Hospital Universitari San Joan de Déu, Universitat de Barcelona, Barcelona 08950, Spain
Address all correspondence to: Justo Callejo, M.D., Department of Obstetrics and Gynecology, Hospital Universitari Sant Joan de Deu, PoSant Joan de Déu no 2., ESPLUGUES Barcelona 08950, Spain. E-mail: . jcallejo{at}medicina.ub.es
To the editor:
We thank Prof. K. Oktay for his interest in our article (1).
We fully agree with Prof. Oktay in that the indications for the cryopreservation of ovarian tissue with the intention of maintaining reproduction should be limited to patients younger than 40 yr of age, preferably, younger than 37 yr, due to the low ovarian follicle reserve, as well as follicles that are not reactive enough, in women older than this age. When in our article we mention that the endocrine function is restored and potentially fertility because of the way we handle ovarian tissue, there is no implication of seeing this technique as an alternative to hormonal replacement treatment. We see the problem in a different light. When the young women, proprietors of the ovarian cortex that we previously cryopreserved to avoid damage by the chemotherapy, are free of their illness and desire to become pregnant, how are we to manipulate the thawed ovarian tissue? The ages of these patients range from 1423 yr old, and therefore, our experience is provided by 1) the experimental model, and 2) the generosity and altruism of voluntary women older than 45 yr old who chose anexectomy when they underwent hysterectomy for benign processes. Obviously, we would have preferred working with ovaries from women younger than 29 yr old, like the case presented by Oktay and Karlikaya (2), however in our department salpingo-oophorectomy because of intractable menometrorrhagia is not performed. Even so, we think that the results obtained in women older than 45 yr of age can be extrapolated to younger women.
We disagree with Oktays technique of reimplanting the whole cryopreserved ovarian cortex together, because we do not intend to maintain ovarian function for the longest possible period of time, for example, 2 yr. What we are striving for is to have more opportunities for developing pregnancy. We obtain 1520 capsules with a few strips of ovarian cortex for each extracted ovary. In the near future, with this tissue rich in follicles and four to five capsules for each attempt, we will have several opportunities to perform different protocols to obtain a first pregnancy and even a second one.
In regard to the localization of the implant, we also have experience in a few cases in transplanting the ovarian cortex in the forearm. Nevertheless, we prefer the insertion in the anterior rectus abdominus muscle or supraponeurotic hypogastrium for comfort, tolerance, and esthetic considerations. This model has been taken from one used by our colleague surgeons with excellent results in heterotopic transplantation without a vascular pedicle of the parathyroid (3, 4).
Finally, we think at this point in time that pelvic radiotherapy by itself is not an indication for cryopreservation of ovarian tissue. There are two alternatives to this that we prefer: 1) the one proposed with excellent results by Leporrier et al. (5) that consists in the heterotopic transplantation with a vascular pedicle, and 2) the one that corresponds to the ovarian transposition via laparoscopy within the abdominal cavity outside the field of irradiation (6).
Received December 17, 2001.
References
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