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Fertility & Pregnancy Channel
Reported November 14, 2009

Ovarian Transplant -- In-Depth Doctor's Interview

Tamer Yalcinkaya, M.D., director of the Wake Forest University Center for Reproductive Medicine in Winston-Salem, N.C., explains how a certain type of ovarian tissue transplant gets hormones functioning.

Why would a patient need an ovarian transplant?

Dr. Tamer Yalcinkaya: Patients who have received or who are about to receive treatment for cancer in the form of cancer drugs or irradiation – sometimes these drugs are administered for certain non-cancerous conditions, such as kidney disease or connective tissue disease. Patients come to me before they receive chemotherapy or radiation therapy, and then they would be expected to come back once their condition is resolved, or in remission. The patient is interested in benefitting from the hormones and the fertility potential from the ovary or eggs that were preserved.

So they would do this to protect their fertility and hormones because it’s something that radiation or chemotherapy can destroy?

Dr. Yalcinkaya: Correct.

Is it a rare procedure?

Dr. Yalcinkaya: It’s a new procedure; it’s still being worked out. The population at risk is actually very big. More and more women are being treated for cancer in various organs, especially with breast cancer, and cancer drugs are being given for kidney disease and rheumatoid disease. Also, more and more women are living long enough after their disease. As a result, they focus back on their fertility or focus on their quality of life, such as normal hormones after their disease is resolved. The population at risk is very big, but because this is a new concept and is still being worked out, some of it is considered experimental. Few patients actually refer themselves, or are referred to a reproductive endocrinologist.

What does the process entail?

Dr. Yalcinkaya: This is multi-disciplinary teamwork. The oncologist treating the patient, the social worker, the psychologist, the internist, and the gynecologist that are initially involved with the patient’s care need to be aware of options that we are offering. Before cancer treatment is initiated, there is a visit to the reproductive endocrinology and fertility specialist to discuss options. After the patient’s eligibility candidacy is determined and the proposed treatment is agreed upon by the other members of the team, such as the patient’s significant other and treating cadre of doctors, then we initiate the treatment. Usually there are actually several options. One is to harvest eggs and fertilize them with their partner’s sperm and freeze the embryos, but because of the expeditious nature of how cancer drugs need to be initiated in some cases or because a person may not have a partner, this is not always a viable option. Another option is to freeze the patient’s eggs, but in order to do that, in most cases, the patient’s ovaries need to be stimulated, and again, the patient may not have time to do that. The other option is to do laparoscopy, remove one ovary, and divide the surface of the ovary by where the eggs or the follicles containing eggs are most abundant into small pieces, and using a certain protocol, freeze these ovarian pieces. Then the patient goes back to her oncologist or radiation therapist and receives and hopefully gets better. Sometime later – that can be a year, five years, even longer – she may want to come back. If she still wants to make fertility a priority or wants to make functioning ovaries in her own body a priority, she comes back to us, and at that point, we consider resuming treatment.

What happens to the small pieces during the laparoscopic procedure?

Dr. Yalcinkaya: In the laparoscopic procedure, they’re thawed and their viability is tested, and then the patient undergoes surgery at the same time. In our case, it was laparoscopy, and a lot of other cases, it has been open incision. Small pockets are created on the remaining ovary. It should be non-functioning by now because of the cancer drugs or radiation, but nevertheless, it is getting blood supply, so these pockets are created and the pieces that were thawed are placed and sewn into what we call the host ovary.

Even though they’re pieces and not the whole ovary, do they still function?

Dr. Yalcinkaya: The amazing thing about the ovary is that everything else being normal, even small pieces of ovary can produce follicles and can grow follicles, and can release eggs which can be fertile and result in a pregnancy. Unlike some other organs, such as heart or brain or kidney, the ovary can function in small fragments, too. What has been the limiting step of making this work actually has been the injury that is expected to occur when you freeze and thaw a tissue. Just like in any living tissue or cells, freezing and thawing does cause some damage to the tissue. That’s why we work with multiple pieces and we count on the multiplicity of small eggs. The limited experience shows that the tissue continues to function, although it may not be at the same efficiency or the same longevity.

Are there other reasons to have this procedure, other than getting pregnant?

Dr. Yalcinkaya: Some women go through this procedure of freezing to receive the frozen thawed tissue because they want to enjoy their normal menstrual cycle and the female hormones, the estrogen, that come with the normal menstrual cycles after the disease is in remission and after they’re fit to return to such normal hormonal function. It’s actually that desire that certain patients who are in the interest of losing their ovarian function, they want to gain it back as soon as possible after their disease is cured or is in remission so they don’t go into early menopause.

