Perinatal outcomes of pregnancies following autologous cryopreserved ovarian tissue transplantation: a systematic review with pooled analysis

OBJECTIVE

This study aimed to synthesize the existing evidence on perinatal outcomes after autologous cryopreserved ovarian tissue transplantation, concurrently identifying key factors influencing these outcomes.

DATA SOURCES

A comprehensive search was performed on MEDLINE, Embase, and Cochrane Library databases to identify relevant studies on the effect of autologous cryopreserved ovarian tissue transplantation on perinatal outcomes from inception to October 22, 2023. Where there was missing information, the authors were contacted for updated data.

STUDY ELIGIBILITY CRITERIA

Observational studies, such as cohort studies, case series, and case reports that reported a live birth after autologous cryopreserved ovarian tissue transplantation, were considered eligible. Studies lacking data on women's demographic characteristics, autologous cryopreserved ovarian tissue transplantation procedure details, or perinatal outcomes were excluded. In addition, cases involving fresh or nonautologous transplantations and those addressing primary ovarian insufficiency were excluded.

METHODS

Two reviewers (M.E. and E.U.) independently performed the study selection, data extraction, and risk of bias assessment, and the results were then reviewed together. The PRISMA guidelines were followed, and the protocol was registered on PROSPERO (CRD42023469296).

RESULTS

This review included 58 studies composed of 122 women with 162 deliveries (154 singletons and 8 twins) after autologous cryopreserved ovarian tissue transplantation, resulting in 170 newborns. Of note, 83.6% of the women had a malignant disease. Moreover, most of these women (51.0%) were exposed to some form of chemotherapy before ovarian tissue cryopreservation. Of the 162 childbirths, 108 (66.7%) were conceived naturally, and 54 (33.3%) were conceived through assisted reproductive techniques. The birthweight of 88.5% of newborns was appropriate for gestational age, whereas 8.3% and 3.1% were small for gestational age and large for gestational age, respectively. The preterm birth rate was 9.4%, with the remaining being term deliveries. Hypertensive disorders of pregnancy were noted in 18.9% of women, including pregnancy-induced hypertension in 7.6%, preeclampsia in 9.4%, and hemolysis, elevated liver enzymes, and low platelet count in 1.9%. The incidences of gestational diabetes mellitus and preterm premature rupture of membranes were 3.8% for each condition. Neonatal anomalies were reported in 3 transplant recipients with 4 newborns: arthrogryposis, congenital cataract, and diaphragmatic hernia in a twin. Finally, among the recipients' characteristics, not receiving chemotherapy before ovarian tissue cryopreservation (odds ratio, 0.23; 95% confidence interval, 0.07-0.72; P=.012) and natural conception (odds ratio, 0.29; 95% confidence interval, 0.09-0.92; P=.035) were associated with a lower perinatal complication rate.

CONCLUSION

On the basis of low certainty evidence from observational studies, perinatal complication rates did not increase after autologous cryopreserved ovarian tissue transplantation compared with the general pregnant population, except for preeclampsia. This could be due to chemotherapy exposure, underlying medical conditions, and the common use of assisted reproductive techniques. Further larger studies are needed to explore the causes of increased preeclampsia incidence in autologous cryopreserved ovarian tissue transplantation pregnancies.

The role of microRNAs in ovarian function and the transition toward novel therapeutic strategies in fertility preservation: from bench to future clinical application

BACKGROUND

New therapeutic approaches in oncology have converted cancer from a certain death sentence to a chronic disease. However, there are still challenges to be overcome regarding the off-target toxicity of many of these treatments. Oncological therapies can lead to future infertility in women. Given this negative impact on long-term quality of life, fertility preservation is highly recommended. While gamete and ovarian tissue cryopreservation are the usual methods offered, new pharmacological-based options aiming to reduce ovarian damage during oncological treatment are very attractive. In this vein, advances in the field of transcriptomics and epigenomics have brought small noncoding RNAs, called microRNAs (miRNAs), into the spotlight in oncology. MicroRNAs also play a key role in follicle development as regulators of follicular growth, atresia and steroidogenesis. They are also involved in DNA damage repair responses and they can themselves be modulated during chemotherapy. For these reasons, miRNAs may be an interesting target to develop new protective therapies during oncological treatment. This review summarizes the physiological role of miRNAs in reproduction. Considering recently developed strategies based on miRNA therapy in oncology, we highlight their potential interest as a target in fertility preservation and propose future strategies to make the transition from bench to clinic.

OBJECTIVE AND RATIONALE

How can miRNA therapeutic approaches be used to develop new adjuvant protective therapies to reduce the ovarian damage caused by cytotoxic oncological treatments?

SEARCH METHODS

A systematic search of English language literature using PubMed and Google Scholar databases was performed through to 2019 describing the role of miRNAs in the ovary and their use for diagnosis and targeted therapy in oncology. Personal data illustrate miRNA therapeutic strategies to target the gonads and reduce chemotherapy-induced follicular damage.

OUTCOMES

This review outlines the importance of miRNAs as gene regulators and emphasizes the fact that insights in oncology can inspire new adjuvant strategies in the field of onco-fertility. Recent improvements in nanotechnology offer the opportunity for drug development using next-generation miRNA-nanocarriers.

WIDER IMPLICATIONS

Although there are still some barriers regarding the immunogenicity and toxicity of these treatments and there is still room for improvement concerning the specific delivery of miRNAs into the ovaries, we believe that, in the future, miRNAs can be developed as powerful and non-invasive tools for fertility preservation.

