Autotransplantation of fragmented ovarian cortical tissue: a laparoscopic demonstration

Abstract

Objective: To describe and demonstrate a simple and secure procedure for laparoscopic autotransplantation of fragmented ovarian cortical tissue in women with diminished ovarian reserve as part of in vitro activation (IVA) of ovarian follicles. Design:Step-by-step video explanation of the surgical procedure with still pictures and surgical video clips to demonstrate the detailed technique. Setting: Fertility clinic and obstetrics and gynecology department at a university hospital. Patient(s): Women with idiopathic diminished ovarian reserve and indication for in vitro fertilization (IVF), aged 25 to 39 years with an antral follicle count bilaterally of %5, antim€ ullerian hormone level of %5 pmol/L, and two ovaries. Intervention(s): The laparoscopic autotransplantation consists of six steps: [1] obtaining ovarian cortical biopsy samples, [2] preparing the peritoneal pocket, [3] fragmenting the ovarian cortical tissue into pieces of approximately 1 mm 3 , [4] installing the tissue fragments into a catheter, [5] transplanting the tissue fragments into the peritoneal pocket, and [6] closing the peritoneal pocket with a surgical clip. After the procedure, the patients are evaluated with blood samples and ultrasound scans followed by controlled ovarian stimulation. Ethics committee approval was obtained. Main Outcome Measure(s): Feasibility of a six-step laparoscopic autotransplantation procedure using fragmented ovarian cortical tissue. Result(s): A simple, fast laparoscopic procedure for taking biopsy samples and autotransplanting cortical tissue fragments in an all-inone procedure ensures the rapid handling and correct placement of the small tissue fragments. The procedure is performed in an outpatient setting with an operation time of 1 hour. We have performed this procedure on 20 patients with no complications. Conclusion(s):In vitro activation is a new, developing option for women in fertility treatment who have diminished ovarian reserve. Fragmentation of murine ovarian tissue has shown to suppress the Hippo pathway, thereby initiating proliferation and growth. This surgical procedure resembles that used when transplanting pieces of frozen-thawed ovarian tissue for fertility restoration, but the fragmented ovarian tissue is only 1 mm 3 , which makes it difficult to transplant. Until now no surgical procedures for transplanting small IVA fragments of cortical tissue has been published. With this video we report in detail a simple way of autotransplanting small fragments of IVA cortical tissue using what is already accessible in the operating theater. Among the many advantages of this procedure are its short duration (1 hour) and outpatient setting, which enable fast recovery and minimal postoperative pain. The procedure also allows fast handling and minimal manipulation of the tissue (limited to the fragmentation). The effect of autotransplantation of fragmented tissue in women with diminished ovarian reserve is currently being studied in ongoing trials. If the technique is combined with chemical IVA, a better ou...

Ovarian Fragmentation and AKT Stimulation for Expansion of Fertile Lifespan

“…Firstly, they conducted a similar drug-free IVA in 20 POI patients. There were no recorded complications and 12 patients could achieve pregnancies ( 74 , 75 ). There was no significant difference in the number of mature follicles and the AMH levels between the treated group and the control one during 10 weeks of observation ( 75 ).…”

Drug-free in-vitro activation of ovarian cortex; can it really activate the ‘ovarian gold reserve’?

“…In short, ovarian cortex fragments from POI patients were vitrified, warmed, fragmented into small pieces (approximately 100 cubes of 1-2 mm 2 ) and incubated with PTENinhibiting and PI3K-Akt-stimulating drugs, respectively, for 2 days before laparoscopic auto-transplantation beneath the serosa of the fallopian tubes. To this day, only a small number of pregnancies and births resulting from this method have been reported in the peer-reviewed literature or in the form of an abstract presentation (Fabregues et al, 2018;Lunding et al, 2018;Lee and Chang, 2019).…”

FertiPROTEKT, Oncofertility Consortium and the Danish Fertility-Preservation Networks – What Can We Learn From Their Experiences?

“…• Schmidt et al 49 • Schmidt et al 50 • Rosendahl et al 16 • Andersen et al 51 • Ernst et al 42 • Greve et al 52 • Schmidt et al 53 • Greve et al 54 • Ernst et al 55 • Rosendahl et al 56 • Macklon et al 57 • Jensen et al 11 • Jensen et al 58 • Jensen et al 59 • Gellert et al 60 • Matthwes et al 61 • Lunding et al 62 • Cryopreservation and transport protocols do not affect tissue quality nor follicle growth…”