Cancer Treatment-Related Ovarian Dysfunction in Women of Childbearing Potential: Management and Fertility Preservation Options

Impact of pembrolizumab on ovarian function in young triple-negative breast cancer patients treated with chemo-immunotherapy

PURPOSE

Pembrolizumab plus neoadjuvant chemotherapy (P-CT) is the new standard in early-stage triple-negative breast cancers (TNBC). Pembrolizumab impact on ovarian reserve remained unknown. We evaluated the impact of pembrolizumab on ovarian reserve, through plasmatic Anti-Müllerian (AMH) analysis, in young TNBC patients.

METHODS

TNBC patients < 43 years treated by P-CT (carboplatin/paclitaxel/epirubicin/cyclophosphamide plus pembrolizumab) of which plasma samples were available before and after treatment were included retrospectively (P-CT group). AMH, FSH, and estradiol were analyzed before and after treatment, then compared to a retrospective cohort of TNBC patients treated with chemotherapy alone (cyclophosphamide/anthracycline/taxanes) (No-P group).

RESULTS

P-CT patients (N = 17) and No-P patients (N = 62) had comparable median age, BMI, smoking exposure, BRCA status, oral hormonal contraceptive use at diagnosis, and baseline AMH. Drugs used were comparable in both groups, except for carboplatin and pembrolizumab, only used in P-CT group. One year after the start of treatment, AMH fell from 1.08 to 0.01 ng/mL (p = 0.0001) and from 1.39 to 0.018 ng/mL (p < 0.0001), in the P-CT and No-P groups, respectively, without difference according to pembrolizumab exposure (p = 0.25). 9/17 P-CT patients (53%), and 21/62 No-P patients (34%), had undetectable AMH after treatment (p = 0.25). FSH and estradiol were comparable between the two groups, before and after treatment.

CONCLUSION

No additional impact of pembrolizumab versus chemotherapy alone on AMH evolution was observed in TNBC patients < 43 years. Nevertheless, undetectable AMH 1 year after the start of treatment was common in the P-CT group. Larger studies are essential to confirm these preliminary results and assess long-term impact of pembrolizumab on ovarian reserve.

Granulosa cell death is a significant contributor to DNA-damaging chemotherapy-induced ovarian insufficiency†

Typically, DNA-damaging chemotherapy (CTx) regimens have a gonadotoxic effect and cause premature ovarian insufficiency (POI), characterized by infertility and estrogen deficiency. However, whether loss of granulosa cells killed directly by CTx contributes significantly to POI has not been determined. To address this issue, we used a previously established mouse model of CTx-induced POI. The alkylating drugs Busulfan (8.75 mg/kg) and Cyclophosphamide (100 mg/kg) were administered to 8-week-old FVB female mice by intraperitoneal (IP) injection three times at 48-h intervals, after which ovarian tissues were harvested and examined by immunofluorescence. The number of primordial follicles was significantly reduced at day (d)6, whereas the number of growing follicles was relatively unchanged. CTx led to DNA double strand breaks in both oocytes and granulosa cells based on the presence of γH2AX foci. However, markers of apoptosis predominantly labeled granulosa cells in growing follicles. We next examined the effect of inhibiting apoptosis in growing granulosa cells by generating Bak-/-Baxfx/fx; Cyp19a1Cre transgenic mice. On d10 after the first CTx, Bak-/-Baxfx/fx; Cyp19a1Cre ovaries had fewer apoptotic granulosa cells and more surviving follicles than controls. Furthermore, Bak-/-Baxfx/fx; Cyp19a1Cre mice showed better fertility than controls after CTx. Our data suggest that granulosa cell death is a significant contributor to follicle depletion and fertility loss after Cyclophosphamide and Busulfan.

Effect of Couple-Based Virtual Intervention on Spousal Support and Quality of Life for Women With Breast and Gynecological Cancers in Nigeria

BACKGROUND

Breast and gynecological cancers contribute significantly to cancer-related mortality among Nigerian women. Despite the proven benefits of spousal support in improving cancer outcomes, male involvement in caregiving remains limited due to cultural norms, stigma, and systemic healthcare challenges.

AIMS

This study evaluated the effectiveness of a couple-based virtual intervention in enhancing spousal support and improving the quality of life (QoL) of women undergoing cancer treatment in Nigeria.

