Undergoing Oocyte Cryopreservation Research Articles

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

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

O-004 Oocyte image assessment by novel artificial intelligence (AI) model predicts blastocyst PGT-A results, outperforming age as a predictor

Abstract Study question Can a non-invasive, image analysis artificial intelligence (AI) model be built to predict the likelihood that a mature oocyte will develop into a euploid blastocyst? Summary answer A novel AI model was developed to assess images of mature oocytes, predicting chromosomal ploidy status of the developed blastocyst with an AUC of 0.71. What is known already The genetic status of blastocysts greatly impacts implantation and cycle success; therefore, PGT-A has become widely adopted as routine to aid in blastocyst selection for transfer and aims to decrease the time to pregnancy. Most chromosomal abnormalities arising in a blastocyst embryo are of maternal meiotic origin–indicating that the oocyte may have valuable information to be harnessed at the earliest stage in the process. Gaining insights into the potential genetic status of a blastocyst at the oocyte stage in a non-invasive manner would provide critical information to the overall fertility cycle. Study design, size, duration This study included a labeled dataset—9,260 images of mature denuded oocytes, immediately post-ICSI—from 3 clinics (Canada, United States (US), Spain) with euploid or aneuploid trophectoderm biopsy results (excluding mosaic/inconclusive embryos, n = 980). The labeled dataset was split into training (60%), validation (20%), and test (20%). An unlabeled dataset was also included—34,709 oocyte images (2 clinics; Canada, US)—and utilized in training. An external dataset (n = 473) from a separate US clinic was assessed for model generalization. Participants/materials, setting, methods Fully-supervised and semi-supervised machine learning models were experimented to predict blastocyst PGT-A from oocyte images. The labeled data were utilized in both methods. The semi-supervised method integrates unlabeled data using the well-known Mixmatch algorithm—learning important features from augmented images (with pseudo labels) that were then utilized in the supervised phase to predict outcomes. Age was incorporated into the models, therefore, a model only using age to predict ploidy was developed to act as a comparison. Main results and the role of chance Following various experiments, the fully-supervised model displayed an AUC 0.61, sensitivity 0.41, specificity 0.76, and accuracy 0.62 on the test set. The semi-supervised model displayed a performance of AUC 0.71, sensitivity 0.63, specificity 0.67, and accuracy 0.65–notably higher AUC and balanced performance on the positive/negative classes. The semi-supervised method benefits from both labeled and augmented unlabeled data for enhanced learning efficacy. The model utilizing age only to predict ploidy was extremely imbalanced in performance on the test set with AUC 0.63, sensitivity 1, specificity 0, and accuracy 0.48, confirming the importance of image features. Performance of the semi-supervised model was assessed by clinic. On Clinic 1 (n = 364; 40% euploid) it displayed AUC 0.61, sensitivity 0.60, specificity 0.56, and accuracy 0.58; on Clinic 2 (n = 675; 52% euploid) it displayed AUC 0.64, sensitivity 0.56, specificity 0.65, and accuracy of 0.60; on Clinic 3 (n = 466; 50% euploid) it displayed significantly better performance with AUC 0.85, sensitivity 0.76, specificity 0.79, and accuracy 0.77–warranting further investigation into model generalizability. On the external dataset (n = 473, 58% euploid), the semi-supervised model displayed improved performance (AUC 0.62, sensitivity 0.61, specificity 0.61, accuracy 0.60) in comparison to the age only model (AUC 0.59, sensitivity 1, specificity 0, accuracy 0.58). Limitations, reasons for caution This dataset includes oocytes that developed into blastocysts and underwent PGT-A. Datasets including oocytes that did not reach the blastocyst stage must also be assessed to validate the model’s clinical utility. Despite utilizing diverse data, advancing the generalizability of the model requires additional investigations to ensure balanced performance across clinics. Wider implications of the findings Utilizing images of mature oocytes, an AI model predicts the ploidy status of resulting blastocysts, providing a powerful tool for assessing oocyte quality and genetic integrity. These preliminary findings are promising for those undergoing oocyte cryopreservation by striving to elucidate genetic potential at the earliest phase of the IVF process. Trial registration number Not applicable.

O-074 Dual trigger is not superior to GnRH Agonist alone for final oocyte maturation in elective fertility preservation. A Randomized Controlled Trial

