Gonadal cryopreservation in the young patient with gynaecological malignancy

Developing a Hospital-Wide Fertility Preservation Service for Pediatric and Young Adult Patients

PURPOSE

Gonadal damage is a common consequence of treatment for pediatric malignancies. Nononcologic conditions may also utilize treatments with potential impact on fertility. Models for oncology fertility preservation programs have emerged and demonstrate that a multidisciplinary team approach can have a positive impact on referral patterns, appropriate risk counseling, and access to fertility preservation options. Expansion of programmatic breadth is needed, providing improved care to nonmalignant conditions where the disease itself may impact reproductive health or treatment modalities.

METHODS

With support from the Department of Pediatrics Chair's Initiative, a multidisciplinary, hospital-wide Fertility Preservation Service was created at the Children's Hospital of Philadelphia. A centralized team provides fertility consults across the institution, allowing for risk-based counseling and facilitation of fertility preservation options (both standard care and experimental).

RESULTS

Team structure, consult process, and available fertility options for prepubertal and pubertal males and females are described. Preinitiative and postinitiative referral patterns were analyzed. Postinitiative referrals from divisions outside oncology more than doubled (34% vs. 15% at baseline).

CONCLUSIONS

A comprehensive model for fertility counseling provides accessible, high-value fertility preservation care to pediatric and young adult patients with a wide variety of diagnoses. A centralized point of contact ensures timely referrals and risk-based counseling and streamlines access to fertility preservation procedures.

The Effect of Erythropoietin in Preventing Ischemia-Reperfusion Injury in Ovarian Tissue Transplantation

Condensation Erythropoietin improved the survival of follicles in ovarian grafts most likely by reducing ischemic injury, by improving neoangiogenesis, and by its antioxidant effects.

OBJECTIVE

Ovarian tissue cryopreservation and transplantation are the only options accepted for prepubertal girls and women requiring immediate chemotherapy. Ischemia-reperfusion injury is the main obstacle for ovarian tissue transplantation. In the present study, we aimed to evaluate the effects of recombinant human erythropoietin (EPO) on tissue viability in autotransplanted rat ovaries.

STUDY DESIGN

Seventeen female rats were randomized into 3 groups as sham control group (n = 5), EPO-treated group (n = 6), and EPO-untreated group (n = 6). Both ovaries were excised and transplanted into a subcutaneous pouch formed at the anterior abdominal wall in the EPO-treated and untreated groups. In the EPO group, 5000 U/kg EPO was applied as local injection to the site that ovarian tissue was placed and the dose was repeated with the same route at the end of the fourth week. After 2 months, ovaries were removed and blood samples were obtained. Levels of estradiol (E₂), vascular endothelial growth factor (VEGF), VEGF-C, and lipid hydroperoxidase (LPO) and the activity of glutathione peroxidase (GPX), superoxide dismutase (SOD), and catalase (CAT) were measured both in blood and tissue samples. Histopathological and morphometric analyses were also performed on tissue samples.

RESULTS

Considering serum levels, mean CAT was significantly higher ( P = .003) and mean SOD ( P = .033), LPO ( P = .050), VEGF ( P = .001), and VEGF-C ( P = .024) were significantly lower in the EPO-treated group than in the untreated group. Mean serum GPX levels were similar. Significantly higher levels of E₂ were determined in the EPO group than in the untreated group. Highest serum E₂ levels were found in the sham group ( P = .001). Tissue levels of GPX (1.23) and CAT (53.17) were significantly higher in the EPO group ( P = .002 and P = .001, respectively). However, tissue levels of SOD and LPO, VEGF, and VEGF-C levels were significantly lower in the EPO group than those in the untreated group ( P = .033, P = .050, P = .002, and P = .003, respectively). In tissue examination, the highest values of x, y axis and epithelial height were in the sham group. Mean value of the EPO group was found statistically significantly higher than that of the untreated group ( P ≤ .05). In terms of antral follicle count, ordering was found as sham > EPO-treated > EPO-untreated group. Follicle counts in the EPO group were significantly higher than those in the untreated group ( P ≤ 0.05).

CONCLUSION

Erythropoietin improved the survival of follicles in ovarian grafts most likely by reducing ischemic injury, by improving neoangiogenesis, and by its antioxidant effects.

Safeguarding Fertility With Whole Ovary Cryopreservation and Microvascular Transplantation: Higher Follicular Survival With Vitrification Than With Slow Freezing in a Ewe Model

BACKGROUND

In young women, ovarian cortex cryopreservation before gonadotoxic chemotherapy and its avascular grafting after cancer healing permitted fertility restoration. However, ischemia reduced the grafts' lifespan. Microvascular transplantation of cryopreserved whole ovary may allow immediate revascularization, ensuring better fertility preservation, but the best cryopreservation method is unknown. We aimed to compare slow freezing and vitrification of whole ovary for fertility preservation purposes, in an ewe model.

