28/03/2014
CLINICA VALLE GIULIA, Roma
SALUS, Marostica (VI)
GENERA Umbertide (PG)
CLINICA RUESCH, Napoli
La preservazione della
fertilità femminile:
aspettative e risultati
Filippo Maria Ubaldi
M.D. M.Sc.
www.generaroma.it
RISULTATI
- crioconservazione ovocitaria
- crioconservazione tessuto ovarico
- uso di analoghi agonisti del GnRH
ASPETTATIVE (attuali)
- maturazione ovocitaria in vitro
ASPETTATIVE (futuribili)
- stem cells
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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)
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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)
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Oocyte vitrification: results
Oocyte vitrification: results
Centre 1:
Centre 2:
IVI Valencia
GENERA Rome
Centre 3:
Mangiagalli Milan
462 oocyte warming cycles and ongoing pregnancy
Infertility factor
Basal FSH
N°MII
N°MII
vitrified
Sperm
parameters
Female age
Incubation period
Endometrial
preparation
Rienzi, et al., Hum Reprod 2012
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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 2012
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Oocyte vitrification: cumulative pregnancy
Oocyte vitrification: cumulative pregnancy
69/120 = 57,5% ongoing pregnancy rate
Ubaldi, et al., Hum Reprod 2010
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Oocyte vitrification: cumulative pregnancy
Ubaldi, et al., Hum Reprod 2010
Oocyte vs embryo vitrification:
GENERA clinical results
Fresh cycles
Oocyte
vitri.
presentence
Embryo
vitri.
postsentence
p
68/182
(37.4)
99/182
(54.4)
<0.001
94/182
(51.6)
106/182
(58.2)
Ns
Oocyte
Warmed
Cycle
Embryo
Warmed
Cycle
N of cycles
503
919
N of patients
373
715
36.4±4.1
36.9±3.8
Warmed cycles clinical
outcomes: GENERA 20092012 (up to 42 y)
Female Age (mean±SD)
2064
1746
1828/2064
(88.5)
1696/1746
(97.1)
437/503
(86.8)
900/919
(97.9)
2,10±0,8
1.86±0.9
Clinical PR per Cycle (%)
131/503
(26.0)
267/919
(29.0)
Clinical PR per ET (%)
131/437
(29.9)
267/900
(29.7)
the pre-sentence group (Mean number: 1.3
Implantation Rate
142/919
(15.4)
280/1680
(16.6)
vs 1.6 respectively, p<0,05).
Delivery Rate per warmed
cycle (%)
106/503
(21.0)
231/919
(25.1)
Delivery Rate per Embryo
transfer (%)
106/437
(24,2)
231/900
(25,6)
I warming
cycles
Warmed Oocytes/Embryos
Survival rate (%)
II warming
cycles
97/182
(53,3)
111/182
(60,1)
Ns
Ubaldi
2010
Although a similar cumulative delivery rate
was obtained, a significantly lower number
of cycles per patient were performed in the
N of ET (%)
Transferred embryo
(mean±SD)
post-sentence group when compared to
Maggiulli, Ubaldi et al., oral presentation
ESHRE Annual Meeting 2012
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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.
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)
Day3: FSH 12 mUI/mL E2 255 pg/ml
Jan 2013: Oocyte Warming cycle
4 oocytes survived
Ongoing Clinical Pregancy
2 oocytes fertilized
Gestational Age: 37 weeks
1 embryo transferred (72h)
Oocyte vitrification in donors: results
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Oocyte vitrification in oocyte donation:
egg banking
Oocyte vitrification
and embryo aneuploidy
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ASRM guideline
ASRM guideline
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Risultati-Crioconservazione tessuto ovarico
Crypreservation and transplantation
of ovarian tissue
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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 reimplantation or follicular isolation and in vitro maturation
(IVM) (Donnez and Bassil, 1998). IVM of follicles isolated from cryopreserved ovarian cortex
has not yet resulted in pregnancy, but the reimplantation technique has yielded pregnan
cies and live births (30 in about 15 years, Donnez, december 2013)
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.
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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
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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
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Cryopreservation and transplantation
of ovarian tissue in hematologic malignancy
Risultati - Uso degli agonisti del GnRH
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Uso degli agonisti del GnRH
Uso degli agonisti del GnRH
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Uso degli agonisti del GnRH
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Uso degli agonisti del GnRH
Aspettative Attuali - IVM
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Aspettative Attuali - IVM
Aspettative Attuali - IVM
Donnez and Dolmans, Nature Reviews, dec 2013
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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): 15-23.
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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.
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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, 145–150 (2004)
White, Y. A. R. et al. Nature
Med. 18, 413–421 (2012)
Aspettative Futuribili - Stem Cells
2012, 98 (1): 1-2
2012, 98 (1): 3-10
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Aspettative Futuribili - Stem Cells
Stem Cells - eventuali applicazioni
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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 still a LONG WAY TO GO
before all the relevant testing can be carried out
www.generaroma.it
Grazie per
l’attenzione
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CLINICA VALLE GIULIA, Roma
SALUS, Marostica (VI)
GENERA Umbertide (PG)
GENERA RUESCH, Napoli
Ginecologia:
Embriologia:
Filippo Ubaldi
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
Antonio Angelini
Laura Buffo
Antonio Ciconte
Silvia Colamaria
Fabrizio Fiorini
A. Giallonardo
Maddalena Giuliani
Enrica Gravotta
Fabio Sapienza
Mauro Schimberni
www.generaroma.it
www.generapreimpianto.it
Silvia Venanzi
Aspettative: attuali – future
Competenza
ovocitaria
Gametogenesi
Gametogenesi
in vitro
in vivo
Coltura da
cortex ovarica
IVG-IVM
Gameti
artificiali
SCNT
hESc
iPS
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