Oncofertility Publications

The stage at which follicle-enclosed cumulus-oocyte complexes achieve developmental competence in primates is unknown. Therefore, studies were designed to characterize the ability of oocytes in small antral follicles present during the menstrual cycle to spontaneously resume meiosis, fertilize, and support early embryo development. Ovaries were removed from adult rhesus monkeys (n = 12) during the early follicular phase (Days 3-4) of spontaneous cycles. Small antral follicles were divided into five groups according to their diameter; group I: <0.5 mm; group II: 0.5-0.99 mm; group III: 1.0-1.49 mm; group IV: 1.5-1.99 mm; and group V: 2.0-2.5 mm. The cumulus-oocyte complex from healthy small antral follicles (devoid of dark oocytes or granulosa cells) were extracted (n = 199) and cultured for 48 h under different conditions: in TALP (tyrode, albumin, lactate, pyruvate) medium alone, SAGE medium alone, or plus gonadotropins. At 48 h, oocyte meiotic status and diameter were measured after treatment of cumulus-oocyte complexes with hyaluronidase. Cumulus-oocyte complexes derived from follicles of 0.5- to 2-mm diameter contain oocytes that typically reinitiate meiosis in the absence or presence of gonadotropins and fertilize via in vitro fertilization or intracytoplasmic sperm injection. Moreover, the inseminated oocytes can reach the morula stage but arrest. Thus, the ability of these oocytes to complete maturation, as monitored from subsequent embryonic development after fertilization, is suboptimal. Further studies on primate IVM of oocytes from SAFs are warranted in order for them to be considered as an additional, novel source of gametes for fertility preservation in cancer patients. Peluffo MC, Barrett SL, Stouffer RL, Hennebold JD, Zelinski MB. Biol Reprod 83:525-532, 2010. PMID 20519694.

Barrett S L., Woodruff T K. Cancer Treatment and Research. 2010; 156: 25-39. PMID: 20811823.

Abstract

BACKGROUND:
Young female adult and adolescent cancer patients facing life-preserving but fertility-threatening chemo- or radiation-therapy are increasingly seeking options to protect their reproductive potential. Ovarian tissue cryopreservation with transplantation is a promising technique to safeguard fertility in cancer patients. However, this method may risk re-introduction of the original cancer to the survivor of the disease. Thus, developing a method for in vitro growth of immature follicles may provide a method for fertility restoration in the future.

METHODS:
Human secondary follicles were isolated from ovarian tissues obtained from cancer patients and grown in vitro within a bio-engineered culture system for 30 days.

RESULTS:
Human ovarian follicles became steroidogenically active, and developed from the early secondary to antral stage in vitro. The follicles contained healthy, growing oocytes that were connected by transzonal projections between the somatic cells and oocyte.

CONCLUSIONS:
Our data support the notion that human follicle development can be achieved in vitro in a bio-engineered culture system. More studies are required to investigate whether the fully sized oocytes obtained from in vitro grown follicle are competent to resume meiosis and be fertilized.

Min Xu, Susan L. Barrett, Erin West-Farrell, Laxmi A. Kondapalli,, Sarah E. Kiesewetter, Lonnie D. Shea, and Teresa K. Woodruff; Human Reproduction Vol.24, No.10 2531-40 Oct. 24, 2009

Female cancer patients who seek fertility preservation but cannot undergo ovarian stimulation and embryo preservation may consider: 1) retrieval of immature oocytes followed by in vitro maturation (IVM); 2) ovarian tissue cryopreservation followed by transplantation or in vitro follicle culture (IVFC). Conventional IVM is carried out during the follicular phase of menstrual cycle. There is limited evidence demonstrating that immature oocyte retrieved during the luteal phase can mature in vitro and be fertilized to produce viable embryos. While in vitro follicle culture is successful in rodents, its application in nonhuman primates has made limited progress. The objective of this study was to investigate the competence of immature luteal-phase oocytes from baboon and to determine the effect of FSH on baboon preantral follicle culture and oocyte maturation in vitro. Oocytes from small antral follicle COCs with multiple cumulus layers (42%) were more likely to resume meiosis and progress to MII than oocytes with a single layer of cumulus cells, or less (23% vs. 3%, respectively). Twenty-four percent of mature oocytes were successfully fertilized by ICSI, and 25% of these developed to morula stage embryos. Preantral follicles were encapsulated in fibrin-alginate-matrigel (FAM) matrices, and cultured to small antral stage in a FSH-independent manner. FSH negatively impacted follicle health by disrupting the integrity of oocyte and cumulus cells contact. Follicles grown in the absence of FSH produced MII oocytes with normal spindle structure. In conclusions, baboon luteal-phase COCs and oocytes from cultured preantral follicles can be matured in vitro. Oocyte meiotic competence correlated positively with the number of cumulus cell layers. This study clarifies the parameters of the follicle culture system in nonhuman primates and provides foundational data for future clinical development as a fertility preservation option for women with cancer.

