Fertility preservation for age-related fertility decline

First report on successful delivery after retransplantation of vitrified, rapid warmed ovarian tissue in Europe

RESEARCH QUESTION

Cryopreservation of ovarian tissue is one feasible option to preserve female fertility prior to cancer treatment. The slow freezing protocol represents the current standard approach, while vitrification has been suggested as a promising alternative. This paper reports the follow-up and first successful delivery after retransplantation of vitrified, rapid warmed ovarian tissue in Europe.

DESIGN

After the patient received a diagnosis of breast cancer, ovarian tissue was removed laparoscopically and sent via overnight transportation to University Hospital Bonn for vitrification on site. The patient was treated with chemotherapy, leading to ovarian failure. After 2 years, retransplantation of the vitrified, rapid warmed tissue was conducted on site.

RESULTS

Two months after grafting, the patient reported regular menstrual cycles. After 1 further month a clinical pregnancy occurred, which ended in a spontaneous abortion at the 8th week of pregnancy. Six months after grafting, another naturally conceived pregnancy was determined, resulting in the birth of a healthy boy 14 months after retransplantation of the ovarian tissue.

CONCLUSIONS

Complementing the successful deliveries reported by the groups of Suzuki (Japan) and Silber (USA) regarding vitrified tissue, the current results confirm the high potential of this cryopreservation method in a clinical routine setting as an alternative approach to the widespread slow freezing method.

Differential analysis of ovarian tissue between high and low-yielded laying hens in the late laying stage and the effect of LECT2 gene on follicular granulosa cells proliferation

The ovaries of high-yield laying hens exhibited signs of aging beyond 400 days of age, subsequently resulting in a decline in both egg production and egg quality. Oxidative stress, characterized by an increase in the production of reactive oxygen species (ROS), stands as one of the principal processes contributing to ovarian aging. Elevated ROS levels are implicated in the induction of apoptosis in granulosa cells (GCs), provoking mitochondrial impairment, and diminishing the capacity of the antioxidant defense system. This investigation stratified laying hens into two distinct groups, predicated upon their egg production levels: high-yield hens (HH) and low-yield hens (LL). The study focused on evaluating oxidative stress markers and identifying differentially expressed genes between these two groups. The findings revealed that the LL group exhibited follicular atresia, mitochondrial disruptions, and apoptotic occurrences in ovarian GCs. Notably, ROS levels, Malondialdehyde (MDA) concentrations, and 8-hydroxy-2'-deoxyguanosine (8-OHdG) concentrations in ovarian tissue and follicular GCs were substantially higher in the HH group. Furthermore, the RNA-sequencing results unveiled differential expression of the LECT2 gene between the HH and LL groups. Consequently, an overexpression vector for the LECT2 gene was successfully constructed and introduced into GCs. The quantitative polymerase chain reaction (QPCR) analysis exhibited significant downregulation (p < 0.01) of key apoptotic genes such as Caspase-3 and C-myc and significant upregulation (p < 0.01) of BCL2 following the overexpression of the LECT2 gene in GCs. In conclusion, oxidative stress emerges as a pivotal factor influencing the laying traits of both high and low-yield laying hens. The accumulation of reactive oxygen species (ROS) within the ovaries precipitates apoptosis in GCs, subsequently leading to follicular atresia and a reduction in egg production. Furthermore, we employed RNA sequencing technology to examine the ovarian matrix tissue in high and low laying hens during the late phase of egg laying. Our analysis revealed a substantial upregulation of the LECT2 gene in the ovarian matrix tissue of high laying hens. This observation implies that the LECT2 gene exerts a pivotal influence on driving the proliferation and differentiation of follicular GCs, thereby exerting a crucial regulatory role in follicular development.

Cryostorage of human ovarian tissue: evaluating the storage and disposal pattern over a 22-year period in 2475 patients

RESEARCH QUESTION

What are the parameters of age, indications for ovarian tissue cryopreservation, storage characteristics and reasons for tissue disposal in a large cohort of individuals undertaking cryopreservation?

DESIGN

The relevant parameters in a single university centre were revised and digitalized in the period from 2019 to 2021. To assess patients' motivation at the end of storage, patients were contacted by letter, e-mails and telephone calls.

RESULTS

A group of 2475 patients with stored ovarian tissue were analysed in the time period between 2000 and 2021; the response rate for contact calls and letters was 28.8% (224/777). Where storage had ended (n = 1155), patients had on average stored for 3.8 years and begun storing at age 30 years; the main indications were breast cancer (53%) and lymphoma (17.5%). Of these participants, 2.5% had a transplantation on site, 10.3% transferred their tissue to another cryobank and 11.5% were deceased. The majority of the group (75.7%) ended their storage due to pregnancy (49.1%), a lack of desire to have children (25.9%), storage fees that were too expensive (8.9%), death (8.5%), recurrence of cancer (8.5%), lack of a partner (4%) and fear of surgery in the future (3.1%); 6.7% retrospectively regretted ending storage.

CONCLUSIONS

The pregnancy rate of 49.1%, resulting from ovarian tissue that was not removed during surgery for scheduled ovarian tissue cryopreservation supports the clinical approach of removing and cryopreserving only 25-50% of one ovary. It is proposed that interdisciplinary counselling should be implemented not only prior to fertility preservation, but also when intending to end storage.

Comparison of angiogenic potential in vitrified vs. slow frozen human ovarian tissue

Vitrification of ovarian tissue is a promising alternative approach to the traditional slow freezing method. Few empirical investigations have been conducted to determine the angiogenic profiles of these two freezing methods. In this study we aimed to answer the question whether one of the cryopreservation methods should be preferred based on the secretion of angiogenic factors. Tissue culture with reduced oxygen (5%) was conducted for 48 h with samples of fresh, slow frozen/thawed and vitrified/rapid warmed ovarian cortex tissue from 20 patients. From each patient, tissue was used in all three treatment groups. Tissue culture supernatants were determined regarding cytokine expression profiles of angiogenin, angiopoietin-2, epidermal growth factor, basic fibroblast growth factor, heparin binding epidermal growth factor, hepatocyte growth factor, Leptin, Platelet-derived growth factor B, placental growth factor and vascular endothelial growth factor A via fluoroimmunoassay. Apoptotic changes were assessed by TUNEL staining of cryosections and supplemented by hematoxylin and eosin and proliferating cell nuclear antigen staining. Comparing the angiogenic expression profiles of vitrified/rapid warmed tissue with slow frozen/thawed tissue samples, no significant differences were observed. Detection of apoptotic DNA fragmentation via TUNEL indicated minor apoptotic profiles that were not significantly different comparing both cryopreservation methods. Vitrification of ovarian cortical tissue does not appear to impact negatively on the expression profile of angiogenic factors and may be regarded as an effective alternative approach to the traditional slow freezing method.

