|Year : 2018 | Volume
| Issue : 2 | Page : 111-121
Proceedings of the fertility preservation – 'Technique and Technology' 2nd congress of the ASFP & FERTIPROTECT 2018 (5th annual conference of the FPSI)
|Date of Web Publication||22-Feb-2019|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Proceedings of the fertility preservation – 'Technique and Technology' 2nd congress of the ASFP & FERTIPROTECT 2018 (5th annual conference of the FPSI). Onco Fertil J 2018;1:111-21
|How to cite this URL:|
. Proceedings of the fertility preservation – 'Technique and Technology' 2nd congress of the ASFP & FERTIPROTECT 2018 (5th annual conference of the FPSI). Onco Fertil J [serial online] 2018 [cited 2019 May 21];1:111-21. Available from: http://www.tofjonline.org/text.asp?2018/1/2/111/252695
| Oral Presentations|| |
| OP 1: Current awareness and practice towards fertility preservation in a developing country: A nationwide survey for oncologists in Indonesia|| |
Sarrah Ayuandari, Budi Wiweko1, Hindun W. Wahab, Ismi W. Rianti, Regina Arumsari, Nurida Khasanah, Diannisa I. Enisar Sangun, Agung Dewanto
Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, 1Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
Background: In Indonesia - as a developing country, further action must be taken to establish fertility preservation (FP) units. This study was conducted as a comprehensive evaluation on the awareness and the practice of oncologists towards FP.
Methods: A nationwide internet survey was filled by the specialists who provided medical care towards cancer patients at hospitals or clinics. The participants (n = 89), with different specialties, were representatives from 4 different islands in Indonesia. The questionnaire assessed knowledge, attitude, awareness and perspective regarding fertility preservation.
Results: Sixty out of 89 specialists (59%) performed chemotherapy and/or radiotherapy on a daily basis. Of those specialists, 30.7% mainly prescribed Cyclophosphamide as the chemotherapeutic agent, and unfortunately 47.6% did not know that Cyclophosphamide has a high risk of gonadotoxicity. Many participants who performed cancer therapies (41%) rarely or never discussed the fertility issue with their patients compared to those who discussed (P < 0.05). Moreover only 30% provided written information about infertility risk to their patients. Meanwhile 61% rarely or never consulted and referred their patients to fertility experts for FP management (P < 0.05). Those who discussed the risk of infertility with the patients had greater odds of consulting and referring patients to a fertility consultant for further FP management (OR = 8.98, 95% CI, P < 0.05). Furthermore 90.6% of the respondents agreed that fertility preservation programs should be offered best to adolescent and reproductive age patients who are planned to receive high risk chemo/radiotherapy.
Conclusion: In Indonesia, fertility issues are less likely to be discussed. Additionally, these results suggest that specialists who are more likely to discuss fertility issues might consult more to the fertility expert for the possibility of further FP management. Therefore, based on these results, increasing awareness on fertility preservation is immensely required.
| OP 2: Recuperative effect of nesfatin-1 in the testicular physiology and improved fertility during type 2-diabetes condition in mice|| |
Ashutosh Ranjan, Amitabh Krishna
Department of Zoology, Banaras Hindu University, Varanasi, Uttar Pradesh, India
Introduction: Recent investigation has reinforced and validated the nesfatin-1 as an adipokine principally involved in whole body energy homeostasis. It imparts several physiological role including puberty onset, sleep, stress regulation, behavior response, reproduction etc. This study was aimed to evaluate the effect of nesfatin-1 in the regulation of testicular physiology in the diabetic mice.
Methods: The diabetic mice were treated intraperitoneally for 14 days (SD) with 1.25nM/gbw nesfatin-1. The serum and testis was used for the further investigation.
Results and Discussion: The treatment produced significant changes in the spermatogenesis and steroidogenesis activity in the diabetic mice. Nesfatin-1 treated diabetic mice showed increased proliferation of germ cells as indicated by increased accumulation of spermatocytes and round spermatid in the seminiferous tubule. Nesfatin-1 treatment increases the testicular expression of Proliferating Cell Nuclear Antigen (PCNA) and B-Cell Lymphoma-2 (BCL-2) expression compared to diabetic control group mice, which further support the importance of nesfatin-1 in germ cell proliferation, their survival and spermatogenesis. The diabetic mice treated with nesfatin-1 showed significant increase in testosterone synthesis compared to diabetic control mice due to stimulatory effect of nesfatin-1 on testicular 3 beta HSD activity and increased expression of Steroidogenic Acute Regulatory protein (StAR) and Luteinizing Hormone (LH-receptor) proteins. In addition, nesfatin-1 treatment also showed increased glucose transport by increasing the expression of glucose transporter (GLUT-8) and insulin receptor (IR) proteins in the testis. This study further explored the increased production of testosterone may be mediated via increased production of nitric oxide.
Conclusion: Altogether, the study suggests the stimulatory role of nesfatin-1 in the regulation of testicular steroidogenesis and spermatogenesis, including testicular metabolism in diabetic mice and may be utilized as a therapeutic strategy for the management of fertility.
| OP 3: The activity of oncofertilty in Gifu University Hospital|| |
Motoki Takenaka, Tatsuro Furui, Akio Yamamoto, Keiko Terazawa, Ken-Ichirou Morishige
Department of Obstetrics and Gynecology, Gifu University Graduate School of Medicine, Gifu, Japan
Introduction: We have started local oncofertility network in Gifu prefecture, Japan, named GPOFs in January 2013. GPOFs is the 1st regional Oncofertility Network in Japan. To assess how this network contribute for the regional oncofertiility, we reviewed of young cancer patients who visited our oncofertility clinic via GPOFs system.
