Fertility preservation in cancer patient

如何保留癌症病患的生育能力

楊曉君醫師2004 年台中榮總專科醫師講座

Fertility preservation in cancer patient

Who is appropriate

Method In vivo protectionConservative surgery and surgery techniqueEmbryo storageMature, immature oocytes freezeOvarian tissue banking

Six distinct issues should be considered Fertility preservation

in cancer patientThe risk of sterility with the proposed treatment programThe overall prognosis for the patientThe potential risks of delaying chemotherapyThe impact of any future pregnancy upon the risk of tumor recurrenceThe impact of any required hormonal manipulation on tumor itselfThe possibility of tumor contamination of the harvested tissue

C/T and R/T in Prepubertal girl(I)

Pre-pubertal ovary extremely resistant to the gonadotoxic chemotherapy agents, such as cyclophosphamide and nitrogen mustardHigh rates of perservation of fertility among pre-pubertal girls exposed to MOPP C/T for Hodgkin’s disease. The mechanisms of resistance: the quiescent cell-cycle status of germ cell in prepubertal ovary?Oral pills and LHRHa: encouraging early report(chapman and Sutcliffe 1981. Protection of ovarian function by oral contraceptives in women receiving chemotherapy for Hodgkin’s disease.)

C/T and R/T in Prepubertal girl(II)

The extremely high doses of C/T prior to bone marrow transplantation for treatment of hematological malignancies frequently result in long term sterility.—ovarian cryopreservation should be considered, when the underlying disease may remission and unlikely to contamination the harvest tissue.

prepubertal ovary remain extremely sensitive to radiation ->with doses of 5-20Gy ->ovarian failure.

Prognosis of early stage Breast cancer

The prognosis for women with ostensibly surgically resectable, early stage breast cancer has improved with the increased application of adjuvant C/T and hormone therapy. The likelihood of woman with node-negative disease remaining free of recurrence at 5 yrs is approximately 85%, 75% for one lymph node is involved, 65% of five nodes are involved. The risk of recurrence for 15-20 yrs.Recurrence rate,8-15yrs, node(-):1-2%, node(+):3-5%

C/T related premature menopause in Breast

cancer The likelihood of premature menopause was significantly lower among women age less than 40 y/o. (Bines, 1996, reviewed more than 2400 cases, s/p CMF type C/T )

M.D. Anderson cancer center : 0% for aged less than 30, 33% for 30-39 y/o, 96% for 40-49y/o, 100% for aged more than 50 yrs.( Hortobagyi et al.1986)

Safety of pregnancy in women with breast cancer

There are many theoretical reasons to be concerned the pregnancy may have an adverse effect.Pregnancy is obviously associated with a prolonged period of extremely high endogenous estrogen levels.The available data : pregnancy with no detectable adverse effect on the natural history on breast cancer.Danforth(1991) reviewed the outcome among 465 reported women with subsequently pregnancy did not differ from matched control.

Contradictory result about post-C/T related

premature menopauseThe differences can be attributed to two basic

factors: The therapeutic regimen: drug ,dose and length of treatment

The maturation stage of the ovary at initiation of treatment.

Additional issues about fertility preserve in cancer

patient Cost/efficacy Australian data from the Monash IVF group: just 7% male

cancer Pt use their stored semen from 1977~1997.

Marriage and divorce

Premature ovarian failure still is higher even retain normal menstrual pattern after C/T.

The prognostic factors in epithelial ovarian tumors

Tumor grade and ploidy state Aneuploid borderline tumor had a 19 fold increased risk of dying of disease co

mpared with those with diploid tumors. Norwegian study: none of the patients with stage 1, grade 1 diploid tumors of

non-clear-cell type did relapse.

Histologic subtypes Mucinous and endometrioid tumors have the best prognosis in stage I disease.

