Fertility preservation in female cancer patients: current knowledge and future perspectives

INTRODUCTION

Protecting fertility in the presence of cancer has become highly significant, as the desire to give birth to a child is increasingly postponed to later in life, and long-term survival with cancer has increased. A variety of fertility-preserving methods have been developed.

EVIDENCE ACQUISITION

To find them, we performed a literature search in Medline using the key words "female fertility preservation in cancer" in December 2017. A total of 2381 different publications were found.

EVIDENCE SYNTHESIS

After screening the abstracts 78 publications in English, French, or German language had been assessed as relevant (17 dealing with medical approaches, six with surgical approaches, 15 with oocyte cryopreservation, 11 with ovarian tissue cryopreservation and 29 were review articles). In general, there are medical (non-surgical) and surgical approaches. Medical approaches comprise administration of GnRH-analogues during gonad toxic oncologic treatment, and cryopreservation of oocytes after ovarian stimulation. Surgical approaches comprise traditional methods of organ-saving surgery and ovarian transposition outside of the radiation portal as well as ovary cryopreservation as standard.

CONCLUSIONS

It is important to inquire about a prospective desire to have children with premenopausal women with cancer and comprehensively explain the fertility conserving methods available. Every premenopausal woman with cancer should be counseled about the methods of fertility protection currently available at a multiprofessional center.

Alleviation of endoplasmic reticulum stress protects against cisplatin-induced ovarian damage

BACKGROUND

Cisplatin (CDDP), a widely used chemotherapeutic agent, can induce excessive granulosa cell apoptosis, follicle loss and even premature ovarian insufficiency (POI). However, the mechanism remains elusive, although some studies have indicated the involvement of endoplasmic reticulum stress (ERS). The aim of our study was to investigate the possible mechanism ERS in CDDP-induced granulosa cell apoptosis and follicle loss.

METHODS

A POI mouse model was generated by CDDP. The ovaries samples were collected and processed for isobaric tags for relative and absolute quantification analysis (iTRAQ) to screen out our interested proteins of HSPA5 and HSP90AB1, and the decline in their expression were verified by a real-time quantitative PCR and a western blotting assay. In vitro, human granulosa cells, KGN and COV434 cells were transfected with siRNA targeting HSPA5 and HSP90AB1 and then treated with CDDP, or treated with CDDP with/without CDDP+ 4-phenylbutyric acid (4-PBA) and 3-methyladenine (3-MA). The levels of ERS, autophagy and apoptosis were evaluated by western blotting, DALGreen staining and flow cytometry. In vivo, ovaries from mice that received intraperitoneal injections of saline, CDDP, CDDP+ 4-PBA and CDDP+ 3-MA were assayed by immunofluorescence, hematoxylin and eosin (H&E) staining for follicle counting, and terminal-deoxynucleotidyltransferase-mediated dUTP nick end labeling (TUNEL) staining for cell apoptosis assay. The plasma hormone levels were measured by an enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

We have clarified the relationships between ERS, autophagy, and apoptosis in CDDP-induced granulosa cell apoptosis, both in vitro and in vivo. Alleviating ERS by inhibiting HSPA5 and HSP90AB1 attenuated CDDP-induced autophagy and apoptosis. 4-PBA treatment significantly attenuated CDDP-induced cell autophagy and apoptosis in cultured KGN and COV434 cells. However, inhibiting cell autophagy with 3-MA negligibly restored the CDDP-induced changes in ERS and apoptosis. In vivo experiments also demonstrated that treatment with 4-PBA, but not 3-MA, prevented CDDP-induced ovarian damage and hormone dysregulation.

CONCLUSIONS

CDDP-induced ERS could promote autophagy and apoptosis in granulosa cells, causing excessive follicle loss and endocrine disorders. Alleviation of ERS with 4-PBA, but not of autophagy with 3-MA, protect against CDDP-induced granulosa cell apoptosis and ovarian damage. Thus, 4-PBA can be used to protect the ovary during chemotherapy in women.

Medical techniques of fertility preservation in the male and female

Therapeutic advances in many medical fields have led to the need to consider patient quality of life after curative medico-surgical treatments for malignancy. Thus, it has become a major issue for young patients to preserve the ability to become "genetic" parents, with their own gametes. While the preservation of male fertility has been an established technique for more than 30 years, it is only in the last decade that progress in cryopreservation techniques has allowed surgeons to offer successful oocyte and ovarian tissue cryobanking. However, in addition to the still experimental nature of some fertility preservation techniques, this practice also raises many ethical and moral questions.

Triptorelin for Fertility Preservation in Adolescents Treated With Chemotherapy for Cancer

BACKGROUND

Triptorelin, a gonadotropin releasing hormone analogue, can be administered to postpubertal female individuals with cancer who receive chemotherapy to obtain menstrual suppression and decrease the risk of hemorrhage caused by thrombocytopenia. Our goal was to assess whether triptorelin also has a protective role against the gonadotoxicity of chemotherapy.

PATIENTS AND METHODS

This retrospective observational study includes all postmenarchal female patients who presented to our Unit from 2000 to 2015 and received chemotherapy for cancer. They were administered depot triptorelin. We evaluated long-term ovarian function in order to detect clinical signs of ovarian damage, miscarriages, and pregnancies. Laboratory follow-up consisted in dosing serum follicle stimulating hormone, luteinizing hormone, prolactin, estradiol, and progesterone. Ultrasound of the ovaries was performed as well.

RESULTS

Of 36 evaluable patients, 9 received hematopoietic stem cell transplantation (HSCT). The remaining 27 patients maintained normal ovarian function at clinical, laboratory, and ultrasound assessment. Five of them achieved spontaneous physiological pregnancy. Four of the 9 patients who underwent HSCT developed premature ovarian failure.

