Vitrification as an alternative means of cryopreserving ovarian tissue

Updates in preserving reproductive potential of prepubertal girls with cancer: Systematic review

INTRODUCTION

With increasing numbers of adult female survivors of childhood cancers due to advances in early diagnosis and treatment, the issue of preserving the reproductive potential of prepubertal girls undergoing gonadotoxic treatments has gained greater attention.

METHODS

According to PRISMA guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English throughout the past 15 years to explore the significant updates in preserving the reproductive potential of prepubertal girls with cancer.

RESULTS

The two established fertility preservation options, embryo freezing and egg freezing, cannot be offered routinely to prepubertal girls as these options necessitate prior ovarian stimulation and subsequent mature oocytes retrieval that are contraindicated or infeasible before puberty. Therefore, the most suitable fertility preservation options to prepubertal girls are (1) ovarian tissue freezing and autotransplantation, (2) in vitro maturation, and (3) ovarian protection techniques. In this review, we discuss in detail those options as well as their success rates, advantages, disadvantages and future directions. We also suggest a new integrated strategy to preserve the reproductive potential of prepubertal girls with cancer.

CONCLUSION

Although experimental, ovarian tissue slow freezing and orthotopic autotransplantation may be the most feasible option to preserve the reproductive potential of prepubertal girls with cancer. However, this technique has two major and serious disadvantages: (1) the risk of reintroducing malignant cells, and (2) the relatively short lifespan of ovarian tissue transplants. Several medical and ethical considerations should be taken into account before applying this technique to prepubertal girls with cancer.

Developmental Potential of Vitrified Mouse Testicular Tissue after Ectopic Transplantation

Objective

Cryopreservation of immature testicular tissue should be considered as an important factor for fertility preservation in young boys with cancer. The objective of this study is to investigate whether immature testicular tissue of mice can be successfully cryopreserved using a simple vitrification procedure to maintain testicular cell viability, proliferation, and differentiation capacity.

Materials and Methods

In this experimental study, immature mice testicular tissue fragments (0.5-1 mm²) were vitrified-warmed in order to assess the effect of vitrification on testicular tissue cell viability. Trypan blue staining was used to evaluate developmental capacity. Vitrified tissue (n=42) and fresh (control, n=42) were ectopically transplanted into the same strain of mature mice (n=14) with normal immunity. After 4 weeks, the graft recovery rate was determined. Hematoxylin and eosin (H&E) staining was used to evaluate germ cell differentiation, immunohistochemistry staining by proliferating cell nuclear antigen (PCNA) antibody, and terminal deoxynucleotidyl transferase (TdT) dUTP Nick- End Labeling (TUNEL) assay for proliferation and apoptosis frequency.

Results

Vitrification did not affect the percentage of cell viability. Vascular anastomoses was seen at the graft site. The recovery rate of the vitrified graft did not significantly differ with the fresh graft. In the vitrified graft, germ cell differentiation developed up to the secondary spermatocyte, which was similar to fresh tissue. Proliferation and apoptosis in the vitrified tissue was comparable to the fresh graft.

Conclusion

Vitrification resulted in a success rates similar to fresh tissue (control) in maintaining testicular cell viability and tissue function. These data provided further evidence that vitrification could be considered an alternative for cryopreservation of immature testicular tissue.

Ovarian tissue freezing: current status

PURPOSE OF REVIEW

This article aims to carefully evaluate a number of critical points related to ovarian tissue freezing and presents factual data in terms of live birth rates and risks.

RECENT FINDINGS

Reimplantation of frozen-thawed ovarian tissue remains an experimental procedure according to the American Society for Reproductive Medicine, despite almost 40 live births reported in the literature. Recent literature on the topic has focused on the risk of reimplanting malignant cells, so the present review assesses the risks according to disease.

SUMMARY

This manuscript emphasizes the crucial importance of not only preserving fertility in young women but also clearly explaining to patients the different available options and their respective success rates. Some previously published reviews have reported inaccurate reimplantation success rates. In this review, we report the true picture, with a live birth rate of 25%. Ovarian tissue freezing may be combined with pickup of immature oocytes (at the time of ovarian biopsy and tissue removal) or mature oocytes (if chemotherapy can be delayed).

An ultra-rapid cryo-technique for complex organisms

The soil nematode Caenorhabditis elegans is an excellent research model in cell biology, human disease and developmental studies. In this study, a novel cryopreservation technique based on a rapid cooling procedure, previously established for juveniles, was applied to adult-worms. Here we demonstrated that adults of C. elegans, a complex metazoan organism, survive to a rapid cooling and storage in liquid nitrogen (-196 °C) with a very high survival percentage (85%). The procedure relies on a Low CryoProtectant Technique (LCPT) and Ultra Rapid Cooling (URC). The high cooling rate is achieved through the reduction of sample volumes and the effectiveness of a nylon carrier. Our technique complies with the requirements for vitrification to occur. The main distinctive characters of this cryopreservation technique compared to other methods, e.g. Slow Freezing and Vitrification, are presented. Our results show that this cryopreservation method is valid for both unicellular and multicellular organisms; it is suitable for short or long time storage in liquid-nitrogen. This technique promises to be a unique and simpler method for cryostorage of cells, organisms and tissues.

Biobanking of patient and patient-derived xenograft ovarian tumour tissue: efficient preservation with low and high fetal calf serum based methods

Using patient-derived xenografts (PDXs) for preclinical cancer research demands proper storage of tumour material to facilitate logistics and to reduce the number of animals needed. We successfully established 45 subcutaneous ovarian cancer PDXs, reflecting all histological subtypes, with an overall take rate of 68%. Corresponding cells from mouse replaced human tumour stromal and endothelial cells in second generation PDXs as demonstrated with mouse-specific vimentin and CD31 immunohistochemical staining. For biobanking purposes two cryopreservation methods, a fetal calf serum (FCS)-based (95%v/v) “FCS/DMSO” protocol and a low serum-based (10%v/v) “vitrification” protocol were tested. After primary cryopreservation, tumour take rates were 38% and 67% using either the vitrification or FCS/DMSO-based cryopreservation protocol, respectively. Cryopreserved tumour tissue of established PDXs achieved take rates of 67% and 94%, respectively compared to 91% using fresh PDX tumour tissue. Genotyping analysis showed that no changes in copy number alterations were introduced by any of the biobanking methods. Our results indicate that both protocols can be used for biobanking of ovarian tumour and PDX tissues. However, FCS/DMSO-based cryopreservation is more successful. Moreover, primary engraftment of fresh patient-derived tumours in mice followed by freezing tissue of successfully established PDXs is the preferred way of efficient ovarian cancer PDX biobanking.

