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Haddadi M, Muhammadnejad S, Sadeghi-Fazel F, Zandieh Z, Rahimi G, Sadighi S, Akbari P, Mohagheghi MA, Mosavi-Jarrahi A, Amanpour S. Systematic review of available guidelines on fertility preservation of young patients with breast cancer. Asian Pac J Cancer Prev 2015; 16:1057-62. [PMID: 25735331 DOI: 10.7314/apjcp.2015.16.3.1057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Since the survival rate of breast cancer patients has improved, harmful effects of new treatment modalities on fertility of the young breast cancer patients has become a focus of attention. This study aimed to systematically review and critically appraise all available guidelines for fertility preservation in young breast cancer patients. MATERIALS AND METHODS Major citation databases were searched for treatment guidelines. Experts from relevant disciplines appraised the available guidelines. The AGREE II Instrument that includes 23 criteria in seven domains (scope and purpose of the guidelines, stakeholder involvement, rigor of development, clarity, applicability, editorial independence, and overall quality) was used to apprise and score the guidelines. RESULTS The search strategy retrieved 2,606 citations; 72 were considered for full-text screening and seven guidelines were included in the study. There was variability in the scores assigned to different domains among the guidelines. ASCO (2013), with an overall score of 68.0%, had the highest score, and St Gallen, with an overall score of 24.7%, had the lowest scores among the guidelines. CONCLUSIONS With the promising survival rate among breast cancer patients, more attention should be given to include specific fertility preservation recommendations for young breast cancer patients.
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Affiliation(s)
- Mahnaz Haddadi
- Cancer Models Research Center, Cancer Institute of Iran, Tehran, Iran E-mail :
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2
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Kovacs P. Fertility preservation in reproductive age women with cancer. J Obstet Gynaecol India 2014; 64:381-7. [PMID: 25489139 DOI: 10.1007/s13224-014-0626-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/22/2014] [Indexed: 11/28/2022] Open
Abstract
Cancer may be detected at any age and could affect children, and reproductive age women as well. In recent years, cancer treatment has become less destructive and more specific. As a result, survival rates and quality of life following successful treatment have continuously improved. Cancer treatment typically involves surgery, chemo- or radiation therapy, or the combinations of these. These interventions often adversely affect the function of the reproductive organs. Chemo- and radiation therapy are known to be gonadotoxic. Survivors of oncologic therapy are typically rendered infertile primarily due to the loss of ovarian function. There are, however, several medical, surgical, and assisted reproductive technology options that could be and should be offered to those diagnosed with cancer and wish to maintain their fertility. Embryo cryopreservation has been available for decades and has been successfully applied for fertility preservation in women diagnosed with cancer. Recent advances in cryobiology have increased the efficacy of not just embryo but even oocyte and ovarian tissue freezing-thawing. Oocyte vitrification just like embryo cryopreservation requires the use of stimulation but does not require the patient to be in a stable relationship or accept the use of donor sperm. Ovarian tissue cryopreservation does not require stimulation and, following successful transplantation, provides the patient with the most eggs but is currently still considered experimental. This paper summarizes the various fertility-sparing medical, surgical and assisted reproductive technology options. It reviews the current status of embryo, oocyte, and ovarian tissue cryopreservation and discusses their risks and benefits.
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Affiliation(s)
- Peter Kovacs
- Kaali Institute, IVF Center, Istenhegyi ut 54/a, Budapest, 1125 Hungary
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Ghazeeri G, Awwad J. Two successful pregnancies in a patient with chemotherapy-induced ovarian failure while on hormone replacement therapy. Gynecol Endocrinol 2012; 28:286-7. [PMID: 22122545 DOI: 10.3109/09513590.2011.633657] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Chemotherapeutic agents administered for the treatment of malignancies can result in the incidence of premature ovarian failure (POF). Ovarian failure is reflected by elevated serum follicle-stimulating hormone (FSH) levels that may reach menopausal levels, at which the chances of a pregnancy are considered extremely rare. We report a case of a 26-year-old female who experienced two successful pregnancies, despite her diagnosis with chemotherapy-induced POF. This case suggests that patients who suffer from POF secondary to chemotherapy might still retain enough ovarian function with good quality oocytes that could support a healthy pregnancy.
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Affiliation(s)
- Ghina Ghazeeri
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon.
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Autotransplantation of cryopreserved ovarian tissue: a procedure with promise, risks, and a need for a registry. Fertil Steril 2011; 95:1879-86. [DOI: 10.1016/j.fertnstert.2011.02.049] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 02/24/2011] [Indexed: 11/20/2022]
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5
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Anchan RM, Ginsburg ES. Fertility concerns and preservation in younger women with breast cancer. Crit Rev Oncol Hematol 2010; 74:175-92. [DOI: 10.1016/j.critrevonc.2009.09.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Revised: 09/12/2009] [Accepted: 09/24/2009] [Indexed: 12/22/2022] Open
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Münter MW, Wengenroth M, Fehrenbacher G, Schardt D, Nikoghosyan A, Durante M, Debus J. Heavy ion radiotherapy during pregnancy. Fertil Steril 2010; 94:2329.e5-7. [PMID: 20493478 DOI: 10.1016/j.fertnstert.2010.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2010] [Revised: 03/19/2010] [Accepted: 04/05/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To provide a safe particle therapy treatment for a pregnant woman with skull-base cancer. DESIGN Case report. SETTING University clinic. PATIENT(S) A 27-year-old woman diagnosed for a skull-base chordoma and whose pregnancy was found during the course of radiotherapy with accelerated carbon ions. INTERVENTION(S) Therapy was continued as scheduled, and fetal dose produced by photons and neutrons was measured at each radiotherapy fraction using passive and active monitors. MAIN OUTCOME MEASURE(S) Radiation dose to the uterus. Health of the mother and the newborn. RESULT(S) Total dose to the uterus was <0.2 mSv. About 30% of this dose was caused by neutrons. Magnetic resonance imaging of the skull base showed no evidence of recurrent disease in the mother. The child was healthy with normal development. CONCLUSION(S) Heavy ion cancer therapy produces a very low dose in distal organs.
