Advancements in fertility preservation strategies for pediatric male cancer patients: a review of cryopreservation and transplantation of immature testicular tissue

Recently, there has been increasing emphasis on the gonadotoxic effects of cancer therapy in prepubertal boys. As advances in oncology treatments continue to enhance survival rates for prepubertal boys, the need for preserving their functional testicular tissue for future reproduction becomes increasingly vital. Therefore, we explore cutting-edge strategies in fertility preservation, focusing on the cryopreservation and transplantation of immature testicular tissue as a promising avenue. The evolution of cryopreservation techniques, from controlled slow freezing to more recent advancements in vitrification, with an assessment of their strengths and limitations was exhibited. Detailed analysis of cryoprotectants, exposure times, and protocols underscores their impact on immature testicular tissue viability. In transplantation strategy, studies have revealed that the scrotal site may be the preferred location for immature testicular tissue grafting in both autotransplantation and xenotransplantation scenarios. Moreover, the use of biomaterial scaffolds during graft transplantation has shown promise in enhancing graft survival and stimulating spermatogenesis in immature testicular tissue over time. This comprehensive review provides a holistic approach to optimize the preservation strategy of human immature testicular tissue in the future.

Outpatient hysteroscopy impact on subsequent assisted reproductive technology: a systematic review and meta-analysis in patients with normal transvaginal sonography or hysterosalpingography images

BACKGROUND

Standard management for intrauterine lesions typically involves initial imaging followed by operative hysteroscopy for suspicious findings. However, the efficacy of routine outpatient hysteroscopy in women undergoing assisted reproductive technology (ART) remains uncertain due to a lack of decisive high-quality evidence. This study aimed to determine whether outpatient hysteroscopy is beneficial for infertile women who have unremarkable imaging results prior to undergoing ART.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines, incorporating data up to May 31, 2023, from databases such as PubMed, Embase, and the Cochrane Library. The primary outcome assessed was the live birth rate, with secondary outcomes including chemical pregnancy, clinical pregnancy rates, and miscarriage rates. Statistical analysis involved calculating risk ratios with 95% confidence intervals and assessing heterogeneity with the I2 statistic.

RESULTS

The analysis included ten randomized control trials. Receiving outpatient hysteroscopy before undergoing ART was associated with increased live birth (RR 1.22, 95% CI 1.03-1.45, I2 61%) and clinical pregnancy rate (RR 1.27 95% CI 1.10-1.47, I2 53%). Miscarriage rates did not differ significantly (RR 1.25, CI 0.90-1.76, I2 50%). Subgroup analyses did not show a significant difference in clinical pregnancy rates when comparing normal versus abnormal hysteroscopic findings (RR 1.01, CI 0.78-1.32, I2 38%). We analyzed data using both intention-to-treat and per-protocol approaches, and our findings were consistent across both analytical methods.

CONCLUSIONS

Office hysteroscopy may enhance live birth and clinical pregnancy rates in infertile women undergoing ART, even when previous imaging studies show no apparent intrauterine lesions. Treating lesions not detected by imaging may improve ART outcomes. The most commonly missed lesions are endometrial polyps, submucosal fibroids and endometritis, which are all known to affect ART success rates. The findings suggested that hysteroscopy, given its diagnostic accuracy and patient tolerability, should be considered in the management of infertility.

DATABASE REGISTRATION

The study was registered in the International Prospective Register of Systemic Review database (CRD42023476403).

Maximize the safety and efficacy of fertility preservation by random start/dual ovarian stimulation for early breast cancer patients

OBJECTIVE

What is the more efficient and safer protocol during controlled ovarian hyperstimulation (COH) for early-stage breast cancer patients seeking emergency fertility preservation before adjuvant chemo/radiotherapy?

MATERIALS AND METHODS

This retrospective, case-series study involved two early-stage (Ia) breast cancer patients that requested for fertility preservation within 3 weeks. Random start/dual stimulation protocols with aromatase inhibitor (AI) were used to maximize oocyte yield and suppress serum estradiol (E2) level.

