Obstetric and perinatal outcome in 200 infants conceived from vitrified oocytes

Planned oocyte cryopreservation: the state of the ART

The objective of this review is to provide an update on planned oocyte cryopreservation. This fertility preservation method increases reproductive autonomy by allowing women to postpone childbearing whilst maintaining the option of having a biological child. Oocyte cryopreservation is no longer considered experimental, and its use has increased dramatically in recent years as more women delay childbearing for personal, professional and financial reasons. Despite increased usage, most patients who have undergone oocyte cryopreservation have not yet warmed their oocytes. Most women who cryopreserve oocytes wait years to use them, and many never use them. Studies have demonstrated that oocyte cryopreservation results in live birth rates comparable with IVF treatment using fresh oocytes, and does not pose additional safety risks to offspring. Based on current evidence, cryopreserving ≥20 mature oocytes at <38 years of age provides a 70% chance of one live birth. However, larger studies from a variety of geographic locations and centre types are needed to confirm these findings. Additional research is also needed to determine the recommended age for oocyte cryopreservation, recommended number of oocytes to cryopreserve, return and discard/non-use rates, cost-effectiveness, and how best to distribute accurate and up-to-date information to potential patients.

Effects of oocyte vitrification on gene expression in the liver and kidney tissues of adult offspring

Oocyte vitrification is an important assisted reproductive technology (ART) that preserves the fertility of unmarried patients with malignant tumors, and promotes the development of the oocyte donation program. In recent years, the effects of ART, including the vitrification of oocytes and embryos on the health of offspring, have attracted much attention; however, it is difficult to conduct long-term follow-up and biochemical evaluation in humans. In this study, we detected the effect of oocyte vitrification on gene expression in the organs of adult mice offspring by RNA sequencing for the first time. Our results showed that only a small amount of gene expression was significantly affected. Seven genes (Tpm3, Hspe1-rs1, Ntrk2, Cyp4a31, Asic5, Cyp4a14, Retsat) were abnormally expressed in the liver, and ten genes (Lbp, Hspe1-rs1, Prxl2b, Pfn3, Gm9008, Bglap3, Col8a1, Hmgcr, Ero1lb, Ifi44l) were abnormal in the kidney. Several genes were related to metabolism and disease occurrence in the liver or kidney. Besides, we paid special attention to the expression of known imprinted genes and DNA methylation-related genes in adult organs, which are susceptible to oocyte cryopreservation in the preimplantation stage. As a result, some of these transcripts were detected in adult organs, but they were not affected by oocyte vitrification. In conclusion, we first report that oocyte vitrification did not significantly change the global gene expression in offspring organs; nonetheless, it can still influence the transcription of a few functional genes. The potential adverse effects caused by oocyte vitrification need attention and further study.

Age-related fertility decline: is there a role for elective ovarian tissue cryopreservation?

Age-related fertility decline (ARFD) is a prevalent concern amongst western cultures due to the increasing age of first-time motherhood. Elective oocyte and embryo cryopreservation remain the most established methods of fertility preservation, providing women the opportunity of reproductive autonomy to preserve their fertility and extend their childbearing years to prevent involuntary childlessness. Whilst ovarian cortex cryopreservation has been used to preserve reproductive potential in women for medical reasons, such as in pre- or peripubertal girls undergoing gonadotoxic chemotherapy, it has not yet been considered in the context of ARFD. As artificial reproductive technology (ART) and surgical methods of fertility preservation continue to evolve, it is a judicious time to review current evidence and consider alternative options for women wishing to delay their fertility. This article critically appraises elective oocyte cryopreservation as an option for women who use it to mitigate the risk of ARFD and introduces the prospect of elective ovarian cortex cryopreservation as an alternative.

The Effect of Freezing Twice during Assisted Reproductive Technology on Perinatal and Neonatal Outcomes

Objective

The aim of this paper was to investigate whether two freeze-thaw cycles before embryo transfer may affect perinatal and neonatal outcomes.

Materials and Methods

A total of 8,028 frozen-thawed embryo transfer patients who became pregnant between March 2013 and September 2019 were included. The patients were divided into two groups: the oocyte cryopreservation (OC) group (N = 96) and the control group (N = 7932). Propensity score matching (PSM) was used to adjust the baseline characteristics of the two groups at a proportion of 1 : 4. There were 96 patients in the OC group and 369 patients in the control group after PSM. The pregnancy-related complications and neonatal conditions after delivery of the two groups were compared.

Results

The OC group had a higher stillbirth rate (3.1% vs. 0.3%, P = 0.029) than the control group after PSM. Moreover, a slightly higher pregnancy defect rate was found in the OC group. There was no significant difference in the rates of diabetes mellitus, hypertension during pregnancy, cesarean section, multiple births, low birth weight (LBW), or premature birth defects between the two groups.

Conclusions

Our findings demonstrate that performing frozen-thawed embryo transfer (FET) with cryopreserved oocytes was associated with a higher rate of stillbirth than FET with fresh oocytes. The incidences of diabetes, gestational hypertension, cesarean section, multiple births, LBW, premature birth, and birth defects of the two groups were not significantly different.

Successful Pregnancies, Births, and Child Development Following Oocyte Cryostorage in Female Cancer Patients During 25 Years of Fertility Preservation

Simple Summary

The study goal is to demonstrate that oocyte cryopreservation is a feasible and efficient option for fertility preservation in cancer patients through the comparison of in vitro fertilization treatments in nononcological patients.

Abstract

The preservation of fertility in cancer patients is a crucial aspect of modern reproductive medicine. Amenorrhea and infertility often occur after cancer therapy, worsening the quality of life. Cryopreservation of oocytes in young cancer patients is a therapeutic option for preserving fertility. A prospective study was conducted on 508 cancer patients who underwent oocyte cryopreservation to preserve fertility between 1996 and 2021 including the COVID-19 pandemic period. Patients underwent ovarian stimulation, followed by egg retrieval, and oocytes were cryopreserved by slow freezing or vitrification. Sixty-four thawing/warming cycles were performed. Survival, fertilization, pregnancy, and birth rate over the thawing/warming cycles were obtained. The data were compared with those from a group of 1042 nononcological patients who cryopreserved supernumerary oocytes. An average of 8.8 ± 6.9 oocytes were retrieved per cycle, and 6.1 ± 4.2 oocytes were cryopreserved. With their own stored oocytes, 44 patients returned to attempt pregnancy. From a total of 194 thawed/warmed oocytes, 157 survived (80%). In total, 100 embryos were transferred in 57 transfer/cycles, and 18 pregnancies were achieved. The pregnancy rate per transfer and pregnancy rate per patient were 31% and 41%, respectively. No statistically significant differences were observed between oncological patients and nononcological patients. A total of 15 babies were born from oncological patients. Children born showed normal growth and development. One minor malformation was detected.

