Volume 166 Issue 7

Evaluation of sexual health services within Australia and New Zealand Caron Marks, Robin L Tideman and Adrian Mindel MJA 1997; 166: 348-352 For comment see Fairley Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - Figure 1 - Figure 2 - - ©MJA1997 Abstract Objective: To examine and compare specialised services for patients with sexually transmitted diseases (STDs) in Australia and New Zealand. Design: Postal questionnaire survey. Participants and Setting: All STD facilities in Australia and New Zealand in 1993. Main Outcome Measures: Patient numbers and demography; staffing levels; the role of nurses; diagnostic and treatment protocols; contact-tracing policies; and the availability of specialist medical services and community and education programs. Results: 83 of 100 clinics responded; 52 were urban, 21 rural, and nine remote. 95% were open to men and women. Staffing levels were similar in Australia and New Zealand and there was considerable consistency in diagnostic techniques and treatment among clinics. Australian clinics more often used ciprofloxacin or ceftriaxone as the treatment of first choice for gonorrhoea; New Zealand clinics were more likely to test for Chlamydia using direct immunofluorescence; and Australian clinics were more likely to test for hepatitis A and offer hepatitis B vaccination to a broader range of patients. 88% of clinics always traced contacts for gonorrhoea, 86% for syphilis and 77% for Chlamydia . 98% of clinics offered HIV test counselling, and 78% STD health education. Conclusions: The number of sexual health services has increased over the past decade. Other improvements include most clinics being open to both men and women, and consistency in the diagnosis, treatment and contact tracing of STDs. However, given the lack of adequate comparative data and the variable quality of national surveillance data, it is difficult to determine whether current facilities are meeting service needs. MJA 1997; 166: 348-352 Introduction The control of sexually transmitted diseases (STDs) depends on health promotion, education, the provision of adequate facilities for the diagnosis, treatment and contact tracing of STDs, and ongoing research.1 One of the more comprehensive national STD services (involving more than 200 standardised clinics) is in the United Kingdom.2,3 By contrast, Australia currently has a fragmented STD control system in which each State and Territory works independently and with different health policies. There are no nationally agreed guidelines for the diagnosis, treatment and tracing of contacts of patients with STDs,4 availability of different tests varies across the continent, and treatment protocols may vary according to antibiotic resistance patterns and financial constraints. A 1983 survey of public STD facilities throughout Australia found that almost all clinics were located in major cities, leaving large areas of rural Australia unserviced by public clinics.5 Other deficiencies identified included inadequate opening times, lack of facilities in some clinics for treating both men and women, insufficient staff, inadequate contact tracing, limited use of facilities for teaching purposes, and inadequate maintenance of their role as reference centres for other practitioners and agencies. This survey included all 20 public STD facilities Australia-wide, and concluded that these facilities were "inadequate to meet the needs of the population".5 Over the past decade there have been many changes to sexual health care, including more clinics and better training for staff. Consequently, we felt that it was timely to establish what STD services were available from public and private STD clinics and Family Planning Clinics (FPCs); whether STD clinical services were adequately staffed; to determine the range of diagnostic, treatment, and contact-tracing services; and whether clinics were providing the community with education, counselling and other specialist services. Finally, we compared services in Australia and New Zealand and noted geographic differences in the provision of services within Australia. Methods In 1993 we identified all STD treatment facilities in Australia and New Zealand. These included all known public and private sexual health clinics, and the main Family Planning Clinic (FPC) in each State. Most facilities were identified through the National Venereology Council of Australia and the Family Planning Association of New South Wales, with the remainder found when clinics identified centres in their area which had been overlooked. A questionnaire and prepaid addressed envelope were posted to the director (senior doctor or nurse) of each clinic. The 65-item questionnaire sought information about the geographic location and physical structure of clinics, as well as staffing, diagnosis, treatment and contact tracing for the various STDs, specialist medical services, and community and educational programs run by the facility. Non-respondents were sent a second questionnaire two months after the first. Statistical analysis The results were analysed using the Statistical Package for the Social Sciences (SPSS).6 Descriptive