The effect of high-throughput vitrification of human ovarian cortex tissue on follicular viability: a promising alternative to conventional slow freezing?

BACKGROUND

The standard procedure most frequently used for ovarian tissue cryopreservation (OTC) is slow freezing, while vitrification has been proposed as promising alternative and has built an impressive catalog of success in fertility laboratories regarding cryopreservation of oocytes and embryos.

METHODS

We developed and evaluated a high-throughput protocol for vitrification of human ovarian tissue suitable for clinical processing. Follicular viability was assessed via calcein staining prior and after cryopreservation analyzing ovarian tissue of a cohort of 30 patients.

RESULTS

We found no significant differences regarding follicular viability between slow frozen and vitrified cortex tissue samples 24 h after thawing and rapid warming. Follicular viability of thawed and rapid warmed samples was not significantly different in comparison to fresh samples, indicating high proportions of follicular survival rates with both methods.

CONCLUSIONS

High-throughput vitrification is a promising option in a clinical setting. More research is required to determine the status of other tissue-specific quality indicators potentially influencing on autotransplantation.

Oncofertility Perspectives for Girls with Cancer

Infertility is a serious early, as well as late, effect of childhood cancer treatment. If addressed in a timely manner at diagnosis, fertility preservation measures can be taken, preferably before the start of cancer treatment. However, pediatric oncologists might remain reluctant to offer counseling on fertility-preservation methods, although infrastructure to freeze ovarian tissue has become available and is currently considered standard care for pre- and postpubertal girls at high risk of gonadal damage. More importantly, risk factors have been identified for cancer treatment-related impairment of gonadal function, and the first successful pregnancies have been reported after autotransplanted ovarian tissue, which has been harvested from children. Additionally, great progress has been made in the field of ex vivo maturation of oocytes in frozen ovarian tissue, which provides opportunities for those at risk of ovarian micrometastasis. Hence, it is time to counsel girls at risk and make every effort to cryopreserve their ovarian tissue, now more than ever before.

In vitro growth (IVG) of human ovarian follicles in frozen thawed ovarian cortex tissue culture supplemented with follicular fluid under hypoxic conditions

Background

Despite its clinical success rates, transplantation after ovarian tissue cryopreservation (OTC) remains a matter of concern. Certain cancer subtypes may lead to the transfer of malignant cells when transplantation of affected ovarian tissue is conducted. IVG and subsequent isolation of vital follicles obtained from frozen thawed ovarian tissue for further in vitro maturation (IVM) would expand current fertility protection techniques while reducing the risk of retransplanting malignant cells.

Methods

A total of 216 cortical biopsies from 3 patients were included in this study in 4 treatment groups. After freezing, thawing and 8 days of hypoxic tissue culture supplemented with different concentrations of human follicular fluid (HuFF) and follicle-stimulating hormone (FSH), follicles were isolated enzymatically and stained with calcein to determine follicular viability. Numbers and size of vital follicles were assessed by fluorescence microscopy (Ti2, Nikon) and specified by computer assisted, semi-automated measurement (NIS software, Nikon). To estimate the effect of in vitro culture on apoptosis, tissue sections were stained for nicked DNA (TUNEL) prior and after tissue culture.

Results

Analysing 3025 vital follicles, we observed significant differences [P < 0.01] regarding follicle size when hypoxic tissue culture was supplemented with HuFF compared with the control group on day 1, individual follicles reached sizes > 100 µm.

Conclusions

The results implicate that HuFF contains valuable factors contributing to significant IVG of follicles in human ovarian tissue and could be regarded as an additional tool in personalized fertility restoration prior to retransplantation of ovarian tissue.

Fertility preservation in the pediatric population-experience from a German Cryobank for ovarian tissue

Counseling children on the possibility of fertility preservation prior to a gonadotoxic treatment supports the decision-making process, taking into account that the patients are in a very vulnerable and mentally exhausting situation following the diagnosis. Referral to specialists can be optimized on-site by routing slips with contact addresses, phone numbers, and mail contacts; available time slots for consultation; possibly offers for cost coverage; and an easy-to-understand information leaflet about the different options available. Some of the options for fertility preservation in the prepubertal population especially are still experimental. The unique possibility of fertility preservation before the onset of the gonadotoxic therapy, which may cause premature ovarian insufficiency or azoospermia in the future, should be highlighted.

Fertility Preservation: How to Preserve Ovarian Function in Children, Adolescents and Adults

Chemotherapy, pelvic radiotherapy and ovarian surgery have known gonadotoxic effects that can lead to endocrine dysfunction, cessation of ovarian endocrine activity and early depletion of the ovarian reserve, causing a risk for future fertility problems, even in children. Important determinants of this risk are the patient’s age and ovarian reserve, type of treatment and dose. When the risk of premature ovarian insufficiency is high, fertility preservation strategies must be offered to the patient. Furthermore, fertility preservation may sometimes be needed in conditions other than cancer, such as in non-malignant diseases or in patients seeking fertility preservation for personal reasons. Oocyte and/or embryo vitrification and ovarian tissue cryopreservation are the two methods currently endorsed by the American Society for Reproductive Medicine, yielding encouraging results in terms of pregnancy and live birth rates. The choice of one technique above the other depends mostly on the age and pubertal status of the patient, and personal and medical circumstances. This review focuses on the available fertility preservation techniques, their appropriateness according to patient age and their efficacy in terms of pregnancy and live birth rates.

Establishment of a Pediatric Ovarian and Testicular Cryopreservation Program for Malignant and Non-Malignant Conditions: The Mayo Clinic Experience

STUDY OBJECTIVES

To describe the structure of a pediatric fertility preservation (FP) program and to share safety and patient satisfaction data.

