Ovarian stimulation and in-vitro fertilization outcomes of cancer patients undergoing fertility preservation compared to age matched controls: a 17-year experience

Current practices in oncofertility counseling: updated evidence on fertility preservation and post-treatment pregnancies in young women affected by early breast cancer

INTRODUCTION

Anticancer treatments have significantly contributed to increasing cure rates of breast cancer in the last years; however, they can also lead to short- and long-term side effects, including gonadotoxicity, and compromised fertility in young women. Oncofertility is a crucial issue for young patients who have not yet completed their family planning at the time of cancer diagnosis.

AREAS COVERED

This review aims to cover all the latest available evidence in the field of oncofertility, including the gonadotoxicity of currently adopted anticancer therapies in the curative breast cancer setting, the available strategies for fertility preservation and the feasibility of achieving a pregnancy following anticancer treatment completion.

EXPERT OPINION

Over the past years, a significant progress has been made in oncofertility care for young women with breast cancer. In the context of the currently available evidence, every young woman with newly diagnosed breast cancer should receive a proper and complete oncofertility counseling before starting any anticancer treatment to increase her chances of future pregnancies.

Patients with gynecological malignancies are similar to other IVF patients without cancer for clinical and molecular reproductive parameters and DNA damage response pattern

This study intended to investigate if gynecological cancers compromise ovarian function and reduce the success of assisted reproduction techniques (ART). No clinical and molecular data together is available on this issue for gynecological or other organ cancers. Steroidogenic pathways and DNA damage response characteristics of the granulosa cells retrieved from the 39 gynecological cancer patients were analyzed together with their clinical ART characteristics in comparison to 31 control ART patients. Patients with gynecological malignancies were similar to the control IVF patients for the number of mature oocytes retrieved, fertilization rates and embryo development competency. Molecular analyses of the granulosa cells retrieved from these cancer patients did not detect any perturbations in gonadotropin receptor expression and response, sex steroid production, cholesterol utilization/storage and, DNA damage response pattern in comparison to control IVF patients without cancer. This study provides the first reassuring clinical and molecular combined data set that the presence of gynecological malignancy does not appear to have any detrimental effect on clinical IVF cycle characteristics and ovarian functioning at molecular level.

Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

Fertility preservation parameters in patients with haematologic malignancy: a systematic review and meta-analysis

Patients with haematologic malignancies represent one of the most common groups referred for fertility preservation before gonadotoxic oncological treatment. The aim of this systematic review and meta-analysis was to evaluate the effect of haematologic cancer on ovarian reserve and response to ovarian stimulation compared with healthy controls. A total of eight observative studies were included in the final quantitative analysis. Despite a younger age (mean difference -4.17, 95% CI -6.20 to -2.14; P < 0.0001), patients with haematologic malignancy had lower serum anti-Müllerian hormone levels compared with the control group (MD -1.04, 95% CI -1.80 to -0.29; P = 0.007). The marginally higher total recombinant FSH dose (MD 632.32, 95% CI -187.60 to 1452.24; P = 0.13) and significantly lower peak oestradiol serum level (MD -994.05, 95% CI -1962.09 to -26.02; P = 0.04) were demonstrated in the study group compared with the healthy controls. A similar number of retrieved oocytes were achieved in both groups (MD 0.20, 95% CI -0.80 to 1.20; P = 0.69). In conclusion, haematologic malignancies may detrimentally affect ovarian function manifesting in decreased AMH serum levels despite a younger age compared with healthy controls. This effect can be overcome by the application of relevant IVF protocols and stimulation doses to achieve an adequate oocyte yield.

Fertility Preservation in Young Women With Breast Cancer: A Review

Fertility preservation is a major concern in young patients diagnosed with breast cancer and planning to receive multimodality treatment, including gonadotoxic chemotherapy with or without age-related decline through long-term endocrine therapy. Most breast cancer patients undergo multimodality treatments; many short-term and long-term side effects arise during these therapies. One of the most detrimental side effects is reduced fertility due to gonadotoxic treatments with resultant psychosocial stress. Cryopreservation of oocytes, embryos, and ovarian tissue are currently available fertility preservation methods for these patients. As an adjunct to these methods, in vitro maturation or gonadotropin-releasing hormone agonist could also be considered. It is also essential to communicate well with patients in the decision-making process on fertility preservation. It is essential to refer patients diagnosed with breast cancer on time to fertility specialists for individualized treatment, which may lead to desirable outcomes. To do so, a multimodal team-based approach and in-depth discussion on the treatment of breast cancer and fertility preservation is crucial. This review aims to summarize infertility risk related to currently available breast cancer treatment, options for fertility preservation and its details, barriers to oncofertility counseling, and psychosocial issues.

The Late Effects of Cancer Treatment on Female Fertility and the Current Status of Fertility Preservation-A Narrative Review

Fertility counseling should be offered to all individuals of young reproductive age early in the patient's trajectory following a cancer diagnosis. Systemic cancer treatment and radiotherapy often have an inherent gonadotoxic effect with the potential to induce permanent infertility and premature ovarian failure. For the best chances to preserve a patient's fertility potential and to improve future quality of life, fertility preservation methods should be applied before cancer treatment initiation, thus multidisciplinary team-work and timely referral to reproductive medicine centers specialized in fertility preservation is recommended. We aim to review the current clinical possibilities for fertility preservation and summarize how infertility, as a late effect of gonadotoxic treatment, affects the growing population of young female cancer survivors.

Physiological and Pharmacological overview of the Gonadotropin Releasing Hormone

Gonadotropin-releasing Hormone (GnRH) is a decapeptide responsible for the control of the reproductive functions. It shows C- and N-terminal aminoacid modifications and two other distinct isoforms have been so far identified. The biological effects of GnRH are mediated by binding to high-affinity G-protein couple receptors (GnRHR), showing characteristic very short C tail. In mammals, including humans, GnRH-producing neurons originate in the embryonic nasal compartment and during early embryogenesis they undergo rapid migration towards the hypothalamus; the increasing knowledge of such mechanisms improved diagnostic and therapeutic approaches to infertility. The pharmacological use of GnRH, or its synthetic peptide and non-peptide agonists or antagonists, provides a valid tool for reproductive disorders and assisted reproduction technology (ART). The presence of GnRHR in several organs and tissues indicates additional functions of the peptide. The identification of a GnRH/GnRHR system in the human endometrium, ovary, and prostate has extended the functions of the peptide to the physiology and tumor transformation of such tissues. Likely, the activity of a GnRH/GnRHR system at the level of the hippocampus, as well as its decreased expression in mice brain aging, raised interest in its possible involvement in neurogenesis and neuronal functions. In conclusion, GnRH/GnRHR appears to be a fascinating biological system that exerts several possibly integrated pleiotropic actions in the complex control of reproductive functions, tumor growth, neurogenesis, and neuroprotection. This review aims to provide an overview of the physiology of GnRH and the pharmacological applications of its synthetic analogs in the management of reproductive and non-reproductive diseases.