statistics, frequency distributions, χ2 and Fisher's exact test were used. There was no weighting of the data by size of clinic. Chi-square tests, when used to compare therapies for the various STDs, involve all treatments, ranging from "most commonly used" to those "never used". When reporting significant differences the χ2 takes into account all these modalities. However, the figures reported show only a description of where the differences lie. The rural/remote areas classification system was used to classify Australian facilities into rural and remote areas by means of postcodes,7 while the New Zealand Yearbook was used to classify those in New Zealand.8 Results We identified 101 STD facilities, one of which had closed down. From the remaining 100 clinics, 83 questionnaires were returned (72 on the first mailout and an additional 11 on the second). Geographic distribution and type of facility Fifty-six clinics were in Australia and 27 were in New Zealand. Sixty-three per cent were in inner-city and suburban areas, 26% in rural areas and 11% in remote areas (Box 1). Seventy-nine clinics (95%) were public and four (5%) were private. There were 71 STD clinics and five FPCs. One private facility identified itself as a specialist venereology practice, and three as general practices specialising in STDs and HIV. The remaining three clinics identified themselves as "other". Seventy-nine clinics (95%) were open to both men and women. Staffing Box 2 shows that the median number of patients seen per year decreased as the facilities became more remote. Clinics in Australia saw a greater median number of patients per year and had more doctors, nurses, laboratory and clerical staff than those in New Zealand. However, the only significant difference was for full-time equivalent clerical staff, with a median of 1 (range, 0-4.3) for Australia, compared with 0 (range, 0-2.4) for New Zealand (P = 0.002). The most common duties of nurses at STD facilities included history taking, clinical examination and testing for STDs. Only 26% of clinics allowed nurses to prescribe treatment; more nurses in rural and remote areas were allowed to prescribe treatment than those in urban areas (36% v. 16%), but this difference was not significant. Nurses took histories "sometimes" (options were "always", "sometimes" and "never") in over 80% of clinics in New South Wales, compared with 39% in Victoria (P = 0.02), and examined patients at 70% of NSW clinics, compared with 22% in Victoria (P = 0.02). There were no significant differences in nursing duties between New Zealand and NSW. However, comparing New Zealand with Victoria showed that New Zealand nurses were more likely to take histories (P = 0.003), examine patients (P = 0.005), and test patients for STDs (P = 0.002). Diagnosis and treatment Gonorrhoea: Eighty-one clinics (99%) used culture, and 77 (94%) used Gram stain to diagnose gonorrhoea. The three most common treatments for gonorrhoea were amoxycillin plus probenecid, ciprofloxacin, and ceftriaxone, used in 63%, 24% and 12% of clinics, respectively (Box 3). New Zealand clinics were more likely than Australian clinics to use amoxycillin plus probenecid as first-line therapy for gonorrhoea (93% v. 49%; P = 0.01). Urban clinics in both Australia and New Zealand were more likely to use ciprofloxacin than rural and remote clinics (51% v. 21%; P = 0.02). Syphilis: Forty-seven clinics (57%) used dark-ground microscopy for diagnosing primary syphilis. For screening, 61 (74%) used the rapid plasma reagin (RPR) test, 58 (71%) the Treponema pallidum haemagglutination antibody (TPHA) test, and 25 (31%) the Ven ereal Disease Research Laboratory (VDRL) test. Fifty Australian clinics (91%), compared with 11 New Zealand clinics (41%), used the RPR test for screening (P < 0.001). The fluorescent treponemal antibody test (FTA) was used by 61 (75%) clinics to confirm the diagnosis. Procaine and benzathine penicillins were the first-choice treatments in all facilities. Chlamydia and non-gonococcal urethritis: Chlamydia was most commonly diagnosed by direct immuno fluorescence (DIF), which was used by 44 clinics (54%), followed by: enzyme immunoassay (EIA) from swabs, 39 clinics (48%); culture from swabs, 35 clinics (43%); and EIA from urine, 10 clinics (12%). Australian clinics were more likely to use culture to diagnose chlamydial infection than New Zealand clinics (58% v. 11%; P < 0.001), while New Zealand clinics were more likely to use DIF than Australian clinics (74% v. 44%; P = 0.01). Urban centres were significantly more likely to use culture to diagnose Chlamydia than rural and remote centres (58% v. 17%; P < 0.001). Most clinics used doxycycline as first-line treatment for Chlamydia and non-gonococcal urethritis (92% and 91%, respectively). Genital herpes: Herpes simplex virus (HSV) was diagnosed by viral culture (79 clinics [96%]), EIA (16 clinics [20%]), and serological testing (10 clinics [12%]). Acyclovir was used to treat primary HSV infections by 79 clinics (98%), for long term suppression by 70 clinics (86%), and for recurrences of HSV infection by 58 clinics (72%). Human immunodeficiency virus (HIV): All