Oncofertility Consortium Research Articles

Engineering the ovarian cycle using in vitro follicle culture.

Can cultured follicles model the ovarian cycle, including follicular- and luteal-phase hormone synthesis patterns and ovulation? Under gonadotrophin stimulation, murine follicles grown in an encapsulated three-dimensional system ovulate in vitro and murine and human follicle hormone synthesis mimics follicular and luteal phases expected in vivo. Studies of the human ovary and follicle function are limited by the availability of human tissue and lack of in vitro models. We developed an encapsulated in vitro follicle growth (eIVFG) culture system, which preserves 3D follicular structure. Thus far, the alginate system has supported the culture of follicles from mice, dog, rhesus macaque, baboon and human. These studies have shown that cultured follicles synthesize steroid hormones similar to those observed during the follicular phase in vivo. Cultured murine follicles were treated with human chorionic gonadotrophin (hCG) and epidermal growth factor (EGF) and either assayed for luteinization or removed from alginate beads and assayed for ovulation. Human follicles were also cultured, treated with follicle-stimulating hormone (FSH), hCG and EGF to mimic gonadotrophin changes throughout the ovarian cycle, and culture medium was assayed for hormone production. Murine and human follicles were cultured in alginate hydrogel and hormone production [17β-estradiol, progesterone, inhibin A, inhibin B, activin A and anti-Müllerian hormone (AMH)] was quantified in medium by enzyme-linked immuno assay (ELISA). Human ovarian tissue was acquired from females between 6 and 34 years of age with a cancer diagnosis. These participants were undergoing ovarian tissue cryopreservation at National Physicians Cooperative sites as part of the Oncofertility Consortium. When grown in this system, 96% of mouse follicles ovulated in response to hCG and released meiotically competent eggs. Ovulated follicles recapitulated transcriptional, morphologic and hormone synthesis patterns post-luteinizing hormone (LH/hCG). In addition to rodent follicles, individual human follicles secreted steroid and peptide hormones that mimicked the patterns of serum hormones observed during the menstrual cycle. This was a descriptive study of an in vitro model of ovulation and the ovarian hormone cycle. The ovulation studies were limited to murine tissue and further studies are needed to optimize conditions using other species. The eIVFG system reliably phenocopies the in vivo ovarian cycle and provides a new tool to study human follicle biology and the influence of cycling female hormones on other tissue systems in vitro. This work was supported by NIH U54 HD041857, NIH U54 HD076188, NIH UH2 E5022920, NIH UH3 TR001207 and F30 AG040916 (R.M.S.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

Direct actions of androgens on the survival, growth and secretion of steroids and anti-Müllerian hormone by individual macaque follicles during three-dimensional culture.

What are the direct effects of androgens on primate follicular development and function at specific stages of folliculogenesis? Androgen addition altered primate follicle survival, growth, steroid and anti-Müllerian hormone (AMH) production, and oocyte quality in vitro, in a dose- and stage-dependent manner. Androgens have local actions in the ovary, particularly in the developing follicles. It is hypothesized that androgen promotes early follicular growth, but becomes detrimental to the antral follicles in primates. In vitro follicle maturation was performed using rhesus macaques. Secondary (125-225 µm) follicles were mechanically isolated from 14 pairs of ovaries, encapsulated into alginate (0.25% w/v), and cultured for 40 days. Individual follicles were cultured in a 5% O2 environment, in alpha minimum essential medium supplemented with recombinant human FSH. Follicles were randomly assigned to experiments of steroid ablation by trilostane (TRL), testosterone (T) replacement and dihydrotestosterone (DHT) replacement. Follicle survival and growth were assessed. Follicles with diameters ≥500 μm at Week 5 were categorized as fast-grow follicles. Pregnenolone (P5), progesterone (P4), estradiol (E2) and AMH concentrations in media were measured. Meiotic maturation and fertilization of oocytes from recombinant human chorionic gonadotrophin-treated follicles were assessed at the end of culture. Compared with controls, TRL exposure reduced (P < 0.05) follicle survival, antrum formation rate and follicle diameters at Week 5. While P5 concentrations increased (P < 0.05) following TRL treatment, P4 levels decreased (P < 0.05) in fast-grow follicles at Week 5. Few healthy oocytes were retrieved from antral follicles developed in the presence of TRL. T replacement with TRL increased (P < 0.05) follicle survival and antrum formation at Week 5, compared with TRL alone, to levels comparable to controls. However, high-dose T with TRL decreased (P < 0.05) diameters of fast-grow follicles. Although P4 concentrations produced by fast-grow follicles were not altered by T in the presence of TRL, there was a dose-dependent increase (P < 0.05) in E2 levels at Week 5. High-dose T with TRL decreased (P < 0.05) AMH production by fast-grow follicles at Week 3. More healthy oocytes were retrieved from antral follicles developed in TRL+T compared with TRL alone. DHT had the similar effects to those of high-dose T, except that DHT replacement decreased (P < 0.05) E2 concentrations produced by fast-grow follicles at Week 5 regardless of TRL treatment. This study reports T and DHT actions on in vitro-developed individual primate (macaque) follicles, which are limited to the interval from the secondary to small antral stage. The above findings provide novel information on the role(s) of androgens in primate follicular development and oocyte maturation. We hypothesize that androgens promote pre-antral follicle development, but inhibit antral follicle growth and function in primates. While androgens can act positively, excess levels of androgens may have negative impacts on primate folliculogenesis. NIH U54 RR024347/RL1HD058294/PL1EB008542 (Oncofertility Consortium), NIH U54 HD071836 (SCCPIR), NIH ORWH/NICHD 2K12HD043488 (BIRCWH), NIH FIC TW/HD-00668, ONPRC 8P51OD011092. There are no conflicts of interest.

