A live birth from vitrified‐warmed oocytes in a Philadelphia chromosome‐positive acute lymphoid leukemia patient 5 years following allogenic bone marrow transplantation and after a magnitude 9.0 earthquake in Japan

Abstract

Purpose

To report a live birth from vitrified‐warmed oocytes for a Philadelphia chromosome‐positive acute lymphoid leukemia (Ph‐ALL) patient.

Methods

A 20‐year‐old single woman with Ph‐ALL requested oocyte cryopreservation at a private fertility clinic using assisted reproduction technology (ART). In cases of leukemia, there is a very short time before chemotherapy, follwed shortly by total body irradiation (TBI), and although she had already received the chemotherapy, ten oocytes were vitrified and stored for 59 months before warming. Soon after the oocyte cryopreservation, she received TBI and bone marrow transplant (BMT). During the storage, a magnitude 9.0 earthquake occurred making oocyte transport necessary. The embryo transfer was planned in a hormone replacement cycle, and intracytoplasmic sperm injection (ICSI) was performed on the vitrified‐warmed oocytes. On day 3, two embryos were transferred.

Results

The patient became pregnant and delivered a healthy girl after ICSI using vitrified‐warmed oocytes.

Conclusions

Oocyte cryopreservation is the best option for fertility preservation of young single women with leukemia. Oncologists and gynecologists who conduct ART should cooperate to improve the quality of life of cancer patients.

Introduction

In 2012, an estimated 790,740 women were newly diagnosed with cancer [1]. The data regarding the survival rate of cancer in women of reproductive age are unclear; however, the survival rate of these patients is increasing. Notable improvements since 1975 in the relative 5‐year survival rates are due to earlier diagnosis and improved treatments [2]. In particular, patients with hematological malignancies such as lymphoma and leukemia have high survival rates. Cancer treatments include surgery, chemotherapy, and radiotherapy; however, chemotherapy and radiotherapy may impact fertility in women of reproductive age. Thus, in recent years, the importance of reducing the side effects of treatment in these patients has increased; in addition, maintaining the quality of life (QOL) and fertility preservation has increased in importance.

Oocyte cryopreservation is an attractive strategy for the preservation of fertility in women; it avoids surgery and there is no risk of cancer cell contamination. In particular, in hematopoietic cancer patients who are single and wish to use their future spouse's sperm for fertilization, oocyte cryopreservation is the only fertility preservation currently available. Worldwide, more than 900 children have been born from frozen oocytes [3]. Young, unmarried women are likely to relocate for reasons such as employment or marriage. Furthermore, ART clinics may also relocate. In addition, the possibility of a disaster striking during the period of oocyte preservation exists. In fact, on March 11, 2011, our facility was struck by a magnitude 9.0 earthquake.

Case Report

In November 2006, a 20‐year‐old single woman with Ph‐ALL requested oocyte cryopreservation before undergoing BMT. At that time, our clinic, Ladies’ Clinic Kyono, was located in Osaki, Miyagi, 45 km from Sendai. The patient received buserelin acetate (GnRH agonist) 1.8 mg s.c. (Suprecur MP 1.8 Mochida, Tokyo, Japan). On October 2 and October 30, 2006, she also received prednisolone (PSL) 60 mg/m² p.o., cyclophosphamide 1,200 mg/m² div, daunorubicin 60 mg/m² div, vincristine 1.3 mg/m² i.v., and imatinib (Glivec, Novartis, Tokyo, Japan) 400 mg/day for 56 days as early phase treatment for Ph‐ALL. After receiving remission induction therapy, her blood count returned to the normal range; she subsequently was in a condition satisfactory for oocyte harvesting. After harvesting, her oocytes were vitrified and stored.

She was scheduled for consolidation therapy on December 12, 2006; therefore, we had to perform oocyte harvesting prior to that date. Starting on the third day of her menstrual cycle (November 18, 2006), her serum FSH level was 1.4 IU/L, her LH level was 1.0 IU/L, and E₂ level was 14.4 pg/mL. Controlled ovarian hyperstimulation was carried out with 3,600 IU of urinary gonadotropin (Pergogreen, Serono, Geneva, Switzerland) as the Gn‐RH analog ultralong protol. When two follicles were >18 mm in diameter, ovulation was triggered with 10,000 IU of hCG (Profasi, Serono, Switzerland). Transvaginal oocyte retrieval was conducted 34 h after hCG administration with a 19‐G needle. On December 1, three oocytes were retrieved and two mature oocytes were vitrified. Before oocyte retrieval, the following laboratory values were obtained: white blood cell count (WBC), 5,600/μL; red blood cell count (RBC), 2,870,000/μL; hemoglobin (Hb), 10.7 g/dL; and platelets, 179,000/μL. After oocyte retrieval, those values were: RBC, 2,540,000/μL; Hb, 9.7 g/dL; and platelets, 176,000/μL.