Methods: We assessed referral and fertility preservation provided in our clinic between January 2013 and December 2017. Cancer patients basically under 40 years old who want further information about oncofertility and/or fertility preservation, were referred to our clinic by oncologists in Gifu prefecture and the surrounding area via GPOFs system.
Results: Two hundread and one (138 women, 63 men) patients visited our clinic including 79 breast, 12 hematological and 47 other malignancies in women, and 32 hematological, 13 testicular, and 18 other malignancies in men. Eighty-seven (42 women, 45 men) patients wished some reproductive treatment after informed consent and 72 (39 women, 33 men) patients were received; 14 embryo cryopreservation, 10 oocyte cryopreservation, 6 ovarian tissue cryopreservation, 6 hormone replacement therapy, 3 gynecological operation in women, and 33 semen cryopreservation in men. 114 patients received counseling without any reproductive procedures.
Discussion: Many young cancer patients were referred to our clinic via GPOFs system and this system may support both oncologists and patients in this area. Many of women received counseling only, which might mean our clinic could help young cancer patients to consider and decide fertility preservation by themselves before cancer treatment. Although, there are 20 of these kind of regional network out of 47 prefectures in Japan at April 2018. It should be necessary to spread in more area in Japan.
Conclusions: GPOFs contributes to progress of regional oncofertiility.
| OP 4: Fertility preservation in female cancer patients presenting at a Tertiary Care Centre: A retrospective study|| |
Reeta Mahey, Monica Gupta, Neena Malhotra, Chithira Vignarajan
Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, New Delhi, India
Introduction: Advances in diagnostic technology and highly efficacious oncological treatment has enabled identification of young cancer patients at early stage and improved life expectancy. A crucial issue in these patients is early referral for fertility preservation (FP) balancing the risks of delayed initiation of cancer treatment and worsening of disease with methods employed for fertility preservation.
Methods: Retrospective review of 21 female cancer patients presenting for FP at a tertiary care centre (2013 to 2018). Seven patients were unable to have any fertility preserving procedure due to financial constraints or late referral or less time between any fertility preservation and start of chemotherapy.
Results: Among 14 patients who opted for FP, five had gynecological malignancy [borderline ovarian tumour (2), endometrial cancer (1), atypical endometrial hyperplasia (1), cervical cancer (1)] and 9 had non gynecological malignancy. Most common indication in non gynecological cancer was breast cancer (7). Most patients 10/14 (71%) were married and underwent embryo cryopreservation and 4 underwent oocyte cryopreservation. Mean age of patients was 28.6±3.2 years. AMH (ng/ml) in patients with gynecological malignancy was 3.4±2.86 and in non gynecological malignancy was 3.3±1.35. Mean number of oocytes retrieved in patients with gynecological malignancy was 3±2.1 and in patients with non gynecological malignancy was 8.6±7.7. Two patients one of carcinoma endometrium and another of breast cancer underwent frozen embryo transfer after completion of cancer treatment. The patient with breast cancer conceived and is ongoing at 8 months pregnancy.
Discussion and Conclusions: The option of FP should be offered to all the patients before going for gonadotoxic therapy. The ovarian stimulation can be started any time irrespective of the previous cycle. Oocyte yield is comparatively less in gynaecological cancers as compared to patients with no-gynecolgical cancers.
| OP 5: Safety management in the oocyte cryopreservation for patients of hematologic disease with severe thrombocytopenia|| |
Kosuke Shigematsu, Yasushi Takai, Shunichiro Ichinose, Yukiko Itaya, Yoshihisa Ono, Shigetaka Matsunaga, Masahiro Saitou, Kazunori Baba, Hiroyuki Seki
Department of Obstetrics and Gynecology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
Introduction: Many patients with hematological disorders have thrombocytopenia, and frequently require blood transfusion as well as chemotherapy. Therefore, severe thrombocytopenia, which increases the risk of hemorrhage, are often experienced during oocyte cryopreservation for fertility preservation. Here we report three cases which required platelet transfusion before oocyte retrieval and cryopreservation.
Cases: Case 1 – A 31-year-old myelodysplastic syndromes (MDS) case, who was transfused with 30 units of platelet concentrate 1 day before oocyte retrieval. Case 2 – A 22-year-old aplastic anemia case, who was transfused with 20 units of platelet concentrate 1 day before oocyte retrieval. Case 3 – A 18-year-old MDS case, who was transfused with platelet concentrate 1 day before and on the day of oocyte retrieval.
Results: In these 3 cases, random-start controlled ovarian stimulation with GnRH antagonist was performed according to the level of anti-Müllerian hormone. Platelet counts more than 50,000/µL was confirmed before egg retrieval, which was uneventfully performed, and 21, 7, and 3 (mature oocytes were cryopreserved. We also used 20G oocyte retrieval needle in order to prevent hemorrhage, while checking the blood vessels under transvaginal ultrasound guidance.
As a result of collecting blood.
Conclusion: Hematologic disease with severe thrombocytopenia, oocyte retrieval could be safely performed under platelet transfusion and proper procedures.
| OP 6: Endometriosis a new epidemic In women with infertility: A cry for fertility preservation|| |
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Endometriosis is one of the most common diseases encountered in gynaecological outdoors, and increasing evidences suggest it to be a part of uterine reproductive dysfunction syndrome. It is a common condition, affecting up to 10% of women. It is a chronic disease, which is characterized by the presence of functional endometrial glands and stroma outside the uterine cavity with locally invasive characteristics. 30–50 % women with endometriosis are infertile, while 25–50 % of infertile women have endometriosis.
