UMIN-CTR Clinical Trial

Public title

Cryopreservation and autografting of ovarian tissues for infertility treatment in patients with primary ovarian in sufficiency (POI)

Acronym

Infertility treatment for patients with primary ovarian insufficiency (POI)

Scientific Title

Cryopreservation and autografting of ovarian tissues for infertility treatment in patients with primary ovarian in sufficiency (POI)

Scientific Title:Acronym

Infertility treatment for patients with primary ovarian insufficiency (POI)

Region

Japan

Condition

POI patients with a chief complaint of infertility.
Patients who are predicted to become POI.

Classification by specialty

Obstetrics and Gynecology

Classification by malignancy

Others

Genomic information

YES

Narrative objectives1

To develop a safe ovarian tissue cryopreservation and subsequent autografting after thawing as well as a method to achieve successful follicle growths by hormonal therapy and PRP injection, and pregnancies for POI patients.

Basic objectives2

Safety,Efficacy

Basic objectives -Others

Trial characteristics_1

Confirmatory

Trial characteristics_2

Pragmatic

Developmental phase

Phase III

Primary outcomes

Comparison of follicle growth rates after IVA (in vitro activation) treatment with those of base line numbers.

Key secondary outcomes

To evaluate the presence of residual follicles, we measure the levels of serum biomarker for early follicles before ovariectomy. Using part of the ovarian tissue, we evaluate the conditions of the follicles and oocytes after thawing structurally and histologically. To evaluate the efficacy and presence of residual follicles, part of the ovarian tissues is used for cultivation, ultrasound/ Far infrared ray scanning and histological examination (follicle count, fibrotic evaluation, antithyroid antibody and inflammatory change) to evaluate the effect of IVA and the presence of residual follicles.
To judge the effect of hCG on induction of angiogenetic factors production after autografting, we collect part of uterine endometrium before autografting and determine the expression levels of related genes and proteins in neovascularization. We further measure serum VEGF levels after hCG administration.
In the case of very rare type of POI, Resistant Ovary Syndrome (ROS), we detect anti-FSH and FSHR antibodies, analyze their responsible genes and ovarian tissue structures, and measure serum levels of CCN growth factors after linear cutting of ovarian cortex..
After IVA, we perform ovarian stimulation by hormonal therapy. Under evaluation of estradiol, progesterone, FSH, LH levels, we stimulate follicle growth for subsequent IVF. We compare the proportions of oocyte retrieval, oocyte maturation, fertilization, high-quality embryos, pregnancy and abortion with those of base line levels.

Study type

Interventional

Basic design

Parallel

Randomization

Non-randomized

Randomization unit

Blinding

Open -no one is blinded

Control

Active

Stratification

Dynamic allocation

Institution consideration

Blocking

Concealment

No. of arms

8

Purpose of intervention

Treatment

Type of intervention

Maneuver

Interventions/Control_1

IVA
1.we measure serum molecular markers before surgeries to evaluate the effect of hippo signal inhibition and presence of residual follicles.
2.whole or part of one ovary is removed under laparoscopic surgery. ovarian cortex is isolated and cut into small tissues (1x1cm,1-2mm thickness ) before vitrification.to induce secondary follicle growth, in situ incision of ovarian cortex is performed on the residual ovary.
3.To determine follicle numbers in ovarian tissues, we count follicles under histological analyses. part of ovarian tissues is used for cultivation,ultrasound,far infrared ray scanning and histological examination.
4.After thawing, ovarian strips are fragmented into 1-2mm cubes and cultured with IVA medium containing a PFC-FD and PI3K activators for 30min.
5.After culture, the activated ovarian cubes are washed with medium without IVA drugs. The ovarian cubes are transplanted beneath serosa of Fallopian tubes and to the residual ovary and Douglas'pouch.
6.We treat patients with estrogen for 2 weeks before autografting. After grafting, hCG is administered to induce production of
angiogenesis factor to help vascularization and survival of grafts. To judge the effect of hCG, part of endometrium is collected to measure related gene and protein levels before autografting. Angiogenesis factor levels are measured after hCG.
7.We measure molecular markers to evaluate the effect of Hippo signal inhibition after grafting. We treat the patients with gonadotropin for ovarian stimulation for IVF-ET. Ovarian stimulation continues for one to two years. If ovarian stimulation is not effective, we perform another autografting.

Interventions/Control_2

Fresh IVA
For patients who have high possibility to have residual follicles, we perform fresh IVA. In fresh IVA, we remove their ovaries and culture the ovarian tissues with IVA medium for 30 minutes without cryopreservation. After culture, we perform autograft of ovarian tissues under the same method of IVA. Remaining ovarian tissues are vitrified using the same method. Other methods and outcome measures are same as IVA.

