Best Practice & Research Clinical Obstetrics & Gynaecology
Volume 24, Issue 1 , Pages 87-100, February 2010

Ovarian tissue cryopreservation and transplantation in cancer patients

Department of Gynecology, Université Catholique de Louvain, 1200 Brussels, Belgium

published online 07 October 2009.

Article Outline

Advances in the diagnosis and treatment of childhood, adolescent and adult cancer have greatly increased the life expectancy of premenopausal women with cancer.

The ovaries are very sensitive to cytotoxic treatment, especially to alkylating agents.

The only established method of fertility preservation is embryo cryopreservation according to the Ethics Committee of the American Society for Reproductive Medicine (2005), but this option requires the patient to be of pubertal age, have a partner or use donor sperm and be able to undergo a cycle of ovarian stimulation, which is not possible when the chemotherapy has to be initiated immediately or when stimulation is contraindicated, according to the type of cancer.

For patients who need immediate chemotherapy, cryopreservation of ovarian tissue is the only possible alternative.

This article reports the techniques and results of orthotopic transplantation of cryopreserved ovarian tissue. Among almost 30 cases reported in the literature, six live births have been achieved to date.

Key words: cryopreservation, fertility preservation, ovary, ovarian tissue, re-implantation, thawing

 

According to previous reports, more or less 700 000 new cancers are expected every year in the female population in the United States1; of these women, 8% will be under the age of 40. By 2010, it is estimated that one in every 250 people in the adult population will be childhood cancer survivors.2

Advances in the diagnosis and treatment of childhood, adolescent and adult cancer have greatly increased the life expectancy of premenopausal women with cancer. Indeed, aggressive chemotherapy and radiotherapy, as well as bone marrow transplantation, can cure more than 90% of girls affected by childhood malignancies3, but have resulted in a growing population of adolescent and adult long-term survivors of childhood malignancies2, who may experience infertility problems due to induced premature ovarian failure (POF).

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Gonadotoxicity of chemotherapy (Table 1) 


1.The ovaries are very sensitive to cytotoxic treatment, especially to alkylating agents (e.g., cyclophosphamide, busulfan, melphalan, chlorambucil, dacarbazine, procarbazine, ifosfamide, thiotepa and nitrogen mustard), which are classified as high risk for gonadal dysfunction (for review, see ref4).
Table 1. Cytotoxic agents according to degree of gonadotoxicity.
High riskIntermediate riskLow/no risk
Cyclophosphamide
Busulfan
Melphalan
Cholarambucil
Dacarbazine
Procarbazine
Ifosfamide
Thiotepa
Nitrogen mustard		Adriamycin (Doxorubicin)
Cisplatin
Carboplatin		Methotrexate
Bleomycin
5-Fluorouracil
Actinomycin D
Mercaptopurine
Vincristine

2.Follicular destruction induced by alkylating agents generally results in loss of both endocrine and reproductive function, depending on the dose and age of the patient. Indeed, Larsen et al.5 reported a fourfold increased risk of POF in teenagers treated for cancer, and a risk increased by a factor of 27 in women between 21 and 25 years of age. Complete amenorrhoea was reported after a dose of 5g of cyclophosphamide in women over 40 years of age, and after doses of 9g and 20g in women of 30–40 and 20–30 years of age respectively.6 A combination of various chemotherapeutic agents further increases gonadal toxicity. After MOPP/ABV hybrid chemotherapy, Schilsky et al.7 found that amenorrhoea developed in 89% and 20% of patients over and under 25 years of age at the time of treatment, respectively. The median age of patients who became amenorrhoeic after therapy was significantly higher than that of patients who maintained normal menses (26 years vs. 20 years; p=0.008).

