Recent advances in the field of ovarian tissue cryopreservation and opportunities for research

Unexpected discovery of fetal bones instead of an intrauterine device: A unique gynecological case report

This case report details an unusual and unexpected finding in a 37-year-old woman with a history of two cesarean sections, who had an intrauterine device implanted. The patient presented with symptoms of abnormal uterine bleeding and dysmenorrhea. An initial ultrasound confirmed the presence of the intrauterine device. However, a startling discovery was made during the intrauterine device removal procedure: fetal bones were found within the patient. This case underscores the importance of thorough diagnostic evaluations in gynecological practice, particularly when dealing with patients who have complex gynecological histories. Significantly, it brings to light the necessity of employing hysteroscopy for comprehensive diagnostic assessment in cases of abnormal uterine bleeding post-abortion. This approach could aid in identifying rare and unexpected findings, such as retained fetal bones, which might be missed by conventional ultrasound. The report emphasizes the need for vigilance and thoroughness in gynecological examinations and contributes to the understanding of potential complications and anomalies associated with intrauterine device usage and post-abortion care.

Prospects for fertility preservation: the ovarian organ function reconstruction techniques for oogenesis, growth and maturation in vitro

Today, fertility preservation is receiving more attention than ever. Cryopreservation, which preserves ovarian tissue to preserve fertility in young women and reduce the risk of infertility, is currently the most widely practiced. Transplantation, however, is less feasible for women with blood-borne leukemia or cancers with a high risk of ovarian metastasis because of the risk of cancer recurrence. In addition to cryopreservation and re-implantation of embryos, in vitro ovarian organ reconstruction techniques have been considered as an alternative strategy for fertility preservation. In vitro culture of oocytes in vitro Culture, female germ cells induction from pluripotent stem cells (PSC) in vitro, artificial ovary construction, and ovaria-related organoids construction have provided new solutions for fertility preservation, which will therefore maximize the potential for all patients undergoing fertility preservation. In this review, we discussed and thought about the latest ovarian organ function reconstruction techniques in vitro to provide new ideas for future ovarian disease research and fertility preservation of patients with cancer and premature ovarian failure.

A comprehensive review and update on human fertility cryopreservation methods and tools

The broad conceptualization of fertility preservation and restoration has become already a major concern in the modern western world since a large number of individuals often face it in the everyday life. Driven by different health conditions and/or social reasons, a variety of patients currently rely on routinely and non-routinely applied assisted reproductive technologies, and mostly on the possibility to cryopreserve gametes and/or gonadal tissues for expanding their reproductive lifespan. This review embraces the data present in human-focused literature regarding the up-to-date methodologies and tools contemporarily applied in IVF laboratories' clinical setting of the oocyte, sperm, and embryo cryopreservation and explores the latest news and issues related to the optimization of methods used in ovarian and testicular tissue cryopreservation.

Ultrastructure of human ovarian tissues and risk of cancer cells re-implantation after transplantation to chick embryo chorioallantois membrane (CAM) following vitrification or slow freezing

Ovarian follicle depletion and premature ovarian failure are significant challenges in cancer patients subjected to radio- or chemotherapy. Ovarian tissue (OT) cryopreservation would be an option when other fertility preservation methods are not accessible. This study aimed to analyze the structure and ultrastructure of human OTs transplanted onto chick embryo chorioallantois membrane (CAM) after cryopreservation by vitrification or slow freezing. OTs from 10 cancer patients underwent cryopreservation. CAM transplantation was done on fresh and cryopreserved OTs, to assign samples to nine study groups as follows: 1) FI-FIII = fresh, 5- and 10-days post-CAM transplantation groups; 2) VI-VIII = vitrified, 5- and 10-days post-transplantation vitrified groups; 3) SFI-SFIII: slow frozen, 5- and 10-days post-transplantation slow freezing groups. Proliferation ability, folliculogenesis, and structural and ultrastructure were analyzed. The density of primordial follicles did not change after both freezing methods, but reduced after 5 (P ≥ 0.05) and 10 days (P ≤ 0.05) post-CAM transplantation. The follicular grade significantly decreased in all transplanted tissues (P ≤ 0.0). The proliferation marker increased after cryopreservation, but reduced after transplantation (P ≤ 0.05). TEM evaluation showed better follicular ultrastructure in the fresh group, after transplantation. Stromal ultrastructure appeared more preserved after vitrification compared with slow freezing. There was no sign of malignant cell contamination after transplantation. Some follicular TEM abnormalities were found in both methods of freezing, with a better transplantation rate after vitrification. Also, enhanced follicular activation resulted in faster follicular depletion in this method. The information regarding post grafting events would improve our knowledge for longer OTs' lifespans.

Tumor-Derived Oxidative Stress Triggers Ovarian Follicle Loss in Breast Cancer

Breast cancer is a common indication for ovarian cryopreservation. However, whether the grafting ovarian tissue meets functional requirements, as well as the need for additional interventions, remains unclear. The current study demonstrates abnormal serum hormones in breast cancer in humans and breast cancer cell line-derived tumor-bearing mice, and for the first time shows tumor-induced loss of primordial and growing follicles and the number of follicles being lost to either growth or atresia. A gene signature of tumor-bearing mice demonstrates the disturbed regulatory network of steroidogenesis, which links to mitochondria dysfunction in oocytes and granulosa cells via the phosphatidylinositol 3-kinase signaling pathway. Notably, increased reactive oxygen species are identified in serum and ovarian tissues in tumor-bearing mice. Furthermore, supplementation with vitamin C promotes follicular quiescence, repairing tumor-induced follicle loss via inactivation of the phosphatidylinositol 3-kinase-Akt-mammalian target of rapamycin pathway, indicating that antioxidants should be a potential fertility therapy to achieve more numbers of healthy follicles ready for ovarian cryopreservation.

Tissue Engineering in Gynecology

Female gynecological organ dysfunction can cause infertility and psychological distress, decreasing the quality of life of affected women. Incidence is constantly increasing due to growing rates of cancer and increase of childbearing age in the developed world. Current treatments are often unable to restore organ function, and occasionally are the cause of female infertility. Alternative treatment options are currently being developed in order to face the inadequacy of current practices. In this review, pathologies and current treatments of gynecological organs (ovaries, uterus, and vagina) are described. State-of-the-art of tissue engineering alternatives to common practices are evaluated with a focus on in vivo models. Tissue engineering is an ever-expanding field, integrating various domains of modern science to create sophisticated tissue substitutes in the hope of repairing or replacing dysfunctional organs using autologous cells. Its application to gynecology has the potential of restoring female fertility and sexual wellbeing.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Ovarian Tissue Cryopreservation in Children and Adolescents

Cancer during childhood and adolescence remains a major public health issue, affecting a significant portion of this age group. Although newer anti-cancer treatments have improved survival rates, this comes at a cost in terms of gonadotoxic effects. As a result, the preservation of fertility is important. Ovarian tissue cryopreservation, one of the newest methods, has some advantages, especially for prepubertal patients: no need for ovarian stimulation, thus, no further risk for estrogen-sensitive cancer types, and preservation of more and better-quality primordial follicles of the ovarian cortex. The most frequent indications include treatment with alkylating agents, ovarian-focused radiotherapy, leukemias, lymphomas, brain and neurological tumors, as well as Turner syndrome and benign hemoglobinopathies. An expected survival exceeding 5 years, the absence of systematic disease and an overall risk of premature ovarian insufficiency over 50% are among the criteria that need to be fulfilled in order for a patient to undertake this method. Orthotopic transplantation is more frequently used, since it can allow both live birth and the recovery of endocrine function. Reimplantation of malignant cells is always a major risk and should always be taken into consideration. Histological analysis, as well as immunohistochemical and molecular methods, are needed in order to improve the search for malignant cells before transplantation. Ovarian tissue cryopreservation appears to be a method with specific benefits, indications and risks which can be an important tool in terms of preserving fertility in younger women.