the clinics surveyed routinely offered counselling and voluntary HIV testing to all persons considered to be at risk of HIV infection. Fifty-two clinics (64%) had facilities to manage HIV- positive patients. Forty-one clinics (51%) provided antiretroviral therapy and prophylaxis and treatment of opportunistic infections. Genital warts: Cryotherapy was the first-line treatment for human papillomavirus infection in 55 clinics (69%), and podophyllin was the second most common treatment option, used in 17 clinics (21%). Australian clinics were more likely to use podophyllin than New Zealand clinics (16/53 [30%] v. 3/27 [11%]; P = 0.03). Trichomoniasis and bacterial vaginosis: To diagnose trichomoniasis, wet-film microscopy was the most common technique, used in 67 clinics (83%), while culture was used by 39 clinics (48%). Gram staining was the most common diagnostic technique for identifying bacterial vaginosis (74 clinics [93%]). Alternative diagnostic techniques used included culture to identify Gardnerella vaginalis and other anaerobes (56 clinics [70%]), vaginal pH testing (44 clinics [55%]), and the potassium hydroxide test (which identifies volatile amines) (41 clinics [51%]). Most clinics used metronidazole to treat trichomoniasis (53/80 [66%]) and bacterial vaginosis (50/79 [63%]). Viral hepatitis: Forty-four clinics (55%) offered antibody testing for hepatitis A and 79 (98%) for hepatitis C. Australian clinics were significantly more likely to offer antibody testing for hepatitis A than New Zealand clinics (36/54 [67%] v. 8/26 [31%]; P = 0.003). When screening for hepatitis B infection, 65 clinics (81%) meas ured surface antigen (HBsAg), 57 (71%) measured core antibody (HBcAb), and 48 (60%) measured surface antibody (HBsAb). Figure 1 shows clinic policies for hepatitis B vaccination. Vaccination was recommended for health care workers by 52/53 (98%) Australian clinics, compared with 19/27 clinics (70%) in New Zealand (P < 0.001); for heterosexuals with multiple partners, these figures were 44/53 (83%) and 15/27 (56%), respectively (P = 0.01); and for intravenous drug users (IVDUs), 52/53 (98%) and 21/27 (78%), respectively (P = 0.002). Contact tracing Seventy-one clinics (87%) offered contact tracing for patients with STDs. Many centres employed multiple techniques. In 67 clinics (94%), staff negotiated with patients to advise their own contacts, 53 clinics (75%) used face-to-face discussions between contacts and clinic staff, 45 (63%) had staff visit contacts at home, and 38 (54%) traced contacts by phone. Twenty-one of the 71 clinics (30%) employed specially trained contact tracers. Doctors were involved in contact tracing in 22 clinics (28%), counsellors in 23 (32%), and nurses in 44 (62%). Patients were encouraged to inform their own contacts in 28 clinics (39%). All 21 clinics in NSW stated that they undertook contact tracing, compared with 9/13 (69%) clinics in Victoria (P = 0.01), and NSW clinics were significantly more likely to involve counsellors in contact tracing than Victorian clinics (62% v. 8%; P = 0.002). There were a number of differences in contact-tracing policies between Australia and New Zealand. Australian facilities were more likely than New Zealand clinics to involve doctors (22/55 [40%] v. 1/27 [4%]; P = 0.001), less likely to trace contacts by telephone (21/55 [38%] v. 18/27 [67%]; P = 0.02), and less likely to trace contacts by having staff visit them (22/55 [40%] v. 23/27 [85%]; P < 0.001). Box 4 summarises the contact-tracing practices for each STD. Most clinics always traced contacts of patients with gonorrhoea, syphilis, Chlamydia , HIV and trichomoniasis. Only one of the five FPCs (20%) provided contact tracing, compared with 65 of 66 (98%) sexual health clinics (Fisher's exact test, P < 0.0005). Additional services provided by STD clinics The facilities surveyed offered a range of additional services. Eighty-one facilities (98%) offered counselling before and after HIV testing, 78 (95%) functioned as a referral service for further specialist counselling, 68 (84%) offered family planning advice, and 48 (59%) offered relationship counselling. Other services are outlined in Figure 2. Sixty-eight (82%) of the responding clinics offered education programs to other health professionals, schools or youth groups, while 46 (55%) offered some form of higher education/university courses. Discussion Our findings show that the number of STD facilities in Australia increased considerably over the past decade, and that facilities in New Zealand and Australia were broadly comparable (although, in Australia, there was still a marked urban predominance of clinics). Other improvements were that most clinics were open to men and women, and offered a wide range of teaching and other special services. Relative to the 1983 survey of Australian STD services by Bradford and Philpot,5 we found an increase in the number of nurses and doctors, while the number of patients seen annually was similar. However, over the past decade clinics have become more involved in managing patients with complex medical problems, including HIV, hepatitis B and C, disseminated herpes simplex virus