Objective: (1) To study the prevalence of advanced disease, clinical, ultrasonographic features of endometriosis in infertile women. (2) To see the response with medical management.
Study Design: This is a hospital-based prospective study. 410 women from July 2012 to 2017 who attended the out-patient department for infertility or sub-fertility were recruited. A detail history, routine investigations and ultrasonographic evaluation was done.
Results: 58 women (14%) were found to have advanced disease. They were either diagnosed earlier by laparoscopy or had severe symptoms and wanted conservative management. Though advanced disease was found in only 14 % of infertile women in our study, more than 30 % had the complaints of menorrhagia, dysmenorrhoea, dyspareunia and chronic pelvic pain as presenting complaints. The management course and outcome would be discussed in detail in the presentation.
Conclusion: Diagnosis and management of endometriosis is a challenge for a gynecologist. As the late diagnosis or inappropriate management can have adverse fertility outcomes in these women.
| OP 7: Vitrification of ovarian tissue prior to neoadjuvant chemotherapy for breast cancer: A case report|| |
Jasneet Kaur, Nalini Mahajan, Surleen Kaur
Mother and Child Hospital, New Delhi, India
Introduction: Ovarian tissue cryopreservation (OTC), though nascent has resulted in over 100 live births. It is the only option available for fertility preservation in pre pubertal girls and post pubertal patients in need of urgent gonadotoxic therapy. Live birth rates of 25%–31% have been reported, majority using slow freezing which is associated with significant cryodamage. Lately few studies have suggested vitrification to be equivalent or rather superior to slow freezing.
Case Report: A 25 years old female, ML 9 months k/c/o of PCOS with grade III invasive ductal breast carcinoma, ER, PR, Her2neu negative, negative for BRCA1 & 2 planned for neoadjuvant chemotherapy was referred for fertility preservation. Available options were discussed and she wanted OTC prior to chemotherapy.
Methodology: After appropriate consent, unilateral laparoscopic resection of sufficient ovarian cortical tissue was done using scissors. Ovarian tissue was washed in saline solution and kept in HEPES flushing media. Small antral follicles were aspirated from ovarian cortical surface with 22G needle/1 mL syringe. COCs obtained were vitrified. Ovarian cortex was then stripped off from the medulla and cut into thin strips measuring 10*10*1 mm. These ovarian strips were then placed into three pertidishes containing equilibrium solution (Kitazato Ova Cryo Kit Type M) with increasing concentration of cryoprotectant over a period of 25 min at 26 degree celsius. Subsequently, ovarian tissue was placed on a gauze piece to remove excess of media. Ovarian strips were then gently mounted onto the cryotissue holder (Kitazato) allowing maximization of its surface area and plunged into liquid nitrogen using tweezers, screwed on tightly, and stored in an assigned canister. After successful vitrification, cortical strips became glassy in appearance while failed vitrification is characterized by the crystalline white appearance of the ovarian tissueSmall pieces of ovarian cortex were sent for HPE before vitrification and showed the presence of abundant primodial follicles.
Discussion: Recent studies have proposed that vitrification causes less primordial follicular DNA strand breaks and a better preservation of stromal cells. Lack of standardization in the technique with regards to the ideal concentration and composition of the cryoprotectant, equilibration time and thawing solution suggests a need for further validation of the technique. We are however eagerly awaiting the thawing results of the cryopreserved ovarian tissue.5,6,7,8
- Shi Q, Xie Y, Wang Y, Li S. Vitrification versus slow freezing for human ovarian tissue cryopreservation: A systematic review and meta-anlaysis. Sci Rep 2017;7:8538.
- Amorim CA, Curaba M, Van Langendonckt A, Dolmans MM, Donnez J. Vitrification as an alternative means of cryopreserving ovarian tissue. Reprod Biomed Online 2011;23:160-86.
- Kagawa N, Kikuchi I, Kuwayama M. Ovarian Tissue Vitri Cation for Fertility Preservation. Vitrification in Assisted Reproduction. India: Springer; 2015. p. 43-9.
- Suzuki N. Ovarian tissue cryopreservation and transplantation using thawed ovarian cortex for fertility preservation. Onco Fertil J 2018;1:3-8.
| OP 8: The pubertal transition impacts egg quality parameters in the mouse|| |
Atsuko Kusuhara, Takayuki Haino, Luhan T. Zhou1, Allison R. Grover1, Sarah R. Wagner1, Teresa K Woodruff1,2, Aikou Okamoto, Francesca E. Duncan1
Department of Obstetrics and Gynecology, Jikei University School of Medicine, Tokyo, Japan, 1Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, 2Department of Molecular Biosciences, Weinberg College of Arts and Sciences, Northwestern University, Evanston, IL, USA
Introduction: Fertility preservation options are important for pediatric cancer patients. Recent improving reproductive technologies, such as ovarian tissue cryopreservation and in vitro maturation (IVM), makes young girls to have a chance to preserve their fertility. Egg quality dictates fertility outcomes, and there is a well-documented decline that occurs with advanced reproductive age that contributes to infertility, miscarriages, and birth defects. However, how egg quality changes at the other age extreme of the pubertal transition is less understood.