METHODS

An embedded mixed-methods design was employed involving 133 Nigerian couples, where women were receiving treatment for breast or gynecological cancer. The intervention consisted of an 8-week virtual peer support program for male partners, delivered via Zoom. Quantitative data were collected using validated instruments assessing spousal support and QoL, and analyzed using descriptive and inferential statistics. Qualitative data were obtained through semi-structured interviews with 21 male participants and analyzed thematically using NVivo 14.

RESULTS

Post-intervention, significant improvements were recorded in spousal support across emotional (p = 0.0413), practical (p = 0.0296), financial (p = 0.0493), and health-related (p = 0.0313) domains. Women's QoL significantly improved in physical (p = 0.0109), psychological (p = 0.0452), social (p = 0.0024), and spiritual (p = 0.0417) domains. Thematic analysis revealed five key themes: emotional growth and support, understanding of partner's needs, building confidence, value of peer connections, and cultural or logistical barriers.

CONCLUSIONS

The couple-based virtual intervention significantly improved male caregiving engagement and the quality of life of women undergoing cancer treatment. Findings support culturally tailored, gender-sensitive interventions in oncology care within resource-limited settings.

Ovarian Function Restoration with Biomimetic Scaffold Incorporating Angiogenic Molecules and Antioxidant in Chemotherapy-Induced Perimenopausal Model

Chemotherapy-induced premature ovarian insufficiency (POI) is a major cause of infertility and hormonal imbalance in young female cancer survivors. In this study, developed a biomimetic scaffold is developed that incorporates polydeoxyribonucleotide (PDRN) and melatonin to restore ovarian function. The scaffold is designed to mimic the ovarian extracellular matrix (ECM), enhancing angiogenesis, promoting antioxidant effects, and reducing reactive oxygen species (ROS). Human embryonic stem cell-derived mesenchymal progenitor cells (hESC-MPCs) are also incorporated to further support tissue regeneration. The scaffold demonstrated strong efficacy in improving cell survival, promoting folliculogenesis, and restoring ovarian function in a chemotherapy-induced perimenopausal mouse model. Results showed that the scaffold enhanced vascularization, reduced fibrosis, and normalized hormone levels, including estrogen (E2) and anti-Müllerian hormone (Amh). Additionally, the transplantation of the scaffold restored fertility rates and increased the number of offspring in treated mice. This approach presents a promising solution for improving ovarian recovery and fertility preservation in patients with chemotherapy-induced POI, offering a novel therapeutic strategy for reproductive health.

AMH decline during chemotherapy reflects breast cancer cell DNA damage response (DDR) proficiency: the ONCO AMH1 pilot study

PURPOSE

The impact of a germline BRCA1/2 pathogenic variant (gBRCApv) on baseline or late post-treatment AMH concentrations in breast cancer patients has been extensively studied, yielding mixed conclusions. However, whether the AMH decline during neo-adjuvant chemotherapy reflects differences in chemotherapy susceptibility between gBRCApv carriers and non-carriers remains unexplored.

METHODS

A monocentric, retrospective, longitudinal study was conducted on breast cancer patients carrying a gBRCApv (n = 12) or wild-type (WT) (n = 35) who received a neo-adjuvant sequential chemotherapy (CT) with anthracyclines followed by taxanes. Serum AMH levels were measured at baseline (AMH0) and at three time points during CT by a hypersensitive assay. Tumor size change was assessed via imaging. The impact of genetic status on AMH decline was evaluated using a linear mixed model with post hoc analysis.

RESULTS

The change of AMH concentrations from baseline to the end of CT tended to be influenced by the genetic status (BRCA * time interaction, p = 0.058). The slope between AMH0 and the end of anthracyclines (after log transformation) was steeper in gBRCApv than in WT patients (mean (SE): - 5.54 (0.63) vs - 3.97 (0.62); p = 0.023). Tumor size change was positively and significantly correlated with the change in AMH levels (AMH MidCT-AMH0) in gBRCApv patients (r = 0.93, p < 0.001) but not in WT patients (r = - 0.05; p = 0.84).