Impact of the cryopreservation technique and vascular bed on ovarian tissue transplantation in cynomolgus monkeys

PURPOSE

The aim of this study was to determine the best combination in terms of cryopreservation techniques and vascular bed preparation before grafting in order to obtain functional ovarian tissue after transplantation.

METHODS

Five cynomolgus monkeys were used. Strips from 10 ovaries were cryopreserved, 5 by vitrification (V), and 5 by slow-freezing (SF). Pieces of fresh ovarian tissue were used for controls. After 1 month, the strips were autografted to two different vascular beds, healed (HB) or freshly decorticated (FDB), constituting four study groups: SF-HB, SF-FDB, V-HB, and V-FDB. These were compared to fresh tissue. After 6 months, the ovaries were removed and several parameters analyzed: follicle quality, stage, density, proliferation, apoptosis, functionality, vascularization, and fibrosis. Mixed effect linear regression models were built to assess the impact of cryopreservation and vascular bed preparation on ovarian tissue viability and functionality. p values were adjusted for multiple testing using the Benjamini-Hochberg method, and q values < 0.20 were considered significant in order to achieve a 20% false discovery rate.

RESULTS

Compared to fresh tissue, no difference was observed in the percentage of morphologically normal follicles, while a significant increase was noted in the follicle proliferation rate (41%, q = 0.19), percentage of antral follicles (12%, q = 0.14), and number of vessels per area (3.3 times, q = 0.07) in the V-FDB group.

CONCLUSIONS

Vitrification associated with FDB vascular bed preparation is the best combination to obtain functional autografted ovarian tissue. Further studies are nevertheless required, with confirmed pregnancies and live births before introducing the procedure into clinical practice.

Damage to fetal bovine ovarian tissue caused by cryoprotectant exposure and vitrification is mitigated during tissue culture

PURPOSE

The objective of this study is to characterize the impact of exposure to cryoprotectants followed by vitrification on primordial follicle survival and activation using a fetal bovine model.

METHODS

In the first study, fetal bovine cortical pieces were exposed to cryoprotectants with or without sucrose and cultured up to 7 days in the presence or absence of insulin. In the second study, cortical pieces were exposed to cryoprotectants with or without sucrose, vitrified, and cultured up to 7 days after warming in the presence or absence of insulin. Viability and morphology of follicles, as well as proliferation and/or DNA repair in ovarian tissue were analyzed.

RESULTS

When compared to non-exposed controls, normal follicular morphology was affected in groups exposed to cryoprotectants only immediately post-exposure and after 1 day of culture, but improved by day 3 and did not significantly differ by day 7. Similarly, normal follicular morphology was compromised in vitrified groups after warming and on day 1 compared to controls, but improved by days 3 and 7. Proliferation and/or DNA repair in ovarian tissue was not affected by vitrification in this model. Cryoprotectant exposure and vitrification of ovarian tissue did not impair the activation of primordial follicles in response to insulin, although activation was delayed relative to non-exposed controls. Interestingly, sucrose had no noticeable protective effect.

CONCLUSION

Vitrified fetal bovine ovarian tissue has the intrinsic capacity to mitigate the immediate damage to primordial follicles' morphology and retains the capacity to activate. These findings provide a basis for a successful cryopreservation protocol for ovarian cortical tissue in other species including humans.

Effect of Human Ovarian Tissue Vitrification/Warming on the Expression of Genes Related to Folliculogenesis

Background:

Ovarian tissue cryopreservation is an alternative strategy to preserve the fertility of women predicted to undergo premature ovarian failure. This study was designed to evaluate the expression of folliculogenesis-related genes, including factor in the germline alpha (FIGLA), growth differentiation factor-9 (GDF-9), follicle-stimulating hormone receptor (FSHR), and KIT LIGAND after vitrification/warming of human ovarian tissue.

Methods:

Human ovarian tissue samples were collected from five transsexual women. In the laboratory, the ovarian medullary part was removed by a surgical blade, and the cortical tissue was cut into small pieces. Some pieces were vitrified and warmed and the others were considered as non-vitrified group (control). Follicular normality was assessed with morphological observation by a light microscope, and the expression of FIGLA, KIT LIGAND, GDF-9,, and FSHR genes was examined using real-time RT-PCR in both the vitrified and non-vitrified groups.

Results:

Overall, 85% of the follicles preserved their normal morphologic feature after warming. The percentage of normal follicles and the expression of FIGLA, KIT LIGAND, GDF-9, and FSHR genes were similar in both vitrified and non-vitrified groups (P > 0.05).

Conclusion:

Vitrification/warming of human ovarian tissue had no remarkable effect on the expression of folliculogenesis-related genes.

Effect of Exogenous Anti-Müllerian Hormone Treatment on Cryopreserved and Transplanted Mouse Ovaries

Follicle loss occurs after ovary cryopreservation and transplantation. To preserve the follicle pool of cryopreserved or grafted ovaries, anti-Müllerian hormone (AMH), which inhibits ovarian follicle recruitment, was used in a mouse model. In experiment 1, ovaries were vitrified warmed with different doses of AMH (0, 5, 15, or 45 μg/mL) supplementation. In experiment 2, AMH (0, 50, 250, and 1250 μg/mL) was injected into mice before and/or after cryopreserved ovary autotransplantation, and the recipients remained for 7 or 28 days after grafting. Ovaries were evaluated by follicle morphology, density, and apoptosis ratio. Additionally, serum follicle-stimulating hormone was measured in experiment 2. Significantly decreased follicle apoptosis were detected in AMH-treated groups when compared to the control ovaries in experiment 1, meanwhile no positive effect of exogenous AMH was found in experiment 2. Thus, we suggest AMH supplementation during ovary vitrification warming has beneficial effect on reducing follicle apoptosis.

