Uterine restoration by radiation sequelae regression with combined pentoxifylline-tocopherol: a phase II study

Treatment options for endometrial hypoproliferation

PURPOSE OF REVIEW

Endometrial hypoproliferation refers to the failure of the endometrium to reach optimal thickness during fresh or frozen embryo transfer cycles in women undergoing infertility treatment with in-vitro fertilization (IVF). This review discusses the treatment options for endometrial hypoproliferation.

RECENT FINDINGS

Apart from factors related to the embryo quality, ultrasonographic findings associated with the endometrium, such as endometrial thickness, endometrial pattern and subendometrial blood flow, are considered key factors associated with the outcome of assisted reproductive treatment. To date, a consensus has not been reached regarding the definition of thin endometrium, while thresholds of 6, 7 or 8 mm have been used in the literature. Strategies to increase endometrial thickness can be reviewed in three groups: endocrine approaches, vitamins & supplements, and new experimental therapeutic interventions. Some of the recently introduced experimental therapeutic interventions such as platelet-rich plasma injection, stem cell treatment and tissue bioengineering are exciting potential therapies that need to be further studied.

SUMMARY

Despite a large number of publications on the topic, diagnosing and treating endometrial hypoproliferation remains a challenge. Well designed studies are needed to establish a widely accepted endometrial thickness cut-off value below which endometrial hypoproliferation is diagnosed and to generate meaningful data that would allow an evidence-based discussion of available therapeutic options with patients.

Strategies for managing asherman's syndrome and endometrial atrophy: Since the classical experimental models to the new bioengineering approach

Endometrial function is essential for embryo implantation and pregnancy, but managing endometrial thickness that is too thin to support pregnancy or an endometrium of compromised functionality due to intrauterine adhesions is an ongoing challenge in reproductive medicine. Here, we review current and emerging therapeutic and experimental options for endometrial regeneration with a focus on animal models used to study solutions for Asherman's syndrome and endometrial atrophy, which both involve a damaged endometrium. A review of existing literature was performed that confirmed the lack of consensus on endometrial therapeutic options, though promising new alternatives have emerged in recent years (platelet-rich plasma, exosomes derived from stem cells, bioengineering-based techniques, endometrial organoids, among others). In the future, basic research using established experimental models of endometrial pathologies (combined with new high-tech solutions) and human clinical trials with large population sizes are needed to evaluate these emerging and new endometrial therapies.

Cell-based endometrial regeneration: current status and future perspectives

Endometrial-related disorders including Asherman's syndrome, thin endometrium, pelvic organ prolapse, and cesarean scar pregnancies can be accompanied by different symptoms such as amenorrhea, infertility, abnormal placental implantation and recurrent miscarriage. Different methods have been introduced to overcome these problems such as surgery and hormonal therapy but none of them has shown promising outcomes. On the other hand, the development of novel regenerative therapeutic strategies has opened new avenues for the treatment of endometrial-related deficiencies. In this regard, different types of scaffolds, acellular matrices and also cell therapy with adult or stem cells have been investigated for the treatment of endometrial-related deficiencies. In this paper, we review the current status of cell-based endometrium regeneration using scaffold dependent and scaffold-free methods and future perspectives in this field. Moreover, we discuss the endometrial diseases that can be candidates for cell-based treatments. Also, the cells with the potential for endometrial regeneration are explained.

Uterine irradiation as a determinant of infertility and pregnancy losses in young cancer survivors

Several concerns exist regarding the impact of anticancer treatments on fertility and pregnancy outcome. The detrimental effects of both chemotherapy and radiotherapy on the ovaries are well reported in the available literature. Fewer data are focused on the importance of a functioning uterus to conceive and carry on a healthy pregnancy. The aim of this paper is to provide a narrative review of the current literature to assess the role of uterine irradiation as a potential determinant of infertility and poor obstetrical outcomes. This review addresses the need for multidisciplinary counselling in order to face the poor reproductive and obstetrical outcomes of women who had uterine radiation, according to the different backgrounds (radiotherapy during adulthood versus childhood; total body irradiation versus pituitary, spinal and/or abdominal-pelvic irradiation).