CONCLUSION

Germline BRCA1/2 status influences AMH decline during neo-adjuvant CT with drugs inducing DNA lesions. AMH decay is positively related to tumor size change assessed by imaging in gBRCApv patients. However, no conclusions can be drawn regarding the relationship with treatment response assessed by histological criteria.

Effects of Chemotherapy on Fertility and Fertility Preservation Strategies for the Women of Childbearing Potential Undergoing Chemotherapy: A Comprehensive Review

Cancer incidence among women of childbearing potential (WCBP) underscores the need for effective fertility preservation strategies. Advances in cancer treatment have significantly improved survival rates, highlighting survivorship issues, particularly fertility concerns in younger patients. Chemotherapy, while a crucial treatment for cancer, often brings with it unintended consequences, particularly regarding fertility. Chemotherapy induces gonadotoxicity through mechanisms such as DNA damage, follicular apoptosis, and hormonal disruption, compromising ovarian function and fertility. The risk of infertility may be low, intermediate, or high depending upon the drug used, the dose, and the duration of use. Quantifying chemotherapy's impact is challenging due to diverse agents and variable effects. Guidelines recommend discussing fertility preservation options with WCBP before treatment, using biomarkers like anti-Mullerian hormone (AMH) to assess ovarian reserve. Strategies include cryopreservation of ovarian tissue, embryos, and oocytes, each with distinct advantages and considerations. Pharmacological interventions like GnRH agonists aim to mitigate gonadotoxic effects, although their efficacy is debated. Surgical approaches like oophoropexy protect ovaries during pelvic radiation but pose logistical challenges. Fertility preservation involves ethical and psychosocial dimensions, including informed consent, financial considerations, and ethical dilemmas, necessitating comprehensive patient counselling. Future research focuses on enhancing techniques such as in vitro maturation, developing artificial ovaries, and refining cryopreservation methods to optimize outcomes.

Health-Related Quality of Life in Breast Cancer Patients during Chemotherapy: A Cross-Sectional Study Using the EORTC QLQ-C30 and BR45

Objective

To assess health-related quality of life (HRQoL) using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire for Breast Cancer (EORTC QLQ-BR45) in conjunction with the Core questionnaire (EORTC QLQ-C30) in breast cancer patients receiving chemotherapy.

Materials and Methods

This prospective, cross-sectional study was conducted in the oncology department of a tertiary care hospital for six months. Patients aged ≥18 years, diagnosed with breast cancer, and who had received at least three chemotherapy cycles were included in the study. The EORTC (QLQ-BR45 and QLQ-C30) questionnaires were used to assess HRQoL at chemotherapy cycle 3 (C3) and at C6 and C9. Data were analyzed using the Mann-Whitney U and Friedman tests for significance (p<0.05).

Results

The study showed improved global health status (C3:37.29%, C6:42.37%, C9:50%), high cognitive functioning (C3:89.83%, C6:91.53%, C9:96.55%), but decreasing emotional functioning (C3:66.10%, C6:49.15%, C9:36.21%). Symptom burden peaked in the sixth cycle but diminished over time with a trend towards fatigue (C3:64.41%, C6:67.80%, C9:37.93%), dyspnea (C3:54.24%, C6:55.93%, C9:32.76%), and pain (C3:42.37%, C6:52.54%, C9:34.48%). The study indicated satisfaction with body image (C3:61.02%, C6:67.80%, C9:67.24%) but decreased sexual functioning (C3:40.68%, C6:44.07%, C9:46.55%). Distress related to hair loss (p = 0.0001) increased over time.

Conclusion

There was increased symptom burden at C6, underscoring the need for early interventions. We observed severe symptoms in elderly. However, lack of comorbidities and metastasis improved the emotional wellbeing in patients. These findings accentuate the importance of personalized and holistic care approaches in oncology.