Vitrification of human ovarian tissue: a practical and relevant alternative to slow freezing

BACKGROUND

Cryopreservation of ovarian tissue can be used to preserve the fertility of patients who are about to receive treatment(s) that could compromise their future ovarian function. Here we evaluate the effectiveness of a vitrification protocol by carrying out a systematic comparison with a conventional slow-freezing method on human ovarian tissue.

METHODS

Human ovarian samples (mean age 28.0 ± 1.1 years) were processed in parallel for each cryopreservation procedure: vitrification and slow-freezing. Following warming/thawing, histological observations and a TUNEL assay in ovarian follicles were performed and compared to unfrozen control.

RESULTS

Both cryopreservation protocols gave comparable histological outcomes. Percentage of intact follicles was 83.6 % following vitrification in a 1.5 M 1,2-propanediol (PrOH), 1.5 M ethylene glycol (EG) and 0.5 M raffinose solution, 80.7 % after slow-freezing in 1.5 M PrOH and 0.025 M raffinose, and 99.6 % in fresh tissue. Follicle density was unchanged by vitrification (0.6 follicles/mm2) or slow-freezing (0.5 follicles/mm2) compared to fresh tissue (0.7 follicles/mm2). Percentage of follicles with DNA fragmentation was not statistically different in vitrified (20.8 %) or slow-frozen (31.3 %) tissues compared to the unfrozen control (35.0 %). There was no difference in proportion of stroma cells with DNA fragmentation in vitrified (6.4 %) and slow-frozen (3.7 %) tissues compared to unfrozen tissue (4.2 %).

CONCLUSIONS

This vitrification protocol enables good preservation of ovarian quality post-warming. The evaluation of endocrine function after vitrification need to be perform in a higher cohort to evaluate if this protocol may offer a relevant alternative to conventional slow-freezing for the cryopreservation of human ovarian tissue.

Successful fertility preservation following ovarian tissue vitrification in patients with primary ovarian insufficiency

STUDY QUESTION

Is ovarian tissue cryopreservation using vitrification followed by in vitro activation (IVA) of dormant follicles a potential approach for infertility treatment of patients with primary ovarian insufficiency (POI)?

SUMMARY ANSWER

Our vitrification approach followed by IVA treatment is a potential infertility therapy for POI patients whose ovaries contain residual follicles.

WHAT IS KNOWN ALREADY

Akt (protein kinase B) stimulators [PTEN (phosphatase with TENsin homology deleted in chromosome 10) inhibitor and phosphatidyinositol-3-kinase (PI3 kinase) stimulator] activate dormant primordial follicles in vitro and ovarian fragmentation disrupts the Hippo signaling pathway, leading to the promotion of follicle growth. We treated POI patients with a combination of ovarian vitrification, fragmentation and drug treatment, followed by auto-transplantation, and reported successful follicle growth and pregnancies.

STUDY DESIGN, SIZE, DURATION

Prospective clinical study of 37 infertile women with POI between 12 August 2011 and 1 November 2013. We enrolled 10 new patients since the previous publication.

PARTICIPANTS/MATERIALS, SETTING, METHODS

POI patients were originally selected based on a history of amenorrhea for more than 1 year and elevated serum FSH levels of >40 mIU/ml (n = 31) but this was later changed to >4 months, age <40 years and serum FSH levels of >35 mIU/ml (n = 6) (mean 71.8 ± 30.8, range 35.5-197.6) so as to include patients with a shorter duration of amenorrhea. Under laparoscopic surgery, ovariectomy was performed and ovarian cortices were dissected into strips for vitrification. Some pieces were examined histologically. After warming, two to three strips were fragmented into smaller cubes before culturing with Akt stimulators for 2 days. After washing, ovarian cubes were transplanted beneath the serosa of Fallopian tubes under laparoscopic surgery. Follicle growth was monitored by ultrasound and serum estrogen levels. After oocyte retrieval from mature follicles, IVF was performed.

MAIN RESULTS AND THE ROLE OF CHANCE

Among 37 patients, 54% had residual follicles based on histology. Among patients with follicles, 9 out of 20 showed follicle growth in auto-grafts with 24 oocytes retrieved from six patients. Following IVF and embryo transfer into four patients, three pregnancies were detected based on serum hCG, followed by one miscarriage and two successful deliveries. For predicting IVA success, we found that routine histological analyses of ovarian cortices and shorter duration from initial POI diagnosis to ovariectomy are valid parameters.

LIMITATIONS, REASONS FOR CAUTION

Although our findings suggest that the present vitrification protocol is effective for ovarian tissue cryopreservation, we have not compared the potential of vitrification and slow freezing in follicle growth after grafting. We chose the serosa of Fallopian tubes as the auto-grating site due to its high vascularity and the ease to monitor follicle growth. Future studies are needed to evaluate the best auto-grafting sites for ovarian tissues. Also, future studies are needed to identify biological markers to indicate the presence of residual follicles in POI to predict IVA treatment outcome.

WIDER IMPLICATIONS OF THE FINDINGS

In POI patients, ovarian reserve, namely the pool of residual follicles, continues to diminish with age. If one ovary is cryopreserved at an earlier stage of POI, patients could undergo additional non-invasive infertility treatments before the final decision for the IVA treatment. Furthermore, in the cases of unmarried POI patients, cryopreservation of ovarian tissues allows their fertility preservation until they desire to bear children.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by Grant-In-Aid for Scientific Research (Research B: 24390376, Challenging Exploratory Research: 24659722, and Innovative Areas, Mechanisms regulating gamete formation in animals: 26114510) and by research funds from the Smoking Research Foundation, and the Takeda Science Foundation. None of the authors has a conflict of interest.