3.Cyclophosphamide is the agent most commonly implicated in causing damage to oocytes and granulosa cells in a dose-dependent manner.8, *9

4.Procarbazine has recently been described as high risk for inducing premature menopause.10 Ten years after treatment, the actuarial risk of premature menopause was 84% after high cumulative doses (>8–4gm−2), and 15% after low doses (≤4.2gm−2) of procarbazine. The authors concluded that as long as alkylating agents are used to treat Hodgkin's lymphoma, premature menopause will remain a frequent adverse effect of treatment, with various clinical implications.10

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Radiotherapy 

Abdominal ionising radiation associated with alkylating agents often induces POF, rendering patients infertile in almost 100% of cases. Indeed, for radiotherapy, it has been stated that a dose of 5–20Gy administered to the ovary is sufficient to completely impair gonadal function11, whatever the age of the patient. The dose of radiation required to destroy 50% of the oocyte reserve has been found to be <2Gy.12 Moreover, uterine irradiation at a young age reduces adult uterine volume.13 Radiation doses between 14 and 30Gy have been reported to result in uterine dysfunction.14, 15, 16 The practitioner should be aware of this effect of radiotherapy on the uterus, which could interfere with the implantation capacity of embryos.

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Chemotherapy and total body irradiation before bone marrow transplantation 

Intensive chemotherapy and/or total body irradiation (TBI) required before bone marrow transplantation (BMT) constitute the treatment combination presenting the greatest risk of premature ovarian failure. Indeed, these high doses of chemotherapy (commonly using the highly cytotoxic cyclophosphamide/busulfan regimen) and/or radiotherapy lead to subsequent ovarian failure in almost all cases, children and adults alike.17, *18 The risk of premature ovarian failure was estimated to be 92% in the study by Meirow and Nugent18, and 100% in an earlier study by Teinturier et al.19 Teinturier et al.19 actually reported 0% of ovarian recovery after busulfan treatment before BMT. A large retrospective survey of pregnancy outcomes after haematopoietic stem cell transplantation (HSCT) (peripheral blood or BMT) involving 37 362 patients revealed that only 0.6% of patients conceived after autologous or allogeneic SCT.20, 21 It is thus obvious that high doses of alkylating agents, irradiation and advancing age increase the risk of gonadal damage.

Cryopreservation should not be reserved solely for women with malignant disease.22 Indeed, HSCT has been increasingly used in recent decades for non-cancerous diseases, such as benign haematological disease (sickle cell anaemia, thalassaemia major and aplastic anaemia) and autoimmune diseases previously unresponsive to immunosuppressive therapy (systemic lupus erythematosus (SLE) and autoimmune thrombocytopaenia).22, 23, 24, 25, *26 Other benign diseases, such as recurrent ovarian endometriosis or recurrent ovarian mucinous cysts, are also indications for ovarian cryopreservation. Patients undergoing oophorectomy for prophylaxis may potentially benefit from ovarian cryopreservation too. The indications for cryopreservation of ovarian tissue in case of malignant and non-malignant disease are summarised in Table 2.

Table 2. Indications for cryopreservation of ovarian tissue in case of malignant and non-malignant disease.
A. Malignant
a) Extrapelvic diseases
Bone cancer (osteosarcoma – Ewing's sarcoma)
Breast cancer
Melanoma
Neuroblastoma
Bowel malignancy
b) Pelvic diseases
- Non-gynecological malignancy
Pelvic sarcoma
Sacroblastoma
Rhabdomyosarcoma
Sacral tumors
Rectosigmoid tumors
- Gynecological malignancy
Early cervical carcinoma
Early vaginal carcinoma
Early vulvar carcinoma
Selected cases of ovarian carcinoma (stage IA)
Borderline ovarian tumors
c) Systemic diseases
Hodgkin's disease
Non-Hodgkin's lymphoma
Leukemia
Medulloblastoma
B. Non-malignant
a) Uni/bilateral oophorectomy
Benign ovarian tumors
Severe and recurrent endometriosis
BRCA-1 or BRCA-2 mutation carriers
b) Risk of premature menopause
Turner's syndrome
Family history
Benign diseases requiring chemotherapy: autoimmune diseases (systemic lupus erythematosus, rheumatoid arthritis, Behçet's disease, Wegener's granulomatosis)
c) Bone marrow transplantation
Benign hematological diseases: sickle cell anemia, thalassemia major, aplastic anemia
Autoimmune diseases unresponsive to immunosuppressive therapy

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Fertility preservation in cancer patients: different cryopreservation options 

The only established method of fertility preservation is embryo cryopreservation, according to the Ethics Committee of the American Society for Reproductive Medicine27, but this option requires the patient to be of pubertal age, have a partner or use donor sperm and be able to undergo a cycle of ovarian stimulation, which is not possible when chemotherapy has to be initiated immediately or when stimulation is contraindicated according to the type of cancer.