Implications of Nonphysiological Ovarian Primordial Follicle Activation for Fertility Preservation

In recent years, ovarian tissue cryopreservation has rapidly developed as a successful method for preserving the fertility of girls and young women with cancer or benign conditions requiring gonadotoxic therapy, and is now becoming widely recognized as an effective alternative to oocyte and embryo freezing when not feasible. Primordial follicles are the most abundant population of follicles in the ovary, and their relatively quiescent metabolism makes them more resistant to cryoinjury. This dormant pool represents a key target for fertility preservation strategies as a resource for generating high-quality oocytes. However, development of mature, competent oocytes derived from primordial follicles is challenging, particularly in larger mammals. One of the main barriers is the substantial knowledge gap regarding the regulation of the balance between dormancy and activation of primordial follicles to initiate their growing phase. In addition, experimental and clinical factors also affect dormant follicle demise, while the mechanisms involved remain largely to be elucidated. Moreover, most of our basic knowledge of these processes comes from rodent studies and should be extrapolated to humans with caution, considering the differences between species in the reproductive field. Overcoming these obstacles is essential to improving both the quantity and the quality of mature oocytes available for further fertilization, and may have valuable biological and clinical applications, especially in fertility preservation procedures. This review provides an update on current knowledge of mammalian primordial follicle activation under both physiological and nonphysiological conditions, and discusses implications for fertility preservation and priorities for future research.

MicroRNA profiling and identification of let-7a as a target to prevent chemotherapy-induced primordial follicles apoptosis in mouse ovaries

Cancer treatments as cyclophosphamide and its active metabolites are highly gonadotoxic leading to follicle apoptosis and depletion. Considering the risk of subsequent infertility, fertility preservation is recommended. Beside the germ cells and gametes cryopreservation options, ovarian pharmacological protection during treatment appears to be very attractive. Meanwhile, the advances in the field of oncology have brought microRNAs into spotlight as a potential feature of cancer treatment. Herein, we investigated miRNAs expressions in response to chemotherapy using postnatal-day-3 (PND3) mouse ovaries. Our results revealed that several miRNAs are differently expressed during chemotherapy exposure. Amongst them, let-7a was the most profoundly downregulated and targets genes involved in crucial cellular processes including apoptosis. Thus we developed a liposome-based system to deliver the let-7a mimic in whole PND3 ovaries in vitro. We showed that let-7a mimic prevented the upregulation of genes involved in cell death and reduced the chemotherapy-induced ovarian apoptosis, suggesting that it can be an interesting target to preserve ovarian function. However, its impact on subsequent follicular development has to be further elucidated in vivo using an appropriate delivery system. In this study, we demonstrated that miRNA replacement approaches can be a useful tool to reduce chemotherapy-induced ovarian damage in the future.

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.

Transplantation of frozen-thawed ovarian tissue: an update on worldwide activity published in peer-reviewed papers and on the Danish cohort

PURPOSE

The purpose of the study is to review all peer-reviewed published reports of women receiving ovarian tissue transplantation (OTT) with frozen/thawed tissue (OTC) with respect to age, diagnosis, transplantation site, fertility outcome, and potential side effects, including data from all women in the Danish program.

METHODS

A systematic review of the literature was performed in PubMed combined with results from all patients who had received OTT in Denmark up to December 2017.

RESULTS

OTT has been reported from 21 different countries comprising a total of 360 OTT procedures in 318 women. In nine women, malignancy was diagnosed after OTT; none were considered to be directly caused by the OTT. Despite a potential under reporting of cancer recurrence, there is currently no evidence to suggest that OTT causes reseeding of the original cancer. Renewed ovarian endocrine function was reported in 95% of the women. Half of all children born following OTT resulted from natural conception, and newborns were reported to be healthy except for one neonate with a chromosome anomaly with a family disposition. Women who conceived after OTT were significantly younger than those who failed.

CONCLUSION

This study found no indications of sufficient numbers of malignant cells present in the ovarian tissue to cause recurrence of cancer after OTT. Further, it is unlikely that OTC affects the well-being of children born. OTC is now an established method of fertility preservation in Denmark with public reimbursement. The current data encourage that women who require gonadotoxic treatment should be offered an individual evaluation considering fertility preservation.

Expectations and limitations of ovarian tissue transplantation

Constant progress in the diagnosis and treatment of cancer disease has increased the number and prognosis of cancer survivors. However, the toxic effects of chemotherapy and radiotherapy on ovarian function have resulted in premature ovarian failure. Patients are, therefore, still expecting methods to be developed to preserve their fertility successfully. Several potential options are available to preserve fertility in patients who face premature ovarian failure, including immature or mature oocyte and embryo cryopreservation. However, for children or prepubertal women needing immediate chemotherapy, cryopreservation of ovarian tissue is the only alternative. The ultimate aim of this strategy is to implant ovarian tissue into the pelvic cavity (orthotopic site) or in a heterotopic site once oncological treatment is completed and the patient is disease free. Transplantation of ovarian tissue with sufficiently large numbers of follicles could potentially restore endocrine function and allow multiple cycles for conception. However, the success of ovarian tissue transplantation still has multiple challenges, such as the low number of follicles in the graft that may affect their longevity as well as the survival of the tissue during ex vivo processing and subsequent transplantation. Therefore, this review aims to summarize the achievements of ovary grafting and the potential techniques that have been developed to improve ovarian graft survival.

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

PURPOSE

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

METHODS

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

RESULTS

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

Chapter 13 Human Ovarian Tissue Vitrification

Ovarian freezing and transplantation has garnered increasing interest as a potential way of preserving fertility in cancer patients as well as for women who just wish to delay childbearing. This chapter spells out our techniques of ovarian cortex vitrification and results for frozen compared to fresh ovarian cortex transplantation (in one single series from one center for the sake of consistency), as well as potentially provides insight into the mechanism behind ovarian follicle recruitment. This represents an effort to simplify and popularize an approach that has yielded favorable results (all cases recovered ovulation and 75% had successful spontaneous pregnancy) in one single, disciplined study. It should be clear that this is a review for the more general reader of our original scientific papers published in Reproductive BioMedicine Online, New England Journal of Medicine, Fertility and Sterility, Human Reproduction, Molecular Human Reproduction, and Journal of Assisted Reproduction and Genetics (JARG).