TRIAL REGISTRATION NUMBER

UMIN000010828.

Assessment of vitrification outcome by xenotransplantation of ovarian cortex pieces in γ-irradiated mice: morphological and molecular analyses of apoptosis

PURPOSE

The aim of this study was the investigation of caspase-3/7 activity and apoptosis related gene expression after vitrification and xenotransplantation of human ovarian fragments.

METHODS

Ovarian specimens were obtained from normal female-to-male transsexual women during laparoscopic surgery and cut into small pieces and were considered as vitrified and non-vitrified groups. The morphological study, terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay, caspase-3/7 activity and apoptosis related gene expression analysis were done in both non-vitrified and vitrified groups in two steps (before transplantation of ovarian tissues and 30 days after transplantation).

RESULT(S)

In spite of high rate of normal follicles in both non-transplanted tissues these rates were significantly decreased in vitrified and non-vitrified grafted tissues, moreover grafted-vitrified tissue showed significantly less normal follicles than grafted-non-vitrified group (P < 0.05). The expression of some pro and anti-apoptotic genes in vitrified-warmed tissues were not changed compared to non-vitrified ones but the expression of Fas and caspase8 was increased and the expression of BRIC5 was decreased in this group (P < 0.05). In transplanted vitrified group the Bcl2, FasL and BRIC5 gene expression was high and caspase8 was low (P < 0.05). The expression of all genes in both grafted groups was more than non-grafted tissues except for caspase8 (P < 0.05). The TUNEL positive signals and caspase-3/7 activity were increased in both grafted groups compared to non-grafted groups and this enzyme activity in grafted-vitrified group was more than grafted-non-vitrified group (P < 0.05).

CONCLUSION(S)

This study provides the first evidence on the significant effect of vitrification on follicular apoptosis of grafted human ovarian tissue at mRNA level. The signs of follicular survival or degeneration detected by morphological assessment and caspase-3/7 activity were closely correlated to the changes in expression of apoptosis-related genes.

Fertility preservation in women with cancer

Enhanced long-term survival rates of young women with cancer and advances in reproductive medicine and cryobiology have culminated in an increased interest in fertility preservation methods in girls and young women with cancer. Present data suggest that young patients with cancer should be referred for fertility preservation counselling quickly to help with their coping process. Although the clinical application of novel developments, including oocyte vitrification and oocyte maturation in vitro, has resulted in reasonable success rates in assisted reproduction programmes, experience with these techniques in the setting of fertility preservation is in its infancy. It is hoped that these and other approaches, some of which are still regarded as experimental (eg, ovarian tissue cryopreservation, pharmacological protection against gonadotoxic agents, in-vitro follicle growth, and follicle transplantation) will be optimised and become established within the next decade. Unravelling the complex mechanisms of activation and suppression of follicle growth will not only expand the care of thousands of women diagnosed with cancer, but also inform the care of millions of women confronted with reduced reproductive fitness because of ageing.

Autotransplantation of cryopreserved ovarian tissue--effective method of fertility preservation in cancer patients

OBJECTIVE

To review the literature and to present the latest advances in the autotransplantation of cryopreserved ovarian tissue.

MATERIALS AND METHODS

A literature review was conducted for all relevant articles assessing the fertility preservation, ovarian tissue transplantation, standard freezing and vitrification of ovarian tissue.

RESULTS

One of the promising and effective methods for fertility preservation may be the autotransplantation of cryopreserved ovarian tissue. At present, 30 babies have been born after orthotopic autotransplantation of frozen-thawed human ovarian tissue. Restoration of ovarian activity occurs between 3.5 months and 6.5 months. The longevity of autotransplanted ovarian tissue is about 5-7 years. The follicles are similarly preserved after all freezing methods; however, the ovarian stroma is significantly better preserved after vitrification than after slow freezing. An important topic for further research is preparation of the "vascular bed", optimization of vitrification technique and the development of alternative procedures to avoid the transmission of cancer cells via ovarian tissue autotransplantation - "artificial ovary".

CONCLUSIONS

Cryopreservation of ovarian tissue has unique advantages over other strategies. This method: (1) does not delay cancer treatment; (2) is safer for hormone dependent malignancy; (3) can be done independent of menstrual cycles; (4) is the only option for prepubertal girls; (5) can restore not only fertility but endocrine function.

Slow-freezing versus vitrification for human ovarian tissue cryopreservation

PURPOSE

Ovarian tissue can be cryopreserved prior to chemotherapy using either the slow-freezing or the vitrification method; however, the data on the equality of the procedures are still conflicting. In this study, a comparison of the cryo-damage of human ovarian tissue induced by either vitrification or slow-freezing was performed.

METHODS

Ovarian tissue from 23 pre-menopausal patients was cryopreserved with either slow-freezing or vitrification. After thawing/warming, the tissue was histologically and immunohistochemically analyzed and cultured in vitro. During tissue culture the estradiol release was assessed.

RESULTS

No significant difference was found in the proportion of high-quality follicles after thawing/warming in the slow-freezing and vitrification group, respectively (72.7 versus 66.7 %, p = 0.733). Estradiol secretion by the ovarian tissue was similar between groups during 18 days in vitro culture (area-under-the-curve 5,411 versus 13,102, p = 0.11). Addition of Sphingosine-1-Phosphate or Activin A to the culture medium did not alter estradiol release in both groups. The proportion of Activated Caspase-3 or 'Proliferating-Cell-Nuclear-Antigen' positive follicles at the end of the culture period was similar between slow-freezing and vitrification.

CONCLUSION(S)

Slow-freezing and vitrification result in similar morphological integrity after cryopreservation, a similar estradiol release in culture, and similar rates of follicular proliferation and apoptosis after culture.