Oncofertility Barriers in Nurses Caring for Women with Breast Cancer

Despite the importance of oncofertility care in supporting women coping with fertility challenges after breast cancer, the practice of oncofertility care among nurses remains suboptimal. There is an urgent need to investigate oncofertility barriers faced by nurses caring for women with breast cancer. A cross-sectional online study was conducted among registered nurses caring for women with breast cancer. A self-developed questionnaire and the Oncofertility Barriers Scale (OBS) were used to assess participants' characteristics and self-perceived barriers. A score ≥ 3 indicates a high level of oncofertility barriers requiring further attention. 372 nurses completed the survey, with 45.54% reporting a score of ≥ 3 on the OBS. Notably, 85% of participants reported high levels of barriers in at least one domain and 27.42% reported barriers in all six domains of the scale. The most commonly reported barrier was "Stereotype of cancer patients" (71%). Nurses without fertility training, those who did not read fertility-related guidelines, and those in departments lacking such guidelines reported significantly higher barriers (all p < 0.05). The prevalence of oncofertility barriers among nurses is high. Educational programs should be developed to address these barriers, improving the quality of oncofertility care for women with breast cancer.

Optimizing treatment efficacy and fertility preservation in patients undergoing hematopoietic stem cell transplantation: A narrative review of ovarian shielding with total-body irradiation or treosulfan-based conditioning regimens

Background

Pediatric and adolescent/young adult (AYA) patients with hematologic malignancies often require hematopoietic stem cell transplantation (HSCT) using conditioning regimens that pose high risks for gonadal toxicity. Traditional protocols, including total body irradiation (TBI) and busulfan-based regimens, can impair fertility. This review explores the potential of gonadal shielding during TBI and treosulfan-based conditioning as strategies to optimize treatment efficacy while preserving fertility.

Methods

A PubMed search up to February 2025 was performed for English, peer-reviewed articles on hematologic malignancies, HSCT, shielding, and treosulfan. Studies on oncologic outcomes and fertility in pediatric and AYA patients were included.

Main Findings

Ovarian shielding during myeloablative conditioning with TBI effectively reduces ovarian radiation exposure, resulting in improved menstrual recovery and hormone profiles. A treosulfan-based regimen demonstrated higher antitumor activity than a reduced-intensity busulfan-based regimen in randomized controlled trials. In a retrospective analysis, the treosulfan-based regimen exhibited lower gonadal toxicity than the busulfan-based regimen, although careful attention must be paid to dosing settings of the regimens.

Conclusion

Ovarian shielding during TBI and a treosulfan-based regimen hold the potential to preserve the reproductive capacity of patients undergoing HSCT. Future clinical studies that appropriately assess both oncological outcomes and fertility are needed to validate these findings.

Successful Pregnancy after Fertility-sparing Surgery and Treatment for Metachronous Multiple Primary Malignancies - A Case Report

The occurrence of metachronous multiple primary malignancies remains relatively rare; however, its incidence is notably rising. We present the case of a 25-year-old woman who underwent fertility-sparing surgery, followed by chemotherapy for ovarian yolk sac tumor. Three years later, the patient was diagnosed with a large B-cell lymphoma in the cecum. She underwent bowel surgery and received chemotherapy postoperatively. Despite her condition, she was able to conceive spontaneously and had a successful pregnancy after treatment. This report highlights the importance of considering fertility-preserving treatment strategies in young patients and the possibility of spontaneous conception and successful pregnancy even in patients diagnosed with metachronous multiple primary malignancies who underwent extensive surgical procedures and heavily treated with chemotherapy.

Hormone receptor-positive early breast cancer in young women: A comprehensive review

The incidence of breast cancer in ≤ 40 yr-old women (YWBC) has been steadily increasing in recent decades. Although this group of patients represents less than 10 % of all newly diagnosed BC cases it encompasses a significant burden of disease. Usually underrepresented in clinical trials, YWBCs are also characterized by late diagnoses and poorly differentiated, aggressive-subtype disease, partly explaining its poor prognosis along with a high recurrence risk, and high mortality rates. On the other hand, YWBC treatment poses unique challenges such as preservation of fertility, and long-term toxicity and adverse events. Herein, we summarize the current evidence in hormone receptor-positive YWBC including specific risk factors, clinicopathologic and genomic features, and available evidence on response to chemotherapy and endocrine therapy. Overall, we advocate for a more comprehensive multidisciplinary healthcare model to improve the outcomes and the quality of life of this subset of younger patients.