Networking necessities in the world of big science

Networking necessities in the world of big science

Vascular endothelial growth factor and angiopoietin production by primate follicles during culture is a function of growth rate, gonadotrophin exposure and oxygen milieu

What is the time course of production of vascular endothelial growth factor-A (VEGF-A), angiopoietin (ANGPT)-1 and ANGPT-2 by primate follicles during encapsulated three-dimensional culture, and what conditions affect their production? Primate follicles produce VEGF-A and ANGPT-2 in vitro, particularly after developing to the antral stage, with VEGF production influenced by FSH concentration and O(2) tension. Folliculogenesis, i.e. the development of primordial follicles into mature, antral follicles, requires the creation of a vascular network in the follicle wall via a process called angiogenesis. Angiogenic factors including VEGFs and ANGPTs have documented roles in angiogenesis. However, direct studies on the production and regulation of angiogenic factors by individual, growing follicles are limited. Ovaries (n = 9 pairs) were obtained from rhesus macaques during the early follicular phase of the menstrual cycle (cycle days 1-4). Secondary (125-225 µm) follicles were isolated mechanically, encapsulated into alginate (0.25% w/v) and cultured for 40 days. Individual follicles were cultured in a 5 or 20% O(2) environment in alpha minimum essential medium supplemented with recombinant human (h) FSH. Half of the follicles had recombinant hLH added to the media from Days 30 to 40. Follicle diameters were measured weekly. Follicles were categorized at Week 5 as no-grow (NG; <250 μm in diameter), slow-grow (SG; 251-499 μm) and fast-grow (FG; >500 μm). VEGF-A, ANGPT-1 and -2 concentrations in media were measured by ELISA. VEGF concentrations were low throughout the culture for NG follicles. SG and FG follicles had detectable VEGF concentrations at Week 2, which continued to rise throughout culture. VEGF concentrations were distinct (P < 0.05) among all three follicle categories during Weeks 4 and 5. VEGF concentrations were higher (P < 0.05) in SG follicles in the presence of high/mid-dose FSH at 5% O(2). In contrast, there were no dose-dependent differences in VEGF production for FG follicles based on FSH concentrations or O(2) tension. At Week 5, follicles that produced metaphase II oocytes, following exposure to an ovulatory hCG dose, secreted higher concentrations of VEGF than those containing germinal vesicle-intact oocytes. Media concentrations of ANGPT-1 were low throughout culture for all three follicle categories. ANGPT-2 concentrations were low throughout culture for NG follicles. In contrast, ANGPT-2 concentrations of SG and FG follicles continued to rise from Weeks 1 to 4. During Weeks 2-4, ANGPT-2 concentrations in FG follicles were significantly higher than those of SG and NG follicles (P < 0.05). This study reports VEGF-A, ANGPT-1 and -2 production by in vitro-developed individual primate (macaque) follicles, that is limited to the interval from the secondary to small antral stage. After VEGF and ANGPT-1 assays, the limited remaining samples did not allow assessment of the independent effects of gonadotrophin and O(2) on the ANGPT-2 production by cultured follicles. Findings await translation to human follicles. The above findings provide novel information on the process of primate follicle maturation. We hypothesize that a symbiotic relationship between elevated concentrations of ANGPT-2 and VEGF allows FG antral follicles to excel in follicle maturation, e.g. by promoting its vascularization. Elevated ANGPT-2 may also offer possible insight into future oocyte quality as early as Week 2, compared with Week 4 for VEGF and follicle size. The study was funded by the following grants: NIH U54 RR024347/HD058294/PL1-EB008542 (Oncofertility Consortium), NIH U54-HD018185 (SCCPIR), NIH ORWH/NICHD 2K12HD043488 (BIRCWH), NIH FIC TW/HD-00668, ONPRC 8P51OD011092. There are no conflicts of interest to declare.

Fibrin promotes development and function of macaque primary follicles during encapsulated three-dimensional culture

