Preservation of fertility in young cancer patients: contribution of transmission electron microscopy

During the last decade, new technologies in reproductive medicine have emerged to preserve the fertility of women whose gonadal function is threatened by premature menopause or gonadotoxic treatments. To offer an individualized approach to these patients, different experimental procedures are under investigation, including oocyte cryopreservation and cryopreservation and transplantation of ovarian tissue in the form of cortical fragments, whole ovary or isolated follicles. This review shows that transmission electron microscopy (TEM), combined with other in-vivo and in-vitro analysis techniques, is a valuable tool in the establishment of new experimental protocols to preserve female fertility. Ultrastructural studies allow in-depth evaluation of the oocyte's unique morpho-functional characteristics, which explain its low cryotolerance, and provide essential information on follicular, stromal and endothelial cell integrity, as well as cellular interactions crucial for normal folliculogenesis. In order to be able to offer appropriate and efficient options in every clinical situation, oocyte in-vitro maturation and ovarian tissue transplantation need to be optimized. Further development of new approaches, such as follicular isolation and whole ovary transplantation, should be encouraged. Fine ultrastructural details highlighted by TEM studies will be useful for the further optimization of these emerging technologies.

Unusual complication after uterine artery embolization and laparoscopic myomectomy in a woman wishing to preserve future fertility

OBJECTIVE

To report a case of uterine fistula arising after laparoscopic myomectomy after a uterine artery embolization.

DESIGN

Case report.

SETTING

A university hospital center.

PATIENT(S)

A 38-year-old woman with a uteroperitoneal fistula after laparoscopic myomectomy after a uterine artery embolization.

INTERVENTION(S)

Laparoscopic excision of the fistula and repair of the myometrial defect with laparoscopic suture.

MAIN OUTCOME MEASURE(S)

Not applicable.

RESULT(S)

Complete correction of the myometrial defect was observed after laparoscopic surgery.

CONCLUSION(S)

Uterine artery embolization before myomectomy may interfere with myometrial cicatrization and thus alter the repair.

Electron paramagnetic resonance as a tool to evaluate human ovarian tissue reoxygenation after xenografting

OBJECTIVE

To develop electron paramagnetic resonance (EPR) oximetry as a tool to characterize the oxygen environment in human ovarian xenografts in the early postgrafting period.

DESIGN

Prospective experimental study.

SETTING

Gynecology research unit in a university hospital.

PATIENT(S)

Biopsies were obtained from 6 women aged 22-35 years.

INTERVENTION(S)

Frozen-thawed human ovarian tissue fragments were grafted to an intraperitoneal site in nude mice. Before grafting, lithium phthalocyanine, an oxygen reporter, was implanted inside the fragments.

MAIN OUTCOME MEASURE(S)

To monitor partial pressure of oxygen (pO(2)) by EPR on postgrafting days 3, 5, 7, 10, 14, 17, and 21 and validate the technique by histologic assessment.

RESULT(S)

A period of hypoxia was identified before day 5, followed by gradual but significant oxygenation over the next 5 days, suggesting an active process of graft revascularization. Reoxygenation kinetics in human ovarian xenotransplants were quantified.

CONCLUSION(S)

Our data validated the EPR oximetry technique as a tool to monitor pO(2) in ovarian grafting. The critical early period of hypoxia was identified, and the first steps of reoxygenation were characterized. In the future, our model may be used to evaluate new freezing and grafting protocols with the aim of reducing potential cryoinjury and initial ischemia-reperfusion damage.

Long-term spermatogonial survival in cryopreserved and xenografted immature human testicular tissue

BACKGROUND

Preservation of the male germ line in prepubertal boys undergoing gonadotoxic treatment is a crucial consideration in terms of their future quality of life. As these patients do not yet produce spermatozoa for freezing, only immature tissue is available for storage. We studied the survival, proliferation and differentiation capacity of spermatogonia after cryopreservation and long-term transplantation of immature testicular tissue pieces.

METHODS

Single pieces of testicular tissue (2-8 mm(3)) from prepubertal boys (7-14 years) were cryopreserved, thawed and transplanted into the scrotum of mice for 6 months. Upon removal, histological, immunohistochemical and ultrastructural analyses and testicular sperm extraction (TESE) were used to evaluate the tissue.