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Affiliation(s)
- Marc W Münter
- Department of Radiation Oncology, University of Heidelberg, Heidelberg, Germany
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7
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Imai A, Furui T. Chemotherapy-induced female infertility and protective action of gonadotropin-releasing hormone analogues. J OBSTET GYNAECOL 2009; 27:20-4. [PMID: 17365452 DOI: 10.1080/01443610601056467] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This review aimed to critically discuss the current protocols using gonadotropin-releasing hormone analogue (GnRHa) for the management of chemotherapy-induced premature ovarian failure. In in-vitro experiments, GnRHa retards doxorubicin-induced granulosa cell damage, suggesting an additional GnRH's activity to protect the gonads during chemotherapy through GnRH receptor-mediated mechanism(s). GnRHa acts to protect the gonads during radiation and/or chemotherapy by preferentially steering cells into cell cycle arrest with a decline in response to the chemotherapeutic agents. The ovarian protection by GnRHa co-treatment against chemotherapy can enable the preservation of future fertility in survivors and prevent the bone demineralisation and osteoporosis associated with hypooestrogenism and ovarian failure.
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Affiliation(s)
- A Imai
- Department of Obstetrics and Gynecology, Gifu University School of Medicine, Japan.
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Mancini J, Rey D, Préau M, Malavolti L, Moatti JP. Infertility induced by cancer treatment: inappropriate or no information provided to majority of French survivors of cancer. Fertil Steril 2008; 90:1616-25. [DOI: 10.1016/j.fertnstert.2007.08.064] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2007] [Revised: 08/27/2007] [Accepted: 08/27/2007] [Indexed: 11/16/2022]
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Abstract
Many cancers that present in children and adolescents are curable with surgery, chemotherapy, and/or radiation therapy. Potential adverse consequences of treatment include sterility, infertility, or subfertility as a result of either gonad removal or damage to germ cells from adjuvant therapy. In recent years, treatment of solid tumors and hematologic malignancies has been modified in an attempt to reduce damage to the gonads. Simultaneously, advances in assisted reproductive techniques have led to new possibilities for the prevention and treatment of infertility. This technical report reviews the topic of fertility preservation in pediatric and adolescent patients with cancer, including ethical considerations.
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10
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Abstract
Improvements in the success of cancer treatments have resulted in increased awareness of the long-term effects of treatment, of which gonadal failure is the most significant. Thus, preservation of fertility potential has become a major goal and could be realized by preventing ovarian toxicity or by cryopreservation of reproductive cells/tissues. This review aimed to critically discuss the current protocols for the management of chemotherapy-inducced/radiotherapy-induced premature ovarian failure (POF). A medical approach using the gonadotropin-releasing hormone analog (GnRHa) may act to protect the gonads during radiation and/or chemotherapy by preferentially steering cells into cell cycle arrest with a decline in responsibility to the chemotherapeutic agents. Ovarian protection by GnRHa cotreatment against chemotherapy can enable the preservation of future fertility in survivors and prevent the bone demineralization and osteoporosis associated with hypestrogenism and POF. In vitro fertilization of retrieved oocytes could enable embryo freezing in some patients. Embryo cryopreservation is considered standard practice and widely available, but may seldom be used because of a lack of a male partner, the need to postpone cancer therapy for a few weeks and the possibility that an estrogen rise may be undesirable in sensitive cancer patients. Improvement in oocyte cryopreservation may offer additional possibilities; the prolonged culture of primordial and primary follicles in vitro is still unfeasible. Currently, the cryopreservation of ovarian cortex, which hosts thousands of immature follicles, is an investigational method, but has the advantage of requiring neither a sperm donor nor ovarian stimulation. Fertility preservation is often possible in women undergoing cancer treatment. To preserve the full range of options, fertility preservation procedures should be considered as early as possible during therapy planning. (Reprod Med Biol 2008; 7: 17-27).
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Affiliation(s)
- Atsushi Imai
- Department of Obstetrics and Gynecology, Gifu University School of Medicine, Gifu, Japan
| | - Tatsuro Furui
- Department of Obstetrics and Gynecology, Gifu University School of Medicine, Gifu, Japan
| | - Akio Yamamoto
- Department of Obstetrics and Gynecology, Gifu University School of Medicine, Gifu, Japan
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Weibliche und männliche Fertilitätsstörungen und Risiken der assistierten Fertilisation. DIE ÄRZTLICHE BEGUTACHTUNG 2008. [PMCID: PMC7119938 DOI: 10.1007/978-3-7985-1564-2_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Ca. 10–15% der Paare im reproduktionsfähigen Alter bleiben ungewollt kinderlos. Der Anteil steigt tendentiell durch den zunehmend „späten Kinderwunsch“. Das durchschnittliche Alter der Erstgebärenden hat sich u.a. aus Gründen der Ausbildungszeit und Berufstätigkeit der Frau zwischen 1970 und 2000 vom 24. auf das 30. Lebensjahr verschoben. Eine gewollte Kinderlosigkeit kommt in ca. 10% der Ehen vor.
