Approach For Fertility Preservation Research Articles

GnRH-a-based fertility-sparing treatment of atypical endometrial hyperplasia (AEH) and early endometrial carcinoma (EC) patients: a multicenter, open-label, randomized designed clinical trial protocol

BackgroundAround 4% of women receive an endometrial cancer diagnosis before turning 40, mainly those without prior childbirth experience and a strong desire to preserve their ability to conceive. Consequently, for young patients diagnosed with atypical endometrial hyperplasia (AEH) or early endometrial carcinoma (EC), a fertility-preserving approach employing high-dose oral progesterone has been adopted. However, previous research has shown a notable relapse rate. Furthermore, the extended use of substantial oral progesterone doses may hinder ovarian function and raise the risk of weight gain, liver issues, blood clotting, and breast cancer. We previously assessed the clinical effectiveness and pregnancy outcomes of gonadotropin-releasing hormone agonist (GnRH-a) based re-treatment for women with EC and AEH who did not respond to oral progestin therapy but achieved favorable treatment results and reproductive outcomes.MethodsThis study will be an open-label, two-armed, randomized, investigator-initiated multicenter trial evaluating the combination of GnRH-a with the levonorgestrel-releasing intrauterine system or the combination of GnRH-a with an aromatase inhibitor (comprising a subcutaneous GnRH-a injection every 4 weeks and daily oral letrozole 2.5 mg). A total of 226 participants will be randomly allocated to one of the two treatment groups in a 1:1 ratio. The primary objective is to determine the effectiveness of GnRH-a-based re-treatment in achieving a complete response (CR) at 24 weeks for patients with AEH or EC. Secondary objectives include assessing the pregnancy rate 12 weeks after treatment, as well as post-treatment pregnancy outcomes and the rate of recurrence.Ethics and disseminationThe protocol received approval from the Institutional Review Board of Peking Union Medical College Hospital and from boards at five other institutions. The trial will adhere to the principles outlined in the World Medical Association’s Declaration of Helsinki and follow Good Clinical Practice standards. The trial results will be disseminated through publication in a peer-reviewed journal.ConclusionsProspective evidence supporting conservative treatment for EC and AEH is limited. There is a need for new approaches that can achieve higher CR rates with fewer side effects. This trial will assess the effectiveness of GnRH-a-based fertility-sparing treatment in obese women and recurrent patients, offering a promising alternative for patients with EC and AEH.Trial registration numberChinese Clinical Trial Registry ChiCTR2200067099. Registered on December 27, 2022.

P-356 Fertility preservation for patients with breast cancer: altered response to ovarian stimulation and loss of cholesterol homeostasis in ovarian follicles

