Fertility Preservation in Women

In vitro maturation of oocytes (IVM): historical landmarks, current status and future perspectives

One of the major advancements in in vitro fertilization (IVF) has been the development of culture media that enhance gamete maturation in vitro and sustain embryo development up to the blastocyst stage. The deep understanding of the mechanisms involved in gametogenesis and the complex sequence of events surrounding nuclear and cytoplasmic maturation has also enabled the development of efficient in vitro maturation (IVM) protocols. This review outlines the major landmarks in the history of in vitro maturation of oocytes, the advantages and importance of its clinical application in human, especially in patients with Polycystic Ovary Syndrome (PCOS), Resistant Ovary Syndrome, high antral follicle count or oncology patients, as well as the safety and efficacy of the technique. IVM has not been shown yet to be as effective as controlled ovarian stimulation in terms of maturation rates, fertilization rates, and clinical outcome, possibly owing to a dysfunctional or asynchronous nuclear/cytoplasmic maturation process. A confusing set of IVM clinical protocols may also have contributed to the slow incorporation of the technology into routine IVF practice. However, recent improvements have led to comparable live birth rates between IVM and IVF, in women with high antral follicle count. The current status of IVM in the Assisted Reproductive Technology (ART) laboratory and its future perspectives, aiming to provide maximum fertility care to patients will be discussed.

Evaluation and preservation of fertility in patients with hematologic malignancies

For patients with hematologic malignancies, novel therapeutic strategies offer the potential to achieve a complete clinical response and long-term survival. However, declining fertility has become a significant concern, impacting long-term quality of life. Conventional high-dose chemotherapy and radiotherapy are known to reduce fertility or cause sterility. Moreover, limited clinical data are available on the effects of newer therapies, such as targeted treatments and chimeric antigen receptor (CAR)-T cell therapy, on fertility. Additionally, there is no standard method for preserving fertility in these patients. Male patients can opt for sperm cryopreservation, whereas female patients may preserve fertility through embryo, oocyte, or ovarian tissue cryopreservation. However, preserving fertility in prepubescent patients remains particularly challenging. Therefore, hematologists must educate patients about the potential gonadal toxicity of cancer treatments and offer the most appropriate fertility preservation options.

Advancing cancer therapy: Mechanisms, efficacy, and limitations of calcium electroporation

Calcium electroporation, an innovative technique, uses high-voltage pulses to introduce calcium ions into cells, leading to cell death and tumor growth inhibition. This review explores the potential of calcium electroporation as a promising therapeutic approach in cancer treatment. We provide an in-depth analysis of the underlying mechanisms by which calcium ions function within cells and how their introduction through electroporation can effectively induce cell death in cancer cells. Furthermore, we present a comprehensive overview of the current literature, covering both preclinical and clinical studies, to highlight the safety and efficacy of calcium electroporation in various cancer types, including melanoma, head and neck cancer, and breast cancer. We also discuss the distinct advantages of calcium electroporation over traditional cancer therapies, such as its specific targeting of cancer cells while sparing healthy cells. However, we also address the challenges and limitations associated with this technique, underscoring the need for further research. By providing a comprehensive examination of calcium electroporation, this review aims to contribute to understanding this emerging field and encourage further investigation into its potential as a novel cancer treatment strategy.

Cryopreserved ovarian tissue autotransplantation in an acute myeloid leukaemia survivor following extensive minimal residual disease screening: first reported live birth in Europe

PURPOSE

We report successful autotransplantation of ovarian tissue in a sterile acute myeloid leukaemia survivor after comprehensive minimal residual disease (MRD) screening.

METHODS

At age 18, the patient underwent ovarian tissue cryopreservation while in complete remission prior to allogeneic stem cell transplantation. Premature ovarian failure and the wish to conceive led her to request transplantation of her cryopreserved ovarian tissue 12 years later. Extensive MRD screening of frozen-thawed biopsy specimens, including histology, immunohistochemistry, PCR and 6-month xenotransplantation to immunodeficient mice, was conducted before ovarian tissue transplantation (OTT).

RESULTS

Histology and immunohistochemistry (MPO, p53, CD4, CD45) of thawed ovarian fragments showed no malignant cell contamination. Nested RT-PCR (MLL::AF9) was negative and the mouse grafted with ovarian tissue showed no disease after 6 months. The xenografted tissue was analyzed again (histology, immunohistochemistry and RT-PCR) and showed no contamination. Laparoscopic transplantation to the patient restored ovarian function after 4 months. Modified natural cycle IVF resulted in pregnancy. At 29 weeks, the patient had preterm premature rupture of membranes and delivered a healthy boy at 34.5 weeks. Three years post-transplantation, the patient remains disease-free.

CONCLUSIONS

Concerns about malignant cell contamination limit cryopreserved OTT in leukemia survivors. This is the first reported European live birth in an acute myeloid leukemia survivor following frozen-thawed OTT. Safe OTT was achieved by retrieving ovarian tissue during complete remission and conducting thorough screening before transplantation. Obstetrical risks in leukemia survivors who had total body irradiation should also be thoroughly discussed during decision making before attempting motherhood.

Second pregnancy in China 5 years after ovarian tissue transplantation to prevent iatrogenic POI

OBJECTIVE

This article reports the second live birth in China after frozen-thawed ovarian tissue transplantation to prevent iatrogenic premature ovarian insufficiency (POI).

METHOD

A patient with aplastic anemia received ovarian tissue cryopreservation before hematopoietic stem cell transplantation, and four ovarian cortex strips were thawed and transplanted into her peritoneal pocket 18 months later.

RESULTS

Pregnancy occurred spontaneously 5 years after grafting, and a healthy girl was born at 39 weeks of gestation. Until now, the child has developed normally without any major diseases.

CONCLUSION

Ovarian tissue cryopreservation and transplantation (OTCT) can be assessed as a successful method especially to prevent iatrogenic POI. In our cryobank for OTCT, which is the first official one in China, intensive research to improve this method has been performed, and we propose after our success for the second pregnancy in China to include this method in the official guidelines for prevention and treatment of (especially iatrogenic) POI.

Development and Applications of Organoids in Gynecological Diseases

Organoids are rapidly self-organizing 3D in vitro cultures derived from pluripotent stem cells (PSCs) or adult stem cells (ASCs) that possess disease-like characteristics with high success rates. Due to their ability to retain tissue structure, biological phenotypes, and genetic information, they have been utilized as a novel in vitro model for disease research. In recent years, scientists have established self-organizing 3D organoids for human endometrium, fallopian tubes, ovaries, and cervix by culturing stem cells with cytokines in 3D scaffolds. The integration of organoids with animal models, organ-on-a-chip systems, and 3D printing technologies offers a novel preclinical model for exploring disease mechanisms and developing treatments. This review elaborate on the recent research progress of stem cells-formed organoids in the field of gynecology from the aspects of constructing gynecological disease organoids, drug screening and new drug development, simulation modeling, allogeneic transplantation, regenerative medicine and personalized treatment."

Ovarian cryopreservation with rapamycin improves fertility restoration in a murine orthotopic transplantation model

Currently, the only fertility preservation option of prepubertal patients is ovarian tissue cryopreservation followed by autotransplantation (OTCTP). Once in remission and patients desire to conceive, autotransplantation of frozen/thawed tissue is performed. A major issue of this technique is follicular loss directly after transplantation, mainly due to follicle activation. Our previous research showed that adding rapamycin to the freezing medium counteracted follicle proliferation and activation induced by OTCTP in heterotopic autotransplantation of ovaries in mice. Our current study aimed to test the potential of this approach to improve fertility restoration in mice. Forty 4-week-old female C57BL/6 mice underwent unilateral oophorectomy followed by slow-freezing of ovaries with or without rapamycin. After chemically disabling the remaining ovary, orthotopic autotransplantation was performed. After recovery, estrous cycle analysis was conducted using daily vaginal smears. The mice were mated with males for 4 months, and pregnancy outcomes were recorded. After mating, half the females were super-ovulated for oocyte quantification and ovarian analysis, while the others had their ovaries collected for analysis of remaining primordial follicles using immunohistochemistry. Female mice whose ovaries were cryopreserved with rapamycin prior to chemically disabling the remaining ovary and orthotopic autotransplantation, gave birth to more pups (102 rapamycin, 48 control). The live birth rate was also higher (P = 0.0025) when ovaries were cryopreserved in rapamycin compared to control medium. Additionally, more mice in the rapamycin group gave birth (13 rapamycin, 8 control) with a higher average litter size (P = 0.0837). More mice had primordial follicles left at the end of the experiment in the rapamycin group (P = 0.0397). Superovulation showed a similar number of oocytes collected (P = 0.4462). While rapamycin did not influence cyst formation after autotransplantation, mice that developed ovarian cysts gave birth to fewer pups per dam (P = 0.0119) with a lower live birth rate compared to mice without ovarian cysts (P = 0.0032). The use of rapamycin improved fertility restoration in mice. Using rapamycin during OTCTP in humans could potentially resolve the massive follicular loss directly after grafting, and thus eventually lead to better opportunities for women to become pregnant.

