Ellen Goossens

A European perspective on testicular tissue cryopreservation for fertility preservation in prepubertal and adolescent boys

STUDY QUESTION What clinical practices, patient management strategies and experimental methods are currently being used to preserve and restore the fertility of prepubertal boys and adolescent males? SUMMARY ANSWER Based on a review of the clinical literature and research evidence for sperm freezing and testicular tissue cryopreservation, and after consideration of the relevant ethical and legal challenges, an algorithm for the cryopreservation of sperm and testicular tissue is proposed for prepubertal boys and adolescent males at high risk of fertility loss. WHAT IS KNOWN ALREADY A known late effect of the chemotherapy agents and radiation exposure regimes used to treat childhood cancers and other non-malignant conditions in males is the damage and/or loss of the proliferating spermatogonial stem cells in the testis. Cryopreservation of spermatozoa is the first line treatment for fertility preservation in adolescent males. Where sperm retrieval is impossible, such as in prepubertal boys, or it is unfeasible in adolescents prior to the onset of ablative therapies, alternative experimental treatments such as testicular tissue cryopreservation and the harvesting and banking of isolated spermatogonial stem cells can now be proposed as viable means of preserving fertility. STUDY DESIGN, SIZE, DURATION Advances in clinical treatments, patient management strategies and the research methods used to preserve sperm and testicular tissue for prepubertal boys and adolescents were reviewed. A snapshot of the up-take of testis cryopreservation as a means to preserve the fertility of young males prior to December 2012 was provided using a questionnaire. PARTICIPANTS/MATERIALS, SETTING, METHODS A comprehensive literature review was conducted. In addition, survey results of testis freezing practices in young patients were collated from 24 European centres and Israeli University Hospitals. MAIN RESULTS AND THE ROLE OF CHANCE There is increasing evidence of the use of testicular tissue cryopreservation as a means to preserve the fertility of pre- and peri-pubertal boys of up to 16 year-old. The survey results indicate that of the 14 respondents, half of the centres were actively offering testis tissue cryobanking as a means of safeguarding the future fertility of boys and adolescents as more than 260 young patients (age range less than 1 year old to 16 years of age), had already undergone testicular tissue retrieval and storage for fertility preservation. The remaining centres were considering the implementation of a tissue-based fertility preservation programme for boys undergoing oncological treatments. LIMITATIONS, REASONS FOR CAUTION The data collected were limited by the scope of the questionnaire, the geographical range of the survey area, and the small number of respondents. WIDER IMPLICATIONS OF THE FINDINGS The clinical and research questions identified and the ethical and legal issues raised are highly relevant to the multi-disciplinary teams developing treatment strategies to preserve the fertility of prepubertal and adolescent boys who have a high risk of fertility loss due to ablative interventions, trauma or genetic pre-disposition.

Spermatogonial stem cell preservation and transplantation: from research to clinic

STUDY QUESTION What issues remain to be solved before fertility preservation and transplantation can be offered to prepubertal boys? SUMMARY ANSWER The main issues that need further investigation are malignant cell decontamination, improvement of in vivo fertility restoration and in vitro maturation. WHAT IS KNOWN ALREADY Prepubertal boys who need gonadotoxic treatment might render sterile for the rest of their life. As these boys do not yet produce sperm cells, they cannot benefit from sperm banking. Spermatogonial stem cell (SSC) banking followed by autologous transplantation has been proposed as a fertility preservation strategy. But before this technique can be applied in the clinic, some important issues have to be resolved. STUDY DESIGN, SIZE DURATION Original articles as well as review articles published in English were included in a search of the literature. PARTICIPANTS/MATERIALS, SETTING, METHODS Relevant studies were selected by an extensive Medline search. Search terms were fertility preservation, cryopreservation, prepubertal, SSC, testis tissue, transplantation, grafting and in vitro spermatogenesis. The final number of studies selected for this review was 102. MAIN RESULTS AND THE ROLE OF CHANCE Cryopreservation protocols for testicular tissue have been developed and are already being used in the clinic. Since the efficiency and safety of SSC transplantation have been reported in mice, transplantation methods are now being adapted to the human testes. Very recently, a few publications reported on in vitro spermatogenesis in mice, but this technique is still far from being applied in a clinical setting. LIMITATIONS, REASONS FOR CAUTION Using tissue from cancer patients holds a potential risk for contamination of the collected testicular tissue. Therefore, it is of immense importance to separate malignant cells from the cell suspension before transplantation. Because biopsies obtained from young boys are small and contain only few SSCs, propagation of these cells in vitro will be necessary. WIDER IMPLICATIONS OF THE FINDINGS The ultimate use of the banked tissue will depend on the patients disease. If the patient was suffering from a non-malignant disease, tissue grafting might be offered. In cancer patients, decontaminated cell suspensions will be injected in the testis. For patients with Klinefelter syndrome, the only option would be in vitro spermatogenesis. However, at present, restoring fertility in cancer and Klinefelter patients is not yet possible. STUDY FUNDING/COMPETING INTEREST(S) Research Foundation, Flanders (G.0385.08 to H.T.), the Institute for the Agency for Innovation, Belgium (IWT/SB/111245 to E.G.), the Flemish League against Cancer (to E.G.), Kom op tegen kanker (G.0547.11 to H.T.) and the Fund Willy Gepts (to HT). E.G. is a Postdoctoral Fellow of the FWO, Research Foundation, Flanders. There are no conflicts of interest.

