female patients diagnosed with cancer who wish to preserve their fertility by vitrifying their oocytes

freezing of the patient's retrieved oocytes via vitrification (rapid freezing)

oocyte vitrification

Avner Hershlag, MD

The purpose of this study is to preserve the fertility potential in females diagnosed with cancer by vitrifying (rapidly freezing) their oocytes (eggs) before undergoing treatment for their cancer.

Fertility Preservation in Female Cancer Patients

Vitrification of Oocytes From Female Cancer Patients to Preserve Their Fertility Potential

the primary objective of this study is the establishment of a successful pregnancy, following a disease-free interval after treatment for her cancer; this interval will be patient-dependent and will undoubtedly vary between participants.

patients will be followed for five years following cancer treatment to assess the risks associated with ovarian stimulation and the recurrence of cancer.

Northwell Health

Neoplasms

All Conditions

Skin and Connective Tissue Diseases

Carcinoma

Breast Neoplasms

Carcinoma, Ductal, Breast

Carcinoma, Ductal

Breast Diseases

Skin Diseases

Adenocarcinoma

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

All Drugs and Chemicals

Hormones

Follicle Stimulating Hormone

Degarelix injection(s)

Michaël GRYNBERG, MD, PhD

The present investigation aims to evaluate the efficacy of an innovative protocol of controlled ovarian stimulation for breast cancer patients, who are candidates for fertility preservation.

Currently, vitrification of oocytes and/or embryos after controlled ovarian stimulation is the most established method for female fertility preservation. However, this stimulation induces an increase in serum estrogen levels, which is theoretically problematic in case of hormone-sensitive tumors such as breast cancer. The majority of oncology teams accept, in very specific situations (particularly when the tumor has been surgically removed), this ovarian stimulation, because the expected benefits of fertility preservation far outweigh the risks. However, everyone agrees that it would be more comfortable to be able to offer vitrification of oocytes and/or embryos using ovarian stimulation without increasing estrogen levels.

In this research, investigators will evaluate the efficacy of degarelix (Firmagon®), currently indicated for the treatment of prostate cancer, as an innovative ovarian stimulation procedure. Administered at the beginning of ovarian stimulation, they believe it should maintain serum estradiol levels at physiological values at the end of stimulation.

Recent improvements in freezing techniques have led to the development of fertility preservation techniques for young women diagnosed with cancer. Currently, vitrification of oocytes or embryos after controlled ovarian stimulation (COS) represents the only established method. This COS is based on the daily administration of exogenous Follicle Stimulating Hormone (FSH) and an ovulation blockage using Gonadotropin Releasing Hormone (GnRH) antagonists (0.25 mg/d) initiated after approximately 6 days of stimulation and continued until ovulation is triggered.

In addition to requiring 15 days, COS induces supraphysiological hyperestradiolaemia (5-10 times normal) which can be problematic in case of hormone-sensitive tumors such as breast cancer. The majority of oncology teams accept, in very specific situations (particularly when the tumor has been surgically removed), this ovarian stimulation, because the expected benefits of fertility preservation far outweigh the risks. However, everyone agrees that it would be more comfortable to be able to offer vitrification of oocytes and/or embryos using ovarian stimulation without increasing estrogen levels.

Therefore, the limitation of serum estradiol concentrations during stimulation represents an important issue. To this end, stimulation protocols combining aromatase inhibitors have been proposed. Inhibition of the P450 aromatase enzyme in the granulosa cells of stimulated follicles prevents the conversion of androgens to estrogens. However, the teratogenic risk of these molecules, although discussed, limits their use in the indication of COS. Recently, a new "natos" protocol was proposed to stimulate the ovaries while maintaining physiological estradiolaemia, without using aromatase inhibitors. Thus, the administration of high doses of Gonadotropin Releasing Hormone (GnRH) antagonists (3 to 6 injections of 0.25 mg/day) from the beginning of COS, would allow a strong Luteinizing Hormone (LH) deprivation, thus limiting the production of androgens according to the 2 cells - 2 gonadotropins theory. In the absence of a precursor, estradiolemia remains at physiological ranges during the total duration of COS. However, the relative heaviness of a protocol combining up to 8 daily injections limits its use in young women who are candidates for fertility preservation.

