Long-term ovarian function and fertility after heterotopic autotransplantation of cryobanked human ovarian tissue: 8-year experience in cancer patients

Ovarian Tissue Collection for Fertility Preservation in Children: The Need for Standardised Surgical Practice Guidance

BACKGROUND

Chemotherapy, pelvic radiotherapy (including total body irradiation) and novel compounds used to treat children and teenagers with benign or malignant diseases can lead to impaired fertility. For prepubertal female patients at high risk of treatment-related infertility, upfront storage of ovarian tissue is increasingly being recognised as standard of care. No surgical guidelines exist to ensure best practice technique. We reviewed current UK practice to assess surgical management.

METHODS

A ten-item, anonymous multiple-choice survey was distributed to the lead surgeons in all paediatric centres in England/Wales undertaking ovarian procurement for cryopreservation.

RESULTS

There are currently 18 centres in England and Wales that provide ovarian procurement for cryopreservation. Responses were received from 100% of the invited paediatric surgical oncology centres in England and Wales. 39.3% of participants stated that in their centre <10 cases of ovarian harvest are performed annually. In 32.1% of centres >20 cases are undertaken per year. In 64% of centres surgery is performed by a paediatric surgeon with interest in oncology or fertility preservation. The majority of cases were performed by a Consultant or Senior Registrar (89%). Regarding the surgical technique, 82% of respondents stated they gain access to the abdominal cavity using standard 3-port laparoscopy, 7% use single-port laparoscopy. Most frequently used energy devices for ovary/ovarian tissue resection were Ligasure™ (44%) and Harmonic Scalpel™ (18.5%). 96% of respondents perform a total oophorectomy, 1 respondent stated they perform a hemi-oophorectomy. 53% stated they place the ovary into a retrieval bag only if the ovary was too big for easy removal via the camera port, 28.5% always place it in a retrieval bag. Most surgeons use the umbilical port site for retrieval (82%).

CONCLUSION

This national survey shows significant heterogeneity in the surgical management of ovarian procurement for cryopreservation. To ensure best outcomes, research into the various surgical methods is necessary to provide data for a standardised best practice approach.

LEVEL OF EVIDENCE

This is a level II evidence study. In itself, it is a national survey of specialists, which was undertaken in a prospective manner.

Heterotopic ovarian transplantation instead hormonal replacement therapy after radical hysterectomy for cervical cancer: case report and review of literature

PURPOSE

Only a few case reports have described heterotopic ovarian tissue transplantation (OTT) with the only objective of restoring ovarian function.

METHODS

Case report and review of the literature for reporting cases of heterotopic OTT with the only aim of restoring ovarian endocrine function. In a cancer survivor woman with a history of hysterectomy and bilateral oophorectomy for cervical cancer and because she poorly tolerated hormone replacement therapy (HRT), we performed a heterotopic OTT in a pelvic subcutaneous "pocket" after an OT cryostorage of 17 years.

RESULTS

A cyclic ovarian endocrine function started 3 months after OTT with an immediate patient self-described improvement of her quality of life. A second OTT was performed 19 months after, due to hot flushes recurrence and FSH increase. Despite a cyclic endocrine function, progesterone levels have always been low, resulting in a relative hyperoestrogenism state.

CONCLUSION

In the future, the indications of heterotopic OTT could be spread in alternative to HRT. However, our data suggest that the heterotopic graft environment is less favorable to corpus luteum development, and further studies are needed to assay the best site of heterotopic graft, the optimal number of ovarian cortex fragments to graft, and the potential risk of relapse in case of malignant residual disease.

Comparison of orthotopic and heterotopic autologous ovarian tissue transplantation outcomes

OBJECTIVE

To compare the outcomes of orthotopic and heterotopic ovarian tissue transplantation (OTT) techniques.

DESIGN

Mixed prospective-retrospective cohort study.

SETTING

Academic hospital.

PATIENTS

A total of 14 recipients of autologous OTT.

INTERVENTIONS

Of the 14 women, 12 who received orthotopic (n = 6) or heterotopic (n = 6) transplants met the inclusion criteria. All orthotopic transplants and one heterotopic ovarian tissue transplant were performed laparoscopically. Although 5 of the 6 remaining heterotopic transplants were performed subcutaneously under local anesthesia or intravenous sedation, one was performed with robotic assistance. With the exception of one recipient who solely desired restoration of endocrine function, all underwent oocyte retrieval either to cryopreserve oocytes and embryos before the graft function ceased or because they could not otherwise conceive (hysterectomy, radiation damage, and heterotopic transplant).

MAIN OUTCOME MEASURES

Primary outcome measures were graft function and longevity, and the number of embryos generated per retrieval.

RESULTS

The mean age at ovarian tissue harvesting and transplantation was lower in patients with orthotopic vs. heterotopic transplants, although the proportion of transplanted ovarian cortex was lower in heterotopic transplant cases. All grafts restored ovarian endocrine function. Fertilization rates, the number of embryos generated per retrieval, and the mean number of nonarrested embryos were significantly lower in heterotopic OTT. However, time to function and graft longevity were similar between the groups. Although 4 of the 6 women conceived and delivered 7 children among orthotopic ovarian tissue recipients, one recipient had 3 spontaneous live births after heterotopic OTT, presumably because of the induction of function in the remaining menopausal ovary.

CONCLUSIONS

It appears that orthotopic OTT results in higher gamete and embryo quality. However, the endocrine function restoration rate and longevity are similar between the 2 approaches. When feasible, orthotopic OTT should be preferred for those who intend to conceive, although a less invasive heterotopic OTT can be performed for those who primarily desire ovarian endocrine function.

Fertility Preservation in Women with Endometriosis

Several mechanisms have been implicated in the pathogenesis of endometriosis-related infertility. For patients considering surgery, the risk of iatrogenic injury is among the most important factors in the context of fertility preservation, along with age and individual reproductive goals. In the case of endometrioma excision, evidence overwhelmingly demonstrates the negative impact of surgery on ovarian reserve, with significant reductions in antimullerian hormone (up to 30% in unilateral versus up to 44% in bilateral endometriomas). The surgical endometriosis patient should be thoroughly counseled regarding fertility preservation and discussion should include tissue, embryo, and oocyte cryopreservation options. For the latter, data support cryopreservation of 10-15 oocytes in women ≤35 years and over 20 for those >35 years for a realistic chance to achieve one or more live births. When performing surgical interventions for endometriosis, reproductive surgeons should employ fertility-conserving surgical methods to reduce the likelihood of postoperative iatrogenic diminished ovarian reserve.