DESIGN

The FP program operates under prospective research protocols approved by the Mayo Clinic Institutional Review Board (IRB).

SETTING

The FP program is a multidisciplinary effort between pediatric gynecology, reproductive endocrinology, pediatric urology, pediatric surgery, and laboratory medicine.

PARTICIPANTS

The FP program enrolls patients between 0-17 years of age who have been diagnosed with a fertility-threatening condition and/or are scheduled to undergo gonadotoxic treatment.

INTERVENTIONS

FP is offered in the form of ovarian tissue cryopreservation (OTC) and testicular (TTC) tissue cryopreservation.

MAIN OUTCOME MEASURES

The outcome measures are the safety of the procedure and results of patient surveys conducted by phone using a standard list of questions to assess attitudes towards FP.

RESULTS

To date, we have enrolled 38 OTC and 37 TTC patients. The median age (range) of OTC and TTC patients was 11 years (0.83-17 years) and 10 years (0.92-17 years) at the time of enrollment, respectively. Childhood cancers currently represent 88% of the fertility-threatening diagnoses. Meanwhile, patients with non-malignant conditions include those with gender dysphoria, aplastic anemia, and Turner's syndrome. To date, no serious adverse events (SAEs) have been reported following surgery. According to n = 34 one-year follow-ups, 100% of parents felt that FP was a good decision.

CONCLUSION

Consistent with the literature, our data suggests FP is safe and improves the quality of care provided to pediatric patients for their fertility-threatening diagnoses and/or treatments.

TRIAL REGISTRATION

NCT02872532, NCT02646384.

Recent advances: fertility preservation and fertility restoration options for males and females

Fertility preservation is the process of saving gametes, embryos, gonadal tissues and/or gonadal cells for individuals who are at risk of infertility due to disease, medical treatments, age, genetics, or other circumstances. Adult patients have the options to preserve eggs, sperm, or embryos that can be used in the future to produce biologically related offspring with assisted reproductive technologies. These options are not available to all adults or to children who are not yet producing mature eggs or sperm. Gonadal cells/tissues have been frozen for several thousands of those patients worldwide with anticipation that new reproductive technologies will be available in the future. Therefore, the fertility preservation medical and research communities are obligated to responsibly develop next-generation reproductive technologies and translate them into clinical practice. We briefly describe standard options to preserve and restore fertility, but the emphasis of this review is on experimental options, including an assessment of readiness for translation to the human fertility clinic.

Current and Future Perspectives for Improving Ovarian Tissue Cryopreservation and Transplantation Outcomes for Cancer Patients

Although advances in cancer treatment and early diagnosis have significantly improved cancer survival rates, cancer therapies can cause serious side effects, including ovarian failure and infertility, in women of reproductive age. Infertility following cancer treatment can have significant adverse effects on the quality of life. However, established methods for fertility preservation, including embryo or oocyte cryopreservation, are not always suitable for female cancer patients because of complicated individual conditions and treatment methods. Ovarian tissue cryopreservation and transplantation is a promising option for fertility preservation in pre-pubertal girls and adult patients with cancer who require immediate treatment, or who are not eligible to undergo ovarian stimulation. This review introduces various methods and strategies to improve ovarian tissue cryopreservation and transplantation outcomes, to help patients and clinicians choose the best option when considering the potential complexity of a patient's situation. Effective multidisciplinary oncofertility strategies, involving the inclusion of a highly skilled and experienced oncofertility team that considers cryopreservation methods, thawing processes and devices, surgical procedures for transplantation, and advances in technologies, are necessary to provide high-quality care to a cancer patient.

Efficacy and safety of controlled ovarian stimulation using GnRH antagonist protocols for emergency fertility preservation in young women with breast cancer-a prospective nationwide Swedish multicenter study

STUDY QUESTION

How efficacious and safe are the current approaches to controlled ovarian stimulation (COS) aimed at fertility preservation (FP) in women with breast cancer (BC)?

SUMMARY ANSWER

In women with BC undergoing COS aiming at egg/embryo cryopreservation, letrozole-based protocols and those randomly started were equally effective compared with conventional COS, and the overall survival was similar between the women that proceeded to FP and those who did not.

WHAT IS KNOWN ALREADY

Cryopreservation of oocytes and embryos is an established method for FP in women with BC. Recent improvements to COS protocols include concomitant use of letrozole, random-cycle start day of stimulation and the use of GnRHa for the egg maturation trigger. To date, limited sample size of the available studies has not allowed investigation of differences in the efficacy of the different approaches to COS for FP in this patient population.

STUDY DESIGN, SIZE, DURATION

A prospective multicenter study with national coverage including 610 women with BC counseled between 1 January 1995 and 30 June 2017 at six Swedish FP regional programs.

PARTICIPANTS/MATERIALS, SETTING, METHODS

After counseling, 401 women elected to undergo COS. Treatments differed in the use or not of concomitant letrozole, a conventional or random-cycle day COS initiation and the use of hCG versus GnRHa trigger for oocyte maturation. Numbers of cryopreserved oocytes and embryos were defined as primary outcome. Pregnancy attempts, reproductive outcomes and long-term survival, investigated by the linking of individuals of the cohort to the total population register of the Swedish Tax Agency (up to 25 November 2018), were evaluated.

MAIN RESULTS AND THE ROLE OF CHANCE

Using letrozole or not resulted in similar numbers of oocytes and embryos cryopreserved (mean_oocytes = 9.7 versus 10 and mean_embryos 4.0 versus 5.3, respectively), similar to COS with random versus conventional start (mean_oocytes 9.0 versus 10.6 and mean_embryos 4.8 versus 4.8). In COS with letrozole, a GnRHa trigger was associated with a higher number of oocytes retrieved (P < 0.05) and embryos cryopreserved (P < 0.005), compared with conventional hCG trigger. Of 99 women who returned to fertility clinics after cancer treatment, 32 proceeded to thawing of oocytes or embryos and 10 of them had live births. The all-cause survival between the women that underwent COS and those who did not was similar and did not differ between the two groups.

LIMITATIONS, REASONS FOR CAUTION

Data on tumor characteristics and estrogen receptor (ER) status were not known for all women at the time of FP counseling and planning of COS, thus protocols with letrozole have been used for both estrogen-sensitive and non-estrogen-sensitive BC. For the same reason, subsequent adjustment for ERs in the BC or tumor characteristics as potential confounders were not performed as these parameters were not available and did not influence the provision of FP through COS.