Abstract Study question Does the presence of breast cancer alter the ovarian response to hormonal stimulation and the cholesterol homeostasis in ovarian follicles? Summary answer The deleterious impact of breast cancer on the ovarian response might be link to an alteration of the cholesterol biosynthesis in cumulus cells. What is known already Breast cancer is the most frequent cancer in reproductive-aged women. The cancer itself seems to exert a deleterious impact on the ovarian functions. Indeed, cancer patients who undergo fertility preservation before cancer therapy initiation show a poorer response to ovarian stimulation than healthy women. Nevertheless, this impact remains controversial, and the mechanisms by which the cancer impairs the ovarian functions are poorly understood. To our knowledge, no study has yet evaluated the impact of breast cancer on the cholesterol biosynthesis pathway in human cumulus cells, a pathway essential for oocyte competence to maturation and fertilization. Study design, size, duration 30 patients with breast cancer (10 triple negative (TNBC), 10 hormone-receptor positive (HR+) and 10 HER2 positive (HER2+)) and 30 women oocytes donors undergoing oocyte cryopreservation will be included from January 2019. We assess ovarian response to stimulation (number, quality of retrieved oocytes; total FSH dose). We quantify the level of enzymes and regulators of the cholesterol biosynthesis pathway in cumulus cells (CC) by RT-qPCR. We plan to quantify cholesterol levels in follicular fluids (FF). Participants/materials, setting, methods Since January 2019, 25 breast cancer patients (9 TNBC, 8 HR+ and 8 HER2+) and 30 oocytes donors (control group) under 37 years old have been included. Ovarian stimulation was performed with antagonist protocol. Following ovarian pick up and denudation, CC and FF were collected. After total RNAs extraction from CC, the expression levels of enzymes and regulators of the cholesterol biosynthesis pathway were quantified by RT-qPCR. Cholesterol levels will be quantified in FF. Main results and the role of chance The clinico-biological characteristics (age, BMI) are comparable between cancer patients and the control group (p > 0.05). Serum AMH levels are lower in the TNBC subgroup (2.3±1.6 ng/mL) than in the control group (4.7±2.8 ng/mL, p = 0.04). A poorer ovarian response to ovarian stimulation is observed in the breast cancer group compared with the control group (number of mature oocytes: 9.4±5.2 vs. 14.5±7.7, p = 0.007). Among the cancer patients group, the TNBC subgroup shows the poorest ovarian response to stimulation (number of mature oocytes: 7.6±4.3 vs. 14.5±7.7 in control group, p = 0.006) despite the highest total administered FSH dose (2480±880 IU vs. 1831±460 IU in control group, p = 0.02). Dysregulation of the cholesterol biosynthesis pathway is observed in the breast cancer group. For TNBC and HR+ cancer patients, we observed an increase in the transcripts levels of CYP51 enzyme (respectively 3.28±1.69 vs. 1.84±2.33, p = 0.0098 and 1.77±1.78 vs. 1.84±2.33, p = 0.03) and SREBP2 activator (respectively 2.04±0.95 vs. 1.27±1.13, p = 0.003 and 1.12±0.47 vs. 1.27±1.13, p = 0.02) of the cholesterol biosynthesis pathway compared to the control group. In HER2+ cancer patients, a significant decrease in the expression levels of SQLE (0.39±0.34 vs 1.81±3.99, p = 0.001) and DHRC7 enzymes (0.33±0.32 vs 1.21±0.88, p = 0.0002) is observed compared to the control group. Limitations, reasons for caution Our preliminary results should be confirmed with the analysis of a larger number of participants. We should confirm that the observed modulations in the expression levels of enzymes and regulators of the cholesterol biosynthesis pathway led to a loss of cholesterol homeostasis by quantifying cholesterol in FF. Wider implications of the findings Our findings strengthen the hypothesis that cancer exerts a deleterious impact on the ovarian functions, as we observed a lower ovarian response in patients with breast cancer. This project will have clinical implications, such as to adapt the fertility preservation approach according to the breast cancer subtype. Trial registration number Not applicable

Successful pregnancy using immature oocytes retrieved from resected borderline ovarian tumor: a case report and literature review

BackgroundDespite the recent progress of fertility preservation technique, achievement of pregnancy in women with ovarian tumor is still challenging. Here, we report a case of OTO-IVM (ovarian tissue oocyte in-vitro maturation) resulting in a successful delivery.Case presentationThe patient, a 33-year-old woman with a history of left borderline ovarian tumor (BOT) who underwent left salpingo-oophorectomy three years ago, presented with an enlarged right ovary during infertility treatment, indicating the recurrence of BOT. Because the patient disagreed with curative surgery and normal part-preservation surgery, we eventually performed OTO-IVM. A right salpingo-oophorectomy was first performed. Eight immature oocytes were immediately aspirated not only from visible follicles, but also from entire cortex for invisible follicles, of the removed ovary. In addition, IVM procedure generated six mature oocytes, and were subjected to intracytoplasmic sperm injection (ICSI). Accordingly, three embryos were obtained and cryopreserved. Three months after surgery, hormone replacement therapy was initiated, and a frozen-thawed embryo was transferred, resulting in a successful pregnancy. Although a cesarean section was performed at 36 weeks due to maternal ileus, the baby was delivered without complications.ConclusionsThis report indicates this treatment to be an effective approach for fertility preservation in BOT patients, especially, the importance of collecting oocytes from the entire ovarian cortex was suggested.

Role of fertility-sparing surgery and further prognostic factors in borderline tumors of the ovary

ObjectiveBorderline tumors of the ovary are a rare group of ovarian neoplasms with distinctive histological features. Considering their favorable prognosis and occurrence at a younger age, fertility-sparing surgery may be...