86 successful births and 9 ongoing pregnancies worldwide in women transplanted with frozen-thawed ovarian tissue: focus on birth and perinatal outcome in 40 of these children

PURPOSE

This study aims to make an account of the children born following transplantation of frozen-thawed ovarian tissue worldwide with specific focus on the perinatal outcome of the children. Furthermore, perinatal outcome of seven deliveries (nine children) from Denmark is reported.

METHODS

PubMed was searched for papers of deliveries resulting from ovarian tissue cryopreservation (OTC). Seven women underwent OTC prior to chemotherapy. Four of these women still had low ovarian function and had tried to conceive. They therefore had tissue autotransplanted to augment their fertility. The other three women had developed premature ovarian insufficiency (POI) after the end of treatment.

RESULTS

Worldwide, approximately 95 children have been born or will be born in the near future from OTC, including these 9 new children. Information on the perinatal outcome was found on 40 children. The mean gestational age was 39 weeks and the mean birth weight was 3168 g of the singleton pregnancies, which is within internationally recognized normal standards. Furthermore, half the singletons resulted from natural conception and all twins resulted from in vitro fertilization treatment. All seven Danish women became pregnant within 1-3 years after transplantation. They gave birth to nine healthy children.

CONCLUSION

The data is reassuring and further suggests that cryopreservation of ovarian tissue is becoming an established fertility preservation method. The seven Danish women reported in this study were all in their early thirties when OTC was performed. Most other reported cases were in the women's twenties. This suggests that the follicular pool in the thirties is large enough and sufficient to sustain fertility.

Fertility preservation through gonadal cryopreservation

Fertility preservation is an area of immense interest in today's society. The most effective and established means of fertility preservation is cryopreservation of gametes (sperm and oocytes) and embryos. Gonadal cryopreservation is yet another means for fertility preservation, especially if the gonadal function is threatened by premature menopause, gonadotoxic cancer treatment, surgical castration, or diseases. It can also aid in the preservation of germplasm of animals that die before attaining sexual maturity. This is especially of significance for valuable, rare, and endangered animals whose population is affected by high neonatal/juvenile mortality because of diseases, poor management practices, or inbreeding depression. Establishing genome resource banks to conserve the genetic status of wild animals will provide a critical interface between ex-situ and in-situ conservation strategies. Cryopreservation of gonads effectively lengthens the genetic lifespan of individuals in a breeding program even after their death and contributes towards germplasm conservation of prized animals. Although the studies on domestic animals are quite promising, there are limitations for developing cryopreservation strategies in wild animals. In this review, we discuss different options for gonadal tissue cryopreservation with respect to humans and to laboratory, domestic, and wild animals. This review also covers recent developments in gonadal tissue cryopreservation and transplantation, providing a systematic view and the advances in the field with the possibility for its application in fertility preservation and for the conservation of germplasm in domestic and wild species.

New advances in ovarian autotransplantation to restore fertility in cancer patients

Human ovary autotransplantation is a promising option for fertility preservation of young women and girls undergoing gonadotoxic treatments for cancer or some autoimmune diseases. Although experimental, it resulted in at least 42 healthy babies worldwide. According to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic literature review was performed for all relevant full-text articles published in English from 1 January 2000 to 01 October 2015 in PubMed to explore the latest clinical and research advances of human ovary autotransplantation. Human ovary autotransplantation involves ovarian tissue extraction, freezing/thawing, and transplantation back into the same patient. Three major forms of human ovary autotransplantation exist including (a) transplantation of cortical ovarian tissue, (b) transplantation of whole ovary, and (c) transplantation of ovarian follicles (artificial ovary). According to the recent guidelines, human ovary autotransplantation is still considered experimental; however, it has unique advantages in comparison to other options of female fertility preservation. Human ovary autotransplantation (i) does not need prior ovarian stimulation, (ii) allows immediate initiation of cancer therapy, (iii) can restore both endocrine and reproductive ovarian functions, and (iv) may be the only fertility preservation option suitable for prepubertal girls or for young women with estrogen-sensitive malignancies. As any other fertility preservation option, human ovary autotransplantation has both advantages and disadvantages and may not be feasible for all cases. The major challenges facing this option are how to avoid the risk of reintroducing malignant cells and how to prolong the lifespan of ovarian transplant as well as how to improve artificial ovary results.

Female fertility preservation strategies: cryopreservation and ovarian tissue in vitro culture, current state of the art and future perspectives

In the present review, the main strategies of female fertility preservation are covered. Procedures of fertility preservation are necessary for women who suffer from diseases whose treatment requires the use of aggressive therapies, such as chemotherapy and radiotherapy. These kinds of therapy negatively influence the health of gametes and their progenitors. The most commonly used method of female fertility preservation is ovarian tissue cryopreservation, followed by the retransplantation of thawed tissue. Another approach to female fertility preservation that has been actively developed lately is the ovarian tissue in vitro culture. The principal methods, advantages and drawbacks of these two strategies are discussed in this article.

How ovarian transplantation works and how resting follicle recruitment occurs: a review of results reported from one center

Ovarian freezing and transplantation has garnered increasing interest as a potential way of preserving fertility in cancer patients. This special report aims to identify the success rate of frozen compared with fresh ovarian cortex transplantation (in one single series from one center for the sake of consistency), as well as potentially provides insight into the mechanism behind ovarian follicle recruitment. A comparison of fresh versus frozen transplantation techniques is presented, highlighting the similarity and differences between the fresh and frozen transplantation procedures. Much of the literature is scattered case reports with different patient populations and different techniques. This represents an effort to simplify and popularize an approach that has yielded favorable results (all cases recovered ovulation and 75% had successful spontaneous pregnancy) in one single, disciplined study.