infection, and cervical intraepithelial neoplasia.4,9 Increased availability of services does not necessarily lead to improvement in the sexual health of the community. The best measure of improvement is a reduction in the incidence of sexually transmitted diseases. In Australia, disease patterns have been difficult to in terpret because the collection of epidemiological data for most STDs (with the exception of gonorrhoea) from the States and Territories is uneven.4 None the less, there is considerable evidence to suggest that there has been a dramatic reduction in reported cases of gonorrhoea, syphilis and chlamydial infections since 1981,10-12 with the most marked improvements in the large metropolitan centres. By contrast, the incidence of gonorrhoea, syphilis, Chlamydia and donovanosis remained extremely high in many rural Aboriginal communities, particularly in the Northern Territory, far north Queensland, and the Pilbara and Kimberley regions of Western Australia.13-15 These areas all have a limited number and quality of sexual health facilities, and improvements in clinical services and intervention programs are urgently needed. Our findings show considerable consistency in diagnosis and treatment of STDs throughout Australia and also between Australia and New Zealand, with most facilities following the diagnostic and treatment guidelines produced by the United States Centers for Disease Control (CDC)16 or those of the Venereology Society of Victoria.17 However, we did identify some differences between Australia and New Zealand in the treatment of first choice for gonorrhoea, the method of detecting chlamydial infection, and in the likelihood that hepatitis A tests would be requested. There were also differing policies on hepatitis B vaccination and on tracing contacts of patients with STDs. Varying patterns of antibiotic resistance in strains of the organism that causes gonorrhoea (penicillinase-producing Neisseria gonorrhoeae ) were more common in Australia, particularly along the east coast,18 than in New Zealand, and resistance to quinolones occurs in strains infecting a sizeable minority of travellers from the Philippines and neighbouring countries;19 this may explain the difference in antibiotic treatment. Other factors contributing to the differences in practice include local availability of diagnostic tests, variation in populations attending clinics (travellers,20,21 sex-industry workers22,23 and homosexual men24-26 ) and local variations in clinical practice. The differences in hepatitis A testing policy and hepatitis B vaccination policy are intriguing, and may include differing financial arrangements between the clinical services in the two countries, availability of testing and vaccination from other sources (in particular, the recommendation for universal HBV vaccination in New Zealand),27 and differing populations28,29 and perceptions of risk.30 Differences in contact-tracing policies probably reflect availability of staff, local working practices, or variation in the understanding of contact tracing. There are a few minor differences between urban clinics and those in rural and remote settings, with a greater proportion of urban clinics using ciprofloxacin to treat gonorrhoea, using culture to diagnose Chlamydia , and requesting hepatitis A testing. This also reflects differences in the population groups attending different clinics (urban centres attract a higher proportion of overseas travellers, sex workers and homosexual and bisexual men than rural and remote centres), antibiotic sensitivities and local availability of tests. Overall, the availability of contact-tracing services was excellent. However, it is of some concern that 4% of clinics never and 9% only sometimes traced contacts for gonorrhoea, 8% never traced contacts for syphilis and 2% never traced contacts for Chlamydia . Although we surveyed only five FPCs, our finding that only one of these five provided contact tracing is of concern, particularly with Chlamydia , which is often diagnosed within these facilities.31 Barriers to contact-tracing services within FPCs should be explored and solutions considered. One possible solution would be to encourage closer links between sexual health and family planning services. Our findings in this survey should be of assistance in future sexual health service planning. In addition, the remarkable consistency in the diagnosis, treatment and contact tracing of STDs in Australia and New Zealand should encourage the development of national guidelines. Acknowledgements We thank Professor G Berry and Associate Professor B Donovan for their assistance with this manuscript. References Adler MW. Sexually transmitted diseases. In: Holland WW, Detels R, Knox G, editors. Oxford textbook of public health. Vol. 21. 