High capacity for leukotriene biosynthesis in peripheral blood during pregnancy

Pregnancy is accompanied by major immunological changes to maintain both tolerance for the fetus and immune competence. Leukotrienes are powerful 5-lipoxygenase-derived inflammatory mediators and the characteristics of leukotriene-related diseases (e.g., asthma, allergic rhinitis) change during pregnancy. Here, we show that pregnancy affects leukotriene synthesis in human blood and leukocytes. 5-Lipoxygenase product formation in stimulated blood of pregnant women was significantly higher than in non-pregnant females. Although a pregnancy-related increase in neutrophil and monocyte counts may explain these observations, granulocytes of pregnant donors have lower leukotriene-synthetic capacities. On the other hand, granulocytes from non-pregnant woman produced more leukotrienes when resuspended in plasma of pregnant women than of non-pregnant females. Together, we show that leukotriene biosynthesis in maternal blood is increased by the interrelations of higher leukocyte numbers, lower cellular capacity for leukotriene synthesis and stimulatory effects of plasma. This bias may affect leukotriene-related diseases during pregnancy and their pharmacological treatment.

Fertility preservation in prepubertal girls prior to chemotherapy and radiotherapy--review of the literature

Significant improvement in the survival rates of children with pediatric cancers has been achieved over the last 25 years, so the number of long-term survivors is increasing and their subsequent quality of life is of increasing importance. One of the most serious side effects of chemotherapy or radiotherapy is damage to the ovarian function, which can lead to loss of fertility. The degree of this damage depends on the substances used, the dose of radiotherapy reaching the ovaries, and the age of the girl at the time of treatment. Up to now, the only established method of fertility preservation has been cryoconservation of fertilized egg cells or embryos, but this is not possible in prepubertal girls because of their sexual immaturity. Removal of ovarian tissue and subsequent cryoconservation with the option of later orthotopic retransplantation is therefore an option to these girls. This method can lead to pregnancy and birth in adult women. Up to now there are no studies about the retransplantation of ovarian tissue which was removed before puberty. Displacement of the ovaries away from the radiation field before radiation to the pelvic area can be considered; however, the data is controversial. One problem in the use of fertility preservation methods in these very young patients is that they undergo procedures which, because of their age, they mostly do not understand and the parents must make a decision based on the assumed later wishes of their daughter.

Fertility preservation methods in young women with systemic lupus erythematosus prior to cytotoxic therapy: experiences from the FertiPROTEKT network

OBJECTIVES

Despite new treatment options, some patients with systemic lupus erythematosus (SLE) need to be treated with the cytotoxic agent cyclophosphamide (CYC). Unlike malignant disease, there are no recommendations for ovarian protection in SLE. The clinical experience of the FertiPROTEKT network as well as recommendations after literature review will be presented in this paper.

METHODS

Retrospective analyses of counselling and treatment data from the FertiPROTEKT register with special respect to SLE patients under 40 years prior to planned CYC treatment.

RESULTS

A total of 2836 patients were advised prior to cytotoxic treatment in one of the FertiPROTEKT centres during January 2007 to November 2011. Of those, 68 patients (mean age 25 +/- 6.07 years) were counselled for severe SLE. Only five women did not make use of a fertility preservation method. Sixty-three patients (92.6%) decided in favour of a fertility preservation method. The largest proportion (91.2%) opted for treatment with a GnRH analogue. Ovarian tissue removal for cryoconservation was performed in 16 patients (25%). Stimulation therapy for cryoconservation of fertilized egg cells was performed in three patients (4.4%).

CONCLUSIONS

When counselling patients with SLE for fertility preservation one has to be aware of the disease-specific risks. According to the literature, a safe and effective option in SLE up to now has been the use of a GnRH analogue. Cryoconservation of ovarian tissue must still be seen as an experimental treatment, but as data on removal, cryoconservation, retransplantation and pregnancies are steadily rising, this presents a promising option for young SLE patients. Cryoconservation of oocytes must be very critically evaluated due to the need for a stimulation therapy and should only be performed after particular consideration of the individual risks.

Pregnancy after successful cancer treatment: what needs to be considered?

Over the last decade, advances in oncology led to improved treatment results and increasing numbers of long-term cancer survivors. Fulfilling the desire to have children is important for many patients after cancer treatment. Consequently, oncologists, gynecologists and obstetricians are seeing more patients who wish to conceive after treatment. The necessary prerequisites that should be considered when supporting a planned pregnancy after cancer treatment are discussed in this article. The possible consequences of chemotherapy and radiotherapy on the course of pregnancy and the health of the offspring, as well as the interactions between cancer and pregnancy, are reviewed with the focus on childhood cancer, malignant lymphomas, and breast cancer. Despite chemo- or radiotherapy, neither the teratogenic risk nor the risk of adventitious cancers appears to be increased for the offspring of cancer survivors. However, there is a slightly higher risk of miscarriage after chemotherapy. In case of radiation to the uterus, there is a higher risk of premature birth, intrauterine growth retardation, and increased perinatal mortality. The effect is more pronounced after prepubertal radiation than for postpubertal radiation. The former cancer patient's desire to conceive can nevertheless be supported, given that pregnancy and birth are closely monitored.

