A 20-year overview of fertility preservation in boys: new insights gained through a comprehensive international survey.

STUDY QUESTION: Twenty years after the inception of the first fertility preservation programme for pre-pubertal boys, what are the current international practices with regard to cryopreservation of immature testicular tissue? SUMMARY ANSWER: Worldwide, testicular tissue has been cryopreserved from over 3000 boys under the age of 18 years for a variety of malignant and non-malignant indications; there is variability in practices related to eligibility, clinical assessment, storage, and funding. WHAT IS KNOWN ALREADY: For male patients receiving gonadotoxic treatment prior to puberty, testicular tissue cryopreservation may provide a method of fertility preservation. While this technique remains experimental, an increasing number of centres worldwide are cryopreserving immature testicular tissue and are approaching clinical application of methods to use this stored tissue to restore fertility. As such, standards for quality assurance and clinical care in preserving immature testicular tissue should be established. STUDY DESIGN SIZE DURATION: A detailed survey was sent to 17 centres within the recently established ORCHID-NET consortium, which offer testicular tissue cryopreservation to patients under the age of 18 years. The study encompassed 60 questions and remained open from 1 July to 1 November 2022. PARTICIPANTS/MATERIALS SETTING METHODS: Of the 17 invited centres, 16 completed the survey, with representation from Europe, Australia, and the USA. Collectively, these centres have cryopreserved testicular tissue from patients under the age of 18 years. Data are presented using descriptive analysis. MAIN RESULTS AND THE ROLE OF CHANCE: Since the establishment of the first formal fertility preservation programme for pre-pubertal males in 2002, these 16 centres have cryopreserved tissue from 3118 patients under the age of 18 years, with both malignant (60.4%) and non-malignant (39.6%) diagnoses. All centres perform unilateral biopsies, while 6/16 sometimes perform bilateral biopsies. When cryopreserving tissue, 9/16 centres preserve fragments sized ≤5 mm3 with the remainder preserving fragments sized 6-20 mm3. Dimethylsulphoxide is commonly used as a cryoprotectant, with medium supplements varying across centres. There are variations in funding source, storage duration, and follow-up practice. Research, with consent, is conducted on stored tissue in 13/16 centres. LIMITATIONS REASONS FOR CAUTION: While this is a multi-national study, it will not encompass every centre worldwide that is cryopreserving testicular tissue from males under 18 years of age. As such, it is likely that the actual number of patients is even higher than we report. Whilst the study is likely to reflect global practice overall, it will not provide a complete picture of practices in every centre. WIDER IMPLICATIONS OF THE FINDINGS: Given the research advances, it is reasonable to suggest that cryopreserved immature testicular tissue will in the future be used clinically to restore fertility. The growing number of patients undergoing this procedure necessitates collaboration between centres to better harmonize clinical and research protocols evaluating tissue function and clinical outcomes in these patients. STUDY FUNDING/COMPETING INTERESTS: K.D. is supported by a CRUK grant (C157/A25193). R.T.M. is supported by an UK Research and Innovation (UKRI) Future Leaders Fellowship (MR/S017151/1). The MRC Centre for Reproductive Health at the University of Edinburgh is supported by MRC (MR/N022556/1). C.L.M. is funded by Kika86 and ZonMW TAS 116003002. A.M.M.v.P. is supported by ZonMW TAS 116003002. E.G. was supported by the Research Program of the Research Foundation-Flanders (G.0109.18N), Kom op tegen Kanker, the Strategic Research Program (VUB_SRP89), and the Scientific Fund Willy Gepts. J.-B.S. is supported by the Swedish Childhood Cancer Foundation (TJ2020-0026). The work of NORDFERTIL is supported by the Swedish Childhood Cancer Foundation (PR2019-0123; PR2022-0115), the Swedish Research Council (2018-03094; 2021-02107), and the Birgitta and Carl-Axel Rydbeck's Research Grant for Paediatric Research (2020-00348; 2021-00073; 2022-00317; 2023-00353). C.E is supported by the Health Department of the Basque Government (Grants 2019111068 and 2022111067) and Inocente Inocente Foundation (FII22/001). M.P.R. is funded by a Medical Research Council Centre for Reproductive Health Grant No: MR/N022556/1. A.F. and N.R. received support from a French national research grant PHRC No. 2008/071/HP obtained by the French Institute of Cancer and the French Healthcare Organization. K.E.O. is funded by the University of Pittsburgh Medical Center and the US National Institutes of Health HD100197. V.B-L is supported by the French National Institute of Cancer (Grant Seq21-026). Y.J. is supported by the Royal Children's Hospital Foundation and a Medical Research Future Fund MRFAR000308. E.G., N.N., S.S., C.L.M., A.M.M.v.P., C.E., R.T.M., K.D., M.P.R. are members of COST Action CA20119 (ANDRONET) supported by COST (European Cooperation in Science and Technology). The Danish Child Cancer Foundation is also thanked for financial support (C.Y.A.). The authors declare no competing interests. TRIAL REGISTRATION NUMBER: N/A.