2nd Ed. Oxford: Oxford University Press, 1991: 345-357. Bingham JS. Genitourinary medicine should remain a separate specialty. Genitourin Med 1996; 27: 312. Adler MW, Belsey EM, O'Connor BH, et al. Facilities and diagnostic criteria in sexually transmitted disease clinics in England and Wales. Br J Vener Dis 1978; 54: 2-9. Mulhall BP, Hart G, Harcourt C. Sexually transmitted diseases in Australia: a decade in change. Epidemiology and surveillance. Ann Acad Med Singapore 1995; 24: 569-578. Bradford DL, Philpot CR. A survey of sexually transmitted disease centres in Australia. Br J Vener Dis 1983; 59: 330-334. SPSS: Statistical package for the social sciences [computer program], version 7.0. Chicago, Ill: SPSS Inc, 1995. Rural/remote areas classification. Canberra: Department of Human Services and Health, 1994. New Zealand Official Yearbook 1993. 96th Ed. Wellington: New Zealand Department of Statistics, 1993. Donovan B, Finlayson RJ, Mutimer K, et al. HIV infection in sexually transmissible disease practice in Sydney: the effects of legislation, public education and changing clinical spectrum. Int J STD AIDS 1990; 1: 21-27. The Australian gonococcal surveillance programme. The incidence of gonorrhoea and the antibiotic sensitivity of gonococci in Australia, 1981-1991. Genitourin Med 1993; 69: 364-369. Hart G. STD epidemiology in Australasia; Syphilis and gonorrhoea. Venereology 1992; 5: 115-120. Garland SM, Gertig DM, McInnes JA. Genital Chlamydia trachomatis infection in Australia. Med J Aust 1993; 159: 90-96. Annual report of the national notifiable diseases surveillance system, 1992 - part 2. Syphilis. Commun Dis Intell 1993; 17(22): 507-508. Bowden FJ. Surveillance of sexually transmitted diseases in the Northern Territory of Australia. Venereology , 1995; 8(1): 21-25. Main J, Patel A, Bowden FJ. Surveillance of donovanosis in the Northern Territory. Venereology 1995: 8: 16-19. sexually transmitted diseases treatment guidelines. Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep 1993; 42(RR-14): 1-102. Management guidelines for sexually transmissible diseases and genital infections. 4th ed. Melbourne: Venereology Society of Victoria, 1995. Anonymous. The incidence of gonorrhoea and the antibiotic sensitivity of gonococci in Australia, 1981-1991 . The Australian Gonococcal Surveillance Programme. Genitourin Med 1993; 69(5): 364-369. Tapsall JW, Schultz TR, Philip EA. Characteristics of Neisseria gonorrhoeae isolated in Australia showing decreased sensitivity to quinolone antibiotics. Pathology 1992; 24: 27-31. Mulhall BP, Hu M, Thompson M, et al. Planned sexual behaviour of young Australian visitors to Thailand. Med J Aust 1993; 158: 530-535. Mulhall BP. Sexually transmissible diseases and travel. Br Med Bull 1993; 49(2): 394-411. O'Connor CC, Berry G, Rohrsheim R, Donovan B. Sexual health and use of condoms among local and international sex workers in Sydney. Genitourin Med 1996; 72: 47-51. Philpot CR, Harcourt JM, Edwards JM. A survey of female prostitutes at risk of HIV infection and other sexually transmissible diseases. Genitourin Med 1991; 67: 384-388. Rowbottom JH, Tapsall JW, Plummer DC, et al. An outbreak of a penicillin-sensitive strain of gonorrhoea in Sydney men. Genitourin Med 1994; 70: 196-199. Forsyth JRL, Sherrard J, Traynor P. Resurgent gonorrhoea in homosexual men [letter]. Lancet 1990; 336: 878. McNulty A. Anorectal gonorrhoea revisited. Venereol 1993; 6(4): 109-111. Goldwater PN. History of hepatitis B vaccination in New Zealand: lessons for Australia? Aust J Pub Health 1993; 17: 221-225. Stewart T, Crofts N. An outbreak of hepatitis A among homosexual men in Melbourne. Med J Aust 1993; 158: 519-521. Stokes ML. Infectious diseases: hepatitis A survey results. NSW Public Health Bull 1992; 3: 7-12. Anderson B, Bodsworth NJ, Rohrsheim R, Donovan B. Hepatitis B virus infection and vaccination status of high risk people in Sydney: 1982 and 1991. Med J Aust 1994; 161: 368-371. Garland SM, Gertig DM, McInnes JA. Genital Chlamydia trachomatis infection in Australia. Med J Aust 1993, 159: 90-96. (Received 9 Apr, accepted 1 Nov, 1996) Authors' details Academic Unit of Sexual Health Medicine, Sydney Hospital, Sydney, NSW. Caron Marks, BSc, MA, Research Assistant; Robin L Tideman, MB BS, Clinical Research Coordinator; Adrian Mindel, FRACP, MD, Professor of Sexual Health Medicine. Reprints: Ms C Marks, Academic Unit in Sexual Health Medicine, Sydney Hospital, GPO Box 1614, Sydney, NSW 2001. E-mail: cmarks AT extro.ucc.su.oz.au - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Caron Marks · Robin L Tideman · Adrian Mindel

Cryopreservation of ovarian tissue Potential "reproductive insurance" for women at risk of early ovarian failure Carl E Wood, Jillian M Shaw and Alan O Trounson Cryopreservation of ovarian tissue is a potential alternative or addition to cryopreservation of embryos or oocytes for sustaining fertility in women at risk of premature ovarian failure. Grafts of cryopreserved ovarian tissue have resulted in live-born mice and sheep. While human applications are in their infancy, frozen human ovarian tissue grafted to the kidney capsules of immunodeficient mice has produced normally developing ovarian follicles. (MJA 1997; 166: 366-369) Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Introduction - Oocyte cryopreservation - Embryo cryopreservation - Ovarian tissue cryopreservation - Conclusion - References - Authors' details - - ©MJA1997 Introduction Premature ovarian failure may occur in women with genetic diseases (such as Turner's syndrome), after chemotherapy or radiotherapy for malignant disease, in severe or recurrent ovarian disease (such as cysts, benign tumours or endometriomas), or after removal of the ovaries to treat endometriosis, ovarian pain or genital cancer. For women at risk of premature ovarian failure, there are now three possibilities for preserving their fertility: cryopreservation of their oocytes, embryos, and, most recently, ovarian tissue. This article provides an overview of these procedures, highlighting the recent developments in ovarian tissue cryopreservation. Oocyte cryopreservation Oocytes can be collected when either mature or immature. Cryopreservation of mature oocytes, although successful in the mouse,1-3 has met with little success in most other species, including man.4,5 All cryopreservation procedures in humans have led to impaired oocyte survival and subsequent reduced rates of fertilisation and embryo cleavage, with the result that fewer than 2% of oocytes are capable of producing a term pregnancy. For example, when Friedler and colleagues published a review of oocyte cryopreservation in 1988,6 fewer than 20% of oocytes were able to be fertilised and even fewer developed as embryos after preservation by both slow cooling and vitrification (cooling in a concentrated cryoprotectant solution that forms a glassy [vitreous] solid). More recent reports on freezing (both slow7-11 and rapid12-14 ) of human oocytes show little, if any, progress in the proportion that can be fertilised normally after thawing (see Box). Despite claims of advances and the establishment of egg banks for women with cancer, no recent births have been reported. The difficulties in cryopreserving human oocytes are related to their large volume and variable membrane permeability. This makes it difficult to achieve sufficient dehydration during cooling to prevent intracellular ice formation, without disrupting other cytoplasmic and nuclear components. It has been documented that cooling an oocyte on its own,13,17 exposure to cryoprotectants13,18 and cryopreservation can increase the incidence of spindle anomalies,8,17 initiate parthogenetic activation (development without a paternal genome)10 and stimulate release of cortical granules (which are usually released at fertilisation, causing the zona to harden, reducing the likelihood of polyspermy).19 Cooling and cryopreservation can also increase the incidence of chromosomal loss from the meiotic spindle, as the temperature-sensitive spindle, which holds the chromosomes in place, disaggregates and reforms abnormally on rewarming.17 Successful fertilisation cannot occur in any of these circumstances. Fertilisation failure can be partially corrected with intracytoplasmic sperm injection, but this does not resolve the problem of reduced cleavage or reduced developmental competence.10,11 Given that the probability of pregnancy and birth is, optimistically, around 10%-15% for a normally fertilised non-frozen oocyte, it is likely that up to 100 unfertilised oocytes will have to be cryopreserved in order to ensure a pregnancy. As mature oocytes are available for only a limited time in each menstrual cycle, and rarely in large numbers, this is simply not feasible. While it is also possible to cryopreserve immature human oocytes,20,21 this offers no advantage over cryopreserving mature oocytes at present, because of the difficulty of obtaining viable oocytes after in-vitro maturation. However, considerable research is being directed to cryopreserving oocytes of domestic animal species, and this may ultimately benefit human oocyte freezing. Embryo cryopreservation Cryopreservation of embryos is reasonably successful.22-25 The pregnancy rate after transfer of two to three cryopreserved embryos is around 15%-25%, and the probability of pregnancy accumulates with repeated transfers. However, there are associated problems: obtaining oocytes for fertilisation is technically difficult, limiting the number that can be used; there is a need for a male partner or sperm donor; unmarried couples may be excluded by government regulations or legal restrictions; and there may be significant ethical problems in disposing any unwanted embryos. Unforeseen circumstances, such as death, divorce or other family problems, may prevent embryos being implanted into the natural mother. Further, recovering oocytes to generate embryos usually requires ultrasound-guided needle aspiration of the leading follicle(s) in several successive menstrual cycles and ovarian stimulation to induce superovulation. Ovarian stimulation involves raising blood levels of oestrogen up to 20-fold above normal and may not be appropriate in women with oestrogen-sensitive cancers of the breast, ovarian epithelial tumours or severe endometriosis. In addition, in women with cancer there is a risk of transferring cancer cells together with the frozen thawed embryos; the embryos should be denuded of all other cells before transfer to the uterus. Ovarian tissue cryopreservation Although still in its infancy, ovarian tissue cryopreservation is a viable alternative to cryopreservation of oocytes or embryos. The