Presentation on theme: "McGill University Health Centre"— Presentation transcript:
1 McGill University Health Centre Hananel Holzer, MDMedical Director, MUHC Reproductive CenterMcGill University Health CenterDirector, REI Division, Dept. of Obstetrics & GynecologyMcGill University
2 A comprehensive approach for fertility preservation
3 Fertility preservation 713,220 new cases of female cancer were diagnosed in 2009 in the U.S. (Jemal 2009)Childhood cancers 1%. 122 new cases per million children (Skinner 2006)By 2010, one in 250 people will be a cancer survivor (Blatt 1999)80% of children and adolescents diagnosed with cancer become long-term survivorsOne of long-term side-effects of cancer therapy is premature gonadal failure – infertility
4 Ovarian reserveFemales born with a finite pool of oocytes ( Zukerman 1951)Challenged by Johnson, Tilly et al; 2004, 2005; Germ line stem cells
10 The effect of chemotherapy on the ovary is not “all or none” No. of surviving primordial follicles following exposure correlates inversely to dose of chemotherapy5001000150020002500mg/kgDose of CyclophosphamideNumber of PMF’s(p = )(Meirow et.al. Hum Reprod 1999)
11 (Meirow et al. Hum Reprod 2007) Cortical fibrosisFocal ovarian cortical fibrosisNo follicles in zone of fibrosis“Wedge shaped”- corresponds to the blood supply(Meirow et al. Hum Reprod 2007)
12 (Meirow et al. Hum Reprod 2007) Chemotherapy: Direct and indirect damageVascularinjuryCorticalfibrosisApoptosismedullacortex(Meirow et al. Hum Reprod 2007)
13 Loss of regulatory mechanisms Loss of local regulatory factors (AMH?)Accelerated recruitment of primordial follicles.Decreasing ovarian reserve
14 Chemotherapy Alkylating agents: Cyclophosphamide,ifosfamide, nitrosoureas, chlorambucil, melphalan, and Busulphannot cell-cycle specific, highest risk of ovarian failure.Antimetabolitesmethotrexate, bleomycin, 5-fluorouracil, actinomycin-D, mercaptopurine, vincristine)impact the cells of the metabolically active ovarian follicles , are considered to be low risk for gonadal dysfunctionPlatin - intermediate risk
15 chemotherapyWomen >40 years have a 90% chance of amenorrhea subsequent to multi-agent chemotherapyyounger patients 20% - 90%.All patients exposed to chemotherapy might have a diminished ovarian reservesignificant predisposition for developing premature ovarian failure. Infertility > 35 years.The estimated probability of early menopause was at least 25% at age 30 years (Letourneau , Cancer 2011)
16 Radiotherapy Direct damage to ovaries Damage to hypothalamic-pituitary axisDose dependent; total dose and fractionation scheduleAge dependent; size of primordial follicle poolRadiation field dependentCould also affect uterine function (M/C, IUGR, Premature deliveries)
17 Radiotherapyfor a given dose of radiation, the younger patients are, the later the onset of premature menopause.LD50 <2 Gy.the effective sterilising dose falls with increasing ageeffective sterilising doses are 20·3 Gy at birth, 18·4 Gy at 10 years, 16·5 Gy at 20 years, and 14·3 Gy at 30 years.model to reliably predict the age of ovarian failure after treatment with a known dose of radiotherapy (W Hamish B Wallace, Lancet 2005, International Journal of Radiation Oncology*Biology*Physics 2005)
18 Reproductive outcomeIn animal studies, the risks of M/C and of malformed fetuses after chemotherapy are high.In humans, no increases in fetal malformation or M/C after anticancer drug treatment.No higher risk of genetic or chromosomal abnormalities in offspring from parents that had been cancer survivors (Winther JF 2004)if conception occurs more than a year after cessation of the treatmentcancer treatment has mutagenic effects on the oocyte that are present in growing follicles and the risk of mutagenesis is related to the stage of oocyte development during exposure and the drug regime used. (Meirow 2005)
20 Fertility preservation Indications:Cancer patients before gonadotoxic treatmentOther diseases before gonadotoxic treatmentYoung patients with Turner syndrome, Fragile X premutation (FMR 1), GalactosemiaWomen in mid-thirties without partner ?
