Ovarian Failure Research Articles

O-088 Effect of low, medium and high risk chemotherapy on the ovarian reserve in children: results of the interim analysis of a prospective multicentric trial (CHANCE)

Abstract Study question How does the ovarian reserve of children diagnosed with cancer recover after chemotherapy that is considered as low or medium risk of future infertility? Summary answer The study showed no evidence that low and medium risk treatments impact the future ovarian function in children. What is known already Acute premature ovarian insufficiency (POI) post childhood cancer treatment is estimated around 6%, varying with treatment type and age at diagnosis. Long-term risk of treatment-related infertility is challenging to assess in this population as most of the data comes from retrospective trials involving adult cohorts of childhood cancer survivors. Benefit of fertility preservation at diagnosis is evident for high risk patients. However, for low or medium risk patients, the lack of knowledge on treatment effect on the ovarian reserve and on marker reliability in children complicates counselling. Study design, size, duration CHANCE is a prospective multicentric observational trial enrolling patients aged between 3 and 14 years at cancer diagnosis. We evaluated factors associated with the risk of future infertility such as hormonal levels, puberty and menstruation, and investigated the fertility preservation strategy. Parameters were assessed at screening, one year post-screening, end of the treatment, and during follow-up (FU) until 18 years of age. An interim analysis was planned considering the duration to reach the final endpoint. Participants/materials, setting, methods Between 2014 and 2023, 144 patients were enrolled. Patients were categorized in 3 groups by cumulative equivalent dose of cyclophosphamide (CED) received: <4000mg/m2 (low), 4000 to 8000mg/m2 (medium) and >8000 mg/m2 (high). Ninety-four patients with at least one year post-treatment follow-up were included in this analysis. Mean age at diagnosis was 8.4±4 years and 38% were prepubertal, with no difference between groups (p = 0.06 and 0.26, respectively). The median time of follow-up was 32.7 months. Main results and the role of chance Patients were categorized as low (n = 58), medium (n = 18) and high (n = 18) risk based on CED. Sarcoma were most frequent in high risk, while leukemia in low/medium risk groups (p < 0.0001). Fertility preservation was performed in 55.6%, 27.8% and 8.6% in high, medium and low risk group, respectively (p < 0.0001). The majority of them underwent ovarian tissue cryopreservation. POI was defined as induced puberty and/or FSH>25IU/l during FU. POI occurred in 10 out of 18 (55.6%) patients in high risk group, while in no patient in the low/medium risk groups except 1 with disease recurrence. POI was associated with high doses of chemotherapy (p < 0.0001) and increased age (p < 0.007). AMH levels significantly decreased in high and medium risk group during treatment. Recovery occurs in medium but not high risk groups (p = 0.84 and 0.02 between screening and values at 1-2 years and >3 years of FU using repeated measures analysis). Low AMH values (<0.5ng/ml) was observed at 2 years of FU in 14.3%, 28.6% and 69.2% of the patients in low, medium and high risk groups respectively. The impact of treatment, particularly in medium risk group, needs confirmation as around 35% of the patients were still prepubertal at the time of the analysis. Limitations, reasons for caution This is an interim analysis of a prospective trial designed to include 275 patients. Data should be cautiously interpreted due to not reaching the calculated optimal power population. Wider implications of the findings Our data confirmed that fertility preservation should be offered to all children and adolescent treated with high risk regimen. We did not provide evidence supporting its benefit for low/medium risk pre-pubertal children. For post-pubertal medium risk patients, fertility preservation may be considered during the FU based on patient decision. Trial registration number NCT02595255

P-733 Discrepancies between self-perceived and diagnosed cases of perimenopause - analysis of health data from 13,932 UK-based women

Abstract Study question Do individuals who self-reported “suspected perimenopause” in health assessments meet the diagnostic criteria for perimenopause, menopause or premature ovarian insufficiency (POI) based on clinical guidance? Summary answer Users were likely to experience more mood symptoms, compared to vasomotor symptoms or cycle irregularities and only 5.5% met the NICE perimenopause diagnostic criteria. What is known already An estimated 13 million individuals are currently experiencing perimenopause or menopause in the United Kingdom. The recent surge in media attention, while helpful in fostering awareness, may also carry the unintended consequence of leading individuals to self-identify with perimenopause without a clear understanding, due to the historical gap in comprehensive education on the subject. This study aims to investigate the prevalent symptoms reported by individuals who self-reported suspected perimenopause in a health assessment and assess whether these individuals meet diagnostic criteria for perimenopause, menopause or premature ovarian insufficiency (POI) based on clinical guidance. Study design, size, duration In this retrospective observational study, data was analysed from 13,932 users approaching women’s health testing services, citing “I think I am perimenopausal” as their reason for using the service between August 2022 and January 2024. We analysed data on age, menstrual cycle characteristics and symptoms self-reported via an online health assessment. A sub group analysis, done on 891 users aged 21-58, also analysed serum follicle-stimulating hormone (FSH) measured via immunoassay using a capillary blood sample. Participants/materials, setting, methods Among the 13,932 users, 8,101 (58.1%) were <40 years old, 4,947 (35.5%) were aged 40-45 and 884 (6.3%) were >45 years old. The dataset was compared with NICE criteria, stating that perimenopause/menopause is diagnosed in women >45 experiencing cycle irregularities and vasomotor symptoms, with the addition of two FSH measurements >30 IU/L to diagnose perimenopause/menopause or POI in those <45 or < 40 respectively. Main results and the role of chance The most frequently reported symptoms were fatigue 10,434 (74.9%), anxiety 8,526 (61.2%), irritability 8,361 (60.0%), depression 8,280 (59.4%), brain fog 7,898 (56.7%), headaches 6,483 (46.5%), hot flushes 5,289 (38.0%), hair thinning/loss 5,224 (37.5%), feeling cold often 4,999 (35.9%), night sweats 4,939 (35.5%), vaginal dryness 3,595 (25.8%) and pain during intercourse 3,525 (25.3%). In terms of menstrual cycle regularity, 7,515 (53.9%) had regular periods, 4243 (30.5%) selected irregular periods, 956 (6.9%) selected ‘I’m not currently/no longer getting periods’, 1195 (8.6%) selected ‘I don’t get periods because of contraception/HRT’. The subgroup analysis found that among users <40 years old, 1.2% (n = 6/524) would potentially fit the POI diagnostic criteria based on a single FSH measurement >30 IU/L, vasomotor symptoms and cycle regularity. Based on the same criteria, 2.9% (n = 8/279) of users aged 40-45 would be diagnosed with perimenopause/menopause and 39.8%(n = 35/88 ) of users >45 years old met the perimenopause/menopause criteria. However, of the total, only 5.5% (n = 49/891) of individuals who self-identified as perimenopausal met the NICE diagnostic criteria. Limitations, reasons for caution The online health assessment collects self-reported data, potentially influencing results. Subgroup analysis included individuals with at least 1 FSH test, however, guidelines advise 2 consecutive high FSH levels for perimenopause diagnosis, possibly reducing the number eligible for a potential perimenopause diagnosis. Wider implications of the findings Our data suggests users are most likely to experience mood symptoms, compared to vasomotor symptoms or cycle irregularities, which are required for a diagnosis. This spotlights the importance of including patient voices in clinical guidelines and the need for improved public awareness regarding perimenopause to promote healthcare-seeking behaviour for symptoms. Trial registration number NA

P-600 Development of human ovarian spheroids as an innovating 3D model to study female hormone-related disorders