RESULTS

E2 levels on trigger day during dual COH were between 112.0 and 407.0 pg/mL. Duration of COH could be shortened to only 17 days, and up to 41 oocytes were successfully retrieved with two retrievals.

CONCLUSION

This remarkable efficient and safe protocol involves the combination of random start/dual stimulation with step-up AI dosage beforehand which not only maximize oocyte yield within the shortest possible timeframe, but also to maintain the low level of E2 to avoid over-stimulating estrogen-sensitive cancer cells and to decrease the risk of developing ovarian hyperstimulation syndrome (OHSS).

Immature Testicular Tissue Engineered from Weaned Mice to Adults for Prepubertal Fertility Preservation—An In Vivo Translational Study

Male pediatric survivors of cancers and bone marrow transplantation often require adjuvant chemoradiation therapy that may be gonadotoxic. The optimal methods to preserve fertility in these prepubertal males are still under investigation. This manuscript presents an in vivo experiment which involved transplantation of immature testicular tissues (ITT) from transgenic donor, to wild-type recipient mice. Donors and recipients were age-mismatched (from 20-week-old donors to 3-week-old recipients, and vice versa) and the transplantation sites involved the abdomen, skin of the head, back muscle, and scrotum. The application of poly-l-lactic acid (PLLA) scaffold was also evaluated in age-matched donors and recipients (both 3-weeks-old). To quantitively evaluate the process of spermatogenesis after ITT transplantation and scaffold application, bioluminescence imaging (BLI) was employed. Our result showed that ITT from 3-week-old mice had the best potential for spermatogenesis, and the optimal transplantation site was in the scrotum. Spermatogenesis was observed in recipient mice up to 51 days after transplantation, and up to the 85th day if scaffold was used. The peak of spermatogenesis occurred between the 42nd and 55th days in the scaffold group. This animal model may serve as a framework for further studies in prepubertal male fertility preservation.

The debated role of bariatric surgery in improving in-vitro fertilization outcomes in morbidly-obese infertile women-a case report and brief overview

OBJECTIVE

Obesity has a negative impact on in-vitro fertilization (IVF) outcomes, and obese women who plan IVF treatments are often encouraged to pursue weight reduction. Bariatric surgery is an effective strategy for the treatment of morbidly obese women. The current case report is to investigate the impact of bariatric surgery on IVF outcome in a morbidly obese woman with subfertility.

CASE REPORT

A 37-year-old, morbidly obese woman with subfertility was indicated for IVF treatment. Due to her high body mass index (47.9 kg/m²), she was advised to lose weight; initial failure at conservative measures of weight loss prompted her to undergo bariatric surgery, combined with post-operative lifestyle change, prior to receiving IVF treatment. The woman successfully conceived at the second cycle and delivered twins by cesarean section smoothly at 36 + 3/7 weeks of gestation. Both twins have normal development up to two years of age.

CONCLUSIONS

Weight reduction mediated by bariatric surgery in subfertile and morbidly obese women can be considered before IVF treatment.

P–445 Successful live birth after repeated high-dose radiotherapy to the uterus

Study question

It has been established that radiotherapy can increase the risk of adverse pregnancy outcomes. However, there is currently no consensus on the effective sterilizing dose for adulthood uterine radiotherapy.

Summary answer

Uterine fertility preservation methods should be guided by the age of the patient receiving radiotherapy and the actual dose of radiation exposure to the uterus.

What is known already

Many experts have suggested that a high dose of radiation to the uterus is a reason to counsel patients against future pregnancy. There are major limitations to the current literature regarding off-target radiation damage to the uterus. One study reported a relative risk of 9.1 for stillbirth and neonatal death after 10 Gy doses.

Study design, size, duration

Case report and review of the literature before December 2020

Participants/materials, setting, methods

A case report of a 36-year-old female with three cancers and received repeated high-dose radiotherapy of 66 Gy and 50 Gy to the pelvis. We used a dose-volume histogram, the most widely used tool to calculate the radiation distribution within a volume of interest of the patient during radiotherapy. We determined that her uterus may have received the highest uterine radiation dosage for full-term live birth in current literature.

