Name: fertility preservation through oocyte vitrification: clinical and laboratory perspectives
Uploaded: 2021-09-16T15:00:00
Description: Watch this Scientific Journal Video about Fertility Preservation Through Oocyte Vitrification: Clinical and Laboratory Perspectives at JoVE.com

1. Work-up and clinical counseling
NOTE: In case of patients requiring fertility preservation for oncologic reasons, ensure that there is no waiting list for scheduling consultation, and the appointment is provided as soon as possible.
<ol>
	<li>Examine the medical history and previous documentation, and assess the patient&#39;s general health status.</li>
	<li>Record all information (including the oncologist&#39;s approval to undergo ovarian stimulation in case of cancer patients) in a rela...

Clinical considerations 
Although emerging strategies, such as ovarian tissue cryopreservation and in vitro maturation, have been explored, oocyte vitrification after COS is the gold standard technique for fertility preservation. In this scenario, the number of oocytes retrieved and cryopreserved should be maximized in the shortest possible time as most cancer patients might benefit solely from one ovarian cycle before they have to commence their cancer treatment(s). Thus, a p...

The development and implementation of an efficient cryopreservation program for human oocytes has been a significant breakthrough in reproductive medicine. According to recent evidence, vitrification is the most effective strategy to cryopreserve metaphase II (MII) oocytes, as it results in statistically higher survival rates compared to slow freezing, independently of the patient population (infertile patients or oocyte donation program)1,2,3. The remarkable achievements of oocyte vitrification led the Practice Committees of the American Society for Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART) to pronounce this technique to be the most effective for elective fertility preservation in postpubertal women, for both medical and non-medical indications4,5,6. Medical indications for fertility preservation include (i) cancer and autoimmune diseases that require therapies7 such as radiotherapy, cytotoxic chemotherapy, and endocrine therapy (whose detrimental effect on the ovarian reserve is associated with maternal age as well as type and dose of the treatment); (ii) ovarian diseases requiring repeated or radical surgery (such as endometriosis)8; and (iii) genetic conditions (e.g., X-fragile) or premature ovarian failure. In addition, fertility preservation has become a valuable option for all women who have not accomplished their parental objective for non-medical reasons (also known as social freezing).
Regardless of the indication for fertility preservation and according to the major international guidelines on fertility preservation, all patients willing to vitrify their oocytes should receive appropriate counseling to be informed about their realistic chance of success, the costs, risks, and limitations of the procedure9,10,11,12,13. Most importantly, it should be clear that vitrifying a cohort of MII oocytes does not ensure a pregnancy, but that it offers a higher chance of success for future in vitro fertilization (IVF) treatment, if necessary14. In this regard, the woman&#39;s age at the time of oocyte vitrification is certainly the most important limiting factor15 as advanced maternal age (AMA; &#62;35 years) is the main cause of female infertility16. Besides a progressive reduction in the ovarian reserve, AMA is associated with an impairment of oocyte competence due to defective physiological pathways such as metabolism, epigenetic regulation, cell cycle checkpoints, and meiotic segregation17. Therefore, the reasonable number of eggs to vitrify mainly depends on maternal age. In women younger than 36 years, at least 8-10 MII oocytes18 are required to maximize the chance of success. In general, the higher the number of vitrified oocytes, the higher is the likelihood of success. Therefore, tailoring ovarian stimulation according to ovarian reserve markers such as anti-M&#252;llerian hormone (AMH) levels or antral follicle count (AFC) is crucial to fully exploit the ovarian reserve in the shortest possible time.
The safety of the whole procedure is the other key issue when enrolling patients for fertility preservation. Clinicians should employ the best strategies to minimize the risks and prevent (i)ovarian hyperstimulation syndrome (OHSS) by using safe approaches such as the gonadotrophin-releasing hormone (GnRH) antagonist protocol followed by a GnRH agonist trigger19 and (ii) the remote, yet possible, risks of peritoneal bleeding, injury to the pelvic structures (ureter, bowel, appendix, nerves), or pelvic infection during oocyte retrieval. Lastly, (iii) traditional regimens for stimulation are associated with supraphysiologic serum estradiol and therefore, are not recommended in estrogen-sensitive diseases such as breast cancer. Protocols involving aromatase inhibitors (such as letrozole or tamoxifen) are more suitable in these cases20,21. In the laboratory setting, the most widespread protocol for oocyte vitrification is still the one first described by Kuwayama and colleagues2,23, which consists of a stepwise procedure involving the gradual addition of cryoprotectants (CPAs). In the first phase (equilibrium/dehydration), oocytes are exposed in a CPA solution containing 7.5% v/v ethylene glycol and 7.5% v/v dimethyl sulfoxide (DMSO), while in the second phase, oocytes are moved to a vitrification solution with 15% v/v ethylene glycol and 15% v/v DMSO, plus 0.5 mol/L sucrose. After a short incubation in the medium of vitrification, the oocytes can be placed in specifically designed, open cryodevices and finally plunged in liquid nitrogen at -196 &#176;C to be stored until use.
