Gonadal Tissue Freezing for Fertility Preservation in Individuals at Risk for Ovarian Dysfunction, Premature Ovarian Insufficiency and Clinically Indicated Gonadectomy

Study Overview
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Brief Summary
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Background: Turner Syndrome, galactosemia, and premature ovarian insufficiency are all conditions that may make it very hard or impossible for a person to become pregnant and have their own child. Researchers want to learn more about why this happens and if freezing Gonadal tissue allows for fertility preservation. Objective: To find out why people with certain conditions have can have premature ovarian insufficiency (POI or early menopause) and individuals with variations in sex characteristics have trouble getting pregnant and if freezing the gonads tissue from them will help to have their own child in the future. Eligibility: Individuals aged 4-12 who have Turner Syndrome or galactosemia. Also, females aged 13-21 with premature ovarian insufficiency and Individuals with variations in sex characteristics Design: Participants will be screened with a medical history. Participants may have a physical exam and blood tests. Their body measurements may be taken. These include weight, height, arm span, skin fold, and sitting height. They may fill out surveys about their quality of life, body image, and health. Participants may have a transabdominal pelvic ultrasound. A probe will be placed on their belly and will take pictures of the organs in the pelvis. They may have a transvaginal pelvic ultrasound performed while asleep in the operating room if needed. Participants may have surgery to remove an gonads and skin biopsy. The removed tissue will be frozen and stored. The tissue will have to be stored for many years. NIH will pay to store the tissue for 1 year. After that, participants will have to pay for storage. A piece of the gonads (no more than 20%) will be used for research Travel, lodging and meals for participants traveling greater than 50 miles will be reimbursed based off the government rate. Local participants will not be reimbursed. Participants will have a checkup 6 weeks after surgery one or more follow-up visits 6-18 months after surgery. They may have phone follow-up every 12-24 months after surgery. Participation will last 30 years.

Detailed Description
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Study Description: Gonadal tissue cryopreservation will be evaluated in individuals with Turner Syndrome, , galactosemia, post-menarcheal adolescents with recent premature ovarian insufficiency, and adolescents with diminished ovarian reserve (DOR) who have contraindication to ovarian stimulation as well as those with diminished ovarian reserve who did not respond to ovarian stimulation, and individuals with variations in sex characteristics (VSD or differences in sex development, DSD) including those with Turner syndrome with Y chromosome material. Objectives: Primary Objectives: After initial evaluation of number and quality of follicles before and after cryopreservation and thawing, the remaining tissue will be utilized to perform research regarding mechanisms of follicle/gametes loss in Turner and galactosemia as well as postmenarcheal adolescent individuals with a recent diagnosis of POI, or VSD/DSD. We will perform single cell/nucleus RNA sequencing on the tissue collected from study participants and ovaries from cadaveric organ donors on cardiopulmonary support. We will perform single cell/nucleus RNA sequencing on fresh gonadal tissue and compare it to frozen and thawed tissue Hypothesis: Single cell/nucleus RNA sequencing from tissue obtained from gonadal in individuals with these conditions will differ significantly from that of controls. Such differences may allow for further hypothesis development regarding the underlying mechanism of follicle loss and/or dysfunction in individuals with these conditions. Secondary Objective: This protocol is designed to evaluate the feasibility (meaning a reasonable expectation of future fertility based on the anatomy, histology, and physiology of fresh gonadal tissue as well as the effects after freezing and thawing) of gonadal tissue cryopreservation (GTC)for fertility preservation in children with increased risk of loss of gonadal function due to Turner syndrome (with or without Y material) or galactosemia and post-menarcheal adolescents with a recent development of premature ovarian insufficiency (POI) or with diminished ovarian reserve (those who do not respond to ovarian stimulation for oocyte cryopreservation due to lower follicle counts) or individuals with variations in sex characteristics. a. The feasibility will be evaluated through evaluation of number and quality of follicles/gametes found in the tissue prior to freezing and after thawing. b. Lack of follicles/gametes in the gonadal tissue will confirm that GTC is not a viable option for fertility preservation for these populations. c. An attempt to correlate laboratory and imaging markers with follicle/gamete presence and number will be made. Hypothesis: Young individuals with Turner syndrome, variations of sex characteristics, classic galactosemia and adolescents with recent POI, harbor populations of follicles/gametes which may be preserved through gonadal tissue cryopreservation for future fertility. There will be a variety of follicular findings which will correlate with patient s anti-Mullerian hormone (AMH), age and underlying condition. Depending on their underlying condition, individuals with VSC will have gametes (follicles and/or spermatogonia). Loss of follicles with cryopreservation and thawing will be similar to that of non-affected individuals. Tertiary Objectives: Research regarding inhibition and activation of follicles within the tissue will be undertaken. 1. Tissue will be treated with known inhibitors and activators and single cell/nucleus RNA sequencing will be performed in order to assess gene expression before and after treatment Hypothesis: Primordial follicles within gonadal tissue in individuals with these conditions may be inhibited from activating. Such techniques may allow for a decrease in follicle loss with freezing and thawing as well as possible future development of novel treatments to prevent accelerated follicle loss in individuals and adolescent affected by these conditions. Promoting follicle activation prior to reimplantation of the tissue may improve the possibility of achieving pregnancy after tissue re-implantation Endpoints: Primary Endpoints: Tissue for research: Single cell/nucleus RNA sequencing will be performed on tissues of affected individuals and compared to age matched controls who will be cadaveric organ donors on cardiopulmonary support. This will allow for specific cellular type comparisons within the ovary and exploratory research regarding possible mechanisms of follicle loss in these populations. Single cell/nucleus RNA sequencing on fresh compared to frozen and thawed tissue. This will assess what transcription changed occur due to the freezing process. Secondary Endpoint: Evaluation of density and quality of follicles/gametes in the gonads of individuals with Turner syndrome (with or without Y material), galactosemia and post-menarcheal adolescent with premature ovarian insufficiency or with diminished ovarian reserve (those who do not respond to ovarian stimulation for oocyte cryopreservation due to lower follicle counts) and individuals with VSC. Correlation of follicle/gamete density and quality with markers such as age, AMH, condition. Comparison of hormone levels such as AMH, FSH, LH, and Estradiol between patients and controls. Tertiary Endpoint Evaluate changes in single cell/nucleus RNA sequencing in tissue before and after treatment with primordial follicle inhibitors and activators. The remaining tissue will be cryopreserved for future experiments.