An Update on Planned Oocyte Cryopreservation (POC) in Italy: Medical, Epidemiological and Legal Consideration

Starting with a brief socioeconomic analysis of the phenomenon of female fertility, this narrative review aims to provide an analysis of the use and possibilities of medically assisted reproductive technology in combating fertility issues, adopting socioeconomic, legal and medical perspectives in Italy. The authors mainly employ data from the annual reports of the National Registry of Medically Assisted Reproduction (PMA Registry) and the Italian Statistical Institute (ISTAT) to understand the evolution of oocyte use in medically assisted reproductive technology in Italy from 2015 to 2018 and in particular to dissect the possibilities of oocyte cryopreservation as a measure to counteract age-related infertility, specifically through Planned Oocyte Cryopreservation (POC), also known as “social freezing”. It seems that the best course of action in the context of medically assisted reproduction would be the use of young and healthy cryopreserved oocytes (autologous or donated), preferably before the age of 40, while encouraging donation of oocytes whenever possible. Italy’s dependence on foreign biobanks for donated oocytes calls for the institution of a national biobank and further specific regulation of gamete donation. For this reason, it would be useful to encourage the acceptance of Planned Oocyte Cryopreservation to allow greater availability of healthy, younger oocytes.

Preserving Oocytes in Oncofertility†

The prodigious rise of cancer survival rates enables many cancer survivors to live long lives. Therefore, the side effects of cancer treatments as well as the long-term quality of life after cancer have become more relevant. Ovarian toxicity is a major off-target effect of anticancer agents for childhood and young adult female cancer patients. Both chemotherapy and irradiation have been demonstrated to damage the ovary and increase the risks of premature ovarian failure (POF), early menopause, ovarian endocrine disorders, and sub- or infertility. Oncofertility is an emerging and multidisciplinary research and medical field that focuses on providing cancer patients with fertility preservation options. Oocyte quality and quantity are one of the most important factors to determine women's fertility success; therefore, preserving oocytes is paramount for maintaining the ability of young female cancer patients' reproduction after their recovery. This review summarizes peer-reviewed literature on current oocyte preservation options in oncofertility. We describe in-depth oocyte and embryo cryopreservation, ovarian suppression, ovarian tissue cryopreservation, in vitro maturation, ovarian transposition, and adjuvant therapy. Further, we discuss current guidelines and practices of female fertility preservation that cover preserving oocytes.

Social Freezing: Pressing Pause on Fertility

Increasing numbers of women are undergoing oocyte or tissue cryopreservation for medical or social reasons to increase their chances of having genetic children. Social egg freezing (SEF) allows women to preserve their fertility in anticipation of age-related fertility decline and ineffective fertility treatments at older ages. The purpose of this study was to summarize recent findings focusing on the challenges of elective egg freezing. We performed a systematic literature review on social egg freezing published during the last ten years. From the systematically screened literature, we identified and analyzed five main topics of interest during the last decade: (a) different fertility preservation techniques, (b) safety of freezing, (c) usage rate of frozen oocytes, (d) ethical considerations, and (e) cost-effectiveness of SEF. Fertility can be preserved for non-medical reasons through oocyte, embryos, or ovarian tissue cryopreservation, with oocyte vitrification being a new and optimal approach. Elective oocyte cryopreservation is better accepted, supports social gender equality, and enhances women's reproductive autonomy. Despite controversies, planned oocyte cryopreservation appears as a chosen strategy against age-related infertility and may allow women to feel that they are more socially, psychologically, and financially stable before motherhood.

Elective oocyte cryopreservation for age-related fertility decline

PURPOSE

Women who pursue fertility at an advanced age are increasingly common. Family planning and sexual education have traditionally focused on contraception and prevention of sexually transmitted diseases. A focus should now also be placed on fertility awareness and fertility preservation. This manuscript aims to give an update on the existing evidence around elective oocyte cryopreservation, also highlighting the need for fertility education and evidence-based, individualized counselling.

METHODS

A thorough electronic search was performed from the start of databases to March 2020 aiming to summarize the existing evidence around elective egg freezing, the logic behind its use, patient counselling and education, success rates and risks involved, regulation, cost-effectiveness, current status and future perspectives.

RESULTS

Clinician-led counselling regarding reproductive aging and fertility preservation is often overlooked. Elective oocyte cryopreservation is not a guarantee of live birth, and the answer regarding cost-effectiveness needs to be individualized. The existing studies on obstetric and perinatal outcomes following the use of egg freezing are, until now, reassuring. Constant monitoring of short-term and long-term outcomes, uniform regulation and evidence-based, individualized counselling is of paramount importance.

CONCLUSIONS

Elective oocyte cryopreservation is one of the most controversial aspects of the world of assisted reproduction, and a lot of questions remain unanswered. However, women today do have this option which was not available in the past. Elective oocyte cryopreservation for age-related fertility decline should be incorporated in women's reproductive options to ensure informed decisions and reproductive autonomy.

Live birth and clinical outcome of vitrification-warming donor oocyte programme: an experience of a single IVF unit

Medically assisted reproductive (MAR) treatments using donated oocytes are commonly applied in several countries to treat women who cannot conceive with their own gametes. Historically, in Italy, gamete donation has been prohibited but, in 2014, the law changed and gamete donation became allowed for couples undergoing MAR treatments. Consequently, in the last decade, there has been an increase in application of the oocyte donation programme. This study reports an egg-donation programme's clinical efficacy, based on importing donated vitrified oocytes from cryo-banks located in a foreign country. For this, we conducted a retrospective analysis of data from a single reproductive unit located in Italy (Donna Salus Women's Health and Fertility, Bozen). The study group consisted of 681 vitrified oocytes, which were warmed and culture to be replaced in 100 recipients. The survival rate after warming was 79.1% (n = 539/681), whereas the fertilization and blastulation rates were 90.2% (n = 486/539) and 47.9% (n = 233/486), respectively. Positive pregnancy test, clinical pregnancy rates, and live-birth rates per embryo transfer were 37.8%, 31.1% and 28.4%, respectively. The multiple pregnancy rate was 0.7%. This study is one of the first to report on the efficacy of a donor oocyte programme in Italy using imported vitrified oocytes. The above data may reassure women who are undertaking donation programmes using vitrified oocytes imported from commercial egg banks.

High-security closed devices are efficient and safe to protect human oocytes from potential risk of viral contamination during vitrification and storage especially in the COVID-19 pandemic

PURPOSE

The main purpose and research question of the study are to compare the efficacy of high-security closed versus open devices for human oocytes' vitrification.

METHODS

A prospective randomized study was conducted. A total of 737 patients attending the Infertility and IVF Unit at S.Orsola University Hospital (Italy) between October 2015 and April 2020 were randomly assigned to two groups. A total of 368 patients were assigned to group 1 (High-Security Vitrification™ - HSV) and 369 to group 2 (Cryotop® open system). Oocyte survival, fertilization, cleavage, pregnancy, implantation, and miscarriage rate were compared between the two groups.

RESULTS

No statistically significant differences were observed on survival rate (70.3% vs. 73.3%), fertilization rate (70.8% vs. 74.9%), cleavage rate (90.6% vs. 90.3%), pregnancy/transfer ratio (32.0% vs. 31.8%), implantation rate (19.7% vs. 19.9%), nor miscarriage rates (22.1% vs. 21.5%) between the two groups. Women's mean age in group 1 (36.18 ± 3.92) and group 2 (35.88 ± 3.88) was not significantly different (P = .297). A total of 4029 oocytes were vitrified (1980 and 2049 in groups 1 and 2 respectively). A total of 2564 were warmed (1469 and 1095 in groups 1 and 2 respectively). A total of 1386 morphologically eligible oocytes were inseminated by intracytoplasmic sperm injection (792 and 594 respectively, P = .304).