Ovarian tissue cryopreservation 

For patients who need immediate chemotherapy, cryopreservation of ovarian tissue is the only possible alternative.*26, 28, 29, 30, 31, 32, 33 The main aim of this strategy is to reimplant cortical ovarian tissue into the pelvic cavity (orthotopic site) or a heterotopic site such as the forearm or abdominal wall once treatment is completed and the patient is free of disease.22, *26, 29, 30, 34, 35, 36, 37, 38, 39, *40, *41, 42, 43, 44, 45, 46

Human ovarian tissue can be successfully cryopreserved, showing good survival and function after thawing. After reviewing all relevant studies since 1996, Hovatta47 concluded that adequate penetration of cryoprotectant through the stroma and granulosa cells to the oocytes is necessary for satisfactory results. Ice crystal formation must also be minimised by choosing optimal freezing and thawing rates. The choice of cryoprotectant with maximum permeation capacity but minimum toxicity and ice crystal formation potential is specific to each cell and tissue type. In the ovary, it is a compromise between the stroma, the follicular cells and the oocytes.47 On the basis of current knowledge, the standard method for human ovarian cryopreservation is slow-programmed freezing using human serum albumin-containing medium and propanediol, dimethylsulphoxide (DMSO) or ethylene glycol as a cryoprotectant, combined or not with sucrose.47

Autotransplantation of cryopreserved human ovarian tissue 

Reported cases of autotransplantation of cryopreserved ovarian tissue, either to an orthotopic or heterotopic site, are summarised on the ISFP (International Society for Fertility Preservation) website (http://www.isfp-fertility.org), detailing, in each case, the age of the patient before freezing, whether she received chemotherapy before freezing, the indications for cryopreservation, the graft site and size, the interval before recovery of ovarian function after grafting and the outcome of transplantation.*4, 22, 25, *26, 37, 38, 39, *40, *41, 42, 43, 44, 46, 48, 49, 50, 51

Orthotopic autotransplantation of cryopreserved human ovarian tissue 

In theory, natural pregnancy may be achieved via orthotopic tissue transplantation if the fallopian tubes remain intact.

In 2000, Oktay and Karlikaya reported laparoscopic transplantation of frozen–thawed ovarian tissue in a 29-year-old patient, who had undergone bilateral oophorectomy for intractable menorrhagia.37 The reason for this bilateral oophorectomy was not made clear and data on restoration of ovarian function were never described for some unknown reason.

Radford et al.38 reported a patient with a history of Hodgkin's disease treated by chemotherapy. Ovarian tissue was biopsied and cryopreserved 4 years after chemotherapy. Histological section of the ovarian cortical tissue revealed only a few primordial follicles due to the previous chemotherapy. Eight months after reimplantation, oestradiol was detected and follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels decreased but, 1 month later, FSH and LH concentrations returned definitively to menopausal levels.

We reported the first successful transplantation of cryopreserved ovarian tissue40 resulting in a pregnancy and live birth. In 1997, a 25-year-old woman presented with clinical stage IV Hodgkin's lymphoma. Ovarian tissue cryopreservation was undertaken before chemotherapy. After laparoscopy, the patient received MOPP/ABV hybrid chemotherapy (chlorethamine, vincristine, procarbazine, prednisone, doxorubicin, bleomycin and vinblastine) from August 1997 to February 1998, followed by supradiaphragmatic radiotherapy (38Gy). According to Schilsky et al7, the risk of POF after such a regimen in a woman aged 26 years is more than 90%, while according to Wallace et al.9 and Lobo52, the risk of subfertility after Hodgkin's treatment with alkylating agents is more than 80%. Indeed, not only the type of drug and dose, but also age, are important factors when evaluating the risk of POF after chemotherapy. In 2003, once the patient had been declared completely free of disease, transplantation was carried out (see Donnez et al.22, *26, *40 for techniques). A large strip and 35 small cubes of frozen–thawed ovarian tissue were implanted into a furrow created by the peritoneal window very close to the ovarian vessels and fimbria on the right side (Fig. 1). Four months after transplantation, a laparoscopy was carried out to check the viability of the orthotopic graft and re-implant the remaining 32 ovarian cortical cubes. From 5 months to 9 months after re-implantation, concentrations of FSH, 17 β-oestradiol and progesterone showed the occurrence of ovulatory cycles. At 11 months, the patient became pregnant and subsequently delivered a healthy baby. This birth was announced in the Lancet in September 2004.40