METHODS

Twelve ewes were allocated at random to slow freezing (n = 6) or vitrification group (n = 6). Ewes' left ovary was removed and cryopreserved. Dimethyl sulfoxide 2 M was used as cryoprotector for slow freezing. Vitrification was obtained using increasing concentrations of a vitrification solution of the latest generation (VM3) and gradual temperature lowering to minimize toxicity. After a month, the right ovary was removed, the left ovary was thawed/warmed, and its vessels were anastomosed to the right pedicle. Fertility and ovarian function were assessed for 3 years. Ovarian follicles in native and transplanted ovaries were counted and compared at study completion.

RESULTS

Hormonal secretion resumed in all ewes of both groups. One ewe of the slow-freezing group delivered healthy twins 1 year 9 months and 12 days after transplantation. Estimated whole follicle survival was very low in both groups but significantly higher after vitrification than after slow freezing (0.3% ± 0.5% vs 0.017% ± 0.019%, respectively; p < 0.05).

CONCLUSIONS

Further progress is needed before whole-ovary cryopreservation can be considered an option for safeguarding fertility. Whole ovary vitrification provides better follicular survival compared to slow freezing and may be a valuable cryopreservation option.

An approach to fertility preservation in prepubertal and postpubertal females: a critical review of current literature

Advancements in childhood cancer treatment have led to increasing survivorship, creating a greater emphasis on long-term management of patients, including quality of life and side effects from therapy; foremost of which is preserving fertility. The American Society of Clinical Oncology (ASCO) recently revised their guidelines and recommend fertility preservation options be discussed at the earliest possible opportunity for newly diagnosed patients, including methods available for children that remain investigational. Herein, we discuss the current barriers to and the impact of these guidelines for pediatric oncologists caring for young female patients, and provide some suggestions on how to approach this complicated topic.

Replacement of sodium with choline in slow-cooling media improves human ovarian tissue cryopreservation

Ovarian tissue cryopreservation is a promising technique for fertility preservation in young female cancer patients and efforts have been made to improve its effectiveness. During cooling and thawing, sodium ions significantly contribute to the 'solute effect' that plays a major role in disrupting cell membranes. Choline ions, which do not cross the cell membrane, should not contribute to the intracellular solute load. The present study assessed the effects of sodium substitution with choline in slow-cooling freezing media on human ovarian cortical strip cryopreservation. A total of 629 follicles (fresh control n=266; cryopreserved n=363), collected from ovarian biopsies of 11 women (22-40years) during laparoscopic surgery, were studied by light microscopy, immunohistochemistry and transmission electron microscopy to evaluate their morphology, apoptosis and ultrastructure. The results demonstrate that choline substitution leads to: (i) an improved preservation of oocytes and follicular cells; (ii) the recovery of a higher percentage of grade-1 follicles negative for p53, p21 and Apaf-1 apoptotic markers; (iii) a reduced mitochondrial damage as observed at an ultrastructural level; and (iv) a better preservation of ovarian tissue stroma. In conclusion, the use of choline-based media may represent a valuable tool to improve human ovarian tissue cryopreservation. Ovarian tissue cryopreservation is a promising fertility preservation approach for cancer patients before undergoing treatments that irreversibly reduce the ovarian reserve. Autotransplantation of ovarian cortical strips has resulted in viable offspring in animal models and human. Worldwide, 20 live births have been reported thus far following autotransplantation of frozen-thawed ovarian tissue. However, currently the success rate of this technology is far from being satisfactory. This could be due to inappropriate cryopreservation procedures that might impair the physiology of ovarian follicles. Sodium ions contained in freezing media significantly contribute to the 'solute effect' that plays a major role in disrupting cell membranes. Choline ions, which do not cross the cell membrane, would not be expected to contribute to the intracellular solute load. In the present study we assessed the effects of sodium substitution with choline in slow-cooling freezing media on human ovarian cortical strip cryopreservation. A total of 629 follicles, collected from ovarian biopsies of 11 women (aged 22-40years) during laparoscopic surgery, have been studied by light microscopy, immunohistochemistry and transmission electron microscopy to evaluate their morphology, apoptosis and ultrastructure. Results demonstrated that choline substitution allowed: (i) a better preservation of oocytes and follicular cells; (ii) the recovery of an higher percentage of healthy follicles negative for apoptotic markers; (iii) a lower mitochondria ultrastructural damage; and (iv) a better preservation of ovarian tissue stroma. In conclusion, the use of choline-based media could represent a valuable tool to cryopreserve human ovarian tissue for fertility preservation.

Factors related to unstained areas in whole ewe ovaries perfused with a metabolic marker

STUDY QUESTION

What factors are associated with the presence of areas unexposed to the perfusate after whole ovary perfusion?

SUMMARY ANSWER

Over half the ovaries perfused with the metabolic marker methylthiazolyl blue tetrazolium (MTT) were incompletely stained. Incomplete staining was statistically significantly associated with a small ovarian slice surface area, inexperience of the experimenter, and the presence of a corpus luteum.

WHAT IS KNOWN ALREADY

Whole ovary cryopreservation followed by vascular auto-transplantation has provided poor outcomes as an alternative way to safeguard fertility. Perfusion, commonly used to expose the ovaries to cryoprotectants, may miss areas excluded from the vascular network, explaining subsequent poor ovarian functionality.

STUDY DESIGN, SIZE, DURATION

An observational study of 360 ewe ovaries stained by in vitro perfusion with MTT as a qualitative marker of tissue blood supply was performed. A logistic regression model was built to identify factors associated with incomplete ovary staining.