Dydrogesterone supplementation in addition to routine micronized progesterone administration for luteal support in cycles triggered with lone GnRH agonist results in an acceptable pregnancy rate and avoids the need to freeze embryos.

BACKGROUND: Ovarian hyperstimulation syndrome (OHSS) is reduced when using antagonist cycle with gonadotrophin releasing hormone (GnRH) agonist trigger before ovum pick up. This trigger induces short luteinizing hormone (LH) and follicle stimulating hormone (FSH) peaks, resulting in an inadequate luteal phase and a reduced implantation rate. We assessed whether the luteal phase can be rescued by supplementing with oral dydrogesterone (duphaston) in antagonist cycles after a lone GnRH agonist trigger. METHODS: A retrospective cohort study. The study group (N.=123) included women who underwent IVF. Patients received a GnRH-antagonist with a lone GnRH-agonist trigger due to imminent OHSS. The control group (N.=374) included patients who underwent a standard antagonist protocol with a dual trigger of a GnRH-agonist and human chorionic gonadotrophin (hCG). All the patients were treated with micronized progesterone (utrogestan) for luteal phase support. Study patients were given duphaston in addition. RESULTS: The fertilization rate was comparable between the two groups. The mean number of embryos transferred, the clinical pregnancy rate and the take-home baby rate were comparable between groups (1.5±0.6 vs. 1.5±0.5 and 46.3% vs. 41.2%, and 66.7% vs. 87.7%, respectively). No OHSS event was reported in either group. CONCLUSIONS: This study was the first to evaluate outcomes of duphaston supplementation for luteal support in an antagonist cycle with lone GnRH agonist trigger. The functionality of the luteal phase of those cycles could be restored by adding duphaston. This approach was found to be safe and prevented the need to postpone embryo transfer in case of pending OHSS.

Transplantation of small ovarian tissue fragments using pipelle device is effective: method evaluation and reproductive outcomes.

PURPOSE: To assess the feasibility, effectiveness, and reproductive outcomes of transplantation of tiny cryopreserved ovarian pieces through a pipelle cannula during laparoscopic surgery. METHODS: A retrospective study of patients who underwent ovarian tissue transplantation for fertility restoration between 2004 and 2022. The "pipelle group" had their ovarian cortex cut into tiny pieces of ~ 1-2 mm3 before cryopreservation. The pieces were too small to be handled and transplanted via standard laparoscopic tools. Transplantation was performed using a pipelle cannula during laparoscopic surgery. The "control group" underwent transplants of ovarian cortex pieces 1-2 mm thick, measuring approximately 25-50 mm2 pieces, using standard procedures. RESULTS: The pipelle group consisted of 4 patients aged 19, 21, 27, and 28 years old at ovarian tissue cryopreservation (OTC). The control group consisted of 14 patients aged 21-30 years old. All pipelle patients restored their endocrine activity, and all of them conceived. FSH levels dropped during the first 3 months following the pipelle transplant. IVF cycle outcomes were similar for both groups. All patients from the pipelle group conceived, resulting in 5 pregnancies and 4 live births (one patient had 2 deliveries, and one additional pregnancy is ongoing), compared to the control group, where 8 patients achieved a total of 20 pregnancies and 18 live births. CONCLUSION: Pipelle transplantation for tiny cryopreserved ovarian pieces is feasible and effective. This study opens a door for patients who had their ovaries cut into small pieces and may even simplify the procedure in some instances, making ovarian transplant more accessible. TRIAL REGISTRATION: (#6531-19-SMC) [18/09/2019].

Establishment of a controlled slow freezing-based approach for experimental clinical cryopreservation of human prepubertal testicular tissues.

Objective: To develop an efficient, clinical-grade, freezing protocol toward experimental clinical cryopreservation of testicular tissues in prepubertal boys suffering from cancer. Design: Experimental cryopreservation of testicular tissue. Setting: University Medical Center. Patients: Adult patients undergoing orchiectomy for various tumors and prepubertal boys scheduled for gonadotoxic treatment. Interventions: None. Main Outcome Measures: Histopathological analysis of tissue architecture, structural integrity, and cellular morphology was performed for control and frozen-thawed cryopreserved tissues.The number of seminiferous tubules per testicular section was calculated. The survival of spermatogonial stem cells (SSCs) and Sertoli cells of the control and frozen-thawed cryopreserved tissues was analyzed by immunofluorescence staining. Results: Uncontrolled Slow Freezing, Controlled slow freezing, and vitrification similarly preserved the integrity of the adult testicular tissues and the survival of SSCs and Sertoli cells. Controlled slow freezing of prepubertal testicular tissues effectively preserved their architecture, the number of tubules, SSCs, and Sertoli cells. In addition, we observed SSC loss after chemotherapy in prepubertal boys, reemphasizing the importance of fertility preservation before gonadotoxic treatment. Conclusions: Future fertility restoration for male survivors of pediatric cancers depends on the development of an optimal prepubertal testicular tissue cryopreservation method. Our findings demonstrate the effectiveness of controlled slow freezing for cryopreservation of human prepubertal testicular tissues and may contribute to more effective banking of these tissues and potential fertility restoration. Clinical Trial Registration Number: NIH research clinical trials number: NCT02529826.