Ameliorative Effect of Chitosan/Spirulina platensis Ethanolic Extract Nanoformulation against Cyclophosphamide-Induced Ovarian Toxicity: Role of PPAR-γ/Nrf-2/HO-1 and NF-kB/TNF-α Signaling Pathways

Cyclophosphamide (CP) is an anticancer drug that causes infertility disorders. This study was designed to evaluate a nanoformulation of chitosan with an ethanolic extract from Spirulina platensis in terms of its protection against cyclophosphamide-induced ovarian toxicity. Nine groups of female Wistar rats were randomly assigned as follows: 1: control vehicle, 2: chitosan polymer, 3: telmisartan, 4: Spirulina platensis extract, 5: nanoformulation of the Spirulina platensis, and 6: single injection of CP; groups 7, 8, and 9 received the same treatments as those used in groups 3, 4, and 5, respectively, with a single dose of CP (200 mg/kg, I.P). The results displayed that the CP treatment decreased estradiol, progesterone, anti-mullerian hormone, and GSH content, and it downregulated PPAR-γ, Nrf-2, and HO-1 gene expression. In addition, the CP treatment caused an increase in the FSH, LH, and MDA levels. In the same manner, the protein expression of caspase-3, NF-kB, and TNF-α was upregulated in response to the CP treatment, while PPAR-γ was downregulated in comparison with the control. The rats treated with SPNPs exhibited a substantial reduction in the detrimental effects of oxidative stress and inflammation of the ovarian tissue. This study's conclusions showed that SPNPs counteracted the effects of CP, preventing the death of ovarian follicles and restoring the gonadotropin hormone balance and normal ovarian histological appearance.

Onset and resolution of ovarian toxicity with nirogacestat treatment in females with desmoid tumors: Updated safety analyses from the DeFi phase 3 study

INTRODUCTION

Nirogacestat is a targeted gamma secretase inhibitor approved in the United States for adults with progressing desmoid tumors. In the phase 3 DeFi study (NCT03785964) of nirogacestat, ovarian toxicity (OT) was identified as a safety signal among females of reproductive potential (FORP). This analysis further describes the incidence, presentation, and resolution of OT.

METHODS

Patients were randomized to twice-daily oral nirogacestat (150 mg) or placebo, taken in continuous 28-day cycles. Investigator-identified OT in FORP was based on abnormal reproductive hormone values or perimenopausal symptoms (or both). Adverse event follow-up was conducted to assess OT resolution. Post hoc analyses included return of menstruation and return of follicle-stimulating hormone (FSH) to within normal limits (WNL) (≤20.4 mIU/mL).

RESULTS

Of 92 randomized females, 73 in the safety population were FORP (n = 36 nirogacestat, n = 37 placebo). OT was identified in 75% (27 of 36) receiving nirogacestat and 0% (0 of 37) receiving placebo. As of October 24, 2022, investigators reported OT resolution in 78% (21 of 27) of patients, with median OT duration of 19.1 weeks. Off-treatment resolution was reported in all 11 patients (100%) who stopped nirogacestat treatment; of these, all nine with available menstruation information experienced return of menstruation and eight had FSH WNL at last reported assessment. Resolution was reported in 10 of 14 (71%) while on nirogacestat; of these, all 10 experienced return of menstruation and seven had FSH WNL. Two patients were lost to follow-up.

CONCLUSION

Most FORP treated with nirogacestat experienced OT, with the majority resolving, including all who stopped treatment, suggesting that OT is transient.

Global, regional, and national burden of female cancers in women of child-bearing age, 1990-2021: analysis of data from the global burden of disease study 2021

Background

The global status of women's health is underestimated, particularly the burden on women of child-bearing age (WCBA). We aim to investigate the pattern and trend of female cancers among WCBA from 1990 to 2021.

Methods

We retrieved data from the Global Burden of Disease Study (GBD) 2021 on the incidence and disability-adjusted life-years (DALYs) of four major female cancers (breast, cervical, uterine, and ovarian cancer) among WCBA (15-49 years) in 204 countries and territories from 1990 to 2021. Estimated annual percentage changes (EAPC) in the age-standardised incidence and DALY rates of female cancers, by age and socio-demographic index (SDI), were calculated to quantify the temporal trends. Spearman correlation analysis was used to examine the correlation between age-standardised rates and SDI.