Xu M, Fazleabas AT, Shikanov A, Jackson E, Barrett SL, Hirshefeld-Cytron J, Kiesewetter SE, Shea LD, Woodruff TK.

Abstract

Cryopreservation of oocytes and embryos is commonly used to preserve fertility. However, women undergoing cancer treatment may not have the time or may not be good candidates for these options. Ovarian cortical tissue cryopreservation and subsequent tissue transplant has been proven successful yet inefficient in preserving larger secondary follicles, and is not recommended as a fertility preservation option for women with certain cancers. We evaluated cryopreservation of individual follicles as an alternative option in rodents, nonhuman primates, and human primates. Under optimal conditions, cryopreserved mouse secondary follicles were able to reestablish granulosa cell-oocyte interactions, which are essential for subsequent follicle growth. Individual secondary follicles survived cryopreservation, were able to be cultured in a three-dimensional alginate hydrogel matrix to the antral stage, and the enclosed oocytes were competent for fertilization. Using a vital imaging technique (pol-scope) employed in many fertility centers, we were able to bioassay the thawed, cultured follicles for the presence of transzonal connections between the somatic and germ cells. Perturbations in these linkages were shown to be reversed when follicles were cryopreserved under optimal freezing conditions. We applied the optimized cryopreservation protocol to isolated rhesus monkey and human secondary follicles, and using the birefringent bioassay, we were able to show good correlation between early follicle growth and healthy somatic cell-oocyte connections. Our results suggest that ovarian follicles can be cryopreserved, thawed, and analyzed noninvasively, making follicle preservation an additional option for young cancer patients.

Susan L. Barrett, Lonnie D. Shea, Teresa K. Woodruff. Biology of Reproduction, 2010.

By Co-editors Teresa K. Woodruff, Laurie Zoloth, Lisa Campo-Engelstein, and Sarah Rodriguez

Part I: The Science and Technology of Oncofertility

1. Reproductive Health After Cancer by Clarisa Garcia
2. Designing Follicle-Environment Interactions with Biomaterials by Rachel M. Smith, Teresa K. Woodruff, and Lonnie D. Shea
3. Gamete Preservation by Susan L. Barrett and Teresa K. Woodruff
4. To Transplant or Not to Transplant – That is the Question by Sherman J. Silber, Teresa K. Woodurff and Lonnie D. Shea
5. Clinical Cases in Oncofertility by Laxmi A. Kondapalli, Fanzhen Hong, and Clarisa R. Gracia
6. Cancer Genetics: Risks and Mechanisms of Cancer in Women with Inherited Susceptibility to Epithelial Ovarian Cancer by Lee Shulman and Jeffrey Dungan
7. Protecting and Extending the Fertility Options for Female Wildlife and Endangered Mammals by Pierre Comizzoli, David Wildt, and Nucharin Songsasen

Part II: Historical and Legal Perspectives

1. Placing the History of Oncofertility by Sarah Rodriguez
2. Medical Hope, Legal Pitfalls: Potential Legal Issues in the Emerging Field of Oncofertility by Gregory Dolin, Dorothy E. Roberts, Teresa K. Woodruff, and Lina M. Rodriguez
3. Domestic and International Surrogacy Laws: Implications for Cancer Survivors by Kiran Sreenivas and Lisa Campo-Engelstein
4. Adoption After Cancer: Adoption Agency Perspectives on the Potential to Parent Post-Cancer by Shauna Gardino, Andrew Russell, and Teresa K. Woodruff

Part III: Clinical and Theoretical Ethics

1. Ovarian Tissue Cryopreservation and Bioethical Discourse by Christina L.H. Traina
2. The Lessons of Oncofertility for Assisted Reproduction by Adrienne Asch
3. Morally Justifying Oncofertility Research by Carolyn McLeod
4. Ethical Dilemmas in Oncofertility: An Exploration of Three Clinical Scenarios by Clarisa R. Gracia, Jorge J.E. Gracia, and Shasha Chen
5. Participation in Investigational Fertility Preservation Research: A Feminist Ethics Approach by Michelle L. McGowan
6. Reproductive “Choice” and Egg Freezing by Angel Petropanagos
7. The Impact of Infertility: Why ART Should Be a Higher Priority for Women in the Global South by Amanda Fleetwood and Lisa Campo-Engelstein
8. Oncofertility and Informed Consent: Addressing Beliefs, Values and Future Decision Making by Felicia Cohn

Part IV: Religious Perspectives

1. Bioethics and Oncofertility: Arguments and Insights from Religious Traditions by Laurie Zoloth and Alyssa A. Hennings
2. Sacred Bodies: Considering Resistance to Oncofertility in Muslim Communities by Rumee Ahmed
3. Unlikely Motherhood in the Qur’an: Oncofertility as Devotion by Ayesha S. Chaudry
4. Technology and Wholeness: Oncofertility and Catholic Tradition by Paul Lauritzen
5. Jewish Perspectives on Oncofertility: The Complexities of Tradition by Laurie Zoloth

