Recent advances in fertility preservation and counseling for female cancer patients

Geographic Access to Fertility Counseling among Adolescent and Young Adult Women with Cancer in North Carolina

BACKGROUND

Fertility counseling is recommended for adolescent and young adult women facing gonadotoxic cancer therapy. However, fertility care is subspecialized medical care offered at a limited number of institutions, making geographic access a potential barrier to guideline-concordant care. We assessed the relationship between geographic access and receipt of fertility counseling among adolescent and young adult women with cancer.

METHODS

Using data from the North Carolina Central Cancer Registry, we identified women diagnosed with lymphoma, gynecologic cancer, or breast cancer at ages 15 to 39 years during 2004 to 2015. Eligible women were invited to complete an online survey on various topics, including fertility counseling. Geographic access was measured, using geocoded addresses, as vehicular travel time from residence to the nearest fertility clinic available at diagnosis. Multivariable regression models were used to examine the association between travel time and receipt of fertility counseling by provider type: health care provider versus fertility specialist.

RESULTS

Analyses included 380 women. The median travel time to a fertility clinic was 31 (IQR: 17-71) minutes. Overall, 75% received fertility counseling from a health care provider and 16% by a fertility specialist. Women who lived ≥30 minutes from a clinic were 13% less likely to receive fertility counseling by a health care provider (prevalence ratio: 0.87; 95% confidence interval, 0.75-1.00) and 49% less likely to receive counseling by a fertility specialist (prevalence ratio: 0.51; 95% confidence interval, 0.28-0.93).

CONCLUSIONS

Women who lived further away from fertility clinics were less likely to receive fertility counseling.

IMPACT

Interventions to improve access to fertility counseling should include strategies to alleviate the burden of geographic access.

Effects of intracellular Ca2+ on developmental potential and ultrastructure of cryopreserved-warmed oocyte in mouse

Maintaining appropriate intracellular calcium of oocytes is necessary to prevent ultrastructure and organelle damage caused by freezing and cryoprotectants. The present study aimed to investigate whether cryoprotectant-induced changes in the calcium concentrations of oocytes can be regulated to reduce damage to developmental potential and ultrastructure. A total of 33 mice and 1381 oocytes were used to explore the effects of intracellular calcium on the development and ultrastructures of oocytes subjected to 2-aminoethoxydiphenyl borate (2-APB) inhibition or thapsigargin (TG) stimulation. Results suggested that high levels intracellular calcium interfered with TG compromised oocyte survival (84.4 % vs. 93.4 %, p < 0.01) and blastocyst formation in fresh and cryopreservation oocytes (78.1 % vs. 86.4 %, and 60.5 % vs. 72.5 %, p < 0.05) compared with that of 2-APB pretreated oocytes in which Ca2+ was stabilized even though no differences in fertilization and cleavage was detected (p > 0.05). Examination by transmission electron microscopy indicated that the microvilli decreased and shortened, cortical granules considerably decreased in the cortex area, mitochondrial vesicles and vacuoles increased, and the proportion of vacuole mitochondria increased after oocytes were exposed to cryoprotectants. The cryopreservation-warming process deteriorated the negative effects on organelles of survival oocytes. By contrast, a low level of intracellular calcium mediated with 2-APB was supposed to contribute to the protection of organelles. These findings suggested oocyte injuries induced by cryoprotectants and low temperatures can be alleviated. More studies are necessary to confirm the relationship among Ca2+ concentration of the cytoplasm, ultrastructural injuries, and disrupted developmental potential in oocytes subjected to cryopreservation and warming.

Successful pregnancy rates amongst patients undergoing ovarian tissue cryopreservation for non-malignant indications: A systematic review and meta-analysis

BACKGROUND

Ovarian tissue cryopreservation (OTC) is a fertility preservation method that has been clinically applied for almost 30 years. Studies specifically evaluating patients presenting with non-malignant indications for OTC and their subsequent pregnancy rates are limited.

OBJECTIVE

To summarise the evidence on the rates of successful pregnancy amongst women who have undergone OTC for non-malignant indications.

METHODS

A systematic review with meta-analysis (PROSPERO registration CRD42022307925) was conducted to investigate the pregnancy outcomes of patients who have undergone ovarian tissue cryopreservation for non-malignant indications. Articles published in EMBASE and Ovid MEDLINE before October 2022 were screened for inclusion based on the following criteria: original human studies pertaining to OTC with a defined non-malignant cohort and pregnancy outcomes. The successful pregnancy rates were pooled with a random-effects model of double-arcsine transformed proportions. Sensitivity analysis involved pooling the results of studies with a low risk of bias after being assessed with NIH tools.

