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Table of Contents
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 35-37

In vitro activation of ovary

1 Department of Reproductive Medicine, Mother and Child Hospital, New Delhi, India
2 Department of Obstetrics and Gynaecology, Max Super Speciality Hospital, Saket, New Delhi, India

Date of Web Publication25-Jun-2019

Correspondence Address:
Dr. Jasneet Kaur
Mother and Child Hospital, D.59 Defence Colony, New Delhi - 110 024
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tofj.tofj_4_19

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Primary ovarian insufficiency (POI) affecting 1% of women leads to infertility due to a lack of follicle growth and ovulation, and oocyte donation is the only treatment option. Studies have reported that ovarian cryopreservation, fragmentation, and in vitro activation with drug treatment followed by autotransplantation can result in the successful pregnancy outcomes. Herein, we report a case of POI, in which we performed the procedure of in vitro ovarian activation (OA) and autotransplantation without using drugs to see if it would induce the follicular growth. This is the first case report from India, and it shows that the procedure of OA works and can be tried as an experimental procedure for women with POI who are very keen on trying pregnancy using their own oocytes.

Keywords: In vitro ovarian activation, ovarian fragmentation, primary ovarian insufficiency

How to cite this article:
Mahajan N, Kaur J, Bhattacharya B, Naidu P, Gupta S. In vitro activation of ovary. Onco Fertil J 2019;2:35-7

How to cite this URL:
Mahajan N, Kaur J, Bhattacharya B, Naidu P, Gupta S. In vitro activation of ovary. Onco Fertil J [serial online] 2019 [cited 2022 Sep 28];2:35-7. Available from: https://www.tofjonline.org/text.asp?2019/2/1/35/261253

  Introduction Top

Human ovaries contain follicles as basic functional units. A small number of dormant primordial follicles are activated by unknown intraovarian mechanisms at a rate of ≈1000/month to initiate growth. Follicles that are not activated remain dormant for years or decades and follicle depletion occurs when <1000 follicles remain. Once activated, primordial follicles develop through primary and secondary stages before acquiring an antral cavity. One follicle in the cohort is destined for ovulation while the rest undergo atresia. In patients with primary ovarian insufficiency (POI), there is an early exhaustion of ovarian follicles due to genetic, immunological, iatrogenic, or ovarian pathology. POI affects 1% of women and is characterized by high circulating follicle-stimulating hormone (FSH) levels together with amenorrhea before the age of 40 years. Although menstrual cycles cease in these patients, some of them still contain residual small ovarian follicles not producing enough circulating estrogens and progesterone to modulate uterine functions.[1] These patients are infertile due to a lack of follicle growth and ovulation; oocyte donation is the only treatment option. Kawamura et al. 2013[2] demonstrated that ovarian fragmentation disrupts the Hippo signaling pathway in the ovary, leading to increased production of downstream CCN growth factors and the promotion of follicle growth. Studies reveal the ability of phosphatase with TENs in homology deleted in chromosome 10 (PTEN) inhibitors and phosphatidylinositol-3-kinase (PI3K) stimulators to activate dormant human primordial follicles in vitro.[3] Kawamura et al. combined ovarian cryopreservation, fragmentation, and in vitro activation with drug treatment (the PTEN inhibitor and the PI3K activator) followed by autotransplantation and reported the successful pregnancies. They proposedin vitro ovarian activation (OA) as a treatment for POI. Silber[4] further suggested that OA could be established by disrupting Hippo signals during ovarian cortex fragmentation alone; the use of activation drugs was not necessary. OA procedure (without use of drugs) has not yet been reported as an established technique.

Proof of concept

Herein, we report a case of POI, in whom we performed the procedure of in vitro OA and autotransplantation without using drugs to see if it would induce the follicular growth. This is the first case report from India.

  Case Report Top

Mrs. S, a 33-year-old female, presented to us with a history of primary infertility. She had been married for 5 years and never conceived despite not using any contraception. She was diagnosed with stage 4 endometriosis in 2014 and underwent a bilateral laparoscopic ovarian cystectomy. At surgery, both  Fallopian tube More Detailss were found to be damaged. Postsurgery, very little ovarian tissue was seen on transvaginal ultrasound (TVS). Her menstrual cycles had become delayed and scanty since her surgery in 2014. Values of initial investigations done on day 2 of the menstrual cycle at our clinic were, FSH – 24 IU/L, LH– 5.4 IU/L, E2 – 18 pg/ml, AMH 0.23 ng/ml. FSH was repeated thrice for confirmation subsequently; all reports showed a value over 25 IU/L. TVS findings were as follows: The right ovary (RO) showed an endometriotic cyst and one antral follicle count (AFC) [Figure 1]. The left ovary was not visualized on ultrasound. The patient was counseled about the need to undergoin vitro fertilization (IVF) with donor oocytes in view of her poor ovarian reserve and tubal factor. She was not willing for donor oocyte and was adamant about trying for pregnancy with her own oocytes. She was given the option of OA and explained about the experimental nature of the procedure, and an appropriate consent was taken.
Figure 1: Right ovary before procedure

