Préservation de la fertilité féminine : place de la maturation ovocytaire in vitro

Préservation de la fertilité chez les personnes transgenres

La majorité des personnes transgenres envisage de fonder une famille, mais leur fertilité peut être altérée par l’affirmation du genre. L’hormonothérapie peut affecter durablement la production de gamètes, notamment chez les femmes trans. La chirurgie de réassignation sexuelle entraîne une stérilité définitive. En France, des réseaux de professionnels de santé se sont organisés. Ils recommandent l’accès à la préservation de la fertilité dans le cadre de la transidentité. Cependant, le recueil de gamètes reste souvent difficile en raison de l’incongruence hormonale pour les femmes trans, ou du caractère invasif de la procédure pour les hommes trans. De futures études permettront de statuer sur l’utilisation des gamètes autoconservés.

[Breast and ovarian cancer due to BRCA1&2 hereditary cancer predisposition syndrome and reproduction: literature review]

INTRODUCTION

Germline mutations BRCA1&2 are responsible in women for breast and ovarian cancers that commonly occur at a young age: as such, there are strong interactions between the oncological risks and the events of reproductive life, pregnancy, breastfeeding, and management of infertility.

MATERIALS AND METHODS

A review of the international literature from the PubMed database was conducted, and recommendations of French health agencies were exposed. Published studies are case-control and cohort studies in the majority, with a low level of evidence.

RESULTS

Pregnancy and lactation have no effect on breast and ovaries or even decreases the risk. The sex ratio among patients carrying the mutation is in favor of girls. It is not observed more infertility in patients carrying a mutation despite a strong suspicion of premature ovarian failure, and infertility treatments do not increase breast and ovarian risk. There are ethical debates concerning the place of pre-natal diagnosis: both experts and concerned patients recommend a case-by-case analysis of the requests.

[Oncofertility program at the Montpellier university hospital 2 years after]

OBJECTIVE

Female fertility preservation in the context of cancer management is crucial for patient's health care. The aim of this study was to evaluate the oncofertility practice at our university hospital of Montpellier since 2011.

PATIENTS AND METHODS

The evaluation of management of young patients referred to Montpellier University Hospital from September 2011 to September 2013 for oncofertility counselling before cancer treatment.

RESULTS

Seventy-one patients were referred to a specialized oncofertility center. Forty-two patients (59.1%) were included in the oncofertility program. Twenty-two patients (31%) were proposed for oocyte vitrification after COS protocol, eight patients (11.3%) for ovarian tissue cryoconservation, seven patients (9.9%) for GnRH injections, three patients (4.2%) ovarian transposition and two patients (2.8%) for embryo cryopreservation. Among the 42 indications of fertility preservation, only 18 will have finally taken place.

CONCLUSION

Oncofertility counselling for young patients should now be part of the cancer management. It involves multidisciplinary teams. Further information of both oncologists and patients is needed to improve this new approach in the field of cancer treatments.

Female fertility preservation in cancer patients: an instrumental tool for the envisioning a postdisease life

ABSTRACT: 

Aim: To verify whether fertility preservation (FP) improves the way women contemplate their life after the disease. Materials & methods: 285 cancer patients referred for FP counseling were prospectively studied. A standardized questionnaire was submitted to all participants. Results: A total of 85 patients (39.0%) returned the questionnaire. None of the women who rejected the FP proposal after oncofertility counseling returned the questionnaire. The median age of responders was 29.1 years (range: 18–40 years). In total, 35 of them (41.1%) were single and 72 (84.7%) were childless. A total of 66 women (77.6%) reported that the possibility of preserving fertility was instrumental to improving their coping with the burden of treatments. Since 61.2% patients perceived their cryopreserved oocytes or embryos as future children or family, the projection in a postdisease life may be at play in this improved subjective experience of treatment. Conclusion: The present results indicate that the simple fact of undergoing FP improves the patients’ subjective experience of cancer treatments.

[Presumed ovarian benign tumors and fertility]

We reviewed the studies about fertility-sparing in young patient presenting a benign ovarian tumor. It appears that more than the histologic nature of the ovarian cysts, it is the surgical treatment of the cyst which may decrease fertility. Some good practice of surgical procedures must be kept in mind when one manages a benign ovarian tumor in a young patient wishing to preserve her fertility: surgery should be avoided as much as possible; kystectomy is better than oophorectomy; no radical surgery should be done without pathological certitudes; electrocoagulation must be avoided on the cyst walls. In some situations, fertility is specially endangered: bilateral ovarian cysts, recurrence or strong probability of recurrence (endometriomas), poor ovarian reserve (previous chemo- or radiotherapy, age>35, premature ovarian failure). In these situations, a pre-operative assessment of the ovarian reserve could be useful. Beside the surgical 'good procedures', gamete cryopreservation procedures could be used. Cryopreservation of mature oocytes (after ovarian hyperstimulation) or in vitro mature oocytes (after antral follicle retrieval) can be proposed. Ovarian tissue cryopreservation is another option. Oocyte (or embryos) cryopreservation can be proposed before or after the surgery. The global management of benign ovarian tumors in young patients should be decided between surgeons and specialists in reproductive biology.