Here, the whole clinical and laboratory work-up of a fertility preservation treatment has been described by (i) outlining recommendations for objective and evidence-based counseling, (ii) focusing on the cost-effectiveness of the procedure, and (iii) describing the most appropriate strategies to fully exploit the ovarian reserve and maximize the number of oocytes retrieved in the shortest possible time. The evaluation of the ovarian reserve, the definition of an ideal stimulation protocol, as well as oocyte retrieval, denudation, and vitrification procedures will be detailed along with approaches to maximize their efficacy, efficiency, and safety. As other protocols or adaptations of this protocol exist in the literature, the representative results and the discussion sections of this manuscript only apply to this procedure.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Collection</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Equipment</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Hot plate</td>
			<td>IVF TECH</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Lab Markers</td>
			<td>Sigma Aldrich</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laminar Flow Hood</td>
			<td>IVF TECH</td>
			<td></td>
			<td>Grade A air flow</td>
		</tr>
		<tr>
			<td>Stereomicroscope</td>
			<td>Leica</td>
			<td>Leica M80</td>
			<td></td>
		</tr>
		<tr>
			<td>Thermometer</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Test tube Warmer</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Tri-gas incubator</td>
			<td>Panasonic</td>
			<td>MCO-5M-PE</td>
			<td>02/CO2</td>
		</tr>
		<tr>
			<td>Vacuum Pump</td>
			<td>Cook</td>
			<td>K-MAR-5200</td>
			<td></td>
		</tr>
		<tr>
			<td>Consumables</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>CSCM (Continuos single culture complete) medium</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>90165</td>
			<td>IVF culture medium supplemented with HSA</td>
		</tr>
		<tr>
			<td>Mineral Oil for embryo culture</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>9305</td>
			<td></td>
		</tr>
		<tr>
			<td>Ovum Aspiration Needle (Single lumen)</td>
			<td>Cook</td>
			<td colspan="2">K-OSN-1730-B-60</td>
		</tr>
		<tr>
			<td>Primaria Dish</td>
			<td>Corning</td>
			<td>353803</td>
			<td>Corning Primaria Dish 100x20 mm style standard cell culture dish</td>
		</tr>
		<tr>
			<td>Round- bottom tubes</td>
			<td>Falcon</td>
			<td>352001</td>
			<td>Falcon 14ml Round Bottom Polystyrene Test tube with snap cap</td>
		</tr>
		<tr>
			<td>Round- bottom tubes</td>
			<td>Falcon</td>
			<td>352003</td>
			<td>Oocyte collection tubes/ Falcon 5ml 12x75 Round Bottom Polipropilene Test tube with snap cap</td>
		</tr>
		<tr>
			<td>Rubber Bulb</td>
			<td>Sigma Aldrich</td>
			<td>Z111589-12EA</td>
			<td></td>
		</tr>
		<tr>
			<td>Sterile glass Pasteur pipettes</td>
			<td>Hunter Scientific</td>
			<td>PPB150-100PL</td>
			<td>Pipette Pasteur Cotonate, 150mm, MEA e CE</td>
		</tr>
		<tr>
			<td>Denudation</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Equipment</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>CO2 incubator</td>
			<td>Eppendorf</td>
			<td>Galaxy 14S</td>
			<td></td>
		</tr>
		<tr>
			<td>Flexipet adjustable handle set</td>
			<td>Cook</td>
			<td>G18674</td>
			<td>Stripper&#160; holder</td>
		</tr>
		<tr>
			<td>Gilson Pipetman</td>
			<td>Gilson</td>
			<td>66003</td>
			<td>p20</td>
		</tr>
		<tr>
			<td>k-System Incubator</td>
			<td>Coopersurgical</td>
			<td>G210Invicell</td>
			<td></td>
		</tr>
		<tr>
			<td>Lab Markers</td>
			<td>Sigma Aldrich</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laminar Flow Hood</td>
			<td>IVF TECH</td>
			<td></td>
			<td>Grade A air flow</td>
		</tr>
		<tr>
			<td>Stereomicroscope</td>
			<td>Leica</td>
			<td>Leica M80</td>
			<td></td>
		</tr>
		<tr>
			<td>Consumables</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Biopur epTIPS Rack</td>
			<td>Eppendorf</td>
			<td>30075331</td>
			<td>Micropipettes epTIPS Biopur 2-200 &#181;l</td>
		</tr>
		<tr>
			<td>Human Serum Albumin</td>
			<td>thermoFisher Scietific</td>
			<td>9988</td>
			<td></td>
		</tr>
		<tr>
			<td>Hyaluronidase</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>90101</td>
			<td>80 IU/mL of hyaluronidase enzyme in HEPES-buffered HTF</td>
		</tr>
		<tr>
			<td>IVF culture dish (60 x 15mm)</td>
			<td>Corning</td>
			<td>353802</td>
			<td>Corning Primaria Falcon Dish 60X15mm TC Primaria standard cell culture dish</td>
		</tr>
		<tr>
			<td>IVF dish 4-well plate with sliding lid</td>
			<td>ThermoFisher Scietific</td>
			<td>176740</td>
			<td>Multidishes 4 wells (Nunc)</td>
		</tr>
		<tr>
			<td>IVF One well dish</td>
			<td>Falcon</td>
			<td>353653</td>
			<td>Falcon 60 x 15 mm TC treated center-well IVF</td>
		</tr>
		<tr>
			<td>Mineral Oil for embryo culture</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>9305</td>
			<td></td>
		</tr>
		<tr>
			<td>Modified HTF Medium</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>90126</td>