CONCLUSIONS

The present study shows that the replacement of the open vitrification system by a closed one has no impact on in vitro and in vivo survival, development, pregnancy and implantation rate. Furthermore, to ensure safety, especially during the current COVID-19 pandemic, the use of the closed device eliminates the potential samples' contamination during vitrification and storage.

Health of 2-year-old children born after vitrified oocyte donation in comparison with peers born after fresh oocyte donation

STUDY QUESTION

Does oocyte vitrification adversely affect the health of 2-year-old children compared with peers born after use of fresh oocytes in a donation programme?

SUMMARY ANSWER

The growth and health of 2-year-old children born after oocyte vitrification are similar to those of peers born after use of fresh oocytes.

WHAT IS KNOWN ALREADY

Although oocyte vitrification is a well-established procedure in ART, the evidence on its safety for offspring is limited. Currently, no disadvantageous effects of oocyte vitrification have been shown in terms of obstetric and neonatal outcome. However, no data beyond the neonatal period are available to date.

STUDY DESIGN, SIZE, DURATION

A combined retrospective and prospective observational study was performed in a tertiary reproductive centre. The retrospective data were available in our extensive database of children born after ART. Donor cycles with an oocyte retrieval between January 2010 and March 2017 and a fresh embryo transfer resulting in the livebirth of a singleton were selected from the established oocyte donation programme. Fresh or vitrified oocytes were used in the donor cycles and all pregnancies in oocyte recipients were achieved after ICSI. Only children residing in Belgium were eligible for follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Biometric and health parameters of 72 children born after oocyte vitrification were compared with those of 41 children born after use of a fresh oocyte. Data were collected by means of questionnaires and physical examinations at the age of 21–30 months. The primary outcome measures were anthropometry and health at 2 years of age.

MAIN RESULTS AND THE ROLE OF CHANCE

Length, weight, BMI, head circumference, left arm circumference and waist circumference at the age of 2 years were comparable between the vitrification and fresh group, also after adjustment for treatment, and maternal and neonatal characteristics (all P > 0.05). Health of the children in terms of hospital admission and surgical intervention rates were comparable between the vitrification and fresh group (both P > 0.05).

LIMITATIONS, REASONS FOR CAUTION

Although the current study is the largest series describing health parameters beyond the neonatal period, the small numbers still preclude definite conclusions.

WIDER IMPLICATIONS OF THE FINDINGS

This study provides the first evidence indicating that oocyte vitrification does not adversely affect the growth and health of offspring beyond the neonatal period.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Methusalem grants and by grants from Wetenschappelijk Fonds Willy Gepts, all issued by the Vrije Universiteit Brussel. All co-authors declared no conflict of interest in relation to this work. Both the Centre for Reproductive Medicine and the Centre for Medical Genetics from the UZ Brussel have received several educational grants from IBSA, Ferring, MSD and Merck for either research on oocyte vitrification or for establishing the database for follow-up research and organizing the data collection.

Clinical outcomes of microdissection testicular sperm extraction-intracytoplasmic sperm injection with fresh or cryopreserved sperm in patients with nonobstructive azoospermia

We performed this study to evaluate the clinical outcomes of microdissection testicular sperm extraction-intracytoplasmic sperm injection (micro-TESE-ICSI) treatment that used fresh or cryopreserved sperm in patients with nonobstructive azoospermia (NOA). A total of 338 NOA patients with 344 consecutive cycles received treatment in the reproductive medicine center of Peking University Third Hospital in Beijing, China, from January 2014 to December 2017. Fresh oocytes and fresh sperm were used in 222 patients with 234 cycles (Group A). Fresh oocytes and cryopreserved sperm were used in 116 patients with 110 cycles (Group B). We compared patient characteristics, embryonic development, and pregnancy outcomes between Groups A and B. There was no statistical difference in the patient characteristics, and no differences were observed with fertilization or quality embryo rates between Groups A and B. The rates of clinical pregnancy and live birth were both higher for Group A than those for Group B (both P < 0.05). In conclusion, fresh testicular sperm appears to produce better ICSI outcomes than cryopreserved testicular sperm in patients with NOA.

Six-year follow-up of children born from vitrified oocytes

RESEARCH QUESTION

Are children born from vitrified-warmed oocytes physically or mentally different from naturally conceived children?

DESIGN

Intracytoplasmic sperm injection (ICSI) of vitrified-warmed oocytes was performed for 282 patients (307 cycles) from August 2000 to March 2020. Long-term follow-up of children born from vitrified-warmed oocytes was performed via a questionnaire that was sent to the parents at regular intervals from 3 to 72 months after the child's birth. Questionnaires were sent 11 times from birth to the age of 6 years. The development of motor function and mental status was evaluated as the primary outcome, based on the reported data. Subsequently, patients were divided into four groups by age at oocyte retrieval (20-29, 30-34, 35-39, and 40 years or older). Clinical outcomes were calculated as a secondary outcome.

RESULTS

For the 282 patients, the birth of 116 babies was reported (110 singletons and three sets of twins), and seven cases are, at the time of writing, unconfirmed. The results of the survey found physical parameters in singletons to be equivalent to the nationally reported average data issued by the Ministry of Health, Labor and Welfare of Japan.

CONCLUSION

This is the first follow-up report of children born from vitrified-warmed oocytes followed by ICSI. The data suggested that the responses from the study participants on the mental and physical development of children were comparable to the data reported by the government, although more responses from patients should be collected to allow further study.

What impact does oocyte vitrification have on epigenetics and gene expression?

Children conceived by assisted reproductive technologies (ART) have a moderate risk for a number of adverse events and conditions. The question whether this additional risk is associated with specific procedures used in ART or whether it is related to the intrinsic biological factors associated with infertility remains unresolved. One of the main hypotheses is that laboratory procedures could have an effect on the epigenome of gametes and embryos. This suspicion is linked to the fact that ART procedures occur precisely during the period when there are major changes in the organization of the epigenome. Oocyte freezing protocols are generally considered safe; however, some evidence suggests that vitrification may be associated with modifications of the epigenetic marks. In this manuscript, after describing the main changes that occur during epigenetic reprogramming, we will provide current information regarding the impact of oocyte vitrification on epigenetic regulation and the consequences on gene expression, both in animals and humans. Overall, the literature suggests that epigenetic and transcriptomic profiles are sensitive to the stress induced by oocyte vitrification, and it also underlines the need to improve our knowledge in this field.

Cryopreservation of human embryos and oocytes for fertility preservation in cancer and non cancer patients: a mini review

The term 'cryopreservation' illustrates the process of freezing cells and storing at very low temperature in liquid nitrogen (-196 °C). Cooling is not a physiological condition for human cells especially due to the high concentration of water in the living matter, whose conversion to ice crystals may be associated with cell death. Human oocytes are particularly sensitive to the freezing process, primarily because of their large size and the presence of the meiotic spindle, which at low temperature can degenerate. In the last decade, the cryopreservation technology has become highly important as an option for fertility preservation (FP) in women with cancer. Anticancer therapy might promote premature ovarian failure and negatively affects the reproductive outcome. Over the years, scientists have proposed different cryopreservation strategies in the effort to maintain the physiological functions of oocytes and embryo. However, despite the first success obtained in the 1980s with frozen oocytes, it was not until recently that a new approach has been proposed: the 'Vitrification' which allowed a breakthrough in this procedure. FP is a major determinant for cancer survivor women in the reproductive age. This article describes the FP options currently available, focusing mainly on oocyte and embryo cryopreservation.