RESULTS

Histology showed 55 +/- 42% of tubules to be intact. MAGE-A4 immunostaining showed mean spermatogonial recovery to be 3.7 +/- 5.5%, with 35% of these cells expressing Ki67, evidencing proliferation in tissue from boys <14 years of age. No apoptosis was found, as demonstrated by the absence of active caspase-3 and TUNEL staining. Numerous premeiotic spermatocytes, a few spermatocytes at the pachytene stage and spermatid-like cells were observed. No immunostaining was observed for lactate dehydrogenase-C, ACE or proacrosin, indicating that the spermatid-like structures observed by histology did not express the meiotic and post-meiotic markers characteristic of normal spermatids. No ultrastructural alterations of the tissue were encountered.

CONCLUSIONS

The present study demonstrates that spermatogonia are able to survive and proliferate after cryopreservation and long-term transplantation. Complete regeneration of normal spermatogenesis was not observed since, beyond the pachytene stage, no adequate characterization of germ cells was obtained. Further studies are thus required to investigate the differentiation potential of cryopreserved germ cells.

Cryopreservation and xenotransplantation of human ovarian tissue: an ultrastructural study

OBJECTIVE

To analyze the ultrastructure of human ovarian follicles after cryopreservation and short-term xenografting.

DESIGN

Prospective experimental study.

SETTING

Academic gynecology and anatomy research units.

PATIENT(S)

Ovarian cortical biopsy specimens were obtained from 13 patients.

INTERVENTION(S)

Each ovarian biopsy specimen was dissected into pieces of 1 mm(3) and divided into three groups: [1] fresh tissue, [2] frozen-thawed tissue, and [3] frozen-thawed tissue xenografted onto the peritoneum of nude mice for 3 weeks.

MAIN OUTCOME MEASURE(S)

Follicular ultrastructure was assessed by light and transmission electron microscopy in [1] fresh, [2] frozen, and [3] frozen-grafted tissue.

RESULT(S)

Thirty-five ovarian follicles were analyzed by light and transmission electron microscopy. Twenty-five primordial and primary ovarian follicles were found. Most of them exhibited ultrastructurally well preserved features (fresh [N = 8/10], frozen [N = 7/10], and frozen-grafted [N = 4/5] tissue). Ten secondary follicles were present in xenografts. By transmission electron microscopy, all the healthy-looking secondary follicles (70%) were shown to contain intact oocytes, with features typical of earlier developmental stages, surrounded by several layers of follicular cells.

CONCLUSION(S)

The present study demonstrates, for the first time, that cryopreservation and xenotransplantation do not appear to greatly affect human primordial/primary follicle ultrastructure. Interestingly, in frozen-thawed xenografts, secondary human ovarian follicles presented a well preserved ultrastructure, but asynchrony between oocyte and granulosa cell development was detected. The possible causes for this asynchrony are discussed.

Increased activation of nuclear factor-kappa B (NF-κB) in isolated peritoneal macrophages of patients with endometriosis

Endometriosis is characterized by pelvic inflammation that shows an increased number of activated peritoneal macrophages and their secreted products such as cytokines, growth factors, and angiogenic factors. Our results show that activation of nuclear factor-kappa B (NF-kappaB), a pro-inflammatory transcription factor, is statistically significantly increased in peritoneal macrophages from patients with endometriosis when compared with controls.

Iron storage is significantly increased in peritoneal macrophages of endometriosis patients and correlates with iron overload in peritoneal fluid

OBJECTIVE

To further investigate peritoneal iron disruption in endometriosis by studying iron storage in peritoneal macrophages of patients with endometriosis compared with controls.

DESIGN

Cross-sectional study.

SETTING

Academic gynecology research unit in a university hospital.

PATIENT(S)

Fifty patients undergoing laparoscopy.

INTERVENTION(S)

Collection of peritoneal fluid samples (N = 50) from patients with (n = 27) and without (n = 23) endometriosis undergoing laparoscopy.

MAIN OUTCOME MEASURE(S)

Quantification of peritoneal macrophage ferritin by immunocytochemical staining and immunodensitometry and measurement of peritoneal iron, transferrin, ferritin, and prohepcidin concentrations.