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  • Fig. 1 

    A large strip and 35 small cubes of frozen-thawed ovarian tissue were implanted in a furrow created by the peritoneal window very close to the ovarian vessels and fimbria.

In 2006, restoration of ovarian function after orthotopic (intra-ovarian and para-ovarian) transplantation of cryopreserved ovarian tissue was reported in a woman treated by BMT for a non-cancerous disease (sickle cell anaemia).22 Vaginal echography and sequential measurement of FSH, LH, 17 β-oestradiol and progesterone concentrations revealed the onset of an ovulatory cycle 4½ months after re-implantation of ovarian tissue.

We applied a technique similar to that used by Silber et al.53 for the transplantation of fresh ovarian cortex between monozygotic twins in a woman who had also undergone BMT and two regimens of alkylating agents in 2000 for non-Hodgkin's lymphoma. Cryopreservation of ovarian tissue was carried out 1 year after first-line chemotherapy. One ovary was removed and biopsies of cortical ovarian tissue revealed the presence of histologically normal primordial follicles. Six ovarian cortical pieces measuring 10×4–5mm were then grafted onto the remaining ovary after the cortex of this ovary had been removed (Fig. 2). The goal was to ‘rebuild’ an ovary. It was 5 months before a mature follicle (21mm) developed and an increase in oestradiol levels (194pgml−1) was noted. The patient experienced an ovulatory cycle every 5 weeks, the preovulatory oestradiol level reaching values between 210 and 356pgml−1.

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  • Fig. 2 

    Ovarian cortical pieces measuring 4–5mm to 1cm in size were grafted onto the remaining ovary after the cortex of this ovary had been removed. a: Cortex of the remaining ovary was removed. b: Cortical pieces were sutured with 7-0 stitches.

In total, nine transplantations have been carried out in our department, according to the previously described technique.*26, *54

Analysis of these cases raises some important points for discussion. First of all, in all cases, it took between 4½ months and 5 months after reimplantation before a follicle could be seen. The process of folliculogenesis takes ∼4–6 months, during which time the oocyte and surrounding somatic cells undergo a series of changes that eventually result in the development of a large antral follicle, capable of producing a mature oocyte.55 Thus, the appearance of the first follicle originating from the grafted tissue 5 months after re-implantation, proved by laparoscopy in one case, is totally consistent with the expected time course. This time interval between implantation of cortical tissue and the first oestradiol peak is also consistent with data obtained from sheep56, 57 and humans, although some variations may be observed. Indeed, as discussed in a recent review4, the delay between transplantation and follicular development was found to vary from 6 weeks to 8 months. Such a variation could be explained by a difference in follicular reserve at the time of cryopreservation.

Another very interesting finding is the persistence of relatively high FSH levels during the follicular phase. FSH levels remained as high as 25mIUml−1 during the follicular phase until ovulation, and then decreased to less than 15mIUml−1 during the luteal phase (Fig. 3). This may constitute an argument against the use of gonadotropin injections. The relatively high FSH levels may be explained by the relatively low number of surviving primordial follicles in the graft. The patient should be considered a poor responder, with reduced inhibin B secretion. These results are in agreement with those obtained in sheep by Campbell et al.58

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  • Fig. 3 

    Mean FSH and 17β-oestradiol levels (±standard deviation) in the 7 cases of frozen-thawed ovarian tissue transplantation. It took between 4 and 6 ½ months after transplantation before a rise in oestradiol and a drop in FSH were observed. (Note that, in the last 4 cases, FSH and oestradiol values at 1 month post-transplantation were not taken into account, as the patients were under GnRH agonist down-regulation).