Interventions/Control_3

Drug-free IVA
For patients who are predicted to become POI but still have irregular menstruation, we fragmented the ovarian tissue into small cubes and autografted them immediately without culture to stimulate secondary follicle growth leading to increase in the number of retrieved oocytes.
1. Excise one side of whole ovary or partial ovarian tissues under laparoscopic surgery. After removal of medulla tissues to prepare the ovarian cortex, the ovarian cortex was dissected into 3x3cm with 1-2mm thickness of tissue stripes and further fragmented into 1-2mm cubes. To measure the number of secondary follicles in the dissected ovarian tissue,10% of the volume of the tissue is fixed and then each developmental stage of follicles are counted under histological analyses.
2. Ovarian strips are fragmented into 1-2 mm cubes and cultured with IVA medium containing PFC-FD and PI3K activator for 30 min. After culture, the ovarian strips are washed in culture medium without PFC-FD and PI3K activator, and implanted under laparoscopic surgery into the fallopian tube serosa, residual ovary, or Douglas fossa. Physical stimulation of the contralateral ovary is performed through an incision in the ovarian cortex directly inside the body. Depending on the condition of the ovary, no incision is made and the ovary is evaluated as a control.
The ovarian cubes are auto-transplanted beneath the serosa of both Fallopian tubes, remaining ovaries and/or Douglus'pouch. We also directly cut ovarian cortex of the contralateral ovary to induce physical stimulation.
3.Remaining ovarian tissues are vitrified using the same method. Other methods and outcome measures are are same as IVA.

Interventions/Control_4

Resistant Ovary Syndrome(ROS) is a very rare type of POI. In contrast to regular POI, ROS patients still have higher number of residual follicles in their ovaries. However, the follicles do not respond to endogenous and exogenous FSH stimulation, resulting in failure to grow. Based on our previous studies, physical stimulation to ovaries induces the production of CCN growth factors, leading to ovarian follicle stimulation. Thus, we perform in situ incision of ovarian cortex as a less invasive approach for ROS patients. When in situ incision of ovarian cortex is not effective, we perform Drug-free IVA. In some cases of ROS patients, auto-antibodies such as anti-FSH/FSHR antibody are found as causes of the disease, we use steroid hormone treatment to suppress the production of auto-antibodies. Using blood tests, we measure the levels of auto-antinodies. We analyze responsible genes for ROS, and perform histological analysis of ovarian structure. We also measure the levels of CCN growth factors after the surgery.
Correct serum from the patients before surgery to measure molecular markers to ensure suppression of Hippo signaling.
We directly cut ovarian cortex or scratch ovarian cortex to induce physical stimulation to the ovary. To measure the number of secondary follicles in the dissected ovarian tissue, 10% of volume of the tissue is fixed and then each developmental stage of follicles are counted under histological analyses.
Correct serum from the patients after surgery to measure molecular markers to ensure suppression of Hippo signaling. After grafting, patients receive ovarian stimulation using gonadotropin drugs to stimulate follicle growth and retrieve oocytes. Mature oocytes are fertilized by in vitro fertilization and preimplantation embryos are transplant into uterus. The treatment continues for 1-2 years. If first auto-transplantation is not successful and patients have cryopreserved ovarian tissues, patients can repeat these procedures.

Interventions/Control_5

IVA-PRP
When performing IVA, Fresh IVA, Drug-free IVA, and ovarian cortex incision, laparoscopically inject PRP between the ovarian cortex and the medulla at several locations in each ovary. PRP is a platelet-rich plasma fraction extracted from blood collected from the patient and contains many growth factors, including those derived from platelets. PRP contains the growth factors (CCN growth factors) whose production is induced by IVA procedures, and also the growth factors (EGF and VEGF), which have been shown to promote early follicle development. PRP is expected to show a synergistic effect with IVA. In this clinical study, we use a PFC-FD (PRP-free cell freeze-dry) as the PRP. PFC-FD is prepared as a freeze-dried product by CellSource Co., LTD. (a government-approved facility number: FA3160006 to obtain permission to manufacture specific cell processed products) after removing the cell components from the patient blood (50ml) before surgery. After preparation of PFC-FD by dissolving in 1ml of distilled water, PFD-FD is injected during IVA surgery.

Interventions/Control_6

PRP
PRP is known to contain multiple growth factors that promote follicle development, injecting PRP into the ovaries is expected to promote follicle development. In this clinical study, we use a PFC-FD as PRP, PFC-FD is prepared as a freeze-dried product by CellSource co., LTD. (a government approved facility / facility number: FA3160006) after removing the cell components from the patient blood (50ml) before injection. When follicle growth is confirmed in the ovaries by ultrasound and the ovaries are identified, PFC-FD is injected into the ovaries in the same way as egg retrieval in IVF treatment. When the ovaries cannot be identified ultrasound, PFC-FD is injected directly into the ovaries under laparoscopic surgery.