Ovarian tissue cryopreservation in girls undergoing haematopoietic stem cell transplant: experience of a single centre

Fertility after childhood haemopoietic stem cell transplant (HSCT) is a major concern. Conditioning regimens before HSCT present a high risk (>80%) of ovarian failure. Since 2000, we have proposed cryopreservation of ovarian tissue to female patients undergoing HSCT at our centre, to preserve future fertility. After clinical and haematological evaluation, the patients underwent ovarian tissue collection by laparoscopy. The tissue was analysed by histologic examination to detect any tumour contamination and then frozen following the slow freezing procedure and cryopreserved in liquid nitrogen. From August 2000 to September 2013, 47 patients planned to receive HSCT, underwent ovarian tissue cryopreservation. The median age at diagnosis was 11.1 years and at the time of procedure it was 13 years, respectively. Twenty-four patients were not pubertal at the time of storage, whereas 23 patients had already experienced menarche. The median time between laparoscopy and HSCT was 25 days. Twenty-six out of 28 evaluable patients (93%) developed hypergonadotropic hypogonadism at a median time of 23.3 months after HSCT. One patient required autologous orthotopic transplantation that resulted in one live birth. Results show a very high rate of iatrogenic hypergonadotropic hypogonadism, highlighting the need for fertility preservation in these patients.

Fresh and cryopreserved ovary transplantation and resting follicle recruitment

Ovary cryopreservation and transplantation has garnered increasing interest as a possible method to preserve fertility for cancer patients and to study ovarian resting follicle recruitment. Eleven consecutive women underwent fresh donor ovary transplantation, and 11 underwent cryopreserved ovary auto-transplantation in the same centre, with the same surgeon. Of the 11 fresh transplant recipients, who were all young but menopausal, nine women had normal ovarian cortex transplanted from an identical twin sister, and two had a fresh allograft from a non-identical sister. In the second group, 11 women with cancer had ovarian tissue cryopreserved before bone marrow transplant, and then after years of therapeutically induced menopause, underwent cryopreserved ovarian cortex autotransplantation. Recovery of ovarian function and follicle recruitment was assessed in all 22 recipients, and the potential for pregnancy was further investigated in 19 (11 fresh and 8 cryopreserved) with over 1-year follow-up. In all recipients, normal FSH levels and menstruation returned by about 150 days, and anti-Müllerian hormone reached much greater than normal concentrations by about 170 days. Anti-Müllerian hormone levels then fell below normal by about 240 days and remained at that lower level. Seventeen babies have been born to these 11 fresh and eight cryopreserved ovary transplant recipients.

Treatment history and outcome of 24 deliveries worldwide after autotransplantation of cryopreserved ovarian tissue, including two new Danish deliveries years after autotransplantation

PURPOSE

To report another two successful pregnancies and deliveries resulting from autotransplanted cryopreserved ovarian tissue several years after the autotransplantation procedure took place. Further, to review the literature on the treatment history, number of live births and their outcome so far reported worldwide.

METHODS

Two women underwent fertility preservation with cryopreservation of their ovarian tissue prior to a potentially sterilizing treatment with bone marrow transplantation. One woman suffered from paroxystic nocturnal hemoglobinuria and one woman from relapse of Hodgkin's lymphoma. Both suffered from premature ovarian insufficiency after treatment. Because of a pregnancy wish they later had pieces of thawed cortical tissue transplanted to the remaining ovary and the anterior abdominal wall. PubMed was searched for reports of deliveries resulting from cryopreserved ovarian tissue in peer-reviewed papers.

RESULTS

Five years after the autotransplantation the first patient became spontaneously pregnant and delivered a healthy baby boy at term. The second patient became pregnant after undergoing one cycle of in vitro fertilisation five years after the autotransplantation. She delivered a healthy baby boy at gestational week 36. Twenty healthy singletons and two sets of twins have been born according to peer-reviewed publications.

CONCLUSION

Contrary to most of the published deliveries our latest two cases occurred several years after the autotransplantation procedure took place. This proves that ovarian grafts are capable of functioning for several years after the autotransplantation has occurred. Today, a total of 26 healthy children have been born as a result of cryopreservation of ovarian tissue.

Strategies for fertility preservation in young early breast cancer patients

Diagnosis of breast cancer in young women poses a threat to fertility. Due to a recent trend of delaying pregnancy, an increasing number of breast cancer patients in reproductive age wish to bear children. Health care providers have the responsibility to know how to manage fertility issues in cancer survivors. Oncofertility counseling is of great importance to many young women diagnosed with cancer and should be managed in a multi-disciplinary background. Most of young breast cancer patients are candidate to receive chemotherapy, which could lead to premature ovarian failure. A baseline evaluation of ovarian reserve may help in considering the different fertility preservation options. The choice of the suitable strategy depends also on age, type of chemotherapy, partner status and patients' motivation. Various options are available, some established such as embryo and oocyte cryopreservation, some still experimental such as ovarian tissue cryopreservation and ovarian suppression with GnRHa during chemotherapy. An early referral to a reproductive specialist should be offered to patients at risk of infertility who are interested in fertility preservation.

Effect of Human Endothelial Progenitor Cell (EPC)- or Mouse Vascular Endothelial Growth Factor-Derived Vessel Formation on the Survival of Vitrified/Warmed Mouse Ovarian Grafts

The aim of this study was to evaluate the effectiveness of improving angiogenesis at graft sites on the survival of follicles in transplanted ovarian tissue. Matrigel containing 5 × 10⁵ of cord blood-derived endothelial progenitor cells (EPCs) or 200 ng of mouse vascular endothelial growth factor (VEGF) was injected subcutaneously into BALB/c-Nu mice. After 1 week, vitrified/warmed ovaries from female B6D2F1 mice were subcutaneously transplanted into the injection sites. After 1, 2, and 4 weeks posttransplantation, the ovaries were recovered and subjected to histological analysis. Oocytes were collected from the transplanted ovaries, and their fertilization, embryonic development, and delivery were also observed. Vitrified/warmed ovaries transplanted into EPC- or VEGF-treated sites developed more blood vessels and showed better follicle survival than those transplanted into sham-injected sites. Normal embryonic development and consequent live births were obtained using oocytes recovered from cryopreserved/transplanted ovaries. Treatment with EPCs or VEGF could prevent the ischemic damage during the early revascularization stage of ovarian transplantation.