CONCLUSION

Our study suggests that gonadotropin releasing hormone-a administered during chemotherapy can prevent premature ovarian failure in patients treated without HSCT and that it is not enough to preserve the ovarian function during HSCT. Hence, a prospective randomized trial with a larger population would be recommended.

Fertility protection: complications of surgery and results of removal and transplantation of ovarian tissue

Fertility-preserving measures are becoming important for patients receiving oncological treatment. One method involves cryopreservation of ovarian tissue and transplanting it when treatment is completed. We report complications resulting from surgical and fertility medicine, and the results of procedures for the removal and transplantation of ovarian tissue carried out within the FertiProtekt network. A survey using a structured questionnaire was conducted among the FertiProtekt network centres between November 2015 and June 2016. The analysis included surgical techniques used to remove and transplant ovarian tissue, surgical complications and results. Laparoscopic removal and transplantation of ovarian tissue have a low risk of complications. Surgical complications occurred in three of the network's 1373 ovarian tissue removals (n = 1302) and transplantations (n = 71); two complications (0.2%) occurred during removal and one during transplantation. Menstruation resumed in 47 out of 58 women (81%) who underwent ovarian tissue transplantation. Hormonal activity occurred in 63.2% of transplantations with a follow-up of 6 months or over. Sixteen pregnancies occurred in 14 patients, with nine births. The risks and complications of removal and transplantation of ovarian tissue are similar to those of standard laparoscopy. These procedures are becoming standard for fertility protection in cancer patients.

Operative techniques and complications of extraction and transplantation of ovarian tissue: the Erlangen experience

PURPOSE

Extracting ovarian tissue before oncologic therapy and transplanting it afterwards are increasingly being used to preserve fertility in women. This study describes standardized and safe operative procedures, with few complications, and reports the resulting ovarian function and pregnancy rates.

METHODS

The standardized operative techniques for removing and transplanting ovarian tissue used at the Erlangen center are: for tissue removal, one-third to half of the tissue from one ovary is excised with scissors, without tissue coagulation; for subsequent transplantation, pieces of ovarian tissue are placed in a retroperitoneal pocket without closure of the pocket.

RESULTS

Between January 2007 and December 2015, ovarian tissue was extracted in 399 women and transplanted following cancer therapy in 38. No surgical complications were observed within 28 days. To date, there have been ten pregnancies and nine live births after transplantation in seven different women; 26 of the 38 women developed hormonal activity, confirmed by a menstrual cycle or raised serum estradiol levels.

CONCLUSIONS

The techniques for laparoscopic removal and transplantation of ovarian tissue described here provide a standardized method with a very low risk of complications. The pregnancy rate after ovarian tissue transplantation, currently 15-30%, can be expected to rise further in the near future.

Pregnancy in the liver transplant recipient

During gestation, the woman's body undergoes various changes, and the line between physiology and pathology is very thin even in healthy women. Today, many of the liver transplant recipients are young women, who at one point in their lives may consider the possibility of pregnancy. Clinicians have to counsel them about the time of conception, the risk of miscarriage, the deterioration of the mother's health status, and the risk of birth defects. This review, based on our 20 years of clinical experience and up-to-date literature, provides comprehensive guidelines on pregnancy management in liver transplant recipients. Pregnancy in liver transplant recipients is possible but never physiological. Proper management and pharmacotherapy lowers the incidence of complications and birth defects. Critical factors for perinatal success include stable graft function before pregnancy, proper preparation for pregnancy, and cautious observation during its course. Liver Transplantation 22 1408-1417 2016 AASLD.

Impact of age on cytotoxic-induced ovarian failure in breast cancer treated with adjuvant chemotherapy and triptorelin

AIM

This study analyzes our single-center, retrospective experience on 63 premenopausal breast cancer patients treated with monthly triptorelin and concomitant chemotherapy.

PATIENTS & METHODS

Concomitant chemotherapy and triptorelin were adopted as part of premature ovarian failure prevention strategy.

RESULTS

Age at diagnosis was the main factor influencing fertility preservation (p = 0.002). Compared with patients aged 41-45 years, the probability of menses resumption was almost threefold than for women aged 35-40 years, and significantly higher for women aged <35 years (hazard ratio: 9.0; p = 0.0001). The cumulative proportion among patients who resumed menses was 33.3% at 6 months, 75% at 12 months and 87.5% at 24 months. Seven patients attempted pregnancy, and five (71%) obtained healthy deliveries.

CONCLUSION

We observed an acceptable rate of fertility preservation. Age at diagnosis influences fertility preservation.

Fertility Protection in Female Oncology Patients: How Should Patients Be Counseled?

Protecting the fertility of patients with oncologic disease is becoming more and more important, as fulfilling the wish to have children is increasingly occurring at a later stage in life and long-term survival rates after cancer are continuing to improve. A number of fertility-preserving options exist. In addition to techniques which have been around for some time such as medical ovarian suppression, ovarian transposition, and organ-preserving surgery, there are other, more recent, innovative methods which have developed over the last few years such as cryopreservation of oocytes or ovarian tissue transplantation after completing cancer therapy. As every procedure has its specific advantages and disadvantages, informed patient consent is essential. The physician's aim must be to select the optimal procedure for each patient. The extent of patients' information about the options to preserve fertility in women with oncologic disease remains limited. One of the main reasons for this is that clinicians are not sure how to inform patients about existing procedures and methods. The aim of this review article is to provide help in clinical practice.