Explorative 3-D culture of early secondary follicles in a time lapse system for up to 36 days gives valuable, but limited insights in follicular development

BACKGROUND

Cryopreservation of ovarian cortical tissue is an important option for female fertility preservation. This is particularly valuable for cancer patients who need to be treated urgently with chemotherapy, leaving no time for hormonal stimulation. The transfer of malignant cells in certain cancers remains as a potential risk after freezing, thawing and transplantation of ovarian tissue while isolation and in vitro growth (IVG) of follicles could be a safe alternate approach of female fertility protection.

METHODS

Ovarian cortex tissue was frozen, thawed and cultured for 8 days prior to isolating and embedding of early secondary follicles in a 3D matrix, suitable for time lapse monitoring for up to 36 days. Continuous growth of a theca-like cell layer and extrafollicular protrusions were visually evaluated with a permanent monitoring system facilitating real-time follicular development without deviations in the culture conditions. Occurrence of theca cell growth was visually characterized by extrafollicular formation of cells, beyond the outer follicle boundaries. To validate the results observed by time-lapse monitoring, live cell imaging was conducted and determined with immunofluorescence staining.

RESULTS

Individual follicles significantly increased in size over time. Time-lapse video monitoring revealed extending and retracting of filopodia-like structures in the outer follicular region adjacent to the 3D environment. Theca-like cells and actin components of filopodia-like structures were identified based on immunofluorescence staining.

CONCLUSIONS

Time lapse monitoring of 3-D cultured follicles is a promising explorative approach to obtain valuable visual insights regarding the many facets of follicular growth and to optimize follicular culture conditions towards a clinical application. As the study is limited by a lack of mechanistic insights into theca cell differentiation and filopodia function, additional studies are necessary to validate the preliminary results of this approach.

Humanin alone and in combination with GnRHa therapy attenuates ovarian dysfunction induced by prepubertal cyclophosphamide chemotherapy in female mice

Prepubertal chemotherapy induced ovarian damage poses a significant threat to female fertility, particularly following cyclophosphamide (CP) treatment. Humanin (HNG), a small molecule polypeptide encoded by mitochondrial DNA, has a variety of effects, this study aimed to investigate the protective effects of HNG and its combination with conventional Gonadotropin Releasing Hormone Agonist (GnRHa) on ovarian function in a CP-induced damage model. The 21-day-old C57BL/6 J female mice were randomly assigned to six groups: Control, CP model, HNG, HNG+CP, GnRHa+CP, and HNG+GnRHa+CP. Reproductive related parameters were assessed through histopathological examination, follicle counts, serum sex hormone levels, estrous cycle monitoring, and oxidative stress evaluation. Results indicated that CP treatment led to significant reproductive dysfunction especially ovarian dysfunction, evidenced by reduced follicles, hormonal imbalances, prolonged estrous cycles, reduced body weight, and diminished ovarian and uterine weights, alongside pathological alterations. Notably, HNG treatment, both alone and in conjunction with GnRHa, significantly mitigated these adverse effects, however the combination did not provide additional benefits over HNG alone regarding follicles preservation and antioxidant capacity. Transcriptomic analysis revealed significant enrichment in inflammation and immune response pathways following HNG treatment. In conclusion, HNG demonstrates potential as a therapeutic agent to protect against CP-induced ovarian damage, offering insights for future strategies aimed at preserving female fertility during chemotherapy.

Fertility preservation in women with endometriosis

BACKGROUND

Endometriosis is a chronic disease that can compromise fertility in up to 30-50% of affected patients, and it is estimated that patients affected by endometriosis represent about 10% of patients undergoing ART treatments. The hypothesized underlying mechanisms explaining infertility are various, but great attention has been given to the relationship between ovarian endometriomas and reduced ovarian reserve.

OBJECTIVE AND RATIONALE

Infertility in patients with endometriosis does not have univocal management, since surgical therapy can increase the chances of natural conception, but at the same time increases the risk of damage to the ovarian reserve. In some cases, IVF procedures should be considered instead of surgery, within a personalized strategy. It has therefore been proposed that patients with endometriosis are eligible for fertility preservation.

SEARCH METHODS

This article is based on a critical review of literature on peer-reviewed article indexing databases including PubMed, Scopus and Medline, using as keywords: 'fertility preservation', 'oocyte vitrification', 'endometriosis', 'endometrioma', 'ovarian reserve' and 'in vitro fertilization'.

OUTCOMES

Data regarding the feasibility of oocyte cryopreservation in patients with endometriosis have increased over recent years, indicating that these patients seem to have the same number of oocytes retrieved and IVF outcomes similar to those who perform fertility preservation for other indications. However, probably due to a reduced ovarian reserve, several cycles of ovarian stimulation may be needed to gather a suitable number of retrieved oocytes per patient. Age, ovarian reserve, and previous ovarian surgery are the main factors affecting the success of fertility preservation. Bilateral endometriomas, a history of unilateral endometrioma surgery with a contralateral recurrence, and preoperative reduced ovarian reserve are the most common indications for fertility preservation. The choice between primary surgery and ART is often complex, requiring a therapeutic strategy tailored to the patient's clinical characteristics and needs, such as age, type and severity of endometriosis lesions, presence of symptoms, surgical history, and desire for pregnancy.

LIMITATIONS REASONS FOR CAUTION

The development of endometriosis-related infertility and the severity of ovarian damage due to endometriosis lesions per se or their surgical treatment are difficult to predict, and data are lacking concerning which subgroups of patients with endometriosis might benefit most from fertility preservation.

WIDER IMPLICATIONS

Women with endometriosis, and in particular women with bilateral ovarian endometriomas or recurrent surgery on the ovaries, should be advised about risk of ovarian reserve damage. Oocyte cryopreservation is an established technique that has been demonstrated as feasible and successful for these patients; however, the specific indications have not yet been established.

STUDY FUNDING/COMPETING INTERESTS

There are no funding sources for the study and no conflicts of interest to declare.

Local delivery of platelet-derived factors mitigates ischemia and preserves ovarian function through angiogenic modulation: A personalized regenerative strategy for fertility preservation

As the most prominent and ideal modality in female fertility preservation, ovarian tissue cryopreservation, and transplantation often confront the challenge of ischemic damage and follicular loss from avascular transplantation. To surmount this impediment, we engineered a novel platelet-derived factors-encapsulated fibrin hydrogel (PFH), a paradigmatic biomaterial. PFH encapsulates autologous platelet-derived factors, utilizing the physiological blood coagulation cascade for precise local delivery of bioactive molecules. In our study, PFH markedly bolstered the success of avascular ovarian tissue transplantation. Notably, the quantity and quality of follicles were preserved with improved neovascularization, accompanied by decreased DNA damage, increased ovulation, and superior embryonic development rates under a Low-concentration Platelet-rich plasma-derived factors encapsulated fibrin hydrogel (L-PFH) regimen. At a stabilized point of tissue engraftment, gene expression analysis mirrored normal ovarian tissue profiles, underscoring the effectiveness of L-PFH in mitigating the initial ischemic insult. This autologous blood-derived biomaterial, inspired by nature, capitalizes on the blood coagulation cascade, and combines biodegradability, biocompatibility, safety, and cost-effectiveness. The adjustable properties of this biomaterial, even in injectable form, extend its potential applications into the broader realm of personalized regenerative medicine. PFH emerges as a promising strategy to counter ischemic damage in tissue transplantation, signifying a broader therapeutic prospect. (197 words).

