1
|
Mottram MR, Feltbower PRG, Jones PG, Gelcich DS, Rostron MH, Allen MM, Glaser PAW. From Storage to Survivorship: A Scoping Review of Young Adult Cancer Survivors' Experiences and Preferences in Reproductive Survivorship Care after Fertility Tissue Preservation. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00273-0. [PMID: 39197581 DOI: 10.1016/j.jpag.2024.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 07/25/2024] [Accepted: 08/14/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND Childhood cancer treatment can lead to subfertility in adulthood. Fertility tissue preservation offers a way to safeguard future fertility, especially for prepubescent children, whose preservation options are limited. While this is a significant technological advance, it also presents unique challenges compared to other methods of fertility preservation. Clinical consensus is that all childhood cancer patients should receive high-quality, personalised survivorship care and that healthcare policy and practice must address the expectations and priorities of care recipients. We report the available information on the experiences of cancer survivors who preserved tissue for future fertility, to support the development of survivorship care informed by recipients' perspectives and experiences to identify future research priorities. METHODS We conducted a scoping review following the recommendations of the Joanna Briggs Institute and the Systematic Reviews and Meta-Analyses Extension for Scoping Review (PRISMA-ScR). We searched for research that included patient reported outcomes from patients who underwent fertility tissue preservation (FTP) in childhood and early adulthood, following a cancer diagnosis, including outcomes reported by parents. Our search terms aimed to identify literature reporting on both ovarian and testicular tissue preservation. We searched Embase, Cinahl, PsycInfo, Medline, Scopus and Cochrane Database of Systematic Reviews alongside sources of grey literature, for relevant articles including all time-frames between 1980-2023, with support from an independent information specialist at the University of Leeds. Descriptive statistics were used to analyze the data and we present the results in tabular form to summarise the key information. RESULTS From 1956 unique records, 5 met our inclusion criteria. No literature was found reporting on the experiences of people who stored testicular tissue. The available literature only included reports from people who had stored ovarian tissue. We found that young women who had stored ovarian tissue faced complex emotional and ethical dilemmas in reproductive decisions post cancer and strongly desired their own biological children. CONCLUSIONS This scoping review is the first to report beyond clinical outcomes by focusing specifically on the self-reported outcomes of patients who preserved ovarian tissue in early life after a cancer diagnosis. It provides valuable insights into their experiences and highlights that ovarian tissue cryopreservation (OTC) presents distinct challenges compared to other forms of fertility preservation. We recommend separate consideration of the needs of patients with stored fertility tissue and call for further research to enable personalized survivorship care. To develop tailored care pathways for long-term well-being, patient-reported outcomes are also needed from individuals with stored testicular tissue, parents who consented to their child's tissue storage, and the healthcare professionals involved in their care. This review underscores a significant evidence gap between rapid FTP advancements and the availability of comprehensive care addressing these advancements. As FTP science evolves, patients need detailed information for informed decisions and ongoing support for their unique reproductive and endocrine health concerns throughout their survivorship journey.
Collapse
Affiliation(s)
| | | | | | | | - Mrs Heather Rostron
- Leeds Teaching Hospitals NHS Trust and School of Medicine, University of Leeds, UK
| | | | | |
Collapse
|
2
|
McElhinney KL, Rowell EE, Laronda MM. Encapsulation of Bovine Primordial Follicles in Rigid Alginate Does Not Affect Growth Dynamics. Bioengineering (Basel) 2024; 11:734. [PMID: 39061816 PMCID: PMC11273846 DOI: 10.3390/bioengineering11070734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/02/2024] [Accepted: 07/07/2024] [Indexed: 07/28/2024] Open
Abstract
The only fertility preservation and subsequent restoration option for many patients facing gonadotoxic treatments is ovarian tissue cryopreservation and transplantation. While this process is successful for some, there is significant room for improvement to extend the life of the transplant and to make it safe for patients that may have metastatic disease within their ovarian tissue. We need a deeper understanding of how the physical properties of the ovarian microenvironment may affect folliculogenesis to engineer an environment that supports isolated follicles and maintains primordial follicle quiescence. Bovine ovaries were used here as a monovulatory model of folliculogenesis to examine the effects of primordial follicle activation and growth under different physical conditions. We found that there were no differences in activation, growth or survival when primordial follicles were cultured in isolation or in situ (remaining in the tissue) under two significantly differently rigid alginate gels. To determine if the extra rigid environment did not affect activation in isolated follicles due to an immediate activation event, we used 5-ethynyl-2'-deoxyuridine (EdU) to track follicle activation during the isolation process. We identified EdU incorporation in granulosa cells after primordial follicles were isolated from the surrounding extracellular matrix (ECM). These findings support that isolation of primordial follicles from the ECM is an activating event and that the differentially rigid environments assessed here had no effect on follicle growth. Further work is needed to suppress activation in primordial follicles to maintain the ovarian reserve and extend the life of an ovarian tissue transplant.
Collapse
Affiliation(s)
- Kathryn L. McElhinney
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA; (K.L.M.)
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Department of Pediatrics, Division of Endocrinology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Erin E. Rowell
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA; (K.L.M.)
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Monica M. Laronda
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA; (K.L.M.)
- Department of Pediatrics, Division of Endocrinology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| |
Collapse
|
3
|
McElhinney KL, Kennedy T, Rowell EE, Laronda MM. A dozen years of ovarian tissue cryopreservation at a pediatric hospital: tracking program and patient metrics while adapting to increasing needs. F S Rep 2024; 5:197-204. [PMID: 38983744 PMCID: PMC11228781 DOI: 10.1016/j.xfre.2024.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/09/2024] [Accepted: 02/13/2024] [Indexed: 07/11/2024] Open
Abstract
Objective To review the program and patient metrics for ovarian tissue cryopreservation (OTC) within a comprehensive pediatric fertility preservation program in its first 12 years of development. Design Retrospective review. Setting A tertiary children's hospital in a large urban center between March 2011 and February 2023. Patients Pediatric patients who underwent OTC. Interventions Unilateral oophorectomy for OTC. Main Outcome Measures Patient demographics and clinical course information were collected for analysis. Results A total of 184 patients underwent OTC in the first 12 years. One hundred fifteen patients were prepubertal at the time of OTC, and 69 were postpubertal. In total, 128 patients (69.6%) received part of their planned therapy before OTC. Starting in 2018, 104 participants (92.0%) donated tissue to research, 99 participants (87.6%) donated blood, and 102 (90.2%) donated media to research. There was a decrease in the median age of patients who underwent OTC from 16.4-6.6 years and an overall increase in the proportion of patients per year that were prepubertal. Forty-eight (26.0%) patients who underwent OTC were outside referrals and traveled from as far as Seattle, Washington. Conclusion During the first 12 years of this program, oncofertility research increased, annual tissue cryopreservation cases increased, and the median age of those who underwent OTC decreased. The program was adapted to build a stand-alone gonadal tissue processing suite and specialized in prepubertal ovarian tissue processing. The program will continue to adapt to patient needs in the upcoming decades because restoration technologies advance through research supported by this and collaborating programs.
