From the bench to bedside to babies: translational medicine made possible by funding multidisciplinary team science

Oncofertility Knowledge and Communication: Comparison Between Medical and Surgical Oncologists and Breast Cancer Patients in Academic Chinese Centers

Background: As cancer has become a major public health issue in China, fertility preservation remains limited despite the wide application of Assisted Reproductive Technology (ART) throughout the country.

Objective: This study aimed to identify gaps in knowledge and communication as well as referrals in the previous year regarding oncofertility among medical and surgical oncologists and breast cancer patients (BCPs) in Chinese academic settings to target areas of needed improvement.

Materials and Methods: A WeChat online questionnaire was designed, distributed, and compared between medical and surgical oncology specialists and reproductive age BCPs in academic teaching settings in Shanghai.

Results: Sixty-one medical and surgical oncologists and 125 BCPs responded to the survey. 63.3% of oncologists were familiar with the term “oncofertility” compared to 25.6% of BCPs (p < 0.001). Oncologists were more likely to correctly know the costs associated with treatment (59.0 vs. 32.0%, p < 0.001); patient did not have to be married to undergo oncofertility treatment (50.8 vs. 24.8%, p < 0.001). Both oncologists and BCPs were similarly unlikely to know when patients could utilize cryopreserved tissue in the future (37.7 vs. 22.2%, p = 0.056). While oncologists reported they discussed all oncofertility options (41.0%) and offered psychological counseling (98.4%), significantly fewer BCPs reported receiving information on all options and offered counseling (3.2%, p < 0.001 and 85.6%, p < 0.01). Knowledge of oncofertility was the most important predictor for providing and receiving counseling from oncologists [OR = 6.44 (95% CI = 1.59–26.1, p = 0.009] and BCPs (OR = 3.73 95% CI: = 1.36–10.2, p = 0.011). Overall, 57.4% of oncologists referred <10 patients and none referred more than 25 patients in the past year.

Conclusion: Data suggests a significant knowledge gap and ineffective communication/comprehension exists between academic Chinese oncologists and BCPs. Continued education and raised awareness are needed to optimize utilization of oncofertility services in China.

Challenging cases in oncofertility: insights from a national specialized e-meeting for fertility preservation specialists

Purpose

To determine the use of a new specialized E-Meeting for Complex Cases in Oncofertility by fertility preservation specialists (FPSs)

Material and methods

We present 3 years of activity of the E-Meeting for Complex Cases in Oncofertility, a new tool created in September 2016 which allows national oncofertility experts to share viewpoints about challenging cases for which they do not have experience or sufficient data in order to provide them an emergency advice within 48 h. Second, a survey was conducted to evaluate the use of this e-meeting for participating FPSs.

Results

One hundred and four experts have joined the e-meeting since its set-up, and 109 challenging cases have been submitted. The mean age of the patients was 22.4 ± 8.9 years, and 87.0% were female. Each submitted case received on average of 1.8 ± 1.1 different strategies for FP and the opinions of 7.1 ± 3.4 experts. Among the FPSs who submitted cases, seeking opinions from other FPSs allowed them to confirm their care plan (N = 49, 84.4%), to offer different options to their patients (N = 34, 58.6%), and to compare their practices with those of other specialists (N = 23, 39.6%). All respondents reported a self-perceived improvement in their practice of oncologic FP (n = 80, 100.0%).

Conclusion

Specific attention should be paid to challenging cases for which the experiences of only a few individuals exist. Enhancing communication between FPSs through oncofertility networks, pooling experiences, and collecting the most complex cases is required to improve the management of these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10815-021-02275-1.

A View from the past into our collective future: the oncofertility consortium vision statement

Purpose

Today, male and female adult and pediatric cancer patients, individuals transitioning between gender identities, and other individuals facing health extending but fertility limiting treatments can look forward to a fertile future. This is, in part, due to the work of members associated with the Oncofertility Consortium.

Methods

The Oncofertility Consortium is an international, interdisciplinary initiative originally designed to explore the urgent unmet need associated with the reproductive future of cancer survivors. As the strategies for fertility management were invented, developed or applied, the individuals for who the program offered hope, similarly expanded. As a community of practice, Consortium participants share information in an open and rapid manner to addresses the complex health care and quality-of-life issues of cancer, transgender and other patients. To ensure that the organization remains contemporary to the needs of the community, the field designed a fully inclusive mechanism for strategic planning and here present the findings of this process.