Diagnosis and Management of Cancers in Pregnancy: The Results of a Dual Battle Between Oncological Condition and Maternal Environment-Literature Review

Cancer during pregnancy presents considerable challenges that arise from various factors, including the diagnostic, prognostic and therapeutic implications of managing cancer in this unique patient population. There is a crucial need for an integrated approach that aligns medical interventions for both the pregnant patient and the developing embryo or fetus. Furthermore, the distinct characteristics associated with each stage of gestation may significantly influence the treatment protocols that can be proposed. Due to all of these factors, the importance of collaboration among healthcare professionals from different specialties (to ensure that both mother and child receive optimal care throughout the pregnancy) is often neglected. This review is designed to provide a thorough overview of the current standard procedures regarding the diagnosis and treatment options for cancer in pregnant patients in order to ensure the safety of mother and child. Furthermore, the review describes the feasibility of current fertility preservation methods, highlights the psychological effects of cancer during pregnancy and examines the risks and benefits of breastfeeding.

Decellularized extracellular matrix from bovine ovarian tissue maintains the protein composition of the native matrisome

Recent approaches of regenerative reproductive medicine investigate the decellularized extracellular matrix to develop a transplantable engineered ovary (TEO). However, a full proteomic analysis is not usually performed after the decellularization process to evaluate the preservation of the extracellular matrix (ECM). In this study, the ECM of the bovine ovarian cortex was analyzed before and after decellularization using mass spectrometry and bioinformatics. A total of 155 matrisome proteins were identified in the native ECM of the bovine ovarian cortex, with 145 matrisome proteins detected in the decellularized ECM. After decellularization, only 10 matrisome proteins were lost, and notably, none belonged to the category of reproductive biological processes. Histology and histochemistry analyses were employed to assess the general morphology of both native and decellularized ECM, allowing for the identification of the most abundant ECM proteins. Moreover, our study highlighted collagen type VI alpha 3 and heparan sulfate proteoglycan 2 as the most abundant components in the bovine ovarian ECM, mirroring the composition observed in the human ovary. These findings enhance our understanding of the composition of both native and decellularized ECM, with the potential implications for the development of a TEO. SIGNIFICANCE: The significance of the present study lies on the possibility of advancing towards developing a bioengineered ovary, which is the ultimate strategy to regain fertility in women. The results demonstrate that the decellularized extracellular matrix of the bovine ovary maintains the protein composition of the native matrisome, using a recently described decellularization protocol. The decellularized matrix may serve as scaffolding for seeding ovarian stromal cells and follicles to create a bioengineered ovary, and as closer its composition is to the native matrix the better. Also, comparing the bovine ovarian matrisome, which was described for the first time here, with the human ovarian matrisome, we could see a great similarity, suggesting that the bovine ovary decellularized matrix may serve as a model for developing a human bioengineered ovary.

Fertility preservation in female cancer patients: Surgical procedures

The surgical management of cancer patients wishing fertility preservation is multidisciplinary, involving surgeon, anesthetist, hematologist, and nursing and laboratory staff. Many oncology patients have a multitude of medical or surgical conditions that require careful planning of all therapy including surgical removal of reproductive material, either oocytes or ovarian tissue. The significant risks related to either transvaginal or abdominal surgery should be discussed and documented and the final decision to proceed must be balanced against the risks, including death. Multidisciplinary communication for individual case management is the safeguard for patient safe return to cancer therapy.

Chemotherapy-induced diminished murine ovarian reserve model and impact of low-dose chemotherapy on fertility

OBJECTIVE

To establish a murine model of chemotherapy-induced diminished ovarian reserve (DOR) and investigate residual fertility after chemotherapy exposure.

DESIGN

Two different chemotherapy protocols were tested to establish a valid DOR model by comparing follicle densities in mice given either protocol or physiological solution. An ovarian stimulation protocol was then selected from among different gonadotropins by counting the number of day 2 embryos obtained from normal mice. Finally, DOR mice were stimulated 5 and 8 weeks after chemotherapy with the chosen gonadotropin protocols, and day 2 embryos were recovered after mating, as was ovarian tissue for further immunohistologic analyses.

SUBJECTS

Seventy-two Naval Medical Research Institute mice.

EXPOSURE

Two different chemotherapy protocols.

MAIN OUTCOME MEASURES

This study compared day 2 embryo counts in both normal and chemotherapy-induced DOR mice. Ovarian histology and morphology were also investigated by follicle counting and classification, as was immunostaining for apoptosis (cleaved caspase-3), activation (phospho-Akt), and proliferation (Ki67).

RESULTS

A dose of 12 mg/kg of busulfan (Bu) + 120 mg/kg of cyclophosphamide (Cy) was chosen to establish the DOR model as it significantly reduced the ovarian reserve compared to both control mice (physiological solution) and the 1.2 mg/kg of Bu + 12 mg/kg of Cy protocol, without depleting it completely. When stimulated with 3.75 IU of Menopur, normal mice produced significantly more embryos than DOR mice given 12 mg/kg of Bu + 120 mg/kg of Cy (41.40 ± 14.74 vs. 23.67 ± 15.55 day 2 embryos). Although the follicle count was statistically diminished after single-dose chemotherapy administration, the remaining follicles did not display any difference in terms of apoptosis, activation, or proliferation rates.

CONCLUSION

We successfully established a chemotherapy-induced DOR model using 12 mg/kg of Bu + 120 mg/kg of Cy, as evidenced by lower, but not completely depleted, follicle numbers and fewer retrieved embryos. Histologic study of ovarian tissue exposed to DOR-inducing chemotherapy revealed that surviving follicles were of the similar quality as tissue not exposed to chemotherapy.

Ovarian tissue cryopreservation in breast cancer patients: glass half empty or glass half full?

This is a commentary to a paper recently published in RBMOnline by Macklon and De Vos, in which they argue for a discontinuation of ovarian tissue freezing for fertility preservation in women with breast cancer. Instead, they suggest the use of oocyte vitrification following ovarian stimulation as the preferred method of fertility preservation. This commentary presents nine separate arguments that should be considered in the context of ovarian tissue freezing and fertility preservation in girls and women. Collectively, the authors support ovarian tissue freezing going forward and suggest continuing this procedure for fertility preservation in women with breast cancer. Ovarian tissue freezing represents several advantages for patients and provides them with more options following treatment compared with oocyte vitrification.

[Fertility preservation and hematopoietic stem cell transplantation (SFGM-TC)]

Conditioning regimen prior to hematopoietic stem cell transplantation have an impact on patient fertility through the use of gonadal irradiation and/or bifunctional alkylating agents. Their impact on fertility depends mainly on the dose used and, in women, on age at the time of treatment. All patients should benefit before treatment from a consultation informing them of the potential impact on fertility and of fertility preservation techniques. In the absence of contraindications, the major toxicity of myeloablative conditioning regimen justifies fertility preservation. There are few data concerning fertility after reduced-intensity conditioning. Despite lower theoretical gonadotoxicity, we also recommend fertility preservation, if possible before transplantation. The fertility preservation techniques used depend on the patient's age, pathology and conditioning. In the event of subsequent use of harvested gonadal tissue in the context of acute leukemia or aggressive lymphoma, it is advisable to assess the risk of reintroduction of tumor cells. Finally, it is recommended to assess gonadal function after transplant, especially after reduced conditioning. If there is persistent residual gonadal function, post-treatment fertility preservation should be discuss.