WIDER IMPLICATIONS OF THE FINDINGS

The results of our study support the premise that recently introduced potential improvements to COS protocols for FP in women with BC are efficacious and safe.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by research grants from the Swedish Cancer Society, the Stockholm County Council, the Percy Falk Stiftelsen, Radiumhemmets Forskningsfonder, The Swedish Breast Cancer Association and Karolinska Institutet to K.A.R.W. J.B. reports grants from Amgen, AstraZeneca, Pfizer, Roche, Sanofi-Aventis and Merck, outside the submitted work, and payment from UpToDate to Asklepios Medicine HB for a chapter on BC prediction and prognostication. All the other authors have no competing interests to report.

Advances in the Treatment and Prevention of Chemotherapy-Induced Ovarian Toxicity

Due to improvements in chemotherapeutic agents, cancer treatment efficacy and cancer patient survival rates have greatly improved, but unfortunately gonadal damage remains a major complication. Gonadotoxic chemotherapy, including alkylating agents during reproductive age, can lead to iatrogenic premature ovarian insufficiency (POI), and loss of fertility. In recent years, the demand for fertility preservation has increased dramatically among female cancer patients. Currently, embryo and oocyte cryopreservation are the only established options for fertility preservation in women. However, there is growing evidence for other experimental techniques including ovarian tissue cryopreservation, oocyte in vitro maturation, artificial ovaries, stem cell technologies, and ovarian suppression. To prevent fertility loss in women with cancer, individualized fertility preservation options including established and experimental techniques that take into consideration the patient’s age, marital status, chemotherapy regimen, and the possibility of treatment delay should be provided. In addition, effective multidisciplinary oncofertility strategies that involve a highly skilled and experienced oncofertility team consisting of medical oncologists, gynecologists, reproductive biologists, surgical oncologists, patient care coordinators, and research scientists are necessary to provide cancer patients with high-quality care.

Fertility preservation in women for medical and social reasons: Oocytes vs ovarian tissue

Approximately 10% of cancers occur in women under 45 years of age. Chemotherapy, radiotherapy, and bone marrow transplantation cure more than 90% of cancer in women, but can result in premature ovarian insufficiency depending on follicular reserve, age, and drugs used. Some benign diseases are also indications for fertility preservation, particularly those requiring chemotherapy (like thalassemia and lupus), recurrent endometriosis, and family history of premature menopause. Social reasons also account for a large proportion of women who wish to postpone pregnancy. This article discusses the two main strategies for fertility preservation, namely oocyte vitrification and ovarian tissue cryopreservation, examining the indications and results of these options. Oocyte cryopreservation is an effective approach, but further studies are needed in cancer patients to ensure the excellent outcomes obtained in women without cancer or in egg donation programs. For prepubertal girls or cases where immediate therapy is required, cryopreservation of ovarian tissue is the only available option.

The Role of Fertility Preservation in Women with Endometriosis: A Systematic Review

OBJECTIVE

To summarize the available evidence concerning fertility preservation techniques in the context of women with endometriosis.

DATA SOURCES

We searched for studies published between 1984 and 2019 on endometriosis and Assisted Reproductive Technology outcomes. We searched MEDLINE and PubMed and performed a manual search of reference lists within identified studies.

METHODS OF STUDY SELECTION

A total of 426 articles were identified, and 7 studies were eligible to be included for the systematic review. We included all published studies, excluding reviews, case reports, and animal studies.

TABULATION, INTEGRATION, AND RESULTS

Despite a significant increase in the number of studies addressing fertility preservation over the study period, we found a relative lack of evidence addressing the use of fertility preservation techniques in women with endometriosis. The studies identified included 2 case reports, 1 histological science study, and 4 retrospective cohort studies.

CONCLUSION

Women with endometriosis may benefit from fertility preservation techniques. However, there currently is a paucity of data in this population, especially when compared with other indications for fertility preservation. Although much knowledge can be translated from the oncofertility discipline, we have identified and discussed endometriosis-related changes to ovarian reserve and oocyte health that justify further well-designed research to confirm that fertility preservation outcomes are similar for women with endometriosis.

Preserving fertility: using cyclophosphamide and other cytotoxics in young people

Cytotoxic agents such as cyclophosphamide are infrequently used in neurological practice. When they are, it is commonly in critically ill patients or in those with refractory inflammatory disorders. Cyclophosphamide in particular has a well-recognised negative impact on both female and male long-term fertility. This article summarises the data with regards the impact of cytotoxics on long-term fertility and describes the current options to preserve fertility in these patients. We hope this will provide neurologists with a useful aid for counselling patients for whom they are considering these treatments.

Current state and future possibilities of ovarian tissue transplantation

BACKGROUND

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

METHOD

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

MAIN FINDINGS

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

CONCLUSION

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

FertiPROTEKT, Oncofertility Consortium and the Danish Fertility-Preservation Networks - What Can We Learn From Their Experiences?

Fertility preservation is an increasingly important discipline. It requires close coordination between reproductive medicine specialists, reproductive biologists, and oncologists in various disciplines. In addition, it represents a particular health policy challenge, since fertility-protection measures are to be understood as a treatment for side effects of gonadotoxic treatments and would therefore normally have to be reimbursed by health insurance companies. Therefore, it is inevitable that fertility-preservation activities should organise themselves into a network structure both as a medical-logistic network and as a professional medical society. The necessary network structures can differ significantly at regional, national, and international level, as the size of the regions to be integrated and the local cultural and geographical conditions, as well as the political conditions are very different. To address these issues, the current review aims to point out the basic importance and the chances but also the difficulties of fertility-protection networks and give practical guidance for the development of such network structures. We will not only discuss network structures theoretically but also present them based on three established, different sized networks, such as the Danish Network (www.rigshospitalet.dk), representing a centralised network in a small country; the German-Austrian-Swiss network FertiPROTEKT® (www.fertiprotekt.com), representing a centralised as well as decentralised network in a large country; and the Oncofertility® Consortium (www.oncofertility.northwestern.edu), representing a decentralised, internationally oriented network, primarily serving the transfer of knowledge among its members.

