Prevention of irreversible chemotherapy-induced ovarian damage in young women with lymphoma by a gonadotrophin-releasing hormone agonist in parallel to chemotherapy

[Fertility preservation for young patients with autoimmune diseases and the need for cytotoxic treatment. Clinical experiences from interdisciplinary consultation]

In cases of severe exacerbation of autoimmune diseases (AID) cytotoxic therapy, in particular with cyclophosphamide (CYC) is needed. As the peak occurrence of such AIDs occurs in young women during the childbearing years, preservation of fertility and the hormonal function of the ovaries are an interdisciplinary challenge.For ovarian protection several options exist. Gonadotropin-releasing hormone analogues in parallel with CYC treatment seem to reduce the cytotoxic effect on the ovaries. Fertilized and unfertilized oocytes can be conserved by cryoconservation after ovarian stimulation. A relatively new strategy uses cryopreservation and autotransplantation of human ovarian tissue prior to cytotoxic therapy. As all these methods are accompanied with side-effects and possible delays in the necessary CYC treatment, a close collaboration of gynecologists and internists is needed. The decision for the optimal preservation therapy should always be based on the individual patient.

Survival and reproductive outcomes in women treated for malignant ovarian germ cell tumors

OBJECTIVE

The objective of this study is to review all malignant germ-cell tumors (MOGCTs) treated at our institution, focusing on reproductive outcomes and menstrual function of patients treated with fertility-sparing surgery and adjuvant chemotherapy.

METHODS

We performed a retrospective chart review of patients treated for MOGCTs between January 1, 1979 and March 31, 2008. Charts of identified patients were abstracted and data were collected. Patients who had fertility-sparing surgery were contacted and a telephone questionnaire was performed to gather reproductive and menstrual history.

RESULTS

Forty patients were treated for MOGCTs at our institution. Mean age at the time of diagnosis was 26.5years (range, 10-48years). Histologic subtypes were: immature teratoma (52.5%), dysgerminoma (27.5%), yolk sac tumor (10.0%), mixed germ cell tumor (7.5%), and choriocarcinoma (2.5%). Thirty-five percent of tumors were FIGO stages II-IV. Twenty-seven patients (67.5%) were treated with chemotherapy postoperatively, 23 (85%) of whom received bleomycin, etoposide and cisplatin (BEP). There were three recurrences, but no deaths. Fertility-sparing surgery was performed in 22 patients (55%), 16 of whom received adjuvant chemotherapy. Fourteen of these patients were contacted. Of the 10 remaining patients desiring pregnancy, 8 (80%) had 11 successful spontaneous pregnancies, one required in-vitro fertilization, and the other required donor egg in-vitro fertilization, resulting in 14 live births. All 14 patients had normal menstrual cycles within one year of completing chemotherapy.

CONCLUSIONS

Overall survival was 100% among patients with both local and advanced MOGCTs, including those who underwent fertility-sparing surgery. Fertility-sparing surgery plus adjuvant chemotherapy appeared to have little or no effect on fertility or menstrual cycles.

[Is there any medical treatment to preserve fertility during chemotherapy in women?]

Intensive use of radio-chemotherapy has greatly improved the prognosis associated with cancer in young girl or women patients. However, improvement of the vital prognosis is frequently associated with impairment of fertility and premature ovarian failure. In vitro fertilization (IVF) followed by embryo cryopreservation is an available method, which needs a partner and a pretreatment stimulation. Ovarian and oocyte cryopreservation are techniques showing great promise. However, the nec plus ultra would be to be able to protect ovaries during chemotherapy. Since more than 10 years Gonadotropin releasing hormone (GnRH) analogues have been investigated as possible means to preserve fertility in young women. However, even recent prospective, randomized studies do not demonstrate clearly their effectiveness. To prevent primordial follicle apoptosis, an inhibitor of tysosine kinase, imatinib, has recently been proposed and positively evaluated in mice. It could represent an interesting hope to preserve female fertility during chemotherapy.

Pharmacological interventions for fertility preservation during chemotherapy: a systematic review and meta-analysis

The rate of chemotherapy-induced ovarian failure (CIOF) has been reported as 14-100% and is age- and agent-dependent. The role of GnRH analogs (GnRHa) and oral contraceptives (OC) in the prevention of CIOF is questionable. We performed a systematic review and a meta-analysis of studies assessing the efficacy of hormonal interventions in reducing CIOF in cancer or systemic lupus erythematosus (SLE) patients treated with chemotherapy. MEDLINE, EMBASE, and conference proceedings were searched until October 2009. From 504 potentially relevant references, 21 comparative studies were included for review and analysis. Data were collected to determine the risk ratio (RR) for amenorrhea, FSH levels, pregnancy rate, and biomarkers for ovarian reserve. Sixteen studies (SLE: 4 studies, 85 patients; malignancy: 12 studies, 596 patients) which assessed GnRHa for fertility preservation prior to chemotherapy were included in the meta-analysis. Five studies which evaluated the use of OC were systematically reviewed. Meta-analysis revealed that GnRHa are effective in reducing amenorrhea rates in all patients (RR 0.26, 95% CI 0.14-0.49). Pregnancy rate was higher in the GnRHa arm. The advantage of GnRHa was shown only in observational studies, but not in randomized controlled trials. Biomarkers for ovarian reserve were similar in both arms. Studies evaluating the efficacy of oral contraceptives in preserving ovarian function showed inconclusive results. GnRHa appears to improve menstruation resumption. Nevertheless, randomized prospective trials are less conclusive for their real value in conserving ovarian reserve and pregnancy. Large-scale prospective randomized trials are warranted to evaluate the role of GnRHa in preventing CIOF.

Assessment of fertility protection and ovarian reserve with GnRH antagonist in rats undergoing chemotherapy with cyclophosphamide

BACKGROUND

Reproductive function following chemotherapy is of increasing importance given that survival rates are improving. We assessed whether a gonadotropin-releasing hormone antagonist (GnRHant; cetrorelix) could promote ovarian protection against damage due to chemotherapy.