Findings

In 2021, an estimated 1,013,475 new cases of overall female cancers were reported globally, with a significant increase in age-standardised incidence rate (EAPC 0.16%), and a decrease in age-standardised DALY rate (-0.73%) from 1990 to 2021. Annual increase trends of age-standardised incidence rate were observed in all cancers, except for that in cervical cancer. Contrary, the age-standardised DALY rate decreased in all cancers. Breast and cervical cancers were prevalent among WCBA worldwide, followed by ovarian and uterine cancers, with regional disparities in the burden of four female cancers. In addition, the age-standardised incidence rates of breast, ovarian, and uterine cancers basically showed a consistent upward trend with increasing SDI, while both the age-standardised incidence and DALY rates in cervical cancer exhibited downward trends with SDI. Age-specific rates of female cancers increased with age in 2021, with the most significant changes observed in younger age groups, except for uterine cancer.

Interpretation

The rising global incidence of female cancers, coupled with regional variations in DALYs, underscores the urgent need for innovative prevention and healthcare strategies to mitigate the burden among WCBA worldwide.

Funding

This study was supported by the Science Foundation for Young Scholars of Sichuan Provincial People's Hospital (NO. 2022QN44 and NO. 2022QN18); the Key R&D Projects of Sichuan Provincial Department of Science and Technology (NO. 2023YFS0196); the National Natural Science Foundation of China (No. 82303701).

Gynotoxic Effects of Chemotherapy and Potential Protective Mechanisms

Chemotherapy is one of the leading cancer treatments. Unfortunately, its use can contribute to several side effects, including gynotoxic effects in women. Ovarian reserve suppression and estrogen deficiency result in reduced quality of life for cancer patients and are frequently the cause of infertility and early menopause. Classic alkylating cytostatics are among the most toxic chemotherapeutics in this regard. They cause DNA damage in ovarian follicles and the cells they contain, and they can also induce oxidative stress or affect numerous signaling pathways. In vitro tests, animal models, and a few studies among women have investigated the effects of various agents on the protection of the ovarian reserve during classic chemotherapy. In this review article, we focused on the possible beneficial effects of selected hormones (anti-Müllerian hormone, ghrelin, luteinizing hormone, melatonin), agents affecting the activity of apoptotic pathways and modulating gene expression (C1P, S1P, microRNA), and several natural (quercetin, rapamycin, resveratrol) and synthetic compounds (bortezomib, dexrazoxane, goserelin, gonadoliberin analogs, imatinib, metformin, tamoxifen) in preventing gynotoxic effects induced by commonly used cytostatics. The presented line of research appears to provide a promising strategy for protecting and/or improving the ovarian reserve in the studied group of cancer patients. However, well-designed clinical trials are needed to unequivocally assess the effects of these agents on improving hormonal function and fertility in women treated with ovotoxic anticancer drugs.

A retrospective study of ovarian tissue cryopreservation in female patients with hematological diseases for fertility preservation

PURPOSES

To investigate the effect and safety of ovarian tissue cryopreservation (OTC) for fertility preservation in female patients with hematological diseases.

METHODS

We designed a retrospective study. The clinical data of patients with hematological diseases undergoing OTC admitted to Peking University People's Hospital from April 2017 to January 2023 were analyzed and summarized.

