Cryopreservation of ovarian tissue for fertility preservation in a large cohort of young girls: focus on pubertal development

STUDY QUESTION

Is there an association between the need for medical puberty induction and the diagnosis or treatment received in girls who have undergone cryopreservation of ovarian tissue for fertility preservation?

SUMMARY ANSWER

There was a clear association between the intensity of treatment received and requirement for medical puberty induction but no association with the diagnosis.

WHAT IS KNOWN ALREADY

Although it cannot be predicted which girls will become infertile or develop premature ovarian insufficiency (POI) following intensive chemotherapy or irradiation, patients who are at high risk of POI should be offered ovarian tissue cryopreservation (OTC). This includes girls who are planned to receive either high doses of alkylating agents, conditioning regimen before stem cell transplantation (SCT), total body irradiation (TBI) or high radiation doses to the craniospinal, abdominal or pelvic area.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study. In total, 176 Danish girls under 18 years of age have had OTC performed over a period of 15 years. An overview of the girls' diagnoses and mean age at OTC as well as the number of deceased is presented. Of the 176 girls, 38 had died and 46 girls were still younger than 12 years so their pubertal development cannot be evaluated yet. For the 60 girls who had OTC performed after 12 years of age, the incidence of POI was evaluated and in the group of 32 girls who were younger than 12 years at OTC, the association between the diagnosis and received treatment and the requirement for medical puberty induction was examined.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The need for medical puberty induction was assessed in 32 girls who were prepubertal at the time of OTC.

MAIN RESULTS AND THE ROLE OF CHANCE

Indications for OTC were allogeneic SCT for leukaemia, myelodysplastic syndrome or benign haematological disorders, autologous SCT for lymphoma or sarcoma, and irradiation to the pelvis or to the spinal axis. The mean age at OTC of the 176 girls were 11.3 years. The two most prevalent diagnoses of the 176 girls were malignant tumours and malignant haematological diseases. Among the 32 prepubertal girls, 12 received high dose chemotherapy and either TBI prior to SCT or irradiation to the pelvis, abdomen or the spinal axis, 13 received high dose alkylating agents but no irradiation prior to SCT, six received alkylating agents as part of conventional chemotherapy and one patient had a genetic metabolic disorder and did not receive gonadotoxic treatment. Among these 32 girls, 23 did not undergo puberty spontaneously and thus received medical puberty induction. Among the nine girls, who went through spontaneous puberty, four had received high dose alkylating agents and five had received conventional chemotherapy.

LIMITATIONS REASONS FOR CAUTION

All information was retrieved retrospectively from patient records, and thus some information was not available.

WIDER IMPLICATIONS OF THE FINDINGS

OTC should be recommended to all young girls, who present a high risk of developing ovarian insufficiency and/or infertility following high dose chemotherapy and/or irradiation.

STUDY FUNDING/COMPETING INTERESTS

The Childhood Cancer Foundation (2012-2016) and the EU interregional project ReproHigh are thanked for having funded this study. They had no role in the study design, collection and analysis of the data or writing of the report. The authors have no conflict of interest to disclose.

Herbalism and the menopause

Herbal medicinal products are often sold as a safe and effective alternative to HRT. Sizeable sets of trial data exist for black cohosh and soy. For other herbal medicines, only isolated trials have emerged, and their number is too low to enable one to arrive at valid conclusions. Collectively the data for black cohosh do not prove efficacy. The evidence for soy is encouraging but not compelling. Neither black cohosh nor soy is associated with major safety problems. Further research is warranted to closer define the role of herbal medicines for the menopause.

Herbal Remedies as a Treatment of Some Frequent Symptoms During Menopause

Many menopausal women try herbal remedies hoping to find an effective and safe form of treatment. The lay literature abounds with recommendations most of which are unsubstantiated. Systematic reviews exist for black cohosh, a promising remedy for neurovegetative menopausal symptoms. Data generated on non-menopausal patient populations also suggest that feverfew has some potential for preventing migraine, St John's Wort is an effective treatment for mild to moderate depression, valerian may alleviate insomnia and kava is an effective anxiolytic. The safety profiles of these remedies are encouraging. Before strong recommendations for the use of these or other herbal remedies can be issued, more conclusive research, in particular trials conducted on menopausal women, need to become available.