Abstract Study question Is Dual trigger for final oocyte maturation associated with a higher number of mature (MII) oocytes compared to GnRH-a trigger alone in elective fertility preservation? Summary answer Adding hCG to GnRH-a for triggering final oocyte maturation does not increase the number of MII oocytes in elective fertility preservation cycles. What is known already Triggering final oocyte maturation represents a key step in ovarian stimulation. In good prognosis patients undergoing oocyte cryopreservation, the current standard approach involves the administration of a single bolus of GnRH-agonist 36 hours before the pick-up. Previous studies have shown a higher number of MII oocytes when Dual Trigger (hCG+ GnRH-a) is performed, compared to recombinant human chorionic gonadotropin (rhCG) alone. Nevertheless, a notable gap exists in the literature, as no studies have investigated the potential additional benefit in final oocyte maturation when dual trigger is compared to GnRH-a alone. Study design, size, duration This is a randomized controlled superiority trial including elective oocyte cryopreservation cycles performed in a University Hospital. A total of 109 women were enrolled in this study between October 2021 to April 2023 with a 1:1 allocation. Eligible patients were ≤40 years old, with an antral follicular count (AFC)<20 and anti-Mullerian hormone (AMH)≤3ng/ml. Patients were randomized to final oocyte maturation triggering with Triptorelin 0,2mg or a dual trigger (Triptorelin 0.2 mg + 250 ug rhCG). Participants/materials, setting, methods Controlled ovarian stimulation was performed using 225-300IU/day of rFSH alfa or beta, or equivalent rFSH delta (15-20μg), tailored to ovarian reserve and BMI. LH surge was suppressed through a progestin-primed ovarian stimulation (PPOS) protocol, with oral administration of micronized progesterone (200mg daily) from the beginning of ovarian stimulation until the trigger day. The primary outcome was the number of MII oocytes. Comparisons are presented as estimated mean difference (EMD) and corresponding 90% confidence interval (CI). Main results and the role of chance Overall, 104 patients were analyzed, 51 in the Dual trigger group and 53 in the control arm (GnRH-a). We found no statistically significant differences in the number of retrieved oocytes comparing Dual Trigger group (8.71 ± 4.90) and GnRH-a group (9.51 ± 5.19). Similarly, the number of MII oocytes demonstrated no significant differences, with 6.86 ± 4.40 in the Dual Trigger group compared to 7.87±4.40 in the GnRH-a group (EMD -1.01 [90%CI: -2.44;0.43]). Exploring the hormonal profile there were no notable variations in estradiol levels (2064.60 ± 890.50 pg/ml vs. 2494.41 ± 1341.05 pg/ml), progesterone levels (7.78 ± 3.88 ng/ml vs. 8.94 ± 5.10 ng/ml), LH (56.28 ± 26.83 IU/L vs. 63.41 ± 32.50 IU/L), and FSH (31.14 ± 7.86 IU/L vs. 31.53 ± 9.89 IU/L) on the day following the trigger. Notably, neither group exhibited any case of Ovarian Hyperstimulation Syndrome (OHSS). Limitations, reasons for caution The sample size was calculated to detect differences on the number of MII oocytes. Therefore, results for secondary outcomes (number of oocytes retrieved and hormonal profile) should be interpreted with caution. Wider implications of the findings Adding hCG to GnRH-a for triggering final oocyte maturation does not confer any additional benefits in elective fertility preservation in term of MII oocytes compared to the administration of GnRH-a alone. Trial registration number NCT04992468

#391 : Oocyte Cryopreservation — A Five Year Follow Up Study on its Utilization and Outcome

Background & Aim: Oocyte cryopreservation is a boon for women undergoing Assisted reproductive technology (ART). Apart from cancer patients it is recently promoted as a mode of fertility insurance to overcome the age-related decline in fertility, endometriosis, primary ovarian insufficiency, etc. The objective of the study was to evaluate the clinical applications of oocyte freezing and its efficacy in terms of pregnancy outcome. Method: Retrospective observational study of all patients undergoing oocyte cryopreservation from 2016 to 2021 in Lilavati Hospital & Research Centre, Mumbai, India. Result: 221 patients undergoing oocyte cryopreservation were included. Oocyte cryopreservation was done for different indications like azoospermia (50.2%, most common), planned oocyte freezing (41.17%), fertility preservation (1.36%), endometriosis (0.45%), ejaculatory dysfunction (1.8%), husband with active hepatitis B infection (3.62%) and unavailability of husband on the day of egg retrieval (3.62%). A total of 1715 mature oocytes were frozen. 41.17% women were normo-responder, 38.91% were poor responder and 19.90% were hyper-responder. The oocytes of 59 patients (return rate-26.7%) have been thawed and 162 women (73.3%) remain in storage. Out of 508 oocytes frozen for these 59 patients utilizing their oocytes, around 474 oocytes were recovered post-warming (recovery rate 93.3%). A total of 59.3% patients created embryos with a partner, and 40.6% used donor sperm. The mean fertilization rate was 65.8% of surviving oocytes. Of 59 patients, 44 (74.5%) planned a fresh embryo transfer, out of which 20 patients tested positive for pregnancy (pregnancy rate 45.45%). Conclusion(s): We report the outcomes of patients opting for oocyte cryopreservation, which is useful for patient counselling. Limited evidence is available in terms of utilization rate, post warming survival of oocytes, fertilization and pregnancy rate. Further studies over long period of time with larger cohorts are needed.

Oocyte cryopreservation and reciprocal in vitro fertilization in a transgender man on long term testosterone gender-affirming hormone therapy: a case report

To report a successful case of oocyte cryopreservation and subsequent invitro fertilization (IVF) in a transgender male receiving continued testosterone gender-affirming hormone therapy, followed by reciprocal embryo transfer (ET). A case report of a rare case of fertility preservation in a transgender man with concomitant use of testosterone therapy for 4 years before and during ovarian stimulation. Private fertility clinic with university affiliation. A 26-year-old transgender man undergoing oocyte cryopreservation before gender-affirming surgery. Fertility preservation using oocyte cryopreservation and IVF with reciprocal fresh ET into a cisfemale partner. Successful oocyte cryopreservation, oocyte thawing, and reciprocal IVF cycle. Oocyte cryopreservation of 29 mature oocytes. Sixteen mature oocytes survived the thaw, and 12 were fertilized with intracytoplasmic sperm injection. A fresh ET of an advanced blastocyst resulted in a clinical pregnancy and live birth. Fertility preservation with oocyte cryopreservation or IVF with embryo cryopreservation is feasible for patients on continued long-term testosterone gender-affirming therapy. Future studies on egg quality and reproductive outcomes are required. Our case report demonstrates a promising outcome in this patient population.