[Fertility preservation among patients with cancer: report of a French regional practical experience]

OBJECTIVE

Improvement in cancer treatments has led to reconsider the importance of quality of life after cancer, especially concerning maintening the potential of fertility since it is often altered after healing. Our objective was to estimate the knowledge and practices of the physicians in the field of Oncology in a French Region (Provence Alpes- Côte d'Azur).

PATIENTS AND METHOD

Prospective survey, conducted between January and April 2012, amongst oncologists working in Provence Alpes Côte d'Azur region, through questionnaires distributed during multidisciplinary meetings in oncology.

RESULTS

Among 225 replies, 54% of the physicians had sent no patient to any oncofertility consultation during the previous six months (n=120). Besides, 33% of the oncologists (n=68) declared they had difficulties in addressing their patients to oncofertility consultation, and 58% of them (n=39) considered they lacked information on techniques and indications of fertility preservation.

CONCLUSION

This study provides an estimation of the current practices in PACA region concerning oncofertility and underlines the physicians' need of information. In this context, the regional oncology network has set up a regional network « cancer and fertility » in order to facilitate the access to fertility preservation prior to any potentially sterilizing treatment for all patients.

[Present and future strategies for women at risk, or suffering from premature ovarian failure (POF)]

The purpose of this review is to present the strategies for fertility preservation that are currently proposed to patients at risk from premature ovarian failure (POF) due to chemotherapy as well as some future solutions that could allow patients already affected by an IOP to recover their fertility. Today, cryo-preservation of pieces of ovarian cortex followed by orthotopic transplantation as well as in vitro maturation of oocytes (IVM) allow preservation of fertility in patients being to undergo an antitumor treatment. However, although promising results have been obtained, the pregnancy rate remains very low. Improvement of these techniques, but also stimulation of resting follicle activation, in vitro folliculogenesis, and culture of putative oogonia that may be present in the adult ovary, are all future opportunities for patients suffering from an IOP, and are currently the subject of intensive researches.

Effect of aging on follicular function may be relieved by exogenous gonadotropin treatment in a sheep model

The current study investigated hormonal and ovarian changes during physiological reproductive aging in Sarda ewes. In a first experiment, follicular and corpus luteum dynamics were compared during an induced oestrus cycle in aged (12-14 years) and young adult ewes (4-5 years). Oestrus cycle characteristics did not differ between the two experimental groups. However, follicular function during the follicular phase showed significant alterations in aged ewes, as determined by a lack of dominance effect and by lower mean values of circulating oestradiol (E(2)) and inhibin levels, compared with young adult ewes. In a second experiment, differences in follicle growth, hormonal milieu and oocyte quality in response to exogenous FSH administration were assessed in aged and adult ewes. No differences were recorded in ovarian response to FSH treatment between young adult and aged ewes, as evaluated by ultrasonographic data and circulating concentrations of LH, E(2) and inhibin-A. Although the total number of recovered oocytes was similar in the two age groups, the number of good quality oocytes selected for IVM was significantly lower in aged ewes compared with adult ones. Thereafter, no differences were recorded in cleavage rates, total blastocyst output, embryo developmental kinetic and quality between aged and adult groups. In conclusion, this study demonstrated that reproductive aging in sheep is associated with impaired follicle functionality and an increase in the proportion of oocytes showing morphological abnormalities. However interestingly, oocyte developmental competence in vitro and embryo cryotolerance were not affected by the aging process, when only good quality oocytes were chosen.

[Cancer, fertility preservation and gonadotropins]

The recent emergence of oncofertility raises the question of ovarian stimulation and its risks when performed for oocyte or/and embryo cryopreservation in a fertility preservation program. The relation between ovarian stimulation and cancer has been marked by the possible direct or indirect tumorigenic role for pituitary gonadotrophins in the tumorogenesis. Although the growth of many gonadal and extragonadal tumors is stimulated by gonadal sex hormones, whose production is regulated by gonadotrophins, there is still a lack of data to consider FSH and LH as tumor promoters. The purpose of this brief review is to present on one hand, the questions raised by the administration of exogenous gonadotrophins in cancer patients and on the other, to evaluate both experimental and clinical data about the possible relation between gonadotrophins and tumorogenesis.