MATERIALS, SETTING, METHODS

Whole ewe ovaries with their vascular pedicles were perfused at 0.35 ml/min with 1 g/l MTT for 2 h at 39°C under 19 experimental conditions. The pedicles were removed and the ovaries cut in half sagittally and photographed. The unstained area of the slice surface was measured. Times from ovary collection to ovary rinsing and to MTT perfusion initiation, ovary weight and slice surface area, presence of a corpus luteum and operator experience (number of ovaries previously perfused) were recorded. Pedicle MTT staining was quantified at 564 nm after solubilization in alcohol.

MAIN RESULTS AND THE ROLE OF CHANCE

Unstained areas were observed in 64.4% of the ovaries. Multivariate analysis found that incomplete ovary staining was independently associated with lower experimenter experience (P < 0.02), smaller ovary slice surface area (P < 0.0001) and presence of a corpus luteum (P < 0.01). The presence of unstained areas was independent from experimental conditions. The rate of incomplete ovary staining decreased from 83 to 60% beyond the 80th perfused ovary (P < 0.0001).

LIMITATIONS, REASONS FOR CAUTION

Descriptive study.

WIDER IMPLICATIONS OF THE FINDINGS

Blood-supply impairments that result in incomplete perfusion might adversely affect outcomes after whole ovary cryopreservation. Improved perfusion techniques should enhance success.

Validation of a new metabolic marker to assess the vascular viability of vitrified whole sheep ovaries

BACKGROUND

Whole ovary cryopreservation has been suggested as a means to preserve fertility. In animal models, autologous cryopreserved ovary transplants frequently undergo thrombosis and a method to assess the vascular viability of cryopreserved ovaries would be valuable. We developed a staining method using methylthiazolyl blue tetrazolium (MTT, a metabolic marker) to assess the pedicle metabolism of whole ovaries vitrified using cryoprotectant called 'VS4'.

METHODS

Whole sheep ovaries were perfused with MTT (1 g/l). In one group, ovarian tissue lesions were induced by immersing the ovarian pedicle in medium at 53°C or 65°C or in liquid nitrogen prior to MTT perfusion. In the second group, several metabolic substrates (d-glucose, l-glucose and pyruvic acid) and inhibitors [2-deoxy-d-glucose for d-glucose metabolism, azide for mitochondrial respiration and diphenyleneiodonium (DPI) for NADPH oxidase (an effector of the pentose phosphate pathway)] were added to the MTT stain. The third group was subjected to VS4 ± vitrification/warming prior to MTT perfusion. Pedicle MTT staining was assessed qualitatively by histological examination of frozen sections or quantified at 564 nm after solubilization in alcohol.

RESULTS

MTT strongly and reproducibly stained the vascular smooth muscle. Heating at 53°C or 65°C or cooling in liquid nitrogen significantly diminished MTT staining by 48% (P = 0.001, n = 10), 94% (P = 0.0002, n = 10) and 94% (P = 0.0002, n = 10), respectively. MTT staining was affected by d-glucose metabolism: absence of d-glucose, substitution of unmetabolized l-glucose for d-glucose or addition of 2-deoxy-d-glucose significantly decreased MTT staining by 44% (P < 0.01, n = 10), 45% (P < 0.01, n = 10) and 29% (P < 0.01, n = 10), respectively. Pyruvic acid failed to correct the MTT staining decrease induced by d-glucose deprivation and azide did not decrease MTT staining, suggesting that MTT staining could be independent of mitochondrial metabolism. Adding DPI significantly inhibited MTT staining by 25% (P < 0.001, n = 10), suggesting involvement of the pentose phosphate pathway's effectors. Compared with controls, VS4-vitrified/warmed pedicles showed significantly less MTT staining (-30%, P < 0.005, n = 10), with unstained foci, whereas unvitrified VS4-exposed pedicles showed no difference.

CONCLUSIONS

MTT can serve as a qualitative and quantitative vascular viability marker.VS4 vitrification caused alterations in ovarian vascular metabolism. MTT staining should allow accurate comparisons of whole-organ cryoprotection protocols.

Which are the ideal donor and recipient vessels for a whole ovarian transplantation?

OBJECTIVE

To compare deep circumflex iliac (DCI) and deep inferior epigastric (DIE) pedicles as potential recipient vessels for a whole ovarian microvascular transplantation.

DESIGN

Anatomical study.

SETTING

Laboratory of anatomy, university center.

PATIENT(S)

Ten fresh human female cadavers.

INTERVENTION(S)

Anatomical dissections, vascular injections, histologic analysis.

MAIN OUTCOME MEASURE(S)

Morphological analysis of the gonadic, DCI, and DIE pedicles; diameter of the vessels at regular intervals along their entire length. Comparisons of the caliber values between receiving (DCI and DIE) and gonadic pedicles aiming to determine the optimal size match.

RESULT(S)

We highlight a tortuous appearance of the gonadic artery. This morphology contrasted with the venous system that included two or three straight veins, one of them being wider than the others. The gonadic vessels converge into a wider artery and vein at 5 cm from the ovary. An optimal size match existed between gonadic and DCI arteries and veins sections, in 13 of 14 gonadic pedicles.