Abstract Study question Can spheroids of theca and granulosa cells serve as a new model to explore the cellular and molecular mechanisms involved in female hormone-related disorders? Summary answer Layered theca-granulosa cell spheroids can be successfully assembled with preserved cellular viability, β-estradiol production, and significant upregulation of extracellular matrix (ECM) components. What is known already Spheroid models can revolutionize reproductive biology research, faithfully replicating the ovarian microenvironment for insights into hormonal regulation, cell-cell interactions, and pathologies like polycystic ovarian syndrome (PCOS) and premature ovarian insufficiency (POI). These models can replicate the spatial configuration of the theca cells (TCs) and granulosa cells (GCs), which are the primary components of the follicle’s somatic compartment. Studies using rodent spheroids demonstrate improved estradiol and progesterone secretion, suggesting potential applicability. Though challenging to obtain, recent studies have successfully derived TCs through the differentiation of stromal cells (SCs), introducing new possibilities for spheroid reproductive research in the context of human models. Study design, size, duration The study included GCs from around 15 IVF patients and SCs from postmortem ovaries of 3 postmenopausal women were used to be differentiated into TCs. Participants/materials, setting, methods TCs and GCs were used to construct three spheroid types: layered theca-collagen-granulosa (TCG), layered theca-granulosa (TG), and non-layered. In TCG, GCs formed granulosa-spheroids, which were coated with collagen-I and combined with TCs. TG-spheroids were produced similarly without the collagen layer. Non-layered spheroids were assembled using isolated GCs and TCs. All embedded in PEGylated fibrin hydrogel. Media estradiol synthesis was measured via enzyme-linked immune assay (ELISA), and immunofluorescence was employed to characterize cellular functionality and ECM. Main results and the role of chance In GCs, positive expressions for AMHR, CYP19A1, and FHSR were observed, while following differentiation, TCs exhibited positivity for CYP17A1, LHR and CD13. A notable distinction emerged when comparing TCs within the spheroids to those in 2D cultures, as the former demonstrated an improvement in longevity. Layered TG-spheroids exhibited significant increases in collagen-IV, EMILIN-1, and collagen type I compared to G-spheroids. Interestingly, TCG-spheroids exhibited a distinct decrease in collagen type IV. Across all spheroid types, collagen type VI and laminin were notably absent from their ECM. Moreover, all spheroids had a significant increase in β-estradiol production. Non-layered spheroids showed a significant viability decrease inside the PEGylated fibrin over 30 days, in contrast to the sustained viability observed in the layered TG- and TCG-spheroids. Limitations, reasons for caution Utilizing primary cells, particularly specific patient-derived cells, poses a limitation due to their short availability, which could impact the study’s size. Wider implications of the findings Theca-granulosa spheroids deepen our understanding of reproductive health, offering insights into conditions such as POI and menopausal symptoms. By investigating the nuanced endocrine interplay, this 3D model paves the way for new toxicity studies, provides insights into PCOS, and hints at potential applications in hormone replacement therapy (HRT). Trial registration number Not applicable

P-351 Reproductive outcomes in a cohort of lymphoma patients

Abstract Study question What are the reproductive outcomes in women with malignant lymphoma Hodgkins (HD) and non-Hodgkins (NH) from a single, experienced center? Summary answer 74 children were born to 43 women (28 with HD, 15 with NH) giving a live birth rate (LBR) of 81% and 72%, respectively. What is known already The risk of premature ovarian insufficiency (POI) after HD and NH is related to female age, type and dose of gonadotoxic treatment. Where ABVD regimens in HD patients and CHOEP regimens in most young NH patients, rarely results in POI and reduced fertility, treatment with BEACOPP or BEAM and stem cell transplantation seems to be associated with a much higher risk of ovarian failure. However, studies are heterogeneous and there is still a need for studies with structural follow up on repeated measurements of ovarian function markers in relation to clinical outcomes. Study design, size, duration This cohort study was conducted as a single center study at the fertility clinic in a large public Danish university hospital. Data was collected retrospectively from medical records from 1999 to 2020 and prospectively from 2020 to 2023. We included all female patients with HD (n = 63) and NH (n = 32), who were referred to our clinic for fertility preservation between 1999 and 2022. End of follow up was December 31st, 2023. Participants/materials, setting, methods Age at referral ranged from 14 to 33 years. Information about diagnoses, gonadotoxic treatment, gynecologic (including endocrine parameters) and obstetric history was retrieved from medical records. Permission to obtain retrospective data from 1999 to 2020 was given by the Danish Patient Safety Authorities (jrn 3-3013-2790/1) and prospective data collection was given by informed consent from the patients from 2020 and onwards. Main results and the role of chance 33% of patients with HD had ABVD only, and the remaining BEACOPP or other high-dose alkylating regimens. 72% of patients with NH had CHOEP, and the rest other high-dose alkylating regimens. 78/95 women had fertility preservation. Of these, 95% had ovarian tissue cryopreservation (OTC), 5% had IVF with vitrification of oocytes or embryos. Following chemotherapy 33 women (52%) with HD and 18 (56%) with NH became pregnant. Of these, 28 women with HD had 51 deliveries, and 15 with NH had 23 deliveries. The LBR was 0,81 for HD and 0,72 for NH. For HD patients, 54% of the deliveries were achieved by women who had ABVD compared to about 40% after other high-dose alkylating regimens. For NH patients, 73% of deliveries were achieved by women who had CHOEP compared to 13% after other high-dose alkylating regimens. Most pregnancies were conceived spontaneously. A total of 15/74 women had ovarian tissue transplantation (OTT). Of these, 7 women with HD became pregnant resulting in 4 deliveries, and 4 women with NH became pregnant resulting in 2 deliveries giving an overall pregnancy rate of 73% in this group of women and a LBR of 40%. Limitations, reasons for caution This study is based on information from medical records in public Danish hospitals, containing information on all deliveries. Pregnancies and deliveries outside of Denmark might therefore not be included. Furthermore, for some women the follow-up period was only one year, which could underestimate the fertility in this group of patients. Wider implications of the findings This study shows a reassuringly high rate of spontaneous pregnancies in female survivors of malignant lymphomas. Only 20% of the women have so far used their tissue stored before chemotherapy. Current results might question whether we overtreat our lymphoma patients by offering OTC to the majority Trial registration number not applicable

P-793 New approaches for treating diminished ovarian reserve: MSC-derived extracellular vesicles and autologous platelet rich plasma

Abstract Study question Does intraovarian injection of MSC-Derived Extracellular Vesicles (EVs) and autologous platelet rich plasma (PRP) improves the outcome of IVF in women with Diminished Ovarian reserve? Summary answer EVs and PRP therapies increse Antral follicle count (AFC), lower FSH level and result in higher amount of mature oocytes and blastocysts What is known already Diminished ovarian reserve (DOR) and premature ovarian insufficiency (POI) are significant impediments to the success of in vitro fertilization (IVF). Current strategies for ovarian stimulation primarily affects only the growth of antral follicles. Even in scenarios where ovarian ovulatory function is compromised, a reservoir of dormant follicles persists, which could potentially be activated by stem cells. Mesenchymal stem cells (MSCs), owing to their multipotent differentiation capabilities and paracrine signaling properties, have emerged as leading candidates for innovative therapeutic approaches. Recent scientific inquiries have highlighted the paracrine impact of EVs secreted by stem cells, underscoring their prospective therapeutic relevance. Study design, size, duration This prospective interventional study was conducted at the V.I. Kulakov Scientific Research Center for Obstetrics, Gynecology, and Perinatology in Russia. It involved 60 infertile female participants aged 20 to 38 years, each with DOR and a history of at least two unsuccessful IVF cycles. These participants were enrolled in the study during their subsequent IVF cycle. Prior to inclusion, all patients provided written informed consent. Participants/materials, setting, methods Patients in group 1 (n = 30) received treatment with exosomes derived from human umbilical cord mesenchymal stem cells (HUC-MSCs-Exos) prior to initiating their in vitro fertilization (IVF) cycle. In contrast, participants in group 2 (n = 30) underwent intraovarian therapy with autologous platelet-rich plasma (PRP) in preparation for their IVF cycle. The comparative analysis encompassed antral follicle count (AFC), anti-Müllerian hormone (AMH) levels, follicle-stimulating hormone (FSH) levels, ovarian stimulation outcomes, and the primary characteristics of oogenesis and embryogenesis. Main results and the role of chance After transplantation of EVs and PRP the ovarian function-related hormone levels and the AFC returned to nearly normal parameteres.Meanwhile, after exosomal treatment the improvement in reproductive outcomes was more significant. FSH concentration was significantly different before and 30 days after the procedure in both groups. In group 1 FSH values were less than the initial data In 95% of cases, in group 2 – in 72% of cases. AMH levels did not change significantly in both groups. The AFC increased in group 1 compared to group 2. All Patients underwent an IVF antagonist cycle after 3 months from the treatment. The number of obtained oocytes in group 1 ranged from 2 to 8, MII from 1 to 6; in group 2: from 0-5, MII – 0-5. The number of blastocysts in group 1 ranged from 1 to 5, in group 2 – from 0 to 3. In group 1, pregnancy occurred in 9 patients (30%): 1 women ( 3,3%) conceived spontaneously in the cycle of procedures, 8 (26,7%) attempted IVF, in group 2 pregnancy occurred in 4 patients (13,3%): 4 attempted IVF. EVs and PRP injections improve outcomes of IVF results in women with low ovarian reserve. Limitations, reasons for caution Limitations may include the fact that the study is single-center and has a rather small amount of patients enrolled in the study. Fundamental approaches to further research in this area are also required to better understand the obtained results. Wider implications of the findings EVs and PRP therapies appear to enhance ovarian reserve metrics and the success rates of IVF programs in patients with DOR. The clinical implementation of these interventions may offer improved reproductive prospects for patients whose sole option was previously oocyte donation. Trial registration number 121040600410-7