FIGO substage Stage IC ,ascites with maligant cells with poorest prognosis

CA125 level 6 wks after OP persistently elevated CA125 , refect the microscopic/hidden residual disease

The place of conservative surgery in epithelial

ovarian tumors –patient with FIGO stage I low risk

group Borderline tumors (especially the diploid ones)

Grade 1 mucinous and endometriod tumors

Diploid grade 1 tumor of serous mixed and undifferentiated histologic types

FIGO stage IA

Normal postoperative serum CA125 level

patient with FIGO stage I high risk group in epithelial

ovarian tumors (I) Postoperative adjuvant C/T is standard

procedureBorderline aneuploid tumor

Aneuploid, grade 1, of serous,mixed and undifferentiated histologic types

Grade 2 and grade 3 tumors

Clear cell adenocarcionomas

Persistent elevationof the postoperative serum CA125 level

FIGO stage IB, IC

patient with FIGO stage I high risk group in epithelial

ovarian tumors (II)Postoperative adjuvant C/T is standard procedureColombo et al. reported the results of conservative surgery in 56/99 Pt, with stage I disease, all Pt received platinum based C/T, after median F/U 75 months. No difference in relapses between conservative surgery(3/5

6) and ablative surgery(5/43). The authors suggested some extension of the conservative

surgery. Even stage Ib, if the tumor is well differentiated and an adequate portion of normal ovary.

The place of conservative surgery in epithelial

ovarian tumors Staging and conservative

surgery Surgery include collection of cytological samples, infra-colic omentectomy, and few sample from the pelvic and bladder peritoneum.

The need for wedge biopsy of contralateral ovary is still controversial. But serous tumors , the contralateral ovary could be sampled.

Lymphadenectomy would be unnecessary in low risk Pt.

Maligant ovarian germ cell tumors(OGCT)

When OGCT grossly confined to one ovary. Unilateral salpingoophorectomy with preservation of the contralateral ovary and uterus is appropriate.

For all OGCT patients, postoperative C/T is recommended. except stage IA pure dysgerminoma.

Pt with metastatic dysgerminoma, C/T has supplanted R/T as standard Tx. C/T has the advantage of preserving fertility.

GnRHa for protection of ovary and preservation of fertility du

ring C/T-a preliminary report(I)

pereyra, Gynecologic Oncology 81, 371-7Method: the patients were divided into three groups: Group A: premenarchal Pt, age 3~7.5(n=5), GnRHa(-). Group B: postmenarchal Pt,age: 14~20(n=12),GnRH(+) Group C: postmenarchal Pt,age: 15~20(n=4),GnRH(-)All Pt, received PCT regimens for Tx lymphoma, leukemia or thymo

ma. In group B, leuprolide acetate inhibition was obtained with a deport injection administered each months before and during treatment.

GnRHa for protection of ovary and preservation of fertility du

ring C/T-a preliminary report(II)

Result: Group A:spontaneous menarche between 12~17.9y/o. followed

by normal menstruction and ovulatory cycles. Group B: After withdrawal GnRHa, continue normal ovulatory c

ycles. 2 Pt became preg. Group C: hypergonadotrophic hypoestreogenic amenorrhea

GnRHa for protection of ovary and preservation of fertility du

ring C/T-a preliminary report(III)

Conclusion: Polychemotherapy(PCT) administered at early age, when

ovarian follicles have not reached maturation, produces less damage.

GnRHa provide a powerful protection of ovarian follicle during C/T.

We suggested GnRHa in all adolescents with maligancies prior and during C/T.

冷凍胚胎 當病人病發突然或需要立即治療，根本不會有時間等到製造出胚胎來冷凍。另外當病人仍是未婚狀況，因此尚未有精子來源，也就不可能保有胚胎，因此保留卵子就成了唯一選擇。 保存期限，雖然真正安全的保存期限目前仍有爭議。但是據統計，英國在 1997 年平均一個月要丟棄 3500 個保存期超過 5 年的冷凍胚胎。 冷凍胚胎的監護權歸屬問題。一旦配偶有離異或一方死亡，則胚胎的擁有權常引爭議，甚至往往對簿公堂，若冷凍卵子就無此疑義。

Surgical procedure and technique for preserve

fertility function Ovarian transposition for prevent R/T injury Ovaries were seperated and IP ligment were disected as long as ov

aries could be fixed to anterolateral abdominal wall to avoid direct irradiation and scattered irradiation.