What is the best cryopreservation protocol for human testicular tissue banking

STUDY QUESTION Is there a better alternative to the conventional cryopreservation protocols for human testicular tissue banking? SUMMARY ANSWER Uncontrolled slow freezing (USF) using 1.5 M dimethylsulphoxide (DMSO) and 0.15 M sucrose as cryoprotectants appears to be a user-friendly and efficient method for the cryopreservation of human testicular tissue. WHAT IS KNOWN ALREADY Currently, time-consuming controlled slow freezing (CSF) protocols that need expensive equipment are commonly used for human testicular tissue banking. USF and vitrification are cryopreservation techniques that were successfully applied in several animal models but need further exploration with human tissue. STUDY DESIGN, SIZE, DURATION Fragments (n = 160) of testicular tissue from 14 patients undergoing vasectomy reversal were assigned to a fresh control group or one of the following cryopreservation procedures: CSF using DMSO at a concentration of 0.7 or 1.5 M in the presence (+S) or absence of sucrose (-S), USF using either 0.7 or 1.5 M DMSO combined with sucrose, solid-surface vitrification (SSV) or direct cover vitrification (DCV). MATERIALS, SETTING, METHODS Light microscopic evaluations were performed to study apoptosis, germ cell proliferation ability, spermatogonial survival, coherence of the seminiferous epithelium and integrity of the interstitial compartment after cryopreservation. Ultrastructural alterations were studied by scoring cryodamage to four relevant testicular cell types. MAIN RESULTS AND THE ROLE OF CHANCE The USF 1.5 M DMSO + S protocol proved not solely to prevent cell death and to preserve seminiferous epithelial coherence, interstitial compartment integrity, SG and their potential to divide but also protected the testicular cell ultrastructure. A significant reduction in the number of SG per tubule from 21.4 ± 5.6 in control tissue to 4.9 ± 2.1, 8.2 ± 5.4, 11.6 ± 5.1, 8.8 ± 3.9, 12.6 ± 4.4 and 11.7 ± 5.7 was observed after cryopreservation combined with at least one other form of cryoinjury when using CSF 0.7 M DMSO -S, CSF 0.7 M DMSO + S, CSF 1.5 M DMSO + S, USF 0.7 M DMSO + S, SSV and direct cover vitrification (DCV), respectively (P < 0.001). LIMITATIONS, REASONS FOR CAUTION Supplementary research is required to investigate the effect on tissue functionality and to confirm this studys findings using prepubertal tissue. WIDER IMPLICATIONS OF THE FINDINGS An optimal cryopreservation protocol enhances the chances for successful fertility restoration. USF, being an easy and cost-effective alternative to CSF, would be preferable for laboratories in developing countries or whenever tissue is to be procured from a diseased child at a site distant from the banking facility.