Tracking Immature Testicular Tissue after Vitrification In Vitro and In Vivo for Pre-Pubertal Fertility Preservation: A Translational Transgenic Mouse Model

Pediatric cancer survivors experiencing gonadotoxic chemoradiation therapy may encounter subfertility or permanent infertility. However, previous studies of cryopreservation of immature testicular tissue (ITT) have mainly been limited to in vitro studies. In this study, we aim to evaluate in vitro and in vivo bioluminescence imaging (BLI) for solid surface-vitrified (SSV) ITT grafts until adulthood. The donors and recipients were transgenic and wild-type mice, respectively, with fresh ITT grafts used as the control group. In our study, the frozen ITT grafts remained intact as shown in the BLI, scanning electron microscopy (SEM) and immunohistochemistry (IHC) analyses. Graft survival was analyzed by BLI on days 1, 2, 5, 7, and 31 after transplantation. The signals decreased by quantum yield between days 2 and 5 in both groups, but gradually increased afterwards until day 31, which were significantly stronger than day 1 after transplantation (p = 0.008). The differences between the two groups were constantly insignificant, suggesting that both fresh and SSV ITT can survive, accompanied by spermatogenesis, until adulthood. The ITT in both groups presented similar BLI intensity and intact cells and ultrastructures for spermatogenesis. This translational model demonstrates the great potential of SSV for ITT in pre-pubertal male fertility preservation.

Artificial Ovary for Young Female Breast Cancer Patients

In recent decades, there has been increasing attention toward the quality of life of breast cancer (BC) survivors. Meeting the growing expectations of fertility preservation and the generation of biological offspring remains a great challenge for these patients. Conventional strategies for fertility preservation such as oocyte and embryo cryopreservation are not suitable for prepubertal cancer patients or in patients who need immediate cancer therapy. Ovarian tissue cryopreservation (OTC) before anticancer therapy and autotransplantation is an alternative option for these specific indications but has a risk of retransplantation malignant cells. An emerging strategy to resolve these issues is by constructing an artificial ovary combined with stem cells, which can support follicle proliferation and ensure sex hormone secretion. This promising technique can meet both demands of improving the quality of life and meanwhile fulfilling their expectation of biological offspring without the risk of cancer recurrence.

Oncofertility and Reproductive Counseling in Patients with Breast Cancer: A Retrospective Study

Introduction. Improving the prognosis of breast cancer patients is of utmost importance in terms of increasing survival rates. Modern medicine has therefore prioritized better quality of life for patients, even after the disease, through a better management of the potential long-term side effects induced by anticancer treatments. Fertility preservation and family planning are therefore crucial issues to be addressed in all cancer patients of reproductive age. Along those lines, a new branch of medicine with distinct multidisciplinary characteristics has developed over the years: oncofertility. Although both national and international guidelines value reproductive counseling as an essential aspect of the diagnostic-therapeutic pathway, part and parcel of the informed consent process, it is not included within the protocols adopted by the operating units for the care and management of neoplastic diseases. Objective. This study aimed to evaluate the activity of the Breast Unit of the Policlinico Umberto I Hospital, Rome, Italy, and the degree of compliance with guidelines. By knowing the strengths and weaknesses of such approaches, the standards of care offered to breast cancer patients can be improved. Materials and methods. A retrospective study based on a review of medical records was conducted between 2014 and 2021. Patients under 40 years of age diagnosed with non-metastatic malignancies were included who received chemotherapy treatment, namely neoadjuvant, adjuvant or adjuvant hormone therapy. Results. The data were extracted from the medical records of 51 patients who met the inclusion criteria, 41% of whom received reproductive counseling, and of these, 43% decided to undertake a path of fertility preservation. Factors such as the absence of children and young age reportedly favored both the interest in counseling proposals by the medical staff and the decision to undertake a path of fertility preservation. Conclusions. The study shows that there has been growing interest in the topic of oncofertility, especially in light of law 219/2017. Therefore, since 2018, multiple proposals for reproductive counseling have been set forth, but there was not an equally growing demand for fertility preservation practices, which can be explained by the invasive nature of such practices, the patients’ concern about their own state of health, and poor or inadequate information. Such impediments highlight the importance of standardized counseling and the need for a multidisciplinary medical team to support the patient in the decision-making process. The study also revealed a drop in the number of patients receiving counseling due to the COVID-19 pandemic, contrary to the positive trend that was recorded prior to the pandemic.

Reproductive health in transgender and gender diverse individuals: A narrative review to guide clinical care and international guidelines

Background

Hormonal treatments and surgical interventions practiced with the aim to affirm gender identity in transgender and gender diverse patients may impact their future reproductive ability, family building, and family planning options. Whereas it is recommended by international guidelines to discuss the potential risks of infertility and to present fertility preservation (FP) options to transgender individuals and their families prior to initiating any of these treatments, many barriers still remain. Further, transgender and gender diverse individuals often experience barriers to accessing contraception, abortion, pre-conception care, and comprehensive perinatal care.

Aims

In this review we summarize the current literature on reproductive healthcare issues reported in transgender people including fertility issues, fertility preservation (FP), contraception, pregnancy and lactation and perinatal health.

Methods

A narrative literature search of major databases (Pubmed, Medline, PsycInfo, Google Scholar, Web of Science) was conducted. Given the paucity and heterogeneity of studies, summative review tactics were not available. The literature was critically reviewed by international experts in the field with focus on the impact of gender-affirming medical interventions on future fertility, current FP options and reproductive health issues in transgender people.

Results

The current literature supports that transgender and gender diverse individuals may wish to have genetically related children in the future, rendering the issue of FP relevant to this patient group. The cryopreservation of mature gametes is an efficacious option for FP for post-pubertal adolescents and adults. It is recommended to discuss these options at time of planning for gender-affirming hormonal therapy (GAHT) or engaging with other gender-affirming procedures that can limit future fertility. Discontinuation of GAHT may allow individuals to undergo FP later, but data are limited and there is the concern of symptoms and consequences of stopping GAHT. For pre-pubertal and early pubertal children, FP options are limited to the cryopreservation of gonadal tissue. At present the tissue can become functional only after re-transplantation, which might be undesirable by transgender individuals in the future. Preconception counseling, prenatal surveillance, perinatal support, contraceptive, and pregnancy termination related healthcare need to be meaningfully adapted for this patient population, and many knowledge gaps remain.

Discussion

Specialized FP reproductive healthcare for transgender and gender diverse individuals is in early evolution. Research should be conducted to examine effects of medical interventions on fertility, timing of FP, gamete preservation and outcome of the fertility treatments. Strategies to inform and educate transgender and gender diverse patients can lead to optimization of reproductive care and counseling and decision making of FP for this population.

Ovarian tissue bank for fertility preservation and anti-menopause hormone replacement

Traditional fertility preservation methods such as embryo or oocyte cryopreservation cannot meet the needs of a cancer patient or for personal reasons. The cryopreservation of ovarian tissue can be an alternative and has become a hot spot to preserve fertility or hormone replacement. The freezing of ovarian tissue can be carried out at any time without ovarian hyperstimulation to retrieve follicles. It is an ideal strategy to preserve reproductive function in children, adolescent cancer patients, and patients who are in urgent need of cancer treatment. With the increasing demands of women with premature ovarian failure or in menopause, ovarian tissue transplantation is also an alternative for hormone replacement that can provide physiological doses of hormone levels, which can avoid a series of risks such as thrombosis, breast cancer, or other hormone-dependent tumors, caused by oral hormone replacement. Hence, ovarian tissue banking can be regarded as a mainstream strategy for fertility preservation and anti-menopause hormone replacement in further clinical investigation.