Fertility Preservation Approach in a Case of Perforating Gestational Trophoblastic Neoplasia

Background: Gestational trophoblastic neoplasia following spontaneous abortion is rare and in majority cases the approach is hysterectomy followed by chemotherapy. Case: We present case of a 22-year-old woman who presented with complaints of vaginal bleeding for 2 months; pain abdomen for 3-4 days. On reviewing history, patient was one and a half months pregnant and had spontaneous abortion for which she underwent twice dilatation and curettage and once laparotomy in outside hospital. Patient continued to bleed & MRI pelvis was done which revealed arteriovenous malformation and was thereafter referred to our hospital. On presentation her vitals were stable with pallor positive. On per-abdominal examination there was generalized tenderness and mild bleeding on per speculum examination. Her serum beta hCG at the time of admission was 98,156IU/L. Ultrasound pelvis revealed a highly vascular heterogenous hypoechoic mass showing significant internal and peripheral vascularity. We decided for uterine artery embolization owing to highly vascular GTN, young age and no live issues with the aim of uterine preservation. This was followed by chemotherapy with serial beta hcg monitoring. She is in her 14th month of follow up with resolution of her complaints. Conclusion: The aim behind presenting this case is its rarity of presentation as well as management to increase awareness among treating gynecologists. Importance of multi-disciplinary approach should not be undermined in challenging cases.

Preserving Fertility for Patients Who are Gender Diverse and Transitioning

Fertility preservation is the process of storing eggs, sperm, or embryos for future use. It can be an option for transgender people who want to have biological children in the future. Because pubertal suppression, gender-affirming hormone therapy, and antiandrogen therapy used alone or in combination during medical transition showed the detrimental impact on the gonadal function and the future fertility, understanding the effects these treatments have on fertility potential is important for practitioners caring for transgender and gender nonbinary patients. Early and regular counselling regarding future fertility, the treatment approach for fertility preservation and/or family-building in transgender and gender nonbinary individuals are very important. Fertility preservation should be offered to all transgender patients ideally prior to medical or surgical treatment. Fertility preservation options for transgender men are oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation with in vitro maturation (IVM). Semen cryopreservation or testicular tissue cryopreservation is one of the fertility preservation options for transwomen. However, there is relatively limited data and clinical information regarding fertility preservation for transgender individuals. Recently, there is a growing awareness of fertility preservation counselling prior to initiation of gender-affirming care. However, numerous studies have reported a limited standard of care with many transgender patients who are experiencing inadequate fertility counselling. Further prospective studies are needed for better quality fertility services and parenting options for transgender and nonbinary individuals. In conclusion, the denial of access to fertility services to transgender individuals and nonbinary persons is not justified.

Preservation of Fertility in Cancer Patients: A Narrative Review.

The survival rates for cancer patients have been steadily improving in recent years due to the improved efficacy of contemporary oncological care, including radiotherapy and chemotherapy. Modern technology makes it feasible to maintain fertility in cancer patients, and this practice needs to be included in oncological care. In many instances, it is impossible to avoid the harm that cancer treatments can cause to a patient's fertility; hence, research in fertility preservation techniques is being conducted to allow cancer patients to have future children biologically related to them. The development of fertility preservation approaches has grown in importance in the field of research over the past few years to increase patient's quality of life and survival. Oncologists must be aware of circumstances in which cancer patients' fertility will be impacted by their therapy and the avenues open for procedures like cryopreservation of the gametes or embryos. When cancer therapy is scheduled, all patients should receive prompt and thorough information on the fertility-related side effects of treatment and the prospects for fertility preservation. The article analyzes the literature, enlisting the factors that contribute to cancer and their effects on fertility, followed by a list of available and newly developed strategies for maintaining fertility in patients. The efficiency of the various fertility preservation techniques following cancer therapy is also discussed.

Summary of the ISFP congress, Brussels, 10-12 November, 2022.

The 7th International Congress of the ISFP was held in Brussels in November 2022. Hundreds of attendees from all over the world had the rare opportunity to hear the most distinguished leaders discuss and debate the latest advances in the field. Participants were also able to attend workshops under the guidance of skilled practitioners. Numerous topics were considered, including a recap on fertility preservation approaches in cancer and benign pathologies and a section on male factor infertility. Other aspects covered were in vitro maturation and poor responders, the impact of chemotherapy on the ovary, and future perspectives. Participants had the chance to listen to a symposium on fertility preservation techniques, and finally, a keynote lecture on fertility preservation in gynecological cancers brought this prominent and highly influential event to a close.