			<td>HEPES-Buffered medium</td>
		</tr>
		<tr>
			<td>Rubber Bulb</td>
			<td>Sigma Aldrich</td>
			<td>Z111589-12EA</td>
			<td>1 mL for pasteur pipettes</td>
		</tr>
		<tr>
			<td>Sterile glass Pasteur pipettes</td>
			<td>Hunter Scientific</td>
			<td>PPB150-100PL</td>
			<td>Pipette Pasteur Cotonate, 150 mm, MEA e CE</td>
		</tr>
		<tr>
			<td>stripping pipette&#160; tips (140 &#181;m)</td>
			<td>Cook</td>
			<td>K-FPIP-1140-10BS-6</td>
			<td>PIPETTE FLEXIPETS PER DENUDING</td>
		</tr>
		<tr>
			<td>stripping pipette tips (130 &#181;m )</td>
			<td>Cook</td>
			<td>K-FPIP-1130-10BS-7</td>
			<td>PIPETTE FLEXIPETS PER DENUDING</td>
		</tr>
		<tr>
			<td>stripping pipette tips (170 &#181;m)</td>
			<td>Cook</td>
			<td>K-FPIP-1170-10BS-5</td>
			<td>PIPETTE FLEXIPETS PER DENUDING</td>
		</tr>
		<tr>
			<td>Vitrification</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Equipment</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Electronic Timer</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Flexipet adjustable handle set</td>
			<td>Cook</td>
			<td>G18674</td>
			<td>Stripper&#160; holder</td>
		</tr>
		<tr>
			<td>Gilson Pipetman</td>
			<td>Gilson</td>
			<td>F123601</td>
			<td>p200</td>
		</tr>
		<tr>
			<td>Lab Markers</td>
			<td>Sigma Aldrich</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laminar Flow Hood</td>
			<td>IVF TECH</td>
			<td></td>
			<td>Grade A air flow</td>
		</tr>
		<tr>
			<td>Stainless Container for Cooling Rack</td>
			<td>Kitazato</td>
			<td></td>
			<td>Liquid nitrogen container for vitrification</td>
		</tr>
		<tr>
			<td>Stereomicroscope</td>
			<td>Leica</td>
			<td>Leica M80</td>
			<td></td>
		</tr>
		<tr>
			<td>Consumables</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Biopur epTIPS Rack</td>
			<td>Eppendorf</td>
			<td>30075331</td>
			<td>Micropipettes epTIPS Biopur 2-200 &#181;L</td>
		</tr>
		<tr>
			<td>Human Serum Albumin</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>9988</td>
			<td></td>
		</tr>
		<tr>
			<td>IVF culture dish (60 x 15 mm)</td>
			<td>Corning</td>
			<td>353802</td>
			<td>Corning Primaria Falcon Dish 60 x 15 mm TC Primaria standard cell culture dish</td>
		</tr>
		<tr>
			<td>IVF dish 6-well</td>
			<td>Oosafe</td>
			<td>OOPW-SW02</td>
			<td>OOSAFE&#160;6 WELL DISH WITH STRAW HOLDER</td>
		</tr>
		<tr>
			<td>Modified HTF Medium</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>90126</td>
			<td>HEPES-Buffered medium</td>
		</tr>
		<tr>
			<td>stripping pipette tips (170 &#181;m)</td>
			<td>Cook</td>
			<td>K-FPIP-1170-10BS-5</td>
			<td>PIPETTE FLEXIPETS PER DENUDING</td>
		</tr>
		<tr>
			<td>Vitrification Freeze kit</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>90133-so</td>
			<td>2 Vials of ES (Equilibration Solution, 2 x 1 mL) and 2 Vials of VS (Vitrification Solution, 2 x 1 mL)</td>
		</tr>
		<tr>
			<td>Vitrifit</td>
			<td>Coopersurgical Origio</td>
			<td>42782001A</td>
			<td>VitriFit&#160; Box</td>
		</tr>
		<tr>
			<td>Warming</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Equipment</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Electronic Timer</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Flexipet adjustable handle set</td>
			<td>Cook</td>
			<td>G18674</td>
			<td>Stripper&#160; holder</td>
		</tr>
		<tr>
			<td>Gilson Pipetman</td>
			<td>Gilson</td>
			<td>F123601</td>
			<td>p200</td>
		</tr>
		<tr>
			<td>k-System Incubator</td>
			<td>Coopersurgical</td>
			<td>G210Invicell</td>
			<td></td>
		</tr>
		<tr>
			<td>Lab Markers</td>
			<td>Sigma Aldrich</td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Laminar Flow Hood</td>
			<td>IVF TECH</td>
			<td></td>
			<td>Grade A air flow</td>
		</tr>
		<tr>
			<td>Stainless Container for Cooling Rack</td>
			<td>Kitazato</td>
			<td></td>
			<td>Liquid nitrogen container for vitrification</td>
		</tr>
		<tr>
			<td>Stereomicroscope</td>
			<td>Leica</td>
			<td>Leica M80</td>
			<td></td>
		</tr>
		<tr>
			<td>Consumables</td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Biopur epTIPS Rack</td>
			<td>Eppendorf</td>
			<td>30075331</td>
			<td>Micropipettes epTIPS Biopur 2-200 &#181;L</td>
		</tr>
		<tr>
			<td>CSCM (Continuos single culture complete) medium</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>90165</td>
			<td>IVF culture medium supplemented with HSA</td>
		</tr>
		<tr>
			<td>IVF culture dish (60 x 15 mm)</td>
			<td>Corning</td>
			<td>353802</td>
			<td>Corning Primaria Falcon Dish 60X15mm TC Primaria standard cell culture dish</td>
		</tr>
		<tr>
			<td>IVF dish 4-well plate with sliding lid</td>
			<td>ThermoFisher Scietific</td>
			<td>176740</td>
			<td>Multidishes 4 wells (Nunc)</td>
		</tr>
		<tr>
			<td>IVF dish 6-well</td>
			<td>Oosafe</td>
			<td>OOPW-SW02</td>
			<td>OOSAFE&#174;&#160;6 WELL DISH WITH STRAW HOLDER</td>
		</tr>
		<tr>
			<td>Mineral Oil for embryo culture</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>9305</td>
			<td></td>
		</tr>
		<tr>
			<td>SAtripping pipette tips (300&#181;m)</td>
			<td>Cook</td>
			<td>K-FPIP-1300-10BS-5</td>
			<td>PIPETTE FLEXIPETS PER DENUDING</td>
		</tr>
		<tr>
			<td>Vitrification Thaw kit</td>
			<td>Fujifilm Irvine Scientific</td>
			<td>90137-so</td>
			<td>4 Vials of TS (Thawing Solution, 4 x 2 mL) + 1 Vial of DS (Dilution Solution, 1 x 2 mL) +1 Vial of WS (Washing Solution, 1 x 2 mL)</td>
		</tr>
	</tbody>
</table>