Xenograft model of heterotopic transplantation of human ovarian cortical tissue and its clinical relevance

In brief

Xenografts of human ovarian cortical tissue provide a tractable model of heterotopic autotransplantation that is used for fertility preservation in patients undergoing ablative chemo/radiotherapy. This study describes the behavior of hundreds of xenografts to establish a framework for the clinical function of ovarian cortex following autotransplantation over short- and long-term intervals.

Abstract

More than 200 live births have been achieved using autotransplantation of cryopreserved ovarian cortical fragments, yet challenges remain to be addressed. Ischemia of grafted tissue undermines viability and longevity, typically requiring transplantation of multiple cortical pieces; and the dynamics of recruitment within a graft and the influence of parameters like size and patient age at the time of cryopreservation are not well-defined. Here, we describe results from a series of experiments in which we xenografted frozen/thawed human ovarian tissue (n = 440) from 28 girls and women (age range 32 weeks gestational age to 46 years, median 24.3 ± 4.6). Xenografts were recovered across a broad range of intervals (1-52 weeks post-transplantation) and examined histologically to quantify follicle density and distribution. The number of antral follicles in xenografted cortical fragments correlated positively with the total follicle number and was significantly reduced with increased patient age. Within xenografts, follicles were distributed in focal clusters, similar to the native ovary, but the presence of a leading antral follicle coincided with increased proliferation of surrounding follicles. These results underscore the importance of transplanting ovarian tissue with a high density of follicles and elucidate a potential paracrine influence of leading antral follicles on neighboring follicles of earlier stages. This temporal framework for interpreting the kinetics of follicle growth/mobilization may be useful in setting expectations and guiding the parameters of clinical autotransplantation.

Failed ovarian cortex transplant but successful ovulation induction in a cancer survivor with premature ovarian failure: A paradox

Better diagnostic and treatment modalities for malignancies occurring in childhood and young age have increased the overall survival of the affected young girls and boys, but this has come at a cost of developing premature ovarian failure in girls and azoospermia in boys because of the gonadotoxicity of chemotherapy and radiotherapy. Thus, young girls and women of reproductive age who are at risk of ovarian failure due to cancer treatment must be mandatorily offered fertility preservation in any form such as cryopreservation of mature metaphase II oocytes after ovarian stimulation with gonadotropins and oocyte recovery and cryopreservation of embryos if the young female has a partner. However, these modalities may require the postponement of chemotherapy. Thus, in such instances, cryopreservation of ovarian tissue remains the only option. Herein, we report a case of a nulligravid young female patient who had stage IV Hodgkin's lymphoma and had to be taken up for immediate fertility preservation owing to the advanced stage of the disease. Therefore, cryopreservation of ovarian tissue was performed. The uniqueness of the case is that after remission of the disease was achieved with chemotherapy, transplantation of the ovarian tissue was carried out which was not successful, but the desire for motherhood prompted to carry out an ovulation induction in the remnant native ovary with a severely compromised ovarian reserve, and she conceived.

Why are women considering ovarian tissue cryopreservation to preserve reproductive and hormonal ovarian function? A qualitative study protocol

INTRODUCTION

Current fertility preservation options available to women are oocyte cryopreservation (egg freezing) or embryo cryopreservation. A newer procedure, ovarian tissue cryopreservation (OTC), has become available in some centres, which offers another option for women and girls considering fertility preservation. These procedures are commonly offered to women about to undergo treatments for cancer. OTC involves removing sections of ovarian tissue and cryopreserving it for future reimplantation, often several years later. OTC offers girls and women who may become infertile with optionality and the possibility of pregnancy. OTC has potential for other applications, including restoring ovarian endocrine function beyond biological menopause. This is not without controversy but has led to some women considering undergoing the procedure for purposes of ovarian hormonal preservation (conservation of ovarian endocrine function). OTC is invasive, involves two surgical procedures with concomitant risks and can be costly. Understanding why women may consider and ultimately undergo OTC is timely, so that evidence-based and women-centred care can be provided.

METHODS

A pragmatic narrative qualitative design will be used. A purposive sample of women aged 18-45 who are considering, or have sought, OTC will be recruited over 1-year period. Potential participants will be approached via a clinic that offers OTC on a private basis or via social media.

ANALYSIS

Participant interviews will be audio and, if consented, video recorded. These will be conducted face-to-face or virtually. The recordings will be transcribed verbatim and analysed using a thematic analysis approach supported by NVivo software.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Institutional Ethical Review ERN_19-1578A. We expect to disseminate the findings of this study through journal articles, conference presentations and multimedia to public.

Ovarian tissue grafting: Lessons learnt from our experience with 55 grafts

Purpose

Uncertainties remain regarding the clinical efficacy of ovarian tissue cryopreservation and grafting. We report a retrospective analysis of reproductive outcomes and lessons learnt following 55 ovarian tissue transplant procedures at our center from 2006 to 2019.

Methods

We analyzed variables related to graft success such as tissue volume, follicular density, total follicular volume, and age on the duration of graft function.

Results

Follicular density and total follicular volume correlate positively with duration of graft function. All clinical pregnancies in our cohort occurred in women who were aged 35 or less at the time of ovarian tissue cryopreservation.

Conclusion

Graft success, as determined by eventual pregnancy and the longevity of graft function, may be impacted by factors including age at cryopreservation, follicular density, and total follicular volume.

Heterotopic transplantation of cryopreserved ovarian tissue in cancer patients: a case series

Transplantation of cryopreserved ovarian tissue offers patients a chance to preserve fertility during cancer treatment. In this study of ten young women with gynecological cancer, heterotopic sites were tested for serum hormones and follicle growth to estimate transplant longevity and prospects for assisted conception. Frozen-thawed grafts were implanted subcutaneously in the forearm (FA) (2 cases), the abdominal wall (AW) (11 cases), and the peritoneal lining (P) (3 cases) . In the follow-up of 36 months, a total of 80 ovarian cycles in different heterotopic sites were analyzed. FA and AW grafts had wildly fluctuating FSH, while estradiol (E2) reached preovulatory levels only in AW and P grafts. Follicular growth was active in P sites (1.2 ± 0.1 mm/d) and sluggish in FA and AW sites (0.4 ± 0.1 mm/d). A mature oocyte was only retrieved from the AW, while seven other aspirations were unsuccessful. Meanwhile, a patient delivered twice after treatment for Hodgkin's lymphoma when orthotopic transplantation was performed, first from an IVF cycle and subsequently from a natural cycle. In conclusion, these findings offer no strong encouragement for fertility preservation by transplanting cryopreserved ovarian tissue to subcutaneous sites, and although the peritoneal site gave better results, graft longevity averaged the same at around 3 years.

