1
|
Eijkenboom L, Saedt E, Zietse C, Braat D, Beerendonk C, Peek R. Strategies to safely use cryopreserved ovarian tissue to restore fertility after cancer: A systematic review. Reprod Biomed Online 2022; 45:763-778. [DOI: 10.1016/j.rbmo.2022.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 05/19/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
|
2
|
Fattahi A, Liverani L, Dittrich R, Hoffmann I, Boccaccini AR, Beckmann MW, Bleisinger N. Optimization of Porcine Ovarian Follicle Isolation Methods for Better Developmental Potential. Tissue Eng Part A 2020; 26:712-719. [PMID: 32598233 DOI: 10.1089/ten.tea.2020.0058] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In the present study, we present a comparative analysis among the outputs of porcine follicle isolation using either mechanical technique alone or in combination with enzymes, proposing an optimized protocol useful for all further applications related to follicle in vitro growth and reproductive tissue engineering. The porcine follicles were isolated using mechanical technique alone (hand blender and scalpels) or in combination with collagenase or Liberase Dispase High (DH) at different doses applying different protocols. Finally, the number, morphology, and stage of isolated follicles were compared between the protocols. Moreover, the follicle viability (live/dead assay) and morphology (rhodamine phalloidin and 4',6-diamidino-2-phenylindole staining and scanning electron microscopy analysis) were evaluated after 10 days of culture. We found an optimum protocol for intact follicle isolation using the mechanical technique in combination with enzymes at a concentration of 0.5 mg/mL. However, the number of total isolated follicles and primordial follicles was significantly higher when collagenase was used compared to Liberase DH (p < 0.05), while Liberase DH could isolate a significantly higher percentage of preantral follicles. After 10 days of culture, the morphology and health status of follicles were statistically higher when Liberase DH was used in comparison with collagenase. Moreover, on the follicles extracted with Liberase DH, it was possible to observe theca cells covering part of the follicle surface. In conclusion, we demonstrated that the intact primary or secondary follicles could not be obtained using only mechanical methods, which led to the isolation of denuded oocytes and dramatically damaged follicles. We concluded that the collagenase-based follicle isolation could negatively affect the morphology and developmental potential of the follicles. Moreover, the incubation of ovarian cortex tissues with Liberase DH solution is an optimized protocol for porcine ovarian follicle isolation with developmental competence. Impact statement Isolation and in vitro maturation of follicles can pave the way for activities on reproductive tissue engineering (REPROTEN) and developing an artificial ovary. In this regard, the standardization and optimization of the extraction methods are pivotal for the design of experiment of follicle in vitro growth. In the present study, we provided a comparative analysis among the outputs of porcine follicle isolation using either mechanical technique alone or in combination with collagenase or Liberase DH, proposing an optimized protocol useful for all further applications related to follicles' in vitro growth and REPROTEN.
Collapse
Affiliation(s)
- Amir Fattahi
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center ER-EMN, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen University Hospital, Erlangen, Germany.,Women's Reproductive Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Liliana Liverani
- Department of Materials Science and Engineering, Institute of Biomaterials, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Ralf Dittrich
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center ER-EMN, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen University Hospital, Erlangen, Germany
| | - Inge Hoffmann
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center ER-EMN, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen University Hospital, Erlangen, Germany
| | - Aldo R Boccaccini
- Department of Materials Science and Engineering, Institute of Biomaterials, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen, Germany
| | - Matthias W Beckmann
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center ER-EMN, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen University Hospital, Erlangen, Germany
| | - Nathalie Bleisinger
- Department of Obstetrics and Gynecology, Comprehensive Cancer Center ER-EMN, Friedrich-Alexander University of Erlangen-Nürnberg, Erlangen University Hospital, Erlangen, Germany
| |
Collapse
|
3
|
Human Ovarian Cortex biobanking: A Fascinating Resource for Fertility Preservation in Cancer. Int J Mol Sci 2020; 21:ijms21093245. [PMID: 32375324 PMCID: PMC7246700 DOI: 10.3390/ijms21093245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 12/21/2022] Open
Abstract
Novel anti-cancer treatments have improved the survival rates of female young patients, reopening pregnancy issues for female cancer survivors affected by the tumor treatment-related infertility. This condition occurs in approximately one third of women of fertile age and is mainly dependent on gonadotoxic protocols, including radiation treatments. Besides routine procedures such as the hormonal induction of follicular growth and subsequent cryopreservation of oocytes or embryos, the ovarian protection by gonadotropin-releasing hormone (GnRH) agonists during chemotherapy as well as even gonadal shielding during radiotherapy, other innovative techniques are available today and need to be optimized to support their introduction into the clinical practice. These novel methods are hormone stimulation-free and include the ovarian cortex cryopreservation before anti-cancer treatments and its subsequent autologous reimplantation and a regenerative medicine approach using oocytes derived in vitro from ovarian stem cells (OSCs). For both procedures, the major benefit is related to the prompt recruitment and processing of the ovarian cortex fragments before gonadotoxic treatments. However, while the functional competence of oocytes within the cryopreserved cortex is not assessable, the in vitro maturation of OSCs to oocytes, allows to select the most competent eggs to be cryopreserved for fertility restoration.