P-710 Comparison of cumulative delivery rates per aspiration cycle in patients fulfilling Bologna and POSEIDON criteria

Abstract Study question Do cumulative delivery rates (CDRs) per aspiration cycle differ in low-prognosis patients according to the Bologna and POSEIDON (Patient-Oriented-Strategies-Encompassing IndividualizeD-Oocyte-Number) classification criteria? Summary answer The CDR was 8.7% in Bologna and 22.7% in POSEIDON. The odds of achieving live-birth were ∼3-fold higher in POSEIDON than in the Bologna group. What is known already Bologna criteria were generated to address the heterogeneity in the definition of the Poor Ovarian Response (POR). However, patients meeting these criteria may not be homogeneous in terms of the number of oocytes retrieved and live birth rate. Subsequently, as a more inclusive classification, the POSEIDON criteria were proposed to stratify low-prognosis patients according to female age and suboptimal response to ovarian stimulation. To our knowledge, there is a paucity of data comparing CDRs between the POSEIDON and Bologna groups. Study design, size, duration Retrospective cohort study including 1250 patients undergoing their first ovarian egg retrieval cycle at Hacettepe University IVF Center in Ankara between 2017 and 2023. Exclusion criteria were female age >45 years old, body mass index >35 kg/m2, azoospermia, pre-implantation genetic testing (PGT) for structural rearrangement or monogenic disorders, fertility preservation cycles, dual-stimulation cycles, premature ovarian insufficiency, and hypogonadotropic hypogonadism. The primary outcome measured was CDR defined by ICMART (International Committee for Monitoring Assisted Reproductive Technologies). Participants/materials, setting, methods The Bologna patients have at least two of the following three features; female-age ≥40 or prior ovarian surgery, AMH<1.1ng/ml or antral-follicle-count (AFC)<5-7, and obtaining ≤3 oocytes in prior conventional stimulation. POSEIDON patients were categorized into four groups; younger(<35) and older(≥35) women with AMH≥1.2/AFC≥5 experiencing an unexpected poor(<4 oocytes-retrieved) or suboptimal(4–9 oocytes-retrieved) response, along with respective younger and older counterparts with AMH<1.1/AFC<5. Non-POSEIDON patients were those with AMH≥1.2/AFC≥5 and >9 oocytes-retrieved. General-Estimated-Equation(GEE) analysis was employed. Main results and the role of chance Out of 1250 patients, 79.6% were classified as POSEIDON, with sub-groups as follows: 5.28% Group 1a, 23.4% Group 1b, 3.6% Group 2a, 10.1% Group 2b, 14.64% Group 3, and 22.48% Group 4. The number of patients meeting Bologna criteria was 17.4% (218). For POSEIDON patients, median[IQR] values were: age 34 [30-38], AMH 1.33 [0.65-2.69], oocytes retrieved 4 [2-6], and embryo transfers 1 [1-2]. For non-POSEIDON patients: age 30 [27-33], AMH 4.63 [2.93-7.07], oocytes retrieved 13 [11-15], and embryo transfers 2 [1-3]. In Bologna patients: age 40 [36-42], AMH 0.46 [0.20-0.76], oocytes retrieved 2 [1-3], and embryo transfers 1 [0-1]. For non-Bologna patients: age 31 [28-36], AMH 2.30 [1.17-4.29], oocytes retrieved 6 [3-9], and embryo transfers 1 [1-2]. CDR for non-POSEIDON: 49.8%; Group 1a, 24.2%; Group 1b, 34.1%; Group 2a, 15.6%; Group 2b, 27.6%; Group 3, 20.8%; Group 4, 10.7%. In clustered-GEE analysis, using non-POSEIDON as reference, odds ratios (ORs) for live birth were: Group 1a OR 0.32 [0.18 - 0.60]; Group 1b OR 0.52 [0.37-0.74]; Group 2a OR 0.19 [0.08-0.43]; Group 2b OR 0.38 [0.24-0.61]; Group 3 OR 0.26 [0.17-0.41]; Group 4 OR 0.12 [0.08-0.19]. CDR for the Bologna group: 8.7% (OR: 0.10, 0.06-0.16); non-Bologna patients: 32.4% [OR: 0.48, 0.39-0.60]. Limitations, reasons for caution The limitations of the study encompass its retrospective cohort design and the variability introduced by different individuals conducting antral follicle counts using 2D ultrasonography. Wider implications of the findings Significant CDR differences exist between Bologna and Poseidon groups. POSEIDON patients show ∼2-fold lower CDR than normal responders, and Bologna patients exhibit ∼4-fold lower CDR than non-Bologna patients. Poseidon criteria cover a broader range of low-prognosis patients, while meeting Bologna criteria indicates a narrower, more specific group with poorer outcomes. Trial registration number N/A

P-665 High FSH level impairs VEGF secretion by thawed human ovarian tissue

Abstract Study question How does a high FSH level as related to POI (premature ovarian insufficiency) affect VEGF secretion by thawed human ovarian tissue? Summary answer After thawing, the high FSH concentration of 175mIU/mL (10ng/mL) significantly decreased VEGF secretion by human ovarian tissue by 25.6%. 17.5mIU/mL did not change VEGF secretion. What is known already Cryopreservation of ovarian cortical tissue has become an important method in fertility preservation. However, 70% of the follicles do not survive the reimplantation process due to an insufficient blood supply and oxidative stress. Human ovarian tissue secretes angiogenic factors, including VEGF, spontaneously. Its regulation by FSH is not known although 50% of the reimplantation patients show increased FSH levels (>25mIU/mL) due to POI. Study design, size, duration Provided a signed consent, biopsy punches of ovarian cortical tissue from 8 patients undergoing fertility preservation were studied. Slow freezing and thawing was applied as in the intern routine instructions. Participants/materials, setting, methods Human ovarian cortical tissue was cultured in full medium at 37 °C for 48h after thawing in presence or absence of 17.5mIU/mL (1ng/mL) or 175mIU/mL (10ng/mL) recombinant human FSH. VEGF-A secretion was measured by ELISA. The expression of VEGF-A, HIF-1α and FSHR was assessed by immunohistofluorescence per follicle. The effect of FSH was assessed by one-way-ANOVA with Tukey’s post test. The effect of culture or follicular maturation stage was analyzed by t test. Main results and the role of chance After thawing, VEGF secretion recovers and rises over time. The addition of 175mIU/mL FSH significantly impaired VEGF-A expression compared to untreated ovarian tissue (p = 0.016). The analysis of 481 follicles showed similar results of FSH affecting VEGF-A expression by immunostaining. In particular, primordial follicles expressed significantly less VEGF-A compared to growing follicles (primary+secondary; p < 0.0001). 48h tissue culture significantly increased VEGF-A expression in primordial follicles (p = 0.0041). The addition of the high FSH level significantly decreased VEGF-A expression in growing follicles (p = 0.0005). Limitations, reasons for caution Although VEGF-A is a key factor in angiogenesis, more factors are known to affect angiogenesis. The direct effect on angiogenesis should be evaluated. Moreover, the conditions in tissue culture may not represent those after reimplantation. Wider implications of the findings High FSH levels, as seen in patients with POI, might impair ovarian VEGF expression and angiogenesis. Hormone replacement therapy (HRT) might be endorsed before and during ovarian tissue reimplantation. More clinical and biological data are required to understand the regulators of angiogenesis after ovarian tissue reimplantation adequately. Trial registration number not applicable

