UMIN-CTR Clinical Trial

Public title

Cryopreservation, activation 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, activation 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 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

4

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 PTEN inhibitor (bpV)
and PI3K activators (740YP,phospharidic acid, and /or propranolol) for 48h.
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 48 hours 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 autograft 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 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 volume of the tissue is fixed and then each developmental stage of follicles are counted under histological analyses.
2.The ovarian cubes are auto-transplanted beneath of the serosa of both Fallopian
tubes, remaining ovaries and/or Douglus' pouch. We also directly cut ovarian cortex of the contra lateral ovary to induce physical stimulation.
3.Remaining ovarian tissues are vitrified using the same method. Other methods and outcome measures 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-antibodies. 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

Interventions/Control_6

Interventions/Control_7

Interventions/Control_8

Interventions/Control_9

Interventions/Control_10

Age-lower limit

Not applicable

Age-upper limit

48

years-old

>

Gender

Female

Key inclusion criteria

1. POI patients
2. IVF patients with severe poor responder who fulfill two out of three following criteria of ESHRE guideline (2011)
1) Over 40 years-old or patients with other risks for poor responder
2) Low responder diagnosed by a previous ovarian stimulation (less than 3 oocytes retrieval under sufficient ovarian stimulation)
3) Abnormal ovarian reserve (AFC:<5-7 or AMH: 0.5-1.1 ng/ml)
3. Reproductive age female patients over 20 years-old

We enroll the patients of 1. or 2. who fulfill 3. criteria.

Key exclusion criteria

1. Female patients younger than 20 years-old and 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.
We exclude the patients who meet one of criteria 1. to 4.

Target sample size

500

Name of lead principal investigator

1st name
Middle name
Last name	Kazuhiro Kawamura

Organization

International University Health and Welfare School of Medicine

Division name

Department of Obstetrics and Gynecology

Zip code

Address

4-3 Koudunomori,Narita-shi,Chiba

TEL

0476-20-7701

Email

kazuhironanami@gmail.com

Name of contact person

1st name
Middle name
Last name	Kazuhiro Kawamura

Organization

International University Health and Welfare School of Medicine

Division name

Department of Obstetrics and Gynecology

Zip code

Address

4-3 Koudunomori,Narita-shi,Chiba

TEL

0476-20-7701

Homepage URL

https://www.iuhw.ac.jp/project/index.html

Email

kazuhironanami@gmail.com

Institute

International University of Health and Welfare School of Medicine
Department of Obstetrics and Gynecology

Institute

Department

Personal name

Organization

Japan Society for the Promotion of Science,
Japan Agency for Medical Research and Development

Organization

Division

Category of Funding Organization

Japanese Governmental office

Nationality of Funding Organization

Japan

Co-sponsor

Sanno Hospital / Stanford University

Name of secondary funder(s)

Organization

Address

Tel

Email

Secondary IDs

NO

Study ID_1

Org. issuing International ID_1

Study ID_2

Org. issuing International ID_2

IND to MHLW

Institutions

国際医療福祉大学　医学部（千葉県）
International University Health and Welfare School of Medicine (Chiba)

Date of disclosure of the study information

2018

Year

10

Month

12

Day

URL releasing protocol

Publication of results

Unpublished

URL related to results and publications

Number of participants that the trial has enrolled

Results

Unpublished

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

2018

Year

03

Month

14

Day

Date of IRB

Anticipated trial start date

2018

Year

10

Month

12

Day

Last follow-up date

Date of closure to data entry

Date trial data considered complete

Date analysis concluded

Other related information

Unpublished

Registered date

2018

Year

10

Month

12

Day

Last modified on

2019

Year

02

Month

15

Day

Link to view the page

Value
https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000039306