Reproductive Health in Women with Major β-Thalassemia: Evaluating Ovarian Reserve and Endocrine Complications

Thalassemia is an autosomal recessive hereditary chronic hemolytic anemia characterized by a partial or complete deficiency in the synthesis of alpha- or beta-globin chains, which are essential components of adult hemoglobin. Mutations in the globin genes lead to the production of unstable globin chains that precipitate within cells, causing hemolysis. This shortens the lifespan of mature red blood cells (RBCs) and results in the premature destruction of RBC precursors in the bone marrow. Regular red blood cell transfusions are the standard treatment for thalassemia. However, these transfusions can lead to increased iron overload, which can impair vital systems such as the liver, heart, ovaries, and endocrine system. Focusing on female reproductive endocrinology, recurrent blood transfusions can cause iron accumulation in the pituitary and hypothalamus, leading to hypogonadotropic hypogonadism (HH), the most common endocrinopathy in these patients, affecting 40-91% of women. Recurrent transfusions and the resulting iron overload can also lead to oxidative stress and ovarian damage in patients with beta-thalassemia major (BTM). Despite advancements in iron chelation therapy, hypothalamic-pituitary damage associated with HH contributes to subfertility and sexual dysfunction, often with little to no recovery. In women exposed to gonadotoxic drugs, particularly those with BTM, anti-Mullerian hormone (AMH)-a marker of ovarian reserve-is frequently used to assess ovarian damage. This review aims to explore the pathophysiology of β-thalassemia and its major clinical manifestations, with a focus on endocrine complications and their impact on ovarian reserve. It also investigates how metabolomics can provide insights into the disease's metabolic alterations and inform current and emerging therapeutic strategies to mitigate complications and optimize patient outcomes, potentially leading to more effective and personalized treatments.

Low doses of alkylating agents do not harm human ovarian tissue destined for cryopreservation

OBJECTIVE

To investigate the impact of nongonadotoxic doses of alkylating agents on human ovarian cortex.

DESIGN

Retrospective study.

SETTING

Academic research center.

PATIENTS

Biopsies from 78 patients who had undergone ovarian tissue cryopreservation were retrieved and analyzed. Among them, 42 had previously been treated with chemotherapy (alkylating agents, dose <3,400 mg/m2), making up the chemotherapy group, whereas 36 had not been given any chemotherapy, constituting the control group.

MEAN OUTCOME MEASURES

Follicle count and classification, morphology study, immunostaining for apoptosis (cleaved caspase-3), immunostaining for activation (phospho-Akt), fibrosis (Masson's trichrome), and vascularization (von Willebrand factor and smooth muscle actin).

RESULTS

In the prepubertal group, 271 follicles/mm3 were detected in control patients and 501 follicles/mm3 in chemotherapy-exposed subjects. In the adult group, 4,916 follicles/mm3 were found in control patients and 6,570 follicles/mm3 in chemotherapy-exposed patients. No difference in follicle density was observed between the 2 groups in any age category. Neither did we encounter any significant difference in follicle viability according to chemotherapy exposure or age. Proportions of nongrowing follicles were >76% in all age groups, irrespective of chemotherapy exposure, and higher, although not significantly, in the chemotherapy group compared with the control group. There were significantly fewer secondary follicles in the adult chemotherapy group than in the adult control group. Concerning apoptosis, no significant difference was observed between control and chemotherapy subjects in any age groups. Numbers of activated follicles were systematically higher in all age categories in the chemotherapy group than the control group. Areas of atypical follicles were noted in 4 out of 14 prepubertal patients in the chemotherapy group. In these areas, follicle density was 84,570 ± 8,837 follicles/mm3 and all follicles appeared nonviable but showed no sign of apoptosis.

CONCLUSION

Low-dose chemotherapy had no major impact on ovarian tissue, suggesting that ovarian tissue exposed to some chemotherapy before cryopreservation is comparable with ovarian tissue free of any chemotherapy, as clinically demonstrated by high pregnancy rates after ovarian tissue transplantation in women exposed to chemotherapy. Previous chemotherapy should therefore no longer be a contraindication to ovarian tissue cryopreservation.

Folliculogenesis resumption after ovarian cortex transplantation: what is the earliest hormonal indicator?

INTRODUCTION

Ovarian tissue cryopreservation (OTC) is recommended by scientific societies for women undergoing highly gonadotoxic cancer treatments. Following transplantation, the restoration of ovarian function is typically characterised by the resumption of spontaneous menstruation. Yet, a few studies have looked at the longitudinal hormonal variations following transplantation. This study aims to investigate the fluctuation of gonadotropins and granulosa/theca cells secretions during the interval between ovarian transplantation and the recovery of menstrual function in two young women with no residual ovarian activity.

METHOD

We selected two patients diagnosed with Hodgkin's lymphoma, initially referred for OTC at the ages of 19 and 15, respectively, and who had both undergone two consecutive stem cell transplants due to recurrent disease episodes. Both patients presented with premature ovarian failure and returned at ages 29 and 26, respectively, for ovarian cortex transplantation. Hormonal secretions and menstrual function were closely monitored both prior and in the months following the ovarian transplantation.

RESULTS

Menstruation resumed at 7 and 5 months post-transplantation, respectively. FSH and LH levels significantly decreased as early as 1 and 3 months before the first menstruation. As for ovarian hormonal secretion, AMH, measured with an ultra-sensitive assay ("pico AMH"), and Inhibin B were the first to increase, starting 1 month before the resumption of menstruation. Subsequently, AMH levels consistently remained very low throughout the follow-up, as did androgens, which showed a slight increase after the graft but remained at postmenopausal levels.

CONCLUSION

Pico AMH, measured by an ultra-sensitive assay, Inhibin B and estradiol are the first ovarian hormones to be secreted following an ovarian graft, with levels rising 1 month prior the return of menstruation. However, the earliest hormonal indicators of graft success are the significant drops in FSH and LH levels, accompanied by a rise in estradiol levels, which occur 1-3 months before menstruation resumes.

Controlled Ice Nucleation With a Sand-PDMS Film Device Enhances Cryopreservation of Mouse Preantral Ovarian Follicles

Ovarian follicle cryopreservation is a promising strategy for fertility preservation; however, cryopreservation protocols have room for improvement to maximize post-thaw follicle viability and quality. Current slow-freezing protocols use either manual ice-seeding in combination with expensive programmable-rate freezers or other clinically incompatible ice initiators to control the ice-seeding temperature in the extracellular solution, a critical parameter that impacts post-cryopreservation cell/tissue quality. Previously, sand has been shown to be an excellent, biocompatible ice initiator, and its use in cryopreservation of human induced pluripotent stem cells enables high cell viability and quality after cryopreservation. This study applies sand as an ice initiator to cryopreserve multicellular microtissue, preantral ovarian follicles, using a simple slow-freezing protocol in the mouse model. Ovarian follicles cryopreserved using the sand partially embedded in polydimethylsiloxane (PDMS) film to seed ice in the extracellular solution exhibit healthy morphology, high viability, and the ability to grow similarly to fresh follicles in culture post-thaw. This sand-based cryopreservation strategy can facilitate convenient ovarian follicle cryopreservation using simple equipment, and this study further demonstrates the translatability of this strategy to not only single cells but also multicellular tissues.

Standardization for ovarian tissue cryopreservation and transplantation in China

Ovarian tissue cryopreservation and transplantation is one of the most advanced and promising fertility preservation methods. Prior to any procedure that may lead to a toxic ovarian injury (such as chemotherapy or radiotherapy), a portion of the ovary is removed and cryopreserved. At an appropriate time, after toxic therapy is concluded, the cryopreserved ovarian tissue is then thawed and transplanted back to the patient when conditions permit. This technique can not only preserve female fertility but also restore ovarian endocrine function. However, there is no standardization for ovarian tissue cryopreservation and transplantation in China. In order to promote the standardized development of ovarian tissue cryopreservation technology in the whole country, it is urgent to establish the standard of this technology.

Exploring stem cell technology: Pioneering new pathways for female fertility preservation and restoration

The fertility of women is crucial for the well-being of individuals and families. However, various factors such as chemotherapy, lifestyle changes, among others, may lead to a decline in female fertility, thus emphasizing the significance of preserving and restoring fertility. Stem cells, with their unique capacity for self-renewal and pluripotent differentiation, have made significant strides in areas such as ovarian tissue cryopreservation, in vitro culture of frozen-thawed ovarian tissue, and construction of ovarian-like organs. This review aims to summarize the latest findings in these fields, highlighting the pivotal role, mechanisms, and future prospects of stem cell technology in preserving and restoring female fertility. Additionally, the importance of interdisciplinary collaboration is underscored, as personalized stem cell therapy regimens tailored through interdisciplinary cooperation between reproductive medicine and stem cell fields hold promise in providing reliable solutions for the preservation and restoration of female fertility.