Collapse
Affiliation(s)
- Kathryn L McElhinney
- Department of Surgery, Division of Pediatric Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Fertility & Hormone Preservation & Restoration Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Tara Kennedy
- Department of Surgery, Division of Pediatric Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Fertility & Hormone Preservation & Restoration Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Erin E Rowell
- Department of Surgery, Division of Pediatric Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Fertility & Hormone Preservation & Restoration Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Monica M Laronda
- Department of Surgery, Division of Pediatric Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Fertility & Hormone Preservation & Restoration Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
- Department of Pediatrics, Division of Endocrinology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| |
Collapse
|
4
|
Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GMT, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International recommendations for screening and preventative practices for long-term survivors of transplantation and cellular therapy: a 2023 update. Bone Marrow Transplant 2024; 59:717-741. [PMID: 38413823 DOI: 10.1038/s41409-023-02190-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 12/08/2023] [Accepted: 12/19/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the volume of HCT performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long-term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pre-, peri- and post-transplant exposures and other underlying risk-factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and updated in 2012. To review contemporary literature and update the recommendations while considering the changing practice of HCT and cellular therapy, an international group of experts was again convened. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed but cGVHD management is not covered in detail. These guidelines emphasize special needs of patients with distinct underlying HCT indications or comorbidities (e.g., hemoglobinopathies, older adults) but do not replace more detailed group, disease, or condition specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
Collapse
Affiliation(s)
- Seth J Rotz
- Division of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
| | | | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, MA, USA
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Nagakute, Japan
- Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, AZ, USA
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, CA, USA
| | - Peggy Burkhard
- National Bone Marrow Transplant Link, Southfield, MI, USA
| | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, SK, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, Halifax, NS, Canada
- QEII Health Sciences Center, Halifax, NS, Canada
| | - Gregory M T Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, Sydney, NSW, Australia
- St Vincent's Clinical School Sydney, University of New South Wales, Sydney, NSW, Australia
- School of Medicine Sydney, University of Notre Dame Australia, Sydney, WA, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, WA, Australia
- PathWest Laboratory Medicine, Nedlands, WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, WI, USA
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, UK
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary Care, ACCENT VV, KU Leuven-University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN, USA
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | - Susan K Stewart
- Blood & Marrow Transplant Information Network, Highland Park, IL, 60035, USA
| | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, TN, USA
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
5
|
Tsui EL, McDowell HB, Laronda MM. Restoring Ovarian Fertility and Hormone Function: Recent Advancements, Ongoing Efforts and Future Applications. J Endocr Soc 2024; 8:bvae073. [PMID: 38698870 PMCID: PMC11065362 DOI: 10.1210/jendso/bvae073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Indexed: 05/05/2024] Open
Abstract
The last 20 years have seen substantial improvements in fertility and hormone preservation and restoration technologies for a growing number of cancer survivors. However, further advancements are required to fill the gaps for those who cannot use current technologies or to improve the efficacy and longevity of current fertility and hormone restoration technologies. Ovarian tissue cryopreservation (OTC) followed by ovarian tissue transplantation (OTT) offers those unable to undergo ovarian stimulation for egg retrieval and cryopreservation an option that restores both fertility and hormone function. However, those with metastatic disease in their ovaries are unable to transplant this tissue. Therefore, new technologies to produce good-quality eggs and restore long-term cyclic ovarian function are being investigated and developed to expand options for a variety of patients. This mini-review describes current and near future technologies including in vitro maturation, in vitro follicle growth and maturation, bioprosthetic ovaries, and stem cell applications in fertility restoration research by their proximity to clinical application.
Collapse
Affiliation(s)
- Elizabeth L Tsui
- Department of Pediatrics, Division of Endocrinology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Hannah B McDowell
- Department of Pediatrics, Division of Endocrinology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Monica M Laronda
- Department of Pediatrics, Division of Endocrinology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| |
Collapse
|
6
|
Rashidian P. An update on oncofertility in prepubertal females. J Gynecol Obstet Hum Reprod 2024; 53:102742. [PMID: 38341083 DOI: 10.1016/j.jogoh.2024.102742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 02/02/2024] [Accepted: 02/08/2024] [Indexed: 02/12/2024]
Abstract
Cancer is a life-threatening event for pediatric patients. Treatment advancements in pediatric cancer have improved prognosis, but some of these treatments have gonadotoxic potential and may affect fertility in different ways. Due to the growing interest of the research community in the life prospects of young cancer survivors, there has been a demand to intersect reproductive medicine and oncology, which is referred to as "oncofertility". There are various fertility preservation options according to gender and pubertal status, and shared decisions must take place at the time of diagnosis. This study aims to provide a critical review of current and emerging strategies for preserving and restoring fertility in prepubertal females, ranging from established methods to experimental approaches that can be offered before, during, and after anticancer therapies. Additionally, the author aims to review how clinicians' awareness of oncofertility options and the latest advancements in this field, timely referral, and proper consultations with patients and their families are vital in addressing their concerns, providing emotional support, and guiding them through the decision-making process, as well as potential barriers that may hinder the fertility preservation process.
Collapse
Affiliation(s)
- Pegah Rashidian
- Reproductive Health Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran.
| |
Collapse
|
7
|
Rotz SJ, Bhatt NS, Hamilton BK, Duncan C, Aljurf M, Atsuta Y, Beebe K, Buchbinder D, Burkhard P, Carpenter PA, Chaudhri N, Elemary M, Elsawy M, Guilcher GM, Hamad N, Karduss A, Peric Z, Purtill D, Rizzo D, Rodrigues M, Ostriz MBR, Salooja N, Schoemans H, Seber A, Sharma A, Srivastava A, Stewart SK, Baker KS, Majhail NS, Phelan R. International Recommendations for Screening and Preventative Practices for Long-Term Survivors of Transplantation and Cellular Therapy: A 2023 Update. Transplant Cell Ther 2024; 30:349-385. [PMID: 38413247 PMCID: PMC11181337 DOI: 10.1016/j.jtct.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 12/04/2023] [Indexed: 02/29/2024]
Abstract
As hematopoietic cell transplantation (HCT) and cellular therapy expand to new indications and international access improves, the number of HCTs performed annually continues to rise. Parallel improvements in HCT techniques and supportive care entails more patients surviving long term, creating further emphasis on survivorship needs. Survivors are at risk for developing late complications secondary to pretransplantation, peritransplantation, and post-transplantation exposures and other underlying risk factors. Guidelines for screening and preventive practices for HCT survivors were originally published in 2006 and then updated in 2012. An international group of experts was convened to review the contemporary literature and update the recommendations while considering the changing practices of HCT and cellular therapy. This review provides updated pediatric and adult survivorship guidelines for HCT and cellular therapy. The contributory role of chronic graft-versus-host disease (cGVHD) to the development of late effects is discussed, but cGVHD management is not covered in detail. These guidelines emphasize the special needs of patients with distinct underlying HCT indications or comorbidities (eg, hemoglobinopathies, older adults) but do not replace more detailed group-, disease-, or condition-specific guidelines. Although these recommendations should be applicable to the vast majority of HCT recipients, resource constraints may limit their implementation in some settings.
Collapse
Affiliation(s)
- Seth J Rotz
- Department of Pediatric Hematology, Oncology, and Blood and Marrow Transplantation, Pediatric Institute, Cleveland Clinic Foundation, Cleveland, Ohio; Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Neel S Bhatt
- Fred Hutchinson Cancer Center, Seattle, Washington
| | - Betty K Hamilton
- Blood and Marrow Transplant Program, Department of Hematology and Oncology, Taussig Cancer Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Christine Duncan
- Dana Farber/Boston Children's Cancer and Blood Disorders Center, Harvard University, Boston, Massachusetts
| | - Mahmoud Aljurf
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Department of Registry Science for Transplant and Cellular Therapy, Aichi Medical University School of Medicine, Japanese Data Center for Hematopoietic Cell Transplantation, Nagakute, Japan
| | - Kristen Beebe
- Phoenix Children's Hospital and Mayo Clinic Arizona, Phoenix, Arizona
| | - David Buchbinder
- Division of Hematology, Children's Hospital of Orange County, Orange, California
| | | | | | - Naeem Chaudhri
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Mohamed Elemary
- Hematology and BMT, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mahmoud Elsawy
- Division of Hematology, Dalhousie University, QEII Health Sciences Center, Halifax, Nova Scotia, Canada
| | - Gregory Mt Guilcher
- Section of Pediatric Oncology/Transplant and Cellular Therapy, Alberta Children's Hospital, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nada Hamad
- Department of Haematology, St Vincent's Hospital Sydney, St Vincent's Clinical School Sydney, University of New South Wales, School of Medicine Sydney, University of Notre Dame Australia, Australia
| | - Amado Karduss
- Bone Marrow Transplant Program, Clinica las Americas, Medellin, Colombia
| | - Zinaida Peric
- BMT Unit, Department of Hematology, University Hospital Centre Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Duncan Purtill
- Fiona Stanley Hospital, Murdoch, PathWest Laboratory Medicine WA, Australia
| | - Douglas Rizzo
- Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Maria Belén Rosales Ostriz
- Division of hematology and bone marrow transplantation, Instituto de trasplante y alta complejidad (ITAC), Buenos Aires, Argentina
| | - Nina Salooja
- Centre for Haematology, Imperial College London, London, United Kingdom
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, Department of Public Health and Primary Care, ACCENT VV, KU Leuven, University of Leuven, Leuven, Belgium
| | | | - Akshay Sharma
- Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Alok Srivastava
- Department of Haematology, Christian Medical College, Vellore, India
| | | | | | - Navneet S Majhail
- Sarah Cannon Transplant and Cellular Therapy Network, Nashville, Tennessee
| | - Rachel Phelan
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
8
|
Affdal AO, Salama M, Ravitsky V. Ethical, legal, social, and policy issues of ovarian tissue cryopreservation in prepubertal girls: a critical interpretive review. J Assist Reprod Genet 2024; 41:999-1026. [PMID: 38430324 PMCID: PMC11052756 DOI: 10.1007/s10815-024-03059-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/07/2024] [Indexed: 03/03/2024] Open
Abstract
PURPOSE Despite the increasing number of childhood cancer survivors, significant advances in ovarian tissue cryopreservation (OTC) technique and medical societies' recommendations, fertility preservation (FP) and FP discussions are not always offered as a standard of care in the pediatric context. The aim of this literature review is to understand what ethical, legal, social, and policy issues may influence the provision of FP by OTC in prepubertal girls with cancer. METHODS A critical interpretive review of peer-reviewed papers published between 2000 and January 2023 was conducted, guided by the McDougall's version of the critical interpretive synthesis (Dixon-Woods), to capture recurring concepts, principles, and arguments regarding FP by OTC for prepubertal girls. RESULTS Of 931 potentially relevant papers, 162 were included in our analysis. Data were grouped into seven thematic categories: (1) risks of the procedure, (2) unique decision-making issues in pediatric oncofertility, (3) counseling, (4) cultural and cost issues, and (5) disposition of cryopreserved reproductive tissue. CONCLUSION This first literature review focusing on ethical, legal, social, and policy issues surrounding OTC in prepubertal girls highlights concerns in the oncofertility debate. Although OTC is no longer experimental as of December 2019, these issues could limit its availability and the child's future reproductive autonomy. This review concludes that specific actions must be provided to enable the offer of FP, such as supporting families' decision-making in this unique and complex context, and providing pediatric patients universal and full access to free or highly subsidized OTC.