P-392 Controlled ovarian hyperstimulation applied before unilateral oophorectomy improves fertility preservation in cancer patients

Abstract Study question Can ovarian tissue cryopreservation (OTC) be performed after controlled ovarian hyperstimulation (COH)? Summary answer Unilateral oophorectomy after transvaginal oocyte retrieval is feasible on stimulated ovaries during one surgical step. What is known already In the fertility preservation (FP) field, the timeframe between patient referral and start of curative treatment is limited. Combining oocyte pick-up with ovarian tissue (OT) extraction has been reported to improve FP but COH applied before OT extraction is not currently recommended. Study design, size, duration This retrospective cohort-controlled study involved 58 patients who underwent oocyte cryopreservation immediately followed by OTC between September 2009 and November 2021. The exclusion criteria were a delay between oocyte retrieval and OTC of greater than 24 hours (n = 5) and in vitro maturation (IVM) of oocytes obtained ex-vivo in the ovarian cortex (n = 2). This FP strategy was performed either after COH (stimulated group, n = 18) or after IVM (unstimulated group, n = 33). Participants/materials, setting, methods Oocyte retrieval followed by OT extraction on the same day was performed either without previous stimulation or after COH. Adverse effects of surgery and ovarian stimulation, mature oocyte yield and pathology findings of fresh OT were retrospectively analysed. Thawed OTs were analysed prospectively, for vascularisation and apoptosis using immunohistochemistry, when patient consent was obtained. Main results and the role of chance No surgical complication occurred after OTC surgery in either group. In particular, no severe bleeding was associated with COH. The number of mature oocytes obtained increased after COH (8.5 [5.3–12.0] MII oocytes) compared to the unstimulated group (2.0 [1.0–5.3] MII oocytes, p < 0.001). Neither ovarian follicle density nor cell integrity was affected by COH. Fresh OT analysis showed congestion in half of the stimulated OT which was higher than in the unstimulated OT (3.1%, p < 0.001). COH also increased haemorrhagic suffusion (COH+OTC: 66.7%; IVM+OTC: 18.8%, p=0.002) and oedema (COH+OTC: 55.6%; IVM+OTC: 9.4%, p < 0.001). After thawing, the pathological findings were similar between both groups. No statistical difference in the number of blood vessels was observed between the groups. The oocyte apoptotic rate in thawed OT was not statistically different between the groups (ratio of positive cleaved caspase-3 staining oocytes/total number of oocytes equal to median 0.50 [0.33-0.85] and 0.45 [0.23-0.58] in unstimulated and stimulated groups respectively, p = 0.720). Limitations, reasons for caution The study reports FP from a small number of women following OTC. Follicle density and other pathology findings are an estimate only. Wider implications of the findings This approach could be proposed to post pubertal patients when the number of mature oocytes expected is low or when the risk of residual pathology is high. The reduction of surgical steps for cancer patients also has positive implications for introducing this approach into clinical practice. Trial registration number not applicable

Laparoscopic oocyte retrieval for fertility preservation in a patient with squamous cell carcinoma of the vagina

To describe a feasible fertility preservation strategy in a woman with vaginal carcinoma. Video case report demonstrating the diagnostic work-up and laparoscopic oocyte retrieval performed under regional anesthesia. University tertiary care hospital. A 35-year-old nullipara woman presenting with vaginal bleeding and foul-smelling vaginal discharge. After a comprehensive diagnostic work-up, a final diagnosis of squamous cell carcinoma of the vagina stage II (FIGO classification) was made. As per the patient's desire, before undergoing chemo-radiotherapy, the patient underwent oocyte cryopreservation. Transvaginal retrieval of oocytes was not feasible due to stenosis of the vaginal introitus and the potential risk of intracavitary tumor cell spillage. Transabdominal ultrasound-guided oocyte retrieval was not possible due to the body habitus. The patient underwent ovarian stimulation for in vitro fertilization. In order to minimize estrogen levels, letrozole was used during the controlled ovarian stimulation (COS). Laparoscopic oocyte retrieval was performed under spinal anesthesia. Successful laparoscopic egg retrieval and cryopreservation in a woman with squamous cell carcinoma of the vagina. A total follicular count of 9 was estimated before the oocyte retrieval. Eight oocytes were retrieved at laparoscopy, and eight mature oocytes were successfully cryopreserved. No complications were encountered, and the patient was discharged on the same day of surgery. To the best of our knowledge, this is the first published case of fertility preservation using the laparoscopic approach in a patient with vaginal cancer. Letrozole is a valuable strategy to reduce high estrogen in patients with gynecological cancer undergoing COS. Laparoscopy oocyte retrieval, performed under regional anesthesia, can be performed in an ambulatory setting and should be considered an effective fertility preservation strategy in patients with large vaginal tumors.

Cost-effectiveness analysis of ovarian function preservation with GnRH agonist during chemotherapy in premenopausal women with early breast cancer.