Does fibrin introduced into the extracellular matrix affect the growth and maturation of individual primate follicles during encapsulated three-dimensional (3D) culture? While not altering follicle survival, fibrin-alginate (FIBRIN) improves macaque primary, but not secondary, follicle development during encapsulated 3D culture in terms of growth, steroidogenesis, anti-Müllerian hormone (AMH)/vascular endothelial growth factor (VEGF) production and oocyte maturation. Efforts to grow non-human primate ovarian follicles from the secondary to the antral stage during encapsulated 3D culture have been successful. However, the growth and maturation of primary follicles in vitro has not been reported in primates, especially in chemically defined conditions. In vitro follicle maturation was investigated using the rhesus macaque (Macaca mulatta). Ovaries (n = 7 pairs) were obtained during the early follicular phase of the menstrual cycle (cycle day 1-4). Primary (80-120 µm diameter) and secondary (125-225 µm diameter) follicles were isolated mechanically, randomly assigned to experimental groups, encapsulated into alginate (0.25% w/v) or FIBRIN (25 mg/ml fibrinogen-0.25% alginate) and cultured for 13 and 5 weeks, respectively. Individual follicles were cultured in alpha minimum essential medium supplemented with FSH. Follicle survival and growth were assessed by microscopy. Follicles that reached the antral stage were treated with recombinant hCG. Metaphase II (MII) oocytes were inseminated via ICSI. Follicle morphology was evaluated by hematoxylin and eosin (H&E) staining. Immunohistochemistry was performed for cytochrome P450 family 17 subfamily A polypeptide 1 (CYP17A1) and 19 subfamily A polypeptide 1 (CYP19A1). Culture medium was analyzed for estradiol (E2) and progesterone by chemiluminescence, androstenedione (A4) by radioimmunoassay, as well as anti-Müllerian hormone (AMH) and vascular endothelial growth factor (VEGF) by enzyme-linked immunosorbent assay. A total of 105 primary and 133 secondary follicles were collected. The presence of fibrin in the alginate matrix had no effect on either primary or secondary follicle survival. Growing primary and secondary follicles formed an antrum at Weeks 9 and 3, respectively. The percentage of growing follicles was higher (P < 0.05) for primary follicles cultured in FIBRIN than alginate at Week 13. The diameters were larger for the growing secondary follicles cultured in alginate than FIBRIN at Week 5 (P < 0.05). H&E staining revealed the typical morphology for small antral follicles. CPY17A1 immunostaining was detected in theca cells, while CYP19A1 was observed in granulosa cells. E2 increased (P < 0.05) during antrum formation in growing follicles at Week 9 for primary and Week 3 for secondary follicles. AMH levels in medium from growing primary follicles increased (P < 0.05) after Week 4 with peak levels at Weeks 9-11. AMH increased (P < 0.05) in growing secondary follicles at Weeks 3-5. VEGF levels in medium were elevated (P < 0.05) in growing primary follicles at Week 9. VEGF increased (P < 0.05) in medium from growing secondary follicles at Weeks 3-5. E2, AMH and VEGF production was higher (P < 0.05) in primary follicle culture with FIBRIN than alginate alone. One primary follicle cultured in FIBRIN (1 of 5 follicles harvested) and a secondary follicle cultured in alginate alone (1 of 15 follicles harvested) yielded an MII oocyte. The fertilized oocyte from primary follicle culture arrested without cell division after fertilization, while the oocyte from secondary follicle culture cleaved and reached the morula stage. The study reports on in vitro development and function of individual macaque follicles, that is limited to the interval from the primary and secondary stage to the small antral stage. The findings await translation to human ovarian follicles. The 3D model for primate follicle development offers a unique opportunity to investigate the growth and regulation of primate primary, as well as secondary follicles, and their enclosed oocytes, as they grow to the antral stage by monitoring and manipulating factors or signaling pathways in vitro. Since primate primary follicles, in addition to secondary follicles, can be cultured to the antral stage to provide mature oocytes, they represent an additional source of pre-antral follicles for in vitro follicle maturation with the potential to provide gametes for assisted reproductive technology as an option for fertility preservation in women, including patients with cancer. This work was supported by The Oncofertility Consortium (NIH U54 RR024347-HD058294, PL1-EB008542), NIH U54-HD18185 (Eunice Kennedy Shriver Specialized Cooperative Centers Program in Reproduction and Infertility Research), NIH ORWH/NICHD 2K12HD043488 (BIRCWH), Oregon National Primate Research Center 8P51OD011092. There are no conflicts of interest.

Future Directions in Oncofertility and Fertility Preservation: A Report from the 2011 Oncofertility Consortium Conference.

Fertility impairment and loss due to cancer or its treatment is a significant survivorship consideration for many pediatric, adolescent, and young adult cancer survivors. Chemotherapeutics, radiation, and surgery can impact the future fertility of men, women, and children with cancer. The field of oncofertility, founded to ensure the reproductive future of cancer survivors, gained momentum with 5 years of funding through a 2007 National Institutes of Health Roadmap Grant for Biomedical Research. This report from working group meetings at the fifth annual Oncofertility Consortium Conference speaks to the present state of oncofertility research and clinical care, existing gaps, and future directions for the field. This summary from conference participants and leaders in the field addresses the science, clinical specialties, and academic scholarship that can guide the field as the Roadmap Grant funding comes to a close.

Morphological and functional preservation of pre-antral follicles after vitrification of macaque ovarian tissue in a closed system