Importance of ovarian tissue cryopreservation in fertility preservation and anti-aging treatment

Various oncological and non-oncological diseases, as well as their treatments, can cause premature ovarian insufficiency and reduce a woman's reproductive potential. Fertility preservation is, therefore, becoming an emerging field of reproductive medicine allowing these patients to have their own biological children. The aim of this review is to analyze the importance of ovarian tissue cryopreservation as a fertility preservation method as well as its new role as a hormone replacement treatment. Although ovarian tissue cryopreservation is currently regarded as an experimental procedure, it is rapidly advancing and may become an established fertility preservation method in the near future. This method does not require ovarian stimulation or a subsequent delay in the initiation of cancer treatment. Furthermore, orthotopic ovarian tissue transplantation offers the unique opportunity of spontaneous conception. Due to the restoration of endocrine function following the procedure, ovarian tissue cryopreservation may also be used as tissue hormone replacement therapy in cases of premature ovarian insufficiency, to postpone menopause and prevent its troublesome symptoms and diseases. Even though the role of ovarian tissue cryopreservation as a new anti-aging treatment modality is quite promising, the safety and efficacy of this approach should be investigated in clinical settings.

Ovarian Tissue Transplantation: Experience From Germany and Worldwide Efficacy

Extraction of ovarian tissue prior to oncologic therapy and subsequent transplantation is being performed increasingly often to preserve fertility in women. The procedure can be performed at any time of the cycle and, therefore, generally does not lead to any delay in oncological therapy. Success rates with transplantation of cryopreserved ovarian tissue have reached promising levels. More than 130 live births have been reported worldwide with the aid of cryopreserved ovarian tissue and the estimated birth rate is currently approximately 30%. In Germany, Austria, and Switzerland, the FertiPROTEKT consortium has successfully achieved 21 pregnancies and 17 deliveries generated after 95 ovarian tissue transplantations by 2015, one of the largest case series worldwide confirming that ovarian tissue cryopreservation and transplantation are successful. Approximately, more than 400 ovarian tissue cryopreservation procedures are performed each year in the FertiPROTEKT consortium, and the request and operations for ovarian tissue transplantation have increased in recent years. Therefore, recommendations for managing transplantation of ovarian tissue to German-speaking reproductive medicine centers were developed. In this overview, these recommendations and our experience in ovarian tissue transplantation are presented and discussed with international procedures.

Cryostorage and retransplantation of ovarian tissue as an infertility treatment

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

Effect of sustained release of basic fibroblast growth factor using biodegradable gelatin hydrogels on frozen-thawed human ovarian tissue in a xenograft model

AIM

Ovarian tissue cryopreservation before cancer treatment is the only option to preserve fertility under some circumstances. However, tissue ischemia after transplantation while awaiting angiogenesis induces dysfunctional folliculogenesis and reduces ovarian reserve and is one of the disadvantages of frozen-thawed ovarian tissue transplantation. Basic fibroblast growth factor (bFGF) is a major regulator of angiogenesis. However, bFGF rapidly loses biological activity when its free form is injected in vivo. This study investigated whether administration of active bFGF helps establish a nurturing environment for follicular survival.

METHODS

A sheet form of a sustained release drug delivery system for bFGF was developed using biodegradable acidic gelatin hydrogel (bFGF sheet). The bFGF sheets or phosphate-buffered saline sheets, as a negative control, were transplanted with frozen-thawed human ovarian tissues subcutaneously into the backs of severe combined immunodeficient mice. Neovascularization, cell proliferation, fibrosis and follicular survival of ovarian grafts were analyzed at 6 weeks after xenografting.

RESULTS

The bFGF sheets were optimized to release bFGF for at least 10 days. The transplantation of bFGF sheets with frozen-thawed ovarian tissues significantly increased human and mouse CD31-positive areas and stromal and endothelial cell proliferations. The administration of bFGF also significantly decreased the percentage of the fibrotic area in the graft, resulting in a significant increase in primordial and primary follicular density.

CONCLUSION

Local administration of a sustained release of biologically active bFGF induced neovascularization in frozen-thawed ovarian tissue grafts, which could establish the nurturing environment required for follicular survival in heterotopic xenografts.

Ovarian tissue cryopreservation and transplantation in patients with cancer

Chemotherapy and radiotherapy improved survival rates of patients with cancer. However, they can cause ovarian failure and infertility in women of reproductive age. Infertility following cancer treatment is considered a major quality of life issue. Ovarian tissue cryopreservation and transplantation is an important option for fertility preservation in adult patients with cancer who need immediate chemotherapy or do not want to undergo ovarian stimulation. Ovarian tissue freezing is the only option for preserving the fertility of prepubertal patients with cancer. In a recent review, it was reported that frozen-thawed ovarian transplantation has lead to about 90 live births and the conception rate was about 30%. Endocrine function recovery was observed in 92.9% between 3.5 and 6.5 months after transplantation. Based on our review, ovarian tissue cryopreservation and transplantation may be carefully considered before cancer treatment in order to preserve fertility and endocrine function in young cancer survivors.

Transplantation of frozen-thawed ovarian tissue: an update on worldwide activity published in peer-reviewed papers and on the Danish cohort

PURPOSE

The purpose of the study is to review all peer-reviewed published reports of women receiving ovarian tissue transplantation (OTT) with frozen/thawed tissue (OTC) with respect to age, diagnosis, transplantation site, fertility outcome, and potential side effects, including data from all women in the Danish program.

METHODS

A systematic review of the literature was performed in PubMed combined with results from all patients who had received OTT in Denmark up to December 2017.

RESULTS

OTT has been reported from 21 different countries comprising a total of 360 OTT procedures in 318 women. In nine women, malignancy was diagnosed after OTT; none were considered to be directly caused by the OTT. Despite a potential under reporting of cancer recurrence, there is currently no evidence to suggest that OTT causes reseeding of the original cancer. Renewed ovarian endocrine function was reported in 95% of the women. Half of all children born following OTT resulted from natural conception, and newborns were reported to be healthy except for one neonate with a chromosome anomaly with a family disposition. Women who conceived after OTT were significantly younger than those who failed.

CONCLUSION

This study found no indications of sufficient numbers of malignant cells present in the ovarian tissue to cause recurrence of cancer after OTT. Further, it is unlikely that OTC affects the well-being of children born. OTC is now an established method of fertility preservation in Denmark with public reimbursement. The current data encourage that women who require gonadotoxic treatment should be offered an individual evaluation considering fertility preservation.

Development of macaque secondary follicles exposed to neutral red prior to 3-dimensional culture

PURPOSE

Neutral red (NR) may assist identification of preantral follicles in pieces of cortical tissue prior to cryopreservation in cancer patients requesting fertility preservation. This study is the first to analyze this effect by follicle growth rate after long-term culture in primates.

METHODS

Ovarian cortex was obtained from adult rhesus macaques, was cut into fragments, and was incubated with NR. Secondary follicles were readily visualized following NR staining and then were encapsulated into alginate beads and cultured individually for 4 weeks in αMEM media supplemented with 10 ng/ml FSH at 5% O2.