Looking beyond the ovary for oncofertility care in women: uterine injury as a potential target for fertility-preserving treatments

Treatment for cancer has the potential to significantly diminish fertility and, further, to negatively impact the obstetrical outcomes of pregnancies that do occur. Cancer survivors have decreased rates of fertility and increased rates of pregnancy complications, such as preterm birth and low birth weight, after exposure to chemotherapy. To date, research on the impact of chemotherapy and radiotherapy on fertility and pregnancy outcomes has focused largely on the gonadotoxic effect of cancer treatments on ovaries, while the uterus and endometrium have not been extensively studied. It is intuitive, however, that decreased fertility and poorer obstetrical outcomes may be substantially mediated through injury to a highly mitotic tissue like the endometrium, which is also central to embryo implantation and utero-placental exchange. Pregnancy complications in cancer survivors might be due to compromised blood supply to the endometrium and myometrium affecting placentation or altered remodeling of the pregnant uterus secondary to radiation fibrosis. Alterations in endometrial receptivity at the molecular level could affect pregnancy implantation and early pregnancy loss, but later complications also can occur. This review focuses on understanding the unintended effects of chemotherapy and radiotherapy on uterine function in female cancer survivors and the impact on pregnancy, and summarizes mechanisms to protect and treat the uterus before and after cancer chemotherapy and radiotherapy.

Mancozeb exposure during development and lactation periods results in decreased oocyte maturation, fertilization rates, and implantation in the first-generation mice pups: Protective effect of vitamins E and C

This study aimed to evaluate the mancozeb (MNZ) impact on oocyte maturation of first-generation mice pups as well as their fertilization rate, embryo development, and implantation along with the preventative effect of vitamins E and C. Pregnant mice were randomly divided into six groups: control, vehicle, and MNZ (500 mg/kg body weight (BW)), vitamin E (200 mg/kg BW), MNZ plus vitamin E, MNZ plus vitamin C (100 mg/kg BW), and MNZ plus two vitamins. All treatments were conducted by oral gavage every 2 days from the second day of gestation until the end of lactation. Vitamin treatment was initiated 30 min before receiving MNZ. After birth, first-generation mice pups were kept until adulthood (8-10 W). Adult female mice pups superovulated and then the collected oocytes were examined for nuclear maturity status. After in vitro fertilization of metaphase II oocytes with sperm of the first-generation male mice pups, fertilization rate and embryo development were evaluated over 24 h. Also, the fecundity rate and the number of implanted embryos in vivo were studied on the eighth day of pregnancy. MNZ exposure during embryo development and lactation significantly decreased the total number of collected oocytes, oocyte maturation, fertilization rate, implantation rate, fecundity rate, and embryo development compared with the control group in the first-generation pups. In contrast, vitamin treatments significantly increased these parameters compared to the MNZ group. Reduction in the quality of oocyte, the rate of fertilization, embryo implantation, and development following MNZ exposure could decrease female reproductive success, while coadministration of vitamins E and C could prevent these complications.

Efficacy of tocopherol and pentoxifylline combined therapy for women undergoing assisted reproductive treatment with poor endometrial development: a retrospective cohort study on 143 patients

Poor endometrial development during in vitro fertilization remains challenging. Indeed, no broadly accepted definition of poor endometrial development exists, and no treatment has shown any improvement in the condition. The aim of this study was to analyze whether treatment with a combination of pentoxifylline and tocopherol increases endometrial volume. This monocentric and retrospective study includes patients with previous miscarriages, in vitro fertilization failure, or poor endometrial development. The patients had an ultrasonography during the mid-luteal phase to assess both endometrial thickness and endometrial volume (EV). If the volume was less than 2 mL, they were given pentoxifylline (PTX) and tocopherol for at least 2 months before a second ultrasound assessment. One hundred and forty-four patients were analyzed. The mean duration of treatment was 132 days. The combination of tocopherol and PTX significantly increased the EV by 0.47 mL (p < 0.0001; 95% CI 0.38-0.57). The mean ± SD EV was 1.34 ± 0.38 mL and 1.82 ± 0.63 mL before and after the treatment respectively. No data concerning pregnancy rates were interpretable. We showed an improvement of poor endometrial proliferation with a treatment including PTX and tocopherol. These promising results should be followed up by a prospective study.