Post-thawing and culture comparison of three routine slow freezing methods for human ovarian tissue cryopreservation: Histological, molecular, and hormonal aspects

To find the gold standard out of three pre-established routine slow freezing (SF) methods, ovarian cortex tissues of nine transsexual individuals were cryopreserved and compared to each other, as well as the control (fresh) samples. Histological, genomic, and endocrinological effects of the SFs were assessed post-thawing and after a seven-day culture period. SF1 included 10% dimethyl-sulfoxide (Me2SO) in the base medium (BM), SF2 had 1.5 M/L ethylene-glycol (EG) and 0.1 M/L sucrose in the BM, and SF3 consisted of 6% Me2SO, 6% EG and 0.15 M/L sucrose in the BM. The cortical tissue strips went under a programmed cooling process and were stored in liquid nitrogen. Histological criteria (tissue damage and follicular quality), as well as gene expression levels, were assessed in the thawed and control tissues. Half of the thawed and control tissues were cultured for seven days and their histology, genetic profile, and hormonal status were examined as the reflection of the avascular tension effect. Post-thawing tissue damage was similar between all groups but significantly increased post-culture (P < 0.05). The percentages of high-quality follicles diminished in all SFs after thawing and culture (P < 0.05) except for the similarity of post-thawing SF3, compared to control. The genetic profile of the tissue after thawing and culture suggested quiescence/activation balance in SF1 and 2 and significant down-regulation in SF3, compared to the control specimens (P < 0.05). Post-thawing BAX:BCL2 was higher than control in SF1 and SF3 (P < 0.05), while this ratio in SF2 was similar to the control. However, after culture this ratio was similar to that of control in SF3 and diminished in SF1 and 2 (P < 0.05). The expression levels of gap-junction genes showed dramatic pre- and post-thawing fluctuations in all groups. After culture, estradiol in SF3 was significantly higher than SF1 and 2 (P < 0.05). In addition, progesterone in SF3 was similar to control but significantly lower in SF1 and 2 (P < 0.05). In conclusion, all SFs showed advantages and disadvantages, and the follicular quality and its function depend on the type of cryoprotectant and the speed of thawing. The effects of freezing/thawing continue to appear during the seven days of culture. According to the results of this study, SF3 seems to be more promising in keeping the follicles functional and safe from cell damage during culture.

The decellularized ovary as a potential scaffold for maturation of preantral ovarian follicles of prepubertal mice

ABBREVIATIONS

GAG: glycosaminoglycan; ECM: extracellular matrix; 2D: two-dimensional; E2: estradiol; P4: progesterone; BMP15: bone morphogenetic protein 15; GDF9: growth differentiation factor 9; ZP2: zona pellucida 2; Gdf9: growth/differentiation factor-9; Bmp6: bone morphogenetic protein 6; Bmp15: bone morphogenetic protein 15.

Applying plastic surgery principles to ovarian tissue transplantation

Ovarian tissue cryopreservation (OTC) and transplantation is an innovative procedure increasingly utilized to help preserve fertility after gonadotoxic treatments especially in cancer patients. Approximately 30% of autotransplanted patients are able to achieve live birth, typically with the help of in-vitro fertilization. Numerous techniques and grafting sites have been described to continue to increase this figure. In the field of plastic surgery, tissue grafting has been successful performed for thousands of years and knowledge in this area has been significantly refined. A qualitative review of the literature using PubMed, Cochrane, SCOPUS and Medline databases was performed to look for articles relating to ovarian tissue transplantation (OTT) and comparisons made to plastic surgery tissue grafting. Many parallels were found between the principles of grafting in plastic surgery and the principles of OTT, including pre-operative patient optimization, suitable donor site selection, tissue harvest and preparation, graft site choice, immobilization of the graft and post-operative care. Consideration of the benefits and risks of using orthotopic versus heterotopic recipient sites is also highly important with regards to graft take, morbidity and ease of access of oocyte collection. We believe that ongoing discussion between disciplines can have the potential to improve knowledge, surgical techniques and patient outcomes.

Methods of Ovarian Tissue Cryopreservation: Is Vitrification Superior to Slow Freezing?-Ovarian Tissue Freezing Methods

After cancer treatment, female survivors often develop ovarian insufficiency or failure. Oocyte and embryo freezing are well-established fertility preservation options, but cannot be applied in pre-pubescent girls, in women with hormone-sensitive malignancies, or when gonadotoxic treatment cannot be delayed. Although ovarian tissue cryopreservation (OTC) has been used to restore fertility and endocrine function, the relative efficacy of its two major protocols, slow freezing and vitrification, remains controversial. This literature review evaluates clinical and lab-based studies published between January 2012 and June 2020 to determine whether vitrification, the optimal technique for oocyte and embryo cryopreservation, preserves ovarian tissue more effectively than slow freezing. Due to limited clinical data involving ovarian tissue vitrification, most clinical studies focus on slow freezing. Only 9 biochemical studies that directly compare the effects of slow freezing and vitrification of human ovarian tissue were noted. Most studies report no significant difference in follicular morphology and distribution between cryopreservation methods, but these findings must be interpreted in the context of high methodological variability. Discrepant findings regarding the effects of cryopreservation method on follicle viability, gene expression, and hormone production require further evaluation. Early clinical outcomes appear favorable for vitrification, but additional studies and longer term follow-up are needed to establish its efficacy. Sharing data through national or international registries would expedite this analysis. However, even if research corroborates conclusions of no clinical or biochemical difference between cryopreservation methods, the decreased costs and increased efficiency associated with vitrification make this method more accessible and cost-effective.

Gynecologic Care for Pediatric and Adolescent Patients Undergoing Hematopoietic Stem Cell Transplantation

Hematopoietic stem cell transplantation is used to treat many chronic and acute malignant and nonmalignant conditions. We review hematopoietic stem cell transplantation and its effect on the gynecologic health of pediatric and adolescent patients, including pretransplantation evaluation, contraception, menstrual suppression, sexual health, fertility, primary ovarian insufficiency, and graft vs host disease. Comprehensive and team-based care provides optimal anticipatory counseling, evaluation, and management of acute and ongoing gynecologic issues.

Prediction Potency of Gonadal Hormone Alterations on Sexual Dysfunction After Hematopoietic Stem Cell Transplantation

Sexual dysfunction (SD) is one of the late complications in survivors after hematopoietic stem cell transplantation (HSCT), and the gonadal hormones might be involved in the pathogenesis of this pathological process. This study aimed to investigate the incidence of SD by questionnaire, to explore the relationship between SD and the comprehensive gonadal hormones in patients post HSCT. We identified 72 survivors of hematological diseases who underwent HSCT. The sociodemographic characteristics and medical histories of participants were ascertained by a modified version of a questionnaire named "PPSAS-HSCT" in our study. Blood samples were regularly assayed for the global gonadal hormones. Forty-four percent of the females and 51% of the males reported a loss of interest in sexual activities. Ninety-two percent (23/25) of females exhibited decreased serum anti-Müllerian hormone (AMH) levels, and 74% (35/47) of males had elevated follicle-stimulating hormone (FSH) levels. The males with a higher level of oestradiol/testosterone (E2/T) had more symptoms of SD after HSCT. Patients with GVHD who received glucocorticoid (GC) therapy exhibited a lower level of testosterone and more serious SD, especially in the female population. SD and abnormal gonadal hormone homeostasis were present in more than half of the survivors after HSCT. Graft-versus-host disease (GVHD) and glucocorticoid treatment were confirmed to have a significant impact on the levels of testosterone among females. A multimodal intervention for the survivors after HSCT and a better consciousness of the medical staff are necessary for improving the quality of life of the recipients.