Sex Hormones and Semen Quality in Welders Exposed to Hexavalent Chromium

Recent experimental studies in rodents document the spermatotoxic effects of watersoluble hexavalent chromium. Welders comprise, worldwide, a major occupational group with acknowledged exposure to chromium. This study examines the relationship between semen quality and chromium in the urine and blood of a population of 30 tungsten inert gas (TIG) stainless steel welders, 30 mild steel welders and 47 non-welding workers. Each subject provided two to three semen samples. The chromium concentration ranged from 0.17 to 4.74 nmol mmol1 creatinine (median 1.08) in post-shift spot urine and from 6.0 to 46.4 nmol 1-1 in blood. None of several semen parameters deteriorated with increasing level of internal exposure to chromium. Low-level exposure to hexavalent chromium associated with TIG stainless steel and mild steel welding do not appear to be a major hazard for human spermatogenesis.

Sex Hormones and Epididymal Sperm Parameters in Rats Following Sub-chronic Treatment with Hexavalent Chromium

Testicular atrophy and reduced epididymal sperm count are known to occur after i.p. administration of high doses of hexavalent chromium to rats.

The effect of 0.5 mg kg -1 hexavalent chromium injected i.p. 5 d a week for 8 weeks was investigated in male Wistar rats.

A significant reduction in epididymal sperm motility was found at the end of the exposure period. The reduction was reversed after an unexposed period of a further 8 weeks.

In addition, a decrease in serum testosterone and an increase in FSH were found at the end of the exposure period.

The results indicate that a number of mechanisms may be involved in the deleterious effects of chromate on male fecundity.

Complementary Treatment of Varicose Veins — A Randomized, Placebo-Controlled, Double-Blind Trial

The aim of this study was to test the effectiveness of a combined homeopathic medication in primary varicosity. A well-defined population of 61 patients was randomized into active medication (Poikiven®) or placebo. Both were given for 24 d. At the start of the trial, after 12 d medication and at the end of the study, objective and subjective parameters were recorded: venous filling time, leg volume, calf circumference, haemorheological measurements and patients' symptoms such as cramps, itching, leg heaviness, pain during standing and the need to elevate the legs. The results show that venous filling time is changed by 44% towards normal in the actively-treated group. The average leg volume fell significantly more in this group, but calf circumferences did not change significantly and blood rheology was not altered in any relevant way. None of the patients reported side-effects. Subjective complaints were relieved significantly more by Poikiven than by placebo. These results suggest that the oral treatment of primary varicosity using Poikiven is feasable.

Blood Rheology in Post-Thrombotic Syndrome — A Pilot Study

Patients suffering from post-thromobotic syndrome are compared to controls in terms of ex-vivo measurements to quantify the rheological behavior of blood: blood and plasma viscosity, haematocrit, red cell aggregation, red cell filterability, erythrocyte sedimentation rate (ESR), plasma fibrinogen. The results show that plasma viscosity, red cell filterability, ESR and fibrinogen are significantly changed indicating a lack of blood fluidity in post-thrombotic disease. It is suggested that the rheological deficit and the venous pathology both contribute to a disturbed microcirculation in the affected limb.

Hydrotherapy for Varicose Veins: A Randomized, Controlled Trial

Objective:

To assess the effectiveness of regular hydrotherapy in primary varicose veins.

Design:

Randomized, single blind, prospective, controlled trial.

Setting:

Social security system related rehabilitation center for employees (nationwide assignment of inpatients).

Patients:

122 patients with primary varicose veins.