Part V: Ramifications for Education and Economics

1. The Oncofertility Saturday Academy: A Paradigm to Expand the Educational Opportunities and Ambitions of High School Girls by Megan Faurot and Teresa K. Woodruff
2. MyOncofertility.org: A Web-Based Patient Education Resource Supporting Decision Making Under Severe Emotional and Cognitive Overload by Kemi Jona and Adam Gerber
3. Anticipating Ovarian Tissue Cryopreservation in the Health-care Marketplace: A Willingness to Pay Assessment by Shauna L. Gardino, Andrew Sfekas, and David Dranove
4. Perspectives on Oncofertility from Demography and Economics by Rosalind King
5. For the Sake of Consistency and Fairness: Why Insurance Companies Should Cover Fertility Preservation Treatment for Iatrogenic Infertility by Lisa Campo-Engelstein

Part VI: Repercussions of Oncofertility for Patients and their Families

1. Health Care Provider Perspectives on Fertility Preservation for Cancer Patients by Caprice A. Knapp and Gwen P. Quinn
2. Counseling and Consenting Women with Cancer on their Oncofertility Options: A Clinical Perspective by Emily S. Jungheim, Kenneth R. Carson, and Douglas Brown
3. The Fertility-Related Treatment Choices of Cancer Patients: Cancer-Related Infertility and Family Dynamics by Karrie Ann Synder, May Kyaw Thazin, William B. Pearse, and Mehwish Moinuddin
4. Whose Future Is It? Ethical Family Decision Making About Daughters’ Treatment in the Oncofertility Context by Marla L. Clayman and Kathleen M. Galvin
5. Choosing Life when Facing Death: Understanding Fertility Preservation Decision-Making for Cancer Patients by Shauna L. Gardino and Linda L. Emanuel

Part VII: Health Care Provider Stories and Final Thoughts

1. Discussing Fertility Preservation with Breast Cancer Patients by Jackie S. Jeruss
2. Warning: Google can be Hazardous to Your Health: Fertility Preservation Is an Important Part of Cancer Care by Jennifer Hirschfield-Cytron
3. The Role of a Patient Navigator in Fertility Preservation by Jill Scott-Trainer
4. Judaism and Reproductive Technology by Sherman J. Silber
5. Reading Between the Lines of Cancer & Fertility: A Provider’s Story by Leonard S. Sender
6. A Rewarding Experience for a Pediatric Urologist by Margarett Shnorhavorian
7. Final Thoughts by Laurie Zoloth

Abstract

BACKGROUND:
An alginate-based matrix supports the three-dimensional (3D) architecture of non-human primate follicles and, in the presence of FSH, permits the in vitro development of pre-antral follicles to the small antral stage, including the production of ovarian steroids and paracrine factors. The current study investigated the ability of gonadotrophins, fetuin and oxygen (O2) to improve primate follicle growth and oocyte maturation in vitro.

METHODS:
Macaque secondary follicles were isolated from the early follicular phase ovaries, encapsulated in a sodium alginate matrix and cultured individually for 40 days in supplemented medium. The effects of recombinant human (rh) FSH (15, 3 and 0.3 ng/ml for high, medium and low FSH, respectively), bovine fetuin (1 or 0 mg/ml) and O2 (5 or 20% v/v) were examined. Half of the follicles in each culture condition received rhLH on Day 30 –40. Follicles that reached antral stage were treated with rh chorionic gonadotrophin for 34 h to initiate oocyte meiotic maturation. Media were analyzed for ovarian steroids and anti-mu¨ llerian hormone (AMH).

RESULTS:
Improved culture conditions supported non-human primate, secondary follicle growth to the antral stage and, for the first time, promoted oocyte maturation to the MII stage. In the presence of fetuin at 5% O2, follicles had the highest survival rate if cultured with high or medium FSH, whereas follicles grew to larger diameters at Week 5 in low FSH. Oocyte health and maturation were promoted under 5% O2. High FSH stimulated steroid production by growing follicles, and steroidogenesis by follicles cultured with low FSH was promoted by LH. AMH biosynthesis was elevated with high compared with low FSH and for longer under 5% O2 than under 20% O2.

CONCLUSIONS:
This encapsulated 3D culture model permits further studies on the endocrine and local factors that influence primate follicle growth and oocyte maturation, with relevance to enhancing fertility preservation options in women.

Xu J, Lawson MS, Yeoman RR, Pau KY, Barrett SL, Zelinski MB, Stouffer RL. Secondary follicle growth and oocyte maturation during encapsulated three-dimensional culture in rhesus monkeys: effects of gonadotrophins, oxygen and fetuin. Hum Reprod. 2011 Feb 28. [Epub ahead of print]