Dominique Demylle

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 Hodgkins 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.

Live birth after transplantation of frozen-thawed ovarian tissue after bilateral oophorectomy for benign disease.

OBJECTIVE To report the restoration of ovarian function and pregnancy in a woman after bilateral oophorectomy for benign disease after autotransplantation of cryopreserved ovarian cortex. DESIGN Case report. SETTING Gynecology research unit in a university hospital. PATIENT(S) A 28-year-old woman who underwent bilateral adnexectomy for ovarian abscesses at the age of 18 years. INTERVENTION(S) We performed ovarian cortex autotransplantation to a peritoneal pocket in the broad ligament. MAIN OUTCOME MEASURE(S) Restoration of ovarian activity and pregnancy. RESULT(S) Restoration of ovarian function began at 20 weeks and was achieved 24 weeks after transplantation. After the fifth stimulation attempt, two mature oocytes were obtained and microinjected. One embryo (seven cells) was obtained and transferred, leading to a normal pregnancy. The patient delivered a healthy baby boy weighing 2,370 g at 38 weeks of gestation. CONCLUSION(S) Ovarian cortex cryopreservation can be performed at the time of surgery for benign diseases when fertility is impaired. We report the first pregnancy to occur after ovarian tissue cryopreservation for benign ovarian pathology after bilateral oophorectomy.

Restoration of ovarian function in orthotopically transplanted cryopreserved ovarian tissue: a pilot experience.

Cryopreservation of ovarian tissue is currently proposed to young cancer patients before chemo- or radiotherapy to preserve their fertility. In this study, ovarian cortex was removed by laparoscopy from five women and cryopreserved before chemotherapy. After chemotherapy, they all experienced amenorrhoea due to premature ovarian failure and requested reimplantation of their cryopreserved ovarian tissue several years later. Thawed fragments were then grafted to an orthotopic site in all five women. Two of them underwent a second reimplantation. Ovarian function recovery was evaluated by hormone concentration measurement, follicular development on ultrasound and menstruation recovery. The first signs of ovarian function restoration (oestradiol peak, decrease in FSH, ultrasound showing follicular development) occurred between 16 and 26 weeks after reimplantation. Elevated FSH concentrations were sometimes observed between series of consecutive ovulatory cycles, demonstrating the presence of a relatively low ovarian reserve. There were no signs of disease recurrence in any patients with malignant disease. In conclusion, restoration of ovarian function was observed in all cases. Grafts remained functional in all the women. Transplantation of cryopreserved ovarian tissue to an orthotopic site appears to restore ovarian endocrine function, without any signs of disease recurrence.

IVF outcome in patients with orthotopically transplanted ovarian tissue

BACKGROUND Chemo- or radiotherapy can induce premature ovarian failure (POF), and ovarian tissue cryopreservation and transplantation may be proposed to restore ovarian function. Our aim was to evaluate the quality of oocytes and embryos derived from frozen-thawed transplanted ovarian tissue. MATERIALS AND METHODS Women were 21-28 years old at tissue cryopreservation. Nine women suffering POF following chemotherapy with or without radiotherapy underwent orthotopic ovarian tissue transplantation. After 12 months of spontaneous cycles without pregnancy, oocyte retrieval was performed in four patients during mildly stimulated or spontaneous cycles. ICSI was performed in all cases, with embryo transfer on day 3. Light and electron microscopy was used to study oocytes and embryos. RESULTS Signs of ovarian function restoration (estradiol peak, decreased FSH, follicular development) began 16-26 weeks after reimplantation. Twenty-one oocyte retrieval attempts were made. At least one oocyte was collected in 15 cases, giving an empty follicle rate per retrieval of 29% (6/21). Sixteen oocytes were recovered, of which 6 were abnormal or immature (38%) and 10 (62%) were in metaphase II (MII). Three MII oocytes failed to fertilize, two showed abnormal fertilization and five normal MII oocytes successfully fertilized with subsequent normal embryo development (Grade 2), yielding an embryo transfer rate of 24% per retrieval. No pregnancy occurred. CONCLUSIONS IVF in women with orthotopically grafted frozen-thawed ovarian tissue involves a higher risk of empty follicles, abnormal or immature oocytes, and low embryo transfer rates.

Pregnancy and live birth after autotransplantation of frozen-thawed ovarian tissue in a patient with metastatic disease undergoing chemotherapy and hematopoietic stem cell transplantation

OBJECTIVE To report a live birth after orthotopic transplantation of cryopreserved ovarian tissue. DESIGN Case report. SETTING Department of Gynecology, Cliniques Universitaires Saint-Luc, Brussels. PATIENT(S) Woman with metastatic cancer who had her ovarian tissue cryopreserved in 2001 before undergoing chemotherapy and hematopoietic stem cell transplantation, resulting in premature ovarian failure. INTERVENTION(S) Orthotopic reimplantation of ovarian cortex performed 7 years after cryopreservation. MAIN OUTCOME MEASURE(S) Restoration of ovarian activity. RESULT(S) Restoration of ovarian activity was observed 3.5 months after reimplantantation, and ongoing pregnancy was diagnosed 9 months after grafting. The patient delivered a healthy baby weighing 2.830 kg. CONCLUSION(S) Our patient represents the thirteenth live birth to occur after orthotopic reimplantation of cryopreserved tissue, but the first in a woman treated for metastatic disease.

