Fertility preservation in ovarian cancer patients

Assessing risks and knowledge gaps on the impact of systemic therapies in early breast cancer on female fertility: A systematic review of the literature

The therapeutic landscape for early breast cancer (eBC) has expanded by introducing novel anticancer agents into clinical practice. During their reproductive years, women with eBC should be informed of the potential risk of premature ovarian insufficiency (POI) and infertility with the proposed systemic therapy. Although the topic of female fertility is becoming increasingly relevant in patients with cancer, limited information is available on the gonadotoxicity of new agents available for eBC treatment. Analyses from clinical trials and prospective data on ovarian function biomarkers are lacking. The purpose of this systematic review is to report the available preclinical and clinical data on female fertility risk with the use of the new agents that are part of clinical practice use or under development for eBC management. This review highlights the clear need to perform additional research efforts to improve our understanding on the gonoadtoxicity of new anticancer agents.

Oncofertility as an Essential Part of Comprehensive Cancer Treatment in Patients of Reproductive Age, Adolescents and Children

The number of children, adolescents and young adults diagnosed with cancer has been rising recently. Various oncological treatments have a detrimental effect on female fertility, and childbearing becomes a major issue during surveillance after recovery. This review discusses the impact of oncological treatments on the ovarian reserve with a thorough explanation of oncologic treatments' effects and modes of oncofertility procedures. The aim of this review is to help clinicians in making an informed decision about post-treatment fertility in their patients. Ultimately, it may lead to improved overall long-term outcomes among young populations suffering from cancer.

FIGO statement: Fertility preservation

Fertility preservation is a growing field in reproductive medicine that may raise ethical questions. Preservation of fertility must be discussed with the patient if gonadotoxic treatment is required, whether in the case of benign or malignant pathology, or in the management of transgender identity. As a result, surgery or chemotherapy that has fewer adverse impacts on fertility should be proposed if this does not alter the prognosis of the disease. If the risk of infertility persists, then fertility cryopreservation should be proposed for children and adults of reproductive age. Sperm, oocytes, and gonadal tissue can be cryopreserved for many years. FIGO wishes to emphasize the importance of fertility preservation in the medical and surgical management of patients, and the importance of a specialized, multidisciplinary approach.

The Usage of Cryopreserved Reproductive Material in Cancer Patients Undergoing Fertility Preservation Procedures

BACKGROUND

Many cancer treatment methods can affect fertility by damaging the reproductive organs and glands that control fertility. Changes can be temporary or permanent. In order to preserve the fertility of cancer patients and protect the genital organs against gonadotoxicity, methods of fertility preservation are increasingly used. Considering that some patients ultimately decide not to use cryopreserved reproductive material, this review analysed the percentage of post-cancer patients using cryopreserved reproductive material, collected before treatment as part of fertility preservation.

METHODS

A systematic search of studies was carried out in accordance with the Cochrane Collaboration guidelines, based on a previously prepared research protocol. The search was conducted in Medline (via PubMed), Embase (via OVID), and the Cochrane Library. In addition, a manual search was performed for recommendations/clinical practice guidelines regarding fertility preservation in cancer patients.

RESULTS

Twenty-six studies met the inclusion criteria. The studies included in the review discussed the results of cryopreservation of oocytes, embryos, ovarian tissue, and semen. In 10 studies, the usage rate of cryopreserved semen ranged from 2.6% to 21.5%. In the case of cryopreserved female reproductive material, the return/usage rate ranged from 3.1% to 8.7% for oocytes, approx. 9% to 22.4% for embryos, and 6.9% to 30.3% for ovarian tissue. In studies analysing patients' decisions about unused reproductive material, continuation of material storage was most often indicated. Recovering fertility or death of the patient were the main reasons for rejecting cryopreserved semen in the case of men.

CONCLUSION

Fertility preservation before gonadotoxic treatment is widely recommended and increasingly used in cancer patients. The usage rate is an important indicator for monitoring the efficacy of these methods. In all of the methods described in the literature, this indicator did not exceed 31%. It is necessary to create legal and organizational solutions regulating material collection and storage and to create clear paths for its usage in the future, including by other recipients.

Optimizing the Ovarian Tissue Cryopreservation in the 'Oncofertility' Institutional Program at an Italian National Cancer Institute

BACKGROUND

The majority of female cancer patients undergoing anticancer treatments are at risk of experiencing 'cancer treatment-related infertility', which can result in permanent damage to their reproductive prospects. Among the fertility preservation methods, ovarian tissue cryopreservation (OTC) has emerged as an alternative for these patients. The Cancer Institute of Bari initiated a research program to assess the feasibility of OTC. This study compares the viability of ovarian cortical fragments cryopreserved using slow freezing (SF) and ultra-rapid freezing (URF) methods.