Fertility preservation in female cancer patients: current knowledge and future perspectives

INTRODUCTION

Protecting fertility in the presence of cancer has become highly significant, as the desire to give birth to a child is increasingly postponed to later in life, and long-term survival with cancer has increased. A variety of fertility-preserving methods have been developed.

EVIDENCE ACQUISITION

To find them, we performed a literature search in Medline using the key words "female fertility preservation in cancer" in December 2017. A total of 2381 different publications were found.

EVIDENCE SYNTHESIS

After screening the abstracts 78 publications in English, French, or German language had been assessed as relevant (17 dealing with medical approaches, six with surgical approaches, 15 with oocyte cryopreservation, 11 with ovarian tissue cryopreservation and 29 were review articles). In general, there are medical (non-surgical) and surgical approaches. Medical approaches comprise administration of GnRH-analogues during gonad toxic oncologic treatment, and cryopreservation of oocytes after ovarian stimulation. Surgical approaches comprise traditional methods of organ-saving surgery and ovarian transposition outside of the radiation portal as well as ovary cryopreservation as standard.

CONCLUSIONS

It is important to inquire about a prospective desire to have children with premenopausal women with cancer and comprehensively explain the fertility conserving methods available. Every premenopausal woman with cancer should be counseled about the methods of fertility protection currently available at a multiprofessional center.

Steroids and miRNAs in assessment of ovarian tissue damage following cryopreservation

Ovarian cortical tissue cryopreservation is a relatively novel approach to preserving fertility in women diagnosed with cancer. However, the effects of freezing-thawing are not fully understood, mainly due to the lack of suitable methods to assess tissue's survival after thawing. Disparities in steroid production have been associated with ovarian failure by disrupting folliculogenesis, ovulation and oocyte apoptosis. Moreover, specific microRNAs, identified in human ovarian follicles, are thought to play a fundamental role in folliculogenesis. In this study, we investigated the possible interplay between the ovarian steroidal production and microRNA expression patterns in spent culture media, as potential non-invasive markers for ovarian tissue damage after cryopreservation. Cryopreservation of ovarian cortical tissue decreased (P<0.05) both steroid production (oestradiol and progesterone) and expression of microRNA-193b and 320A in spent culture media over 5 days, however, expression of microRNA-24 increased (P<0.05). The number of primordial follicles were also reduced (P<0.05) in fresh-cultured and cryopreserved-cultured cortical tissues when compared with fresh tissues. Downregulation of microRNA-193b and microRNA-320A together with upregulation of microRNA-24 could have a synergistic role in cell apoptosis, and consequently leading to reduced oestradiol and progesterone production. Thus, there appears to be an interplay between these microRNAs, ovarian steroid production and cell damage, which can be further explored as novel non-invasive markers of cell damage following cryopreservation.

Electrospun patterned porous scaffolds for the support of ovarian follicles growth: a feasibility study

Recently, the interest of the scientific community is focused on the application of tissue engineering approach for the fertility restoration. In this paper innovative patterned electrospun fibrous scaffolds were fabricated and used as 3D system for porcine follicles culture. The obtained scaffolds demonstrated to be a suitable support which did not alter or interfere with the typical spherical follicles morphology. The fibrillar structure of the scaffolds mimics the morphology of the healthy native tissue. The use of porcine follicles implied many advantages respect to the use of mouse model. Relevant results showed that more than the scaffold pattern and struts dimension, the selection of proper biomaterials improve the follicles adhesion and development.

Investigation of Each Society for Fertility Preservation in Asia

Fertility preservation (FP) remains a future direction for reproductive medicine. FP development is needed to keep up with advancements in other areas of medicine, such as cancer research that has successfully prolonged patients' survival. The demand for optimum FP is sought by both patients and practitioners alike. The American Society of Clinical Oncology has published and updated several FP guidelines. However, these guidelines need to be optimized for each country due to the nature of FP that interacts with the local policy, social decorum, and economic factors. Furthermore, the availability and success rate for each procedure might differ since there is a requirement for advanced and innovative technologies involved in FP. These guidelines should ideally be supported by the FP society to overcome unique barriers that may arise in each country. Here we try to illustrate the most recent update on the condition of FP practice in several countries in Asia. This hopefully will encourage future FP development and might become a useful reference for other countries, especially in Asia.

Fertility preservation options in transgender people: A review

Gender affirming procedures adversely affect the reproductive potential of transgender people. Thus, fertility preservation options should be discussed with all transpeople before medical and surgical transition. In transwomen, semen cryopreservation is typically straightforward and widely available at fertility centers. The optimal number of vials frozen depends on their reproductive goals and treatment options, therefore a consultation with a fertility specialist is optimal. Experimental techniques including spermatogonium stem cells (SSC) and testicular tissue preservation are technologies currently under development in prepubertal individuals but are not yet clinically available. In transmen, embryo and/or oocyte cryopreservation is currently the best option for fertility preservation. Embryo cryopreservation requires fertilization of the transman's oocytes with a donor or partner's sperm prior to cryopreservation, but this limits his future options for fertilizing the eggs with another partner or donor. Oocyte cryopreservation offers transmen the opportunity to preserve their fertility without committing to a male partner or sperm donor at the time of cryopreservation. Both techniques however require at least a two-week treatment course, egg retrieval under sedation and considerable cost. Ovarian tissue cryopreservation is a promising experimental method that may be performed at the same time as gender affirming surgery but is offered in only a limited amount of centers worldwide. In select places, this method may be considered for prepubertal children, adolescents, and adults when ovarian stimulation is not possible. Novel methods such as in-vitro activation of primordial follicles, in vitro maturation of immature oocytes and artificial gametes are under development and may hold promise for the future.

