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CASE HISTORY

Case History

image A 22-year-old woman presented to the emergency department with high grade fever, shortness of breath, night sweats and irritating cough. A chest X-ray revealed an 8 cm mediastinal mass. Ultrasound guided biopsy of the mediastinal mass showed findings consistent with Non-Hodgkin’s Lymphoma. A fertility unit consultation was organized to address toxicity of chemotherapy on her gonads and the different options of fertility preservation (FP). Her baseline anti-müllerian hormone (AMH) was 25.4 pmol/l. Because of the severity of her case, it was recommended to receive urgent chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone). In view of the urgency ovarian tissue cryopreservation (OTC) was considered to be her only option. About one-third of her left and right ovarian cortices were laparoscopically retrieved before initiating chemotherapy. Twenty small ovarian fragments were cryopreserved using the slow-freeze protocol. She reached complete remission after finishing her cycles of chemotherapy and mediastinal radiotherapy. Post-treatment, she developed post-menopausal symptoms (amenorrhoea, sleep disturbance, dyspareunia and hot flushes) confirmed by several FSH readings as high as 110 mIU/ml, low E2<20 pg/ml and an AMH of 1.14 pmol/l. She was therefore maintained on hormone replacement therapy to manage premature ovarian insufficiency (POI).

Five years following her treatment, she remained in complete remission and presented for restoration of her fertility. A histological and immunohistochemical examination of the previously frozen tissue did not reveal any tumour infiltration. A total of 10 fragments were thawed and transplanted in both ovaries. Tubal chromoperturbation confirmed bilateral tubal patency. Menstruation occurred 5 months post-transplantation and was followed by subsequent regular cycles. A midcycle ultrasound scan (USS) of ovaries revealed a dominant follicle. She had an AMH of 3.6 pmol/l, FSH 6.5 mIU/ml, LH 5.3 mIU/ml and E2 229 pg/ml on day 3 of cycle. Her healthy 31-year-old partner had normal semen parameters. She was followedup for several months to optimize her natural conception. One year following the transplant, she underwent controlled ovarian stimulation (COS) with an antagonist protocol (300 IU Menopur®). Ultrasound monitoring showed two follicles and two oocytes were collected. One mature oocyte was injected, and one embryo (9 cells grade 3) was transferred on day 3; unfortunately, this did not result in a pregnancy.

Why was OTC chosen instead of oocyte or embryo cryopreservation for FP?

What are the chances of her endocrine function returning after ovarian tissue transplantation (OTT)?

What are her chances of having a live birth after OTT?

What are the advantages and the major limitations of OTC as an option for FP?

What risks need to be considered after OTT?

What are the recent advances in the field of OTC?

Why was OTC chosen instead of oocyte or embryo cryopreservation for FP?

It would take 2–3 weeks to undergo COS and delaying cancer treatment was not an option in this patient. Although OTC was considered an experimental technique until very recently in the UK, it is a well-established and ...

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