Ferritlity preservation techniques

1. FERTILITY PRESERVATION
CURRENT PROGRESS
DR ARCHITA SRIVASTAVA
DR TANIA GURIA
DR BAISHAKHI MANDAL
DR AISWARYA GHOSHAL
DR DEBSRITA BHATTACHARJEE
MODERATORS
DR SUBESHA BASU
ROY
DR BISWAJIT GHOSH
DR SHUBENDU
CHAUDHURY
DR CHAITALI
SENGUPTA

2. THE FETAL OVARY
The indifferent gonad stage
• 5 weeks of gestation paired gonads consolidate
over lying the mesonephros forming gonadal
ridges (together forming urogenital ridge)
• Gonads consists of primordial germ cells
• Coelomic epithelium and mesonephric cells
provide somatic cells for follicular cells
• Germ cells are formed by primitive endoderm at
caudal end in dorsal wall of yolk sac and then
appear in splanchnic mesoderm of hindgut
• germ cells migrate to genital ridge along dorsal
mesentry by active amoebic movements.
• Germ cells proliferate and differentiate into
oogonia
• Coelomic epithelium of genital rigde
proliferates and irregular cords of cells
(primitive sex cords)invaginate the
underlyng mesenchyme
• The gonad is differentiated into ovary by
the control of WT1,FTZI gene
• 20 th week of gestation the oocyte
which are not surrounded by granulosa
cell envelop are destroyed
• By 28 th week these follicles are exposed
to maternal gonadotropin and undergo
maturation and atresia
Primitive Gonad

3. In utero, GnRH neurons develop in the olfactory placode
11 weeks' gestation-neurons migrate through the forebrain to the arcuate nucleus of the
hypothalamus
They form axons that extend to the median eminence and to the capillary plexus of the pituitary
portal system
GnRH is influenced by higher cortical centers and is released from these neurons in a pulsatile fashion
into the pituitary portal plexus.
by mid gestation, the GnRH "pulse generator" stimulates secretion of gonadotropins, that is, FSH ,LH
from the anterior pituitary stimulating ovarian synthesis and release of gonadal steroid hormones.
5 months' gestation- accelerated germ cell division and follicular development begins, resulting in the
the creation of 6 to7 million oocytes

4. By late gestation,gonadal steroids exert a negative feedback on secretion of both hypothalamic
GnRH and pituitary gonadotropins.
During this time, 0ocyte number decreases through a process of gene-related apoptosis to reach a
level of 1 to 2 million by birth
At birth, FSH and LH concentrations rise abruptly response to the fall in placental estrogen levels
and are highest in the first 3 months of life
This transient rise in gonadotropin levels is followed by an increase in gonadal steroid
concentrations, leads to neonatal breast budding, minor bleeding from endometrial shedding
,short-lived ovarian cysts, and transient white vaginal mucous discharge
Following these initial months, gonadotropin levels gradually decline to reach prepubertal levels by
age 1 to 2 years.

7. INTRODUCTION
• Fertility preservation (FP) is the process of saving gametes (eggs, sperm)
or reproductive tissue, so that a person can use them to have biological
children in the future.
• It's a new field in reproductive medicine that focuses on helping
reproductive age women and men who are faced with cancer treat
mentor some benign conditions (non-cancerous tumours) understand
their risks of infertility and possible treatment options.
• The objective of any FP intervention is to minimise or eliminate primary
disease burden and to ensure maintaining or preserving reproductive
health.

8. INDICATIONS
• Patients with malignant or benign disease(endometriosis, ovarian cysts,
borderline tumours)
• Auto-immune diseases (Lupus, CREST syndrome, multiple sclerosis,Behçet
disease, Takayasu arteritis, antineutrophil cytoplasmic antibody.associated
vasculitis, polyarteritis nodosa,Rheumatoid artheritis)
• Genetic disease(fragile X, Turner syndrome, BPES, galactosaemia),exposure
to toxins
• Haematological diseases (thalassemia, sickle cell disease, Fanconianemia,
aplastic/myelodysplastic anaemia)
• Family history
• Social reasons

9. MALIGNANT DISEASES
• A frequent side effect of some
chemotherapy and radiotherapy is
premature ovarian failure (POF) after
treatment, due to reduction of the
primordial follicle pool, ovarian atrophy,
fibrosis of ovarian cortex, and damage of
gonadal vascularization.
• Risk of gonado-toxicity depends on type
of agent used in chemotherapy and their
dose
• And in Radiotherapy it depends from
irradiation area (total body, abdominal,
pelvic) and total dose of irradiation.
• Turner syndrome and fragile X mental
retardation 1 premutation are
associated with diminished fertility
• Galactosaemia, which is an autosomal
recessive disorder of galactose
metabolism resulting from a deficiency
of the galactose-1-
phosphateuridylyltransferase enzyme, is
associated with POF
• Females with BRCA mutations have a
higher risk of ovarian cancer; hence,
they should be offered FP counselling
to complete family planning by the age
of 35 to 40 years before undergoing
prophylactic bilateral salpingo-
oophorectomy
GENETIC