Official Title
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Gonadal Tissue Freezing for Fertility Preservation in Individuals at Risk for Ovarian Dysfunction, Premature Ovarian Insufficiency and Clinically Indicated Gonadectomy

Conditions
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Turner Syndrome, Post-menarcheal Adolescents, Ovarian Disfunction, Galactosemia, Variations in Sex Characteristics, Differences in Sex Development

Participation Criteria
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Eligibility Criteria
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INCLUSION CRITERIA: In order to be eligible to participate in this study, an individual must meet all of the following criteria: Individuals with Turner Syndrome and galactosemia prior to menarche aged 4 years to 12 years who have not demonstrated signs of premature ovarian insufficiency (one FSH>25 IU/L) whose families seek to store ovarian tissue for possible future use. Or Adolescent females up to age 21 years old, who have undergone menarche and are subsequently diagnosed with premature ovarian insufficiency and their last menstrual period occurred within 2 years of presentation. Diagnosis of POI is based on 2 elevated FSH concentrations obtained over 1 month apart. Or Adolescents who have diminished ovarian reserve who respond poorly to ovarian stimulation for egg freezing. Or Individuals with variations in sex characteristics (or differences in sex development, DSD) including Turner syndrome with Y chromosome material who undergo prophylactic gonadectomy for clinical indications Stated willingness to comply with all study procedures and availability for the duration of the study. Ability of subject, parents or guardian to understand and the willingness to sign a written informed consent document. EXCLUSION CRITERIA: An individual who meets any of the following criteria will be excluded from participation in this study: Individuals older than 7 years with psychological, psychiatric, or other conditions which prevent giving fully informed consent or assent. Individuals with a pelvic mass tumor noted on pre-operative ultrasound, will undergo usual care for the underlying condition and will not undergo oophorectomy for ovarian tissue cryopreservation Individuals whose underlying medical condition significantly increases their risk of complications from anesthesia and surgery. Females with POI due to chemotherapy or radiation treatment Pregnancy or lactation Individuals with VSC who choose to retain gonads after clinical consulting.

Ages Eligible for Study
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Minimum Age: 4 Years
Maximum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Adolescents with DOR<br>Adolescents with diminished ovarian reserve (DOR) who respond poorly to ovarian stimulation for egg freezing | |
| Adolescents with POI<br>Adolescent females up to age 21 years old, who have undergone menarche and are subsequently diagnosed with POI and their last menstrual period occurred within 2 years of presentation. | |
| Individuals with variations in sex characteristics (or differences in sex development, DSD)<br>Individuals with variations in sex characteristics (or differences in sex development, DSD) who undergo gonadectomy for clinical indications. | |
| Turner Syndrome and galactosemia<br>Individuals with Turner Syndrome and galactosemia prior to menarche aged 4 years to 12 years who have not demonstrated signs of premature ovarian insufficiency (one FSH>25 IU/L) | |
| Turner Syndrome with Y material<br>Children and adolescents who have Turner syndrome with Y material and undergo prophylactic gonadectomy. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Single cell/nucleus RNA sequencing | Single cell/nucleus RNA sequencing on fresh compared to frozen and thawed tissue. This will assess what transcription changed occur due to the freezing process. | before and after cryopreservation | 
| Tissue for research | initial evaluation of number and quality of follicles before and after cryopreservation | before and after cryopreservation | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Evaluate gonadal tissue | The ability to safely offer a fertility preservation option to individuals who are at high risk such as POI, DOR and VSC. | before and after cryopreservation | 
| Evaluate changes in single cell/nucleus RNA sequencing | Evaluate changes in single cell/nucleus RNA sequencing in tissue before and after treatment with primordial follicle inhibitors and activators. | before and after cryopreservation | 
| Compare hormone levels | Comparison of hormone levels such as AMH, FSH, LH, and Estradiol between patients and controls. | before and after cryopreservation | 
| density and quality of follicles in the ovaries | Evaluation of density and quality of follicles in the ovaries of girls with Turner syndrome, galactosemia and post-menarcheal adolescent with premature ovarian insufficiency before and after cryopreservation and thawing | before and after cryopreservation | 
| Correlation of follicle density and quality with markers such as age, AMH, condition. | Correlation of follicle density and quality with markers such as age, AMH, condition. | before and after cryopreservation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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OVARIAN FUNCTION, Natural History, follicle loss, Variations in Sex Characteristics, Differences in Sex Development