Collapse
Affiliation(s)
| | | | - Vardit Ravitsky
- University of Montreal, Montreal, Canada
- The Hastings Center, Garrison, USA
- Harvard Medical School, Boston, USA
| |
Collapse
|
9
|
Ruan X. Chinese Expert Consensus on ovarian function and fertility preservation of cervical cancer in pregnancy (2023). Front Endocrinol (Lausanne) 2023; 14:1280631. [PMID: 38152134 PMCID: PMC10751331 DOI: 10.3389/fendo.2023.1280631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/08/2023] [Indexed: 12/29/2023] Open
Abstract
Cervical cancer in pregnancy (CCIP) refers to cervical cancer diagnosed during pregnancy, the most common gynecological malignant tumor. Because of the special physiological changes of CCIP, although preserving ovarian function and fertility is very important, the methods are very limited. There is no guideline or consensus on the preservation methods of ovarian function and fertility in this special period. Therefore, the Committee of Fertility Protection and Preservation of China Association for the Promotion of Health Science and Technology, combined with the Chinese Society of Gynecological Endocrinology affiliated to the International Society of Gynecological Endocrinology, Society Endocrinology Branch of Beijing Institute of Obstetrics & Gynecology, combined with Society on Fertility Preservation affiliated with the Chinese Preventive Medicine Association, organized relevant experts from different disciplines to formulate this consensus, in order to guide ovarian function and fertility preservation of CCIP patients.
Collapse
Affiliation(s)
- Xiangyan Ruan
- Department of Gynecological Endocrinology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, Beijing, China
- Department of Women’s Health, University of Tuebingen, University Women’s Hospital and Research Centre for Women’s Health, Tuebingen, Germany
| |
Collapse
|
10
|
Pawłowski P, Ziętara KJ, Michalczyk J, Fryze M, Buchacz A, Zaucha-Prażmo A, Zawitkowska J, Torres A, Samardakiewicz M. Fertility Preservation in Children and Adolescents during Oncological Treatment-A Review of Healthcare System Factors and Attitudes of Patients and Their Caregivers. Cancers (Basel) 2023; 15:4393. [PMID: 37686669 PMCID: PMC10487203 DOI: 10.3390/cancers15174393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/31/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Oncofertility is any therapeutic intervention to safeguard the fertility of cancer patients. Anti-cancer therapies (chemotherapy, radiation therapy, etc.) entail the risk of reproductive disorders through cytotoxic effects on gamete-building cells, especially those not yet fully developed. This literature review analyzes the available data on securing fertility in pediatric and adolescent populations to identify the methods used and describe aspects related to financing, ethics, and the perspective of patients and their parents. Topics related to oncofertility in this age group are relatively niche, with few peer-reviewed articles available and published studies mostly on adults. Compared to pubertal individuals, a limited number of fertility preservation methods are used for prepubertal patients. Funding for the procedures described varies from country to country, but only a few governments choose to reimburse them. Oncofertility of pediatric and adolescent patients raises many controversies related to the decision, parents' beliefs, having a partner, ethics, as well as the knowledge and experience of healthcare professionals. As the fertility of young cancer patients is at risk, healthcare professionals should make every effort to provide them with an opportunity to fulfill their future reproductive plans and to have a family and offspring. Systemic solutions should form the basis for the development of oncofertility in pediatric and adolescent populations.
Collapse
Affiliation(s)
- Piotr Pawłowski
- Student Scientific Association at the Department of Psychology, Faculty of Medicine, Medical University of Lublin, 20-093 Lublin, Poland; (P.P.); (J.M.)
| | - Karolina Joanna Ziętara
- Student Scientific Association at the Department of Psychology, Faculty of Medicine, Medical University of Lublin, 20-093 Lublin, Poland; (P.P.); (J.M.)
| | - Justyna Michalczyk
- Student Scientific Association at the Department of Psychology, Faculty of Medicine, Medical University of Lublin, 20-093 Lublin, Poland; (P.P.); (J.M.)
| | - Magdalena Fryze
- Department of Psychology, Psychosocial Aspects of Medicine, Medical University of Lublin, 20-093 Lublin, Poland; (M.F.); (M.S.)
| | - Anna Buchacz
- Youth Cancer Europe, 400372 Cluj-Napoca, Romania;
| | - Agnieszka Zaucha-Prażmo
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland; (A.Z.-P.); (J.Z.)
| | - Joanna Zawitkowska
- Department of Pediatric Hematology, Oncology and Transplantology, Medical University of Lublin, 20-093 Lublin, Poland; (A.Z.-P.); (J.Z.)
| | - Anna Torres
- Department of Pediatric and Adolescent Gynecology, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Marzena Samardakiewicz
- Department of Psychology, Psychosocial Aspects of Medicine, Medical University of Lublin, 20-093 Lublin, Poland; (M.F.); (M.S.)
| |
Collapse
|
11
|
Najafi A, Asadi E, Benson JD. Ovarian tissue cryopreservation and transplantation: a review on reactive oxygen species generation and antioxidant therapy. Cell Tissue Res 2023; 393:401-423. [PMID: 37328708 DOI: 10.1007/s00441-023-03794-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 05/31/2023] [Indexed: 06/18/2023]
Abstract
Cancer is the leading cause of death worldwide. Fortunately, the survival rate of cancer continues to rise, owing to advances in cancer treatments. However, these treatments are gonadotoxic and cause infertility. Ovarian tissue cryopreservation and transplantation (OTCT) is the most flexible option to preserve fertility in women and children with cancer. However, OTCT is associated with significant follicle loss and an accompanying short lifespan of the grafts. There has been a decade of research in cryopreservation-induced oxidative stress in single cells with significant successes in mitigating this major source of loss of viability. However, despite its success elsewhere and beyond a few promising experiments, little attention has been paid to this key aspect of OTCT-induced damage. As more and more clinical practices adopt OTCT for fertility preservation, it is a critical time to review oxidative stress as a cause of damage and to outline potential ameliorative interventions. Here we give an overview of the application of OTCT for female fertility preservation and existing challenges; clarify the potential contribution of oxidative stress in ovarian follicle loss; and highlight potential ability of antioxidant treatments to mitigate the OTCT-induced injuries that might be of interest to cryobiologists and reproductive clinicians.
Collapse
Affiliation(s)
- Atefeh Najafi
- Department of Biology, University of Saskatchewan, S7N 5E2, Saskatoon, SK, Canada
| | - Ebrahim Asadi
- Department of Biology, University of Saskatchewan, S7N 5E2, Saskatoon, SK, Canada
| | - James D Benson
- Department of Biology, University of Saskatchewan, S7N 5E2, Saskatoon, SK, Canada.
| |
Collapse
|
12
|
Nelson M, Levine J. Current Issues in Fertility Preservation Among Pediatric and Adolescent Cancer Patients. Curr Oncol Rep 2023; 25:793-802. [PMID: 37036623 DOI: 10.1007/s11912-023-01401-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2023] [Indexed: 04/11/2023]
Abstract
PURPOSE OF REVIEW Although fertility preservation is not yet fully integrated into the comprehensive cancer care of pediatric and adolescent patients, advances continue to take place. This review summarizes recent updates and trends for health care professionals caring for these patients. RECENT FINDINGS The creation of standardized infertility risk assessment guidelines offers the opportunity to provide greater consistency in clinical care and to provide a current baseline for future research studies seeking to refine risk stratification for individual patients. New agents are being introduced into cancer care; as their use increases, information about their impact on fertility is being studied. Ovarian tissue cryopreservation offers a new standard of care option for fertility preservation, but additional studies are needed to further assess efficacy and impact on ovarian reserve among pediatric and adolescent patients. Standardization of fertility preservation recommendations among certain sub-populations may also make it easier to provide greater consistency in clinical care. Advances continue to be made in the field of fertility preservation, but dissemination of this information is critical to moving toward fertility preservation truly being a part of comprehensive cancer care.