Microencapsulation and nanowarming enables vitrification cryopreservation of mouse preantral follicles

Preantral follicles are often used as models for cryopreservation and in vitro culture due to their easy availability. As a promising approach for mammalian fertility preservation, vitrification of preantral follicles requires high concentrations of highly toxic penetrating cryoprotective agents (up to 6 M). Here, we accomplish low-concentration-penetrating cryoprotective agent (1.5 M) vitrification of mouse preantral follicles encapsulated in hydrogel by nanowarming. We find that compared with conventional water bath warming, the viability of preantral follicles is increased by 33%. Moreover, the cavity formation rate of preantral follicles after in vitro culture is comparable to the control group without vitrification. Furthermore, the percentage of MII oocytes developed from the vitrified follicles, and the birth rate of offspring following in vitro fertilization and embryo transfer are also similar to the control group. Our results provide a step towards nontoxic vitrification by utilizing the synergistic cryoprotection effect of microencapsulation and nanowarming.

Bridging the Gap: Robotic Approach to Isthmocele Dehiscence

<h3>Study Objective</h3> To describe a minimally invasive fertility preserving approach to emergent surgery in the setting of an isthmocele dehiscence. <h3>Design</h3> Narrated video of surgical technique with descriptions of key steps. <h3>Setting</h3> Uterine isthmoceles are usually asymptomatic but can cause abnormal uterine bleeding, pain, secondary infertility and have been associated with uterine rupture or cesarean scar dehiscence. There have been only a few case reports of isthmocele dehiscence following uterine instrumentation. Often in cases of acute bleeding, an abdominal hysterectomy is performed. We present the case of a 36-year-old G2P1001 patient who underwent dilation & evacuation at 14 weeks for holoprosencephaly which was complicated by post-operative hypotension and vaginal bleeding. Emergent laparoscopic exploration revealed concealed bleeding leading to hematoma formation at the site of isthmocele dehiscence. The hematoma was evacuated and the isthmocele was resected and repaired, allowing for a uterine preserving procedure. <h3>Patients or Participants</h3> One patient was included in this case report. <h3>Interventions</h3> Robotic assisted laparoscopic hematoma evacuation and isthmocele repair was performed with 5 key interventions: 1. Bladder mobilization using sharp dissection and cautery 2. Dilute vasopressin injected circumferentially around isthmocele 3. Monopolar cautery used to refresh dilated edges of isthmocele 4. Uterine sound introduced into endometrial cavity to delineate anatomy 5. Defect repair with 2-0 barbed suture in multiple layers <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> In patients with a history of cesarean delivery, it is important to consider isthmocele dehiscence in the setting of post-procedural bleeding or hemodynamic instability. In cases of isthmocele dehiscence, specifically when there is concealed bleeding into the isthmocele, one could consider a uterine sparing minimally invasive approach. Hemodynamic stability of the patient, access to necessary resources, efficiency of ancillary staff, and surgeon experience are key factors for success in such surgical emergencies.

8122 Butterfly Peritonectomy & Rectal Shaving in Deep Infiltrating Endometriosis Surgery

<h3>Study Objective</h3> Todescribe in detail the butterfly peritonectomy procedure developed by the author for effective dissection of the peritoneum in cases where deep infiltrating endometriosis has affected the peritoneum. <h3>Design</h3> The procedure has been developed over several years of the author performing laparoscopic surgeries on patients of DIE with involvement of the peritoneum; and has found this technique to be the most efficient, preserving, and effective for managing the involvement. <h3>Setting</h3> The patient is positioned in the dorsal lithotomy in Trendelenburg position. Primary tracer is through the umbilicus, 3 operative ports are used, 2 at respective right and left flank and middle at supra pubic port. <h3>Patients or Participants</h3> The procedure presented in this video has been compiled over several years with observations from numerous surgeries. For the purpose of simplicity, the author presents a single case of peritoneal involvement of endometriosis managed using butterfly peritonectomy. <h3>Interventions</h3> The surgery displayed in this video presentation is a laparoscopic surgery for a case of peritoneal involvement of endometriosis. <h3>Measurements and Main Results</h3> Adopting the Butterfly peritonectomy procedure for cases of peritoneal involvement see a reduced rate of recurrence in patients, reduced pelvic pain, and fertility preservation where applicable, along with effective safeguarding of the peripheral organs including lateral pelvic vessels, the ureter, the hypogastric nerve, and the rectum. <h3>Conclusion</h3> Butterfly peritonectomy enables surgeons to treat deep infiltrating endometriosis within the tricky folds of the peritoneum that engulfs some major vasculature, nerves, and organs. It provides the doctor with a fertility preserving approach to treating the disease thereby increasing adaptability within patients while also providing better surgical outcomes than before.