CONCLUSION(S)

A safe microsurgical whole ovarian transplantation is feasible if the gonadic pedicle is harvested with a minimal length of 5 cm from the ovary. The DCI pedicle seems to have the best size match with the ovarian vessels to perform a reliable end-to-end microvascular anastomosis.

Clinical grade vitrification of human ovarian tissue: an ultrastructural analysis of follicles and stroma in vitrified tissue

BACKGROUND

Cancer therapy is one of many conditions which may diminish the ovarian reserve. Banking of human ovarian tissue has become an option for the preservation of female fertility. We have shown that vitrification is an excellent method to cryopreserve ovarian tissue. To carry out vitrification in a clinical setting, we have developed a clinical grade closed system to avoid direct contact of ovarian tissue with liquid nitrogen.

METHODS

Ovarian tissue was obtained by biopsy from 12 consenting women undergoing Caesarean section. Tissues were vitrified in cryotubes, using dimethyl sulphoxide, 1,2-propanediol, ethylene glycol and polyvinylpyrrolidon as cryoprotectants. Non-vitrified and warmed-vitrified tissue was compared by light and electron microscopic morphology of the follicles within the tissues.

RESULTS

We did not see any differences in the light or electron microscopic ultrastructure of oocytes between non-vitrified and vitrified tissues. No irreversible subcellular alterations in vitrified tissues were seen.

CONCLUSIONS

The ultrastructure of follicles within the vitrified human ovarian tissue was well preserved using cryotube in a closed vitrification system to avoid direct contact of liquid nitrogen. The system is compatible with the European tissue directive.

Serous Papillary Cystadenocarcinoma Arising From Autografted Ovary of the Abdominal Wall

A 58-year-old-woman developed a serous papillary cystadenocarcinoma between the fascia and peritoneum of the left abdominal wall. The patient had undergone bilateral oophorectomy for serous cystadenoma 17 years earlier and her residual normal ovarian parenchyma had also been transplanted to the abdominal wall. Grossly and microscopically, the current tumor arises from the autografted ovarian parenchyma. Literature review indicates that carcinoma arising from autografted ovarian tissue is extremely rare.

Female fertility preservation: practical and ethical considerations of an underused procedure

PURPOSE

Cancer treatments for young women can permanently or temporarily affect fertility. The purpose of this retrospective analysis was to present the clinical experience and ethical considerations of fertility preservation in female oncology patients in a tertiary gynaecological department.

METHODS

Since 2002, in 37 patients fertility preservation was performed according to an institutional review board approved protocol in a University hospital in the Netherlands; 33 patients were not treated.

RESULTS

Embryo cryopreservation was performed in 10 patients, ovarian tissue cryopreservation in 24, and an ovarian transposition was performed in 3 patients; in one patient combined with an ovarian transplantation and in one patient with ovarian tissue cryopreservation.

DISCUSSION

Approved protocols and timing are essential in performing female fertility preservation. Referral for ovarian tissue and embryo cryopreservation is minimal in the Netherlands. Future research focuses on the psychosocial aspects of fertility preservation and explores patients' and professionals' expectations and attitudes regarding fertility preservation and aims to be in line with technical developments.

Cancer and fertility preservation in females: where we stand and where we are heading

It is estimated that, in 2010, one in every 250 adults will be a childhood cancer survivor. This review discusses the impact of current cancer treatment on fertility potential and the assisted-reproduction innovations available today for the most common cancers in young women. As the emerging discipline of fertility preservation is steadily attracting increasing interest, developments in the near future promise to be very exciting. However, in everyday routine work, better interdisciplinary cooperation between gynecological and pediatric oncologists, surgeons, immunologists and endocrinologists is necessary so that individualized options for fertility preservation can be offered in advance of surgical procedures or cancer treatments.

Beneficial effect of desialylated erythropoietin administration on the frozen-thawed canine ovarian xenotransplantation

PURPOSE

The main drawback of ovarian cryopreservation followed by transplantation is that a large proportion of follicles are lost after transplantation. Thus, effects of erythropoietin (EPO) and desialylated EPO administration on the frozen-thawed canine ovarian xenotransplantation were examined.

METHODS

The protective and survival-promoting effects of EPO and desialylated EPO on the follicles of frozen-thawed canine ovaries after transplantation were examined using NOD-SCID mice. Frozen-thawed dog ovarian tissue with 400 U/kg of EPO or asialo EPO was placed into the ovarian bursa.

RESULTS

At 4 weeks after the transplantation, the ovaries were removed and subjected to histological examination. The survival rate of early primary follicles was 15.2% in the EPO group and 157.6% in the asialo EPO group, in contrast to 10.1% in the untreated group.

CONCLUSIONS

These results demonstrate that administration of asialo EPO could be effectively used to enhance the survival of the follicles of transplanted cryopreserved ovaries.

