Hila Raanani

Searching for evidence of disease and malignant cell contamination in ovarian tissue stored from hematologic cancer patients

BACKGROUND Storing ovarian tissue for fertility preservation in cancer patients carries the risk of the presence of malignant cells that could lead to recurrence of cancer after reimplantation. Methods to exclude presence of cancer cells were used to improve the safety of cryopreservation-reimplantation procedures. METHODS Fifty-eight patients with hematological malignancies were referred for the storage of ovarian tissue for fertility preservation. Investigation included preoperative imaging and histological evaluation of fresh ovarian tissue. After thawing markers to detect minimal residual disease (MRD) were used and compared with patients disease used as positive control (five patients). RESULTS Preoperative imaging detected disease in the ovaries (two patients). Conventional histology post-tissue harvesting did not disclose malignant cells (56 patients). MRD results post-thawing were negative in Hodgkins disease (CD30 immunohistochemical staining), in T- and B-cell lymphoma (PCR for T-cell receptor and Ig clones, respectively) and in two chronic myelogenous leukemia patients (RT-PCR for BCR-ABL gene expression). However, highly sensitive real-time RT-PCR was positive in one CML patient and, this alarming result avoided tissue transplantation. CONCLUSIONS Preoperative imaging prevented operations and storage of tissue with cancer. Evaluation of stored ovarian tissue for MRD using sensitive markers is essential to increase safety and to prevent reimplantation of tissue with malignant cells.

Second international consensus guidelines for breast cancer in young women (BCY2)

The 2nd International Consensus Conference for Breast Cancer in Young Women (BCY2) took place in November 2014, in Dublin, Ireland organized by the European School of Oncology (ESO). Consensus recommendations for the management of breast cancer in young women (BCYW) were updated from BCY1 with incorporation of new evidence to inform the guidelines, and areas of research priorities were identified. This manuscript summarizes these international consensus recommendations, which are also endorsed by the European Society of Breast Specialists (EUSOMA).

Luteal phase oocyte retrieval and in vitro maturation is an optional procedure for urgent fertility preservation

OBJECTIVE To compare the results of in vitro maturation (IVM) of oocytes for fertility preservation performed during the luteal phase of the cycle with those of IVM performed during the follicular phase. DESIGN Retrospective chart review (August 2007 to June 2009). SETTING Academic tertiary referral fertility center. PATIENT(S) Cancer patients who underwent treatment for fertility preservation. INTERVENTION(S) IVM treatment during either luteal or follicular phase. MAIN OUTCOME MEASURE(S) Number of oocytes, maturation and fertilization rates, and number of oocytes and embryos that were frozen. RESULT(S) Eighteen cancer patients underwent IVM fertility preservation, five in their luteal phase and 13 in their follicular phase. The baseline characteristics of both groups were similar. There were no significant differences in the number of retrieved oocytes, maturation rates, fertilization rates, or the total number of oocytes and embryos that were cryopreserved. CONCLUSION(S) These results suggest that IVM during the luteal phase can be offered to patients as an optional treatment for urgent fertility preservation when there is insufficient time for conventional follicular phase oocyte retrieval before chemotherapy must be initiated.

Selection of patients before and after anticancer treatment for ovarian cryopreservation

BACKGROUND Although ovarian cryopreservation in patients with cancer should ideally be performed before the initiation of therapy, cryopreservation from such patients often becomes an option only later. The justification for the procedure needs to be elucidated. METHODS Eighteen cancer patients before chemotherapy and 23 others after chemotherapy participated in the study. Freshly dissected ovarian samples were prepared for light microscopy to demonstrate follicular numbers and apoptosis, transmission electron microscopy to enhance intracellular changes, and staining with fluorescent markers (calcein AM, rhodamin 123 and ethidium homodimer) to test for viability. RESULTS High numbers of preantral follicles were detected in ovaries of patients < or =20 years. No antral follicles were detected. All the follicles were viable and not apoptotic. Deterioration in follicular quality was observed after chemotherapy, manifested mainly as an increase in abnormal granulosa cell nuclei (P < 0.05-0.0001) and in oocyte vacuolization (P < 0.0001). CONCLUSIONS Our study stresses the importance of prechemotherapy ovarian cryopreservation. However, the large number of viable, non-apoptotic follicles in ovaries of younger patients (age < or = 20 years) indicates that ovarian cryopreservation might be considered after treatment in this age group. Further studies of ovarian samples from women aged 20-30 years are needed to determine the exact age margin wherein postchemotherapy ovarian cryopreservation can be suggested.