Fertility preservation for adolescent and young adult cancer patients in Japan

Adolescent and young adult (AYA) patients are generally defined as being from 15 to 39 years old. For preservation of fertility in AYA cancer patients, the best-known guideline in this field was released by the American Society of Clinical Oncology (ASCO) in 2006. However, the ASCO guideline is not necessarily applicable to Japanese cancer patients. The Japan Society for Fertility Preservation (JSFP) was formed in 2012, and a system and guideline for fertility preservation in Japanese AYA cancer patients plus children was released in July 2017. According to this guideline, patients should receive psychological and social support from health care providers such as doctors, nurses, psychologists, pharmacists, and social workers. In 2013, the American Society for Reproductive Medicine stated that freezing oocytes is a method that has passed beyond the research stage. However, freezing ovarian tissue is still a research procedure. While slow freezing of ovarian tissue is generally performed, rapid freezing (vitrification) is more popular in Japan. We have developed a new closed technique for ovarian tissue cryopreservation. It has been suggested that optical coherence tomography might be applied clinically to measure the true ovarian reserve and localize follicles in patients undergoing ovarian tissue transplantation. Combining gonadotropin-releasing hormone agonist therapy with anticancer agents might be useful for ovarian protection and it is expected that discussion of such combined treatment will continue in the future. This article outlines practical methods of fertility preservation using assisted reproductive techniques for AYA cancer patients in Japan.

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.

Ovarian tissue cryopreservation (OTC) in prepubertal girls and young women: an analysis of parents' and patients' decision-making

PURPOSE

The purpose of this study was to explore the decision-making influences, perceived level of control over decision-making, and mood states of parents and patients who were offered OTC prior to gonadotoxic therapy.

METHODS

Parents and patients, at least 12 years old, who required gonadotoxic therapy and were offered OTC prior to therapy, were asked to complete questionnaires. Two validated instruments were also used: the Decision-Making Control Instrument (DMCI) and the Profile of Mood States (POMS). The factors that influenced decision-making were compared using Student's t test, and the scores of DMCI and POMS were compared using the Mann-Whitney test.

RESULTS

Thirty-six parents and 16 patients who elected ovarian tissue cryopreservation (OTC) completed questionnaires. Five parents who declined OTC also completed questionnaires. Accepters thought OTC was a good idea and that, in the future, science would enable cryopreserved ovarian tissue to be used to restore fertility (100% parents, 93.8% patients). Among accepters, the desire for genetically related children and prevention of the stress of infertility drove parents' and patients' decisions (90.9 and 100%, respectively). The desire to prevent the stress of infertility was important to parents, but patients were less likely to report that a desire to prevent the stress of infertility factored into their decision-making (66.7 vs. 50.0%; p < 0.001). All respondents felt in control of their decision and displayed low levels of mood disturbance.

CONCLUSIONS

Though the decision to undergo experimental OTC is difficult and often urgent, this study suggests that families feel in control of their decision-making and report little emotional disturbance.

Long-term outcomes in cancer patients who did or did not pursue fertility preservation

OBJECTIVE

To compare long-term outcomes of cancer patients who pursued fertility preservation (FP) with those who did not and compare random-start (RS) and menstrual cycle-specific (CS) protocols for FP.

DESIGN

Retrospective cohort.

SETTING

Single urban academic institution.

PATIENT(S)

Oncology patients who contacted the FP patient navigator, 2005-2015.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Time to cancer treatment, disease-free survival, and reproductive outcomes in FP versus no-FP patients and cycle outcomes for RS versus CS protocols. Data were analyzed by χ² and logistic regression.

RESULT(S)

Of 497 patients who met the inclusion criteria, 41% elected FP. The median number of days to cancer treatment was 33 and 19 days in the FP and no-FP groups, respectively. There was no difference in cancer recurrence or mortality. There were no differences in stimulation parameters, outcomes, or days to next cancer treatment in RS versus CS protocols. Twenty-one patients returned to use cryopreserved specimens, resulting in 16 live births. Eight of 21 returning patients used a gestational carrier. Thirteen FP (6.4%) and 16 no-FP (5.5%) patients experienced a spontaneous pregnancy.

CONCLUSION(S)

FP is both safe and efficacious for eligible cancer patients. Only 10% of patients returned to use cryopreserved specimens, and almost half used a gestational carrier, suggesting the need for further research into reproductive decision-making in cancer survivors.

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

PURPOSE

The purpose of this study was to summarize the latest advances and successes in the field of ovarian tissue cryopreservation while identifying gaps in current knowledge that suggest opportunities for future research.

METHODS

A systematic review was performed according to PRISMA guidelines for all relevant full-text articles in PubMed published in English that reviewed or studied historical or current advancements in ovarian tissue cryopreservation and auto-transplantation techniques.

RESULTS

Ovarian tissue auto-transplantation in post-pubertal women is capable of restoring fertility with over 80 live births currently reported with a corresponding pregnancy rate of 23 to 37%. The recently reported successes of live births from transplants, both in orthotopic and heterotopic locations, as well as the emerging methods of in vitro maturation (IVM), in vitro culture of primordial follicles, and possibility of in vitro activation (IVA) suggest new fertility options for many women and girls. Vitrification, as an ovarian tissue cryopreservation technique, has also demonstrated successful live births and may be a more cost-effective method to freezing with less tissue injury. Further, transplantation via the artificial ovary with an extracellular tissue matrix (ECTM) scaffolding as well as the effects of sphingosine-1-phosphate (SIP) and fibrin modified with heparin-binding peptide (HBP), heparin, and a vascular endothelial growth factor (VEGF) have demonstrated important advancements in fertility preservation. As a fertility preservation method, ovarian tissue cryopreservation and auto-transplantation are currently considered experimental, but future research may pave the way for these modalities to become a standard of care for women facing the prospect of sterility from ovarian damage.

The PREgnancy and FERtility (PREFER) study: an Italian multicenter prospective cohort study on fertility preservation and pregnancy issues in young breast cancer patients

Background

Fertility and pregnancy issues are of key importance for young breast cancer patients. Despite several advances in the field, there are still multiple unmet needs and barriers in discussing and dealing with these concerns. To address the significant challenges related to fertility and pregnancy issues, the PREgnancy and FERtility (PREFER) study was developed as a national comprehensive program aiming to optimize care and improve knowledge around these topics.