21 Options for fertility preservation Should be tailored according to:Patient’s ageType of diseaseSpread of the diseasePlanned treatmentTime availableWhether she has a partner(Holzer Tan 2005)
22 Options for fertility preservation Ovarian protection:Ovarian shieldingOvarian transposition prior to local radiotherapy:reduces dose to 5-15%patients <40LaparoscopyLocation depends on the planned radiation.Does not protect against chemotherapy.(Tulandi 2004)
23 Options for fertility preservation GnRH agonist acts to protect gonads during chemotherapy by preferentially steering cells into less active cell cycle stage with decline in response to chemotherapeutic agentsSimulating pre-puberty.Direct effect?Decreased perfusion?Young patients.(Blumenfeld 2007 ,Huser 2008)
24 Options for fertility preservation 3 meta-analyses were published:GnRHa are effective in preserving ovarian function and in reducing amenorrhoea (Clowse 2009, Ben Aharon 2010)only prospective randomized studies:odds ratio of 3.5 favouring the use of GnRHa.Higher rates of resumption of menses and ovulationNo improvement of pregnancy rates (Bedaiwy 2010)
25 Options for fertility preservation Some evidence that GnRHa has a protective effect.the final conformation is still awaited.GnRH antagnist – faster desensitization.Flare up effect; combined treatment? (Mardesik 2004 von Wolff 2011)The GnRHa could be used to induce ovulation in a stimulated cycle.Reduced tumour cell sensitivity to chemo in E+ cases ?
26 Options for fertility preservation Apoptosis inhibition:Ceramide – 2nd messenger signals apoptosisSphingosine 1 phosphate (S1P) ceramid antagonistInteresting and promising; still far from clinical implementation(Morita, Paris, Perez, Tilly et al 1999,2000, 2002)
27 Cryopreservation for fertility preservation Transplantation of whole intact ovary by vascular anastomosisWang et al Nature 2002;Imhof et al 2006; Bedaiwy et al 2007Huge technical challenge, perfusion of the cryoprotectantIn theory, risk of cancer cell transmission
28 Options for fertility preservation: Cryopreservation of ovarian tissue Available for pre- and post-puberty patientsHundreds to thousands of primordial follicles may be preserved.No medical delay.No ovarian stimulation.Does not require a male partnerAt least 2 surgical procedures (+ IVF)Anesthesia- risksTheoretic risk of neoplastic cells in transplanted tissue – recurrence?
29 Risk of presence of neoplastic cells in the transplanted tissue Subclinical involvement of Hodgkin’s Lymphoma has not been identified in ovarian tissue (Seshadri Gook et al 2006)detection of Hodgkin lymphoma within ovarian tissue taken at the time of harvest for cryopreservation. (Bittinger 2011)58 patients with hematological malignancies underwent ovarian tissue cryopreservationafter thawing, markers to detect minimal residual disease usedreal-time RT-PCR positive in one patient with CML.this alarming result avoided tissue transplantation (Meirow et al 2008)Positive markers of CML and AML in cryopresrved harvested ovarian tissue (Dolmans 2010)
30 Risk of presence of neoplastic cells in the transplanted tissue Other organ transplants: donor derived malignancy ( Kauffman 2002, Ison 2011 AM J Transplant)Extreme caution is warranted before we assume that we understand tumour biology well enough to estimate the risk of transmission of malignant cells in autotransplanted ovarian cortex.BRCA 1&2 carriers - potential of developing ovarian cancer (Colgan 2001)Prophylactic BSO, transplant ovarian fragments?
31 Options for fertility preservation: Cryopreservation of ovarian tissue Loss of follicles during transplantation and initial ischemia. Absence of inhibitory mechanism? Longevity of the graft?14 pregnancies and live births reported :Donnez, Meirow*Rosendahl* (6 pregnancies,3 live births, 2 women)/12 cases.Demeestere (OTx2)*IVFBias due to selective reporting?
32 Options for fertility preservation: Cryopreservation of ovarian tissue Culture and IVM of primordial follicles: 2 step culture system: culture of tissue followed by isolation of follicles and culture. Or using 3D supportive matrix. Culturing to MII is the next chalange (Abir et al. Histol. Histopatho 2006 Picton et al. Reproduction 2008, Tefler et al. Hum Rep. 2008, Woodruff 2009)Suspension of isolated primordial follicles (Dolmans et al 2008)Xenotransplantation: human ovarian tissue to SCID mice. Aberrant microtubule and chromatin patern. Transmission of pathogens, short life span ethical issues, and … ( Lucifero 2002, Kim 2001)
33 Embryo cryopreservation Integral part of IVF programs >25 yearsSuccess rates 30-50% per embryo transfer, depending on the age at the time of oocytes retrieval.Only well-established option of fertility preservationPost pubertal patients.Partner requiredDonor sperm?
