제목 : Oncofertility 연자 : 박찬우 선생님 대상 : 관심 있는 의료인 및 연구원 일시 : 2014년 12월 2일 AM 7: 00 화요일 장소 : 제일병원 수련관 1층 주관 : 마더리스크 프로그램

1. Oncofertility
산부인과 / 난임·생식내분비과 박 찬 우

2. Oncofertility

3. Resources of Fertility Preservation (FP)
ESHRE, Task force
1999
2012
2013
2007
2006
ASRM, FPSIG
ISFP
Oncofertility consortium
fertiPROTEKT
KSFP
JSFP
Professional society
National
interdisciplinary
initiative

4. Oncofertility Consortium®
National interdisciplinary initiative

5. The UT System
Health Institutions
•UT Southwestern Medical Center
•UT Medical Branch at Galveston
•UT Health Science Center at Houston
•UT Health Science Center at San Antonio
•UT MD Anderson Cancer Center
•UT Health Science Center at Tyler
Oncofertility Consortium
National physicians cooperative

7. Pre-treatment fertility counseling and fertility preservation
 The risk of treatment associated infertility and premature menopause is a top concern for patients.
Carter J, et al. (2005) Nakayama K, et al. (2009)
 Potential iatrogenic loss of fertility – the loss of a potential child – has profound impact on young
women and may be, at times, more stressful than the cancer diagnosis itself.
Partridge AH, et al.(2004) Schover LR, et al. (2004)
 Up to 75% of young women are interested in the opportunity to have
children after a cancer diagnosis. Schover LR. (2009)
 If women are not informed of the risks to their fertility, they may lose
their ability to take action towards preserving their fertility before cancer
treatment. Lee SJ,, et al. (2006)

8. Pre-treatment fertility counseling and fertility preservation
• Only 34–72% of reproductive-age women treated for cancer recall having
a discussion about the effects of cancer treatment on future fertility.
Tschudin S, et al. (2010)
• Most patients have this discussion just before starting cancer treatment
and therefore believe they have no time to pursue a fertility consultation
without delaying planned treatments. Madrigrano A, et al. (2007)

9. Pre-treatment fertility counseling and fertility preservation
Retrospective survey study, using the California Cancer Registry
 1041 women diagnosed between the ages of 18 and 40
• 61% (560 / 980 pts) were counseled about potential reproductive loss by a member of the
oncology team.
• 45 pts (5%) were counseled by fertility specialists
• 36 pts (4%) took action to preserve fertility.
 80% of the patients who visited a fertility specialist took action to preserve fertility.
Letourneau JM, et al. (2012)

10. Potential targets of chemotherapeutic damage within the ovary

11. Ovarian follicle burnout
PMFs are under balanced regulation

12. Medical mitigate strategies
Fetoprotective agent
Reagent Radiation Chemotherapy Mechanism Clinical setting Efficacy
GnRH analogue Yes Yes
Suppression of ovarian
function
Yes Controversial
S1P Yes Yes Anti-apotosis No In progress
AS101 Yes Yes Immunomodurator No In progress
Imatinib
(Gleevec)
Cisplatin c-Abl No Controversial

13. Imatinib prevents cisplatin-induced loss of follicles in the ovarian reserve
Kim SY, et al. (2013)

14. Ovary is Robust Source of Tissue that Can Be Used for Numerous FP Options

15. Oocyte Banking
• Still considered to be experimental by the ASRM until October 2012.
• Median reported fertilization rate of thawed oocytes with the use of ICSI was 67%,
and the median reported pregnancy rate per cycle was 33%. Rudick B, et al. (2010)
• The rate of congenital abnormalities (1.3%) was not increased compared with the rate
in spontaneously conceived infants (N=936). Noyes N, et al. (2009)

16. Clinical outcome according to the type of oocytes received
Prospective controlled-randomized, clinical trial in an ovum donation program
Egg-bank Fresh
No. of embryos transferred 267 (90.5) 259 (89.6)
Mean No. of embryos replaced 513 (1.74 ± 0.7) 498 (1.72 ± 0.7)
No. cycles with embryo ‘re-vitrification'/cryopreservation 196 (66.7) 216 (74.7)*
Mean No. of re-vitrified or cryopreserved embryos 592 (2.0 ± 2.1) 743 (2.5 ± 2.3)*
Implantation rate 205 (39.9) 204 (40.9)
Positive hCG test/cycle 165 (55.9) 159 (55.0)
Clinical pregnancy rate/cycle 148 (50.2) 144 (49.8)
Clinical pregnancy rate/transfer 148 (55.4) 144 (55.6)
Twin pregnancy rate 48 (32.4) 54 (37.5)

17. Emergency IVF
COS in Patients with Estrogen-Sensitive Cancers
• Both embryo and oocyte cryopreservation require COS.
• Supraphysiologic E2 levels resulting from OS may promote the growth of estrogen-sensitive tumors,
such as endometrial and estrogen receptor–positive breast cancers
Letrozole ( Selective third-generation aromatase inhibitor )