Orthotopic transplantation of cryopreserved mouse ovaries and gonadotrophin releasing hormone analogues in the restoration of function following chemotherapy-induced ovarian damage

Therapy advances are constantly improving survival rates of cancer patients, however the toxic effects of chemotherapy drugs can seriously affect patients' quality of life. In women, fertility and premature ovarian endocrine dysfunction are of particular concern. It is urgently we find methods to preserve or reconstruct ovarian function for these women. This study compares GnRHa treatment with ovarian tissue cryopreservation and orthotopic transplantation in a chemotherapy-induced ovarian damage murine model. 56 inbred Lewis rats were divided into 4 treatment groups: Saline control (group I); cyclophosphamide only (group II); cyclophosphamide plus GnRHa (group III); cyclophosphamide and grafting of thawed cryopreserved ovaries (group IV). Body weight, estrous cycle recovery time, ovarian weight, morphology and follicle count, as well as breeding and fertility were compared among groups. Only group IV was able to restore to normal body weight by the end of the observation period and resumed normal estrous cycles in a shorter time compared to other treatment groups. There was a decrease in primordial follicles in all treatment groups, but group III had the greatest reduction. Although, there was no difference in pregnancy, only one animal littered normal pups in group II, none littered in group III and four littered in group IV. Thus, cryopreservation and orthotopic transplantation of ovarian tissue can restore the fertility of rats subjected to chemotherapy in a manner that is superior to GnRHa treatment. We also observed increased rates of hepatic, splenic and pulmonary haemorrhage in group III, suggesting there may be synergistic toxicity of GnRHa and cyclophosphamide.

Gonadotrophin-releasing hormone agonists for fertility preservation: unraveling the enigma?

STUDY QUESTION

Can gonadotrophin-releasing hormone agonists (GnRH-a) preserve long-term fertility when administered prior to and concomitantly with chemotherapy?

SUMMARY ANSWER

GnRH-a display a differential protective effect on fertility, depending upon the specific chemotherapy-induced mechanism of ovarian injury.

WHAT IS KNOWN ALREADY

The role of GnRH-a in fertility preservation has been constantly debated and their use is considered experimental due to conflicting clinical evidence and paucity of data regarding their mechanism for ovarian protection.

STUDY DESIGN, SIZE, DURATION

In vivo model: 7-8 weeks old imprinting control region (ICR) mice were injected with GnRH-a (Leuprolide-acetate) or saline prior to and concomitantly with cyclophosphamide, doxorubicin or saline and sacrificed at various time-points on a longitudinal follow-up; 24 h (n = 36), 1 week (n = 40), 1 month (n = 36) and 9 months (n = 66) post chemotherapy treatment. Blood samples were drawn on Day 0 and on a monthly basis after chemotherapy treatment. On the day of sacrifice, blood samples were drawn and ovaries excised and processed for either immunohistochemistry (IHC), protein or RNA extraction. In vitro model: 21-23 days old Wistar-derived rats were sacrificed, their ovaries excised and primary granulosa cells (PGC) were either isolated for in vitro culture, or processed for immunofluorescence (IF) as well as for protein or RNA extraction.

MATERIALS, SETTING, METHODS

Ovarian reserve was estimated by serial measurements of serum anti-mullerian hormone (AMH), quantified by the AMH Gen II ELISA assay. Ovarian AMH and phosphorylated Akt (pAkt) were detected by immunoblotting. Vascular endothelial growth factor (VEGF) was measured by quantitative PCR. Ovarian GnRH receptor (GnRHR), AMH and CD34 were visualized by IHC, and apoptosis was evaluated using TdT (terminal deoxynucleotidyl transferase)-mediated dUDP nick-end labeling (TUNEL).

MAIN RESULTS AND THE ROLE OF CHANCE

Cyclophosphamide-induced ovarian injury caused a prompt decrease in AMH level (P < 0.01) and a further long-term decline in serum AMH (P = 0.017), indicating damage to the ovarian reserve. Pretreatment with GnRH-a diminished AMH-decrease (P < 0.05) and maintained serum AMH level in the long run (P < 0.05). Doxorubicin-exerted ovarian-vascular-injury is also displayed by an acute increase in ovarian VEGF level (P < 0.05) and a sustained decrease in serum AMH level (P < 0.001). This was followed by ovarian recovery manifested by increased neovascularization. GnRH-a delayed the recovery in AMH level and decreased the level of VEGF (P < 0.001), thus interfering with the vascular recovery subsequent to doxorubicin-induced vascular damage.

LIMITATIONS, REASONS FOR CAUTION

To portray the differential mechanism of each chemotherapy, cyclophosphamide and doxorubicin were given separately, whereas most of the clinical protocols include several types of chemotherapies. Thus, future study should explore a prospective evaluation of various chemotherapies, as well as combined chemotherapeutic protocols.

WIDER IMPLICATIONS OF THE FINDINGS

Our study demonstrates that different chemotherapy agents affect the ovary via diverse mechanisms and thus the administration of GnRH-a concomitantly, could be beneficial to a subpopulation of patients treated with cyclophosphamide-based protocols.

STUDY FUNDING/COMPETING INTERESTS

This work was partially supported by a grant from the Israel Science Foundation (ISF) to I.B.-A. The authors have no conflict of interest to disclose.