Outcomes after assisted reproductive technology in women with cancer: a systematic review and meta-analysis

STUDY QUESTION

What are the associations between a history of cancer and outcomes after ART?

SUMMARY ANSWER

Compared to women without cancer, on average, women with cancer had a lower return for embryo transfer and a lower likelihood of clinical pregnancy and live birth after ART.

WHAT IS KNOWN ALREADY

Small, single-institution studies have suggested that cancer and its treatment may negatively affect ART outcomes.

STUDY DESIGN, SIZE, DURATION

We conducted a systematic review with meta-analysis of studies comparing ART outcomes between women with and without cancer. PubMed, Embase and Scopus were searched for original, English-language studies published up to June 2021.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Inclusion criteria required reporting of ART outcomes after controlled ovarian stimulation (COS) among women with a history of cancer compared to women without cancer who used ART for any indication. Outcomes of interest ranged from duration of COS to likelihood of live birth after embryo transfer. Random-effects meta-analysis was used to calculate mean differences and odds ratios (ORs) with 95% CIs and 95% prediction intervals (PIs). We assessed heterogeneity by age-adjustment, referent group indication for ART, study location and among women with breast cancer and women who initiated ART before cancer treatment. We used visual inspection, Egger's test and the trim-and-fill method to assess funnel plot asymmetry.

MAIN RESULTS AND THE ROLE OF CHANCE

Of 6094 unique records identified, 42 studies met inclusion criteria, representing a median per study of 58 women with cancer (interquartile range (IQR) = 159) and 114 women without cancer (IQR = 348). Compared to women without cancer, on average, women with cancer had a lower return for embryo transfer (OR: 0.22; 95% CI: 0.07, 0.74; 95% PI: 0.00, 64.98); lower likelihood of clinical pregnancy (OR: 0.51; 95% CI: 0.35, 0.73; 95% PI: 0.19, 1.35); and lower likelihood of live birth (OR: 0.56; 95% CI: 0.38, 0.83; 95% PI: 0.19, 1.69). Substantial among-study heterogeneity was observed for COS duration, gonadotropin dose, cycle cancellation, total oocytes and mature oocytes. Fertilization percentage showed less heterogeneity, but study-specific estimates were imprecise. Similarly, number of embryos showed less heterogeneity, and most studies estimated minimal differences by cancer history. Funnel plot asymmetry was observed for estradiol peak and oocyte maturation percentage.

LIMITATIONS, REASONS FOR CAUTION

Appreciable confounding is possible in 11 studies that lacked adequate control for group differences in age, and among-study heterogeneity was observed for most outcomes. Lack of data limited our ability to assess how cancer clinical factors (e.g. cancers other than breast, cancer stage and treatment) and ART cycle characteristics (e.g. fresh versus frozen embryo transfers and use of gestational carriers) may affect outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Women with cancer may be less likely to achieve pregnancy and live birth after embryo transfer. Further examination of reproductive outcomes and sources of heterogeneity among studies is warranted to improve evidence of the expected success of ART after a cancer diagnosis.

STUDY FUNDING/COMPETING INTEREST(S)

This research was supported in part by R01 CA211093 and P30 ES010126. C.M. was supported by the University of North Carolina Lineberger Cancer Control Education Program (T32 CA057726) and the National Cancer Institute (F31 CA260787). J.A.R.-H. was supported by the National Cancer Institute (K08 CA234333, P30 CA016672). J.A.R.-H. reports receiving consulting fees from Schlesinger Group and Guidepoint. The remaining authors declare no competing interests.

REGISTRATION NUMBER

N/A.

Oocyte Quality Assessment in Breast Cancer: Implications for Fertility Preservation

BACKGROUND

The aim of this study was to evaluate the effects of breast cancer on the ovarian response and on oocyte quality following controlled ovarian hyperstimulation (COH).

METHODS

This retrospective case-control study evaluated the effects of breast cancer on the ovarian response and on the oocyte quality. Oncological patients with breast cancer undergoing controlled ovarian stimulation cycles for fertility preservation, and age- and date-matched controls undergoing COH for in vitro fertilization (IVF) for male or tubal factor infertility were included in the study. Two hundred and ninety-four women were enrolled: 105 affected by breast cancer and 189 healthy women in the control group. Both groups were comparable in terms of age, BMI, and AMH value. Maximal estradiol levels on the triggering day, duration of stimulation, total amount of gonadotropins administered, number of oocytes retrieved, rate of metaphase 2 oocyte production, and numbers of immature and dysmorphic oocytes were analyzed.

RESULTS

Considering factors influencing the oocyte quality, such as age, BMI, AMH, duration of stimulation, E2 level on the triggering day, total FSH cumulative dose, stage, histotype, BRCA status, and hormone receptors, the univariate and multivariate analyses identified breast cancer as a risk factor for the presence of dysmorphic oocytes.

CONCLUSIONS

The diagnosis of breast cancer does not seem to be associated with the impairment of the ovarian reserve, but is linked to a worsening oocyte quality.

What should be done in terms of fertility preservation for patients with cancer? The French 2021 guidelines

AIM

To provide practice guidelines about fertility preservation (FP) in oncology.

METHODS

We selected 400 articles after a PubMed review of the literature (1987-2019).

RECOMMENDATIONS

Any child, adolescent and adult of reproductive age should be informed about the risk of treatment gonadotoxicity. In women, systematically proposed FP counselling between 15 and 38 years of age in case of treatment including bifunctional alkylating agents, above 6 g/m2 cyclophosphamide equivalent dose (CED), and for radiation doses on the ovaries ≥3 Gy. For postmenarchal patients, oocyte cryopreservation after ovarian stimulation is the first-line FP technique. Ovarian tissue cryopreservation should be discussed as a first-line approach in case of treatment with a high gonadotoxic risk, when chemotherapy has already started and in urgent cases. Ovarian transposition is to be discussed prior to pelvic radiotherapy involving a high risk of premature ovarian failure. For prepubertal girls, ovarian tissue cryopreservation should be proposed in the case of treatment with a high gonadotoxic risk. In pubertal males, sperm cryopreservation must be systematically offered to any male who is to undergo cancer treatment, regardless of toxicity. Testicular tissue cryopreservation must be proposed in males unable to cryopreserve sperm who are to undergo a treatment with intermediate or severe risk of gonadotoxicity. In prepubertal boys, testicular tissue preservation is: - recommended for chemotherapy with a CED ≥7500 mg/m2 or radiotherapy ≥3 Gy on both testicles. - proposed for chemotherapy with a CED ≥5.000 mg/m2 or radiotherapy ≥2 Gy. If several possible strategies, the ultimate choice is made by the patient.

Clinical outcome of embryo cryopreservation in Japanese breast cancer patients: pregnancy rates after transfer of thawed embryos

PURPOSE

To examine pregnancy outcomes after cryopreserved embryo transfer (ET) in breast cancer patients and to investigate the effect of controlled ovarian hyperstimulation (COH) as well as that of aromatase inhibitor (AI) administration and of the random start (RS) ovarian stimulation method.