Collapse
Affiliation(s)
- Marie Nelson
- Children's National Medical Center, Center for Cancer and Blood Disorders, 111 Michigan Avenue NW, Room W4-604, Washington, D.C., 20010, USA
| | - Jennifer Levine
- Children's National Medical Center, Center for Cancer and Blood Disorders, 111 Michigan Avenue NW, Room W4-604, Washington, D.C., 20010, USA.
| |
Collapse
|
13
|
Giovannopoulou E, Karakasi MV, Kouroupi M, Giatromanolaki A, Tsikouras P, Pavlidis P. Safety and efficacy of ovarian tissue autotransplantation: A systematic literature review. Folia Med (Plovdiv) 2023; 65:362-370. [PMID: 38351810 DOI: 10.3897/folmed.65.e89198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/30/2022] [Indexed: 02/16/2024] Open
Abstract
Ovarian tissue autotransplantation is an innovative fertility preservation technique that has provoked ongoing investigations. The purpose of the present study was to assess the safety and reproductive performance of ovarian tissue autotransplantation. This review is conducted according to PRISMA guidelines. Seven studies met the inclusion criteria. A total of 3427 patients underwent ovarian tissue cryopreservation and 205 received an autotransplantation. Tissue retrieval was mainly performed by laparoscopy and only one major complication occurred. Transplantations were predominantly performed by open procedures and data on safety were insufficient. A total of 295 autotransplantations were analyzed, resulting in 104 pregnancies. Sixty-five pregnancies led to live births, while nine were ongoing at that time. A pregnancy rate (PR) of 50.7% and a live-birth rate (LBR) of 32.7% were observed. Natural conception accounted for 46.3% of live births. No birth deficits were recorded. Ovarian tissue autotransplantation seems to be a safe procedure with acceptable pregnancy rates.
Collapse
Affiliation(s)
| | | | - Maria Kouroupi
- General University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | | | | |
Collapse
|
14
|
Hanna MT, Handa N, Laronda MM, Rowell EE. Efficacy of Video-based Education in Improving Understanding of Pediatric Fertility Preservation. J Pediatr Hematol Oncol 2023; 45:e487-e495. [PMID: 36716087 DOI: 10.1097/mph.0000000000002611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/08/2022] [Indexed: 01/31/2023]
Abstract
Eighty percent of children diagnosed with cancer in childhood survive into adulthood. Fertility preservation (FP) is an important consideration, and procedures are available to reduce the risk of infertility following gonadotoxic therapies. Discussing FP options eases decision-making and minimizes regret; however, poor comprehension of these topics remains a challenge. This study evaluates if video-based educational tools increase understanding of FP options among pediatric patients and families. Videos were first tested among participants not at risk of infertility to ensure objective utility and optimize quality. In part 1, parents of pediatric surgical patients were randomized to view 2 publicly available educational videos on FP in differing orders. Each group completed pre-surveys and post-surveys assessing the comprehension and perception of video quality. In part 2, the parent and patient participants completed a comprehension assessment before and after viewing our institution-specific educational video, designed based on participant feedback from part 1. Part 1 results demonstrated a significant increase in participant knowledge and perceived understanding after viewing the videos ( P <0.001), regardless of order. In part 2, the post-test comprehension scores were significantly improved for all participants and all subgroups, P <0.01. Results suggest that video-based educational tools may help to reduce barriers to FP in pediatric oncology.
Collapse
Affiliation(s)
- Maria T Hanna
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Department of Surgery
| | - Nicole Handa
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Department of Surgery
| | - Monica M Laronda
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University
- Stanley Manne Children's Research Institute, Chicago, IL
| | - Erin E Rowell
- Ann & Robert H. Lurie Children's Hospital of Chicago
- Department of Surgery
| |
Collapse
|
15
|
Dwiggins M, Shim J, Galloway LA, Hoefgen H, Patel V, Breech L, Gomez-Lobo V. Effects of Ovarian Tissue Cryopreservation on Primary Ovarian Insufficiency in Girls Undergoing Bone Marrow Transplantation. J Pediatr Adolesc Gynecol 2023; 36:128-133. [PMID: 36481215 PMCID: PMC11070932 DOI: 10.1016/j.jpag.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 11/08/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine if removing an ovary for ovarian tissue cryopreservation (OTC) increased rates of primary ovarian insufficiency (POI) in girls undergoing bone marrow transplantation (BMT). Institutional review board approval was obtained from all 3 clinical sites. DESIGN Multicenter retrospective cohort study SETTING: Academic children's hospitals PATIENTS: Females aged 2-21 who underwent BMT with or without OTC from 2010 to 2017. INTERVENTIONS None MAIN OUTCOME MEASURES: Rates of POI in girls who underwent OTC vs those who underwent BMT alone as determined by serum markers, presence of menses, or clinical diagnosis. RESULTS A total of 142 patients were identified, 43 who had OTC and 99 with BMT alone. The rate of POI in girls undergoing OTC was 65% vs 41.8% in those who underwent BMT alone (P = .26). CONCLUSIONS Although this study was not powered to detect a lack of difference, it is reassuring that there does not seem to be a clinically significant increase in POI in patients undergoing OTC.
Collapse
Affiliation(s)
- Maggie Dwiggins
- Norton Children's Hospital, University of Louisville Medical School, Louisville, Kentucky.
| | - Jessica Shim
- Boston Children's Hospital, Boston, Massachusetts
| | | | - Holly Hoefgen
- Washington University School of Medicine, St. Louis, Missouri
| | - Vrunda Patel
- Nemours A.I. DuPont Hospital for Children, Wilmington, Delaware
| | - Lesley Breech
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| |
Collapse
|
16
|
Hartman N, James C, Barrera EP, Grimstad FW, El-Arabi AM. Effects on Fertility and the Preservation of Fertility in the Transgender Patient. CURRENT SEXUAL HEALTH REPORTS 2023. [DOI: 10.1007/s11930-023-00355-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
17
|
Salama M, Nahata L, Jayasinghe Y, Gomez-Lobo V, Laronda MM, Moravek MB, Meacham LR, Christianson MS, Lambertini M, Anazodo A, Quinn GP, Woodruff TK. Pediatric oncofertility care in limited versus optimum resource settings: results from 39 surveyed centers in Repro-Can-OPEN Study Part I & II. J Assist Reprod Genet 2023; 40:443-454. [PMID: 36542312 PMCID: PMC9768400 DOI: 10.1007/s10815-022-02679-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE As a secondary report to elucidate the diverse spectrum of oncofertility practices for childhood cancer around the globe, we present and discuss the comparisons of oncofertility practices for childhood cancer in limited versus optimum resource settings based on data collected in the Repro-Can-OPEN Study Part I & II. METHODS We surveyed 39 oncofertility centers including 14 in limited resource settings from Africa, Asia, and Latin America (Repro-Can-OPEN Study Part I), and 25 in optimum resource settings from the USA, Europe, Australia, and Japan (Repro-Can-OPEN Study Part II). Survey questions covered the availability of fertility preservation and restoration options offered in case of childhood cancer as well as their degree of utilization. RESULTS In the Repro-Can-OPEN Study Part I & II, responses for childhood cancer and calculated oncofertility scores showed the following characteristics: (1) higher oncofertility scores in optimum resource settings than in limited resource settings for ovarian and testicular tissue cryopreservation; (2) frequent utilization of gonadal shielding, fractionation of anticancer therapy, oophoropexy, and GnRH analogs; (3) promising utilization of oocyte in vitro maturation (IVM); and (4) rare utilization of neoadjuvant cytoprotective pharmacotherapy, artificial ovary, in vitro spermatogenesis, and stem cells reproductive technology as they are still in preclinical or early clinical research settings. CONCLUSIONS Based on Repro-Can-OPEN Study Part I & II, we presented a plausible oncofertility best practice model to help optimize care for children with cancer in various resource settings. Special ethical concerns should be considered when offering advanced and innovative oncofertility options to children.
