Practical recommendations for fertility preservation in women by the FertiPROTEKT network. Part II: fertility preservation techniques.

PURPOSE: In addition to guidelines focusing on scientific evidence, practical recommendations on fertility preservation are also needed. METHODS: A selective literature search was performed based on the clinical and scientific experience of the authors. This article (Part II) focuses on fertility preservation techniques. Part I, also published in this journal, provides information on disease prognosis, disease-specific therapy, and risks for loss of fertility. RESULTS: Ovarian stimulation including double stimulation and freezing of oocytes is the best-established therapy providing live birth chances in women < 35 years with high ovarian reserve of around 30-40%. Ovarian tissue freezing is especially useful in young women with good ovarian, if spontaneous conception is favoured and if < 1 week until chemotherapy is provided. Data on success rates are still limited, but this further evolving technique will possibly reach similar success rates as ovarian stimulation. GnRH agonists seem to reduce the risk of premature ovarian failure up to 50%; however, the effect is possibly not long-lasting. Ovarian transposition can easily be combined with freezing of ovarian tissue and is the preferred technique before pelvic radiotherapy. Other techniques, such as in vitro maturation, are limited to women with high ovarian reserve and remain less effective. In addition, procedures such as in vitro growth of follicles, etc. are still experimental. CONCLUSIONS: Fertility preservation in women provides realistic chances of becoming pregnant. The choice of technique needs to be based on the time required, the woman's age, its risks and efficacy, and the individual preference of the patient.

Anti-Müllerian hormone in women with hypopituitarism diagnosed before or during adolescence.

In women, anti-Müllerian hormone (AMH) is exclusively expressed in granulosa cells and an established marker of ovarian reserve. In menstrual cycle disorders, low AMH is usually interpreted as an indicator of primary ovarian insufficiency. This study is a case series of 11 patients with hypopituitarism. AMH concentrations were on or below the age-specific 25th percentile in three of the four patients diagnosed in infancy, but not in the remaining seven patients, who were diagnosed during adolescence or later. In patients with hypopituitarism, the detection of low AMH serum concentrations can present a diagnostic pitfall and its value in the interpretation of ovarian reserve in these patients is challenging.

Fertility preservation and management of pregnancy in melanoma patients requiring systemic therapy.

Melanoma is one of the most common cancers in adolescents and adults at fertile age, especially in women. With novel and more effective systemic therapies that began to profoundly change the dismal outcome of melanoma by prolonging overall survival, the wish for fertility preservation or even parenthood has to be considered for a growing portion of melanoma patients-from the patients' as well as from the physicians' perspective. The dual blockade of the mitogen-activated protein kinase pathway by B-Raf proto-oncogene serine/threonine kinase and mitogen-activated protein kinase inhibitors and the immune checkpoint inhibition by anti-programmed cell death protein 1 and anti-cytotoxic T-lymphocyte-associated protein-4 monoclonal antibodies constitute the current standard systemic approaches to combat locally advanced or metastatic melanoma. Here, the preclinical data and clinical evidence of these systemic therapies are reviewed in terms of their potential gonadotoxicity, teratogenicity, embryotoxicity and fetotoxicity. Recommendations for routine fertility and contraception counseling of melanoma patients at fertile age are provided in line with interdisciplinary recommendations for the diagnostic work-up of these patients and for fertility-protective measures. Differentiated recommendations for the systemic therapy in both the adjuvant and the advanced, metastatic treatment situation are given. In addition, the challenges of pregnancy during systemic melanoma therapy are discussed.

Detection of herpes simplex virus DNA in plasma of patients with primary but not with recurrent infection: implications for transfusion medicine?

Among the family of herpes viruses, only cytomegalovirus (CMV) and, to a lesser extent, human herpes virus 8 (HHV-8) are of relevance in transfusion medicine. Due to neutropism, herpes simplex viruses (HSV) types 1 and 2 are considered to be of minor relevance. However, several reports gave evidence that a HSV DNAemia might occur and HSV could therefore be transmissible by blood products. The aim of our study was to collect data about prevalence of HSV antibodies among blood donors and to clarify whether HSV DNAemia is possible. HSV antibody states of 653 blood donors were investigated. Blood specimens of 46 patients with primary and recurrent HSV infection were tested for HSV-1 and HSV-2 DNA using TaqMan polymerase chain reaction. In 505 of the 653 blood donors HSV antibodies were detectable, most of which were HSV-1 antibodies. HSV DNA was detected in plasma, but not in peripheral blood mononuclear cells (PBMCs) of seven rather seriously ill patients with primary herpes genitalis. No HSV viraemia was detectable in otherwise healthy patients with recurrent herpes labialis. Thus, HSV DNAemia is possible, but seems to be limited to primary infections and could not be detected in the recurrent infection. Therefore, blood donors with primary herpes infection should be deferred from donation. Blood donors with recurrent HSV infection are probably not at risk of transmitting HSV, but further studies are necessary to prove this hypothesis. Detection of HSV DNA in PBMCs as described formerly could not be confirmed by this study.