Collapse
|
4
|
Wiweko B, Soebijanto S, Boediono A, Mansyur M, Siregar NC, Suryandari DA, Aulia A, Djuwantono T, Affandi B. Survival of isolated human preantral follicles after vitrification: Analyses of morphology and Fas ligand and caspase-3 mRNA expression. Clin Exp Reprod Med 2019; 46:152-165. [PMID: 31813207 PMCID: PMC6919210 DOI: 10.5653/cerm.2019.00143] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 07/15/2019] [Indexed: 11/16/2022] Open
Abstract
Objective This study aimed to examine the effect of vitrification on apoptosis and survival in human preantral follicles after thawing. Methods This experimental study was conducted at an acute tertiary care hospital from March 2012 to April 2013. Ovaries were sliced into 5×5×1-mm pieces and divided into the following three groups: preantral follicle isolation, ovarian tissue vitrification-warming followed by follicle isolation, and immunohistochemistry of fresh ovarian tissue. For statistical analyses, the Student t-test, chi-square test, Kruskal-Wallis test, and Kaplan-Meier survival analysis were used. Results A total of 161 preantral follicles (70% secondary) were collected from ovarian cortex tissue of six women between 30 and 37 years of age who underwent oophorectomy due to cervical cancer or breast cancer. There were no significant differences in the follicular morphology of fresh preantral follicles and vitrified follicles after thawing. The mean Fas ligand (FasL) mRNA expression level was 0.43±0.20 (relative to β-actin) in fresh preantral follicles versus 0.51±0.20 in vitrified follicles (p=0.22). The mean caspase-3 mRNA expression level in fresh preantral follicles was 0.56±0.49 vs. 0.27±0.21 in vitrified follicles (p=0.233). One vitrified-thawed secondary follicle grew and developed to an antral follicle within 6 days of culture. Conclusion Vitrification did not affect preantral follicle morphology or mRNA expression of the apoptosis markers FasL and caspase-3. Further studies are required to establish whether vitrification affects the outcomes of in vitro culture and the maturation of preantral follicles.
Collapse
Affiliation(s)
- Budi Wiweko
- Department of Obstetrics and Gynecology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.,Indonesian Medical Education and Research Institute (IMERI), Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Soegiharto Soebijanto
- Department of Obstetrics and Gynecology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | | | - Muchtaruddin Mansyur
- Department of Public Health, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Nuryati C Siregar
- Department of Pathology Anatomy, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Dwi Anita Suryandari
- Department of Biology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Ahmad Aulia
- Department of Histology, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Tono Djuwantono
- Department of Obstetrics and Gynecology, Dr. Hasan Sadikin Hospital, Faculty of Medicine Universitas Padjajaran, Bandung, Indonesia
| | - Biran Affandi
- Department of Obstetrics and Gynecology, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| |
Collapse
|
5
|
Cho E, Kim YY, Noh K, Ku S. A new possibility in fertility preservation: The artificial ovary. J Tissue Eng Regen Med 2019; 13:1294-1315. [DOI: 10.1002/term.2870] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 04/02/2019] [Accepted: 04/22/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Eun Cho
- College of MedicineSeoul National University Seoul South Korea
| | - Yoon Young Kim
- College of MedicineSeoul National University Seoul South Korea
- Department of Obstetrics and GynecologySeoul National University Hospital Seoul South Korea
| | - Kevin Noh
- College of Human EcologyCornell University Ithaca New York USA
| | - Seung‐Yup Ku
- College of MedicineSeoul National University Seoul South Korea
- Department of Obstetrics and GynecologySeoul National University Hospital Seoul South Korea
| |
Collapse
|
6
|
Zhao H, Jin L, Li Y, Zhang C, Wang R, Li Y, Huang W, Cui C, Zhang H, Wang H, Ma D, Liao S. Oncofertility: What can we do from bench to bedside? Cancer Lett 2019; 442:148-160. [DOI: 10.1016/j.canlet.2018.10.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/03/2018] [Accepted: 10/16/2018] [Indexed: 12/11/2022]
|
7
|
Mulder CL, Eijkenboom LL, Beerendonk CCM, Braat DDM, Peek R. Enhancing the safety of ovarian cortex autotransplantation: cancer cells are purged completely from human ovarian tissue fragments by pharmacological inhibition of YAP/TAZ oncoproteins. Hum Reprod 2018; 34:506-518. [DOI: 10.1093/humrep/dey384] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 10/22/2018] [Accepted: 12/04/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Callista L Mulder
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, The Netherlands
| | - Lotte L Eijkenboom
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, The Netherlands
| | - Catharina C M Beerendonk
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, The Netherlands
| | - Didi D M Braat
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, The Netherlands
| | - Ronald Peek
- Radboud University Medical Center, Department of Obstetrics and Gynecology, Nijmegen, The Netherlands
| |
Collapse
|
8
|
Mouloungui E, Zver T, Roux C, Amiot C. A protocol to isolate and qualify purified human preantral follicles in cases of acute leukemia, for future clinical applications. J Ovarian Res 2018; 11:4. [PMID: 29304838 PMCID: PMC5756359 DOI: 10.1186/s13048-017-0376-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 12/26/2017] [Indexed: 12/21/2022] Open