Results

This interprofessional network of medical specialists, scientists, and scholars in the law, medical ethics, religious studies and other disciplines associated with human interventions, explore the relationships between health, disease, survivorship, treatment, gender and reproductive longevity.

Conclusion

The goals are to continually integrate the best science in the service of the needs of patients and build a community of care that is ready for the challenges of the field in the future.

Creating a Global Community of Practice for Oncofertility

Fertility preservation in the cancer setting, known as oncofertility, is a field that requires cross-disciplinary interaction between physicians, basic scientists, clinical researchers, ethicists, lawyers, educators, and religious leaders. Funded by the National Institutes of Health, the Oncofertility Consortium (OC) was formed to be a scientifically grounded, transparent, and altruistic resource, both intellectual and monetary, for building this new field of practice capable of addressing the unique needs of young patients with cancer. The OC has expanded its attention to include other nonmalignant conditions that can threaten fertility, and the work of the OC now extends around the globe, involving partners who together have created a community of shared effort, resources, and practices. The OC creates materials that are translated, disseminated, and amended by all participants in the field, and local programs of excellence have developed worldwide to accelerate the pace and improve the quality of oncofertility research and practice. Here we review the global oncofertility programs and the capacity building activities that strengthen these research and clinical programs, ultimately improving patient care.

Technologies for the Production of Fertilizable Mammalian Oocytes

Women affected by ovarian pathologies or with cancer can usually preserve fertility by egg/embryo freezing. When oocyte retrieval is not feasible, the only option available is ovarian tissue cryopreservation and transplantation. The culture of follicles isolated from fresh or cryopreserved ovaries is considered still experimental, although this procedure is considered safer, because the risk of unintentional spreading of cancer cells eventually present in cryopreserved tissue is avoided. Animal and human small follicles can be cultured in vitro, but standardized protocols able to produce in vitro grown oocytes with the same developmental capacity of in vivo grown oocytes are not available yet. In fact, the different sizes of follicles and oocytes, the hormonal differences existing between mono- (e.g., human, goat, cow, and sheep) and poly-ovulatory (rodents and pig) species, and the incomplete identification of the mechanisms regulating the oocyte–follicle and follicle–ovary interrelationships affect the outcome of in vitro culture. From all these attempts, however, new ideas arise, and the goal of assuring the preservation of female reproductive potential appears a more realistic possibility. This review surveys and discusses advances and challenges of these technologies that, starting from a simple attempt, are now approaching the biosynthesis of a functional engineered ovary.

Bovine eggs release zinc in response to parthenogenetic and sperm-induced egg activation

Upon fertilization or parthenogenesis, zinc is released into the extracellular space through a series of exocytic events termed zinc sparks, which are tightly coordinated with intracellular calcium transients. The zinc spark reduces the total amount of intracellular zinc, and this reduction is necessary and sufficient to induce egg activation even in the absence of calcium transients. In addition, this zinc release contributes to the block to polyspermy through modification of the zona pellucida. The zinc spark has been documented in all organisms examined to date including the mouse, two species of nonhuman primates, and human. Here we determined whether zinc sparks occur in the bovine, an important model of gamete development in mono-ovulatory mammalian species. We obtained metaphase II-arrested (MII) bovine eggs following in vitro maturation. Total zinc, assessed in single cells using X-Ray Fluorescence Microscopy, was significantly more abundant in the bovine egg compared to iron and copper. Studies with intracellular fluorescent probes revealed that labile zinc pools are localized to discrete cytoplasmic punctae enriched at the cortex. To determine whether zinc undergoes dynamic fluxes during egg activation, we parthenogenetically activated bovine eggs using two approaches: ionomycin or bovine phospholipase C zeta (bPlcζ). Both these methods induced zinc sparks coordinately with intracellular calcium transients. The zinc spark was also observed in bovine eggs following intracytoplasmic sperm injection. These results establish that zinc is the most abundant transition metal in the bovine egg, and zinc flux during egg activation - induced by chemical activation or sperm - is a highly conserved event across mammalian species.

