Two cases of ovarian tumours in women who had undergone multiple ovarian stimulation attempts

Assessment of cells in the ascitic fluid of women with ovarian hyperstimulation syndrome: the clinical implications for subsequent ovarian malignancy

BACKGROUND

Although some studies have reported a potential connection between ovulation induction therapy (OIT) and malignant ovarian diseases, the results have been inconclusive. In the present study, we sought to determine whether women undergoing OIT at our in vitro fertilization (IVF) clinic, especially those with severe ovarian hyperstimulation syndrome (OHSS) and suspicious cytologic findings, were at risk for developing malignant ovarian tumours after treatment.

METHODS

Patients who underwent OIT at our IVF clinic were enrolled in this study and assessed for any evidence of malignant ovarian tumours. Patients who developed severe OHSS as a result of OIT were treated with a culdocentesis. Cells from the ascitic fluid were cytologically scored for abnormality and malignancy. Peripheral blood samples were obtained from patients with severe OHSS to determine serum levels of the tumour markers (CA-125 and HE4) that were used to calculate the Risk for Ovarian Malignancy Algorithm (ROMA) index.

RESULTS

Follow-up data were available for 1,353 of the 1,587 patients (85%) who underwent OIT at our IVF clinic between January 2006 and December 2012. Twenty-three patients (1.4%) were hospitalized with OHSS. Culdocentesis was performed 16 times in nine patients with severe OHSS (age range, 23-34 years; mean, 27.1 years). Although cytological examination of the ascitic cells of these patients suggested malignant ovarian neoplasia, over the course of the observation period, the ovarian volume gradually decreased and became normal. Subsequent cytological and histological examinations failed to find evidence of any malignant tumours in these nine patients. None of the 1,353 participants who underwent OIT developed any malignant ovarian tumours during the study period. Moreover, none of the 462 patients who were in our ovarian tumour registry were also participants in the IVF program.

CONCLUSIONS

The presence of atypical cells in the ascitic fluid of women with severe OHSS does not likely indicate malignancy; therefore, radical surgical intervention is not justified. The risk of malignancy is minimal shortly after OIT. At our centre, OIT has not been associated with any cases of ovarian tumour.

Ovarian stimulation: is there a long-term risk for ovarian, breast and endometrial cancer?

Adverse effects have been related to infertility treatments. Infertility in general, and female infertility in particular, is a well established risk factor for cancer development, especially ovarian, breast and endometrial cancer. This article addresses the possible association between infertility and cancer development, with an emphasis on the influence of infertility treatments, through a meticulous search of the literature published thus far. While results regarding the possible association of infertility, ovulation induction medications and invasive ovarian cancer show no increased risk and are reassuring, results for increased risk for breast cancer and endometrial cancer following exposure to ovarian stimulation medications are inconclusive. Larger population studies with longer periods of follow-up and better adjustment for confounding factors are needed.

Effects of ovulation induction agents on ovarian surface epithelium in rats

The aim of this study was to examine the effects of ovulation induction agents on the ovarian surface epithelium in rats. Sixty adult females were randomly divided into six groups, each containing 10 rats. In four of these groups ovulation induction was applied with six cycles of clomiphene citrate, human menopausal gonadotrophin (HMG), recombinant FSH (rFSH) or human chorionic gonadotrophin (HCG), respectively, followed by unilateral oophorectomy, and another six cycles of the same treatment. After a total of 12 cycles of ovulation induction, the remaining ovary was taken out and the alterations in ovarian surface epithelium were examined. No malignancies were observed on the ovarian surface epithelium of the rats that were given clomiphene citrate, rFSH or HMG as ovulation induction agents, while identification rates of histopathological parameters constituting epithelial dysplasia were found to be significant (P < 0.05). There was no significant dysplasia in the epithelium of the group which was given HCG only, relative to control groups. The findings suggest that the ovulation induction agents except for HCG bring about dysplasia in the ovarian surface epithelium. It is not clear whether these dysplasias are precursory lesions of ovarian malignancies.

The ovarian hyperstimulation syndrome

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication induced by exogenous administration of substances that are used to stimulate follicular growth and ovulation. There has only been one reported incidence of a spontaneous occurrence of OHSS and that was in 1992. The crucial event in the development of the syndrome is the administration of human chorionic gonadotropin (HCG), although several studies have reported the onset of OHSS after gonadotropin stimulation despite withholding HCG. OHSS is represented by a broad spectrum of clinical and laboratory manifestations which, in the severest form, can induce a life-threatening condition.