Autologous spermatogonial stem cell transplantation in man: current obstacles for a future clinical application

Fertility preservation is becoming an important issue in the management of the quality of life of prepubertal boys undergoing cancer treatment. At present, the only theoretical option for preservation of fertility in these boys is the preservation of the spermatogonial stem cells for autologous intratesticular stem cell transplantation. In animal models, this technique has shown promising results. However, before translation to the clinic, some major concerns should be evaluated. Improving the efficiency of the technique is one of the first goals for further research, besides evaluation of the safety of the clinical application. Also, the cryopreservation of the spermatogonial stem cells needs extra attention, since this first step will be crucial in the success of any clinical application. Another concern is the risk of malignant contamination of the testicular tissue in childhood cancer patients. Extensive research in this field and especially on the feasibility of decontaminating the testicular tissue will be inevitable. Another important, though overlooked, issue is the prevention of damage to the testicular niche cells. Finally, xenografting and in vitro proliferation/maturation of the spermatogonia should be studied as alternatives for the transplantation technique.

Spermatogonial survival in long-term human prepubertal xenografts.

Although childhood cancer treatments are yielding higher survival rates, sterility remains one of their major side effects. For prepubertal boys, there currently are no options to preserve fertility. Testicular tissue banking, together with subsequent grafting, may become a strategy in the future. In this study, prepubertal human testicular tissue was xenografted. Testicular tissue from two patients who had severe sickle-cell anemia and who needed to undergo chemotherapy and bone marrow transplantation was grafted onto the backs of six Swiss nude mice. Four months after grafting, spermatogonia could be observed by immunohistochemistry with MAGE-A4 antibodies, and Sertoli cells could be visualized by vimentin staining. Because both Sertoli cells and spermatogonia survived, tissue grafting may become a means for restoring future fertility in prepubertal male cancer patients.

Can pubertal boys with Klinefelter syndrome benefit from spermatogonial stem cell banking

BACKGROUND Although early development of testes appears normal in boys with Klinefelter syndrome (KS), spermatogonial stem cell (SSC) depletion occurs in mid puberty, leading to infertility. Cryopreservation of SSCs prior to stem cell loss is an option that is currently offered to boys who have to undergo gonadotoxic treatments. This study aimed to explore the possibility of preserving SSCs in pubertal KS adolescents by testicular tissue banking. METHODS A retrospective study was conducted in seven non-mosaic 47,XXY adolescents, aged 13-16 years, who were invited for an experimental testicular tissue banking programme during their follow-up at the Paediatric Endocrinology Department of the UZ Brussel between 2009 and 2011. Paraffin-embedded testicular tissue was sectioned and stained with haematoxylin-eosin, and immunostainings were performed for Mage-A4, anti-Mullerian hormone, Inhibin α and steroidogenic acute regulatory protein. The presence of spermatogenesis and/or spermatogonia was evaluated. RESULTS Massive fibrosis and hyalinization was observed in all but one KS patients. Although spermatogonia were seen in five patients, spermatogonia were only present in tubules showing normal architecture in the youngest patient who also had normal follicle-stimulating hormone and inhibin B concentrations. CONCLUSIONS Testicular tissue cryopreservation in KS adolescents should be recommended as soon as possible, probably before hormonal changes of failing Sertoli cell function are detected.

Regeneration of spermatogenesis by grafting testicular tissue or injecting testicular cells into the testes of sterile mice: a comparative study.

OBJECTIVE To make a comparison between two different approaches-spermatogonial stem cell transplantation and intratesticular grafting, for preservation and reintroduction of spermatogonial stem cells. DESIGN Prospective experimental study. SETTING Academic medical center and teaching hospital. PATIENT(S) N/A. INTERVENTION(S) Intratesticular transplantation, histologic evaluation of testes. MAIN OUTCOME MEASURE(S) Testicular weight, amount of green fluorescence in the testis, and immunostaining for green fluorescent protein. RESULT(S) In a first experiment donor-derived spermatogenesis was found in 65% of the injected testes (41.8 +/- 72.2 mm) compared with 75% of the testes (122.1 +/- 45.6 mm) after tissue grafting. In the second series of experiments complete spermatogenesis was found in 75% of the testes after fresh grafting (93.8 +/- 21.8 mm) compared with 88% after frozen-thawed tissue grafting (84.8 +/- 45.6 mm). CONCLUSION(S) Both approaches show that spermatogonial stem cells can successfully be introduced to the testis resulting in spermatogenesis. Tissue grafting produced a larger mean donor colony length and there was no significant difference between colonization efficiency using either fresh or frozen-thawed grafts. In a future clinical setting, grafting would be a simple and efficient way for reintroducing stem cells to the testis.

