Cryopreservation of Ovarian Tissue

Procedure: The patient will undergo preoperative sonographic assessment of both ovaries to
determine if either ovary is diseased or compromised. Patient will undergo preoperative blood
sampling to measure AMH, FSH, LH and estradiol as indicators of current ovarian function
(less than 8 teaspoons) if time allows and assessment of ovarian reserve is appropriate;
menopausal levels of FSH (≥ 30 miu/ml) will be a contraindication to participation in this
study. The patient may have infectious disease testing as part of the evaluation for
fertility preservation treatment. Patient will undergo preoperative assessment and clearance
for surgery by an anesthesiologist.

Intraoperative management will include laparotomy or laparoscopy, depending on the individual
patient's history, exam and oncology plans. Removal of one or both ovaries will depend on
preoperative ovarian assessment and recommendation of the oncologist. If ovarian survival for
the anticipated treatment has never been documented then both ovaries will be removed. Both
ovaries may also be removed if diseased or if the condition requires prophylactic
oophorectomy to prevent risk of malignant transformation, e.g. 46 XX/46 XY chimera and BRCA
mutation carriers. If ovarian function has rarely been documented for the anticipated
treatment then one ovary will be removed and one may be left in situ or repositioned to avoid
the field of radiation. The decision to leave the ovary in situ or to reposition will be made
pre-operatively by the physician performing the surgery in consultation with the patient and
the radiation oncologist. If there is no normal ovarian tissue, as determined by pathology,
we will take biopsies of ovarian tissue not to exceed 50% of the ovarian volume from the
contra-lateral side for freezing. Additionally, the remaining ovary may be repositioned and
sutured to the posterior wall of the uterus or above the pelvic brim with a radio-opaque clip
placed to identify this ovary for shielding during irradiation.

Ovarian tissue will be removed and treated as follows: (a) the cortex will be stripped from
the remaining ovarian tissue as this outer layer contains most of the immature eggs or
primordial follicles. The cortex will be sectioned into 8mm x 1mm strips, each to be frozen
in vials containing 1-3 strips. One strip will be sent to pathology for paraffin embedding to
be available for future assessment of occult lymphoma cells markers; (b) the central or
medullary portion will be frozen separately for potential scientific analysis since this
section would not be of any clinical utility. The amount of tissue frozen may vary depending
in part by whether one or two ovaries are removed. At some point in the future, thawing of
ovarian tissue, with either in vitro maturation or autologous transplantation into the pelvis
or other area of the body could be performed. The patient would receive routine postoperative
care. The patient's oncologist will be consulted regarding proper timing of the surgery and
the need for any special intraoperative or postoperative management

However, since the survival of the primordial follicles in transplanted ovarian tissue is
quite low (<10%), methods for in vivo maturation of these eggs and improved methods of
transplantation need to be developed. One or two vials of tissue (<10% of all tissue frozen)
will be thawed to develop the techniques of maturing oocytes. This may include
transplantation of the tissue into an animal model for in vivo maturation.

Six months to 1 year following surgery and/or treatment for the medical condition, eg
chemotherapy, hormone testing will be performed for evaluation of ovarian reserve. This may
include AMH and FSH hormone levels as well as pelvic ultrasounds and dominant antra follicle
count.

If the subject does not wish to utilize the ovarian tissue for her own clinical use, the
options include discarding the cryopreserved ovarian tissue or donating the cryopreserved
tissue for approved research studies.

Inclusion Criteria:

- Females 0-45 years of age who are premenopausal

- Treatment plan that will likely result in premature menopause or premature ovarian
failure

- This includes patients receiving:

- Cancer treatment with abdominal pelvic irradiation and/or high dose chemotherapy

- Surgery that requires removal of ovaries for medical condition or disease, e.g.
Prophylactic oophorectomy in BRCA patients

- Patient is unable or unwilling to pursue fertility preservation by freezing oocytes or
embryos.

- Previous treatment for cancer is acceptable if patient still has ovarian function

- Patient is medically stable enough to undergo surgery (cleared for anesthesia)

Exclusion Criteria:

- Patients not meeting the above criteria

- Patients who have not received medical clearance from their physicians to undergo
surgery

- Patients already experiencing menopause.