METHODS

Forty-two female Wistar rats were used in this study. Animals were divided into four groups: group I (n=9) received placebo twice; group II (n=12) received placebo+cyclophosphamide (CPA); group III (n=12) received GnRHant+CPA; and group IV (n=9) received GnRHant+placebo. After medication, the estrous cycle was studied through vaginal smears. Rats were mated, pregnancy was documented and the number of live pups evaluated. Afterwards, rat ovaries were removed and prepared for histological studies. The ovarian cross-sectional area was measured and follicles were counted.

RESULTS

Cyclic changes in vaginal smears were observed in all but one animal after treatment, but group II had a significantly lower rate of animals with proestrus or estrus (p<0.01). The offspring was markedly reduced by CPA treatment (group II, 3.00+/-1.33 pups vs. group I, 11.44+/-0.78 pups, p<0.01) and this effect was partly reversed by pre-treatment with GnRHant (group III, 7.00+/-1.31 pups). The ovarian cross-sectional area was not significantly different between groups, neither was the number of individual follicle types. However, rats in Group IV had a higher total number of ovarian follicles than those in the control group (17.1+/-1.22 vs. 10.9+/-0.70, p<0.05).

CONCLUSION

The use of a GnRHant before CPA chemotherapy provided protection of fertility.

[Fertility preservation before puberty: from mice to men]

Malignant tumors account for 1% of childhood cancers. The incidence is to the order of 122 cases per million children. The five-year survival after cancer before the age of 16years has improved from 50 to 80% in 40years. Assessment of potential for preservation of fertility should thus be a systematic element of care for children treated for a malignant tumor (high-dose chemotherapy with alkylizing agents, radiation therapy including the gonads) or those receiving hematopoietic stem cell grafts for malignant or benign disease (sickle-cell anemia, immune deficit). Among the techniques proposed, cryopreservation of ovarian tissue appears to be the most promising, or perhaps the only one available before puberty with encouraging result. Nevertheless the uncertainties, or even risks, related to these treatments, should not be neglected.

Protective effect of a gonadotropin-releasing hormone analogue on chemotherapeutic agent-induced ovarian gonadotoxicity: a mouse model

OBJECTIVE

To demonstrate the protective effect of triptorelin, a GnRH analogue, on chemotherapy-induced ovarian gonadotoxicity.

STUDY DESIGN

Twenty-four sexually mature, virgin, female FVB/NJNarl mice were divided into four groups: busulfan (B); low-dose triptorelin plus busulfan (T(L)+B); high-dose triptorelin plus busulfan (T(H)+B); and control. Mice in the T(L)+B and T(H)+B groups were injected with 3.8 and 38 mg/kg of triptorelin subcutaneously, respectively. Four weeks later, mice in the B, T(L)+B, and T(H)+B groups were injected with busulfan intraperitoneally at a dose of 36 mg/kg. Histologic examinations were performed 4 weeks later.

RESULTS

Obvious destruction of ovarian structure and significant depletion of primordial, primary, and secondary follicles were demonstrated in the B group compared with the control group, affirming the gonadotoxicity of busulfan. In the T(L)+B group, a greater number of larger primordial and primary follicles were enumerated compared with the B group; however, statistical significance was not achieved. In the T(H)+B group, the number of primordial and primary follicles was significantly greater than in the B group, and the ovarian tissue in the T(H)+B group was spared, demonstrating the effect of triptorelin pre-treatment on ovarian protection.

CONCLUSION

Our results have demonstrated a dose-dependent protective effect against gonadotoxic chemotherapy of a GnRH analogue on ovarian reserve, thus suggesting a novel application of GnRH analogues in fertility preservation.

GnRH agonist therapy to protect ovarian function in young Korean breast cancer patients

The increased survival of patients with breast cancer has given rise to other problems associated with the complications of chemotherapy. One major complication is premature ovarian failure, an especially harmful outcome for women of reproductive age. This study was performed to evaluate the efficacy of GnRH agonist (GnRHa) treatment on protecting ovarian function in young breast cancer patients (30.59+/-5.1 yr) receiving chemotherapy after surgery. Twenty-two women were enrolled and given subcutaneous injections of leuprolide acetate (3.75 mg) every 4 weeks during chemotherapy. Follow-up laboratory tests (luteinizing hormone [LH], follicle stimulating hormone [FSH], and estradiol) were performed 1, 3, and 6 months after chemotherapy. Menstruation patterns and clinical symptoms were followed up for a mean duration of 35.6+/-1.7 months. FSH and LH levels were normal in all patients 6 months after completing chemotherapy (8.0+/-5.3, 4.4+/-2.7 mIU/mL, respectively). During follow-up, none of the patients complained of menopausal symptoms and 81.8% experienced recovery of menstruation. This report is the first trial of GnRHa as a treatment modality to protect ovarian function during adjuvant chemotherapy in young Korean breast cancer patients.

Women's health, breast health: a review of the gynecologic effects of breast cancer

Breast cancer is very common and seen in both premenopausal and postmenopausal women. Research into prevention, better screening, and more effective treatments is occurring continually, and changes are translated into clinical practice relatively quickly. It is important for women's health care providers to have an understanding of breast cancer treatments and the gynecologic side effects. For premenopausal women interested in fertility, options should be discussed prior to chemotherapy. Issues pertaining to pregnancy after breast cancer should be discussed in a multidisciplinary fashion, involving the obstetrician/gynecologist, breast surgeon, and oncologist. Ovarian suppression is often used as part of breast cancer treatment in premenopausal women with hormone positive disease, and menopausal symptoms may be severe. Hormonal therapies including tamoxifen and the aromatase inhibitors are used in the treatment of hormone positive breast cancers. Each of these drugs has a variety of gynecologic implications. Understanding the options for treatment for menopausal complaints in breast cancer patients is important for women's health providers. Although most breast cancers are sporadic, a small percentage will be due to mutations in the BRCA genes. It is important for women's health providers to take an appropriate family history and refer to genetic counselors for possible testing when hereditary cancer is suspected. This review focuses on the various women's health issues pertaining to breast cancer and treatment.