Autotransplantation of cryopreserved ovarian tissue in cancer survivors and the risk of reintroducing malignancy: a systematic review

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.

Morphological and functional preservation of pre-antral follicles after vitrification of macaque ovarian tissue in a closed system

STUDY QUESTION

What are the appropriate conditions to vitrify the macaque ovarian cortex in a large-volume, closed system that will preserve functional pre-antral follicles?

SUMMARY ANSWER

The combination of glycerol, ethylene glycol (EG) and polymers with cooling in liquid nitrogen (LN2) vapor and a two-step warming procedure was able to preserve tissue and follicle morphology as well as function of a small population of secondary follicles in the macaque ovarian cortex following vitrification in a closed system.

WHAT IS KNOWN ALREADY

For prepubertal cancer patients or those who require immediate cancer therapy, ovarian tissue cryopreservation offers the only hope for future fertility. However, the efficacy of live birth from the transplantation of cryopreserved ovarian tissue is still unclear. In addition, live birth from cryopreserved ovarian tissue has only been demonstrated after tissue autotransplantation, which poses the risk of transmitting metastatic cancer cells back to the cancer survivor in certain cancers.

STUDY DESIGN, SIZE, DURATION

Non-human primate model, n = 4, randomized, control versus treatment. End-points were collected from tissue histology, tissue culture (48 h) and isolated secondary follicle culture (6 weeks).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Two vitrification solutions (VSs) containing EG + glycerol (VEG) and EG + dimethylsulfoxide (VED) were examined for vitrification, devitrification and thermodynamic properties. Once the optimal VS was determined, macaque ovarian cortical pieces (3 × 3 × 0.5 mm(3)) were divided into fresh and two vitrified groups (VEG and VED). For the vitrification groups, tissues were exposed to 1/4, 1/2 and 1× VS for 5 min/step as well as 1× VS + polymers for 1 min at 37°C, loaded into high-security straws with 1 ml of VS + polymers, heat sealed and cooled in LN2 vapor. Samples were warmed in a 40°C water bath and cryoprotective agents were diluted with 1, 0.5, 0.25 and 0 M sucrose. Tissues were fixed for histological analysis and cultured with bromodeoxyuridine (BrdU). Secondary follicles from VEG tissues were encapsulated and cultured (n = 24/treatment/animal). Follicle health, diameter and steroid [progesterone, androstenedione (A4), estradiol (E2)] production were analyzed weekly.

MAIN RESULTS AND THE ROLE OF CHANCE

Dense stroma and intact pre-antral follicles were observed using VS containing 27% glycerol, 27% EG and 0.8% polymers with cooling in LN2 vapor and a two-step warming. Higher cooling and warming rates led to fracturing. BrdU uptake was evident in granulosa cells of growing follicles in fresh and vitrified tissues. Secondary follicles from fresh tissues (70 ± 12%) and tissues vitrified with VEG (52 ± 2%) showed similar survival rates (all data: mean ± SEM; P > 0.05). For both groups, the initial follicle diameter was similar and increased (P < 0.05) by Week 3, but diameters in vitrified follicles were smaller (P < 0.05) by Week 6 (566 ± 27 µm) than those of the fresh follicles (757 ± 26 µm). Antrum formation rates were lower (P < 0.05) for vitrified (37 ± 6%) relative to fresh (64 ± 8%) follicles. There was no significant change in levels in culture media of E2, P4 and A4 between fresh and VEG groups at any time point during culture.

LIMITATIONS, REASONS FOR CAUTION

Only in vitro studies are reported. Future in vivo tissue transplantation studies will be needed to confirm long-term function and fertility potential of vitrified ovarian tissues.

WIDER IMPLICATIONS OF THE FINDINGS

This is the first demonstration of antral follicle development during 3D culture following ovarian tissue vitrification in a closed system using primate ovarian tissue. While diminished antrum formation and slower growth in vitro reflect residual cryodamage, continued development of ovarian tissue vitrification based on cryobiology principles using a non-human primate model will identify safe, practical and efficient protocols for eventual clinical use. Tissue function following heterotopic transplantation is currently being examined.

STUDY FUNDING/COMPETING INTEREST(S)

National Institutes of Health (NIH) Oncofertility Consortium UL1 RR024926 (1RL1-HD058293, HD058295, PL1 EB008542), the Eunice Kennedy Shriver NICHD/NIH (U54 HD018185) and ONPRC 8P51OD011092-53. G.M.F. works for the company that makes the polymers used in the current study.

The safety of transplanting cryopreserved ovarian tissue in cancer patients: a review of the literature

BACKGROUND

Transplantation of frozen/thawed ovarian tissue from patients with a malignant condition is associated with a risk of re-introduction of the disease as the tissue usually is removed before anti-cancer therapy and may thus contain malignant cells. We review studies investigating the presence of malignant cells in cryopreserved ovarian tissue from patients with malignant disease and based on the strength of the evidence, recommendations for transplantations are proposed.

MATERIALS AND METHODS

A systematic review of the literature. All peer reviewed studies evaluating the presence of malignant cells in cryopreserved human ovarian tissue were included. Data were searched in Pubmed and Embase with no language restrictions.

RESULTS

The majority of the reviewed papers were casuistic reports and few of the included papers were specifically designed to search for malignant cells. Ovarian tissue from 422 patients has been subject to testing for malignant cells by imaging, histology, immunohistochemistry, molecular biology, animal- or clinical transplantation. In 31 (7 %) of the cases the applied test raised suspicion of malignant cell infiltration. No transplantation-related relapse of cancer has been reported after 33 transplantations of frozen/thawed ovarian cortex.