Methods: We established a mouse model of the pubertal transition that spans postnatal day (PND) 11 to PND40. In this model, animal weight and the incidence of vaginal opening increased across the age spectrum, and serum levels of inhibin B, a marker of gonadal maturation, increased after PND11-15. Together these results validate the pubertal transition model, which we then used to systematically evaluate egg quality parameters.
Results: Both oocyte yield and diameter increased across puberty, and there was an age-associated acquisition of meiotic competence, or the ability of oocytes to resume meiosis and reach metaphase of meiosis II (MII) following in vitro maturation (IVM). The meiotic spindle was analyzed in mature eggs following IVM. The spindle-to-cytoplasmic volume ratio decreased across the pubertal transition, and eggs from the youngest age cohort (PND16-20) had a higher incidence of chromosome configuration abnormalities relative to the other ages. Analysis of ovarian tissue histologic sections across the pubertal transition revealed that oocytes from the youngest cohort of mice were derived from the smallest antral follicles with the least number of cumulus layers per oocyte.
Conclusion: Understanding egg quality during this developmental period has important clinical implications because mature eggs from prepubertal and adolescent girls obtained through ex vivo IVM are cryopreserved in the fertility preservation setting.
| OP 9: Surrogate pregnancy after percutaneous oocyte retrieval following modified radical hysterectomy with left salpingo-oopherectomy and right ovarian transposition to anterior abdominal wall - First in India|| |
Priya Selvaraj, Kamala Selvaraj, Vijaya, Kalaichelvi, Mahalakshmi
GG Fertility and Women Speciality Centre, Chennai, Tamil Nadu, India
Objective: To evaluate the outcome of an IVF procedure and subsequent pregnancy in a patient, post modified radical hysterectomy with left salpingo-oopherectomy and right ovarian transposition to anterior abdominal wall (subcutaneous plane) for endometrial adenocarcinoma grade II.
Design: Case report.
Setting: GG Fertility and Women’s Specialty hospital, Chennai (tertiary care and referral center).
Patient(s): A 30-year-old woman, known case of PCOS, who underwent modified radical hysterectomy with left salpingo-oopherectomy and right ovarian transposition to the anterior abdominal wall at a hospital in Kerala. She then visited us for IVF and surrogacy in the year 2016.
Intervention(s): Three cycles of IVF were performed using antagonist in first two attempts and analog in third attempt, with percutaneous technique of oocyte retrieval from the transpositioned right ovary located in the right subcutaneous plane of the abdominal wall. The procedure was deemed successful when in the third attempt in July 2017, short protocol was employed and we were able to freeze three embryos and one blastocyst. The surrogate underwent sequential transfer in June 2018 which resulted in a positive clinical pregnancy (single).
Main Outcome Measures: The outcome of IVF, post hysterectomy with right ovarian transposition, and percutaneous oocyte retrieval.
Results: A successful pregnancy corresponding to 10 weeks of gestation.
Conclusion: This is possibly the first reported case of ovarian hyperstimulation and percutaneous aspiration of oocytes from a transpositioned right ovary (subcutaneous plane). Literature survey showed published case reports of transabdominal aspiration for retrieval but none using percutaneous technique resulting in a successful pregnancy.
| OP 10: Fertility preservation in a premenarcheal female with sickle cell anemia|| |
Artemis Health Institute, Gurgaon, Haryana, India
Objective: Fertility preservation in a pre-menarcheal female with Sickle cell anemia using controlled ovarian hyperstimulation and oocyte preservation.
Design: Case report.
Setting: Reproductive medicine unit of a tertiary care private hospital.
Patient: A15-year-old pre-menarcheal female with Tanner stage 3 breast development and Tanner stage1pubic hair diagnosed with sickle cell anaemia, referred by the medical oncologist for fertility preservation before undergoing chemotherapy required before bone marrow transplant.
Intervention: Evaluation of ovarian reserve, ovarian stimulation, transvaginal oocyte aspiration, and oocyte cryopreservation.
Main Outcome Measure: Cryopreservation of mature oocytes before the antineoplastic therapy.
Results: Controlled ovarian hyperstimulation allowed for cryopreservation of 10 mature oocytes before the start of the patient’s gonadotoxic treatment.
Conclusion: Ovarian stimulation and oocyte cryopreservation can be successfully performed in pre-menarcheal/peripubertal patients before undergoing chemotherapy, thus providing a viable option for fertility preservation.
| Poster Presentations|| |
| P 1: Fertility preservation in endometrial carcinoma: Case series|| |
Deepa Khobragade, Madhuri Patil, Nalini Mahajan
Dr. Patils Fertility and Endoscopy Clinic, Bengaluru, Karnataka, India
Introduction: Endometrial cancer comprises 7.1% of all new cancer cases in females. Carcinoma of the endometrium is one of the long-term complications of polycystic ovarian syndrome (PCOS) due to unopposed estrogen action due to chronic anovulation. The standard treatment involves hysterectomy and bilateral salpingo-oophorectomy, due to its hormonal sensitivity. In endometrial cancer without infiltration to the myometrium and no extrauterine involvement, conservative treatment can be offered to women who wish to preserve fertility.