Comparison of G1.2/G2.2 and Sydney IVF cleavage/blastocyst sequential media for the culture of human embryos: a prospective, randomized, comparative study

OBJECTIVE To compare two commercially available sequential media, G1.2/G2.2 and Sydney IVF cleavage/blastocyst media, as supports for human embryo culture. DESIGN Prospective randomized study. SETTING University-based IVF clinic. PATIENT(S) Two hundred forty-nine patients undergoing IVF treatment for the first or second time, randomly allocated at the time of oocyte retrieval, to either culture in G1.2/G2.2 or Sydney IVF media. INTERVENTION(S) Oocyte recovery, IVF or intracytoplasmic sperm injection, embryo culture, transfer on day 3 or day 5/6. MAIN OUTCOME MEASURE(S) Developmental stage on day 3, blastocyst rate, pregnancy outcome as assessed by beta hCG positive test, implantation rates, and ongoing pregnancies. RESULT(S) Embryos cultured in G1.2/G2.2 media displayed a faster kinetics of cleavage, compaction, blastulation, and hatching, but a lower day 3 embryo quality than those grown in Sydney IVF media. For patients with at least five embryos, G1.2/G2.2 media yielded higher implantation rates (26.2%) in our day 3 embryo transfer program when compared to Sydney IVF medium (15.5%), whereas similar implantation rates were obtained for day 5/6 embryo transfer for both media (43.1% and 36.1%, respectively). CONCLUSION(S) In our day 3 embryo transfer program, G1.2/G2.2 media were superior to Sydney IVF media, whereas both media yielded similar outcomes in our blastocyst transfer program.

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.

Live birth after allografting of ovarian cortex between genetically non-identical sisters

Aggressive chemotherapy generally results in the loss of both endocrine and reproductive functions. If the patient has not undergone previous oocyte, embryo or ovarian tissue cryopreservation, orthotopic allotransplantation of fresh ovarian tissue from a genetically non-identical sister may be considered. Here, we describe a case report. The patient, aged 15 years and presenting with homozygous sickle cell anemia, underwent chemotherapy (busulfan, cyclophosphamide) and total body irradiation before bone marrow transplantation, the donor being her HLA-compatible sister. HLA group analysis later revealed complete chimerism. When the patient was 32 years old, ovarian allografting was performed, with the ovarian tissue donor being the same sister who had already donated bone marrow. The goal was to restore ovarian activity and natural fertility. No immunosuppressive therapy was administered. No sign of rejection was observed. Restoration of ovarian function was achieved 3.5 months after transplantation, as proved by the first estradiol peak and follicular development detected by ultrasound. After 9 months of regular ovulatory cycles, IVF was attempted because proximal tubal stenosis (unknown at the time of grafting) could not be repaired by tubal reanastomosis. After stimulation, three oocytes were retrieved. Two embryos were obtained. One embryo was frozen and the other was transferred, resulting in an ongoing pregnancy. The patient delivered a healthy baby girl weighing 3.150 g at 37 2/7 weeks of gestation.

Livebirth after cryopreserved ovarian tissue transplantation – Authors' reply

www.thelancet.com Vol 380 July 14, 2012 107 Authors’ reply Since 2003, Corinne Hubinont and colleagues have had open access to all documents and protocols archived in the clinical database (Medical Explorer) at our university. Here we respond to their specifi c concerns. The patient was undoubtedly in primary ovarian failure: she was amenorrhoeic; concentrations of antiMullerian hormone and inhibin were at 0; concentrations of luteinising hormone and follicle-stimulating hormone were greater than 80 IU/L; and biopsy of the native ovary revealed no primordial follicles. Occasional ovulations are known to occur in patients in primary ovarian failure after chemotherapy, and we expressly stated that the patient had three ovulatory cycles over 3 years. We also clearly mentioned that a small corpus luteum was visible on the left ovary, and this of course implies the presence of progesterone. We would like to reiterate the numerous lines of evidence that lend support to our assertion that the origin of the pregnancy was the auto transplanted cryopreserved tissue. First, the patient had only a few ovulatory cycles over more than 3 years, all of which originated from the left native ovary, as proved by laparoscopy, echography, or both. The native right ovary showed no signs of ovarian activity. Second, laparoscopy done 4 months after the fi rst reimplantation showed, by direct visualisation, development of a follicle from the grafted tissue (see original fi gure 3A), clearly at some distance from the native atrophic right ovary. Biopsy of this follicle was done and histology of the follicular wall showed the presence of cells expressing inhibin A (fi gure 3B). Third, 5 months after reimplantation, the patient had regular menstrual bleeding with progesterone concentrations of greater than 10 μg/L. Vaginal echography revealed the presence of a preovulatory follicle at the reimplantation site during the cycle leading to the pregnancy. No follicles were seen on either of the native ovaries. Bilateral oophorectomy was never done for obvious ethical reasons, so the presence of isolated follicles in the atrophic native ovary cannot be absolutely excluded, as clearly stated in the Discussion section of our original paper. However, a woman who under went bilateral oophorectomy for bilateral abscesses in endometrial cysts recently gave birth to a healthy baby after orthotopic (broad ligament) reimplantation of ovarian tissue that was frozen at the time of bilateral oophorectomy, and we believe this corroborates our arguments beyond doubt. This is the 20th livebirth after cryopreserved ovarian tissue transplantation worldwide since 2004 (the fourth in our department), clearly showing that ovarian tissue cryopreservation should be regarded as an eff ective procedure that should be off ered to all young women diagnosed with cancer, in conjunction with other existing options for fertility preservation such as immature oocyte retrieval, in-vitro maturation of oocytes, oocyte vitrifi cation, and embryo cryopreservation.