Diverse Approaches to Ovarian Tissue Cryopreservation Have Equivalent Outcomes in Markers of Tissue Viability

Ovarian tissue cryopreservation (OTC) is an accepted method of fertility preservation. However, OTC is not standardized and many variations exist in the freezing strategy, tissue processing, and surgical approach. In this pilot study, we used a sheep model to compare slow freezing versus vitrification techniques, as well as the feasibility of processing ovarian tissue into a hyaluronan suspension of small ovarian units. Twelve ovaries were harvested from six female ewes. Paired tissues from each animal were assigned to different treatments and underwent freezing, thawing, autotransplantation, and second-look surgery, for a total of 18 surgical procedures and 3 measured time points. Treatments included whole tissue strips versus gel suspension and slow freezing versus vitrification. At each of the time points, tissue viability was measured by immunohistochemical analysis of CD31 and cleaved caspase-3 (CCASP3). CD31 and CCASP3 expression levels were equivalent between slow freezing and vitrification, and between whole ovarian tissue strips and gel suspension of fragmented ovarian tissue, at all time points. These preliminary data using a sheep model suggest that ovarian tissue is robust and likely to be minimally affected by aggressive fragmentation using a hyaluronan suspension. Furthermore, we provide evidence in support of vitrification as a viable option in OTC. Hyaluronan suspension of ovarian cortical fragments is novel and may represent a desirable method for reimplantation of frozen-thawed ovarian tissue in patients where occult malignant cells are a concern.

Fertility preservation for female patients with childhood, adolescent, and young adult cancer: recommendations from the PanCareLIFE Consortium and the International Late Effects of Childhood Cancer Guideline Harmonization Group

Female patients with childhood, adolescent, and young adult cancer are at increased risk for fertility impairment when treatment adversely affects the function of reproductive organs. Patients and their families desire biological children but substantial variations in clinical practice guidelines reduce consistent and timely implementation of effective interventions for fertility preservation across institutions. As part of the PanCareLIFE Consortium, and in collaboration with the International Late Effects of Childhood Cancer Guideline Harmonization Group, we reviewed the current literature and developed a clinical practice guideline for fertility preservation in female patients who were diagnosed with childhood, adolescent, and young adult cancer at age 25 years or younger, including guidance on risk assessment and available methods for fertility preservation. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to grade the available evidence and to form the recommendations. This clinical practice guideline leverages existing evidence and international expertise to develop transparent recommendations that are easy to use to facilitate the care of female patients with childhood, adolescent, and young adult cancer who are at high risk for fertility impairment. A complete review of the existing evidence, including a quality assessment, transparent reporting of the guideline panel's decisions, and achievement of global interdisciplinary consensus, is an important result of this intensive collaboration.

Fertility Preservation and Long-Term Monitoring of Gonadotoxicity in Girls, Adolescents and Young Adults Undergoing Cancer Treatment

Chemo- and radio-therapy can often affect reproductive organs impairing hormonal regulation, fertility, and sexual function. As cancer treatments become more effective and many patients have long term survival, concerns related to patient's quality of life and reproductive health become relevant. It is especially important for girls and young females facing cancer therapy who have not yet started family planning. Chemotherapy protocols using alkylating agents and abdominal radiotherapy, which are frequently used in the treatment of childhood and adolescent cancer, can cause gonadal injury. The most common clinical manifests are ovarian hormone insufficiency, premature ovarian insufficiency, early menopause and infertility. In this review we assess current literature and summarize current recommendations on the reproductive function of girls and young females undergoing cancer treatment and their follow-up. Fertility preservation methods are discussed, including psychological and ethical considerations and barriers. Improvement of reproductive health and quality of life of adolescents and young adults (AYA) undergoing cancer treatment is an important issue. Further research should be continued to develop efficient and accessible methods for fertility preservation in young patients. An expert panel including oncologists, radiation oncologists, endocrinologists and gynecologists should always consider fertility preservation in pediatric, adolescent and AYA cancer patients, minding patients' medical condition, cancer staging and potential risk of treatment-related gonadotoxicity.

Human umbilical cord perivascular cells maintain regenerative traits following exposure to cyclophosphamide

Chemotherapies can cause germ cell depletion and gonadal failure. When injected post-chemotherapy, mesenchymal stromal cells (MSCs) from various sources have been shown to have regenerative effects in rodent models of chemotherapy-induced gonadal injury. Here, we evaluated two properties of a novel source of MSC, first trimester (FTM) human umbilical cord perivascular cells (HUCPVCs) (with increased regenerative potential compared to older sources), that may render them a promising candidate for chemotherapeutic gonadal injury prevention. Firstly, their ability to resist the cytotoxic effects of cyclophosphamide (CTX) in vitro, as compared to term HUCPVCs and bone marrow cells (BMSCs); and secondly, whether they prevent gonadal dysfunction if delivered prior to gonadotoxic therapy in vivo. BMSC, FTM HUCPVC, term HUCPVC, and control NTERA2 cells were treated with moderate (150 μmol/L) and high (300 μmol/L) doses of CTX in vitro. Viability, proliferative capacity, mesenchymal cell lineage markers and differentiation capacity, immunogenicity, and paracrine gene expression were assessed. CTX was administered to Wistar rats 2 days following an intra-ovarian injection of FTM HUCPVC. HUCPVC survival and ovarian follicle numbers were assessed using histological methods. We conclude that FTM HUCPVC maintain key regenerative properties following chemotherapy exposure and that pre-treatment with these cells may prevent CTX-induced ovarian damage in vivo. Therefore, HUCPVCs are promising candidates for fertility preservation.

In-vitro fragmentation of ovarian tissue activates primordial follicles through the Hippo pathway

STUDY QUESTION

What is the role of the Hippo and PI3K/Akt pathway in follicles during ovarian tissue culture in tissue derived from oncological patients and transgender men?

SUMMARY ANSWER

Results highlight a Hippo pathway driven primordial follicle activation in vitro, predominantly from Day 0 to Day 4.

WHAT IS KNOWN ALREADY

In-vitro ovarian tissue culture aims at activating and maturing primordial follicles for fertility restoration in patients with a threatened ovarian reserve. Not all patients are eligible for ovarian cortex transplantation and therefore several groups are attempting to culture ovarian tissue in-vitro. Cortex fragmentation disrupts the Hippo pathway, leading to increased expression of downstream growth factors and follicle growth. The PI3K/Akt pathway is considered the intracellular pathway to where different extracellular factors involved in primordial follicle activation in-vivo converge. In order to optimise current ovarian tissue culture models, information on progression of these pathways during tissue culture is mandatory.

STUDY DESIGN SIZE DURATION

The first step of a multistep cortex culture system was performed using 144 ovarian cortex pieces from a total of six patients. Per patient, 24 cortical strips were cultured for 6 days and six pieces per patient were collected for downstream analysis of follicle development and Hippo and PI3K/Akt pathway targets every second day.

PARTICIPANTS/MATERIALS SETTING METHODS

Ovarian tissue was obtained from oncological (N = 3; 28.67 ± 4.51 years) and transgender (N = 3; 23.33 ± 1.53 years) patients. Follicles were analysed using haematoxylin-eosin staining and pathways were studied using immunohistochemistry and precise follicle excision by laser capture micro-dissection for RT-qPCR analysis. MIQE guidelines for RT-qPCR were pursued. Reference gene selection (GAPDH, RPL3A, 18s rRNA) was performed using GeNorm Reference Gene Selection Kit. Statistical analysis was conducted with IBM SPSS Statistics 23 (Poisson regression, negative binomial regression, ANOVA and paired t-test).

MAIN RESULTS AND THE ROLE OF CHANCE

Immunohistochemical analysis confirmed a Hippo pathway driven primordial follicle activation due to mechanical manipulation of the cortical strips. Ovarian tissue preparation and culture induced the inhibitory phosphorylated Yes-associated protein (pYAP) to disappear in granulosa cells of primordial follicles on Day 2. The stimulatory YAP on the contrary appeared in primordial granulosa cells over increasing culture days. Looking at the YAP target connective tissue growth factor (CTGF), a significantly up-regulated CTGF was noted in primordial follicles when comparing Day 2 and Day 4 (ratio Day 2/4 = 0.082; P < 0.05), clearly showing an effect on the Hippo pathway in primordial follicles during tissue culture. Follicle classification showed a significant drop in estimated primordial follicle counts in the oncological cohort (-78%; P = 0.021) on Day 2 and in the transgender cohort on Day 4 (-634%; P = 0.008). Intermediate follicle counts showed a non-significant increasing trend to during culture and this follicle recruitment and growth resulted in a significant rise in estimated primary follicle counts on Day 6 in oncological patients (170%; P = 0.025) and, although limited in absolute numbers, a significant increase in secondary follicles on Day 4 (367%; P = 0.021) in the transgender cohort. Subsequent antral follicle development could not be observed.