10. High Risk Medium risk (20-80%) Low risk(>20%)
Total body irradiation Leukaemia Leukaemia
Pelvic irradiation Cerebral tumour>24 Gy Cerebral tumor<24 Gy
Bone marrow
transplantation
Non-Hodgkin’s
lymphoma
Wilms’s tumor
Hodgkin’s
lymphoma:alkylant
Edwin’s sarcoma(no
mets)
Germinal cell tumour(no
radio)
Hodgkin’s lymphoma
Osteosarcoma
Hepato/Neuroblastoma
Risk of infertility after malignancy treatment

11. ENDOMETRIOSIS
Leads to
• Focal inflammation
• Destruction of surrounding normal
cortex
• Fibrosis and loss of cortex-specific
stroma,enhanced recruitment
• Atresia
Clinicians counsel women with
endometrioma regarding the risks of
reduced ovarian function after surgery
and the possible loss of the ovary
• In women, fertility starts to decline from
the 30's and this process continues
rapidly after the age of 35 due to the
fact that the number and also the
quality of the eggs drop with the age.
• The eggs are frozen before the age of
35.
• For a woman, her eggs can be frozen
for many years, which gives her the
freedom to become a mother when she
is ready, regardless of age.
• The eggs can be thawed out and
fertilized later on with a partner or
donor's sperm
• In males, freezing of sperm is done out
of social reasons, it is recommended to
do this before the age of 50
SOCIAL

12. 5. Concerns regarding impact of fertility
preservation on cancer treatment should be
addressed
6. Appropriate referral to psychosocial supportive
providers if they experience distress about
potential Patients should be encouraged to
participate in registries and clinical studies,
8. Patient should be informed about both
established(embryo and oocyte cryopreservation)
and experimental (ovarian tissue cryopreservation)
methods of fertility preservation.
9.Patient should be informed about conservative
fertility sparing surgeries and the option of
ovarian transposition (oophoropexv) should be
discussed when pelvic radiation therapy is
performed as cancer treatment.
10. Patients should be informed that there is
insufficient evidence regarding the effectiveness
of ovarian suppression (gonadotropin-releasing
hormone analogs)as a fertility preservation
method, and these agents should not be relied on
to preserve fertility.
American Society of Clinical Oncology
recently made recommendations on fertility
preservation strategies.-
Some of the principle recommendations are as
follows:
1.Fertility preservation should be discussed
with all patients of reproductive age group
about to embark on cancer treatment.
2. Interested patients should be referred to
reproductive specialists.
3. Fertility preservation should be addressed
before the GnRH Analogs treatment starts.
4. All the discussions pertaining to fertility
preservation should be documented in the
medical record.

13. FERTILITY PRESERVING OPTIONS
FERTILITY PRESERVATION IN
WOMEN
ESTABLISHED TECHNIQUES INVESTIGATIONAL TECHNIQUES
EMBRYO CRYOPRESERVATION OOCYTE CRYOPRESERVATION
OVARIAN TRANSPOSITION
OVARIAN CRYOPRESERVATION
OVARIAN SUPPRESSION

14. MALE FERTILITY PRESERVATION
SPERM
CRYOPRESERVATION
STEM CELL
TRANSPLANTATION
GONADAL SHIELDING

15. EMBRYO CRYOPRESERVATION
• Also called embryo freezing.
• Most common and successful
option.
• Oocyte retrival
• in vitro fertilisation with partner or
donor sperm
storing the embryo to extremely
low temperature(-196
degree centi.)
• Prior to an embryo transfer, thawing
process takes place and embryos
are warmed from a cooled state to
prepare for transfer to the uterus.
• Cryoprotectants (CPAs) used to protect cells/tissues
from the damage that may occur during the freezing
process.
• This technique is feasible only for post-pubertal
women with a partner or those using donor sperm.
• Embryo cryopreservation is not recommended after
chemotherapy initiated.
• the procedure is not practicable in patients who need
to begin chemotherapy as soon as possible, as it
requires 10-15 days for controlled ovarian stimulation
(COS) to induce multiple follicular growth and oocytes
pick up.
• There are two methods for embryo cryopreservation –
 slow freezing
 vitrification.