Differential indication for histological evaluation of endometrial fluid in postmenopause.

OBJECTIVES: The endometrium carcinoma is the most frequent malignancy of the female genital tract. Approximately, 10-20% of all patients with an endometrial carcinoma are free of symptoms until the time of diagnosis. The frequent occurrence of an endometrial carcinoma in connection with intrauterine cavity fluid collection (sero- or mucometra) has been discussed controversially in literature. What are the hysteroscopic and histological findings in patients with sonographically determined endometrial fluid in postmenopause, and how should these findings be interpreted? METHODS: 74 patients, in whom endometrial fluid without bleeding disorders had been diagnosed during routine transvaginal sonography, underwent hysteroscopy conducted with a 4.5 mm optics and dilatation and curettage (D&C). The median age of the patients was 68 years with a range of 32 years. RESULTS: The simple thickness of the endometrium, i.e. single layer measured sonographically at the point of maximal thickness, was on average 5.7 mm +/- 3.6 mm (2-15 mm). Hysteroscopically, an endometrium polyp was found in 23 cases (31.1%), endometrium hyperplasia in 12 (16.2%), and an atrophy in 35 cases (47.3%). In four cases (5.4%), an endometrial carcinoma was suspected. The histological results were consistent with the hysteroscopic findings. In all instances, in which the simple endometrial thickness amounted to 3 mm or less, an atrophic endometrium was found. The frequency of intrauterine pathologies increased significantly with a greater thickness of the endometrium. In 80% of patients, a cervical stenosis existed. CONCLUSIONS: Endometrial fluid by itself, without assessment of the endometrium, does not indicate the requirement for additional histological clarification. As diagnostics, the authors suggest especially the endometrial morphology.

Recurrent Miscarriage: Diagnostic and Therapeutic Procedures. Guideline of the DGGG (S1-Level, AWMF Registry No. 015/050, December 2013).

Purpose: Official guideline coordinated and published by the German Society of Gynecology and Obstetrics (DGGG). Aim of the guideline was to standardize the diagnosis and treatment of patients with recurrent miscarriage (RM). Recommendations were proposed, based on the current national and international literature and the experience of the involved physicians. Consistent definitions, objective assessments and standardized therapy were applied. Methods: Members of the different involved societies developed a consensus in an informal process based on the current literature. The consensus was subsequently approved by the heads of the scientific societies. Recommendations: Recommendations for the diagnosis and treatment of patients with RM were compiled which took the importance of established risk factors such as chromosomal, anatomical, endocrine, hemostatic, psychological, infectious and immunological disorders into consideration.

Possibilities of sterility therapy in a patient with a premature menopause due to an X-chromosomal anomaly - a case report.

Our report concerns a patient with a climacterium praecox and an X-chromosomal anomaly (86% 46, XX; 7% 47, XXX; 7% 45, X0) desiring to give birth. She conceived once after down-regulation of the gonadotrophins by means of a cyclical hormone replacement therapy followed by gonadotrophin stimulation, as well as a second time under down-regulation with a GnRH-analogue and gonadotrophin stimulation. On the basis of the case report and of the literature, a possible interval therapy in such a patient, especially one even with increasing ovarian insufficiency, will be portrayed and discussed.

Bilateral ovarian fibromas and endometrial adenocarcinoma in a postmenopausal patient with growing uterine myomas.

Bilateral ovarian fibromas are a rare condition. We report a case of bilateral ovarian fibromas with endometrial adenocarcinoma in a postmenopausal woman who clinically showed symptoms of an estrogen-producing tumour. Clinical and histopathological problems in the pre- and intraoperative diagnostics of fibromas are discussed.

Cryopreservation of human ovarian tissue by direct plunging into liquid nitrogen.