Oncofertility in Children and Adolescents

Major improvements have been seen in oncofertility care over the last decade. Clinical ethics frameworks support new populations, including children, having access to novel fertility preservation techniques. Oncofertility consultation requires a multidisciplinary approach. Clinicians need to develop competencies in infertility risk-assessment, counseling regarding fertility preservation procedures and alternate family planning options, and managing individualised supportive care needs to minimize medical and psychological morbidity.

Color Doppler Ultrasonographic Examination of Ovarian Grafts in Goats

The aim of this study was to evaluate the effectiveness of color Doppler ultrasonography for examination of the blood flow areas in superficial grafts after 7 or 15 days of heterotopic allotransplantation, comparing an in-ear subcutaneous area (IE) with an in-neck cervical intramuscular area (IN) in goats. To monitor the local blood flow in the graft areas, color Doppler signals were assessed daily until days seven and fifteen, when the left and right implants, respectively, were removed. The areas of blood flow around the transplanted ovarian fragments were significantly larger (p < 0.05) in the IE area compared to the IN area after 7 (IE: 4.70 ± 0.33A vs. IN: 3.67 ± 0.33B) and 15 (IE: 5.27 ± 0.21A vs. IN: 4.66 ± 0.22B) days of transplantation. A positive and significant correlation was observed between the area of blood flow and the day of assessment after 7 (IE: r = 0.43; p < 0.05) and 15 (IE: r = 0.52; p = 0.001; IN: r = 0.42; p = 0.001) days of transplantation. In conclusion, color Doppler ultrasonography can be used for real-time assessment of local blood perfusion in ovarian grafts, making it possible to identify alterations in the blood flow area in the period following a transplant procedure.

MSCs-derived EVs protect against chemotherapy-induced ovarian toxicity: role of PI3K/AKT/mTOR axis

Chemotherapy detrimentally impacts fertility via depletion of follicular reserves in the ovaries leading to ovarian failure (OF) and development of estrogen deficiency-related complications. The currently proposed options to preserve fertility such as Oocyte or ovarian cortex cryopreservation are faced with many technical obstacles that limit their effective implementation. Therefore, developing new modalities to protect ovarian function remains a pending target. Exosomes are nano-sized cell-derived extracellular vesicles (EVs) with documented efficacy in the field of regenerative medicine. The current study sought to determine the potential beneficial effects of mesenchymal stem cells (MSCs)-derived EVs in experimentally induced OF. Female albino rats were randomly allocated to four groups: control, OF group, OF + MSCs-EVs group, OF + Rapamycin (mTOR inhibitor) group, and OF + Quercetin (PI3K/AKT inhibitor) group. Follicular development was assessed via histopathological and immunohistochemical examination, and ovarian function was evaluated by hormonal assay. PI3K/Akt/mTOR signaling pathway as a key modulator of ovarian follicular activation was also assessed. MSCs-EVs administration to OF rats resulted in restored serum hormonal levels, preserved primordial follicles and oocytes, suppressed ovarian PI3K/AKT axis and downstream effectors (mTOR and FOXO3), modulated miRNA that target this axis, decreased expression of ovarian apoptotic markers (BAX, BCl2) and increased expression of proliferation marker Ki67. The present study validated the effectiveness of MSCs-EVs therapy in preventing ovarian insufficiency induced by chemotherapy. Concomitant MSCs-EVs treatment during chemotherapy could significantly preserve ovarian function and fertility by suppressing the PI3K/Akt axis, preventing follicular overactivation, maintaining normal ovarian cellular proliferation, and inhibiting granulosa cell apoptosis.

Clinical dilemmas in ovarian tissue cryopreservation

Ovarian tissue cryopreservation (OTC) is increasingly offered globally as a fertility preservation strategy for both postpubertal women and prepubertal girls, with subsequent reimplantation of cryopreserved ovarian cortex resulting in a rapidly growing number of live births. There remains very limited evidence of efficacy from tissue stored when the patient was prepubertal or from conditions affecting the ovary directly, e.g., Turner syndrome. Although OTC is becoming a more established practice, several clinical dilemmas remain from a practical and ethical standpoint. This review discusses the challenges regarding optimal patient selection for the procedure, the use of OTC in patients with a poor prognosis, the potential of reimplantation of tissue contaminated with malignant cells, and the role of OTC in those with an intrinsic ovarian disorder.

Factors associated with successful intraoperative oocyte retrieval for fertility preservation during open pelvic surgery for gynecologic indications

OBJECTIVE

The study investigated factors associated with successful intra-operative oocyte retrieval for fertility preservation during transabdominal gynecologic surgery.

STUDY DESIGN

A total of 29 patients who underwent intraoperative oocyte retrieval during staging surgery at a single academic hospital from May 2014 to August 2022 were enrolled in this study, and their outcomes were analyzed.

RESULTS

Among 29 patients who underwent intra-operative oocyte retrieval during staging surgery, oocytes were obtained in 24 patients, representing 82.8 % of the retrieval rate (24/29), and two patients returned to use cryopreserved oocytes (6.9 %). Among 24 women who succeeded in obtaining oocytes, 20 patients succeeded in oocyte cryopreservation, and two patients proceeded to embryo cryopreservation. The cryopreservation rate was 91.7 % (22/24). All patients with failed oocyte retrieval (n = 5) and cryopreservation (n = 7) were diagnosed with malignancy. AMH of those with successful cryopreservation oocytes was higher than those without cryopreservation (4.10 ng/mL vs. 1.18 ng/mL, p = 0.003). A higher portion of the unstimulated cycle was observed in those with failed cryopreservation (8.3 % vs. 40.0 %, p = 0.01). No complications were noted.

CONCLUSION

For women planning to undergo open pelvic surgery, intra-operative oocyte retrieval is a feasible option. High serum AMH and ovarian stimulation before surgery may predict successful oocyte cryopreservation.

New Insights on In Vitro Maturation of Oocytes for Fertility Preservation

In the last decade, the evolution of oncofertility has sparked a resurgence of interest in in vitro maturation (IVM) due to its suitability in certain oncological scenarios where controlled ovarian hyperstimulation may not be feasible. The retrieval of immature cumulus-oocyte complexes from small antral follicles, regardless of the menstrual cycle phase, presents a swift opportunity to vitrify mature oocytes or embryos post-IVM in urgent situations or when stimulation is not advisable. Harvesting immature cumulus-oocyte complexes and immature oocytes can be achieved transvaginally or directly in the laboratory from extracorporeal ovarian tissue. Although IVM has transitioned from an experimental status due to safety validations, it relies on the intricate process of oocyte maturation. Despite successful live births resulting from IVM in fertility preservation contexts, the comparatively lower developmental competence of in vitro matured oocytes highlights the necessity to enhance IVM culture systems. Recent advancements in IVM systems hold promise in bolstering oocyte competence post-IVM, thereby narrowing the gap between IVM and outcomes from ovarian stimulation. Additionally, for optimizing the chances of conception in cancer survivors, the combination of IVM and ovarian tissue cryopreservation stands as the favored choice when ovarian stimulation is unfeasible.

Thawing fertility: a view of ovarian tissue cryopreservation processes and review of ovarian transplant research

Individuals with a disease or treatment that increases their risk of premature gonadal insufficiency may opt to undergo fertility preservation. Those who are postpubertal can often cryopreserve gametes, sperm, or eggs to expand their biologic family using assisted reproductive technologies. Ovarian tissue cryopreservation (OTC) and testicular tissue cryopreservation may be an option for individuals who are unable to use standard fertility preservation techniques. The development of OTC was critical for many patients, including prepubertal children with ovaries that do not yet produce eggs, adolescents who make few good-quality eggs, and adult women with ovaries who cannot undergo ovarian stimulation. The only option to restore fertility and hormone production after OTC is through ovarian tissue transplantation (OTT). Ovarian tissue cryopreservation and OTT have been successful for some patients. Although OTC is no longer considered experimental by the American Society for Reproductive Medicine, the process is far from standardized. Significant research needs to be done, especially at the point of OTT, to improve the success and longevity of ovarian tissue function. This article lists the main steps from surgical procurement of the ovarian tissue to transplantation and restoration of function. Our pediatric hospital program has had to decide which options in procurement, processing, cryopreservation, and warming will be used in our clinical laboratory. The options and limitations within the research and analyses are briefly discussed. Literature focusing on techniques to improve OTT effectiveness and longevity was reviewed. Ovarian tissue transplantation studies that performed xenograft experiments after pretreatment of the tissue graft by a ligand or drug, treatment of the host, or encapsulation of the ovarian tissue were identified. The intended effects of the treatments include increasing vascularization, reducing apoptosis, and directing activation or suppression of primordial follicles. Robust research in this area must continue with rigorous analyses to make strides in improving fertility preservation and restoration options for patients.

