Ovarian function, reproduction and strategies for fertility preservation after breast cancer

The protective effect of co-administration of platelet-rich plasma (PRP) and pentoxifylline (PTX) on cyclophosphamide-induced premature ovarian failure in mature and immature rats

Cyclophosphamide (CP), as an antineoplastic agent, causes premature ovarian failure (POF) due to ovarian toxicity and subsequent infertility in women. Platelet-rich plasma (PRP) has accumulated significant attention in regenerative medicine. Pentoxifylline (PTX) as a methylxanthine derivative has been shown to have antioxidant and antiapoptotic properties. The aim of this study was to evaluate the protective effect of PRP and PTX on CP-induced POF. Fifty mature and immature female rats were assigned into five groups: control, CP (75 mg/kg, intraperitoneal [ip] on days 1 and 10 to induce POF), CP + PRP (200 μl, ip, half an hour after CP injection on day 1 and 10), CP + PTX (50 mg/kg, orally, half an hour after CP injection daily for 21 day), and CP + PRP + PTX. At the end of experiments on day 21, measurement of body weight, ovarian parameters (ovarian volume, follicular granulosa cell layers diameter, oocyte diameter, and the number of granulosa cells), measurement of ovarian hormone in sera for estradiol (E₂), and anti-Mullerian hormone (AMH), as well as biochemical assessment were performed.The results showed that CP significantly reduced the ovarian parameters, E₂, AMH, superoxide dismutase (SOD) activity and increased Malondialdehyde (MDA) levels compared to the control group (p < 0.001). Our results also indicated that all histomorphometric parameters and biochemical markers in CP-induced POF, were preserved close to normal by PRP and PTX treatments in both mature and immature rats (p < 0.001). Therefore, it is concluded that the co-administration of PRP and PTX can protect the ovary from CP-induced POF.

Special issues in fertility preservation for gynecologic malignancies

Gynecologic malignancies account for 1,09 million new cancer cases worldwide consisting of about 12% of tumors affecting female population. About 10% of all female cancer survivors are younger than 40 years of age. Since cancers affecting female genital organs are usually treated by radical surgery, chemotherapy or chemoradiation approaches that induce permanent damage of reproductive functions, the development of strategies for fertility preservation represent one of the most important goals for gynecologic oncology. In this scenario, the newly defined oncofertility discipline acquires increasing interest, offering patients maximal chances to make an adequate decision about future fertility, based on their oncologic diagnosis and prognosis. However, the majority of physicians do not pay particular attention to these issues, even if impressive progresses have been made in this field in the last decades. Possibly, it is due to the lack of strong evidences from clinical trials without an adequate number of cases to establish safety and efficacy of these procedures. In this review we will discuss the most recently debated options for fertility preservation in gynecologic oncology, highlighting issues and controversies related to oncofertility.

Fertility drugs, reproductive strategies and ovarian cancer risk

Several adverse effects have been related to infertility treatments, such as cancer development. In particular, the relationship between infertility, reproductive strategies, and risk of gynecological cancers has aroused much interest in recent years. The evaluation of cancer risk among women treated for infertility is very complex, mainly because of many factors that can contribute to occurrence of cancer in these patients (including parity status). This article addresses the possible association between the use of fertility treatments and the risk of ovarian cancer, through a scrupulous search of the literature published thus far in this field. Our principal objective was to give more conclusive answers on the question whether the use of fertility drug significantly increases ovarian cancer risk. Our analysis focused on the different types of drugs and different treatment schedules used. This study provides additional insights regarding the long-term relationships between fertility drugs and risk of ovarian cancer.

Breast cancer risk after exposure to fertility drugs

In recent years, there has been an increase in the diagnosis of infertility. In industrialized countries, approximately 15% of couples experience this problem today, with a negative impact on quality of life. For this reason, assisted reproductive technologies and other treatments, finalized to overcome infertility, have become very common in clinical practice. For a long time, different ovulation-inducing drugs have been used for ovarian follicle stimulation, either as independent therapies or treatments used during in vitro fertilization cycles. Despite this long-term use, the medical care for infertility gave rise to a lively debate about the potential risk of developing breast cancer that has never been settled. Many studies have been conducted to address this question; but their results have been, and still are, contradictory. The aim of this review is to determine the potential link between the use of fertility drugs and the risk of developing breast cancer in women treated for infertility.

Effects of spirulina on cyclophosphamide-induced ovarian toxicity in rats: biochemical and histomorphometric evaluation of the ovary

Cyclophosphamide (Cyc) is known to cause ovotoxicity and infertility in women. Our aim is to investigate the possible ovotoxic effects of Cyc and possible antioxidant and protective effects of blue-green algae, Spirulina (Sp), in rat ovaries. Eighteen rats were given: group I (n = 6, control); group II (n = 6, CP), a single dose Cyc; group III (n = 6, Sp+Cyc), 7 days Sp+single dose Cyc. Tissue malondialdehyde (MDA) levels, superoxide dismutase (SOD), and catalase (CAT) activities are assessed biochemically. Normal and atretic primordial and primary follicle counts for all sections obtained for each ovary are calculated. Mean number of follicle counts for each group are compared. In Sp+Cyc group, tissue MDA levels were significantly lower than those in the CP and higher than those in the C group (CP > Sp+Cyc > C). Tissue SOD activity was significantly higher in Sp+Cyc group than that in the CP group and lower than that in the C group (C > Sp+Cyc > C). No statistically significant difference was found between the ovarian CAT activities in any group. Histomorphometrically, there was also no significant difference between the mean numbers of normal and atretic small follicle counts. Our results suggest that single dose Cyc has adverse effects on oxidant status of the ovaries and Sp has protective effects in Cyc-induced ovotoxicity.