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Fauque P, Ben Amor A, Joanne C, Agnani G, Bresson JL, Roux C. Use of trypan blue staining to assess the quality of ovarian cryopreservation. Fertil Steril 2007; 87:1200-7. [PMID: 17307173 DOI: 10.1016/j.fertnstert.2006.08.115] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2006] [Revised: 08/07/2006] [Accepted: 08/07/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To check the efficiency of the cryopreservation procedure by using trypan blue staining of ovarian test fragments to assess the quality of frozen-thawed ovarian tissue. DESIGN Prospective study. SETTING University hospital. PATIENT(S) Patients with polycystic ovary syndrome undergoing laparoscopic ovarian drilling. INTERVENTION(S) Ovarian cortical biopsies obtained from polycystic ovary syndrome patients were frozen using a slow freezing-rapid thawing protocol. MAIN OUTCOME MEASURE(S) Primordial and primary follicle viability was assessed with trypan blue staining. Unstained isolated follicles were studied by transmission electron microscopy. Histologic and immunohistochemical analysis of apoptosis was performed on tissue sections. RESULT(S) The percentage of unstained follicles considered live was lower (P=.015) after freezing/thawing (71.9%) than before cryopreservation (87.3%). Transmission electron microscopy on follicles considered live confirmed the lack of ultrastructural damage. After freezing/thawing, tissue morphology was preserved, but immunohistochemical analysis shows a significant increase in the apoptosis process. CONCLUSION(S) Ovarian cortical test fragments combined with trypan blue staining on enzymatically isolated follicles is a useful and quick method of assessing the initial quality and viability of follicles in cryopreserved ovarian tissue. This type of test should be used routinely as quality control in ovarian cryopreservation procedures.
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Affiliation(s)
- Patricia Fauque
- Service de Génétique, Histologie, Biologie du Développement et de la Reproduction, Centre d'Etude et de Conservation des Oeufs, Hôpital Saint Jacques, University of Franche-Comté, Besançon, France
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13
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Abstract
Ovarian tissue preservation and transplantation are intended for women undergoing aggressive regimens of chemical and/or radiological therapy, bone marrow transplantation or stem cell transplantation. Main indications for the procedure are neoplastic diseases and autoimmune disorders. The first live human birth after ovarian tissue autotransplantation was successfully done in 2002. Cryopreserved ovarian tissue can be autografted either orthotopically or heterotopically. Neovascularization of the implanted tissue is essential for the procedure. Vascular transplantation seems to be the best approach for avoiding follicular loss and extending the lifespan of the ovarian grafts. The procedure, regardless of whether ortho- or heterotopic, is connected with a risk of reimplantation of neoplastic cells. This can be minimized by multiple ovary biopsies, thorough histological examination and molecular genetic techniques. Introducing ovarian tissue transplantation into clinical practice requires many problems to be solved. Standardization of the freeze-thaw protocol is one of the most important issues. Solving the problem of transient graft ischemia is also essential. Eventually, the future safety of the method requires the development of efficient tests to detect the presence of neoplastic cells in the transplanted tissue.
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Affiliation(s)
- Artur J Jakimiuk
- Department of Obstetrics and Gynecology, Central Clinical Hospital of Ministry of Interior and Administration, Woloska Str. 137, 02-507 Warsaw, Poland.
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14
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Abstract
PURPOSE OF REVIEW To summarize current knowledge about premature ovarian failure (POF) with an emphasis on recent developments regarding its management. RECENT FINDINGS The incidence of POF is increasing largely due to improved survival rates of cancer patients treated with radiation and chemotherapy. Delayed diagnosis and management of POF leads to suboptimal outcomes. Anticipation and early detection of this condition in high-risk women by means of ovarian function testing, followed by early institution of appropriate management could improve outcomes. Choice of strategies should vary depending on the age of onset, associated symptoms and fertility aspirations of the individual, and should change with the patient's advancing age. SUMMARY Early assessment of the individual's risk of developing POF, development of a strategic management plan, and timely commencement of infertility and hormone deficiency treatment, together with counselling in an integrated management plan should improve both the short and long-term health of those with POF.
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Affiliation(s)
- Apollo Meskhi
- Academic Unit of Obs & Gynae, University of Manchester, St Mary's Hospital, Manchester, UK
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15
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Imai A, Sugiyama M, Furui T, Tamaya T, Ohno T. Direct Protection by a Gonadotropin-Releasing Hormone Analog from Doxorubicin-Induced Granulosa Cell Damage. Gynecol Obstet Invest 2006; 63:102-6. [PMID: 17028438 DOI: 10.1159/000096062] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2005] [Accepted: 08/08/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Recent clinical applications suggest a beneficial effect of gonadotropin-releasing hormone analog (GnRHa) as a gonadal protector from chemotherapy-induced premature ovarian failure. This study aimed to determine cellular mechanisms involved in the protective action of GnRHa against granulosa cell damage caused by doxorubicin. METHODS Granulosa cells were obtained by ultrasound-guided follicular aspiration from patients undergoing in vitro fertilization, and screened for GnRH receptor expression prior to analyses. The cellular function was assessed by measuring the conversion of exogenously supplied androstenedione to estradiol-beta (E2) in response to follicle-stimulating hormone (FSH) (1 microM). RESULTS Exposing to doxorubicin for 12 h before FSH stimulation caused a concentration-dependent inhibition of the E2 secretion to a minimum level of 20% of control. When the cells were incubated with a GnRHa for 12 h before and during exposure to doxorubicin, granulosa cells produced an equal level of E2 to that of control cells. The protective action of GnRHa was dose-dependent; a half-maximal effect occurred at 10 nM. Preincubation with GnRHa alone had no effect on FSH-induced E2 production. CONCLUSION These findings demonstrate that a GnRHa may retard doxorubicin-induced granulosa cell damage, suggesting an additional GnRH activity to protect the gonads during chemotherapy through GnRH receptor-mediated mechanism(s).