Endometrial preparation for third-party parenting and cryopreserved embryo transfer

The advent of third party parenting ushered in the era of artificial stimulation of the endometrium. Initially intended only for patients with ovarian failure, exogenous induction of endometrial receptivity was quickly shown to be as good as natural endometrial preparation, with the advantage that the timing of embryo transfer could be controlled. It is perhaps surprising that even though the ovary produces a variety of steroids, that estradiol (E₂) and progesterone (P) alone would be needed to achieve optimal receptivity; no other substance has ever been shown to improve on the basic regimen of E₂ and P. A variety of routes of administration are available for both E₂ and P and physiologic (or supraphysiologic) serum or endometrial tissue levels of both can be achieved. The optimal duration of E₂ stimulation and the timing of the onset of P administration continue to be debated, but it appears that imitating the sequence that normally occurs in nature leads to optimal results. The poorly responsive endometrium and cases of recurrent implantation failure remain a challenge, but the clear majority of patients can successfully achieve pregnancy as long as embryos of adequate quality are transferred.

Management of thin endometrium in assisted reproduction: a clinical practice guideline from the Canadian Fertility and Andrology Society

The impact and management of thin endometrium is a common challenge for patients undergoing assisted reproduction. The objective of this Canadian Fertility and Andrology Society (CFAS) guideline is to provide evidence-based recommendations using the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) framework on the assessment, impact and management of thin endometrium in assisted reproduction. The effect of endometrial thickness on pregnancy and live birth outcomes in ovarian stimulation and IVF (fresh and frozen cycles) is addressed. In addition, recommendations on the use of adjuvants to improve endometrial thickness and pregnancy outcomes are provided.

Pentoxifylline Enhances the Apoptotic Effect of Carboplatin in Y79 Retinoblastoma Cells

BACKGROUND/AIM

Retinoblastoma (RB) is the most common primary intraocular malignancy. Carboplatin (CPt) is a DNA damage-inducing agent that is widely used for the treatment of RB. Unfortunately, this drug also activates the transcription factor nuclear factor-kappa B (NF-ĸB), leading to promotion of tumor survival. Pentoxifylline (PTX) is a drug that inhibits the phosphorylation of I kappa B-alpha (IĸBα) in serines 32 and 36, and this disrupts NF-ĸB activity that promotes tumor survival. The goal of this study was to evaluate the effect of the PTX on the antitumor activity of CPt.

MATERIALS AND METHODS

Y79 RB cells were treated with CPt, PTX, or both. Cell viability, apoptosis, loss of mitochondrial membrane potential, the activity of caspase-9, -8, and -3, cytochrome c release, cell-cycle progression, p53, and phosphorylation of IĸBα, and pro- and anti-apoptotic genes were evaluated.

RESULTS

Both drugs significantly affected the viability of the Y79 RB cells in a time- and dose-dependent manner. The PTX+CPt combination exhibited the highest rate of apoptosis, a decrease in cell viability and significant caspase activation, as well as loss of mitochondrial membrane potential, release of cytochrome c, and increased p53 protein levels. Cells treated with PTX alone displayed decreased I kappa B-alpha phosphorylation, compared to the CPt treated group. In addition, the PTX+CPt combination treatment induced up-regulation of the proapoptotic genes Bax, Bad, Bak, and caspases- 3, -8, and -9, compared to the CPt and PTX individual treated groups.

CONCLUSION

PTX induces apoptosis per se and increases the CPt-induced apoptosis, augmenting its antitumor effectiveness.