Acute myeloid leukemia in adolescents and young adults: challenging aspects

Treating adolescents and young adults (AYAs) diagnosed with cancer is a challenge. Acute myeloid leukemia (AML) which is usually diagnosed in a previously healthy kid, requiring immediate aggressive chemotherapy, brings difficulties and conflicts associated with severe illness to extremes. The incidence of AML in adolescents aged 15-19 years approaches 8.5 per million. Only in recent years has it become evident that the prognosis of AYAs diagnosed with AML is poorer compared to younger children diagnosed with AML with similar characteristics. No specific genetic aberration or other known poor risk factor was found to explain the inferior prognosis of AYAs. In acute lymphoblastic leukemia the contribution of differences between adult and pediatric protocols to AYA outcome is established. It has been suggested that pediatric protocols should also apply to AYAs with AML; however, data supporting this are vague. Herein, existing evidence regarding special considerations in treating AYAs with AML is discussed. Mental and psychological age-specific aspects important to consider when treating AYAs with AML are overviewed. Awareness for adolescent special needs, adherence to protocols and intensive supportive care are important. Multidisciplinary adolescent-oriented staff should be involved in the therapy of any AYA with AML escorting this special patient population on the road to cure.

Preserving Fertility in Children and Adolescents with Cancer

In the face of excellent survival rates for pediatric and adolescent cancer, preserving the opportunity to have biological children is an important component of long term quality of life. Yet, modern chemotherapeutic regimens continue to pose a threat to fertility. The only fertility preservation methods available to pre-pubertal children of both genders is cryopreservation of gonadal tissue, a highly experimental intervention, or shielding/re-location of reproductive tissue in the setting of radiation. These techniques are available in the post pubertal population as well, but post pubertal patients also have the option for cryopreservation of gametes, a process that is much simpler in males than females. For this reason, prior to the initiation of therapy, sperm banking should be considered standard of care for males, while consideration of embryo or oocyte cryopreservation should be limited to those females at risk of developing ovarian failure. Attention to reproductive health and fertility preservation should continue after the completion of therapy. Establishing programs that streamline access to current fertility preservation techniques will assist in ensuring that all eligible patients can avail themselves of current options.

Clinical guide to fertility preservation in hematopoietic cell transplant recipients

With broadening indications, more options for hematopoietic cell transplantation (HCT) and improvement in survival, the number of long-term HCT survivors is expected to increase steadily. Infertility is a frequent problem that long-term HCT survivors and their partners face and it can negatively impact on the quality of life. The most optimal time to address fertility issues is before the onset of therapy for the underlying disease; however, fertility preservation should also be addressed before HCT in all children and patients of reproductive age, with referral to a reproductive specialist for patients interested in fertility preservation. In vitro fertilization (IVF) and embryo cryopreservation, oocyte cryopreservation and ovarian tissue banking are acceptable methods for fertility preservation in adult women/pubertal females. Sperm banking is the preferred method for adult men/pubertal males. Frequent barriers to fertility preservation in HCT recipients may include the perception of lack of time to preserve fertility given an urgency to move ahead with transplant, lack of patient-physician discussion because of several factors (for example, time constraints, lack of knowledge), inadequate access to reproductive specialists, and costs and lack of insurance coverage for fertility preservation. There is a need to raise awareness in the medical community about fertility preservation in HCT recipients.

Oncofertility in Canada: gonadal protection and fertility-sparing strategies

BACKGROUND

Cancer can be a devastating diagnosis. In particular, malignancy and its indicated treatments have profoundly negative effects on the fertility of young cancer patients. Oncofertility has emerged as a new interdisciplinary field to address the issue of gonadotoxicity associated with cancer therapies and to facilitate fertility preservation. In Canada, fertility issues are often inadequately addressed despite the availability of resources. The goal of this four-part series is to facilitate systemic improvements in fertility preservation for adolescent and young adult Canadians with a new diagnosis of cancer.

METHODS

Here, we review the fertility preservation measures currently available. Medical and surgical strategies are both outlined.

RESULTS

Fertility-preserving strategies and gonadal protection have demonstrated variable success in a number of approaches. The value of hormone suppression is still in question for women. Progestins for endometrial cancer and alternative chemotherapies are other medical approaches. Gonadal shielding and protective surgical approaches have also been attempted.

CONCLUSIONS

The techniques discussed here may be selectively considered and integrated into patient care in an attempt to preserve future fertility before initiating cancer treatment.

Fertility preservation and reproduction in patients facing gonadotoxic therapies: a committee opinion

Chemotherapy and radiation therapy often result in reduced fertility, and patients receiving gonadotoxic treatment should be informed of options for fertility preservation and future reproduction prior to such treatment. Reproduction in the context of cancer also raises a number of ethical issues related to the welfare of both patients and offspring. This document replaces the document titled, "Fertility preservation and reproduction in cancer patients," last published in 2005 (Fertil Steril 2005;83:1622-8).

Fertility preservation in patients with haematological disorders: a retrospective cohort study

This study investigated the factors associated with utilization of fertility preservation and the differences in treatments and outcomes by prior chemotherapy exposure in patients with haematological diseases. This study included all 67 women with haematological diseases seen for fertility preservation consultation at two university hospitals between 2006 and 2011. Of the total, 49% had lymphoma, 33% had leukaemia, 7% had myelodysplastic syndrome and 4% had aplastic anaemia; 46% had prior chemotherapy; and 33% were planning for bone marrow transplantation, 33% pursued ovarian stimulation and 7% used ovarian tissue banking; and 48% of patients did not pursue fertility preservation treatment. All five cycle cancellations were in the post-chemotherapy group: three patients with leukaemia and two with lymphoma. Patients with prior chemotherapy had lower baseline antral follicle count (10 versus 22) and received more gonadotrophins to achieve similar peak oestradiol concentrations, with no difference in oocyte yield (10.5 versus 10) after adjustment for age. Embryo yield was similar between those who had prior chemotherapy and those who had not. Half of the patients with haematological diseases who present for fertility preservation have been exposed to chemotherapy. While ovarian reserve is likely impaired in this group, oocyte yield may be acceptable.