Main results and the role of chance

Due to iatrogenic ovarian failure, she could only use donor eggs. After endometrium preparation for 18 days, the endometrium reached 8.7 mm with a triple-line appearance. We transferred two cleavage-staged embryos and one of them implanted successfully. The course of the pregnancy was uneventful. Finally, the patient gave birth to a healthy baby via Cesarean section at 38 5/7 weeks of gestation.

Limitations, reasons for caution

It should be noted that the success of our case may not apply to all patients with cancer after they have received RT. We should inform patients about the increased risk of preterm birth, low birth weight infants, uterine rupture, and neonatal death.

Wider implications of the findings: The patient’s age and the dose of RT exposure to the uterus are important factors for the prognosis of a future pregnancy. More well-designed studies will be needed to allow future standard guidelines for uterine fertility preservation.

Trial registration number

TMU-JIRB N20204149

ART outcomes following ovarian stimulation in the luteal phase:a systematic review and meta-analysis

PURPOSE

This study aimed to evaluate the impact of luteal phase ovarian stimulation (LPS) on the outcomes of assisted reproductive technology (ART) for infertile couples and patients desiring non-urgent egg cryopreservation.

METHODS

We included all studies reported patients who received LPS and that used follicular phase ovarian stimulation (FPS) as a comparison group until January 2021. Prior meta-analysis regarding the outcomes of LPS in double stimulation and fertility preservation have already been published, so these studies were excluded. Risk of Bias in Non-randomized Studies of Interventions was used to assess the study quality. The study was registered in the International Prospective Register of Systematic Reviews database (CRD42020183946).

RESULTS

Twelve studies with a total of 4433 patients were included. The regimen employed can be categorized into two groups, but there is currently no evidence to support one over the other. After we excluded the largest study, the clinical pregnancy rate and live birth rate were similar after FPS and LPS. There were significantly more stimulation days and total gonadotropins used in the LPS group. After subgroup analysis, we found that poor responders received significantly more cumulus oocyte complexes (+0.64) in the LPS group.

CONCLUSION

Current evidence indicates that patients in the LPS group could achieve pregnancy outcomes non-inferior to those in the FPS group. Because of current debate over freeze-all policy and the limited data about live birth rate, the universal use of LPS is considered controversial. In the future, more well-designed studies are necessary to investigate the indications for LPS and its cost-effectiveness.

Differentiation of clinical patterns and survival outcomes of hepatocellular carcinoma on hepatitis B and nonalcoholic fatty liver disease

BACKGROUND

The main etiologies of hepatocellular carcinoma (HCC) were often hepatitis B virus (HBV) or C and alcohol, rarely autoimmune and biliary diseases. Nonalcoholic fatty liver disease (NAFLD) has been an emerging role that could lead to chronic liver disease, nonalcoholic steatohepatitis, cirrhosis, and eventually HCC in recent years. The aim of our study is to investigate and compare the clinical features of HCC in patients with NAFLD and HBV, including age, gender, cirrhosis, liver function tests, largest tumor size, and cancer stage at the time of diagnosis. The survival outcome was compared between the two groups and the significant predictors of mortality were also analyzed in all patients with HCC.

METHODS

Most patients with HCC were recruited from the database of Cancer Registries in Taipei City Hospital, Ren-Ai Branch, from 2011 to 2017; and the other patients consecutively from the HCC multidisciplinary conference between January 2018 and December 2019. NAFLD was defined as nonviral hepatitis B (negative HBsAg and either positive anti-HBs or negative anti-HBc), nonviral hepatitis C (negative antihepatitis C virus [HCV]), nonalcoholic (alcohol consumption of <30 g/d for men and <20 g/d for women) liver disease, or present or past histological or ultrasonographic evidence of fatty liver. Totally, 23 NAFLD-related and 156 HBV-related HCC patients were enrolled in our study for further analysis.