What are the appropriate conditions to vitrify the macaque ovarian cortex in a large-volume, closed system that will preserve functional pre-antral follicles? The combination of glycerol, ethylene glycol (EG) and polymers with cooling in liquid nitrogen (LN2) vapor and a two-step warming procedure was able to preserve tissue and follicle morphology as well as function of a small population of secondary follicles in the macaque ovarian cortex following vitrification in a closed system. For prepubertal cancer patients or those who require immediate cancer therapy, ovarian tissue cryopreservation offers the only hope for future fertility. However, the efficacy of live birth from the transplantation of cryopreserved ovarian tissue is still unclear. In addition, live birth from cryopreserved ovarian tissue has only been demonstrated after tissue autotransplantation, which poses the risk of transmitting metastatic cancer cells back to the cancer survivor in certain cancers. Non-human primate model, n = 4, randomized, control versus treatment. End-points were collected from tissue histology, tissue culture (48 h) and isolated secondary follicle culture (6 weeks). Two vitrification solutions (VSs) containing EG + glycerol (VEG) and EG + dimethylsulfoxide (VED) were examined for vitrification, devitrification and thermodynamic properties. Once the optimal VS was determined, macaque ovarian cortical pieces (3 × 3 × 0.5 mm(3)) were divided into fresh and two vitrified groups (VEG and VED). For the vitrification groups, tissues were exposed to 1/4, 1/2 and 1× VS for 5 min/step as well as 1× VS + polymers for 1 min at 37°C, loaded into high-security straws with 1 ml of VS + polymers, heat sealed and cooled in LN2 vapor. Samples were warmed in a 40°C water bath and cryoprotective agents were diluted with 1, 0.5, 0.25 and 0 M sucrose. Tissues were fixed for histological analysis and cultured with bromodeoxyuridine (BrdU). Secondary follicles from VEG tissues were encapsulated and cultured (n = 24/treatment/animal). Follicle health, diameter and steroid [progesterone, androstenedione (A4), estradiol (E2)] production were analyzed weekly. Dense stroma and intact pre-antral follicles were observed using VS containing 27% glycerol, 27% EG and 0.8% polymers with cooling in LN2 vapor and a two-step warming. Higher cooling and warming rates led to fracturing. BrdU uptake was evident in granulosa cells of growing follicles in fresh and vitrified tissues. Secondary follicles from fresh tissues (70 ± 12%) and tissues vitrified with VEG (52 ± 2%) showed similar survival rates (all data: mean ± SEM; P > 0.05). For both groups, the initial follicle diameter was similar and increased (P < 0.05) by Week 3, but diameters in vitrified follicles were smaller (P < 0.05) by Week 6 (566 ± 27 µm) than those of the fresh follicles (757 ± 26 µm). Antrum formation rates were lower (P < 0.05) for vitrified (37 ± 6%) relative to fresh (64 ± 8%) follicles. There was no significant change in levels in culture media of E2, P4 and A4 between fresh and VEG groups at any time point during culture. Only in vitro studies are reported. Future in vivo tissue transplantation studies will be needed to confirm long-term function and fertility potential of vitrified ovarian tissues. This is the first demonstration of antral follicle development during 3D culture following ovarian tissue vitrification in a closed system using primate ovarian tissue. While diminished antrum formation and slower growth in vitro reflect residual cryodamage, continued development of ovarian tissue vitrification based on cryobiology principles using a non-human primate model will identify safe, practical and efficient protocols for eventual clinical use. Tissue function following heterotopic transplantation is currently being examined. National Institutes of Health (NIH) Oncofertility Consortium UL1 RR024926 (1RL1-HD058293, HD058295, PL1 EB008542), the Eunice Kennedy Shriver NICHD/NIH (U54 HD018185) and ONPRC 8P51OD011092-53. G.M.F. works for the company that makes the polymers used in the current study.

Pathways toward the future: points to consider for oncofertility oversight.

In September 2007, Northwestern University's Feinberg School of Medicine received a $21.1 million dollar, 5-year grant from the National Institutes of Health to fund the Oncofertility Consortium (OFC). Over the course of the grant, those engaged with the psychological, legal, social, and ethical issues arising from oncofertility provided recommendations to the OFC. The inclusion of serious, real-time consideration of ethical issues as a funded focus of the grant and the work of scholars in law, bioethics, and economics was a key part of the process of research. Now that this grant has ended, this commentary points to some of the issues that came forward during the 5 years of this project. Because of the emerging status of oncofertility, these issues are ones that need continued discussion and clarification, prompting our call for an oversight mechanism to provide guidance for how this technology should proceed. An initial draft of this commentary arose from notes taken during a small colloquium held to discuss the oversight of oncofertility following the conclusion of the grant. This colloquium occurred in the fall of 2011. Using these notes as a starting point, the draft was then sent to other researchers who had been involved with the OFC in considering the psychological, legal, social, and ethical issues related to fertility preservation for cancer patients during the course of the grant. Finally, this commentary was further framed by the authors' review of existing published and gray literature regarding issues concerning fertility preservation for cancer patients. We provide several points to consider and then offer two suggestions for an oversight mechanism for research as it continues. We assert the need not just for guidelines for the clinical practice of oncofertility, but also for oversight of the scope of this emerging technology because of its profound implications. We recognize that many long to a have a child and form a family and that, for some, cancer interrupts this path. With the conclusion of this grant, we call for the creation of a permanent oversight mechanism to thoughtfully and earnestly consider how to guide oncofertility to allow this emerging technology to be carefully considered as it develops. The circumstances in which fertility preservation should be discussed and the patients for whom fertility preservation would be most suitable are important guideline issues for people who survive cancer and for their treatment team. Oversight of the field of oncofertility would strengthen the rights of cancer patients and help protect them from abuses as well as alert health care professionals to their correlative duties to these vulnerable patients and families.

Ovarian tissue cryopreservation in a prepubertal girl after fertility impairing therapy.

e20001 Background: Advances in cancer therapy have improved the long-term survival of patients suffering from malignancies. High doses of alkylating agents and radiation are known to cause infertility in cancer survivors. Ovarian stimulation is not an option for prepubertal females, leaving experimental ovarian tissue cryopreservation (OTC) as the only option for preserving the reproductive potential of prepubescent girls. Little data is available regarding the condition of a prepubertal ovary after cancer treatment is received. This case study demonstrates the possibility of OTC post cancer treatment in a prepubertal female. Methods: A 9-year-old girl with multiply recurrent vaginal rhabdomyosarcoma presented for fertility preservation upon local recurrence of her tumor. Prior therapy included 32,200 mg/m2 of cyclophosphamide, 9,000 mg/m2 of ifosfamide and vaginal brachytherapy after ovarian transposition. A unilateral oophorectomy was performed with therapeutic partial vaginectomy, total hysterectomy and bilateral salpingectomy. A 1 cm section of the ovary was dissected and sent to pathology. The ovarian tissue planes were separated and the cortical tissue removed from the medulla. The cortical tissue was then cut into approximately 2 cm x 0.5cm x 0.1cm strips. 80% of this tissue was cryopreserved using a slow-freeze method for the patient’s future reproductive use and 20% was provided to the Oncofertility Consortium for research as per the ovarian tissue cryopreservation protocol. Results: Follicle stimulating hormone (FSH) level prior to oophorectomy was 0.5 mIU/mL (Normal 1-6 mlU/mL).The ovary was small and fibrotic. Microscopically, primordial follicular density was 1.41/mm2. No follicles of more mature stage were noted. There was no evidence of malignancy in the tissue. Conclusions: The presence of viable follicles in the ovarian tissue suggests that fertility preservation may still be possible even in patients who have received therapy that is considered to be likely to impair fertility. For this patient, who was scheduled to have an invasive surgery, adding on ovarian tissue cryopreservation presented a very minimal risk with a potential for a great benefit.

