Successful fertility preservation following ovarian tissue vitrification in patients with primary ovarian insufficiency
Successful fertility preservation following ovarian tissue vitrification in patients with primary ovarian insufficiency
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DOI：
10.1093/humrep/deu353
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发表时间：
2015-03-01
影响因子：
6.1
通讯作者：
Kawamura, Kazuhiro
中科院分区：
文献类型：
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作者：
Suzuki, Nao;Yoshioka, Nobuhito;Kawamura, Kazuhiro
研究问题：采用玻璃化冷冻法冷冻保存卵巢组织，然后体外激活（IVA）休眠卵泡，是否是治疗原发性卵巢功能不全（POI）患者不孕症的潜在方法？总结回答：我们的玻璃化冷冻方法，然后IVA治疗是卵巢含有残留卵泡的POI患者的一种潜在的不孕治疗方法。Akt（蛋白激酶B）刺激剂[PTEN（在10号染色体中缺失与TENSin同源的磷酸酶）抑制剂和磷脂酰肌醇-3-激酶（PI 3激酶）刺激剂]在体外激活休眠的原始卵泡，卵巢碎裂破坏Hippo信号通路，从而促进卵泡生长。我们治疗POI患者的卵巢玻璃化冷冻，破碎和药物治疗相结合，然后通过自体移植，并报告成功的卵泡生长和pregnances.Study设计，大小，持续时间：37不孕妇女与POI 2011年8月12日和2013年11月1日之间的前瞻性临床研究。自上次发表以来，我们招募了10名新患者。POI患者最初是根据闭经超过1年的病史和血清FSH水平升高>40 mIU/ml（n = 31）选择的，但后来改为>4个月，年龄35 mIU/ml（n = 6）（平均71.8 ± 30.8，范围35.5-197.6），以便纳入闭经持续时间较短的患者。在腹腔镜手术下，进行卵巢切除术，并将卵巢皮质解剖成条用于玻璃化冷冻。对一些碎片进行了组织学检查。升温后，将两至三个条带破碎成较小的立方体，然后用Akt刺激剂培养2天。冲洗后，在腹腔镜手术下将卵巢立方体移植到输卵管浆膜下。通过超声和血清雌激素水平监测卵泡生长。从成熟卵泡中取出卵母细胞后，进行IVF。主要结果和机会的作用：在37例患者中，54%有残留的卵泡组织学的基础上。在有卵泡的患者中，20例中有9例在自体移植物中显示卵泡生长，其中6例患者获得了24个卵母细胞。在对4名患者进行IVF和胚胎移植后，根据血清hCG检测到3例妊娠，随后是1例流产和2例成功分娩。对于预测IVA的成功，我们发现，卵巢皮质的常规组织学分析和较短的时间从最初的POI诊断卵巢切除术是有效的parameters.LIMITATIONS，原因回避：虽然我们的研究结果表明，目前的玻璃化方案是有效的卵巢组织冷冻保存，我们还没有比较的潜力，玻璃化和缓慢冷冻移植后的卵泡生长。我们选择输卵管浆膜作为自动光栅网站，因为它的高血管和易于监测卵泡生长。未来的研究需要评估卵巢组织的最佳自体移植部位。此外，未来的研究需要确定的生物标志物，以表明残留卵泡在POI的存在，预测IVA治疗outcome.WIDER的影响的调查结果：在POI患者，卵巢储备，即池的残留卵泡，继续减少随着年龄的增长。如果一个卵巢在POI的早期阶段被冷冻保存，患者可以在最终决定IVA治疗之前接受额外的非侵入性不孕治疗。此外，在未婚POI患者的情况下，卵巢组织的冷冻保存允许他们的生育能力保存，直到他们想要生育。
STUDY QUESTION: Is ovarian tissue cryopreservation using vitrification followed by in vitro activation (IVA) of dormant follicles a potential approach for infertility treatment of patients with primary ovarian insufficiency (POI)?SUMMARY ANSWER: Our vitrification approach followed by IVA treatment is a potential infertility therapy for POI patients whose ovaries contain residual follicles.WHAT IS KNOWN ALREADY: Akt (protein kinase B) stimulators [PTEN (phosphatase with TENsin homology deleted in chromosome 10) inhibitor and phosphatidyinositol-3-kinase (PI3 kinase) stimulator] activate dormant primordial follicles in vitro and ovarian fragmentation disrupts the Hippo signaling pathway, leading to the promotion of follicle growth. We treated POI patients with a combination of ovarian vitrification, fragmentation and drug treatment, followed by auto-transplantation, and reported successful follicle growth and pregnancies.STUDY DESIGN, SIZE, DURATION: Prospective clinical study of 37 infertile women with POI between 12 August 2011 and 1 November 2013. We enrolled 10 new patients since the previous publication.PARTICIPANTS/MATERIALS, SETTING, METHODS: POI patients were originally selected based on a history of amenorrhea for more than 1 year and elevated serum FSH levels of >40 mIU/ml (n = 31) but this was later changed to >4 months, age 35 mIU/ml (n = 6) (mean 71.8 +/- 30.8, range 35.5-197.6) so as to include patients with a shorter duration of amenorrhea. Under laparoscopic surgery, ovariectomy was performed and ovarian cortices were dissected into strips for vitrification. Some pieces were examined histologically. After warming, two to three strips were fragmented into smaller cubes before culturing with Akt stimulators for 2 days. After washing, ovarian cubes were transplanted beneath the serosa of Fallopian tubes under laparoscopic surgery. Follicle growth was monitored by ultrasound and serum estrogen levels. After oocyte retrieval from mature follicles, IVF was performed.MAIN RESULTS AND THE ROLE OF CHANCE: Among 37 patients, 54% had residual follicles based on histology. Among patients with follicles, 9 out of 20 showed follicle growth in auto-grafts with 24 oocytes retrieved from six patients. Following IVF and embryo transfer into four patients, three pregnancies were detected based on serum hCG, followed by one miscarriage and two successful deliveries. For predicting IVA success, we found that routine histological analyses of ovarian cortices and shorter duration from initial POI diagnosis to ovariectomy are valid parameters.LIMITATIONS, REASONS FOR CAUTION: Although our findings suggest that the present vitrification protocol is effective for ovarian tissue cryopreservation, we have not compared the potential of vitrification and slow freezing in follicle growth after grafting. We chose the serosa of Fallopian tubes as the auto-grating site due to its high vascularity and the ease to monitor follicle growth. Future studies are needed to evaluate the best auto-grafting sites for ovarian tissues. Also, future studies are needed to identify biological markers to indicate the presence of residual follicles in POI to predict IVA treatment outcome.WIDER IMPLICATIONS OF THE FINDINGS: In POI patients, ovarian reserve, namely the pool of residual follicles, continues to diminish with age. If one ovary is cryopreserved at an earlier stage of POI, patients could undergo additional non-invasive infertility treatments before the final decision for the IVA treatment. Furthermore, in the cases of unmarried POI patients, cryopreservation of ovarian tissues allows their fertility preservation until they desire to bear children.