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Affiliation(s)
- Atsushi Imai
- Department of Obstetrics and Gynecology, Gifu University School of Medicine, Gifu, Japan.
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16
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Haukvik UKH, Dieset I, Bjøro T, Holte H, Fosså SD. Treatment-related premature ovarian failure as a long-term complication after Hodgkin's lymphoma. Ann Oncol 2006; 17:1428-33. [PMID: 16831852 DOI: 10.1093/annonc/mdl149] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND One of the medical sequelae that chemo- and radiotherapy may cause is premature ovarian failure (POF). The scope of this study was to investigate the risk of developing POF as a long-term complication in young women treated for Hodgkin's lymphoma. PATIENTS AND METHODS The 99 women included in the study were treated between 1975 and 1992 at the Norwegian Radium Hospital. All patients received radiotherapy and 67 of the women also received chemotherapy. RESULTS POF was found in 37.4% of the patients. The risk of developing POF was significantly higher if the patient received chemotherapy in addition to radiotherapy. Furthermore, the risk increased if chemotherapy included alkylating agents. Long-term follow-up revealed that women who at the time of treatment were under 30 years of age developed POF later, but with the same cumulative risk as women above 30 years of age. CONCLUSIONS The risk of developing POF after radio- and chemotherapy is higher than earlier estimates suggest. After an observation time of 15 years the cumulative risk is 38% independent of age at the time of treatment. Age below 30 years at the time of treatment delays the development of POF, but does not decrease the life-time risk.
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Danforth DR, Arbogast LK, Friedman CI. Acute depletion of murine primordial follicle reserve by gonadotropin-releasing hormone antagonists. Fertil Steril 2005; 83:1333-8. [PMID: 15866565 DOI: 10.1016/j.fertnstert.2004.12.030] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2004] [Revised: 12/14/2004] [Accepted: 12/14/2004] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To examine the effects of GnRH antagonists on preantral follicle survival in vivo and to investigate whether GnRH antagonist use during cyclophosphamide treatment would protect the ovary and preserve primordial follicle survival in a murine model. DESIGN Prospective basic research study. SETTING Research laboratory in an academic medical center. ANIMAL(S) Adult C57Bl/6 mice (5 to 6 weeks old). INTERVENTION(S) Mice received either a single injection of GnRH agonist (leuprolide acetate) on study day -10 or injections of the GnRH antagonist (antide or cetrorelix) on study days -3 and 0. Some animals also received the chemotherapeutic agent cyclophosphamide on day 0. All animals were killed by CO2 asphyxiation on day 7. To examine direct vs. indirect effects, some mice received GnRH antagonist under the bursa of one ovary, with the contralateral ovary receiving vehicle. Ovaries were fixed in Kahle's solution; 7-mum tissue sections were stained with Lillie's allochrome, and preantral follicles were counted on every fifth section. MAIN OUTCOME MEASURE(S) Numbers of primordial, primary, and secondary follicles. RESULT(S) Systemic administration of both GnRH antagonists caused a significant destruction of primordial follicles compared with control mice. Similar results were obtained whether the antagonists were administered systemically or directly to the ovary. Gonadotropin-releasing hormone agonist had no effect on primordial follicle numbers by itself but reduced the follicular depletion caused by cyclophosphamide. CONCLUSION(S) In contrast to the effects of GnRH agonists to reduce chemotherapeutic destruction of primordial follicles, GnRH antagonists do not protect the ovary from the damaging effects of cyclophosphamide. More importantly, GnRH antagonists alone deplete primordial follicles in this murine model, likely through a direct effect on the ovary. Whether these observations apply to other species requires further study.
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Affiliation(s)
- Douglas R Danforth
- Department of Obstetrics and Gynecology, The Ohio State University, Columbus, Ohio 43210, USA.
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Benshushan A. Endometrial adenocarcinoma in young patients: evaluation and fertility-preserving treatment. Eur J Obstet Gynecol Reprod Biol 2005; 117:132-7. [PMID: 15541846 DOI: 10.1016/j.ejogrb.2004.05.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2004] [Indexed: 12/20/2022]
Abstract
Carcinoma of the endometrium is the most common female pelvic malignancy in the US. Although it is primarily a disease of the postmenopausal female, 25% of patients are premenopausal, with 3-5% in women 40 years old or younger. The younger group of women with endometrial carcinoma are frequently nulligravid with a history of infertility, and a strong desire to preserve fertility. This may pose a therapeutic dilemma for both patients and treating physicians. Medical treatment for young patients with grade 1 endometrial carcinoma who wish to preserve fertility is a reasonable and appealing option. A comprehensive evaluation prior to counseling the patient should include. A complete history and physical examination. A formal D&C with review of histology with an experienced gyn-onc pathologist. Evaluation of the pelvic and abdomen preferably with contrast-enhanced MRI or transvaginal ultrasound. In patients found to have a clinical stage I grade 1 tumor and who want to preserve fertility, thorough counseling including risks and benefits, and explanation that the data is partial and incomplete due to the lack of appropriate controlled studies is mandatory. In patients considered for medical treatment, a high dose progestin regimen should be started with endometrial sampling every 3 months until complete regression of the tumor is documented. For patients willing to conceive at this stage, treatment options should be discussed. In women who do not want pregnancy at this stage, a maintenance treatment with oral contraceptive agent or Depo-provera (medroxyprogesterone acetate 150 mg i.m. q 12 weeks) should be recommended, with periodic ultrasound evaluation of the endometrium. When the patient finishes her fertility plans, the option of hysterectomy should be considered. Although most responses are long standing, there is a small risk of progression during or after cessation of progestin therapy.