fertility preservation through oocyte vitrification: clinical and laboratory perspectives

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women, for both medical and non-medical indications. The main medical indications are oncologic diseases, gynecologic diseases such as severe endometriosis, systemic diseases compromising the ovarian reserve, and genetic conditions involving premature menopause. This paper describes the whole clinical and laboratory work-up of a fertility preservation treatment by outlining recommendations for objective and evidence-based counseling. Furthermore, it focuses on the effectiveness of the procedure and describes the most appropriate strategies to fully exploit the ovarian reserve and maximize the number of oocytes retrieved in the shortest possible time. The evaluation of the ovarian reserve, the definition of an ideal stimulation protocol, as well as oocyte retrieval, denudation, and vitrification procedures have been detailed along with approaches to maximize their efficacy, efficiency, and safety.

Overview of the fertility preservation program at the center
Over a 12-year period (2008-2020), 285 women underwent at least one oocyte retrieval entailing the vitrification of the whole cohort of mature eggs collected. Most of these women (n=250) underwent a single retrieval, and 35 underwent multiple retrievals. The reasons for undergoing oocyte retrieval for egg vitrification are summarized into 4 categories: medical (except for cancer), cancer, non-medical, and others. Amo...

Watch this Scientific Journal Video about Fertility Preservation Through Oocyte Vitrification: Clinical and Laboratory Perspectives at JoVE.com

Fertility Preservation Through Oocyte Vitrification: Clinical and Laboratory Perspectives

Oocyte cryopreservation is recognized by several international scientific societies as the gold standard for fertility preservation in postpubertal women. Appropriate clinical and laboratory strategies ensure maximum efficacy, efficiency, and safety of fertility preservation treatments.

Preserving female fertility is crucial in a multifunctional healthcare system that takes care of patients' future quality of life. Oocyte cryopreservation ...

