Moving the context of preserving fertility into an expanded domain

Closing out the past year brings an opportunity to review all that has happened in the fields of reproductive medicine and genetics. And as luck would have it, looking beyond some of the dominating subjects of the past, such as embryo selection strategies, sperm DNA fragmentation, or the prevailing winds of “what’s new (or maybe old)” gained the attention of attendees at the recent ASRM Congress and Expo while walking through the exhibit hall. My how things can change.

The flow of papers through the reviewing process generally avails a sampling of most things ARTs but as history has shown the opportunity to bring our readership up to date for certain special topics comes only on those rare occasions when a flurry of papers converge on subject matter that has had a distinct and compelling history in the pages of JARG. So it is that we deliver this special issue on advances in fertility preservation at a time when the purview of this subdiscipline has matured and extended the implications for ARTs across the basic science to clinical spectrum. Just one more sign of just how reproductive medicine and biology are engaging broader public and commercial interests beyond the original purpose of treating infertility.

Both fertility preservation and oncofertility took their roots initially from an imperative that sought to find solutions to the psychologically devastating and gonad-damaging consequences from both radiation and chemo therapies that patients would be subjected to. While efforts were targeted to adults undergoing treatments, the field quickly pivoted to pediatric care in hopes of establishing clinical paradigms suitable for regaining reproductive competence in boys and girls who survived treatments, subject matter spanning current and future options such patients will have moving forward (Preservation of fertility in female and male prepubertal patients diagnosed with cancer. 10.1007/s10815-023-02945).

Standards of care evolved over the past decade plus whereby women would have a single ovary removed from which cortical strips would be culled and cryopreserved for subsequent replacement in hopes of regaining menstrual cycles. In the process of honing this technology the residual medullary tissues harboring antral follicles were found to yield immature oocytes within cumulus complexes that as described below have set the stage for fundamental research into the basic biology of human oocytes. This sourcing of oocytes has established opportunities not only for regaining fertility for patients, and moreover has availed an unexpected resource with which to advance our knowledge base on the human female gamete (1).

Multiple examples of the value of medulla-derived human oocytes now exist including attempts to support in vitro maturation (IVM) with subsequent cryopreservation as proof of principle for potential clinical uses (2), and better defining culture conditions for optimizing complete nuclear maturation to metaphase of meiosis-2 (3). Defining FSH concentrations that are best suited for achieving maturation is but one further example of how this rich source of material will better provide answers to fundamental questions relevant to aspects of ovarian physiology that have so far escaped deep analysis of import to problems associated with ovarian aging among other relevant issues (4). From such foundational contributions has emerged an ever growing need to expand the utility of IVM for this special group of patients and add to an already selective but broadening application for IVM within the ART enterprise.

Among these are cases applied to patients at risk of premature ovarian insufficiency (Oocyte cryopreservation with in vitro maturation for fertility preservation in girls at risk for ovarian insufficiency 10.1007/s10815-023-02932) and sorting out technical details required to optimize retrieval of immature oocytes against the backdrop of a variety of complicating conditions (see Factors associated with the collection of isolated immature oocytes during ovarian tissue cryopreservation. 10.1007/s10815-023-02948; and The study of the efficiency of in vitro maturation of ovarian tissue oocytes in pediatric patients. 10.1007/s10815-023-02958).

These types of studies remind us that applications of IVM are extending well beyond the purview of fertility preservation as indicated for pediatric patients as it becomes more evident that the advancing age of patients seeking infertility care may not be aligned well with older patients undergoing the conventional ovarian stimulation motif. Efforts like this could lead to more affordable care for a broader age spectrum of patients, a welcomed trend away from the “cookie cutter” serving plate consonant with precision medical care. One recent example of a more age-appropriate use of rescue IVM for older patients has recently been reported by Nicholas and colleagues (5).

Looking to 2024, big changes are in store for JARG including adjustments to the composition and expertise reflected in our outstanding editorial board that have stood witness to the fast changing pace of innovations and discoveries, giving pause to the checkered history of human ARTs and its impending future directives. While change is challenging, in order to best appraise our readership of both the advances and concerns raised by the expanded purviews of ARTs and the parallel demands ushered in by genetic testing, it is both a duty and necessity as educators and purveyors of this arena of health care to make adjustments as we the editorial board seek to serve our field in the most transparent and effective ways offered by current standards of medical publishing. We thank the following members of the board for their past services and graciously acknowledge their roles: John Bromfield, Ron Green, Eva Hoffmann, Karla Hutt, Emily Jungheim, Mary Mahony, Winifred Mak, Daniela Nogueira, and Corrado Spadafora. Finally, we express our gratitude to Professor Evelyn Telfer, CBE who has served JARG admirably as our Associate Editor for Fertility Preservation, a key role in our longstanding coverage of this field from its humble origins in 2010 to the ever-expanding impact it is having in the ART domain, as noted in this year-ending focus issue.