Collapse
Affiliation(s)
- M Salama
- grid.17088.360000 0001 2150 1785Oncofertility Consortium, Michigan State University, 965 Wilson Road, Room A626B, East Lansing, MI 48824-1316 USA
| | - L. Nahata
- grid.240344.50000 0004 0392 3476Endocrinology and Center for Biobehavioral Health, The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH 43205 USA
- grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH 43205 USA
| | - Y. Jayasinghe
- grid.416107.50000 0004 0614 0346Royal Children’s Hospital, Flemington Rd, Parkville, Melbourne, Vic 3054 Australia
| | - V. Gomez-Lobo
- grid.239560.b0000 0004 0482 1586Children’s National Hospital, 111 Michigan Avenue NW, Washington, DC 20010 USA
- grid.420089.70000 0000 9635 8082Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda MD, Annapolis, 20892 USA
| | - MM. Laronda
- grid.413808.60000 0004 0388 2248Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 East Chicago Ave, Box 63, Chicago, IL 60611 USA
| | - MB. Moravek
- grid.412590.b0000 0000 9081 2336Center for Reproductive Medicine, Michigan Medicine, 475 Market Place, Building 1, Suite B, Ann Arbor, MI 48108 USA
| | - LR. Meacham
- grid.428158.20000 0004 0371 6071Aflac Cancer Center Children’s Healthcare of Atlanta, Atlanta, GA USA
- grid.189967.80000 0001 0941 6502Department of Pediatrics, Emory University, 2015 Uppergate Dr, Atlanta, GA 30322 USA
| | - MS. Christianson
- grid.21107.350000 0001 2171 9311Johns Hopkins Fertility Center, Division of Reproductive Endocrinology and Infertility, Johns Hopkins University School of Medicine, 10751 Falls Road, Suite 280, Lutherville, MD 21093 USA
| | - M. Lambertini
- grid.410345.70000 0004 1756 7871Department of Medical Oncology, UOC Clinica Di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- grid.5606.50000 0001 2151 3065Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
| | - A. Anazodo
- grid.414009.80000 0001 1282 788XKids Cancer Centre, Sydney Children’s Hospital, High Street Randwick, Sydney, Randwick 2031 Australia
| | - GP. Quinn
- grid.137628.90000 0004 1936 8753New York University, NYU Langone Fertility Center, 660 First Ave, 5Th Floor, New York, NY 10016 USA
| | - TK. Woodruff
- grid.17088.360000 0001 2150 1785Oncofertility Consortium, Michigan State University, 965 Wilson Road, Room A626B, East Lansing, MI 48824-1316 USA
| |
Collapse
|
18
|
Chattha AJ, Salama M, Jayasinghe Y. Editorial: Fertility preservation in the pediatric population. Front Endocrinol (Lausanne) 2023; 14:1149532. [PMID: 36875479 PMCID: PMC9979307 DOI: 10.3389/fendo.2023.1149532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 02/18/2023] Open
Affiliation(s)
- Asma J. Chattha
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Asma J. Chattha,
| | - Mahmoud Salama
- Department of Obstetrics, Gynaecology and Reproductive Biology, Michigan State University, East Lansing, MI, United States
| | - Yasmin Jayasinghe
- Department of Obstetrics and Gynaecology, University of Melbourne, Royal Women's Hospital, Parkville, VIC, Australia
- Oncofertility Program, Royal Children's Hospital, Melbourne, VIC, Australia
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| |
Collapse
|
19
|
Ataman LM, Laronda MM, Gowett M, Trotter K, Anvari H, Fei F, Ingram A, Minette M, Suebthawinkul C, Taghvaei Z, Torres-Vélez M, Velez K, Adiga SK, Anazodo A, Appiah L, Bourlon MT, Daniels N, Dolmans MM, Finlayson C, Gilchrist RB, Gomez-Lobo V, Greenblatt E, Halpern JA, Hutt K, Johnson EK, Kawamura K, Khrouf M, Kimelman D, Kristensen S, Mitchell RT, Moravek MB, Nahata L, Orwig KE, Pavone ME, Pépin D, Pesce R, Quinn GP, Rosen MP, Rowell E, Smith K, Venter C, Whiteside S, Xiao S, Zelinski M, Goldman KN, Woodruff TK, Duncan FE. A synopsis of global frontiers in fertility preservation. J Assist Reprod Genet 2022; 39:1693-1712. [PMID: 35870095 PMCID: PMC9307970 DOI: 10.1007/s10815-022-02570-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022] Open
Abstract
Since 2007, the Oncofertility Consortium Annual Conference has brought together a diverse network of individuals from a wide range of backgrounds and professional levels to disseminate emerging basic and clinical research findings in fertility preservation. This network also developed enduring educational materials to accelerate the pace and quality of field-wide scientific communication. Between 2007 and 2019, the Oncofertility Consortium Annual Conference was held as an in-person event in Chicago, IL. The conference attracted approximately 250 attendees each year representing 20 countries around the world. In 2020, however, the COVID-19 pandemic disrupted this paradigm and precluded an in-person meeting. Nevertheless, there remained an undeniable demand for the oncofertility community to convene. To maintain the momentum of the field, the Oncofertility Consortium hosted a day-long virtual meeting on March 5, 2021, with the theme of "Oncofertility Around the Globe" to highlight the diversity of clinical care and translational research that is ongoing around the world in this discipline. This virtual meeting was hosted using the vFairs ® conference platform and allowed over 700 people to participate, many of whom were first-time conference attendees. The agenda featured concurrent sessions from presenters in six continents which provided attendees a complete overview of the field and furthered our mission to create a global community of oncofertility practice. This paper provides a synopsis of talks delivered at this event and highlights the new advances and frontiers in the fields of oncofertility and fertility preservation around the globe from clinical practice and patient-centered efforts to translational research.
Collapse
Affiliation(s)
- L M Ataman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - M M Laronda
- Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - M Gowett
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - K Trotter
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - H Anvari
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - F Fei
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - A Ingram
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - M Minette
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - C Suebthawinkul
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - Z Taghvaei
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - M Torres-Vélez
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - K Velez
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - S K Adiga
- Department of Clinical Embryology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
| | - A Anazodo
- Kids Cancer Centre, Sydney Children's Hospital, Nelune Comprehensive Cancer Centre, Sydney, Australia
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - L Appiah
- Department of Obstetrics and Gynecology, The University of Colorado School of Medicine, Aurora, CO, USA
| | - M T Bourlon
- Hemato-Oncology Department, Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - N Daniels
- The Oncology and Fertility Centres of Ekocorp, Eko Hospitals, Lagos, Nigeria
| | - M M Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale Et Clinique, Université Catholique de Louvain, Av. Mounier 52, 1200, Brussels, Belgium
- Department of Gynecology, Cliniques Universitaires Saint-Luc, Av. Hippocrate 10, 1200, Brussels, Belgium
| | - C Finlayson
- Department of Pediatrics (Endocrinology), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - R B Gilchrist
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - V Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, USA
| | | | - J A Halpern
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - K Hutt
- Anatomy & Developmental Biology, Monash Biomedicine Discovery Institute, Monash University, Clayton, Australia
| | - E K Johnson
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Division of Urology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - K Kawamura
- Department of Obstetrics and Gynecology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - M Khrouf
- FERTILLIA, Clinique la Rose, Tunis, Tunisia
| | - D Kimelman
- Centro de Esterilidad Montevideo, Montevideo, Uruguay
| | - S Kristensen
- Department of Fertility, Copenhagen University Hospital, Copenhagen, Denmark
| | - R T Mitchell
- Department of Developmental Endocrinology, University of Edinburgh, Edinburgh, UK
| | - M B Moravek
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, University of Michigan, Ann Arbor, MI, USA
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - L Nahata
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA
- Endocrinology and Center for Biobehavioral Health, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - K E Orwig
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - M E Pavone
- Department of Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D Pépin
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - R Pesce
- Reproductive Medicine Unit, Obstetrics and Gynecology Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - G P Quinn
- Departments of Obstetrics and Gynecology, Center for Medical Ethics, Population Health, Grossman School of Medicine, New York University, New York, NY, USA
| | - M P Rosen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Reproductive Endocrinology and Infertility, University of California, San Francisco, CA, USA
| | - E Rowell
- Department of Surgery (Pediatric Surgery), Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - K Smith
- Department of Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - C Venter
- Vitalab, Johannesburg, South Africa
| | - S Whiteside
- Fertility & Reproductive Health Program, Department of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus, OH, USA
| | - S Xiao
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy, Environmental Health Sciences Institute, Rutgers University, New Brunswick, NJ, USA
| | - M Zelinski
- Division of Reproductive & Developmental Sciences, Oregon National Primate Research Center, Oregon Health & Science University, Beaverton, OR, USA
| | - K N Goldman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA
| | - T K Woodruff
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - F E Duncan
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, 303 E. Superior Street, Lurie 7-117, Chicago, IL, 60611, USA.
| |
Collapse
|
20
|
Brunette MA, Kinnear HM, Hashim PH, Flanagan CL, Day JR, Cascalho M, Padmanabhan V, Shikanov A. Human Ovarian Follicles Xenografted in Immunoisolating Capsules Survive Long Term Implantation in Mice. Front Endocrinol (Lausanne) 2022; 13:886678. [PMID: 35721740 PMCID: PMC9205207 DOI: 10.3389/fendo.2022.886678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/15/2022] [Indexed: 01/25/2023] Open
Abstract
Female pediatric cancer survivors often develop Premature Ovarian Insufficiency (POI) owing to gonadotoxic effects of anticancer treatments. Here we investigate the use of a cell-based therapy consisting of human ovarian cortex encapsulated in a poly-ethylene glycol (PEG)-based hydrogel that replicates the physiological cyclic and pulsatile hormonal patterns of healthy reproductive-aged women. Human ovarian tissue from four donors was analyzed for follicle density, with averages ranging between 360 and 4414 follicles/mm3. Follicles in the encapsulated and implanted cryopreserved human ovarian tissues survived up to three months, with average follicle densities ranging between 2 and 89 follicles/mm3 at retrieval. We conclude that encapsulation of human ovarian cortex in PEG-based hydrogels did not decrease follicle survival after implantation in mice and was similar to non-encapsulated grafts. Furthermore, this approach offers the means to replace the endocrine function of the ovary tissue in patients with POI.
