Oocyte and embryo freezing for oncofertility

1. Fertility preservation for
oncological causes
D R . S HE R I F A N I S H E B I S H A , M D
A . P RO F ES S O R O F G Y N ECO LO GY, A L EX A N D R I A U N I V ERS I T Y

2. Oncofertility..
Cancer impact on female fertility
FP… HCPs perspectives
Role of Health Care Providers
FP… Current facts
FP… Safety
Current options of FP
Outcomes of FP EC/OC

3. Oncofertility..
Oncofertility is an exciting new interdisciplinary field that
encompasses the obstetrician gynecologist, gynecologic oncologist,
reproductive endocrinologist, and primary care physician in a
common goal to provide FP options for cancer patients
Lange etal., 2013; Von Wolf et al., 2019

4. Oncofertility..
All patients
have the right to information about the consequences of cancer or
cancer treatment on their fertility, as well as the right to make
decisions about fertility preservation, if it is available
ASRM,2013

5. Oncofertility..
The incidence rate of cancer among reproductive-age women
is 7%
Rajabi et al., 2018
Steadily increasing survival rates (efficacy of novel oncological
treatments)

6. Oncofertility..
Options of FP, are the second most important aspect among young
patients, following survival
In addition to fertility, the preservation of the ovarian reserve is
necessary to maintain overall women's health such as the cardiovascular
system & osseous system Lérida etal., 2019

7. Impact of Cancers on female fertility
Impaired ovarian function at the time of cancer diagnosis
Chemotherapy and radiotherapy may induce POI in women
Surgical removal or damage to reproductive organs

8. Impact of Cancers on female fertility
Chemotherapy:
The younger the patient, the lesser the risk of ovarian failure
alkylating agents being of greatest risk
 The duration of the treatment

9. Impact of Cancers on female fertility
Radiotherapy:
 Ovary: Exposure to 20-30 Gy or total body radiation of 15 Gy lead to POF
Uterus: Reduced vascularity, myometrium fibrosis & hormone-
dependent insufficiency
Martinez et al., 2017
Impact of recent biological or targeted cancer female fertility therapies is
also limited except for bevacizumab, with a rate of 34% POI reported
Loren et al., 2013

10. HCPs perspectives on FP
HCPs play a key role in providing information and counselling on FP
HOWEVER…Many patients do not receive such information
Only 50% of doctors and nurses, reported that they always addressed
this issue
Ussher et al., 2016

11. HCPs perspectives on FP
The primary barriers to discussing fertility are:
poor patient prognosis
patient gender or age
time constraints
and absence of appropriate resources and materials
Ussher et al., 2016

12. HCPs perspectives on FP
Only 29% of HCPs had undergone training in discussing fertility with
cancer patients
HCPs agreed that a number of resources would assist them to raise
fertility with their patients, including:
 a list of appropriate referral sources
fact sheets
 information booklets
a fertility consultation checklist and on-line resources

13. Role of Health Care Providers: ASCO, 2018
1. All oncologic health care providers should be prepared to
discuss infertility as a potential risk of therapy
2. This discussion should take place as soon as possible once a
cancer diagnosis is made
3. Health care providers should refer patients who express an
interest in fertility preservation to reproductive specialists

14. FP.. Current facts
OPU:
minimally invasive
can be readily completed in a 2-3 weeks time period, thus
minimally delaying intended treatments for cancer
Robson et al., 2019
The lack of high‐quality data on long‐term outcomes, risks and
side effects to patients prevented uptake of services provided
McQuillan et al., 2013

15. FP…safety
Theoretical concern that COS with associated elevated E2 levels
can promote tumour growth in ER‐positive cancers
(RCTs that have shown no significant increased risk in patients with
breast cancer Azim et al., 2008; Checa et al.,2012)
A meta‐analysis outlining the safety of COS in breast cancer
patients; this provides a baseline data set to suggest positive safety
profiles in patients
Sergentanis et al., IVF and breast cancer: a systematic review and meta‐analysis. Hum Reprod Update.
2014