CONCLUSION

The quality and strength of the evidence is generally low and prospective studies are needed. The risk of re-introducing a malignant condition when transplanting ovarian tissue depends on the particular disease. Based on the available data, the risk was estimated: Leukaemia: HIGH. Gastrointestinal cancers: MODERATE. Breast cancer, sarcomas of the bone and connective tissue, gynaecological cancers, Hodgkin's and Non-Hodgkin's Lymphoma: LOW.

Live birth after orthotopic grafting of autologous cryopreserved ovarian tissue and spontaneous conception in Italy

OBJECTIVE

To describe a live birth obtained in Italy after autologous orthotopic transplantation of cryopreserved ovarian cortical tissue.

DESIGN

Case report.

SETTING

University department of gynecology and obstetrics, reproductive medicine and IVF unit.

PATIENT(S)

A 29-year-old patient affected by β-thalassemia (intermedia phenotype) who underwent chemotherapy and bone marrow transplantation at age 21 years, resulting in a complete precocious ovarian failure.

INTERVENTION(S)

Before being treated with chemotherapy (busulfan, cyclophosphamide, and cyclosporine) for bone marrow transplantation, the patient underwent laparoscopic sampling of ovarian cortical tissue that was frozen and cryopreserved in liquid nitrogen. Eight years later, the ovarian tissue was thawed and grafted during laparoscopy at an orthotopic site.

MAIN OUTCOME MEASURE(S)

Ultrasound and endocrine monitoring of the postgrafting restoration of ovarian function; conception, pregnancy, and live birth.

RESULT(S)

Three months after grafting, the decrease of circulating FSH levels and the parallel increase of E(2) levels demonstrated ovarian function restoration, which was confirmed by bidimensional ultrasound and color Doppler examinations. After some ovulatory cycles, the patient spontaneously conceived 16 months after transplantation. After 39 weeks of uneventful gestation, a healthy girl weighing 3,970 g was born.

CONCLUSION(S)

Autologous grafting of cryopreserved ovarian cortex at an orthotopic site may allow ovarian function restoration, spontaneous conception, and birth of a healthy baby.

Cryopreservation of ovarian tissue for fertility preservation in young female oncological patients

Girls and women suffering from a cancer that requires treatment with gonadotoxic drugs may experience cessation of reproductive function as a side effect due to obliteration of the ovarian pool of follicles. Techniques are now available for fertility preservation, such as cryopreservation of mature oocytes, embryos or ovarian cortical tissue. Whereas collection of mature oocytes and embryos requires at least a 2-week period, ovarian tissue may on short notice be frozen prior to treatment and can be transplanted back into women with ovarian failure. Transplanted frozen/thawed tissue supports survival and growth of follicles, giving rise to menstrual cycles and hormone production for several years. Worldwide, the procedure has resulted in the birth of 15 healthy children. Many cancer patients including girls and young women want fertility preservation, and the techniques are now being further developed and implemented in several centers.

Ovarian tissue and follicle transplantation as an option for fertility preservation

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.

Recent advances in oocyte and ovarian tissue cryopreservation and transplantation

Options for preserving fertility in women include well-established methods such as fertility-sparing surgery, shielding to reduce radiation damage to reproductive organs, and emergency in-vitro fertilisation after controlled ovarian stimulation, with the aim of freezing embryos. The practice of transfering frozen or thawed embryos has been in place for over 25 years, and today is a routine clinical treatment in fertility clinics. Oocytes may also be frozen unfertilised for later thawing and fertilisation by intracytoplasmic sperm injection in vitro. In recent years, oocyte cryopreservation methods have further developed, reaching promising standards. More than 1000 children are born worldwide after fertilisation of frozen and thawed oocytes. Nevertheless, this technique is still considered experimental. In this chapter, we focus on options for fertility preservation still in development that can be offered to women. These include freezing of oocytes and ovarian cortex and the transplantation of ovarian tissue.

Synthetic polymers improve vitrification outcomes of macaque ovarian tissue as assessed by histological integrity and the in vitro development of secondary follicles

Ovarian tissue cryopreservation is the only proven option for fertility preservation in female cancer patients who are prepubertal or require immediate treatment. However it remains unclear which cryopreservation protocol is best in cases where the tissue may contain cancerous cells, as these should be matured in vitro rather than autografted. This study evaluated different cryoprotectant exposure times and whether the addition of synthetic polymers (Supercool X-1000, Z-1000 and polyvinylpyrrolidone [PVP K-12]) to the vitrification solution is beneficial to tissue morphology, cellular proliferation and subsequent in vitro function of secondary follicles. Pieces of macaque (n=4) ovarian cortex were exposed to vitrification solution containing glycerol (25%, v/v) and ethylene glycol (25%, v/v) for 3 or 8 min, without (V3, V8) or with (VP3, VP8) polymers (0.2% [v/v] X-1000, 0.4% Z-1000 and 0.2% PVP). Fresh and vitrified tissues were fixed for histology and phosphohistone H3 (PPH3) analysis, or used for secondary follicle isolation followed by encapsulated 3D culture. Five-week follicle survival and growth, as well as steroid hormones (estradiol [E(2)], progesterone, androstenedione) were measured weekly. Morphology of the stroma and preantral follicles as well as PPH3 expression, was preserved in all vitrified tissues. Vitrification with polymers and shorter incubation time (VP3) increased in vitro follicle survival and E(2) production compared to other vitrified groups. Thus, a short exposure of macaque ovarian tissue to a vitrification solution containing synthetic polymers preserves morphology and improves in vitro function of secondary follicles.

Evaluation of the ovarian reserve in women transplanted with frozen and thawed ovarian cortical tissue

OBJECTIVE

To investigate ovarian reserve and ovarian function in women transplanted with frozen/thawed ovarian tissue.

DESIGN

Retrospective cohort study.

SETTING

University hospital.