RESULTS

The database search retrieved 3,225 results, of which 16 were included in the meta-analysis. The pooled successful pregnancy rate was 23.52 % (16 studies, 95 % CI 6.48 to 44.79 %). When subgroup analysis of study types was performed, the successful pregnancy rate was higher amongst case series (47.02 %, 9 studies, 95 % CI 6.98 to 89.00 %) than cohort studies (14.64 %, 7 studies, 95 % CI 3.59 to 29.78 %). Sensitivity analysis limited to studies at low risk of bias revealed a similar pooled successful pregnancy rate of 23.35 % (12 studies, 95 % CI 2.50 to 51.96 %).

CONCLUSIONS

Approximately one quarter of women who underwent OTC for non-malignant indications had a successful pregnancy. These findings are clinically important for fertility preservation counselling by providing greater evidence for more informed care.

Fertility preservation in women with haematological malignancies

The incidence of haematological malignancies is increasing in women of childbearing age. Survival rates accompany this increase, making it essential to assess the impact of treatments on their future quality of life, evaluate the impact of each treatment on ovarian reserve and define the fertility preservation techniques used by women with haematologic malignancies. A retrospective study was conducted after data collection from 61 women diagnosed with haematological malignancies and followed-up in a fertility preservation centre between January 2008 and June 2019. Cancer treatments caused a decrease in ovarian reserve, demonstrated by an increase in FSH levels and a decrease in AMH levels. When assessing which treatments have the greatest impact on AMH levels, we found that the BEACOPP regimen, and the agents vincristine, etoposide, procarbazine, prednisone and the haematopoietic stem cell transplantation were mainly responsible. Regarding pregnancy after oncological treatments, of the eleven women who became pregnant, ten did so spontaneously. This study reinforces the importance of referring patients to a fertility preservation consultation before starting oncological treatment, as most of them opt to preserve fertility. This work also helps to clarify the impact of each chemotherapeutic agent on the ovarian reserve.

Identification of transcriptome characteristics of granulosa cells and the possible role of UBE2C in the pathogenesis of premature ovarian insufficiency

BACKGROUND

Premature ovarian insufficiency (POI) is an important cause of infertility characterized by the functional decline of the ovary. Granulosa cells (GCs) around oocytes are critical for folliculogenesis, and GC dysfunction is one of the important etiologies of POI. The aim of this study was to explore the potential biomarkers of POI by identifying hub genes and analyze the correlation of biomarkers with immune infiltration in POI using RNA profiling and bioinformatics analysis.

METHODS

RNA sequencing was performed on GCs from biochemical POI (bPOI) patients and controls. Differential expression analysis and weighted gene co-expression network analysis (WGCNA) were used to explore the candidate genes. qRT‒PCR was performed to verify the expression of hub genes. Western blot, Cell Counting Kit-8, 5-ethynyl-2'-deoxyuridine (EdU) assays, TUNEL (TdT-mediated dUTP Nick-End Labeling) and flow cytometry analysis were used to validate the possible role of ubiquitin-conjugating enzyme 2C (UBE2C) in POI. CIBERSORT was adopted to explore immune cell infiltration and the correlation between UBE2C and immune cells in bPOI.

RESULTS

Through analysis of differentially expressed genes (DEGs) and WGCNA, we obtained 143 candidate genes. After construction of the protein‒protein interaction (PPI) network and analysis with Cytoscape, 10 hub genes, including UBE2C, PBK, BUB1, CDC20, NUSAP1, CENPA, CCNB2, TOP2A, AURKB, and FOXM1, were identified and verified by qRT‒PCR. Subsequently, UBE2C was chosen as a possible biomarker of POI because knockdown of UBE2C could inhibit the proliferation and promote the apoptosis of GCs. Immune infiltration analysis indicated that monocytes and M1 macrophages may be associated with the pathogenesis of POI. In addition, UBE2C was negatively correlated with monocytes and M1 macrophages in POI.

CONCLUSIONS

This study identified a hub gene in GCs that might be important in the pathogenesis of POI and revealed the key role of UBE2C in driving POI. Immune infiltration may be highly related with the onset and etiology of POI.

Actual situation of decision-making support from medical staff when cancer patients make treatment choices

Background: We investigated factors involved in decision-making support provided by physicians, nurses, pharmacists and medical and psychiatric social workers involved in cancer care. Materials & methods: A questionnaire survey on decision-making support was conducted. The level of clinician support was classified as 'supporting patients' 'decision-making process regarding cancer treatment', 'no support for patients' 'decision-making process regarding cancer treatment' or 'team-based support for patients' 'decision-making process regarding cancer treatment'. Results: Physicians estimated that 83.7% of patients made a cancer treatment decision within 1 week, but 45.4% of patients had difficulty making a decision. Conclusion: Medical personnel should support patients who have difficulty making decisions, establish a screening method to identify those needing support and develop a system providing decision-making support through interprofessional work.

