Laxmi A. Kondapalli

In vitro grown human ovarian follicles from cancer patients support oocyte growth

BACKGROUND Young female adult and adolescent cancer patients facing life-preserving but fertility-threatening chemo- or radiation-therapy are increasingly seeking options to protect their reproductive potential. Ovarian tissue cryopreservation with transplantation is a promising technique to safeguard fertility in cancer patients. However, this method may risk re-introduction of the original cancer to the survivor of the disease. Thus, developing a method for in vitro growth of immature follicles may provide a method for fertility restoration in the future. METHODS Human secondary follicles were isolated from ovarian tissues obtained from cancer patients and grown in vitro within a bio-engineered culture system for 30 days. RESULTS Human ovarian follicles became steroidogenically active, and developed from the early secondary to antral stage in vitro. The follicles contained healthy, growing oocytes that were connected by transzonal projections between the somatic cells and oocyte. CONCLUSIONS Our data support the notion that human follicle development can be achieved in vitro in a bio-engineered culture system. More studies are required to investigate whether the fully sized oocytes obtained from in vitro grown follicle are competent to resume meiosis and be fertilized.

Results from the survey for preservation of adolescent reproduction (SPARE) study: gender disparity in delivery of fertility preservation message to adolescents with cancer

PurposeDiminished reproductive capacity is a devastating consequence of life-sparing therapies for childhood malignancy. In 2006, the American Society of Clinical Oncology (ASCO) published fertility preservation recommendations (ASCOR) emphasizing the importance of early discussion and intervention for fertility preservation strategies. Using the Survey for Preservation of Adolescent REproduction (SPARE), we sought to determine fertility preservation attitudes and practice patterns post-ASCOR from pediatric oncology specialists nationwide.Materials and methodsThe SPARE survey consists of 22 questions assessing pediatric oncology specialists’ attitudes and practice patterns toward fertility preservation. Broad perspectives on fertility preservation, including a willingness to discuss fertility, knowledge of current fertility preservation methods and awareness of ASCOR, were assessed.ResultsThe majority of respondents acknowledged that fertility threats are a major concern for them and agreed that all pubertal cancer patients should be offered a fertility consultation, but only 46% reported they refer male pubertal cancer patients to a fertility specialist prior to cancer treatment >50% of the time, and only 12% reported they refer female pubertal cancer patients to a fertility specialist prior to cancer treatment > 50% of the time. While 44% of respondents were familiar with the 2006 ASCOR, only 39% of those utilized them to guide decision-making in greater than half of their patients.ConclusionOur study demonstrates pediatric oncologists’ motivation to preserve fertility in pediatric cancer patients; however, barriers to both gamete cryopreservation and referral to fertility specialists persist. Female pubertal patients are referred to fertility preservation specialists with much less frequency than are male pubertal patients, highlighting a disparity.

Preserving female fertility following cancer treatment: Current options and future possibilities

Children and women of reproductive age are increasingly surviving cancer diagnoses, and therefore long‐term quality‐of‐life issues are of greater importance at the time of diagnosis. Cancer therapies including radiation and chemotherapy can be detrimental to fertility, and therefore many patients are motivated to preserve fertility prior to cancer treatment. The only highly successful method in preserving fertility to date is embryo cryopreservation, which may not be appropriate for some patients due to age, delay in treatment, cancer type and stage, as well as availability of an acceptable sperm donor. Alternative methods including oocyte cryopreservation and ovarian tissue banking may also preserve fertility while providing additional flexibility to patients. In vitro ovarian follicle maturation following tissue banking is one potential approach that would not require a delay in cancer therapy for ovarian stimulation, would not require an immediate sperm donor, and does not carry the risk of reintroducing malignant cells following tissue transplantation. In vitro follicle culture systems have resulted in successful live births in the mouse. However, many challenges must be addressed in translating the system to the human. This review summarizes current approaches to fertility preservation and discusses recent developments and future challenges in developing a human in vitro follicle culture system. Pediatr Blood Cancer 2009;53:289–295.