Interventions:

Group A (n=60) received daily treatments during 24 days that consisted of external application of alternating cold and warm water to both lower extremities. Group B (n=62) served as controls and was not treated with hydrotherapy. Both groups were comparable in terms of concomitant diseases and treatments.

Main outcome measures:

Foot volume, ankle circumference and venous re-fill time, using light reflex rheo-graphy, served as objective variables, while a number of typical symptoms were recorded as subjective parameters.

Results:

A more pronounced improvement in all objective signs in group A compared to B was observed. Four out of seven subjective symptoms improved more frequently in group A than in B.

Conclusions:

Hydrotherapy is effective in treating primary varicose veins. It can be considered as an adjunct measure to compression therapy and other conservative treatments.

Limited Blood Fluidity as a Contributory Factor of Venous Stasis in Chronic Venous Insufficiency

Patients with chronic venous insufficiency were compared to matched controls in terms of blood and plasma viscosity, haematocrit, blood cell filterability, red cell aggregation, fibrinogen and ESR. The results show that in chronic venous insufficiency plasma viscosity and red cell aggregation are elevated, while blood cell filterability is reduced. Furthermore, the venous blood flow velocity (as determined by Doppler technique) correlates inversely with both plasma viscosity and red cell aggregation. We conclude that the systematic rheological abnormality increases the resistance to venous blood flow and may represent a contributory factor of venous stasis in this disorder.

Ultrasound for Cutaneous Wound Healing

Objective:

To review the published data on ultrasound as a means to enhance wound healing.

Study selection:

A combined computerized (Medline 1980–94) and manual search of the world literature was performed.

Data extraction:

All controlled trials on cutaneous wound healing were admitted. Three experimental and five clinical studies were retrieved.

Data synthesis:

The experimental studies imply that cutaneous wounds treated with ultrasound heal quicker than untreated wounds. Clinical trials suggest that ultrasound speeds the healing of leg ulcers and possibly also of pressure sores

Conclusion:

Ultrasound is a promising adjunct to the complementary treatment of wounds, which would need more detailed, definitive study.

Placebo Treatment for Varicosity: Don't Eat It, Rub it!

Objective:

To define and compare the clinical effectiveness of two different placebo applications, oral and topical, in the management of primary varicose veins.

Design:

Prospective, controlled trial with two parallel treatment groups.

Setting:

Social security system related rehabilitation centre in Germany with nationwide assignment of inpatients.

Patients:

Sixty-one patients with the clinical diagnosis of varicose veins.

Interventions:

Group A ( n = 30) received an oral placebo, group B ( n = 31) applied a topical placebo preparation to both legs. The treatment period was 24 days; both therapies were applied daily.

Main outcome measures:

Foot volume, ankle circumference, light reflex rheography and subjective complaints.

Results:

In both groups there were significant improvements in several outcome measures concerning both objective signs and subjective symptoms. Light reflex rheography yielded significantly better results in the topically compared with the orally treated group. Other variables followed this trend without, however, reaching the level of statistical significance.

Conclusions:

Symptoms of varicose veins are highly prone to respond to placebo. There are some indications to suggest that a topical placebo induces stronger effects than an oral one.

WITHDRAWN: Artichoke leaf extract for treating hypercholesterolaemia

Withdrawal: The editors of Cochrane Heart consider this title as low priority for the current portfolio of the Heart Group and therefore this title is not open to a new author team.

The editorial group responsible for this previously published document have withdrawn it from publication.

Abstract P5-10-01: Patient advocates as partners in breast cancer research at Georgetown University Lombardi Comprehensive Cancer Center

The integration of patient advocate input into biomedical research grant proposals is a relatively new phenomenon and represents a paradigm shift for basic, translational and clinical researchers seeking funding for their proposed studies. In 2011, the Lombardi Comprehensive Cancer Center (LCCC) at Georgetown University (GU) established the Georgetown Breast Cancer Advocates (GBCA) to facilitate collaboration between researchers and advocates. The mission of GBCA is to ensure research is patient-centered, innovative, evidence-based, and accessible. Working with researchers and clinicians at GU-LCCC early in proposal development, the members of the GBCA evaluate the feasibility of research, emphasizing the need for bench-to-bedside studies, the importance of quality of life, health care disparities and a reduction in breast cancer mortality. This integrated and early approach has resulted in GU-LCCC researchers being awarded a PCORI Grant, a DOD Idea Expansion Award, and a prestigious NIH U01 award.