Abstract
Background Autotransplantation of cryopreserved ovarian cortex can be associated with a risk of cancer cell reseeding. This issue could be eliminated by grafting isolated preantral follicles. Collagenase NB6 is an enzyme produced under good manufacturing practices (GMP) in compliance with requirements for tissue engineering and transplantation in humans and thus can be used to isolate preantral follicles from ovarian tissue in the framework of further clinical applications. Multicolor flow cytometry is an effective tool to evaluate the potential contamination of follicular suspensions by leukemic cells. Methods The efficiency of collagenase NB6 was evaluated in comparison to collagenase type IA and Liberase DH, in terms of yield, morphology and viability. A short-term in vitro culture of follicles isolated with collagenase NB6 was conducted for 3 days in a fibrin matrix. A modelization procedure was carried out to detect the presence of leukemic cells in follicular suspensions using multicolor flow cytometry (MFC). Results No statistical differences were found between collagenase NB6, Liberase DH (p = 0.386) and collagenase type IA (p = 0.171) regarding the number of human preantral follicles isolated. The mean diameter of isolated follicles was significantly lower with collagenase NB6 (p < 0.0001). The survival rate of isolated follicles was 93.4% (n = 272) using collagenase NB6 versus 94.9% (n = 198) with Liberase DH and 92.6% (n = 298) using collagenase type IA. Even after 3 days of in vitro culture in a fibrin scaffold, most of the isolated follicles were still alive after using collagenase NB6 (90.7% of viable follicles; n = 339). The rate of isolated Ki67-positive follicles was 29 ± 9.19% before culture and 45 ± 1.41% after 3 days. In 23 out of 24 follicular suspensions analyzed, the detection of leukemic cells by MFC was negative. The purification had no significant impact on follicle viability. Conclusion The isolation and purification of human preantral follicles were performed following good manufacturing practices for cell therapy. Multicolor flow cytometry was able to confirm that final follicular suspensions were free from leukemic cells. This safe isolation technique using collagenase NB6 can be considered for future clinical applications.
Collapse
Affiliation(s)
- Elodie Mouloungui
- University Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-25000, Besançon, France
| | - Tristan Zver
- University Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-25000, Besançon, France.,Department of Reproductive Medicine and Biology, Cryobiology, University Hospital of Besançon, 3 boulevard Fleming, 25000, Besançon Cedex, France
| | - Christophe Roux
- University Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-25000, Besançon, France.,INSERM CIC-1431, University Hospital of Besançon, Clinical Investigation Center in Biotherapy, F-25000, Besançon, France.,Department of Reproductive Medicine and Biology, Cryobiology, University Hospital of Besançon, 3 boulevard Fleming, 25000, Besançon Cedex, France
| | - Clotilde Amiot
- University Bourgogne Franche-Comté, INSERM, EFS BFC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, F-25000, Besançon, France. .,INSERM CIC-1431, University Hospital of Besançon, Clinical Investigation Center in Biotherapy, F-25000, Besançon, France. .,Department of Reproductive Medicine and Biology, Cryobiology, University Hospital of Besançon, 3 boulevard Fleming, 25000, Besançon Cedex, France.
| |
Collapse
|
9
|
Kniazeva E, Hardy AN, Boukaidi SA, Woodruff TK, Jeruss JS, Shea LD. Primordial Follicle Transplantation within Designer Biomaterial Grafts Produce Live Births in a Mouse Infertility Model. Sci Rep 2015; 5:17709. [PMID: 26633657 PMCID: PMC4668556 DOI: 10.1038/srep17709] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 11/04/2015] [Indexed: 11/09/2022] Open
Abstract
The gonadotoxic effects of chemotherapy and radiation may result in premature ovarian failure in premenopausal oncology patients. Although autotransplantation of ovarian tissue has led to successful live births, reintroduction of latent malignant cells inducing relapse is a significant concern. In this report, we investigated the design of biomaterial grafts for transplantation of isolated ovarian follicles as a means to preserve fertility. Primordial and primary ovarian follicles from young female mice were extracted and encapsulated into biomaterials for subsequent transplantation into adult mice. Among the formulations tested, aggregated follicles encapsulated within fibrin had enhanced survival and integration with the host tissue following transplantation relative to the fibrin-alginate and fibrin-collagen composites. All mice transplanted with fibrin-encapsulated follicles resumed cycling, and live births were achieved only for follicles transplanted within VEGF-loaded fibrin beads. The extent to which these procedures reduce the presence of metastatic breast cancer cells among the isolated follicles was evaluated, with significantly reduced numbers of cancer cells present relative to intact ovaries. This ability to obtain live births by transplanting isolated primordial and primary follicles, while also reducing the risk of re-seeding disease relative to ovarian tissue transplantation, may ultimately provide a means to preserve fertility in premenopausal oncology patients.