Results: We report 11 cases of endometrial carcinoma either diagnosed during workup for infertility or referred for fertility preservation (FP) before definitive treatment. About 72.7% (7/11) of patients had PCOS, it becomes important for clinicians to suspect and rule out endometrial carcinoma by regular endometrial surveillance which, includes transvaginal ultrasound and/or endometrial biopsy in all PCOS women who have abnormal uterine bleeding, prolonged amenorrhea, unopposed estrogen exposure, and thick endometrium especially on day 3 of the menstrual cycle. About 36.36% (4/11) of our patients were not convinced for FP and were either lost to follow-up or underwent definitive therapy. Thus, it is important that all patients with endometrial carcinoma should be counseled not only by the oncologist but also by a reproductive endocrinologist and a psychosocial counselor, both together and separately. This will enable the patient to make a right choice of the treatment modality.
Conclusion: Conservative treatment with progestogen therapy in selected young patients with well-differentiated carcinoma limited to the endometrium helps in preserving fertility. If they fail to conceive in the first attempt of in vitro fertilization, it is mandatory to monitor them for recurrence till a definitive treatment is planned. If definitive treatment is required fertility can be preserved either by oocyte or embryo freezing. Some women with low risk of ovarian involvement can benefit by ovarian tissue cryopreservation.
| P 2: Pregnancy with intrauterine insemination using cryopreserved – thawed semen sample in patient with testicular seminoma - A case report|| |
Nanda Bugude, Madhuri Patil
Dr. Patils Fertility and Endoscopy Clinic, Bengaluru, Karnataka, India
Case Report: Testicular cancers, 95% of which are germ-cell tumours (GCT) is the most common solid malignant tumour in men aged 15-35 years. It accounts for only about 1% of all cancers in men and bilateral in 3% of cases. A case of infertile couple in which husband was diagnosed with metastatic testicular seminoma with oligozoospermia. Semen sample was frozen before patient underwent chemotherapy. Ovulation induction and intrauterine insemination was planned using cryopreserved – thawed semen sample. A healthy baby was born.
Discussion: Testicular tumours impair fertility in majority of patients. Fertility preservation using methods like semen freezing, sperm freezing using MESA, PESA and testicular sperm provides hope for those who wish to father a child prior to initiation of oncology treatment.
| P 3: Large abdominopelvic mass during pregnancy|| |
Kavita Khoiwal, Amrita Gaurav, Om Kumari, Jaya Chaturvedi
Department of Obstetrics and Gynaecology, AIIMS, Rishikesh, Uttarakhand, India
Background: Adnexal masses may complicate 2% to 10% of pregnancies. Around 2% to 3% of these masses removed during pregnancy are found to be malignant. Borderline ovarian tumour comprises 10mprisesses may complicate 2% to 10% of pregnancies. Around 2% to 3% of
Case: We report a case of a 22 year-old primigravida at 18 weeks POG presented to us with complaint of abdominal distension for 3 months. No history of pain abdomen. On examination, abdomen was grossly distended, uterus corresponded to 18 weeks period of gestation, A 25x20 cm cystic mass felt in epigastric and left hypochondriac region. USG whole abdomen suggested a large multi cystic lesion displacing liver and spleen superiorly, kidneys posteriorly and uterus inferiorly, bilateral ovaries not seen. Tumour markers were within normal limit. An abdominal MRI was performed afterwards and it revealed a 20 x 20 x 12 cm multilocular cystic lesion in omentum, bilateral ovaries were reported as separate and normal. An exploratory laparotomy was performed. Intra-operatively, the tumour was arising from left ovary, right ovary and omentum was healthy. Left salpingo-ovariotomy was done. Histopathology revealed a borderline mucinous ovarian tumour. Postoperative course was uneventful. Presently, she comes for routine antenatal check ups. Further plan of staging laparotomy or close follow up has to be established after delivery.
Conclusion: Large ovarian masses need surgical removal during pregnancy to allow optimum growth of fetus and to relieve pressure symptoms for mother. Second trimester is the best time for any surgery during pregnancy, route can vary according to the size of mass, surgeons, surgeonallow optimum growth of
| P 4: Gradual cryoprotectant exchange during equilibration process of oocyte vitrification improves embryonic outcomes|| |
Akiko Yabuuchi, Hidetaka Tasaki, Kazuki Ohata, Kenji Ezoe, Tamotsu Kobayashi, Keiichi Kato
Kato Ladies Clinic, Tokyo, Japan
Introduction: Oocyte vitrification is preferred option for fertility preservation in women with cancer. One of concerns associated with oocyte vitrification is that the developmental competence after fertilization tends to be lower compared with non-vitrified oocytes. Therefore, further improvement is preferred for oocyte vitrification protocols. The aim of the present study was to examine whether the degree of CPA exchange during vitrification is critical for survival rate and developmental potential of oocytes.
Methods: 252 oocytes were collected from C57BL/6J mice after induction of superovulation. Cryotop safety kit (Kitazato Co. Ltd.) was used. 225 oocytes were destined for vitrification and were allocated to 3 groups according to the degree of CPA change during equilibration process; equilibration in ES for 15 min (1-step, n=70), in 50%, 67% and 100% of ES diluted in WS for 3, 3 and 9 min (3-steps, n=79) and in 20%, 40%, 60%, 80% and 100% of ES for 3 min each (5-steps, n=76). Non-vitrified oocytes (fresh, n=27) were served as control. After warming, survival rates were examined. Embryonic outcomes of fertilized oocytes following ICSI were compared among the groups.
Results: The survival rates in 1-Step, 3- and 5-steps group were 97.1%, 97.5% and 100%, respectively. There were no significant differences among the groups. The blastocyst formation rates in fresh, 1-Step, 3- and 5-steps group were, 74.1%, 49.0%, 58.8% and 72.5%, respectively. 1-Step group showed significantly lower blastocyst formation rate compared with fresh group (P<0.05), but these rates improved and became comparable to fresh group when 5-Steps oocyte equilibration was performed.