The GBCA consists of survivors and community stakeholders from diverse ethnic, racial, and age groups. It ranges from women at high risk for breast cancer to both short- and long-term survivors of various sub-types of breast cancer and those with recurrent disease. Several advocates were trained by the National Breast Cancer Coalition's scientific education program, Project LEAD, and others participate in the Susan G. Komen for the Cure Advocates in Science Program. Members have served as consumer reviewers for the DOD's Breast Cancer Research Program at both the peer review and programmatic review levels, and as patient representatives on American Society of Clinical Oncology (ASCO) clinical practice guideline panels. GU-LCCC researchers and oncologists serve as advisors for the group.

This poster describes the evolution and work of the GBCA and how the group has influenced breast cancer research at GU-LCCC. GBCA works with researchers in the pre-award phase, providing input to investigators regarding methodologies to increase participant recruitment, retention, and adherence to research protocols. The advocates also provide input on study designs and patient education strategies. Through their contributions, the advocates have become an integral and respected part of the breast cancer research community at GU-LCCC.

Citation Format: Brundage S, Charles Chisholm D, Holloway JN, Lucas W, Salamone J, Winarsky S, London M, Greenwood N, Stahl S, Carbine N, Goyes R, Price E, Ernst E, Leventhal K-G, Isaacs C, Clarke R, Shajahan-Haq AN. Patient advocates as partners in breast cancer research at Georgetown University Lombardi Comprehensive Cancer Center. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-10-01.

Outcomes of transplantations of cryopreserved ovarian tissue to 41 women in Denmark

STUDY QUESTION

What are the results of transplanting cryopreserved ovarian tissue?

SUMMARY ANSWER

The transplanted ovarian tissue can last up to 10 years, with no relapses following the 53 transplantations, and the chance of a successful pregnancy is currently around one in three for those with a pregnancy-wish.

WHAT IS KNOWN ALREADY

Cryopreservation of ovarian tissue is now gaining ground as a valid method for fertility preservation. More than 36 children worldwide have now been born following this procedure.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study of 41 women who had thawed ovarian tissue transplanted 53 times over a period of 10 years, including 1 patient who was lost to follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 41 Danish women, who had in total 53 transplantations, were followed for ovarian function and fertility outcome. Safety was assessed by monitoring relapse in cancer survivors.

MAIN RESULTS, AND THE ROLE OF CHANCE

Among 32 women with a pregnancy-wish, 10 (31%) had a child/children (14 children in total); this included 1 woman with a third trimester on-going pregnancy. In addition, two legal abortions and one second trimester miscarriage occurred. A total of 24 clinical pregnancies were established in the 32 women with a pregnancy-wish. The tissue remained functional for close to 10 years in some cases and lasted only a short period in others. Three relapses occurred but were unlikely to be due to the transplanted tissue.

LIMITATIONS, REASONS FOR CAUTION

Self-report through questionnaires with only in-one hospital formalised follow-up of transplanted patients could result in unreported miscarriages. The longevity of the tissue may vary by few months compared with those reported because some patients simply could not remember the date when the tissue became non-functional.

WIDER IMPLICATIONS OF THE FINDINGS

Cryopreservation of ovarian tissue is likely to become integrated into the treatment of young women, with cancer, who run a risk of losing their fertility. The full functional lifespan of grafts is still being evaluated, because many of the transplanted women have continued to maintain ovarian activity. Some of our first cases have had tissue functioning for ∼ 10 years.