Collapse
Affiliation(s)
- E Kniazeva
- Department of Chemical and Biological Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208, USA.,Department of Obstetrics and Gynecology, Institute for Women's Health Research, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - A N Hardy
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA 19111, USA
| | - S A Boukaidi
- Department of Obstetrics and Gynecology and Reproductive Medicine, CHU de Nice, Archet 2 Hospital, Nice, France
| | - T K Woodruff
- Department of Obstetrics and Gynecology, Institute for Women's Health Research, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - J S Jeruss
- Department of Obstetrics and Gynecology, Institute for Women's Health Research, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.,Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| | - L D Shea
- Department of Chemical and Biological Engineering, McCormick School of Engineering, Northwestern University, Evanston, IL 60208, USA.,Department of Obstetrics and Gynecology, Institute for Women's Health Research, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI 48109, USA
| |
Collapse
|
10
|
Soares M, Sahrari K, Amorim CA, Saussoy P, Donnez J, Dolmans MM. Evaluation of a human ovarian follicle isolation technique to obtain disease-free follicle suspensions before safely grafting to cancer patients. Fertil Steril 2015; 104:672-80.e2. [DOI: 10.1016/j.fertnstert.2015.05.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 05/18/2015] [Accepted: 05/18/2015] [Indexed: 01/23/2023]
|
11
|
Peek R, Bastings L, Westphal JR, Massuger LFAG, Braat DDM, Beerendonk CCM. A preliminary study on a new model system to evaluate tumour-detection and tumour-purging protocols in ovarian cortex tissue intended for fertility preservation. Hum Reprod 2015; 30:870-6. [DOI: 10.1093/humrep/dev013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
|
12
|
Lierman S, Tilleman K, Cornelissen M, De Vos WH, Weyers S, T'Sjoen G, Cuvelier CA, De Sutter P. Follicles of various maturation stages react differently to enzymatic isolation: a comparison of different isolation protocols. Reprod Biomed Online 2014; 30:181-90. [PMID: 25530035 DOI: 10.1016/j.rbmo.2014.10.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 10/14/2014] [Accepted: 10/15/2014] [Indexed: 11/25/2022]
Abstract
Isolation of human follicles is based on digestion of the tissue by combinations of enzymes. Follicle vitality and morphology are often based on the analysis of pooled follicles of different maturation stages. Information is therefore lacking on the effect of the isolation protocol to individual follicles of different maturation stages. A study was conducted using five protocols combining different enzymes and varying concentrations. Isolated follicles were classified according to their maturation stages, counted and characterized for vitality, morphology, early apoptosis and organization of transzonal projections. No statistical differences were found between the protocols when outcome parameters were analysed on a pool of follicles regardless of their maturation status. Differences were observed in quality when the follicles were analysed separately according to their maturation status. Combining morphologic characteristics and vitality, both Liberase DH and Liberase TM combined with collagenase IV were better at isolating high-quality primordial follicles, compared with collagenase IV. No statistical difference between the isolation protocols was found for primary follicles. If only high-quality isolated secondary follicles are needed, collagenase IV is found to be most advantageous. Follicles of different maturation stages react differently when enzymatic isolation protocols are compared.
Collapse
Affiliation(s)
- Sylvie Lierman
- Department of Reproductive Medicine, Ghent University Hospital, 9000 Ghent, Belgium.
| | - Kelly Tilleman
- Department of Reproductive Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| | - Maria Cornelissen
- Department of Basic Medical Science, Faculty of Medicine and Health Science, Ghent University, 9000 Ghent, Belgium
| | - Winnok H De Vos
- Department of Veterinary Sciences, Faculty of Biochemical, Pharmaceutical and Veterinary Sciences, Antwerp University, 2020 Antwerp, Belgium; Department of Molecular Biotechnology, Faculty of Bioscience Engineering, Ghent University, 9000 Ghent, Belgium
| | - Steven Weyers
- Department of Gynaecology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Guy T'Sjoen
- Department of Endocrinology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Claude A Cuvelier
- Department of Pathology, Ghent University Hospital, 9000 Ghent, Belgium
| | - Petra De Sutter
- Department of Reproductive Medicine, Ghent University Hospital, 9000 Ghent, Belgium
| |
Collapse
|
13
|
Abstract
Enhanced long-term survival rates of young women with cancer and advances in reproductive medicine and cryobiology have culminated in an increased interest in fertility preservation methods in girls and young women with cancer. Present data suggest that young patients with cancer should be referred for fertility preservation counselling quickly to help with their coping process. Although the clinical application of novel developments, including oocyte vitrification and oocyte maturation in vitro, has resulted in reasonable success rates in assisted reproduction programmes, experience with these techniques in the setting of fertility preservation is in its infancy. It is hoped that these and other approaches, some of which are still regarded as experimental (eg, ovarian tissue cryopreservation, pharmacological protection against gonadotoxic agents, in-vitro follicle growth, and follicle transplantation) will be optimised and become established within the next decade. Unravelling the complex mechanisms of activation and suppression of follicle growth will not only expand the care of thousands of women diagnosed with cancer, but also inform the care of millions of women confronted with reduced reproductive fitness because of ageing.