Air pollutants and ovarian reserve: a systematic review of the evidence

Background

Growing evidence indicates an association between ambient air pollution and decreased human reproductive potential. This study aims to systematically review the association between air pollutants and female ovarian reserve.

Methods

The literature was searched in six electronic databases through June 2024. Screening the 136 articles retrieved for inclusion criteria resulted in the selection of 15 human observational studies that evaluated the effect of environmental pollutants on ovarian reserve markers. The study protocol was registered on the International Prospective Register of Systematic Reviews (PROSPERO, registration code: CRD42023474218).

Results

The study design of the selected studies was found to be cross-sectional (2 of 15), retrospective cohort (10 of 15), prospective cohort (2 of 15), and case-control (1 of 15). The study population was distributed as follows: Asians (53%, eight studies), Americans (33%, five studies), and Europeans (14%, two studies). The main findings showed a higher body of evidence for the environmental pollutants PM2.5, PM10, and NO2, while a low body of evidence for PM1, O3, SO2, and a very low body of evidence for benzene, formaldehyde, and benzo(a)pyrene, yet consistently showing significant inverse association data. The overall methodological quality of the selected studies was rated moderated across the 14 domains of the National Institutes of Health (NIH) toolkit.

Conclusion

The data suggest that increased exposure to air pollutants seems to be associated with reduced ovarian reserve, with the most substantial evidence for pollutants such as PM2.5, PM10, and NO2. However, more evidence is needed to draw conclusions about causality.

Anti-Müllerian hormone: biology and role in endocrinology and cancers

Anti-Müllerian hormone (AMH) is a peptide belonging to the transforming growth factor beta superfamily and acts exclusively through its receptor type 2 (AMHR2). From the 8th week of pregnancy, AMH is produced by Sertoli cells, and from the 23rd week of gestation, it is produced by granulosa cells of the ovary. AMH plays a critical role in regulating gonadotropin secretion, ovarian tissue responsiveness to pituitary hormones, and the pathogenesis of polycystic ovarian syndrome. It inhibits the transition from primordial to primary follicles and is considered the best marker of ovarian reserve. Therefore, measuring AMH concentration of the hormone is valuable in managing assisted reproductive technologies. AMH was initially discovered through its role in the degeneration of Müllerian ducts in male fetuses. However, due to its ability to inhibit the cell cycle and induce apoptosis, it has also garnered interest in oncology. For example, antibodies targeting AMHR2 are being investigated for their potential in diagnosing and treating various cancers. Additionally, AMH is present in motor neurons and functions as a protective and growth factor. Consequently, it is involved in learning and memory processes and may support the treatment of Alzheimer's disease. This review aims to provide a comprehensive overview of the biology of AMH and its role in both endocrinology and oncology.

Multifunctional Laser-Induced Graphene-Based Microfluidic Chip for High-Performance Oocyte Cryopreservation with Low Concentration of Cryoprotectants

Oocyte cryopreservation is essential in the field of assisted reproduction, but due to the large size and poor environmental tolerance of oocytes, cell freezing technology needs further improvement. Here, a Y-shaped microfluidic chip based on 3D graphene is ingeniously devised by combining laser-induced graphene (LIG) technology and fiber etching technology. The prepared LIG/PDMS microfluidic chip can effectively suppress ice crystal size and delay ice crystal freezing time by adjusting surface hydrophobicity. In addition, LIG endows the microfluidic chip with an outstanding photothermal effect, which allows to sharply increase its surface temperature from 25 to 71.8 °C with 10 s of low-power 808 nm laser irradiation (0.4 W cm-2). Notably, the LIG/PDMS microfluidic chip not only replaces the traditional cryopreservation carriers, but also effectively reduces the dosage of cryoprotectants (CPAs) needed in mouse oocyte cryopreservation. Even when the concentration of CPAs is cut in half (final concentration of 7.5% ethylene glycol (EG) and 7.5% dimethyl sulfoxide (DMSO)), the survival rate of oocytes is still as high as 92.4%, significantly higher than the control group's 85.8%. Therefore, this work provides a novel design strategy to construct multifunctional microfluidic chips for high-performance oocytes cryopreservation.

Molecular Factors Predicting Ovarian Chemotoxicity in Fertile Women: A Systematic Review

Background: Recent advances in cancer diagnosis and treatment have significantly improved survival rates among women of reproductive age facing cancer. However, the potential iatrogenic loss of fertility caused by chemotherapeutic agents underscores the need to understand and predict chemotherapy-induced ovarian damage. This study addresses this gap by systematically reviewing the literature to investigate genetic markers associated with chemotherapy-induced ovarian failure (CIOF). Objective: The primary objective is to identify genetic markers linked to CIOF, contributing to a comprehensive understanding of the factors influencing fertility preservation in female cancer survivors. Methods: A systematic review was conducted using PubMed, EMBASE, Web of Science, Scopus, and OVID electronic databases from inception through December 2023. Studies were included if they featured genomic assessments of genes or polymorphisms related to CIOF in women with histologically confirmed tumors. Exclusion criteria comprised in vitro and animal studies, reviews, and pilot studies. The resulting four human-based studies were scrutinized for insights into genetic influences on CIOF. Results: Of the 5179 articles initially identified, four studies met the inclusion criteria, focusing on alkylating agents, particularly cyclophosphamide, and anthracyclines. Su et al. explored CYP3A41B variants, revealing modified associations with CIOF based on age. Charo et al. investigated GSTA1 and CYP2C19 polymorphisms, emphasizing the need to consider age and tamoxifen therapy in assessing associations. Oktay et al. delved into the impact of BRCA mutations on anti-Müllerian hormone (AMH) levels post-chemotherapy, supported by in vitro assays. Van der Perk et al. focused on childhood cancer survivors and revealed significant associations of CYP3A43 and CYP2B6*2 SNPs with AMH levels. Conclusions: This systematic review analyzes evidence regarding genetic markers influencing CIOF, emphasizing the complex interplay of age, specific genetic variants, and chemotherapy regimens. The findings underscore the need for a personalized approach in assessing CIOF risk, integrating genetic markers with traditional ovarian reserve testing. The implications of this study extend to potential advancements in fertility preservation strategies, offering clinicians a comprehensive baseline assessment for tailored interventions based on each patient's unique genetic profile. Further research is essential to validate these findings and establish a robust framework for integrating genetic markers into clinical practice.

Oncofertility and Fertility Preservation for Women with Gynecological Malignancies: Where Do We Stand Today?

Oncofertility is a growing medical and research field that includes two main areas: oncology and reproductive medicine. Nowadays, the percentage of patients surviving cancer has exponentially increased, leading to the need for intervention for fertility preservation in both men and women. Specifically, gynecological malignancies in women pose an additional layer of complexity due to the reproductive organs being affected. In the present review, we report fertility preservation options with a cancer- and stage-specific focus. We explore the drawbacks and the necessity for planning fertility preservation applications during emergency statuses (i.e., the COVID-19 pandemic) and comment on the importance of repro-counseling for multifaceted patients during their oncological and reproductive journey.

Fertility preservation in hematological cancer patients

Among adolescents and young adults, hematological malignancies are the most common malignancies. Although the survival rate of hematological malignancies in young patients has been dramatically improved, due to the continuous improvement and development of tumor diagnosis and treatment options, cytotoxic therapies can significantly reduce a patient's reproductive capacity and cause irreversible infertility. The most two established solutions are embryo cryopreservation and oocyte cryopreservation which can be considered in single female. Sperm or testicular tissue cryopreservation in adult male are feasible approaches that must be considered before gonadotoxic therapy. A comprehensive consultation with reproductive specialists when once diagnosed is a significantly issue which would help those survivors who want to have children. In this article, we review germ cell toxicity, which happens during the treatment of hematological malignancies, and aims to propose safety, efficacy fertility preservation methods in younger patients with hematological malignancies.