BRCA mutation carriers show normal ovarian response in in vitro fertilization cycles

OBJECTIVE To evaluate the association between carriage of BRCA1/2 mutations and ovarian performance, as demonstrated by in vitro fertilization (IVF) outcomes. DESIGN Retrospective cohort study. SETTING Two tertiary IVF centers. PATIENT(S) BRCA mutation carriers undergoing IVF for preimplantation genetic diagnosis (PGD) or fertility preservation were compared with non-BRCA PGD or fertility preservation patients, matched by age, IVF protocol, IVF center, and cancer disease status. INTERVENTION(S) In vitro fertilization cycles for PGD and fertility preservation. MAIN OUTCOME MEASURE(S) Outcome of IVF: oocyte yield, poor response rate, number of zygotes, pregnancy rates. RESULT(S) A total of 62 BRCA mutation carriers and 62 matched noncarriers were included; 42 were fertility preservation breast cancer patients, and 82 were PGD non-cancer patients. Mean (± SD) age of patients was 32 ± 3.58 years. Number of stimulation days and total stimulation dose were comparable between carriers and noncarriers. Their cycles resulted in comparable oocyte yield (13.75 vs. 14.75) and low response rates (8.06% vs. 6.45%). Number of zygotes, fertilization rates, and conception rates were also comparable. CONCLUSION(S) Both healthy and cancer-affected BRCA mutation carriers demonstrated normal ovarian response in IVF cycles.

Fertility Preservation in Young Females with Hematological Malignancies

Impaired reproductive function and possible infertility are major concerns in long-term survivors of hematological malignancies. The ongoing increase in the survival rates of these patients is therefore accompanied with a growing demand for effective, safe and specifically tailored fertility preservation options. When approaching patients facing hematological malignancy, an individual evaluation of potential infertility risks and possible preventive or preserving measures should be performed. This review aims to provide up-to-date knowledge on female reproductive risks, and ovarian, uterine and genital injuries associated with therapy regimens currently used in hemato-oncological disorders. Recent progress in fertility preservation methods including ovarian tissue cryopreservation and transplantation, egg and embryo freezing, ovarian transposition and their specific role in hematological disorders are presented. The efficacy of these methods, possible risks and future challenges are critically discussed.

BRCA1/2 mutations and FMR1 alleles are randomly distributed: a case control study

BRCA mutation carriers were reported to display a skewed distribution of FMR1 genotypes, predominantly within the low normal range (CGG repeat number <26). This observation led to the interpretation that BRCA1/2 mutations are embryo-lethal, unless rescued by ‘low FMR1 alleles’. We undertook to re-explore the distribution of FMR1 alleles subdivided into low, normal and high (<26, 26–34, and >34 CGG repeats, respectively) subgenotypes, on a cohort of 125 Ashkenazi women, carriers of a BRCA1/2 founder mutation. Ashkenazi healthy females (n=368), tested in the frame of the Israeli screening population program, served as controls. BRCA1/2 carriers and controls demonstrated a comparable and non-skewed FMR1 subgenotype distribution. Taken together, using a homogeneous ethnic group of Ashkenazi BRCA1/2 mutation carriers, we could not confirm the reported association between FMR1 low genotypes and BRCA1/2 mutations. The notion that BRCA1/2 mutations are embryo-lethal unless rescued by the low FMR1 subgenotypes is hereby refuted.

Medical egg freezing: How cost and lack of insurance cover impact women and their families

Medical egg freezing (MEF) is being recommended increasingly for women at risk of losing their reproductive ability due to cancer chemotherapy or other fertility-threatening medical conditions. This first, binational, ethnographic study of women who had undergone MEF sought to explore womens experiences under two different funding systems: (i) the USA, where the cost of MEF is rarely covered by private or state health insurance; and (ii) Israel, where the cost of MEF is covered by national health insurance. Women were recruited from four American and two Israeli in-vitro fertilization clinics where MEF is offered. In-depth, semi-structured interviews were conducted with 45 women (33 Americans, 12 Israelis) who had completed at least one cycle of MEF. All of the Israeli women had cancer diagnoses, but were not faced with the additional burden of funding an MEF cycle. In marked contrast, the American women – 23 with cancer diagnoses and 10 with other fertility-threatening medical conditions – struggled, along with their families, to ‘piece together’ MEF funding, which added significant financial pressure to an already stressful situation. Given the high priority that both American and Israeli women in this study placed on survival and future motherhood, it is suggested that insurance funding for MEF should be mandated in the USA, as it is in Israel. This article concludes by describing new state legislative efforts in this regard.