RESULT(S)

The optical density of peritoneal macrophage ferritin staining was statistically significantly higher in endometriosis patients than in controls. Higher iron concentrations, transferrin saturations, and ferritin concentrations were also detected in case of endometriosis. A statistically significant positive correlation was found between the optical density of macrophage ferritin staining and peritoneal iron concentrations in endometriosis and control patients.

CONCLUSION(S)

Iron storage is statistically significantly increased in peritoneal macrophages of patients with endometriosis and correlates with iron overload in peritoneal fluid. The potential implications of iron accumulation in peritoneal macrophages in case of endometriosis are discussed.

Laparoscopic repair of wide and deep uterine scar dehiscence after cesarean section

OBJECTIVE

To propose a new laparoscopic technique for repair of scar dehiscence after cesarean section.

DESIGN

The dehiscent scars were evaluated by ultrasound, hysterography, hysteroscopy, and magnetic resonance imaging. The results were correlated with those after laparoscopic repair.

SETTING

University hospital.

PATIENT(S)

Three patients underwent cesarean section and presented with symptomatic dehiscence at the level of the incision.

INTERVENTION(S)

Laparoscopic repair of the dehiscence, including excision of the fibrotic tissue and laparoscopic closure of the anterior uterine wall.

MAIN OUTCOME MEASURE(S)

Evaluation by ultrasound and magnetic resonance imaging of the sagittal depth of the scar and the thickness of the residual myometrium covering the dehiscence.

RESULT(S)

The defect was completely corrected by laparoscopic repair in all cases.

CONCLUSION(S)

Evaluation of uterine scar dehiscence after cesarean section can be performed by ultrasound and magnetic resonance imaging, and laparoscopic surgical repair may be performed with good postoperative anatomic outcomes.

Chick embryo chorioallantoic membrane (CAM) model: a useful tool to study short-term transplantation of cryopreserved human ovarian tissue

OBJECTIVE

To investigate the chorioallantoic membrane (CAM) model for the study of short-term transplantation of frozen human ovarian tissue.

DESIGN

Prospective study.

SETTING

Academic research unit.

PATIENT(S)

Ovarian tissue was obtained from three women.

INTERVENTION(S)

Frozen-thawed human cortical fragments were grafted onto traumatized CAM or beneath the CAM of 10-day-old chick embryos. Grafts were retrieved after 1, 2, 3, 4, and 5 days in ovo.

MAIN OUTCOMES MEASURE(S)

Viability was assessed by calcein-AM and ethidium homodimer I. Tissue integrity, ischemic injury, and neovascularization were evaluated by histology. Cell proliferation was analyzed by Ki-67 immunohistochemistry.

RESULT(S)

All the grafts showed adhesion when placed onto CAM, compared with only 30.4% beneath the CAM. Follicles were healthy, apart from a few degenerated follicles in necrotic and fibrotic areas. After 5 days, the majority of follicles were intermediate (32%) or primary (45.7%). Ki-67 immunohistochemistry revealed 12.5% proliferative follicles on day 2, reaching 20.7% on day 5. Fibrosis appeared on day 1; necrosis, follicular degeneration and follicular proliferation on day 2; and neovascularization and stromal cell proliferation on day 3.

CONCLUSION(S)

The present study showed that the CAM model provides a new approach to study human ovarian tissue transplantation in its first ischemic stages, yielding information on the timing of tissue changes before the establishment of neovascularization.

Identification of novel antigens in blood vessels in rectovaginal endometriosis

To identify specific markers of rectovaginal endometriotic nodule vasculature, highly enriched preparations of vascular endothelial cells and pericytes were obtained from endometriotic nodules and control endometrial and myometrial tissue by laser capture microdissection (LCM), and gene expression profiles were screened by microarray analysis. Of the 18 400 transcripts on the arrays, 734 were significantly overexpressed in vessels from fibromuscular tissue and 923 in vessels from stromal tissue of endometriotic nodules, compared with vessels dissected from control tissues. The most frequently expressed transcripts included known endothelial cell-associated genes, as well as transcripts with little or no previous association with vascular cells. The higher expression in blood vessels was further corroborated by immunohistochemical staining of six potential markers, five of which showed strong expression in pericytes. The most promising marker was matrix Gla protein, which was found to be present in both glandular epithelial cells and vascular endothelial cells of endometriotic lesions, although it was barely expressed at all in normal endometrium. LCM, combined with microarray analysis, constitutes a powerful tool for mapping the transcriptome of vascular cells. After immunohistochemical validation, markers of vascular endothelial and perivascular cells from endometriotic nodules could be identified, which may provide targets to improve early diagnosis or to selectively deliver therapeutic agents.