Is it economically worthwhile to use GnRH agonist (GnRHa) to prevent menopausal symptoms (MS) and protect fertility in premenopausal women with breast cancer (BC) during chemotherapy from the US perspective? It is cost-effective to administer GnRHa during chemotherapy in order to forefend MS in premenopausal patients with BC when the willingness-to-pay (WTP) threshold is $50 000.00 per quality-adjusted life-year (QALY), and to preserve fertility in young patients with BC who undergo oocyte cryopreservation (OC), or no OC, when the WTP thresholds per live birth are $71 333.33 and $61 920.00, respectively. Chemotherapy often results in premature ovarian insufficiency (POI) in premenopausal survivors of BC, causing MS and infertility. Administering GnRHa during chemotherapy has been recommended for ovarian function preservation by international guidelines. Two decision-analytic models were developed, respectively, for preventing MS and protecting fertility over a 5-year period, which compared the cost-effectiveness of two strategies: adding GnRHa during chemotherapy (GnRHa plus Chemo) or chemotherapy alone (Chemo). The participants were early premenopausal women with BC aged 18-49 years who were undergoing chemotherapy. Two decision tree models were constructed: one for MS prevention and one for fertility protection from the US perspective. All data were obtained from published literature and official websites. The models' primary outcomes included QALYs and incremental cost-effectiveness ratios (ICERs). The robustness of the models was tested by sensitivity analyses. In the MS model, GnRHa plus Chemo resulted in an ICER of $17 900.85 per QALY compared with Chemo, which was greater than the WTP threshold of $50 000.00 per QALY; therefore, GnRHa plus Chemo was a cost-effective strategy for premenopausal women with BC in the USA. Probabilistic sensitivity analysis (PSA) results showed an 81.76% probability of cost-effectiveness in the strategy. In the fertility model, adding GnRHa for patients undergoing OC and those who were unable to undergo OC resulted in ICERs of $67 933.50 and $60 209.00 per live birth in the USA, respectively. PSA indicated that GnRHa plus Chemo was more likely to be cost-effective over Chemo when the WTP for an additional live birth exceed $71 333.33 in Context I (adding GnRHa to preserve fertility in young patients with BC after OC) and $61 920.00 in Context II (adding GnRHa to preserve fertility in young patients with BC who cannot accept OC). The indirect costs, such as disease-related mental impairment and non-medical costs (e.g. transportation cost) were not included. All data were derived from previously published literature and databases, which might yield some differences from the real world. In addition, the POI-induced MS with a lower prevalence and the specific strategy of chemotherapy were not considered in the MS model, and the 5-year time horizon for having a child might not be suitable for all patients in the fertility model. When considering the economic burden of cancer survivors, the results of this study provide an evidence-based reference for clinical decision-making, showing that it is worthwhile to employ GnRHa during chemotherapy to prevent MS and preserve fertility. This work was supported by the Natural Science Foundation of Fujian Province [2021J02038]; and the Startup Fund for Scientific Research, Fujian Medical University [2021QH1059]. All authors declare no conflict of interest. N/A.

Ovarian tissue cryopreservation can be combined simultaneously with oocyte retrieval after controlled ovarian hyperstimulation.

Can ovarian tissue cryopreservation (OTC) be performed after controlled ovarian hyperstimulation (COH)? Unilateral oophorectomy after transvaginal oocyte retrieval is feasible on stimulated ovaries during one surgical step. In the fertility preservation (FP) field, the timeframe between patient referral and start of curative treatment is limited. Combining oocyte pick-up with ovarian tissue (OT) extraction has been reported to improve FP but COH applied before OT extraction is not currently recommended. This retrospective cohort-controlled study involved 58 patients who underwent oocyte cryopreservation immediately followed by OTC between September 2009 and November 2021. The exclusion criteria were a delay between oocyte retrieval and OTC of >24 h (n = 5) and IVM of oocytes obtained ex vivo in the ovarian cortex (n = 2). This FP strategy was performed either after COH (stimulated group, n = 18) or after IVM (unstimulated group, n = 33). Oocyte retrieval followed by OT extraction on the same day was performed either without previous stimulation or after COH. Adverse effects of surgery and ovarian stimulation, mature oocyte yield and pathology findings of fresh OT were retrospectively analysed. Thawed OTs were analysed prospectively, for vascularization and apoptosis using immunohistochemistry, when patient consent was obtained. No surgical complication occurred after OTC surgery in either group. In particular, no severe bleeding was associated with COH. The number of mature oocytes obtained increased after COH (median = 8.5 (25% = 5.3-75% = 12.0)) compared to the unstimulated group (2.0 (1.0-5.3), P < 0.001). Neither ovarian follicle density nor cell integrity was affected by COH. Fresh OT analysis showed congestion in half of the stimulated OT which was higher than in the unstimulated OT (3.1%, P < 0.001). COH also increased haemorrhagic suffusion (COH + OTC: 66.7%; IVM + OTC: 18.8%, P = 0.002) and oedema (COH + OTC: 55.6%; IVM + OTC: 9.4%, P < 0.001). After thawing, the pathological findings were similar between both groups. No statistical difference in the number of blood vessels was observed between the groups. The oocyte apoptotic rate in thawed OT was not statistically different between the groups (ratio of positive cleaved caspase-3 staining oocytes/total number of oocytes equal to median 0.50 (0.33-0.85) and 0.45 (0.23-0.58) in unstimulated and stimulated groups respectively, P = 0.720). The study reports FP from a small number of women following OTC. Follicle density and other pathology findings are an estimate only. Unilateral oophorectomy can be successfully performed after COH with limited bleeding risk and an absence of impact on thawed OT. This approach could be proposed to post pubertal patients when the number of mature oocytes expected is low or when the risk of residual pathology is high. The reduction of surgical steps for cancer patients also has positive implications for introducing this approach into clinical practice. This work was made possible through the support of the reproductive department of Antoine-Béclère Hospital and of the pathological department of Bicêtre Hospital (Assistance Publique Hôpitaux de Paris, France). The authors have no conflict of interest to disclose in this study. N/A.