METHODS

This retrospective study covered 126 patients who underwent embryo cryopreservation between 2010 and 2019. Thirty-one patients underwent frozen embryo transfer (FET), and we examined resulting pregnancy rates (PRs) and live birth rates (LBRs) in those who did and did not undergo COH and in relation to the AI and RS methods.

RESULTS

PR and LBR per patient were higher among patients who underwent COH than among those who did not. PR per ET did not differ from that documented for non-cancer infertility patients, after adjustment for age. The PR and LBR did not differ between use and non-use of AI (27.8% vs 35.2%). In addition, there was no significant difference in the PR or LBR between RS and conventional start ovarian stimulation (33.3% vs 30.8%). No prenatal fetal abnormalities were observed in 8 cases (including 5 AI cases and 2 RS cases).

CONCLUSIONS

This study showed that the outcome of FET after FP was equivalent to that seen in non-cancer patients. Further, neither use of AI nor the RS method influenced LBR. COH including use of AI and the RS method are useful in FP for collecting and freezing many embryos within a short period and for increasing the per patient LBR after cancer treatment.

A prospective, observational study of chemotherapy-induced ovarian damage on follicular reserve and maturation

BACKGROUND

Chemotherapy negatively affects gonadal function, often resulting in premature ovarian failure (POF) due to ovarian reserve depletion. Mechanisms of gonadotoxicity, such as primordial follicle overactivation and "burnout", remain to be established. Ovarian tissue cryopreservation (OTC) before treatment plays an important role in safeguarding fertility.

METHODS

This is a prospective observational study that aims to evaluate the feasibility of OTC after chemotherapeutic treatment initiation. Patients were divided into 2 groups depending on whether they received chemotherapy before the harvesting procedure (Group 1) or not (Group 2). The main outcomes of this study are serum anti-Mullerian hormone (AMH) levels and histological follicular counts on ovarian tissue biopsies.

RESULTS

Between 2012 and 2020, 79 patients underwent OTC at our Hospital. Follicular counts from the ovarian biopsies of 30 post-pubertal patients and respective serum AMH levels were included in the analysis. AMH levels did not significantly differ between the 2 groups (P = 0.70) as well as the number of primordial follicles (P = 0.73). Ovarian biopsies of patients from Group 1 showed a higher number of primary follicles (P = 0.04) and atretic follicles (P = 0.05) with respect to Group 2.

CONCLUSIONS

In conclusion, OTC appears to be feasible even after the start of chemotherapeutic treatment, since in treated patients, the main ovarian reserve indicators (number of primordial follicles and serum AMH levels) were not significantly reduced compared to untreated patients. The "burnout" theory of chemotherapeutic damage to the ovary seems to be supported by the higher number of primary follicles found in the ovaries of patients who received chemotherapy before OTC.

Fertility after Cancer: Risks and Successes

Simple Summary

Approximately one million new cases of cancer are diagnosed in women of reproductive age every year. In the last few decades, advances in early diagnosis and treatment have improved the survival rate. However, the adverse effects of anticancer therapy on the ovaries and uterus have a significant impact on future fertility and may affect the quality of life of cancer survivors. Unfortunately, evidence about the trend of ovarian reserve loss over time is insufficient for predicting the duration of the fertile period. Currently, impaired fertility in cancer survivors is a growing issue that is complicated by an increasing number of women delaying childbearing. This review focuses on the detrimental effects of chemotherapy, radiotherapy, and surgery on reproductive functions and describes the mechanisms causing reduced fertility in cancer survivors. Moreover, in this review, the available fertility preservation strategies to guarantee the chance of motherhood in cancer survivors are illustrated.

Abstract

The incidence of cancer in reproductive-aged women is 7%, but, despite the increased number of cancer cases, advances in early diagnosis and treatment have raised the survival rate. Furthermore, in the last four decades, there has been a rising trend of delaying childbearing. There has been an increasing number of couples referred to Reproductive Medicine Centers for infertility problems after one partner has been treated for cancer. In these cases, the main cause of reduced fertility derives from treatments. In this review, we describe the effects and the risks of chemotherapy, radiotherapy, and surgery in women with cancer, and we will focus on available fertility preservation techniques and their efficacy in terms of success in pregnancy and live birth rates.

Assessment of female fertility preservation in Auvergne 3 years after implementation of the PREFERA platform (PREservation FERtilité Auvergne)

INTRODUCTION

Fertility preservation (FP) in patients with cancer or pathology at risk of gonadotoxicity is now according to legislation, an integral part of the treatment protocol. for this reason, clinical-biological platforms have emerged with the aim of developing and improving this practice, such as the PREFERA platform (PREservation FERtilité Auvergne) MATERIAL ET METHOD: This is an observational cohort study to evaluate female fertility preservation activity in Auvergne at the AMP-CECOS center of the Clermont-Ferrand University Hospital from March 2013 to March 2019. This period covering 3 years before and after the creation of PREFERA in 2015.

RESULTS

205 patients were referred for fertility preservation consultations, including 77 before the platform was set up and 128 after, corresponding to an increase of 66%. 190 patients (92.7%) referred were eligible for FP, of whom 169 (88.9%) received treatment. Thirty-nine patients underwent oocyte vitrification before the platform was set up and 74 after (+89.7%), twenty patients underwent ovarian cortex freezing before the platform was set up and 27 after (+35%). Only 54 patients (26.2%) were seen for follow-up with an increased number of consultations following the implementation of PREFERA. (8% vs 33%, p<0.001).

CONCLUSION

Creation of the PREFERA platform facilitated patient access and management of fertility preservation procedures. However, at the regional level, it is necessary to continue to raise awareness of fertility issues, particularly in the context of post-cancer follow-up, both among patients and health professionals.

History of cancer and fertility treatment outcomes: a registry linkage study in Massachusetts

PURPOSE

To investigate assisted reproductive technology (ART) outcomes among adolescent and young-adult female cancer survivors.

METHODS

The Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) data were linked to the Massachusetts Cancer Registry for 90,928 ART cycles in Massachusetts to women ≥ 18 years old from 2004 to 2013. To estimate relative risks (RR) and 95% confidence intervals (CI), we used generalized estimating equations with a log link that accounted for multiple cycles per woman and a priori adjusted for maternal age and cycle year. The main outcomes of interest were ART treatment patterns; number of autologous oocytes retrieved, fertilized, and transferred; and rates of implantation, clinical intrauterine gestation (CIG), live birth, and pregnancy loss.

RESULTS

We saw no difference in number of oocytes retrieved (aRR: 0.95 (0.89-1.02)) or proportion of autologous oocytes fertilized (aRR: 0.99 (0.95-1.03)) between autologous cycles with and without a history of cancer; however, cancer survivors required a higher total FSH administered (aRR: 1.12 (1.06-1.19)). Among autologous cycle starts, cycles in women with a history of cancer were less likely to result in CIG compared to no history of cancer (aRR: 0.73 (0.65-0.83)); this relationship was absent from donor cycles (aRR: 1.01 (0.85-1.20)). Once achieving CIG, donor cycles for women with a history of cancer were two times more likely to result in pregnancy loss (aRR: 1.99 (1.26-3.16)).