Fertility preservation in women with vasculitis: experiences from the FertiPROTEKT network

OBJECTIVES

Fertility preservation is not only important for malignant diseases but should also be offered to patients with autoimmune diseases (AID) like vasculitides, prior to cyclophosphamide therapy. No recommendations are available for patients with AID.

METHODS

Analysis from the Fertiprotekt registry of all female patients with age <40 and the diagnosis of a vasculitis. The number of counselled patients, their diagnosis and age, the number of children before the start of therapy as well as the fertility preservation treatment chosen were evaluated.

RESULTS

From January 2007 to November 2011, 47 patients with the diagnosis AID were counselled at 17 of the 69 Fertiprotekt centres. 80.9% decided for at least one of the offered preservation methods. Ovarian cryopreservation was performed in 6 patients, 36 patients opted for GnRH-analogue treatment. Two patients decided for a stimulation therapy for cryopreservation of oocytes.

CONCLUSIONS

Regarding the experiences from the registry and the literature gonadotropin releasing hormone analogues are evaluated best and recommended to most of the patients with AID. Cryoconservation of ovarian tissue is a promising option. Stimulation for oocyte cryopreservation can be offered to patients with vasculitis. A combination of the methods might have the biggest preservative effect.

Impact of systemic lupus erythematosus on ovarian reserve in premenopausal women: Evaluation by using anti-Muellerian hormone

Systemic lupus erythematosus (SLE) is an autoimmune disease which may negatively influence fertility. Treatment with cyclophosphamide can damage the ovaries. The ovarian function can also be reduced by autoimmune oophoritis in lupus patients. We analysed the influence of SLE on the ovarian reserve against disease intensity and duration of illness. We determined the ovarian reserve in 33 premenopausal SLE patients without previous cyclophosphamide-treatment by measuring the anti-Muellerian hormone (AMH) and compared these with the AMH values of 33 age-matched healthy controls. Numbers of children and miscarriages were reported. Disease intensity of the SLE patients was determined using SLEDAI and ECLAM and duration of illness was taken into account. We found that the AMH values in the SLE group were significantly lower than in the healthy control group. No significant differences between the groups regarding number of children and miscarriages were noted and no correlation between the AMH value and the duration of illness or the SLEDAI as an indicator of disease activity was found. Despite mild disease activity SLE patients had a significantly lower ovarian reserve than age-matched healthy women. This could be a sign that SLE itself has a negative influence on the ovarian reserve.

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.

Fertility preservation in young female lymphoma patients: review of available options and initial experiences with their implementation in clinical routine

BACKGROUND

High cure rates in women suffering from Hodgkin's disease or aggressive non-Hodgkin's lymphoma are often achieved at the cost of impaired ovarian function or infertility. Different strategies can be offered to protect fertility. Early experiences with the implementation of a specialised fertility preservation clinic are analysed with the aim to assess the need for and acceptance of the clinic, as well as the delay of treatment caused by the different approaches. Available options are reviewed.

PATIENTS AND METHODS

Data on underlying malignancy and fertility preservation measures in women of childbearing age treated for aggressive lymphoma and Hodgkin's disease with curative intent between November 2006 and January 2010 were retrospectively analysed.

RESULTS

Among 111 female lymphoma patients, 30 were eligible for counselling. Nineteen accepted the offer. The main reason for declining was completed family planning. Eight further patients were referred from elsewhere. Of the counselled patients, 96% decided to pursue at least 1 protective strategy, 39% chose an invasive procedure (cryopreservation of ovarian tissue or oocyte aspiration following hormonal stimulation). These procedures deferred the start of systemic treatment within the expected range, no undue delays were observed.

CONCLUSIONS

Female lymphoma patients have a large demand for counselling about measures to protect fertility. In a proper setting, counselling and intervention can be offered without undue delays menacing the chance for cure.

Pregnancy after breast cancer: case report and review of the literature

Despite breast cancer diagnosis and treatment, women of childbearing age often desire a pregnancy. Since the average age of women giving birth for the first time is increasing, many young patients diagnosed with breast cancer have not started or completed their family planning. Thus, gynecologists and oncologists are confronted more often with the question of childbearing after breast cancer. Current data from retrospective trials do not suggest an increased risk of a recurrence or progress of the disease associated with pregnancy after stage-adjusted treatment. Also, the risk of fetal malformations and damage to the fetus after chemotherapy and/or hormone therapy seems similar to that in the general population. Women who receive chemotherapy are advised to wait at least 6 months before they attempt to conceive. The question whether to become pregnant must be discussed individually with the patient, based on tumor characteristics, stage of the disease and patient's wishes.

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.