Ovarian tissue cryopreservation for fertility preservation in cancer patients: Successful establishment and feasibility of a multidisciplinary collaboration

As advancements in cancer therapies have led to dramatic improvements in long term survival, there has been increasing interest in methods to expand fertility preservation options for cancer patients. An experimental protocol for ovarian tissue cryopreservation was developed at the University of Pennsylvania for patients requiring gonadotoxic therapies. The protocol for adults was implemented at the Hospital of the University of Pennsylvania and for children at the Children's Hospital of Philadelphia in collaboration with the Oncofertility Consortium and the National Physicians Cooperative (NPC). A total of twenty-one patients (age range: 8-36 years) have cryopreserved ovarian tissue as part of this study. While patients had a variety of diagnoses and treatment exposures, 10/21 (48 %) patients suffered from hematologic disorders and 43 % were anticipating stem cell transplantation. No patients have requested that the tissue be used for clinical purposes. Ovarian tissue cryopreservation protocols can be implemented at pediatric and adult institutions through multi-disciplinary collaboration. While more research is needed to determine the safety and efficacy of ovarian tissue cryopreservation, this procedure provides hope for preserving the ability to have biological offspring to patients facing gonadotoxic therapies for a variety of medical conditions.

Improved Fertility Preservation Care for Male Patients With Cancer After Establishment of Formalized Oncofertility Program

Survival to reproductive age among men with cancer has steadily increased and yet cancer therapy and cancer itself may carry the risk of infertility. Since 2006, we have used a formalized fertility preservation program with expedited fertility care at our institution. We assessed the impact of this program by comparing the frequency of sperm cryopreservation and patient characteristics before and after its implementation. Men 18 to 55 years old diagnosed with cancer at our institution from 2002 to 2010 were included in our study. We retrospectively reviewed patient charts to identify those who were offered and subsequently used fertility preservation services before and after program formalization. From 2002 to 2010 at our institution 4,818 men 18 to 55 years old were diagnosed with cancer, of whom 411 were offered fertility preservation consultation and 249 underwent sperm cryopreservation. Since program implementation, the annual number of men receiving fertility preservation consultation and undergoing sperm cryopreservation increased by 2.4 and 2.7-fold, respectively, while the total number diagnosed with cancer remained fairly constant. Upon substratifying patients into the more conventional reproductive age range of 18 to 40 years 23.4% of all men with cancer in this group were offered consultation before formalization vs 43.3% after formalization (p <0.05). The overall sperm use and discard rates were 8.4% and 14.8%, respectively. A formalized institutional fertility preservation program significantly increased the overall number and percent of male patients with cancer who received fertility preservation consultation and pursued sperm cryopreservation. These increases were seen in men with all types of cancer and across all demographics assessed at our institution.

ES6-1: Oncofertility: Translation in Multiple Dimensions.

Abstract Cancer is now a disease with a variety of treatment options, which are leading to longer and more productive lives by survivors. Globally, there are 10 million people diagnosed with cancer. 10% of these newly diagnosed men and women are under the age of 45 years old. Infertility can be a consequence of many of the more aggressive chemo- and radiation therapies that prolong and save lives. The ability to easily preserve sperm prior to cancer treatment provides hope at the time of diagnosis and families later in life for male survivors. A notable example is Tour de France winner Lance Armstrong who has three children conceived using sperm frozen days before he underwent the massive chemo- and radiation therapy that saved his life. Unlike sperm, the female germ cell, the oocyte or egg must be retrieved surgically. Moreover, the vast majority of collected oocytes will be immature and cannot be used immediately by a woman who is ready to start a family. The overall hypothesis of the program is that effective fertility-extending options can be provided to young women undergoing life-preserving cancer treatment. The purpose of our work is to bring physicians, medical ethicists, social scientists and basic scientists together to develop new strategies for fertility preservation for female cancer survivors under the new discipline of oncofertility. At the basic science level, complex issues of ovarian function and preservation must be addressed including the problem of follicle growth and development in vitro. Our investigative group has developed a 3-dimensional system that supports follicle development, largely, we believe, because the links between the oocyte and its surrounding cells are maintained. The goal of our program and the broader Oncofertility Consortium is to explore and expand the reproductive options available to young people facing a fertility-threatening but life-preserving cancer treatment. This work is supported by NIH/NICHD Structure-Function Relationships in Reproductive Science, U54 HD041857; and, the Oncofertility Consortium, UL1DE019587 and RL1HD05829 http://oncofertility.northwestern.edu/ Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr ES6-1.