The oocyte vitrification and the warming procedures are essential for fertility preservation. Following this protocol as demonstrated allow a user to maximize the effectiveness of these procedures. Fertility preservation for oocyte vitrification is today an established and ethically acceptable approach.It allow to achieve effective and consistent clinical outcomes and overcome the moral and legal limitation associated with embryo cryopreservation. To achieve proficiency with the vitrification process, it is important to become familiar with all the critical points of the protocol, paying particular attention to the exposure time of the samples to the cryoprotectants. Within 38 hours of retrieval and immediately after denudation, label all of the plastic supplies with the patient's name, ID, and type of solution, and ask a witness to confirm the patient's information on the cryo device.When all of the supplies have been labeled, carefully invert each vial of oocytes several times to mix and place a 30 microliter drop of HEPES buffer medium supplemented with human serum albumin and a 30 microliter adjacent drop of equilibration solution on a petri dish. Use the stripper pipette to place the oocytes in the first drop and create a bridge of medium to a 30 microliter drop of equilibration solution to obtain a gradual increase in concentration of the cryoprotectants. After three minutes, add a second 30 microliter drop of equilibration solution to the plate and use the pipette to create a medium bridge between the drops of solution.While the oocytes are equilibrating, add one 30 microliter drop of equilibration solution for each cryo device to be used onto the plate. After three minutes, move the oocytes into the pure equilibration solution for six to nine minutes to allow the oocytes to return to their initial size. When the oocytes have recovered, prepare a central well IVF dish containing one milliliter of vitrification solution.Transfer the oocytes to the dish in as little medium as possible and carefully move them to remove any excess equilibration solution. Approximately 10 seconds before the end of the incubation, place a cryo device labeled with the patient's information under the microscope and adjust the focus on the tip of the cryo device. Place the oocytes on the cryo device beside the tip in the minimum amount of vitrification solution and move the stripper pipette away from the oocytes to remove any excess vitrification solution, leaving the oocytes covered with a thin layer of medium.Quickly plunge the cryo device into liquid nitrogen and rapidly shake the device to remove any air bubbles from its surface. Holding the protective cap of the cryo device with tweezers, fill the cap with liquid nitrogen before inserting the device into the cap while keeping the propylene strips in liquid nitrogen. Then store the cryo device in a visotube labeled with the patient's information and update the laboratory sheet.For oocyte warming, carefully invert each vial of thawing, dilution, and washing solution warmed to room temperature, and add one milliliter of thawing solution to the central well of a petri dish for an at least one hour incubation at 37 degrees Celsius. Label all of the plastic supplies with the patient's name and ID and the type of solution, and ask a witness to confirm the patient's information on the cryo device. For each device to be warmed, add 200 microliters of dilution solution to the first well of a six well plate and add an equal volume of washing solution to the second and third wells of the plate.Add PBS to the area on the outside of the wells to prevent solution evaporation. Place the dish of thawing solution under the stereo microscope and adjust the focus to the center of the dish. Carefully twist to remove the protective cap of a cryo device while keeping the propylene strips in liquid nitrogen and transfer the cryo device from the liquid nitrogen into the thawing solution as quickly as possible to avoid the risk of devitrification.After one minute, focus on the tip of the cryo device to locate the oocytes and eventually use a stripper pipette to gently release the oocytes from the device. Use a 170 micron diameter stripper pipette to transfer the oocytes and a small volume of thawing solution into the dilution solution in the first well of the six well plate. After three minutes, move the oocytes into the first well of washing solution for five minutes.At the end of the incubation, transfer the oocytes to the second well of washing solution and incubate at 37 degrees Celsius for one minute before transferring the oocytes into an appropriate volume of pre-equilibrated IVF culture medium for one hour and updating the laboratory sheet. Over a 12 year period, 285 women underwent at least one oocyte retrieval entailing the vitrification of the whole cohort of mature eggs collected. Most of these women underwent a single retrieval.35 underwent multiple retrievals. The reasons for undergoing oocyte retrieval for egg vitrification were generally characterized as medical other than cancer, cancer, nonmedical, and other. Patients with a medical reason for egg vitrification and patients undergoing fertility preservation because of cancer were younger and showed higher antral follicular counts than patients with nonmedical or other reasons.However, as the mean maturation rates were slightly lower in the medical reasons patients, the number of oocytes vitrified on average was similar between the groups. Approximately half of the patients with medical reasons other than cancer, and the majority of patients with other reasons for egg vitrification actually returned for warming. Conversely, very few patients who underwent fertility preservation for cancer or nonmedical reasons used their vitrified oocytes for IVF.Despite differences in the time elapsed between vitrification and warming, the survival rate of the oocytes was similar between patient groups, confirming the efficacy and safety of the oocyte vitrification and warming protocols. Moreover, the survival rate was independent of the vitrification and warming operator's experience. The most crucial steps that may affect the consistency of the results are the one related with warming.Therefore, it is really important to carefully control the volume and the temperature of the thawing solutions. Ovarian tissue cryopreservation the only strategy currently under investigation as an option for pre-pubertal patients. Although promising, this approach has important limitation which limited its application.