Pediatric Cancer Immunotherapy and Potential for Impact on Fertility: A Need for Evidence-Based Guidance

The use of immunotherapies for the treatment of cancer in children, adolescents, and young adults has become common. As the use of immunotherapy has expanded, including in earlier lines of therapy, it has become evident that several aspects of how these immunotherapies impact longer-term outcomes among survivors are understudied. Traditional cancer therapies like alkylating and platin agents carry the greatest risk of infertility, but little is known about the impact of novel immunotherapies on fertility. This topic is of great interest to patients, patient advocates, and clinicians. In this article, we review immunotherapeutic agents used to treat childhood and young adult cancers and discuss potential mechanisms by which they may impact fertility based on the known interplay between the immune system and reproductive organs. We highlight the relative paucity of high-quality literature examining these late effects. We discuss interventions to optimize fertility preservation (FP) for our patients. Conducting longitudinal, collaborative, and prospective research on the fertility outcomes of pediatric and young adult patients with cancer who receive immunotherapy is critical to learn how to effectively counsel our patients on long-term fertility outcomes and indications for FP procedures. Collection of patient-level data will be necessary to draft evidence-based guidelines on which providers can make therapy recommendations.

Encapsulation of Bovine Primordial Follicles in Rigid Alginate Does Not Affect Growth Dynamics

The only fertility preservation and subsequent restoration option for many patients facing gonadotoxic treatments is ovarian tissue cryopreservation and transplantation. While this process is successful for some, there is significant room for improvement to extend the life of the transplant and to make it safe for patients that may have metastatic disease within their ovarian tissue. We need a deeper understanding of how the physical properties of the ovarian microenvironment may affect folliculogenesis to engineer an environment that supports isolated follicles and maintains primordial follicle quiescence. Bovine ovaries were used here as a monovulatory model of folliculogenesis to examine the effects of primordial follicle activation and growth under different physical conditions. We found that there were no differences in activation, growth or survival when primordial follicles were cultured in isolation or in situ (remaining in the tissue) under two significantly differently rigid alginate gels. To determine if the extra rigid environment did not affect activation in isolated follicles due to an immediate activation event, we used 5-ethynyl-2'-deoxyuridine (EdU) to track follicle activation during the isolation process. We identified EdU incorporation in granulosa cells after primordial follicles were isolated from the surrounding extracellular matrix (ECM). These findings support that isolation of primordial follicles from the ECM is an activating event and that the differentially rigid environments assessed here had no effect on follicle growth. Further work is needed to suppress activation in primordial follicles to maintain the ovarian reserve and extend the life of an ovarian tissue transplant.

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.

First Childbirth after Fertility Preservation and Gender Reassigning Surgery from Indian Transgender Community

Fertility preservation (FP) is critical for those members of the transgender community who desire biological offspring in the future. As gender-affirming hormone therapy and gender-affirming surgeries (GASs) negatively affect future fertility potential, awareness amongst care providers and the transgender population regarding FP and family-building options is the need of the hour. As the first case of childbirth after transgender FP and GAS in India, this will be a beacon of hope for transgender family-building options in India.

Laparoscopic medulla-sparing ovarian tissue biopsy for cryopreservation: step-by-step surgical technique

OBJECTIVE

To describe a laparoscopic technique for ovarian tissue biopsy (OTB) for fertility preservation. In the last years, the demand for fertility preservation has grown because of the increasing survival rates among patients with cancer and the rising awareness of the importance of quality of life after gonadotoxic therapy. Among fertility-sparing approaches, ovarian tissue cryopreservation is a valid strategy to preserve ovarian endocrine and reproductive function in prepubertal and postpubertal women who will undergo gonadotoxic cancer treatments. Currently, there is no universal consensus regarding ovarian tissue retrieval technique for fertility preservation.

DESIGN

Step-by-step description of the surgical technique with narrated video footage.

SETTING

Academic tertiary hospital.

PATIENT(S)

Patients with a high risk of premature ovarian insufficiency, usually due to gonadotoxic treatments, who undergo OTB for fertility preservation were included in the study. In this video, we present the clinical case of a 28-year-old patient affected by Hodgkin lymphoma who underwent laparoscopy for OTB before chemotherapy.

INTERVENTION(S)

After exposing the chosen ovary, an incision at the tubal pole of the ovary is made with scissors. Through section and dissection, a large cortical biopsy of the ovary is performed without removing and avoiding any damage to the medulla. At the end of the procedure, hemostasis was achieved with selective coagulation using bipolar coagulation.

MAIN OUTCOME MEASURE(S)

Step by step educational video.

RESULT(S)

The post-operative course was uneventful and the patient was discharge 24 hours after surgery.

CONCLUSION(S)

Standardization of a step-by-step laparoscopic technique can provide an effective method to optimize ovarian tissue removal while minimizing tissue injury. Medulla-sparing ovarian biopsy allows retrieval of only the cortical part of the ovary, maximizing the number of primordial follicles obtained without damaging the vascular supply of the ovary contained within the medulla. Primordial follicles are resistant to cryoinjury owing to their relatively inactive metabolism, and they are usually found at approximately 0.8 mm below the surface of the cortex. This technique could also reduce the back-table processing time of the ovarian tissue before cryopreservation. One disadvantage could be the difficulty of the technique compared to an oophorectomy because it requires a skilled surgeon that can easily find the cleavage plane between the medulla and the cortex, even in patients submitted to previous chemoradiotherapy or during gonadotropin-releasing hormone analogue therapy.

Ovarian Tissue Cryopreservation for Fertility Preservation in Patients with Hemoglobin Disorders: A Comprehensive Review

Hemoglobin diseases like sickle cell disease (SCD) and β-thalassemia (BT) present fertility challenges for affected patients. SCD and BT result from abnormal hemoglobin production or structure and pose numerous health concerns. Despite medical advancements improving the quality of life or even providing cures, SCD and BT pose unique fertility concerns for women. Young women with these disorders already contend with reduced ovarian reserve and a narrower fertile window, a situation that is compounded by the gonadotoxic effects of treatments like medications, transfusions, stem cell transplants, and gene therapy. While crucial for disease control, these interventions may lead to reproductive health issues, increasing infertility and early menopause risks. Ovarian tissue cryopreservation (OTC) offers potential for future motherhood to women with hemoglobin disorders facing infertility related to curative treatments. OTC involves surgically removing, preparing, and freezing ovarian tissue containing primordial follicles capable of producing mature oocytes, offering advantages over oocyte cryopreservation alone. However, the application of OTC for patients with hemoglobin disorders presents unique challenges, including special health risks, financial barriers, and access to care. This comprehensive literature review delves into the current state of ovarian tissue cryopreservation for fertility preservation in patients with hemoglobin disorders. Empowering patients with informed reproductive choices in the context of their hemoglobin disorders stands as the ultimate goal.

A dozen years of ovarian tissue cryopreservation at a pediatric hospital: tracking program and patient metrics while adapting to increasing needs

Objective

To review the program and patient metrics for ovarian tissue cryopreservation (OTC) within a comprehensive pediatric fertility preservation program in its first 12 years of development.

Design

Retrospective review.

Setting

A tertiary children's hospital in a large urban center between March 2011 and February 2023.

Patients

Pediatric patients who underwent OTC.

Interventions

Unilateral oophorectomy for OTC.

Main Outcome Measures

Patient demographics and clinical course information were collected for analysis.

Results

A total of 184 patients underwent OTC in the first 12 years. One hundred fifteen patients were prepubertal at the time of OTC, and 69 were postpubertal. In total, 128 patients (69.6%) received part of their planned therapy before OTC. Starting in 2018, 104 participants (92.0%) donated tissue to research, 99 participants (87.6%) donated blood, and 102 (90.2%) donated media to research. There was a decrease in the median age of patients who underwent OTC from 16.4-6.6 years and an overall increase in the proportion of patients per year that were prepubertal. Forty-eight (26.0%) patients who underwent OTC were outside referrals and traveled from as far as Seattle, Washington.

Conclusion

During the first 12 years of this program, oncofertility research increased, annual tissue cryopreservation cases increased, and the median age of those who underwent OTC decreased. The program was adapted to build a stand-alone gonadal tissue processing suite and specialized in prepubertal ovarian tissue processing. The program will continue to adapt to patient needs in the upcoming decades because restoration technologies advance through research supported by this and collaborating programs.