Investigators therefore propose to evaluate the efficacy and tolerance of a new natos-like COS protocol based on the administration of a long-acting GnRH antagonist, degarelix. This drug is currently off-label for women.

The expected duration of the research is 14 months and participation will be 2 months.

After signature of the consent, during the first visit (oncofertility counseling), the the research (consultations and examinations) will be carried out within the Antoine Béclère hospital. All visits and examinations performed are part of routine care, except for the injection(s) of degarelix which belongs to the research.

Inclusion visit During the oncofertility consultation, the physician will make sure that the patient can be included in the research. Once the consent has been signed, the doctor will schedule the following visits based on the biological results obtained as part of the usual care.

Research follow-up visits

Stimulation: between the day of oncofertility counseling and the following 7 days, the doctor will check that patients are in the early follicular phase of the cycle, Degarelix injection: 1 injection, under the skin (possibly renewable after 5-7 days if the serum LH is ≥2 IU / L and / or the estradiol is ≥400 pg / mL), Concomitant initiation of ovarian stimulation by administration of recombinant FSH - Follitropin alfa (usual care). The injections will be given by the patient or a nurse at home, between 7pm and 10pm.

Stimulation follow-up visit #1 :

After 5 days of ovarian stimulation, transvaginal pelvic ultrasound (counting of ovarian follicles and measurement of their diameters) and blood sampling for serum hormone assays (estradiol, LH, progesterone) will be performed as part of the usual care.

Stimulation follow-up visits #2 and #3 Visits #2 and #3: transvaginal pelvic ultrasound (counting of ovarian follicles and measurement of their diameters) and a blood test for serum hormone assays (estradiol, LH, progesterone) will be required to monitor the response to stimulation, as part of routine care.

Visits are repeated until 4 follicles 16 to 20 mm in diameter are obtained, which is the criterion for ovulation trigger using 1 injection of Human Chorionic Gonadotropin (hCG) (Ovitrelle 250 mcg, SC) (usual care). Thus visits #2 and #3 are systematic. One or two additional visits with the same examinations may sometimes be necessary if the trigger criteria are not met.

Thirty-six hours after Human Chorionic Gonadotropin (hCG) , oocyte retrieval will be performed.

Visit on the day of the oocyte retrieval:

Patients will have a venous blood sample for serum hormone assays (estradiol, LH, progesterone) as part of the usual care.

Oocyte collection will be scheduled, and those which are mature will then be frozen (by vitrification) or fertilized in vitro in case of embryo freezing.

Visit following egg retrieval:

A blood test for serum hormone assays (estradiol, LH, progesterone) will be performed 3-4 days after oocyte retrieval.

End of research visit Participants will be contacted by phone 2 months after the injection of degarelix (Firmagon®) to make sure they are fine.

Efficacy and Tolerance of an Ovarian Stimulation Protocol Combining Follicle Stimulating Hormone (FSH) and Degarelix Acetate in Female Candidates for Fertility Preservation Before Chemotherapy for Breast Cancer

Efficacy and Tolerance of an Ovarian Stimulation Protocol Combining FSH and Degarelix Acetate in Female Candidates for Fertility Preservation Before Chemotherapy for Breast Cancer

Success of the procedure if at least 4 follicles 16 to 20 mm in diameter are obtained on the day of ovulation trigger (36 hours before oocyte collection) with estradiolemia \<500 pg / mL

Percentage of women with hyperestradiolemia during controlled ovarian stimulation (COS)

Outcome of ovarian stimulation evaluated by the number of oocytes collected, and the number of mature oocytes vitrified

Description : Serious side effects associated with treatment with degarelix (MedDRA coding)

Assistance Publique - Hôpitaux de Paris

Immature oocytes were vitrified using closed system vitrification. After warming, they were cultured during 36 hours in IVM medium and fixed for cellular analysis

Immature oocytes were cultured in vitro in IVM medium during 36 hours. After IVM, they were vitrified. After warming, they were fixed for cellular analysis.

Immature oocytes were cultured in vitro in IVM medium during 36 hours and subsequently, fixed for cellular analysis.