Customised Oocyte Donation Enhancement and New Findings Regarding the Role of Growth Hormone

In vitro fertilisation (IVF) with donated oocytes is the most effective assisted reproduction treatment currently available; however, repeated implantation failure (RIF) can occur with this treatment. The protocol of patient preparation for IVF with donated oocytes is relatively simple and works well in most cases; however, it can fail in a minority of women, which is what occurs in RIF patients. While the probability of RIF occuring is 20–35%, it is reasonable to take adequate measures in all patients in order to avoid procedural failure. The risk of oocyte donation failure can be minimised by applying a customised oocyte donation enhancement (CODE) protocol, in which pitfalls of the standard protocol are detected and corrected in the pretreatment phase, during the patient’s uterus preparation for embryo transfer, and after the transfer. Growth hormone, recently reported to improve pregnancy outcomes in women with RIF after oocyte donation, is a possible component of the CODE protocol, but it cannot be considered a unique solution to RIF. This article reviews possible causes of RIF and places growth hormone treatment in the context of other important measures to be followed in the CODE protocol.

Vasodilators for women undergoing fertility treatment

BACKGROUND

The rate of successful pregnancies brought to term has barely increased since the first assisted reproductive technology (ART) technique became available. Vasodilators have been proposed to increase endometrial receptivity, thicken the endometrium, and favour uterine relaxation, all of which could improve uterine receptivity and enhance the chances for successful assisted pregnancy.

OBJECTIVES

To evaluate the effectiveness and safety of vasodilators in women undergoing fertility treatment.

SEARCH METHODS

We searched the following electronic databases, trial registers, and websites: the Cochrane Gynaecology and Fertility Group (CGF) Specialised Register of controlled trials, the Cochrane Central Register of of Controlled Trials, via the Cochrane Register of Studies Online (CRSO), MEDLINE, Embase, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Knowledge, the Open System for Information on Grey Literature in Europe (OpenSIGLE), the Latin American and Caribbean Health Science Information Database (LILACS), clinical trial registries, and the reference lists of relevant articles. We conducted the search in October 2017 and applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing vasodilators alone or in combination with other treatments versus placebo or no treatment or versus other agents in women undergoing fertility treatment.

DATA COLLECTION AND ANALYSIS

Four review authors independently selected studies, assessed risk of bias, extracted data, and calculated risk ratios (RRs). We combined study data using a fixed-effect model and assessed evidence quality using Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) methods. Our primary outcomes were live birth or ongoing pregnancy and vasodilator side effects. Secondary outcomes included clinical pregnancy, endometrial thickness, multiple pregnancy, miscarriage, and ectopic pregnancy.

MAIN RESULTS

We included 15 studies with a total of 1326 women. All included studies compared a vasodilator versus placebo or no treatment. We judged most of these studies as having unclear risk of bias. Overall, the quality of evidence was low to moderate for most outcomes. The main limitations were imprecision due to low numbers of events and participants and risk of bias due to unclear methods of randomisation.Vasodilators probably make little or no difference in rates of live birth compared with placebo or no treatment (RR 1.18, 95% confidence interval (CI) 0.83 to 1.69; three RCTs; N = 350; I² = 0%; moderate-quality evidence) but probably increase overall rates of side effects including headache and tachycardia (RR 2.35, 95% CI 1.51 to 3.66; four RCTs; N = 418; I² = 0%; moderate-quality evidence). Evidence suggests that if 236 per 1000 women achieve live birth with placebo or no treatment, then between 196 and 398 per 1000 will do so with the use of vasodilators.Compared with placebo or no treatment, vasodilators may slightly improve clinical pregnancy rates (RR 1.45, 95% CI 1.19 to 1.77; 11 RCTs; N = 1054; I² = 6%; low-quality evidence). Vasodilators probably make little or no difference in rates of multiple gestation (RR 1.15, 95% CI 0.55 to 2.42; three RCTs; N = 370; I² = 0%; low-quality evidence), miscarriage (RR 0.83, 95% CI 0.37 to 1.86; three RCTs; N = 350; I² = 0%; low-quality evidence), or ectopic pregnancy (RR 1.48, 95% CI 0.25 to 8.69; two RCTs; N = 250; I² = 5%; low-quality evidence). All studies found benefit for endometrial thickening, but reported effects varied (I² = 92%) and ranged from a mean difference of 0.80 higher (95% CI 0.18 to 1.42) to 3.57 higher (95% CI 3.01 to 4.13) with very low-quality evidence, so we are uncertain how to interpret these results.