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Affiliation(s)
- Abraham Benshushan
- Department of Obstetrics and Gynecology, Division of Gynecologic-Oncology, Hadassah Medical Center, The Hebrew University P.O. Box 12000, Jerusalem 91120, Israel.
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Lutchman Singh K, Davies M, Chatterjee R. Fertility in female cancer survivors: pathophysiology, preservation and the role of ovarian reserve testing. Hum Reprod Update 2005; 11:69-89. [PMID: 15569700 DOI: 10.1093/humupd/dmh052] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The improved long-term survival of adolescents and young women treated for cancer has resulted in an increased focus on the effects of chemotherapy on ovarian function and its preservation. These women may seek advice and treatment regarding their reproductive status, including ways of preserving their fertility and preventing a premature menopause--factors that can have a profound impact on their quality of life. This article comprehensively reviews ovarian reserve testing (ORT) in general. Special emphasis is placed on patients with cancer, including the pathophysiology of gonadal damage following chemotherapy, fertility preservation and the potential role of ORT. Baseline parameters of ovarian reserve [FSH LH, estradiol, inhibin B and anti-Mullerian hormone (AMH)] have not yet performed sufficiently well in predicting poor outcome in assisted reproduction, but biochemical markers of ovarian reserve appear to be better than chronological age. Inhibin B and AMH show potential for future use. Dynamic testing appears to show much promise, especially stimulated levels of inhibin B and estradiol. The most promising tests of ovarian reserve are the biophysical markers, where total antral follicle count was found to be most discriminatory followed by ovarian volume. Combination of biochemical, biophysical and clinical markers of ovarian reserve may also improve predictive capacity. However, there is a lack of data pertinent to ORT in cancer. As yet there is no single clinically useful test to predict ovarian reserve accurately. Patients with cancer represent a distinct cohort who have particular concerns about their future fertility and the possibility of a premature menopause, they can benefit greatly from knowledge of their functional ovarian reserve. Large, prospective, randomized, adequately controlled studies specific to different geographical areas are required in a control population of comparable reproductive age to determine the potential role of ORT in clinical practice.
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Affiliation(s)
- Kerryn Lutchman Singh
- Department of Obstetrics and Gynaecology, Reproductive Medicine Unit, Elizabeth Garrett Anderson and Obstetric Hospital, University College London Hospital, Huntley Street, London WC1E 6DH, UK.
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Lo Presti A, Ruvolo G, Gancitano RA, Cittadini E. Ovarian function following radiation and chemotherapy for cancer. Eur J Obstet Gynecol Reprod Biol 2004; 113 Suppl 1:S33-40. [PMID: 15041128 DOI: 10.1016/j.ejogrb.2003.11.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
High-dose chemotherapy and radiotherapy have increased the long-term survival of young patients with cancer; nevertheless, the toxic effects on ovarian function causing amenorrhoea, premature menopause and infertility, are still severe.
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Affiliation(s)
- A Lo Presti
- Centro di Biologia della Riproduzione, Palermo, Italy.
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Abstract
Cancer in adolescents 15-19 years of age occurs at nearly twice the rate observed in 5- to 14-year-olds, but as of yet they have no explicit organisation for research and care, such as that structured for younger paediatric patients. Adolescents with cancer must be recognised as a subgroup of oncology patients with specific characteristics and needs requiring dedicated interest and management. The need is made most evident as outcome data indicates that adolescents are lagging behind in survival gains made in recent decades by both children and adults with cancer. Improvements in the overall survival, quality of care and quality of survival of adolescents with cancer will only occur by surmounting the challenges, discussed in this review, unique to this group of patients.
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Affiliation(s)
- K Albritton
- Huntsman Cancer Institute, University of Utah, USA
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Abstract
PURPOSE OF REVIEW Due to the improved long-term survival of adolescents and young women with systemic malignancies such as lymphomas and leukaemia undergoing gonadotoxic chemotherapy, preservation of future fertility has been the focus of recent ubiquitous interest. This review summarizes, in brief, the recent progress in the various attempts to prevent premature ovarian failure in these young women with unconsumed fertility potential. RECENT FINDINGS The investigational endeavours of ovarian cryopreservation await the clinical experience of auto- or xenotransplantation, or in-vitro maturation of thawed primordial follicles, and in-vitro fertilization. Although promising, this procedure is not available yet. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryopreserved ovary has been highlighted following experimental animal observations. The gonadotropin-releasing hormone agonist has been efficient in primates in a prospective study, and in young women in several nonrandomized series. The disruption of the acid sphingomyelinase gene, or sphingosine-1-phosphate, in rodents can prevent follicle destruction by ionizing radiation, possibly indicating in-vivo protection in cancer patients at risk of iatrogenic sterilization. SUMMARY The recent enormous scientific advance lends hope that the future may hold answers to the questions regarding safety and efficiency of oocyte, follicle, or ovarian tissue cryopreservation, and the most efficient means of using the thawed tissue - auto-, hetero-, or xenotransplantation versus IVM on the one hand, and in-vivo pharmacological attempts to minimize follicle depletion by gonadotropin-releasing hormone agonist or other modalities on the other hand. Until then, a combination of all the clinically available modalities should be offered to these young women with unconsumed fertility potential who face gonadotoxic therapy.