LIMITATIONS REASONS FOR CAUTION

A limitation is the small sample size, inherent to this study subject, especially as a large amount of tissue was needed per patient to reduce inter-patient variation in different downstream analysis techniques. A particular and specific weakness of this study is the inability to include an age-matched control group.

WIDER IMPLICATIONS OF THE FINDINGS

These findings support an adapted tissue preparation for Hippo pathway disruption and a shorter first phase of tissue culture. This work may also have implications for transplantation of cryopreserved tissue as larger strips (and thus slower burnout due to less Hippo pathway disruption) could be a benefit.

STUDY FUNDING/COMPETING INTERESTS

This research was financially supported by the Foundation Against Cancer (Stichting tegen Kanker, TBMT001816N), the Flemish Foundation of Scientific Research (FWO Vlaanderen, FWO G0.065.11N10) and the Gender Identity Research and Education Society (GIRES) foundation. The authors declare no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Reproductive outcomes after in vitro fertilization treatment in a cohort of Danish women transplanted with cryopreserved ovarian tissue

OBJECTIVE

To evaluate ovarian stimulation regimens and reproductive outcomes in a cohort of women undergoing ovarian tissue cryopreservation (OTC) and ovarian tissue transplantation (OTT).

DESIGN

Retrospective cohort study.

SETTING

University hospital and fertility clinics.

PATIENTS

Twenty-eight women undergoing OTT and in vitro fertilization (IVF) from 2012 to 2017.

INTERVENTION

OTC, OTT, and IVF.

MAIN OUTCOME MEASURES

Ovarian stimulation and IVF outcomes.

RESULTS

In total, 99 cycles were performed in 28 patients. In 19 patients responding to stimulation, a median of 3.0 cycles per patient (range: 1-14 cycles) was performed, and 2.0 mature oocytes were retrieved per cycle. The empty follicle rate was 35.9%. Eleven women achieved 15 pregnancies, of which 60% were lost during the first or second trimester, resulting in 5 of 28 women having ≥1 live births, and seven healthy children being born. In breast cancer patients (mean age at OTC: 33.0 years), the pregnancy rates (PR) and live birth rates (LBR) were 35.0% and 5.0% per embryo transfer, respectively. Patients aged ≥34.5 years at OTC all had breast cancer and did not achieve any pregnancies. For all other diagnoses (mean age at OTC: 26.6 years), PR and LBR were 50.0% and 37.5% per embryo transfer, respectively. Collectively, 39% of patients conceived at least once, and 17.9% delivered. Frozen-thawed embryo transfer (FET) resulted in more pregnancies than did fresh embryo transfer.

CONCLUSION

Our results suggest that women of advanced maternal age undergoing OTC and IVF have a poor ovarian reserve, resulting in a poor reproductive outcome. Interestingly, FET appeared to be superior to fresh transfer.

Fertility-sparing treatment for early-stage epithelial ovarian cancer: Contemporary oncologic, reproductive and endocrinologic perspectives

AIM

Epithelial ovarian cancer (EOC) can be a devastating diagnosis in women of reproductive age who desire future fertility. However, in early-stage disease, fertility-sparing surgery (FSS) can be considered in appropriately selected patients.

METHODS

This is a narrative descriptive review of the recent literature on FSS for EOC from oncologic, reproductive and endocrinologic perspectives.

RESULTS

The recurrence rate following FSS performed for stage I EOC in published retrospective studies collectively is 13% but ranges from 5 to 29%, while mortality ranges from 0 to 18%. Five-year disease-free survival following FSS is over 90% but decreases with higher stage and grade. Recurrences following FSS are more likely to be localized with a more favorable prognosis compared to recurrences following radical surgery. Adjuvant chemotherapy is recommended in women with high-risk disease, and strategies to minimize gonadotoxicity during chemotherapy such as gonadotropin-releasing hormone (GnRH) agonists may be considered. Oocyte, embryo and/or ovarian cryopreservation can also be offered to patients desiring future biologic children. Reproductive outcomes following FSS, including pregnancy and miscarriage rates, resemble those of the general population, with a chance of successful pregnancy of nearly 80%.

CONCLUSION

In retrospective data, FSS appears to be oncologically safe in stage IA and IC grade 1-2 non-clear cell EOC. In patients with grade 3 tumors or clear cell histology, treatment can be individualized, weighing a slightly higher risk of recurrence with fertility goals. A multidisciplinary approach with oncology and reproductive endocrinology may be of utility to help these patients achieve their fertility goals.

VIP activates primordial follicles of rat through ERK-mTOR pathway in tissue culture

In vitro activation of primordial follicles is becoming more essential in assisted reproductive technologies. Vasoactive intestinal peptide (VIP) is one of the members of the neurotrophin family which has demonstrated to have an impact on follicle development in recent years. This study aims to investigate the effect of VIP on the activation of primordial follicles in neonatal rat in an in vitro culture system and to determine the relevant molecular mechanism of their activation. Ovaries of 4-day-old rats were examined for the expression of VIP receptors and were cultured in mediums containing VIP with or without inhibitors of the ERK–mTOR signalling pathway. They were then collected for histological analysis or measurement of the molecular expression of this pathway. The receptors of VIP were found in granular cells and oocytes of primordial and early-growing follicles in neonatal ovary. The ratio of growing follicle increased in the presence VIP at different concentrations, with the highest level of increase being observed in the 10⁻⁷ mol/L VIP-treated group. The ratio of PCNA-positive granular cells was also increased, while that of the apoptotic oocytes were decreased, and protein analysis showed increased phosphorylation of ERK1/2, mTOR and RPS6 in the VIP-treated group. However, the effect of VIP on the activation of primordial follicle became insignificant with the addition of MEK inhibitor (U0126) or mTORC1 inhibitor (rapamycin). This study indicated that VIP could activate neonatal rat primordial follicle through the ERK-mTOR signalling pathway, suggesting a strategy for in vitro primordial follicle recruitment.

Effects of Different Vitrification Solutions and Protocol on Follicular Ultrastructure and Revascularization of Autografted Mouse Ovarian Tissue

Objective

Many attempts have been made to preserve fertility by improving the cryopreservation of the ovarian tissue. This current studyaimed to improve of direct cover vitrification (DCV) protocol on follicular preservation and angiogenesis in autografted ovarian tissue.

Materials and Methods

In this experimental study, sixty five female Balb/c mice (5-6 week-old) were anesthetized and their ovaries were dissected. The left ovaries were vitrified by DCV solution, thawed by descending concentrations of sucrose, and then autografted subcutaneously. The right ovaries were autografted with no vitrification procedure prior to transplantation. The animals were sacrificed under anesthesia on the 7thday after transplantation to obtain ovarian tissue. Follicular quality was assessed by histological and ultrastructure observations, and angiogenesis was examined by immunohistochemical staining and real-time polymerase chain reaction (PCR) analysis.

Results

The histological and ultrastructure features of the follicles preserved well after vitrification of the ovarian tissue by 10% ethylene glycol (EG) and 10% dimethyl sulfoxide (DMSO). Revascularizationwas manifested prominently in the DCV1-vitrified/grafted ovaries by von Willebrand factor (vWF) and alpha smooth muscle actin (α-SMA) immunostaining. The ovarian tissue vitrified in DCV1 protocol had higher expression levels of angiopoietin-2 (Ang-2) and vascular endothelial growth factor (VEGF) 7 days after autotransplantation (P<0.01).

Conclusion

These findings suggest that DCV with 10% of both EG and DMSO, is an effective cryopreservation solution for preservation of good quality follicles as well an upregulation of angiogenic factors after ovarian tissue transplantation.