How successful is the treatment?

Dr. Yalcinkaya: It’s hard to tell because of the limited experience with this. Incases when a patient’s own ovary was frozen and then later thawed and then transplanted, in the whole world there have been only six live births. Last time I searched the medical literature, the number of patients in whom the ovaries were thawed and transplanted were probably 30, so it’s that new. On the other hand, there is a growing number of attempts to freeze ovarian tissue in patients who are undergoing, but because it’s relatively new, those patients have not come back to receive their tissue or cells to benefit from them.

Are there some risks that women need to consider before going through with this?

Dr. Yalcinkaya: Yes, there are potential risks. Number one, I think we need to set the patient’s expectations as to the experimental nature of this, and that we don’t know how long these ovaries are expected to function. In some cases, in our medical literature, after a few years, the patient’s ovaries have ceased to function, but then again, there are usually numerous other pieces that can be transplanted again. That’s one – the emotional nature and the expectations of the patient.

The medical risk potential is  second:In certain types of cancer like leukemia and sarcomas, the tissue can contain some cancer cells that have the theoretic risk of restarting the disease. In fact, we go through careful consideration with the oncologist of the patient and other specialists in this field to determine whether it’s safe to even consider freezing in every cancer case, and also in the patient receiving the tissue, even if their disease is in remission or is cured. Certain types of cancer that do not spread to the ovaries, such as breast cancer and lymphomas and numerous other diseases that young, reproductive age women occasionally develop, and also those benign conditions that require cancer therapy-type drugs for effective treatment, they will not pose a risk to the patient upon transplanting the frozen thawed ovarian tissue into the patient, so it is a case by case consideration. Of course, there are surgical risks of initially performing the operation when the patient has just been diagnosed with cancer, and then there are surgical risks associated with transplanting the tissue back into the host ovary.

What are the benefits are of doing this laparoscopically?

Dr. Yalcinkaya: As far as we know, this is the first time that the ovarian tissue has been transplanted in the way we are currently transplanting ovarian tissue into its normal location with laparoscopic robotic assistance. The advantage, of course, is that we are not compromising on the fine technique that is needed to form these pockets in the host ovary, and carefully and quickly transfer the frozen thawed tissue into the host ovary, due to the constraints that ordinary laparoscopy would otherwise place, being that it provides small holes and limited exposure. The robotic assisted version has enabled us to do fine maneuvers and apply fine technique to make these incisions, and sew the ovarian pieces into the host ovary.

Because it is a laparoscopy, is it easier for the patient to recover?

Dr. Yalcinkaya: Yes, it’s a same-day procedure and patients have a very short recovery, a shorter pain medication requirement period, and also less pain medication is needed during the recovery, as well as earlier return to the activities of daily life and work.

Can you tell us a little bit about the patient that we’re going to see today?

Dr. Yalcinkaya: Our patient, Jennifer, had been treated for a lymphoma. At the time, she was in another city, in New York, and she had already received some chemotherapy. When her lymphoma was found resistant, refractory, at that point, she was offered more aggressive chemotherapy. Then she hooked up with her local fertility clinic in New York and they were able to freeze her ovarian tissue, and then she moved to North Carolina and her disease was in remission. She contacted us and we evaluated her case, made the appropriate consultations with oncologists and her local doctors here, and decided that she would be a candidate. By that time, the tissue was transferred to our center in frozen state and our laboratory staff thawed the tissue. We scheduled her for a laparoscopy and a robotic assisted transplant of her ovarian tissue and performed the procedure with relative ease. She went home the same day. As expected from such frozen thawed tissue, the tissue pieces are expected to go through a period of anchoring into the host ovary and the egg-carrying fluid filled sacs called follicles. They actually take three months to grow from the primordial follicle stage to an ovulation stage, and that’s why all of these events cause a five-month lag on the average. That’s been consistent in the experience of everybody in the different centers of the world trying to perform these procedures and in our occupation. About five months later, she started having periods. We’ve been able to see her at certain times in her menstrual cycle and actually visualize a growing follicle (an egg-carrying sac) during multiple menstrual cycyles in her ovary where the transplantation took place. As far as what she is reporting, she is feeling a lot better in terms of menopausal vasomotor symptoms.

END OF INTERVIEW

This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.

If you would like more information, please contact:

 

Ann Hopkins

Public Relations

Wake Forest University Baptist Medical Center

ahopkins@wfubmc.edu

 

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Read the full report, Ovarian Transplant.

 

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