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Affiliation(s)
- Zeev Blumenfeld
- Reproductive Endocrinology & Infertility, Department of Obstetrics and Gynecology, Rambam medical Center, Israel Institute of Technology, Haifa, Israel.
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Laschke MW, Menger MD, Vollmar B. Cryopreservation does not affect neovascularization of freely transplanted ovarian follicles. Fertil Steril 2003; 79:1458-60. [PMID: 12798902 DOI: 10.1016/s0015-0282(03)00359-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fabbri R, Venturoli S, D'Errico A, Iannascoli C, Gabusi E, Valeri B, Seracchioli R, Grigioni WF. Ovarian tissue banking and fertility preservation in cancer patients: histological and immunohistochemical evaluation. Gynecol Oncol 2003; 89:259-66. [PMID: 12713989 DOI: 10.1016/s0090-8258(02)00098-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE A combination of chemotherapy and radiotherapy in young females with cancer has greatly enhanced the life expectancy of these patients, even if these treatments have a highly deleterious effect on the ovary and cause a severe depletion of the follicular store. Cryopreservation of ovarian tissue before chemotherapy and/or radiotherapy, followed by autograft after remission or in in vitro maturation, could restore gonadal function and fertility. The aim of this study is to verify the efficiency of the ovarian tissue cryopreservation procedure by histological and immunohistochemical analyses. METHODS Ovarian tissue was obtained by laparoscopy from 22 patients affected with different malignant diseases. Tissue specimens were frozen using a combination of PROH (1,2-propanediol) and sucrose as cryoprotectants, and the cryopreservation protocol used consisted of a slow freezing-rapid thawing program. Both fresh and frozen/thawed tissues were embedded in paraffin blocks for histological and immunohistochemical analyses. RESULTS Good stromal and follicular morphology was found in fresh and frozen/thawed tissue. No significant differences were found in follicular density, distribution, and diameters in fresh and frozen/thawed tissue. Follicle immunohistochemical analysis showed a high percentage of negative staining for both estrogen receptor (ER) (100% both in fresh and frozen/thawed specimens) and progesterone receptor (PR) (97% versus 91%, respectively). Regarding the Ki67 protein, positive staining was found in both the granulosa cells and/or the oocytes (36% in fresh and 56% in frozen/thawed). For the Bcl2 protein, positive staining was observed in the follicle granulosa cells but not in the oocytes in 74% of the fresh and in 79% of the frozen/thawed specimens. For the stromal cells, ER showed a negative staining distribution in 97% of the fresh and 100% of the frozen/thawed specimens. The stroma staining distribution was diffuse/focal in fresh versus frozen/thawed specimens (50% versus 74% respectively) for PR, patch/focal (70% versus 80%, respectively) for Ki67 protein, and diffuse (55% versus 54%, respectively) for Bcl2. CONCLUSIONS These results suggest that human ovarian tissue morphology, antigenicity, cellular proliferation, and anti-apoptotic index were well preserved by cryopreservation in PROH and sucrose.
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Affiliation(s)
- R Fabbri
- Human Reproductive Medicine Unit, University of Bologna, S. Orsola Hospital, Italy.
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Blumenfeld Z, Dann E, Avivi I, Epelbaum R, Rowe JM. Fertility after treatment for Hodgkin's disease. Ann Oncol 2002; 13 Suppl 1:138-47. [PMID: 12078896 DOI: 10.1093/annonc/13.s1.138] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The investigational endeavors of ovarian cryopreservation await the clinical experience of auto- or xenotransplantation, in vitro maturation of thawed primordial follicles, their in vitro fertilization and embryo transfer. Although promising, this experience is not yet available. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryoperserved ovary has been raised following experimental animal observations. Therefore, until these innovative endeavors prove successful, we have attempted to minimize the gonadotoxic effect of chemotherapy by the co-treatment with a gonadotropin-releasing hormone agonistic analog (GnRH-a) to induce a temporary prepubertal milieu. The immunoreactive inhibin-A and -B in these patients was measured before, during and following the gonadotoxic chemotherapy. METHODS A prospective clinical protocol was undertaken in 60 women aged 15-40 years with lymphoma, 10 with leukemia and 10 undergoing chemotherapeutic treatments for non-malignant diseases such as systemic lupus erythematosus or other autoimmune diseases. A monthly injection of depot D-TRP(6)-GnRH-a was administered from before starting the chemotherapy until its conclusion, up to a maximum of 6 months. Hormonal profile [follicle-stimulating hormone (FSH), luteinizing hormone (LH), E2, T, P4, insulin-like growth factor (IGF)-1, IGF-BP3 and prolactin) was taken before starting the GnRH-a/chemotherapy co-treatment, and monthly thereafter until resumtion of spontaneous ovulation. This group was compared with a control group of 60 women who have been treated with similar chemotherapy. RESULTS Whereas all but three (40, 36 and 34 year old) of the surviving patients within the GnRH-a/ chemotherapy co-treatment group resumed spontaneous ovulation and menses within 12 months, less than half of the patients in the 'control' group (chemotherapy without GnRH-a co-treatment) resumed ovarian function and regular cyclic activity (P <0.05). The remaining 55% experienced premature ovarian failure (POF). Temporarily increased FSH concentrations were experienced by about one-third of the patients resuming cyclic ovarian function, suggesting reversible ovarian damage in a larger proportion of women than those experiencing POF. Inhibin-A and -B decreased during the GnRH-a/ chemotherapy co-treatment but increased to normal levels in patients who resumed regular ovarian cyclicity, and/or spontaneously conceived, as compared with low levels in those who developed POF. CONCLUSIONS If these preliminary data are consisent in a larger group of patients, GnRH-a co-treatment should be considered in every woman of reproductive age receiving chemotherapy, in addition to assisted reproductive technologies and the investigation into ovarian cryopreservation for future in vitro maturation, autotransplantation or xenotransplantation.