16. FP…safety
Ovarian stimulation protocols using the aromatase inhibitor letrozole
have been developed and may ameliorate this concern
Studies do not indicate increased cancer recurrence risk as a result of
subsequent pregnancy
ASCO, 2018

17. FP techniques
Embryo cryopreservation
Immature or mature oocyte cryopreservation
Ovarian tissue cryopreservation (OTC)
Ovarian transposition
Other experimental techniques, such as:
o The activation of ovarian follicles
oIn vitro follicle culture
oArtificial ovaries
oNovel fertoprotective agents

18. Options for FP in oncology patients
Robsonet al., 2019

19. Oocyte and embryo cryopreservation
The well-established method
Oocyte retrieval should be performed before
cancer treatment begins
The timing of oocyte retrieval usually
depends on the patient’s menstrual cycle

20. Oocyte and embryo cryopreservation
Prepubertal patients OR those requiring urgent
treatment, ovarian tissue offers another option
However, in patients with a hematological
malignancy, may cause recurrence when ovarian
transplantation is performed

21. Oocyte and embryo cryopreservation
The best option best options directly depend on:
oType of cancer
o Patient’s age
oAvailable time
oLikelihood of ovarian involvement
The decision should be acceptable to the oncologist, gynecologist,
patient, and the patient’s partner or family

22. Ovarian stimulation
For patients with estrogen-sensitive cancers, the FP network
FertiPROTEKT recommends stimulation combined with lertrozole 5
mg daily to prevent a rise in estradiol levels
This does not affect the number of oocytes and embryos
retrieved compared with standard protocols, without affecting
short-term recurrence of cancer
Harada & Osuga, 2016

23. Cryopreservation techniques
Slow-freezing
ultra-rapid
vitrification

24. Cryopreservation techniques: Slow-freezing
Step-wise programmed decrease in temperature
Achieving a freezing equilibrium
(due to the exchange of the extra- and intracellular fluids without
causing meaningful osmotic and deformation cellular effects)

25. Cryopreservation techniques: Slow-freezing
Disadvantages:
oIce crystals, can result in extremely harmful effects
oLong-lasting (approximately 1 or 2 h)
oRequires expensive instrumentation and large quantities of liquid
nitrogen, among others

26. Cryopreservation techniques: Vitrification
oConverts water into solid glass-like cells, avoiding ice crystal
formation
oExpensive instrumentation it is not required
oOnly several minutes are needed

27. Cryopreservation techniques: Vitrification
A meta-analysis in 2013 revealed that the rates of oocyte survival,
fertilization and implantation where higher in vitrification than in
slow-freezing methods
Cil et al., 2013
vitrification is nowadays the preferred technique

28. Embryo cryopreservation
widely used and reliable method
Steps:
1) COS with gonadotropin injections to promote multifollicular growth
2) After 10-14 days, OPU is performed, normally under conscious sedation
and with TV/US -guided needle aspiration
3) The oocytes are then fertilized in the laboratory and are cryopreserved
for future use, commonly in their blastocyst phase

29. Embryo cryopreservation
COS normally begins during the early follicular phase
If cancer diagnosed in her early follicular phase, ovarian stimulation
with GnRH antagonist begins immediately
If the patient is in any other phase, the IVF standard protocols require
the patient to wait upto 3 weeks before the process begins
Lérida etal., 2019

30. Embryo cryopreservation
Oocyte harvesting now possible on a cycle day–independent schedule
ASCO, 2018
For a patient who cannot wait for her next menstrual period but still has 2 weeks
before her cancer treatment, random-start COS may be recommended
Random-start COS:
Does not affect the number of oocytes and embryos retrieved
pregnancy and neonatal outcomes are similar to those in standard COS cycles
in infertile patients
Harada & Osuga, 2016

31. Embryo cryopreservation
Therefore..
Is not a viable option for women whose aggressive cancer treatment
is of highest priority
Not recommended in women with hormone-sensitive cancers and is
not possible for prepubertal girls
Lérida etal., 2019

32. Embryo cryopreservation
Disadvantages
The need of a stable male partner
Ethical issues regarding embryo disposition
The time required for ovarian stimulation
Lérida etal., 2019