A further significant observation is the return to an FSH level of >35mIUml−1 immediately after each menstrual bleed, which supports the theory suggested by Baird et al.57 that some inhibitory mechanisms, such as inhibin B or anti-Müllerian hormone (AMH) normally produced by developing follicles in intact human ovaries, are probably almost non-existent in transplanted tissue. After transplantation, the patient would have been regarded a poor responder because, of the 500–1000 primordial follicles that would have been transplanted, more than 50% would have been lost owing to hypoxia.40 This raises the question of the evaluation of the ovarian reserve. There is a lack of data on the ovarian reserve in cancer. Qu et al59, Gook et al.60 and Schmidt et al.61 have all demonstrated an unequal distribution of primordial follicles in ovarian cortex.

In 2005, Meirow et al. also published a live birth after orthotopic autotransplantation of cryopreserved ovarian tissue in a patient with POF after chemotherapy.41 Eight months after orthotopic transplantation, the patient spontaneously menstruated. The rise in AMH and increased inhibin B levels were consistent with the presence of early growing follicles and ovulation, respectively. Nine months after transplantation, the patient experienced a second spontaneous menstrual period. After a modified natural cycle, a single mature oocyte was retrieved and fertilised. Two days later, a four-cell embryo was transferred. The patient became pregnant from this embryo transfer and delivered a healthy infant weighing 3000g. The possibility that the oocyte was derived from the native ovary is highly unlikely, given the consistent evidence of POF after high-dose chemotherapy in this patient, from whom ovarian tissue was harvested after administration of a first-line conventional chemotherapy regimen, prior to second-line high-dose chemotherapy.

Demeestere et al.62 recently reported a pregnancy after natural conception in a woman who had undergone orthotopic and heterotopic transplantation of cryopreserved ovarian tissue. They observed follicular development in all three transplantation sites: large follicles in the ovarian site, only one dominant follicle in the peritoneal site and follicles <13mm in size in the heterotopic site. Detectable hCG levels and ultrasonography confirmed the presence of a viable intrauterine pregnancy. Unfortunately, this pregnancy, obtained by natural conception, ended in miscarriage at 7 weeks due to aneuploidy. Thereafter, this patient underwent a second transplantation, became pregnant and delivered a healthy baby.62

Andersen et al.46 reported a series of six women (some already described in the paper by Schmidt et al.42). Orthotopic autotransplantation was performed in all patients, two of whom received additional heterotopic transplants. These authors also observed restoration of ovarian function in all women within 20 weeks. Four of the six women conceived following assisted reproduction. One woman miscarried in gestational week 7 and another had a positive hCG test but no clinical pregnancy. Two became pregnant after follicle puncture and ovum pick-up during natural cycles. Each delivered a healthy baby. Both these women had undergone orthotopic transplantation of cryopreserved ovarian tissue to the remaining ovary.46

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Whole ovary 

As previously stated, the main drawback of ovarian tissue cryopreservation followed by avascular transplantation is that the graft is completely dependent on the establishment of neo-vascularisation and, as a result, a large proportion of follicles are lost during the initial ischaemia occurring after transplantation.43, 56, 63, 64, 65, 66, 67, 68 Reducing the ischaemic interval between transplantation and re-vascularisation is, therefore, essential to maintaining the follicular reserve and extending the life span and function of the graft. In theory, the best way to achieve this is by transplantation of intact ovary with vascular anastomosis, allowing immediate re-vascularisation of the transplant.

Ovarian vascular transplantation has already been successfully performed using intact fresh ovaries in rats69, 70, rabbits71, sheep72, 73, dogs74, monkeys75 and humans.76, 77, 78 In the past few years, attempts at freezing and grafting whole ovaries in rats69, 70, rabbits79 and sheep80, 81, 82, 83 have also yielded encouraging results.

The first case of restoration of fertility after whole frozen–thawed ovary transplantation was described by Wang et al. in 2002.69 They described successful vascular transplantation of frozen–thawed rat ovaries and reproductive tract in four out of seven (57%) transplants, which survived for 60 days or more, and resulted in one pregnancy. Chen et al.79 showed that frozen–thawed rabbit ovaries remained functional for at least 7 months after microvascular transplantation in 13 out of 15 (86.7%) animals.