Endometrial Cancer in Reproductive Age: Fertility-Sparing Approach and Reproductive Outcomes.

Endometrial cancer is the most common gynecologic malignancy in developed countries and approximately 7% of the women with endometrial cancer are below the age of 45. Management of endometrial cancer in young women who desire to maintain fertility presents a unique set of challenges since the standard surgical treatment based on hysterectomy and salpingo-oophorectomy is often not compatible with the patient's goals. A fertility-preserving approach can be considered in selected patients with early stage and low-grade endometrial cancer. An increasing amount of data suggest that oncologic outcomes are not compromised if a conservative approach is utilized with close monitoring until childbearing is completed. If a fertility-preserving approach is not possible, assisted reproductive technologies can assist patients in achieving their fertility goals.

LIPID SUPPLEMENTATION IN WARMING MEDIA IMPROVES DEVELOPMENTAL POTENTIAL OF MOUSE OOCYTES AND ZYGOTES

Oocyte and embryo vitrification has been widely used in human assisted reproductive technology (ART) as the preferred approach for fertility preservation. However, vitrified oocytes had compromised developmental potential compared to the fresh oocytes. The objective of this study to examine whether additional of exogenous lipid during warming would improve developmental potential of mouse oocyte and zygotes. We also tested the longevity of the lipid-supplemented media by examining lipid peroxidation and the performance of the media after extended period of storage.

O-225 Endometrioma and fertility preservation: how can we save the oocytes?

Abstract Endometriosis is a benign estrogen-dependent disease In the ovary, endometrioma formation may cause local inflammation, giving rise to structural alterations to the ovarian cortexwhich manifest as massive fibrosis and loss of cortex-specific stroma that maintains follicular nests. Subsequent dysregulation of folliculogenesis results in “burn out” of the stockpile of dormant follicles. Moreover, endometriomas contain much higher concentrations of free iron, reactive oxygen species (ROS) and proteolytic enzymzes which could reach adjacent ovarian tissue and lead to follicular loss and intraovarian vascular injury. Fertility preservation is a major challenge when therapeutic approaches of ovarian endometrioma are contemplated. Surgery is often proposed in cases of endometrioma more than 3 cm in size but there are two main risks associated with the surgical treatmant of endometrioma : 1. the risk of excessive surgery (removal or destruction of normal ovarian cortex together with the endometrioma pseudocapsula).Close the ovarian hilus, ovarian tissue removed with the endometrioma wall contained follicles in more than 60% of cases in a study of Muzii and some meta-analyses have revealed significant decreases in AMH after excision. 2. The risk of incomplete surgery with subsequent early recurrence. A correct surgical approach is therefore the first step to preserve oocytes and several techniques are discussed. How to preserve fertility in women at risk of premature ovatian insufficiency (POI) due to severe and/or recurrent ovarian endometriosis? Two main options are currently available : 1. COS,ovum pick-up and vitrification of oocytes is an important fertility preservation approach. Cobo et all published several series and reported high cumulative live birth rates in women less than 35 years, suggesting that patients with endometrioma should be encouraged to freeze oocytes at a younger age. 2. In some circonstances, orthotopic autotransplantation of cryopreserved ovarian cortex (which has led to more than 200 live births ) could be proposed to maintain the follicular pool.