In December 2006, she received methotrexate (MTX) 1,330 mg, Ara‐C 2,600 mg for two days, and PSL 50 mg for three days. The following month, she began receiving imatinib 600 mg/day. We planned a repeat oocyte retrieval because only two oocytes had been vitrified. She was scheduled to undergo TBI and BMT on February 10, 2007; therefore, we had to schedule oocyte retrieval prior to that day.

Starting on the third day of her menstrual cycle (January 5, 2007), controlled ovarian hyperstimulation (Gn‐RH antagonist protocol) was carried out with 3,000 IU of urinary gonadotropin (Pergogreen, Serono). On that date, her serum FSH was 11.0 IU/L, her LH was 2.7 IU/L, and her E2 level was 17.7 pg/ml. When two follicles attained a diameter >18 mm, ovulation was triggered with 10,000 IU of hCG. Transvaginal oocyte retrieval was carried out 34 h after hCG administration. On January 16, 2007, eight oocytes were retrieved and frozen. Subsequently, the ten oocytes were stored. Before oocyte retrieval, her WBC was 6,100/μL, her RBC was 3,080,000/μL, her Hb was 11.2 g/dL, and her platelet count was 167,000/μL. After oocyte retrieval, her WBC was 5,200/μL, her RBC was 2,720,000/μL, her Hb was 9.4 g/dL, and her platelet count was 156,000/μL. The vitrification protocol was similar to that previously reported [4].

In February 2007, the patient, 21 years old, was considered to be in complete remission.

The patient received an HLA matched, non‐reactive sibling bone marrow transplant (BMT) in February 2007 after conditioning therapy consisting of cyclophosphamide (60 mg/kg) and total body irradiation (TBI) at a dose of 12 Gy in three fractions. The patient underwent hormone replacement therapy (HRT) after BMT.

In March 2007, our clinic was relocated to Sendai (Kyono ART Clinic). Vitrified oocytes were transported to the Kyono ART Clinic in a liquid nitrogen tank. In order to provide medical care more broadly, the clinic was moved to a highly convenient location. All the frozen embryos, sperm and oocytes also needed to be moved. The tanks with the frozen embryos, sperm, and oocytes were tightly covered with buffer for protection and divided into 4 groups for risk diversification. They were transported by a professional carrier on a wagon car using a highway at four different times.

On March 11, 2011, we experienced a major earthquake in Miyagi, Japan (magnitude 9.0); however, because of the stability of our storage facility, no oocytes were lost or damaged. Our patient was married by that time and during the same year, she presented to our clinic and requested warming of the oocytes. She had become completely amenorrheic after BMT and she received cyclic estrogen and progestin replacement therapy at her local hospital. Hormonal analysis revealed hypergonadotrophic hypogonadism (FSH, 40.9 IU/L; LH, 23.8 IU/L; E₂, <5 pg/mL; P₄, 0.5 ng/mL). We planned to perform the embryo transfer under hormonal replacement cycle. The oocytes were then stored for 59 months before warming. We warmed six oocytes. The protocol of warming oocytes was as previously reported [4]. On day 3, two embryos (seven‐cell grade 1 and eight‐cell grade 1) were transferred via transvaginal ultrasound guidance (Fig. 1). Endometrial thickness on the day of transfer was 9.3 mm. The embryo transfer was smooth. The remaining embryos were cultured for two more days; one embryo developed into a blastocyst and was vitrified. Eleven days after embryo transfer, the serum β‐hCG level was 368.1 mIU/mL. A viable intrauterine pregnancy was confirmed by transvaginal ultrasonography at 7 weeks’ gestation (Fig. 2). The patient delivered a girl in 2012. She and her baby were healthy.

Figure 1.

Image of two embryos transferred at day 3 (7‐cell and 8‐cell)

Figure 2.

