A 6-year-old girl freezes her ovarian tissue to avoid chemotherapy damage. Is it necessary to preserve her fertility?

Recently, the topic #6-year-old girl freezes ovarian tissue to avoid chemotherapy damage# made the treatment case of Hunan Provincial People's Hospital a hot topic, and also brought the relatively new concept of "fertility preservation" into the public eye.

Image source: Weibo screenshot

Fertility preservation is still unfamiliar to most people. Even in the tenth edition of the obstetrics and gynecology textbook published by the People's Medical Publishing House this year, the concept of fertility preservation is only briefly mentioned in the context of premature ovarian insufficiency (commonly known as premature ovarian failure) and assisted reproductive technology. Although some foreign gynecology, reproductive, and pediatric surgery textbooks contain content on fertility preservation, many technical, legal, and ethical issues are still being explored. Although this attempt by Hunan Provincial People's Hospital is the first in Hunan, the medical team's advanced medical concepts and technical level are already worthy of praise.

What is fertility preservation?

Fertility refers to the ability of women to become pregnant or men to give birth. Clinically, some diseases and treatments, as well as certain special workplaces, can harm the reproductive systems of women and men. Fertility preservation is to preserve the fertility of patients using various technical means, so that patients still have the opportunity to have biological children after being exposed to harmful environments, disease progression, and receiving reproductive toxic treatments, or when they need to postpone their childbearing plans for some reason.

Copyright images in the gallery. Reprinting and using them may lead to copyright disputes.

There are different solutions for female fertility preservation depending on the specific situation. Generally speaking, there are three methods:

Cryopreservation:

① For married women who wish to have children, or unmarried women who wish to have children and have a sperm donor, they can undergo in vitro fertilization after egg retrieval and freeze the embryos for future use.

② If there is no clear sperm donor but you are willing to have children, you can choose to freeze mature oocytes. Oocytes have a higher water content and are more susceptible to ice crystal damage than frozen embryos, so freezing is more difficult. However, with the advancement of cryopreservation technology, eggs frozen using improved methods have developmental potential close to that of fresh eggs.

③For young patients who have not yet reached puberty and patients who need immediate gonadotoxic treatment, freezing immature oocytes or ovarian tissue is an alternative option. These options involve more technical difficulties and are still in the research stage, but the results are worth looking forward to.

④Preserving the entire ovary with blood vessels is not yet possible.

1. Protects Ovaries:

① For women who receive pelvic radiotherapy, surgery can be performed to reposition the ovaries to protect them from radiation; for women who receive radiotherapy to other parts of the body, protective equipment is worn to avoid affecting the ovaries.

② The use of GnRH agonist therapy to suppress ovarian function during chemotherapy can also preserve fertility to a certain extent, but its effect is not as certain as cryopreservation. It is not recommended as a priority for fertility preservation, but only as a trial remedial measure when cryopreservation is not available.

③There are also medical teams that try to transplant ovaries to other parts of the body and subsequently help patients give birth successfully.

1. Protects the Uterus:

In the treatment of some borderline or early-stage malignant tumors, uterus-preserving surgery is chosen for patients who wish to have children.

Male fertility preservation mainly includes sperm cryopreservation and gonad protection during treatment.

Why Girls in the News Need

Need fertility preservation?

According to the description in the news, the girl needs a hematopoietic stem cell transplant and chemotherapy before the transplant. It is speculated that she may need to undergo myeloablative therapy before the hematopoietic stem cell transplant. This treatment generally requires the use of one or more chemotherapy drugs to completely destroy the hematopoietic cells in the bone marrow and the original malignant tumor cells in the body, thereby preventing the body's immune rejection of the transplanted cells and eradicating the original malignant lesions. This process requires extremely high doses of chemotherapy drugs, and there are also varying degrees of damage to normal body tissues in other parts. Because the ovaries are very sensitive to related chemotherapy drugs, their functional failure after chemotherapy is often not spared. The patient is a 6-year-old girl who has a long life ahead of her, so the choice of freezing ovarian tissue for fertility preservation is just right and necessary.

Copyright images in the gallery. Reprinting and using them may lead to copyright disputes.