RESULTS

The survival rates of secondary follicles during culture were similar between those derived from control tissue (71 ± 13%) and those treated with NR (68 ± 9%). The proportion of surviving follicles that formed an antrum were also similar in both groups (70 ± 17% control; 48 ± 24% NR-treated). Follicle diameters were not different between control follicles (184 ± 5μm) and those stained with NR (181 ± 7 μm) on the day of isolation. The percentages of surviving follicles within three cohorts based on their diameters at week 4 of culture were similar between the control group and NR-stained tissue group, fast-grow follicles (24 ± 6% vs. 13 ± 10%), slow-grow follicles (66 ± 5% vs. 60 ± 9%), or no-grow (10 ± 9% vs. 27 ± 6%), respectively. There were no differences in follicle diameters between groups during the culture period. Pre-exposure of secondary follicles to NR diminished their capacity to produce both estradiol and androstenedione by week 4 of culture, when follicles are exhibiting an antrum. Inhibitory effects of NR on steroid production by slow-grow follicles was less pronounced.

CONCLUSIONS

NR does not affect secondary follicle survival, growth, and antrum formation during long-term culture, but steroid hormone production by fast-grow follicles is compromised. NR can be used as a non-invasive tool for in situ identification of viable secondary follicles in ovarian cortex before tissue cryopreservation without affecting follicle survival and growth in vitro. Whether maturation or developmental competence of oocytes derived from antral follicles in 3D culture that were previously isolated from NR-stained tissue is normal or compromised remains to be determined. Likewise, the functional consequences of pre-exposure to NR prior to ovarian cortical tissue cryopreservation and transplantation are unknown.

Expectations and limitations of ovarian tissue transplantation

Constant progress in the diagnosis and treatment of cancer disease has increased the number and prognosis of cancer survivors. However, the toxic effects of chemotherapy and radiotherapy on ovarian function have resulted in premature ovarian failure. Patients are, therefore, still expecting methods to be developed to preserve their fertility successfully. Several potential options are available to preserve fertility in patients who face premature ovarian failure, including immature or mature oocyte and embryo cryopreservation. However, for children or prepubertal women needing immediate chemotherapy, cryopreservation of ovarian tissue is the only alternative. The ultimate aim of this strategy is to implant ovarian tissue into the pelvic cavity (orthotopic site) or in a heterotopic site once oncological treatment is completed and the patient is disease free. Transplantation of ovarian tissue with sufficiently large numbers of follicles could potentially restore endocrine function and allow multiple cycles for conception. However, the success of ovarian tissue transplantation still has multiple challenges, such as the low number of follicles in the graft that may affect their longevity as well as the survival of the tissue during ex vivo processing and subsequent transplantation. Therefore, this review aims to summarize the achievements of ovary grafting and the potential techniques that have been developed to improve ovarian graft survival.

Current Success and Efficiency of Autologous Ovarian Transplantation: A Meta-Analysis

CONTEXT

Ovarian cryopreservation followed by autotransplantation is still considered an experimental strategy for fertility preservation (FP) mainly because the success rates are unknown.

OBJECTIVE

To determine cohort epidemiologic characteristics and success rates of autologous ovarian tissue transplantation (OTT) with previously cryopreserved tissue.

MATERIALS AND METHODS

Literature review from 1999 to October 1, 2016. Additional cases were retrieved from meeting abstracts and own database. We selected studies that reported autologous OTT with previously banked tissue in humans. We did not include any cases involving fresh ovarian tissue transplantation or those performed to treat idiopathic premature ovarian failure/insufficiency. Both authors reviewed and selected studies for eligibility, which resulted in 59 full-text studies assessed for eligibility. Cases were extracted from original reports and reviews by the junior author, and the senior author reviewed and verified the extracted data.

RESULTS

Nineteen reports were included for qualitative synthesis. In 10 studies, detailed data were available to determine clinical and live birth + ongoing (LB + OG) pregnancy as well as endocrine restoration rates. Three hundred nine OTTs were performed with cryopreserved tissue, resulting in the birth of 84 children and 8 OG pregnancies. The cumulative clinical and LB + OG rates were 57.5% and 37.7%, respectively, and the endocrine restoration rate was 63.9%.

CONCLUSION

Success rates with cryopreserved OTT have reached promising levels. Given these recent data, ovarian tissue cryopreservation should be considered as a viable option for FP.

A review of reported surgical techniques in fertility preservation for prepubertal and adolescent females facing a fertility threatening diagnosis or treatment

BACKGROUND

Ovarian tissue cryopreservation is increasing as a preferred option for fertility preservation for prepubertal and young adolescent females facing a fertility threatening diagnosis or treatment.

DATA SOURCES

Ovid MEDLINE and PubMed searches for terms related to ovarian tissue removal for fertility preservation revealed there is no current consensus on operative technique for surgical ovarian cortical tissue removal in adult females. Additionally, there are limited published reports of surgical approach and outcomes in the pediatric population. In total, 22 publications were reviewed for their operative approach, ovarian tissue harvesting techniques, complications and outcomes.

CONCLUSIONS

Reported operative approaches and techniques for ovarian tissue cryopreservation for pediatric and adolescent patients are variable. Further investigations into operative technique and tissue harvesting that maintains healthy ovarian follicles for transplant will help establish standard technical principles for surgery in pediatric and adolescent females undergoing fertility preservation.

Chapter 12 Human Ovarian Tissue Slow Freezing

Cryopreservation of human ovarian tissue is now being accepted as a mainstream ART laboratory procedure. The procedure described has been validated for use at the histological and functional level, and, recently, unequivocal evidence of preservation of primordial follicles has been demonstrated following twin births from cryopreserved ovarian tissue grafted at a heterotopic site.

Reproductive issues in patients undergoing Hematopoietic Stem Cell Transplantation: an update

In 1963 George Mathé announced to the world that he had cured a patient of leukaemia by means of a bone-marrow transplant. Since than much progress has been made and nowadays Hematopoietic Stem Cell Transplantation (HSCT) is considered the most effective treatment of numerous severe haematological diseases. Gynaecological complications in HSCT women represent a serious concern for these patients, but often underestimated by clinicians in the view of Overall Survival. The main gynaecological complications of HSCT are represented by: premature ovarian failure (POF), thrombocytopenia-associated menorrhagia, genital symptoms or sexual problems in course of chronic GVHD (cGVHD), osteoporosis, secondary solid tumours due to immunosuppressive drugs to treat cGVHD and severity of cGVHD, and fertility and pregnancy issues. In particular fertility-related issues are always more relevant for patients, whose life expectation is constantly growing up after HSCT.