33. Embryo cryopreservation

34. Embryo cryopreservation..clinical
outcome
Embryo cryopreservation has high pregnancy success rates
However, outcomes in cancer patients are scarce
LBR in non-oncological patients <35 years of age amount to 38.7% per
FET and to 34,8% for oocyte donor cycles
Mahajan et al., 2015

35. Embryo cryopreservation..clinical
outcome
LBR per patient and cumulative live birth rate (CLBR) among women
with cancer undergoing IVF and embryo cryopreservation
similar to that achieved with fresh embryos in non-cancer patients has
been reported
Dolmans et al., 2015

36. Oocyte cryopreservation
Alternative to embryo cryopreservation
Overcomes the ethical and religious issues that
emerge from the embryo preservation
Oocyte cryopreservation is increasingly preferred

37. Oocyte cryopreservation
Preferred option for:
opostpuberal and adolescent females
oSingle females
Not appropriate for:
opatients who are in urgent need of treatment
opatients with hormone-sensitive cancers, as the procedure also
includes COS

38. Oocyte cryopreservation
Mature oocyte cryopreservation
With the oocytes in metaphase II
Preferred method for:
opostpuberal patients
opatients when gonadotoxic treatment can be delayed

39. Oocyte cryopreservation
Immature oocyte cryopreservation
Immature oocytes btained by aspiration or during an OTC procedure
and followed by IVM techniques
Suitable for:
oPrepubertal girls
oWomen with aggressive or hormone-sensitive cancers or PCOS, since
COS is not required
Allows immediate cancer treatment

40. I
Lérida etal., 2019

41. Lérida etal., 2019

42. Oocyte cryopreservation.. Clinical
outcome
Immature Oocytes will be matured in vitro as the cryopreservation of
mature oocytes has yielded better survival outcomes than immature
cryopreserved oocytes
Lim et al., 2010
Clinical outcomes in the oocyte vitrification are superior to slow-freezing
Donnez et al., 2017; Cil et al., 2013

43. Oocyte cryopreservation.. Clinical
outcome
In women undergoing oocyte vitrification because of non-
oncological medical conditions, a LBR per patient:
50% among women aged %35 years was found,
22.9% among those aged >36 years
Cobo et al., 2016
These success rates are comparable to those achieved with fresh
oocytes
Rienzi et al.,2010; Sol e et al., 2013

44. Oocyte cryopreservation.. Clinical
outcome
Outcomes after oocyte vitrification among female cancer patients are scarce
Alvarez et al., first reported a successful birth in a woman with invasive
ovarian cancer
Alvarez et al., 2014
Martinez et al., reported fertilization rates up to 76.6%
& a mean (SD) number of ET of 1.8–0.7 among 11 women with cancer,
four of whom gave birth at term with no negative perinatal outcomes
Martinez et al., 2014

45. FP..clinical outcomes

46. EC & OC
Rajabi et al., 2018

47. Ovarian tissue cryopreservation: OTC
COS independent experimental technique
Invasive procedure (requires general anesthesia to surgically remove
the ovarian tissue)
Multiple ovarian biopsies are removed from young patients through
either laparoscopy section or oophorectomy
Rajabi et al., 2018

48. A. Ovarian cortical tissue cryopreservation
All egg-containing follicles are in the outer one-millimeter layer of
the ovary >>> thus sufficient for cryopreservation
Preparation of the ovarian cortex, followed by subsequent freezing
by slow‐freeze technologies or increasingly, vitrification

49. B. Whole ovary cryopreservation
Remains a technical challenge due to:
1. The bigger size of the tissue, which hinders a homogeneous and
adequate dispersion of cryoprotectant
2. The vascular damage in form of ice crystals

50. OTC
Cryopreserved tissue used for
1. Reimplantation of this tissue either in:
 the pelvic cavity (orthotopic) usually carried out by laparoscopy e.g.,
remaining ovarian tissue or peritoneum
 or elsewhere (heterotopic) e.g., rectum, pectoralis muscle,
abdominal wall and chest wall
Has the potential of restoring fertility and ovarian hormone secretion