The ovaries have two main functions, one is endocrine function, and the other is ovulation. When women grow to puberty, with the release of the hypothalamus-pituitary-ovarian axis inhibition, the ovarian function begins to "wake up", secreting estrogen and progesterone to participate in the development of female secondary sexual characteristics and participate in various physiological mechanisms of women until they "exit the stage of history" after menopause. Some women still need to use hormone replacement therapy after menopause to relieve discomfort and maintain health. Estrogen and progesterone are of great significance to women's physical and mental health, and are closely related to bone health, cardiovascular health, reproductive and urinary system health, and life expectancy. After being transplanted back into the body, the frozen ovarian tissue can restore endocrine and ovulation functions to a certain extent, preserve ovarian tissue, and retain the endocrine function of the ovaries. Not only does it give the girl a certain right to choose whether to have children in the future, but it is also planning for the girl's overall health in the long term.

Medicine needs more than just technology to advance

Humanistic care also needs to improve

Medical decisions are often accompanied by complex risk considerations and trade-offs. When we choose some options, we often need to pay some price for more important treatment purposes. For example, in order to treat a malignant disease, the girl in the news needs to destroy her own hematopoietic system first and bear the additional damage caused by the treatment of the disease. The goal of medical progress includes not only conquering more difficult and complicated diseases, but also continuously improving medical methods so that people can reduce additional costs while treating diseases. Fertility preservation has become a separate topic and is widely used in various reproductive toxic diseases and treatments. It is a glimpse of the patient's current treatment needs and long-term quality of life. I also hope that the medical treatment plans we receive in our daily lives can add more and more humanistic care. Medicine requires technology and warmth, and every need related to the quality of life deserves attention.

References

[1]Shazly, S., Laughlin-Tommaso, SK (2020). Fertility Preservation. In: Gynecology. Springer, Cham. https://doi.org/10.1007/978-3-030-41128-2_14

[2]Patrizio,P.,Molinari,E.,Falcone,T.,Westphal,LM(2022).FertilityPreservation.In:Falcone,T.,Hurd,WW(eds)ClinicalReproductiveMedicineandSurgery.Springer,Cham. https://doi.org/10.1007/978-3-030-99596-6_13

[3]Rowell,EE,Laronda,MM(2022).PediatricFertilityPreservation.In:Mattei,P.(eds)FundamentalsofPediatricSurgery.Springer,Cham. https://doi.org/10.1007/978-3-031-07524-7_124

[4]Mertes,H.,Pennings,G.(2022).EthicalConsiderationsofFertilityPreservation.In:Grynberg,M.,Patrizio,P.(eds)FemaleandMaleFertilityPreservation.Springer,Cham. https://doi.org/10.1007/978-3-030-47767-7_46

[5]WangCT,LiangL,WitzC,etal.Optimizedprotocolforcryopreservationofhumaneggsimprovesdevelopmentalcompetenceandimplantationofresultingembryos.JOvarianRes.2013;6(1):15.Published2013Feb13.doi:10.1186/1757-2215-6-15

[6]AtaB,Shalom-PazE,ChianRC,TanSL.Invitromaturationofoocytesasastrategyforfertilitypreservation.ClinObstetGynecol.2010;53(4):775-786.doi:10.1097/GRF.0b013e3181f9718f

[7]PachecoF,OktayK.CurrentSuccessandEfficiencyofAutologousOvarianTransplantation:AMeta-Analysis.ReprodSci.2017;24(8):1111-1120.doi:10.1177/1933719117702251

[8]HossayC,DonnezJ,DolmansMM.WholeOvaryCryopreservationandTransplantation:ASystematicReviewofChallengesandResearchDevelopmentsinAnimalExperimentsandHumans.JClinMed.2020;9(10):3196.Published2020Oct2.doi:10.3390/jcm9103196

[9]LorenAW,ManguPB,BeckLN,etal.Fertilitypreservationforpatientswithcancer:AmericanSocietyofClinicalOncologyclinicalpracticeguidelineupdate.JClinOncol.2013;31(19):2500-2510.doi:10.1200/JCO.2013.49.2678

[10]SternCJ,GookD,HaleLG,etal.Firstreportedclinicalpregnancyfollowingheterotopicgraftingofcryopreservedovariantissueinawomanafterabilateraloophorectomy.HumReprod.2013;28(11):2996-2999.doi:10.1093/humrep/det360

[11]PracticeCommitteeofAmericanSocietyforReproductiveMedicine.Ovariantissuecryopreservation:acommitteeopinion.FertilSteril.2014;101(5):1237-1243.doi:10.1016/j.fertnstert.2014.02.052

Planning and production

Author: Doctor Feidao Duanyu

Reviewer: Lan Yibing, deputy chief physician, Department of Obstetrics and Gynecology, Zhejiang University School of Medicine