The National Physicians Cooperative: transforming fertility management in the cancer setting and beyond

Once unimaginable, fertility management is now a nationally established part of cancer care in institutions, from academic centers to community hospitals to private practices. Over the last two decades, advances in medicine and reproductive science have made it possible for men, women and children to be connected with an oncofertility specialist or offered fertility preservation soon after a cancer diagnosis. The Oncofertility Consortium's National Physicians Cooperative is a large-scale effort to engage physicians across disciplines – oncology, urology, obstetrics and gynecology, reproductive endocrinology, and behavioral health – in clinical and research activities to enable significant progress in providing fertility preservation options to children and adults. Here, we review the structure and function of the National Physicians Cooperative and identify next steps.

Oncofertility-An emerging discipline rather than a special consideration

Originally absent from the oncologist's consult, then placed in a 'quality of life' rubric, oncofertility should now be an essential part of a comprehensive cancer treatment plan in patients of reproductive age, including adolescents and young adults (AYAs). Oncofertility encompasses the endocrine health of the patient, as well as fertility management options. Thus, pubertal transitions in males and females, bone health, and menstrual health are all part of this discipline, enabling practitioners to work in interdisciplinary teams to solve problems in reproductive health. This review provides a summary of the essential considerations required for the assessement of reproductive risk and choice of fertility preservation options as well as considerations for developing oncofertility services for AYAs.

The use of a virtual journal club to promote cross-cultural learning in the reproductive sciences

PURPOSE

Scientific literacy and communication are critical skills in the biological sciences. Journal clubs, in which peer-reviewed academic literature is discussed, are traditionally used to teach students to evaluate the literature, review scientific findings, and learn about historical, controversial, or current topics.

METHODS

We used a virtual journal club to facilitate the international interaction between two universities with master's degree programs in the reproductive sciences: the University of Murcia (Spain) and Northwestern University (USA). The virtual journal club occurred over a 2-hour period and was held using Blue Jeans Conferencing Service software and involved a total of 29 students. During this event, the students who were separated physically by thousands of miles discussed and exchanged ideas about a high-impact publication in real time. A survey assessment was administered to students at the University of Murcia following the event.

RESULTS

Positive perceptions included the establishment of cross-institutional interactions and the ability to practice scientific communication in another language. Areas noted for improvement included preparation time and engagement opportunities.

CONCLUSION

Overall, the virtual journal club is an innovative technology that can easily be broadened and has the potential to foster collaboration, ameliorate multilingual communication, improve cultural competencies, and expand professional global networks.

Ovarian tissue cryopreservation in young females through the Oncofertility Consortium's National Physicians Cooperative

AIM

To characterize the clinical indications of females (<15 years old) undergoing ovarian tissue cryopreservation (OTC) through the Oncofertility Consortium's National Physicians Cooperative (OC-NPC).

PATIENTS & METHODS

The clinical indications of 114 females who underwent OTC were classified, and their incidence was compared with childhood cancer databases.

RESULTS

Leukemias/myeloproliferative diseases/myelodysplastic diseases and hemoglobinopathies were the most prevalent oncologic and nononcologic indications for OTC, respectively. The frequencies of malignant bone tumors and soft tissue and other extraosseous sarcomas were higher in the OC-NPC cohort relative to the general population, while CNS/intracranial/intraspinal neoplasms, retinoblastoma and hepatic tumors were lower.

CONCLUSION

Those opting for OTC through the OC-NPC are at highest fertility risk, indicating that the appropriate patient populations are being identified. [Formula: see text].

Anticancer treatments and female fertility: clinical concerns and role of oncologists in oncofertility practice

INTRODUCTION

Anticancer treatments such as aggressive chemotherapy and radiotherapy have deleterious gonadotoxic side effects and are considered the most common causes of pathological and iatrogenic fertility loss in women. Areas covered: In order to preserve fertility of young women and girls with cancer, several established, experimental, and debatable options can be offered in the emerging field of oncofertility. This article reviews the effects of anticancer treatments on female fertility and discusses the current challenges and future directions of fertility preservation options that can be offered to the female patients with cancer. Expert commentary: Although promising, several medical, economic, social and legal barriers face oncofertility practice around the globe especially in underserved areas. To overcome such barriers, more effective solutions should be provided to spread awareness and enhance communication between patients, oncologists and gynecologists. Early referral by oncologists before initiation of chemotherapy and radiotherapy is an important key factor for success in female fertility preservation strategies.