fertility-preservation-through-oocyte-vitrification-clinical

Research

JoVE Journal

Medicine

Clinical Assessment of Spatiotemporal Gait Parameters in Patients and Older Adults

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and neurological patients1-4, but also in healthy older adults5,6. The quantitative gait analysis described in this protocol is performed with a recently-introduced photoelectric system (see&#160;Materials table) which has the potential to be used in the clinic because it is portable, easy to set up (no subject preparation is required before a test), and does not require maintenance and sensor calibration. The photoelectric system consists of series of high-density floor-based photoelectric cells with light-emitting and light-receiving diodes that are placed parallel to each other to create a corridor, and are oriented perpendicular to the line of progression7. The system simply detects interruptions in light signal, for instance due to the presence of feet within the recording area. Temporal gait parameters and 1D spatial coordinates of consecutive steps are subsequently calculated to provide common gait parameters such as step length, single limb support and walking velocity8, whose validity against a criterion instrument has recently been demonstrated7,9. The measurement procedures are very straightforward; a single patient can be tested in less than 5 min&#160;and a comprehensive report can be generated in less than 1&#160;min.

This protocol is used to evaluate spatial and temporal gait variables of neurological/orthopedic patients and older persons by means of a recently-introduced floor-based photocell system.

Spatial and temporal characteristics of human walking are frequently evaluated to identify possible gait impairments, mainly in orthopedic and ...

Methodology for Sputum Induction and Laboratory Processing

The technique of sputum induction and processing is a recognized non-invasive method allowing the collection and analysis of cells from the airways, which is interesting in various respiratory diseases like asthma, chronic obstructive pulmonary disease (COPD), chronic cough, or idiopathic pulmonary fibrosis. This technique is well tolerated, safe and non-invasive, but is currently limited to research services and specialized centers in clinical practice because it is technically demanding, time-consuming, and requires trained staff. The success rate of sputum induction and analysis is about 80%.
Here, we describe the induction and laboratory processing of sputum samples. Sputum is induced by inhalation of hypertonic or isotonic saline with salbutamol. For the processing, we use the whole sputum technique. Dithiothreitol (DTT) is used to allow mucolysis of sputum samples. The primary aim of sputum processing is to obtain a differential cell count to study the cell types present in the airway lumen. Additional analyses may also be performed on sputum supernatant and sputum cells, which may allow further investigation into inflammatory processes and immune mechanisms. Examples include studying mediators in sputum supernatant and performing a large spectrum of analysis on sputum cells such as flow cytometry, genomics, or proteomics.
Finally, representative results of sputum analysis in healthy controls, asthmatics, and COPD patients are presented.

Here we describe the technique of sputum induction. This protocol also explains the sputum processing to perform a differential cell count and to collect sputum supernatant and cells for further analysis.

The technique of sputum induction and processing is a recognized non-invasive method allowing the collection and analysis of cells from the airways, which ...

Introduction of Intracapsular Rotary-cut Procedures (IRCP): A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For patients desiring pregnancy, laparoscopic intracapsular myomectomy (LM) is an alternative surgery option. Although LM is widely accepted to treat fibroids, it is technically demanding with risk of excessive bleeding and difficult suturing, especially in cases with large fibroids or tumors in unusual locations. Therefore, we developed an intracapsular rotary-cut procedure (IRCP) as a modification of laparoscopic intracapsular myomectomy, with the intention to minimize risks of LM and help uterine healing. A summary of the improvements to the IRCP is described: 1) making an incision at the site of the fibroid with a length of one-third to one-half of the fibroid&#39;s diameter at a depth reaching the fibroid&#39;s surface; 2) holding the fibroid stably and making rotary cuts on the fibroid at a depth of 0.5&#8211;1 cm within its pseudo-capsule while pulling it outward slightly, making sure not to cut off any pieces of the fibroid; and 3) repeating the cutting-and-pulling until the longest dimension of the fibroid is outside the incision. The multiple cuts are to minimize the diameter and extend the length of the fibroid. When the multiple cuts cause half of the fibroid body to &#34;shrink&#34;, the fibroid is squeezed out by contraction of the surrounding myometrium. Evaluation of the outcomes of IRCP showed that the time of enucleation and suturing, intraoperative bleeding, and decline of hemoglobin were significantly lower in the IRCP group than the LM group. As for reproductive outcomes, the full-term live birth rate of the IRCP group was significantly higher than that of LM group. However, there was no difference in delivery modes between the two groups. In conclusion, IRCP significantly benefits fertility preservation by minimizing damage to the uterus, protecting myofibers of the pseudo-capsule, and resulting in a shallower residual cavity, which eases stitching and causes less bleeding. It is worthwhile to adopt IRCP in younger patients who desire preservation of their fertility.

Introduction of Intracapsular Rotary-cut Procedures IRCP: A Modified Hysteromyomectomy Procedures Facilitating Fertility Preservation

Here, we present a protocol for performing an intracapsular rotary-cut procedure (IRCP), a modified laparoscopic intracapsular myomectomy that promotes fertility preservation.