A Federated Blockchain Approach for Fertility Preservation and Assisted Reproduction in Smart Cities

Modern life is making people infertile. Giving birth later in life is wreaking havoc on our fertility and threatening human survival. Smart cities intend to optimize the quality of life of their citizens by utilizing technology for smarter living. This research first identifies the requirements and business opportunities of using advanced technology for smarter fertility preservation and assisted reproduction in smart cities. A federated blockchain approach is proposed for the alliance of integrated commercial egg banks (ICEBs). In particular, we designed a membership fee rebate (MFR) mechanism that offers incentives for blockchain creations in the egg banking alliance. We formulated the MFR problem into a leader–followers Stackelberg game whose objectives are (1) to maximize the benefits of forming the alliance (the leader) and (2) to maximize the benefits in each ICEB (the follower). We developed an iterative scheme that utilizes mathematical programming techniques to solve the two-level, Stackelberg game problem. With a given set of parameters of the alliance and membership fee function, and the average number of blocks generated for an oocyte, the iterative scheme achieves the optimal solution for the MFR rate per block created. A numerical example demonstrates the feasibility and applicability of the proposed iterative scheme. Numerical results show that it achieves good solutions in adding a small to medium-sized new ICEB to the existing alliance. The proposed federated approach lays the foundation for developing a blockchain-based egg banking platform.

Fertility preservation techniques in cervical carcinoma.

AstractThe usefulness of this review is to highlight how a fertility preservation (FP) approach is currently feasible for patients diagnosed with uterine cervical cancer. To this regard, a fertility sparing surgery has just overcome its traditional limits, gained acceptance within the major gynecologic oncology societies thanks to the ability to identify the “ideal” candidates to this conservative treatment. On the other hand, the use of other FPs for oocyte and ovarian cortex cryopreservation is still extremely debated. In fact, the existing risk of tumor spreading during oocyte retrieval necessary for oocyte cryostorage for patients’ candidates for neo-adjuvant therapy, as well as the potential hazard of cancer cell dissemination after ovarian tissue replacement in cases of non-squamous type cervical carcinomas should not be underestimated. Therefore, in consideration of the encountered limitations and the need to ensure adequate reproductive health for young uterine cervical cancer survivors, translational research regarding the FP has progressively collected innovative insights into the employment of stemness technology. In this context, the property of ovarian stem cells obtained from the ovarian cortex to generate functional oocytes in women could represent a promising therapeutic alternative to the current procedures for a novel and safer FP approach in cancer survivors.

Innovations for Optimizing Fertility and Ovarian Functionality in Female Cancer Patients

The survival rates and quality of life of patients undergoing cancer treatments have significantly increased in recent years. However, these advanced treatments are known to exert a potentially gonadotoxic effect, impairing the female population of germ cells and, consequently, leading to ovarian failure through hormonal dysfunction and premature menopause. Nowadays, it is strongly recommended that oncologists discuss the risks of infertility and alternatives with each patient individually, recommending a consultation with a reproductive specialist as early as possible. In this context, remarkable progress has been made in assisted reproductive techniques aimed at fertility preservation for female patients. The main currently applied methods to avoid total loss of ovarian activity as a result of chemo or radiotherapy include oocyte, embryo, or ovarian tissue cryopreservation. This topic review summarizes the recent advances in these techniques, which have increased the chances of fertility preservation and family planning, as well as providing hope for cancer survivors. Oocyte cryopreservation followed by in vitro fertilization and embryo transfer are currently the recommended first-line fertility preservation approaches. However, for prepubertal individuals, the technique of ovarian tissue cryopreservation is advised; this is, moreover, the best method for efficient maintenance of the follicular reserve and allows future tissue transplantation, which not only restores fertility but also resumes natural ovarian hormonal activity. Recently, the discussion about the reestablishment of ovarian function in a defective tissue has raised compelling arguments, based on the theory about the presence of germ stem cells in the ovary. Despite the relevance of the results and the psychological benefits, the number of female patients diagnosed with cancer who are offered any method of fertility preservation is low. Multidisciplinary teams working jointly with oncologists and fertility specialists are essential for better outcomes regarding the wellness of patients who recover from cancer. Although further studies are needed to improve some of the available approaches, for now, comprehensive availability of oocyte/embryo or ovarian tissue freezing services is necessary worldwide to meet patient needs.