Methods

The PREFER study is a prospective cohort study conducted across several Italian institution affiliated with the Gruppo Italiano Mammella (GIM) group evaluating patterns of care and clinical outcomes of young breast cancer patients dealing with fertility and pregnancy issues. It is composed of two distinctive studies: PREFER-FERTILITY and PREFER-PREGNANCY. The PREFER-FERTILITY study is enrolling premenopausal patients aged 18–45 years, diagnosed with non-metastatic breast cancer, who are candidates to (neo)adjuvant chemotherapy and not previously exposed to anticancer therapies. The primary objective is to obtain and centralize data about patients’ preferences and choices towards the available fertility preserving procedures. The success and safety of these strategies and the hormonal changes during chemotherapy and study follow-up are secondary objectives. The PREFER-PREGNANCY study is enrolling survivors achieving a pregnancy after prior history of breast cancer and patients diagnosed with pregnancy-associated breast cancer (PABC). The primary objectives are to obtain and centralize data about the management and clinical outcomes of these women. Patients’ survival outcomes, and the fetal, obstetrical and paediatric care of their children are secondary objectives. For both studies, the initial planned recruitment period is 5 years and patients will remain in active follow-up for up to 15 years. The PREFER-FERTILITY study was first activated in November 2012, and the PREFER-PREGNANCY study in May 2013.

Discussion

The PREFER study is expected to support and improve oncofertility counseling in Italy, to explore the real need of fertility preserving procedures, and to acquire prospectively more robust data on the efficacy and safety of the available strategies for fertility preservation, on the management of breast cancer survivors achieving a pregnancy and of women with PABC (including the possible short- and long-term complications in their children).

Trial registration number

ClinicalTrials.gov identifier: NCT02895165 (Retrospectively registered in August 2016).

Fertility preservation in women with CNS tumors

INTRODUCTION

Fertility impairment due to treatments is a major concern for adolescents and young adult patients who survived cancer. Areas covered: Chemotherapy may determine a detrimental effect on ovary function, leading to infertility, and premature ovarian failure. Embryo and oocyte cryopreservation is a standard strategy for fertility preservation; other strategies, such as gonadal tissue cryopreservation and the use of gonadotropin - releasing hormone agonist, are still considered experimental. There are few data available regarding the effect of pregnancy on glioma, which indicates tumor progression during pregnancy in 33-45% of patients. Expert commentary: Glioma patients need to be advised about the risk of tumor progression during pregnancy, and about the possible, even if not proven, interaction between hormone stimulation and tumor growth.

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.

Twenty-five-year-old Woman with Bilateral Borderline Ovarian Tumour Desiring to Preserve Fertility - Case Report and Literature Review on the Current State of Fertility Preservation in Women with Borderline Ovarian Tumours

Borderline ovarian tumours are semimalignant tumours occurring unilaterally or bilaterally with a peak incidence among women of reproductive age. Since the affected women often wish to preserve fertility, particular precautions must be taken when counselling the patient and obtaining consent prior to planning an individual treatment. Options for preserving fertility include an organ-sparing surgical procedure and cryopreservation of oocytes and/or ovarian tissue. In this article, we report on a 25-year-old patient with a bilateral seromucinous borderline tumour who desired all fertility-preserving options. In order to perform the procedure without delay, we opted to perform luteal phase stimulation prior to oocyte retrieval. We conclude by discussing the current literature on the state of fertility preservation in the treatment of borderline ovarian tumours.

A grafted ovarian fragment rescues host fertility after chemotherapy

STUDY QUESTION

Can host fertility be rescued by grafting of a fragment of a healthy ovary soon after chemotherapy?

SUMMARY ANSWER

We found that grafting a green fluorescent protein (GFP)-positive fragment from a healthy isogenic ovary to the left ovary of a chemo-treated host rescued function and fertility of the grafted host ovary, and resulted in the production of host-derived offspring as late as the sixth litter after chemotherapy (CTx) treatment, whereas none of the ungrafted controls produced a second litter.

WHAT IS KNOWN ALREADY

In women and girls undergoing chemotherapy, infertility and premature ovarian failure are frequent outcomes. There are accumulating reports of improved endocrine function after autotransplantation of an ovarian fragment, raising the possibility that the transplant is beneficial to the endogenous ovary.

STUDY DESIGN, SIZE, DURATION

We first established a CTx treatment regimen that resulted in the permanent loss of fertility in 100% of female mice of the FVB inbred strain. We grafted an isogenic ovary fragment from a healthy female homozygous for a GFP transgene to the left ovary of 100 CTx-treated hosts, and compared fertility to 39 ungrafted controls in 6 months of continuous matings, using GFP to distinguish offspring derived from the graft, and those derived from the host.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Immunofluoresece and western blot analysis of 39 treated ovaries during and 15 days after CTx treatment revealed elevated apoptosis, rapid loss of granulosa cells and an increased recruitment of growing follicles. Using immunofluorescence and confocal imaging, we tracked the outcome of the grafted tissue over 4 months and its effect on the adjacent and contralateral ovary of the host.

MAIN RESULTS AND THE ROLE OF CHANCE

Fifty-three percent of grafted females produced a second litter whereas none of the ungrafted females produced a second litter. The likelihood that this could occur by chance is very low (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

These results are shown only in mice, and whether or how they might apply to chemotherapy patients subjected to different CTx regimens is not yet clear.

WIDER IMPLICATIONS OF THE FINDINGS

Our experiments prove that rescue of a chemo-treated ovary is possible, and establish a system to investigate the mechanism of rescue and to identify the factors responsible with the long-term goal of developing therapies for preservation of ovarian endocrine function and fertility in women undergoing chemotherapy.

LARGE SCALE DATA

No large datasets were produced.

STUDY FUNDING/COMPETING INTERESTS

Duke University Medical Center Chancellor's Discovery Grant to BC; ESJ was supported by an NRSA 5F31CA165545; SK was supported by NIH RO1 GM08033; RWT was supported by the Duke University School of Medicine Ovarian Cancer Research Fellowship; XBM was supported by CONICYT. The authors have no conflicts of interest to declare.

Fertility considerations and the pediatric oncology patient

Recent years have witnessed marked improvement in cytotoxic treatments with a parallel increase in patient survival. Despite efforts done to minimize long-term side effects of these treatment regimens, it is estimated that 40% of survivors of pediatric cancer will suffer from those. Some will be mild whereas others such as impaired fertility will be a heavy load on parents׳ expectations and patient׳s quality of life. Gonadal damage and severe loss of function is not a rare condition among children cured for cancer. Despite the young age of those patients, methods exist to try to reduce gonadal insult or to preserve gonadal function. Some of them are well studied and controlled; others are more experimental with encouraging results so far. This article aims to summarize all the procedures that can be offered to young patients treated for cancer in order to protect, as possible, their fertility potential.