Collapse
Affiliation(s)
- Margaret A. Brunette
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Hadrian M. Kinnear
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, United States
- Medical Scientist Training Program, University of Michigan, Ann Arbor, MI, United States
| | - Prianka H. Hashim
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| | - Colleen L. Flanagan
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - James R. Day
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Marilia Cascalho
- Department of Surgery, University of Michigan, Ann Arbor, MI, United States
- Department of Microbiology & Immunology, University of Michigan, Ann Arbor, MI, United States
| | - Vasantha Padmanabhan
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
- Department of Pediatrics & Communicable Diseases, University of Michigan, Ann Arbor, MI, United States
| | - Ariella Shikanov
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
- Program in Cellular and Molecular Biology, University of Michigan, Ann Arbor, MI, United States
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
21
|
Siebert AL, Gomez-Lobo V, Johnson EK, Nahata L, Orwig KE, Pyle LC, Witchel SF, Finlayson C, Laronda MM. Differences in gonadal tissue cryopreservation practices for differences of sex development across regions in the United States. Front Endocrinol (Lausanne) 2022; 13:990359. [PMID: 36733807 PMCID: PMC9886870 DOI: 10.3389/fendo.2022.990359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/15/2022] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Some individuals with differences of sex development (DSD) conditions undergo medically indicated prophylactic gonadectomy. Gonads of individuals with DSD can contain germ cells and precursors and patients interested in future fertility preservation and hormonal restoration can participate in DSD-specific research protocols to cryopreserve this tissue. However, it is unclear how many providers or institutions offer gonadal tissue cryopreservation (GTC) and how widespread GTC for DSD is across the United States (US). The Pediatric Initiative Network (PIN) and Non-Oncologic Conditions committees of the Oncofertility Consortium sought to assess the current state of GTC for patients with DSD. METHODS An electronic survey was sent to providers caring for patients with DSD via special interest groups of professional societies and research networks. RESULTS The survey was administered between November 15, 2021 and March 14, 2022. A total of 155 providers responded to the survey, of which 132 respondents care for patients with DSD, and 78 work at facilities that offer medically indicated gonadectomy to patients with DSD diagnoses. They represented 55 US institutions including 47 pediatric hospitals, and 5 international sites (Canada, Denmark, Germany, Qatar). Of individual providers, 41% offer cryopreservation after prophylactic gonadectomy for patients with DSD (32/78). At an institutional level, GTC after medically indicated gonadectomy is available at 54.4% (24/46) of institutions. GTC is offered for a variety of DSD diagnoses, most commonly 45,X/46,XY DSD (i.e., Turner Syndrome with Y-chromosome material and mixed gonadal dysgenesis), ovotesticular DSD, complete androgen insensitivity syndrome (CAIS), and complete gonadal dysgenesis. Responses demonstrate regional trends in GTC practices with 83.3% of institutions in the Midwest, 66.7% in the Northeast, 54.6% in the West, and 35.3% in the South providing GTC. All represented institutions (100%) send gonadal tissue for pathological evaluation, and 22.7% preserve tissue for research purposes. CONCLUSIONS GTC after gonadectomy is offered at half of the US institutions represented in our survey, though a minority are currently preserving tissue for research purposes. GTC is offered for several DSD conditions. Future research will focus on examining presence and quality of germ cells to support clinical decision making related to fertility preservation for patients with DSD.
Collapse
Affiliation(s)
- Aisha L. Siebert
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Veronica Gomez-Lobo
- Pediatric and Adolescent Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Emilie K. Johnson
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- Division of Urology, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, United States
| | - Leena Nahata
- Department of Pediatrics, Pediatric Endocrinology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Kyle E. Orwig
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Louise C. Pyle
- Roberts Individualized Medical Genetics Center, Division of Human Genetics and Department of Pediatrics, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Selma F. Witchel
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Courtney Finlayson
- Division of Endocrinology, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, United States
| | - Monica M. Laronda
- Stanley Manne Children’s Research Institute, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, United States
- Division of Endocrinology, Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
- *Correspondence: Monica M. Laronda,
| |
Collapse
|
22
|
Grégoire-Briard F, Mitsakakis N, Hayawi L, Dumont T. Evaluation of Fertility Preservation Counseling and Treatments for Female Oncology Patients in an Urban Pediatric Canadian Center. J Adolesc Young Adult Oncol 2021; 11:518-524. [PMID: 34936499 DOI: 10.1089/jayao.2021.0149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Purpose: Several international organizations and guidelines have recommended implementation of structured fertility preservation (FP) discussions with patients and their families before initiation of chemotherapy and radiation treatments in children. This study aimed to identify current trends and rates in FP counseling and treatments at a Canadian pediatric tertiary care center. Objectives were to measure guideline adherence for FP counseling at our institution by determining (1) the frequency of FP counseling in pediatric female oncological patients at our institution, (2) the frequency of FP treatment in this study population, and (3) the factors associated with FP pre-treatment counseling. Methods: A retrospective chart review was performed, including all pediatric and adolescent female patients (age <18) seen in consultation by the oncology team. Demographic data, as well as documentation of FP counseling and referral to a reproductive endocrinology and infertility (REI) specialist and subsequent FP treatment were collected. Results: A total of 89 female pediatric patients were included in our study. Forty-two patients received fertility counseling (47.2%; 95% confidence interval [CI] 37.2-57.5). Only 29/42 (69.0%; 95% CI: 54-80.9) received counseling before onset of treatment. A 12/42 (41.4%; 95% CI: 25-59.3) of the patients who received FP counseling were referred to an REI specialist and 11/12 proceeded with FP treatment (37.9%, 95% CI: 22.7-56). Conclusion: This study presents contemporary data on the rates of FP counseling in Canadian pediatric female oncological patients and demonstrates low rates of FP counseling in our patient population.
Collapse
Affiliation(s)
- Florence Grégoire-Briard
- Division of Gynecology, Department of Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Nicholas Mitsakakis
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Lamia Hayawi
- CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Tania Dumont
- Division of Gynecology, Department of Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,CHEO Research Institute, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| |
Collapse
|
23
|
Pampanini V, Hassan J, Oliver E, Stukenborg JB, Damdimopoulou P, Jahnukainen K. Fertility Preservation for Prepubertal Patients at Risk of Infertility: Present Status and Future Perspectives. Horm Res Paediatr 2021; 93:599-608. [PMID: 33887724 DOI: 10.1159/000516087] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 03/23/2021] [Indexed: 11/19/2022] Open
Abstract
The increasing cure rate of cancer has led to a vast population of survivors having to face the late adverse effects of oncological treatments, with fertility impairment being one of the most sensitive issues for patients. Different options to preserve the fertility of adult patients are routinely used in clinical practice. However, fertility preservation strategies for prepubertal patients at risk of infertility are limited to the cryopreservation of immature gonadal tissue. In recent decades, many research efforts have been focused on the future use of cryopreserved gonadal tissue. This review discusses the common status of fertility preservation measures for pediatric patients undergoing gonadotoxic treatment, focusing especially on the challenges that remain to be solved in order to implement this fundamental service.
