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In the USA alone, >650 000 women will be afflicted by cancer in 2003, and 8% of these cases will be aged <40 years. Due to improvements in cancer therapy, cure rates of both adult and childhood cancers increased significantly over the past three decades. However, long-term consequences of cancer therapy and impact on quality of life are now being recognized. One of the major sequelae of cytotoxic chemotherapy is gonadal failure. Cytotoxic chemotherapy and/or radiotherapy are not only used to treat malignant diseases, but also non-malignant systemic conditions. Upon reviewing the extent and mechanism of gonadal damage due to chemo-/radiotherapy, this article discusses indications and the wide range of methods of fertility preservation in a comprehensive manner. All current, emerging, experimental as well as controversial approaches are reviewed. A comprehensive algorithm to manage fertility preservation through an individualized approach is presented.

Laboratory research on ovarian cryopreservation and transplantation began in the 1950s leading to clinical studies in the 2000s. The research that was performed during this half century indicated that cryopreserved ovarian tissue has the potential to restore fertility in women who face premature ovarian failure due to chemotherapy, radiotherapy or surgery. To date, ovarian function has been restored in at least four women. Even though no pregnancies have been reported so far from these clinical studies, animal studies indicate that this is a valid prospect for humans. Future clinical trials will determine on a larger number of patients the longevity of ovarian grafts, normality of hormone production and ovarian follicle development, possibility and safety of pregnancy, and the safety of auto-transplantation in cancer patients. However, the major improvement in the efficiency of ovarian transplantation is anticipated to come from research exploring the revascularization process.

BACKGROUND:Cancer treatments, including chemotherapy, radiotherapy, and radical surgery, can induce premature menopause and infertility in hundreds of thousands of women of reproductive age every year. One of the ways to possibly preserve fertility before these treatments is to cryopreserve ovarian tissue for later transplantation. We aimed to restore fertility by cryopreservation and transplantation of ovarian tissue. METHODS:Ovarian tissue was cryopreserved from a 30-year-old woman with breast cancer before chemotherapy-induced menopause, and this tissue was transplanted beneath the skin of her abdomen 6 years later. FINDINGS/RESULTS:Ovarian function returned in the patient 3 months after transplantation, as shown by follicle development and oestrogen production. The patient underwent eight oocyte retrievals percutaneously and 20 oocytes were retrieved. Of the eight oocytes suitable for in-vitro fertilisation, one fertilised normally and developed into a four-cell embryo. INTERPRETATION/CONCLUSIONS:Fertility and ovarian endocrine function can be preserved in women by long-term ovarian tissue banking.

While ovarian tissue cryopreservation has commonly been equated with fertility preservation in cancer patients, there is a range of alternative options to preserve fertility. Based on the type and timing of chemotherapy, the type of cancer, the patient's age and the partner status, a different strategy of fertility preservation may be needed. If the patient has a partner or accepts donor sperm, embryo cryopreservation should be considered first, since this is a clinically well established procedure. Despite relatively low pregnancy rates, when there is time for ovarian stimulation and the patient is single, oocyte cryopreservation may also be preferred to ovarian tissue banking. In breast cancer patients, tamoxifen or aromatase inhibitors can be used for ovarian stimulation prior to oocyte or embryo cryopreservation. In endometrial cancer patients, aromatase inhibitors may be the only choice for ovarian stimulation. When only pelvic radiotherapy is used, ovarian transposition can be performed, but the success rates vary because of scatter radiation and vascular compromise. Lack of FSH and GnRH receptors on primordial follicles and oocytes does not make gonadal suppression an effective strategy of gonadal protection. Fertility preservation should be an integral part of improving the quality of life in cancer survivors; however, it is neither possible nor ethical to recommend the same recipe for every cancer patient.

OBJECTIVE:To describe a forearm heterotopic ovarian transplantation technique. DESIGN/METHODS:Case study. SETTING/METHODS:Academic medical center. PATIENT(S)/METHODS:One patient with stage IIIB squamous cell cervical carcinoma and one patient with recurrent benign ovarian cysts. INTERVENTION(S)/METHODS:Preparation of thin ovarian cortical slices and transplantation under the skin of the forearm. MAIN OUTCOME MEASURE(S)/METHODS:Follicular development and oocyte retrieval; cyclical estradiol (E(2)) and progesterone (P(4)) production; restoration of serum follicle-stimulating hormone (FSH) and luteinizing hormone (LH) levels to reproductive age range. RESULT(S)/RESULTS:Both patients were menopausal immediately after oophorectomy. The first patient developed a dominant follicle 10 weeks after transplantation, and her gonadotropin levels decreased to nonmenopausal levels. Percutaneous aspiration of ovarian follicles yielded a metaphase I (M-I) oocyte that was matured to metaphase II (M-II). The first patient's graft was functional for at least 21 months. In the second patient, ovarian follicle development was detected 6 months after transplantation, and periodic menstruation occurred thereafter. Spontaneous ovulation was confirmed by a midluteal increase in her P(4) levels. Menstruation and follicle development continued for more than 2 years after the transplant. CONCLUSION(S)/CONCLUSIONS:Heterotopic transplantation of ovarian tissue to the forearm is a simple and promising technique to restore ovarian function in women who become menopausal due to chemotherapy, surgery, or radiation.