Outcomes within Five Years from Diagnosis in Pediatric Hodgkin Lymphoma Patients Following Contemporary Therapy

Background: Survival rates for pediatric Hodgkin lymphoma (HL) exceed 95% with contemporary therapy. To reduce long-term morbidity while maintaining excellent survival, risk-adapted therapy including tailored use of radiation has been developed. Studies of 5-year survivors and cohorts treated in the 1970s-1990s have shown pediatric HL survivors are at increased risk for treatment-related chronic health conditions, including subsequent malignancies, cardiopulmonary disease, thyroid dysfunction, and infertility. However, little is known about chronic conditions associated with contemporary therapy presenting during the first 5 years from diagnosis (early outcomes). The purpose of this study was to analyze survival and early outcomes of pediatric HL patients treated with contemporary therapy.Methods: We conducted a retrospective review of HL patients diagnosed <21 years of age and treated at our institution from 2011-2014. Three patients treated with surgery only were excluded. Three-year overall (OS) and event-free (EFS) survival were calculated with Kaplan Meier statistics using SAS 9.4. Results of screening (per Children's Oncology Group and Institutional Fertility Preservation Screening Guidelines) for targeted toxicities that developed between 2 and 5 years from diagnosis were identified and graded per CTCAE criteria. Censoring occurred at date of death, 5 years after diagnosis, or December 31, 2016. Data from the last collection point were used for prevalence calculations in cases with multiple evaluations. Descriptive statistics were calculated for the cohort.Results: We identified 62 patients (52% male; 39% non-Hispanic white; mean age at diagnosis 13.6 ± 3.6 years) with a median time since diagnosis of 3.3 years (range 0.06-5.0). Initial treatment included: 49 (79%) chemotherapy only and 13 (21%) multimodality treatment. Chemotherapy comprised ABVE-PC (56%), BEACOPP (19%), COPP/ABV (16%), or other (8%). Four patients with relapsed/refractory disease received salvage treatment including chemotherapy (n=1), multimodality therapy (n=1), or multimodality treatment including stem cell transplant (SCT; n=2). One patient remained on treatment at the time of censoring.The 3-year OS across all stages was 98.4% with an EFS of 91.9% (89.7% chemotherapy only, 100% multimodality treatment). The one mortality was due to toxic death during chemotherapy.At our institution, patients are referred to survivor clinic at 2 years from completion of therapy. Of the 44 patients eligible for survivor clinic, 35 (80%) attended during the study period, 5 (11%) were seen after the study period, 3 (7%) were lost to follow-up, and 1 (2%) was followed by the primary oncologist only. Early outcomes for patients who received exposure-based screening are listed in Table 1. No patients developed pulmonary dysfunction greater than CTCAE Grade 1, hyperthyroidism, thyroid nodules, cardiac dysfunction, or a subsequent neoplasm during the study period.Anti-mullerian hormone (AMH) below the normal range was found in all 8 evaluated females who received procarbazine-based regimens (BEACOPP or COPP/ABV; 6 received chemotherapy alone, 2 received chemotherapy with supradiaphragmatic radiation). All 8 females who received ABVE-PC with or without radiation (1 abdominal) had normal AMH levels. No males had abnormal gonadotropins.Conclusions: With the incorporation of novel agents in HL therapy, defining the baseline early outcomes of contemporary regimens is germane to future comparative medicine initiatives. This study is the first to evaluate early outcomes in pediatric HL survivors. While the cohort is young, the results indicate contemporary chemotherapy and a lower rate of radiation therapy utilization leads to excellent 3 year survival rates with minimal early toxicities. Females treated with procarbazine-based regimens are at increased risk for diminished ovarian reserve compared to those receiving ABVE-PC and should be prioritized for fertility preservation approaches prior to initiation of therapy. We plan to further expand our experience to include patients diagnosed since 2005 and evaluate the relationship between cumulative alkylating agent exposure and female gonadal dysfunction.[Chemotherapy abbreviations: (A) Adriamycin, (B) Bleomycin, (C) Cyclophosphamide, (E) Etoposide, (O) Vincristine, (P) Prednisone, (P) Procarbazine, (V) Vinblastine] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Reversing complete mechanical transzonal projections disruption during mouse in vitro follicle culture with unaltered oocyte competence†.