Collapse
Affiliation(s)
- Michel De Vos
- Centre for Reproductive Medicine, UZ Brussel, Brussels, Belgium.
| | - Johan Smitz
- Laboratory of Clinical Chemistry and Radioimmunology, UZ Brussel, Brussels, Belgium
| | - Teresa K Woodruff
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
14
|
Smith RM, Shikanov A, Kniazeva E, Ramadurai D, Woodruff TK, Shea LD. Fibrin-mediated delivery of an ovarian follicle pool in a mouse model of infertility. Tissue Eng Part A 2014; 20:3021-30. [PMID: 24802617 DOI: 10.1089/ten.tea.2013.0675] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
The cryopreservation and autotransplantation of ovarian tissue is emerging as a powerful approach for preserving fertility. However, for cancer patients, it may not be possible to transplant ovarian tissue due to the risk of re-seeding disease. We investigated strategies for transplantation of individually isolated follicles to minimize the risk of re-introducing cancer cells present within the vasculature of ovarian stroma. Procedures for large-scale isolation of early-stage follicles and their encapsulation into fibrin hydrogels were developed. For in vivo validation studies, mice were ovariectomized and transplanted with encapsulated follicles into the ovarian bursa. A substantial increase in the number of secondary follicles was observed in the graft at 9 days after transplantation, and antral follicles by day 21, demonstrating primordial follicle recruitment into the growing pool. Initially, elevated follicle-stimulating hormone levels declined substantially by day 21, indicating feedback from the graft; presence of corpora lutea showed the graft's capability of restoring hormone cyclicity. Taken together, the transplanted follicles were able to engraft, mature, and restore ovarian function in an infertile mouse. This biomaterial may, thus, provide a platform for follicle transplantation with a low risk of cancer contamination and for developing strategies that preserve fertility for women facing a cancer diagnosis.
Collapse
Affiliation(s)
- Rachel M Smith
- 1 Department of Chemical and Biological Engineering, Northwestern University , Evanston, Illinois
| | | | | | | | | | | |
Collapse
|
15
|
Bastings L, Beerendonk CCM, Westphal JR, Massuger LFAG, Kaal SEJ, van Leeuwen FE, Braat DDM, Peek R. Autotransplantation of cryopreserved ovarian tissue in cancer survivors and the risk of reintroducing malignancy: a systematic review. Hum Reprod Update 2013; 19:483-506. [PMID: 23817363 DOI: 10.1093/humupd/dmt020] [Citation(s) in RCA: 156] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The risk of recurrent oncological disease due to the reintroduction of cancer cells via autotransplantation of cryopreserved ovarian tissue is unknown. METHODS A systematic review of literature derived from MEDLINE, EMBASE and the Cochrane Library was conducted. Studies on follow-up after autotransplantation; detection of cancer cells in ovarian tissue from oncological patients by histology, polymerase chain reaction or xenotransplantation; and epidemiological data on ovarian metastases were included. RESULTS A total of 289 studies were included. Metastases were repeatedly detected in ovarian tissue obtained for cryopreservation purposes from patients with leukaemia, as well as in one patient with Ewing sarcoma. No metastases were detected in ovarian tissue from lymphoma and breast cancer patients who had their ovarian tissue cryopreserved. Clinical studies indicated that one should be concerned about autotransplantation safety in patients with colorectal, gastric and endometrial cancer. For patients with low-stage cervical carcinoma, clinical data were relatively reassuring, but studies focused on the detection of metastases were scarce. Oncological recurrence has been described in one survivor of cervical cancer and one survivor of breast cancer who had their ovarian tissue autotransplanted, although these recurrences may not be related to the transplantation. CONCLUSIONS It is advisable to refrain from ovarian tissue autotransplantation in survivors of leukaemia. With survivors of all other malignancies, current knowledge regarding the safety of autotransplantation should be discussed. The most reassuring data regarding autotransplantation safety were found for lymphoma patients.
Collapse
Affiliation(s)
- L Bastings
- Department of Obstetrics and Gynaecology (791), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Grynberg M, Poulain M, Sebag-Peyrelevade S, le Parco S, Fanchin R, Frydman N. Ovarian tissue and follicle transplantation as an option for fertility preservation. Fertil Steril 2012; 97:1260-8. [PMID: 22656306 DOI: 10.1016/j.fertnstert.2012.04.042] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 04/26/2012] [Accepted: 04/26/2012] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To review and summarize data from the scientific literature on ovarian tissue and follicle transplantation as an option for fertility preservation. DESIGN Review of pertinent literature. SETTING University hospital. PATIENT(S) Women having undergone ovarian tissue transplantation. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Review of the literature. RESULT(S) Over the last decade, the field of ovarian transplantation and cryopreservation has significantly progressed, becoming applicable in humans. Indeed, fresh and frozen cortical ovarian tissue transplantations have been successfully reported worldwide, resulting in around 28 healthy babies. Although ovarian-tissue harvesting seems to be safe, the risk of reimplantation of cancer from ovarian cortical transplants cannot be estimated at this time. As a consequence, auto-transplantation of ovarian tissue in women having suffered from systemic hematological malignancies is not recommended. In these situations, reimplantation of isolated ovarian follicles might represent an interesting option in the future. CONCLUSION(S) Although the clinical experience is limited, the robust results obtained open new perspectives for the management of premature ovarian failure resulting or not from gonadotoxic treatments.