Immature oocytes were collected from patients (≤37 years old, without endometriosis, Polycystic syndrome or other ovulatory desease) who underwent to ICSI. In addition, immature oocytes collected from patient diagnosed with cancer will be included in this study. Oocytes were matured in vitro with IVM medium and vitrified in closed system (Vitrolife). Kinetic of maturation were analyzed by Primovision (Vitrolife) and actin, and spindle organization were studied by microscopy, immunostaining techniques and quantitive analysis.

Oocyte vitrification

Patrick LACARIN

Florence BRUGNON

Aïcha METCHAT

Human oocyte cryopreservation is routinely used for fertility preservation of women who will be exposed to gonadotoxic effect of cancer treatment. After ovarian stimulation, matured oocytes are vitrified. However, this strategy cannot always be used, particularly for hormone-sensitive cancer or when ovarian stimulation is not possible. An approach including immature oocytes and in vitro maturation (IVM) could be considered in these cases. While some qualitative analysis of oocytes vitrified before or after IVM suggest that vitrification should be performed after IVM, little is known about vitrification effects on actin and tubulin cytoskeleton and kinetic of maturation of human ovocytes.

To answer to this question, Investigator performed quantitive analyses comparing matured oocytes from three different groups: vitrified before IVM or after IVM and non-vitrified oocytes. Non-vitrified matured oocytes were used as a control. Different parameters have been analysed during maturation and in matured oocytes.

Immature oocytes were collected from patients (≤37 years old, without endometriosis, Polycystic syndrome or other ovulatory desease) who underwent to ICSI. In addition, immature oocytes collected from patient diagnosed with cancer will be included in this study. Oocytes were matured in vitro with IVM medium and vitrified in closed system ("Vitrolife"). Kinetic of maturation were analyzed by Primovision ("Vitrolife") and actin, and spindle organization were studied by microscopy, immunostaining techniques and quantitive analysis.

Comparison of Vitrification Effect Before or After In Vitro Maturation

Characterization of a Method of Fertility Preservation for Patients Diagnosed for a Cancer

After oocytes retrieval, immature oocytes will be vitrified (Rapid Vit Ovocyte®, Vitrolife) in a closed system (Rapid-I®, Vitrolife) and thawed for in vitro maturation few days after. The meiotic process will be analyzed by time lapse technology (Primovision®, Vitrolife). This will permit to score the time of maturation from resumption to polar body extrusion of ovocytes.

Metaphase-II stage oocytes from both protocols will be used for Immuno-Fluorescence experiments to stain actin, tubulin and chromosomes. Oocytes will be imaged using confocal microscope to perform high resolution imaging and quantitative image analysis. The length, position and orientation of the second meiotic spindle will be quantifying. The actin network and chromosomes will be analyzed quantitatively. All measurements will be compared with fresh Metaphase-II oocytes used as a control group.

The first asymmetric division is highly error prone. To investigate whether chromosomes are segregated accurately after vitrification, we will perform Fluorescence In Situ Hybridization to paint each chromosome after chromosome spread from Metaphase-II stage oocytes from both conditions

A staining with Lectin will be used to mark cortical granules of matured oocytes from both protocols to observe whether the vitrification does modify their spatial distribution. To analyze this staining, we will use quantitative image analysis method.

Maternal factors stored in the oocyte cytoplasm during oogenesis as proteins and transcripts are essential for the early embryonic development. To know if the stock of maternal factors is diminished by the vitrification procedure, we will perform Reverse Transcription combined with Real Time PCR to quantify transcript amounts of candidates genes selected from human oocytes databases.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Fertility Preservation in Female Cancer Patients	NCT01268592	Fertility	oocyte vitrific...	14 Years - 42 Years	Northwell Health
Efficacy and Tolerance of an Ovarian Stimulation Protocol Combining Follicle Stimulating Hormone (FSH) and Degarelix Acetate in Female Candidates for Fertility Preservation Before Chemotherapy for Breast Cancer	NCT03947151	Invasive Ductal...	Degarelix injec...	18 Years - 40 Years	Assistance Publique - Hôpitaux de Paris
Comparison of Vitrification Effect Before or After In Vitro Maturation	NCT03416400	Oocytes Vitrifi... Oocytes Matured...	Oocyte vitrific...	18 Years - 37 Years	University Hospital, Clermont-Ferrand

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