Simultaneous determination of masked forms of deoxynivalenol and zearalenone after oral dosing in rats by LC-MS/MS

In vivo metabolism of masked or conjugated mycotoxins is poorly documented as standards are not commercially available and indirect analysis using hydrolytic enzymes is difficult to validate and cumbersome. We synthesised zearalenone-14-glucoside (ZEA-14G) chemically. Deoxynivalenol-3-glucuronide (DON-3GlcA) and glucuronides of 3- and 15-acetyl-deoxynivalenol (3- and 15-ADON-GlcAs), de-epoxydeoxynivalenol, zearalenone (ZEA), α- and β-zearalenol (α- and β-ZOL) were synthesised using rat microsomes. For the first time three ADON-GlcAs were synthesised: two 3-ADON-GlcAs and one 15-ADON-GlcA. After purification, the masked mycotoxin and the metabolites were characterised by NMR (DON-3GlcA, ZEA-14G) or by full scan MS, MS/MS fragmentation, UV-spectra, β-glucosidase and β-glucuronidase treatment. In a first experiment, rats were fed orally DON-3-glucoside (DON-3G) and ZEA-14G, together with 13C-DON and 13C-ZEA and were sacrificed after 55 minutes. A total of 21 masked metabolites, metabolites and parent mycotox...

Orthotopic grafting of cryopreserved prepubertal testicular tissue: in search of a simple yet effective cryopreservation protocol.

OBJECTIVE To investigate whether solid-surface vitrification (SSV) is an effective cryopreservation strategy regarding the integrity and function of prepubertal mouse testicular tissue. DESIGN Prospective experimental study. SETTING Academic research unit. ANIMAL(S) Mice. INTERVENTION(S) Testicular tissue from 5- to 10-day-old GFP(+) mice was cryopreserved with the use of a conventional uncontrolled slow freezing (USF) technique and SSV before intratesticular grafting in busulfan-treated GFP(-) mice. MAIN OUTCOME MEASURE(S) Ultrastructural cryoinjury to spermatogonial stem cells (SSCs) and somatic cells was assessed by electron microscopy. Tubular structure was evaluated by histology, and graft survival and spermatogenic recovery by immunohistochemistry. RESULT(S) The tubular morphology and the proportion of ultrastructural cryodamage were similar between vitrified and slow-frozen testicular fragments. Allografting of tissue after both USF and SSV resulted in a recovery of spermatogenesis similar to fresh samples. CONCLUSION(S) SSV resulted in success rates similar to USF in maintaining testicular cell ultrastructure, tubular morphology, and tissue function. These data provide further evidence that vitrification, being an inexpensive and simple technique, can be considered as an alternative for cryopreservation of prepubertal testicular tissue.

DNA methylation patterns of spermatozoa and two generations of offspring obtained after murine spermatogonial stem cell transplantation

BACKGROUND Apart from its use in research, spermatogonial stem cell transplantation (SSCT) may have important clinical applications. This controlled study aimed at evaluating the safety of SSCT by analyzing the DNA methylation pattern of Igf2, Peg1 and alpha-Actin both in spermatozoa and live born offspring obtained after SSCT in mice. METHODS Testicular cell suspensions were transplanted to the testes of genetically sterile WW recipients. Transplanted males were mated with fertile females and their first and second generation offspring were examined and compared with controls with respect to weight, length and DNA methylation patterns. Sodium-bisulfite treated genomic DNA extracted from post-transplantation spermatozoa, liver, kidney and placenta of first and second generation offspring was PCR-amplified to obtain Igf2, Peg1 and alpha-Actin gene fragments. Pyrosequencing was used to individually quantify the resulting artificial C/T sequence variation at CpG sites. RESULTS First and second generation offspring developed normally with their length and weight not being different from controls. Also the DNA methylation patterns of Igf2, Peg1 and alpha-Actin were not different among controls and first and second generation offspring after SSCT. CONCLUSIONS SSCT between syngenic individuals was not associated with changes in fetal development nor with differences in the DNA methylation patterns of Igf2, Peg1 and alpha-Actin in spermatozoa or other tissues from two subsequent generations of offspring obtained after SSCT.