P-522 Impact of TGFß/BMP/SMAD Pathway on Premature Ovarian Insuffiency (POI)

Abstract Study question Is TGFß/BMP/SMAD pathway altered in women with POI and can results be detected from peripheral blood samples? Summary answer The TGFß/BMP/SMAD pathway mRNA-expression-alterations are detectable in leukocytes of women with Premature Ovarian Insufficiency (POI) paving the way to use it as predictive tool. What is known already A proper ovarian function relies on a complex system of signalling molecules including several BMP/TGFß-superfamily-members expressed in the ovary at different stages of folliculogenesis acting via two types of Serine/Threonine Kinase receptors. The downstream located SMAD proteins are classified into three subclasses according to their function as activated R-SMADs1,2,3,4,9, common-partner SMAD4 or inhibitory SMADs6,7. Mutations in BMPR2 and its ligands have been shown to be related to POI. Recently neurologic studies demonstrated that FMRP(Fragile-X-Mental-Retardation-1-Protein) represses BMPR2 and its gene FMR1(Fragile X Mental-Retardation-1) is one major regulator of follicular development and the most frequent genetic cause of POI if premutated. Study design, size, duration RT-q-PCR was performed to measure the mRNA-levels of SMAD 1,3,4,5, BMPR2 and FMR1. cDNA was synthesized using RNA obtained from leucocytes of patients with POI and of the control group with a normal ovarian reserve. 163 patients diagnosed with POI and 51 women in the control group were recruited between 2008 and 2022 at Heidelberg University’s Women’s Hospital. Participants/materials, setting, methods Blood samples were drawn from every participant to extract leucocyte-RNA and synthesize non-specific cDNA. RT-q-PCR was performed with TaqMan reagents to quantify relative mRNA-expression levels of SMAD 1,3,4, 5, BMPR2 and FMR1. Statistical analysis was performed with Microsoft Excel and GraphPad Prism 10 using the 2–ΔΔCt method and Mann-Whitney-Test. Statistical significance was set to p = 0.05. Main results and the role of chance In our investigation, we observed a consistent and statistically significant decrease in the expression levels of all tested SMADs—SMAD1, SMAD3, SMAD4, and SMAD5—in leukocytes of women diagnosed with POI compared to unaffected controls. The p-values amounted to p < 0.0001 for SMAD1, p = 0.0340 for SMAD3, p < 0.0001 for SMAD4, and p = 0.0076 for SMAD5. However, we did not identify notable differences in the expression levels of FMR1 and BMPR2 between the two groups. These results suggest an alteration in the regulation of the activated downstream elements SMAD 1, 3, and 5 and their common partner SMAD4 in women with POI, emphasizing its potential role as a contributing factor to diminished ovarian function. These effects seem to be independent of BMPR2 and FMR1 and regulated by other receptors and or ligands. Limitations, reasons for caution Our data are limited to mRNA-levels. So further experiments including protein-level and their phosphorylation-status are needed to receive an overall assessment of its impact on ovarian damage. It’s worth noting that the study is concentrated on leukocytes as potential diagnostic tool and results should be cross-checked in ovarian-tissue and cells. Wider implications of the findings The identified alteration in TGFß/BMP/SMAD pathway gene expression in women with POI suggest a role in ovarian damage. Lower expression levels in the aforementioned mRNAs could serve as a potential predictive biomarker for POI risks and putatively used in consultations of women prior to fertility treatment and/or preservation. Trial registration number not applicable

P-709 A retrospective cohort study of the stability of ovarian reserve in women with Turner Syndrome (TS) and spontaneous menstruation

Abstract Study question What is the stability of ovarian reserve, as measured by anti-Müllerian hormone (AMH), over time in women with TS and spontaneous menstruation beyond age 16? Summary answer Ovarian reserve, as measured by AMH, is stable over time in adult (>16 years) women with TS and spontaneous menstruation. What is known already TS is associated with gonadal dysgenesis and premature ovarian insufficiency (POI). In a minority of TS women, ovarian function is maintained with ongoing menstruation and the possibility of achieving spontaneous pregnancy. There is uncertainty as to the role of fertility preservation in this population. The 2016 Clinical practice guidelines for the care of girls and women with TS recommend counselling women with TS that their probability to conceive spontaneously decreases rapidly with age. However, the natural history of AMH over time in this sub-population has not been reported. Study design, size, duration Retrospective cohort study of patients attending the TS clinic at University College London Hospital between December 2020 and December 2022. This time interval was chosen to ensure that the entire UCLH TS cohort was screened, even if one year of annual follow-up was missed during COVID-19. Clinical records were reviewed to identify adult patients (>16years old) with spontaneous menstruation at any time and at least one measurement of AMH. Participants/materials, setting, methods To assess the stability of the AMH values, the rate of change was calculated using the formula: ratechangeAMH = (lastAMH-baselineAMH)/(time in months between readings). The distribution of the rate of change in the PCOS and non-PCOS groups was then compared using a non-parametric Mann-Whitney test: a regression analysis was performed with the outcome as the ratechangeAMH and the explanatory variables being baseline AMH and age at baseline AMH. Main results and the role of chance 55 patients were identified, median age 25.9 (range 16 to 41).Their karyotypes were 45X (n = 2) 45X/46XX mosaic (n = 28), 45X/47XXX mosaic (n = 11), and other (n = 14). The number of AMH measurements varied from 1-10 and the longest duration of AMH follow-up was 11 years. A subgroup of 9 patients met diagnostic criteria for PCOS. Median AMH for the 45X/46XX group was 21.25pmol/L (range 0.45-59.36), for the 45X group the median was 1.39pmol/L (range 0.20-2.57), in the 47XXX mosaic group the median was 5.05pmol/L (range 0.70-13.97) and in the other group the median was 9.35pmol/L (0.20-54.40). There was a significantly higher mean AMH, adjusted for age and baseline AMH, in the PCOS group than non PCOS group, mean 26.83 vs 16.23 pmol/L (p < 0.01). Overall, the mean rate of change of AMH was +0.0386pmol/L per month 95%CI [-0.0454, +0.1227] and the median was 0.0000pmol/L per month. In the PCOS group, the mean rate of change was +0.0034 pmol/L per month, median 0.0000pmol/L per month. Regression analyses determined that neither age or baseline AMH had a significant impact on the rate of change. Only one patient in the cohort went onto develop POI during the period of follow up. Limitations, reasons for caution The average age of this cohort at the end of the reported follow up period is 25.9. Ongoing prospective follow up is needed to assess the stability of ovarian reserve into the later part of the typical reproductive window to confirm ongoing stability and assess age reated decline. Wider implications of the findings These findings question the necessity and efficacy of fertility preservation in this subset of TS patients as ovarian reserve is stable over time. Until further data is available, we advocate offering observation with annual AMH masurement rather than immediate recourse to fertility preservation. Trial registration number Not applicable

Changes in Rehmanniae Radix processing and their impact on ovarian hypofunction: potential mechanisms of action.