Evaluation of minimal disseminated disease in cryopreserved ovarian tissue from bone and soft tissue sarcoma patients

STUDY QUESTION

What is the risk of finding malignant cells in cryopreserved ovarian tissue from sarcoma patients?

SUMMARY ANSWER

Minimal disseminated disease (MDD) was not detected in frozen-thawed ovarian tissue from 26 patients by any of the sensitive methods applied.

WHAT IS KNOWN ALREADY

In case of leukemia, the risk of malignant cell transmission through the graft is well known and widely documented. However, for bone cancer, like Ewing sarcoma or osteosarcoma, only a small number of case reports, have been published. These cancers often affect prepubertal girls, in whom ovarian tissue cryopreservation and transplantation is the only option to preserve fertility.

STUDY DESIGN, SIZE, DURATION

The presence of malignant cells in cryopreserved ovarian tissue from patients with bone/soft tissue sarcoma was investigated with disease-specific markers for each patient, using immunohistochemistry (IHC), FISH and real-time quantitative RT-PCR (qPCR), with the original tumor serving as a positive control.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Forty-eight sarcoma patients were enrolled in the study, 12 of whom subsequently died. In each case, tissue from the primary tumor was investigated in order to identify markers (immunohistochemical and/or molecular) to analyze the ovarian tissue case by case. Ovarian tissue from osteosarcoma (n = 15), liposarcoma (n = 1) and undifferentiated sarcoma (n = 5) patients could not be evaluated, as no specific markers were detected by FISH or sensitive IHC in any of their primary tumoral tissue. One patient with Li-Fraumeni syndrome was also excluded from the study. IHC analyses were therefore performed on ovarian tissue from 26 patients and qPCR on 19. The primary tumors involved were Ewing sarcoma family of tumors (n = 14), rhabdomyosarcoma (n = 7), synovial sarcoma (n = 2), clear cell sarcoma (n = 2) and a malignant peripheral nerve sheath tumor (n = 1).

MAIN RESULTS AND THE ROLE OF CHANCE

MDD was not detected in any of the 26 analyzed samples using sensitive techniques in this largest reported series, even from patients who subsequently died and/or those who presented with metastasis (11/26), hence the most aggressive forms of bone cancer. Indeed, anti-CD99 IHC and PCR performed on patients presenting with Ewing sarcoma family of tumors (n = 14) was negative in all cases. In patients with soft tissue sarcoma (n = 12) primitive tumor markers were detected by IHC and were negative in ovarian tissue. PCR could only be performed in 6/12 of these patients, again proving negative.

LIMITATIONS, REASONS FOR CAUTION

Cryopreserved ovarian fragments to be transplanted cannot be tested, so this analysis of malignant cells cannot guarantee that all cryopreserved fragments will not contain any disseminated disease. Moreover, molecular markers are not readily available for all types of tumors.

WIDER IMPLICATIONS OF THE FINDINGS

These results are reassuring regarding the risk of malignant cells in the ovary for transplantation, as the study involves a large series including different types of sarcomas. We believe this will help clinicians in their patient counseling for fertility preservation and restoration.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the Fonds National de la Recherche Scientifique de Belgique-FNRS under Grants Nos 7.4578.14 (Télévie to MS) and 5/4/150/5 to MMD. The authors declare no competing financial interests.

Fertility preservation in BRCA-mutated breast cancer patients

A possible side effect of anticancer treatments in premenopausal women is the occurrence of premature ovarian failure and subsequent infertility. The inheritance of a deleterious genetic mutation in the BRCA1 or 2 genes generates the hereditary breast and ovarian cancer syndrome. Additional fertility counseling for breast cancer patients with BRCA mutations is warranted to educate them about the available fertility preservation options in the context of their unique concerns (i.e., prophylactic gynecologic surgery, pre-implantation genetic diagnosis and risk of developing long-term treatment-related premature ovarian failure). In this report we discuss the available options for fertility preservation in women with breast cancer, with a particular focus on the specific issues in breast cancer patients with BRCA mutations.

Fertility Preservation: A Key Survivorship Issue for Young Women with Cancer

Fertility preservation in the young cancer survivor is recognized as a key survivorship issue by the American Society of Clinical Oncology and the American Society of Reproductive Medicine. Thus, health-care providers should inform women about the effects of cancer therapy on fertility and should discuss the different fertility preservation options available. It is also recommended to refer women expeditiously to a fertility specialist in order to improve counseling. Women’s age, diagnosis, presence of male partner, time available, and preferences regarding use of donor sperm influence the selection of the appropriate fertility preservation option. Embryo and oocyte cryopreservation are the standard techniques used while ovarian tissue cryopreservation is new, yet promising. Despite the importance of fertility preservation for cancer survivors’ quality of life, there are still communication and financial barriers faced by women who wish to pursue fertility preservation.

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.

Primordial Follicle Transplantation within Designer Biomaterial Grafts Produce Live Births in a Mouse Infertility Model

The gonadotoxic effects of chemotherapy and radiation may result in premature ovarian failure in premenopausal oncology patients. Although autotransplantation of ovarian tissue has led to successful live births, reintroduction of latent malignant cells inducing relapse is a significant concern. In this report, we investigated the design of biomaterial grafts for transplantation of isolated ovarian follicles as a means to preserve fertility. Primordial and primary ovarian follicles from young female mice were extracted and encapsulated into biomaterials for subsequent transplantation into adult mice. Among the formulations tested, aggregated follicles encapsulated within fibrin had enhanced survival and integration with the host tissue following transplantation relative to the fibrin-alginate and fibrin-collagen composites. All mice transplanted with fibrin-encapsulated follicles resumed cycling, and live births were achieved only for follicles transplanted within VEGF-loaded fibrin beads. The extent to which these procedures reduce the presence of metastatic breast cancer cells among the isolated follicles was evaluated, with significantly reduced numbers of cancer cells present relative to intact ovaries. This ability to obtain live births by transplanting isolated primordial and primary follicles, while also reducing the risk of re-seeding disease relative to ovarian tissue transplantation, may ultimately provide a means to preserve fertility in premenopausal oncology patients.