Collapse
Affiliation(s)
- Valentina Pampanini
- Dipartimento Pediatrico Universitario Ospedaliero, Ospedale Pediatrico Bambino Gesù, Rome, Italy.,Childhood Cancer Research Unit, Department of Women's and Children's Health, NORDFERTIL Research Laboratory Stockholm, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Jasmin Hassan
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Elizabeth Oliver
- Childhood Cancer Research Unit, Department of Women's and Children's Health, NORDFERTIL Research Laboratory Stockholm, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Jan-Bernd Stukenborg
- Childhood Cancer Research Unit, Department of Women's and Children's Health, NORDFERTIL Research Laboratory Stockholm, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Pauliina Damdimopoulou
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden
| | - Kirsi Jahnukainen
- Childhood Cancer Research Unit, Department of Women's and Children's Health, NORDFERTIL Research Laboratory Stockholm, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.,Division of Hematology-Oncology and Stem Cell Transplantation, Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
24
|
Christianson MS, Lukish DA, McCarter R, Pryor H, Lukish JR. Ovarian tissue cryopreservation in young females with cancer and its impact on ovarian follicle density. J Pediatr Surg 2021; 56:2354-2359. [PMID: 34172282 DOI: 10.1016/j.jpedsurg.2021.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 04/24/2021] [Accepted: 05/05/2021] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cancer therapy in young females results in irreversible damage to their ovaries potentially leading to premature ovarian failure (POF) and infertility. Ovarian follicle density (FD) serves as a key predictor of reproductive potential for a woman. FD is significantly reduced after cryopreservation in adult women with cancer. FD in young females with cancer has not been investigated. The specific aim of this study was to assess the efficacy of ovarian tissue cyropreservation (OTC) in young females with cancer by evaluating its impact on FD. METHODS An IRB approved prospective human and animal trial enrolled girls (ages 6-18 years) with cancer at high risk for POF from July 1, 2012 through June 30, 2018. All participants underwent pre-operative ultrasounds evaluating their ovaries. Following a normal ultrasound, each patient underwent a left ovarian tissue harvest prior to cancer therapy. The ovarian tissue was sectioned for use in pathologic analysis, fertility preservation and xenotransplantation before and after cryopreservation. Comparative statistical analyses of the means of FD before and after cryopreservation were implemented using mixed regression modeling that accounted for the correlation among samples from the same patient and differences in age. RESULTS Six girls were enrolled (mean, 12 years; median, 13 years, range, 6-17 years). Pathologic analysis was carried out in all viable grafts and ovarian follicle densities were determined. Mean ovarian follicle density (+/- SEM) before cryopreservation was 50.5 +/- 4.26 follicles/mm2 and after cryopreservation was 44.1 +/- 4.25 follicles/mm2, p < 0.001. Following cryopreservation, on average the ovarian tissue retained 89.0.% of the FD of paired fresh samples (95% CI 82.8%, 95.2%). CONCLUSIONS FD in young females with cancer is significantly reduced following OTC. However, the degree of reduction may be less than that reported in adult women. This is the first study in adolescent girls to provide histologic evidence of preservation of ovarian follicle density and potential efficacy of the ovarian tissue cryopreservation strategy. By providing this evidence base, the potential benefit to young females with cancer and their family may be prognostically and clinically significant.
Collapse
Affiliation(s)
- Mindy S Christianson
- Division of Reproductive Endocrinology and Infertility, Johns Hopkins University, Baltimore, MD, United States
| | - Danielle A Lukish
- Division of Biostatistics and Study Design, Children's National Hospital, Washington D.C., United States
| | - Robert McCarter
- Division of Biostatistics and Study Design, Children's National Hospital, Washington D.C., United States
| | - Howard Pryor
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C., United States; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Jeffrey R Lukish
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C., United States; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States; Department of Surgery, The George Washington University, Washington D.C., United States.
| |
Collapse
|
25
|
Coker Appiah L, Fei YF, Olsen M, Lindheim SR, Puccetti DM. Disparities in Female Pediatric, Adolescent and Young Adult Oncofertility: A Needs Assessment. Cancers (Basel) 2021; 13:5419. [PMID: 34771582 PMCID: PMC8582476 DOI: 10.3390/cancers13215419] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/21/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
Advancements in cancer screening and implementation of targeted treatments have significantly improved survival rates to 85% for pediatric and AYA survivors. Greater than 75% of survivors will live to experience the long-term adverse outcomes of cancer therapies, termed late effects (LE), that disrupt quality of life (QoL). Infertility and poor reproductive outcomes are significant disruptors of QoL in survivorship, affecting 12-88% of survivors who receive at-risk therapies. To mitigate risk, fertility preservation (FP) counseling is recommended as standard of care prior to gonadotoxic therapy. However, disparities in FP counseling, implementation of FP interventions, and screening for gynecologic late effects in survivorship persist. Barriers to care include a lack of provider and patient knowledge of the safety and breadth of current FP options, misconceptions about the duration of time required to implement FP therapies, cost, and health care team bias. Developing strategies to address barriers and implement established guidelines are necessary to ensure equity and improve quality of care across populations.
Collapse
Affiliation(s)
- Leslie Coker Appiah
- Division of Academic Specialists in Obstetrics and Gynecology, Department of Obstetrics and Gynecology, The University of Colorado School of Medicine, Denver, CO 80045, USA
- Pediatric and Adolescent Gynecology, Children’s Hospital Colorado, Denver, CO 80045, USA
| | - Yueyang Frances Fei
- Pediatric and Adolescent Gynecology, Nationwide Children’s Hospital, Columbus, OH 43205, USA;
| | - Mallery Olsen
- Department of Medicine, The University of Wisconsin School of Medicine, Madison, WI 53705, USA; (M.O.); (D.M.P.)
- Pediatric Hematology/Oncology, American Family Children’s Hospital, Madison, WI 53705, USA
| | - Steven R. Lindheim
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wright State University, Dayton, OH 45409, USA;
- School of Medicine, Shanghai Jiao Tong University, Shanghai 200240, China
| | - Diane M. Puccetti
- Department of Medicine, The University of Wisconsin School of Medicine, Madison, WI 53705, USA; (M.O.); (D.M.P.)
- Pediatric Hematology/Oncology, American Family Children’s Hospital, Madison, WI 53705, USA
| |
Collapse
|
26
|
Hanfling SN, Parikh T, Mayhew A, Robinson E, Graham J, Gomez-Lobo V, Maher JY. Case report: two cases of mature oocytes found in prepubertal girls during ovarian tissue cryopreservation. F S Rep 2021; 2:296-299. [PMID: 34553154 PMCID: PMC8441562 DOI: 10.1016/j.xfre.2021.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 12/02/2022] Open
Abstract
Objective To report two cases of mature oocytes found in prepubertal girls undergoing ovarian tissue cryopreservation (OTC). Design Case report. Setting Large tertiary care children’s hospital and a private fertility clinic. Patient(s) An 8-year-old prepubertal girl with β-thalassemia and a 2-year-old girl with sickle cell disease who both underwent OTC before bone marrow transplantations. Intervention(s) Laparoscopic right oophorectomy was performed in each patient. The ovarian cortical tissue was processed for slow freezing and long-term storage, and all oocytes were subsequently vitrified. Main Outcome Measure(s) Oocytes found at the time of OTC processing for fertility preservation. Result(s) After a complete right oophorectomy, one mature metaphase II oocyte was discovered on tissue processing for OTC in each patient. Neither patient has yet returned for use of tissue or oocytes. Conclusion(s) To our knowledge, this is the first report of mature oocytes found during prepubertal OTC processing. These findings may indicate the need for increased research regarding prepubertal oocyte development and suggest that the technique of examining the media for both mature and immature oocytes at the time of OTC should become more widespread and perhaps recommended in prepubertal patients to optimize fertility preservation methods.
Collapse
Affiliation(s)
- Sarina N Hanfling
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Pediatric and Adolescent Gynecology Division, Bethesda, Maryland.,Children's National Hospital, Pediatric and Adolescent Gynecology Division, Department of Surgery, Northwest, Washington, D.C
| | | | - Allison Mayhew
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Pediatric and Adolescent Gynecology Division, Bethesda, Maryland.,Children's National Hospital, Pediatric and Adolescent Gynecology Division, Department of Surgery, Northwest, Washington, D.C
| | | | | | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Pediatric and Adolescent Gynecology Division, Bethesda, Maryland.,Children's National Hospital, Pediatric and Adolescent Gynecology Division, Department of Surgery, Northwest, Washington, D.C
| | - Jacqueline Y Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Pediatric and Adolescent Gynecology Division, Bethesda, Maryland.,Children's National Hospital, Pediatric and Adolescent Gynecology Division, Department of Surgery, Northwest, Washington, D.C
| |
Collapse
|
27
|
Abstract
Puberty is the process through which reproductive competence is achieved and comprises gonadarche and adrenarche. Breast development is the initial physical finding of pubertal onset in girls and typically occurs between 8 and 13 years. Menarche normally occurs 2 to 3 years after the onset of breast development. Pubertal onset is controlled by the gonadotropin-releasing hormone pulse generator in the hypothalamus; however, environmental factors such as alterations in energy balance and exposure to endocrine-disrupting chemicals can alter the timing of pubertal onset. Improvement in nutritional and socioeconomic conditions over the past two centuries has been associated with a secular trend in earlier pubertal onset. Precocious puberty is defined as onset of breast development prior to 8 years and can be central or peripheral. Delayed puberty can be hypogonadotropic or hypergonadotropic and is defined as lack of breast development by 13 years or lack of menarche by 16 years. Both precocious and delayed puberty may have negative effects on self-esteem, potentially leading to psychosocial stress. Patients who present with pubertal differences require a comprehensive assessment to determine the underlying etiology and to devise an effective treatment plan.