RESULTS

NAFLD-related HCC patients were significantly older (median age: 70.0 [61.0-79.0] years vs. 63.0 [56.0-72.0] years, p = 0.012) and heavier (median body mass index [BMI]: 26.6 [24.2-30] kg/m2 vs. 24.8 [22.0-27.1] kg/m2, p = 0.044) than those with HBV-related HCC. They were also more susceptible to diabetes mellitus (DM), and 60.9% (14 of 23) of them had this comorbidity compared with 29.5% (46 of 156) of those with HBV-related HCC (p = 0.003). Only 34.8% (8 of 23) and 71.2% (111 of 156) of patients with NAFLD- and HBV-related HCC were cirrhotic, respectively (p = 0.001). However, gender, tobacco use, international normalized ratio, albumin, creatinine, and cholesterol levels were not significantly different between the two groups. Tumor characteristics such as the Barcelona clinic liver cancer stage, largest tumor size, tumor number, extrahepatic metastasis, and treatment modalities had no significant difference between such groups.According to the Kaplan-Meier method analysis, the overall survival was not significantly different between these two patient groups (log-rank test, p = 0.101). To evaluate which patient group would lead to poor prognosis, we analyzed the survival of all patients through multivariate Cox proportional hazard regression after controlling other factors that may influence the hazard ratio. The analysis revealed that NAFLD and HBV infection as the cause of HCC are not risk factors of poor prognosis.

CONCLUSION

In conclusion, our study showed NAFLD-related HCC patients were older, heavier, and more had DM than HBV-related. In addition, more NAFLD-related HCC patients were noncirrhotic than HBV-related. The survival rate was similar between NAFLD and HBV-related HCC patients.

Successful live birth after repeated high-dose radiotherapy to the uterus

RESEARCH QUESTION

It has been established that radiotherapy can increase the risk of adverse pregnancy outcomes. However, there is currently no consensus on the effective sterilizing dose of adulthood uterine radiotherapy.

DESIGN

This is a case report of a 36-year-old women with three different cancer types who received repeated high-dose radiotherapy of 66 Gy and 50 Gy to the pelvis. The study used a dose-volume histogram, the most widely used tool to calculate the radiation distribution within a volume of interest in a patient during radiotherapy. It was determined that the current patient's uterus might have received the highest uterine radiation dosage for full-term live birth that has been reported in the current literature.

RESULTS

Due to iatrogenic ovarian failure, the woman was only able to use donor eggs. After preparation of the endometrium for 18 days, it had reached 8.7 mm in thickness with a triple-line appearance. Two cleavage-stage embryos were transferred, one of which implanted successfully. The course of the pregnancy was uneventful. Finally, the patient gave birth to a healthy baby via Caesarean section at 38⁺⁵ weeks of gestation.

CONCLUSIONS

The uterus may be more resistant to radiotherapy than previously understood. Uterine fertility preservation methods should be guided by the age of the patient receiving radiotherapy and the actual dose of radiation exposure of the uterus. Future studies should implement a dose-volume histogram to calculate the radiation exposure of the reproductive organs.

Serum hepatitis B surface antigen correlates with fibrosis and necroinflammation: A multicentre perspective in China

The kinetics of serum hepatitis B surface antigen (HBsAg) during the natural history of hepatitis B virus (HBV) infection has been studied, but the factors affecting them remain unclear. We aimed to investigate the factors affecting HBsAg titres, using data from multicentre, large-sized clinical trials in China. The baseline data of 1795 patients in 3 multicentre trials were studied, and the patients were classified into 3 groups: hepatitis B early antigen (HBeAg)-positive chronic HBV infection (n = 588), HBeAg-positive chronic hepatitis B (n = 596), and HBeAg-negative chronic hepatitis B (n = 611). HBsAg titres in the different phases were compared, and multiple linear progression analyses were performed to investigate the implicated factors. HBsAg titres varied significantly in different phases (P = .000), with the highest (4.60 log10 IU/mL [10%-90% confidence interval: 3.52 log10 IU/mL-4.99 log10 IU/mL]) in patients with HBeAg-positive chronic HBV infection. In all phases, age and HBV DNA were correlated with serum HBsAg level. In HBeAg-positive chronic hepatitis B patients, a negative correlation between HBsAg titres and fibrosis stage was observed. Alanine amonitransferase or necroinflammatory activity was also correlated with HBsAg titres in HBeAg-negative chronic hepatitis B patients. In conclusion, decreased HBsAg titres may be associated with advancing fibrosis in HBeAg-positive chronic hepatitis B patients or increased necroinflammation in those with HBeAg-negative chronic hepatitis B. Our findings may help clinicians better understand the kinetics of HBsAg and provide useful insights into the management of this disease.