AUTHORS' CONCLUSIONS

Evidence was insufficient to show whether vasodilators increase the live birth rate in women undergoing fertility treatment. However, low-quality evidence suggests that vasodilators may slightly increase clinical pregnancy rates. Moderate-quality evidence shows that vasodilators increase overall side effects in comparison with placebo or no treatment. Adequately powered studies are needed so that each treatment can be evaluated more accurately.

[Efficacy of gamma-irradiated adipose-derived stem cells for treatment of thin endometrium in rats]

OBJECTIVE

Transplantation of adipose-derived stem cells (ADSCs) is associated with potential risks of late complications including tumorigenesis due to the active proliferation of the cells. We aimed to test the effect of transplantation of ADSCs with suppressed proliferation by gamma irradiation in the treatment of thin endometrium in rats.

METHODS

ADSCs were isolated from female SD rats and identified by detecting the surface antigens with flow cytometry. After exposure to gamma irradiation at 0, 5 Gy and 10 Gy, the cells were examined for changes in colony-forming ability. Twenty-four female rats with chemically induced thin endometrium were randomized into 4 equal groups and at 6-8 h after modeling, the rats received intrauterine injection of non-irradiated ADSCs (group Ⅰ), 5 Gy irradiated ADSCs (group Ⅱ), 10 Gy irradiated ADSCs (group Ⅲ), or PBS only (group Ⅳ). Endometrial pathology was analyzed with HE staining in these rats in the third estrus phase following the cell transplantation.

RESULTS

The ADSCs showed a complete loss of proliferative capacity after exposure to 10 Gy irradiation. After the cell transplantation, the endometrium thickness was thicker in group Ⅰ and Ⅱ than in group Ⅳ (P < 0.01), but there was no significant difference between groups Ⅲ and Ⅳ.

CONCLUSIONS

Gamma irradiation impairs the proliferative capacity of ADSCs in vitro. Exposure to 10 Gy irradiation causes a total loss of proliferation capacity of the ADSCs, which have no therapeutic potential; 5 Gy irradiation causes partial loss of proliferation capacity of the cells, which still retain the activity to promote endometrial cell regeneration.

Current Status of Targeted Radioprotection and Radiation Injury Mitigation and Treatment Agents: A Critical Review of the Literature

As more cancer patients survive their disease, concerns about radiation therapy-induced side effects have increased. The concept of radioprotection and radiation injury mitigation and treatment offers the possibility to enhance the therapeutic ratio of radiation therapy by limiting radiation therapy-induced normal tissue injury without compromising its antitumor effect. Advances in the understanding of the underlying mechanisms of radiation toxicity have stimulated radiation oncologists to target these pathways across different organ systems. These generalized radiation injury mechanisms include production of free radicals such as superoxides, activation of inflammatory pathways, and vascular endothelial dysfunction leading to tissue hypoxia. There is a significant body of literature evaluating the effectiveness of various treatments in preventing, mitigating, or treating radiation-induced normal tissue injury. Whereas some reviews have focused on a specific disease site or agent, this critical review focuses on a mechanistic classification of activity and assesses multiple agents across different disease sites. The classification of agents used herein further offers a useful framework to organize the multitude of treatments that have been studied. Many commonly available treatments have demonstrated benefit in prevention, mitigation, and/or treatment of radiation toxicity and warrant further investigation. These drug-based approaches to radioprotection and radiation injury mitigation and treatment represent an important method of making radiation therapy safer.