Pediatric and Teen Ovarian Tissue Removed for Cryopreservation Contains Follicles Irrespective of Age, Disease Diagnosis, Treatment History, and Specimen Processing Methods

PURPOSE

Fertility preservation in a pediatric and teen female population is challenging because standard technologies of egg and embryo freezing may not be possible due to premenarcheal status. Ovarian tissue cryopreservation (OTC) with the intent of future ovarian tissue transplantation or in vitro follicle growth may be the only option to preserve fertility. The purpose of this study was to add to the general understanding of primordial follicle dynamics in young patients.

METHODS

First, the unique infrastructure of the Oncofertility Consortium National Physicians Cooperative (OC-NPC) is described, which simultaneously drives clinical fertility preservation and basic research to explore and expand the reproductive options for those in need. Then, the OC-NPC research resource is used to perform a histological evaluation of ovarian tissue from 24 participants younger than 18 years of age.

RESULTS

Primordial follicles, which comprise the ovarian reserve, were observed in all participant tissues, irrespective of variables, including age, diagnosis, previous treatment history, tissue size, and tissue processing methods. Primordial follicles were present in ovarian tissue, even in participants who had a previous history of exposure to chemotherapy and/or radiation treatment regimens, which placed them at risk for iatrogenic infertility or premature ovarian failure.

CONCLUSION

Primordial follicles were observed in ovarian tissue from all participants examined, despite population and tissue heterogeneity. These results increase the understanding of human follicle dynamics and support OTC as a promising fertility preservation modality in the young female population. Future studies to evaluate follicle quality within these tissues are warranted.

Young Adults' Access to Fertility Preservation Services at National Cancer Institute Community Oncology Research Program Minority/Underserved Community Sites: A Qualitative Study

PURPOSE

This qualitative study aims to characterize the factors that influence access to fertility preservation (FP) resources and services after cancer diagnosis at NCI Community Oncology Research Program (NCORP) minority/underserved community sites, which serve patient populations comprising at least 30% racial/ethnic minorities or rural residents.

METHODS

Phone interviews were conducted from 2014 to 2015 with interested and knowledgeable healthcare providers practicing at NCORP minority/underserved community sites, using a semi-structured interview guide. Data were transcribed, de-identified, and analyzed using qualitative analysis software, Dedoose, to determine the most common themes in access to FP resources and services.

RESULTS

Interviews were conducted with 10 board-certified physicians practicing at 10 of the 12 NCORP minority/underserved community sites; five respondents identified as oncologists, and five were reproductive endocrinology/infertility specialists (n = 4) or obstetricians/gynecologists (n = 1). Findings revealed highly variable access to FP resources at each site. Notable barriers to FP services were cost, time, provider education, lack of clinical guideline application, and perceptions among healthcare providers that negatively affect the discussion of options and risks with eligible patients.

CONCLUSION

Clinical FP guidelines and resources for cancer patients and healthcare providers need to be better integrated into existing cancer networks that serve minority and underserved patient populations. Providers need more education regarding timely provision of FP services to all newly diagnosed cancer patients of reproductive age.

Creating a Global Community of Practice for Oncofertility

Fertility preservation in the cancer setting, known as oncofertility, is a field that requires cross-disciplinary interaction between physicians, basic scientists, clinical researchers, ethicists, lawyers, educators, and religious leaders. Funded by the National Institutes of Health, the Oncofertility Consortium (OC) was formed to be a scientifically grounded, transparent, and altruistic resource, both intellectual and monetary, for building this new field of practice capable of addressing the unique needs of young patients with cancer. The OC has expanded its attention to include other nonmalignant conditions that can threaten fertility, and the work of the OC now extends around the globe, involving partners who together have created a community of shared effort, resources, and practices. The OC creates materials that are translated, disseminated, and amended by all participants in the field, and local programs of excellence have developed worldwide to accelerate the pace and improve the quality of oncofertility research and practice. Here we review the global oncofertility programs and the capacity building activities that strengthen these research and clinical programs, ultimately improving patient care.