Agents blocking the nuclear factor-kappaB pathway are effective inhibitors of endometriosis in an in vivo experimental model

BACKGROUND

In vitro studies suggest that the transcription factor nuclear factor-kappa B (NF-kappaB) is implicated in the transduction of proinflammatory signals in endometriosis. The aim of this study was to investigate the involvement of NF-kappaB and the processes regulated by NF-kappaB in the initial development of endometriotic lesionsin vivo.

METHODS

Endometriosis was induced in nude mice by intraperitoneal injection of fluorescent-labeled menstrual endometrium. Two NF-kappaB inhibitors (BAY 11-7085 and SN-50) were injected intraperitoneally on days 0, 2 and 4 after endometriosis induction, and endometriotic lesions were recovered on day 5. Number, mass, fluorimetry and surface (morphometry) of endometriotic lesions were quantified. NF-kappaB activation, intercellular adhesion molecule (ICAM)-1 expression, cell proliferation and apoptosis were evaluated by immunohistochemical analyses and the TUNEL method.

RESULTS

Both NF-kappaB inhibitors induced a significant reduction in lesion development compared to control mice. NF-kappaB activation and ICAM-1 expression of endometriotic lesions were significantly reduced in treated mice, and cell proliferation was significantly reduced in BAY 11-7085-treated mice. Both inhibitors produced a significant increase in apoptosis of endometriotic lesions, as assessed by active caspase-3 immunostaining and the TUNEL method.

CONCLUSION

This study demonstrates, for the first time, that the NF-kappaB pathway is implicated in the development of endometriotic lesions in vivo and that NF-kappaB inhibition reduces ICAM-1 expression and cell proliferation, but increases apoptosis of endometriotic lesions, diminishing the initial development of endometriosis in an animal model.

Small cell carcinoma of pulmonary type inside a microinvasive mucinous cystadenocarcinoma of the ovary: a case report

We report the occurrence of a small cell carcinoma of pulmonary type developed within a large borderline mucinous cystic tumor of the ovary, with another focus of microinvasive mucinous adenocarcinoma, in a 32-year-old woman. The small cell carcinoma expresses several neuroendocrine markers, thyroid transcription factor 1 and parathyroid hormone. Carbohydrate antigen 15.3 and carcinoembryonic antigen were focally detected but not cancer antigen 125. Cytokeratin 20 was immunolabeled in several mucinous carcinomatous glands but not in the neuroendocrine cells. The p53 protein was abnormally abundant, including in the borderline tumor. Progesterone receptor was heterogeneously immunodetected, whereas estrogen receptor labeling was weak and limited. This unusual immunohistochemical pattern further enhances the singularity of this quite exceptional tumor association.

Expression of intercellular adhesion molecule-1 and vascular cell adhesion molecule-1 in human endometrial stromal and epithelial cells is regulated by interferon-gamma but not iron

BACKGROUND/AIMS

Endometrial cells are chronically exposed to iron due to cyclic menstrual bleeding. Iron induces expression of adhesion molecules in endothelial cells. The purpose of this study was to investigate iron incorporation by human endometrial cells and to test whether iron may stimulate expression of intercellular adhesion molecule (ICAM)-1 and vascular cell adhesion molecule (VCAM)-1.

METHODS

Endometrial stromal and epithelial cells were cultured in medium alone or supplemented with INF-gamma or transferrin (Tf). Iron incorporation by cells was quantified by densitometry of ferritin immunostaining. ICAM-1 and VCAM-1 expression were evaluated at the transcriptional level by real-time RT-PCR. Membrane-bound and soluble protein levels of ICAM-1 were measured by quantitative immunohistochemistry and ELISA, respectively.

