La preservazione della fertilitàfemminile: aspettative e risultati

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1 CLINICA VALLE GIULIA, Roma SALUS, Marostica (VI) GENERA Umbertide (PG) CLINICA RUESCH, Napoli La preservazione della fertilitàfemminile: aspettative e risultati Filippo Maria Ubaldi M.D. M.Sc. RISULTATI - crioconservazione ovocitaria - crioconservazione tessuto ovarico -uso di analoghi agonisti del GnRH ASPETTATIVE (attuali) - maturazione ovocitaria in vitro ASPETTATIVE (futuribili) -stemcells 1

2 Risultati-Crioconservazione Ovocitaria Congelamento ovocitario in Italia Registro Italiano PMA anno 2011, 19/7/2013 Ovociti Ovociti/Embrioni Oocyte (and embryo) cryopreservation is not performed in all Italian ART Centres (and in the vast majority of ART Centres in the world) 2

3 PRINCIPALE PREGIUDIZIO oocyte cryopreservation gives low pregnancy rates Validation of oocyte vitrification 2008: Efficiency in donation program not compromised with vitrification (Cobo, 2008; Nagy, 2008) Evidence based medicine 2008: The clinical pregnancy rate double with the introduction of vitrification (RCT) (Tulandi, 2008; Cao, 2009; Smith, 2010) 2010: Prospective randomized study with own sibling oocytes demonstrates the lab efficiency of the technique (RCT) (Rienzi, 2010) 2010: Cumulative ongoing pregnancy rate with oocyte vitrification in a standard infertility program (Ubaldi, 2010) 2010: Prospective randomized study with donor oocytes demonstrates clinical efficiency of the technique (RCT) (Cobo, 2011) 2011: Efficiency of oocytes vitrification in the infertile population (RCT) (Parmegiani, 2011) 2011: Meta-analysis of randomized controlled studies (Cobo 2011) 2012: Multicentric longitudinal cohort study to confirm reproducibility (Rienzi, 2012) 3

4 Oocyte vitrification: results Oocyte vitrification: results Centre 1: Centre 2: Centre 3: IVI Valencia GENERA Rome Mangiagalli Milan 462 oocyte warming cycles and ongoing pregnancy Infertility factor N MII N MII vitrified Sperm parameters Basal FSH Female age Incubation period Endometrial preparation Rienzi, et al., Hum Reprod

5 Oocyte vitrification: results Rienzi, et al., Hum Reprod 2012 Success rate depends on the age of the woman and on the number of vitrified oocytes MULTICENTRER STUDY GENERA, Rome IVI, Valencia University of Milan, Milan 46,4% 12,6% 2721 vitrified oocytes 147 new born Rienzi et al., Human Reproduction

6 Oocyte vitrification: cumulative pregnancy Oocyte vitrification: cumulative pregnancy 69/120 = 57,5% ongoing pregnancy rate Ubaldi, et al., Hum Reprod

7 Oocyte vitrification: cumulative pregnancy Ubaldi, et al., Hum Reprod 2010 Oocyte vs embryo vitrification: GENERA clinical results Oocyte vitri. presentence Fresh cycles 68/182 (37.4) I warming cycles II warming cycles 94/182 (51.6) 97/182 (53,3) Ubaldi 2010 Although a similar cumulative delivery rate was obtained, a significantly lower number of cycles per patient were performed in the post-sentence group when compared to the pre-sentence group (Mean number: 1.3 vs 1.6 respectively, p<0,05). Embryo vitri. postsentence 99/182 (54.4) 106/182 (58.2) 111/182 (60,1) Maggiulli, Ubaldi et al., oral presentation ESHRE Annual Meeting 2012 p <0.001 Ns Ns Warmed cycles clinical outcomes: GENERA (up to 42 y) Oocyte Warmed Cycle Embryo Warmed Cycle N of cycles N of patients Female Age (mean±sd) 36.4± ±3.8 Warmed Oocytes/Embryos Survival rate (%) N of ET (%) Transferred embryo (mean±sd) Clinical PR per Cycle (%) Clinical PR per ET (%) Implantation Rate Delivery Rate per warmed cycle (%) Delivery Rate per Embryo transfer (%) 1828/2064 (88.5) 437/503 (86.8) 1696/1746 (97.1) 900/919 (97.9) 2,10±0,8 1.86± /503 (26.0) 131/437 (29.9) 142/919 (15.4) 106/503 (21.0) 106/437 (24,2) 267/919 (29.0) 267/900 (29.7) 280/1680 (16.6) 231/919 (25.1) 231/900 (25,6) 7

8 Case Report (paziente oncologica) Age: 22 years (2008) 2006: Solid vascolarized cyst 103x70x80 mm right ovary and 26x30x20 mm left ovary. Ascitis. Laparoscopy: omentectomy, re-moval of both cysts - border line ovarian cancer 2008: Solid vascolarized cysts right and left ovary. Laparoscopy: removal of both cycsts border line ovarian cancer. Day3: FSH 12 mui/ml E2 255 pg/ml Ubaldi et al., Current Oncology 2014 In revisione 2008 Oocyte vitrification Flare-up protocol 300 IU FSH/die x 11 days 7 oocytes retrieved 6 MII vitrified (Kitazato) Jan 2013: Oocyte Warming cycle 4 oocytes survived 2 oocytes fertilized 1 embryo transferred (72h) Ongoing Clinical Pregancy Gestational Age: 37 weeks Oocyte vitrification in donors: results 8