CONCLUSIONS

Our analysis suggests that cancer may influence ovarian stimulation response, requiring more FSH and resulting in lower CIG among cycle starts.

Male and Female Fertility: Prevention and Monitoring Hodgkin' Lymphoma and Diffuse Large B-Cell Lymphoma Adult Survivors. A Systematic Review by the Fondazione Italiana Linfomi

BACKGROUND

Adult patients with Hodgkin lymphoma (HL) and diffuse large B-cell lymphoma (DLBCL) have prolonged survival but face the risk of treatment-induced impaired fertility. This systematic review, conducted by Fondazione Italiana Linfomi (FIL) researchers, aims to evaluate the incidence of treatment-related infertility, fertility preservation options, fertility assessment measures, and the optimal interval between the end of treatment and conception.

METHODS

MEDLINE, the Cochrane Library, and EMBASE were systematically searched up to September 2020 for published cohort, case-control, and cross-sectional studies on fertility issues.

RESULTS

Forty-five eligible studies were identified. Gonadotoxicity was related to sex, type and dosage of treatment, and, in females, to age. After receiving alkylating-agent-containing regimens, less than 30% of males recovered spermatogenesis, and 45% of females ≥30 years in age retained regular menstrual cycles. Sperm cryopreservation was offered to the majority of patients; sperm utilization resulted in a 33-61% pregnancy rate. After ovarian tissue transplantation, the spontaneous pregnancy and live birth rates were 38% and 23%; after IVF, the live birth rate was 38.4%. No data could be extracted on the utilization rate of cryopreserved mature oocytes. The results of studies on GnRH analogs are controversial; therefore, their use should not be considered an alternative to established cryopreservation techniques. Sperm count, FSH, and inhibin-B levels were appropriate measures to investigate male fertility; serum AMH levels and antral follicle count were the most appropriate markers for ovarian reserve. No data could be found regarding the optimal interval between the end of treatment and conception.

CONCLUSIONS

The risk of infertility should be discussed with adult lymphoma patients at the time of diagnosis, and fertility preservation options should be proposed before first-line treatment with alkylating-agent-containing regimens.

Hot Topics on Fertility Preservation for Women and Girls-Current Research, Knowledge Gaps, and Future Possibilities

Fertility preservation is a novel clinical discipline aiming to protect the fertility potential of young adults and children at risk of infertility. The field is evolving quickly, enriched by advances in assisted reproductive technologies and cryopreservation methods, in addition to surgical developments. The best-characterized target group for fertility preservation is the patient population diagnosed with cancer at a young age since the bulk of the data indicates that the gonadotoxicity inherent to most cancer treatments induces iatrogenic infertility. Since improvements in cancer therapy have resulted in increasing numbers of long-term survivors, survivorship issues and the negative impact of infertility on the quality of life have come to the front line. These facts are reflected in an increasing number of scientific publications referring to clinical medicine and research in the field of fertility preservation. Cryopreservation of gametes, embryos, and gonadal tissue has achieved quality standards for clinical use, with the retrieval of gonadal tissue for cryopreservation being currently the only method feasible in prepubertal children. Additionally, the indications for fertility preservation beyond cancer are also increasing since a number of benign diseases and chronic conditions either require gonadotoxic treatments or are associated with premature follicle depletion. There are many remaining challenges, and current research encompasses clinical health care and caring sciences, ethics, societal, epidemiological, experimental studies, etc.

Female fertility preservation: Impact of cancer on ovarian function and oocyte quality

OBJECTIVE

To evaluate the influence of cancer on ovarian response and oocyte quality in controlled ovarian hyperstimulation (COH).

METHODS

This prospective study conducted at the Physiopathology of Reproduction and Andrology Unit of Sandro Pertini Hospital enrolled 82 cancer patients undergoing controlled ovarian stimulation (COH) cycles for fertility preservation, and age- and date-matched controls undergoing COH for in vitro fertilization for male-factor infertility from June 2016 to November 2019. The interventions performed were COH, oocyte retrieval, and quality evaluation. Main outcome measures were maximal estradiol levels on the day of human chorionic gonadotropin administration, duration of stimulation, total amount of gonadotropins administered, number of oocytes retrieved, and rates of metaphase 2 oocytes and abnormal oocytes. All data were analyzed using the Statistical Package for the Social Sciences (IBM Corp., Armonk, NY, USA) 22.0.

RESULTS

Intergroup comparisons (82 cancer patients and 180 patients in control group) showed a significant difference in ovarian response, especially for a significant higher number of abnormal oocytes in cancer patients (P < 0.0001). Regression analysis to assess the influence of the neoplastic process, regardless of the type, on ovarian response showed an effect on the main outcome measured due to cancer itself.

CONCLUSION

Cancer influences the ovarian response, particularly the oocyte quality, during COH performed for fertility preservation.

Live birth rate after use of cryopreserved oocytes or embryos at the time of cancer diagnosis in female survivors: a retrospective study of ten years of experience

PURPOSE

The aim of this study was to evaluate the outcomes of frozen oocytes or embryos cryopreserved after controlled ovarian stimulation (COS) or in vitro maturation (IVM) for female cancer patients who underwent a fertility preservation (FP) prior to gonadotoxic therapy.

METHODS

A retrospective cohort study from 2009 to December 2017 was conducted. Among the 667 female cancer patients who underwent oocytes or embryos cryopreservation for FP, 40 (6%) have returned to the fertility clinic between 2011 and 2019 to use their frozen material after being cured. We compared these thaw cycles outcomes according to the techniques used at the time of cryopreservation.

RESULTS

Among the 40 women cancer survivors who used their cryopreserved material, thirty patients have benefited from at least one embryo transfer. Ten patients did not have an embryo transfer since the oocytes did not survive after the thawing process or because no embryo was obtained after fertilization. We related three live births following FP using IVM (two from frozen oocytes and one after embryo cryopreservation). Five live births were obtained when COS was performed at the time of FP (one from frozen oocytes and four after embryo cryopreservation).

CONCLUSIONS

Our preliminary results, although they are obtained in a small sample, are encouraging and show that different FP techniques can be used in female cancer patients and lead to live births. IVM is one of the options available that does not delay the start of chemotherapy or if ovarian stimulation using gonadotropins is contraindicated.

Gonadotropin-Releasing Hormone and GnRH Receptor: Structure, Function and Drug Development

BACKGROUND

Gonadotropin-Releasing Hormone (GnRH) is a key element in sexual maturation and regulation of the reproductive cycle in the human organism. GnRH interacts with the pituitary cells through the activation of the Gonadotropin Releasing Hormone Receptors (GnRHR). Any impairments/dysfunctions of the GnRH-GnRHR complex lead to the development of various cancer types and disorders. Furthermore, the identification of GnRHR as a potential drug target has led to the development of agonist and antagonist molecules implemented in various treatment protocols. The development of these drugs was based on the information derived from the functional studies of GnRH and GnRHR.