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A minilaparotomy was done. The left ovary was not visualized, the adnexa being buried under adhesions. RO was 0.5 cm in size (size of a pinhead). Cortical tissue was removed and processed. Medullary tissue was scraped off, and the ovarian cortex was cut into multiple tiny pieces. These tiny pieces were then loaded into an endometrial aspiration cannula. Since there was insufficient area to make a pocket on the ovary, pockets were made in the right mesosalpinx close to the tube and broad ligament. Ovarian cortical pieces were deposited into these pockets, and the peritoneal defect was closed with sutures [Figure 2]a and [Figure 2]b. One small piece was sent for histopathology (HPE). HPE report showed an absence of primordial follicles in that area. The patient was asked to come for follow-up investigations after 2 weeks; however, she came in after 4 weeks. She had a period 4 weeks after the surgery. Subsequent investigations revealed that the FSH had dropped and AMH had increased; day 2 FSH – 6.7 IU/L and AMH – 1.1 ng/ml (4 weeks after OA), respectively. TVS showed multiple antral follicles in the area of the right mesosalpinx. The follicles (ovarian tissue) were spread over an area of 3.9 cm × 2.1 cm × 1.7 cm in the mesosalpinx and broad ligament [Figure 3]a,[Figure 3]b, [Figure 3]c, [Figure 3]d. The patient was asked to proceed with IVF as the ovarian activity might be short lived. However, she came in after 2 months. A gonadotropin-releasing hormone antagonist protocol was planned. Stimulation was started with recombinant FSH 225 IU (follitropin alfa Gonal-f®, EMD Serono, Inc.) and Menopur 75 IU (highly purified HMG-Ferring Pharmaceutical Ltd.). After 10 days of ovarian stimulation, four follicles were seen above 16 mm. The dual trigger was given with human chorionic gonadotropin 5000 IU and luperide 1 mg. Oocyte retrieval was scheduled after 33 h to avoid premature rupture of follicles. Two mature oocytes were recovered, and 2 were germinal vesicle. One of the two oocytes fertilized and a poor-quality embryo developed which did not result in a pregnancy. A second IVF was done as a modified natural cycle IVF; however, the egg quality was not good and oocyte did not fertilize.
Figure 2: Reimplantation of ovarian cortical pieces. (a) Into mesosalpinx. (b) Endometrial aspiration cannula being used for depositing tissue pieces

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Figure 3: (a-d) Follicular activity after procedure in ovarian tissue in mesosalpinx and broad ligament. (a) Ovarian tissue mesosalpinx at the start of stimulation. (b and c) Follicular growth during stimulation in mesosalpinx and (d) Broad ligament

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The patient came for follow-up for approximately 7–8 months after the procedure. Her periods had become regular with a cycle length of 26 days. Subsequent cycle monitorings showed that follicular development was being maintained; however, she was having a luteinized unruptured follicle (LUF). LUF could be due to the fact that the ovarian tissue was in the mesosalpinx and broad ligament, and this thick peritoneal covering would not allow for oocyte expulsion. LUF is also encountered frequently in patients of pelvic endometriosis.

  Discussion Top

Approximately 1% of women in their reproductive years face POI,[5] necessitating the use of donor eggs to achieve pregnancy. This may not be acceptable for social, religious, or personal reasons. Kawamura et al. 2013[2] demonstrated that it is possible to activate dormant follicles within such ovaries and achieve pregnancy. Regulation of primordial follicular recruitment is largely unknown. It has been hypothesized that tissue pressure inside the stroma in the ovarian cortex arrests continuation of early meiosis of the oocyte to prevent all eggs being lost at once.[4] Cell proliferation and organ size are regulated by Hippo signals; disruption of this signaling system promotes follicle growth from the secondary to early antral follicle stages.[2] The promotion of follicular growth and development of mature oocytes by fragmentation of the murine ovaries was demonstrated by Kawamura et al.[3]

Our case report, the first in India, shows that the procedure of OA works and can be tried as an experimental procedure for women with POI who are very keen to go with their own oocytes. Our choice of the first case was improper as we took a patient of endometriosis – a disease process known to compromise oocyte quality. Oocyte quality and poor embryo quality in our case could be a result of that. The fact that the transplanted ovarian tissue was activated was proven by the follicular development seen on ultrasound, a drop in FSH levels and a rise in AMH. These results prove that the procedure is effective in obtaining follicular activation in dormant follicles within an ovary depleted of follicles. Further procedures need to be performed to confirm our findings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

De Vos M, Devroey P, Fauser BC. Primary ovarian insufficiency. Lancet 2010;376:911-21.  Back to cited text no. 1
Kawamura K, Cheng Y, Suzuki N, Deguchi M, Sato Y, Takae S, et al. Hippo signaling disruption and Akt stimulation of ovarian follicles for infertility treatment. Proc Natl Acad Sci U S A 2013;110:17474-9.  Back to cited text no. 2
Li J, Kawamura K, Cheng Y, Liu S, Klein C, Liu S, et al. Activation of dormant ovarian follicles to generate mature eggs. Proc Natl Acad Sci U S A 2010;107:10280-4.  Back to cited text no. 3
Silber S. Ovarian tissue cryopreservation and transplantation: Scientific implications. J Assist Reprod Genet 2016;33:1595-603.  Back to cited text no. 4
Nelson LM. Clinical practice. Primary ovarian insufficiency. N Engl J Med 2009;360:606-14.  Back to cited text no. 5


  [Figure 1], [Figure 2], [Figure 3]

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