PATIENT(S)

18 women transplanted with their own frozen/thawed ovarian tissue.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Levels of antimüllerian hormone (AMH), duration of function of the transplanted ovarian tissue, outcome of assisted reproduction.

RESULT(S)

Of the 18 women who received transplanted ovarian tissue, levels of AMH were measured in 12 women; AMH never exceed a concentration of 1 ng/mL, and in several cases they were below the detection limit of the assay in combination with regular menstrual cycles. Two women with AMH below the detection limit conceived spontaneously. The duration of function of the transplants was between 9 months and 7 years and still functioning. Twelve women received assisted reproduction therapy; in 72 cycles, 65 oocytes were retrieved. The pregnancy rate and live-birth rate per cycle were 6.9% (5 of 72) and 2.8% (2 of 72), respectively.

CONCLUSION(S)

The relatively poor outcome of assisted reproduction in women transplanted with frozen/thawed ovarian tissue may reflect reduced follicular selection rather than defective or aged oocytes. In normal women, reduced follicular selection with age may be part of explaining the decline in female fecundity with increasing age.

Retransplantation of cryopreserved ovarian tissue: the first live birth in Germany

BACKGROUND

Cryopreserved ovarian tissue can be retransplanted to restore fertility after radiation or chemotherapy. To date, 15 live births after retransplantation have been reported worldwide. We report the first pregnancy and the first live birth after retransplantation in Germany.

CASE REPORT

A 25-year-old female patient received initial chemotherapy and radiation of the mediastinum for Hodgkin's lymphoma in 2003 and suffered a relapse two years later. Ovarian tissue was laparoscopically removed and cryopreserved, and she was then treated with high-dose chemotherapy and stem cell transplantation. She remained in remission for 5 years and she could not conceive during this time. The cryopreserved ovarian tissue was thawed and laparoscopically retransplanted into a peritoneal pouch in the ovarian fossa of the right pelvic wall. Three months later, her menopausal symptoms resolved, and she had her first spontaneous menstruation. Six months after retransplantation, after two normal menstrual cycles, low-dose follicle stimulating hormone (FSH) treatment induced the appearance of a dominant follicle in the tissue graft. Ovulation was then induced with human chorionic gonadotropin (HCG), whereupon the patient conceived naturally. After an uncomplicated pregnancy, she bore a healthy child by Caesarean section on 10 October 2011. Histological examination of biopsy specimens revealed that the ovarian tissue of the graft contained follicles in various stages of development, while the original ovaries contained only structures without any reproductive potential.

CONCLUSION

This was the first live birth after retransplantation of cryopreserved ovarian tissue in Germany and also the first case with histological confirmation that the oocyte from which the patient conceived could only have come from the retransplanted tissue. In general, young women who will be undergoing chemotherapy and/or radiotherapy for cancer must be informed and counseled about the available options for fertility preservation.

Safety of ovarian tissue autotransplantation for cancer patients

Cancer treatments can induce premature ovarian failure in almost half of young women suffering from invasive neoplasia. Cryopreservation of ovarian cortex and subsequent autotransplantation of frozen-thawed tissue have emerged as promising alternatives to conventional fertility preservation technologies. However, human ovarian tissue is generally harvested before the administration of gonadotoxic treatment and could be contaminated with malignant cells. The safety of autotransplantation of ovarian cortex remains a major concern for fertility preservation units worldwide. This paper discusses the main tools for detecting disseminated cancer cells currently available, their limitations, and clinical relevance.

Fertility preservation in girls and young women

There is increasing interest and experience in the options available to preserve fertility in those about to undergo potentially gonadotoxic chemotherapy or radiation therapy, usually related to treatment for cancer. Recent years have seen the development of methods for prepubertal girls, female adolescents and adult women, although these remain less established than sperm cryopreservation for men. At present, the options for prepubertal boys remain experimental. Embryo cryopreservation following ovarian stimulation and IVF is a routine procedure technically and its success in the management of infertility is established. However, there are no data on uptake or success rates in the context of fertility preservation in women with cancer. Oocyte cryopreservation is technically challenging and requires ovarian stimulation, thus potentially resulting in a delay in cancer treatment. Oocyte vitrification offers increased success rates in comparison with slow freezing; however, this approach is also limited by the number of oocytes that can be obtained. The third possibility, ovarian tissue cryopreservation, can be performed without significant delay and is the only option for prepubertal girls. Worldwide, a small number of children have been born following reimplantation of frozen/thawed ovarian tissue. It is clear that fertility preservation is important for some girls and young women facing treatments that will compromise their fertility, but the availability of all approaches varies widely. Effective approaches for prepubertal boys are also required.

In vitro development of secondary follicles from cryopreserved rhesus macaque ovarian tissue after slow-rate freeze or vitrification

BACKGROUND

Ovarian tissue cryopreservation is the only option for preserving fertility in prepubertal girls and cancer patients requiring immediate treatment. Following ovarian tissue cryopreservation, fertility can be restored after tissue transplant or in vitro follicle maturation.

METHODS

Macaque (n= 4) ovarian cortex was cryopreserved using slow-rate freezing (slow freezing) or vitrification. Tissues were fixed for histology or phosphohistone H3 (PPH3) analysis, cultured with bromodeoxyuridine (BrdU) or used for three-dimensional secondary follicle culture. Follicular diameter and steroid hormones were measured weekly.

RESULTS

Slow freezing induced frequent cryo-injuries while vitrification consistently maintained morphology of the stroma and secondary follicles. PPH3 was similar in fresh and vitrified, but sparse in slow-frozen tissues. BrdU uptake appeared diminished following both methods compared with that in fresh follicles. In vitro follicle survival and growth were greater in fresh than in cryopreserved follicles. Antrum formation appeared similar after vitrification compared with the fresh, but was reduced following slow freezing. Steroid production was delayed or diminished following both methods compared with fresh samples.