Timing of testosterone discontinuation and assisted reproductive technology outcomes in transgender patients: a cohort study

To determine if there is an association between the timing of testosterone discontinuation and assisted reproductive technology (ART) outcomes. Retrospectivse cohort study. Single academic center. We included consecutive transgender patients seeking fertility preservation between October 2019 and April 2021. Patients who identified as transgender on androgens for >1 month on presentation were included. None. A linear regression model was used to evaluate the effect of testosterone discontinuation duration on the number of mature oocytes retrieved. Eighteen patients (mean age 27.7 [SD 5.2] years, mean body mass index 27.3 [SD 4.6] kg/m2, mean antimüllerian hormone 27.2 [SD 11.8], median antral follicle count 20 [interquartile range (IQR) 14-32]) were included in the analysis. No patient underwent transition-related surgery (eg, oophorectomy, hysterectomy). None of the patients were previously pregnant. Mean time o,n testosterone was 44 (SD 29.6) months. The median time off testosterone until the start of ovarian stimulation was 7.7 weeks (IQR 4.3-20.7). All patients underwent oocyte cryopreservation except one who had embryo cryopreservation. The median total number of oocytes was 11 (IQR 7-14). The median number of mature oocytes was 7.5 (IQR 5-12) oocytes. The univariate regression model evaluating the duration of time off testosterone before ART demonstrated no significant association with the outcome of mature oocytes (regression coefficient, 0.19; 95% confidence interval, -0.13 to 0.50). In a retrospective analysis of transgender patients recently on testosterone undergoing ART, no association was detected between the timing of testosterone cessation and the number of mature oocytes.

The effect of aromatase inhibitor on controlled ovarian stimulation for oocyte cryopreservation in adolescent and young cancer patients.

To determine the impact of aromatase inhibitor (AI) use in oocyte cryopreservation among Japanese adolescent and young adult (AYA) cancer patients for fertility preservation, we evaluated the oocyte cryopreservation outcomes following AI therapy in combination with the follicular phase start (FPS) and random start (RS) protocols. This retrospective study included 81 cycles of controlled ovarian stimulation (COS) among 73 AYA patients with cancer who underwent oocyte cryopreservation to maintain fertility. The outcome measures were the total number of matured oocytes that were retrieved and cryopreserved, as well as their maturation rates. The AI (+) and AI (-) groups were compared using the RS and FPS protocols. Our results showed that the combined use of AI and COS decreases serum E2 levels and maintains the number of retrieved and cryopreserved mature oocytes. We also confirmed the efficacy of the RS protocol, which was found to have comparable outcomes to that of the FPS protocol in both AI (+) and AI (-) groups. The combined use of AI and COS is beneficial for oocyte cryopreservation in patients with estrogen-sensitive cancer, regardless of the menstrual cycle phase of COS initiation.

Transabdominal ultrasound-guided oocyte retrieval for oocyte cryopreservation using a vaginal probe: a comparison of applicability, effectiveness, and safety with conventional transvaginal approach.

We aimed to compare the feasibility, effectiveness, and safety of transabdominal ultrasound-guided oocyte retrieval (TUGOR) using a vaginal probe and traditional vaginal approach in virgin patients undergoing oocyte cryopreservation. A total of 116 virgin patients who underwent transabdominal ultrasound-guided oocyte retrieval using a vaginal ultrasound probe and 33 patients matched for BMI, antral follicle count, age, day 3 FSH, estradiol, and AMH who underwent vaginal approach were enrolled. Mean number of total oocytes collected, mean number of cryopreserved MII oocytes, duration of the procedure, duration of stimulation, mean gonadotropin consumption, mature oocyte ratio, and a modified follicle-oocyte index were compared between the groups. No statistical difference was found between the groups in mean number of follicles > 12mm (4.62 ± 4.54 vs. 5.44 ± 4.52), mean number of oocytes collected (4.44 ± 4.14 vs. 5.33 ± 4.52), mean number of cryopreserved MII oocytes (4.01 ± 3.67 vs. 4.53 ± 4.13), mean duration of the procedure (12.4 ± 1.2 vs. 13.4 ± 1.6min), mean days of stimulation (8.05 ± 1.91 vs. 8.35 ± 1.72days), mean gonadotropin consumption (1507.9 ± 475.3 vs. 1571.74 ± 404.6 units), mature oocyte ratio (0.78 ± 0.24 vs. 0.82 ± 0.26), and modified follicle oocyte index (0.86 ± 0.63 vs. 0.84 ± 0.19). In the TUGOR group, superficial epigastric artery injury occurred in two patients and resolved spontaneously. Transabdominal oocyte retrieval using a vaginal ultrasound is a safe, effective, and feasible method of oocyte retrieval in some selected patient groups.

Why are they not coming back? A single-center follow-up study on oncological women oocyte's storing for fertility preservation.

Oocyte cryopreservation is a valid option for female cancer patients to preserve fertility. The number of patients undergoing fertility preservation (FP) cycles has increased over the past years. Nevertheless, the rates of patients returning to use their cryopreserved material have shown to be considerably low, ranging from 5-8%, but significant data regarding the reasons of such low return rates are scarce. This study is a single-center follow-up retrospective study evaluating the return rate of oncological women who underwent FP at a tertiary care Fertility Center and assessing the reasons influencing the patients who did not return. Data about patients who returned to attempt pregnancy were retrieved from internal registries. Non-returned patients were assessed with a standardized phone survey investigating health condition, marital status and family projects, spontaneous conceptions, and the reasons why they had not returned to use their gametes. A univariate analysis between returned and non-returned patients was performed. Of the 397 patients who received counseling about FP, 171 (43.1%) underwent oocyte cryopreservation between 2001 and 2017. Nine (5%) died, and 17 (10%) were lost at follow-up. A total of 20 patients (11.7%) returned and 125 did not. In the non-returned group, 37 (29.6%) did not have a partner, 10 (8%) had a previous spontaneous conception, and 15 (12%) had recurrent malignancy at the time of follow-up. In the univariate analysis, younger age at freezing (31.8±6.2 vs. 35.2±4.7; p 0.018), lack of a partner (p 0.002), type of cancer (other than breast cancer; p 0.024) were the significant factors in the non-returned group. As for the personal reason for not coming back, patients mainly answered as follows: lack of a partner (29, 23.2%), the desire for spontaneous motherhood (24, 19.2%), previous spontaneous pregnancies after FP procedures (16, 12.8%), and still ongoing hormonal therapy for breast cancer (13, 10.4%). All patients confirmed their will to keep the storage of their oocytes. The impact of a cancer diagnosis on a woman's maternal desire, sentimental status and life priorities should be studied more thoroughly. Studies investigating hormonal therapy suppression in breast cancer patients seeking pregnancy should be encouraged. https://clinicaltrials.gov, identifier NCT05223764.