The mTOR Inhibitor Rapamycin Counteracts Follicle Activation Induced by Ovarian Cryopreservation in Murine Transplantation Models

Background and Objectives: Ovarian tissue cryopreservation followed by autotransplantation (OTCTP) is currently the only fertility preservation option for prepubertal patients. Once in remission, the autotransplantation of frozen/thawed tissue is performed when patients want to conceive. A major issue of the procedure is follicular loss directly after grafting mainly due to follicle activation. To improve follicular survival during the OTCTP procedure, we inhibited the mTOR pathway involved in follicle activation using rapamycin, an mTOR inhibitor. Next, we compared two different in vivo models of transplantation: the recently described non-invasive heterotopic transplantation model between the skin layers of the ears, and the more conventional and invasive transplantation under the kidney capsule. Materials and Methods: To study the effects of adding rapamycin during cryopreservation, 4-week-old C57BL/6 mouse ovaries, either fresh, slow-frozen, or slow-frozen with rapamycin, were autotransplanted under the kidney capsule of mice and recovered three weeks later for immunohistochemical (IHC) analysis. To compare the ear with the kidney capsule transplantation model, fresh 4-week-old C57BL/6 mouse ovaries were autotransplanted to either site, followed by an injection of either LY294002, a PI3K inhibitor, vehicle control, or neither, and these were recovered three weeks later for IHC analysis. Results: Rapamycin counteracts cryopreservation-induced follicle proliferation, as well as AKT and mTOR pathway activation, in ovaries autotransplanted for three weeks under the kidney capsule of mice. Analyses of follicle proliferation, mTOR activation, and the effects of LY294002 treatment were similar in transplanted ovaries using either the ear or kidney capsule transplantation model. Conclusions: By adding rapamycin during the OTCTP procedure, we were able to transiently maintain primordial follicles in a quiescent state. This is a promising method for improving the longevity of the ovarian graft. Furthermore, both the ear and kidney capsule transplantation models were suitable for investigating follicle activation and proliferation and pharmacological strategies.

Current Trends on Bioengineering Approaches for Ovarian Microenvironment Reconstruction

Ovarian tissue has a unique microarchitecture and a complex cellular and molecular dynamics that are essential for follicular survival and development. Due to this great complexity, several factors may lead to ovarian insufficiency, and therefore to systemic metabolic disorders and female infertility. Techniques currently used in the reproductive clinic such as oocyte cryopreservation or even ovarian tissue transplant, although effective, have several limitations, which impair their wide application. In this scenario, mimetic ovarian tissue reconstruction comes as an innovative alternative to develop new methodologies for germ cells preservation and ovarian functions restoration. The ovarian extracellular matrix (ECM) is crucial for oocyte viability maintenance, once it acts actively in folliculogenesis. One of the key components of ovarian bioengineering is biomaterials application that mimics ECM and provides conditions for cell anchorage, proliferation, and differentiation. Therefore, this review aims at describing ovarian tissue engineering approaches and listing the main limitations of current methods for preservation and reestablishment of ovarian fertility. In addition, we describe the main elements that structure this study field, highlighting the main advances and the challenges to overcome to develop innovative methodologies to be applied in reproductive medicine. Impact Statement This review presents the main advances in the application of tissue bioengineering in the ovarian tissue reconstruction to develop innovative solutions for ovarian fertility reestablishment.

Photodynamic therapy using OR141-loaded nanovesicles for eradication of leukemic cells from ovarian tissue

In 2020, the estimated number of new leukemia cases was higher than 30,000 in girls between 0 and 19 years old. Due to cancer treatment, some of these patients may lose both endocrine and reproductive functions. Transplantation of cryopreserved ovarian tissue is not advised after cancer remission because it has a high risk of reintroducing malignant cells in the patient, potentially leading to leukemia recurrence. To safely transplant the ovarian tissue from these patients and restore their fertility, our goal was to develop a photodynamic therapy (PDT) strategy to eliminate leukemia ex vivo. To this end, we designed, optimized, and characterized OR141-loaded niosomes (ORN) to develop the most effective formulation for ex vivo purging ovarian fragments from chronic myelogenous leukemia cells. After establishing the best ORN formulation, the PDT efficiency of optimized ORN was determined for human ovarian stromal cells and acute myeloid leukemia cell line (HL60). Blank niosomes treatment on ovarian stromal cells causes no significant toxicity, showing that the composition of the nanoparticle is not toxic. On the other hand, the in vitro studies showed that while ovarian stromal cells were still viable (82.04 ± 2.79%) after the treatment by 0.5 µM ORN, the same treatment yielded 95.43 ± 3.89% toxicity and cell death in the cancer cells. In conclusion, our results showed that our novel PDT procedure could be a promising strategy to destroy leukemia cells in ovarian tissue fragments allowing safe transplantation in cancer survivors.