Urinary tract injuries during cesarean delivery: long-term outcome and management.

OBJECTIVE: Urinary tract injury during cesarean delivery is a rare but severe complication. Due to the high prevalence of cesarean delivery, this injury may pose a high burden of morbidity. We reviewed the cases of lower urinary tract injuries identified during cesarean delivery in a tertiary medical center and identified diagnosis and treatment methods, as well as short and long-term outcomes, to establish a protocol of care for such cases. METHODS: We included women with urinary tract injury during cesarean delivery between 2004 and 2018. The cases were identified according to ICD-9 codes, as well as free text in the medical report and discharge letter. Data were collected retrospectively. Telephone interviews were conducted to obtain additional data regarding long-term outcomes. RESULTS: In14 years, a total of 17,794 cesarean deliveries were performed at our institution (17.5% of all deliveries), 14 cases of bladder injury, and 11 cases of ureteral injury were identified featuring an incidence of 0.08 and 0.06%, respectively. All bladder injuries were diagnosed and repaired intra-operatively. Six (55%) cases of ureteral injury were diagnosed in the post-operative period, and 3 of these patients required further surgery for definitive treatment. None of the patients suffered long-term adverse effects. Most bladder injuries occurred in women with previous cesarean delivery in the presence of abdominal adhesions. In contrast, most ureteral injuries occurred in women with emergency cesarean delivery during the second stage of labor, and were accompanied by an extension of the uterine incision. All women had normal kidney function in follow up and did not suffer from long term sequelae. CONCLUSION: Urinary tract injury is an uncommon complication of cesarean delivery. A high index of suspicion is recommended to avoid late diagnosis and complications. We propose a comprehensive protocol for the management of these injuries.

Reproductive and obstetric outcomes following operative hysteroscopy for treatment of retained products of conception.

BACKGROUND: Retained products of conception following delivery or early pregnancy failure are often treated by operative hysteroscopy. We aimed to evaluate reproductive and obstetric outcomes following operative hysteroscopy for treatment of retained products of conception. We also investigated the effect of time interval between operative hysteroscopy and pregnancy on these outcomes. METHODS: A retrospective cohort study conducted at the gynecology department of a tertiary teaching hospital between January 2012 and December 2016. Included were women who underwent operative hysteroscopy for treatment of retained products of conception and became pregnant following the procedure. Reproductive and obstetric data were retrieved from electronic medical records and by telephone questionnaire. The effect of time interval between operative hysteroscopy and pregnancy on reproductive outcomes was also evaluated by comparing women who conceived 6 months or less and women who conceived more than 6 months following surgery. RESULTS: Seventy-nine women who underwent operative hysteroscopy for treatment of retained products of conception and who conceived later were included. Mean time from women's attempt to conceive to conception was 4.6 (SD=6.4) months. Conception rate was 84.8% at 6 months and reached 92.4% at 12 months postsurgery. Miscarriage rate for the consecutive pregnancy following hysteroscopy was 15.2% and delivery rate was 84.8%. Two cases of obstetric complications including one case of retained placenta and one case of post-partum hemorrhage were noted. Time interval between operative hysteroscopy and pregnancy did not affect reproductive or obstetric outcomes. CONCLUSIONS: Women treated by operative hysteroscopy for retained products of conception have no negative reproductive and obstetric outcomes. Time interval between the procedure and pregnancy has no effect on these outcomes.

Risk factors for recurrent Pelvic Inflammatory Disease.