Impact of legislation and public funding on oncofertility: a survey of Canadian, French and Moroccan pediatric hematologists/oncologists

BACKGROUND

Chemotherapy and/or radiotherapy treatments may cause premature ovarian failure and irreversible loss of fertility. In the context of childhood cancers, it is now acknowledged that possible negative effects of therapies on future reproductive autonomy are a major concern. While a few options are open to post-pubertal patients, the only immediate option currently open to pre-pubertal girls is cryopreservation of ovarian tissue and subsequent transplantation. The aim of the study was to address a current gap in knowledge regarding the offer of fertility preservation by Ovarian Tissue Cryopreservation (OTC) for prepubescent girls with cancer, and to explore current practices and attitudes of Canadian, French and Moroccan pediatric heme oncologists. The comparative perspective is relevant since legal frameworks surrounding fertility preservation and funding offered by the healthcare system vary greatly.

METHODS

An online survey was sent to the 45 pediatric oncology centers in Canada, France and Morocco.

RESULTS

A total of 39 centers responded (86.6%). OTC is offered by almost all pediatric heme oncologists in France (98%), very few in Canada (5%), and none in Morocco (0%). For pediatric hematologists/oncologists who do not propose fertility preservation in Canada, the reasons are: the technique is still experimental (54%), it is not available locally (26%) and cost of the technique for the family (14%). 97% of Canadian and 100% of Moroccan pediatric hematologists/oncologists think OTC should be funded by the healthcare system as it is in France and in the province of Quebec in Canada.

CONCLUSIONS

The results of this study show tremendous diversity in the provision of OTC across countries, whereby its offer is correlated with legislation and funding. We argue that the current reality, in which this technology is often not offered to families, raises ethical issues related to justice and equity of access, as well as informed consent and future reproductive autonomy.

Cold case: Small animal gametes cryobanking

Germplasm preservation of animals, whether they are valuable domestic breeds or rare species, is the main goal of gamete cryobanking. Dogs and cats act as models for this purpose thanks to the wide availability of biological material which can be employed to experiment protocols that can then be applied to wild animals. This review is focused on spermatozoa, oocytes and gonadal tissues cryobanking in small domestic animals, which is still an unsolved case. Like in a courtroom, evidences of cryoinjuries affecting cellular structures will be presented, penalties as loss of functionality due to cellular alterations will be described, and appeal as strategies to protect gametes from damages or rescue their functionality will be discussed. Differences and similarities between single cell or tissue cryopreservation will be highlighted, together with the rationale for the choice of one type of preservation or another and the fundamental principles which they are based on. The deep analysis of different aspects that still hamper the success of cryopreservation in small animals can help clarify where research is most needed. Therefore, as in a cold case, investigation should remain open in order to hopefully find the solution and make these procedures more and more efficient in the future.

SIRT1 facilitates primordial follicle recruitment independent of deacetylase activity through directly modulating Akt1 and mTOR transcription

In female mammals, the majority of primordial follicles (PFs) are physiologically quiescent, and only a few of them are activated and enter the growing follicle pool. Specific molecules, such as mammalian target of rapamycin (mTOR) and the serine/threonine kinase Akt (AKT), have been proven to be important for PF activation. However, how the transcription of these genes is regulated is not clear. Although activators of mTOR or AKT have been successfully used to rescue the fertility of patients with premature ovarian insufficiency, the low efficacy and unclear safety profile of these drugs hinder their clinical use in the in vitro activation (IVA) of PFs. Here, sirtuin 1 (SIRT1), an NAD-dependent deacetylase, was demonstrated to activate mouse PFs independent of its deacetylase activity. SIRT1 was prominently expressed in pregranulosa cells (pGCs) and oocytes, and its expression was increased during PF activation. PF activation was achieved by either up-regulating SIRT1 with a specific activator or overexpressing SIRT1. Moreover, SIRT1 knockdown in oocytes or pGCs could significantly suppress PF activation. Further studies demonstrated that SIRT1 enhanced both Akt1 and mTOR expression by acting more as a transcription cofactor, directly binding to the respective gene promoters, than as a deacetylase. Importantly, we explored the potential clinical applications of targeting SIRT1 in IVA via short-term treatment of cultured ovaries from mice and human ovarian tissues to activate PFs by applying the SIRT1 activator resveratrol. RSV-induced IVA could be a candidate strategy to develop more efficient procedures for future clinical treatment of infertility.-Zhang, T., Du, X., Zhao, L., He, M., Lin, L., Guo, C., Zhang, X., Han, J., Yan, H., Huang, K., Sun, G., Yan, L., Zhou, B., Xia, G., Qin, Y., Wang, C. SIRT1 facilitates primordial follicle recruitment independent of deacetylase activity through directly modulating Akt1 and mTOR transcription.

Preserving fertility in female patients with hematological malignancies: a multidisciplinary oncofertility approach

Oncofertility is a new interdisciplinary field at the intersection of oncology and reproductive medicine that expands fertility options for young cancer patients. The most common forms of hematological malignancies that occur in girls and young women and therefore necessitate oncofertility care are acute lymphocytic leukemia, acute myeloid leukemia, non-Hodgkin's lymphoma, and Hodgkin's lymphoma. Aggressive gonadotoxic anticancer regimens including alkylating chemotherapy and total body irradiation are used often in treating girls and young women with hematological malignancies. The risks of gonadotoxicity and subsequent iatrogenic premature ovarian insufficiency and fertility loss depend mainly on the type and stage of the disease, dose of anticancer therapy as well as the age of the patient at the beginning of treatment. To avoid or at least mitigate the devastating complications of anticancer therapy-induced gonadotoxicity, effective and comprehensive strategies that integrate different options for preserving and restoring fertility ranging from established to experimental strategies should be offered before, during, and after chemotherapy or radiotherapy. A multidisciplinary approach that involves strong coordination and collaboration between hemato-oncologists, gynecologists, reproductive biologists, research scientists, and patient navigators is essential to guarantee high standard of care.

Fertility and hormone preservation and restoration for female children and adolescents receiving gonadotoxic cancer treatments: A systematic review

BACKGROUND/PURPOSE

The purpose of this systematic review by the American Pediatric Surgical Cancer Committee was to summarize evidence from the current medical literature regarding fertility restoration and hormone replacement for female children and adolescents treated with gonadotoxic treatments.

METHODS

Using PRISMA guidelines, questions were addressed by searching Medline, Cochrane, Embase Central and National clearing house databases using relevant search terms. Eligible studies included those that addressed ovarian tissue cryopreservation (OTC), oocyte harvest, ovarian transposition, and ovarian tissue auto-transplantation for females under the age of 20. Four reviewers independently screened studies for eligibility, extracted data and assessed the risk of bias. Study outcomes were summarized in a narrative synthesis.

RESULTS

Two thousand two hundred seventy-six studies were identified by database search and manual review and 2185 were eliminated based on defined exclusion criteria. Ninety-one studies served as the basis for the systematic review. There were 1019 patients who underwent OTC with ages ranging from 0.4 to 20.4 years old, with 298 under the age of 13. Twenty patients aged 13-20 years old underwent successful oocyte harvest. Thirty-seven children underwent ovarian transposition as a means of fertility preservation. Eighteen patients underwent auto-transplantation of thawed ovarian cortical tissue that was harvested before the age of 21 years resulting in 10 live births.

CONCLUSIONS

Clinically accepted and experimental fertility preservation options such as OTC, oocyte cryopreservation, and ovarian transposition are available to females aged 20 years and younger who are at risk for premature ovarian insufficiency and infertility due to gonadotoxic treatments. There is a large cohort of pediatric-aged patients, with a wide variety of diagnoses and treatments, who have undergone fertility preservation. Currently, fertility and hormone restoration experience for patients who were 20- years of age or younger at the time of fertility preservation remains limited.