9 Oocyte vitrification in oocyte donation: egg banking Oocyte vitrification and embryo aneuploidy 9

10 ASRM guideline ASRM guideline 10

11 Risultati-Crioconservazione tessuto ovarico Crypreservation and transplantation of ovarian tissue 11

12 Crypreservation and transplantation of ovarian tissue Pregnancies and outcome after ovarian tissue cryopreservation and transplantation. Ovarian cortex cryopreservation was initiated more than 15 years ago and performed with a view to either future reimplantationor follicular isolation and in vitro maturation (IVM) (Donnezand Bassil, 1998). IVM of follicles isolated from cryopreservedovarian cortex has not yet resulted in pregnancy, but the reimplantation technique has yielded pregnan ciesand live births (30 in about 15 years, Donnez, december2013) Most of patients undergoing ovarian cortex reimplantation have demonstrated restoration of ovarian function, experiencing follicular development and ovulation. Cryopreservation of ovarian tissue is the only fertility preservation option available for pre-pubertal girls and for women who cannot delay the start of chemotherapy Maltaris et al., 2009 Crypreservation and transplantation of ovarian tissue At present 30 healty babies have been born from frozen-thawed ovarian tissue grafting orthotopically. How much is the denumerator, 30/? Grynberg et al., 2012 Orthotopic transplantation allow to the resumption of menstrual cycle and to natural conception, with endocrinological function up to 2-5 y. 12

13 Crypreservation and transplantation of ovarian tissue Conclusion: VT offers similar conditions to fresh tissue for follicular density proliferation, viability, cell death and preserves a larger population of quiescent follicles than S.F. after transplantation, thus ensuring the maintenance of graft potential fertility Crypreservation and transplantation of ovarian tissue Conclusions: An approach using ovarian stimulation first, followed by laparoscopic collection of ovarian tissue, is a useful strategy for increasing the efficacy of fertility preservation techniques. The ovarian tissue is not affected by prior ovarian stimulation 13

14 Crypreservation and transplantation of ovarian tissue A strategic combination of approaches may maximize efficiency while avoiding any compromise to cancer treatment: ovarian tissue cryobanking with immature oocyte aspiration and IVM or ovarian stimulation and mature oocyte retrieval and ovarian tissue cyobanking Criopreservazione e trapianto di tessuto ovarico Controindicazioni al reimpianto di tessuto ovarico 14

15 Cryopreservation and transplantation of ovarian tissue in hematologic malignancy Risultati - Uso degli agonisti del GnRH 15

16 Uso degli agonisti del GnRH Uso degli agonisti del GnRH 16

17 Uso degli agonisti del GnRH 17

18 Uso degli agonisti del GnRH Aspettative Attuali - IVM 18

19 Aspettative Attuali - IVM Aspettative Attuali - IVM Donnez and Dolmans, Nature Reviews, dec

20 Aspettative Attuali - IVM Aspettative Attuali - IVM The development of follicles is regulated by a complex mixture of inhibitory and stimulatory endocrine, paracrine and autocrine signalling by the somatic cells (granulosa and surrounding theca cells) enhanced by a range of oocyte specific regulatory factors mediated through bidirectional communication within the follicle TELFER EE, MCLAUGHLIN M (2011) Semin Reprod Med 29(1):

21 Aspettative Futuribili Ovaio artificiale - Stem Cells Aspettative Attuali Ovaio artificiale For women diagnosed with leukemia, transplantation of cryopreserved ovarian tissue after disease remission is not advisable. Therefore, to restore fertility in these patients, we aim to develop a biodegradable artificial ovary that offers an environment where isolated follicles and ovarian cells (OCs) can survive and grow. After transplantation, this matrix was able to degrade, allowed vascularization and elicited a low inflammatory response. 21

22 Aspettative Futuribili - Stem Cells Le ovaie contengono un pool di follicoli predeterminato durante la vita fetale e mai piu rinnovabile Dimostrata l esistenza di OSC oogonial stem cells aventi la capacità di mantenere la produzione di ovociti e follicoli anche dopo la nascita con concentrazione decrescente in base alla età Johnson, J. et al. Nature 428, (2004) White, Y. A. R. et al. Nature Med. 18, (2012) Aspettative Futuribili - Stem Cells 2012, 98 (1): , 98 (1):

23 Aspettative Futuribili - Stem Cells Stem Cells - eventuali applicazioni 23

24 The future: making oocytes from germ line stem cells? Development of culture systems that support human oocyte development MAY WELL OFFER practical solutions to fertility preservation for many women for whom conventional methods cannot be used but there is stillalong WAY TO GO before all the relevant testing can be carried out Grazie per l attenzione 24

25 CLINICA VALLE GIULIA, Roma SALUS, Marostica (VI) GENERA Umbertide (PG) GENERA RUESCH, Napoli Ginecologia: Filippo Ubaldi Antonio Angelini Laura Buffo Antonio Ciconte Silvia Colamaria Fabrizio Fiorini A. Giallonardo Maddalena Giuliani Enrica Gravotta Fabio Sapienza Mauro Schimberni Silvia Venanzi Embriologia: Laura Rienzi Stefania Romano Roberta Maggiulli Laura Albricci Antonio Capalbo Nicoletta Barnocchi Benedetta Iussig Danilo Cimadomo Federica Sanges Catello Scarica Elena Ievoli Marta Stoppa Ludovica Dusi Letizia Papini Lisa Dovere Aspettative: attuali future Competenza ovocitaria Gametogenesi in vitro Gametogenesi in vivo Coltura da cortex ovarica Gameti artificiali IVG-IVM SCNT hesc ips 25