A decrease in serum estradiol levels after human chorionic gonadotrophin administration predicts significantly lower clinical pregnancy and live birth rates in in vitro fertilization cycles

BACKGROUND Although close observation of serum estradiol (E2) levels remains a mainstay of assessing clinical response to controlled ovarian stimulation, the prognostic value of any change in E2 levels after administration of hCG remains unclear. The objective of this study is to evaluate the relationship between serum E2 response after hCG administration and the clinical pregnancy and live birth rates in fresh IVF cycles. METHODS We conducted a retrospective cohort study of women aged 21-45 years undergoing their first IVF cycle from 1999 to 2008 at a single practice. We compared the post-hCG serum E2 level with values on the day of hCG trigger. IVF cycles were stratified by post-hCG E2 response and appropriate parametric and non-parametric statistics were performed. Clinical intrauterine pregnancy and live births were the primary outcomes of interest. Multivariable logistic regression models were created to identify predictive factors associated with outcomes while adjusting for potential confounders. RESULTS Among the 1712 IVF cycles, 1065 exhibited a >10% increase (Group A), 525 had a plateau (± 10%, Group B) and 122 showed a >10% decrease (Group C) in post-hCG E2 levels. While the E2 levels on the day of hCG were similar across groups, Group C had more patients with diminished ovarian reserve, required higher gonadotrophin doses and had the lowest implantation rates. After adjusting for age, total gonadotrophin dose, infertility diagnosis, number of oocytes and number of transferred embryos, the associations between post-hCG E2 decline (Group C) and clinical pregnancy [adjusted odds ratio (aOR): 0.53; 95% confidence interval (CI): 0.33-0.84, P= 0.007] and live birth (aOR: 0.40; 95% CI: 0.22-0.71, P= 0.002) were significant. We also found significant associations between E2 plateau (Group B) and clinical pregnancy (aOR: 0.73; 95% CI: 0.57-0.94, P= 0.013) and live birth (aOR: 0.74; 95% CI: 0.56-0.97, P= 0.032) when adjusting for the same factors. CONCLUSIONS In our study, >10% decrease in E2 levels after hCG administration was associated with 40-50% reduction in clinical pregnancy and live birth rates. Similarly, post-hCG E2 plateau (± 10%) lowered the clinical pregnancy and live birth rates by >25%. Our study suggests that the change in the post-hCG E2 level is another parameter that can be used by clinicians to counsel patients regarding their likelihood of success with assisted reproductive technologies prior to oocyte retrieval.

Oncofertility Consortium Consensus Statement: Guidelines for Ovarian Tissue Cryopreservation

In vitro fertilization (IVF) and storage of the resulting embryos is currently a proven method of fertility preservation for women who face an immediate threat to their future fertility. This method, however, is suitable for a fraction of patients and depends on a number of factors that may include her diagnosis, age, partner status, willingness to accept donor sperm, desire to freeze embryos, and ability to pay for these services. As fertility preservation techniques evolve, it is critical that physicians continue to evaluate practice guidelines in order to offer a wider menu of fertility preservation options tailored to each patient’s specific clinical scenario, to the risk-benefit ratio and takes into consideration the patient’s values. Practice guidelines and consensus statements for fertility preservation for oncology patients reflect the current evidence based and ethical practices in the related disciplines of oncology and reproductive endocrinology. Both the American Society of Clinical Oncology (ASCO) and the American Society of Reproductive Medicine (ASRM) recently published guidelines to describe the circumstances under which fertility preservation should be discussed and to describe patients for which experimental methods, such as ovarian cryopreservation, may be suitable [1–3]. Taken together, these documents are comprehensive in their description of: 1. The need for discussion with patients about impaired fertility resulting from cancer treatment,

Quantification of anti-Müllerian hormone (AMH) in dried blood spots: validation of a minimally invasive method for assessing ovarian reserve

BACKGROUND Biological markers of ovarian reserve have the potential to advance research on fecundability, infertility and reproductive aging. Anti-Müllerian hormone (AMH) has emerged as a clinically useful measure of ovarian reserve, but the requirement for venous blood is an obstacle to application in non-clinical settings. This paper validates a new method for quantifying AMH in dried blood spot (DBS) samples--drops of whole blood collected on filter paper following a simple finger stick. METHODS Matched serum and DBS samples were obtained from n=101 women of reproductive age, and AMH values were compared using regression analyses and scatter plots. The precision, reliability, linearity, recovery and lower detection limit of the DBS assay were evaluated, as well as the stability of AMH in DBS across a range of storage conditions. RESULTS There was a strong agreement between AMH concentrations measured in DBS and serum samples across the entire assay range. Analysis of within-assay (percent coefficient of variation, 4.7-6.5%) and between-assay (3.5-7.2%) variability indicated a high level of assay precision and reliability, respectively. The minimum detectable dose of AMH was 0.065 ng/ml. Concentrations of AMH remained stable in DBS samples stored for 2 weeks at room temperature, and for 4 weeks when refrigerated. CONCLUSIONS The DBS assay performs at a level that is comparable to serum-based methods, with the advantage of lower burdens and costs associated with blood collection that may be advantageous for research in clinical as well as non-clinical settings on the causes and consequences of variation in ovarian reserve.