Secure transplantation by tissue purging using photodynamic therapy to eradicate malignant cells

The field of photodynamic therapy (PDT) for treating various malignant neoplasms has been given researchers' attention due to its ability to be a selective and minimally invasive cancer therapy strategy. The possibility of tumor cell infection and hence high recurrence rates in cancer patients tends to restrict autologous transplantation. So, the photodynamic tissue purging process, which consists of selective photoinactivation of the malignant cells in the graft, is defined as a compromising strategy to purify contaminated tissues before transplantation. In this strategy, the direct malignant cells' death results from the reactive oxygen species (ROS) generation through the activation of a photosensitizer (PS) by light exposure in the presence of oxygen. Since new PS generations can effectively penetrate the tissue, PDT could be an ideal ex vivo tissue purging protocol that eradicates cancer cells derived from various malignancies. The challenge is that the applied pharmacologic ex vivo tissue purging should efficiently induce tumor cells with minor influence on normal tissue cells. This review aims to provide an overview of the current status of the most effective PDT strategies and PS development concerning their potential application in ex vivo purging before hematopoietic stem cell or ovarian tissue transplantation.

Shortening the duration between ovarian removal and cryopreservation helps preserve fertility and maintain ovarian reserve after transplantation in mice

OBJECTIVE

To evaluate the effect of storage of ovaries before cryopreservation on long-term fertility and ovarian reserve after transplantation in mice.

DESIGN

Experimental study.

SETTING

University hospital.

ANIMAL(S)

C57BL/6J and C57BL/6J-Tg (CAG-GFP) female mice.

INTERVENTION(S)

Storage and cryopreservation of mouse ovaries. Long-term fertility analysis of mice transplanted with thawed ovaries.

MAIN OUTCOME MEASURE(S)

Estrous cycles, number of live births, ovarian weight, and follicular counts of ovarian grafts.

RESULT(S)

At the first mating 3 months after ovarian transplantation, the mean number of live births was 2.6 ± 0.6 in the control group (no storage); in the storage groups, the mean number of live births was 2.9 ± 0.7 after 4 hours, 1.3 ± 0.5 after 8 hours, 0.2 ± 0.2 after 12 hours, and 0.8 ± 0.5 after 24 hours of storage; the difference from the control group was significant in the 12-hour storage group. At the second mating 6 months after ovarian transplantation, the mean number of live births was 1.8 ± 0.6 in the control group and 2.4 ± 0.6 and 0.3 ± 0.2 in the 4- and 8-hour storage groups, respectively; no live births occurred in the 12- and 24-hour storage groups. Seven months after ovarian transplantation, the numbers of primordial, primary, early secondary, and late secondary follicles were significantly lower in the 8-, 12-, and 24-hour storage groups than in the control group.

CONCLUSION(S)

In mice, shortening the storage time of ovaries before cryopreservation preserved fertility and ovarian reserve after transplantation, indicating that human ovaries might be cryopreserved immediately after harvesting or transported as quickly as possible to a cryopreservation facility to allow young patients with cancer to preserve long-term fertility and ovarian reserve.

Updates in Enhanced Recovery Pathways for Gynecologic Surgery

Gynecologic surgery encompasses over a quarter of inpatient surgical procedures for US women, and current projections estimate an increase of the US female population by nearly 50% in 2050. Over the last decade, US hospitals have embraced enhanced recovery pathways in many specialties. They have increasingly been used in multiple institutions worldwide, becoming the standard of care for patient optimization. According to the last updated enhanced recovery after surgery (ERAS) guideline published in 2019, there are several new considerations behind each practice in ERAS protocols. This article discusses the most updated evidence regarding ERAS programs for gynecologic surgery.

Oncofertility and Reproductive Counseling in Patients with Breast Cancer: A Retrospective Study

Introduction. Improving the prognosis of breast cancer patients is of utmost importance in terms of increasing survival rates. Modern medicine has therefore prioritized better quality of life for patients, even after the disease, through a better management of the potential long-term side effects induced by anticancer treatments. Fertility preservation and family planning are therefore crucial issues to be addressed in all cancer patients of reproductive age. Along those lines, a new branch of medicine with distinct multidisciplinary characteristics has developed over the years: oncofertility. Although both national and international guidelines value reproductive counseling as an essential aspect of the diagnostic-therapeutic pathway, part and parcel of the informed consent process, it is not included within the protocols adopted by the operating units for the care and management of neoplastic diseases. Objective. This study aimed to evaluate the activity of the Breast Unit of the Policlinico Umberto I Hospital, Rome, Italy, and the degree of compliance with guidelines. By knowing the strengths and weaknesses of such approaches, the standards of care offered to breast cancer patients can be improved. Materials and methods. A retrospective study based on a review of medical records was conducted between 2014 and 2021. Patients under 40 years of age diagnosed with non-metastatic malignancies were included who received chemotherapy treatment, namely neoadjuvant, adjuvant or adjuvant hormone therapy. Results. The data were extracted from the medical records of 51 patients who met the inclusion criteria, 41% of whom received reproductive counseling, and of these, 43% decided to undertake a path of fertility preservation. Factors such as the absence of children and young age reportedly favored both the interest in counseling proposals by the medical staff and the decision to undertake a path of fertility preservation. Conclusions. The study shows that there has been growing interest in the topic of oncofertility, especially in light of law 219/2017. Therefore, since 2018, multiple proposals for reproductive counseling have been set forth, but there was not an equally growing demand for fertility preservation practices, which can be explained by the invasive nature of such practices, the patients’ concern about their own state of health, and poor or inadequate information. Such impediments highlight the importance of standardized counseling and the need for a multidisciplinary medical team to support the patient in the decision-making process. The study also revealed a drop in the number of patients receiving counseling due to the COVID-19 pandemic, contrary to the positive trend that was recorded prior to the pandemic.