Preservation of fertility in young cancer patients: contribution of transmission electron microscopy

During the last decade, new technologies in reproductive medicine have emerged to preserve the fertility of women whose gonadal function is threatened by premature menopause or gonadotoxic treatments. To offer an individualized approach to these patients, different experimental procedures are under investigation, including oocyte cryopreservation and cryopreservation and transplantation of ovarian tissue in the form of cortical fragments, whole ovary or isolated follicles. This review shows that transmission electron microscopy (TEM), combined with other in-vivo and in-vitro analysis techniques, is a valuable tool in the establishment of new experimental protocols to preserve female fertility. Ultrastructural studies allow in-depth evaluation of the oocyte's unique morpho-functional characteristics, which explain its low cryotolerance, and provide essential information on follicular, stromal and endothelial cell integrity, as well as cellular interactions crucial for normal folliculogenesis. In order to be able to offer appropriate and efficient options in every clinical situation, oocyte in-vitro maturation and ovarian tissue transplantation need to be optimized. Further development of new approaches, such as follicular isolation and whole ovary transplantation, should be encouraged. Fine ultrastructural details highlighted by TEM studies will be useful for the further optimization of these emerging technologies.

Human oocyte and ovarian tissue cryopreservation and its application

PURPOSE

To review the recent progress in human oocyte and ovarian tissue cryopreservation, and in the application of these two technologies for preserving female fertility of patients who are undergoing cancer treatment.

DESIGN

The literature on human oocyte and ovarian tissue freezing was searched with PubMed. The scientific background, current developments and potential future applications of these two methods were reviewed.

RESULTS

Chemotherapy and/or radiotherapy can induce premature ovarian failure in most of female cancer patients. Consequently, there has been a greater need for options to preserve the reproductive potential of these individuals. However, options are somewhat limited currently, particularly following aggressive chemotherapy and/or radiotherapy treatment protocols. In recent years, there have been considerable advances in the cryopreservation of human oocytes and ovarian tissue. For women facing upcoming cancer therapies, cryopreservation of ovarian tissue and oocytes is a technology that holds promise for banking reproductive potential for the future. Recent laboratory modifications have resulted in improved oocyte survival, oocyte fertilization, and pregnancy rates from frozen-thawed oocytes in IVF. This suggests potential for clinical application.

CONCLUSIONS

In the case of patients who are facing infertility due to cancer therapy, oocyte cryopreservation may be one of the few options available. Ovarian tissue cryopreservation can only be recommended as an experimental protocol in carefully selected patients. In ovarian tissue transplantation, more research is needed in order to enhance the revascularization process with the goal of reducing the follicular loss that takes place after tissue grafting. These technologies are still investigational, although tremendous progress has been made. The availability of such treatment will potentially lead to its demand not only from patients with cancer but also from healthy women who chose to postpone childbearing until later in life and therefore wish to retain their fertility.

Apoptosis and ultrastructural assessment after cryopreservation of whole human ovaries with their vascular pedicle

OBJECTIVE

To investigate possible damage caused by freeze-thawing whole human ovaries.

DESIGN

Prospective experimental study.

SETTING

Academic gynecology research unit in a university hospital.

PATIENT(S)

Ovaries were obtained from three women (aged 29-36 years).

INTERVENTION(S)

Ovaries were perfused and bathed in cryoprotective solution, and slow freezing was performed. Rapid thawing was achieved by perfusion and bathing with a decreased sucrose gradient.

MAIN OUTCOME MEASURE(S)

Apoptosis was assessed by the terminal deoxynucleotidyl transferase-mediated biotinylated deoxyuridine triphosphates nick end-labeling (TUNEL) method and by immunohistochemistry for active caspase-3 in fresh ovaries, after cryoprotectant exposure, and after thawing. Morphometric analysis of TUNEL-positive surface area was performed. Ultrastructure was assessed by transmission electron microscopy (TEM) in the thawed tissue.

RESULT(S)

No primordial or primary follicles were found to be positive for either TUNEL or active caspase-3. No statistically significant difference in mean TUNEL-positive surface area values was found between the three groups: fresh, 0.05% +/- 0.03%, with 134 high-power fields (HPFs); cryoperfused, 0.02% +/- 0.01%, with 130 HPFs; and thawed, 0.09% +/- 0.03%, with 622 HPFs. By means of TEM, follicles and vessels showed a well-preserved ultrastructure, with 96.7% (29/30) healthy-looking primordial and primary follicles, and 96.3% (180/187) healthy-looking endothelial cells.

CONCLUSION(S)

Cryopreservation of intact human ovary with its vascular pedicle, according to the freeze-thawing protocol described here, is not associated with any signs of apoptosis or ultrastructural alterations in any cell types. Whole-organ vascular transplantation may thus be a viable option in the future.

Safe fertility-preserving management in gynecological malignancies

OBJECTIVE

To provide a review in the available literature about the safe fertility-preserving management in gynecological malignancies, focusing on the selection criteria of the patients, treatment options and follow-up.

DESIGN

Literature survey.

RESULTS

The incidence of cancer in women who still want to get pregnant is increasing significantly. An early detection in gynecological malignancies allows less aggressive approaches to cure such disorders. A more conservative management, which preserves fertility, is considered safe and an option for those who have not completed their child-bearing.

CONCLUSIONS

Selected patients with cervical, endometrial and ovarian cancer may be candidates to a safe fertility-preserving management. A careful stage and follow-up of the patients is essential to achieve success with this practice.