AIM: To establish a prospective direction for further development of the protocol for cryopreservation of ovarian tissue by direct plunging into liquid nitrogen. MATERIALS AND METHODS: Human ovarian biopsies from 20 patients (cut in approximately 0.5mm(3) pieces) were exposed to: 40% ethylene glycol+0.35 M sucrose+5% egg yolk; 40% ethylene glycol+18% Ficoll-70+0.35 M sucrose; 20% ethylene glycol+20% dimethyl sulphoxide. Cryopreservation of pieces was accomplished by plunging 0.25 ml straws or copper grids into liquid nitrogen or 0.25 ml straws into precooled (-196 degrees C) metallic powder. Thawed pieces were transferred to sucrose solution for incremental dilution of cryoprotectants. Histological observation of the tissue was performed after cryopreservation and in vitro culture was done to study hormone production ability after cryopreservation. RESULTS: Only ultrarapid cooling in ethylene glycol-sucrose-egg yolk solution protected both follicles and stroma from damage. CONCLUSION: The following parameters were established as required for a protocol of human ovarian tissue cryopreservation by direct plunging into liquid nitrogen: the vitrification medium should include ethylene glycol, disaccharide and egg yolk; ultrarapid cooling/thawing should take place using standard 0.25 straws or copper grids.

Menorrhagia and adenomyosis in a patient with hyperhomocysteinemia, recurrent pelvic vein thromboses and extensive uterine collateral circulation treatment by supracervical hysterectomy.

A 37-year-old patient had recurring thromboses, occlusion of the left femoral vein with hereditary hyperhomocysteinemia, hypermenorrhea and anaemia. Conservative therapy with endometrium ablation and gestagene failed. A supracervical hysterectomy was done to preserve the presacral and left lateral, dorsal and caudal collaterals beside the uterus, and prevent a postoperative congestion, especially of the left leg.

IGFBP-1 and glycodelin serum levels before and after hysterectomy with and without bilateral oophorectomy in premenopausal women.

OBJECTIVES: The aim of our study was to investigate the role of the intact endometrium and ovaries for serum levels of insulin-like growth factor binding protein-1 (IGFBP-1) and glycodelin. STUDY DESIGN: In 35 premenopausal patients with a planned hysterectomy, serum measurements of IGFBP-1 and glycodelin were done before surgery and 1, 3, 5, and 10 days after surgery. Patients were divided into three groups according to the kind and time of operation: (1) hysterectomy with bilateral adnexectomy in the luteal phase and (2) hysterectomy without adnexectomy in the follicular phase or (3) the luteal phase. RESULTS: IGFBP-1-we could not show any differences in IGFBP-1 serum levels before and after hysterectomy with or without bilateral oophorectomy. Glycodelin-hysterectomized and oophorectomized patients showed decreasing serum levels up to day 3. After day 5, circulating concentrations of glycodelin increased continuously but remained below pre-operative levels. In both non-adnexectomized groups we saw a reduction up to day 5 but a rise at day 10. None of the results reached statistical significance. CONCLUSION: The results indicate that endometrium and ovary are not the only sources of IGFBP-1 and glycodelin.

Conservative treatment of ectopic pregnancy in a cesarean section scar with methotrexate: a case report.

Ectopic pregnancies sited in dehiscent cesarean section scars have a high risk of rupture and bleeding. Attempts at operative therapy frequently end in loss of the uterus. A connection with the cavum uteri justifies an attempt at dilatation and curettage. We describes a patient with combined systemic and local intra-amniotic methotrexate (MTX). The uterus was preserved.

Cryopreservation of human ovarian tissue by direct plunging into liquid nitrogen: negative effect of disaccharides in vitrification solution.

Given that it has been possible to successfully cryopreserve human ovarian tissue by direct plunging into liquid nitrogen, this study was designed to establish the future direction to be taken in this line of research. Bovine oviductal epithelial fragments (as a tissue model) and large biopsy fragments (approximately 2.0 cubic mm) of human ovarian tissue were used for cryopreservation. Two protocols were tested: with permeable cryoprotectants (dimethyl sulphoxide, propylene glycol, glycerol) + egg yolk + sucrose or trehalose + a synthetic blocker of ice nucleation, Supercool X-1000; and using only permeable cryoprotectants (glycerol and ethylene glycol) + egg yolk + Supercool X-1000. The cryopreserved tissue specimens were subsequently thawed and the cryoprotectants removed by dilution in graded sucrose solutions. Both the dynamic growth and hormonal activity of the ovarian tissue pieces, vitrified using only permeable cryoprotectants, were greater than after vitrification in a mixture of permeable cryoprotectants and sucrose. Unlike the case for other reproductive tissue (spermatozoa, oocytes, embryos), these findings suggest that the cryopreservation of ovarian tissue by direct plunging into liquid nitrogen must be achieved by vitrification using only permeable cryoprotectants and agents that prevention ice formation.

The open pulled straw vitrification of ovine GV-oocytes: positive effect of rapid cooling or rapid thawing or both?