OR25-4 Active Testosterone Treatment Impairs In Vitro Fertilization (IVF) Outcomes in a Female Mouse Model for Gender-Affirming Testosterone with Improvement in Outcomes Following Cessation of Testosterone Treatment

Abstract Introduction The impact of testosterone (T) on reproductive potential is poorly understood. Masculinizing hormones have demonstrated mixed effects on ovarian histology and data on assisted reproductive outcomes are limited to small case series. There is consensus among major medical societies to encourage fertility preservation counseling prior to initiation of gender-affirming hormone care, however, it is uncertain whether a break in T treatment prior to undergoing oocyte cryopreservation is beneficial. We hypothesized that T treatment would not have an impact on IVF outcomes. Methods C57BL/6N female mice were implanted with silastic tubing with either 10 mg testosterone enthanate in ethanol (n = 20) or ethanol alone (n = 18) at 10 weeks of age. Four groups of C57BL/6N female mice were used in this study: 1) current T implant 2) current sham implant 3) T cessation 4) control cessation. Biweekly blood samples and vaginal cytology were undertaken to monitor T levels and estrous cycles. For groups 1 and 2, mice were stimulated twelve weeks following implantation. For groups 3 and 4, implants were removed after twelve weeks and mice were stimulated two weeks after explantation. All mice were stimulated with 0.2 mL intraperitoneal CARD HyperOva followed 48 hours later by 7.5 IU intraperitoneal human chorionic gonadotropin (hCG). Oocytes were collected 14 hours after hCG injection and fertilized in vitro with sperm from 12-week-old B6D2F1/J male mice. 2-cell embryos were transferred into the oviducts of pseudopregnant recipient females. The study was powered to detect a 25% difference in 2-cell embryos. Data were analyzed using Chi-squared and unpaired t-tests with Prism 9.0. Results All T treated mice ceased cycling within one week of implantation and developed clitoromegaly. The current T implant group had fewer total oocytes retrieved (17.00 vs 36.00; p &amp;lt; 0.0001), mature oocytes (13.00 vs 28.10; p = 0.0002) and 2-cell embryos (12.78 vs 26.90; p = 0.0007) as compared to the current sham implant group. There was no significant difference in maturity (76.47% vs 78.06%; p = 0.6937) or fertilization rate (75.16% vs 74.72%; p = 0.9161). Pseudopregnant females who had 2-cell embryos transferred from current T implant mice were less likely to have a live birth than those with transfers from current sham implant mice (25.00% vs 80.00%; p = 0.0196). In contrast, comparison of IVF outcomes in the T cessation group with corresponding control cessation group revealed no significant differences between total oocytes (22.30 vs 30.75; p = 0.0708), mature oocytes (20.80 vs 27.75; p = 0.1288), or 2-cell embryos (20.40 vs 27.38; p = 0.104). Conclusion In a mouse model of gender-affirming testosterone, active T treatment negatively impacted IVF outcomes. Improved outcomes following cessation of T treatment support reversibility of T impact on reproductive potential. Presentation: Monday, June 13, 2022 11:45 a.m. - 12:00 p.m.

P069: Characterisation of influencing parameters on oocyte quality preservation in a cohort of Hodgkin lymphoma patients

Background: Hodgkin lymphoma (HL) is the most frequent lymphoma in the young population. The standard of treatment is chemotherapy including alkylating agents known to affect fertility. Fertility preservation is usually proposed before treatment with oocyte cryopreservation as a reference. In different cohorts of healthy women, some factors are well known to have an impact on oocyte quality preservation such as age, anti-Müllerian hormone (AMH), body mass index (BMI). German Hodgkin Study Group (GHSG) distinguishes 3 prognostic groups: early, intermediate, advanced stages (respectively defined GHSG I, II, III in our study). In literature, the parameters influencing fertility preservation outcomes in HL are not clear, namely HL’s stage and inflammation. In this study we evaluated the impact of HL’s stage using GHSG criteria on fertility preservation outcomes. Methods: We performed a retrospective study on 79 women, with newly diagnosed and previously untreated HL who underwent oocyte cryopreservation between 2012 and 2021. The patients were extracted from a cohort of fertility observatory in Lille University Hospital. The primary outcome was the number of metaphase 2 oocyte retrieved (M2). Estradiol level at the ovulation induction and the ratio of M2/follicles >15mm were secondary outcomes. We compared fertility outcomes between two groups: early and intermediate stage (GHSG I+II) and advanced stage (GHSG III). We evaluated in univariate and multivariate analyses the following factors: AMH, BMI, use of hormonal contraception, age and C reactive protein (CRP). Results: The two groups (GHSG I-II and GHSG III) were comparable. In univariate analyses, AMH was the only statistically significant factor regarding the number of M2 (p<0,0001) and Estradiol level (p<0,0001). In multivariate analysis, GHSG score was not statistically significant concerning Estradiol level (p=0,5) contrary to AMH level (p<0,0001). Conclusion: In our study, AMH level is doubtlessly a factor impacting the quality of oocyte preservation. HL’s stage and inflammation do not seem to affect fertility preservation outcomes in the whole cohort. These results, based on the largest cohort of HL patients evaluating HL’s risk groups provide important information about expected cryopreservation outcomes. According to this study, oocyte cryopreservation should be considered even for patients with advanced HL’s stage.