It appears that, in large mammals and humans, cryopreserving such a large-sized intact ovary may prove more problematic than in small animals due to the difficulty of adequate diffusion of cryoprotective agents into large tissue masses and vascular injury caused by intravascular ice formation. Nevertheless, Arav et al.81 reported progesterone activity 36 months after vascular transplantation of frozen–thawed sheep ovaries in three out of eight transplants, and retrieval of six oocytes, resulting in embryonic development up to the eight-cell stage after parthenogenic activation. Bedaiwy et al.80, 84 reported restoration of ovarian function after autotransplantation of intact frozen–thawed sheep ovaries with microvascular anastomosis, but it should be noted that 8 out of 11 ovaries were lost due to thrombotic events in the re-anastomosed vascular pedicle. Imhof et al.83 recently demonstrated that autotransplantation of whole cryopreserved sheep ovaries with microanastomosis of the ovarian vascular pedicle could lead to pregnancy and delivery. Moreover, in this study, major ovarian vessels in six out of eight ovaries were free of thrombosis, with the structural integrity of the ovarian stroma largely retained 18–19 months after transplantation.

Martinez-Madrid et al. described a cryopreservation protocol for intact human ovary with its vascular pedicle and proved high survival rates of follicles (75.1%), small vessels and stroma, and a normal histological structure in all ovarian components after thawing.85

After freeze–thawing whole human ovaries using this protocol, no induction of apoptosis was observed in any cell types, assessed by both the TUNEL method and immunohistochemistry for active caspase-3.86 Transmission electron microscopy (TEM) confirmed that the majority (96.7%) of primordial follicles were intact after cryopreservation (Fig. 4).87 Particular attention was paid to the evaluation of the endothelial cells: TEM revealed that 96.3% of these cells had a completely normal ultrastructure, and the percentage of active caspase-3-positive endothelial cells was less than 1%.

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  • Fig. 4 

    Primordial follicle in frozen-thawed whole human ovary. (4a and inset) The oocyte (O) is surrounded by a single layer of flattened follicular cells (Fc) on a continuous basal membrane (bm). Note the presence of rounded mitochondria (m) with a pale matrix and peripheral cristae in the oocyte cytoplasm. Follicular cells show indented nuclei containing peripheral patches of heterochromatin and numerous rod-shaped mitochondria in the cytoplasm. N: oocyte nucleus. (4b) A well preserved arteriole in frozen-thawed human ovary. L: vascular lumen. Original magnification: LM: 400x; TEM: 4400x (4a); 3000x (4b).

Our results in humans have led us to seriously consider proposing this option to women in the future, when there is no risk of transmitting malignant cells via the graft after transplantation. So far, in our department, 16 whole ovaries have been cryopreserved with a view to future re-implantation (grafting) and vascular anastomosis.

Developing new cryochambers and improving protocols for whole ovary cryopreservation are therefore vital directions in ongoing research to make transplantation of an entire ovary a feasible objective.33, 88, *89 Research and development of technology to cryopreserve whole organs, as well as surgical techniques for the autotransplantation of an entire ovary with its vascular pedicle, should be encouraged (Fig. 5). This could lead to the transplantation of intact ovaries with microvascular anastomosis carried out to restore immediate vascularisation and minimise post-transplantation ischaemia, responsible for the reduction in follicular density.

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  • Fig. 5 

    The ovarian pedicle is dissected cranially as high as possible, above the iliac vessels and psoas muscle. A) Psoas muscle. B) Ovarian pedicle. C) Left iliac artery. D) Ureter.

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Ethical issues and safety 

One of the most important ethical issues is to ensure that the intervention does not harm the patient by dangerously delaying cancer treatment and that no remnant cells are re-introduced by subsequent transplantation. Taking these points into account, we agree with Dudzinski90 that policies to protect the patient's future rights to her gametes should be developed, as well as policies addressing the disposition of the gametes if the patient dies.

