Current status of fertility preservation in a Spanish tertiary public hospital: multidisciplinary approach and experience in over 1500 patients

PURPOSE

Currently, 15% of gynaecological and 9% of haematological malignancies are diagnosed before the age of 40. The increased survival rates of cancer patients who are candidates for gonadotoxic treatments, the delay in childbearing to older ages, and the optimization of in vitro fertilisation techniques have all contributed to an increased interest in fertility preservation (FP) treatments. This study reviews the experience of the Fertility Preservation Programme (FPP) of a tertiary public hospital with a multidisciplinary approach.

METHODS

This retrospective study included all the available (FP) treatments, performed in patients of childbearing age between 2006 and 2022.

RESULTS

1556 patients were referred to the FPP: 332 oocyte vitrification cycles, 115 ovarian cortex cryopreservation with 11 orthotopic autotransplantations, 175 gonadotropin-releasing hormone (GnRH) agonist treatments, 109 fertility-sparing treatments for gynaecological cancer, and 576 sperm cryopreservation were performed. Malignancy was the main indication for FP (the main indications being breast cancer in women and haematological malignancies in men), although non-oncological pathologies, such as endometriosis and autoimmune diseases, have increased in recent years. Currently, the most widely used FP technique is oocyte vitrification, the increase of which has been associated with a decrease in the use of cortex CP and GnRH agonists.

CONCLUSIONS

The increase in FP treatment reflects the implementation of reproductive counselling in oncology programmes. A multidisciplinary approach in a tertiary public hospital allows individualised FP treatment for each patient. In recent years, there has been a change in trend with the introduction of new indications for FP and a change in techniques due to their optimisation.

Comparison between slow freezing and vitrification of ovarian tissue cryopreservation in assigned female at birth transgender people receiving testosterone therapy: data on histological and viability parameters

PURPOSE

The use of fertility preservation (FP) techniques has significantly increased in recent years in the assigned female at birth (AFAB) transgender population. Oocyte cryopreservation is the established method for FP, but ovarian tissue cryopreservation may be considered an alternative option, especially during gender-affirming surgery (GAS). The slow freezing (SF) cryopreservation technique is the standard method for human ovarian tissue, but recently, several studies have shown good results with the vitrification (VT) technique. The objective of this study was to compare the effectiveness of VT and SF techniques in ovarian tissue from AFAB transgender people.

METHODS

This was a prospective study including 18 AFAB transgender people after GAS. Ovarian tissue pieces from each ovary were cryopreserved by SF and VT and compared with fresh tissue. Study by light microscopy (LM) assessed follicular morphology and density. The percentage of surviving and degenerated follicles was studied with the tissue viability test. Oocytes, granulosa cells and stroma were analysed separately by transmission electron microscopy.

RESULTS

The VT technique preserves follicle and stromal tissue as well as the SF method, but with some differences. Evaluation by LM showed better follicle preservation with VT, but the ultrastructural study showed the presence of minor damage with both techniques compared to fresh tissue.

CONCLUSION

Both cryopreservation techniques are accurate for maintaining the follicular population and stromal tissue. Further studies are needed to determine the impact of VT on ovarian tissue and the subsequent follicular activation mechanisms in AFAB ovarian tissue.

Drug-free in-vitro activation of follicles and fresh tissue autotransplantation as a therapeutic option in patients with primary ovarian insufficiency

RESEARCH QUESTION

Could in-vitro action of follicles and fresh tissue autotransplantation without tissue culture (drug-free IVA) be useful in patients with primary ovarian insufficiency (POI)?

DESIGN

Prospective observational cohort study in a tertiary university hospital. Drug-Free IVA was carried out in 14 women with POI with a median age of 33 years (29-36 years), median length of amenorrhoea of 1.5 years (1-11 years), median FSH levels 69.2 mIU/ml (36.9-82.8 mIU/ml) and anti-Müllerian hormone of 0.02 ng/ml (0.01-0.1 ng/ml). The surgical procedure included laparoscopic removal of ovarian cortex, fragmentation of tissue and autografting. Human menopausal gonadotrophin (HMG) was started immediately after surgery.

RESULTS

Follicle development was detected in seven out of the 14 patients, and five women achieved successful oocyte retrieval. In six women, HCG was administered in 10 cycles. Six embryo transfers were carried out in five women resulting in four pregnancies; a clinical pregnancy rate of four in seven oocyte retrievals and four in six embryo transfers.