Thus, taking care of a patient undergoing HSCT should primarily include gynaecological evaluation, even before conditioning regimen or chemotherapy for the underlying malignancy, as, in our opinion, it is of great importance to ensure a complete diagnostic work-up and intervention options to guarantee maximum reproductive health and a better quality of life in HSCT women.

The present review aims at describing principal features of the aforementioned gynaecological complications of HSCT, and to define, on the basis of current international literature, a specific protocol for the prevention, diagnosis, management and follow-up of gynaecological complications of both autologous and heterologous transplantation, before and after the procedure.

Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ≥2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease.

FINDINGS

Available literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors ≥ 2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions ≥ 2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation.

CONCLUSION

Today, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.

Fertility preservation in women with cervical, endometrial or ovarian cancers

Background

Although cancer in general affects an aged population, a significant number of women develop cancer at childbearing age. Long-term survival rates after gynecological cancer, especially in young patients are increasing and all quality-of-life aspects, including preservation of fertility have become of major relevance.

Outcomes

Surgical techniques aimed at sparing reproductive organs and preserving fertility have been developed for women presenting with gynecological cancer found at early stages. Indications for fertility-sparing surgery are in general restricted to women presenting with a well-differentiated low-grade tumor in its early stages or with low malignant potential. Up to now, use of fertility-sparing techniques in well-selected patients has not been shown to affect overall survival negatively and fertility outcomes reported have been favorable. Still larger amounts of data and longer follow-up periods are needed. Several current fertility-sparing cancer treatments may result in sub-fertility and in those cases assisted reproductive techniques are indicated. Overall quality of life has been satisfactory in cancer patients after fertility-sparing surgery.

Conclusions

Fertility-sparing surgery is a viable tool to enable gynecological cancer patients of young age to fulfill their family building without impairment of oncological outcome. Cancer patients of reproductive age should undergo fertility counseling to analyze this sensitive subject. Further studies are needed to investigate the role of fertility-sparing treatment and combined adjuvant therapy in higher-grade cancers.

Female fertility preservation strategies: cryopreservation and ovarian tissue in vitro culture, current state of the art and future perspectives

In the present review, the main strategies of female fertility preservation are covered. Procedures of fertility preservation are necessary for women who suffer from diseases whose treatment requires the use of aggressive therapies, such as chemotherapy and radiotherapy. These kinds of therapy negatively influence the health of gametes and their progenitors. The most commonly used method of female fertility preservation is ovarian tissue cryopreservation, followed by the retransplantation of thawed tissue. Another approach to female fertility preservation that has been actively developed lately is the ovarian tissue in vitro culture. The principal methods, advantages and drawbacks of these two strategies are discussed in this article.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Heterotopic ovarian transplantation results in less apoptosis than orthotopic transplantation in a minipig model

Background

Ovarian autotransplantation has shown increasing promise as a clinical method for the preservation of fertility and hormonal function. However, information regarding the success rate of this type of transplantation is limited. We hypothesized that results vary according to the site of the ovarian transplantation. To test this hypothesis, fresh or cryopreserved ovarian strips were autotransplanted to orthotopic or heterotopic sites. The strips were later collected, and the morphology and expression of selected markers of apoptosis were evaluated. We compared the Bax, Bcl-2 and cleaved caspase-3 staining levels and the morphometric aspects of autotransplanted fresh and cryopreserved ovarian strips placed at orthotopic and heterotopic sites in minipigs.

Methods

Forty female minipigs were allocated to the following five groups: group 1 (control), ovarian tissue removed during oophorectomy; group 2, transplantation of fresh ovarian strips to a heterotopic site; group 3, transplantation of fresh ovarian strips to an orthotopic site; group 4, transplantation of cryopreserved ovarian strips to a heterotopic site; and group 5, transplantation of ovarian trips to an orthotopic site. On day 7 after transplantation, ovarian strips were collected, and the morphology and expression of apoptosis markers were evaluated.

Results

In all groups, follicles across all stages of development were detected. The numbers of primordial, primary and secondary follicles were similar in all groups, but the numbers of antral follicles were lower in the cryopreserved groups in comparison with freshly derived ovarian tissue, with no significant differences observed between fresh and cryopreserved transplants. In all transplanted groups, Bcl-2 expression was lower and Bax expression was higher than in the control group. Furthermore, increased expression of apoptosis markers was detected in fresh intraperitoneal transplants. Lastly, the expression of cleaved caspase-3 was higher in the cryopreserved orthotopic group compared with the heterotopic group.

Conclusions

Orthotopic and heterotopic ovarian strip transplantations are feasible options using these techniques. Importantly, we found that heterotopic transplantation preserves ovarian follicle integrity to a greater degree (i.e., lower expression of apoptosis markers) than orthotopic transplantation, and cryopreservation does not exacerbate expression of apoptosis’s markers. These findings have major clinical applications and enhance the discussion regarding the heterotopic transplantation of ovarian tissue.

Cancer and fertility preservation: international recommendations from an expert meeting

In the last years, thanks to the improvement in the prognosis of cancer patients, a growing attention has been given to the fertility issues. International guidelines on fertility preservation in cancer patients recommend that physicians discuss, as early as possible, with all patients of reproductive age their risk of infertility from the disease and/or treatment and their interest in having children after cancer, and help with informed fertility preservation decisions. As recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology, sperm cryopreservation and embryo/oocyte cryopreservation are standard strategies for fertility preservations in male and female patients, respectively; other strategies (e.g. pharmacological protection of the gonads and gonadal tissue cryopreservation) are considered experimental techniques. However, since then, new data have become available, and several issues in this field are still controversial and should be addressed by both patients and their treating physicians.In April 2015, physicians with expertise in the field of fertility preservation in cancer patients from several European countries were invited in Genova (Italy) to participate in a workshop on the topic of "cancer and fertility preservation". A total of ten controversial issues were discussed at the conference. Experts were asked to present an up-to-date review of the literature published on these topics and the presentation of own unpublished data was encouraged. On the basis of the data presented, as well as the expertise of the invited speakers, a total of ten recommendations were discussed and prepared with the aim to help physicians in counseling their young patients interested in fertility preservation.Although there is a great interest in this field, due to the lack of large prospective cohort studies and randomized trials on these topics, the level of evidence is not higher than 3 for most of the recommendations highlighting the need of further research efforts in many areas of this field. The participation to the ongoing registries and prospective studies is crucial to acquire more robust information in order to provide evidence-based recommendations.