Clinical Cases in Oncofertility

As an emerging interdisciplinary field, oncofertility bridges oncology and reproductive endocrinology and infertility with the goal of expanding reproductive options for women with cancer. In this chapter, we present a series of clinical scenarios encountered in medical practice to illustrate some of the complex issues that arise in this field and offer suggestions for patient care.

Oncofertility: a new medical discipline and the emerging scholar.

Cancer is often considered a disease of aging, and many times it is, as the risk of malignancy increases with age. In fact, according to the American Cancer Society, 77% of all cancers are diagnosed in patients older than age 55 [1]. However, it is not a disease isolated to the older population alone. Any person can develop cancer; it targets children and young adults, and it does not discriminate by gender, race, socioeconomic status, political belief, or religious affiliation. Data collected from the National Cancer Institute (NCI) registry of cancer patients estimated that there were 10,500,000 survivors of cancer in 2003 and roughly 1,440,000 new cancer cases are expected to be diagnosed in 2007 (see Fig. 16.1). Among survivors, 5% are between 20 and 39 years old, resulting in at least 525,000 young survivors of cancer, a number that increases every year. More than 200,000 men and women under the age of 45 are diagnosed with cancer annually. Moreover, 25% of breast cancer patients are younger than 40 years of age. Though over 12,400 children and adolescents (less than 19 years old) are diagnosed with cancer each year, the cure rate for all childhood cancers has reached 80 % [2]. While this is a remarkable statistic, the improvement in survival reflects progress in earlier detection of certain malignancies and the extraordinary rise in cancer curing therapies. Cancer is now a disease with a variety of treatment options that are leading survivors to live longer and more productive lives. With the advent of improved cancer treatments and the subsequent rise in survival, a host of new health care and quality-of-life issues has emerged for young cancer patients. Many of these issues were not anticipated at the time of diagnosis. While advances in radiation and chemotherapy have improved survival rates, these therapeutic agents may also permanently impact the reproductive capacity of cancer survivors. Systemic chemotherapy, although targeted at a specific cancer cell, can have detrimental effects on the reproductive axis at the level of the hypothalamus, pituitary gland, or the gonads. Pelvic radiation and alkylating agents are two known causes of induced sterility in cancer patients [3–6]. Consequently, the survivor may face immediate infertility or premature loss of reproductive function due to the toxic damage. For example, men may experience decreased hormone production and its sequelae, including decreased or lost spermatogenesis or increased sperm abnormalities. In women, treatment-induced premature ovarian failure results in a hormonal milieu similar to the natural menopause.

Incorporating Insurance Education into the Fertility Preservation Process

Over the last several decades, cancer survival rates have tremendously increased, largely due to enhanced early detection and improved therapeutics. What was once considered a “death sentence,” now allows survivors to imagine a life after cancer with expectations beyond survival [1]. These medical achievements should be tempered by the resultant gonadotoxic effects. As such, survivorship issues are of increasing importance. Fertility loss is of particular concern for the approximately 135,000 pediatric, adolescent, and young adults (AYA) diagnosed each year [2]. Infertility caused by cancer treatment is iatrogenic, meaning any adverse condition induced by medical interventions including reactions from prescribed drugs or from medical and surgical procedures. Iatrogenic infertility is typically caused by cancer treatments such as chemotherapy, radiation, or surgical removal of reproductive organs. While the focus of this chapter will be specific to cancer patients, fertility may be compromised by treatments for other conditions such as autoimmune disorders.

Noninvasive Approaches to Enhance Ovarian Function

While it is widely accepted that in vitro fertilization (IVF) utilizing donor oocytes provides the most reliable, evidence-based treatment for patients with POI desiring pregnancy, there is some evidence suggesting that POI can be treated with less invasive therapy, especially in the earlier stages of diagnosis. Ovulation induction, superovulation, supplemental hormone therapy, and lifestyle changes may be considered as noninvasive methods to improve ovarian function, although the evidence is limited by size and methodology. While further research is needed to improve the noninvasive options for fertility treatment in patients with POI, it is reasonable to consider these methods if the patient is unable or unwilling to undergo donor oocyte IVF. This chapter will highlight several noninvasive methods for potentially improving ovarian function and introduce emerging therapies that may be worth consideration prior to more aggressive treatment.