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

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

AlPc/ZnPc-based oncological photodynamic therapy for a selective eradication of leukemic cells from ovarian tissue

Due to the risk of reintroducing malignant cells, autotransplantation of cryopreserved ovarian tissue is not allowed in leukemia patients. In order to restore fertility in these patients, ex vivo purging of ovarian fragments could be proposed as a strategy to eradicate malignant cells before grafting. Photodynamic therapy (PDT), as a clinical-approved modality, is a minimally invasive and selective therapeutic for eliminating malignant cells. The present work aims therefore to evaluate the phototoxicity of two photosensitizers (aluminum phthalocyanine (AlPc) and zinc phthalocyanine (ZnPc)) on leukemia cells. To this end, two lines of malignant cells (K562 and HL-60) and isolated ovarian stromal cells (control) were treated by PDT using a diode laser with various energy densities. Cell viability after the treatment, the amount of generated reactive oxygen species, dark toxicity of the photosensitizers, and single-cell morphology were studied. Our results demonstrated that using irradiation with the energy density of 10 J/cm², 1 µM AlPc could significantly reduce the viability of K562 (4.73 ± 0.14%) and HL-60 (2.74 ± 0.31%). Similarly, the viability of these cells was reduced (K562 cells: 3.84 ± 0.81%; HL-60 cells: 6.82 ± 3.21%) with 1 µM ZnPc and an energy density of 50 J/cm². On the other hand, these PDT protocols had no significant effect on stromal cells. These findings indicate that our approach can be a promising strategy for the safe restoration of fertility in leukemia patients. However, further studies are necessary to assess its efficiency in ovarian fragments containing malignant cells to determine their eradication rate and the effect of our treatment on the survival of stromal cells and preantral follicles.

Pharmacological inhibition of the PI3K/PTEN/Akt and mTOR signalling pathways limits follicle activation induced by ovarian cryopreservation and in vitro culture

BACKGROUND

Cryopreservation and transplantation of ovarian tissue (OTCTP) represent a promising fertility preservation technique for prepubertal patients or for patients requiring urgent oncological management. However, a major obstacle of this technique is follicle loss due to, among others, accelerated recruitment of primordial follicles during the transplantation process, leading to follicular reserve loss in the graft and thereby potentially reducing its lifespan. This study aimed to assess how cryopreservation itself impacts follicle activation.

RESULTS

Western blot analysis of the PI3K/PTEN/Akt and mTOR signalling pathways showed that they were activated in mature or juvenile slow-frozen murine ovaries compared to control fresh ovaries. The use of pharmacological inhibitors of follicle signalling pathways during the cryopreservation process decreased cryopreservation-induced follicle recruitment. The second aim of this study was to use in vitro organotypic culture of cryopreserved ovaries and to test pharmacological inhibitors of the PI3K/PTEN/Akt and mTOR pathways. In vitro organotypic culture-induced activation of the PI3K/PTEN/Akt pathway is counteracted by cryopreservation with rapamycin and in vitro culture in the presence of LY294002. These results were confirmed by follicle density quantifications. Indeed, follicle development is affected by in vitro organotypic culture, and PI3K/PTEN/Akt and mTOR pharmacological inhibitors preserve primordial follicle reserve.

CONCLUSIONS

Our findings support the hypothesis that inhibitors of mTOR and PI3K might be an attractive tool to delay primordial follicle activation induced by cryopreservation and culture, thus preserving the ovarian reserve while retaining follicles in a functionally integrated state.