Three protocols for the open pulled straw (OPS) vitrification of ovine GV-oocytes with slow cooling-rapid thawing, rapid cooling-slow thawing, and rapid cooling-rapid thawing were tested. The effect of ultra-rapid cooling in liquid nitrogen slush and superfine open pulled straws (SOPS) was also studied. Our results prove that both rapid cooling and rapid thawing are contributing in improved results achieved with the OPS technology. The use of liquid nitrogen slush is beneficial for ovine GV stage oocyte nitrification.

Vitrification of human spermatozoa without cryoprotectants.

The aim of our study was to investigate the effects of vitrification (cooling rate approximately 10000(C/min) without cryoprotectants on swim-up prepared human spermatozoa in comparison to standard conventional freezing with cryoprotectants. Motility, morphology, rate of viability and acrosome reaction of spermatozoa were evaluated. The described method of cryopreservation of human spermatozoa by direct plunging into liquid nitrogen slush without cryoprotectants was effective and could be recommended for routine IVF.

[Persistent anovulation following laparoscopic electrocoagulation of the ovarian surface in a patient with polycystic ovary syndrome (PCOS)]. / Persistierende Anovulation nach laparoskopischer Elektrokoagulation der Ovaroberflächen bei einer Patientin mit einem Polyzystischen-Ovar-Syndrom (PCOS).

We report on a 32-year-old woman with polycystic ovarian syndrome (PCOS) who showed no ovarian reaction (oestradiol increase, leading follicle) to clomiphene and gonadotropin stimulation before and after laparoscopic electrocoagulation of the ovarian surface (LEOS) although hormone values (LH-FSH ratio, androstenedione) after LEOS were within normal range. The case is discussed in terms of the literature.

[Pregnancy and hormone replacement therapy in a patient with resistant ovary syndrome]. / Schwangerschaft unter Hormonersatztherapie bei einer Patientin mit einem passageren "Resistant-Ovary-Syndrome".

We report on the case of a 32-year-old woman with "resistant ovary syndrome". The patient received hormone replacement therapy sequentially with 2 mg estradiol valerate and 2 mg estradiol valerate/0.15 mg levonorgestrel (Klimonorm, Jenapharm, Germany) respectively, because of secondary amenorrhea and premature menopause. Under this therapy she conceived and had a delivery at term following an inconspicuous pregnancy. The case report emphasizes the rare but possible spontaneous remission of "resistant ovary syndrome" as a variant of premature menopause and is discussed in terms of the literature.

[Severe ovarian hyperstimulation syndrome and tubal pregnancy after in vitro fertilization]. / Schweres ovarielles Hyperstimulationssyndrom und Tubargravidität nach In-vitro-Fertilisation.

We report a case of a 38 year old woman with tubal pregnancy and severe ovarian hyperstimulation syndrome (OHSS) following in-vitro fertilization and intrauterine embryo transfer. The diagnostic and therapeutic problems in the coexistence of ectopic pregnancy and OHSS are discussed both in terms of the case-history and the literature.

Effect of soy supplementation on endogenous hormones in postmenopausal women.

AIM: The purpose of this study was to investigate the effect of soy supplementation with isoflavones on plasma hormone levels in postmenopausal women. METHODS: 16 postmenopausal women (mean age 56.21 +/- 5.01 years) were assigned to 24 weeks of dietary soy supplementation. A defined soy protein amount per day (20 g) with a low dosage of isoflavones (20 mg) was used. Plasma samples were analyzed for estradiol, FSH, LH, prolactin, testosterone and DHEAS. RESULTS: After 24 weeks of soy supplementation, plasma levels of estradiol did not increase. Gonadotropins, prolactin and the measured plasma androgens remained unchanged. We did not see any significant treatment effects. CONCLUSIONS: In the postmenopausal hypoestrogenic situation, soy protein consumption with low isoflavones does not influence endogenous hormone levels of estradiol and gonadotropins.

[Spontaneous pregnancy after laparoscopic salpingostomy and electrocoagulation of the ovarian surfaces in a patients with polycystic ovary syndrome]. / Spontangravidität nach laparoskopischer Salpingostomie und Elektrokoagulation der Ovaroberflächen bei einer Patientin mit einem Polyzystischen-Ovar-Syndrome (PCOS).

We report a case of a 25 year-old woman with repeated ovarian stimulation and laparoscopy because of anovulatory and tubal infertility due to polycystic ovarian syndrome (PCOS), who then spontaneously conceived. The complex nature of the multivariate cause of sterility is discussed together with therapeutic possibilities both in terms of the case-history and the literature.