Fertility preservation outcomes in women with gliomas: a retrospective case-control study

Fertility preserving techniques in neuro-oncology patients: A systematic review

Background

Advancements in cancer treatments have enhanced survival rates and quality of life for patients with central nervous system (CNS) tumors. There is growing recognition of the significance of fertility preservation methods. Currently, techniques, including oocyte cryopreservation and sperm cryopreservation are established. Nevertheless, oncologists may exhibit reluctance when referring patients to reproductive specialists. This review aimed to assess the best evidence for fertility preservation techniques used in patients with CNS cancers and evaluate outcomes relating to their success and complications.

Methods

Two reviewers performed a search of Pubmed, Embase, Medline, Cochrane, and Google Scholar. Papers were included if they reported at least 1 fertility preservation technique in a neuro-oncology patient. Non-English studies, editorials, animal studies, and guidelines were excluded. Meta-analysis was performed using the random effects model.

Results

Sixteen studies containing data from 237 participants (78.8% female) were included in the systematic review and meta-analysis, of whom 110 (46.4%) underwent fertility preservation techniques. All patients (100%) successfully underwent fertility preservation with 1 participant (2.9%) returning to rewarm their oocytes, embryos or sperm. On average, 17.8 oocytes were retrieved with 78%, ultimately being cryopreserved. Five (6.0%) patients successfully conceived 9 healthy-term children after utilizing their cryopreserved sperm, embryos, or oocytes. Moreover, 6 patients successfully conceived naturally or using intrauterine insemination, resulting in 7 healthy-term children.

Conclusions

Fertility preservation techniques could offer a safe and effective way for neuro-oncology patients to deliver healthy-term babies following treatment. However, further studies concerning risks, long-term pregnancy outcomes, and cost-effectiveness are needed.

Ovarian reserve in reproductive-aged patients with cancer before gonadotoxic treatment: a systematic review and meta-analysis

STUDY QUESTION

Does cancer itself, before any gonadotoxic treatment, affect ovarian function in reproductive-aged patients?

SUMMARY ANSWER

Our study revealed that women with cancer may have decreased ovarian reserve markers even before cancer therapy.

WHAT IS KNOWN ALREADY

With the field 'oncofertility' improving rapidly, cancer therapy-mediated ovarian damage is well characterized. However, there is a controversy about whether cancer itself affects ovarian function before gonadotoxic treatment.

STUDY DESIGN SIZE DURATION

We conducted a systematic meta-analysis investigating the association between cancer and ovarian function prior to gonadotoxic treatment. Titles or abstracts related to ovarian reserve (e.g. anti-Müllerian hormone (AMH), antral follicle count (AFC), or basal follicle-stimulating hormone (FSH)) combined with titles or abstracts related to the exposure (e.g. cancer*, oncolog*, or malignan*) were searched in PubMed, Embase, and Web of Science databases from inception to 1 February 2022.

PARTICIPANTS/MATERIALS SETTING METHODS

We included cohort, case-control, and cross-sectional studies in English that examined ovarian reserve in reproductive-aged patients (18-45 years) with cancer compared to age-matched controls before cancer treatment. The quality of the included studies was assessed by ROBINS-I. Fixed or random effects were conducted to estimate standard or weighted mean difference (SMD or WMD, respectively) and CI. Heterogeneity was assessed by the Q test and I² statistics, and publication bias was evaluated by Egger's and Begg's tests.

MAIN RESULTS AND THE ROLE OF CHANCE

The review identified 17 eligible studies for inclusion. The results showed that cancer patients had lower serum AMH levels compared to healthy controls (SMD = -0.19, 95% CI = -0.34 to -0.03, P = 0.001), especially women with hematological malignancies (SMD = -0.62, 95% CI = -0.99 to -0.24, P = 0.001). The AFC was also decreased in patients with cancer (WMD = -0.93, 95% CI = -1.79 to -0.07, P = 0.033) compared to controls, while inhibin B and basal FSH levels showed no statistically significant differences.

LIMITATIONS REASONS FOR CAUTION

Serum AMH and basal FSH levels in this meta-analysis showed high heterogeneity, and the small number of studies contributing to most subgroup analyses limited the heterogeneity analysis. Moreover, the studies for specific cancer subtypes may be too small to draw conclusions; more studies are needed to investigate the possible impact of cancer type and stage on ovarian function.

WIDER IMPLICATIONS OF THE FINDINGS

Our study confirmed the findings that cancer per se, especially hematological malignancies, negatively affects serum AMH level, and AFC values of reproductive-aged women. However, the lower AMH levels and AFC values may also be due to the changes in ovarian physiology under oncological conditions, rather than actual lower ovarian reserves. Based on the meta-analysis, clinicians should raise awareness about the possible need for personalized approaches for young women with cancer who are interested in pursuing fertility preservation strategies before anticancer treatments.

STUDY FUNDING/COMPETING INTERESTS

This work was financially supported by the National Natural Science Foundation of China (nos 81873824, 82001514, and 81902669) and the Applied Basic Research Program of Wuhan Municipal Bureau of Science and Technology (2019020701011436). The authors declare that they have no conflicts of interest.

REGISTRATION NUMBER

PROSPERO (CRD42021235954).

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.