METHODS

Ovarian cortex biopsies were obtained from 11 fertile women enrolled in our oncofertility service between June 2022 and January 2023. After tissue collection, a histological assessment was performed before cryopreservation. OTC was carried out using both SF and URF methods. Six months later, thawed samples were evaluated for follicle counts and histological integrity.

RESULTS

No statistically significant difference was observed in the proportion of intact follicles (means of 31.5% and 73.0% in the SF and URF groups, respectively; p = 0.064). However, there was a significant difference in the number of follicles between the SF group (n = 149) and the URF group (n = 37) (p = 0.046).

CONCLUSIONS

We assessed the viability of ovarian cortex after freezing and thawing, focusing on the structural integrity of follicles. Our findings suggest that there are no significant differences between the SF and URF methods.

Current limits of conservative treatment in ovarian cancer

PURPOSE OF REVIEW

Fertility-sparing surgery in ovarian cancer is an increasing need in gynecology-oncology clinical practice because of the frequent childbearing delay in developed countries. As the evidence in literature is based on observational studies, this review focuses on summarizing the most recent and relevant evidence for the conservative management of young patients with ovarian cancer.

RECENT FINDINGS

Staging surgery is mandatory in epithelial ovarian tumors. In sex cord-stromal tumors, fertility-sparing surgery is only recommended in FIGO stage IA. Due to its good prognosis, conservative treatment is possible in some cases of advanced disease of germ cell tumors and borderline tumors. Cystectomy is a reasonable option in serous borderline tumors but is not recommended in other tumor subtypes. Successful conception rates after fertility-sparing surgery ranges from 30 to 60%.

SUMMARY

Fertility-sparing surgery is a well tolerated option in young women with early-stage ovarian cancer with acceptable reproductive outcomes.

The Glycerol-Induced Perfusion-Kinetics of the Cat Ovaries in the Follicular and Luteal Phases of the Cycle

The method of immersion optical clearing reduces light scattering in tissues, which improves the use of optical technologies in the practice of clinicians. In this work, we studied the optical and molecular diffusion properties of cat ovarian tissues in the follicular (F-ph) and luteal (L-ph) phases under the influence of glycerol using reflectance spectroscopy in a broad wavelength range from 200 to 800 nm. It was found that the reflectance and transmittance of the ovaries are significantly lower in the range from 200 to 600 nm than for longer wavelengths from 600 to 800 nm, and the efficiency of optical clearing is much lower for the ovaries in the luteal phase compared to the follicular phase. For shorter wavelengths, the following tissue transparency windows were observed: centered at 350 nm and wide (46 ± 5) nm, centered at 500 nm and wide (25 ± 7) nm for the F-ph state and with a center of 500 nm and a width of (21 ± 6) nm for the L-ph state. Using the free diffusion model, Fick's law of molecular diffusion and the Bouguer-Beer-Lambert radiation attenuation law, the glycerol/tissue water diffusion coefficient was estimated as D = (1.9 ± 0.2)10^-6 cm²/s for ovaries at F-ph state and D = (2.4 ± 0.2)10^-6 cm²/s-in L-ph state, and the time of complete dehydration of ovarian samples, 0.8 mm thick, as 22.3 min in F-ph state and 17.7 min in L-ph state. The ability to determine the phase in which the ovaries are stated, follicular or luteal, is also important in cryopreservation, new reproductive technologies and ovarian implantation.

Gonadotropin-releasing hormone agonist protects ovarian function in young patients with ovarian malignancy undergoing platinum-based chemotherapy: A prospective study

Purpose

We aimed to ascertain the effectiveness of gonadotropin-releasing hormone (GnRH) agonist co-therapy for the preservation of ovarian function in patients with ovarian malignancy who underwent unilateral salpingo-oophorectomy and platinum-based chemotherapy.

Methods

We enrolled 158 patients with ovarian malignancy who underwent fertility preservation surgery and postoperative platinum-based chemotherapy between January 2018 and December 2020. Patients were divided into two groups based on the use of GnRH agonist (GnRHa) during chemotherapy. Two patients withdrew from the study. Laboratory tests (serum follicle-stimulating hormone [FSH], serum luteinizing hormone [LH], and serum anti-Müllerian hormone [AMH]) were performed pre-chemotherapy and one year post-chemotherapy. Data on menstruation resumption, perimenopausal symptoms (modified Kupperman Menopausal Index [KMI]), health-related quality of life (Medical Outcomes Study Short Form-36 [MOS SF-36]), and obstetric outcomes were collected.

Results

One year post-chemotherapy, the serum AMH level in the GnRHa group was higher than that in the control group (P<0.001), while the serum FSH and FSH/LH levels in the GnRHa group were lower than those in the control group (P<0.001). The mean period from last chemotherapy to menstrual resumption was 3.86 and 5.78 months in the GnRHa and control groups (P<0.001), respectively. The rate of menstrual resumption post-chemotherapy was 93.5% and 82.3% in the GnRHa and control groups (P<0.05), respectively. GnRHa co-administration during chemotherapy reduced the likelihood of low AMH levels post-chemotherapy and was significant in the multivariate analysis (P<0.05). The modified KMI scores and MOS SF-36 scores were better in the GnRHa group than in the control group (both P<0.001).