Primary fallopian tube carcinoma associated with ovulation induction; a case report

The potential relationship between ovulation induction and gynecological cancer has been raised recently. Primary fallopian tube carcinoma (PFTC) is an uncommon malignancy, not previously associated with fertility drugs use. We describe a case of a 38-year-old woman with primary infertility and a history of three ovulation inductions with gonadotropin-releasing hormone agonist and gonadotrophins, referred for treatment of bilateral ovarian cysts, which were discovered in the beginning of the last cycle. During laparotomy, bilateral adnexal masses were identified, presumed to be of ovarian origin, and total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, and retroperitoneal lymph nodes sampling were performed. Histologic examination showed a primary right fallopian tube endometrioid adenocarcinoma and bilateral adnexal endometriosis. Surgery was followed by six cycles of combination chemotherapy using paclitaxel and carboplatin without significant complications. Although evidence of a direct causal link between ovarian stimulation and PFTC does not yet exist, this case highlights the importance for careful evaluation of all discovered adnexal masses in women undergoing ovulation induction treatment.

Safety of drugs used in assisted reproduction techniques

Infertility may affect one in six couples; however, the development of the assisted reproduction technique (ART) created the opportunity for a large proportion of the infertile population to bear children. Pharmacological agents are routinely used in ART, and new ones are introduced regularly, with the aim of retrieving multiple oocytes to increase the prospect of pregnancy. The combinations of drugs that are used have specific adverse effects, but it is mostly the combined action of more than one agent that causes the greatest concern. The matter is complicated by the suspicion that some techniques in ART, for example intracytoplasmic sperm injection for severe male infertility problems (including azoospermia), may also contribute to the increase in adverse effects, especially congenital malformation. Gonadotropin releasing hormone (GnRH) agonists are widely used in controlled ovarian hyperstimulation. It may give rise to a short period of estradiol withdrawal symptoms and it may also lead to luteal phase deficiency. Similarly GnRHa antagonists, which have been recently introduced to control ovarian hyperstimulation, can lead to luteal phase deficiency and may cause some local injection site reactions. The more pure form of gonadotropin leads to less local injection site reactions and their main adverse effects are associated with the consequences of multiple ovulations. It has been proposed that gonadotropins may be a factor in the increasing risk of ovarian cancer and possibly breast cancer, but this has not been substantiated. Prion infection is another potential hazard, although no cases have been reported. Ovarian hyperstimulation syndrome is a well recognised complication of controlled ovarian hyperstimulation in ART. It is usually a result of recruitment of a large number of ovarian follicles. Efforts to minimise the incidence of this syndrome and its severity are now well developed. Congenital malformations are another possible adverse effect of fertility drugs, but it is more probable that the increase in congenital abnormality that is reported in ART is because of the population studied, i.e. patients already at high risk of congenital malformation, rather than the fertility drugs used or the technique employed. High order multiple pregnancy and its sequela is a well established complication of controlled ovarian hyperstimulation. This could be a result of multiple ovulations or more than one embryo replacement. Reducing the number of embryos transferred can reduce this more serious adverse effect for expectant mothers and for children conceived from ART.

Effects of ovulation induction on ovarian morphology: an animal study

OBJECTIVE

The aim of this study was to investigate whether the ovulation induction has relation with postneoplastic lesions.

MATERIALS AND METHODS

Seventy-eight female, 90-day-old rats were enrolled for the trial. They were divided into three groups. In the first group, 13 rats received one cycle of ovulation induction with Follitropin Beta and human chorionic gonadotropin. The second group of 13 rats received three cycles of ovulation induction, and the third study group consisted of 13 rats which received six cycles of ovulation induction. Each group had a control group consisting of same number of rats that had not received ovulation induction. At the 12th month after the ovulation induction protocols ended, rat ovaries were extirpated for histopathological examination. In histopathological examination, malignant lesions, ovarian cyst and cyst diameter, epithelial stratification, epithelial tufting, mitotic index, polymorphism of epithelial cells and nucleus, epithelial cell nuclear diameter, chromatin density nuclear atypia, and mitotic activity in ovarian cyst epithelium were evaluated.