This study evaluates the research developments concerning Rehmanniae Radix in ovarian hypofunction diseases. It explores the processing methods of Rehmanniae Radix, the variations in its compounds before and after processing, the mechanism of Rehmanniae Radix and its active compounds in improving ovarian function, and the advancements in clinical applications of traditional Chinese medicine (TCM) compound that include Rehmanniae Radix. Comprehensive literature search was conducted using databases such as China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database, National Science and Technology Library, the Pharmacopoeia of the People's Republic of China, Pubmed, and the Web of Science Database. The search utilized the following Medical Subject Headings (MeSH) and keywords: "Rehmanniae Radix," "Drying Rehmannia Root," "Rehmannia glutinosa," "Rehmanniae Radix Praeparata," "Traditional Chinese Medicine Processing," "Pharmacological Effects," "Ovarian Aging," "Diminished ovarian reserve," "Premature ovarian insufficiency," "Premature Ovarian Failure," "Ovarian hypofunction diseases". The ancient Chinese medical books document various processing techniques for Rehmanniae Radix. Contemporary research has identified changes in its compounds processing and the resultant diverse therapeutic effects. When processed into Rehmanniae Radix Praeparata, it is noted for its ability to invigorate the kidney. TCM compound containing Rehmanniae Radix is frequently used to treat ovarian hypofunction diseases, demonstrating significant clinical effectiveness. The key changes in its compounds processing include cyclic dilute ether terpene glycosides, phenylethanol glycosides, sugars, and 5-hydroxymethylfurfural. Its pharmacological action is primarily linked to the improvement of granulosa cell proliferation, antioxidative and anti-aging properties, and modulation of the immune and inflammatory microenvironment. Furthermore, Rehmanniae Radix also offers therapeutic benefits for cardiovascular and cerebrovascular diseases, osteoporosis and cognitive dysfunction caused by low estrogen levels. Thereby Rehmanniae Radix mitigates both the short-term and long-term health risks associated with ovarian hypofunction diseases. Processed Rehmanniae Radix has shown potential to improve ovarian function, and its compound prescriptions have a definite effect on ovarian dysfunction diseases. Therefore Rehmanniae Radix was garnering interest for both basic and clinical research, with promising application prospects as a future therapeutic agent for ovarian hypofunction diseases. However, further studies on its toxicology and the design of standardized clinical trials are necessary to fully establish its efficacy and safety.

P-423 Fertility outcomes of an egg donation program for hematologic cancer survivors: an 11-year retrospective cohort study

Abstract Study question What is the effectiveness of IVF/intracytoplasmic sperm injection with egg donation (IVF/ICSI-ED) in hematological cancer survivors (HCS) with reproductive desire and iatrogenic ovarian failure (IOF)? Summary answer The probability of clinical pregnancy and having a live birth does not significantly differ between women treated for hematological cancer and non-oncological patients using IVF/ICSI-ED. What is known already The most common hematological malignancies in women before or during reproductive age are lymphoma and leukemia. Oncological therapies cause premature ovarian failure, uterine fibrosis and infertility. Fertility preservation measures are not always possible or advisable. Egg vitrification in post-pubertal women has temporary implications as it requires ovarian stimulation; cryopreservation of ovarian tissue carries the risk of introducing back malignant cells. Fertility preservation is performed in 4-20% of cases: only 5% of patients have the chance to consult a reproductive specialist before cancer treatment. There are no published comparative studies on the effectiveness of ED in hematologic cancer survivors. Study design, size, duration We conducted a retrospective cohort study of 47 HCS with IOF, all of them nulliparous and without infertility diagnosis nor fertility preservation prior to oncological treatment and compared them with a control group (CG) of 19 infertile non-oncologic patients who underwent IVF/ICSI-ED with eggs from the same donors obtained during the same period of time (2012-2022). After evaluation by the center’s Oncofertility Committee, 45 HCS were eligible for IVF/ICSI-ED, and 23 agreed to undergo treatment. Participants/materials, setting, methods On the 47 patients HCS group we studied all the oncologic information: mean age at cancer diagnosis, mean age at IVF/ICS-ED treatment, type of tumor and oncologic treatment received. We compared the 23 patients HCS group with the 19 patients CG for: mean age of the egg recipient, mean age of the egg donor, single embryo transfers performed per patient, pregnancy and life bith rate per IVF/ICSI-ED treatment. We used chi-square statistic for the comparison. Main results and the role of chance The 47 women HCS group was aged between 25 to 50 years. The mean age at cancer diagnosis was 25.9 ± 7.6 years. The most frequent neoplasms were Hodgkin lymphoma (46.8%), non-Hodgkin lymphoma (21.2%), acute myeloid leukemia (12.7%), chronic myeloid leukemia (10.6%), other leukemias (8.5%). Lymphomas (68%) predominated over leukemias (32%). In this group 95.8% of the HCS were treated with chemotherapy: 21.2% as monotherapy, 14.8% combined with radiotherapy, 6.3% with surgery, and 6.3% with tyrosine kinase inhibitors (TKIs). Bone marrow transplantation was required in 46.8% of cases. At least 5 years elapsed from diagnosis to evaluation by the Oncology Committee. The mean egg recipient age was 36.5 ± 4.9 years for the HCS group and 41.3 ± 2.6 years for the CG (p < 0.05); there were no significant differences in the egg donor’s mean age (26.5±4.5 Vs 26.1±4.9, p=ns). We found no significant differences between the HCS and the CG in the mean single embryo transfers performed per patient (1.7 Vs 1.9, p=ns), in the pregnancy rate per ED cycle (88.4% vs 89.4%, p=ns), nor in the live birth rate per ED cycle (73% vs 64%, p=ns). Limitations, reasons for caution The retrospective nature of the study, the small number of cases and the under-recording of data in the medical history are the main limitations of this study. Wider implications of the findings It is important to have a comprehensive understanding of cancer therapies on fertility so that both doctors and patients can make informed decisions. Fertility preservation methods must be proposed before initiating oncological treatment, so multidisciplinary teamwork and timely referral to reproductive medicine centers specialized in fertility preservation are recommended. Trial registration number Not applicable

P-582 Analysis of assisted reproductive outcomes for gynecologic cancer survivors: a retrospective study

Abstract Study question Do women diagnosed with gynecologic cancer have worse pregnancy and neonatal outcomes of assisted reproductive technology (ART) ? Summary answer Decreased live birth rate was observed in female gynecologic cancer patients undergoing ART, particularly in endometrial cancers and cervical cancers. What is known already Gynecologic malignancies comprise approximately 13% of female cancer diagnoses, and oncological treatments such as surgery, chemotherapy, abdominal or pelvic radiotherapy, and hormonotherapy may induce infertility, premature ovarian failure, or early menopause, resulting in a loss of reproductive potential. ART has emerged as an important option for cancer patients undergoing treatment, but the reproductive outcomes of ART among cancer survivors remain poorly understood. Limited research exists regarding the impact of a history of gynecologic cancer on reproductive outcomes of ART. Study design, size, duration 136 women diagnosed with gynecologic cancer who underwent their first IVF/ICSI treatment between 2013 and 2021 were retrospectively enrolled in this study. 241 infertile women without any history of cancer were matched to the cancer group. Participants/materials, setting, methods Women diagnosed with gynecologic cancer who underwent their first IVF/ICSI treatment between 2013 and 2021 were included. Infertile women without any history of cancer were matched to the cancer group. The primary outcome was the cumulative live birth rate. A propensity score-based patient-matching approach was adopted to ensure comparability between individuals with and without specific cancer type. Main results and the role of chance A total of 136 patients with a history of gynecologic cancer and 241 healthy infertile controls were included in this study. Endometrial cancer constituted 50.70% of the cases and cervical cancer constituted 34.60% of the cases. The cancer group exhibited significant shorter duration of stimulation, lower levels of estradiol, lower number of retrieved oocytes, day-3 embryos, and blastocysts compared to the control group (P < 0.05). The cumulative live birth rate of the gynecologic cancer group was significantly lower than that of the control group (36.10% vs. 60.50%, P < 0.001). Maternal and neonatal complications did not significantly differ between the groups (P > 0.05). The endometrial cancer and cervical cancer groups showed significantly lower cumulative live birth rates than their matched controls (38.60% vs. 64.50%, P = 0.011 and 24.20% vs. 68.60%, P < 0.001, respectively). Limitations, reasons for caution Our study was limited by the retrospective design in nature and small sample size of its patient cohort. In addition, the effect of cancer treatments was not evaluated specifically in the current study due to the limited number of patients and possible inconsistency in surgical operations. Wider implications of the findings Our study provides data support for further exploration of the effects of endometrial cancer, cervical cancer, and other gynecologic cancers on fertility. Comprehensive ovarian function assessment, detailed counseling, individualized fertility guidance, and close follow-up after ART therapy are recommended for patients with gynecologic malignancy history. Trial registration number Not applicable