Probing lasting cryoinjuries to oocyte-embryo transcriptome

Clinical applications of oocytes cryopreservation include preservation of future fertility of young cancer patients, substitution of embryo freezing to avoid associated legal and ethical issues, and delaying childbearing years. While the outcome of oocyte cryopreservation has recently been improved, currently used vitrification method still suffer from increased biosafety risk and handling issues while slow freezing techniques yield overall low success. Understanding better the mechanism of cryopreservation-induced injuries may lead to development of more reliable and safe methods for oocyte cryopreservation. Using the mouse model, a microarray study was conducted on oocyte cryopreservation to identify cryoinjuries to transcriptionally active genome. To this end, metaphase II (MII) oocytes were subjected to standard slow freezing, and then analyzed at the four-cell stage after embryonic genome activation. Non-frozen four-cell embryos served as controls. Differentially expressed genes were identified and validated using RT-PCR. Embryos produced from the cryopreserved oocytes displayed 200 upregulated and 105 downregulated genes, associated with the regulation of mitochondrial function, protein ubiquitination and maintenance, cellular response to stress and oxidative states, fatty acid and lipid regulation/metabolism, and cell cycle maintenance. These findings reveal previously unrecognized effects of standard slow oocyte freezing on embryonic gene expression, which can be used to guide improvement of oocyte cryopreservation methods.

Prevalence of a Good Perinatal Outcome With Cryopreserved Compared With Fresh Donor Oocytes

OBJECTIVE

To compare the odds of a good perinatal outcome between cryopreserved and fresh donor oocytes.

METHODS

We used the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System to conduct a retrospective cohort study of women undergoing donor oocyte in vitro fertilization (IVF) from 2012 to 2015. Cycles using cryopreserved embryos, a gestational carrier, or preimplantation genetic testing were excluded. The primary outcome was a good perinatal outcome, defined as a singleton live birth at 37 weeks of gestation or more with birth weight at or within 2,500 g and 4,000 g. Secondary outcomes included live birth, multiple birth, and prematurity. Generalized estimating equation models were used to test the effect of oocyte type on the primary outcome while accounting for covariates and the correlation induced by repeated cycles within a patient.

RESULTS

Of the 36,925 cycles included in the analysis, 8,381 (22.7%) used cryopreserved and 28,544 (77.3%) used fresh oocytes. The odds of a good perinatal outcome were marginally but significantly lower with cryopreserved than with fresh oocytes before and after covariate adjustment (22.0% vs 24.1%, unadjusted odds ratio [OR] 0.90, 95% CI 0.85-0.96, adjusted OR 0.88, 95% CI 0.81-0.95). Compared with fresh oocytes, cryopreserved oocytes were associated with lower rates of live birth (39.6% vs 47.7%, OR 0.75, 95% CI 0.72-0.79), multiple birth (22.3% vs 31.2%, OR 0.63, 95% CI 0.58-0.69), and prematurity (27.6% vs 30.6%, OR 0.86, 95% CI 0.79-0.94).

CONCLUSION

This retrospective national study demonstrated that the use of cryopreserved compared with fresh donor oocytes in IVF cycles is associated with marginally lower odds of a good perinatal outcome.

Fertility Preservation for Pediatric and Adolescent Patients With Cancer: Medical and Ethical Considerations

Many cancers presenting in children and adolescents are curable with surgery, chemotherapy, and/or radiotherapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of gonad removal, damage to germ cells as a result of adjuvant therapy, or damage to the pituitary and hypothalamus or uterus as a result of irradiation. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonadal axis. Simultaneously, advances in assisted reproductive technology have led to new possibilities for the prevention and treatment of infertility. This clinical report reviews the medical aspects and ethical considerations that arise when considering fertility preservation in pediatric and adolescent patients with cancer.

A follow-up survey on the reproductive intentions and experiences of women undergoing planned oocyte cryopreservation

RESEARCH QUESTION

What are the current reproductive attitudes and experiences of women who have previously undergone planned oocyte cryopreservation (OoC)?

DESIGN

Retrospective questionnaire-based cohort study involving women who had previously undergone planned OoC between January 2009 and September 2016 at a single centre. Eligible women were contacted via e-mail and invited to complete an anonymous standardized questionnaire that had been developed to evaluate their current relationship status and reproductive situation, their attitudes towards planned OoC and their future reproductive intentions.

RESULTS

Of 460 women who had completed at least one OoC cycle, questionnaires were obtained from 138 women. After a mean (± SD) follow-up of 4.5 ± 2.4 years, two-thirds of respondents (65%) anticipated using their oocytes at some point in the future. The respondents reported an overwhelmingly positive attitude towards planned OoC, with 98% indicating they would recommend this intervention to others. Overall, 83% of respondents were single at the time they requested OoC but only 44% were single at the time they completed the survey. While 43/62 (69%) of women became pregnant after undergoing OoC, the majority 30/43 (70%) of these pregnancies were achieved without using their vitrified oocytes. Finally, 13/28 (46%) who used their cryopreserved oocytes stated that they had achieved a live birth.

CONCLUSIONS

The majority of women who undergo OoC do not regret their experience and many have found a partner in subsequent years. Twenty-one per cent of respondents who attempted to conceive after OoC had a live birth using their cryopreserved oocytes.

Dynactin pathway-related gene expression is altered by aging, but not by vitrification

The storage of surplus oocytes by cryopreservation (OC) is a widely used tool in assisted reproductive technology, but there is a great debate about the effects of cryopreservation on oocyte competence. It is known that OC may affect meiotic spindles but remains unclear if OC may increase the risk of aneuploidy. The aim of this study was to test the effects of OC and women aging on the expression of cytokinesis-related genes playing an important role in the segregation of chromosomes (DCTN1, DCTN2, DCTN3, DCTN6 and PLK1). Results highlighted that OC do not modify the expression of the selected genes, whereas women aging modulate the expression of all transcripts, confirming that aging is the crucial factor affecting meiosis and aneuploidy risk. A new role for Dynactin and PLK1 was shed in light, providing information on the ageing process in the oocyte which may be associated to reduced fertility.

For whom the egg thaws: insights from an analysis of 10 years of frozen egg thaw data from two UK clinics, 2008-2017

PURPOSE

To better understand the characteristics of patients who returned to thaw their frozen eggs to attempt conception and their outcomes.

METHODS

A retrospective analysis of clinical records for all own egg thaw patients in two UK fertility clinics across 10 years, 2008-2017.

RESULTS

There were 129 patients who returned to thaw their eggs, of which 46 had originally frozen their eggs for social reasons and 83 for a variety of clinical, incidental, and ethical reasons (which we have called "non-social"). Women who had frozen their eggs for social reasons were single at time of freeze, with an average age of 37.7. They kept their eggs in storage for just under 5 years, returning to use them at the average age of 42.5. 43.5% were single at time of thaw, and 47.8% used donor sperm to fertilise their eggs. Women whose eggs were frozen for non-social reasons were almost all (97.6%) in a relationship at both time of freeze and thaw. They had an average age of 37.2 at first freeze and 37.6 at thaw, having kept their eggs in storage for an average of 0.4 years. Overall, there was a 20.9% success rate among women attempting conception with frozen-thawed eggs.