Understanding Technology and Human Interaction to Catalyze Oncofertility and Adolescent and Young Adult Oncology Research

Journal of Adolescent and Young Adult OncologyVol. 1, No. 4 PerspectiveUnderstanding Technology and Human Interaction to Catalyze Oncofertility and Adolescent and Young Adult Oncology ResearchKate E. Waimey, Angela D. Krausfeldt, Robert L. Taylor, Harlan D. Wallach, and Teresa K. Woodruff, on behalf of the Oncofertility ConsortiumKate E. WaimeyOncofertility Consortium, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.Search for more papers by this author, Angela D. KrausfeldtOncofertility Consortium, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.Search for more papers by this author, Robert L. TaylorNorthwestern University Information Technologies, Northwestern University, Evanston, Illinois.Search for more papers by this author, Harlan D. WallachNorthwestern University Information Technologies, Northwestern University, Evanston, Illinois.Search for more papers by this author, and Teresa K. Woodruff, on behalf of the Oncofertility ConsortiumOncofertility Consortium, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.Search for more papers by this authorPublished Online:28 Aug 2012https://doi.org/10.1089/jayao.2012.0001AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View articleFiguresReferencesRelatedDetailsCited byFamily-building After Breast Cancer: Considering the Effect on Adherence to Adjuvant Endocrine TherapyClinical Breast Cancer, Vol. 17, No. 3Future Directions in Oncofertility and Fertility Preservation: A Report from the 2011 Oncofertility Consortium Conference Kate E. Waimey, Francesca E. Duncan, H. Irene Su, Kristin Smith, Harlan Wallach, Kemi Jona, Christos Coutifaris, Clarisa R. Gracia, Lonnie D. Shea, Robert E. Brannigan, R. Jeffrey Chang, Mary B. Zelinski, Richard L. Stouffer, Robert L. Taylor, and Teresa K. Woodruff, on behalf of the Oncofertility Consortium7 March 2013 | Journal of Adolescent and Young Adult Oncology, Vol. 2, No. 1 Volume 1Issue 4Dec 2011 InformationCopyright 2011/2012, Mary Ann Liebert, Inc.To cite this article:Kate E. Waimey, Angela D. Krausfeldt, Robert L. Taylor, Harlan D. Wallach, and Teresa K. Woodruff, on behalf of the Oncofertility Consortium.Understanding Technology and Human Interaction to Catalyze Oncofertility and Adolescent and Young Adult Oncology Research.Journal of Adolescent and Young Adult Oncology.Dec 2011.160-163.http://doi.org/10.1089/jayao.2012.0001Published in Volume: 1 Issue 4: August 28, 2012Online Ahead of Print:July 10, 2012KeywordsoncofertilityfertilitycancertechnologycommunicationPDF download

In-vitro maturation of oocytes from ovarian tissue expands fertility preservation options

Ovarian tissue cryopreservation is a fertility preservation option for pre-menarchal girls and women who cannot delay their cancer treatment. While oocyte and embryo cryopreservation have become standard procedures in many in vitro fertilization laboratories, ovarian tissue cryopreservation remains experimental. We report our unique experience of isolating, maturing, fertilizing and cryopreserving oocytes directly from ovarian tissue in cryopreservation cases. Case series. Ovarian tissue was harvested from consented patients undergoing ovarian tissue cryopreservation. Antral follicles were aspirated and cryopreserved according to the protocol of the National Physicians Cooperative of the Oncofertility Consortium. The follicular aspirates, medullary tissue, and holding media in which the ovaries were processed were examined for oocytes. Immature oocytes were placed in standard media or in maturation media supplemented with menotropins. Maturation was assessed at 24-48 hours post-isolation. Oocytes were cryopreserved or fertilized with intracytoplasmic sperm injection. Embryos were cryopreserved 2 days post-fertilization. From 2008-2011, 8 patients, ranging in age from 17 months to 42 years underwent ovarian tissue cryopreservation at Women & Infants Hospital. Eighteen oocytes were recovered from 5 patients. Ten oocytes were cultured in standard media for 24 hours and did not mature. The remaining 8 oocytes were cultured in supplement maturation media, resulting in 1 M1 oocyte and 5 M2 oocytes (62.5% maturation). In one case, 3 M2 oocytes were fertilized resulting in 3 embryos. Oocytes isolated from ovarian tissue can be matured with in vitro maturation media, fertilized and cryopreserved. This technique offers an additional form of fertility preservation for girls and women choosing ovarian tissue cryopreservation.