CONCLUSIONS

Secondary follicle morphology was improved after vitrification relative to slow freezing. Following vitrification, stroma was consistently more compact with intact cells typical to that of fresh tissue. BrdU uptake demonstrated follicle viability post-thaw/warming. For the first time, although not to the extent of fresh follicles, macaque follicles from cryopreserved tissue can survive, grow, form an antrum and produce steroid hormones, indicating some functional preservation. The combination of successful ovarian tissue cryopreservation with in vitro maturation of follicles will offer a major advancement to the field of fertility preservation.

Limited value of ovarian function markers following orthotopic transplantation of ovarian tissue after gonadotoxic treatment

CONTEXT

In young women, some treatments for cancer or other conditions (such as sickle cell anemia) may give rise to primary ovarian insufficiency. Ovarian transplantation is one of the available options for fertility preservation, with highly variable pregnancy rates.

OBJECTIVE

The objective of the study was to investigate markers of ovarian reserve and ovarian function in women up to 7 yr after orthotopic ovarian transplantation. Secondary objectives were to assess the relationship between markers of ovarian reserve and pregnancy rate along with the duration of ovarian function.

DESIGN

This was a prospective cohort study in 10 women, with a mean follow-up of 2.5 yr.

SETTING

The study was conducted at a university hospital in Brussels, Belgium.

PATIENTS

Patients included 10 women who were about to receive or had previously received gonadotoxic treatment. In seven women cryopreservation of ovarian tissue was performed before starting treatment. Subsequently autografts were orthotopically transplanted in these women. Three women, who had already developed primary ovarian insufficiency due to treatment, underwent orthotopic transplantation of ovarian allograft tissue originating from their human leukocyte antigen-compatible sisters.

MAIN OUTCOME MEASURES

Serum concentrations of FSH, LH, estradiol, inhibin B, and anti-Müllerian hormone (AMH) were measured.

RESULTS

On average, first menses took place after 4.7 months. Duration of graft functioning varied from 2 to more than 60 months. FSH concentrations remained elevated, whereas estradiol levels normalized and AMH was low to undetectable. Inhibin B varied among women and was not associated with the duration of ovarian function (hazard ratio 0.966, 95% confidence interval 0.881-1.059). Two spontaneous pregnancies occurred. Endocrine characteristics were not significantly different in these women.

CONCLUSIONS

Low AMH and inhibin B concentrations may suggest decreased ovarian reserve in women after ovarian transplantation. AMH and inhibin B levels may not be associated with the duration of ovarian graft function or probability to achieve a pregnancy.

Micro-organ ovarian transplantation enables pregnancy: a case report

A 19-year-old thalassemic woman had tissue from one of her ovaries cryopreserved prior to bone marrow transplantation, total body irradiation and sterilizing chemotherapy. As expected, premature ovarian failure resulted from this treatment. Transplantation of her thawed ovarian tissue resulted in return of menstrual cycling and the patient then underwent several IVF cycles. The patient, however, had poor ovarian response to hyperstimulation. We thus considered an alternative approach based on the observation that very thin ovarian fragments that preserve the basic ovarian structure [ovarian micro-organs (MOs)] induce angiogenesis and remained viable after autologous transplantation in animals. We report that preparation of autologous tiny ovarian fragments (MO)s and reimplantation into our patient resulted in IVF pregnancy and delivery of a healthy baby.

Oocyte cryopreservation as a fertility preservation measure for cancer patients

Advances in cancer treatment have allowed women to live longer, fuller lives. However, gonadotoxic therapies used to effect cancer 'cures' often significantly impair a woman's reproductive potential. Thus, in accordance with improved survival rates,there is an increase in demand for fertility preservation. Initially, fertility preservation was limited to embryo cryopreservation;therefore, the number of patients enrolling was relatively low. Recently, substantial improvements have increased available options, specifically oocyte cryopreservation, thereby expanding and altering the make-up of the patient population under going treatment for fertility preservation. Patient diversity requires the treating physician(s) to be cognizant of issues specific to cancer type and stage. Furthermore, patients often have comorbidities which must be attended to and addressed. Although not all patients will be candidates for, or will elect to pursue, fertility preservation, all should receive counselling regarding their options. This practice will ensure that the reproductive rights of those patients facing impending sterility are maintained. Here, fertility preservation protocols, practices and special considerations, categorized by most frequently encountered cancer types, are reviewed to guide reproductive endocrinologists in the management of fertility preservation in such patients. The formation of a multidisciplinary patient-structured team will ensure a successful, yet safe, fertility-preservation outcome .

Autotransplantation of cryopreserved ovarian tissue in 12 women with chemotherapy-induced premature ovarian failure: the Danish experience

OBJECTIVE

To describe a cohort of 12 Danish women who received autotransplantation of frozen-thawed cryopreserved ovarian tissue because of premature ovarian failure after cancer treatment.

DESIGN

Retrospective study.

SETTING

University hospitals.

PATIENT(S)

Twelve women with autotransplanted frozen-thawed ovarian tissue.

INTERVENTION(S)

Monitoring of hormonal parameters and results of 56 IVF cycles in 10 women.

MAIN OUTCOME MEASURE(S)

Levels of gonadotropins and sex steroids, functional life span of the grafts, and results of IVF.

RESULT(S)

All 12 women regained ovarian function between 8 and 26 weeks (mean 19 weeks) after transplantation. Ten women underwent a total of 56 IVF cycles, 76 follicles developed, 49 oocytes were aspirated, 18 were fertilized, and 16 embryos were transferred resulting in six pregnancies: two biochemical, one clinical that miscarried in week 7, and two ongoing resulting in the delivery of two healthy infants born at term to two women. One of these women subsequently conceived spontaneously and delivered another healthy infant. The life span of the transplanted tissue has been between 6 months and still functioning after 54 months.

CONCLUSION(S)

Autotransplantation consistently leads to recovery of ovarian function after treatment-induced ovarian failure. Four women became pregnant, after IVF or spontaneously, resulting in the delivery of three healthy infants.