CONCLUSIONS

Despite widespread assumptions, many women attempting conception with thawed eggs had not initially frozen them for social reasons. Women who froze their eggs for social reasons presented distinctly and statistically different characteristics at both time of freeze and thaw to women whose eggs were frozen for non-social reasons.

A brief history of oocyte cryopreservation: Arguments and facts

The term "cryopreservation" refers to the process of cooling cells and tissues and storing them at subzero temperatures in order to stop all biological activity and preserve their viability and physiological competences for future use. Cooling to subzero temperatures is not a physiological condition for human cells; this is probably due to the high content of water in the living matter, whose conversion to ice crystals may be associated with severe and irreversible damage. Among reproductive cells and tissues, metaphase II oocytes are notably vulnerable to cryopreservation, mainly because of their large size, low surface area to volume ratio, relatively high water content and presence of the meiotic spindle. As human biological systems lack efficient internal defense mechanisms against chilling injuries, it is of the utmost importance to supply adequate external support, in terms of cryoprotectant additives, appropriate cooling/warming rates, and suitable long-term storage. Over the years, scientists have proposed different cryopreservation strategies in the effort to achieve an optimized recipe ensuring cell survival and, at the same time, maintenance of the physiological functions and abilities necessary to continue life. However, despite the first success obtained in the 1980s with frozen oocytes, it was not until recently that notable improvements in the cryopreservation technique, thanks to the advent of vitrification, allowed a breakthrough of this fine procedure.

Postponing Pregnancy Through Oocyte Cryopreservation for Social Reasons: Considerations Regarding Clinical Practice and the Socio-Psychological and Bioethical Issues Involved

Oocyte freezing for 'social reasons' refers to women of reproductive age who are aiming to prolong, protect and secure their fertility. The term emerged to describe application of the highly promising technique, namely vitrification on oocytes retrieved through controlled ovarian stimulation (COS) from women intending to preserve their fertility for social reasons. These women opt to cryopreserve their oocytes at a point in their life when they need to postpone childbearing on the grounds of so called 'social' reasons. These reasons may include a highly driven career, absence of an adequate partner, financial instability, or personal reasons that make them feel unprepared for motherhood. This is a sensitive and multifaceted issue that entails medical, bioethical and socio-psychological components. The latest trend and the apparent increase noted on oocyte freezing for 'social reasons' has prompted our team of fertility specialists, embryologists, obstetricians, gynecologists and psychologists to proceed with a thorough, critical and all-inclusive comprehensive analysis. The wide range of findings of this analysis involve concerns of embryology and epigenetics that shape decisions made in the IVF laboratory, issues regarding obstetric and perinatal concerns on the pregnancy concluding from these oocytes and the respective delivery management and neonatal data, to the social and bioethical impact of this trend's application. This literature review refers to matters rising from the moment the 'idea' of this option is 'birthed' in a woman's thoughts, to proceeding and executing it clinically, up until the point of the pediatric follow up of the children born. We aim to shed light to the controversial issue of oocyte freezing, while objectively exhibit all aspects regarding this complex matter, as well as to respectfully approach how could the prospect of our future expectations be shaped from the impact of its application.

Debating social egg freezing: arguments from phases of life

So-called "social egg freezing" allows a woman to retain the possibility of trying to have a child with her own oocytes later in life, even after having become infertile in the strict sense of the word (that is, infertile without assistance in reproduction).There is a debate about whether it is morally permissible at all, the extent to which it should be permitted legally or even supported, and whether it is ethically desirable. This paper contributes some thoughts to the issue of ethical desirability. More precisely it deals with the question of whether there is any valuable argument to be made on the basis of the idea of life phases and normative expectations related to them. So the question is: Is there a right time in life to have a child, and does this speak against or in favor of social freezing? This question is answered in three steps. First, I will give an overview of ethical arguments that are mostly put forward in favor or against the use of social egg freezing and show that and why the question of life phases should be taken into account. Second, I will sketch what I understand by phases of life, more precisely, what I understand by normatively conceptualized life stages, that are to be distinguished from other kinds of life phases, and how they relate to a good life. Third, I will present two arguments that rely on the idea of life stages and speak against social egg freezing. However, I will criticize them and instead show that from the perspective of life stages nothing speaks against using the technique within certain limits.

Counseling patients on reproductive aging and elective fertility preservation-a survey of obstetricians and gynecologists' experience, approach, and knowledge

PURPOSE

What are the experience, approach, and knowledge of US Obstetricians and Gynecologists' (ob-gyn) towards counseling patients on reproductive aging (RA) and elective fertility preservation (EFP).

METHODS

A cross-sectional survey emailed by the American College of Obstetricians and Gynecologists (ACOG) to 5000 ACOG fellows consisting of 9 demographic and 28 questions relating to counseling patients on RA and EFP.

RESULTS

Seven hundred and eighty-four responders completed the survey. Although 82.8% agreed that conversations relating to RA should take place with patients desiring future childbearing and delaying due to social reasons, only 27.6% stated that they frequently counsel these women aged 18-34 years old, compared to 75.8% aged 35-44 years old (P < 0.01). Limited time (75.8%) and limited knowledge (41.4%) were amongst the most frequent reported barriers towards counseling patients on RA. Fifty-eight percent stated that they have been asked about EFP by patients. Although 74.8% agreed that conversations should take place related to EFP in women desiring future childbearing and delaying due to social reasons, only 27.6% stated that they frequently counsel these patients on EFP (P < 0.01). Limited time (75%) and limited knowledge (59.9%) were amongst the most frequent barriers towards counseling on EFP.

CONCLUSIONS

In the USA, methods to improve patient counseling and provider knowledge on RA and EFP are warranted and further studies are needed to address optimal methods to improve counseling and knowledge related to these topics.

Risks in Surrogacy Considering the Embryo: From the Preimplantation to the Gestational and Neonatal Period

Surrogacy is an assisted reproduction-based approach in which the intended parents assign the gestation and birth to another woman called the surrogate mother. The drivers of surrogacy refer largely to infertility, medical conditions, same-sex couples' parenting, and cases of diversity regarding sexual identity and orientation. Surrogacy consists of a valid option for a variety of conditions or circumstances ranging from medical to social reasons. However, surrogacy may be associated with risks during the preimplantation, prenatal, and neonatal period. It became obvious during the exhaustive literature research that data on surrogacy and its association with factors specific to the IVF practice and the options available were not fully represented. Could it be that surrogacy management adds another level of complexity to the process from the ovarian stimulation, the subsequent IVF cycle, and the techniques employed within the IVF and the Genetic Laboratory to the fetal, perinatal, and neonatal period? This work emphasizes the risks associated with surrogacy with respect to the preimplantation embryo, the fetus, and the infant. Moreover, it further calls for larger studies reporting on surrogacy and comparing the surrogate management to that of the routine IVF patient in order to avoid suboptimal management of a surrogate cycle. This is of particular importance in light of the fact that the surrogate cycle may include not only the surrogate but also the egg donor, sperm donor, and the commissioning couple or single person.