RESULTS

Tf induced a significant increase in ferritin immunostaining in both endometrial cell types. Endometrial cells treated with INF-gamma expressed more ICAM-1 and VCAM-1 than untreated cells. By contrast, Tf treatment did not alter ICAM-1 and VCAM-1 expression in cultured endometrial cells.

CONCLUSIONS

Endometrial cells are able to incorporate iron from Tf and to metabolize it to ferritin. Iron, unlike interferon-gamma, does not appear to be involved in the regulation of ICAM-1 and VCAM-1 expression in cultured endometrial cells.

Allograft of ovarian cortex between two genetically non-identical sisters: case report

Aggressive chemotherapy and radiotherapy generally result in the loss of both endocrine and reproductive functions. In 1990, a woman aged 20 years, presenting with beta-thalassemia major, underwent chemotherapy (busulfan and cyclophosphamide) and total body irradiation (TBI) before bone marrow transplantation (BMT), the donor being her 17-year-old HLA-compatible sister. The treatment resulted in premature ovarian failure. In 2006, after excision of ovarian cortical fragments from the HLA-compatible sister, these fragments were immediately sutured to the ovarian medulla of the patient. Both procedures were performed by laparoscopy. Six months after reimplantation, vaginal ultrasonography and hormone concentrations indicated recovery of ovarian secretion and function. From 6 to 11 months, the patient experienced menstrual bleeding and the development of a follicle concomitant with high estradiol levels. Eleven months after reimplantation, two follicles were detected and punctured under vaginal ultrasonographic control. Two mature oocytes were retrieved and inseminated by ICSI. Two embryos (2- and 3-cell) were obtained. Allotransplantation of fresh ovarian tissue was laparoscopically performed between two genetically non-identical sisters. Restoration of ovarian function was achieved after six months. Oocyte retrieval and embryo development were demonstrated.

Short-term transplantation of isolated human ovarian follicles and cortical tissue into nude mice

This study was designed to evaluate follicular survival and growth after short-term transplantation of fresh isolated human follicles and ovarian cortical tissue to nude mice. Ovarian biopsies were obtained from nine women undergoing laparoscopy. Twelve nude mice were xenografted with an ovarian cortical fragment in the right ovarian bursa, and a clot containing isolated follicles in the left, for a period of 7 days. One ungrafted fragment was used as a control. Histological sections were analyzed to determine follicle number and stage. The proliferative status of follicular cells was assessed by Ki-67 immunostaining. A total of 659 follicles was analyzed by histology and 545 follicles by immunohistochemistry. The percentage of primordial follicles was found to be markedly reduced 1 week post-grafting when compared with ungrafted tissue, while the percentage of primary follicles had significantly increased. Only 8% of follicles showed Ki-67-positive granulosa cells before grafting, whereas 1 week after grafting, 71% of follicles in fragments and 67% of isolated follicles were Ki-67-positive (P<0.001). Moreover, the histological aspect of isolated follicle grafts was similar to that of grafted fragments: follicles were surrounded by vimentin-positive stroma-like tissue of human origin, as confirmed by fluorescent in situ hybridization with human-specific probes. Our results demonstrate, for the first time, that isolated human follicles are able to survive and grow after xenografting. This study also shows massive in vivo follicular activation after transplantation of grafted fragments and isolated follicles. One week after grafting, well-structured stroma-like tissue of human origin was observed around the isolated follicles. The potential origin of this stroma is discussed.

Combined laparoscopic and vaginal approach for nephrectomy, ureterectomy, and removal of a large rectovaginal endometriotic nodule causing loss of renal function

A late consequence of ureteral endometriosis is the silent loss of renal function caused by progressive "enclosure" of the lower part of the ureter by the endometriosis. In our experience, in cases of severe loss of renal function with cortical atrophy and residual kidney function (evaluated by Tc99 DMSA scintigraphy) of less than 15%, removal of the endometriosis combined with ureterolysis does not allow recovery of renal function. A nonfunctioning kidney associated with hydronephrosis is a risk factor for vascular hypertension, recurrent pyelonephritis, or kidney stones and therefore an indication for nephrectomy. By means of a case report, this paper describes the combination of laparoscopic nephrectomy, ureterectomy, removal of the rectovaginal endometriotic nodule, and extraction of the kidney through the vagina.