Uterine fibroids are common benign tumors in the female reproductive system. A hysterectomy is the most effective treatment for symptomatic fibroids. For ...

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is almost completely reserved to a few referral centers that deal with a large proportion of this pathology. Practice on human specimens is not always possible for ethical, economic, or availability reasons. The aim of this study is to provide a reproducible method for the organization of a laryngeal laboratory on ex vivo animal models where it is possible to approach, learn, and refine laryngeal techniques. Porcine and ovine larynges are ideal, affordable, models to simulate laryngeal surgery given their similarity to the human larynx in their anatomical layout and tissue composition. Herein, the surgical steps of transoral laser surgery, open partial horizontal laryngectomy, and total laryngectomy are reported. The merging of endoscopic and exoscopic views guarantees an inside-out perspective, which is vital for the comprehension of the complex laryngeal anatomy. The method was successfully adopted during three sessions of a dissection course &#34;Lary-Gym&#34;. Further perspectives on robotic surgical training are described.

The purpose of this paper is to illustrate how to organize a reproducible laboratory for laryngeal surgery on affordable and closely similar animal laryngeal models in order to improve anatomical and surgical knowledge and skills.

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is ...

Orthotopic Kidney Auto-Transplantation in a Porcine Model Using 24 Hours Organ Preservation And Continuous Telemetry

In the present era of organ transplantation with critical organ shortage, various strategies are employed to expand the pool of available allografts for kidney transplantation (KT). Even though, the use of allografts from extended criteria donors (ECD) could partially ease the shortage of organ donors, ECD organs carry a potentially higher risk for inferior outcomes and postoperative complications. Dynamic organ preservation techniques, modulation of ischemia-reperfusion and preservation injury, and allograft therapies are in the spotlight of scientific interest in an effort to improve allograft utilization and patient outcomes in KT.
Preclinical animal experiments are playing an essential role in translational research, especially in the medical device and drug development. The major advantage of the porcine orthotopic auto-transplantation model over ex vivo or small animal studies lies within the surgical-anatomical and physiological similarities to the clinical setting. This allows the investigation of new therapeutic methods and techniques and ensures a facilitated clinical translation of the findings. This protocol provides a comprehensive and problem-oriented description of the porcine orthotopic kidney auto-transplantation model, using a preservation time of 24 hours and telemetry monitoring. The combination of sophisticated surgical techniques with highly standardized and state-of-the-art methods of anesthesia, animal housing, perioperative follow up, and monitoring ensure the reproducibility and success of this model.

Large animal models play an essential role in preclinical transplantation research. Due to its similarities to the clinical setup, the porcine model of orthotopic kidney auto-transplantation described in this article provides an excellent in vivo setting for the testing of organ preservation techniques and therapeutic interventions.

In the present era of organ transplantation with critical organ shortage, various strategies are employed to expand the pool of available allografts for ...

OP-IVM: Combining In vitro Maturation after Oocyte Retrieval with Gynecological Surgery

The use of in vitro maturation (IVM) before gynecological operation (OP-IVM) is an extension of conventional IVM that combines IVM following oocyte retrieval with routine gynecological surgery. OP-IVM is suitable for patients undergoing benign gynecological surgery who have the need for fertility preservation (FP) or infertility treatments such as in vitro fertilization and embryo transfer (IVF-ET). In the operating room, patients undergoing benign gynecological surgery are first anesthetized and receive ultrasound-guided immature follicle aspiration (IMFA) treatment. As the subsequent gynecological surgery is performed, the cumulus-oocyte complexes (COCs) are examined, and the immature COCs are transferred into the IVM medium and cultured for 28-32 hours in the IVF laboratory. After assessment, mature oocytes in the MII stage will be selected and cryopreserved in liquid nitrogen for FP or fertilized by intracytoplasmic sperm injection (ICSI) for IVF-ET. By combining IVM with gynecological surgery, immature oocytes that would have been discarded can be saved and used for assisted reproductive technology (ART). The procedure, significance and critical aspects of OP-IVM are described in this article.

In vitro maturation (IVM) before gynecological operation (OP-IVM) combines IVM following oocyte retrieval with routine gynecological surgery and serves as an extension of conventional IVM applications for fertility preservation.

The use of in vitro maturation (IVM) before gynecological operation (OP-IVM) is an extension of conventional IVM that combines IVM following oocyte ...