Clinical aspects of fertility preservation in female patients

There are several methods of fertility preservation available for female patients facing infertility following gonadotoxic treatment of cancer or systemic disease. Embryos, oocytes or ovarian tissue can be cryopreserved and stored until the time when the patient is cured of her main disease and is expecting parenthood. The individual's choice depends on the nature and stage of the main disease, expected treatment, their condition, and age and existence of the partner. It is important to inform all such women about the options, and together with them, choose the most appropriate ones. It is often possible to save ovarian tissue even though the first chemotherapy courses have been undergone, but many more follicles can be stored before cancer treatment.

Fertility preservation medicine: a new field in the care of young cancer survivors

Treatment modalities for numerous oncological and non-oncological conditions result in gonadal insufficiency and infertility. Furthermore, pelvic-abdominal radiation may result in uterine damage resulting in poor reproductive outcomes such as preterm birth, low birth weight, and spontaneous abortion in adult survivors of childhood cancers. In response to the recognition of the impact of cancer treatments on fertility, several fertility preservation techniques have been developed. In prepubertal children, fertility preservation options are usually limited to ovarian cryopreservation because of sexual immaturity, but oocyte freezing can be performed in adolescent children. Two prospective randomized studies showed no benefit of gonadal suppression with GnRH analogs to preserve gonadal function and thus this treatment should not be recommended. For adult survivors of childhood cancer who experienced reproductive failure, third party reproduction techniques are highly successful.

Chemotherapy-induced female infertility and protective action of gonadotropin-releasing hormone analogues

This review aimed to critically discuss the current protocols using gonadotropin-releasing hormone analogue (GnRHa) for the management of chemotherapy-induced premature ovarian failure. In in-vitro experiments, GnRHa retards doxorubicin-induced granulosa cell damage, suggesting an additional GnRH's activity to protect the gonads during chemotherapy through GnRH receptor-mediated mechanism(s). GnRHa acts to protect the gonads during radiation and/or chemotherapy by preferentially steering cells into cell cycle arrest with a decline in response to the chemotherapeutic agents. The ovarian protection by GnRHa co-treatment against chemotherapy can enable the preservation of future fertility in survivors and prevent the bone demineralisation and osteoporosis associated with hypooestrogenism and ovarian failure.

Fertility preservation in female cancer survivors

The advancement of cancer therapies over the last few decades has significantly improved long-term survival of cancer patients, especially children and adolescents. As many of the therapeutic agents used are highly cytotoxic, cancer survivors have to pay the price of enduring various immediate and long-term side-effects. Unfortunately, gonadal failure and infertility are among the most common long-term side-effects, resulting in distress, lowered self-esteem and quality of life. Three modalities of fertility preservation can be offered to female patients prior to commencing their cancer treatment: embryo, oocyte and ovarian tissue cryopreservation. This paper reviews the outcomes for female patients who underwent fertility preservation in University College Hospital between 1995 and 2005, and post-therapeutic use of their frozen specimens. In addition, the effects of cytotoxic agents on fertility and ovarian function, and the range of fertility preservation available for female cancer sufferers are also discussed.

A critical evaluation of ovarian tissue cryopreservation and grafting as a strategy for preserving the human female germline

Ovarian tissue freezing has been used successfully in animals and it has recently begun to be offered clinically to young women who have medical conditions with a high risk of sterility. Although no frozen human ovarian grafts have yet been returned to the donor and resulted in a pregnancy, there are many indications that this procedure should be feasible. Although live young have been derived from frozen grafts in several species, research should aim to make further improvements to the cryopreservation and grafting procedures to optimize follicle survival, and hence minimize the amount of tissue that needs to be collected, stored and returned. Ovarian tissue freezing, particular if used in combination with egg and embryo freezing, should allow a patient to safeguard their chance of becoming a parent later (Table 1). In cases where the patient has a systemic cancer or infection and malignant cells or viruses may be present in the systemic circulation and the gonadal tissue, ovarian tissue could be collected and frozen, but grafting is not currently recommended (Table 3).

Cyclophosphamide therapy in pediatric multiple sclerosis

OBJECTIVE

To review our multicenter experience with cyclophosphamide in the treatment of children with multiple sclerosis (MS).

METHODS

Retrospective chart review of children with MS treated with cyclophosphamide. Demographic, clinical, treatment, and MRI parameters were collected.

RESULTS

We identified 17 children with MS treated with cyclophosphamide. All but one had worsening of Expanded Disability Status Scale scores or multiple relapses prior to treatment initiation. Children were treated with one of three regimens: 1) induction therapy alone; 2) induction therapy with pulse maintenance therapy; or 3) pulse maintenance therapy alone. Treatment resulted in a reduction in relapse rate and stabilization of disability scores assessed 1 year after treatment initiation in the majority of patients. Longer follow-up was available for most cases. Cyclophosphamide was well tolerated in most patients. However, side effects included vomiting, transient alopecia, osteoporosis, and amenorrhea. One patient developed bladder carcinoma that was successfully treated.

CONCLUSIONS

Cyclophosphamide is an option for the treatment of children with aggressive multiple sclerosis refractory to first-line therapies. Recommendations regarding patient selection, treatment administration, and monitoring are discussed.