ovarian cortex of young women contains several hundred thousand primordial follicles;26 even small pieces (1 mm3) may contain several hundred follicles. Although it has not yet been demonstrated that cryopreserved ovarian tissues can restore fertility in humans, live young have been obtained from fresh and frozen ovarian tissue grafts in mice2,27 and sheep.28 Cryopreserved ovarian tissue from marmosets grafted into immunodeficient mice develops apparently normal antral follicles.29 Human studies: Human ovarian cortical tissue, both fresh and frozen, grafted to the kidney capsule of immunodeficient mice also results in apparently normal developing follicles.30 A month after implanting a small piece of frozen thawed human ovarian tissue into these mice, the tissue contained numerous follicles which had been recruited into their growth phase.28 These increased in diameter from 37 µm, with few granulosa cells, to 85 µm, with one or two complete layers of granulosa cells (Figure). A large proportion of the follicles in the graft had been recruited. A similar study has reported successful storage and grafting of human ovarian tissue in immunodeficient mice.31 Advantages of ovarian cryopreservation: Ovarian cryo preservation has the advantage that wedges of ovarian tissue (about 2 cm2 in area) can be collected by laparoscopy from each ovary at any stage of the menstrual cycle without compromising a woman's health or fertility. Unlike embryo and oocyte cryopreservation, collection of ovarian cortical material does not delay hysterectomy and oophorectomy for severe endometriosis and does not involve use of "fertility drugs". The amount of ovarian tissue needed to restore regular menses and fertility after ovarian failure or removal is not currently known, but ovulation can occur with as few as 100 oocytes (in women and mice) to 400 oocytes (in cattle) remaining in the ovary.24,32,33 Applications of ovarian cryopreservation: Ovarian tissue cryopreservation might benefit patients with recurrent ovarian cysts or severe endometriosis, who are at risk of premature menopause. It could be combined with embryo cryo preservation, with cortical ovarian strips (1 mm x 10 mm) taken at the time of egg retrieval in an in-vitro fertilisation treatment cycle. Used alone, ovarian cryopreservation might be of particular benefit to those women, such as single women, who are unable to avail themselves of embryo cryo preservation. Oocyte preservation might be an option if women have access to a reproductive unit with an established record of pregnancies after this procedure. At present, these do not exist. The value of ovarian tissue grafting for cancer patients is debatable. Viruses, including HIV34-36 and hepatitis virus,37,38 and cancers39 can be transmitted by grafts, and cancers have been known to recur in patients in remission after the replacement of autologous cryopreserved bone marrow.40-42 It is therefore possible that bloodborne cancers such as leukaemia, systemic cancers such as lymphoma and metastasising cancers could be transmitted by ovarian tissue grafts. Shaw et al.43 have shown that when small pieces (around 1 mm3 ) of ovarian tissue obtained from donor mice with lymphoma were grafted into normal healthy recipient mice, 13 of 14 recipients developed the lymphoma. This occurred with both fresh and cryopreserved ovarian grafts, highlighting a significant risk for clinical applications of the procedure. Separating primordial follicles from stromal tissue or cancer cells is currently not possible. Polymerase chain reaction (PCR) techniques have increased the sensitivity of tests to detect the presence of remnant cancer cells,40,44,45 and it may be possible to culture tissue in vitro under conditions aimed at eliminating cancer cells.42 However, it is unlikely that cancer cells can be flushed out of an ovary or removed from the graft by cytotoxic drugs at the time of replacement, because of the deleterious effect on the graft. The alternative of removing primordial follicles from the graft and using matured eggs for in-vitro fertilisation, or replacing follicles in the patients, is currently not feasible as the enzymatic procedure used to obtain human primordial follicles46 results in separation of the oocyte and its surrounding support cells in culture.47 Future advances in collection and culture procedures for primordial follicles may allow in-vitro maturation of follicles in humans, as a live birth has recently been reported for mouse primordial follicles matured and inseminated in vitro and returned to the recipient as an embryo.48 Although treatment for cancer may affect fertility and produce premature menopause, it is known that many young women treated for cancer recover their fertility and bear children. The incidence of congenital and other malformations in these children is not statistically different from that in the general population,49 indicating that the follicles that survive cancer therapy are normal. However, cancer therapy may deplete the germ cell population. A study of 2283 long term female survivors of childhood or adolescent cancer found they were less likely to become pregnant