RESULTS

No malignant ovarian lesion was found in the three groups. Ovarian cyst development was most frequent in the rats that underwent six cycles of ovulation induction. Epithelial stratification and tufting were most frequent in the rats which underwent ovulation induction six times. Significant difference was found between induction and control groups in second and third groups for cellular and nuclear polymorphism, presence of nucleolus, and nuclear chromatin density.

CONCLUSIONS

Although development of malignant lesion were not found in any of the rat ovaries after ovulation induction, increase in the prevalence of epithelial dysplasia especially with increase in the number of induction cycles shows that some ovarian pathologies can occur subsequent to ovulation induction.

The possible association between in vitro fertilization treatments and cancer development

The objective of this paper is to assess whether ovarian hyperstimulation and in vitro fertilization (IVF) are associated with increased risk of cancer development, using an historical cohort analysis of infertile women who attended the IVF unit, Lis Maternity Hospital Tel Aviv Medical Center, Tel Aviv, Israel. One thousand and 82 women participated in the IVF treatment program between 1984 and 1992. Cancer incidence rates were determined through the National Cancer Registry and were compared to the expected rates with respect to appropriate age and continent of birth. Twenty-one cases of cancer were observed as compared to 11 that were expected (SIR 1.91; 95% CI 1.18-2.91). When cancer cases that were diagnosed within one year of the IVF treatment were excluded from the analysis (SIR = 1.46; 95% CI 0.83-2.36), no significant excess risk of cancer was noted. We conclude that in this cohort of infertile women, the higher than expected cancer rate could not be attributed to IVF treatments. Special attention should be made to women who may be diagnosed with cancer during or shortly after IVF treatment.

Cancer incidence in a cohort of infertile women who underwent in vitro fertilization

OBJECTIVE

To assess whether ovarian hyperstimulation and IVF increase the risk for cancer.

DESIGN

Historical cohort analysis. SETTING; IVF units of two medical centers in Israel.

PATIENT(S)

Five thousand twenty-six women who underwent IVF between 1981 and 1992. INTERVENTION(S); Cancer incidence rates were determined through linkage to the National Cancer Registry and were compared with expected rates with respect to age, sex, and place of birth.

MAIN OUTCOME MEASURE(S)

Development of cancer.

RESULT(S)

Twenty-seven cases of cancer were observed, and 35.6 were expected (standardized incidence ratio, 0.76 [95% CI, 0.50-1.10]). Eleven cases of breast cancer were observed, whereas 15.86 were expected (standardized incidence ratio, 0.69 [95% CI, 0.46-1.66]). One case of ovarian cancer and 1 case of cervical cancer were observed, compared with 1.74 and 1.73 cases expected, respectively. The type of infertility, number of IVF cycles, and treatment outcome did not significantly affect risk for cancer.

CONCLUSION(S)

In a cohort of women treated with IVF, no excess risk for cancer was noted.

Characteristics of ovarian and uterine cancers in a cohort of in vitro fertilization patients

OBJECTIVE

The aim of this study was to describe the features of cancers of the uterus, ovary, and other uterine adnexae in a large cohort of in vitro fertilization (IVF) patients and to thereby assist gynecologic oncologists in counseling patients with a history of infertility.

METHODS

Record-linkage to population-based cancer registries was used to determine the incidence of invasive cancer in a cohort of 29,700 IVF patients. Pathology reports were made available by the cancer registries and reviewed blind to IVF treatment status. Patient information was abstracted from IVF clinic records.

RESULTS

Twelve cancers of the uterus and 13 cancers of the ovary and other uterine adnexae were identified and pathology reports were reviewed for all but 1. Patients ranged in age at diagnosis from 28 to 48 years. Five cancers were diagnosed within 8 months of referral for IVF or IVF treatment; the others were diagnosed between 1 and 12 years later. The ovarian cancers were of the following histologic types: serous (4), mucinous (1), seromucinous (1), endometrioid (3), clear cell (2), and unknown type (1). A choriocarcinoma of the fallopian tube was diagnosed in a woman with a history of tubal infertility. Cancers of the uterus included endometrial adenocarcinomas (8), stromal sarcomas (2), and leiomyosarcomas (2). Ovarian cancer was diagnosed in a woman with Bloom's syndrome, a rare autosomal recessive disorder associated with increased cancer risk.

CONCLUSION

Cancer cases in this large, well-defined cohort of IVF patients show a broad range of patient and tumor characteristics. We found an increased incidence of uterine sarcoma in women with a history of infertility. Increased ascertainment of preexisting cancers in the course of infertility investigations and management is to be expected.