Classical Hodgkin's lymphoma in adults: guidelines of the Italian Society of Hematology, the Italian Society of Experimental Hematology, and the Italian Group for Bone Marrow Transplantation on initial work-up, management, and follow-up

The Italian Society of Hematology (SIE), the Italian Society of Experimental Haematology (SIES) and the Italian Group for Bone Marrow Transplantation (GITMO) commissioned a project to develop practice guidelines for the initial work-up, therapy and follow-up of classical Hodgkin's lymphoma. Key questions to the clinical evaluation and treatment of this disease were formulated by an Advisory Committee, discussed and approved by an Expert Panel (EP) composed of senior hematologists and one radiotherapist. After a comprehensive and systematic literature review, the EP recommendations were graded according to their supporting evidence. An explicit approach to consensus methodologies was used for evidence interpretation and for producing recommendations in the absence of a strong evidence. The EP decided that the target domain of the guidelines should include only classical Hodgkin's lymphoma, as defined by the WHO classification, and exclude lymphocyte predominant histology. Distinct recommendations were produced for initial work-up, first-line therapy of early and advanced stage disease, monitoring procedures and salvage therapy, including hemopoietic stem cell transplant. Separate recommendations were formulated for elderly patients. Pre-treatment volumetric CT scan of the neck, thorax, abdomen, and pelvis is mandatory, while FDG-PET is recommended. As to the therapy of early stage disease, a combined modality approach is still recommended with ABVD followed by involved-field radiotherapy; the number of courses of ABVD will depend on the patient risk category (favorable or unfavorable). Full-term chemotherapy with ABVD is recommended in advanced stage disease; adjuvant radiotherapy in patients without initial bulk who achieved a complete remission is not recommended. In the elderly, chemotherapy regimens more intensive than ABVD are not recommended. Early evaluation of response with FDG-PET scan is suggested. Relapsed or refractory patients should receive high-dose chemotherapy and autologous hemopoietic stem cells transplant. Allogeneic transplant is recommended in patients relapsing after autologous transplant. All fertile patients should be informed of the possible effects of therapy on gonadal function and fertility preservation measures should be taken before the initiation of therapy.

Hormonal strategies for fertility preservation in patients receiving cyclophosphamide to treat glomerulonephritis: a nonrandomized trial and review of the literature

BACKGROUND

Prepubertal patients receiving chemotherapy are relatively resistant to cyclophosphamide-induced germinal cell alterations. We studied the possible protective effect of testosterone and triptorelin to inhibit gonadal activity in men and women receiving cyclophosphamide, respectively.

STUDY DESIGN

Nonrandomized trial.

SETTING & PARTICIPANTS

28 consecutive patients, 11 men and 17 women, from a university medical center with various forms of glomerulonephritis, treated with cyclophosphamide.

INTERVENTION

Men received cyclophosphamide plus testosterone; women were divided into 2 groups: 13 patients (group A) received cyclophosphamide plus triptorelin; 4 (group B) received only cyclophosphamide.

OUTCOMES & MEASUREMENTS

Serum follicle-stimulating hormone (FSH) and serum luteinizing hormone levels and, in addition, sperm counts and testosterone levels in men and estradiol levels in women were measured before and after treatment with cyclophosphamide.

RESULTS

All 10 men became azoospermic or severely oligospermic during treatment; after 12 months, all except 1 had a normal sperm count and FSH levels were normal. In women during cyclophosphamide therapy, amenorrhea occurred in all patients. After cessation of therapy, all women in group A started to menstruate regularly, and at the end of follow-up, ovulatory cycles were demonstrated in all women. Hormone levels showed no significant changes throughout the observation period. Six women conceived, and the pregnancies were brought to term successfully without complications. In group B, all 4 women developed sustained amenorrhea; serum FSH and luteinizing hormone levels at the end of therapy and follow-up were significantly higher with respect to baseline; estradiol levels at the end of follow-up were significantly lower compared with baseline and corresponding values in group A.

LIMITATIONS

The substudy in men is uncontrolled, the substudy in women is nonrandomized.

CONCLUSIONS

The study suggests a protective effect of testosterone and triptorelin against cyclophosphamide-induced gonadal damage in men and women with various forms of kidney disease, respectively.

Addressing fertility needs of breast cancer patients: oncology perspective

Premenopausal women represent approximately 23% of women diagnosed with breast cancer. As the medial age of first pregnancy increases in developed countries, a greater proportion of women are diagnosed with breast cancer at a time when they have not yet completed their family. For these women, the impact of breast cancer treatment on their reproductive capacity can be of significant concern and may influence their treatment decisions. Despite these concerns only a proportion of premenopausal women with breast cancer are informed about their treatment choices in light of their reproductive needs. The diagnosis of cancer itself as well as systemic cancer treatments, including chemotherapy and hormonal therapy, can delay and/or reduce the reproductive capacity. Treatment decisions need to consider not only adjuvant treatment efficacy but also its risks, including impact on fertility. The risk of chemotherapy-associated amenorrhea varies according to the regime and is age-dependent. Hormonal treatments may delay reproduction further. A variety of fertility preservation strategies have been tried including gonadal protection during chemotherapy, ovarian cryopreservation and in vitro fertilization, but their potential benefits need to be considered in light of risks and, for most of them, the evidence for efficacy is limited. Special fertility considerations are required in women with family history and/or evidence of genetic predisposition to breast cancer as strategies for risk reduction may impact on their fertility choices. Finally, as survival of women with metastatic breast cancer increases, women with advanced cancer who become pregnant pose unique management challenges for oncologists and obstetricians alike.

Preservation of menstrual function in adolescent and young females

Every year thousands of young teenagers are afflicted with different types of cancer and receive gonadotoxic chemotherapy and radiotherapy regimens, causing depletion of germ cells in the gonads and premature gonadal failure. In this review, we discuss and outline the current strategies and the future directions of fertility preservation and ovarian cryopreservation and transplantation in adolescents and young females.

Effects of cancer treatment on ovarian function

Causes of primary ovarian failure are reviewed, focusing specifically on cancer treatment-related modalities. Strategies and future directions for protection of the ovaries during cancer therapy, including ovarian transposition, and conformal radiation techniques are presented.

Fertility preservation in patients with non-oncological conditions

In addition to cancers, many non-oncological conditions, including chromosomal abnormalities and autoimmune disorders, are currently treated with gonadotoxic agents that can lead to premature ovarian failure. Because of the young age of some of the women affected by these conditions, attempts to preserve fertility and ovarian function are recommended. To date, retrieval of immature oocytes followed by in-vitro maturation and vitrification has been found to be especially useful for women who cannot undergo ovarian stimulation, or when there is a contraindication.

Gonadotropin-releasing hormone agonists for prevention of chemotherapy-induced ovarian damage: prospective randomized study

OBJECTIVE

To determine whether GnRHa administration before and during combination chemotherapy for breast cancer could preserve posttreatment ovarian function in young women or not.