Radical trachelectomy in cervix ca. Preserve uterine courpus and anastomosis of vagina to uterine corp

us Dargent described the first radical trachelectomy plus laparoscopic

pelvic lymphadenectomy for early stage IB1(<2cm) cervical ca. 1994.

Stage Ia2~Ib1, lesion<2 cm,limited endocervical involvement at colposcopy, no evidence of pelvic node metastases after LSC biopsy.

冷凍卵子 (I)

精子及胚胎的冷凍已行之多年，但卵子冷凍保存的發展遲遲未成熟，其原因在於卵子經過冷凍解凍後，常有冰晶形成而造成卵子破壞，即使仍存活的卵也常有產生細胞質的胞器、微導管、紡綞絲異位等現象。卵子冷凍對於不孕症的治療有其潛在之重要價值，它可提供因為放射線、或化學治療可能失去卵巢機能的病人，或目前仍不適合懷孕的婦女保存卵子的機會，也可能提供卵子銀行，幫助需要卵子捐獻的病患。然而卵子冷凍解凍之存活率及受精率仍不高，因此經由冷凍卵子、解凍、受精、而植入胚胎成功懷孕的例子並不多。因此如果能解決這些問題，將可有效的應用於臨床幫助病人。

冷凍卵子 (II)

為了提高冷凍卵子的存活率，有不少的冷凍保存技術及研究被發表，而最近發現 vitrification 的冷凍保存技術，可以提高冷凍卵子的存活率。它是使用高濃度的冷凍保護劑 ，直接將卵子放入液態氮中冷凍保存。因為無法克服成熟卵子對低溫敏感的問題。因此，成熟卵子冰凍再解凍後常會有染色體不分離的現象，往往在受精後造成染色體套數異常的現象。若冰凍未成熟卵子就可避免這些困擾。此外，使用未成熟卵子作卵子銀行，除了可以減少解凍後的染色體異常外，最大的好處是來源不怕短缺，只要在濾泡早期抽取即可得到豐富的來源。

不成熟卵子體外培養 (IVM)

Dr.Cha 在 1991 年首先報告使用不成熟卵子體外培養後體外授精 (IVM-IVF) ，再將胚胎植入而成功懷孕。他們所使用的不成熟卵子來源是接受開腹手術病人（例如： c/s, ectopic pregnancy or ATH 等）。利用開腹同時，以空針抽取卵巢上的卵泡 (2~10mm)抽出後再放入培養液中培養。待卵子培養到 M2 stage 時，再與精蟲結合。再把受精卵取出培養使發育為胚胎後植入母體子宮。

Cryopreservation of oocytes

Method:Traditional slow cooling Vitrification: a process that produces a glasslike

solidification of living cells that completely avoids ice crystal formation during colling.

outcomes

Success rate of slow oocytes freezing

The most consistent and long-term study resulted in only 9 pregnancies and the birth of 11 babies from transfers after the insemination of 1502 thawed eggs, giving a success rate of 0.7%.

- Porcul. Cycle of human oocytes cryopreservation and intracytoplasmic sperm injection: result of 112 cycles. Fertil & Steril 1999;72: 2

Tucker et al ,conducted an elegant study on slow-cooled human oocytes and reports viable pregnancies involving several advanced fetuses with success rate: 1%

-Tucker. Clinical application of human egg cryopreservation. Hum Reprod 1998;13: 3156-9

Oocytes freeze

from the University of Bologna studied 11 pregnancies from frozen eggs, which resulted in 13 children. In all but one of the pregnancies, amniocentesis was performed, showing that all of the fetuses were normal. They report that the gestational age at delivery was normal, and post-natal growth and development have all been reported normal.