Conclusion

GnRHa protects ovarian function during platinum-based adjuvant chemotherapy in young patients with ovarian malignancy. This study provides a therapeutic reference for gynecologists, especially for those in economically and medically underdeveloped areas.

Trial registration

Chinese Clinical Trial Registry (chiCTR1800019114; October 26, 2018; http://www.chictr.org.cn/index.aspx)

Ovarian Tissue Cryopreservation in Children and Adolescents

Cancer during childhood and adolescence remains a major public health issue, affecting a significant portion of this age group. Although newer anti-cancer treatments have improved survival rates, this comes at a cost in terms of gonadotoxic effects. As a result, the preservation of fertility is important. Ovarian tissue cryopreservation, one of the newest methods, has some advantages, especially for prepubertal patients: no need for ovarian stimulation, thus, no further risk for estrogen-sensitive cancer types, and preservation of more and better-quality primordial follicles of the ovarian cortex. The most frequent indications include treatment with alkylating agents, ovarian-focused radiotherapy, leukemias, lymphomas, brain and neurological tumors, as well as Turner syndrome and benign hemoglobinopathies. An expected survival exceeding 5 years, the absence of systematic disease and an overall risk of premature ovarian insufficiency over 50% are among the criteria that need to be fulfilled in order for a patient to undertake this method. Orthotopic transplantation is more frequently used, since it can allow both live birth and the recovery of endocrine function. Reimplantation of malignant cells is always a major risk and should always be taken into consideration. Histological analysis, as well as immunohistochemical and molecular methods, are needed in order to improve the search for malignant cells before transplantation. Ovarian tissue cryopreservation appears to be a method with specific benefits, indications and risks which can be an important tool in terms of preserving fertility in younger women.

Women With Ovarian Cancer and With Fertility Preservation: A Survival Analysis Using the Surveillance, Epidemiology, and End Results Database and Construction of Nomograms to Predict Cancer-Specific Survival

Objective

This study aimed to determine the risk and prognostic factors of ovarian cancer (OC) in women having fertility-sparing surgery, as well as survival outcomes of those with stage I epithelial ovarian cancer (EOC). We also determined the effect of chemotherapy in OC treatment and used multiple independent risk factors to establish a prognostic nomogram model for patients with stage I EOC.

Patients and Methods

Individuals with OC and with fertility-sparing surgery (FSS) between 1998 and 2016 were identified in the SEER database. Univariate and multivariate logistic regression was performed to identify the distributions of patient characteristics according to chemotherapy. Cancer-specific survival (CSS) was assessed using Kaplan–Meier curves and log-rank tests. Univariate and multivariate Cox regression was conducted to determine the independent prognostic factors for CSS. Cox analysis was used to construct a nomogram model. The C-index and calibration plots showed the performance evaluation results.

Results

A total of 1,839 women with OC with FSS were identified in the SEER database. Factors associated with significantly higher odds of undergoing chemotherapy included younger age, being unmarried, having grades 2–4, stages II–III, or clear cell and non-epithelial histologic type following a multivariate logistic regression analysis. Multivariate Cox regression analysis confirmed that age, marital status, chemotherapy, histologic type, grade, and the International Federation of Gynecology and Obstetrics (FIGO) stage were independent prognostic factors for CSS. In stage I EOC, the prognosis in patients with stage IA/IB-grade 3 (5-year CSS 85.3%) or stage IC (5-year CSS 80.6%) was worse than that in those with stage IA/IB-grade 1 (5-year CSS 95.2%), or stage IA/IB-grade 2 (5-year CSS 94.7%). However, chemotherapy improved the survival of patients with stage IA/IB-grade 3 (5-year CSS 78.1% vs. 94.6%, p = 0.024) or stage IC (5-year CSS 75.1% vs. 86.7%, p = 0.170).

Discussion

The study provided population-based estimates of risk factors and prognoses in patients with OC and with FSS as well as the survival outcomes of patients with stage I EOC and the effect of chemotherapy. The constructed nomograms exhibited superior prognostic discrimination and survival prediction for patients with stage I EOC.

Thyroid cancer in women of reproductive age: Key issues for the clinical team

Women who are fertile experience a significant burden from thyroid cancer. In reality, delaying childbirth is the current trend in maternity. Women who have thyroid cancer may later want to get pregnant after it has been treated, which presents a multidisciplinary issue for their doctors. A variety of specialists are frequently involved in the treatment of thyroid cancer. This review aims to address the key elements of the strategy and places special emphasis on the significance of fertility in women with thyroid cancer diagnosis and remission. We will cover topics including the role of thyroid hormones in pregnancy and fertility.