The effect of cancer treatment on female fertility and strategies for preserving fertility

Aggressive chemotherapy and radiotherapy in young patients with cancer has greatly enhanced the life expectancy of these patients, but these treatments often cause infertility because of the massive destruction of the ovarian reserve resulting in premature ovarian failure (POF). This review focuses on the effect of cancer treatments on fertility and on the various surgical and assisted-reproduction innovations that are available to provide the patient with the option of future pregnancies. As the emerging discipline of fertility preservation is steadily attracting increasing interest, developments in the near future promise to be very exciting. However, in everyday routine work, better interdisciplinary cooperation between gynecological and pediatric oncologists, surgeons, immunologists and endocrinologists is necessary so that individualized options for fertility preservation can be offered in advance of surgical procedures or cancer treatments. GnRH analog treatment can preserve fertility in some patients, but not in all. At present, cryopreservation of ovarian tissue appears as a very promising method of providing the cancer patient with a realistic chance of preserving fertility-a prospect that is also extremely important to patients for psychological reasons.

Ovarian tissue cryopreservation and transplantation: a review

The review covers current options for ovarian tissue cryopreservation and transplantation and provides a systematic review of the existing literature from the last 10 years, taking into account all previously published reviews on the subject. The different cryopreservation options available for fertility preservation in cancer patients are embryo cryopreservation, oocyte cryopreservation and ovarian tissue cryopreservation. The choice depends on various parameters: the type and timing of chemotherapy, the type of cancer, the patient's age and the partner status. The different options and their results are discussed, as well as their putative indications and efficacy. The review concludes that advances in reproductive technology have made fertility preservation techniques a real possibility for patients whose gonadal function is threatened by premature menopause, or by treatments such as radiotherapy, chemotherapy or surgical castration.

Preventing organ-specific chemotherapy toxicity

Recent advances in treatment for pediatric cancers has increased overall survival rates. As more and more survive pediatric cancer, we continue to see the emergence of late effects of treatment within pediatric and the growing adult survivor population. The evaluation of late effects was initiated approximately two decades ago, and has become an extremely important facet of pediatric oncology. This review delves into several of the most serious organ-specific late effects of pediatric cancer treatment, outline what we know and what we do not currently understand about preventing or reducing them. Clinical and bench research are necessary to develop interventions that will avoid or mitigate late effects and improve the health of pediatric cancer survivors.

Oocyte recovery, embryo development and ovarian function after cryopreservation and transplantation of whole sheep ovary

BACKGROUND

Successful cryopreservation of a whole ovary may provide a solution for women with premature ovarian failure. The aim of this study was to evaluate the function of cryopreserved whole sheep ovaries both in vitro and in vivo.

METHODS

Transplantation of frozen-thawed intact ovaries was performed on eight sheep by artery and vein anastomosis to the contralateral ovarian artery and vein. The remaining ovary was removed. Oocyte aspiration was performed 1 and 4 months post-transplantation. Serum progesterone levels were measured after 24 and 36 months. Magnetic resonance imaging (MRI) was carried out 12 months after transplantation.

RESULTS

Progesterone activity was detected in three sheep from 24 to 36 months post-transplantation. Oocyte retrieval was successful in two sheep and parthenogenic activation has resulted in embryonic development up to the 8-cell stage. MRI revealed an intact ovary with small follicles and intact blood vessels.

CONCLUSIONS

Whole ovaries, and the follicles and blood vessels they contain, are able to survive cryopreservation. In addition, MRI has shown that blood vessels were intact and that normal blood flow had resumed to the transplant. We conclude that immediate and long-term hormonal restoration and normal ovulation is possible after cryopreservation and transplantation of whole ovaries in sheep.

Restoration of ovarian function after orthotopic (intraovarian and periovarian) transplantation of cryopreserved ovarian tissue in a woman treated by bone marrow transplantation for sickle cell anaemia: Case report

Ovarian function after orthotopic transplantation of cryopreserved ovarian tissue has been restored in women with malignant disease. Here the techniques are adapted for a non-cancer patient. In 1999, right oophorectomy was performed in a 21 year old woman before chemotherapy, prior to bone marrow transplantation. Ovarian cortex was frozen, according to a strict protocol. After thawing, ovarian cortex was reimplanted into the ovary and in a peritoneal window close to the ovary in 2004. Four-and-a-half months after reimplantation, LH, FSH, 17beta-estradiol and progesterone levels, as well as ultrasonography, demonstrated the presence of an ovulatory cycle. After this cycle, the patient experienced two other ovulatory cycles, evidenced by FSH and 17beta-estradiol concentrations, as well as ultrasound demonstration of a follicle. Follicular development was clearly observed in both the intraovarian site (1st and 2nd cycle) and the peritoneal window (3rd cycle). Restoration of endocrine ovarian function occurred after ovarian cortical strips, biopsied and cryopreserved before chemotherapy, were reimplanted into the ovary itself and a periovarian peritoneal window.

The role of cryopreservation for women prior to treatment of malignancy

PURPOSE OF REVIEW

The purpose of this review is to investigate recent advances in xenografting, as well as in orthotopic and heterotopic autotransplantation of human cryopreserved ovarian tissue.