Fertility preservation in ovarian cancer patients

Ovarian cancer is more frequent in post-menopausal women, however it can also occur in young premenopausal women. After diagnosis and cancer staging, health care providers should address the possibility of infertility and might offer fertility preservation options. Chemotherapy, frequently used when treating ovarian cancer, has proven to cause extensive ovarian damage. Standard surgery may be aggressive and the recurrence risk may not be relevant enough to opt for these approaches. Fertility sparing surgery has been progressively accepted and many alternative surgical approaches have proven to be successful in both cancer treatment, fertility preservation and low recurrence rates. Though there are several techniques available for fertility preservation in cancer patients, when dealing with ovarian cancer patients, oocyte and embryo cryopreservation are the only suitable. Ovarian tissue cryopreservation has been largely studied, but no data on ovarian cancer patients exist, due to the risk of reimplanting cancer cells.

Female fertility preservation: Impact of cancer on ovarian function and oocyte quality

OBJECTIVE

To evaluate the influence of cancer on ovarian response and oocyte quality in controlled ovarian hyperstimulation (COH).

METHODS

This prospective study conducted at the Physiopathology of Reproduction and Andrology Unit of Sandro Pertini Hospital enrolled 82 cancer patients undergoing controlled ovarian stimulation (COH) cycles for fertility preservation, and age- and date-matched controls undergoing COH for in vitro fertilization for male-factor infertility from June 2016 to November 2019. The interventions performed were COH, oocyte retrieval, and quality evaluation. Main outcome measures were maximal estradiol levels on the day of human chorionic gonadotropin administration, duration of stimulation, total amount of gonadotropins administered, number of oocytes retrieved, and rates of metaphase 2 oocytes and abnormal oocytes. All data were analyzed using the Statistical Package for the Social Sciences (IBM Corp., Armonk, NY, USA) 22.0.

RESULTS

Intergroup comparisons (82 cancer patients and 180 patients in control group) showed a significant difference in ovarian response, especially for a significant higher number of abnormal oocytes in cancer patients (P < 0.0001). Regression analysis to assess the influence of the neoplastic process, regardless of the type, on ovarian response showed an effect on the main outcome measured due to cancer itself.

CONCLUSION

Cancer influences the ovarian response, particularly the oocyte quality, during COH performed for fertility preservation.

Purging human ovarian cortex of contaminating leukaemic cells by targeting the mitotic catastrophe signalling pathway

PURPOSE

Is it possible to eliminate metastasised chronic myeloid leukaemia (CML) and acute myeloid leukaemia (AML) cells from ovarian cortex fragments by inhibition of Aurora B/C kinases (AURKB/C) without compromising ovarian tissue or follicles?

METHODS

Human ovarian cortex tissue with experimentally induced tumour foci of CML, AML and primary cells of AML patients were exposed to a 24h treatment with 1 μM GSK1070916, an AURKB/C inhibitor, to eliminate malignant cells by invoking mitotic catastrophe. After treatment, the inhibitor was removed, followed by an additional culture period of 6 days to allow any remaining tumour cells to form new foci. Ovarian tissue integrity after treatment was analysed by four different assays. Appropriate controls were included in all experiments.

RESULTS

Foci of metastasised CML and AML cells in ovarian cortex tissue were severely affected by a 24h ex vivo treatment with an AURKB/C inhibitor, leading to the formation of multi-nuclear syncytia and large-scale apoptosis. Ovarian tissue morphology and viability was not compromised by the treatment, as no significant difference was observed regarding the percentage of morphologically normal follicles, follicular viability, glucose uptake or in vitro growth of small follicles between ovarian cortex treated with 1 μM GSK1070916 and the control.

CONCLUSION

Purging of CML/AML metastases in ovarian cortex is possible by targeting the Mitotic Catastrophe Signalling Pathway using GSK1070916 without affecting the ovarian tissue. This provides a therapeutic strategy to prevent reintroduction of leukaemia and enhances safety of autotransplantation in leukaemia patients currently considered at high risk for ovarian involvement.

Gynecologic Malignancies in Children and Adolescents: How Common is the Uncommon?

The aim of this study is to assess the projected incidence and prognostic indicators of gynecologic malignancies in the pediatric population. In this population-based retrospective cohort study, girls ≤18 years with ovarian, uterine, cervical, vaginal and vulvar malignancies diagnosed between 2000 and 2016 were identified from the Surveillance, Epidemiology and End Results (SEER)-18 registry. The Kaplan-Meier method was used to analyze overall survival (OS). The age-adjusted annual incidence of gynecologic malignancies was 6.7 per 1,000,000 females, with neoplasms of the ovary accounting for 87.5%, vagina 4.5%, cervix 3.9%, uterus 2.5% and vulva 1.6% of all gynecologic malignancies. Malignant germ-cell tumors represented the most common ovarian neoplasm, with an increased incidence in children from 5-18 years. Although certain subtypes were associated with advanced disease stages, the 10-year OS rate was 96.0%. Sarcomas accounted for the majority of vaginal, cervical, uterine and vulvar malignancies. The majority of vaginal neoplasms were observed in girls between 0-4 years, and the 10-year OS rate was 86.1%. Overall, gynecologic malignancies accounted for 4.2% of all malignancies in girls aged 0-18 years and the histologic subtypes and prognosis differed significantly from patients in older age groups.