Long-Time Cooling before Cryopreservation Decreased Translocation of Phosphatidylserine (Ptd-L-Ser) in Human Ovarian Tissue

Objectives

To translocation (externalization) of phosphatidylserine lead at least the five negative effects observed during cells cryopreservation: hypoxia, increasing of intracellular Ca²⁺, osmotic disruption of cellular membranes, generation of reactive oxygen species (ROS) and lipid peroxidation. The aim of this study was to test the intensiveness of the phosphatidylserine translocation immediately after thawing and after 45 d xenografting of human ovarian tissue, which was either frozen just after operative removal from patient or cooled before cryopreservation to 5°C for 24 h and then frozen.

Materials and Methods

Ovarian fragments from twelve patients were divided into small pieces in form of cortex with medulla, and randomly divided into the following four groups. Pieces of Group 1 (n=30) were frozen immediately after operation, thawed and just after thawing their quality was analyzed. Group 2 pieces (n=30) after operation were cooled to 5°C for 24 h, then frozen after 24 h pre-cooling to 5°C, thawed and just after thawing their quality was analyzed. Group 3 pieces (n=30) were frozen immediately after operation without pre-cooling, thawed, transplanted to SCID mice and then, after 45 d of culture their quality was analyzed. Group 4 pieces (n=30) were frozen after 24 h pre-cooling to 5°C, thawed, transplanted to SCID mice and then, after 45 d their quality was analyzed. The effectiveness of the pre-freezing cooling of tissuewas evaluated by the development of follicles (histology) and by intensiveness of translocation of phosphatidylserine (FACS with FITC-Annexin V and Propidium Iodide).

Results

For groups 1, 2, 3 and 4 the mean densities of follicles per 1 mm³ was 19.0, 20.2, 12.9, and 12.2, respectively (P_{1-2, 3-4} >0.1). For these groups, 99%, 98%, 88% and 90% preantral follicles, respectively were morphologically normal (P_{1-2, 3-4} >0.1). The FACS analysis showed significantly decreased intensiveness of translocation of phosphatidylserine after pre-cooling of frozen tissue (46.3% and 33.6% in Groups 2 and 4, respectively), in contrast with tissue frozen without pre-cooling (77.1% and 60.2 % in Groups 1 and 3, respectively, P_{1, 3-2, 4} <0.05).

Conclusions

Long time (24 h) cooling of ovarian tissue to 5°C before cryopreservation decreased translocation of phosphatidylserine that evidences about increases the viability of the cells in the tissue after thawing.

Pregnancy following breast cancer using assisted reproduction and its effect on long-term outcome

INTRODUCTION AND AIMS

We have previously shown that pregnancy is safe following breast cancer, even in endocrine sensitive disease. Yet infertility remains common following systemic treatment. To date, no study has evaluated the safety of assisted reproductive technology (ART) after breast cancer treatment. In this study, we evaluated the impact of ART on pregnancy and long-term outcomes of young breast cancer survivors.

METHODS

This is a multi-centre retrospective study in which women who were diagnosed with breast cancer between 2000 and 2009, and had a pregnancy following breast cancer diagnosis were eligible. Patients were divided into two groups according to whether ART following primary systemic therapy was performed to achieve pregnancy. We evaluated the association between ART use and clinic-pathological characteristics, pregnancy outcome and long-term breast cancer outcome.

RESULTS

A total of 198 patients were evaluated; of whom 25 underwent ART. No significant differences in tumour characteristics were observed between both groups, except for histological grade 3 tumours, which were fewer in the ART group (36% versus 59%, p=0.033). Around 90% of patients received primary adjuvant chemotherapy and more than 50% had an endocrine sensitive disease. Patients in the ART group were older at diagnosis (31.4 versus 33.7 years, p=0.009), at conception (38 versus 35 years, p<0.001), and experienced more miscarriages (23.5 versus 12.6%, p=0.082). Full term pregnancies were achieved in 77% and 76% of the spontaneous and ART groups, respectively. Mean follow-up between conception and last follow-up was 63 and 50 months in the spontaneous and ART groups, respectively with no difference in breast cancer outcome observed between the two groups (p=0.54).

CONCLUSION

Pregnancy using ART in women with history of breast cancer is feasible and does not seem to be detrimental to cancer outcome. Larger studies are needed to further confirm this observation.

Transplantation of mouse ovarian tissue: comparison of the transplantation sites

Many studies have shown that ischemic injuries during the transplantation process were more detrimental than cryoinjuries for follicle survival and death, and it has been reported that transplantation sites can affect the outcomes of grafted ovarian tissue (OT). The purpose of this study was to assess the impact of different OT transplantation sites on follicular integrity and function of OT grafts. B6D2F1 mice were randomly assigned to control (sham) and four experimental groups according to transplantation sites (back muscle [BM], fat pad [FP], kidney capsule [KC], and subcutaneous [SC]). The ovaries from four groups were autotransplanted to each site. The OT recovery ratios on Days 2, 7, and 21 were significantly decreased in the FP group. The mean numbers of follicles were significantly lower in all the grafting groups compared with the sham group, except in the KC group on Days 7 and 21 and the BM group on Day 21. On Day 2, all the experimental groups showed low intact (G1) follicle ratio when compared with the sham group; however, the BM, KC, and FP groups recovered their morphologic integrity on Day 7, and only the SC group presented a significant decrease in G1 follicle ratios. On Day 21, the G1 follicle ratios of the FP and KC groups were greater than the sham control group. The proportion of apoptotic follicles of the four OT graft groups was higher than in the sham group on Day 2, followed by a significant decrease in the KC group and an increase in the SC group on Day 7. The serum follicle-stimulating hormone levels were significantly increased in all grafting groups on Day 2. On Day 7, only the SC group showed the high follicle-stimulating hormone level compared with the other groups. The mean numbers of oocytes from OT grafts were the highest in the KC group, except in the control group, and the lowest in the SC group. The ratios of mature oocytes were also significantly greater in the sham and KC groups. However, the ratios of normal spindle did not differ among the five groups. In conclusion, the KC was the optimal site for OT transplantation in this murine model, whereas the SC site was unfavorable for this procedure. In this study, we confirmed that the different grafting sites influenced the outcomes of transplantation.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Ovarian tissue cryopreservation: a committee opinion

Ovarian tissue cryopreservation is an option to preserve reproductive potential in patients who must urgently undergo aggressive chemotherapy and/or radiotherapy or who have other medical conditions requiring treatment that may threaten ovarian function and subsequent fertility. Ovarian tissue cryopreservation may be the only option available to prepubertal girls undergoing such treatments. However, these techniques are still considered to be experimental. This document outlines the current technology, clinical outcomes, and risks of ovarian tissue cryopreservation and recommendations for clinical applications. This document and the document "Mature Oocyte Cryopreservation: A Guideline" published in 2013 (Fertil Steril 2013;99:37-43) replace the document "Ovarian Tissue and Oocyte Cryopreservation" last published in 2008 (Fertil Steril 2008;90:S241-6).