P-353 Perfluorooctanoic acid (PFOA) impacts murine ovarian follicle development through apoptotic signaling pathways and exhibits transgenerational effects

Abstract Study question How does Perfluorooctanoic Acid (PFOA) exposure impact ovarian function and the physiological and reproductive health of subsequent offspring? Summary answer PFOA exposure leads to ovarian dysfunction, characterized by follicular depletion and hormonal imbalances, and adversely affects the reproductive health of offspring. What is known already Mass spectrometry reveals higher perfluorinated compound levels in premature ovarian failure patients compared to healthy individuals. PFOA, an environmental contaminant, is known for its endocrine-disrupting effects, but its specific impact on ovarian function and transgenerational health remains less explored. This study addresses the gap by examining PFOA’s direct ovarian effects and its consequential impacts on offspring, using both in vivo and in vitro models. Study design, size, duration This study employs mouse models and ovarian granulosa cells to assess PFOA’s impact. Mice were administered PFOA (50mg/Kg) and evaluated for ovarian function and offspring health. Ovarian tissue underwent histological analysis and hormone assays. RNA transcriptome sequencing identified activated apoptotic pathways post-PFOA exposure. Offspring physiological and reproductive parameters were also examined. Parallel in vitro experiments with ovarian granulosa cells at 50uM PFOA concentration provided insights into cellular apoptosis. Participants/materials, setting, methods Clinically, we collected serum samples from approximately 100 Premature Ovarian Insufficiency (POI) patients and 100 healthy individuals, analyzed using mass spectrometry. In murine experiments, we simulated human environmental exposure to PFOA (particularly in high-exposure professions) using a 50mg/Kg dose administered via gavage. Transcriptome sequencing analyzed potential signaling pathways in both experimental and control mice. Offspring underwent physiological metabolic assessments and fertility evaluations, including fertilization and blastocyst rates. Main results and the role of chance Mass spectrometry results from human samples revealed significantly higher levels of perfluorinated compounds in POI patients compared to healthy controls, suggesting a potential link between PFOA exposure and ovarian dysfunction. In murine models, PFOA administration at 50mg/Kg resulted in notable ovarian changes. Histological analysis showed a reduction in follicle counts and abnormalities in AMH and FSH levels, indicative of premature ovarian failure. Transcriptome sequencing of these mice highlighted the activation of apoptotic pathways, especially the PI3K/Akt/mTOR signaling, post-PFOA exposure. This suggests a mechanistic pathway through which PFOA may induce ovarian dysfunction. Furthermore, offspring of PFOA-exposed mice displayed significant reproductive health challenges. They exhibited irregularities in estrous cycles and a decrease in oocyte fertilization rates, pointing to potential transgenerational effects of PFOA exposure. These findings in murine models align with the elevated perfluorinated compound levels observed in human POI patients, reinforcing the hypothesis of PFOA’s detrimental impact on ovarian health and subsequent generational fertility. The consistency of results across human clinical data and animal models strengthens the argument for a causal relationship between PFOA exposure and reproductive health risks. Limitations, reasons for caution While these findings highlight PFOA’s detrimental effects on ovarian function and offspring health, translating results from animal models to humans necessitates caution. The specific mechanisms and potential variability in human response to environmental PFOA exposure require further investigation. Wider implications of the findings This research underscores the far-reaching impacts of environmental contaminants like PFOA on reproductive health. It emphasizes the need for stringent regulation of such pollutants and further studies to understand their long-term effects on human health, particularly regarding fertility and intergenerational wellbeing. Trial registration number not applicable

O-061 Ovarian cancer and fertility - current understanding

Abstract Introduction Ovarian cancer is a significant health concern worldwide and is the leading cause of death from gynecologic malignancies. While fertility preservation is essential for many young women diagnosed with cancer, concerns have been raised regarding the potential impact of fertility treatments on the risk of ovarian cancer development. 1. Ovarian Cancer Risk Factors Ovarian cancer is a multifactorial disease with various risk factors contributing to its development. A woman has a risk of 1 in 78 of having ovarian cancer in her life time, risk factors include: • Age: Ovarian cancer risk increases with age, with the highest incidence observed in women over 50 years old. About 12.1% of Ovarian Cancer patients are younger than 44 years old. • Family History: Women with a family history of ovarian or breast cancer, especially first-degree relatives, have an increased risk. • BRCA Mutations: Inherited mutations in BRCA1 and BRCA2 genes significantly elevate the risk of ovarian cancer. • Reproductive Factors: Factors such as nulliparity, early menarche, late menopause, and infertility have been associated with an increased risk of ovarian cancer. 2. Fertility Treatments and Ovarian Cancer Risk Understanding the mechanisms underlying ovarian cancer development is crucial for assessing the potential impact of fertility treatments : • Ovulation Hypothesis: The repeated ovulation theory suggests that each ovulatory cycle increases the risk of DNA damage to ovarian epithelial cells, potentially leading to cancer development. The use of fertility drugs to stimulate ovulation, such as clomiphene citrate and gonadotropins, has been studied , the early studies suggested a potential increased risk, more recent evidence has been conflicting, with some studies reporting no association. • In Vitro Fertilization (IVF): Several large-scale studies have investigated the relationship between IVF and ovarian cancer risk found no significant increase in ovarian cancer risk . • Hormonal Influence: Fertility drugs alter hormonal levels, particularly estrogen and progesterone, which may influence ovarian cancer risk. • Selection Bias: Some studies have suggested that the ovarian cancer risk may be confounded by underlying infertility factors rather than the treatments themselves. 3. Clinical Implications and Recommendations • Individual Risk Assessment: Clinicians should assess each patient's individual risk factors for ovarian cancer, including age, family history, and reproductive history, before initiating fertility treatments. • Informed Consent: Patients should be provided with comprehensive information regarding the potential risks and benefits of fertility treatments • Regular Surveillance: Women undergoing fertility treatments should receive regular gynecologic screenings and follow-up care to monitor for any signs or symptoms of ovarian cancer. • Shared Decision Making: Shared decision making between patients and healthcare providers is essential to ensure that treatment decisions align with patients' preferences and values. 4. Fertility Preservation Options • Most therapeutic options for Ovarian Cancer cause infertility, either by premature ovarian failure caused by cytotoxic agents in chemotherapy or surgical approaches that include unilateral or bilateral oophorectomy • In ovarian cancer patients, Oocyte cryopreservation is still the best option and the only one established along with embryo cryopreservation. Fertility preservation surgery can be suggested depending on histology, stage of disease and pre-existing ovarian reserve. • Ovarian tissue cryopreservation will not be an option as long as the risk of reseeding cancer cells is not fully eliminated. 5. Future Directions Advancements in molecular biology and genetics may shed light on the underlying mechanisms of ovarian cancer development and its potential association with fertility treatments. The artificial ovary and in vitro maturation of oocytes is a very attractive option in these patients, but further milestones have to be achieved

P-803 Intra-ovarian injection of plasma rich in stem cell-secreted and platelet-enclosed factors to promote follicle rescue and reproductive outcomes in women with very low ovarian reserve