Use of pentoxifylline and tocopherol in radiation-induced fibrosis and fibroatrophy

Radiation-induced fibrosis in the head and neck is a well-established pathophysiological process after radiotherapy. Recently pentoxifylline and tocopherol have been proposed as treatments to combat the late complications of radiation-induced fibrosis and a way of dealing with osteoradionecrosis. They both have a long history in the management of radiation-induced fibrosis at other anatomical sites. In this paper we review their use in sites other than the head and neck to illustrate the potential benefit that they offer to our patients.

Thin endometrium after radiation therapy as an unresolved treatment challenge: a case report

Receptive endometrium is essential for successful implantation and ongoing pregnancy. Significant health issues and associated therapies, especially oncologic therapies, have potential to negatively impact future fertility in young women. Irradiation and chemotherapeutic alkylating agents are known to cause ovarian failure in most females; however, less well is characterized the impact of irradiation on uterine development and integrity. With an increasing number of cancer survivors, women are seeking infertility treatment after such therapies. Here, we present a young woman who developed ovarian failure after the treatment of acute myeloid leukemia with bone marrow transplant and preceding irradiation and chemotherapy and who was diagnosed with thin endometrial lining while seeking infertility therapy.

Fulminant spinal cord compression caused by postradiation inflammatory pseudotumor with rapid response to steroids: case report

Radiation therapy continues to play an extremely valuable role in the treatment of malignancy. The effects of radiation therapy on normal tissue can present in a delayed fashion, resulting in localized damage with pseudomalignant transformation, producing a compressive effect on the spinal cord or exiting nerve roots. Infiltration of inflammatory cells and the subsequent fibrotic response can result in the development of an inflammatory pseudotumor (benign tumor-like lesion) with subsequent mass effect. Herein, the authors present a rare case of inflammatory pseudotumor with fulminant cervicothoracic cord compression, developing 7 years after radiation therapy for breast cancer. The lesion recurred following resection but subsequently displayed complete and rapid resolution following steroid therapy. To the best of the authors' knowledge, no previous studies have reported such an incident.

Survey of Policies and Guidelines on Antioxidant Use for Cancer Prevention, Treatment, and Survivorship in North American Cancer Centers: What Do Institutions Perceive as Evidence?

BACKGROUND

Health care policies and guidelines that are clear and consistent with research evidence are important for maximizing clinical outcomes. To determine whether cancer centers in Canada and the United States had policies and/or guidelines about antioxidant use, and whether policies were aligned with the evidence base, we reviewed current research evidence in the field, and we undertook a survey of the policies and guidelines on antioxidant use at cancer institutions across North America.

METHODS

A survey of policies and guidelines on antioxidant use and the development and communication of the policies and guidelines was conducted by contacting cancer institutions in North America. We also conducted a Website search for each institution to explore any online resources.

RESULTS

Policies and guidelines on antioxidant use were collected from 78 cancer institutions. Few cancer institutions had policies (5%) but most provided guidelines (69%). Antioxidants from diet were generally encouraged at cancer institutions, consistent with the current research evidence. In contrast, specific antioxidant supplements were generally not recommended at cancer institutions. Policies and guidelines were developed using evidence-based methods (53%), by consulting another source (35%), or through discussions/conference (26%), and communicated mainly through online resources (65%) or written handouts (42%). For cancer institutions that had no policy or guideline on antioxidants, lack of information and lack of time were the most frequently cited reasons.

CONCLUSIONS

Policies and guidelines on antioxidants from diet were largely consistent with the research evidence. Policies and guidelines on antioxidant supplements during treatment were generally more restrictive than the research evidence might suggest, perhaps due to the specificity of results and the inability to generalize findings across antioxidants, adding to the complexity of their optimal and safe use. Improved communication of comprehensive research evidence to cancer institutions may aid in the development of more evidence-based policies and guidelines.

Oocyte donation outcome after oncological treatment in cancer survivors

OBJECTIVE

To study reproductive outcome in patients cured of cancer who required oocyte donation (OD) owing to iatrogenic ovarian dysfunction.