Postmenopausal labial agglutination mimics urinary incontinence and hidden vaginal lesion

Labial agglutination has rarely been reported in postmenopausal women and its treatment has been based on experience with prepubertal girls. We describe an 83-year-old woman who presented with labial agglutination and severe urinary incontinence. She had been treated intermittently with a topical estrogen cream for 3 years, but her symptoms persisted. Surgery was performed and her urinary incontinence was instantly resolved. Incidental vaginal low-grade squamous intraepithelial neoplasia was noted. Later, the lesion progressed and was confirmed to be condyloma acuminata. No recurrence of labial agglutination was noted 3 months after the surgery. We emphasize that surgical intervention should be the first consideration for labial agglutination with urinary symptoms in postmenopausal women. This case also highlights that surgery can not only resolve patients' symptoms early, but can also enable access to the region for essential gynecologic procedures.

Urethral Diverticulum in Young Nulliparous with Unusual Presentation

CASE

We highlight a case of chronic skenitis leading to the formation of Urethral diverticulum. A young nulliparous woman presented with dysuria, intermittent hematuria and a 3 cm cystic swelling adjacent to the left distal urethra. Aspiration of the cyst was done initially. Excisional biopsy was followed when it recurred. Urethral diverticulum was revealed when the excisional operation traced up to left distal urethral wall. The cystic swelling urethral diverticulum was completely enucleated.

OUTCOME

The pathology report showed fibrous tissue with cystic spaces lined by squamous epithelium with inflammation, which was consistent with a urethral diverticulum.

CONCLUSION

The presenting symptoms and signs of female urethral diverticulum are often diverse and easily overlooked, we have to keep in mind that cases with unusual age, location and presentation can also exist.

[Effect of shengmaisan on serum lipid peroxidation in acute viral myocarditis]

The effect of Shengmaisan (SMS) on 62 acute viral myocarditis patients and its peroxidation damage was studied. The results revealed that the activities of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) in blood were decreased and the content of malondialdehyde (MDA) in plasma was increased in acute viral myocarditis patients in comparison with the healthy controls (P < 0.001). 62 acute viral myocarditis patients were divided into two groups: SMS group and placebo group. After treatment, both SOD and GSH-Px activities were increased and the level of MDA decreased (P < 0.001) in SMS group, while those in placebo group were not changed (P < 0.05). The results suggested that the myocardial damage of viral myocarditis is closely related with lipid peroxidation SMS acts as an effective free radical scavenger and anti-lipid peroxidation drug. SMS could prevent the damage of myocardia and might be taken as one of the effective therapeutic methods in treatment of acute viral myocarditis.

[Effect of sheng mai san on lipid peroxidation in acute myocardial infarction patients]

The effect of Sheng Mai San (SMS) on the coronary heart disease (CHD) patients (30 angina pectoris and 68 acute myocardial infarction, AMI) and its peroxidation damage was studied. It was shown that the activities of superoxide dismutase (SOD) and glutathione peroxidase (GSH-Px) in blood were decreased and the content of malondialdehyde (MDA) in plasma was increased in CHD patients in comparison with the healthy controls (P < 0.001). When SMS was orally administered in 38 AMI patients, both SOD and GSH-Px activities were increased and the level of MDA decreased (P < 0.05), and these changes were even more significant when SMS was further ingested for another two weeks (P < 0.001). At the same time, it was found that the changes of SOD, GSH-Px and MDA in the control group (30 AMI patients not taking SMS) were not significantly different (P > 0.05). It could be assumed that the pathogenesis of CHD is associated with free radical (FR) triggering a chain reaction of the lipid peroxidation, and that SMS is acting as an effective free radical scavenger, which would ameliorate the lipid peroxidation damage. Thus, SMS could be administered in the prevention and the treatment of CHD.