Image of the gestational sac and fetus at 7 weeks of gestation

Discussion

For Ph‐ALL, BMT is performed following remission induction therapy and consolidation therapy. Ph‐ALL is the most common form of leukemia in infants; unlike acute myeloid leukemia (AML), Ph‐ALL in infants usually has a good prognosis. Conversely, as in this case, Ph‐ALL often has a poor prognosis in adults.

We vitrified ten oocytes from this Ph‐ALL patient, who received remission induction therapy before oocyte retrieval; she then underwent TBI and received BMT. Since Ph‐ALL patients require early remission induction therapy (chemotherapy), she was not a candidate for oocyte retrieval at the time when she had a diagnosis of Ph‐ALL.

There have been some reports about the efficacy of in vitro fertilization after chemotherapy. Many female patients who receive imatinib opt to preserve fertility [5]. Some reports on imatinib administration in the first trimester of pregnancy in a woman with chronic myelogenous leukemia (CML) have described an uncomplicated conception, pregnancy and delivery [6]. Dolmans MM. et. al. [7] reported that eleven patients underwent stimulation and IVF just before or in the course of their chemotherapy treatment for cancer (including one ALL patient). According to the paper, in the group underwent IVF before chemotherapy, the embryo scores ranged from grade 1 to 3 (no grade 4), but in the group that underwent IVF in the interval between two chemotherapeutic regimens, only one grade 2 embryo was obtained [7]. Generally, chemotherapy is known to induce a marked loss of the number of follicles and to lower the embryo grade, causing reduced chance of embryo cryopreservation. So if the patient underwent chemotherapy before oocyte retrieval, the outcome of ART may be poor.

On the other hand, Lee et al. [8] reported the risk of chemotherapy for ALL is not so high. Loren et al. [9] reported that many female patients who received cyclophosphamide subsequently achieved a pregnancy. The treatment for leukemia is often urgent, and the patient comes to the ART center after receiving chemotherapy. Depending on the kind of the chemotherapy drug, it is important to note that several oocytes can be retrieved even after chemotherapy. There are some reports of successful pregnancies achieved in women who received a high dose of TBI [10, 11], but few women have become pregnant following TBI. In 2000, Yoon et al. [12] reported the delivery of healthy infants from vitrified oocytes in a stimulated in vitro fertilization–embryo transfer, and it is thought that it is one option for the patient who needs to undergo chemotherapy.

In our case, only three oocytes were retrieved in the first oocyte retrieval. Since TBI can damage oocytes tremendously, we thought it important to obtain as many oocytes as possible before performing the TBI, so we tried the second oocyte retrieval and eight oocytes were retrieved. The reason why there were more oocytes retrieved the second time around was unclear. In cases of leukemia, there is very short time before chemotherapy which is followed shortly by TBI; a much shorter time is allowed for oocyte retrieval before treatment than the time that the patients with other diseases have, so the number of oocytes that can be taken may be limited. So the number of patients that can get pregnant is limited. This indicates that if enough oocytes were not obtained the first time, it is important to try a few more times as quickly as possible. And it is an important point that we could retrieve mature oocytes, even after the patient received chemotherapy.

There have been some reports regarding live births following the use of slow vitrified‐warmed oocytes in cancer patients [13, 14]. Kim et al. [15] reported the first case of a live birth following the use of vitrified‐warmed oocytes in a cancer patient. Thus, the use of vitrified‐warmed oocytes for cancer patients may be a safe technique. There are some reports about the pregnancy rate from vitrified‐warmed oocytes [16]; these reported that the vitrified‐warmed oocyte survival rate is 92 %, the 2‐PN fertilization rate was 79 %, and the blastocyst formation rate was 43 %. On the other hand, Roberts et al. [17] reported that the pregnancy rate does not exceed 20 % per transfer. Low pregnancy rates relate to several technical challenges encountered during the vitrified‐warming process. Oktay et al. [18] reported and considered that the outcome of a vitrified‐warmed oocyte is poor; the fertilization rate is 70.6 %, both clinical pregnancies or live birth per warmed oocytes are only 2 %, mean number of embryos transferred is 4, clinical pregnancies per transfer is 29.4 %, implantation rate is 8.8 %. In a recent guideline, the outcome of vitrified‐warmed oocytes does not differ from that of fresh oocytes [19]. In addition, the incidence of all birth anomalies found to date in babies born from cryopreserved oocytes does not appear to be different from that of infants born through natural conception [3]. Overall, the prognosis for cancer patients has improved; thus, the need and importance for fertility preservation is increasing steadily. Oocyte cryopreservation and banking is the best and important option for safe fertility preservation in cancer patients in cases of single women. We feel that at least 15 collected oocytes is an appropriate number. Of this number, one can expect about eleven to be fertilized, and approximately five to reach the blastocyst stage. A pregnancy is likely if five blastocysts are available.