Preservation of Fertility in Female Cancer Patients Desiring Future Child Bearing; What is Available and What can be Offered

The aim of this review is to present an overview of available methods for preservation of ovarian function and fertility in female cancer patients who desire to maintain their child-bearing capacity for future pregnancies. A Medline search was conducted. Published articles from American and European studies from 1976 to present were reviewed. The effect of cancer treatment on the ovary, as well as different methods of fertility preservation and their reproductive outcomes are presented. Pregnancy rates vary according to the type of primary malignancy, stage of disease, method of fertility preservation (for example, hormonal therapy, cryopreservation, fertility-sparing surgery), and other confounding factors such as the patient's age, reproductive capacity, status of partnership, and genetic disposition. The highest rates of successful pregnancy were observed with embryo cryopreservation. Today, higher cure rates and longer survival are a result of earlier cancer diagnosis and treatment. In conjunction with the advances in assisted reproduction, the preservation of ovarian function and fertility is a major part of multidisciplinary care that should be offered to any young female patient with cancer. Fertility preservation in young cancer patients raises a number of ethical issues particularly regarding standard versus experimental therapies, and long-term financial cost.

Pediatric hormonal disturbances after hematopoietic stem cell transplantation

Hematopoietic stem cell transplantation (HSCT) is the treatment of choice for various malignant and nonmalignant diseases. Improvement of HSCT in children has resulted in many long-term survivors with substantial long-term morbidities. Endocrine complications are most frequently observed as late effects in HSCT recipients. Growth failure, pubertal disorders, thyroid dysfunctions, obesity, metabolic syndrome and bone loss are usually encountered after HSCT in children, while infertility is an important problem in adulthood. Patient age at HSCT, characteristics of primary diseases, intervention duration, preparative conditioning regimens, dose of irradiation and specificity of chemotherapeutic agents affect the prevalence of endocrine late effects. Awareness of endocrine late effects of HSCT and close follow-up of patients would help to increase the quality of health of patients.

Effect of a gonadotropin-releasing hormone analogue on cyclophosphamide-induced ovarian toxicity in adult mice

PURPOSE

To evaluate the possible protective effect of low and high dose of triptorelin, a GnRH analogue, on cyclophosphamide-induced ovarian toxicity in adult female mice.

METHODS

Thirty-six sexually mature, virgin, female mice were divided randomly into six groups of six each: control group, low-dose triptorelin (TL) group, high-dose triptorelin (TH) group, cyclophosphamide (CPA) group, low-dose triptorelin plus cyclophosphamide (TL + CPA) group and high-dose triptorelin plus cyclophosphamide (T + CPA) group. Mice in both the TL + CPA and the TH + CPA groups were injected with 3.8 and 38 mg/kg of triptorelin subcutaneously, respectively. Four weeks later, mice in the CPA, TL + CPA and TH + CPA groups were injected with cyclophosphamide, intraperitoneally, at a dose of 50 mg/kg. Ovaries were removed 4 weeks later and processed for light microscopic examinations.

RESULTS

Obvious destruction of ovarian structure and significant depletion of primordial, primary, secondary and antral follicles were demonstrated in the CPA group and compared with the control group, the difference was statistically highly significant (p < 0.001), affirming the ovarian toxicity of cyclophosphamide. In the TL + CPA group, there was a significant increase in primordial, primary, secondary and antral follicles compared with the CPA group (p < 0.05), showing the effect of triptorelin on ovarian protection. Regarding, the high-dose GnRH agonist the difference was statistically highly significant for primordial and primary follicles (p < 0.001).

CONCLUSIONS

This study has showed a dose-dependent protective effect of GnRH analogue on ovarian reserve against ovarian toxic chemotherapy, thus demonstrating an important role of GnRH analogues in fertility preservation.

Adolescent urologic oncology: current issues and future directions

Recent Surveillance Epidemiology and End Results (SEER) data indicate that the annual cancer incidence in adolescents is higher than in children, and is on the rise. However, the amount of attention, research funding, and therapeutic progress made in the adolescent oncology population pales in comparison with that of pediatric oncology. Issues of adolescent oncology have only recently been acknowledged by leaders in the field, and current efforts now focus on raising awareness of this unique patient group. In urology, there have been many gains made in pediatric urologic oncology, most notably in Wilms tumor and genitourinary rhabdomyosarcoma (genitourinary [GU] rhabdomyosarcoma [RMS]); however, there has been little to no progress in the adolescent population. In general, adolescent cancer represents the interface between pediatric and adult oncology. Similarly, adolescent urologic oncology must be approached as a distinct entity because of the unique disease processes, treatment-related comorbidities, and psychosocial issues. This article will serve to review the most pertinent adolescent urologic oncologic diagnoses (testicular germ call malignancy, the second peak of the bimodal age distribution of GU-RMS, and adolescent renal malignancies). Also, we focus on such issues as the therapeutic impact on fertility, radiation exposure during therapy, and surveillance, risk of secondary malignancy, the long-term impact of chemotherapy, and the psychosocial burden of cancer in this population. Lastly, we highlight future directions and the foreseeable obstacles towards achieving the same research and therapeutic success enjoyed in pediatric urologic oncology.

Gonadotropin-releasing hormone agonist for the prevention of chemotherapy-induced ovarian failure in patients with lymphoma: 1-year follow-up of a prospective randomized trial

PURPOSE

To assess the efficacy of gonadotropin-releasing hormone agonist (GnRHa) in preventing chemotherapy-induced ovarian failure in patients treated for Hodgkin or non-Hodgkin lymphoma within the setting of a multicenter, randomized, prospective trial.