18. Breast cancer patients (n = 47)
Keep E2 levels <500 pg/mL
Letrozole+FSH (N=47) Control (N=56) P value
Age at IVF (yr) 36.4 ± 3.6 36.9 ± 3.9 0.44
No. of days stimulated 11.7 ± 2.3 12.2 ± 1.5 0.09
Total FSH dose 1317.8 ± 578.2 2382.5 ± 1062.8 <0.001
E2 at hCG 483.4 ± 278.9 1464 ± 644.9 <0.001
Total oocytes (n) 12.4 ± 7.0 11.1 ± 5.5 0.43
Mature oocytes (n) 8.7 ± 4.8 9.7 ± 5.1 0.43
Mature oocytes (%) 73.2 ± 22.9 86.3 ± 12.7 0.003
No. of 2 pn zygotes 6.6 ± 4.0 6.9 ± 4.1 0.73
Fertilization rate 74.1 ± 24.0 73.2 ± 21.5 0.71

19. OS can be started at a random cycle time
Minimize delays to treatment,
every patient proceed cancer treatment in 2–3 weeks after presentation
Conventional start
(n = 88; 103 cycles)
Random start
(n = 35; 35 cycles)
P value
Late follicular phase start
(n = 13; 13 cycles)
Luteal phase start
(n = 22; 22 cycles)
P value a
Antral follicle count (AFC) 13.0 (11.7–14.5) 11.5 (9.6–13.8) NS 10.5 (7.8–14.2) 12.1 (9.6–15.2) NS
Days of ovarian stimulation 9.3 (9.0–9.5) 10.9 (10.4–11.5) <.001 10.5 (9.6–11.4)b 11.2 (10.5–12.0)c <.001
Total dose of gonadotropins (IU) 3,404 (3,180–3,628) 4,158 (3,774–4,542) .001 3,842 (3,213–4,472) 4,344 (3,860–4,827)e .005
Oocytes retrieved 14.4 (12.8–16.2) 14.5 (11.8–17.8) NS 13.0 (9.3–18.2) 15.5 (11.9–20.1) NS
Mature oocytes (MII) retrieved 9.7 (8.4–11.2) 9.9 (7.7–12.7) NS 9.1 (6.0–13.7) 10.3 (7.5–14.2) NS
MII oocytes/total oocytes ratio 0.66 (0.62–0.71) 0.67 (0.59–0.76) NS 0.68 (0.56–0.82) 0.67 (0.58–0.78) NS
Fertilization rate after ICSI
(2PN/MII)
0.72 (0.65–0.80) 0.87 (0.72–1.00) NS 0.85 (0.67–1.00) 0.88 (0.70–1.00) NS

20. Ovarian tissue cryopreservation
• It is the only option available for prepubertal girls, and may be the best option for patients who
should start their chemotherapy or radiation straightaway.
• Surgical removal of ovarian tissue causes no delay in cancer treatment initiation and abundant
primordial follicles, containing small, less differentiated oocytes can be stored
• In young cancer patients who have recently been exposed to chemotherapy treatments,
ovarian tissue cryopreservation is the only option to preserve fertility, because it mainly
preserves primordial follicles, which are not subject to the deleterious effects of chemotherapy
on growing and mature follicles.

21. Worldwide series of live births obtained to 2013
24 live births reported in the literature to date
References
Cryopreservation
procedure
Graft site
Live birth
Spont. IVF
Donnez et al. SF Peritoneal window (2 steps) +
Peritoneal window (1 step) ++
Ovarian medulla +++
Meirow et al. SF Beneath the ovarian cortex − +
Demeestere et al. SF Ovarian and peritoneal windows (2 steps) ++ −
Andersen et al. SF
Subcortical ovarian pocket + +
Ovarian medulla + +
Silber et al. SF Ovarian medulla ++ −
Piver et al.
SF
Ovarian and peritoneal windows (1 and 2 steps) +
+
−
Roux et al.
Sanchez et al. SF Ovarian medulla − ++ (twins)
Revel et al. SF Peritoneal window (slice) −
+
+
Dittrich et al. SF Peritoneal window + −
Revelli et al. SF Ovarian medulla +
García Rada SF Peritoneal pocket +

22. Cortical strip 5 × 10 mm2 pieces / Thickness 1~1.5 mm
Immature egg retrieval can be performed for IVM

23. Transplantation
Orthotopic vs. Heterotopic

24. Orthotopic transplantation
Peritoneal pocket / Ovarian decortication
Decortication Creation of the peritoneal window of the ovarian cortex
in the anterior leaf of the broad ligament.

