stapler. Ovarian tissue was immediately prepared for cryopreservation in the operating theatre. The whole sample was divided into small slices. For each ovary, a count of small slices was made. Additionally, one slice was examined to determine the presence of primordial follicles.

RESULTS

Ovary was successfully removed and cryopreserved in 13 patients. Two bleeding events occurred with the direct technique, without consequences for patients. The number of fragments obtained between indirect and direct techniques was respectively 19 vs 15, P=0.18; the number of primordial follicles was 38 vs 36, P=0.87. The automatic stapler consumed too much ovarian tissue to be interesting. There were fewer fragments, 15 vs 20, P<0.05 and primordial follicles, 35 vs 40, P=0.65, after a first cycle of chemotherapy.

DISCUSSION AND CONCLUSION

The vascular clamping technique is safer but with no difference in the quality of the sample tissue. One cycle of chemotherapy has a pejorative impact on the quality of the sample tissue.

[Oocyte vitrification and its impact on the clinical practice of assisted reproduction]

Oocyte vitrification is a new technique in cryobiology that will lead to a number of improvements in assisted reproduction practices, oocyte donation and the preservation of female fertility. Professionals already versed in the techniques of micromanipulation will be able to master the new procedures, which should not be delegated to unqualified staff. When adopted by clinical units, oocyte vitrification will require changes in laboratory and administrative organization. The technique will also modify the ethical outlines of reproductive biology. France today is running behind in the application of this major development in cryobiology. The reasons are many and have to do with a long waiting period for authorization from national health authorities, a lack of material and human resources and a foreseeable shake-up in the nationally established egg donation program. However, recently a new law of bioethics has recognized the breakthrough that this new technique represents by allowing couples covered by the French national health care program for Assisted Reproductive Technologies (ART) to choose oocyte vitrification as an option.

[Female fertility preservation: feasibility of emergency IVF for embryo freezing]

With the improvement of the anticancerous treatments, the preservation of the feminine fertility before gonadotoxic treatment tends at present to stand out as a legal obligation, with a duty of information to patients. When emergency IVF can be performed, the cryopreservation of embryos is the best mastered method which offers most chances to patients to obtain a pregnancy after cancer remission thanks to the transfer of frozen embryos. This article proposes an overview about the indications, the feasibility and the ethical and practical limitations of IVF emergency for embryo freezing before gonadotoxic anticancerous treatment.