Female fertility preservation: past, present and future

Anti-cancer therapy, particularly chemotherapy, damages ovarian follicles and promotes ovarian failure. The only pharmacological means for protecting the ovaries from chemotherapy-induced injury is gonadotrophin-releasing hormone agonist, but its efficiency remains controversial; ovarian transposition is used to shield the ovary from radiation when indicated. Until the late 1990s, the only option for fertility preservation and restoration in women with cancer was embryo cryopreservation. The development of other assisted reproductive technologies such as mature oocyte cryopreservation andin vitromaturation of oocytes has contributed to fertility preservation. Treatment regimens to obtain mature oocytes/embryos have been modified to overcome various limitations of conventional ovarian stimulation protocols. In the last decades, several centres have begun cryopreserving ovarian samples containing primordial follicles from young patients before anti-cancer therapy. The first live birth following implantation of cryopreserved-thawed ovarian tissue was reported in 2004; since then, the number has risen to more than 130. Nowadays, ovarian tissue cryopreservation can be combined within vitromaturation and vitrification of oocytes. The use of cryopreserved oocytes eliminates the risk posed by ovarian implantation of reseeding the cancer. Novel methods for enhancing follicular survival after implantation are presently being studied. In addition, researchers are currently investigating agents for ovarian protection. It is expected that the risk of reimplantation of malignant cells with ovarian grafts will be overcome with the putative development of an artificial ovary and an efficient follicle class- and species-dependentin vitrosystem for culturing primordial follicles.

Clinical outcomes of a vitrified donor oocyte programme: A single UK centre experience

OBJECTIVE

To assess the survival rate of vitrified oocytes used in an egg recipient programme and compare the clinical outcomes of pregnancy and live-birth rates per warmed oocyte with fresh autologous oocytes. The differences in the obstetrical outcomes between the two groups were also studied.

DESIGN

A prospective case control study from a single in-vitro fertilisaton (IVF) Centre in UK SETTING: Centre of Reproductive and Genetic Health (CRGH), London POPULATION: Vitrified oocytes from egg donors and autologous fresh oocytes from patients attending for an IVF cycle METHODS: The study group consisted of 1490 vitrified oocytes, which were obtained from 145 egg donors who underwent a stimulation cycle at CRGH Centre. The control group included 145 age-matched women who underwent intra cytoplasmic sperm injection (ICSI) treatment with their own oocytes (n = 1528). The clinical outcomes clinical pregnancy rates (CPR) and live-birth rates (LBR) and obstetrical outcomes (gestational age and weight at delivery) were compared between the two groups. Statistical analysis of the summary data and logistic regression analysis was performed using statistical packages (SPSS Version 23 and Stata 2015). The percentages of all parameters in the cases and control groups were compared by Fisher's exact test. A statistical significance level of 5% was adopted throughout the study.

MAIN OUTCOME MEASURES

Survival rate per thawed oocyte, clinical pregnancy rate and live-birth rate per embryo transfer was compared to the autologous oocyte group RESULTS: The survival rate of vitrified oocytes was 73.6% (95% CI: 71.3-75.8%). The clinical pregnancy rate (per embryo transfer) using vitrified oocytes was found to be 51.8% compared to 59.3% in the control group. The live birth rate per embryo transfer in the vitrified oocyte group was 46% (95% CI 37.4-54.7%) compared to 57.1% (95% CI 48.5-68.5%) in the control group. The live-birth rate per thawed oocyte was found to be 4.2%. The gestational ages of the fetus at delivery in both the groups were comparable 39.0 (95% CI 32.7-41.9%) and 39.1 (95% CI 25.6-42.0) (p = 0.38). There was no statistically significant difference in the birth weight between the study and the control group 3100 g (750-4337) and 3232 g (1616-4500) respectively (p = 0.28).

CONCLUSIONS

This is the first study reporting on the efficacy of a vitrified donor oocyte programme from within the UK. There were no significant differences in the obstetrical outcomes between vitrified donor oocytes and autologous oocytes. The above data will be encouraging for women who are undertaking egg freezing for medical and or social reasons.

Outcome of Oocyte Vitrification Combined with Microdissection Testicular Sperm Extraction and Aspiration for Assisted Reproduction in Men

Background

As a safety and efficacy protocol, oocyte vitrification has been widely used in IVF treatment. The aim of this study was to evaluate the outcome of ICSI-ET utilizing vitrified oocytes with sperm obtained from non-obstructive azoospermia (NOA) patients via micro-TESE.

Material/Methods

A total of 150 NOA patients underwent micro-TESE. Ten patients were unable to ejaculate and refused to accept TESA at the time of oocyte retrieval; later, these patients underwent TESA. A total of 174 obstructive azoospermia (OA) patients underwent TESA. Vitrified oocytes were used with micro-TESE in 35 cycles (group 1), and TESA in 10 cycles (group 2). Fresh oocytes were used with micro-TESE in 38 cycles (group 3) and TESA in 174 cycles (group 4).

Results

The overall sperm retrieval rate of the 150 NOA patients was 48.7% (73/150). A total of 257 cycles of ICSI-ET were conducted with testicular spermatozoa; 212 cycles utilized fresh oocytes and 45 cycles utilized vitrified oocytes. No differences were observed with fertilization (73.8%, 77.2%,72.8%, 73.6%), implantation (33.3%, 34.7%, 33.8%, 37.5%), or clinical pregnancy rates (51.4%, 60%, 52.6%, 51.7%) for groups 1 through 4, respectively (P>0.05). Developmental competence was greatest among couples using sperm obtained via TESA rather than micro-TESE, not dependent on whether vitrified or fresh oocytes were utilized. Fertilization, implantation, and clinical pregnancy rates did not differ between using fresh vs. vitrified oocytes, nor did they differ between using testicular sperm derived from men with NOA vs. men with OA.

Conclusions

Vitrified oocytes combined with micro-TESE showed similar clinical efficacy when compared with fresh oocytes.

The Impact of Vitrification in Artificial Reproductive Technology Programmes

Cryopreservation is an integral part of the current methods of assisted reproductive technology (ART). In the past two decades, slow freezing has been replaced worldwide by vitrification due to its association with improved survival rates and clinical outcomes comparable to fresh embryo transfers. Successful embryo vitrification programmes have led to a significant reduction in the incidences of two major complications of ART: ovarian hyperstimulation syndrome and multiple gestations. Multiple embryo transfer cycles from the single ovum aspiration cycle have had a cumulative effect on the numbers of live births. Oocyte vitrification has also helped women to delay their pregnancies for medical or social reasons. This has made oocyte banking a viable option for better synchronisation of oocyte donation programmes. The emerging field of ovarian tissue vitrification has made fertility preservation possible for women undergoing gonadotoxic therapy. In this review, we have discussed the basic principles and methodology of slow freezing and vitrification along with its need and impact on ART.

Embryogenesis of vitrified mature bovine oocytes is improved in the presence of multi-layered cumulus cells

This study was aimed at evaluating the effects of multi-layered cumulus cells (MCCs) during vitrification and in vitro fertilization (IVF) of mature bovine oocytes and embryogenesis after IVF. The rates of cleavage and blastocyst formation were higher in vitrified and fertilized oocytes with MCCs than in denuded oocytes (P < 0.05), but were comparable to the rates in fresh oocytes with MCCs or without (denuded). When the MCC-enclosed oocytes were denuded before IVF, blastocyst formation rate reduced compared with that in vitrified oocytes with MCCs (P < 0.05). This suggested that the MCCs surrounding the mature bovine oocytes play important roles during cryopreservation: protecting them against freezing and promoting their survival and development post IVF, thereby increasing the success rates of IVF and embryonic development. Herein, we showed for the first time that calves could be produced using only 14-19 vitrified mature oocytes with MCCs from the ovaries of individual cows post slaughter.