Oncofertility: a grand collaboration between reproductive medicine and oncology

In 2007, I was asked by the University of Calgary to participate in a symposium called 'Pushing the Boundaries--Advances that Will Change the World in 20 Years'. My topic was oncofertility, a word I had just coined to describe the intersection of two disciplines--oncology and fertility--and I was thrilled to share my passion for this new field and help young women with cancer protect their future reproductive health. Fertility preservation in the cancer setting lacked a concerted effort to bridge the disciplines in an organized manner. In early 2015, I was delighted to deliver a presentation for the Society for Reproduction and Fertility titled 'Sex in Three Cities', where I gave an update on the oncofertility movement, a remarkable cross-disciplinary, global collaboration created to address the fertility preservation needs of young cancer patients. During my tour of the UK, I was impressed by the interest among the society and its members to engage colleagues outside the discipline as well as the public in a dialogue about cutting-edge reproductive science. In this invited review, I will describe the work of the Oncofertility Consortium to provide fertility preservation options in the cancer setting and accelerate the acceptance of this critical topic on a global scale. I hope that one day this word and field it created will change the world for women who had been left out of the equation for far too long.

Resilience of oocyte germinal vesicles to microwave-assisted drying in the domestic cat model

The ability to compact and inject the cat germinal vesicle (GV) into a recipient cytoplast allows exploration of a new fertility preservation strategy that avoids whole oocyte freezing. The objective of the present study was to understand the impact of water loss and storage time on GV DNA integrity. Immature cat oocytes were exposed to 1.5 M trehalose for 10 min before microwave-assisted dehydration for 0, 5, 10, 15, 20, 25, 30, or 40 min. Oocytes then were rehydrated to assess chromatin configuration and the incidence of DNA fragmentation (TUNEL assay). The moisture content progressively decreased (p<0.05) from 1.7 to 0.1 gH2O/gDW over the first 30 min, but did not decrease further (p>0.05) after 40 min. Chromatin configuration was unaffected (p>0.05) over time. The percentage of GVs with DNA fragmentation was unaltered (p>0.05) from 0 to 30 min of treatment (range, 6.1%-12%), but increased (p<0.05) to 32.5% after 40 min. Next, the influence of storage at two different supra-zero temperatures after 30 min of drying was investigated. Oocyte-loaded, microwave-treated filters were individually sealed in Dri-Shield moisture barrier bags and stored at 4°C or ambient temperature for 0 to 8 weeks. Moisture contents gradually decreased (p<0.05) from 0.12 to 0.10 gH2O/gDW after 8 weeks of storage at 4°C or ambient temperature. The percentage of GVs with DNA fragmentation more than doubled (p<0.05) from 0 (14.3%) to 2 days (30.0%-33.0%), but remained stable (p>0.05) thereafter (1 through 4 weeks, 25.0%-35.0%). Collective results demonstrate the feasibility of using microwave processing to dehydrate the mammalian GV to a moisture content that is nonlethal and enables nonfrozen storage, an alternative approach for preserving the maternal genome at cool or ambient temperature.

Alginate encapsulation supports the growth and differentiation of human primordial follicles within ovarian cortical tissue

PURPOSE

In vitro follicle growth (IVFG) is an investigational fertility preservation technique in which immature follicles are grown in culture to produce mature eggs that can ultimately be fertilized. Although progress has been made in growing primate primary and secondary follicles in vitro, it has been a relatively greater challenge to isolate and culture primordial follicles. The purpose of this study was to develop methods to grow human primordial follicles in vitro using alginate hydrogels.

METHODS

We obtained human ovarian tissue for research purposes through the National Physicians Cooperative from nationwide sites and used it to test two methods for culturing primordial follicles. First, primordial follicles were isolated from the ovarian cortex and encapsulated in alginate hydrogels. Second, 1 mm × 1 mm pieces of 500 μm-thick human ovarian cortex containing primordial follicles were encapsulated in alginate hydrogels, and survival and follicle development within the tissue was assessed for up to 6 weeks.

RESULTS

We found that human ovarian tissue could be kept at 4 °C for up to 24 h while still maintaining follicle viability. Primordial follicles isolated from ovarian tissue did not survive culture. However, encapsulation and culture of ovarian cortical pieces supported the survival, differentiation, and growth of primordial and primary follicles. Within several weeks of culture, many of the ovarian tissue pieces had formed a defined surface epithelium and contained growing preantral and antral follicles.

CONCLUSIONS

The early stages of in vitro human follicle development require the support of the native ovarian cortex.