Cortical ovarian strips transplant

Ovarian
Cortical Strips
Transplantation
• Dr Muhammad El Hennawy
• Ob/gyn Consultant
• 59 Street - Rass el barr –dumyat - egypt
• www.mmhennawy.co.nr
• Mobile 01222503011

The Ovaries
• The ovaries are two nodular bodies, situated one
on either side of the uterus in relation to the lateral
wall of the pelvis, and attached to the back of the
broad ligament of the uterus, behind and below the
uterine tubes
• Ovaries are of a grayish-pink color, and present
either a smooth or a puckered uneven surface.
• They are each about 4 cm. in length, 2 cm. in
width, and about 1 cm in thickness,

Why? !
• Ovarian tissue transplantation is an option for women who want to
protect their fertility and hormones while they undergo treatment
for cancer, including chemotherapy and radiotherapy
• For women undergoing oophorectomy (in severe or recurrent
ovarian disease such as cysts, benign tumours or endometriomas
or ovarian pain ), accidental bilateral salpingo-oophorectomy for
huge uterine fibroids and dense pelvic adhesion--- not only to
maintain endocrine functions but also for fertility preservation
• Ovarian dysgenesis with missing normal ovarian complement and
premature ovarian failure has come in the forefront.
• Women in their 20s or 30s could theoretically have an ovary
removed and frozen, and then have it reimplanted years later when
they are ready to have children as “We are in the middle of an
infertility epidemic

Types
• Fresh or Frozen-thawed
• Whole ovary (with vascular anastomosis) immediate restoration
of vascular supply and ovarian hormonal functions is possible.
or ovarian cortical strips (without vascular anastomosis )
• xenografting (human to animal ) to avoid recurrence of cancer
• Orthotopic (near the infundibulopelvic ligament or on an present
ovary) lead to natural conception or Heterotopic (the tissue is
grafted subcutaneously to the forearm or suprapubic area) does
not require general anesthesia or abdominal surgery. It is also easy to
monitor follicle development and to remove the transplanted tissue from the
subcutaneous site when necessary
• allotransplantation ( human to human ) or Autotransplantation
( Human to herself or to monozygotic twin) without
immunosuppressant treatments

Xenograft
• The growth of ovarian tissue from one species within
another species
• This technique has shown early promise, and even
patients with ovarian cancers may be able to use this
technique to recover normal eggs without the risk the
restoration of any associated cancer cells.
• Furthermore this technique allows the more efficient
maturation and retrieval of eggs for IVF.
• Moreover the limited quantity of ovarian tissue allows
strips to be unfrozen gradually over time to allow
additional attempts to produce offspring.
• Even small biopsies of tissue, if proven adequate for
IVF, may be taken to create an egg bank for later use

Orthotopic Whole Fresh
Ovary Microsurgical
Transplantation
• (A) Depiction of donor
oophorectomy.
• (B) Microsurgical isolation
of donor ovary blood supply.
• (C) End-to-end anastomosis
of ovarian blood vessel.
• (D) Completed anastomosis
of ovarian artery and veins.

Heterotopic Whole Fresh Ovary
Microsurgical Transplantation
• the patients' own ovaries
were transplanted to their
upper limb to avoid the
effect of pelvic radiation
as a treatment of
Hodgkin lymphoma in
one patient and uterine
cervical cancer in the
other

How To Prepare Ovarian
Cortical Strips
• Under general anesthesia
• One ovary was removed laparoscopically or minilaparotomy,
• The whole ovary was transferred to a Petri dish
• Under Microscope . dissection with a scalpel and toothed
forceps.
• It was felt important to prepare a cortical tissue slice no thicker
than ~1.0 mm to facilitate rapid revascularization
• While keeping the tissue constantly irrigated with ice-cold
medium
• Its cortex was prepared in 8 strips of 50x 5 x 1 to 2 mm
• DEPENDING ON PATIENT SIZE : from 5 to 15 pieces
• The cortex of each ovary was cut into pieces 10 × 10 × 1 mm.
---- 2 or 3 pieces for woman
or The cortex of each ovary was cut into pieces 15 × 5 × 1 mm.
---- 3 or 4 pieces for woman

An Ovarian Cortical-
Tissue Grafting
• Under general anesthesia, one ovary was
removed from donors using laparoscopy or
minilaparotomy.
• prepare a cortical tissue slice no thicker than
~1.0 mm to facilitate rapid revascularization
• The pared cortex was divided into three or four
pieces of approximately equal size for grafting,
one piece to each recipient ovary.
• The tissue graft was trimmed to the dimensions
of the exposed surface of the recipient organ
and attached using 9–0 interrupted sutures
under an operating microscope
• The medullary bed was sutured to the under
surface of the cortical graft with 9–0 sutures to
maintain tight tissue approximation.