Conclusion: CPA exchange is considerable factor to influence the outcomes of oocytes after vitrification-warming. Gradual CPA exchange during equilibration process improves the developmental potential of oocytes.
| P 5: The availability of “RANDOM START” ovarian stimulation for Japanese breast cancer patients|| |
Kentaro Nakamura, Seido Takae, Kaori Uwajima, Eriko Shiraishi, Yuki Suzuki, Shino Sawada, Hideyuki Iwahata, Yodo Sugishita, Yuki Horage, Nao Suzuki
Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
Introduction: The traditional approach of ovarian stimulation as fertility preservation depends on their menstrual cycle. As a result, some of the patients may give up fertility preservation, because there are the possibilities of a significant delay of cancer treatment and increasing psychologic stress for the patients. For that reason, to prevent any delay in cancer treatment, the “Random start” ovarian stimulation has been reported as effective for cryopreservation at any point during the menstrual cycle in 2013.
Study Design, Size, Duration: Data were retrospectively obtained from the clinical records of 44 breast cancer patients who were referred to the Oncofertility Unit at the Center for Reproductive Medicine of St. Marianna University Hospital from March 2014 to December 2017.
Participants/Materials, Setting, Methods: The breast cancer patients who hope to preserve own fertility were received controlled ovarian hyperstimulation regardless menstruation cycle for oocyte or embryo cryopreservation. We checked back the clinical records of patients and figured out their backgrounds, the way of stimulation, the phase of menstruation (follicular, peri-ovulatory, luteal), and the level of serum anti-Müllerian hormone (AMH), the number of oocytes per cycle and the mature oocytes rates.
Main Results and the Role of Chance: Mean age of 44 participants was 34.9 (±3.8) years-old, and 18 of them were unmarried. They had normal menstrual cycles prior to treatment and their average level of serum AMH was 5.1 (±2.8) ng/ml. The period from consultation to the first visit to our hospital was 7.4 (±5.1) days. And the surplus period, which was period for fertility preservation from visiting our hospital to starting the cancer therapy, was around 1.4 (±0.6) months. Nineteen of them used GnRH antagonist for ovarian stimulation, 24 of them were stimulated with short protocol. In addition, 33 of them used aromatase-inhibitor combined FSH agents. Altogether 8.9 (±6.8) oocytes per cycle were retrieved, the mature oocytes rate was 0.86 (±0.2), which outcomes were comparable to previous reports. The phase of menstruation did not affect either the number of oocytes extracted (p=0.34) or maturation oocytes (p=0.10). Also, no complications (e.g. OHSS, infection, etc.) resulted from the procedure.
Discussion and Conclusion: Although present research outcome is consistent with published data, it need to consider including the numbers of oocytes per cycle and the mature oocytes rates, and the fertilization rates, pregnancy rates, for verification of the availability of “RANDOM START” ovarian stimulation.
| P 6: Current status of fertility preservation in male cancer patients in Kato ladies clinic|| |
Hirofumi Morita, Kazuo Uchiyama, Akiko Yabuuchi, Tamotsu Kobayashi, Keiichi Kato
Kato Ladies Clinic, Tokyo, Japan
Introduction: Current advances of cancer treatments have improved the prognosis of patients. Considering quality of life of cancer patients, oocyte, embryo, ovarian tissue and sperm cryopreservation will pave the way of hope for preserving their fertility. The aim of the present study was to investigate the current status of sperm cryopreservation in cancer patients performed at Kato Ladies Clinic.
Methods: In the period of January 2012 to June 2017, 228 patients who inquired about sperm cryopreservation in Kato Ladies Clinic were analyzed. Informed consents were obtained from all patients. We retrospectively analyzed the following criteria; consultation rate after inquiry by phone, age distribution, marital status, type of malignancy, history of cancer treatments before cryopreservation, semen quality (sperm concentration and motility) and current status of the use of cryopreserved sperm after cancer treatments.
Results: Consultation rate was 80.3% (183/228). The mean age of patients was 30.1 years old and age distribution was as follows: 10s:14.2%, 20s: 36.6%, 30s: 33.3%, 40s: 14.8%. 128 out of 183 (68.8%) patients were unmarried. Types of malignancy were blood cancers (55.2%), testicular cancer (13.1%), brain tumor (10.9%), others (20.8%). 26.8% of patients who had cancer treatments such as chemotherapy prior to consultation exhibited reduced sperm concentration and motility rate. 182 patients successfully performed sperm cryopreservation. 27 patients (14.8%) returned for IVF and there have been 12 live births.
Conclusion: Sperm cryopreservation as fertility preservation would encourage cancer patients but it should be initiated before cancer treatment. Utilization of cryopreserved sperm is still low, therefore further follow-up studies of patients who performed sperm cryopreservation are needed.
| P 7: Successful pregnancy and delivery via in vitro fertilization with cryopreserved sperm from patients with leukemia and balanced chromosomal translocations detected at diagnosis of leukemia: Case reports|| |
Satoshi Ueno, Tomoko Kuroda, Kazuo Uchiyama, Tadashi Okimura, Akiko Yabuuchi, Tamotsu Kobayashi, Keiichi Kato
Kato Ladies Clinic, Tokyo, Japan
Introduction: Here, we presented our experiences of successful deliveries through in vitro fertilization (IVF) for two couples with leukemia and balanced chromosomal translocations detected at diagnosis of leukemia.