Sexual Dysfunction of Patients with Diffuse Low-Grade Glioma: A Qualitative Review of a Neglected Concern

Simple Summary

Patients suffering from diffuse Low-Grade Glioma (LGG) are usually young adults and present long life expectancy thanks to multimodal therapeutic management. In this context, the preservation of quality of life (QoL) is essential, and sexual health is part of it. We reviewed here the current knowledge about sexual dysfunction in LGG patients. We highlighted how this issue has been largely neglected, despite an incidence from 44 to 62% in the rare series of the literature. Thus, there is a need to assess more systematically the occurrence of SD in clinical routine in order to adapt cancer treatments accordingly, to manage actively these troubles, and finally to improve patients’ QoL in the long run.

Abstract

Diffuse low-grade gliomas (LGG) commonly affect young adults and display a slow evolution, with a life expectancy that can surpass 15 years, thanks to multimodal therapeutic management. Therefore, preservation of quality of life (QoL), including sexual health, is mandatory. We systematically searched available medical databases of Pubmed, Cochrane, and Scopus for studies that reported data on sexual activity or dysfunction (SD) in LGG patients. We analyzed results to determine incidence of SD and its association with QoL in this population. Three studies focused on SD incidence in patients presenting specifically LGG, or brain tumors including LGG. They comprised 124 brain tumor patients, including 62 LGG, with SD incidence ranging from 44 to 63%. SD was reported by more than 50% of interrogated women in the three studies. Regarding QoL, two out of the three studies found significant associations between SD and alterations of QoL parameters, particularly in the field of social and functional wellbeing. Finally, we discussed those results regarding methods of evaluation, inherent biases, and therapeutic implications regarding antiseizure medications and also planning of surgery, chemo-, and radiotherapy. Our review showed that SD is highly prevalent but still poorly studied in LGG patients. As those patients are usually young and enjoy an active life, there is a need to assess more systematically the occurrence of SD in clinical routine, in order to adapt cancer treatments accordingly, to manage actively these troubles, and finally to improve patients’ QoL in the long run.

A comparison of fertility preservation outcomes in patients who froze oocytes, embryos, or ovarian tissue for medically indicated circumstances: a systematic review and meta-analysis

OBJECTIVE

To compare obstetric outcomes in patients cryopreserving reproductive cells or tissues before gonadotoxic therapy.

DESIGN

A literature search was conducted following PRISMA guidelines on Embase, Medline, and Web of Science. Studies reporting obstetric outcomes in cancer patients who completed cryopreservation of oocyte, embryo, or ovarian tissue were included.

SETTING

Not applicable.

PATIENT(S)

Cancer patients attempting pregnancy using cryopreserved cells or tissues frozen before cancer therapy.

INTERVENTION(S)

Oocyte, embryo, or ovarian tissue cryopreservation for fertility preservation in cancer.

MAIN OUTCOME MEASURE(S)

The total numbers of clinical pregnancies, live births, and miscarriages in women attempting pregnancy using cryopreserved reproductive cells or tissues were calculated. A meta-analysis determined the effect size of each intervention.

RESULT(S)

The search returned 4,038 unique entries. Thirty-eight eligible studies were analyzed. The clinical pregnancy rates were 34.9%, 49.0%, and 43.8% for oocyte, embryo, and ovarian tissue cryopreservation, respectively. No significant differences were found among groups. The live birth rates were 25.8%, 35.3%, and 32.3% for oocyte, embryo, and ovarian tissue cryopreservation, respectively, with no significant differences among groups. The miscarriage rates were 9.2%, 16.9%, and 7.5% for oocyte, embryo, and ovarian tissue cryopreservation, respectively. Significantly fewer miscarriages occurred with ovarian tissue cryopreservation than with embryo cryopreservation.

CONCLUSION(S)

This enquiry is required to counsel cancer patients wishing to preserve fertility. Although the limitations of this study include heterogeneity, lack of quality studies, and low utilization rates, it serves as a starting point for comparison of reproductive and obstetric outcomes in patients returning for family-planning after gonadotoxic therapy.

In vitro maturation of immature oocytes for fertility preservation in cancer patients compared to control patients with fertility problems in an in vitro fertilization program

Background

The aim of this study was to determine whether in vitro maturation (IVM) of immature oocytes after controlled hormonal stimulation of the ovaries could be important in cancer patients to improve their chances of conception in the future.

Patients and methods

After ovarian stimulation in cancer patients, the number of oocytes and their quality and maturity were compared to control patients with fertility problems in the in vitro fertilization (IVF) program. In both groups of patients, immature oocytes at the developmental stage of germinal vesicle were matured in vitro and the proportion of oocytes that matured in vitro was compared between groups. In a subset of women with fertility problems, intracytoplasmic sperm injection (ICSI) was performed on IVM oocytes to assess their ability to be fertilized and develop into an embryo compared to vivo matured oocytes in the same cycles and consider the procedure in cancer patients.

Results

In patients with different cancers, the disease did not affect the number and quality of retrieved oocytes. In cancer patients, there was even a significantly lower proportion of immature oocytes than in patients with fertility problems (30.0% vs. 43.6%; P < 0.05). However, in patients with cancer, fewer oocytes per patient matured in vitro than in patients with fertility problems (1.39 ± 1.04 vs. 2.48 ± 1.83; P < 0.05). After ICSI, the proportions of fertilized oocytes and fertilized oocytes developing into an embryo did not differ between oocytes matured in vitro and in vivo in the same cycles.

Conclusions

Oocyte IVM is proving to be a reliable procedure for resolving immature oocytes after controlled ovarian stimulation in cancer patients.