Transplantation of fresh
ovarian cortical pieces
under the tunica
albuginea
• Three pairs of 5-mm transverse incisions were
made in the left ovary through the tunica albuginea
• With blunt dissection, cavities were formed
beneath the cortex for each of the three strips.
• Each piece of thawed ovarian tissue (1.5 by 0.5 cm
in area and 0.1 to 0.2 cm in thickness) was gently
placed in a cavity, and the incisions were closed
with 4/0 Vicryl sutures.

Transplantation of fresh ovarian cortical
pieces between monozygotic twins
• Ovarian cortical pieces
measuring 4–5 mm to 1 cm in
size were grafted onto the
remaining ovary after the
cortex of this ovary had been
removed.
• (a) Cortex of the remaining
ovary was removed.
• (b) Cortical pieces were
sutured with 7-0 stitches.

Transplantation Of Fresh
Ovarian Cortex Strips In
Lateral Wall Of The Pelvis
• Ovarian strips strung with a 6.0 delayed
absorbable suture and 3 strings of pieces
were attached to an cellulose membrane
• The grafts were sutured to a peritoneal
pocket created in the left pelvic ovarian
fossa and to ovarian fossa caudal to the first
by pulling on the suture , thus The graft is
flattened against the vascular pelvic wall
• The placement of 2 grafts side by side
• Closure of peritonium with interrupted
sutures

Ovarian Cortical Strips
Transplantation into a muscle pocket
in the rectus muscle of abdomen
• Cortical ovarian tissue was minced into 40–45
fragments 2–3 mm3 and then placed into a muscle
pocket in the rectus muscle of abdomen according
to the technique principles used for the heterotopic
parathyroid autotransplantation in the
sternocleidomastoid muscle
• The muscle pocket and fascia were closed with
stiches of vicryl

Ovarian Cortical
transplantation under the skin
of the forearm• after oophorectomy, ovarian cortical strips are prepared
• if the tissue will be cryopreserved 1x 0.5 cm strips 1-3 mm in
thickness are prepared
• if transplantation will be performed with the fresh tissue , the strips
can be cut longer 5 x 0.5 cm strips 1-3 mm in thicknesss will
facilitate the transplantation procedure
• a 1 cm transeverse incision is made over brachioradialis muscle , 5
cm below the antecubital fossa
• using blunt dissection , a pocket is created between the fascia and
subcutaneous tissue
• this area is relatively vascular , so attention must be focused on
preventing major bleeding , because the ovarian tissue will acquire
its blood supply from these vessels , it is not desirable to perform
extensive cauterization
• then each piece is ragged with 4.0 vicryl by passing the needle
between stroma and cortex under an operating microscope

• once the dissection is completed , the free end of the
suture is threaded onto a reusable needle specially half
circle cutting needle with chord length 25 to 38 mm
• this needle is inserted into the subcutsneous pocket as
far as possible
• the needle is then is passed through the skin and the
cortical piece is wedged into subcutaneous pocket by
pulling on the suture
• pieces are always inserted with the cortical side facing
up
• the needle is then removed
• and free end of the suture is held with a mosquito clamp
• the purpose of this suture pull-through technique is to
guide the tissue placement
• depnding on the patient size, 5 – 15 cortical pieces can
be fanned out between the forearm skin
• once satisfied with the tissue placement , the sutures are
cut

• after the skin is closed subcuticalarly , a nonpressure
dressing is applied
• pressure be avoided to prevent reducing the blood flow to
the area
• starting on the afternoon of the surgery , 75 IU/ dav of FSH
in injected directly in the graft for 7 days
• in addition , 80 mg of aspirin is admistered for 7 days
• the patient,s forearm is splinted for 72 hours to prevent
dislodgment due to muscle movement
• hormone replacement therapy is started within 48 hours of
transplantation and discontinued with the first sign of graft
function
• the return of ovarian function may take 2-3 months as
heralded by development of ovarian follicles beneath the
skin

Ovarian Cortical Strips Transplantation
to the anterior abdominal wall at incision
site of Pfannenstiel
• Under local anaesthesia, implant 5- 15
ovarian cortical pieces according the size
of the patient
• with sizes ranging from 5 x 5x 1 mm to 15
x 5x 1 mm—beneath the skin of the
patient’s lower abdominal wall with a
suture pull-through technique, similar to
technique applied in forearm
transplantaion

How To Diagnose Success?!
• Follicular development evident after few
months by ultrasound examination
• Restoration of serum FSH and LH levels to
nonmenopausal range
• Disappearance of menopausal symptoms
• And last for few years

In The Future
• Women in their 20s or 30s could theoretically
have an ovary removed and frozen, and then
have it reimplanted years later when they are
ready to have children as
“We are in the middle of an infertility epidemic

Cortical ovarian strips transplant

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