Strategies for fertility preservation in young patients with cancer: a comprehensive approach

As a result of treatment innovations, the survival rates of young people with cancer have increased substantially. The cancers most frequently diagnosed in adults aged 25-49 years include breast, colorectal and cervical cancer and malignant melanoma (Cancer Research UK, 2009). The 5-year survival rates of over 90 % for many malignancies are now reported in young people. But the diagnosis and treatment of cancer often poses a threat to fertility. Methods of fertility preservation are evolving quickly and awareness needs to grow in the medical community regarding these methods. Studies suggest that the ability to have biological children is of great importance to many people. The possible future effects of chemotherapy or radiotherapy on fertility should be discussed with all cancer patients who have reproductive potential. Moreover, fertility preservation should be considered for all young people undergoing potentially gonadotoxic treatment. This article covers the various methods of fertility preserving options in young men and women with respect to the various treatment modalities that they may be subjected to. Sperm banking is a simple and low cost intervention. Embryo cryopreservation is the only established method of female fertility preservation. Oocyte cryopreservation offers a useful option for women without a male partner. Emergency ovarian stimulation and cryopreservation of ovarian tissue (followed by tissue transplantation or in-vitro maturation of oocytes) are experimental techniques for women who require urgent cancer treatment. Large, well-controlled studies are also required to identify any unexpected long-term sequelae of cryopreservation of oocytes and ovarian tissue.

Follicle activation and 'burn-out' contribute to post-transplantation follicle loss in ovarian tissue grafts: the effect of graft thickness

STUDY QUESTION

What are the effects of thin ovarian grafts compared with grafts of the standard thickness on follicle loss post-transplantation?

SUMMARY ANSWER

Transplantation of reduced-thickness ovarian grafts led to intense activation and 'burn-out' a short time after transplantation resulting in significant folllicle loss.

WHAT IS KNOWN ALREADY

Transplantation of fresh and frozen-thawed ovarian tissue has been proved successful, but techniques vary and are not optimised, often resulting in significant follicular loss. Follicle loss is mostly related to the freezing-thawing process and to post-transplantation hypoxia.

STUDY DESIGN, SIZE, DURATION

Bovine ovarian tissue strips (n = 55) were prepared in two groups of conventional-thickness strips (1-2 mm) or thin strips (0.5-0.9 mm). Fresh or frozen-thawed samples were xenotransplanted into sterilized immune-deficient mice (n = 49). Non-transplanted conventional size fresh samples were used as controls (n = 6). Grafts from all study groups were recovered after 7 days for analysis.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Morphometric differential counting of follicle classes was performed by two observers. Immunohistochemistry was conducted for proliferation (Ki67), cortical fibrosis (Masson tri-chrome) and blood-vessel density (CD31). Results were expressed as the mean number of dormant or growing follicle (GF) type per section or total follicle counts per graft. Blood-vessel density was calculated per mm(2). P-values <0.05 were considered statistically significant.

MAIN RESULTS AND THE ROLE OF CHANCE

The loss of all follicle types, and most noteably of primordial follicles (PMFs), was observed 7 days post-transplantation (P < 0.05). The relatively high number of GFs and the positive Ki67 staining in all recovered grafts indicated that follicle activation was depleting the resting follicle pool. The reduced graft thickness had an adverse effect on the number of recovered follicles, especially on the resting non-GFs in the fresh, and more so in the frozen-thawed, samples (P < 0.05). Extensive stromal fibrosis and high blood-vessel density were observed in all grafts with no advantage in the thin prepared grafts.

LIMITATIONS, REASONS FOR CAUTION

This study used only one species of ovaries (bovine) for xenotransplantation. The immediate post-transplantation events were not visualized directly nor were the molecules involved in follicle activation studied.

WIDER IMPLICATIONS OF THE FINDINGS

Follicle activation and 'burn-out' appear to be important in follicle loss after transplantation. Reducing graft thickness in an attempt to improve freezing conditions and reduce post-transplantation ischemia has adverse effects on the graft follicle pool due to increased activation and loss. Agents which prevent 'burn-out' will potentially improve follicle pool survival.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by research grants from the Israeli Science Foundation (No. 1675/10), the Israeli Jack Craps foundation and the Israel Cancer Research Fund (ICRF No. 12-3081). The authors have no competing interest to declare.

Is transplantation of cryopreserved ovarian tissue from patients with advanced-stage breast cancer safe? A pilot study

PURPOSE

To assess the safety of reimplantation of cryopreserved ovarian tissue from advanced-stage breast cancer patients.

METHODS

Cryopreserved ovarian cortical fragments were obtained from 13 advanced-stage breast cancer patients aged 17-35 years. After thawing, part of the ovarian cortical tissue was grafted to severe combined immunodeficient mice for 6 months. The presence of malignant mammary cells in ovarian tissue was evaluated after thawing as well as after grafting by 1) histology and immunohistochemistry (epithelial membrane antigen, Her2/neu and gross cystic disease fluid protein 15 identification), and 2) detection of the MGB2 gene by qPCR.

RESULTS

No malignant cells were evidenced by histology and immunohistochemistry. None of the mice died during the 6-month grafting period, nor developed macroscopically visible masses. MGB2 gene expression was detected by qPCR and confirmed by sequencing in frozen-thawed ovarian tissue in 4 cases and in grafts in 1 case.

CONCLUSIONS

This pilot study is the first to evaluate the risk of contamination of cryopreserved ovarian tissue from advanced-stage breast cancer patients by xenotransplantation for 6 months to immunodeficient mice, associated with more conventional screening methods. Our xenografting results are reassuring, but caution needs to be exercised, as MGB2 gene expression was detected in some cases. Larger numbers of ovarian tissue samples from patients with advanced-stage breast cancer are required to confirm our findings before ovarian tissue transplantation can be contemplated in these patients.

Fertility counseling of young breast cancer patients

Approximately 6% of women with breast cancer are diagnosed before the age of 40. Young age is an independent predictor of adverse outcome and most young breast cancer patients receive systemic treatment with chemotherapy, hormonal therapy or both. The loss or impairment of fertility is a potential side effect of antineoplastic treatments. Due to the rising trend to delaying pregnancy in life, an increasing proportion of young cancer patients who are yet to have a pregnancy will face the problem of iatrogenic menopause in the future. The incidence of anticancer-treatment-related ovarian failure depends on the type of chemotherapy regimen administered, the use of tamoxifen and the age of patients. It rises with increasing age, in the range of 22-61% and 61-97% in women aged <40 years and >40 years respectively. Although there is a clear trend to increasing incidence of ovarian failure with the rise in aging, there may be a small proportion of patients who became amenorrhoeic despite the very young age, thus indicating that also individual factors still unknown may affect the probability of treatment-related ovarian failure. A prompt referral of patients to reproductive counseling and a multidisciplinary team including Oncology and Reproductive Units are essential to face the management of fertility issues in cancer patients. Fertility counseling should include a detailed description of all the available techniques to preserve fertility. The main available fertility preservation techniques, standard and experimental, for young breast cancer patients include: temporary ovarian suppression during chemotherapy with gonadotropin-releasing hormone analogues, embryo cryopreservation, cryopreservation of oocytes and cryopreservation of ovarian tissue. Research efforts are still necessary to improve the efficacy and safety of the available fertility preservation strategies as well as an efficient collaboration between oncologists and gynecologists is necessary to improve patients' access to the strategies themselves.