PATIENTS AND METHODS

Patients age 18 to 45 years were randomly assigned to receive either the GnRHa triptorelin plus norethisterone (GnRHa group) or norethisterone alone (control group) concomitantly with alkylating agents containing chemotherapy. The primary end point was the premature ovarian failure (POF) rate (follicle-stimulating hormone [FSH] ≥ 40 IU/L) after 1 year of follow-up.

RESULTS

Eighty-four of 129 randomly assigned patients completed the 1-year follow-up. The mean FSH values were higher in the control group than in the GnRHa group during chemotherapy; however, this difference was no longer observed after 6 months of follow-up. After 1 year, 20% and 19% of patients in the GnRHa and control groups, respectively, exhibited POF (P = 1.00). More than half of patients in each group completely restored their ovarian function (FSH < 10 IU/L), but the anti-Müllerian hormone values were higher in the GnRHa group than in the control group (1.4 ± 0.35 v 0.5 ± 0.15 ng/mL, respectively; P = .040). The occurrence of adverse events was similar in both groups with the exception of metrorrhagia, which was more frequently observed in the control group than the GnRHa group (38.4% v 15.6%, respectively; P = .024).

CONCLUSION

Approximately 20% of patients in both groups exhibited POF after 1 year of follow-up. Triptorelin was not associated with a significant decreased risk of POF in young patients treated for lymphoma but may provide protection of the ovarian reserve.

Adjunctive GnRH-a treatment attenuates depletion of ovarian reserve associated with cyclophosphamide therapy in premenopausal SLE patients

BACKGROUND

We measured antimullerian hormone (AMH), a marker of ovarian reserve, in women with lupus treated with cyclophosphamide (CYC) (group I), CYC plus gonadotropin-releasing hormone agonist (GnRH-a) (group II) or neither (group III). We hypothesized that AMH would be diminished in women exposed to CYC versus women receiving adjunctive GnRH-a treatment or no CYC exposure.

METHODS

Forty-eight premenopausal lupus patients were retrospectively divided into three treatment groups: CYC alone (group I, n = 11), CYC + GnRH-a (group II, n = 10) and neither (group III, n = 27). Serum AMH levels between groups were compared using a nonparametric test (Wilcoxon rank-sum). Multiple linear regression adjusting for age was performed.

RESULTS

AMH (ng/mL) levels at the last collection were significantly lower in group I versus group III (mean ± SD: 0.18 ± 0.20 group I vs 1.33 ± 1.59 group III; p = 0.015), and versus group II (mean ± SD: 0.86 ± 1.06; p = 0.018). When centered on age 30 years, average AMH levels for group I, group II and group III were 0.20, 0.44 and 1.00, respectively. When adjusted for age, AMH between all groups was significantly different (p<0.0001).

CONCLUSION

Posttreatment AMH levels were significantly higher among patients receiving CYC + GnRH-a compared to CYC alone, suggesting that GnRH-a coadministration mitigates CYC-induced ovarian injury.

How do chemotherapeutic agents damage the ovary?

BACKGROUND

Chemotherapy treatment in premenopausal women is associated with an increased risk of premature ovarian failure (POF) but the exact mechanism through which this occurs is uncertain. In this review we examine the current evidence for the direct action of chemotherapeutic agents on the ovary and discuss possible molecular pathways through which follicle loss may occur.

METHODS

A systemic search of the databases, PubMed and Google Scholar, was made for all English language articles through to 2011 in each subject area discussed.

RESULTS

POF results from the loss of primordial follicles but this is not necessarily a direct effect of the chemotherapeutic agents. Instead, the disappearance of primordial follicles could be due to an increased rate of growth initiation to replace damaged developing follicles. Likewise, the loss of oocytes need not necessarily be a direct result of damage: evidence suggests that chemotherapy drugs can also induce oocyte death indirectly via damage to somatic cells. Specific molecular mechanisms and likely ovarian targets are discussed for some of the anti-cancer drugs most commonly used to treat premenopausal women. Finally, we consider current and prospective methods of preserving fertility.

CONCLUSIONS

It is likely that different chemotherapeutic drugs act through a range of mechanisms and on different target cells. More research into the cellular mechanisms underpinning chemotherapy-induced follicle loss could lead to the generation of treatments specifically designed to prevent POF.

Multiple approaches for individualized fertility protective therapy in cancer patients

In the last decade, fertility preservation has risen as a major field of interest, creating new interactions between oncologists and gynecologists. Various options, such as cryopreservation of ovarian tissue, have been developed and are currently routinely proposed in many centers. However, many of the options remain experimental and should be offered to patients only after adequate counseling. This paper addresses the efficiency and the potential of the different fertility preservation approaches.

NCI, NHLBI/PBMTC first international conference on late effects after pediatric hematopoietic cell transplantation: endocrine challenges-thyroid dysfunction, growth impairment, bone health, & reproductive risks

The endocrine system is highly susceptible to damage by high-dose chemotherapy and/or irradiation before hematopoietic cell transplantation (HCT) during childhood. The specific endocrine organs most affected by HCT include the thyroid gland, the pituitary, and the gonads. In addition, hormones that support development and stability of the skeletal system are also affected. Insufficiency of thyroid hormone is 1 of the most common late sequelae of HCT, and occurs more often in young children. Deficiency in the pituitary's production of growth hormone is a problem of unique concern to the pediatric population. The reproductive risks of HCT depend on the patient's gender and pubertal status at the time of HCT. Pubertal or gonadal failure frequently occurs, especially in females. Infertility risks for both genders remain high, whereas methods of fertility preservation are limited in all but postpubertal males. Bone health post-HCT can be compromised by low bone mineral density as well as avascular necrosis, but the data on both problems in the pediatric HCT population are limited. In this paper, the current state of knowledge, gaps in that knowledge, and recommendations for future research are addressed in detail for each of these systems.