Administration of gonadotropins stimulates proliferation of normal mouse ovarian surface epithelium

Little is known concerning the proliferation of the ovarian surface epithelium or the factors which control this process. To define when and under what circumstances this epithelium proliferates, we have studied the proliferation of mouse ovarian surface epithelium (OSE) during embryogenesis, early postnatal life, various physiological circumstances in the adult and in response to gonadotropic hormones, using the bromodeoxyuridine technique. Proliferation of the OSE is greatest during embryonic development, and falls gradually after birth until sexual maturity is reached. Very little proliferation of the OSE is detectable in adult life in non-pregnant, pregnant or lactating mice. The basal proliferation of the OSE can be increased significantly by inducing follicular development with pregnant mare serum gonadotropin (PMSG) or by administration of the pure recombinant gonadotropins follicle-stimulating hormone (FSH) or luteinizing hormone (LH). These results show that administration of gonadotropins to sexually mature mice induces proliferation of ovarian surface epithelium concurrently with the process of folliculogenesis.

Messenger ribonucleic acid expression of LH/hCG receptor gene in human ovarian carcinomas

The mRNA expression of luteinizing hormone (LH)/human chorionic gonadotropin (hCG) receptors was analysed by the RT-nested PCR method in five normal ovarian tissues, 62 ovarian tumours (5 benign, 7 borderline and 43 malignant epithelial tumours, 3 sex cord-stromal tumours and 4 germ cell tumours) and in 2 ovarian cancer cell lines. In normal ovaries, two cDNA fragments of different sizes were detected using primers designed to amplify a region including exon 9. Sequencing revealed that the larger fragment was derived from a full-length receptor, while the smaller fragment was a splice variant lacking exon 9. In ovarian tumours, the larger fragment of LH/hCG receptors was detected in 40% of the epithelial ovarian carcinomas, none of the germ cell tumours, all of the sex cord-stromal tumours and one of the 2 ovarian cancer cell lines. Immunohistochemistry confirmed the localisation of LH/hCG receptor protein in the tumour cells which correlated with mRNA expression. Patients with full-length LH/hCG receptors in carcinomas showed a better prognosis compared with those without the receptors.

Fertility drugs and ovarian cancer

Recent case reports of ovarian cancer associated with infertility treatment raise the question of a possible etiopathogenetic role of fertility drugs in ovarian cancer. In this paper, the possible relationship between infertility treatment and ovarian cancer is reviewed with respect to the epidemiological and pathogenetic profiles of ovarian cancer and the potential risk factors associated with fertility drugs; a case report review and a critical reappraisal are also provided within this article. Currently available data in the literature, from epidemiological studies and case reports, suggest that a direct causal effect of infertility treatment on ovarian cancer seems unlikely. Since infertile women are likely to have a higher risk for the development of ovarian cancer, and the role of fertility drugs in the etiopathogenesis of ovarian carcinoma is not established, a close clinical examination of infertile patients before, during and after infertility treatment is recommended. Moreover, further investigation is required to resolve the question of the possible association between fertility drugs and ovarian cancer through large prospective epidemiological or retrospective case-control studies.

Ovulation induction, infertility, and ovarian cancer risk

OBJECTIVE

To review critically the published data regarding the proposed association of ovulation induction, infertility, and an increased risk of ovarian cancer.

DESIGN

A medline search was conducted to identify all case reports, epidemiologic studies, and clinical investigations containing data relevant to infertility, treatment of infertility, and the associated risk of ovarian cancer. Additional sources were obtained from reference lists of original research and review articles. Particular emphasis was placed on the most recently published reports examining these associations.

RESULTS

Four case-control studies and three retrospective cohort studies, as well as a large meta-analysis of three additional case-control studies were identified as presenting the most pertinent clinical data.

CONCLUSION

Currently available data in the literature suggest that an association between ovulation induction and ovarian cancer does not indicate necessarily a causal effect. Infertility alone is an independent risk factor for the development of ovarian cancer. Nulliparous women with refractory infertility may harbor a particularly high risk of ovarian cancer, irrespective of their use of fertility drugs. Furthermore, the apparent association between fertility drug use and ovarian cancer may arise because these women are the most likely to have used ovulation-stimulating agents as part of their infertility treatment. Close clinical surveillance of patients before, during, and after treatment of infertility is warranted.