DESIGN

Prospective randomized controlled study.

SETTING

Department of Obstetrics and Gynecology, Mansura University Hospital, Mansura, Egypt.

PATIENT(S)

Eighty patients with unilateral adenocarcinoma of the breast and with no metastasis who had undergone modified radical mastectomy or breast-conserving surgery plus full axillary lymph node dissection were included in the study. Patients were assigned randomly to receive combined GnRHa and chemotherapy or chemotherapy alone. One woman in each group dropped out.

MAIN OUTCOME MEASURE(S)

Return of spontaneous menstruation and ovulation. Hormonal changes (FSH, LH, E(2), P) during and after the course of treatment.

RESULT(S)

In the study group, 89.6% resumed menses and 69.2% resumed spontaneous ovulation within 3-8 months of termination of the GnRHa/chemotherapy cotreatment; 11.4% experienced hypergonadotrophic amenorrhoea and ovarian failure 8 months after treatment. In the control group (chemotherapy without GnRHa), 33.3% resumed menses and 25.6% resumed normal ovarian activity. The median FSH and LH concentrations, 6 months after completion of the GnRHa/chemotherapy cotreatment group, were significantly less than the control group. During the GnRHa/chemotherapy cotreatment the concentrations of FSH, LH, and P decreased to almost prepubertal levels. However, within 1-3 months after the last GnRHa injection, an increase in LH and FSH concentrations was detected, followed several weeks later in by an increase in P concentrations to within normal levels.

CONCLUSION(S)

GnRHa administration before and during combination chemotherapy for breast cancer may preserve posttreatment ovarian function in women <40 years. Long-term studies are required.

GnRH agonist acts as ovarian protection in chemotherapy induced gonadotoxicity: an experiment using a rat model

To reduce chemotherapy induced gonadotoxicity, co-treatment with gonadotropin releasing hormone against analogue (GnRHa) was tested using rat model. Leuprorelin acetate (Leuplin) with or without cisplatin (CDDP) was given subcutaneously at a dose of 9.4 microg/ml to Wistar strain female rats. The total number of follicles was counted and the maturation of follicles was evaluated at the largest section of the ovary on the 5th and 10th day after administration. Leuplin led the ovary to a resting phase in which primordial follicle occupied 80% of all follicles in only 5 days after administration. The serum E2 level was also down by the 5th day and maintained a low level to the 10th day. In co-treatment with GnRHa and CDDP rats, the primordial follicle occupied 90% of all follicles and the total number of follicles was higher than in CDDP alone rats. This rat model verified that GnRHa co-treatment well minimized CDDP induced gonadotoxocity by desensitization of the ovary. These results were promising for the clinical application introducing GnRHa co-treatment as ovarian protection in cancer chemotherapy in young women.

A case of metastatic struma ovarii treated with 131I therapy: focus on preservation of fertility and selected review of the literature

Struma ovarii is a rare monodermal ovarian teratoma composed predominantly of mature thyroid tissue. We describe herein the case of a 22-year-old woman who underwent a right salpingo-oophorectomy for struma ovarii at the age of 12 years, who was admitted 8 years later with signs and symptoms of a left pelvic tumor. Laparoscopy detected a left ovarian endometriotic cyst and multiple nodules on the pelvic peritoneum, right lateral abdominal wall, diaphragm, vesical plica and liver. The diagnosis was abdominal and pelvic widespread dissemination of recurrent struma ovarii, with features consistent with the follicular variant of papillary thyroid carcinoma. The patient was treated with a combination of conservative surgery and two 131I administrations (cumulative activity of 350 mCi after dosimetric evaluation). Because of the high degree of hormonogenesis shown by the metastases, the first administration was performed following use of recombinant human (rh) thyroid-stimulating hormone (TSH) to reach adequate TSH levels. To avoid the 'stunning effect' and to obtain high-quality scintigraphy, a whole-body scan was performed with 123I after rh-TSH and before the 131I therapy. We also discuss the potential role and the possible benefit of using gonadotropin-releasing hormone analogs and ovarian tissue cryopreservation to preserve fertility in women treated with 131I for pelvic metastases from malignant struma ovarii.

Therapy Insight: preserving fertility in cyclophosphamide-treated patients with rheumatic disease

Cyclophosphamide remains a necessary treatment for severe rheumatic diseases, despite the continued search for alternative therapies with less gonadal toxicity. The risk of premature gonadal failure and sterility might lead young patients to delay treatment with cyclophosphamide. The patient's age at treatment and the cumulative dose received remain important risk factors for cyclophosphamide-induced gonadal failure in both males and females. Estrogen-containing oral contraceptives for females and testosterone for males are suggested to reduce the gonadal toxicity of cyclophosphamide, although few studies support these interventions. Owing to increased side effects, hormonal therapy is often avoided in patients with edema, hypertension, nephrotic syndrome or antiphospholipid antibodies. Agonists and antagonists of gonadotropin receptors are under study. Gonadotropin-receptor agonists might have beneficial effects in addition to suppression of sex-hormone production. The outcome of attempted cryopreservation of eggs, embryos or ovaries remains uncertain for women seeking to preserve their reproductive potential. Storing male gametes before chemotherapy is widely practiced and technically successful. As recovery of menses or production of testosterone does not predict individual fertility, identification of biomarkers of gonadal function and reserve, including serum levels of several hormones, ultrasonographic measurements of ovarian volume and antral follicle count, are necessary.