BACKGROUND:Cyclins regulate the cell cycle in association with cyclin dependent kinases (CDKs). CDKs are under inhibitory control of cyclin dependent kinase inhibitors (CDKIs). METHOD/METHODS:In this study we tested the expression of CDKIs p15, p16, p21 and p27 by immunohistochemistry to determine the role of CDKIs in the initiation of primordial follicle growth. Ovaries were collected from 60-day-old cycling B6D2F1/J mice (n = 16). RESULTS:Expression of p15, p16, p21 and p27 did not vary in granulosa and theca cells by the follicle stage. However, p16 staining was stronger (++) in the oocytes of all primordial, and 57.4 +/- 3.1% of primary follicles compared to the remaining primary and more advanced follicles (+). Interestingly, primary follicles with weaker (+) oocyte staining for p16 had significantly larger mean follicle diameter compared to the primary and primordial follicles with stronger (++) oocyte staining (55.6 +/- 2.1 vs. 32.0 +/- 1.0 and 26.5 +/- 0.7 microm, respectively, p < 0.0001). This difference in follicle diameter was mainly due to a larger mean oocyte diameter (primary follicles, stronger vs. weaker, 19.6 +/- 0.6 vs. 31.5 +/- 1.4 microm, p < 0.0001). Oocytes of atretic follicles showed stronger staining with all four CDKIs. CONCLUSIONS:These preliminary findings suggest that the initiation of oocyte growth, which seems to lead follicle growth, is associated with diminished p16 expression in the mouse ovary. Further studies are needed to investigate the factors that regulate the expression of p16 in the oocyte, which might also govern the initiation of primordial follicle growth.

Integrins mediate cell adhesion to extracellular matrix and stimulate signals involved in cell proliferation, survival, and migration. Focal adhesion kinase (FAK) is considered the central molecule in integrin-mediated signaling. Previously, FAK has been implicated in invasive tumor behavior based on Northern or Western blot (immunoblot) using total tumor tissue homogenates. We used immunohistochemistry to demonstrate FAK expression in benign cervical epithelium, dysplasia, carcinoma in situ (CIS), and invasive cervical squamous cell carcinomas (SCCs), as well as in benign breast tissue, atypical ductal hyperplasia, and ductal carcinoma in situ (DCIS) and invasive carcinomas of the breast. We also used polymerase chain reaction to analyze whether infection with the high-risk human papillomavirus (HPV) subtypes correlated with FAK overexpression in CIS of the cervix. We found minimal FAK expression in benign cervical and breast epithelium and in low-grade squamous dysplasia (CIN I and CIN I-II) of the cervix, and variable FAK expression in CIS lesions of the cervix (10 of 14 cases). Most of the invasive SCCs of the cervix (13 of 16 cases) and DCIS of the breast (6 of 8 cases) were positive for FAK. Surprisingly, all DCIS of the breast were also strongly positive (7 of 7). Only 3 of 13 cases of atypical ductal hyperplasia were focally positive for FAK. Regardless of the intensity of FAK staining, all CIS of the cervix were positive for either HPV 16 or 18. We conclude that FAK overexpression is not restricted to invasive phenotype, but rather appears to be a marker for malignant transformation.

Laboratory research on ovarian cryopreservation and transplantation began in the 1950s leading to clinical studies in the 2000s. The research that was performed during this half a century indicated that cryopreserved ovarian tissue has the potential to restore fertility in women who face premature ovarian failure due to chemotherapy, radiotherapy or surgery. Until today, ovarian function has been restored in at least four women. Even though no pregnancies have been reported to date from these clinical studies, animal studies indicate that this is a valid prospect for humans. Future clinical trials will determine in a larger number of patients the longevity of ovarian grafts, normalcy of hormone production and ovarian follicle development, possibility and safety of pregnancy and the safety of auto-transplantation in cancer patients. In addition, further basic research may be needed to develop better cryoprotectants and cryopreservation techniques. However, the major improvement in the efficiency of ovarian transplantation is anticipated to come from research exploring the revascularisation process.