Original Research
Gynecology
First pregnancies, live birth, and in vitro fertilization outcomes after transplantation of frozen-banked ovarian tissue with a human extracellular matrix scaffold using robot-assisted minimally invasive surgery

A preliminary version of this work was orally presented at the annual meeting of American Society of Reproductive Medicine in Honolulu, Hawaii, Oct, 18-22, 2014.
https://doi.org/10.1016/j.ajog.2015.10.001Get rights and content

Background

Ovarian tissue cryopreservation is an experimental fertility preservation method and the transplantation techniques are still evolving.

Objective

We attempted to improve the technique with the utility of a human decellularized extracellular tissue matrix (ECTM) scaffold, robot-assisted minimally invasive surgery, and perioperative pharmacological support.

Study Design

We prospectively studied 2 subjects with hemophagocytic lymphohistiocytosis (patient A) and non-Hodgkin lymphoma (patient B) who underwent ovarian tissue cryopreservation at the age of 23 years, before receiving preconditioning chemotherapy for hematopoietic stem cell transplantation. Both experienced ovarian failure postchemotherapy and we transplanted ovarian cortical tissues to the contralateral menopausal ovary 7 and 12 years later, using a human ECTM scaffold and robotic assistance. The ECTM scaffold tissue compatibility was shown in preclinical studies. Patients also received estrogen supplementation and baby aspirin preoperatively to aid in the revascularization process.

Results

Ovarian follicle development was observed approximately 10 (patient A) and 8 (patient B) weeks after ovarian tissue transplantation. Following 8 and 7 cycles of in vitro fertilization, 9 and 10 day-3 embryos were cryopreserved (patients A and B, respectively). While the baseline follicle-stimulating hormone (range 3.6-15.4 mIU/mL) levels near normalized by 7 months and remained steady postovarian transplantation in patient A, patient B showed improved but elevated follicle-stimulating hormone levels throughout (range 21-31 mIU/mL). Highest follicle yield was achieved 14 (8 follicles; patient A) and 11 (6 follicles; patient B) months postintervention. Patient A experienced a chemical pregnancy after the third frozen embryo transfer attempt. She then conceived following her first fresh in vitro fertilization embryo transfer and the pregnancy is currently ongoing. Patient B conceived after the first frozen embryo transfer attempt and delivered a healthy girl at term.

Conclusion

We report the first pregnancies after the minimally invasive transplantation of previously cryopreserved ovarian tissue with an ECTM scaffold. This approach seems to be associated with steady ovarian function after a follow-up of up to 2 years.

Introduction

Ovarian cryopreservation is one of the key strategies in fertility preservation. Utilizing the previously accumulated knowledge from animal1 and human2 ovarian xenografting studies, we performed the first autologous ovarian tissue transplantation (OTT) case with frozen-thawed tissue in 1999.3, 4 Although the patient did not desire pregnancy, she demonstrated ovarian follicle development 8 weeks after the transplant with documented function for up to 9 months.5 The live births were to follow several years later as reported by numerous investigators.6, 7, 8, 9 In addition, we reported heterotopic OTT techniques where the tissues were grafted subcutaneously under the forearm or abdominal skin.10, 11 The latter resulted in oocyte retrievals and embryo development.

With the current techniques, akin to skin grafting, one has to rely on the natural process of revascularization from the recipient site. Because it takes up to 10 days for new human ovarian microvessels to reach full maturity, the graft suffers an initial ischemic injury.12 This initial ischemic injury has been shown to result in the loss of nearly two thirds of all primordial follicles in ovarian xenograft models.13 This inefficiency largely explains the unpredictable longevity of ovarian transplants. The length of ovarian function has been reported to range from 1 to >7 years14, 15 with an average of 4-5 years in successful orthotopic and heterotopic ovarian transplants with frozen-banked ovarian tissue.15

In addition, issues with oocyte quality have been cited by some after in vitro fertilization (IVF); one possible explanation being the restricted blood flow.16 The baseline follicle-stimulating hormone (FSH) levels remain high and anti-müllerian hormone (AMH) levels tend to be low in the majority of ovarian transplants with cryopreserved tissue, possibly reflecting the restriction in blood flow.17 Therefore, there is convincing evidence to support the view that vascularization issues curb OTT success both acutely in the form of follicle loss and chronically with limited microvascular flow.

AlloDerm (LifeCell Corp, Branchburg, NJ) is a decellularized human extracellular tissue matrix (ECTM) generated from cadaver skin. It has been used in cosmetic surgery, breast reconstruction, and dentistry and other surgical reconstructive fields to augment tissue grafts and aid in revascularization.18 In this study we hypothesized that the cryopreservation of ovarian tissue may preserve fertility. We also hypothesized that the use of the ECTM with robotic surgical assistance may improve outcomes, presumably by aiding the revascularization process.

Section snippets

Materials and Methods

This translational work represents the outcomes ovarian cryopreservation and transplantation research protocol after up to 14-year follow-up of 2 subjects who consecutively underwent grafting. The study was approved by the institutional review board and the preclinical animal studies were also approved by the Institutional Animal Care and Use Committee at New York Medical College.

Patient A was diagnosed with familial hemophagocytic lymphohistiocytosis in April 2006, at the age of 23 years.

Patient A

The first sign of ovarian activity was detected approximately 10 weeks after OTT in October 2013, by the demonstration of a 14.5-mm follicle on a transvaginal ultrasound exam. The hormone replacement was then discontinued and the patient resumed cyclical menstruation (Figure 2, A).

Subsequently, she underwent 8 IVF cycles with peak E2 levels as high as 833 pg/mL (Table 1) (see Supplement 2 for monitoring and IVF protocol). The highest follicle yield (8 follicles) was obtained on her last

Comment

Ovarian cryopreservation is a highly important fertility preservation strategy, which has several advantages over gamete and embryo freezing. It can be performed in prepubertal girls and children,22, 23 does not require ovarian stimulation and delay in chemotherapy, restores ovarian endocrine function, and provides the possibility of natural conception. However, despite the mounting number of live births, the technique still remains in the experimental realm. Those who defend the experimental

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  • Cited by (0)

    K.O. is supported by RO1 HD053112 by Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and National Cancer Institute; in addition, the laboratory work was supported by R21 HD061259 by NICHD.

    The authors thank Ronald Reiss for the obstetrical care of Patient B and providing the second trimester ultrasound image.

    The authors report no conflict of interest.

    Cite this article as: Oktay K, Bedoschi G, Pacheco F, et al. First pregnancies, live birth, and in vitro fertilization outcomes after transplantation of frozen-banked ovarian tissue with a human extracellular matrix scaffold using robot-assisted minimally invasive surgery. Am J Obstet Gynecol 2016;214;94.e1-9.

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