Collapse
Affiliation(s)
- Michael Grynberg
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hôpital Antoine Béclère, Clamart, France.
| | | | | | | | | | | |
Collapse
|
17
|
Detti L, Martin DC, Williams LJ. Applicability of adult techniques for ovarian preservation to childhood cancer patients. J Assist Reprod Genet 2012; 29:985-95. [PMID: 22821588 DOI: 10.1007/s10815-012-9821-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 06/12/2012] [Indexed: 12/23/2022] Open
Abstract
PURPOSE To appraise the feasibility of current adult medical and surgical techniques for ovarian preservation in pre-pubertal and adolescent girls with cancer. METHODS Literature search using PubMed and SCOPUS up to February 2012. In addition, the reference lists of selected studies and all identified systematic and narrative reviews were scanned for relevant references. Inclusion criteria were ovarian preservation and cancer. Exclusion criteria were non-English publications, letters, personal communications, and ovarian preservation for conditions other than cancer. RESULTS Data from the selected publications was interpreted and discussed in the relevant sections. Cryopreservation of ovarian tissue followed by autologous transplant represents the only surgical option available for pre-pubertal girls and adolescents who cannot delay the start of chemotherapy. Few studies report on pre-pubertal and adolescent girls undergoing ovarian preservation surgeries with good harvesting, and no follow-up has been conveyed, to date. Outcomes of ovarian function after ovarian suppression with GnRH-analogs in adults have been controversial and no reports are available for pre-pubertal girls. CONCLUSIONS Autologous transplantation of cryopreserved ovarian cortex probably represents the best option for preservation of fertility and hormonal function in childhood cancer females; however, future research needs to address the safety of this technique, especially in patients with blood-borne cancers. Ovarian suppression with GnRH-analogs at the time of chemotherapy treatment has not proven to be superior to non-suppression for fertility preservation purposes in adults. Not enough evidence is presently available in childhood cancer patients.
Collapse
Affiliation(s)
- Laura Detti
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Rout Center, 853 Jefferson Avenue, Memphis, TN 38163, USA.
| | | | | |
Collapse
|
18
|
Peccatori FA, Pup LD, Salvagno F, Guido M, Sarno MA, Revelli A, Piane LD, Dolfin E, Franchi D, Molinari E, Immediata V, Chiavari L, Vucetich A, Borini A. Fertility Preservation Methods in Breast Cancer. ACTA ACUST UNITED AC 2012; 7:197-202. [PMID: 22872792 DOI: 10.1159/000339671] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Thanks to the recent advances in reproductive medicine, more and more young women with breast cancer may be offered the possibility of preserving their fertility. Fertility can be endangered by chemotherapy, by treatment duration and by patient's age at diagnosis. The currently available means to preserve a young woman's fertility are pharmacological protection with gonadotrophin-releasing hormone analogues during chemotherapy, and ovarian tissue or oocyte/embryo freezing before treatment. New future venues, including in vitro maturation, will improve the feasibility and efficacy of the fertility preservation methods in breast cancer patients.
Collapse
Affiliation(s)
- Fedro A Peccatori
- Fertility and Procreation in Oncology Unit, Department of Medicine, European Institute of Oncology, Milan, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Autotransplantation of cryopreserved ovarian tissue: a procedure with promise, risks, and a need for a registry. Fertil Steril 2011; 95:1879-86. [DOI: 10.1016/j.fertnstert.2011.02.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 11/20/2022]
|
20
|
Silber S, Kagawa N, Kuwayama M, Gosden R. Duration of fertility after fresh and frozen ovary transplantation. Fertil Steril 2010; 94:2191-6. [PMID: 20171622 DOI: 10.1016/j.fertnstert.2009.12.073] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 12/04/2009] [Accepted: 12/23/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To evaluate the function of human ovarian transplants. DESIGN Follow a series of fresh ovarian transplants for up to 5 years, and compare fresh and frozen ovarian tissue transplantation. SETTING Tertiary referral community hospital. PATIENT(S) Nine women with premature ovarian failure who received an ovary donated from a monozygotic twin sibling, and 16 young cancer patients undergoing ovarian cryopreservation. Two of the transplant recipients were cancer survivors rendered sterile by their therapy. INTERVENTION(S) Fresh ovary transplantation between monozygotic twin sisters, as well as transplantation of previously frozen ovarian tissue, and study of cryopreserved tissue in cancer patients. MAIN OUTCOME MEASURE(S) Return of normal menstrual cycling, hormone levels, pregnancy, healthy babies, duration of transplant function, and ovarian tissue evaluation. RESULT(S) Normal serum FSH and regular menstrual cycles returned by 5 months after surgery in all cases, both fresh and frozen. Fourteen spontaneous pregnancies were established leading to eight healthy live births and two healthy ongoing conceptions. All three frozen tissue transplants conceived spontaneously, one delivered, and two were ongoing. Oocyte survival with slow freezing was 42% and after vitrification 89%. CONCLUSION(S) Ovarian transplantation in humans is a robust procedure, even after cryopreservation, and vitrification might prove to be more effective than slow freezing.