The use of fertility preservation services for cancer patients: a single institution experience

To analyze the use of services regarding fertility preservation (FP) in cancer patients at a single institution. A retrospective cohort study. Academic medical center. A total of 208 FP referrals. None. Method of FP; time from referral to FP intervention. A total of 553 patients were referred to a reproductive specialist for FP in the setting of a medical diagnosis from 2011 to 2016. Of these, 208 patients satisfied the inclusion criteria and met with a reproductive specialist. Ninety patients underwent FP services. The average age at referral was 30.9 ± 7.9 years. Breast cancer (n=94, 45%) and leukemia/lymphoma (n=62, 30%) were the most prevalent cancer diagnoses. A 68.9% of patients underwent oocyte cryopreservation (n=62), 26.7% underwent embryo cryopreservation (n=24) and 4.4% underwent ovarian tissue preservation (n=4). The time interval from the referral to the FP intervention ranged from 1 to 810 days, with a median of 17 days. In the setting of a cancer diagnosis, most patients undergoing FP intervention underwent oocyte cryopreservation, were <35 years old, and underwent FP intervention in <30 days from referral. Whereas FP should ideally be initiated at the time of cancer diagnosis, all patients with a cancer diagnosis should be referred to a reproductive specialist and counseled on options for FP to preserve the optionality for the reproductive future they desire.

P-476 Why are they not coming back? A single-center follow-up study on oncological women oocyte's storing for fertility preservation

Abstract Study question Which is the return rate and which factors are responsible for the non-return in cancer patients who underwent oocyte cryopreservation for fertility preservation? Summary answer Return rate was 11.7%. Young age at freezing, lack of a partner and type of cancer were the main factors responsible for the non-return. What is known already Improvements in oncological early diagnoses and therapies have significantly increased the survival rates of patients, allowing clinicians to focus on long-term quality-of-life issues, such as access to motherhood. An extensive literature on the importance of fertility preservation (FP) has been produced thanks to the growing number of patients undergoing FP cycles over the years. Nevertheless, the rates of patients returning to use their cryopreserved material have shown to be considerably low, ranging from 5 to 8%. Significant data regarding the reasons that might explain such low return rates are still scarce. Study design, size, duration This is a single-center follow-up retrospective study that includes all women who underwent oocyte cryopreservation cycles for oncological purposes at referral University affiliated center, from January 2001 to December 2017. Participants/materials, setting, methods The database consists of 171 patients, among those 110 (64%) were diagnosed with breast cancer, 45 (26%) hematological cancer, 5 (3%) gynecologic cancer and 11 (7%) other cancers. Data about returned patients were retrieved from internal registries. Non-returned patients were assessed by standardized phone survey on health and marital status, family projects, spontaneous conceptions, and reasons why they had not returned to use their gametes. A univariate analysis between returned and non-returned patients was performed. Main results and the role of chance Among the 171 women who underwent oocyte cryopreservation, 9 (5%) died and 17 (10%) were lost at follow up. In the remaining 145-patient group, the mean age at freezing was 32.2±6.1 and at follow-up 38.2±6.7 years. A total of 20 patients (11.7%) returned to use their frozen material and 125 did not. In the non-returned group, 37 (29.6%) did not have a partner, 10 (8%) had a previous spontaneous conception and 15 (12%) had recurrent malignancy at the time of follow-up. In the univariate analysis, younger age at freezing (31.8±6.2 vs 35.2±4.7; p 0.018), lack of a partner (p 0.002), type of cancer (other than breast cancer; p 0.024) were the significant factors in the non-returned group. As for the personal reason for not coming back, patients mainly answered as follows: lack of a partner (29, 23.2%), desire of spontaneous motherhood (24, 19.2%), previous spontaneous pregnancies after FP procedures (16, 12.8%), and still ongoing hormonal therapy for breast cancer (13, 10.4%). Nonetheless all of them confirmed their will to keep the storage of their oocytes. Limitations, reasons for caution The study population consists of a limited number of patients from a single Italian Fertility Center. Since the Italian law limits ART access to heterosexual couples, this setting may limit any possible adaptation of the study to other countries, with different legislations. Wider implications of the findings The impact of a cancer diagnosis on a woman’s maternal desire, sentimental status and life priorities should be studied more thoroughly. Moreover, it is important to encourage studies investigating so long hormonal therapy suppression in breast cancer patients seeking pregnancy in order to reduce their time to pregnancy. Trial registration number na

P-673 GnRH Agonist Early Follicular Challenge Test as a Predictor of Ovarian Response in Short Antagonist Cycles for Fertility Preservation