CONCLUSIONS

Drug-free IVA could be a useful therapeutic option for patients with POI, leading to successful IVF outcomes.

Pregnancy after drug-free in vitro activation of follicles and fresh tissue autotransplantation in primary ovarian insufficiency patient: a case report and literature review

BACKGROUND

The aim of this report was to describe a case of pregnancy after drug-free in vitro activation (IVA) of follicles and fresh tissue autotransplantation in primary ovarian insufficiency (POI) patient and to review the pertinent literature.

METHODS

We present a case in wich a 32 - years old patient with POI became pregnant after IVA without tissue culture and with ovarian tissue transplantation. We also reviewed the literature using Pubmed database.

CASE PRESENTATION

Pretreatment with estradiol/progesterone stopped the day before surgery. The removal of the ovarian cortex and autotransplantation were performed by laparoscopy in the same surgical act. Ovarian fragments were transplanted in contralateral ovary and peritoneal pocket near to the ovary. Immediately after surgery GnRH agonist together HMG injections started, leading the growth of 3 preovulatory follicles and the retrieval of two mature eggs. After IVF two embryos were transferred and singleton pregnancy was established and currently she is 25 weeks pregnant.

RESULTS

A total of 51 patients with POI in whom an in vitro activation of ovarian tissue was performed, were collected from the revieew of the literature. In 29.4% of them, follicular development was obtained and in 4 of them a pregnancy. In all of them, a combined technique (fragmentation and activation) was performed in two laparoscopies. No case has been reported successfully after drug-free in vitro activation.

CONCLUSIONS

This is the first report about a case with pregnancy after drug-free in vitro activation of follicles and fresh tissue autotransplantation in POI patient.

Multiple aneuploidies in the oocytes of balanced translocation carriers: a preimplantation genetic diagnosis study using first polar body

Preimplantation genetic diagnosis (PGD) of first polar bodies (1PBs) has been used in carriers of balanced chromosomal reorganizations and also for aneuploidy screening. Although an acceptable number of normal or balanced embryos is usually obtained using PGD in translocation carriers, the pregnancy rate is disappointingly low. To determine whether aneuploidy of chromosomes not involved in the chromosome rearrangements could be the cause of the low pregnancy rates achieved, the present authors analysed the segregation products of three translocation carriers, t(8;13)(q24.1;q22) and two Robertsonian (Rob)(13;14), using 1PBs, and afterwards another eight chromosomes in the same 1PBs, for a total of 10 chromosomes in each 1PB, that is chromosomes 1, 8, 13, 14, 15, 16, 17, 18, 21, 22 and X. In the reciprocal translocation, chromosomes with different chromatids due to meiotic recombination were found. Only one out of nine 1PBs was normal for the reorganization products but no aneuploidies were found after PGD in this case. In the two balanced Rob(13;14), six out of 12 and four out of 11 1PBs were normal or balanced for the reorganization but only one oocyte was euploid for all the chromosomes analysed in each case; a single embryo transfer was made in both but no pregnancy was achieved. The incidence of aneuploidy for the chromosomes not involved in the Robertsonian translocations was extremely high (91.7% and 81.8%). Extra chromosomes were present in most of the aneuploid oocytes (81.8% and 90%). The reason for this increase could be the tendency to non-disjunction related to advanced maternal age combined with an interchromosomal effect resulting in the presence of synaptic errors in other chromosome pairs.

PGD in female carriers of balanced Robertsonian and reciprocal translocations by first polar body analysis