Ovarian tissue cryopreservation in young cancer patients for fertility preservation

Several options are currently available to preserve fertility and give female cancer survivors a chance to have children at a later date, including the cryopreservation of embryos, oocytes, and ovarian tissue. Selection of the most suitable strategy to preserve fertility depends on the type and timing of anticancer therapy, the cancer, the patient's age, and the presence of the patient's partner. Several studies have shown that the ovarian tissue can be successfully frozen and later grafted in the human womb. To date, approximately 30 live births have been achieved after the transplantation of frozen-thawed ovarian tissue. At present, the standard procedure for cryopreservation of ovarian tissue is the slow-cooling method. The slow-cooling method uses an optimal cooling rate for the target cells, and relies on extracellular ice crystals to gradually dehydrate and equilibrate the tissue. Several groups reported that slow cooling is more efficient than vitrification for the cryopreservation of human ovarian tissue. However, vitrification can be performed under a variety of conditions, and therefore, the choice of methods is important. In addition, vitrification traps aqueous solutions in an amorphous, "vitreous" solid phase that prevents ice crystal formation in tissues. Vitrification methods that were developed using mice and monkey have recently been shown to improve the viability of vitrified ovarian tissues. In this review article, recent topics of ovarian tissue cryopreservation are described.

Human ovarian tissue vitrification/warming has minor effect on the expression of apoptosis-related genes

BACKGROUND

In this study, we evaluated the incidence of apoptosis at the ultrastructural levels and expression of some apoptosis-related genes in vitrified human ovarian tissue just after warming.

METHODS

Human ovarian tissue biopsies from 23 women after caesarean section were transported to the laboratory within 2 hours, and then they were cut into small pieces. Some pieces were vitrified and warmed and the other samples were considered as control. Apoptosis was assessed by a transmission electron microscope and also by molecular analysis of pro-apoptotic (Fas, FasL, Bax, p53, caspase8, and caspase3) and antiapoptotic (Bcl-2 and BIRC5) genem RNA levels using real-time RT-PCR before and after vitrification.

RESULTS

No sign of apoptosis was shown ultrastructurally in vitrified samples. The level of FasL, Bcl-2, Bax, p53, and caspase3 mRNA and Bax:Bcl-2 ratio were similar in non-vitrified and vitrified groups; however, the expression of Fas and caspase8 genes was higher and BIRC5 was lower in vitrified samples compared to non-vitrified group (P<0.05).

CONCLUSION

The fine structure of human vitrified ovarian tissue was well preserved; moreover, vitrification was shown to affect the expression of some apoptosis-related genes. However, additional study is needed to confirm this observation.

Good preservation of stromal cells and no apoptosis in human ovarian tissue after vitrification

The aim of this study was to develop a vitrification procedure for human ovarian tissue cryopreservation in order to better preserve the ovarian tissue. Large size samples of ovarian tissue retrieved from 15 female-to-male transgender subjects (18–38 years) were vitrified using two solutions (containing propylene glycol, ethylene glycol, and sucrose at different concentrations) in an open system. Light microscopy, transmission electron microscopy, and TUNEL assay were applied to evaluate the efficiency of the vitrification protocol. After vitrification/warming, light microscopy showed oocyte nucleus with slightly thickened chromatin and irregular shape, while granulosa and stromal cells appeared well preserved. Transmission electron microscopy showed oocytes with slightly irregular nuclear shape and finely dispersed chromatin. Clear vacuoles and alterations in cellular organelles were seen in the oocyte cytoplasm. Stromal cells had a moderately dispersed chromatin and homogeneous cytoplasm with slight vacuolization. TUNEL assay revealed the lack of apoptosis induction by vitrification in all ovarian cell types. In conclusion after vitrification/warming the stromal compartment maintained morphological and ultrastructural features similar to fresh tissue, while the oocyte cytoplasm was slightly damaged. Although these data are encouraging, further studies are necessary and essential to optimize vitrification procedure.

Fertility preservation in women

In women, ∼10% of cancers occur in those <45 years old. Chemotherapy, radiotherapy and bone marrow transplantation can cure >90% of girls and young women with diseases that require such treatments. However, these treatments can result in premature ovarian failure, depending on the follicular reserve, the age of the patient and the type and dose of drugs used. This article discusses the different fertility preservation strategies: medical therapy before chemotherapy; ovarian transposition; embryo cryopreservation; oocyte vitrification; and ovarian tissue cryopreservation. The indications, results and risks of these options are discussed. Whether medical therapy should be used to protect the gonads during chemotherapy remains a source of debate. Fertility preservation needs to be completed before chemotherapy and/or irradiation is started and might take 2-3 weeks with established techniques such as embryo or oocyte cryopreservation. Further studies are needed in patients with cancer to confirm the excellent outcomes obtained in patients without cancer or in egg donation programmes. For prepubertal girls or cases where immediate therapy is required, cryopreservation of ovarian tissue is the only available option. Finally, possible future approaches are reviewed, including in vitro maturation of nonantral follicles, the artificial ovary, oogonial stem cells and drugs to prevent follicle loss.

In vitro development of human primordial follicles to preantral stage after vitrification

PURPOSE

The aim was to culture primordial follicles in vitro to reach preantral stage in vitrified human ovarian tissue.

METHODS

Ovarian tissue samples were obtained from six women. Tissue strips were vitrified by infiltration with a cryoprotectant followed by mounting on a stainless steel carrier. After culturing for 7 days the morphology and developmental stages of follicles enclosed in fresh and vitrified groups were analyzed.

RESULTS

High proportion of viable follicles in vitrified ovarian strips was obtained. After culturing for 7 days the percentage of secondary and preantral follicles increased significantly (P < 0.05) whereas primordial and transitory follicles showed a significant decrease (P < 0.05) compared to their respective counterparts at day 0 of culture.

CONCLUSIONS

Vitrification of ovarian strips with an improved carrier device and culturing of follicles in ovarian strips after warming yielded developed follicles with high viability and morphological integrity that may be suitable for use in fertility preservation among cancer patients.