Gonadal dysfunction and fertility problems in cancer survivors

Gonadal dysfunction and fertility problems are adverse effects of cancer treatment or may be associated with specific malignancies. This review focuses on these problems in the young cancer survivors, where methods of protecting or restoring endocrine function and fertility need to be considered. In females, treatment adverse effects can result in infertility, but premature ovarian failure (POF) is probably relevant for more female cancer survivors, affecting also those who do not wish post-treatment parenthood. POF affects present and future health, especially through oestrogen deficiency symptoms and an increased risk of developing osteoporosis. A lower risk of developing POF has been considered in young females than in older due to a larger pool of oocytes. However, a recent long-term follow-up study reported a prevalence of POF in young females with Hodgkin's lymphoma of 37% showing that young age at time of treatment only delays the development of POF. In male gonads, germ cells are much more sensitive to irradiation and chemotherapy than Leydig cells. Thus, infertility is a more common adverse effect than hypogonadism. Some malignancies are particular relevant. Persistent azoospermia was formerly common after treatment for Hodgkin's lymphoma, but currently, most patients recover spermatogenesis. Modern treatment of childhood acute lymphoblastic leukemia is also unlikely to cause infertility. Norwegian testicular cancer survivors diagnosed in 1980-1994 who attempted conception had an overall 15-year actuarial post-treatment paternity rate of 71% (range 48-92% depending on the treatment). However, the rate was significantly higher among men diagnosed in1989-1994 (over 80%) than in 1980-1988 (about 63%). Patients at risk for hypogonadism and infertility should be defined prior to treatment, and available methods for gonadal preservation should maximally be utilised. During follow-up, oncologists should routinely address these issues.

Preservation of female fertility during cancer treatment

Improvements in the success of cancer treatments have resulted in increased awareness of the long-term effects of treatment, of which gonadal failure is the most significant. Thus, preservation of fertility potential has become a major goal and could be realized by preventing ovarian toxicity or by cryopreservation of reproductive cells/tissues. This review aimed to critically discuss the current protocols for the management of chemotherapy-inducced/radiotherapy-induced premature ovarian failure (POF). A medical approach using the gonadotropin-releasing hormone analog (GnRHa) may act to protect the gonads during radiation and/or chemotherapy by preferentially steering cells into cell cycle arrest with a decline in responsibility to the chemotherapeutic agents. Ovarian protection by GnRHa cotreatment against chemotherapy can enable the preservation of future fertility in survivors and prevent the bone demineralization and osteoporosis associated with hypestrogenism and POF. In vitro fertilization of retrieved oocytes could enable embryo freezing in some patients. Embryo cryopreservation is considered standard practice and widely available, but may seldom be used because of a lack of a male partner, the need to postpone cancer therapy for a few weeks and the possibility that an estrogen rise may be undesirable in sensitive cancer patients. Improvement in oocyte cryopreservation may offer additional possibilities; the prolonged culture of primordial and primary follicles in vitro is still unfeasible. Currently, the cryopreservation of ovarian cortex, which hosts thousands of immature follicles, is an investigational method, but has the advantage of requiring neither a sperm donor nor ovarian stimulation. Fertility preservation is often possible in women undergoing cancer treatment. To preserve the full range of options, fertility preservation procedures should be considered as early as possible during therapy planning. (Reprod Med Biol 2008; 7: 17-27).

Gonadotropin-releasing hormone agonist decreases chemotherapy-induced gonadotoxicity and premature ovarian failure in young female patients with Hodgkin lymphoma

OBJECTIVE

To minimize the gonadotoxic effect of chemotherapy by the cotreatment with a GnRH agonistic analogue (GnRH-a).

DESIGN

Prospective nonrandomized study with concurrent and historical controls.

SETTING

University medical center.

PATIENT(S)

One hundred fifteen female patients with Hodgkin lymphoma (HL).

INTERVENTION(S)

Sixty-five patients received a monthly injection of GnRH-a, administered before starting chemotherapy until its conclusion, up to a maximum of 6 months. Thirty-five patients were treated with ABVD and 76 with a procarbazine-containing regimen. This group was compared with a control group of 46 women who were treated concurrently with similar chemotherapy (n = 26) without GnRH-a or were historical controls (n = 20).

MAIN OUTCOME MEASURE(S)

Cyclic ovarian function (COF) versus premature ovarian failure (POF).

RESULT(S)

The ovarian function could be determined in 111 patients. In the GnRH-a/chemotherapy group, 63 out of 65 patients resumed ovulation and regular menses (96.9 %), compared with 63% of the 46 control subjects. Twenty of the 22 patients in the BEACOPP/escalated BEACOPP/GnRH-a cotreatment resumed cyclic ovarian function versus 9 of the 14 in the chemotherapy-only group. All 17 MOPP/ABV/GnRH-a cotreated patients resumed COF versus 11 of the 22 in the chemotherapy-only group. There was no significant effect of the GnRH-a cotreatment regarding COF in the ABVD group. There were no significant differences in the cumulative doses of the various alkylating agents between the two groups.

CONCLUSION(S)

Cotreatment with GnRH-a may reduce ovarian damage significantly in female patients treated for HL and should be considered in addition to assisted reproduction for women in reproductive age receiving gonadotoxic chemotherapy.

How to preserve fertility in young women exposed to chemotherapy? The role of GnRH agonist cotreatment in addition to cryopreservation of embrya, oocytes, or ovaries

The possibilities to preserve fertility in women exposed to chemotherapy are: in vitro fertilization plus embryo cryopreservation, ovarian cryopreservation, unfertilized ova cryopreservation, and the administration of a gonadotropin-releasing hormone (GnRH) agonist. Because none of these methods is ideal, combination of several methods should be considered. Because the chances of preserving gonadal function following combined-modality treatment are significantly better for girls than for boys, simulation of a prepubertal milieu was applied only to women of reproductive age. The administration of GnRH agonists to women with Hodgkin's disease, breast cancer, and other malignancies, or to patients with lupus nephropathy, in parallel with chemotherapy, by others and by us, has demonstrated a significantly lower rate of premature ovarian failure in survivors than in nonrandomized controls. Several prospective, randomized studies are ongoing. A recent meta-analysis found that the administration of a GnRH agonist, in addition to chemotherapy, to patients with breast cancer was associated with less recurrence and superior survival. Several possibilities to explain the beneficial effect of GnRH agonists to minimize chemotherapy-associated gonadotoxicity are suggested: (a) The hypogonadotropic milieu decreases the number of primordial follicles entering the differentiation stage, which is more vulnerable to chemotherapy; (b) The hypoestrogenic state decreases ovarian perfusion and delivery of chemotherapy to the ovaries; (c) A direct effect of the GnRH agonist on the ovary occurs independently of the gonadotropin level; (d) GnRH agonists may upregulate an intragonadal antiapoptotic molecule such as sphingosine-1-phosphate; (e) The GnRH agonist may protect ovarian germline stem cells.