Preimplantation genetic diagnosis (PGD) using the first polar body (1PB) is a modality of PGD that can be used when the woman is the carrier of a genetic disease or of a balanced chromosomal reorganization. PGD using 1PB biopsy in carriers of balanced chromosome reorganizations has not become generalized. Here, we describe our experience based on the analysis of unfertilized or fresh, non-inseminated control oocytes, by fixing separately the 1PB and the corresponding oocyte, and on the study of six clinical cases of PGD using 1PB biopsy (four Robertsonian translocations and two reciprocal translocations). In fresh oocytes, the chromosome morphology of the 1PB was well preserved, and the results were always concordant for each oocyte-1PB pair. This indicates that the 1PB can be reliably used for the diagnosis of chromosome reorganizations. In these studies the technical problems encountered when performing PGD using 1PB biopsies for chromosome studies are also addressed. Three different strategies of 1PB biopsy (laser beam, partial zona dissection and acid Tyrode's) and two different protocols (intracytoplasmic sperm injection before or after 1PB biopsy) and their effect on the percentage of oocytes diagnosed and the fertilization rate, are discussed. In reciprocal translocation cases, published in the literature or studied by us, in which at least nine oocytes had been diagnosed, a correlation has been found between the frequency of nondisjunction observed and the theoretical recombination rate. To date, PGD by 1PB analysis alone or combined with blastomere biopsies in female carriers of chromosomal rearrangements has been used in 18 cases, with a further six cases reported here. A total of 325 cumulus-oocyte complexes have been obtained, of which 294 were biopsied and 224 were diagnosed. A total of 52 embryos was transferred, 19 of which implanted and 17 produced full-term pregnancies.

Serum inhibin B determination is predictive of successful testicular sperm extraction in men with non-obstructive azoospermia

Recent work indicates that serum inhibin B is a useful marker of spermatogenesis and inhibin B production sufficient to maintain detectable serum concentrations in adults depends on spermatogenic activity. The purpose of the present study was to investigate the usefulness of serum inhibin B measurement to predict the success of testicular sperm extraction (TESE) in 17 men with nonobstructive azoospermia to be treated by intracytoplasmic sperm injection (ICSI) (group 1). Two additional groups were used as positive controls; group 2 comprised 22 infertile men having obstructive azoospermia, and group 3, which included 29 semen donors having normal seminal parameters. Follicle stimulating hormone (FSH) was significantly higher (P < 0.01) and inhibin B significantly lower (P < 0.001), in group 1 as compared with groups 2 and 3. Serum inhibin B concentrations were significantly higher (P < 0.001) among successful TESE men as compared with those having failed TESE. In contrast, no differences were detected between these two groups with respect to serum FSH or testicular size. In addition, serum inhibin B but not FSH discriminated between successful and failed TESE in group 1 subjects as compared with control groups. According to the receiver operating characteristics curve analysis, the best inhibin B value for discriminating between successful and failed TESE was >40 pg/ml (sensitivity 90%, specificity 100%). It is concluded that inhibin B measurement is a useful non-invasive predictor of spermatogenesis and thus, all azoospermic males should have serum inhibin B concentrations determined in addition to FSH measurement and karyotyping prior to undergoing TESE.

Day 5 inhibin B serum concentrations as predictors of assisted reproductive technology outcome in cycles stimulated with gonadotrophin-releasing hormone agonist-gonadotrophin treatment

The present study investigates the usefulness of inhibin A, inhibin B and serum oestradiol concentrations obtained in the fifth day of gonadotrophin therapy in predicting ovarian response and assisted reproductive treatment outcome in women undergoing ovarian stimulation under pituitary desensitization. A total of 80 women undergoing their first cycle of in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment were studied. Twenty consecutive cycles which were cancelled because of a poor follicular response were initially selected. As a control group, 60 women were randomly selected from our assisted reproductive treatment programme matching by race, age, body mass index, and indication for IVF/ICSI to those in the cancelled group. For each cancelled cycle, three IVF/ICSI women who met the matching criteria were included. Basal follicle stimulating hormone (FSH) concentrations were significantly higher in the cancelled than in the control group, whereas basal inhibin B was significantly higher in the latter. Basal oestradiol concentrations were similar in both groups of patients. On day 5 of gonadotrophin therapy serum concentrations of oestradiol, inhibin A and inhibin B were significantly lower in the cancelled group as compared with controls. Logistic regression analysis showed that the association for day 5 inhibin B (with a predictive value of ovarian response of 91.03%) with cancellation rate was significant, independent of, and stronger than, the effects of any other hormone variable investigated. In addition, day 5 inhibin B concentrations were correlated directly with parameters of ovarian response, ovum retrieval and oocyte and fertilization outcome. However, day 5 inhibin B was not a better predictor of pregnancy than the other hormone variables studied on this day. It is concluded that inhibin B concentrations obtained early in the follicular phase during ovarian stimulation under pituitary suppression for assisted reproductive treatment are highly predictive of ovarian response.