51. OTC
2. Isolation of follicles from the thawed tissue for in IVG,IVM and
IVF
During OTC, it is possible to aspirate immature oocytes from antral
follicles of the ovarian tissue
Isolated oocytes can be cryopreserved or matured in vitro for later
vitrification

52. OTC
Benefits
Allows immediate cancer treatment
The only FP option in paediatric patients and in hormone-
dependent diseases
This remains to be a promising area of innovation in the field of
oncofertility and warrants further research
robson et al., 2019

53. OTC
Further investigation is needed to confirm whether it is safe in patients
with leukemias
Emerging data may prompt reconsideration of this designation in the
future
(this technique is already considered non experimental in some
countries, and its experimental status is undergoing evaluation in the
USA)
ASCO, 2018

54. OTC

55. Ovarian transposition: Oophoropexy
Appropriate for prepubertal and adolescent girls
Ovaries removal replacing them to under the uterus or intra‐abdominally
out of radiation field
Achieved by transecting the ovarian ligament, while maintaining the
blood supply via the infundibular‐pelvic ligament
Aim: to avoid damage from pelvic radiotherapy where there is no concern
about ovarian malignancy
Hanet al., 2011

56. Ovarian transposition: Oophoropexy
However..
Irritation has detrimental effects on the function of the uterus
Because of radiation scatter, ovaries are not always protected
Because of the risk of remigration of the ovaries, this procedure should
be performed as close to the time of radiation treatment as possible
ASCO, 2018

57. Ovarian transposition: Oophoropexy

58. Ovarian suppression: GnRH agonist
Can theoretically minimise damage to gonads from gonadotoxic agents
Administrated 10 days prior to the commencement of the
chemotherapy
May be through:
oInterruption in FSH secretion
oDecreased utero‐ovarian perfusion
oThe upregulation of intra‐gonadal anti‐apoptotic molecules

59. Ovarian suppression: GnRH agonist
A recent meta‐analysis showed increased rates of recovery of regular
menses(at both six and 12 months) following successful completion of
treatment in premenopausal women undergoing chemotherapy for
early‐stage breast cancer
Munhoz et al., 2016
Return to menses was globally considered a ‘return to fertility’ in the
included papers

60. Ovarian suppression
There is conflicting evidence to recommend GnRHa and other means of ovarian
suppression for FP
When proven FP methods such as oocyte, embryo, or OTC are not feasible, and
in the setting of young women with breast cancer, GnRHa may be offered to
patients in the hope of reducing the likelihood of chemotherapy-induced POI
However, GnRHa should not be used in place of proven fertility preservation
methods
ASCO, 2018

61. Emerging techniques
In vitro follicle culture
Artificial ovaries.

62. In vitro follicle culture
OTC carries the risk of re-seeding original cancer cells into the patient
This risk can be minimised by using complete IVG and IVM of oocytes

63. In vitro follicle culture
Useful in:
Cancers whose metastasis appear often in the ovary or
Patients with BRAC1 and BRAC2 mutations, due to the increased risk of
an ovarian cancer
However, the complete maturation of primordial follicles has not been
achieved in humans yet
Martinez et al., 2017

64. Artificial ovaries
An alternative to the in vitro culture of primordial follicles is their
development into an engineered "transplantable artificial ovary“
For eliminating the the risk of transmission of malignant cells

65. Artificial ovaries
Isolated primordial follicles are transferred into matrices, mostly using
fibrin, and then grafted to the inner part of the peritoneum to create an
artificial organ
Once transplanted to the patient, this ‘artificial ovary’ would potentially
restore fertility and endocrine function
Rajabi et al., 2018

66. THM
Oncology female patients should be counselled regarding potential
fertility loss
Patients should be referred to fertility specialists to discuss options for FP
and current results
 Embryo and oocyte cryopreservation are first-line FP methods in
postpubertal women

67. THM
Metaphase II oocyte cryopreservation (vitrification) is the preferred
option
Cumulative evidence for restoration of ovarian function and
spontaneous pregnancies after ART following orthotopic transplantation
of cryopreserved ovarian tissue supports its future consideration as an
open clinical application