OBJECTIVE

This review aims at shedding light on the versatile function of GnRH and GnRH receptor and offers an apprehensive summary regarding the development of different agonists, antagonists and non-peptide GnRH analogues.

CONCLUSION

The information derived from these studies can enhance our understanding of the GnRH-GnRHR versatile nature and offer valuable insight into the design of new more potent molecules.

Advances in the Treatment and Prevention of Chemotherapy-Induced Ovarian Toxicity

Due to improvements in chemotherapeutic agents, cancer treatment efficacy and cancer patient survival rates have greatly improved, but unfortunately gonadal damage remains a major complication. Gonadotoxic chemotherapy, including alkylating agents during reproductive age, can lead to iatrogenic premature ovarian insufficiency (POI), and loss of fertility. In recent years, the demand for fertility preservation has increased dramatically among female cancer patients. Currently, embryo and oocyte cryopreservation are the only established options for fertility preservation in women. However, there is growing evidence for other experimental techniques including ovarian tissue cryopreservation, oocyte in vitro maturation, artificial ovaries, stem cell technologies, and ovarian suppression. To prevent fertility loss in women with cancer, individualized fertility preservation options including established and experimental techniques that take into consideration the patient’s age, marital status, chemotherapy regimen, and the possibility of treatment delay should be provided. In addition, effective multidisciplinary oncofertility strategies that involve a highly skilled and experienced oncofertility team consisting of medical oncologists, gynecologists, reproductive biologists, surgical oncologists, patient care coordinators, and research scientists are necessary to provide cancer patients with high-quality care.

Does type of cancer affect ovarian response in oncofertility patients?

INTRODUCTION

To evaluate the influence of type of cancer and cancer itself on the ovarian response during controlled ovarian stimulation (COS) for fertility preservation (FP).

MATERIALS AND METHODS

This was a retrospective cohort study performed at a single academic tertiary-care infertility center. Women diagnosed with cancer who underwent COS with GnRH antagonist protocol between January 2009 and December 2018 were included in this study. Patients were categorized into three groups; breast/gynecologic, hematologic, and other cancers. We secondarily compared the COS parameters and ovarian reserve markers in oncofertility cases against non-cancer patients who pursued FP for deferred reproduction. The primary outcome was number of mature oocytes. Secondary outcomes included oocyte yield (number of retrieved oocytes/number of follicles aspirated at time of retrieval) and oocyte-maturity index, defined as number of mature oocytes/total oocytes retrieved.

RESULTS

A total of 96 cancer patients were referred for FP counseling before starting their anti-cancer therapy. Clinical characteristics and ovarian response parameters were comparable between the three groups. Type of cancer was not a predictor for number of mature oocytes (p = 0.329), oocyte-maturity index (p = 0.815), or oocyte yield, (p = 0.161) after adjustment to cycle covariates. Moreover, cancer did not have impact on the number of mature oocytes (p = 0.699), oocyte-maturity index (p = 0.251) and oocyte yield (p = 0.094).

DISCUSSION

There is no difference observed in outcomes of ovarian stimulation based on primary cancer diagnosis in oncofertility patients undergoing FP. Interestingly, no significant impact for cancer itself was observed on ovarian reserve or response to gonadotrophins stimulation.

Fertility Preservation in Women: Indications and Options for Therapy

Fertility preservation (FP) is a vital issue for individuals in either reproductive or prepubescent stage of life when future fertility may be compromised. The objective of any FP intervention is to minimize or eliminate primary disease burden and to ensure maintaining or preserving reproductive health. Fertility potential can be affected by cancer therapy and numerous other factors, including advancing age, metabolic conditions, autoimmune diseases, specific surgical interventions, and sex affirmation procedures. A paradigm shift focusing on quality-of-life issues and long-term survivorship has emerged, especially because of advances in cancer diagnostics and treatment. Several FP techniques have been widely distributed, while others are still in the research stage. In addition, specific procedures and some potentially fertoprotective agents are being developed, aiming to minimize the hazards of gonadal damage caused by cancer therapy and decrease the need for more costly, invasive, and time-consuming FP methods. This review highlights the advances, indications, and options for FP, both experimental and well-established, in females of various age groups. An electronic search in PubMed, Embase, and Google Scholar databases was conducted, including retrospective studies, prospective clinical trials, meta-analyses, original reviews, and online abstracts published up to June 30, 2019. The search terms used included fertility preservation, oncofertility, embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation. The meeting proceedings of the American Society for Reproductive Medicine and the European Society of Human Reproduction and Embryology were also hand searched.

Counseling young women with early breast cancer on fertility preservation

PURPOSE

Women with early-stage breast cancer may still have a future child wish, while chemotherapy may impair fertility. To pursue on fertility preservation shortly after breast cancer diagnosis is complex. This review holds a critical reflection on all topics that need to be counseled to give them the opportunity to make a well-informed decision before starting any oncological treatment.

METHODS

A comprehensive literature review was performed on papers published in English language on breast cancer in young women, risk of chemotherapy-induced infertility, fertility preservation techniques, impact of possible mutation carriership, and future pregnancy outcome.

RESULTS

Below 40 years of age, the risk of permanent chemotherapy-induced ovarian function failure is approximately 20%, where taxanes do not significantly add to this risk. Overall, 23% of reported women who performed fertility preservation by cryopreserving oocytes or embryos returned for embryo transfer. Of these, 40% gave live birth. Both fertility preservation in women diagnosed with breast cancer and pregnancy after treatment seem safe with respect to breast cancer survival. Women who have a genetic predisposition for breast cancer like BRCA gene mutation should also be informed about the possibility of pre-implantation genetic diagnosis.

CONCLUSIONS

Women with an early stage of breast cancer and a possible future child wish should be referred to an expertise center in breast cancer, fertility preservation, and genetics in this complex decision-making process, shortly after diagnosis.

Influence of stage and grade of breast cancer on fertility preservation outcome in reproductive-aged women

RESEARCH QUESTION

Does breast cancer spread and aggressiveness affect fertility-preservation results?

DESIGN

Retrospective cohort study of women with breast cancer undergoing fertility-preservation treatment.

INCLUSION CRITERIA

age 18-38 years and use of gonadotrophin releasing hormone antagonist protocol; exclusion criteria: recurrent cancer, previous oncological treatment, previous ovarian surgery and known ovarian pathology. Stimulation cycle outcomes of women with low-stage breast cancer were compared with those with high-stage disease. Patients with low-grade (G_1-2) were compared with those with high-grade (G₃) malignancies.

PRIMARY OUTCOME

total number of mature oocytes; secondary outcomes: oestradiol level and number of follicles wider than 14 mm on the day of trigger, number of retrieved oocytes and cryopreserved embryos.