Evaluation of apoptosis in long-term culture of vitrified mouse whole ovaries

The purpose of the present study was to investigate the development of follicles and incidence of apoptosis in vitrified neonatal mouse ovaries cultured in vitro in the presence of leukemia inhibitory factor (LIF). The vitrified and non-vitrified ovaries of 1-week-old mouse were cultured in the presence or absence of LIF for 7 days. At the beginning and at the end of culture period in each ovary of all groups of study the mean area and the development of ovarian follicles were analyzed; moreover, the incidence of apoptosis was assessed by transmission electron microscopy, terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling (TUNEL) method, DNA laddering and caspase-3/7 activity technique. The hormonal assay was done on the conditioned media collected during culture period. The proportion of preantral follicles and the levels of hormones increased in all cultured groups and it was significantly higher in LIF treated groups than in their control (P<0.001). The ultrastructural characteristics of cell death, DNA fragmentation and TUNEL positive signals were prominent in vitrified cultured ovaries. The level of caspase-3/7 activity was higher in vitrified cultured ovaries. LIF supplementation during 7 days of culture appeared to significantly preserve cells function and increase the follicular development of both vitrified and non-vitrified ovaries.

Does prepubertal testicular tissue vitrification influence spermatogonial stem cells (SSCs) viability?

PURPOSE

Testicular cryopreservation prior to chemotherapy or radiotherapy in children with cancer is one of the ways to preserve fertility. However, cryopreservation may cause damage to the testicular parenchyma cells. The objective of this study was to investigate effects of vitrification on the intracellular LDH leakage, cell cycle/apoptotic responses and apoptosis-related gene expression patterns in the spermatogonial stem cells (SSCs) obtained from the vitrified testis.

METHODS

The testes of the mice pups (6-day-old, BALB/c) both vitrified and fresh groups were digested with enzymes (collagenase, DNaseΙ, trypsin-EDTA) to disperse the cells. The SSCs, type A, were isolated from the rest of testicular cells by MACS. The amount of damage to the SSCs immediately was evaluated by Cytotoxicity assay, Flow cytometry assay and Real-time PCR.

RESULTS

The intracellular LDH leakage in the SSCs,harvested from the vitrified testes, was less reported compared with the fresh ones. Moreover, the percentage of apoptotic and necrotic SSCs obtained from the vitrified testes was lower than that of yielded from the fresh samples. Also, the apoptosis-related genes of the SSCs,collected from the vitrified testes, changed their expression profile as increasing P53 and BCL-2 expression levels and decreasing Bax and Fas expression levels.

CONCLUSIONS

The study indicates that vitrification of prepubertal testicular tissue does not increase the expression profile of apoptosis-related genes such as Bax and Fas in the testicular SSCs consistent with diminished cell apoptotic/necrotic responses and no increasing intracellular LDH leakage.

Preservation of human ovarian follicles within tissue frozen by vitrification in a xeno-free closed system using only ethylene glycol as a permeating cryoprotectant

OBJECTIVE

To study the preservation of follicles within ovarian tissue vitrified using only one or a combination of three permeating cryoprotectants.

DESIGN

Experimental study.

SETTING

University hospital.

DONOR(S)

Ovarian tissue was donated by consenting women undergoing elective cesarean section.

INTERVENTION(S)

Ovarian tissue was vitrified in closed sealed vials using either a combination of dimethyl sulfoxide, 1,2-propanediol, and ethylene glycol (EG), or only EG as permeating cryoprotectants.

MAIN OUTCOME MEASURE(S)

Ovarian tissue was vitrified with the use of two vitrification methods. Tissue from the same donor was used for comparison of two different solutions. The morphology of the follicles was evaluated after vitrification, warming, and culture by light microscopy and transmission electron microscopy. Apoptosis was assessed by immunohistochemistry for active caspase-3 in fresh and vitrified tissue.

RESULT(S)

Light and electron microscopic analysis showed equally well preserved morphology of oocytes, granulosa cells, and ovarian stroma when either of the vitrification solutions was used. No apoptosis was observed in primordial and primary follicles.

CONCLUSION(S)

Using only EG as a permeating cryoprotectant in a closed tube gives as good ultrastructural preservation of ovarian follicles as a more complicated system using several cryoprotectants.

Stem cell therapeutic possibilities: future therapeutic options for male-factor and female-factor infertility?

Recent advances in assisted reproduction treatment have enabled some couples with severe infertility issues to conceive, but the methods are not successful in all cases. Notwithstanding the significant financial burden of assisted reproduction treatment, the emotional scars from an inability to conceive a child enacts a greater toll on affected couples. While methods have circumvented some root causes for male and female infertility, often the underlying causes cannot be treated, thus true cures for restoring a patient's fertility are limited. Furthermore, the procedures are only available if the affected patients are able to produce gametes. Patients rendered sterile by medical interventions, exposure to toxicants or genetic causes are unable to utilize assisted reproduction to conceive a child - and often resort to donors, where permitted. Stem cells represent a future potential avenue for allowing these sterile patients to produce offspring. Advances in stem cell biology indicate that stem cell replacement therapies or in-vitro differentiation may be on the horizon to treat and could cure male and female infertility, although significant challenges need to be met before this technology can reach clinical practice. This article discusses these advances and describes the impact that these advances may have on treating infertility.

Cryobanking of farm animal gametes and embryos as a means of conserving livestock genetics

In the last few decades, farm animal genetic diversity has rapidly declined, mainly due to changing market demands and intensification of agriculture. But, since the removal of single species can affect the functioning of global ecosystems, it is in the interest of international community to conserve the livestock genetics and to maintain biodiversity. Increasing awareness on the reduction of breed diversity has prompted global efforts for conservation of farm animal breeds. The goals of conservation are to keep genetic variation as gene combinations in a reversible form and to keep specific genes of interest. For this purpose two types of strategies are usually proposed: in situ and ex situ conservation. In situ conservation is the breed maintaining within the livestock production system, in its environment through the enhancement of its production characteristics. Ex situ in vivo conservation is the safeguard of live animals in zoos, wildlife parks, experimental farms or other specialized centres. Ex situ in vitro conservation is the preservation of genetic material in haploid form (semen and oocytes), diploid (embryos) or DNA sequences. In the last few years, ex situ in vitro conservation programs of livestock genetic resources have focused interest on cryopreservation of gametes, embryos and somatic cells as well as testis and ovarian tissues, effectively lengthening the genetic lifespan of individuals in a breeding program even after the death. However, although significant progress has been made in semen, oocytes and embryo cryopreservation of several domestic species, a standardized procedure has not been established yet. The aim of the present review is to describe the cryobanking purposes, the collection goals, the type of genetic material to store and the reproductive biotechnologies utilized for the cryopreservation of farm animal gametes and embryos.