Abstract Study question Could intraovarian injection of plasma rich in stem-cell and platelet growth factors optimize ovarian reserve and IVF outcomes in women with very low ovarian reserve? Summary answer Intraovarian injection of G-CSF mobilized plasma rich in grown factors improved follicle count since first follow-up and led to better fecundation, implantation and pregnancy’ rates. What is known already Autologous stem cell ovarian transplantation (ASCOT) of bone marrow derived stem cells optimized ovarian reserve and reproductive outcomes in poor responders (POR) and this effect seems to be due to the growth factors secreted by the stem cells, acting through paracrine pathways. Similarly, platelet-rich Plasma (PRP) has been also offered to promote ovarian reactivation in patients with impaired ovarian reserve by providing positive growth factors contained in platelets. Indeed, a technique that combines both the non-cellular components of ASCOT and PRP (ASCOT-1) has been proposed to optimize follicle rescue and IVF outcomes in women with very low reproductive prognosis. Study design, size, duration Retrospective observational study with 159 women (≤ 45 years) diagnosed with POR and primary ovarian insufficiency (POI) according to ESHRE criteria, who underwent the ASCOT-1 technique after refusing oocyte donation, between June 2021-October 2023 at IVIRMA Alicante, Spain (IRB approval 2310-FIVI-188-SH). The ASCOT-1 consisted in the intraovarian injection of plasma rich in both stem cell-secreted and platelet-enclosed factors obtained after granulocyte colony stimulating factor (G-CSF) mobilization and PRP obtention (Endoret Kit BTI, Biotechnology institute). Participants/materials, setting, methods Medical records of patients who underwent the ASCOT-1 as an ovarian reactivation treatment were examined. Follow up of AFC and AMH was carried out for a maximum of 4 menstrual cycles to evaluate follicular activation. Moreover, when follicle growth was detected, patients underwent a controlled ovarian stimulation (COS). IVF and reproductive outcomes were compared with previous COS cycles started in our clinics, when available. T-test was used where appropriate. Main results and the role of chance Overall 159 POR/POI women (age 38.7±4.2years, AMH0 0.22±0.41ng/ml; AFC0 1.4±1.9) underwent the ASCOT-1 technique. Mean volume of plasma injected was 6.8±0.8ml, distributed equally in both ovaries. First follow-up was done in 131 women showing statistically significant improvements in the AFC during the entire follow-up compared to the basal levels measured before the treatment (AFC1 3.3±3.4, p < 0.001; AFC2 3.3±3.6, p < 0.001; AFC3 2.9±2.6, p < 0.001; AFC4 2.4±2.6, p = 0.07). After ASCOT-1, 98 COS were initiated in 48 women in our clinics, which were compared to their previous 66 cycles. Although age was significantly higher in their posterior cycles (38.0±2.9 vs40.0±3.6; p < 0.001), after ASCOT-1 oocyte retrieval was reached in a greater amount of cases (75.5% vs87.5%, p=NS). ASCOT-1 showed a positive, but non statistically significant effect in the number of MII-oocytes (2.8±4.1 vs3.2±3.9, p=NS) and blastocysts obtained (1.8±2.8 vs2.4±3.1, p=NS), but relevant improvements were observed in quality related parameters such as oocyte maturation (61.5%, 95%IC 45.8-77.3, vs86.1%, 95I%IC 69.9-85.5; p 0.03), fertilization (62.6%, 95%CI 53.0-71.3, vs76.5%, 95%CI 70.0-82.0; p < 0.001), implantation (25.0%, 95%CI 8.3-52.5 vs41.1%, 95%CI 19.4-66.5; p < 0.001) and clinical pregnancy rate (25.0%, 95%CI 8.3-52.5 vs46.6%, 95%CI 22.2-72.5; p < 0.001). Ultimately, 14 clinical pregnancies (7 after ET and 7 by natural conception) were obtained after ASCOT-1. Limitations, reasons for caution This retrospective study involves short periods of follow up and limited amount of IVF attempts. Thus, further prospective studies with increased sample size are required to validate our results, to establish the duration of the effects, and to identify which subgroups of patients could benefit the most from this treatment. Wider implications of the findings Growth factors contained in the G-CSF mobilized PRP could play a role in follicular development, providing a new tool to increase the reproductive potential of women with very low ovarian reserve where oocyte donation is the only practical option, allowing them to access to homologous IVF treatment. Trial registration number 2310-FIVI-188-SH

P-506 Oocyte/zygote/embryo maturation arrest: a functional and clinical study expanding the phenotype of NOBOX variants

Abstract Study question Are pathogenic NOBOX variants causal for oocyte/zygote/embryo maturation arrest (OZEMA) and what is their molecular mechanism? Summary answer Expression analysis of NOBOX target genes indicates that the examined variants do not influence early folliculogenesis, suggesting a potential involvement in later developmental stages. What is known already Primary ovarian insufficiency (POI) affects around 1% of women under 40 with pathogenic variants in the transcription factor NOBOX being causal in 5-7% of cases. Historically, NOBOX has been linked to premature oocyte depletion. Functional studies in female Nobox knockout (-/-) mice reveal a substantial disruption in germ cell cyst breakdown. This disruption impairs the formation of primordial follicles and the subsequent transition from primordial to primary stages, leading to the early loss of all oocytes. Study design, size, duration Three OZEMA families are presented with two distinct NOBOX variants. A functional study is conducted to explore alterations in mRNA expression associated with the investigated NOBOX variants. Participants/materials, setting, methods Three infertile women with OZEMA underwent multiple in vitro fertilization cycles. Subsequent, exome analysis targeting fertility-related genes revealed the presence of distinct NOBOX variants. To assess their impact on NOBOX target gene expression, we generated mutant NOBOX expressing plasmids via site-directed mutagenesis and transfected them into HEK293T cells. The expression of known NOBOX target genes was monitored by RT-qPCR. Main results and the role of chance We examined three families affected by OZEMA, in which the affected women were heterozygous for NOBOX variants. In one family, we found a heterozygous paternally inherited NM_001080413.3(NOBOX): c.1797_1798delCT, p.(Arg600Aspfs*6) variant in a female with oocyte maturation arrest. In two other families, a heterozygous probably pathogenic paternally inherited NM_001080413.3(NOBOX): c.1849C>T, p.(His617Tyr) variant was detected in females experiencing embryo maturation arrest. Analysis of NOBOX target genes in HEK293T cells revealed that both variants had no impact on the mRNA expression of MOS and OCT4, both of which are implicated in early folliculogenisis. Since both MOS and OCT4 are implicated in earlier folliculogenesis stages, this supports that NOBOX might also be implicated in later stages. Contrastingly, a known pathogenic NOBOX variant, used as a positive control, showed decreased MOS and OCT4 expression. Limitations, reasons for caution Verification of our findings is necessary, given that this is the first report of NOBOX variants in individuals with OZEMA. The precise molecular mechanism underlying OZEMA remains undisclosed at this stage. These results warrant the need of genome-wide mRNASeq to confirm and expand our findings. Wider implications of the findings Since NOBOX pathogenic variants are typically linked to POI, our findings suggest a broader clinical impact, where NOBOX plays a role in oocyte maturation and early embryo development. Hence, the investigation of NOBOX variants is advisable for individuals diagnosed with OZEMA. Trial registration number Not applicable

O-168 The therapeutic potential of stem cells for ovarian rejuvenation

Abstract Stem cells and induced pluripotent stem cells (iPSCs), hold immense promise in regenerative medicine due to their ability to differentiate into various cell types. However, in the context of ovarian rejuvenation, controversies surround the concept of post-natal oogenesis in mammals, challenging the established belief that female mammals are born with a finite pool of oocytes. Recent studies refute the presence of ovarian stem cells, sparking debates in the scientific community. The proposed use of ovarian stem cell-derived mitochondria for oocyte rejuvenation, known as AUGMENT, aimed to enhance fertility but fell short of expectations in clinical trials. Conversely, autologous stem cell ovarian transplantation (ASCOT) seems to offer a promising avenue to increase reproductive potential by replenishing ovarian function. While still under investigation, initial results show encouraging outcomes. Furthermore, recent advancements in in vitro generation of oocytes from stem cells present a groundbreaking approach to overcome infertility associated with ovarian failure. By mimicking the natural process of oogenesis, researchers aim to provide new opportunities for fertility preservation and treatment. These developments underscore the dynamic landscape of stem cell research in reproductive medicine, offering hope for addressing infertility and expanding our understanding of reproductive biology.