LEVEL OF EVIDENCE

IV.

Hard and soft X-ray imaging to resolve human ovarian cortical structures

Laboratory and synchrotron X-ray tomography are powerful tools for non-invasive studies of biological samples at micrometric resolution. In particular, the development of phase contrast imaging is enabling the visualization of sample details with a small range of attenuation coefficients, thus allowing in-depth analyses of anatomical and histological structures. Reproductive medicine is starting to profit from these techniques, mainly applied to animal models. This study reports the first imaging of human ovarian tissue where the samples consisted of surgically obtained millimetre fragments, properly fixed, stained with osmium tetroxide and included in epoxydic resin. Samples were imaged by the use of propagation phase contrast synchrotron radiation micro-computed tomography (microCT), obtained at the SYRMEP beamline of Elettra light source (Trieste, Italy), and X-ray absorption microCT at the Theoretical Biology MicroCT Imaging Laboratory in Vienna, Austria. The reconstructed microCT images were compared with the soft X-ray absorption and phase contrast images acquired at the TwinMic beamline of Elettra in order to help with the identification of structures. The resulting images allow the regions of the cortex and medulla of the ovary to be distinguished, identifying early-stage follicles and visualizing the distribution of blood vessels. The study opens to further application of micro-resolved 3D imaging to improve the understanding of human ovary's structure and support diagnostics as well as advances in reproductive technologies.

Current state and future possibilities of ovarian tissue transplantation

BACKGROUND

As a result of recent developments in cancer treatment, cancer survivorship and survivors' quality of life have been emphasized. Although ovarian tissue cryopreservation (OTC) is an experimental technique, it would be the sole technique for fertility preservation treatment for girls with malignant disease. Indeed, OTC requires ovarian tissue transplantation (OTT) for conception. As for OTC, there is room to investigate OTT. The present review focused on the current state and progress of OTT.

METHOD

The literature regarding OTT, which is currently under development, was reviewed.

MAIN FINDINGS

To improve the outcome of OTT, both efficacy and safety are important. Good surgical technique and the optimal site are important surgical factors, with orthotopic transplantation increasing. Treatment of growth factors, gonadotropins, antioxidants, apoptosis suppression factors, and cell therapy may improve the efficacy of OTT by inducing neo-angiogenesis and preventing damage. Artificial ovaries, complete in vitro primordial follicle culture technique, and non-invasive ovarian imaging techniques, such as optical coherence tomography, to select the best ovarian tissue are future possibilities.

CONCLUSION

Improving neo-angiogenesis and preventing damage with optimization, as well as investigation of future techniques, may bring us to the next stage of a fertility preservation strategy.

Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: A Systematic Review

BACKGROUND

The incidence of colorectal cancer among reproductive-aged women is increasing. Concerns regarding future fertility are secondary only to concerns regarding survival and may significantly impact quality of life among reproductive-aged female cancer survivors. Fertility preservation counseling reduces long-term regret and dissatisfaction among cancer survivors. Health care providers counseling patients with colorectal cancer must understand the impact of cancer treatment on future reproductive potential.

OBJECTIVE

This review aims to examine the effects that colorectal cancer treatments have on female fertility and summarize existing and emerging options for fertility preservation.

DATA SOURCES

EMBASE, National Library of Medicine (MEDLINE)/PubMed, Cochrane Review Library were the data sources for this review.

STUDY SELECTION

A systematic literature review was performed using exploded MeSH terms to identify articles examining the effect of surgery, chemotherapy, and radiation, as well as fertility preservation options for colorectal cancer on female fertility. Relevant studies were included.

MAIN OUTCOME MEASURES

The primary outcome was the effect of colorectal cancer treatment on fertility.

RESULTS

There are limited data regarding the impact of colorectal surgery on fertility. The gonadotoxic effects of chemotherapy on reproductive capacity depend on age at the time of chemotherapy administration, cumulative chemotherapy, radiation dose, type of agent, and baseline fertility status. Chemotherapy-induced risks for colorectal cancers are considered low to moderate, whereas pelvic radiation with a dose of 45 to 50 Gray induces premature menopause in greater than 90% of patients. Ovarian transposition may reduce but not eliminate the damaging effect of radiation on the ovaries. Embryo and oocyte cryopreservation are considered standard of care for women desiring fertility preservation, with oocyte cryopreservation no longer being considered experimental. Ovarian tissue cryopreservation remains experimental but may be an option for select patients. The use of gonadotropin-releasing hormone agonists remains controversial and has not been definitively shown to preserve fertility.

LIMITATIONS

The limitations of this review are the lack of randomized controlled trials and high-quality studies, as well as the small sample sizes and the use of surrogate fertility markers.

CONCLUSION

Reproductive-aged women with colorectal cancer benefit from fertility preservation counseling before the initiation of cancer treatment.

Fertility preservation in women with cancer and afterward

Women are surviving cancer in greater numbers. For this population, fertility becomes an important issue to be discussed before treatment to ensure maximal chances of fertility after treatment completion. Options for fertility preservation include egg or embryo freezing, ovarian tissue freezing, as well as gonadotropin releasing hormone analogs. The option for each individual patient will depend on the type of cancer, its aggressiveness and the time before treatment needs to commence, the type of treatment, the health of the patient, and whether the patient has a male partner.

Determination of the effects of bone marrow derived mesenchymal stem cells and ovarian stromal stem cells on follicular maturation in cyclophosphamide induced ovarian failure in rats

OBJECTIVE

Chemotherapy causes depletion of primordial follicles that leads to premature ovarian failure in female cancer survivals. We investigated the effect of bone marrow derived mesenchymal (BMMSCs) and ovarian stromal stem cells (OSSCs) on follicle maturation in chemotherapy induced ovarian failure.

MATERIAL AND METHODS

Thirty six Wistar Albino female rats were divided into three groups. Cyclophosphamide at a dose of 200 mg/kg was intraperitoneally (IP) given to the rats in all groups two times. 4 × 10⁶ BMMSCs (IP) was injected to the group-2 and 4 × 10⁶ OSSCs (IP) was injected to the group-3. Serum Anti-Müllerian Hormone (AMH) levels was determined with ELISA and primordial follicles were counted for investigation of primordial follicle reserve. The ovarian structure were evaluated histomorphologically. Localization of BrdU labeled stem cells, the expression of the cell cycle regulator p34Cdc2, gap junction protein p-connexin43 and intraovarian regulators of folliculogenesis Bone Morphogenic Protein 6 and 15 (BMP-6 and BMP-15) were investigated by immunohistochemistry.

RESULTS

The immunstaining of BMP-6 was higher in oocytes of group-3 more than group-1 and group-2. The immunpositivity of p34cdc2 and BMP-15 were also higher in follicular cells of group-3 than the other groups. The presence of p-connexin43 in group-3 was determined more than group-1 and group-2. The ovarian follicles with normal histological structure were observed just in group-3. Although, The AMH levels were decreased in rats from all groups at the end of experimental procedure the primordial follicle counts in group-3 was significantly higher than group-1.

CONCLUSION

Our findings suggest that OSSCs have more protective effect on follicle maturation than BMMSCs in cyclophosphamide induced ovarian damage.

Cryostorage and retransplantation of ovarian tissue as an infertility treatment

While still considered an experimental procedure in most countries, ovarian tissue cryopreservation and transplantation has been increasingly applied worldwide to restore fertility in patients with malignant and non-malignant pathologies with risk of premature ovarian insufficiency. It has yielded more than 130 live births up to now and almost all transplanted patients recovered their ovarian function. This study summarizes ovarian tissue cryopreservation and transplantation indications, procedures, their efficacy and main results and proposes different strategies to improve this strategy. Although the main focus of this study is on ovarian tissue cryopreservation and transplantation as a strategy to restore fertility, we believe that it is also important to discuss other applications for this approach.

Survey of Reproductive Experiences and Outcomes of Cancer Survivors Who Stored Reproductive Material Before Treatment

STUDY QUESTION

What are the reproductive experiences and outcomes of people who store reproductive material before cancer treatment?