34 No male partner: Oocyte cryopreservation 1st live birth 1986 (Chen et al)But:oocytes vulnerable to freezing processintracellular ice formationmembrane rupture, abnormal cortical granule reaction, zona hardening, meiotic spindle and cytoskeleton damage: 5 live births
35 No male partner: Oocyte cryopreservation Using PROH/sucrose slow freezing protocol and introduction of ICSI improved pregnancy rates (Porcu et al 1997)Reported survival rates for mature oocytes (collected from stimulated ovaries) are 50-70%
36 Oocyte vitrificationCryoprotectants in high concentration used to induce glasslike state, cell then rapidly frozen avoiding formation of intracellular iceKuleshova et al, 1999: survival rate 65%, PR/ET 21%Yoon et al, 2003: survival rate 69%, implantation rate 6.4%, PR/ET 21.4%Katayama et al, 2003: survival rate 94%, PR/ET 33%
37 Oocyte vitrification165 live births (Chian et al ASRM 2007: McGill Reproductive Center in Canada, Instituto Mexicano de Infertilidad in Mexico and CECOLFES in Colombia)A few thousand babiesVitrification is emerging to be a better technique.
38 Embryo or oocyte cryopreservation after ovarian stimulation Pregnancies reported are result of fertilization of frozen/thawed oocytes collected after ovarian stimulationHowever:time interval needed for ovarian stimulation 2-6 weeks.Starting during menstruationTime may not be available for cancer patientsRecent studies: stimulation luteal phase. (Von Wolff 2009, Sonmezer 2011)ovarian stimulation associated with high estrogen levels which may not be safe in cases of hormone sensitive tumors such as breast cancerEstrogens may have an indirect mitogenic effect on receptor negative cancers. (Gupta PB 2006)
39 Embryo or oocyte cryopreservation after ovarian stimulation Aromatase inhibitor + FSH:letrozole started 2 days before FSH administration, then given concomitantly, no increased risk of relapse (Oktay 2005, 2007, Azim 2008)Lower estradiol levelsdoes not totally avoid stimulationEarly follicular start of treatment.More studies are needed
40 Collection of immature oocytes from unstimulated ovaries Pincus, J Exp Med 1935; Edwards, Nature, 1965,1969.Cha et al,1991: Immature oocyte laparotomy for oocyte donationTrounson et al, 1994: IVM: vaginal collection of immature oocytes, for PCO related infertility
43 Mature oocytes at oocyte collection in IVM cycles 8mm12mm14mm
44 Vitrification of IVM oocytes? Could oocytes collected from unstimulated ovaries, matured in vitro, then vitrified survive thawing and be fertilized?Could transfer of these embryos result in a viable pregnancy ?
45 Vitrification of IVM oocytes No. of patients20Mean age30.7 ±3.7No. of mature oocytes retrieved7No. of immature oocytes retrieved295Mean oocyte maturation rate (%)No. of oocytes vitrified and thawed215No. of oocytes survived (mean % + SEM )148 ( )No. of oocytes fertilized (mean % + SEM)96 ( )No. of embryos transferred (median; range)64 (3.2; range 1 - 6)No. of implantations (mean % + SEM)5 ( )No. of clinical pregnancies (%)4 (20.0)No. of live births (%)4 (20)Holzer et al ESHRE 2007
46 ConclusionsVitrification of in-vitro matured oocytes collected from unstimulated ovaries followed by later thawing and fertilization can result in successful pregnancies and live births
47 Conclusions Preliminary results 20 patients, all with PCO 20% pregnancy rate (vs. 35% in “Fresh IVM” )Lower implantation rate (10.8% vs. 14.4%)Learning curve?
