Combined ovarian tissue cryopreservation and in vitro maturation of ovarian- tissue oocytes (OTO-IVM) for emergency fertility preservation in the early postpartum period: a case report and systematic review of the literature
This case highlights the challenges of oocyte retrieval and maturation in the early postpartum period, suggesting that fertility preservation efforts may be less effective during lactation.
Where it sits
this study against the rest of the hcg (human chorionic gonadotropin) corpusSummary and findings
This study reports on a 23-year-old woman who underwent ovarian tissue cryopreservation and in vitro maturation of ovarian-tissue oocytes (OTO-IVM) for fertility preservation following a cesarean delivery. Despite follicular growth to greater than 10 mm, no oocytes were successfully retrieved or matured. The study also includes a systematic review of existing literature on the subject.
Abstract
<title>Abstract</title> <p>Purpose. In vitro maturation of oocytes recovered ex vivo from ovarian cortex (OTO-IVM), combined with ovarian tissue cryopreservation (OTC), is an adjunct for urgent fertility preservation (FP) when controlled ovarian stimulation is precluded; its performance in the immediate postpartum, lactating patient has not been described. Methods. We searched PubMed/MEDLINE along two axes: a PRISMA-guided systematic review of IVM (OPU-IVM, OTO-IVM) for FP (Axis A), and a scoping search of fertility treatment after the end of a pregnancy (Axis B). Results. A 23-year-old woman, three weeks after a cesarean delivery and still lactating, was diagnosed with metastatic Ewing-type pelvic sarcoma and referred for FP before VAC-IE chemotherapy. Prolactin was 504.8 mIU/L and antral follicle count ~ 19. Truncated gonadotropin priming (4 days) followed by an hCG trigger preceded right oophorectomy for OTC, transvaginal aspiration and OTO-IVM. Despite follicular growth to > 10 mm, aspiration yielded no oocytes. The cortex yielded 11 cumulus–oocyte complexes; 6 were degenerate, and 5 were at the germinal-vesicle stage, none of which matured after 48 h of IVM. Thirty-five ovarian cortical fragments were cryopreserved. A systematic review (13 IVM studies; 15 post-pregnancy reports) found no prior report of IVM-based FP in a postpartum or lactating woman. Conclusion. In this first reported attempt at OTO-IVM in the immediate postpartum period, oocyte retrieval and maturation failed despite adequate follicular growth, although medication exposure and concurrent illness are important confounders. OTC remained the durable component of FP. The case is hypothesis-generating regarding reduced oocyte maturational competence in the early postpartum, lactational ovary and informs counseling.</p>
Background
This paper addresses the clinical question of fertility preservation in postpartum women, particularly those who cannot undergo controlled ovarian stimulation due to medical conditions. Prior knowledge indicates that in vitro maturation (IVM) of oocytes is a potential strategy for fertility preservation, but its application in lactating women has not been documented. This study is significant as it explores the feasibility and outcomes of ovarian tissue cryopreservation combined with IVM in a unique patient population.
Methods
The study involved a case report of a 23-year-old woman who was three weeks postpartum and lactating, diagnosed with metastatic Ewing-type pelvic sarcoma. Gonadotropin priming was conducted for 4 days, followed by hCG triggering before right oophorectomy for ovarian tissue cryopreservation. The primary outcome measure was the retrieval and maturation of oocytes from the ovarian tissue.
Results
The primary endpoint indicated that despite adequate follicular growth to greater than 10 mm, aspiration yielded no oocytes. Eleven cumulus-oocyte complexes were retrieved, with 6 being degenerate and 5 at the germinal-vesicle stage. None of the oocytes matured after 48 hours of in vitro maturation.
Interpretation
The findings suggest that oocyte retrieval and maturation may be compromised in the early postpartum period, potentially due to hormonal changes or the lactational state. This aligns with previous literature indicating challenges in oocyte quality and maturation under similar conditions. However, the small sample size and the unique clinical scenario limit the generalizability of the results, and further research is needed to understand the implications for fertility preservation in postpartum women.
Key findings
- Prolactin was 504.8 mIU/L.
- Antral follicle count was approximately 19.
- Despite follicular growth to greater than 10 mm, aspiration yielded no oocytes.
- Of 11 cumulus-oocyte complexes, 6 were degenerate and 5 were at the germinal-vesicle stage.
- None of the oocytes matured after 48 hours of in vitro maturation.
Limitations
- Single case report with no successful oocyte retrieval.
- No generalizable findings due to unique patient circumstances.
- Short follow-up with no assessment of long-term outcomes.
- Lack of control group for comparison.