RECENT FINDINGS

The first livebirth after orthotopic transplantation of cryopreserved ovarian tissue was reported recently. We discuss this case and other cases of reimplantation of cryopreserved ovarian tissue, bearing in mind that many questions remain.

SUMMARY

Finally, we report the latest developments in research on the transplantation of an intact ovary and the reimplantation of isolated follicles.

Evaluation of urine toxicology screens in an oocyte donor population

PURPOSE

To assess the accuracy of drug self-reporting in oocyte donors.

METHODS

Retrospective chart review of donors at Stanford University.

RESULTS

7% of the donor population had a significant positive urine toxicology screen.

CONCLUSIONS

Donors may not fully disclose details of drug use, so urine toxicology screening should be considered in this patient population.

Livebirth after orthotopic transplantation of cryopreserved ovarian tissue

BACKGROUND

The lifesaving treatment endured by cancer patients leads, in many women, to early menopause and subsequent infertility. In clinical situations for which chemotherapy needs to be started, ovarian tissue cryopreservation looks to be a promising option to restore fertility. In 1997, biopsy samples of ovarian cortex were taken from a woman with stage IV Hodgkin's lymphoma and cryopreserved before chemotherapy was initiated. After her cancer treatment, the patient had premature ovarian failure.

METHODS

In 2003, after freeze-thawing, orthotopic autotransplantation of ovarian cortical tissue was done by laparoscopy.

FINDINGS

5 months after reimplantation, basal body temperature, menstrual cycles, vaginal ultrasonography, and hormone concentrations indicated recovery of regular ovulatory cycles. Laparoscopy at 5 months confirmed the ultrasonographic data and showed the presence of a follicle at the site of reimplantation, clearly situated outside the ovaries, both of which appeared atrophic. From 5 to 9 months, the patient had menstrual bleeding and development of a follicle or corpus luteum with every cycle. 11 months after reimplantation, human chorionic gonadotrophin concentrations and vaginal echography confirmed a viable intrauterine pregnancy, which has resulted in a livebirth.

INTERPRETATION

We have described a livebirth after orthotopic autotransplantation of cryopreserved ovarian tissue. Our findings suggest that cryopreservation of ovarian tissue should be offered to all young women diagnosed with cancer.

Morphodynamics of the follicular-luteal complex during early ovarian development and reproductive life

Female reproductive activity depends upon cyclic morphofunctional changes of the ovarian tissue during the female's fertile period, but the primum movens of an active gonadal rearrangement can be found from early phases of embryo development. To offer a basic account of the main steps of ovarian dynamics, we review the morphofunctional behavior of the follicular-luteal complex in an integrated study using light microscopy and transmission and scanning electron microscopy as well as through the use of numerous drawings. Particular emphasis is given to some reproductive aspects including (1) germ-somatic cell relationships and onset of folliculogenesis during early gonadal development; (2) follicular development and oocyte-follicle cell associations through adult folliculogenesis, finally leading to ovulation; (3) morphodynamics of corpus luteum formation, development, and regression, and (4) degenerative processes involving germ and somatic cells. The results reported, many of which originated in our laboratory, arise from some experiments on laboratory mammals but mostly from a large selection of human specimens. The data obtained are integrated and correlated with classic reports as well as with current views. Crucial biochemical, histophysiological, and clinical aspects are also emphasized.

Reproductive function after treatment of malignant germ cell ovarian tumors

The outcome and reproductive function were examined among patients with malignant ovarian germ cell tumors treated since 1980. Between 1980 and 2001, fertility-sparing surgery was performed in 26 women, 23 of whom received adjuvant chemotherapy. With a median follow-up of 66.6 months, all patients have been alive, with histological types of 6 immature teratomas, 8 dysgerminomas, 6 yolk sac tumors, and 6 mixed types. Clinical stages were involved of 17 early stage and 9 advanced stage patients. After treatment, 20 women out of 26 recovered menstruation within 6 months. During follow-up, two chemotherapy-untreated and one treated patients experienced 4 conceptions in total. A treated patient conceived but selected artificial termination by affection of chemotherapy. Conservative surgery with adjuvant chemotherapy is the standard approach to treat patients with malignant ovarian germ cell tumors. In these 20 years, we experienced no delivery, so that fertility seems to be seriously affected by treatments.

Fertility after treatment for Hodgkin's disease

BACKGROUND

The investigational endeavors of ovarian cryopreservation await the clinical experience of auto- or xenotransplantation, in vitro maturation of thawed primordial follicles, their in vitro fertilization and embryo transfer. Although promising, this experience is not yet available. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryoperserved ovary has been raised following experimental animal observations. Therefore, until these innovative endeavors prove successful, we have attempted to minimize the gonadotoxic effect of chemotherapy by the co-treatment with a gonadotropin-releasing hormone agonistic analog (GnRH-a) to induce a temporary prepubertal milieu. The immunoreactive inhibin-A and -B in these patients was measured before, during and following the gonadotoxic chemotherapy.