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Affiliation(s)
- Z Blumenfeld
- Department of Obstetrics/Gynecology, Hematology and Oncology, Rambam Medical Center, The B. Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa.
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Chatterjee R, Kottaridis PD. Treatment of gonadal damage in recipients of allogeneic or autologous transplantation for haematological malignancies. Bone Marrow Transplant 2002; 30:629-35. [PMID: 12420200 DOI: 10.1038/sj.bmt.1703721] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Management of iatrogenic gonadal reproductive failure and sexual morbidity assumes a priority, especially in young recipients of high-dose chemotherapy and stem cell transplantation (SCT). Hormone replacement treatment (HRT) is beneficial for correction of sexual symptoms and osteoporosis in both sexes, especially in females. Sperm banking is the standard technique for preservation of fertility in adult and sexually mature adolescent males. Testicular tissue cryopreservation has a place in well-selected azoospermic adults and in mentally and sexually competent adolescents. In vitro fertilisation using superovulation with embryo-cryopreservation (for future embryo transfer) is the most tried method in female SCT recipients with good results. In mentally and sexually competent adolescents and adults without a partner, ovarian cortical tissue cryopreservation has a place for subsequent re-implantation to orthotopic or heterotopic sites. Gonadotrophin releasing hormone (GnRH) co-treatment during chemotherapy, is a promising method for the future. Although generally reassuring, continued monitoring of the offspring of SCT survivors and follow-up of all recipients of SCT is important for return of spontaneous or induced fertility.
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Affiliation(s)
- R Chatterjee
- Department of Obstetrics, University College London Medical School, London, UK
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Kwon JS, Case AM. Effects of cancer treatment on reproduction and fertility. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2002; 24:619-27. [PMID: 12196840 DOI: 10.1016/s1701-2163(16)30192-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE (1) To review the effects of cancer treatment on reproduction and fertility in both women and men and (2) to review current and new techniques that could be used to preserve fertility and hormone production in women who have undergone cancer treatment. DATA SOURCES Entries to MEDLINE and CANCERLIT through to October 2001 were searched for evidence relevant to this article. METHODS OF STUDY SELECTION This document is primarily based on large retrospective cohort series and case reports, as no randomized trials were available. TABULATION, INTEGRATION, AND RESULTS The first part of this review article focuses on the effects of radiation and chemotherapy on reproductive function and innovative medical and surgical techniques employed to minimize these effects. The second part of this article describes conservative methods of managing cervical, endometrial, and ovarian cancer for women who wish to preserve their fertility. CONCLUSIONS Over the last decade, there has been a trend toward trying to preserve reproductive function in young patients with malignancy. Information acquired over the last century on the reproductive effects of radiation and chemo-therapy has enabled us to tailor our treatment of various malignancies affecting young patients. As we learn more about the biology and clinical behaviour of gynaecologic malignancies, we are able to modify surgical management to preserve fertility in select cases. All of these trends are in keeping with our goal to optimize quality of life in cancer care without compromising safety or survival.
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Affiliation(s)
- Janice S Kwon
- Department of Obstetrics and Gynecology, University of Western Ontario, London, ON, Canada
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Kovacs P, Stangel JJ, Santoro NF, Lieman H. Successful pregnancy after transient ovarian failure following treatment of symptomatic leiomyomata. Fertil Steril 2002; 77:1292-5. [PMID: 12057745 DOI: 10.1016/s0015-0282(02)03091-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To report a case of transient ovarian failure after treatment of symptomatic leiomyomata and review other iatrogenic causes of transient ovarian failure. DESIGN Case report and literature review. SETTING University-affiliated private practice. PATIENT(S) A 35-year-old woman with symptomatic leiomyomata. INTERVENTION(S) Bilateral uterine artery embolization with subsequent abdominal myomectomy to treat unchanged regular heavy menstrual flow. MAIN OUTCOME MEASURE(S) Ovarian function. RESULT(S) Because medical therapy failed to control her menorrhagia, the patient proceeded with uterine artery embolization. She had persistent menorrhagia after bilateral uterine artery embolization and underwent exploratory laparotomy and myomectomy. After surgery, she had amenorrhea, hot flushes, and elevated FSH levels for 3 months. Ovarian function recovered after a short course of oral contraceptives, and the patient conceived without assistance. CONCLUSION(S) Several interventions can affect normal ovarian function and can lead to permanent or transient ovarian failure. Possible causes of transient ovarian failure are radioactive iodine treatment, radiation, chemotherapy, pelvic surgery, stress, and uterine artery embolization. Before these interventions are applied, the possibility of ovarian failure and available preventive measures should be discussed with the patient.