Discussing Fertility Preservation Options With Patients With Cancer

IN JUNE 2006, THE AMERICAN SOCIETY OF CLINICAL ONcology published a series of recommendations on fertility preservation for patients with cancer, concluding that “To preserve the full range of options, fertility preservation approaches should be considered as early as possible during treatment planning.” These guidelines reflect the greater attention that has been given in recent years to the fertility complications that can occur as a result of cancer treatment (eg, chemotherapies and radiation). Other professional and collaborative societies, including the Oncofertility Consortium, Fertile Hope, the American Academy of Pediatrics, and the American Society for Reproductive Medicine, also have developed best-practice guidelines and educational resources to provide patients and physicians with the most recent research on fertility preservation treatments. Investigators within the field of oncofertility have examined how patients with a cancer diagnosis learn about the potential of cancer-related infertility, including how such patients weigh fertility preservation options. In understanding this information exchange and medical decision, researchers and best-practice guidelines have looked to the patient-physician relationship, particularly those relationships between patients and oncologists, as the primary opportunity for patients to become aware of potential fertility complications related to cancer treatment. However, a distressing information gap has been identified in which oncologists often do not discuss the issue of possible infertility with patients prior to initiating potentially damaging cancer treatments. Research (including studies of men and women patients and of patients diagnosed when younger than 18 years) has consistently shown that patients diagnosed with cancer do not routinely discuss cancer-related infertility with their physicians. This information gap severely limits the ability of patients with cancer to take proactive steps to help safeguard their future fertility potential prior to fertility-compromising cancer treatments (TABLE). In light of these findings, researchers have begun to examine factors that may have prevented this exchange of information between patient and oncologist. Some research has suggested that oncologists may not be aware of bestpractice guidelines, including ASCO recommendations, and that their knowledge on the topic may not be up to date. The lack of interprofessional networks with reproductive endocrinologists and fertility preservation facilities may further hinder oncologists from raising the issue. Another inhibiting factor is the nature of the relationship between patient and oncologist. For example, Rieker et al have suggested that oncologists may be more likely to discuss sperm banking with patients with whom they share a perceived similar status (eg, highly educated patients). Physicians have reported that certain patient characteristics can influence the likelihood that they would discuss fertility preservation, including a patient’s prognosis, sex, parenting status, marital status, age/pubertal status, ability to pay for such treatments, and even whether a patient is homosexual or is infected with human immunodeficiency virus. The inability of cancer survivors to become parents is an increasing concern within the oncofertility community, and, as the above research suggests, some patient groups may have less access to fertility preservation options prior to cancer treatment. More research is needed to identify additional constituents who may be missing this information, and best-practice guidelines would benefit from highlighting potentially vulnerable groups and suggesting strategies to meet their unique fertility concerns. Research is needed to examine the conditions under which this sensitive issue is effectively discussed in the clinical setting. Among patients who do discuss potential infertility, many feel their concerns are not adequately addressed. The topic of fertility preservation may be understated when it is presented along with myriad other potential adverse effects. Additionally, more effective educational materials may be required to help facilitate these conversations. Researchers also should consider how other health care professionals can be integrated into these discussions, along with an understanding of what fertility concerns may remain fol-

A New Journal to Improve Care for Adolescent and Young Adult Oncology Patients and Survivors.

A New Journal to Improve Care for Adolescent and Young Adult Oncology Patients and Survivors.

Ovarian Rigidity Regulates Follicle Function and Egg Quality.

The application of tissue-engineering principles to the study of structure-function relationships in ovarian follicle growth and maturation has led to the development of versatile in vitro culture systems in which follicles can be studied in conditions that mimic the complex 3D environment of the ovary. The use of 3D follicle culture systems has facilitated the characterization of the cell-cell interactions and intracellular signaling events that are required for follicle growth, maturation and function as well as oocyte quality. Our alginate-based 3D culture system provides an important tool for studying how mechanical forces affect cellular responses. The culture of early-stage follicles in alginate has led to the successful development of two-layer secondary follicles and mature antral follicles that contain healthy and fertilizable oocytes. In the course of our research, we observed that follicle growth was dependent upon the concentration the alginate matrix. Two alginate preparations with specific physical properties were characterized as "permissive" or "non-permissive" to follicle development and gene products identified in each condition. These studies provide evidence that the physical environment of the ovary contributes to the function of the follicle and health of the oocyte. This work was supported by the National Institutes of Health and the Eunice Kennedy Shriver National Institutes of Child Health and Human Development, grant numbers: 5U54HD041857-07 (Northwestern University Center for Reproductive Research), UL1DE019587 (The Oncofertility Consortium), and RL1HD058295 (The Oncofertility Consortium) (platform)

The Oncofertility Consortium—addressing fertility in young people with cancer

The number of young cancer survivors is increasing owing to advances in cancer therapeutics, but many face infertility as a result of their treatment. Technologies that already exist for cancer patients concerned about their future fertility include sperm banking for men and hormonal intervention followed by in vitro fertilization and embryo cryopreservation for women. However, logistical barriers to timely patient referral and coordination of care between specialties can limit patient access to all the available options. Moreover, there are few alternatives for young women and girls who cannot delay their cancer treatment, or who are unable to undergo hormonal intervention. The Oncofertility Consortium is a network of researchers, physicians and scholars who are advancing fertility preservation options for young cancer patients. Research into the societal, ethical, and legal implications is also an important part of the work performed by the Oncofertility Consortium, which is providing new perspectives on patient decision-making about how to access these emerging reproductive technologies. Experts in the fields of oncology, reproductive medicine, the social sciences, law, education, and the humanities are working together to develop next-generation reproductive interventions and promote communication between scholars, clinicians, patients, and the public to ensure that young cancer patients are equipped with the most appropriate information and options for having a family in the future.