Recurrent in vitro fertilization failure evaluated by fluorescence in situ hybridization: a case report

OBJECTIVE

To present a case of IVF failure evaluated by fluorescence in situ hybridization (FISH).

DESIGN

Case report.

SETTING

Research university laboratory and clinical IVF laboratory.

PATIENT(S)

An infertile couple with recurrent IVF failure.

INTERVENTION(S)

Fluorescence in situ hybridization study of the complete cohort of "zygotes" obtained at the third IVF attempt.

MAIN OUTCOME MEASURE(S)

Fluorescence in situ hybridization studies of chromosomes X, Y, 13, 18, and 21.

RESULT(S)

All the recovered putative zygotes were abnormal for the expected ploidy, presumably as a result of abnormal oocytes.

CONCLUSION(S)

Fluorescence in situ hybridization techniques represent a promising approach to analyze zygotes that fail to divide normally in vitro and eggs that fail to become fertilized. In cases of recurrent IVF failure, the results of FISH could be used to counsel couples and thus to help them choose among methods other than IVF for assisted reproduction.

Origin of tripronucleate zygotes after intracytoplasmic sperm injection

Zygotes morphologically classified as tripronuclear (3PN) after intracytoplasmic sperm injection (ICSI), which are thought to be digynic in their origin, were studied by fluorescent in-situ hybridization (FISH). FISH results allowed us to assess the suspected ploidy after morphological evaluation of the zygote and to determine the origin of the third pronuclei. Our results show that, firstly, 36% of those zygotes classified as 3PN following their morphological evaluation were, in fact, diploid, and secondly, the main cause for triploidy after ICSI is the non-extrusion of the second polar body.

Evaluation of cytogenetic analysis for clinical preimplantation diagnosis

OBJECTIVE

To evaluate the feasibility of using cytogenetic analysis in preimplantation diagnosis.

DESIGN

Two different biopsy protocols (chemical drilling and zona cutting) and two fixation methods were tested in a mouse model. Afterwards, the efficiency of obtaining chromosome preparations from untransferable human embryos depending on the method used to obtain the blastomeres (embryos biopsy or removal of the zona pellucida and blastomere disaggregation) was determined. The chances of obtaining chromosome preparations depending on the type of embryo (haploid, diploid, triploid, and apparently unfertilized) were also evaluated.

RESULTS

Results from the mouse model showed that chemical drilling yields better results than cutting in terms of metaphases per biopsied embryo and surviving rate after biopsy. In human embryos, biopsy of diploid embryos produced 46.6% chromosome preparations, while 29% were obtained after blastomere disaggregation and 20.4% when biopsying triploid embryos.

CONCLUSIONS

These results suggest that the disaggregating procedure and triploid embryos cannot be considered as good models to assess the feasibility of cytogenetic analysis in preimplantation diagnosis. Poor chromosome quality and loss during fixation are the main problems to use cytogenetics in preimplantation diagnosis; a combination of cytogenetics and other techniques is suggested in cases of balanced translocations.

Effect of anti-human sperm monoclonal antibodies on mouse in vitro fertilization

We employed anti-human sperm monoclonal antibodies to investigate how sperm membrane antigens are involved in gamete interactions. We have produced seven monoclonal antibodies specific for human sperm antigens, that showed reaction with mouse sperm by ELISA and by immunofluorescence. These antibodies did not react with zona pellucida or any other somatic human tissue. Some degree of toxicity was detected for oocytes at high antibody concentration and this was correlated with their inhibitory effect on fertilization. Unrelated to the degree of antigen expression or localization on sperm membrane, the antibodies showed several degrees of inhibition. The participation in sperm-zona pellucida interaction for every antigen could be evidenced by the impaired penetration of sperm caused by the presence of several concentrations of antibody. Thus, DAN-2, MOU-8 and VAC-4 inhibit mouse in vitro fertilization.

The genetic risks of in vitro fertilization techniques: the use of an animal model

PURPOSE

The influence of some technical and biological parameters on the genetic characteristics of embryos derived from in vitro fertilization (IVF) techniques was studied.

METHOD

Using a murine model, we assessed the effect of gamete manipulation, gamete maturation stage, and maternal age on the chromosome complements of first-cleavage embryos.