METHODS

A prospective clinical protocol was undertaken in 60 women aged 15-40 years with lymphoma, 10 with leukemia and 10 undergoing chemotherapeutic treatments for non-malignant diseases such as systemic lupus erythematosus or other autoimmune diseases. A monthly injection of depot D-TRP(6)-GnRH-a was administered from before starting the chemotherapy until its conclusion, up to a maximum of 6 months. Hormonal profile [follicle-stimulating hormone (FSH), luteinizing hormone (LH), E2, T, P4, insulin-like growth factor (IGF)-1, IGF-BP3 and prolactin) was taken before starting the GnRH-a/chemotherapy co-treatment, and monthly thereafter until resumtion of spontaneous ovulation. This group was compared with a control group of 60 women who have been treated with similar chemotherapy.

RESULTS

Whereas all but three (40, 36 and 34 year old) of the surviving patients within the GnRH-a/ chemotherapy co-treatment group resumed spontaneous ovulation and menses within 12 months, less than half of the patients in the 'control' group (chemotherapy without GnRH-a co-treatment) resumed ovarian function and regular cyclic activity (P <0.05). The remaining 55% experienced premature ovarian failure (POF). Temporarily increased FSH concentrations were experienced by about one-third of the patients resuming cyclic ovarian function, suggesting reversible ovarian damage in a larger proportion of women than those experiencing POF. Inhibin-A and -B decreased during the GnRH-a/ chemotherapy co-treatment but increased to normal levels in patients who resumed regular ovarian cyclicity, and/or spontaneously conceived, as compared with low levels in those who developed POF.

CONCLUSIONS

If these preliminary data are consisent in a larger group of patients, GnRH-a co-treatment should be considered in every woman of reproductive age receiving chemotherapy, in addition to assisted reproductive technologies and the investigation into ovarian cryopreservation for future in vitro maturation, autotransplantation or xenotransplantation.

Late effects of childhood cancer therapy

This study reviews the common long-term sequalae of childhood cancer and its therapy. It discusses the clinical and research challenges posed by such late effects. The authors address related topics of late effects research and clinical care, methodological issues, barriers and directions for the future.

Female reproductive potential post-treatment for childhood cancer

Survival post-treatment for childhood malignancy is now in excess of 70%. Hence female reproductive potential following treatment must be addressed. Issues concerning subsequent uterine and ovarian function, fertility options and importantly the ethics and safety of treatment approaches are discussed herein.

Protecting female fertility from cancer therapy

Recent advances in cancer therapy have improved the long-term survival of young cancer patients who are then commonly faced with iatrogenic infertility and premature ovarian failure. Preservation of fertility potential has thus become a major goal and could be realized by preventing ovarian toxicity or by cryopreservation of reproductive cells (i.e. oocytes, embryos) and tissues (i.e. ovarian cortex). GnRH analogs prevent chemotherapy-induced-ovarian-damage in rats, however human results are controversial. Anti-apoptotic agents (i.e. sphingosine-1-phosphate) may present an innovative treatment to prevent oocyte destruction during cancer therapy. Although cryopreservation of mouse oocytes is successful, the results obtained in other mammalian species were worse, probably due to their extreme sensitivity to suboptimal conditions during the process of cryopreservation. This resulted in low oocyte survival and fertilization rates, a high incidence of polyploidy, and poor embryonic developmental ability. Ovarian tissue cryopreservation is currently considered as the optimal procedure for follicle banking. Transplantation offers the best prospect of using frozen-thawed ovarian tissue, since no reliable ovarian in-vitro culture technology exists.

Intimacy issues: sexuality, fertility, and relationships

OBJECTIVES

To provide a review of the intimacy issues, (sexuality, fertility, and interpersonal relationships) that have an impact on the lives of cancer survivors.

DATA SOURCES

Published articles, research studies, and textbook chapters.

CONCLUSION

The experience of living with cancer impacts the survivors interpersonal relationships, sexuality, and fertility. As cancer treatments become more effective in prolonging life, options that preserve sexual function and fertility will be more prevalent.

IMPLICATIONS FOR NURSING PRACTICE

It is the responsibility of the oncology health care professional to become educated about options that preserve sexual function and fertility and inform patients before treatment decisions are made.

Ovarian tissue cryopreservation and gynecologic oncology: a review

Sperm cryopreservation permits young men, undergoing cancer treatments, to preserve their fertility. Ovarian tissue cryopreservation have the same goal for young women and could also be an option for children. However, only primordial follicles survive after freezing and a follicular maturation is needed after thawing. This maturation has not yet been realized in humans, pregnancies have only been obtained in animal models. As cryopreservation is yet effective in humans, many teams have already cryopreserved the ovarian tissue of patients who have nothing to lose as their follicular reserve would have been destroyed or severely depleted by cancer treatment. The preservation of fertility is rarely an issue in gynecologic oncology because it usually concerns post-menopausal women. However, they are early-onset forms of gynecologic cancers and in these cases fertility is often threatened. Ovarian tissue cryopreservation may be performed when curative or prophylactic ovariectomy must be undergone, when chemotherapy with high-dose alkylating agents is planned or when pelvic radiation is needed (particularly in cases requiring chemotherapy combined with radiotherapy). In some of these situations it would be dangerous to graft back the tissue to the patient as cancer cells could remain within the grafts, the best solution in this case would be the in vitro follicular maturation.