T(3) preserves ovarian granulosa cells from chemotherapy-induced apoptosis

Infertility is a dramatic and frequent side effect in women who are undergoing chemotherapy. Actual strategies are mainly focused on oocyte cryopreservation, but this is not always a suitable option. Considering the key role that granulosa cells play in follicle life, we studied whether thyroid hormone 3,5,3'-triiodothyronine (T(3)) protects rat ovarian granulosa cells from chemotherapy-induced apoptosis. To this aim, a cell line was established from fresh isolated rat granulosa cells and named rGROV. Cells were exposed to paclitaxel (PTX) and T(3), and apoptosis, cell viability, and cell cycle distribution were analyzed under different conditions. First, the integrity of the steroidogenic pathway was demonstrated, and the presence of thyroid receptors, transporters, and deiodinases was confirmed by quantitative PCR. Cells were then exposed to PTX alone or contemporary to T(3). MTT and TUNEL assays revealed that while there was a relevant percentage of dying cells when exposed to PTX (40-60%), the percentage was sensibly reduced (20-30%) in favor of living cells if T(3) was present. Cell cycle analysis showed that cells exposed to PTX alone were first collected in G2 and then died by apoptosis; on the other hand, the T(3) granted the cells to cycle regularly and survive PTX insult. In addition, western blot and FCM analyses confirmed that caspases activation, casp 3 and Bax, were downregulated by T(3) and that Bcl2 and cyclins A and B together with cdk1 were upregulated by T(3). In conclusion, we demonstrated that thyroid hormone T(3) can counteract the lethal effect of taxol on granulosa cells.

Quality of life in women during and after treatment for breast cancer: a systematic review of qualitative evidence

EXECUTIVE SUMMARY

Background Breast cancer is the most common cancer in women. With increasing numbers of women surviving breast cancer, there is a need to move beyond the traditional ways of evaluating clinical outcomes and include patient-based outcomes such as the quality of life.Objectives To integrate and summarise the best evidence related to the quality of life of women diagnosed with breast cancer during and up to ten years after treatment for breast cancer.

INCLUSION CRITERIA

Types of participants: Adult women (over the age of 18 years) diagnosed with breast cancer who are or have received treatment for breast cancer in the last ten years (i.e. surgery, chemotherapy, radiation therapy and/or hormonal therapy).

PHENOMENA OF INTEREST

The quality of life of women diagnosed with breast cancer during and up to ten years after treatment.

CONTEXT

Women with breast cancer from both developed and developing countries.Types of studies: Studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory and ethnography, action research and feminist research.Search strategy The search sought to find both published and unpublished studies between 1990 and 2010, limited to the English language. Eleven electronic databases were searched including CINAHL, PubMed, Scopus and PsycArticles.Methodological quality Methodological quality was assessed independently by two reviewers using a standardised critical appraisal instrument from the Joanna Briggs Institute.Data extraction Qualitative data were extracted from the included studies using a standardised data extraction tool from the Joanna Briggs Institute.

RESULTS

A total of 42 findings from seven qualitative studies were extracted and rated as unequivocal or credible. Eleven categories were produced. Three synthesised findings were generated based on the meta-aggregation of the categories: (1) "effective care for patients will be achieved if clinicians are aware of the impact of breast cancer and its treatment on the physical and psychosocial domains of women's quality of life"; (2) "for effective patient-centred care, clinicians must be cognisant of the ways breast cancer and its treatment modalities affect social relationships"; (3) "clinicians should be aware that women use religion and spirituality to cope with breast cancer treatment and improve their quality of life".

CONCLUSIONS

This review concludes that the breast cancer diagnosis and its treatment can have a significant effect on several domains of women's quality of life. Healthcare providers caring for patients need to be well informed about each individual woman's physical and psychosocial concerns and be cognisant that any attempt to offer support must be targeted to meet the specific challenges faced by each individual woman.

IMPLICATIONS FOR PRACTICE

Support and guidance could be provided by healthcare providers through the use of counselling services, psycho-education and organisation of support groups. Elements of counselling and psycho-education should include, when appropriate, joint sessions with the woman's spouse/partner. As spirituality emerged as a coping mechanism, it is important that women be able to nurture their spiritual relationship in an environment which is supportive.

IMPLICATIONS FOR RESEARCH

The lack of studies within the Asian context indicates that further research is warranted to examine the impact of breast cancer and its treatment on the quality of life of women from diverse multi-ethnic populations. Further research into self-help strategies to improve the psychosocial well-being of women with breast cancer is warranted.It is noted that when faced with adversity, women seek comfort in religion and spirituality and a study into the relationship between spirituality and quality of life, as well as the effect of culture and religion on the quality of life, is warranted.