SUMMARY ANSWER

Of respondents who had tried to achieve pregnancy since completing cancer treatment almost all had succeeded, in most cases through natural conception.

WHAT IS KNOWN ALREADY

People of reproductive age who are diagnosed with cancer can cryopreserve reproductive material to guard against the adverse effects on fertility of gonadotoxic treatment. Little is known about the reproductive outcomes of people who undergo fertility preservation before cancer treatment.

STUDY DESIGN, SIZE, DURATION

Cross-sectional survey.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women and men who had stored reproductive material before cancer treatment at two private and one public fertility clinics up to June 2014 and were at least 18 years old at the time were identified from medical records and invited to complete an anonymous questionnaire about their reproductive experiences.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 870 potential respondents 302 (171 female and 131 male) returned completed questionnaires yielding a response rate of 34.5% (39.5% and 29.7% for female and male respondents, respectively). Current age was similar for women and men (37.2 years) but men had been diagnosed with cancer significantly earlier in life than women (28.2 versus 30.3 years, P = 0.03). Almost two-thirds of respondents wished to have a child or another child in the future, some of whom knew that they were unable to. One in ten respondents was a parent before the cancer diagnosis and around one-third had had a child since diagnosis or was pregnant (or a partner in pregnancy) at the time of the survey. Of those who had tried to conceive since completing cancer treatment (N = 119) 84% (79% of women and 90% of men) had had a child or were pregnant (or a partner in pregnancy). Most of the pregnancies since the diagnosis of cancer occurred after natural conception (58/100, 58%). Of the 22 women (13% of all women) and 35 men (27% of all men) who had used their stored reproductive material four women (18%) and 28 men (80%) had had a child or were pregnant or a partner in pregnancy at the time of completing the survey. The most commonly stated reason for not using the stored material was not being ready to try for a baby.

LIMITATIONS, REASON FOR CAUTION

The relatively low response rate, particularly among men, means that participation bias may have influenced the findings. As type of cancer was self-reported and we did not ask questions about respondents' cancer treatments, it is not possible to link reproductive outcomes to type of cancer or cancer treatment. Also, there is no way of comparing the sample with the populations they were drawn from as data on reproductive outcomes of people who store reproductive material before cancer treatment are not collected routinely. This might have led to over- or underestimates of the reproductive experiences and outcomes reported in this paper.

WIDER IMPLICATIONS OF THE FINDINGS

The findings add to the limited evidence about the reproductive outcomes of this growing group of people and can be used to inform the advice given to those contemplating fertility preservation in the context of cancer.

STUDY FUNDING/COMPETING INTERESTS

The study was funded by the National Health and Medical Research Council (APP1042347). The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

Not applicable.

Towards biobanking technologies for natural and bioengineered multicellular placental constructs

Clinical application of a large variety of biomaterials is limited by the imperfections in storage technology. Perspective approaches utilizing low-temperature storage are especially challenging for multicellular structures, such as tissues, organs, and bioengineered constructs. Placenta, as a temporary organ, is a widely available unique biological material, being among the most promising sources of various cells and tissues for clinical and experimental use in regenerative medicine and tissue engineering. The aim of this study was to analyse the mechanisms of cryoinjuries in different placental tissues and bioengineered constructs as well as to support the viability after low temperature storage, which would contribute to development of efficient biobanking technologies. This study shows that specificity of cryodamage depends on the structure of the studied object, intercellular bonds, as well as interaction of its components with cryoprotective agents. Remarkably, it was possible to efficiently isolate cells after thawing from all of the studied tissues. While the outcome was lower in comparison to the native non-frozen samples, the phenotype and expression levels of pluripotency genes remained unaffected. Further progress in eliminating of recrystallization processes during thawing would significantly improve biobanking technologies for multicellular constructs and tissues.

Fertility Preservation: Current and Future Perspectives for Oncologic Patients at Risk for Iatrogenic Premature Ovarian Insufficiency

Progress in recent years in the efficacy of oncologic treatment and early diagnosis of cancer has determined an increase in life expectance in cancer patients. About 10% of all cancer cases affect women younger than 45 years; therefore nowadays approximately 5-6% of the population in childbearing age consists in cancer survivors. A crucial issue is the high risk of premature ovarian insufficiency due to possible gonadotoxic effects of oncologic treatments. Considering combined chemotherapy, radiation therapy, and bone marrow transplantation, this risk can reach 92-100%, depending on the age and ovarian reserve of the patient, as well as the schedule and type of therapy. International guidelines recommend addressing all the patients diagnosed with a neoplasia treatable with potentially gonadotoxic therapies to fertility preservation. Moreover, fertility preservation also seems to reserve fascinating implications for women who want to delay childbearing for social reasons or women affected with endometriosis, who could receive unexpected opportunities. At present, the most widespread techniques to preserve fertility in adult women are embryo or oocyte cryopreservation, depending on the presence of a partner or according to legislative issues, but these procedures require time for ovarian stimulation. In prepubertal patients or when there is no possibility of delaying chemotherapy, ovarian tissue cryopreservation and subsequent transplantation represent the main strategy.

GnRH in the Human Female Reproductive Axis

Gonadotropin-releasing hormone (GnRH) is recognized as the central regulator of the functions of the pituitary-gonadal axis. The increasing knowledge on the mechanisms controlling the development and the function of GnRH-producing neurons is leading to a better diagnostic and therapeutic approach for hypogonadotropic hypogonadisms and for alterations of the puberty onset. During female life span, the function of the GnRH pulse generator may be affected by a number of inputs from other neuronal systems, offering alternative strategies for diagnostic and therapeutic interventions. Moreover, the identification of a GnRH/GnRH receptor system in both human ovary and endometrium has widened the spectrum of action of the peptide outside its hypothalamic functions. The pharmacological use of GnRH itself or its synthetic analogs (agonists and antagonists) provides a valid tool to either stimulate or block gonadotropin secretion and to modulate the female fertility in several reproductive disorders and in assisted reproduction technology. The use of GnRH agonists in young female patients undergoing chemotherapy is also considered a promising therapeutic approach to counteract iatrogenic ovarian failure.

Fertility counseling and preservation: considerations for the pediatric endocrinologist

Infertility is a distressing consequence of numerous pediatric medical conditions and treatments. The field of pediatric fertility preservation has expanded rapidly over the past decade, and clinical guidelines emphasize the importance of discussing infertility risk and fertility preservation options with patients and families in a timely manner. Understanding the various mechanisms and presentations of fertility issues across diagnoses is imperative to provide counseling to patients and families, and identify individuals who may benefit from fertility preservation. The goals of this manuscript are to outline current fertility preservation options in pediatrics, review populations at-risk for infertility that are seen in pediatric endocrinology, and discuss other important issues related to fertility preservation including ethical considerations.

Advances in fertility preservation of female patients with hematological malignancies

INTRODUCTION

The most common forms of hematological malignancies that occur in female reproductive years are lymphoma and leukemia. Areas covered: Several aggressive gonadotoxic regimens such as alkylating chemotherapy and total body irradiation are used frequently in treatment of lymphoma and leukemia leading to subsequent iatrogenic premature ovarian failure and fertility loss. In such cases, female fertility preservation options should be offered in advance. Expert commentary: In order to preserve fertility of young women and girls with lymphoma and leukemia, several established, experimental, and debatable options can be offered before starting chemotherapy and radiotherapy. However, each of those female fertility preservation options has both advantages and disadvantages and may not be suitable for all patients. That is why a fertility preservation strategy should be individualized and tailored distinctively for each patient in order to be effective. Artificial human ovary is a novel experimental in vitro technology to produce mature oocytes that could be the safest option to preserve and restore fertility of young women and girls with hematological malignancies especially when other fertility preservation options are not feasible or contraindicated. Further research and studies are needed to improve the results of artificial human ovary and establish it in clinical practice.