Although an adolescent is more vulnerable when consent is sought in the rush to begin chemotherapy, she must be mature enough to understand the risks and benefits of the procedure. Consent must then be discussed extensively, the discussion including both the adolescent patient and her parents, to minimise the risk of conflict of interest or inadvertent caution.91 Respecting the code of good practice, all patients who may become infertile have the right to receive proper consideration of their interests for future possibilities in the field of ovarian function preservation. Case selection should be carried out on the basis of a multidisciplinary staff discussion including oncologists, gynaecologists, biologists, psychologists and paediatricians. Counselling should be given and informed consent obtained from the patient. Cancer treatment takes priority over potential restoration of fertility, but offering the chance to preserve fertility may greatly enhance quality of life for cancer survivors.

The transmission of lymphoma via grafts of ovarian tissue from diseased donor mice to healthy recipients was reported by Shaw et al.92 This study highlighted the risks of clinical transplantation of ovarian biopsy samples to women recovering from cancer, especially a blood-borne cancer.92, 93 However, there are certain circumstances where the risk of cancerous involvement of the ovary is absent or minimal31, and where autografting would present little or no danger.34, 94, *95 Screening methods must be developed to eliminate the risk of cancer cell transmission with re-implantation.68, 96 In some diseases, other options must be considered, such as transplantation of isolated follicles, as recently described by Dolmans et al.97 Meanwhile, the debate rages on.

The Practice Committee of the ASRM98 summarised some important points to be taken into consideration, while Dudzinski90, focusing on the need to develop policies to protect the patient's right to self-determination with respect to her gametes, concluded that more research is required before adolescents can ethically be enrolled in clinical trials.

We do not fully agree with this conclusion, however. Indeed, approximately one-third of young women exposed to chemotherapy develop ovarian failure. In 2009, we believe it is our ethical responsibility to propose cryopreservation of ovarian tissue to all adolescents and young women, under IRB protocols, having to undergo chemotherapy with alkylating agents. Indeed, is it ethical to simply accept the existing discrepancy between males and females with regard to their chances of preserving their fertility following cancer treatments? What do we then say to young women facing POF after chemotherapy, knowing that ovarian cryopreservation has been an option for more than 10 years? It will be too late to say “we should have done something.”

This is why, since 1996, we have systematically proposed cryopreservation prior to chemotherapy to all women under 35 years of age when there is a risk of POF and, so far, more than 300 patients have undergone this procedure. We accept that ovarian tissue cryopreservation is a more innovative and invasive procedure than sperm cryopreservation and that all possible applications in adolescents are ethically complex. However, we wholeheartedly agree with Revel and Schenker99, who contributed to a debate published in Human Reproduction, arguing that ovarian cortex banking should be offered before chemotherapy in all cases where emergency in vitro fertilisation (IVF) is not possible.

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Conclusion 

Cryopreservation of ovarian tissue should be seriously considered for any patient undergoing treatment likely to impair future fertility, the indications being pelvic, extrapelvic and/or systemic malignant diseases, as well as non-malignant diseases. The age of the patient should be taken into consideration, since the follicular reserve of the ovary is age dependent. Because a decline in fertility is now well documented after the age of 38 years, the procedure should probably be restricted to patients below this limit. Nevertheless, irradiation and chemotherapy appear to be less harmful to the gonads of prepubertal than postpubertal women.17, *18, 100

In conclusion, live births obtained after transplantation of frozen–thawed ovarian tissue in humans give hope to young cancer patients, but there is still much work to be done. Research programmes need to determine whether active angiogenesis can be induced to accelerate the process of neo-vascularisation in grafted tissue, if isolated human follicles can be grafted, or indeed if microvascular re-anastomosis of an entire cryopreserved ovary is a valuable option.

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Conflict of interest statement 

All authors disclose no financial or personal relationships with other people or organisations that could inappropriately influence the content of this article.

Practice points

 


•Ovaries are very sensitive to cytotoxic treatment, especially to alkylating agents.

•For patients who need immediate chemotherapy, cryopreservation of ovarian tissue is the only possible option to preserve fertility.

•Six live births have been achieved to date after orthotopic transplantation of cryopreserved ovarian tissue.

Research agenda

 


•Less toxic agents

•Value of cryoprotectant

•Value of orthotopic re-implantation

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PII: S1521-6934(09)00117-5

doi:10.1016/j.bpobgyn.2009.09.003

Best Practice & Research Clinical Obstetrics & Gynaecology
Volume 24, Issue 1 , Pages 87-100, February 2010

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