RESULTS

The final analysis included 155 patients. Patients with high-grade tumours (n = 80; age 32 years [28-35]) had significantly lower number of mature oocytes compared with patients with low-grade cancer (n = 75; age 32 years [28-35]; seven mature oocytes [4-10] versus 13 mature oocytes [7-17]; P = 0.0002). The number of cryopreserved embryos was also lower in the high-grade group (three [2-5] versus five [3-9]; P = 0.02). Stage-based analysis revealed a similar number of mature oocytes in high-stage (n = 73; age 32 years [28-35]) compared with low-stage group (n = 82; age 33 years [28-35]; eight mature oocytes [4-13] versus nine mature oocytes [7-15]; P = 0.06).

CONCLUSIONS

High-grade breast cancer has a negative effect on total number of mature oocytes and cryopreserved embryos.

A Practical Guide to Gynecologic and Reproductive Health in Women Undergoing Hematopoietic Stem Cell Transplant

Optimum care of female transplant recipients requires gynecologic care at several stages through the allogeneic hematopoietic stem cell transplantation (HCT) process. Sex-based considerations in women post-HCT span gynecologic sequelae of transplant along with assessment and maintenance of optimal sexual and gynecologic health. Pre-HCT, managing menstruation and abnormal uterine or genital bleeding, considering fertility preservation, and assessing for sexually transmitted infections, including human papillomavirus (HPV)-related disease and cervical cancer, enhance women's health. While inpatient during transplant when women are thrombocytopenic, menstrual bleeding requires suppression. Whenever graft-versus-host disease (GVHD) is assessed, screening for genital GVHD merits consideration. After the first 100 days, periodic assessments include obtaining a menstrual history, assessing ovarian function, and reviewing current hormonal use and contraindications to hormonal methods. Regular assessment for primary ovarian insufficiency, dyspareunia, and intimacy guides provision of contraception and hormone replacement options. As part of ongoing screening for genital GVHD and HPV-related disease, including sexually transmitted infections, periodic pelvic examinations are performed. Once successful long-term survival is achieved, planning for fertility may be considered. This article offers a comprehensive approach to these aspects of gynecologic care of patients throughout the trajectory of HCT and beyond into survivorship. We review the effects of HCT treatment on sexual health, ovarian function, and resulting menstrual changes and fertility challenges. Identification, treatment, and prevention of subsequent malignancies, including breast cancer, are discussed, with a focus on regular assessment of genital HPV disease and GVHD in long-term follow-up.

Fertility preservation in patients with hematologic malignancies and recipients of hematopoietic cell transplants

Patients with hematologic malignancies and those undergoing hematopoietic cell transplantation (HCT) face a complex set of challenges when considering options for fertility preservation (FP). There are no standard options for prepubertal children, and women with hematologic malignancies may not be eligible for standard FP options. Fortunately, initial therapies for most blood cancers are not highly gonadotoxic, affording an important opportunity for postremission counseling and referrals to fertility specialists. These patients face a high risk of relapse, and many will be referred for autologous or allogeneic HCT, which carries an extremely high risk of infertility. The expanding indications for HCT to include benign hematologic disorders as well as autoimmune diseases mandate that all hematologists are familiar with these risks. Oncofertility researchers are continually pushing the boundaries of what may be possible for our patients; in the meantime, communication and shared decision-making between hematologists and patients, as well as program-building, education, and outreach are essential to ensure that these patients, many of whom will be cured, maintain all of their options for a fulfilling life after intensive therapy.

Elective and Onco-fertility preservation: factors related to IVF outcomes

STUDY QUESTION

Is the indication for fertility preservation (FP) related to success in IVF cycles after elective-FP (EFP) for age-related fertility decline and FP before cancer treatment (Onco-FP)?

SUMMARY ANSWER

Although success rates were lower in cancer patients, there was no statistically significant association between malignant disease and reproductive outcome after correction for age and controlled-ovarian stimulation (COS) regime.

WHAT IS KNOWN ALREADY

FP is increasingly applied in assisted reproduction, but little is known about the outcome of IVF cycles with vitrified oocytes in FP patients.

STUDY DESIGN, SIZE, DURATION

Retrospective, observational multicenter study of vitrification cycles for FP and of the warming cycles of women who returned to attempt pregnancy from January 2007 to May 2018.

PARTICIPANTS/MATERIALS, SETTING, METHODS

In all, 6362 women (EFP = 5289 patients; 7044 cycles + Onco-FP = 1073 patients; 1172 cycles) had their oocytes vitrified for FP. A logistic regression analysis was performed to examine the impact of indication for FP corrected for age at vitrification. The protocol used for COS was also included as a possible confounder. The main outcome measures were oocyte survival and live birth. A detailed description of the baseline and clinical data is provided, with comparisons between EFP and Onco-FP. The cumulative live birth rate (CLBR) per utilized oocyte according to age at vitrification was analyzed in those patients returning to use their oocytes.

MAIN RESULTS AND ROLE OF CHANCE

Age at vitrification was significantly older in EFP patients (37.2 ± 4.9 vs. 32.3 ± 3.5 year; P < 0.0001). Fewer oocytes were retrieved and vitrified per cycle in EFP (9.6 ± 8.4 vs. 11.4 ± 3.5 and 7.3 ± 11.3 vs. 8.7 ± 2.1, respectively; P < 0.05), but numbers became comparable when analyzed per patient (12.8 ± 7.4 vs. 12.5 ± 3.2 and 9.8 ± 6.4 vs. 9.5 ± 2.6). Storage time was shorter in EFP (2.1 ± 1.6 vs. 4.1 ± 0.9 years; P < 0.0001). In all, 641 (12.1%) EFP and 80 (7.4%) Onco-FP patients returned to attempt pregnancy (P < 0.05). Overall oocyte survival was comparable (83.9% vs. 81.8%; NS), but lower for onco-FP patients among younger (≤35 year) subjects (81.2% vs. 91.4%; P > 0.05). Fewer EFP cycles finished in embryo transfer (50.2% vs. 72.5%) (P < 0.05). The implantation rate was 42.6% and 32.5% in EFP versus Onco-FP (P < 0.05). Ongoing pregnancy (57.7% vs. 35.7%) and live birth rates (68.8% vs. 41.1%) were higher in EFP patients aged ≤35 than the Onco-FP matching age patients (P < 0.05). The reason for FP per se had no effect on oocyte survival (OR = 1.484 [95%CI = 0.876-2.252]; P = 0.202) or the CLBR (OR = 1.275 [95%CI = 0.711-2.284]; P = 0.414). Conversely, age (<36 vs. ≥36 y) impacted oocyte survival (adj.OR = 1.922 [95%CI = 1.274-2.900]; P = 0.025) and the CLBR (adj.OR= 3.106 [95%CI = 2.039-4.733]; P < 0.0001). The Kaplan-Meier analysis showed a significantly higher cumulative probability of live birth in patients <36 versus >36 in EFP (P < 0.0001), with improved outcomes when more oocytes were available for IVF.