國內冷凍卵子進展

台大成功完成冷凍卵子的動物試驗後，才運用在臨床上；迄今冷凍了十多名婦女的卵子，並將兩名婦女進行人工受孕，經解凍的十四顆冷凍卵子活性都未受損，受精成功率為 60% ，受精卵存活率則是 100% ，但植入子宮後僅有一名婦女受孕。這名因輸卵管病變而切除的三十多歲婦女，先前曾接受試管嬰兒，在取出卵子後，第一次胚胎植入失敗，而後將剩餘的卵子冷藏在零下一百九十六度液態氮中；兩個月後予以解凍、受精，二度植入，一舉中的。

卵巢冷凍卵巢冷凍則是胚胎冷凍及卵子冷凍的人工生殖技術之延續。近年來治療癌症的技術不斷更新改善，使得愈年愈多的年輕癌症患者得以存活下來，這類患者由於必須接受大量化學藥物或放射線治療，因此卵巢功能會喪失而失去排卵生育的能力。如果能事先將健康的卵巢組織冷凍保存，待其恢復健康後，再將卵巢組織解凍移植回體內或直接進行解凍後不成熟卵子的體外成熟培養，可使這類病患保存孕育後代能力的機會。由於卵子保存成功率不高，醫界也轉而直接保存卵巢組織，卵巢組織會有許多未發育的卵子，它比卵子保存容易，且卵子數量較多，效益較高。

Ovarian tissue banking

Frozen–thawed and grafted ovarian tissue can restore ovulatory cycles in sheep study.Primordial follicles are relatively robust to freezing and thawing.2000, Dr. Kutluk Oktay from Cornell University, reported the first case of laparoscopic transplantation of frozen-thrawed ovarian tissue to the pelvic sidewall with subsequent ovulation.No one has achieved a pregnancy from frozen human ovarian tissue yet.

Ovarian tissue autotransplantation

2001, Dr. Kutluk Oktay transplanted a section of a woman's ovary into her forearm. Egg development and normal hormone production was achieved. Theoretically, the eggs could be removed and used for in vitro fertilization to achieve a pregnancy. Dr. Oktay had similar results with a second patient.

Consideration of Ovarian tissue autotransplantation

Safety: the residual disease in autografted ovarian tissues might cause recrudescence of disease.

kim et. al. : total 30 non-obese diabetic severe combined immunodeficient (SCID) mice were individually xenografted s.c. with frozen-thawed ovarian tissue from 18 patients with lymphoma,

Endocrine function and oocyte retrieval after autologous transplantation of ovarian cortical strips to the forearm

(I)oktay, JAMA, september 26, 2001-286: 1490-3

Method:Patient A, 35y/o woman, stage IIIb squamous cell Cx Ca. she consulted to fresh transplantation prior to pelvic radiotherapy.Both ovaries were removed laparoscopically, and after frozen section showed no metastasis, their cortices were prepared in 16 strips were of 5x50x1-3mm.Ovarian strips were wedged subcutaneously to the forearm prior to pelvic radiotherapy.Patient B, 37 y/o woman with recurrent serous cyct in her only one ovary. Dense pelvic adhesion was noted.

Endocrine function and oocyte retrieval after autologous transplantation of ovarian cortical strips to the forearm

(II)Result:

Menopause was confirmed immediately after the transplantation in both Pt(A: 47mIU/ml, B:50.7mIU/ml)Patient A: follicle development was noted by physical and ultrasound examination approximately 10 weeks after transplantation. The mean FSH, LH decreased to 8.6mIU/ml and 12.8 mIU/ml. The peripheral E2 showed cyclical variation, dominant follicle developed each months. Percutaneous oocyte aspiration yielded a mature oocyte after COH. Fertilization failure after ICSIPatient B: spontaneous MC since 6 months after transplantation. mid-cycle LH surge and USG:a 9 mm follicle. Ovulation was confirmed via progesterone level after LH surge.

Ovarian tissue Xenotransplantation

加拿大多倫多醫院的研究人員將冷凍的人類卵巢組織片植入老鼠背部，他們以賀爾蒙刺激老鼠，而培養出人類卵子。 意味不能生育的婦女可利用她們本身卵巢組織所培養出的卵子獲得試管嬰兒。 令人擔心的是，是否會造成一種奇特的病毒可能從動物跳至人類身上 。

國內冷凍卵巢進展

如馬偕醫院已進行卵巢組織冷凍動物試驗， 該院已將母鼠的卵巢組織解凍後，植入腎臟夾膜中，母鼠順利排卵、受孕，產下小老鼠，下一步將進行皮下植入試驗，植入老鼠的手臂中，讓取卵更容易。

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