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

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

Whole Ovary Cryopreservation and Transplantation: A Systematic Review of Challenges and Research Developments in Animal Experiments and Humans

Ovarian tissue cryopreservation and transplantation is the only fertility preservation option that enables both restoration of fertility and resumption of ovarian endocrine function, avoiding the morbidity associated with premature menopause. It is also the only technique available to prepubertal patients and those whose treatment cannot be delayed for life-threatening reasons. Ovarian tissue cryopreservation can be carried out in two different ways, either as ovarian cortical fragments or as a whole organ with its vascular pedicle. Although use of cortical strips is the only procedure that has been approved by the American Society for Reproductive Medicine, it is fraught with drawbacks, the major one being serious follicle loss occurring after avascular transplantation due to prolonged warm ischemia. Whole ovary cryopreservation involves vascular transplantation, which could theoretically counteract the latter phenomenon and markedly improve follicle survival. In theory, this technique should maintain endocrine and reproductive functions much longer than grafting of ovarian cortical fragments. However, this procedure includes a number of critical steps related to (A) the level of surgical expertise required to accomplish retrieval of a whole ovary with its vascular pedicle, (B) the choice of cryopreservation technique for freezing of the intact organ, and (C) successful execution of functional vascular reanastomosis upon thawing. The aim of this systematic review is to shed light on these challenges and summarize solutions that have been proposed so far in animal experiments and humans in the field of whole ovary cryopreservation and transplantation.

Progress in Fertility Preservation Strategies in Turner Syndrome

Growth retardation and gonadal dysgenesis are two of the most important clinical manifestations of Turner syndrome (TS). As premature ovarian failure generally occurs early in life in women with TS, these patients should be counseled and evaluated as early as possible for discussion of optimal and individualized fertility preservation strategies. Infertility seriously affects the quality of life of women with TS. For those who have ovarian reserve, the theoretical options for future fertility in TS patients include cryopreservation of oocytes, ovarian tissues, and embryos. For those who have already lost their ovarian reserve, oocyte or embryo donation, gestational surrogacy, and adoption are strategies that allow fulfillment of desire for parenting. This review describes the etiologies of infertility and reviews the fertility preservation strategies for women with TS.

Challenging iatrogenic menopause. Oncofertility programme in Poland - a single-centre experience

Introduction

Menopause is defined as a 12-month period of time when menstruation permanently ceases. In some cases, menopause may be caused by external factors – for example gonadotoxic treatment that irreversibly damages ovarian tissue leading to loss of its hormonal and reproductive function. Oncofertility is a discipline that merges oncology and reproductive medicine, giving patients a chance to experience parenthood after gonadotoxic treatment is finished.

Aim of the study

The purpose of the study is to present the implementation and first outcomes of the Oncofertility Programme in the University Clinic of Endocrinological Gynaecology and Gynaecology, University Hospital in Krakow, Poland.

Material and methods

Patients interested in fertility preservation have been consulted in the University Clinic of Endocrinological Gynaecology and Gynaecology in Krakow since April 2016. Preliminary qualification to one of the available methods (embryo cryopreservation, oocyte cryopreservation, ovarian tissue cryopreservation) was conducted. Patients declaring a wish to join the programme were then referred to one of the three infertility treatment centres cooperating with the University Clinic, in order to undergo the chosen procedure.

Results

During a period of 24 months, 18 patients were consulted. The youngest consulted patient was 20 years old, the oldest 39. Two years after the first consultation, a telephone survey among consulted patients was carried out to verify whether the patients finally underwent oncofertility procedures, and to ask about their reproductive status.

Conclusions

The problem of fertility issues being inadequately addressed results in low referral rates to oncofertility programmes. Attempts to raise awareness of oncofertility possibilities among oncologists should be undertaken because critically few patients are being referred to oncofertility centres.

A Japanese nationwide survey on the cryopreservation of embryos, oocytes and ovarian tissue for cancer patients

AIM

The survival rates of cancer patients have greatly improved owing to the advances in oncology. The preservation of fertility in cancer patients is an important task. To determine the reality of cryopreservation of embryos, oocytes and ovarian tissue in cancer patients, large-scale survey analysis was performed in Japan.

METHODS

We sent 613 Japan Society of Obstetrics and Gynecology-certified assisted reproductive technology institutions a questionnaire about their experience of performing cryopreservation for cancer patients between January 2011 and December 2015. Subsequently, the institutions that conducted cryopreservation for cancer patients were sent a second questionnaire.