Egg donation of vitrified oocytes bank produces similar pregnancy rates by blastocyst transfer when compared to fresh cycle

PURPOSE

Advances in reproductive techniques, mainly the introduction of oocyte vitrification, have provided the opportunity to conceive from oocyte banks. The aim of this study was to compare the clinical outcomes of fresh and vitrified oocytes in an egg donation program following blastocyst transfer.

METHODS

This retrospective observational study included 504 oocyte donation cycles. All donor women were younger than 30 years of age. The recipient cycles were divided into two groups: fresh oocytes (n = 78) or vitrified oocytes (n = 426). All oocytes were fertilized by ICSI using ejaculated sperm, followed by blastocyst transfer. Endometrium preparation was performed with estradiol valerate plus micronized progesterone according to standard protocols.

RESULTS

Recipients were of similar age (fresh 42.0 ± 4.5 years vs vitrified 41.8 ± 4.8 years; p = 0.790). The fresh group received more mature oocytes for injection compared to the vitrified group (10.1 ± 2.8 vs 9.2 ± 2.2; p = 0.005). The two pronuclei (2PN) rate (74.5 vs 77.4%; p = 0.195) and blastocyst rate (48.8 vs 51.6%; 0.329) were similar between the fresh and vitrified groups, respectively. The rates of clinical pregnancy were 60.9% in the fresh and 59.0% in the vitrified groups (p = 0.771).

CONCLUSIONS

Our findings suggest that vitrified oocytes result in similar pregnancy rates when compared to fresh oocytes with blastocyst transfer in an egg donation program. Moreover, vitrified oocytes may allow for a better cycle schedule, starting with a lower number of oocytes to be fertilized. Therefore, we hypothesize that egg banks with vitrified oocytes could be safely utilized in an egg donation program.

Safety and efficiency of oocyte vitrification

As the oocyte is the starting point for a new life, artificial reproductive technology (ART) techniques should not affect the (ultra) structural and functional integrity, or the developmental competence. Oocyte vitrification -one of the most significant achievements in human ART during the past decade- should therefore be a safe and efficient technique. This review discusses the principles and developments of the existing and future techniques, applications possibilities and safety concerns. The broad range of vitrification media and devices that are currently available, show differences in their effects on the oocyte ultrastructure and preimplantation development. It is not yet fully decided whether this has an influence on the obstetric and neonatal outcome, since only limited information is available with different media and devices. For autologous oocytes, the obstetric and neonatal outcomes appear promising and comparable to pregnancies obtained with fresh oocytes. This however, is not the case for heterologous fresh or vitrified oocytes, where the immunological foreign foetus induces adverse obstetric and neonatal outcomes. Besides the oocyte vitrification process itself, the effect of multiple stimulations (for oocyte banking or for oocyte donors), seems to influence the possibility to develop gynaecological cancers further in life. Automated vitrification/warming should offer a consistent, cross-contamination free process that offers the highest safety level for the users. They should also produce more consistent results in survival, development and clinical pregnancies between different IVF clinics.

New Promising Strategies in Oncofertility

INTRODUCTION

Approximately 70,000 adolescent and young adults (AYA) are diagnosed with cancer each year. While advancements in treatment have led to improved prognosis and survival for patients, these same treatments can adversely affect AYA reproductive capacity. Localized treatments such as surgery and radiation therapy may affect fertility by removing or damaging reproductive organs, and systemic therapies such as chemotherapy can be toxic to gonads, (ovaries and testicles), thus affecting fertility and/or endocrine function. This can be traumatic for AYA with cancer as survivors often express desire to have genetic children and report feelings of regret or depression as a result of infertility caused by cancer treatments.

AREAS COVERED

Emerging technologies in the field of assisted reproductive technology offer new promise for preserving the reproductive capacity of AYA cancer patients prior to treatment as well as providing alternatives for survivors. The following review revisits contemporary approaches to fertility preservation as well newly developing technologies.

EXPERT COMMENTARY

There are several advances in ART that hold promise for patients and survivors. However there are challenges that inhibit uptake including poor communication between providers and patients about risks and fertility preservation options; high costs; and lack of insurance coverage for fertility preservation services.

Chapter 3 Current Challenges in Immature Oocyte Cryopreservation

Current freezing technology, especially the vitrification method, has markedly improved oocyte survival rate after warming, and the pregnancy rate is comparable to that achieved with fresh oocytes. However, most groups report using oocytes matured in vivo for vitrification. Although immature oocytes can be vitrified successfully, clinical outcomes do not reach that of vitrification of matured oocytes. The current literature suggests that oocytes should be vitrified at mature metaphase II (M-II) stage following IVM rather than at the immature germinal vesicle (GV) stage, because the potential for oocyte maturation is reduced when vitrification is performed on immature oocytes at the GV stage.

Claims for fertility interventions: a systematic assessment of statements on UK fertility centre websites

OBJECTIVES

Fertility services in the UK are offered by over 200 Human Fertilisation and Embryology Authority (HFEA)-registered NHS and private clinics. While in vitro fertilisation (IVF) and intracytoplasmic sperm injection (ICSI) form part of the National Institute for Health and Care Excellence (NICE) guidance, many further interventions are offered. We aimed to record claims of benefit for interventions offered by fertility centres via information on the centres' websites and record what evidence was cited for these claims.

METHODS

We obtained from HFEA a list of all UK centres providing fertility treatments and examined their websites. We listed fertility interventions offered in addition to standard IVF and ICSI and recorded statements about interventions that claimed or implied improvements in fertility in healthy women. We recorded which claims were quantified, and the evidence cited in support of the claims. Two reviewers extracted data from websites. We accessed websites from 21 December 2015 to 31 March 2016.

RESULTS

We found 233 websites for HFEA-registered fertility treatment centres, of which 152 (65%) were excluded as duplicates or satellite centres, 2 were andrology clinics and 5 were unavailable or under construction websites. In total, 74 fertility centre websites, incorporating 1401 web pages, were examined for claims. We found 276 claims of benefit relating to 41 different fertility interventions made by 60 of the 74 centres (median 3 per website; range 0 to 10). Quantification was given for 79 (29%) of the claims. 16 published references were cited 21 times on 13 of the 74 websites.

CONCLUSIONS

Many fertility centres in the UK offer a range of treatments in addition to standard IVF procedures, and for many of these interventions claims of benefit are made. In most cases, the claims are not quantified and evidence is not cited to support the claims. There is a need for more information on interventions to be made available by fertility centres, to support well-informed treatment decisions.

[Female age - related fertility decline: Far from the myth of the "selfish working-girl" and the "right to have a child"]

OBJECTIVES

To study the social dimension of age-related female infertility through an analysis of three key themes: the personal life histories of infertile women over 40 years of age; representations of age and the desire to become pregnant after age 40; opinions of French legislations framing Assisted Reproductive Technologies, age limits, egg donation, and egg freezing for non-medical reasons.