Autotransplantation of cryopreserved ovarian tissue in cancer survivors and the risk of reintroducing malignancy: a systematic review

BACKGROUND The risk of recurrent oncological disease due to the reintroduction of cancer cells via autotransplantation of cryopreserved ovarian tissue is unknown. METHODS A systematic review of literature derived from MEDLINE, EMBASE and the Cochrane Library was conducted. Studies on follow-up after autotransplantation; detection of cancer cells in ovarian tissue from oncological patients by histology, polymerase chain reaction or xenotransplantation; and epidemiological data on ovarian metastases were included. RESULTS A total of 289 studies were included. Metastases were repeatedly detected in ovarian tissue obtained for cryopreservation purposes from patients with leukaemia, as well as in one patient with Ewing sarcoma. No metastases were detected in ovarian tissue from lymphoma and breast cancer patients who had their ovarian tissue cryopreserved. Clinical studies indicated that one should be concerned about autotransplantation safety in patients with colorectal, gastric and endometrial cancer. For patients with low-stage cervical carcinoma, clinical data were relatively reassuring, but studies focused on the detection of metastases were scarce. Oncological recurrence has been described in one survivor of cervical cancer and one survivor of breast cancer who had their ovarian tissue autotransplanted, although these recurrences may not be related to the transplantation. CONCLUSIONS It is advisable to refrain from ovarian tissue autotransplantation in survivors of leukaemia. With survivors of all other malignancies, current knowledge regarding the safety of autotransplantation should be discussed. The most reassuring data regarding autotransplantation safety were found for lymphoma patients.

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

OBJECTIVE

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

DESIGN

Experimental study.

SETTING

University hospital.

DONOR(S)

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

INTERVENTION(S)

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

MAIN OUTCOME MEASURE(S)

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

RESULT(S)

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

CONCLUSION(S)

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

Risk of transferring malignant cells with transplanted frozen-thawed ovarian tissue

Ovarian tissue cryopreservation and transplantation is a real option to preserve and restore fertility in young cancer patients. However, there is a concern regarding the possible presence of malignant cells in the ovarian tissue, which could lead to recurrence of the primary disease after reimplantation. A review of the existing literature was done to evaluate the risk of transplanting malignant cells in case of the main malignant indications for ovarian tissue cryopreservation. For ovarian tissue from patients with hematologic malignancies, it is of paramount importance to identify minimal residual disease before ovarian tissue transplantation. Indeed, these pathologies, reviewed here in detail, are considered to be most at risk of ovarian metastasis.

The safety of transplanting cryopreserved ovarian tissue in cancer patients: a review of the literature

BACKGROUND

Transplantation of frozen/thawed ovarian tissue from patients with a malignant condition is associated with a risk of re-introduction of the disease as the tissue usually is removed before anti-cancer therapy and may thus contain malignant cells. We review studies investigating the presence of malignant cells in cryopreserved ovarian tissue from patients with malignant disease and based on the strength of the evidence, recommendations for transplantations are proposed.

MATERIALS AND METHODS

A systematic review of the literature. All peer reviewed studies evaluating the presence of malignant cells in cryopreserved human ovarian tissue were included. Data were searched in Pubmed and Embase with no language restrictions.

RESULTS

The majority of the reviewed papers were casuistic reports and few of the included papers were specifically designed to search for malignant cells. Ovarian tissue from 422 patients has been subject to testing for malignant cells by imaging, histology, immunohistochemistry, molecular biology, animal- or clinical transplantation. In 31 (7 %) of the cases the applied test raised suspicion of malignant cell infiltration. No transplantation-related relapse of cancer has been reported after 33 transplantations of frozen/thawed ovarian cortex.

CONCLUSION

The quality and strength of the evidence is generally low and prospective studies are needed. The risk of re-introducing a malignant condition when transplanting ovarian tissue depends on the particular disease. Based on the available data, the risk was estimated: Leukaemia: HIGH. Gastrointestinal cancers: MODERATE. Breast cancer, sarcomas of the bone and connective tissue, gynaecological cancers, Hodgkin's and Non-Hodgkin's Lymphoma: LOW.

Cryopreservation of ovarian tissue for fertility preservation in young female oncological patients

Girls and women suffering from a cancer that requires treatment with gonadotoxic drugs may experience cessation of reproductive function as a side effect due to obliteration of the ovarian pool of follicles. Techniques are now available for fertility preservation, such as cryopreservation of mature oocytes, embryos or ovarian cortical tissue. Whereas collection of mature oocytes and embryos requires at least a 2-week period, ovarian tissue may on short notice be frozen prior to treatment and can be transplanted back into women with ovarian failure. Transplanted frozen/thawed tissue supports survival and growth of follicles, giving rise to menstrual cycles and hormone production for several years. Worldwide, the procedure has resulted in the birth of 15 healthy children. Many cancer patients including girls and young women want fertility preservation, and the techniques are now being further developed and implemented in several centers.

Ovarian reserve in women treated for acute lymphocytic leukemia or acute myeloid leukemia with chemotherapy, but not stem cell transplantation

Purpose. It is well known that chemotherapy regimens may have a negative effect on ovarian reserve, leading to amenorrhea or premature ovarian failure. There are little data regarding the effects of leukemia chemotherapy on ovarian reserve, specifically in women who received the chemotherapy as adults and are having regular menstrual periods. Our primary objective was to determine if premenopausal women with a history of chemotherapy for leukemia, without subsequent stem cell transplantation, have decreased ovarian reserve. Materials and Methods. We measured ovarian reserve in five women who had been treated for acute lymphocytic leukemia (ALL) or acute myeloid leukemia (AML) and compared them to age-matched control women without a history of chemotherapy. Results. There appeared to be a trend towards lower antimullerian hormone and antral follicle counts and higher follicle-stimulating hormone levels in the leukemia group. Conclusion. Our results indicate that chemotherapy for AML or ALL without stem cell transplantation may compromise ovarian reserve. Although our results should be confirmed by a larger study, oncologists, infertility specialists, and patients should be aware of the potential risks to ovarian function and should be counseled on options for fertility preservation.