Fertility Preservation in Patients with Severe Ovarian Dysfunction

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, chemo- and radiation-therapies, as well as ovarian surgeries. In unmarried women with severe ovarian dysfunction, fertility preservation is important for future pregnancies. Although oocyte cryopreservation is an established method for fertility preservation, these patients could only preserve a limited number of oocytes even after ovarian hyperstimulation, leading to repeated stimulations to ensure sufficient oocytes to guarantee future pregnancy. To solve this issue, we have recently developed a drug-free in vitro activation (IVA) procedure, which enable us to stimulate early stages of ovarian follicles to develop to the preantral follicle stage. These preantral follicles can respond to the unique protocol of gonadotropin stimulation, resulting in increased number of retrieved oocytes per ovarian stimulation for cryopreservation. The drug-free IVA comprised from the surgical approach and ovarian stimulation. We removed a part of cortex from one or both ovaries from patients under laparoscopic surgery. The ovarian cortical tissues were cut into small cubes to disrupt the Hippo signaling pathway and stimulate the development of early stage follicles. These cubes were grafted orthotropically into remaining ovaries as well as beneath the serosa of both Fallopian tubes. We have already published the surgical procedure of the drug-free IVA and the protocol of subsequent ovarian stimulation, but herein we present the details of laboratory methods required for drug-free IVA.

We present details of laboratory procedures for drug-free in vitro activation (IVA) of ovarian follicles for patients with severe ovarian dysfunction. This method could increase the number of retrievable oocytes per ovarian hyperstimulation and benefit fertility preservation for those patients.

Ovarian function progressively declines during aging and in some pathophysiological conditions including karyotype abnormality, autoimmune diseases, ...

Improved Rodent Model of Myocardial Ischemia and Reperfusion Injury

Myocardial ischemia and reperfusion injury (MIRI), induced by coronary heart disease (CHD), causes damage to the cardiomyocytes. Furthermore, evidence suggests that thrombolytic therapy or primary percutaneous coronary intervention (PPCI) does not prevent reperfusion injury. There is still no ideal animal model for MIRI. This study aims to improve the MIRI model in rats to make surgery easier and more feasible. A unique method for establishing MIRI is developed by using a soft tube during a key step of the ischemic period. To explore this method, thirty rats were randomly divided into three groups: sham group (n = 10); experimental model group (n = 10); and existing model group (n = 10). Findings of triphenyltetrazolium chloride staining, electrocardiography, and percent survival are compared to determine the accuracies and survival rates of the operations. Based on the study results, it has been concluded that the improved surgery method is associated with a higher survival rate, elevated ST-T segment, and larger infarct size, which is expected to mimic the pathology of MIRI better.

Myocardial ischemia-reperfusion model of rat heart is improved by using a self-made retractor, polyvinyl chloride tube, and a unique knotting method. Electrocardiogram, triphenyltetrazolium chloride and histological staining, and percent survival analysis results showed that the improved model group has higher success and survival rates than the already existing model group.

Myocardial ischemia and reperfusion injury (MIRI), induced by coronary heart disease (CHD), causes damage to the cardiomyocytes. Furthermore, evidence ...

Fertility Sparing Procedure using Carbon Dioxide Fiber Laser Vaporization of Ovarian Endometrioma

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated with a potential reduction in the ovarian reserve due to the inadvertent removal and thermal damage of healthy ovarian tissue. New ablative techniques with reduced tissue penetration depth and less thermal spread to the surrounding parenchyma may represent a viable alternative to cystectomy. For these reasons, the aim of this manuscript is to demonstrate the ablation of the endometrioma capsule using a CO2 fiber laser technique and discuss the clinical outcomes. Once the cyst has been drained and washed, a biopsy is taken. After cyst eversion, vaporization of the inner surface of the cyst is performed using a CO2 fiber laser. The technique is simple and reproducible as even young surgeons without any surgical experience were more confident in performing laser CO2 vaporization instead of cystectomy. The positive effects of CO2 technology are reported in a randomized controlled trial, where the postoperative changes in the antral follicular count (AFC) and antimullerian hormone (AMH) levels were compared between patients who had their endometrioma excised (cystectomy) and those who had undergone endometrioma vaporization with CO2 laser. The patients treated with CO2 laser showed significantly increased AFC without a reduction in serum AMH levels as compared to the cystectomy group, in which both parameters were significantly reduced. The postoperative pregnancy rate was also assessed, and comparable pregnancy rates were found after both treatments. On the contrary, patients treated with the CO2 fiber laser technique had more favorable in-vitro fertilization (IVF) outcomes compared to cystectomy.
In conclusion, the CO2 fiber laser technique may represent a viable alternative to cystectomy in the surgical treatment of endometrioma in terms of ovarian preservation, pregnancy rates, and IVF outcomes. Moreover, it has the advantage of being independent of the surgeon's skills and personal experience.

In this protocol, CO2 fiber laser technique is demonstrated for the surgical treatment of ovarian endometriosis, which represents a viable alternative in terms of fertility preservation with the major advantage of not being dependent on the surgeon's skills and personal experience.

The surgical management of endometrioma is still a matter of debate. Cystectomy, which is recognized as the standard technique, seems to be associated ...

Laparoscopic Oocyte Retrieval and Cryopreservation during Vaginoplasty for Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 &#176;C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.

A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.

In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, ...