LIMITATIONS, REASONS FOR CAUTION

Statistical power to compare IVF outcomes is limited by the few women who came to use their oocytes in the Onco-FP group. The patients' ages and the COS protocols used were significantly different between the EFP and ONCO-PP groups.

WIDER IMPLICATIONS OF THE FINDINGS

Although the implantation rate was significantly lower in the Onco-FP patients the impact of cancer disease per se was not proven'. EFP patients should be counseled according to their age and number of available oocytes.

STUDY FUNDING/COMPETING INTEREST(S)

No external funding was used for this study. The authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Fertility preservation in female oncology patients: the influence of the type of cancer on ovarian stimulation response

STUDY QUESTION

Does the type of cancer influence on the ovarian response to stimulation for fertility preservation (FP) in female oncology patients?

SUMMARY ANSWER

Patients with gynaecological cancer have less number of retrieved mature oocytes compared with haematological and breast cancer patients.

WHAT IS KNOWN ALREADY

Concerns about the impact of cancer therapy on future fertility have been raised and FP has become an important component in cancer management. Previous studies analysing FP results in cancer patients have shown conflicting findings.

STUDY DESIGN, SIZE, DURATION

This was a retrospective analytical study performed in the Centre for Reproductive Medicine, at St Bartholomew's Hospital, between January 2000 and December 2014. The aim of this study was to analyse the response to ovarian stimulation in cancer patients before undergoing cancer treatment and to determine whether any difference can be attributed to underlying cancer diagnosis. We also report the pregnancy outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 531 female patients recently diagnosed with cancer were referred for counselling on FP. A total of 306 patients underwent ovarian stimulation for oocyte or embryo cryopreservation. We compared the baseline characteristics and ovarian response in five main subgroups: breast cancer, haematological cancer, gynaecological cancer, gastrointestinal cancer and others. The primary outcome was the total number of mature oocytes retrieved and pregnancy outcomes.

MAIN RESULTS AND THE ROLE OF CHANCE

The main cancer diagnosis was breast cancer with 145 patients (47.4%); 79 patients (25.8%) had haematological malignancies; 42 (13.7%) had gynaecological malignancies; 20 (6.5%) had gastrointestinal cancer and 20 (6.5%) had other types of cancer. Patients with breast cancer were older (P < 0.001). Patients with haematological malignancies had higher number of mature oocytes retrieved (P = 0.003). The number of mature oocytes retrieved was lower in patients with gynaecological malignancy compared with haematological and breast cancer patients (P = 0.005 and P = 0.045, respectively). The fertilization rate and the number of cycles cancelled were comparable between all the groups. Thirty-two embryo transfer cycles have been done in 22 patients who have returned to attempt pregnancy. Pregnancy rate per transfer cycle was 43.75%, and cumulative pregnancy rate per patient was 54.5%. Live birth rate per patient was 22.72%.

LIMITATIONS, REASONS FOR CAUTION

Apart from the retrospective nature of the study, patients were included over the period of 15 years, and over that time technology has changed and protocols have evolved. The results obtained from subcategory analyses should be interpreted with caution, as in each subgroup there are different types of malignancies with different number of patients in different age groups. Different ovarian stimulation protocols were applied. Only a few patients have come back to attempt pregnancy after being cured from their disease. We do not have follow-up data on these patients; as a result, we are not able to report the survival rate and the reason for non-return for embryo transfer. In addition, we cannot report information on spontaneous conceptions and births. Slow freezing used for embryo cryopreservation, high miscarriage rate and low live birth rate per transfer are other limitations of this study.

WIDER IMPLICATIONS OF THE FINDINGS

The current study is the largest series analysing each group of cancer separately and showing pregnancy outcomes in oncology patients undergoing FP. These results provide valuable information about the success of this technique in oncology patients.

STUDY FUNDING/COMPETING INTEREST(S)

The authors have not received any funding to support this study. There are no conflicts of interest to declare.

Oocyte cryopreservation for future fertility: comparison of ovarian response between cancer and non-cancer patients

Objective:

This study aimed to assess whether a diagnosis of cancer interferes with ovarian function prior to the treatment of the disease.

Methods:

This observational retrospective study used data from medical records of ovarian stimulation cycles performed for purposes of oocyte cryopreservation.

Results:

The included patients had a mean age of 35.13±3.72 years and 51.6% of them were aged between 36 and 40 years. More than half of the patients (57.6%) were single and 82.1% had a normal body mass index (BMI). Most women had not become pregnant (85.5%) or had babies (95.1%) or miscarriages (89.6%) prior to cryopreservation. The mean number of oocytes obtained from non-cancer patients was 11.4±8, while for cancer patients the number was 13.8±9. The mean number of frozen mature oocytes was 9.7±7 for the non-cancer group and 11.2±7.2 for the cancer group. The majority (63.1%) of the patients had up to 10 oocytes frozen per cycle. Breast cancer had the highest incidence among the included patients. There was no significant difference in ovarian response between patients with different types of cancer.

Conclusion:

The number of harvested and frozen oocytes from cancer and non-cancer patients indicated that in the two groups response to ovarian stimulation was similar.

Sexuality, fertility and pregnancy following breast cancer treatment

For women facing a new diagnosis of breast cancer, treatments can result in changes to intimate issues, including sexual health. For women of reproductive age, other significant concerns include the potential impact on fertility and the safety of pregnancy after treatment. These issues are important to acknowledge and to address, as they can impact on quality of life, not only for the patient, but may impact relationships, both present and future. In this paper we review sexual health after cancer, the importance of proactively addressing fertility, and important issues related to pregnancy following breast cancer.

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.

Responses to fertility treatment among patients with cancer: a retrospective cohort study

Background

Cancer treatments have significant negative impacts on female fertility, but the impact of cancer itself on fertility remains to be clarified. While some studies have shown that compared with healthy women, those with cancer require higher doses of gonadotropins resulting in decreased oocyte yields, others have shown comparable oocyte yields between the two groups. The purpose of this study is to evaluate whether there is an association between any cancer and/or type of cancer, and response to ovarian stimulation for egg and embryo banking.

Methods

In this retrospective cohort study, ovarian stimulation cycles performed from June 2007 through October 2014 at a single academic medical center were reviewed to identify those undertaken for women with cancer undergoing fertility preservation (n = 147) or women with no cancer undergoing their first cycle due to male factor infertility (n = 664). Of the 147 women undergoing fertility preservation, 105 had local cancer (Stage I-III solid malignancies) and 42 had systemic cancer (hematologic or Stage IV solid malignancies). Response to ovarian stimulation was compared among these two groups and women with no cancer.

Results

Adjusting for age and BMI, women with systemic cancer had lower baseline antral follicle counts (AFC) than women with no cancer or local cancer. Women with systemic cancer required higher doses of FSH than women with no cancer or local cancer, and they had higher oocyte to AFC ratios than women with no cancer or local cancer, but greater odds of cycle cancellation as compared to women with no cancer or local cancer. No significant differences were observed among the three groups for duration of stimulation, number of oocytes and mature oocytes retrieved, or number of embryos created.