Collapse
Affiliation(s)
- Sherman Silber
- Infertility Center of St. Louis, St. Luke's Hospital, St. Louis, Missouri, USA.
| | | | | | | |
Collapse
|
21
|
|
22
|
Sánchez-Serrano M, Novella-Maestre E, Roselló-Sastre E, Camarasa N, Teruel J, Pellicer A. Malignant cells are not found in ovarian cortex from breast cancer patients undergoing ovarian cortex cryopreservation. Hum Reprod 2009; 24:2238-43. [PMID: 19491203 DOI: 10.1093/humrep/dep196] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Breast cancer is a frequent indication for ovarian cortex cryopreservation due to its high incidence. The main concern of this procedure is the possibility of reintroducing metastatic cells within the implant, an issue that has not been addressed systematically. Thus, a study was designed to analyse the presence of ovarian metastases in breast cancer patients undergoing ovarian tissue cryopreservation. METHODS Morphological and immunohistochemical studies following the concept of the sentinel lymph node (SLN) were performed on 100 cortical ovarian biopsies obtained from 63 patients and on six frozen-thawed entire cortex from patients with the diagnosis of infiltrating ductal breast carcinoma undergoing ovarian cortex extraction and cryopreservation. The antibody panel included Cytokeratin CAM 5.2, Gross Cystic Disease Fluid Protein-15 (GCDFP15), Wilms' tumour antigen-1 (WT1) and Mammaglobin 1. RESULTS Employing only morphologic criteria, suspicious neoplastic cells were detected in five biopsies, but in none of the six entire cortex analysed. These five cases were reclassified as hyperplasic surface epithelium-inclusion cysts (CAM 5.2+, WT1+) or apoptotic granulosa cells (CAM 5.2-, GCDFP15+, WT1-). CONCLUSIONS Using the methodology of the SLN our data suggest the absence of tumour cells in biopsies obtained from patients undergoing ovarian cortex cryopreservation to preserve their fertility potential, although future methods of cancer screening may change our perception of this procedure.
Collapse
Affiliation(s)
- María Sánchez-Serrano
- Department of Obstetrics and Gynaecology, Hospital Universitario Dr Peset, Av Gaspar Aguilar 90, 46017 Valencia, Spain
| | | | | | | | | | | |
Collapse
|
23
|
Affiliation(s)
- Jacqueline S Jeruss
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
| | | |
Collapse
|
24
|
Dolmans MM, Martinez-Madrid B, Gadisseux E, Guiot Y, Yuan WY, Torre A, Camboni A, Van Langendonckt A, Donnez J. Short-term transplantation of isolated human ovarian follicles and cortical tissue into nude mice. Reproduction 2007; 134:253-62. [PMID: 17660235 DOI: 10.1530/rep-07-0131] [Citation(s) in RCA: 142] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study was designed to evaluate follicular survival and growth after short-term transplantation of fresh isolated human follicles and ovarian cortical tissue to nude mice. Ovarian biopsies were obtained from nine women undergoing laparoscopy. Twelve nude mice were xenografted with an ovarian cortical fragment in the right ovarian bursa, and a clot containing isolated follicles in the left, for a period of 7 days. One ungrafted fragment was used as a control. Histological sections were analyzed to determine follicle number and stage. The proliferative status of follicular cells was assessed by Ki-67 immunostaining. A total of 659 follicles was analyzed by histology and 545 follicles by immunohistochemistry. The percentage of primordial follicles was found to be markedly reduced 1 week post-grafting when compared with ungrafted tissue, while the percentage of primary follicles had significantly increased. Only 8% of follicles showed Ki-67-positive granulosa cells before grafting, whereas 1 week after grafting, 71% of follicles in fragments and 67% of isolated follicles were Ki-67-positive (P<0.001). Moreover, the histological aspect of isolated follicle grafts was similar to that of grafted fragments: follicles were surrounded by vimentin-positive stroma-like tissue of human origin, as confirmed by fluorescent in situ hybridization with human-specific probes. Our results demonstrate, for the first time, that isolated human follicles are able to survive and grow after xenografting. This study also shows massive in vivo follicular activation after transplantation of grafted fragments and isolated follicles. One week after grafting, well-structured stroma-like tissue of human origin was observed around the isolated follicles. The potential origin of this stroma is discussed.