Fertility preservation in girls and young women

There is increasing interest and experience in the options available to preserve fertility in those about to undergo potentially gonadotoxic chemotherapy or radiation therapy, usually related to treatment for cancer. Recent years have seen the development of methods for prepubertal girls, female adolescents and adult women, although these remain less established than sperm cryopreservation for men. At present, the options for prepubertal boys remain experimental. Embryo cryopreservation following ovarian stimulation and IVF is a routine procedure technically and its success in the management of infertility is established. However, there are no data on uptake or success rates in the context of fertility preservation in women with cancer. Oocyte cryopreservation is technically challenging and requires ovarian stimulation, thus potentially resulting in a delay in cancer treatment. Oocyte vitrification offers increased success rates in comparison with slow freezing; however, this approach is also limited by the number of oocytes that can be obtained. The third possibility, ovarian tissue cryopreservation, can be performed without significant delay and is the only option for prepubertal girls. Worldwide, a small number of children have been born following reimplantation of frozen/thawed ovarian tissue. It is clear that fertility preservation is important for some girls and young women facing treatments that will compromise their fertility, but the availability of all approaches varies widely. Effective approaches for prepubertal boys are also required.

Fertility Preservation in Women with Cancer: Importance of a Multidisciplinary Approach

For all patients affected by a disease that could impair fertility before or during the reproductive lifespan, strategies to preserve their fertility and the ability to bear their own children is likely to be of utmost importance. While fertility preservation is a promising option, most of the technologies currently used are far from being well-established or are still experimental. Patients should be aware that no method guarantees success. Psychological and ethical impacts of fertility preservation are major concerns and should be included in the multidisciplinary approach to the patients.

In vivo delivery of FTY720 prevents radiation-induced ovarian failure and infertility in adult female nonhuman primates

OBJECTIVE

To determine whether sphingosine-1-phosphate (S1P), or the S1P mimetic FTY720 shields ovaries of adult female rhesus monkeys from damage caused by 15 Gy of targeted radiotherapy, allowing for the retention of long-term fertility, and to evaluate whether S1P protects human ovarian tissue (xenografted into mice) from radiation-induced damage.

DESIGN

Research animal study.

SETTING

Research laboratory and teaching hospital.

PATIENT(S)

Adult female rhesus macaques (8-14 years of age; n = 21) and two women (24 and 27 years of age) undergoing gynecologic surgery for benign reasons, after informed consent and approval.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Ovarian histologic analysis, ovarian reserve measurements, and fertility in mating trials.

RESULT(S)

Rapid ovarian failure was induced in female macaques by ovarian application of 15 Gy of radiation. Females given S1P or FTY720 by direct intraovarian cannulation for 1 week before ovarian irradiation rapidly resumed menstrual cycles because of maintenance of follicles, with greater beneficial effects achieved using FTY720. Monkeys given the S1P mimetic before ovarian irradiation also became pregnant in mating trials. Offspring conceived and delivered by radioprotected females developed normally and showed no evidence of genomic instability, as measured by micronucleus frequency in reticulocytes. Adult human ovarian cortical tissue xenografted into mice also exhibited a reduction in radiation-induced primordial oocyte depletion when preexposed to S1P.

CONCLUSION(S)

S1P and its analogs hold clinical promise as therapeutic agents to preserve ovarian function and fertility in female cancer patients exposed to cytotoxic treatments.

Fertility preservation in women--a practical guide to preservation techniques and therapeutic strategies in breast cancer, Hodgkin's lymphoma and borderline ovarian tumours by the fertility preservation network FertiPROTEKT

PURPOSE

Fertility preservation methods are playing an increasing role in women up to the age of 40 years because of rising survival rates in those affected by cancer. However, balanced practical recommendations concerning all relevant fertility preservation, to support doctors in counselling and treating patients, are still rare.

METHODS

These recommendations were prepared by the network FertiPROTEKT ( http://www.fertiprotect.eu ), a collaboration of around 70 centres in Germany, Switzerland and Austria. The recommendations were developed by specialists in reproductive medicine, reproductive biology and oncology, which gave a comprehensive overview of all named techniques as well as their benefits and risks. Furthermore, practice-orientated recommendations for the individual use of fertility preservation methods for various indications such as breast cancer, Hodgkin's lymphoma and borderline ovarian tumours are given.

RESULTS

Various options such as ovarian stimulation and cryopreservation of unfertilised or fertilised oocytes, cryopreservation and transplantation of ovarian tissue, GnRH-agonist administration and transposition of the ovaries can be offered. All the techniques can be performed alone or in combination within a maximum of 2 weeks with low risk and different success rates.

CONCLUSIONS

Fertility preservation in women has become an option with realistic chances to become pregnant after cytotoxic therapies. The information provided allows a well balanced and realistic counselling and treatment.

Fertility conservation in breast cancer patients

Breast cancer is the most common malignant tumor in women. Increasing survival rates after breast cancer, new reproductive techniques and growing interest regarding the quality of life after cancer have brought the possibilities of fertility-preserving treatment to the center of attention of oncologists and affected patients. Many of these women suffer from infertility and premature menopause as a result of chemotherapy. Several measures, for example gonadotropin-releasing hormone analogs, hormonal stimulation to cryopreserve oocytes, ovarian tissue cryoconservation or a combination of the methods, can be undertaken depending on the hormone receptor status of the tumor, and the patient's age and partner status. Embryo cryopreservation is currently the most promising fertility preservation option. Early counseling on fertility-preserving strategies is of utmost importance, so that the fertility-preserving method can be integrated into the oncologic therapy regime.