Ovarian tissue cryopreservation is another of possible options for fertility preservation, but there is a potential risk that frozen‐thawed ovarian tissue might harbor malignant cells inducing recurrence of the disease after re‐implantation.

Oocyte cryopreservation is the best fertility preservation option for young single women. Cooperation between oncologists and gynecologists performing ART is essential for maintaining the QOL of cancer survivors. In facing the diagnosis of a malignancy, it is difficult for a 15‐year‐old girl to ponder future childbearing; furthermore, her parents may have difficulty assessing that situation. However, despite the fact that oocyte retrieval is an invasive procedure, it must be explained and offered to young cancer patients who may be desirous of pregnancy at a future date.

Our clinic is the only outpatient clinic; patients who undergo egg collection in our clinic return home within a few hours after surgery. Complications from the procedure such as bleeding and infection can occur. The probability of requiring hospitalization for management of a hemoperitoneum after egg collection is about 0.2 % [20]. However, the risk of bleeding and infection in leukemia patients is high. Therefore, for a leukemia patient who has undergone egg collection, anti‐bleeding and anti‐infection measures are of the utmost importance; thus, hospitalization for the procedure is indicated. Our clinic is not equipped to hospitalize patients; therefore, following egg collection, the patient was transferred to a hospital for observation. For patients such as ours, communication with a nearby hospital is necessary for management following egg collection. Another precaution that should be taken with these patients is to reduce the number of punctures to the vaginal wall, abdominal wall, and oocytes.

We conducted the egg collection with a 19‐gauge needle as the use of a thin gauge needle reduces the risk of bleeding and infection. For infection prevention, it is important that we wash the vagina well before oocyte retrieval. We disinfected the patient's vagina well using povidone‐iodine, and rinsed it out using normal saline solution.

Because the oocytes were affected by both chemotherapy and oocyte cryopreservation, we speculated that the outcome of treatment with the retrieved oocytes might be poor, so we transferred two embryos into her uterus. There is a possibility that the quality of the patient's frozen oocytes was relatively poorer than fresh oocytes. In 2008, Japan Society of Obstetrics and Gynecology stated that single embryo transfer is recommended except for cases over 35 years old or with repeated failure. In this case, she was 25 years old, and it was her first embryo transfer, so we should transfer only one embryo into her uterus according to the guideline. We know a recent guideline that says the outcome of a vitrified‐warmed oocyte does not differ from that of a fresh oocyte; however, her vitrified oocytes were retrieved after chemotherapy. Five years later, we performed ICSI on the warmed oocytes and transferred two embryos considering her medical history and the concern over the quality of embryos.

As previously mentioned, the oocytes were subjected to a massive earthquake during storage. East Japan experienced a great earthquake disaster on March 11, 2011. We reported about our clinic [21], and Ishihara et al. [22] reported about the earthquake damage that another clinic in Japan experienced. We protected storage tanks with buffer on a firm locked shelf. After the earthquake disaster, the storage tanks did not show any abnormality on the surface, there were no embryo and oocytes lost, and there was no physical change in the frozen embryos and oocytes. There was no change in fertility outcome at our clinic before and after earthquake.

This relocation posed a risk of oocyte deterioration during the process. Our experience stresses the need for a storage location with long‐term stability to increase oocyte survival. Because we performed prompt and effective anti‐disaster measures, no oocytes were lost. In addition to our experience with the earthquake, other situations such as patient relocation can necessitate transport of frozen oocytes. It is very important to carefully transport oocytes if the clinic and/or patient relocate.

This is the first report of cryopreserved oocytes from a patient with malignant disease that required transport because of a massive earthquake. We have vitrified an ALL patient's oocytes after chemotherapy and transported them after a massive earthquake, the warmed oocytes were subjected to ICSI, and a successful pregnancy ensued. Currently, oocyte cryopreservation and banking is the best fertility preservation option for these patients. Cryopreservation of unfertilized oocytes improves the QOL of cancer patients after treatment for their disease.

Acknowledgments

The authors would like to thank the entire IVF team at the Ladies’ Clinic Kyono and Kyono ART Clinic.

Conflict of interest

We have no conflict of interest