16. • Slow freezing is the traditional method of
freezing embryos.
 These techniques lower the temperature of the
embryos gradually.
 It is a conventional cryopreservation method,
known as equilibrium freezing , where exchange of
fluids occurs between the extracellular and
intracellular spaces with slowly decreasing
temperature.
 Without major osmotic and deformation effects to
cell.
 This leads to less toxicity to cells/tissues : however,
it does not eliminate ice formation.
 The entire freezing process takes approximately2.5
hours.
 Thawing of these embryos requires a fast
 Prior to embryo transfer, the storage straw is
removed from the liquid nitrogen and rapidly
wormed to room temperature to prevent ice
damage.
• Vitrification is the method of freezing an egg or
embryo with extremely rapid cooling, so fast that
that the water molecules don't have time to form
ice crystals.
 The difference from slow freezing is that it avoids the
formation of ice crystals intra and extracellularly.
 The avoidance of ice formation, particularly
intracellular ice , is known to be one of the most
important factors contributing to successful
cryopreservation.
 Vitrification of human blastocysts allows to maximise
the potential for conception from any one IF cycle
and prevents wastage of embryos.
 This technique is also helpful for best utilise of
patient's supernumerary ooctes after retrieval,
maximising the use of embryos from a single
stimulation cycle.
 This method is easier to conduct, does not require
expensive equipment like programmable freezers,
and is not that time consuming when compared to
the conventional slow freezing.

18. CRYOPRESERVATION OF
OVARIAN TISSUE
• Applied worldwide to preserve fertility in cancer patients,
especially in young girls and women who cannot delay the
onset of their treatment.
• Candidates-
 benign pathologies with a risk of POF.
 Patients with clinical symptoms of POF such as
amenorrhoea/oligospaniomenorrhoea or biological
signs of POF (high FSH levels, very low MH levels,
decreased ovarian volume, antral follicle count
nearly zero)
• the only FP alternative for pre-pubertal patients.
• The procedure involves surgical removal of ovarian tissue
followed by freezing of the cortical tissue prepared to a
thickness of approximately 1-2 mm.
• The freezing process may be performed using either the
slow-freezing or the vitrification technique and requires
introduction of cryoprotectants to avoid ice-crystal
formation and damage of cell integrity.
• The tissue is than stored in liquid nitrogen until time of
reimplantation.
• After thawing, the tissue may be transplanted to the woman
from whom it originated.
• As the cortical tissue primarily contains early stages of
follicular development, it takes 3-6 months for the tissue to
regain full activity including sustaining development of
preovulatory follicles and release of fertilisable oocytes.

19. • The anatomic feature of the ovary which allow to freeze
and store ovarian cortex is the simple fact that
primordial follicles comprise more than 90% of all
follicles in an ovary and they are located in the outer 1
mm of the ovarian cortex .
• This fact explains why frozen/thawed ovarian tissue can
restore an ovarian organ function, since each of
primordial follicles has the potential to grow to the
preovulatory stage.
• There are two main approaches for auto transplantation
of human ovarian tissue:
 heterotopic and orthotopic.
 In the heterotopic transplantation, cortical fragments can
be grafted subcutaneously at various sites of abdominal
wall or the peritoneal lining.
 In orthotopic transplantation cortical pieces are
transplanted into its original physiological area.

20. OVARIAN TRANSPOSITION
• Ovarian transposition is a procedure used to help
keep a woman fertile by preventing damage to
the ovaries during radiation therapy.
• The objective of this method is to transpose
ovaries out of radiation field.
• Before radiation therapy begins, a health care
provider performs a minor surgery to move one
or both ovaries and fallopian tubes and suturing
them to the posterior uterus or to the wall of the
abdomen away from where the radiation will be
given.
• The vascular pedicle remains intact in ovarian
transposition , which distinguishes this procedure
from ovarian transplantation.
• Contemporary procedures transpose the ovaries
above the pelvic brim and as lateral as possible,
which minimises the ovarian dose of radiation
and improves efficacy compared with medial
approaches.
• Various lateral locations have been used, including
the base of the round ligament, the level of lower
kidney pole, and the paracolic gutters.
• Ovarian transposition is also called oophoropexy.

21. MEDICAL THERAPY
• GnRH agonists used.
• Goal of this treatment is to shut down the ovaries during cancer
treatmentin order to protect them from damaging effects.
• Reducing activity in theovaries during treatment will reduce the number
of eggs that are damagedso women will resume normal menstrual
cycles after treatment.
• not considered a proven FP method.

22. THANK YOU