Fertility Preservation During Treatment Is a Growing Issue for Women

A merican Society of Clinical Oncology (ASCO) guidelines recommend that oncologists refer patients of childbearing age to a reproductive endocrinologist to discuss options for preserving fertility during treatment. But two recent surveys of oncologists suggest that fewer than half of respondents routinely make this referral. Fertility preservation experts say that the referrals are now more crucial than ever because of advances in cancer research, improvements in reproductive technologies, and major social trends. “There is a perfect storm going on right now,” said Teresa Woodruff, Ph.D. , director of the Oncofertility Consortium at Northwestern University in Evanston, Ill. Patient advocacy groups have pushed to raise awareness of the importance of fertility preservation, and advances in technologies, such as ovarian transplants and the maturation of follicle cells in vitro, have met with increasing success, she said. Combined with increases in cancer survival and delayed childbearing, fertility preservation is a growing quality-of-life issue. In one survey, 47% of respondents said that they routinely refer patients to reproductive endocrinologists. Led by Gwendolyn Quinn, Ph.D., at the H. Lee Moffi tt Cancer Center in Tampa, Fla., the analysis was based on responses from 516 physicians (a 32% response rate) who work in both academic settings and private practice. Male physicians were less likely to say they routinely referred (41% vs 58%). And among oncologists whose patients often ask about the effects of cancer treatment on their fertility, 64% routinely refer patients. Among those who said their patients seldom ask about the effects of treatment on fertility, 42% said they routinely refer. “Our results surprised me; I thought that number was too high,” said Quinn, whose work was published in the Journal of Clinical Oncology in December. Making the referral can be diffi cult and requires a working relationship between the oncologist and the reproductive endocrinologist, which doesn’t always exist, even in National Cancer Institute – designated cancer centers, she said. The other survey, led by Eric Forman, M.D., a resident at Duke University Medical Center, Durham, N.C., focused on female patients. It found that 39% of oncologists surveyed routinely refer women to fertility specialists. Forman’s work included responses from 249 physicians (a 15% response rate) from the top 25 cancer hospitals as ranked by U.S. News and World Report and was published in Fertility and Sterility in November. Quinn said that her survey was modeled after earlier work on sperm banking by Leslie Schover, Ph.D., at the University of Texas M. D. Anderson Cancer Center in Houston. Schover found that 91% of physicians who responded to a survey said that sperm banking should be offered to all men who may become infertile as the result of cancer treatment. But 48% of respondents either never brought up the topic or mentioned it to less than one-quarter of eligible men.

Consistency in Insurance Coverage for Iatrogenic Conditions Resulting From Cancer Treatment Including Fertility Preservation

Insurance companies generally cover treatment for iatrogenic conditions that result from cancer treatment, including treatment for conditions that may be considered elective when “naturally” occurring (note that in this article, I am using the word “iatrogenic” to refer only to nonnegligent treatment-induced conditions). One notable exception is fertility preservation for iatrogenic infertility. In this brief article, I argue that for insurance companies to maintain consistency, they should cover fertility preservation treatment for female patients with cancer because it does not differ significantly from other treatments for iatrogenic conditions they currently cover for women, such as breast reconstruction after mastectomy and wigs for alopecia. (Although my focus in this article in on female fertility preservation, one could presumably make a similar argument that male fertility preservation should be covered by insurance.) One reason many insurance companies refuse to cover fertility preservation treatments, and infertility treatments more generally, is that they are often viewed as elective procedures, not medically necessary ones. When it comes to iatrogenic infertility, however, the controversy over whether fertility preservation is a medically necessary treatment should be moot because other so-called elective procedures are covered when they are iatrogenic, even if they are not covered when naturally occurring. Because my focus is on iatrogenic conditions—many of which, as I will discuss in this article, are generally not considered medical conditions when they are not iatrogenic—I put aside the debate about whether infertility should be classified as a “real” disease. One example of an iatrogenic condition typically covered by insurance is breast reconstruction after lumpectomy or mastectomy. Although having only one breast is rarely, and perhaps never, a naturally occurring condition, naturally occurring breast asymmetry is quite common. Most would not classify breast asymmetry as a medical problem that insurance should cover. However, when breast asymmetry results from a lumpectomy, surgery to achieve symmetry is usually covered regardless of whether the patient had symmetric breasts beforehand. This discrepancy in coverage between iatrogenic and naturally occurring breast asymmetry can be explained, at least in part, by looking at the harm principle through the lens of responsibility: because members of the medical profession caused the harm—something they are not supposed to do—the medical profession as a whole must take responsibility for mitigating the harm. (Another factor is the static understanding of the body that dominates medicine and science. Briefly, this is the idea that the body stays the same over time and disease is aberration that must be eradicated to restore the body to its natural and “normal” state. See Eckenwiler for a discussion of how this static understanding of the body has lead to women’s exclusion from clinical research trials.) Certain acts and laws were passed to institutionalize the medical realm’s responsibility for iatrogenic harms. For instance, the Women’s Health and Cancer Rights Act, which was passed in 1998, mandates that if health insurance companies cover the costs of mastectomy for cancer patients, then they must also cover the costs of breast reconstruction for mastectomy patients. Health care providers and insurance companies sometimes assume responsibility for iatrogenic harms by the way they code for billing. For example, breast reconstruction surgery after a mastectomy is coded as cancer treatment rather than under elective treatment. By allowing treatments for iatrogenic conditions to be subsumed into the larger category of disease treatment, insurance companies are tacitly accepting financial responsibility to cover these treatments. In addition to breast reconstruction surgery, there are other treatments that may not be covered by insurance when the disease is naturally occurring (in part because treatment is not seen as medically necessary), but are covered when iatrogenic; for example, wigs after cancer treatment are usually covered, whereas wigs for thinning hair or cosmetic reasons often are not. The same pattern of insurance coverage exists in the fertility/ infertility realm. Many insurance companies do not cover infertility or fertility preservation treatments for some of the following reasons: in/fertility treatments are experimental, they do not treat an underlying disease but rather produce a desired outcome (ie, a child), and they are an elective procedure, not a medical one. An exception to the lack of coverage is iatrogenic infertility. Although no formal studies have been done, there is anecdotal evidence that insurance companies will sometimes take financial responsibility for iatrogenic infertility. At the Northwestern University branch of the Oncofertility Consortium (www.oncofertility.northwestern.edu), a national, interdisciplinary initiative designed to explore the reproductive options for patients diagnosed with cancer or other serious diseases, female patients with cancer have the option to chose a fertility preservation method— embryo, egg, or ovarian tissue cryopreservation—before beginning cancer treatment. These fertility preservation treatments have been billed under a primary diagnosis of cancer and a secondary diagnosis JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 28 NUMBER 8 MARCH 1