Serum androgen dynamics in young women aged 18-40 treated with chemotherapy for breast cancer: an observational, multicentric, prospective study in France

Although the deleterious impact of chemotherapy regimen used to treat women of reproductive age with breast cancer on ovarian reserve has been extensively studied, hardly anything has been reported on the effect of these protocols on theca cell function and ovarian androgen secretion. The aim of this prospective multicentric cohort study was to describe serum levels of total testosterone and androstenedione during chemotherapy and 24-month follow-up in 250 patients <40 years treated for breast cancer. Mean basal levels of androstenedione and total testosterone at diagnosis were 1.68 ng/mL and 0.20 ng/mL respectively. No correlation with age was found. Serum levels of androstenedione and total testosterone rapidly decreased after chemotherapy completion, before slowly increasing and almost returning to basal levels in all patients during 2-year follow-up. In conclusion our study demonstrates a chemotherapy-induced alteration of ovarian thecal function, resulting in a significant decrease in serum androgen levels. This alteration of theca cell function adds to the well-known alteration of granulosa cell function, resulting in a global, but partly transient, ovarian failure in young women treated for breast cancer. These data bring new insight into ovarian physiology and emphasize the need for pre and post-treatment ovarian follow-up. Trial registration: ClinicalTrial.gov identifier NCT01114464

P-782 Are pregnancy complications associated with the method of conception in female same-sex couples? Results of a retrospective, matched cohort study comparing ROPA and IUI

Abstract Study question Are pregnancies in female same-sex couples at a higher risk when using reception of oocytes from partner (ROPA) compared to those following intrauterine insemination (IUI)? Summary answer In female same-sex couples, pregnancies following ROPA demonstrated a higher incidence of preterm birth and first-trimester bleeding. What is known already Reception of Oocytes from PArtner (ROPA) enables both partners to contribute biologically to the desired pregnancy. However, oocyte donation, often performed in case of (premature) ovarian failure, is associated with an increased risk of hypertensive disorders of pregnancy/preeclampsia. Female same-sex couples typically comprising healthy, young women without underlying subfertility problems, are a priori at low absolute risk for pregnancy complications. Few studies have investigated the incidence of pregnancy complications and/or obstetrical outcomes in this specific group of women. Further insights and formal data could guide clinicians and patients in making informed decisions regarding the preferred method of conception. Study design, size, duration A retrospective, single-center, matched cohort study was performed including 577 unique female same-sex couples using donor semen who became pregnant after reproductive treatment (88 pregnancies following ROPA and 489 following IUI). None of the patients who opted for ROPA had (failed) IUI before. The study covered the period from January 2015 to January 2023. Participants/materials, setting, methods Pregnancies following ROPA were matched with pregnancies following IUI for age (+/-4 years), BMI (+/-4 kg/m2), parity (nulliparous vs multiparous) and date of embryo transfer/IUI (+/-1year) in a 1:1 ratio. Statistical Package for Social Sciences (SPSS) v26.0 was used for statistical analysis. Kolmogorov-Smirnov test was used to evaluate the normal distribution of continuous variables. Normally distributed data were analyzed with the student t-test and categorical variables were analyzed with the chi-square test. Main results and the role of chance After matching, 154 pregnancies (77 ROPA versus 77 IUI) were eligible for the study. Age (mean age 31.4±4.0 for ROPA versus 31.2±4.3 years for IUI, p = 0.48) and BMI (24.5±3.9 kg/m2 versus 25.2±4.4 kg/m2, for respectively ROPA versus IUI, p = 0.32) were comparable between groups after matching. Two ROPA pregnancies were excluded from further analysis due to elective termination of pregnancy (radiusaplasia and trisomy 21). Both groups experienced two stillbirths (two unexplained mors in utero, one chorioamnionitis and one intrapartum death). No significant difference in hypertensive disorders of pregnancy (HDP) (10.7% (8/75) versus 13.7% (10/73) for ROPA and IUI respectively, p = 0.53) or preeclampsia rates (11.0% (8/73) and 6.7% (5/75) for ROPA and IUI respectively, p = 0.33) was observed. ROPA-associated preeclampsia cases were often preterm (&amp;lt;37weeks’ gestation) compared to IUI (5/8 versus 1/5). ROPA pregnancies had a higher incidence of preterm birth (15.1% vs 1.3%,p&amp;lt;0.002) and first trimester bleeding was significantly more frequent (12.3% vs 0%,p&amp;lt;0.001). No statistically significant differences were observed between groups in neonatal weight, fetal structural malformations and cesarean section delivery rates. Limitations, reasons for caution The study is limited by its retrospective design and inherent bias. Despite reducing the sample size, matching enhanced study robustness. Recognized risk factors for hypertensive disorder of pregnancy, like the use of donor sperm, may mitigate differences associated with conception methods in this population. Wider implications of the findings The study points out potentially increased obstetrical risks following ROPA. These data are crucial to counsel and guide female same-sex couples in their decision regarding the method of conception. The risk of hypertensive disorders of pregnancy, specifically preterm preeclampsia, associated with ROPA warrants further attention, urging larger prospective studies. Trial registration number not applicable

O-227 First successful ovary allotransplants to Turner’s syndrome patients requiring immunosuppression

Abstract Study question To determine whether we can safely and successfully transplant an ovary tissue allograft from a non-identical donor to her Turner’s syndrome sister. Summary answer We report the first successful cases (with pregnancy) of ovarian tissue allotransplantation to Turners syndrome women using a safe immunosuppression protocol. What is known already Young women with Turner’s have been unable to have children without the use of donor egg IVF, but many Turner’s women would like to have normal hormonal function and to become pregnant naturally. Frozen ovarian cortex tissue can be successfully auto-transplanted back to women with ovarian failure and result in normal pregnancy and live birth with a success rate of 41-76%. This has never been accomplished between a non-identical donor to her Turner syndrome sister. Added benefits are hormonal function obviates the need for hormone replacement, and pregnancy can occur naturally rather than with donor egg IVF. Study design, size, duration 1.) 20 year-old woman with non-mosaic XO Turner’s, no menses, and AMH (Anti-Mullerian hormone) of 0.015 ng/mL, whose 22 year-old sister had two children, normal menses, and an AMH of 4.97. They were HLA identical but ABO incompatible. 2.) A 21 year-old woman with non-mosaic XO Turner’s, no menses and AMH of 0.015 whose 28 year old sister had 2 children, normal menses, and AMH of 2.92. They were ABO compatible, but one HLA mismatch. Participants/materials, setting, methods The left ovary of the donor was removed and dissected. One third of the cortex was transplanted to the right streak ovary of the recipient and the remaining two-thirds were cryopreserved. The immunosuppression protocol consisted of methylprednisolone the morning of surgery along with anti- thymocyte globulin, and for maintenance, tacrolimus 3 mg orally BID with a target trough of 5-10 ng/mL, azathioprine 100 mg orally, and prednisone only 5 mg po daily. Main results and the role of chance By 168 days post-op the first Turner’s recipient was menstruating and ovulating normally with no sign of rejection. Her AMH began to rise at 168 days from 0.05 to 0.35ng/mL by 223 days, typical for a successful ovary cortical graft, and her FSH varied from 4.5 to 8.5 mIU/mL. By one year her uterus grew from infantile to that of a normal adult and she became spontaneously pregnant 10 months later and delivered a healthy baby. The donor FSH was 6.8 mIU/mL, unchanged from pre-op, she continued menstruating normally, and became spontaneously pregnant with her third child (despite having an IUD in place) by six months post op. The second Turner’s syndrome began menstruating monthly at 4 months post-op, and her AMH rose to 0.25 mg/mL as her FSH dropped to 5.3 mIU/mL. At the time of this writing she is 6.5 months post-op and continues to menstruate and ovulate normally. Limitations, reasons for caution There are only the first two cases and therefore at this stage, the conclusions are only a proof of concept. Wider implications of the findings We have demonstrated successful ovarian tissue transplantation with spontaneous pregnancy to Turner’s syndrome females using a safe immunosuppression protocol. The fact that ABO incompatibility did not cause rejection indicates that an ovary tissue graft can survive on diffusion alone. Furthermore, HLA mismatch does not preclude success with this immunosuppression protocol. Trial registration number not applicable