In vitro oocyte growth is widely studied as an alternative fertility preservation approach. Several animal models are used to generate extensive information on this complex process regulated by the constant and dynamic interaction between the oocyte and its somatic compartment throughout follicle growth and maturation. A two-dimensional attachment mouse secondary follicle culture system was used to assess the oocyte's capacity to overcome disconnection from its somatic companions at different developmental stages for final competence acquisition. To test this, complete mechanical denudation of oocytes from preantral (PA) and early antral (EA) follicles was performed. Established endpoints were the oocyte's potential to reconnect with somatic cells and the impact of connectivity disruption on mature oocyte quality. This study proves that oocytes from PA and EA cultured mouse follicles can overcome complete denudation, restoring likely functional transzonal projections with no significant differences in meiotic and developmental competence compared with those from intact cultured follicles. These novel findings constitute good premises for developing successful strategies to rescue human oocyte competence in the context of in vitro culture approaches such as nonhuman chorionic gonadotropin triggered in vitro maturation.

Matrix-free 3D culture supports human follicular development from the unilaminar to the antral stage in vitro yielding morphologically normal metaphase II oocytes.

Can group culture with stage-specific anti-Müllerian hormone (AMH) modulation support human follicular development and oocyte maturation in vitro? In the presence of FSH, AMH supplementation at the secondary-to-early antral stage followed by AMH depletion promotes the coordinated growth and function of human follicles during group culture, thereby yielding mature oocytes. Stage-specific AMH modulation promotes in-vitro development of nonhuman primate follicles. The group culture method supports nonhuman primate follicle growth from the primary to antral stage, producing developmentally competent oocytes. Ovarian tissue samples were collected from 19 patients of reproductive age (22-47 years old having menstrual cycles) who underwent oophorectomy or hysterectomy for clinical purposes. Tissue pieces were cultured in a matrix-free system for 3 weeks followed by isolation of follicles for the subsequent 6-week individual or group culture. Pieces of ovarian cortical tissue were cultured to support primordial follicle activation and early-stage follicle growth. Secondary follicles isolated from cultured tissue were then randomly assigned to two groups for individual culture: control and AMH modulation, i.e., recombinant human AMH protein supplementation during the secondary-to-early antral stage followed by the addition of neutralizing anti-human AMH antibody. Secondary follicles were also cultured in groups with the same AMH modulation. Follicle survival, growth, steroid hormone and paracrine factor production, steroidogenic protein expression, as well as oocyte maturation and morphology were assessed. Follicles grew to the secondary stage during 3 weeks of ovarian tissue culture. In-vitro-developed follicles expressed AMH and levels of secreted AMH increased (P < 0.05) in the culture media over time. Secondary follicles isolated from cultured ovarian tissue survived and grew to the antral stage during 6 weeks of individual follicle culture. In-vitro-developed antral follicles produced granulosa and theca cell-derived steroid hormones and paracrine factors, which were detectable in the culture media. Germinal vesicle oocytes obtained from cultured follicles exhibited a perinucleolar chromatin rim configuration. AMH modulation did not alter follicle survival or oocyte maturation relative to those of the control follicles. However, follicle diameters, as well as steroid hormone and paracrine factor production, increased (P < 0.05) in the AMH-modulation group compared with the control group. Secondary follicles isolated from cultured ovarian tissue formed aggregates and grew to the antral stage during 6 weeks of group culture. In-vitro-developed antral follicles expressed steroidogenic enzymes and secreted steroid hormones were detectable in the culture media. Oocytes obtained from cultured follicle aggregates with AMH-modulation progressed to the metaphase II stage after IVM, containing a normal-sized first polar body and meiotic spindle. Oocytes exhibited a typical ultrastructure. Follicles were obtained from fresh ovarian tissue of adult patients. Oocyte maturation rates were relatively low and oocytes were assessed by morphological evaluation. Owing to the lack of a control group, the beneficial effects of AMH modulation remained undetermined for the group culture in this study. Stage-specific AMH modulation supports human follicular development in the matrix-free group culture, which is consistent with previously reported AMH actions on growing follicles in nonhuman primates. Oocytes generated by in-vitro-developed follicles achieve meiotic maturation with a typical morphology and ultrastructure, which supports in-vitro follicle maturation as a potential approach for fertility preservation in women. NICHD R01HD082208 and NIH Office of the Director P51OD011092. The authors have no competing interest to declare. N/A.