Conclusions

Women with cancer achieve similar oocyte and embryo yields as women with no cancer, although those with systemic cancer require higher FSH doses and are at greater risk of cycle cancellation.

Thirteen years' experience in fertility preservation for cancer patients after in vitro fertilization and in vitro maturation treatments

PURPOSE

This study aims to describe the experience and outcomes of in vitro maturation without ovarian stimulation (IVM-FP) and conventional in vitro fertilization after ovarian stimulation (IVF-FP) in a fertility preservation (FP) program for women with cancer.

METHODS

Retrospective cohort study from 2003 to 2015 was conducted. The study population consisted of 353 women with cancer who underwent 394 FP cycles (187 IVF-FP cycles and 207 IVM-FP) for oocytes and/or embryos cryopreservation.

RESULT(S)

Comparatively with IVM-FP, IVF-FP had a higher median [25th-75th percentile] number of oocytes collected-12 [8-18] vs 7 [5-13]; oocytes cryopreserved-10 [6-15] vs 5 [2-8]; and, where applicable, embryos cryopreserved-5 [3-7] vs 3 [2-5] (p < 0.000001). Following FP treatment, 32 patients (9.0%) died, 18 patients (5.6%) conceived spontaneously, and 23 patients (6.5%) returned to attempt pregnancy with a median lapse of returning of 4.6 [3.1-6.1] years. Of these, cryopreserved oocytes or embryos were used in 33 cycles (19 after IVF-FP and 14 after IVM-FP). Overall, the cumulative pregnancy rate (CPR) was 47.6% (10/21) and the live birth rate (LBR) was 38.1% (8/21). Per cycle, CPR and LBR were 37 and 31% following IVF-FP and 14 and 7% following IVM-FP, although these differences did not reach statistical significance. We report the fourth live birth after IVM-FP in cancer, and the first one after IVM embryo warming resulting from in vivo oocyte retrieval and IVM procedure.

CONCLUSION(S)

Both IVF-FP and IVM-FP are possible options for FP women with cancer. Due to minimal data regarding ultimate outcomes, further follow-up is needed.

Long-term outcomes in cancer patients who did or did not pursue fertility preservation

OBJECTIVE

To compare long-term outcomes of cancer patients who pursued fertility preservation (FP) with those who did not and compare random-start (RS) and menstrual cycle-specific (CS) protocols for FP.

DESIGN

Retrospective cohort.

SETTING

Single urban academic institution.

PATIENT(S)

Oncology patients who contacted the FP patient navigator, 2005-2015.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Time to cancer treatment, disease-free survival, and reproductive outcomes in FP versus no-FP patients and cycle outcomes for RS versus CS protocols. Data were analyzed by χ² and logistic regression.

RESULT(S)

Of 497 patients who met the inclusion criteria, 41% elected FP. The median number of days to cancer treatment was 33 and 19 days in the FP and no-FP groups, respectively. There was no difference in cancer recurrence or mortality. There were no differences in stimulation parameters, outcomes, or days to next cancer treatment in RS versus CS protocols. Twenty-one patients returned to use cryopreserved specimens, resulting in 16 live births. Eight of 21 returning patients used a gestational carrier. Thirteen FP (6.4%) and 16 no-FP (5.5%) patients experienced a spontaneous pregnancy.

CONCLUSION(S)

FP is both safe and efficacious for eligible cancer patients. Only 10% of patients returned to use cryopreserved specimens, and almost half used a gestational carrier, suggesting the need for further research into reproductive decision-making in cancer survivors.

Recent advances in fertility preservation and counseling for female cancer patients

INTRODUCTION

Ensuring quality of life for increasing numbers of women surviving cancer has become a key challenge. Patients need to be counseled on potential fertility loss resulting from gonadotoxic treatments, and referred to fertility specialists to discuss existing options and available results. Areas covered: Fertility preservation options have existed for over twenty years. The proposed fertility preservation approach depends on patient age, the urgency of required chemotherapy, and psychosocial factors such as financial concerns, especially in countries where techniques are not covered by social security. Efficacy in terms of pregnancy rates has been demonstrated with frozen-thawed embryos, oocytes and re-implanted ovarian tissue. Appropriate counseling by oncologists is on the increase, despite persistently low rates of referral to fertility specialists. Expert commentary: Access to oncofertility services is steadily improving, facilitated by the growing involvement of public healthcare systems and sustained efforts all over the world to establish specific oncofertility programs. Early referral to reproductive specialists before initiation of chemo/radiotherapy is crucial to success in the field of female fertility preservation. In the near future, efforts should focus on increasing patient referrals and establishing international registries on short- and long-term outcomes of fertility preservation strategies.

Antral follicle responsiveness to FSH, assessed by the follicular output rate (FORT), is altered in Hodgkin's lymphoma when compared with breast cancer candidates for fertility preservation

PURPOSE

Oocyte and/or embryo cryopreservation after controlled ovarian hyperstimulation (COH) represents the most established method for female fertility preservation (FP) before cancer treatment. Whether patients suffering from malignancies, candidates for FP, have a normal ovarian capacity to respond to stimulation is controversial. Reduced responsiveness of antral follicle to exogenous FSH might be at play. The percentage of antral follicles that successfully respond to FSH administration may be estimated by the follicular output rate (FORT), which presumably reflects the health of granulosa cells. The present study aims at investigating whether the FORT differs between Hodgkin's lymphoma (HL) and breast cancer (BC) patients.

METHODS

Forty-nine BC and 33 HL patient candidates for FP using oocyte vitrification following COH were prospectively studied. FORT was calculated by the ratio between the pre-ovulatory follicle count (16-22 mm) on the day of oocyte triggering × 100/antral follicle count before initiation of the stimulation.

RESULTS

Overall, women in the HL group were younger in comparison with BC patients (26.4 ± 3.9 vs 33.6 ± 3.3 years, p < 0.0001, respectively). The FORT was significantly decreased in patients with HL when compared with BC group (27.0 ± 18.8 vs 39.8 ± 18.9%, p = 0.004, respectively), further leading to a comparable number of oocytes vitrified (10.8 ± 5.9 vs 10.2 ± 7.7 oocytes, p = 0.7, respectively).

CONCLUSION

The present findings indicate that the percentage of antral follicles that successfully respond to FSH administration is reduced in HL when compared to BC patients, supporting the hypothesis of a detrimental effect of hemopathy on follicular health. In vitro experimentations might provide additional data to confirm this hypothesis.

Fertility Preservation in Breast Cancer

As more young women survive breast cancer, fertility preservation (FP) is an important component of care. This review highlights the importance of early pretreatment referral, reviews the risks of infertility associated with breast cancer treatment, and defines existing and emerging techniques for FP. The techniques reviewed include ovarian suppression, embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation and transplantation. The barriers women face, such as not being appropriately referred and the costs of treatment, also are addressed. Multidisciplinary, patient-centered care is essential to discussing FP with patients with breast cancer and ensuring appropriate care that includes quality of life in survivorship.