RESULTS

A total of 24 patients were included in the study, including 19 patients with malignant hematological diseases and 5 patients with non-malignant hematological diseases. The former included 14 patients with acute leukemia, 1 patient with chronic leukemia, and 4 patients with myelodysplastic syndrome, while the latter 5 patients were aplastic anemia (AA). 16 patients had received chemotherapy before OTC. The average age of 24 patients was 22.80 ± 6.81 years. The average anti-Mullerian hormone (AMH) was 1.97 ± 2.12 ng/mL, and the average follicle-stimulating hormone (FSH) was 7.01 ± 4.24 IU/L in examination before OTC. FSH was greater than 10.0 IU/L in 4 cases. The pre-OTC laboratory tests showed that the average white blood cell (WBC) count was (3.33 ± 1.35) × 109/L, the average hemoglobin was 91.42 ± 22.84 g/L, and the average platelet was (147.38 ± 114.46) × 109/L. After injection of recombinant human granulocyte colony-stimulating factor (rhG-CSF), blood transfusion, and iron supplementation in pre-OTC treatment, the average WBC count was (4.91 ± 3.07) × 109/L, the average hemoglobin was 98.67 ± 15.43 g/L, and the average platelet was (156.38 ± 103.22) × 109/L. Of the 24 patients, 22 underwent laparoscopic bilateral partial oophorectomy and oophoroplasty, and 2 underwent laparoscopic unilateral oophorectomy. The average duration of OTC was 59.54 ± 17.58 min, and the average blood loss was 32.1 ± 41.6 mL. The maximum blood loss was 200 mL. There was no significant difference in WBC count and hemoglobin concentration after OTC compared to pre-OTC period. Only the platelet count after OTC surgery was significantly different from that before surgery ([134.54 ± 80.84 vs. 156.38 ± 103.22] × 109/L, p < 0.05). None of the 24 patients had serious complications after OTC. 2 patients had mild infection symptoms, but both recovered well. 23 patients underwent hematopoietic stem cell transplantation (HSCT) after OTC. The median and interquartile range from OTC to the pretreatment of HSCT was 33 (57) days, and the median and interquartile range from OTC to HSCT was 41 (57) days. Seven of them began pretreatment of HSCT within 20 days and began HSCT within 30 days after OTC. All patients were followed up. Of the 23 patients who underwent HSCT after surgery, 22 presented with amenorrhea and 1 with scanty menstrual episodes. Seven patients underwent hormone replacement therapy (HRT) after HSCT. A patient with AA underwent ovarian tissue transplantation (OTT) 3 years after HSCT and resumed regular menstruation 6 months after OTT.

CONCLUSIONS

Ovarian tissue cryopreservation has a promising future in fertility protection in patients with hematological diseases. However, patients with hematological malignancies often have received gonadotoxic therapy before OTC, which may be accompanied by myelosuppression while patients with non-malignant hematological diseases often present with severe hemocytopenia. So perioperative complete blood count of patients should be paid attention to. There was no significant difference in the WBC count and hemoglobin concentration in patients with hematological diseases before and after OTC surgery, and the platelet count decreased slightly within the normal range. Infection is the most common post-OTC complication, and HSCT pretreatment can be accepted as early as the 10th day after OTC. OTC has no adverse effects on patients with hematological diseases and does not delay HSCT treatment. For young patients with hematological diseases, OTC is an effective method of fertility preservation.

Future of Treatment of Adolescents and Young Adults With ALL: A Vision for Collaboration and Equity

Over the past several decades, survival of children with ALL has improved dramatically with treatment regimens refined through cooperative group trials. Despite aggressive treatment and iterative therapy changes for adolescents and young adults (AYAs), improvement has not been as promising. Comparisons between pediatric and adult clinical trials have consistently demonstrated superior outcomes for AYAs treated on pediatric ALL protocols, leading to the implementation of pediatric-inspired ALL protocols by several groups worldwide and/or expansion of the age limit of pediatric trials to include the full spectrum of the AYA population. Despite these efforts, AYAs in both pediatric and adult settings continue to have inferior survival compared with younger children with ALL. Real-world data suggest that uptake of pediatric-style treatment is variable, and even with identical pediatric-style treatment, AYAs still fare worse than younger children. As we enter an era of immunotherapy and precision medicine for newly diagnosed ALL, now is an opportune time to consider how best to approach future therapy for AYA patients. Comparisons of pediatric and adult treatment approaches and subanalyses of AYA patients will help guide harmonization of treatment. The focus of the next stage of ALL therapy for AYA should not only involve novel treatment approaches but also standardization and optimization of supportive care measures, psychosocial support, adherence interventions, oncofertility treatment, and survivorship care. All these efforts should simultaneously work to address health disparities to ensure that a future of improved outcomes is experienced equitably for all AYA patients.

Neurotrophin-4 promotes in vitro development and maturation of human secondary follicles yielding metaphase II oocytes and successful blastocyst formation

STUDY QUESTION

Does a matrix-free culture system supplemented with neurotrophic factor 4 (NT4) improve human in vitro follicular development and meiotic maturation, ultimately resulting in fertilizable oocytes?

