a new technique to preserve women's fertility

Cancer treatments not only hunt tumor cells, they also affect fertility. Preserving it has become a major issue since 17,200 people of childbearing age are diagnosed with cancer every year. For men, the process is simple: it involves collecting and freezing sperm. But for women, sometimes it's a different story.

Laura has experienced it. In September 2013, when she was 27 years old, the young woman learned that she had cancer of the lymphatic system in one of its orbits. "I was told that chemotherapy should start very quickly and that it would affect my fertility," she says. It was a shock when I realized that I probably could not have children. "

"Chemotherapy is toxic to the ovaries," says Professor Michael Grynberg, head of reproductive medicine and fertility preservation at the Antoine-Béclère Hospital in Clamart. It destroys the stock of ovarian follicles (structure containing the eggs, NDLR), which can lead to early menopause. As for radiotherapy, if it targets the bads, it can alter the uterus and make it unfit to accommodate an embryo. "However, chemotherapy does not systematically sterile. "The younger the patient, the more likely she is to remain fertile because she has more follicles," says Grynberg. However, women who have had cancer treatment are more likely to have a miscarriage compared to women who have not had cancer. "

Faced with the urgency of its situation, the doctors of Strasbourg University Hospitals (HUS) propose to Laura a preservation technique reserved for specific cases: the autograft of ovarian tissue. An intervention that, until June 2018, was authorized only as part of a research project. Fewer than ten centers practice it in France. "In normal times, we take mature eggs that we keep and are ready to be fertilized once thawed," says Dr. Olivier Pirrello, head of the reproductive health care center of the Strasbourg University Hospitals. But this procedure takes about ten days because of the hormonal stimulation, we could not wait so long in the case of Laura.

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Before starting her treatments, the young woman goes through a half-hour surgery, during which doctors take a piece of each ovary, cut and freeze them. Seven chemotherapies later, Laura is out of the woods. And in May 2017 the long-awaited transplant takes place. Ovarian fragments, which have been dormant for four years at a temperature of minus 196 degrees, are reimplanted. "We opened the ovary in half to introduce the fragments threaded on a wire, then we sewed the organ," reports Dr. Pirrello.

And it works: the ovaries go back to work, as if nothing had happened. Four months after the operation, Laura has menstruations again after she was menopausal since the end of treatment. "We did not know how long the transplant was going to work, so we quickly made two in vitro fertilization attempts that both failed," says the young woman. Finally, the couple decides to stop for a moment. "We went on vacation, my companion asked me to marry and a few days later, I became pregnant," she smiled. Currently seven months pregnant, Laura is preparing to give birth to the first child conceived following an autograft of ovarian tissue in Alsace. In the world, there are only a hundred.

In addition to therapeutic emergencies, ovarian tissue removal is the only possible technique for small girls with cancer. "Being prepubescent, they do not have mature oocytes," says Grynberg. Ditto for women whose chemotherapy started before the preservation of fertility was considered. "It is too late to take oocytes because there is a risk of genetic abnormalities induced by chemotherapy," says Dr. Pirrello. The only thing to do is to take ovarian tissue. "At the University Hospitals in Strasbourg, about fifteen ovarian samples are taken each year.

The autograft of ovarian tissue is, however, not without risk. "Our obsession is not to reintroduce tumor cells during the transplant," says Dr. Pirrello. To prevent this, badyzes are made at the time of sampling and before the transplant. But this does not always detect the presence of cancer cells. The technique is also not recommended for certain cancers. "Since the blood is affected, as in leukemia, there are tumor cells everywhere. The risk of reintroducing the disease is too great, "says the doctor.

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While the preservation of the fertility of women with cancer is progressing slowly, the techniques are still far from being fully effective. "It's a little pretentious to say that we are preserving fertility," says Dr. Pirrello. There's a huge step between the ovarian tissue transplant and a baby. "An opinion shared by Professor Grynberg. "At the moment, our techniques are not extraordinarily effective," he admits. Many women will not be able to have a pregnancy despite what we are doing and will be reoriented towards oocyte donation or adoption. "

Every year, 3,500 women under the age of 35 are affected by cancer, according to the National Cancer Institute, and many still miss the preservation of their fertility. "Until now, 70 to 80% of women do not see themselves offered by their oncologist while it is mandatory since 2011, says Professor Grynberg. It's changing as they are more aware of the techniques. "Women are not the only ones to know a lack of information. "Not all men and boys are routinely referred to us before chemotherapy. Fertility is a delicate subject to address, which adds to a lot of information that the oncologist must deliver, it's not easy, "says Dr. Pirrello.

To make up for these shortcomings, the cancer plan launched in 2014 by the health authorities has included the preservation of fertility in its priorities. "Some patients realize a posteriori that information about the toxicity of the treatments on their fertility and the possible strategies to remedy it was not given, admits Dr. Françoise Merlet, doctor referent on the questions of medical badistance to procreation at the Agency of Biomedicine. There is still a real lack of information and our work aims to reduce it, to allow equitable access to the preservation of fertility for all cancer patients. "