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Affiliation(s)
- Peter Kovacs
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
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Schover LR, Brey K, Lichtin A, Lipshultz LI, Jeha S. Knowledge and experience regarding cancer, infertility, and sperm banking in younger male survivors. J Clin Oncol 2002; 20:1880-9. [PMID: 11919248 DOI: 10.1200/jco.2002.07.175] [Citation(s) in RCA: 357] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The goal of this study was to survey male patients aged 14 to 40 years at diagnosis and recently treated in two cancer centers to determine their knowledge, attitudes, and experiences regarding cancer-related infertility and sperm banking. PATIENTS AND METHODS A postal survey about cancer-related infertility and sperm banking was offered to 904 men diagnosed with cancer within the previous 2 years. Eight percent opted out of the study. The others were sent the survey, with a cover letter stating elements of informed consent. RESULTS Although the return rate was only 27%, yielding a sample of 201 men, responders did not differ significantly from nonresponders by institution, age, ethnicity, or cancer site. Overall, 51% of men wanted children in the future, including 77% of men who were childless at cancer diagnosis. Despite some anxieties about their own survival and risks to their children's health, men felt that the experience of cancer increased the value they placed on family closeness and would make them better parents. Only 60% of men recalled being informed about infertility as a side effect of cancer treatment, and just 51% had been offered sperm banking. Those who discussed infertility with their physicians had higher knowledge about cancer-related infertility and were significantly more likely to bank sperm. Only 24% of men banked sperm, including 37% of childless men. Lack of information was the most common reason for failing to bank sperm (25%). CONCLUSION All men who are about to receive cancer treatment that could impair fertility should be counseled about such side effects and given adequate information to make an informed decision about banking sperm.
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Affiliation(s)
- Leslie R Schover
- Department of Behavioral Science and Pediatrics, University of Texas M.D. Anderson Cancer Center, Houston, TX 77030-4009, USA.
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Blumenfeld Z. Preservation of fertility and ovarian function and minimalization of chemotherapy associated gonadotoxicity and premature ovarian failure: the role of inhibin-A and -B as markers. Mol Cell Endocrinol 2002; 187:93-105. [PMID: 11988316 DOI: 10.1016/s0303-7207(01)00712-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Following the improved long term survival in young women with lymphoma and leukemia undergoing chemotherapy, the preservation of future fertility has been the focus of recent interest. The investigational endeavors of ovarian cryopreservation awaits the clinical experience of in-vitro maturation of thawed primordial follicles, their in-vitro fertilization and ET. Although promising, this experience is not available yet. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryopreserved ovary has been raised, following experimental animal observations. Therefore, until these innovative endeavors prove successful, and in parallel to them we attempted to minimize the gonadotoxic effect of chemotherapy by the co-treatment with a GnRH agonistic analogue to induce a temporary prepubertal milieu. Whereas, inhibin-B concentrations in serum may reflect the ovarian granulosa cell compartment, inhibin-A reflects luteal function. The immunoreactive inhibin-A and -B in these patients, before, during, and following the gonadotoxic chemotherapy were measured. METHODS A prospective clinical protocol was undertaken in 55 women with lymphoma, aged 15-40 years, ten with leukemia and eight undergoing chemotherapeutic treatments for non malignant diseases such as systemic lupus erythematosus (SLE) or other autoimmune diseases. A monthly injection of depot D-TRP6-GnRH-a was administered from before starting the chemotherapy until its conclusion, up to a maximum of 6 months. Hormonal profile (FSH, LH, E2, T, P4, IGF-1, IGF-BP3, and PRL) was taken before starting the GnRH-a/chemotherapy co-treatment, and monthly thereafter, until resuming spontaneous ovulation. This group was compared with a control group of 55 women who have been treated with similar chemotherapy. Inhibin-A and -B immunoactivity was measured by an ELISA commercial kit (Serotec). RESULTS Whereas, all but three (40- and 36-year-old) of the surviving patients with GnRH-a/chemotherapy co-treatment group resumed spontaneous ovulation and menses within 12 months, less than half of the patients in the control group (chemotherapy without GnRH-a co-treatment) resumed ovarian function and regular cyclic activity (P<0.05). The remaining 56% experienced premature ovarian failure (POF). Temporary increased FSH concentrations were experienced by about a third of the patients resuming cyclic ovarian function, suggesting a reversible ovarian damage in a larger proportion of women than those experiencing POF. Inhibin-A and -B decreased during the GnRH-a/chemotherapy co-treatment but increased to normal levels in patients who resumed regular ovarian cyclicity, and/or spontaneously conceived, as compared with low levels in those who developed POF. CONCLUSIONS If these preliminary data are consistent in a larger group of patients, inhibin-A or -B concentrations may serve as prognostic factors for predicting the resumption of ovarian function, in addition to the levels of FSH, LH and E2. The GnRH-a co-treatment should be considered in every woman in the reproductive age receiving chemotherapy, in addition to ART, and to the investigational attempts of ovarian cryopreservation for future in-vitro maturation, autotransplantation, or xenotransplantation.
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Affiliation(s)
- Z Blumenfeld
- Reproductive Endocrinology and Infertility Section, Department of Obstetrics and Gynecology, Rambam Medical Center, Technion-Faculty of Medicine, Technion-Israel Institute of Technology, 31096, Haifa, Israel.
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Abstract
OBJECTIVES To provide a review of the intimacy issues, (sexuality, fertility, and interpersonal relationships) that have an impact on the lives of cancer survivors. DATA SOURCES Published articles, research studies, and textbook chapters. CONCLUSION The experience of living with cancer impacts the survivors interpersonal relationships, sexuality, and fertility. As cancer treatments become more effective in prolonging life, options that preserve sexual function and fertility will be more prevalent. IMPLICATIONS FOR NURSING PRACTICE It is the responsibility of the oncology health care professional to become educated about options that preserve sexual function and fertility and inform patients before treatment decisions are made.
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Affiliation(s)
- D Thaler-DeMers
- Department of Hematology-Oncology, Stanford Hospital and Clinics, Stanford, CA, USA
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