Absence of conclusive evidence for the safety and efficacy of gonadotropin-releasing hormone analogue treatment in protecting against chemotherapy-induced gonadal injury

Every year, an increasing number of women with malignant and nonmalignant diseases is successfully treated with cytotoxic chemotherapy and/or radiotherapy. Many of these patients suffer from infertility and gonadal failure as a result of these treatments. At present, these patients may resort to assisted-reproduction techniques to protect their future childbearing potential before the implementation of cytotoxic therapy. While embryo cryopreservation is an established technology, oocyte and ovarian tissue freezing techniques are still investigational. Nevertheless both of these techniques have resulted in live births. Apart from assisted-reproduction techniques, it has been extensively debated whether administration of gonadotropin-releasing hormone (GnRH) analogues in conjunction with chemotherapy can protect ovarian reserve against cytotoxic insult. In this manuscript, we debate the rationale for the effectiveness of GnRH analogue coadministration in preservation of fertility by reviewing the literature, and provide preliminary data to support our views.

Ovarian function and childbearing issues in breast cancer survivors

The increasing number of breast cancer survivors makes the issues of ovarian dysfunction and childbearing ability more and more relevant for the quality of life of these patients. The incidence of ovarian dysfunction is related to patient age, the specific agents used and the total dose administered, especially the dose of alkylating agents such as cyclophosphamide. Amenorrhea rates following combination chemotherapy consisting of cyclophosphamide + methotrexate + 5-flurouracil (CMF regimen) range from 21 to 71% in women aged 40 years and younger, and from 40 to 100% in older ones. In most series anthracycline-based adjuvant chemotherapy regimens appear to have a lower incidence of amenorrhea, which is probably due to the lower cumulative cyclophosphamide dose administered compared with that given in the CMF regimen. Few data are currently available regarding ovarian function in women treated with taxane-based chemotherapy. In a recent retrospective study on 191 patients, the amenorrhea rate was 64% for women who received doxorubicin + cyclophosphamide (AC regimen) followed by a taxane, compared with 55% (p = 0.05) for those treated with AC alone. Forty percent of women aged 40 years or younger resumed menstruation, whereas the amenorrhea was more likely to be irreversible in older women; however, the addition of a taxane did not change the reversibility rate. Ovarian reserve can be tested with serum assays of follicle-stimulating hormone, inhibin B, estradiol and anti-Müllerian hormone, as well as by ultrasound assessment of antral follicle count. A review of literature data failed to show that a subsequent pregnancy increases the risk of recurrence and death in breast cancer survivors, and some series have even detected longer survival for patients who get pregnant after breast cancer treatment. This apparent survival benefit, probably due to a selection bias called the 'healthy mother effect', suggests that breast cancer survivors who subsequently conceive are a self-selecting group of women with better prognosis. The little available information appears to show no increase in the incidence of prematurity, stillbirth or congenital malformations in their babies. In conclusion, future pregnancy is a viable option for a woman treated for early-stage breast cancer and does not appear to be detrimental to either the mother or her offspring.

Fertility issues in survivors from adolescent cancers

Infertility is a common and distressing late-effect of cancer treatment. Whist sperm banking for post-pubertal males and embryo freezing for women (who are in a stable relationship at the time of treatment) are highly successful fertility preservation strategies, for females without a partner (including young and pre-pubescent girls) and pre-pubescent boys (or azoospermic men), there remain no effective approaches. Whilst the biological effects of cancer treatments on the reproductive system are well described, there are few data on the relative incidence of infertility (failure to conceive after one year of trying) in cancer survivors. This makes it difficult to advise survivors about their future fertility prospects. Whilst some will undoubtedly conceive naturally with their partner, others will require assisted conception treatment of which in vitro fertilisation (IVF) and intra-cytoplasmic sperm injection (ICSI) are the most common. Pregnancy outcomes of cancer survivors are generally good, although there is increased risk of pre-term birth and low birth-weight in the offspring of women who have received pelvic irradiation. There is no increased incidence of genetic disease or cancer incidence in the offspring of cancer survivors. Current research directions are focussing on alternative fertility preservation strategies including in vitro maturation techniques, xenotransplantation and the development of technology to create artificial gametes in the laboratory. Finally, although the reproductive techniques discussed are highly effective, country specific differences in the legal framework means that cancer survivors may be denied access to certain treatments (e.g. embryo cryopreservation) because they are forbidden by specific national legislation.

Ovarian recovery after stem cell transplantation

Autologous or allogeneic SCT with conventional conditioning (chemotherapy with or without irradiation) has emerged as an effective and potentially curative therapy in patients with hematologic malignancies and in other selected solid tumors; however, several patients experience significant early and delayed side effects, including long-term endocrine imbalance and infertility. In spite of several reproductive recovery and pregnancy reports published in the oncology literature, review of medical literature reveals a paucity of comparable information in the SCT field. We report here four cases of ovarian recovery in patients who received hormonal replacement therapy after diagnosis of primary ovarian failure due to high-dose chemotherapy and SCT.

Ovarian protection with goserelin during adjuvant chemotherapy for pre-menopausal women with early breast cancer (EBC)

PURPOSE

Ovarian failure and infertility following adjuvant chemotherapy for early breast cancer are major concerns for some young women. Techniques for oocyte harvesting are associated with delay in starting treatment, potentially undesirable estrogen stimulation and a relatively low success rate. We report an audit of our experience with the luteinising hormone-releasing hormone agonist, goserelin, to achieve transient ovarian suppression during chemotherapy as a means of preserving ovarian function.

PATIENT AND METHODS

Pre-menopausal women were offered goserelin 3.6 mg by subcutaneous injection every 28 days during chemotherapy, starting 0-14 days prior to treatment. The primary end-point was recovery of menstruation. Serum luteinising hormone, follicle stimulating hormone and oestradiol were measured at recovery of menstruation or at first year follow-up if amenorrhoea persisted. Subsequent pregnancies were recorded.

