1. Fertility preservation for girls - current treatment options Dr Sheila Lane July 8 th 2016

2. Childhood and Young Adult Cancer Survival Data Over 80% Survival 1 in 10 survivors will be a high risk of infertility

3. Primordial follicles in the outer layer of the ovary (“ovarian cortex”)

4. Effect of Chemotherapy and Radiotherapy

5. NICE Quality standard QS 55 Children and young people (aged 0–24 years) with cancer should be assessed for potential future fertility problems and advised about their options for fertility preservation before treatment is started. February 2014

6. Risk assessment for Fertility preservation Intrinsic factors –Heath status of patient –Consent (Patient/Parent) –Assessment of ovarian reserve Extrinsic factors –Nature of predicted treatment High/Medium/Low/Uncertain Risk –Time available –Expertise available Wallace WH, Critchley HOD & Anderson RA. JCO, 2012

7. Shielding/Ovarian Transposition Cryopreservation Post Pubertal Pre- Pubertal Ovarian TissueEmbryos Hormone Stimulation Sperm Oocyte Medical Management Watch and wait

8. Ovarian Shielding/Transposition

9. Shielding/transposition /treatment option DXT – proton,IMRT Surgical options Chemotherapy options

10. Shielding/Ovarian Transposition Cryopreservation Pubertal Pre- Pubertal Ovarian TissueEmbryos Hormone Stimulation Sperm Oocyte Medical Management

11. Medical Management – GnRHa

12. Down Regulation with GnRH analogues Data is limited May delay menopause but unclear if protects ovarian reserve Some evidence for use in triple negative early breast cancer

13. Shielding/Ovarian Transposition Cryopreservation Post Pubertal Pre- Pubertal Ovarian TissueEmbryos Hormone Stimulation + Sperm Oocyte Medical Management

14. Hormonal Stimulation Post Pubertal Minimum 2 weeks stimulation – delays Rx Daily injections/regular scanning/transvaginal collection Exposure to High dose gonadotropins Risk of Hyperstimulation

15. Egg and Embryo Freezing for use in IVF Treatment Egg Freezing 15 -20% success rate Ideally need at least 20 eggs Embryo Freezing 30+% success rate Need a partner or donor sperm

16. Shielding/Ovarian Transposition Cryopreservation Post Pubertal Pre- Pubertal Ovarian TissueEmbryos Hormone Stimulation + Sperm Oocyte Medical Management

17. Ovarian Tissue Cryopreservation Laparoscopic Procedure 1

18. Ovarian Tissue Cryopreservation Processing of Ovarian Tissue

19. Current options for use of stored tissue Autotransplantation

20. Ovarian Function Post Auto Transplantation

21. Children Born from Transplantation of Frozen Ovarian Tissue (Andersen 2014 and others) 141512 3 3 1131 7 4 Donnez et al 2013 Belgium, Denmark, Spain – 60 women – 20% Jensen et al, 2015, Copenhagen, Denmark -32 women – 31% Meirow et al 2016 Israel - 20 women – 32% success rate

22. Oxford Tissue Cryopreservation Service Started Clinical service in 2013 Over 100 referrals Ovarian and testicular tissue

23. In Conclusion Potential future fertility problems and fertility preservation options should be discussed with ALL patients before treatment starts where ever possible About 1 in 10 patients will be at high risk of infertility following cancer treatment There are options for all patients so seek advice

24. Jill Davies & Tissue Bank Team Stephen Kennedy Enda McVeigh Chandi Ratnatunga Christian Becker Muhammad Fatum Kokila Lakhoo Sanjiv Manek Clare Verrill Kevin Coward and research team Suzannah Williams & research team Anne Goriely & research team Future Fertility Trust www.futurefertilitytrustuk.org www.futurefertilitytrustuk.org