SUMMARY ANSWER

NT4 supplementation of in vitro culture significantly enhances the growth, steroid hormone production, and maturity potential of human secondary follicles derived from fresh ovarian medulla (from post- and pre-pubertal patients), thereby yielding fertilizable oocytes.

WHAT IS KNOWN ALREADY

Reconstituting folliculogenesis in vitro is of paramount importance in the realms of fertility preservation, reproductive biology research, and reproductive toxicity assessments. However, the efficiency of in vitro culture systems remains suboptimal, as the attainment of fertilizable oocytes from in vitro growth (IVG) of human follicles remains unachieved, with the data being particularly scant regarding follicles from prepubertal girls. We have previously found that mouse oocytes from secondary follicles derived from IVG are deficient in neuroendocrine regulation. NT4 and its corresponding receptor have been identified in human follicles. Significantly, the addition of NT4 during the IVG process markedly enhances both follicle growth and oocyte maturation rates in mice.

STUDY DESIGN SIZE DURATION

Fresh medulla tissue obtained during tissue preparation for ovarian tissue cryopreservation (OTC) were collected from 10 patients aged from 6 to 21 years old, all of whom had undergone unilateral oophorectomy as a means of fertility preservation. Isolated secondary follicles were individually cultured in vitro with or without NT4 in a matrix-free system.

PARTICIPANTS/MATERIALS SETTING METHODS

Secondary follicles, extracted via enzymatic digestion and mechanical disruption from each patient, were randomly allocated to either a control group or an NT4-supplemented group (100 ng/ml), followed by individual culture on an ultra-low attachment plate. Follicle growth and viability were assessed by microscopy. Levels of anti-Müllerian hormone (AMH), estradiol, and progesterone in the medium were quantified. An oocyte-specific marker was identified using confocal fluorescence microscopy following DEAD box polypeptide 4 (DDX4) staining. The competence of individual oocytes for maturation and fertilization were assessed after IVM and ICSI with donated sperm samples.

MAIN RESULTS AND THE ROLE OF CHANCE

Overall, isolated follicles from both groups survived up to 6 weeks with increasing diameters over the duration (P < 0.05), reaching terminal diameters of almost 1 mm with confirmed steroidogenesis and expression of oocyte marker (DDX4), and producing morphologically normal MII oocytes. When compared with the control group, the NT4 group had a similar initial follicular diameter (206 ± 61.3 vs 184 ± 93.4 μm) but exhibited a significant increase in follicular diameter from the ninth day of culture onwards (P < 0.05). From Week 3, estradiol and progesterone production were significantly increased in the NT4 group, while no significant difference was observed in AMH production between groups. The proportion of 'fast-growth' follicles in the NT4 group was significantly higher than that in the control group (13/23 vs 6/24, P < 0.05). An increased efficiency of MII oocyte maturation per live follicle in the NT4 group was also observed (control group vs NT4 group, 4/24 vs 10/23, P < 0.05). It is noteworthy that an MII oocyte obtained from the control group exhibited abnormal fertilization after ICSI. In contrast, an MII oocyte acquired from the NT4 group progressed to the blastocyst stage and showed potential for transfer.

LARGE SCALE DATA

N/A.

LIMITATIONS REASONS FOR CAUTION

The cohort examined in this study was all patients diagnosed with beta-thalassemia major. Whether this culture system is effective for patients with other diseases remains unknown. Since the chosen dose of NT4 was established based on dose finding in mice, the optimal dose for use in a human IVG system needs further confirmation. The oocytes and embryos procured from this study have not been quantified for ploidy status or epigenetic signatures.

WIDER IMPLICATIONS OF THE FINDINGS

Fresh medulla tissue obtained during tissue preparation for OTC may serve as a precious source of fertilizable oocytes for female fertility preservation, even for pre-pubertal girls, without the threat of tumour reintroduction. After further characterization and optimization of the system, this culture system holds the potential to provide a powerful future research tool, for the comprehensive exploration of human follicular development mechanisms and for conducting reproductive toxicity evaluations.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the National Key R&D Program of China (grant number 2022YFC2703000) and National Natural Science Foundation of China (grant numbers 82271651 and 81871214). The medium used in human follicle in vitro culture in this study has been applied for a national invention patent in China (No. 202211330660.7). The inventors of the patent, in order, are: Y.G., C.F., and X.L.