Interventions/Control_7

IVA-LE
When performing IVA, Fresh IVA, Drug-free IVA, and ovarian cortical incision, LE is injected laparoscopically between the ovarian cortex and the medulla at several locations in each ovary. It has been found that LE (Loteprednol Etabonate: Lotemax eye drops) which is approved in the US FDA as an eye drop used to treat steroid-responsive inflammation has been shown by in vitro culture studies in ovaries to activating primordial follicles. For the patients who PRP injection or IVA-PRP are not effective, a follicle growth cannot be detected, or an egg retrieval is performed but does not result in pregnancy, LE is injected laparoscopically.

Interventions/Control_8

LE
For the patients who PRP injection or IVA-PRP are not effective, a follicle growth cannot be detected, or an egg retrieval is performed but does not result in pregnancy, LE is injected vaginally or laparoscopically. When follicle growth is confirmed in the ovaries by ultrasound and the ovaries are identified, LE is injected into the ovaries in the same way as egg retrieval in IVF treatment. When the ovaries cannot be identified under ultrasound, LE is injected directly into the ovaries under laparoscopic surgery.

Interventions/Control_9

Interventions/Control_10

Age-lower limit

Not applicable

Age-upper limit

48

years-old

>=

Gender

Female

Key inclusion criteria

[IVA]
1. POI patients
2. Patients with all the following criteria
1) Over 40 years old
2) Low responder diagnosed by previous ovarian stimulation (less than 3 oocytes retrieval)
3) Abnormal ovarian reserve (AFC: <5-7, AMH: 0.5-1.1 ng/ml)

[PRP][LE]
1. DOR patients with a history of ovulation induction in the past
2. DOR patients with no history of ovulation induction in the past, and POI patients aged 35 years or older who have follicle growth by ovarian stimulation for 6 months or more but do not lead to embryo cryopreservation.
3. POI patients under 35 years old with amenorrhea more than 4 years.

Key exclusion criteria

1. Patients over reproductive age
2. Patients with high risk for laparoscopy.
3. Patients without permission of pregnancy due to complications
4.Patients judged to be inappropriate for the study by the physicians.

Target sample size

200

Name of lead principal investigator

1st name	Bunpei
Middle name
Last name	Ishizuka

Organization

Rose Ladies Clinic

Division name

Division of clinical treatment

Zip code

158-0082

Address

2-3-18 Todoroki, Setagaya-ku,Tokyo

TEL

03-3703-0116

Email

ishizuka@marianna-u.ac.jp

Name of contact person

1st name	Eri
Middle name
Last name	Ozasa

Organization

Rose Ladies Clinic

Division name

Department of information and research

Zip code

158-0082

Address

2-3-18 Todoroki, Setagaya-ku,Tokyo

TEL

03-3703-0116

Homepage URL

http://roseladiesclinic.jp/

Email

eriozasa@roseladiesclinic.jp

Institute

Rose Ladies Clinic

Institute

Department

Personal name

Organization

None

Organization

Division

Category of Funding Organization

Self funding

Nationality of Funding Organization

Co-sponsor

St. Marianna University / Stanford University

Name of secondary funder(s)

Organization

Biomedical Ethics Committee of the Rose Ladies Clinic

Address

2-3-18 Todoroki, Setagaya-ku, Tokyo

Tel

03-3703-0116

Email

chikaishii@roseladiesclinic.jp

Secondary IDs

NO

Study ID_1

Org. issuing International ID_1

Study ID_2

Org. issuing International ID_2

IND to MHLW

Institutions

ローズレディースクリニック　
Rose Ladies Clinic

Date of disclosure of the study information

2017

Year

11

Month

16

Day

URL releasing protocol

Publication of results

Partially published

URL related to results and publications

https://www.frontiersin.org/articles/10.3389/fendo.2021.795724/full

Number of participants that the trial has enrolled

Results

Results date posted

Results Delayed

Results Delay Reason

Date of the first journal publication of results

Baseline Characteristics

Participant flow

Adverse events

Outcome measures

Plan to share IPD

IPD sharing Plan description

Recruitment status

Open public recruiting

Date of protocol fixation

2017

Year

06

Month

01

Day

Date of IRB

2017

Year

06

Month

29

Day

Anticipated trial start date

2017

Year

08

Month

01

Day

Last follow-up date

2027

Year

08

Month

01

Day

Date of closure to data entry

Date trial data considered complete

Date analysis concluded

Other related information

Unpublished

Registered date

2017

Year

11

Month

02

Day

Last modified on

2024

Year

04

Month

16

Day

Link to view the page

Value
https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000033876