OBJECTIVE: Pelvic inflammatory disease (PID) is a common infection which can result in severe long term morbidity, such as chronic pelvic pain and infertility. The morbidity increases in correlation to the number of PID events. Our study aim to assess the risk factors for recurrence of pelvic inflammatory disease. METHODS: A retrospective case control study was conducted using data for all women who were admitted to a tertiary medical center for a recurrent PID over a duration of 15 years. Women who had a recurrent PID were compared to women admitted for PID treatment without further recurrence. Forward stepwise multivariate logistic regression analysis was subsequently carried out. RESULTS: The study included 133 women of whom 33 had recurrent PID. Women in the recurrent PID group had a higher rate of previous pelvic surgery (12 (36 %) vs. 20 (20 %), adjusted odds ratio [OR] 2.2 (95 % confidence interval CI 1.06-5.4, p = 0.05) and more had intrauterine devices (IUD) still in place if they had been previously present (5 (71.4 %) vs. 9(25.7 %), OR 7.2, (95 % CI 1.18-43.9), p = 0.02). The majority were treated with a combination of Ampicillin and Gentamycin, fewer received Augmentin or a cephalosporin base regimen (28 (84.8 %) vs 56 (56.0 %), OR 4.4, (95 % CI 1.5-12.3, p = 0.02), (1 (3.0 %) vs 27 (27.0 %), OR 0.08, (95 % CI 0.01-0.64), (4 (12.2 %) vs 17 (17.0 %)) respectively. In addition, invasive treatment had been required in more patients who later had a recurrent PID (6 (18.1 %) vs. 4(4.0 %), OR 5.3 (95 % CI 1.1.4-20.2), p = 0.007). Antibiotic regimens and invasive treatment were independently associated with recurrent PID (OR 2.69; 95 % CI 1.13-6.41, OR 2.10; 95 % CI 1.19-3.71, respectively). CONCLUSION: Among women with PID, special awareness should be given to women with previous pelvic surgery, who required an additional interventional treatment and have an IUD inserted. Efforts should be made to achieve treatment success and optimal prevention to prevent recurrent PID.

Selective Progesterone Receptor Modulators for the Treatment of Uterine Leiomyomas.

Uterine leiomyomas have drawn much attention since being described more than 200 years ago. These common benign uterine tumors often present with prolonged menstrual bleeding, pelvic pressure, and reproductive disorders and pose a true financial burden on health care systems all over the world. Over the past few decades, surgical treatment of uterine leiomyomas has received most of the focus compared with other treatment options. Choosing the appropriate surgical technique depends on many factors such as uterine leiomyoma location, patient's age, interest in future fertility, concomitant comorbidities, and the patient's preference. Pharmacologic treatments such as gonadotropin-releasing hormone agonists and antagonists have been used for the treatment of symptomatic uterine leiomyomas with only partial success. Myriad side effects and limited clinical results have rendered them less popular and have exposed a true need for new effective medical treatments. Recently, treatment with selective progesterone receptor modulators has shown promising results with shrinkage of uterine leiomyomas and a prolonged clinical effect. Selective progesterone receptor modulators provide hope for women with this challenging condition and are a promising new option in the armamentarium of medical treatments for uterine leiomyomas.

Influence of ethnicity and improved outcome of acute myeloid leukaemia: two decades of follow-up of Israeli patient cohort.

Acute myeloid leukaemia is a disease with unfavourable prognosis. The significance of various prognostic parameters is not fully understood. We studied 293 patients to examine the influence of ethnicity and molecular markers. The median survival for all patients was correlated with age, white blood cell count and karyotype, and marginally with FLT3 internal tandem duplication. Arab patients were younger than Jewish patients; however, their survival was poorer albeit being treated with the same protocols and having more favourable cytogenetics. Survival rates improved over time but only for patients undergoing allogeneic bone marrow transplantation (alloBMT). We conclude that in our young patient cohort, recent improvement in survival is attributed to alloBMT therapy and that ethnicity affected treatment outcome.

Contribution of gross chromosomal changes to HPV16-induced transformation.

Cervical cancer is initiated by infection with high-risk human papillomavirus (HPV). The viral E6 and E7 oncogenes are required for the initiation of cervical epithelial cell immortalization, but do not suffice to cause cervical cancer. Human oncogenes and tumor suppressor genes with altered activity in cervical carcinoma have been recognized, but none of these appears to be an absolute precondition for the development of the cancer. To examine the contribution of chromosomal aberrations to the development of cervical carcinoma, we used an in vitro model system consisting of primary keratinocytes (K) and papillomavirus transformed keratinocytes from early (E) and late (L) passages and from benzo[a]pyrene treated L cells (BP). Using DIGMAP software we compared alterations in gene expression as a function of chromosomal location. SKY chromosomal painting confirmed that the alterations identified by DIGMAP include gross chromosomal aberrations. Nearly half of the transcripts that were significantly reduced or increased in BP cells mapped to chromosomal regions showing coordinate changes in expression. These included transcripts involved in previously characterized phenotypic changes involved in transformation, such as the switch from apoptosis to necrosis and the reduction in cap-dependent translation. The global chromosomal changes that occurred during transformation are highly correlated with the phenotypic changes in HPV transformed keratinocytes. Our data are consistent with the theory that global chromosomal change is a necessary step in the process of cervical transformation.