Collapse
Affiliation(s)
- Aviva B Sopher
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Sharon E Oberfield
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Selma F Witchel
- Division of Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| |
Collapse
|
28
|
Hagen-Lillevik S, Rushing JS, Appiah L, Longo N, Andrews A, Lai K, Johnson J. Pathophysiology and management of classic galactosemic primary ovarian insufficiency. REPRODUCTION AND FERTILITY 2021; 2:R67-R84. [PMID: 35118398 PMCID: PMC8788619 DOI: 10.1530/raf-21-0014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 06/25/2021] [Indexed: 12/14/2022] Open
Abstract
Classic galactosemia is an inborn error of carbohydrate metabolism associated with early-onset primary ovarian insufficiency (POI) in young women. Our understanding of the consequences of galactosemia upon fertility and fecundity of affected women is expanding, but there are important remaining gaps in our knowledge and tools for its management, and a need for continued dialog so that the special features of the condition can be better managed. Here, we review galactosemic POI and its reproductive endocrinological clinical sequelae and summarize current best clinical practices for its management. Special consideration is given to the very early-onset nature of the condition in the pediatric/adolescent patient. Afterward, we summarize our current understanding of the reproductive pathophysiology of galactosemia, including the potential action of toxic galactose metabolites upon the ovary. Our work establishing that ovarian cellular stress reminiscent of endoplasmic reticulum (ER) stress is present in a mouse model of galactosemia, as well as work by other groups, are summarized. LAY SUMMARY Patients with the condition of classic galactosemia need to maintain a strict lifelong diet that excludes the sugar galactose. This is due to having mutations in enzymes that process galactose, resulting in the buildup of toxic metabolic by-products of the sugar. Young women with classic galactosemia often lose the function of their ovaries very early in life (termed 'primary ovarian insufficiency'), despite adherence to a galactose-restricted diet. This means that in addition to the consequences of the disease, these women also face infertility and the potential need for hormone replacement therapy. This article summarizes current strategies for managing the care of galactosemic girls and women and also what is known of how the condition leads to early primary ovarian insufficiency.
Collapse
Affiliation(s)
- Synneva Hagen-Lillevik
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Nutrition and Integrative Physiology, University of Utah College of Health, Salt Lake City, Utah, USA
| | - John S Rushing
- Divisions of Reproductive Sciences, Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado Denver (AMC), Aurora, Colorado, USA
| | - Leslie Appiah
- Division of General Obstetrics and Gynecology, Department of Obstetrics and Gynecology, University of Colorado Denver (AMC), Anschutz Outpatient Pavilion, Aurora, Colorado, USA
| | - Nicola Longo
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Nutrition and Integrative Physiology, University of Utah College of Health, Salt Lake City, Utah, USA
| | - Ashley Andrews
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Kent Lai
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Nutrition and Integrative Physiology, University of Utah College of Health, Salt Lake City, Utah, USA
| | - Joshua Johnson
- Divisions of Reproductive Sciences, Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Colorado Denver (AMC), Aurora, Colorado, USA
| |
Collapse
|
29
|
Lukish JR. Laparoscopic assisted extracorporeal ovarian harvest: A novel technique to optimize ovarian tissue for cryopreservation in young females with cancer. J Pediatr Surg 2021; 56:626-628. [PMID: 33267946 DOI: 10.1016/j.jpedsurg.2020.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Advances in pediatric cancer therapy have improved the long-term survival for many children with cancer. The awareness of quality of life aspects, specifically fertility preservation, has become a reality for many of these families and children. Ovarian tissue cryopreservation has emerged as an available fertility option for young females with cancer. Safe and effective removal of ovarian tissue in these girls is paramount. We report a laparoscopic assisted extracorporeal ovarian harvest technique that achieves this goal. OPERATIVE TECHNIQUE We place a 5 mm port at the umbilicus and in the right lower quadrant. Under laparoscopic guidance we place a 12 mm port in the left suprapubic area. Utilizing the 12 mm port site a monofilament traction suture is placed through the left ovary. The traction suture is used to translocate the ovary to an extracorporeal position via the 12 mm port site. Ovarian tissue is then excised utilizing standard surgical technique with the scalpel. Hemostasis is obtained and the capsule is closed with a running absorbable suture. The ovary is placed back in its native position laparoscopically. CONCLUSIONS The use of this extracorporeal ovarian harvesting technique is a safe and effective method to optimize removal and minimize tissue injury. Utilization of this technique, may have potential benefit to the young female with cancer.
Collapse
Affiliation(s)
- Jeffrey R Lukish
- Division of Pediatric Surgery, Children's National Hospital, Washington D.C, USA; George Washington University, Washington D.C, USA; Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA.
| |
Collapse
|
30
|
Lautz TB, Burns K, Rowell EE. Fertility Considerations in Pediatric and Adolescent Patients Undergoing Cancer Therapy. Surg Oncol Clin N Am 2021; 30:401-415. [PMID: 33706908 DOI: 10.1016/j.soc.2020.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Survivors of pediatric cancer are at increased risk for infertility and premature hormonal failure. Surgeons caring for children with cancer have an important role to play in understanding this risk, as well as advocating for and performing appropriate fertility preservation procedures. Fertility preservation options in males and females vary by pubertal status and include nonexperimental (oocyte harvest, ovarian tissue cryopreservation, sperm cryopreservation) and experimental (testicular tissue cryopreservation) options. This review summarizes the basics of risk assessment and fertility preservation options and explores unique considerations in pediatric fertility preservation.
Collapse
Affiliation(s)
- Timothy B Lautz
- Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 63, Chicago, IL 60611, USA.
| | - Karen Burns
- University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA
| | - Erin E Rowell
- Northwestern Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 63, Chicago, IL 60611, USA
| |
Collapse
|
31
|
Installing oncofertility programs for common cancers in optimum resource settings (Repro-Can-OPEN Study Part II): a committee opinion. J Assist Reprod Genet 2021; 38:163-176. [PMID: 33452592 PMCID: PMC7810602 DOI: 10.1007/s10815-020-02012-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE The main objective of Repro-Can-OPEN Study Part 2 is to learn more about oncofertility practices in optimum resource settings to provide a roadmap to establish oncofertility best practice models. METHODS As an extrapolation for oncofertility best practice models in optimum resource settings, we surveyed 25 leading and well-resourced oncofertility centers and institutions from the USA, Europe, Australia, and Japan. The survey included questions on the availability and degree of utilization of fertility preservation options in case of childhood cancer, breast cancer, and blood cancer. RESULTS All surveyed centers responded to all questions. Responses and their calculated oncofertility scores showed three major characteristics of oncofertility practice in optimum resource settings: (1) strong utilization of sperm freezing, egg freezing, embryo freezing, ovarian tissue freezing, gonadal shielding, and fractionation of chemo- and radiotherapy; (2) promising utilization of GnRH analogs, oophoropexy, testicular tissue freezing, and oocyte in vitro maturation (IVM); and (3) rare utilization of neoadjuvant cytoprotective pharmacotherapy, artificial ovary, in vitro spermatogenesis, and stem cell reproductive technology as they are still in preclinical or early clinical research settings. Proper technical and ethical concerns should be considered when offering advanced and experimental oncofertility options to patients. CONCLUSIONS Our Repro-Can-OPEN Study Part 2 proposed installing specific oncofertility programs for common cancers in optimum resource settings as an extrapolation for best practice models. This will provide efficient oncofertility edification and modeling to oncofertility teams and related healthcare providers around the globe and help them offer the best care possible to their patients.
Collapse
|
32
|
Nahata L, Quinn GP. 'Harm threshold': capacity for decision-making may be reduced by long-term pubertal suppression. JOURNAL OF MEDICAL ETHICS 2020; 46:759-760. [PMID: 32839229 DOI: 10.1136/medethics-2020-106625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/01/2020] [Accepted: 07/11/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Leena Nahata
- Endocrinology and Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Gwendolyn P Quinn
- Obstetrics and Gynecology, NYU Langone Health, New York, New York, USA
| |
Collapse
|
33
|
Abstract
Recently, greater attention has been paid to the care of gender dysphoric and gender incongruent individuals. Gynecologists may be called upon to care for individuals who were assigned female at birth throughout or following social, medical, or surgical gender transition. Thus, gynecologists need to be aware of language regarding sex and gender, treatment typically used for the care of gender dysphoric or incongruent individuals, and aspects of well gynecologic care necessary for these individuals. This review highlights these aspects of care for transgender males to aid the general gynecologist in the care and treatment of these individuals.
Collapse
Affiliation(s)
- Allison C. Mayhew
- Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
| | | | - Veronica Gomez-Lobo
- Children’s National Medical Center, Division of Pediatric and Adolescent Gynecology
- Eunice Kennedy Shriver National Institute of Child Health and Human Development
| |
Collapse
|