than their sibling controls (relative fertility, 0.85; 95% confidence interval, 0.78-0.92).50 In females, radiation therapy below the diaphragm had the most marked effect, depressing fertility by about 25%, while alkylating agents administered alone had no apparent effect. Infertility was most marked after treatment for Hodgkin's disease (relative fertility, 0.77) and soft tissue sarcoma (relative fertility, 0.82) and apparently unaffected after treatment for melanoma, Wilms' tumour and female genital cancer. As there is a risk of transferring cancer cells with ovarian grafts and as follicles which survive cancer therapy appear normal, patients with cancer that may spread systemically should wait until full remission before storing ovarian tissue. Ethical issues: Transplantation of cryopreserved ovarian tissue may raise new ethical issues. It could be transplanted into women beyond the age of the menopause as a form of hormone replacement therapy. It could also facilitate older women having access to their own "younger eggs", which have been stored for 10 or more years. At present, IVF units in Australia limit the use of donor eggs to women within the reproductive age span, a generous upper limit being healthy women up to 52 years of age. Storage of the woman's own ovary from a younger age may avoid the use of donor eggs at an older age. Ovarian tissue could not be transplanted into other women on medical grounds, as it would require use of drugs such as cyclosporin to prevent rejection, increasing the risk of malignant disease. The use of such drugs for transplantation of organs on grounds other than a threat to a person's life was not accepted by an ethics committee at the Epworth Hospital, Melbourne, when tubal transplantation was proposed to assist in the treatment of infertility. Conclusion Patients with endometriosis or other conditions which may perturb their fertility, but which carry little risk of transmitting cancer cells or infectious agents, may choose to have oocytes or ovarian tissue collected and frozen. Those with a partner could also have embryos frozen. Current evidence suggests that ovarian tissue should not be collected from patients with a malignant cancer until they have reached full remission. Patients can return to have their frozen eggs, embryos or ovarian tissue thawed and replaced if they enter menopause or suffer infertility before they are ready to have children. Return of cryopreserved ovarian tissue has the potential to restore the patient's menstrual cycles, allowing natural conception and pregnancy without the need for assisted conception techniques. Unlike oocyte and embryo cryopreservation, ovarian tissue can be collected before or after puberty and at any stage of the menstrual cycle. At the moment, the efficacy of cryopreservation of oocytes is very low, while that of embryos is reasonable and that of ovarian tissue is unknown. References Carroll J, Wood MJ, Whittingham DG. Normal fertilization and development of frozen thawed mouse oocytes: protective action of certain macromolecules. Biol Reprod 1993; 48: 606-612. Carroll J, Gosden RG. Transplantation of frozen-thawed mouse primordial follicles. Hum Reprod 1993; 8: 1163-1168. 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Fresh and cryopreserved ovarian tissue samples from donors with lymphoma transmit the cancer to graft recipients. Hum Reprod 1996; 11: 1668-1673. Drobyski WR, Baxter-Lowe LA, Truitt RL. Detection of residual leukaemia by the polymerase chain reaction and sequence specific oligonucleotide probe hybridization after allogenic bone marrow transplantation for AKR leukaemia: a murine model for minimal residual disease. Blood 1993; 81: 551-559. Lion T. Clinical implications of qualitative and quantitative polymerase chain reaction analysis in the monitoring of patients with chronic myelogenous leukemia. Bone Marrow Transplant 1994; 4: 505-509. Roy SK, Treacy BJ. Isolation and long term culture of human preantral follicles. Fertil Steril 1993; 59: 783-790. Shaw JM, Wood EC, Trounson AO. Transplantation and cryopreservation of ovarian tissue. In: Trounson RO, Gardner D, editors. Handbook of in vitro fertilization. 2nd ed. Boca Raton: CRC Press, 1997. In press. Eppig JJ, O'Brien MJ. Development in vitro of mouse oocytes from primordial follicles. Biol Reprod 1996; 54: 197-207. deVita Jr VT, Hellman S, Rosenberg SA. Cancer: principles and practice of oncology. 4th ed. Philadelphia: Lippincott 1993: 2394-2405. Byrne J, Mulvihill JJ, Myers MH, et al. Effects of treatment on fertility in long term survivors of childhood or adolescent cancer. N Engl J Med 1987; 317: 1315-1321. (Received 8 May, accepted 14 Nov, 1996) Authors' details Monash IVF, Epworth Hospital, Melbourne, VIC. Carl E Wood, FRCS, FRACOG, Director; and Emeritus Professor, Monash University, Melbourne, VIC. Institute for Reproduction and Development, Monash University, Melbourne, VIC. Jillian M Shaw, PhD, Research Fellow. Alan O Trounson, PhD, Deputy Director. Reprints: Professor E C Wood, 284 High Street, Ashburton, VIC 3147. - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Carl E Wood · Jillian M Shaw · Alan O Trounson