Fertility Preservation in Pediatric Female Cancer Patients

18 May 2018 07:36 0
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Authors:
Sara Arian, MD; Rebecca Flyckt, MD; Richard Herman, MD; Hadi Erfani, MD; Tommaso Falcone, MD

Abstract:

OBJECTIVE
To describe and demonstrate ovarian tissue cryopreservation (OTC) as an emerging fertility preservation technique. Ovarian tissue cryopreservation is currently the only proven fertility preservation option for prepubertal girls and pediatric patients with cancer.

DESIGN
Video presentation of clinical article. The video uses animations and images and presents a surgical case to demonstrate the detailed surgical technique for laparoscopic oophorectomy in a 6 year old female patient followed by creating strips of ovarian tissue for ovarian freezing. Institutional Review Board approval was not required for this video presentation. Institutional Review Board approval is not required at the Cleveland Clinic for a case report of a single patient.

SETTING
OTC is not only an emerging option for fertility preservation for pediatric patients and prepubertal girls with cancer, it is also an evolving option for reproductive-aged women with cancer or benign conditions such as autoimmune diseases (e.g. multiple sclerosis and severe rheumatic diseases) or aplastic anemia, who may also need to undergo high doses of gonadotoxic chemotherapy or bone marrow transplant. This promising investigational option may also serve as a fertility preserving opportunity for adult female cancer patients with hormone sensitive malignancies who are advised against controlled ovarian stimulation associated with in vitro fertilization (IVF), or in patients who cannot delay cancer treatment in order to undergo oocyte or embryo cryopreservation. Approximately 95 children have been born or will be born in the near future worldwide following OTC and transplantation of cryopreserved ovarian tissue. OTC in the United States can currently only be offered under IRB-approved experimental protocols. At our institution, under an IRB-approved tissue registry, women desiring OTC undergo extensive counseling prior to the procedure. Recently a pediatric IRB at our institution has allowed children with cancer and other conditions whose treatments threaten future fertility to bank ovarian tissue as well. The experimental nature of this procedure is discussed with patients/families extensively prior to signing a consent form.

PATIENT(S)
In this video, we outline our technique for laparoscopic ovarian tissue harvesting followed by OTC. The video presents the case of a 6 year old female patient diagnosed with aplastic anemia with plan for bone marrow transplantation. She underwent laparoscopic unilateral oophorectomy in conjunction with the surgical procedure for port placement by the pediatric surgeon, followed by cryopreservation of ovarian tissue.

INTERVENTION(S)
The patient underwent laparoscopic unilateral oophorectomy followed by ovarian decortication in the operating room, and ovarian tissue freezing prior to undergoing bone marrow transplantation.

MAIN OUTCOME MEASURE(S)
To present the principle surgical techniques of ovarian tissue harvesting prior to OTC in pediatric patients. We also describe different surgical techniques for ovarian autotransplantation of cryobanked ovarian tissue after completion of gonadotoxic treatment and when the patient is ready to conceive.

RESULT(S)
This video demonstrates the detailed surgical technique for ovarian tissue harvesting. This harvesting can be performed laparoscopically or via mini-laparotomy and can involve a complete oophorectomy versus removing a portion of the ovary (a procedure also known as ovarian decortication). In the prepubertal child, due to the small size of the ovaries, we recommend oophorectomy rather than decortication owing to the small size of prepubertal gonadal tissue.

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