Abstract Study question Does the response to GnRH agonist can be used to predict ovarian function in short GnRH antagonist cycles in women undergoing oocyte cryopreservation IVF cycles? Summary answer Response to a single GnRH agonist dose at the beginning of stimulation during short antagonist cycle can predict the outcome of the fertility preservation cycle What is known already There is a need for a reliable test for ovarian reserve. Gonadotrophin agonist stimulation test (GAST) is considered a valid marker for ovarian reserve but the test was never validated for short antagonist protocol. The reported dose for this test was 0.1 mg, however, from the vast experience with GnRH agonist triggering, it is now agreed that the optimal dose for GnRH agonist flare effect is 0.2 mg. Study design, size, duration A prospective observational study of fertility preservation cycles patient in an academic hospital setting. Seventy-four Short GnRH antagonist cycles that underwent an oocyte retrieval between 1 December 2020 and 1 January 2022. Participants/materials, setting, methods On day 2, blood was sampled for basal FSH, LH, and E2 measurements, followed by a subcutaneous injection of 0.2mg GnRH agonist as part of the initial ovarian stimulation. Twelve hours later blood sampling was repeated. E2 response was used as test parameter. The major outcome was the number of cryopreserved oocytes. Main results and the role of chance Participants were divided to groups according to Day 3 E2 to Day 2 E2 response (E3/E2 ratio) to lower and upper third percentiles (&amp;lt;3.32, n = 24 and &amp;gt;5.41, n = 25). Age (32.68 vs. 32.79, p = 0.965), total gonadotropin dose injected 3216.67 vs. 2773.42 IU p = 0.16) and day 3 FSH levels (7.39 vs. 7.16, p = 0.768) were not significantly different between groups. Ovarian response as measured by E2 levels on ovulation trigger (7879.72 vs. 17572.54 pmol/ml, p = 0.001) and number of M2 oocytes retrieved were significantly different (17.92 vs. 6.24, p &amp;lt; 0.001). Linear correlation between E3/E2 ratio and number of M2 oocytes was calculated (R = 0.48, p &amp;lt; 0.001). ROC curve analysis of E3/E2 ratio for more than fifteen M2 oocytes indicate AUC value of 0.82 (cutoff value of 4.22, p &amp;lt; 0.001, 84.6% sensitivity, 70.8% specificity) and for less than five M2 oocytes AUC value of 0.84 (cutoff value of 3.34, p &amp;lt; 0.001, 76.3% sensitivity, 73.3% specificity). The results suggest that the testing response to 0.2mg GnRH agonist positively correlates with treatment outcome of the current cycle. Limitations, reasons for caution Although all patients were tested for FSH levels for ovarian reserve, they were not tested for AMH levels. Wider implications of the findings The response to single GnRH agonist dose during short antagonist cycle can be used as another biomarker of ovarian reserve. This simple, widely available marker, which reflect the estradiol response of small follicles, might predict accurately the outcome of the specific cycle, and potentially used to adjust the treatment dose. Trial registration number NCT04973969

Effects of Chemotherapy on Fertility Preservation in Patients with Tumors of the Hematopoietic and Lymphoid Tissues

Fertility preservation is an important concern for young cancer patients. Oocyte or embryo cryopreservation prior to chemotherapy administration is desirable but often difficult for patients with hematopoietic and lymphoid tissue tumors. In this study, we examined the results of fertility preservation therapy in patients with hematopoietic and lymphoid tissue tumors. We retrospectively examined hematopoietic and lymphoid tissue tumors of five patients who underwent oocyte cryopreservation as a fertility preservation therapy after chemotherapy, at Showa University Hospital from February 2017 to September 2020. Eleven treatment cycles were administered (one of which was cancelled). The mean age of the patients was 28.6 years. The mean controlled ovarian stimulation duration for 10 cycles was 15.9 days, the mean total gonadotropin dose was 3705 IU, and the mean peak E2 was 502.8 (pg/mL). The mean number of eggs retrieved was 3.2, the mean number of mature oocytes was 2.1, and the mean maturation rate (mature oocytes/returned oocytes) was 70.7%. Fertility preservation procedures in the early period after chemotherapy may be viable because they allow for the acquisition of mature oocytes, even though the procedures may take longer and yield fewer oocytes.

Fertility Preservation for Adolescent and Young Adult Transmen: A Case Series and Insights on Oocyte Cryopreservation.

BackgroundThe opportunity for fertility preservation in adolescent and young adult (AYA) transmen is growing. Many AYA transmen desire future biologic children and are interested in ways to preserve fertility through oocyte cryopreservation prior to full gender affirmation, yet utilization of oocyte cryopreservation remains low. Additionally, standard practice guidelines currently do not exist for the provision of oocyte cryopreservation to AYA transmen. Our objective was to review our experience with oocyte cryopreservation in adolescent and young adult transmen in order to synthesize lessons regarding referral patterns, utilization, and oocyte cryopreservation outcomes as well as best practices to establish treatment guidance.MethodsThis is a case series of all AYA transmen (aged 10 to 25 years) who contacted, consulted or underwent oocyte cryopreservation at a single high volume New York City based academic fertility center between 2009 and 2021.ResultsForty-four adolescent and young adult transmen made contact to the fertility center over the study period. Eighty percent (35/44) had a consultation with a Reproductive and Endocrinology specialist, with a median age of 16 years (range 10 to 24 years) at consultation. The majority were testosterone-naive (71%, 25/35), and had not pursued gender affirming surgery (86%, 30/35). Expedited initiation of testosterone remained the most commonly cited goal (86%, 30/35). Fifty-seven percent (20/35) pursued oocyte cryopreservation. Ninety-five percent (19/20) underwent successful transvaginal oocyte aspiration, with a median of 22 oocytes retrieved and 15 mature oocytes cryopreserved. There were no significant adverse events. At time of review, no patient has returned to utilize their cryopreserved oocytes.ConclusionsOocyte cryopreservation is a safe fertility preservation option in AYA transmen and is an important aspect of providing comprehensive transgender care. Insights from referral patterns, utilization, and oocyte cryopreservation outcomes from a single center’s experience with adolescent and young adult transmen can be integrated to identify lessons learned with the goal of providing transparency surrounding the oocyte cryopreservation process, improving the education and comfort of patients and providers with fertility preservation, and easing the decision to pursue an oocyte cryopreservation cycle in parallel to gender-affirmatory care.