METHODS

This qualitative sociological study was based on semi-structured interviews with infertile women over age 40 going through fertility treatments. The interviews contained three parts: personal and relationship histories; experiences related to age; opinions related to French legislation.

RESULTS

Twenty-three interviews were conducted; each lasting between 90 to 120minutes. Far from having similar life histories, the women interviewed had very different backgrounds leading to their desire for a pregnancy after 40 years of age. From the beginning of their fertility treatments, they perceived a "race against the clock". This feeling of urgency accompanied their experiences and was related to the desire to not be too old for their future child. The women interviewed were mainly in favor of loosening French bioethical laws in order to avoid the need to travel abroad to pursue fertility treatments.

CONCLUSION

The profiles studied attest to a growing gap between biological and biographical temporalities, as well as an inability of women to reduce their desire for a child. Faced with this disparity, egg donation and egg freezing were seen as practical solutions.

Open versus closed oocyte vitrification in an oocyte donation programme: a prospective randomized sibling oocyte study

STUDY QUESTION

Is the survival of donor oocytes with the CryotopSC device superior to the survival with the closed CBSvit device?

SUMMARY ANSWER

The CryotopSC device and the CBSvit device showed similar survival rates.

WHAT IS KNOWN ALREADY

Health authorities are cautious about possible cross contamination during liquid nitrogen storage or handling when working with open vitrification devices. At present, the use of open devices is still allowed since little information is available on the efficiency of closed devices.

STUDY DESIGN, SIZE, DURATION

A prospective randomized sibling oocyte study was performed in the Centre for Reproductive Medicine (UZBrussel) between January 2014 and July 2015. The survival after warming and the embryological outcome of donor oocytes vitrified using two devices was compared: the CBSvit device (closed vitrification and closed storage) and the CryotopSC device (open vitrification and closed storage). A difference of 10% was defined to prove the superiority of the CryotopSC device. In total, 250 warmed oocytes were needed in each arm.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Oocytes from 48 donors were included in the study: 253 vitrified with the CBSvit device and 257 with the CryotopSC device. Equal numbers of oocytes from both devices and originated from the same donor cycle were allocated to each of 78 recipients, in order to exclude donor and recipient (male factor) effects.

MAIN RESULTS AND THE ROLE OF CHANCE

There were no differences found between the CBSvit and the CryotopSC in terms of survival after warming (93.7 versus 89.9%) or fertilization per injected oocyte (74.3 versus 81.4%). The degeneration rate after ICSI was significantly higher for the CBSvit device: 11.4 versus 6.1% (P = 0.041). A significantly higher number of zygotes in the CryotopSC group finished their first mitosis 25-27 h post-injection (34.1 versus 52.1%, P = 0.001). On Day 3, the overall embryo quality distribution did not vary between groups, but a significantly higher cell number was obtained in the CryotopSC device: 6.8 ± 2.8 versus 7.6 ± 2.8 (P = 0.01). The utilization rate per mature oocyte, per surviving oocyte or per fertilized oocyte did not differ. The embryos with the highest quality were selected for transfer on Day 3. The clinical pregnancy rate per transfer cycle was 36.5%.

LIMITATIONS, REASONS FOR CAUTION

The results of this study should not be extrapolated to other female groups, since oocytes from young fertile donors were used in this study.

WIDER IMPLICATIONS OF THE FINDINGS

In many countries, the use of open devices is still allowed due to the limited reports on the efficiency of closed devices. Knowing the caution of health authorities about the use of open devices, there is an urgent need for efficiency studies with closed devices. The results obtained in the current study shows the efficiency of a safe closed vitrification device, leaving behind any concern about possible cross contamination during handling or storage.

STUDY FUNDING/COMPETING INTERESTS

No funding was obtained. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

NCT01952184.

TRIAL REGISTRATION DATE

24 September 2013.

DATE OF FIRST PATIENT'S ENROLMENT

23 January 2014.

Comparison of the Developmental Potential and Clinical Results of In Vivo Matured Oocytes Cryopreserved with Different Vitrification Media

Background:

Oocyte vitrification is widely used throughout the world, but its clinical efficacy is inconsistent and depends on the vitrification media. This study compared the developmental potential and clinical results of in vivo matured oocytes cryopreserved with different vitrification media.

Methods:

This retrospective study involved vitrified-warmed oocytes at one in vitro fertilization laboratory. Vitrification media kits comprised the MC kit (ethylene glycol [EG] plus 1,2-propanediol [PROH]), the KT kit (EG plus dimethyl sulphoxide [DMSO]), and the Modified kit (EG plus DMSO and PROH kit). Rates of oocyte survival and subsequent developmental potential were recorded and analyzed. The t-test and the Chi-square test were used to evaluate each method's efficacy.

Results:

Oocyte survival rate was significantly higher for the Modified kit (92.0%) than for the MC kit (88.2%) (P < 0.05) and the KT kit (77.3%) (P < 0.001). The rate of high-quality embryo development in the Modified kit group (35.8%) was significantly higher than in the MC kit group (29.0%) and the KT kit group (28.3%) (P < 0.001). No significant differences were observed in the clinical pregnancy and implantation rates among the MC, KT, and Modified kit groups (37.2% vs. 30.2% vs. 39.6%; 21.9% vs. 18.8% vs. 27.4%, respectively) (P > 0.05). The high-quality embryo rate per warmed oocyte was significantly higher (23.4%) in the Modified kit group than in the other groups (P < 0.001). The embryo utilization and live birth rates per warmed oocyte were the highest in the Modified kit group, but not significantly (P > 0.05).

Conclusions:

Modified vitrification media are efficient for oocyte vitrification and, with further verification, may be able to replace commercially available media in future clinical applications.

Developmental Competence of Vitrified-Warmed Bovine Oocytes at the Germinal-Vesicle Stage is Improved by Cyclic Adenosine Monophosphate Modulators during In Vitro Maturation

Cryopreservation of mature oocytes and embryos has provided numerous benefits in reproductive medicine. Although successful cryopreservation of germinal-vesicle stage (GV) oocytes holds promise for further advances in reproductive biology and clinical embryology fields, reports regarding cryopreservation of immature oocytes are limited. Oocyte survival and maturation rates have improved since vitrification is being performed at the GV stage, but the subsequent developmental competence of GV oocytes is still low. The purpose of this study was to evaluate the effects of supplementation of the maturation medium with cyclic adenosine monophosphate (cAMP) modulators on the developmental competence of vitrified-warmed GV bovine oocytes. GV oocytes were vitrified-warmed and cultured to allow for oocyte maturation, and then parthenogenetically activated or fertilized in vitro. Our results indicate that addition of a cAMP modulator forskolin (FSK) or 3-isobutyl-1-methylxanthine (IBMX) to the maturation medium significantly improved the developmental competence of vitrified-warmed GV oocytes. We also demonstrated that vitrification of GV oocytes led to a decline in cAMP levels and maturation-promoting factor (MPF) activity in the oocytes during the initial and final phases of maturation, respectively. Nevertheless, the addition of FSK or IBMX to the maturation medium significantly elevated cAMP levels and MPF activity during IVM. Taken together, our results suggest that the cryopreservation-associated meiotic and developmental abnormalities observed in GV oocytes may be ameliorated by an artificial increase in cAMP levels during maturation culture after warming.