Case Presentation: Case 1 – Acute myeloid leukemia with a balanced reciprocal translocation. The husband was diagnosed acute myeloid leukemia with a balanced reciprocal translocation (46,XY,t(2;18)(q33;q21.3). Before chemotherapy and bone marrow transplantation, he preserved sperm that dividing into eight vials. After chemotherapy, he became very severe oligozoospermia. After approval of preimplantation genetic diagnosis (PGD), his wife performed egg retrieval for five times and obtained two blastocysts by ICSI using frozen sperm. She performed single vitrified-warmed blastocyst transfer, and the healthy baby girl was born carrying no chromosomal abnormalities. Case 2 – Philadelphia chromosome-positive acute biphenotypic leukemia with a balanced Robertsonian translocation (45,XY,der(13;14)(q10;q10)). The husband was diagnosed Philadelphia chromosome-positive acute biphenotypic leukemia with a Robertsonian translocation. Before diagnosis of leukemia, the couples had performed IVF because of severe oligozoospermia. Therefore, he already had four vials of sperm cryopreserved. After leukemia treatment, he became azoospermia. IVF was performed by ICSI using frozen sperm. This sperm has no motility. Therefore, theophylline was used for sperm motility activation. A fresh single cleavage embryo was transferred on day 2, and the healthy baby boy was born carrying the same Robertsonian translocation inherited from his father.
Conclusions: Treatment with chemotherapy would be associated with significant gonadal damage. Sperm cryopreservation is favorable option to achieve successful pregnancies although it should be performed prior to cancer treatments. Carriers of chromosomal translocations are known to be at risk for reproductive difficulties, such as recurrent miscarriages. Thus, additional cryopreserved sperm would be required in case of recurrent IVF failure.
| P 8: Case report on conservative surgery for recurrent serous borderline ovarian tumor|| |
Srinivas Priya Hospital, Chennai, Tamil Nadu, India
Introduction/Background: Borderline tumors make up approximately 15% of all epithelial ovarian tumors. The mean age of occurrence is approximately 10 years younger. Approximately 23% of patients were asymptomatic. The histology landmarks of serous BOT include- branching papillae, Variable nuclear atypia, no stromal invasion. The recurrence rate in patients who underwent conservative surgery is significantly higher (6.5–29.5%) than in patients who underwent radical surgery (0–8%). Invasive recurrent disease is a rare event after conservative treatment. Most recurrences are borderline lesions that can be treated by curative surgery without any impact on survival. Conservative surgical approach is essential as patients with BOTs are younger at the time of diagnosis.
Case Study: A committed couple willing for meticulous follow up, compliant to counselling can achieve their parenthood dream.27/f Mrs X, married 4 years was anxious to conceive. In June 2012, laparoscopic evaluation of infertility, left ovarian polar mass noted and excision of noncapsulated, cauliflower like, tumor was sent for HPE which showed left ovary serous borderline ovarian tumor. Hence a repeat laparoscopy -, left ovarian lower pole resection and surgical staging -frozen section–HPE showed disease free margin. She then fell pregnant with ovulation induction, delivered by caesarean in july 2013 a female 3 kg, same left ovary smooth but enlarged intraovarian 3 cm capsulated cyst conservative cystectomy done- HPE -BOT, serous type. Postnatally, exploratory laparotomy, left salpingo oopherectomy done, right adnexa retained as she desired further fertility. She did a stringent follow up. With further treatment she became pregnant again inspite of reduced ovarian reserve and delivered her second daughter on 2/2017 by caesarean when prophylactic right salpingo oopherectomy was done when a residue of BOT was noted in HPE. On march 2018, as planned earlier, Pelvic clearance done by laparoscopy when her second child was a year old. This case study showed that even recurrent disease is not a contraindication and young women can be offered fertility sparing surgery.
Conclusion: The best treatment approach remains contentious with no international guidelines available. Ten years overall survival rate for those in the initial stages is 90%, and 60–70% of those in the advanced stages. Hence, If an ovarian borderline tumor or malignancy is suspected preoperatively, patients who desire to retain fertility should be offered a consultation with a fertility specialist to review options, fertility sparing surgery including embryo or oocyte cryopreservation.
| P 9: Use of autologous intrauterine platelet rich plasma in patients with thin endometrium undergoing frozen embryo transfer cycles: A pilot study|| |
Anju Madhavan, Jasneet Kaur, Padmaja Naidu, Kumkum Rani. Nalini Mahajan
Mother and Child Hospital, New Delhi, India
Background: Thin endometrium, though poorly defined is a concern in ART cycles as it is associated with reduced implantation and clinical pregnancy rates. A number of treatment options have been tried, however we do encounter cases of thin endometrium which are refractory to conventional therapy. Autologous Platelet Rich Plasma (PRP) is a new modality to help patients with a refractory thin endometrium. PRP is the portion of autologous blood having platelet concentrations 4-5 higher than normal. Platelets contain high concentrations of cytokines and growth factors stored within alpha-granules. Platelet activation triggers the release of these growth factors and cytokines which might stimulate and accelerate regeneration of the endometrium.
Objective: To determine if instilling intrauterine platelet rich plasma helps in improving endometrial thickness in patients with a thin endometrium undergoing frozen embryo transfer (FET) cycles.