RESULTS

Fifty-one evaluable women were audited. Amenorrhoea occurred in all but one. All received combination anthracycline-containing chemotherapy regimens with a mean cumulative cyclophosphamide dose of 3.9 g/m(2). Forty-five (90%) recovered menstruation during the first year of follow-up; mean time to recovery 5 months. Eight pregnancies in 10 women attempting this so far.

CONCLUSION

Using goserelin concurrently with chemotherapy is associated with a high rate of ovarian function preservation.

Fertility preservation in gynecologic cancers

PURPOSE OF REVIEW

This review focuses on the current options for fertility preservation in young women facing the risk of premature ovarian failure and infertility as a sequel to the treatment of gynecologic cancer.

RECENT FINDINGS

There is a wide range of options to preserve fertility. Embryo freezing is the most established method and the success rate of in-vitro fertilization using frozen-thawed embryos now approaches that of using fresh embryos. Success rates with oocyte cryopreservation are on the rise and begin to approach that of embryo freezing. Exposure to high levels of estrogen during ovarian stimulation can be minimized by utilizing aromatase inhibitors in women with estrogen-sensitive cancers undergoing embryo or oocyte cryopreservation. Ovarian-tissue cryopreservation is used to preserve fertility in children and in patients with time restraints; however, the number of reported cases is very small. Likewise, in-vitro maturation and xenografting are experimental and their potential to preserve fertility remains to be determined.

SUMMARY

A number of fertility-preservation techniques have been developed and many others are in the experimental stages. Consistent with recent ASCO clinical guidelines, all young individuals with gynecologic cancer should be counseled about the available fertility preservation techniques.

[What are at present the real hopes of pregnancy after ovarian cryopreservation?]

Survival rates for cancers that occur in childhood and adolescence have improved over the last decades, and preservation of future fertility in these patients has become a relevant issue. Premature ovarian failure is a consequence of exposing women to chemotherapeutic drugs and ionizing radiation. Ovarian cryopreservation is an alternative to cryopreservation of embryos or oocytes for theses patients. Ovarian cryopreservation aims to reimplant ovarian tissue after complete remission into the pelvic cavity (orthotopique site) or a heterotopic site like the abdominal wall or the forearm. In vitro folliculogenesis, that aims at the maturation of ovarian cortex primordial follicles cryopreserved for a FIV, is still in an experimental research stage. In this review, the objective was to evaluate the real hopes of pregnancy after ovarian cryopreservation. Indeed, many teams offer ovarian cryopreservation at present time, although only two pregnancies have been achieved to date. In both cases, it can be discussed whether the fertilized oocyte originated from the transplant or from the native ovary. Furthermore, the potential for reintroduction of cancerous cells may limit this technique in cancers that are known to have a risk of ovarian dissemination. The hopes engendered by ovarian cryopreservation, but also its limits, must be explained to the patients before an ovarian surgery for cryopreservation.

Estrogen-progestin therapy in women after stem cell transplant: our experience and literature review

Women undergoing stem cell transplantation (SCT) are mostly young and have more than 90% probability of ovarian failure, which is often permanent. A woman's age, use of radiotherapy and alkylating chemotherapy, and the allogeneic type of transplant are associated with a higher rate of premature ovarian failure and worse residual ovarian function. Premature ovarian failure has serious systemic and psychological effects that may need treatment and should be managed by practitioners trained to treat this particular population of women. Ultrasonographic evidence of ovarian follicles is often associated with a future resumption of cycles, but there are no serum markers to predict the return of ovarian function in these patients. In our center, the rate of ovarian function recovery was 7% after allogeneic SCT and 25% after autologous SCT (P<0.05). There are no guidelines on how to manage premature ovarian failure induced by myeloablative treatments followed by SCT. Because of the likelihood of the need for long-lasting estrogen plus progestin therapy (EPT) and the increased risk of secondary neoplasia after SCT, the EPT should be as physiological as possible. In our experience, the cyclical sequential combination of estradiol (2 mg daily) plus dydrogesterone (10 mg for 14 d/mo) was associated with excellent compliance because of its simple administration and few adverse effects. Such a treatment led to a dramatic improvement in vasomotor, urogenital, and psychological symptoms related to estrogen deficiency. However, in the allogeneic transplantation setting, up to 25% of women may suffer from gynecological chronic graft-versus-host disease, which may become apparent as hematocolpometra after introduction of EPT. Thus, accurate pretreatment evaluation and frequent monitoring during treatment are required. Moreover, EPT absorption may be reduced in patients who received allotransplants and have gastrointestinal or skin chronic graft-versus-host disease.

Protection of ovarian function and fertility using a combination of gonadotropin-releasing hormone (GnRH) agonist and GnRH antagonist during cancer treatment in young females

Cytotoxic treatment can cause early loss of ovarian function associated with loss of fertility in younger women. To investigate if co-treatment with a combination of gonadotropin-releasing hormone (GnRH) agonist and GnRH antagonist may be useful in preserving ovarian function and fertility in younger women during chemotherapy, we prospectively observed nine young patients receiving different chemotherapies for various malignant diseases and other severe medical conditions who also received simultaneous GnRH agonist and GnRH antagonist. Mean age of the patients was 26.56 +/- 8.78 years, all were < or =35 years old. Eight (88.9%) patients regained normal basal hormonal profile within 3 - 6 months after the completion of chemotherapy. Median level of follicle-stimulating hormone, luteinizing hormone and estradiol was 6.3 +/- 8.8 U/l, 8.2 +/- 25.4 U/l and 118.0 +/- 130.8 pg/ml, respectively. Eight (88.9%) patients resumed spontaneous menses within 3 - 11 months following discontinuation of chemotherapy. Two (22.2%) patients conceived: one spontaneously, and the second following induction of ovulation by injection of gonadotropins. It seems that combined usage of GnRH agonist and GnRH antagonist during chemotherapy may be useful in preserving ovarian function and fertility in a group of young females receiving chemotherapy treatment.