Collapse
|
25
|
Moffa F, Biacchiardi CP, Fagioli F, Biasin E, Revelli A, Massobrio M, Madon E. Ovarian tissue cryostorage and grafting: an option to preserve fertility in pediatric patients with malignancies. Pediatr Hematol Oncol 2007; 24:29-44. [PMID: 17130112 DOI: 10.1080/08880010600970468] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Fertility preservation in childhood cancer has become an important area of investigation due to increasing survival rates after cancer therapy. For these patients with an increased risk of infertility and premature ovarian failure, cryopreservation of ovarian tissue is a promising tool to preserve at least part of the reproductive potential. In recent years significant improvements have been achieved in this area, and 2 live births after autografting of frozen-thawed ovarian tissue have been reported. However, further research is needed to assess the clinical effectiveness of ovarian cryopreservation, to optimize the technique, and to limit the risk of reintroducing cancer cells in the patient with the graft.
Collapse
Affiliation(s)
- Federica Moffa
- Reproductive Medicine and IVF Unit, Department of Gynaecological and Obstetrical Sciences, University of Turin, OIRM-S., Anna Hospital, Turin, Italy
| | | | | | | | | | | | | |
Collapse
|
26
|
Jahnukainen K, Ehmcke J, Söder O, Schlatt S. Clinical potential and putative risks of fertility preservation in children utilizing gonadal tissue or germline stem cells. Pediatr Res 2006; 59:40R-7R. [PMID: 16549547 DOI: 10.1203/01.pdr.0000205153.18494.3b] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Rapid progress in the development of novel experimental strategies to generate fertile gametes from cryo-preserved ovarian and testicular tissue motivates oncologists to investigate ways in which gonadal tissue might be preserved. Childhood cancer patients remain the major pediatric group which can benefit from these techniques. Other potential candidates include patients with systemic diseases, which require gonadotoxic chemotherapy, patients undergoing gonadectomy, patients with Turner or Kleinefelter's syndrome, and boys with cryptorchid testes. This review aims to present an overview of the current state of knowledge in experimental germ stem cell transplantation in higher primates including humans, and the clinical risks and limitations related to such procedures in children. This area of research is discussed in the context of the potential future options that may become available for preserving fertility in boys and girls.
Collapse
Affiliation(s)
- Kirsi Jahnukainen
- Department of Cell Biology and Physiology, Center for Research in Reproductive Physiology, University of Pittsburgh, School of Medicine, PA 15261, USA.
| | | | | | | |
Collapse
|
27
|
Akar M, Oktay K. Restoration of ovarian endocrine function by ovarian transplantation. Trends Endocrinol Metab 2005; 16:374-80. [PMID: 16126406 DOI: 10.1016/j.tem.2005.06.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2005] [Revised: 05/05/2005] [Accepted: 06/16/2005] [Indexed: 02/03/2023]
Abstract
Cancer treatment can cause changes in sex hormone production, premature ovarian failure and infertility. As survival rates for young cancer patients improve, protection against iatrogenic infertility caused by chemotherapy or radiotherapy assumes a higher priority.
Collapse
Affiliation(s)
- Munire Akar
- The Center for Reproductive Medicine and Infertility, Joan and Sanford I. Weill Medical College of Cornell University, 505 East 70(th) Street, HT-340, New York, New York 10021, USA
| | | |
Collapse
|
28
|
Dolmans MM, Michaux N, Camboni A, Martinez-Madrid B, Van Langendonckt A, Nottola SA, Donnez J. Evaluation of Liberase, a purified enzyme blend, for the isolation of human primordial and primary ovarian follicles. Hum Reprod 2005; 21:413-20. [PMID: 16199426 DOI: 10.1093/humrep/dei320] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the effectiveness of a standardized mixture of purified enzymes (Liberase), for the isolation of human ovarian follicles. METHODS This is an experimental prospective study. Ovarian biopsies were obtained from eight young women undergoing laparoscopy for benign gynaecological disease. Follicles were isolated by Liberase or collagenase enzymatic digestion. Follicle quality was assessed by evaluating their general morphology and viability after fluorescent staining, and the ultrastructure by electron microscopy. RESULTS The number of fully isolated follicles recovered from the Liberase-treated group was lower than from the collagenase group (156 versus 263) despite equal-sized biopsies being taken. A high proportion of follicles (98.6%, 70/71) were viable after Liberase isolation and most follicles were of good morphology with a complete granulosa cell layer (70.4%, 31/44). Ultrastructural studies indicated that Liberase-isolated follicles showed signs of atresia only occasionally and that the oolemma-follicular cell interface was well preserved. CONCLUSIONS Liberase treatment allows the isolation of highly viable follicles from human ovarian tissue, with an unaltered morphology and ultrastructure. This purified endotoxin-free enzyme preparation is a promising alternative to impure collagenase preparations for the reproducible isolation of intact primordial and primary follicles for culture and grafting purposes.
Collapse
Affiliation(s)
- Marie-Madeleine Dolmans
- Department of Gynecology, Université Catholique de Louvain, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | | | | | | | | | | | | |
Collapse
|
29
|
Affiliation(s)
- Tariq A Shah
- Division of Reproductive Endocrinology & Infertility, Wiilliam Beaumont Hospital, 3535 West Thirteen Mile Road, Suite 344 Royal Oak, MI 48073, USA.
| | | |
Collapse
|