48 ConclusionsCollection of immature oocytes from unstimulated ovaries followed by IVM and vitrification of mature oocytes could be offered to patients with hormone-sensitive disease and/or when there is not enough time to stimulate ovariesno risk of aggravating diseaseno theoretic risk of re-instituting metastatic malignant diseasedoes not require same amount of time as that needed for ovarian stimulation, no need to wait for next cycle
49 When ovarian tissue is being harvested Additional strategy of fertility preservation combines ovarian tissue cryobanking with retrieval of immature oocytes from excised ovarian tissue, followed by in vitro maturation (IVM) and vitrification (Huang, Tulandi, Holzer, Tan, Chian Fertil Steril 2007)When surgery performed to remove ovarian tumor or for other therapeutic indications
50 Fertility preservation in prepubertal children Childhood and adolescence period of emotional and psychological instability; issues of sexuality, including fertility, are of particular importanceDepletion of primordial oocytes after gonadotoxic treatment proportional to size of oocyte poolYounger patients have more oocytes; thus gonadal damage could seem to be less severe than in older patients
51 Fertility preservation in prepubertal children Global incidence of acute ovarian failure in childhood cancer survivors ranges from 6.3 to 12% (Bakker 2004)In Childhood Cancer Survivor Study ;the relative risk for survivors of ever being pregnant was 0.81 (Green DM 2009)Very few treatments benefit younger patients at risk of infertility after treatment
52 Fertility preservation in prepubertal children; Ovarian tissue cryobanking Primary method of fertility preservation for prepubertal girlsOne ovary removed from 47 patients aged y (median: 5)Ovarian tissue fragments frozenstrong inverse correlation found between age and follicular densitynone of the cases had visible ovarian tumour components (Poirot 2007)58 patients years, underwent ovariantissue cryopreservation.1 case of ovarian lymphoma infiltration (Jadoul 2010)
53 Fertility preservation in prepubertal children: Combined approach Unilateral oophorectomy: 19 patients aged 5-20 years (median 15 yrs.)Antral follicles aspirated, average no. of oocytes: 9 (0-37)GV oocytes – IVMmature oocytes – frozenOvarian tissue – cryopreserved in fragments(Revel 2008)
54 Fertility preservation in prepubertal children: Ovarian tissue cryobanking Reimplantation of ovaries cryopreserved before puberty not yet performed in either nonpubertal or pubertal recipientsAnimal models: puberty and fertility restored (Sauvat 2008)Removal of entire ovary, although strongly advocated by some, may not be recommended for pediatric patients in whom fertility outcome is often uncertain.How much? Based on the risk of the planned treatment and the ovarian volume.
55 Fertility preservation in pre-pubertal children Fertility preservation should now be considered in children facing cancer treatment with high risk of gonadal toxicity, including high-dose chemotherapy and bilateral irradiation of gonads at toxic dosesMultidisciplinary team
56 McGill Fertility Preservation Center: Catchment Area Greater MontrealQuebecOther Canadian provincesUSATrance AtlanticPhysicians: Oncology, Haematology, Radiation Oncology, Surgery, Paediatrics.Nurses: nursing coordinators.Non- medical professionals, self referrals
57 Accessibility Available and accessible:” next day appointment” policy. Reciprocal: referring physician should be available, take part in planning.Counsellor onsite or available via phone, Skype, webcamOn-going collaboration, individual casesBy-pass, current “road blocks” of the medical system.Medico legal issues
58 Issues discussed with treating physician Treatment: drugs, dose.Time frame- coordinate treatments and tests.Survival?Risks of:StimulationCollectionAnaesthesia.
59 Appointment at the fertility preservation center Long term follow upUS (AFC)FSH AMHConsultationCounselling2nd collectionLuteal collectionAdditional cycleTreatmentOocyte CPEmbryo CPOvarian tissue CPGnRH-aFollow upNursing consultationDiscuss and teach planned treatmentDraw blood testsFeedback to physicianConsultation review of all options, tailored optionsGnRH analogDo nothing3rd partyOvarian tissueOocyte (IVF/IVM)Embryo (IVM/IVM)Appointment at the fertility preservation centerHistory taking (Fellow)Ultrasound (AFC, cycle stage)Initial contact secretaryInformationScheduleTREATINGPHYSCANCOUNSELLING
60 McGill Fertility Preservation Center 396 women with various malignancies underwent oocyte retrieval184 underwent oocyte retrieval without ovarian stimulation followed by IVM :113 IVM cycles with vitrification of oocytes71 IVM cycles, matured oocytes fertilized, resulting embryos vitrified
61 McGill Fertility Preservation Center 212 women underwent ovarian stimulation:156 stimulation cycles, mature oocytes vitrified56 stimulation cycles, mature oocytes fertilized and resulting embryos vitrified
62 Disease Categories for those who Froze Oocytes/embryos Type of CancerN=183Breast cancer75Hematological malignancies47Brain malignancies15Gynecological cancers14Sarcoma11Desmoid Tumour5Autoimmune disease9Melanoma1Colorectal cancerGIT Malignancymean age = 29.7, SD =±5.6
63 ConclusionsCurrent methods of fertility preservation should be considered as investigationalPatients and their families should be advised about experimental nature of processCancer treatments should NOT be compromised
64 ConclusionsFertility preservation is of utmost importance to patients and families of patients undergoing potentially gonadotoxic treatmentWe provide option to try to preserve fertility potentialThis hope alone may help in struggle to overcome the disease
65 Proper counseling and shared decision making Fertility preservation center
66 C.K.N: Cancer Knowledge Network. http://multimed.current-oncology.com ICRF: Israel Cancer Resreach Fund