Materials and Methods: Source of Data – Patients with a persistently thin endometrium undergoing frozen embryo transfer (FET) at our ART center during the study period (Jan 2018 till Aug 2018) were enrolled after obtaining written and informed consent. Inclusion Criteria – Patients with suboptimal endometrium (6 mm or less) during ovulatory or HRT (hormone replacement therapy) cycles where other medical modalities to improve endometrial thickness have failed. These modalities included 3 or more cycles of administration of high dose estradiol valerate (E2V) for an extended time frame of approximately 21 days, instillation of intra uterine G-CSF (Granulocyte colony stimulating factor), addition of Tamoxifen and HMG (to stimulate production of endogenous estrogen), low dose aspirin and l-arginine. Exclusion Criterion – Patients with congenital uterine anomalies, previous h/o Endometrial pathology (atypia on HPE), Asherman’s syndrome (untreated), cancer survivors.
Methodology: Patients included in our study had a persistently thin endometrium not responding to high dose extended HRT, intra-uterine G-CSF, ovulation induction with Tamoxifen, HMG and adjuvant treatments like low dose aspirin, L-arginine. Apart from routine investigations patients were investigated for endometrial tuberculosis and a hysteroscopic examination of the uterine cavity was performed, if not done previously. Estradiol valerate was started in a dose of 4mg orally on the 2nd or 3rd day of the menstrual cycle and was escalated to 8 mg/day after 2 days with a maximal oral dose of 12 mg and an additional transdermal dose of 5 mg daily. Serial ultrasound examinations were performed using an 8 MHz transvaginal probe. If the endometrium was <6 mm on day 9/10 of the cycle intrauterine instillation of PRP was performed under all aseptic precautions. 15 ml of peripheral venous blood was drawn in a syringe containing 5 ml of Acid Citrate A Anticoagulant solution (ACD-A) and centrifuged immediately at 200 g for 10 min to separate the red blood cells. The plasma and buffy coat obtained were centrifuged again at 500 g for 8 min to obtain 0.3-0.4 ml of PRP which was infused into the uterine cavity with the help of an embryo transfer (ET) catheter under ultrasound guidance. An ultrasound was performed 3 - 4 days later and the endometrial thickness and character was assessed. Frozen embryo transfer was performed in the patients who achieved an endometrial thickness of >6 mm.
Results: A total of 17 women aged 28 to 43 years having a thin endometrium refractory to conventional treatment and undergoing frozen embryo transfer were included in the study. Out of these 9/17 (53%) were cases of primary infertility while 47% (8/17) had secondary infertility. A history of previous curettage was found in majority of the patients with secondary infertility. Amongst patients with primary infertility, history of a treated infective pathology was found more frequently. 94% (16/17) of these patients had a previous history of 1 or more fresh/frozen embryo transfer failure. An increase in endometrial thickness was achieved in 88% of the patients and they were taken up for FET. Procedure was cancelled in 22% due to poor endometrial growth (<6 mm). The mean endometrial thickness before IU- PRP was 5.7mm and it increased to a mean of 6.9mm on post PRP assessment. An average increase in of 1.2 mm endometrial thickness was achieved. 67% (10/15) of frozen embryo transfer cycles were self cycles while 33% (5/15) were oocyte donation cycles. All patients in whom embryo transfer was performed had good quality embryos and we achieved a clinical pregnancy rate of 47% (7/15).
Conclusion: IU PRP seems to be a novel, safe and effective tool in improving endometrial thickness in patients with a thin endometrium thus optimizing ART outcomes.1,2,3,4
- Lebovitz O, Orvieto R. Treating patients with “thin” endometrium - an ongoing challenge. Gynecol Endocrinol 2014;30:409-14.
- Senturk LM, Erel CT. Thin endometrium in assisted reproductive technology. Curr Opin Obstet Gynecol 2008;20:221-8.
- Zadehmodarres S, Salehpour S, Saharkhiz N, Nazari L. Treatment of thin endometrium with autologous platelet-rich plasma: A pilot study. JBRA Assist Reprod 2017;21:54-6.
- Chang Y, Li J, Chen Y, Wei L, Yang X, Shi Y, et al. Autologous platelet-rich plasma promotes endometrial growth and improves pregnancy outcome during in vitro fertilization. Int J Clin Exp Med 2015;8:1286-90.
| P 10: An audit of feasibility of fertility preservation in gynaecological malignancies at a tertiary care Institute in South India|| |
Sonal Garg, Paapa Dasari
Department of Obstetrics and Gynaecology, JIPMER, Puducherry, India
Background: Fertility preserving surgery is a method to permit completion of family of young age Gynaecological cancer patients without having an impact on Oncological outcome.
Aim: To find out the percentage of women with Gynaecological malignancies requiring fertility preservation and to know the type or spectrum of malignancies.
Methods: Retrospective analysis of data from case records of 558 women with Gynaecological malignancies managed in the department of Obstetrics and Gynaecology, Women and children hospital, JIPMER, Puducherry over a period of 2 years (January 2016 to December 2017).
Results: Out of 558 women who presented to our hospital for the treatment of Gynaecological tumors, 22.75% (n=127) were ≤40 years of age and 8.96% (n=50) of patients had histopathologically proven Gyanecological malignancies. The most common malignancy was Ovarian (58%) followed by Cervix (24%) and Endometrium (14%). In Ovarian carcinoma, surface epithelial tumors were the commonest (62%) followed by Germ cell tumors (31%) others (6.8%).
Conclusion: In this retrospective cohort, fertility preservation was feasible only in ovarian malignancies. In ovarian carcinoma, in 51% of women fertility preservation was done. In 30% of women ≥40 years of age who underwent surgeries for Gyanecological malignancies, fertility preservation was done.