RESULTS

We received replies from 481 (78.5%) institutions. Among them, 126 (26.2%) conducted cryopreservation for cancer patients. These 126 institutions were sent a second questionnaire. Of these, 108 (85.7%) institutions responded. At the 108 institutions, 1085 embryo or oocyte cryopreservation procedures and 122 ovarian tissue cryopreservation procedures were conducted for cancer patients. Cryopreservation was mainly performed for breast cancer patients (~70%), followed by patients with hematological malignancy. A total of 361 and 19 embryo transfer cycles were performed for patients whose embryos and oocytes were cryopreserved, respectively, and 42 and seven institutions reported pregnancy outcomes after embryo transfer in patients that underwent embryo and oocyte cryopreservation, respectively. However, pregnancy was not observed in the seven cases that underwent ovarian tissue transfer.

CONCLUSION

Indications, age limits and ovarian stimulation protocols for cryopreservation widely varied between the institutions. A national registration system for oncofertility must be established to evaluate the safety and efficacy of the current system.

Recent Advances in Fertility Preservation and Counseling for Reproductive-Aged Women with Colorectal Cancer: A Systematic Review

BACKGROUND

The incidence of colorectal cancer among reproductive-aged women is increasing. Concerns regarding future fertility are secondary only to concerns regarding survival and may significantly impact quality of life among reproductive-aged female cancer survivors. Fertility preservation counseling reduces long-term regret and dissatisfaction among cancer survivors. Health care providers counseling patients with colorectal cancer must understand the impact of cancer treatment on future reproductive potential.

OBJECTIVE

This review aims to examine the effects that colorectal cancer treatments have on female fertility and summarize existing and emerging options for fertility preservation.

DATA SOURCES

EMBASE, National Library of Medicine (MEDLINE)/PubMed, Cochrane Review Library were the data sources for this review.

STUDY SELECTION

A systematic literature review was performed using exploded MeSH terms to identify articles examining the effect of surgery, chemotherapy, and radiation, as well as fertility preservation options for colorectal cancer on female fertility. Relevant studies were included.

MAIN OUTCOME MEASURES

The primary outcome was the effect of colorectal cancer treatment on fertility.

RESULTS

There are limited data regarding the impact of colorectal surgery on fertility. The gonadotoxic effects of chemotherapy on reproductive capacity depend on age at the time of chemotherapy administration, cumulative chemotherapy, radiation dose, type of agent, and baseline fertility status. Chemotherapy-induced risks for colorectal cancers are considered low to moderate, whereas pelvic radiation with a dose of 45 to 50 Gray induces premature menopause in greater than 90% of patients. Ovarian transposition may reduce but not eliminate the damaging effect of radiation on the ovaries. Embryo and oocyte cryopreservation are considered standard of care for women desiring fertility preservation, with oocyte cryopreservation no longer being considered experimental. Ovarian tissue cryopreservation remains experimental but may be an option for select patients. The use of gonadotropin-releasing hormone agonists remains controversial and has not been definitively shown to preserve fertility.

LIMITATIONS

The limitations of this review are the lack of randomized controlled trials and high-quality studies, as well as the small sample sizes and the use of surrogate fertility markers.

CONCLUSION

Reproductive-aged women with colorectal cancer benefit from fertility preservation counseling before the initiation of cancer treatment.

Cryopreservation of Human Ovarian Tissue: A Review

BACKGROUND

Cryopreservation of human ovarian tissue has been increasingly applied worldwide to safeguard fertility in cancer patients, notably in young girls and women who cannot delay the onset of their treatment. Moreover, it has been proposed to patients with benign pathologies with a risk of premature ovarian insufficiency. So far, more than 130 live births have been reported after transplantation of cryopreserved ovarian tissue, and almost all patients recovered their ovarian function after tissue reimplantation.

SUMMARY

This review aims to summarize the recent results described in the literature regarding human ovarian tissue cryopreservation in terms of methods and main results obtained so far. To cryopreserve human ovarian tissue, most studies describe a slow freezing/rapid thawing protocol, which is usually an adaptation of a protocol developed for sheep ovarian tissue. Since freezing has been shown to have a deleterious effect on ovarian stroma and granulosa cells, various research groups have been vitrifying ovarian tissue. Despite promising results, only 2 babies have been born after transplantation of vitrified/warmed ovarian tissue. Optimization of both cryopreservation strategies as well as thawing/warming protocols is therefore necessary to improve the survival of follicles in cryopreserved ovarian tissue.

KEY MESSAGES

Human ovarian tissue cryopreservation has been successfully applied worldwide to preserve fertility in patients with malignant or nonmalignant pathologies that have a detrimental effect on fertility. Human ovarian tissue cryopreservation could also be applied as an alternative to postpone pregnancy or menopause in healthy women. Slow freezing and vitrification procedures have been applied to cryopreserve human ovarian tissue, but both alternatives require optimization.