25. How successful in transplant?
LBR 10% (6/60 patients) / CPR 18% (18/60 patients)
Team Patients
Freezing
technique
Graft site Outcome Pregnancy
Live birth
Ovarian
medulla
Peritoneal
window
Ovarian
activity
(no. of Pts)
Average time
for restoration
of ovarian activity
Total no.
of pregnancies
Natural IVF
No.
of Pts
Belgium 13 SF
61.5%
(8/13)
54% (7/13) 10a/13 4.5 mo 6 4 2 3 6
Denmark 25 SF
84%
(21/25)
36% (9/25) 25/25b 4.7 mo 8 6 2 2 4
Spain 22 SF
95.5%
(21/22)
36.5% (8/22) 17c/18 4.7 mo 4 3 1 1 2 (twin)
Donnez J, et al. (2013)

26. Minimize ischemia & enhance revascularization
 After reimplantation, >50% of primordial follicles are lost, mainly due to tissue
ischemia after transplantation while awaiting angiogenesis.
 Reoxygenation of ovarian grafts occurs from day 5 onward from day 5 after grafting.
• Angiogenic factors (vascular endothelial growth factor (VEGF), gonadotropins, etc.),
Antiapoptotic factors (Kit ligand, c-Kit, insulin-like growth factor I and II,
8br–cyclic guanosine monophosphate, growth and differentiation factor 9, etc.)
could also play a role in the survival of follicles.
• However, most studies were performed on the basis of in vitro culture experiments
and there is no robust evidence that these agents would work in vivo in human.

27. Risk of recurrent due to the reintroduction of cancer cells via autotransplantation of
cryopreserved ovarian tissue
• Great concern : Leukaemia
• Serious reasons for concern : Gastric, Colorectal, Endometrial cancer
• Less concern : Cervical, Breast cancer
• Least concern : Lymphoma

28. Follicles develop from secondary to the preovulatory antral stage

29. Follicular growth in a 2-D vs 3-D culture system.

30. 3D follicle culture in vitro.
Soft hydrogels provide a more permissive environment for follicle growth

31. Encapsulated in vitro follicular growth (eIVFG)

32. Follicle growth (In Macaque)
3 cohorts : No-grow vs. Slow-grow vs. Fast-grow
Monkeys
• Prepubertal ( 1-3 years )
• Young, adult ( 4-11 years )
• Older adult ( 13-16 years)

33. Oocyte maturation and diameter
3 cohorts : No-grow vs. Slow-grow vs. Fast-grow
Age group
Number (n) of Diameter (μm)*
Follicles harvested Oocytes retrieved Degenerate oocytes GV-intact oocytes GV-intact oocytes
Prepubertal 14 8 5 3 (38%) 69±10a
Young adult
(slow-grow) 25 13 7 6 (46%) 85±3a,b
(fast-grow) 10 7 1 6 (86%) 99±4b
Older adult 5 2 0 2 71±27

34. AMH / VEGF
3 cohorts : No-grow vs. Slow-grow vs. Fast-grow

35. IVFG has been applied successfully across large mammalian speicies

36. Major milestones have been achieved in human IVFG

37. Ovarian tissue encapsulation in degradable fibrin allows physical connectivity
Controlled release of VEGF promoted revascularization

38. Fibrin encapsulation and vascular endothelial growth factor delivery promotes
ovarian graft survival in mice.

39. Extending IVFG beyond FP

41. IVM OOCYTE CRYOPRESERVATION AFTER EX-VIVO OOCYTE RETRIEVAL
IN GYNECOLOGIC CANCER PATIENTS UNDERGOING RADICAL SURGERY
2014 ASRM
Patient No. Age Cancer Type Stage
1 31 Endometrial cancer IIIC1
2 29 Endometrial cancer IB
3 19 Ovarian cancer IC
4 19 Ovarian cancer IV
5 39 Ovarian cancer IC
6 37
Double primary tumor
(Endometrial & Ovarian cancer)
II / IC

42. No.5 Ovarian cancer patient.
Small and fibrotic both ovarian tissue by oncologist
resulting in ex-vivo oocyte retrieval failure
No.4 Ovarian cancer patient.
Smooth surface cortical tissue, devoid of follicle, resulting in one IVM oocyte cryopreservation
No.1 Endometrial cancer patient
Macroscopically normal ovarian tissue resulting in 15 IVM oocyte cryopreservation

43. IVM OOCYTE CRYOPRESERVATION AFTER EX-VIVO OOCYTE RETRIEVAL
IN GYNECOLOGIC CANCER PATIENTS UNDERGOING RADICAL SURGERY
Patient
No.
Age
Marital
Status
FP option
AMH
(ng/ml)
E2
(pg/ml)
P4
(ng/ml)
No. of
retrieved
oocyte
No. of
IVM
oocyte
Freezing
( No.)
1 31 V
Oocyte
freezing
- - - 19 15
Oocyte
(15)
2 29 V
Oocyte
freezing
- - - 9 5
Oocyte
(5)
3 19 S
Oocyte
freezing
9.4 87.6 0.23 11 7
Oocyte
(7)
4 19 V
Oocyte
freezing
- - - 3 1
Oocyte
(1)
5 39 V
Oocyte
freezing
< 0.1 583.5 0.24 Failed - -
6 37 M
Embryo
freezing
0.4 37.0 0.03 11 8
Embryo
(5)

44. Global Oncofertility Community

45. Thank you for your attention !