State-of-the-art issues in Hodgkin's lymphoma survivorship

The prognosis of Hodgkin's lymphoma (HL) has markedly improved as management strategies evolved. In the modern era, less than 15% of patients with early-stage, non-bulky HL will relapse, and less than one third of those with advanced disease will relapse. As therapy for HL intensified, and as disease-related outcomes improved, the impact of the late effects of therapy has become increasingly important. There is a growing body of literature describing the late morbidity experienced by survivors of HL, including risks of second primary malignancy, cardiac disease, pulmonary disease, and endocrine dysfunction. Additionally, the impact of disease and treatment on psychosocial function and quality of life has been a subject of investigation, with survivors often suffering from impairment. An understanding of these risks and the management implications inherent to them is central to the care of survivors of HL.

[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.

Fertility preservation in >1,000 patients: patient's characteristics, spectrum, efficacy and risks of applied preservation techniques

INTRODUCTION

Data on the characteristics of female patients counselled for fertility preservation and the efficacy and risk of the applied procedures are still poor. We therefore analysed the registry of a network of 70 infertility centers which are involved in fertility preservation in Germany, Switzerland and Austria, called FertiPROTEKT ( hhtp://www.fertiprotekt.eu ).

MATERIALS AND METHODS

1,280 counselled patients (15-40 years) were analysed regarding characteristics and different fertility preservation treatments before cytotoxic therapy in 2007-2009.

RESULTS

34.8% of the counselled patients were diagnosed with breast cancer, 30.5% with Hodgkin's lymphoma, 25.4% with other malignancies and 9.3% with non-malignant diseases. 89.6% of the treated breast cancer patients were 25-40 years of age, and 87.5% of the lymphoma patients were 15-30 years of age. At the time of counselling, 85.3% of the breast cancer patients and 92.7% of the lymphoma patients were childless. 1,080 patients received a single or combined therapy such as GnRH agonists (n = 823), cryopreservation of ovarian tissue (n = 500), ovarian stimulation (n = 221) and transposition of the ovaries (n = 24). Only one severe complication, requiring postponement of the chemotherapy, was documented. In stimulated patients, 2,417 oocytes (mean n = 11.6, SD ± 7.7) were received. Fertilisation rate per received oocyte was 61.3%.

CONCLUSIONS

Fertility preservation programmes mainly involve women without children, diagnosed with breast cancer or Hodgkin's lymphoma. Fertility preservation techniques can be applied with low risk. The limited and age-dependant success rate of the different therapies require individualised approaches of single or combined fertility preservation techniques.

Fertility Preservation in Adolescents and Young Adults With Cancer

Preservation of fertility is important to adolescent and young adult (AYA) survivors of cancer. Many survivors will maintain their reproductive potential after the successful completion of treatment for cancer. However total-body irradiation, radiation to the gonads, and chemotherapy regimens containing high-dose alkylators can place women at risk for acute ovarian failure or premature menopause and men at risk for temporary or permanent azoospermia. The most effective and established means of preserving fertility in this population is embryo cryopreservation in women and sperm cryopreservation in men before the initiation of cancer-directed therapy. Cryopreservation of mature oocytes is also becoming more commonplace as methods of thawing become more sophisticated. The use of in vitro fertilization and intracytoplasmic sperm injection has added to the viability of sperm and oocyte cryopreservation. Cryopreservation and transplantation of gonadal tissue in both males and females remains experimental but continues to be evaluated. Hormonal suppression has not been shown to be effective in males but may have promise in females, although larger scale trials are needed to evaluate this. Providing information about risk of infertility and possible interventions to maintain reproductive potential are critical for the AYA population at the time of diagnosis. Given the competing demands of providing complicated and detailed information about cancer treatment, the evolving information related to fertility preservation, and the ethical issues involved, it may be preferable, where possible, to have a specialized team, rather than the primary oncologist, address these issues with AYA patients.

No protection of the ovarian follicle pool with the use of GnRH-analogues or oral contraceptives in young women treated with escalated BEACOPP for advanced-stage Hodgkin lymphoma. Final results of a phase II trial from the German Hodgkin Study Group

BACKGROUND

The reduction of treatment-related toxic effects is the main goal in the current trials of the German Hodgkin Study Group (GHSG). In this regard, the protection of the ovarian reserve in young women is very important. Therefore, the GHSG investigated the use of gonadotropin-releasing hormone-analogues (GnRH-a) and oral contraceptives (OC) in young women with advanced-stage Hodgkin lymphoma (HL).

PATIENTS AND METHODS

Women (18-40 years) were randomly assigned either to receive daily OC or monthly GnRH-a during escalated combination therapy with bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPPesc). Hormonal levels were determined at baseline, during therapy, and at follow-up.

RESULTS

The study was closed prematurely after an interim analysis of 12 patients in arm A (OC) and 11 in arm B (GnRH-a), 9 and 10 are assessable for the primary end point. Women's median age was 25 years in both arms. The anti-Mullerian hormone level after at least 12 months was reduced in all patients. For the entire study cohort, the respective ovarian follicle preservation rate was 0% (95% confidence interval 0% to 12%).

CONCLUSION

We observed no protection of the ovarian reserve with hormonal co-treatment during BEACOPPesc. This result supports efforts of ongoing trials to reduce chemotherapy intensity and toxicity. Alternative strategies for the protection of fertility must be offered to young female HL patients before the start of BEACOPPesc therapy.

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.