Synthetic human gonadal tissues for toxicology

The process of mammalian reproduction involves the development of fertile germ cells in the testis and ovary, supported by the surrounders. Fertilization leads to embryo development and ultimately the birth of offspring inheriting parental genome information. Any disruption in this process can result in disorders such as infertility and cancer. Chemical toxicity affecting the reproductive system and embryogenesis can impact birth rates, overall health, and fertility, highlighting the need for animal toxicity studies during drug development. However, the translation of animal data to human health remains challenging due to interspecies differences. In vitro culture systems offer a promising solution to bridge this gap, allowing the study of mammalian cells in an environment that mimics the physiology of the human body. Current advances on in vitro culture systems, such as organoids, enable the development of biomaterials that recapitulate the physiological state of reproductive organs. Application of these technologies to human gonadal cells would provide effective tools for drug screening and toxicity testing, and these models would be a powerful tool to study reproductive biology and pathology. This review focuses on the 2D/3D culture systems of human primary testicular and ovarian cells, highlighting the novel approaches for in vitro study of human reproductive toxicology, specifically in the context of testis and ovary.

Ovarian Insufficiency and Fertility Preservation During and After Childhood Cancer Treatment

Premature ovarian insufficiency (POI) is one of many potential long-term consequences of childhood cancer treatment in females. Causes of POI in this patient population can include chemotherapy, especially alkylating agents, and radiation therapy. Rarely, ovarian tumors lead to ovarian dysfunction. POI can manifest as delayed pubertal development, irregular menses or amenorrhea, and infertility. This diagnosis often negatively impacts emotional health due to the implications of impaired ovarian function after already enduring treatment for a primary malignancy. The emerging adult may be challenged by the impact on energy level, quality of life, and fertility potential. POI can also lead to low bone density and compromised skeletal strength. This review discusses the health consequences of POI in childhood cancer survivors (CCS). We also explore the role of fertility preservation for CCS, including ovarian tissue cryopreservation and other available options. Lastly, knowledge gaps are identified that will drive a future research agenda.

Generation of Tailored Extracellular Matrix Hydrogels for the Study of In Vitro Folliculogenesis in Response to Matrisome-Dependent Biochemical Cues

While ovarian tissue cryopreservation (OTC) is an important fertility preservation option, it has its limitations. Improving OTC and ovarian tissue transplantation (OTT) must include extending the function of reimplanted tissue by reducing the extensive activation of primordial follicles (PMFs) and eliminating the risk of reimplanting malignant cells. To develop a more effective OTT, we must understand the effects of the ovarian microenvironment on folliculogenesis. Here, we describe a method for producing decellularized extracellular matrix (dECM) hydrogels that reflect the protein composition of the ovary. These ovarian dECM hydrogels were engineered to assess the effects of ECM on in vitro follicle growth, and we developed a novel method for selectively removing proteins of interest from dECM hydrogels. Finally, we validated the depletion of these proteins and successfully cultured murine follicles encapsulated in the compartment-specific ovarian dECM hydrogels and these same hydrogels depleted of EMILIN1. These are the first, optically clear, tailored tissue-specific hydrogels that support follicle survival and growth comparable to the "gold standard" alginate hydrogels. Furthermore, depleted hydrogels can serve as a novel tool for many tissue types to evaluate the impact of specific ECM proteins on cellular and molecular behavior.

Current status of fertility preservation in a Spanish tertiary public hospital: multidisciplinary approach and experience in over 1500 patients

PURPOSE

Currently, 15% of gynaecological and 9% of haematological malignancies are diagnosed before the age of 40. The increased survival rates of cancer patients who are candidates for gonadotoxic treatments, the delay in childbearing to older ages, and the optimization of in vitro fertilisation techniques have all contributed to an increased interest in fertility preservation (FP) treatments. This study reviews the experience of the Fertility Preservation Programme (FPP) of a tertiary public hospital with a multidisciplinary approach.

METHODS

This retrospective study included all the available (FP) treatments, performed in patients of childbearing age between 2006 and 2022.

RESULTS

1556 patients were referred to the FPP: 332 oocyte vitrification cycles, 115 ovarian cortex cryopreservation with 11 orthotopic autotransplantations, 175 gonadotropin-releasing hormone (GnRH) agonist treatments, 109 fertility-sparing treatments for gynaecological cancer, and 576 sperm cryopreservation were performed. Malignancy was the main indication for FP (the main indications being breast cancer in women and haematological malignancies in men), although non-oncological pathologies, such as endometriosis and autoimmune diseases, have increased in recent years. Currently, the most widely used FP technique is oocyte vitrification, the increase of which has been associated with a decrease in the use of cortex CP and GnRH agonists.

CONCLUSIONS

The increase in FP treatment reflects the implementation of reproductive counselling in oncology programmes. A multidisciplinary approach in a tertiary public hospital allows individualised FP treatment for each patient. In recent years, there has been a change in trend with the introduction of new indications for FP and a change in techniques due to their optimisation.

[Live birth rates after breast cancer among women who desired a child]

INTRODUCTION

In France, the breast cancer is the most common cancer among women under the age of 40. From 38 to 70% of women have not fulfilled their parental plans at the time of diagnosis. The gonadotoxicity of the treatments and the follicular physiological decline linked to age can become an obstacle to this project.

METHODS

Among the patients, 386 were treated for breast cancer at the Centre Georges-François-Leclerc in Dijon between January 2011 and December 2018 were identified. 192 patients aged under 39 met the inclusion criteria. We excluded metastatic cancers, cancer in situ and pregnant patients at diagnosis. A total of 124 patients agreed to participate in the study. The included patients filled out a self-questionnaire. Data were collected from the patient's electronic medical. The primary endpoint of this study was the live birth rate.

RESULT

Among women who desired a child after breast cancer, the overall rate of live births was 36.2 % (21/58). Most achieved pregnancies were spontaneous (90.5 %). No factor was significantly associated with the absence of obtaining birth. Fertility was preserved by oocyte cryopreservation in 13.8 % of patients (17/124). The median time to conception in patients who received chemotherapy was 8 months [1.0-60.0] vs 2 months [1.0-7.0] in women who did not receive chemotherapy.

DISCUSSION

The non-negligible proportion of live births following spontaneous pregnancy after breast cancer allows us to be reassuring for patients. However, the emergence of new chemotherapy protocols whose consequences on long-term gonadotoxicity are still not well known requires further studies and prompts the promotion of fertility preservation as a precautionary measure.

In Vitro Maturation, In Vitro Oogenesis, and Ovarian Longevity

This paper will review a remarkable new approach to in vitro maturation "IVM" of oocytes from ovarian tissue, based on our results with in vitro oogenesis from somatic cells. As an aside benefit we also have derived a better understanding of ovarian longevity from ovary transplant. We have found that primordial follicle recruitment is triggered by tissue pressure gradients. Increased pressure holds the follicle in meiotic arrest and prevents recruitment. Therefore recruitment occurs first in the least dense inner tissue of the cortico-medullary junction. Many oocytes can be obtained from human ovarian tissue and mature to metaphase 2 in vitro with no need for ovarian stimulation. Ovarian stimulation may only be necessary for removing the oocyte from the ovary, but this can also be accomplished by simple dissection at the time of ovary tissue cryopreservation. By using surgical dissection of the removed ovary, rather than a needle stick, we can obtain many oocytes from very small follicles not visible with ultrasound. A clearer understanding of ovarian function has come from in vitro oogenesis experiments, and that explains why IVM has now become so simple and robust. Tissue pressure (and just a few "core genes" in the mouse) direct primordial follicle recruitment and development to mature oocyte, and therefore also control ovarian longevity. There are three distinct phases to oocyte development both in vitro and in vivo: in vitro differentiation "IVD" which is not gonadotropin sensitive (the longest phase), in vitro gonadotropin sensitivity "IVG" which is the phase of gonadotropin stimulation to prepare for meiotic competence, and IVM to metaphase II. On any given day 35% of GVs in ovarian tissue have already undergone "IVD" and "IVG" in vivo, and therefore are ready for IVM.