Morphological and functional preservation of pre-antral follicles after vitrification of macaque ovarian tissue in a closed system

STUDY QUESTION

What are the appropriate conditions to vitrify the macaque ovarian cortex in a large-volume, closed system that will preserve functional pre-antral follicles?

SUMMARY ANSWER

The combination of glycerol, ethylene glycol (EG) and polymers with cooling in liquid nitrogen (LN2) vapor and a two-step warming procedure was able to preserve tissue and follicle morphology as well as function of a small population of secondary follicles in the macaque ovarian cortex following vitrification in a closed system.

WHAT IS KNOWN ALREADY

For prepubertal cancer patients or those who require immediate cancer therapy, ovarian tissue cryopreservation offers the only hope for future fertility. However, the efficacy of live birth from the transplantation of cryopreserved ovarian tissue is still unclear. In addition, live birth from cryopreserved ovarian tissue has only been demonstrated after tissue autotransplantation, which poses the risk of transmitting metastatic cancer cells back to the cancer survivor in certain cancers.

STUDY DESIGN, SIZE, DURATION

Non-human primate model, n = 4, randomized, control versus treatment. End-points were collected from tissue histology, tissue culture (48 h) and isolated secondary follicle culture (6 weeks).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two vitrification solutions (VSs) containing EG + glycerol (VEG) and EG + dimethylsulfoxide (VED) were examined for vitrification, devitrification and thermodynamic properties. Once the optimal VS was determined, macaque ovarian cortical pieces (3 × 3 × 0.5 mm(3)) were divided into fresh and two vitrified groups (VEG and VED). For the vitrification groups, tissues were exposed to 1/4, 1/2 and 1× VS for 5 min/step as well as 1× VS + polymers for 1 min at 37°C, loaded into high-security straws with 1 ml of VS + polymers, heat sealed and cooled in LN2 vapor. Samples were warmed in a 40°C water bath and cryoprotective agents were diluted with 1, 0.5, 0.25 and 0 M sucrose. Tissues were fixed for histological analysis and cultured with bromodeoxyuridine (BrdU). Secondary follicles from VEG tissues were encapsulated and cultured (n = 24/treatment/animal). Follicle health, diameter and steroid [progesterone, androstenedione (A4), estradiol (E2)] production were analyzed weekly.

MAIN RESULTS AND THE ROLE OF CHANCE

Dense stroma and intact pre-antral follicles were observed using VS containing 27% glycerol, 27% EG and 0.8% polymers with cooling in LN2 vapor and a two-step warming. Higher cooling and warming rates led to fracturing. BrdU uptake was evident in granulosa cells of growing follicles in fresh and vitrified tissues. Secondary follicles from fresh tissues (70 ± 12%) and tissues vitrified with VEG (52 ± 2%) showed similar survival rates (all data: mean ± SEM; P > 0.05). For both groups, the initial follicle diameter was similar and increased (P < 0.05) by Week 3, but diameters in vitrified follicles were smaller (P < 0.05) by Week 6 (566 ± 27 µm) than those of the fresh follicles (757 ± 26 µm). Antrum formation rates were lower (P < 0.05) for vitrified (37 ± 6%) relative to fresh (64 ± 8%) follicles. There was no significant change in levels in culture media of E2, P4 and A4 between fresh and VEG groups at any time point during culture.

LIMITATIONS, REASONS FOR CAUTION

Only in vitro studies are reported. Future in vivo tissue transplantation studies will be needed to confirm long-term function and fertility potential of vitrified ovarian tissues.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first demonstration of antral follicle development during 3D culture following ovarian tissue vitrification in a closed system using primate ovarian tissue. While diminished antrum formation and slower growth in vitro reflect residual cryodamage, continued development of ovarian tissue vitrification based on cryobiology principles using a non-human primate model will identify safe, practical and efficient protocols for eventual clinical use. Tissue function following heterotopic transplantation is currently being examined.

STUDY FUNDING/COMPETING INTEREST(S)

National Institutes of Health (NIH) Oncofertility Consortium UL1 RR024926 (1RL1-HD058293, HD058295, PL1 EB008542), the Eunice Kennedy Shriver NICHD/NIH (U54 HD018185) and ONPRC 8P51OD011092-53. G.M.F. works for the company that makes the polymers used in the current study.

A review of 15 years of ovarian tissue bank activities

PURPOSE

To review 15 years of activities in ovarian tissue cryobanking from medical database files, including patient indications, histological evaluation and clinical characteristics.

METHODS

Retrospective longitudinal analysis of data from an ovarian tissue bank in an academic hospital. Five hundred and eighty-two patients had their ovarian tissue cryobanked between April 1997 and January 2012. Analysis of cryobanking database: precryopreservation patient characteristics, indications and safety issues, laboratory files and postcryopreservation clinical data.

RESULTS

Of the 582 patients who had their ovarian tissue cryopreserved, 106 patients donated for research purposes and 476 patients for fertility preservation and long-term cryopreservation. Clinical data analysis of the 476 patients revealed a mean age at the time of cryopreservation of 23 ± 8.5 years (range: 9 months - 39 years), with 96.2 % of subjects aged ≤35 years (n = 458). Among 391 cases of malignant disease, hematological malignancies (39.9 %, n = 156) and breast cancer (21.7 %, n = 85) were the two main indications. At histology, malignant cells were found in ovarian tissue from leukemia patients (n = 3) and non-Hodgkin's lymphoma patients (n = 2). Eleven patients underwent autotransplantation, resulting in 5 live births and 1 ongoing pregnancy.