RESULTS AND CONCLUSIONS

We found a positive correlation between some of these parameters and the incidence of the different chromosome abnormalities studied. Regarding aneuploidy, we observed an influence of maternal age, using both prepubertal and old females. Polyspermy showed a positive correlation with in vitro fertilization, the immaturity and overmaturity of the oocytes employed, and the use of prepubertal females. The appearance of diploid female complements was related to oocyte immaturity and prepubertal females, while diploid male complements were directly related to in vitro fertilization. Premature chromosome condensation (PCC) had a direct relationship with oocyte immaturity and in vitro maturation of the oocyte. Finally, structural abnormalities were associated with the process of sperm aging in vitro.

Zona pellucida surface of immature and in vitro matured mouse oocytes: analysis by scanning electron microscopy

PURPOSE

The aim of this work was to determine the morphology of the zona pellucida surface of immature and in vitro matured mouse oocytes by scanning electron microscopy. For this purpose two groups of immature oocytes (germinal vesicle group and metaphase I group) were studied either before or after in vitro maturation.

RESULTS

Before in vitro maturation, the germinal vesicle immature group showed mainly an unstructured zona pellucida surface with smooth cumulus cells. The metaphase I immature group showed a more structured zona pellucida with smooth or blebbing cumulus cells. After in vitro maturation, development of the zona pellucida toward a mature surface, related to the initial degree of oocyte maturity, was observed in both groups.

CONCLUSIONS

These observations show a correlation between the morphology of the zona pellucida surface and the degree of oocyte maturity; the in vitro maturation process can give rise to a proper development of this endowment when immature oocytes are used.

Premature chromosome condensation as a sign of oocyte immaturity

In this work we report the possibility that oocyte immaturity is associated with premature chromosome condensation (PCC) after in-vitro fertilization (IVF). Using a murine model, we have related PCC and endoreduplicated-like oocytes to oocyte immaturity as a basis for a prognosis in oocyte immaturity problems. The cytogenetic analysis was performed in 511 embryos obtained from immature oocytes that were directly fertilized in vitro and in 1363 embryos obtained from immature oocytes that were matured in vitro with different concentrations of human chorionic gonadotrophin (HCG) added to the culture medium. As a control we used 507 embryos obtained from freshly ovulated oocytes. PCC at the G1-phase-(G1-PCC) was observed only when immature oocytes were immediately fertilized in vitro (45.4%) and PCC at the S-phase (S-PCC) only when using in-vitro matured oocytes with the highest HCG concentration (3.3%). Neither G1-PCC nor S-PCC were found in the control group. Endoreduplicated-like oocytes appeared in a significant percentage (27.3%) only in the immature group. Immature oocytes yielded a low fertilization rate (16.6%) while in-vitro maturation seemed to confer a higher fertilization capacity compared to the control group (90.1% versus 78.2%). The possible correlation between PCC and oocyte immaturity provides new prospects in the determination of human IVF failures of unknown origin. Thus, when a problem of oocyte immaturity is diagnosed through the presence of PCC, a special programme of in vitro oocyte maturation, such as a longer preincubation time or addition of hormones to the media, would be recommended.

Effect of the degree of maturation of mouse oocytes at fertilization: a source of chromosome imbalance

It has been suggested that the abnormal maturation of the human oocyte during fertilization in vitro may result in chromosome imbalance and induce embryonic loss. Using a mouse model, we have studied the influence of the degree of oocyte maturation (either immaturity or overmaturity) on the chromosome characteristics of embryos at the first-cleavage division. Immature oocytes were obtained 2-3 h or 3-4 h before the expected ovulation time (b.o.). Overmaturation was induced by aging the newly ovulated oocytes in vitro for 3, 6, and 12 h. Our results show a significant decrease in the fertilization rate in the immature groups (65.53% at 2-3 h b.o. and 16.59% at 3-4 h b.o. vs. 78.22% at control) and after 12 h of in vitro aging (69.39%), while a significant increase of this parameter was found at 3 h of aging (82.59%) as compared to the other groups. No significant differences were found in the occurrence of aneuploidy or hyperhaploidy in embryos obtained from immature, newly ovulated, and overmature oocytes. Finally, an increased incidence of polyploidy was detected in immature, 2-3 h b.o. (31.20%), and overmature, 3 h (23.04%) and 6 h (31.61%), groups as compared to the control group (14.59%).