CONCLUSION

This is the largest and most comprehensive study to describe and analyze indications and clinical patient characteristics before and after ovarian tissue cryopreservation. The procedure is safe, easy and promising. The database concept is a useful tool in patient selection for autotransplantation.

Optimising vitrification of human oocytes using multiple cryoprotectants and morphological and functional assessment

Oocyte vitrification is a clinical practice that allows preservation of fertility potential in women. Vitrification involves quick cooling using high concentrations of cryoprotectants to minimise freezing injuries. However, high concentrations of cryoprotectants have detrimental effects on oocyte quality and eventually the offspring. In addition, current assessment of oocyte quality after vitrification is commonly based only on the morphological appearance of the oocyte, raising concerns regarding its efficiency. Using both morphological and functional assessments, the present study investigated whether combinations of cryoprotectants at lower individual concentrations result in better cryosurvival rates than single cryoprotectants at higher concentrations. Surplus oocytes from IVF patients were vitrified within 24 h after retrieval using the Cryotop method with several cryoprotectants, either individually or in combination. The morphological and functional quality of the vitrified oocytes was investigated using light microscopy and computer-based quantification of mitochondrial integrity, respectively. Oocyte quality was significantly higher using a combination of cryoprotectants than vitrification with individual cryoprotectants. In addition, the quality of vitrified oocyte varied depending on the cryoprotectants and type of combination used. The results of the present study indicate that observations based purely on the morphological appearance of the oocyte to assess the cryosurvival rate are insufficient and sometimes misleading. The outcome will have a significant implication in the area of human oocyte cryopreservation as an important approach for fertility preservation.

[Ovarian cryopreservation: what future?]

Ovarian cortex cryobanking is a technique of fertility preservation that led to the birth of about 20 children in the world since 2004. Its main limitations are low follicular survival rate after thawing and transplantation and the risk of disease reintroduction. A lot of research is currently conducted in order to optimize both efficacy and safety of the graft and to develop alternative techniques to restore fertility. These advances will allow oncologists to offer this technique to a growing number of patients in the context of fertility preservation (for medical or social indications), but also in other indications such as puberty induction or menopause treatment.

Apoptosis of human ovarian tissue is not increased by either vitrification or rapid cooling

This study evaluated the incidence of morphological changes, as assessed by light microscopy, and apoptosis in vitrified and rapidly cooled human ovarian tissue. Apoptosis was assessed 30 min and 24h after warming using transmission electron microscopy, terminal deoxynucleotidyl transferase-mediated dUDP nick-end labelling (TUNEL) assay and DNA fragmentation, as determined by gel electrophoresis. The results showed no significant changes in morphology, chromatin condensation, DNA fragmentation or TUNEL-positive cells in follicles attributable to cryopreservation or exposure to the cryoprotectant solutions alone. In conclusion, the cryopreservation protocols did not affect the incidence of apoptosis and either protocol could be an alternative to slow cooling of ovarian tissue. This study evaluated the incidence of morphological changes, as assessed by light microscopy, and apoptosis in human ovarian tissue cryopreserved using two different methods, i.e. vitrification and rapid cooling. Apoptosis was assessed in tissue 30 min and 24h after warming using transmission electron microscopy and terminal deoxynucleotidyl transferase-mediated dUDP nick-end labelling (TUNEL) assay and DNA fragmentation as determined by gel electrophoresis. The results showed no significant changes in morphology, chromatin condensation, DNA fragmentation or TUNEL-positive cells in follicles attributable to cryopreservation or exposure to the cryopreservation solutions alone. In conclusion, the cryopreservation protocols did not affect the incidence of apoptosis in human ovarian tissue and either protocol could be an alternative to slow cooling for the preservation of ovarian tissue.

Fertility Preservation Methods in Breast Cancer

Thanks to the recent advances in reproductive medicine, more and more young women with breast cancer may be offered the possibility of preserving their fertility. Fertility can be endangered by chemotherapy, by treatment duration and by patient's age at diagnosis. The currently available means to preserve a young woman's fertility are pharmacological protection with gonadotrophin-releasing hormone analogues during chemotherapy, and ovarian tissue or oocyte/embryo freezing before treatment. New future venues, including in vitro maturation, will improve the feasibility and efficacy of the fertility preservation methods in breast cancer patients.

Follicular dynamic and immunoreactions of the vitrified ovarian graft after host treatment with variable regimens of melatonin

PROBLEM

This study investigates dose-dependent effects of melatonin on ovarian graft.

METHOD OF STUDY

Vitrified-thawed whole ovaries of newborn mice were grafted into ovariectomized mature ones. Melatonin (20, 50, 100, and 200 mg/kg/day) was administrated to separate groups of host mice for 32 days. IgM and IgG antibodies, Th1 and Th2 cytokines, and melatonin in recipient's blood were measured. Subsequent survival of the grafted ovaries was scored. An assessment of follicular morphology was performed using TUNEL assay and hematoxylin-eosin staining.

RESULTS

The administration of melatonin did not disturb the circadian rhythm of melatonin concentration. The ovarian graft lifespan was prolonged at 200 mg/kg/day melatonin (P < 0.001). However, in doses of higher than 20 mg/kg/day melatonin, the proportion of healthy follicles and ovary size decreased. Th1 cytokines levels were reduced dose dependently. However, the effect of melatonin on Th2 cytokines was not pronounced. IgM and IgG2a decreased in recipients receiving 200 mg/kg/day melatonin in comparison with non-treated group (P < 0.001), while this variables were significantly increased at the dose of 50 mg/kg/day (P < 0.001).

CONCLUSION

Melatonin at 200 mg/kg/day has an immunosuppresent effect and produce prolongation of graft survival. However, the associated reduction in healthy follicles suggests that melatonin in doses of higher than 20 mg/kg/day has no preventative ischemic action.