DESIGN

Multicenter, unmatched, retrospective cohorts study.

SETTING

Private, university-affiliated group of clinics.

PATIENT(S)

Women treated and cured of cancer (n = 142) who underwent 333 cycles of OD (exposed group) and women without a previous cancer diagnosis (n = 17,844) who underwent 29,778 cycles of OD (unexposed cohort) between January 2000 and January 2012.

INTERVENTION(S)

Retrospective chart review.

MAIN OUTCOME MEASURE(S)

Pregnancy, implantation, miscarriage, and ongoing pregnancy rates.

RESULT(S)

There were no differences in terms of pregnancy (55.7% vs. 54.7%), implantation (39.8% vs. 38.2%), miscarriage (29.5% vs. 26.9%), or delivery rates (39.3% vs. 39.9%) between the unexposed group and the patients previously diagnosed and cured of cancer, respectively. There was no correlation between OD outcome and cancer type.

CONCLUSION(S)

Endometrial receptivity in women treated and cured of cancer was comparable to that of general patients without previous malignancies who had received OD, based on the largest series available in the literature.

Vasodilators for women undergoing fertility treatment

BACKGROUND

Since 1978, when Patrick Steptoe and Robert Edwards achieved the birth of the first test tube baby, assisted reproductive techniques have been refined and improved. However, the rate of successful pregnancies brought to term has barely increased. Therefore closer evaluation of the interventions is needed along with working towards improving uterus receptivity. Vasodilators have been proposed to increase endometrial receptivity, thicken the endometrium and favour uterine relaxation, all of which could improve uterine receptivity and enhance the chances for successful assisted pregnancies.

OBJECTIVES

To evaluate the effectiveness and safety of vasodilators in women undergoing fertility treatment.

SEARCH METHODS

We searched the following electronic databases, trial registers and websites: the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of controlled trials, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), The Cochrane Library, Web of Knowledge, the Open System for Information on Grey Literature in Europe (OpenSIGLE), the Latin American and Caribbean Health Science Information Database (LILACS) and ClinicalTrials.gov. The search was conducted in February 2014. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of vasodilators alone or in combination with other treatments compared with placebo or with other agents in women undergoing fertility treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies, assessed the risk of bias and extracted data. Risk ratios (RRs) were calculated using the numbers of events in the control and intervention groups of each study. Study data were combined using a random-effects model, and evidence quality was assessed using Grades of Recommendation, Assessment, Development and Evaluation Working Group (GRADE) methods.

MAIN RESULTS

Ten studies with a total of 797 women were included in this review. Most of the studies were judged as having an unclear risk of bias. Three studies reported live births, two reported vasodilator-related side effects, 10 reported clinical pregnancies (diagnosed by differing criteria) and four reported other side effects (multiple gestation, miscarriage, ectopic pregnancy).Overall, no evidence suggested that treatment with vasodilators increased live birth rates compared with placebo or no treatment (RR 1.18, 95% confidence interval (CI) 0.82 to 1.69, P value 0.37, three RCTs, 350 women, I(2) = 0%, moderate-quality evidence). This indicates that among women undergoing fertility treatment who have a 24% chance of live birth without the use of vasodilators, between 19% and 40% will achieve live birth with the use of vasodilators.No evidence was found of a difference between vasodilators and placebo or no treatment in the incidence of treatment side effects (RR 1.63, 95% CI 0.33 to 7.93, P value 0.55, two RCTs, 258 women, I(2) = 32%, low-quality evidence). Nor did any evidence show a difference between them in terms of multiple gestation, spontaneous abortion/miscarriage or ectopic pregnancy rates. However few relevant data were available.Overall, treatment with vasodilators was associated with an increased clinical pregnancy rate compared with placebo or no treatment (RR 1.38, 95% CI 1.00 to 1.92, P value 0.05, eight RCTs, 717 women, I(2) = 0%, low-quality evidence). However, confidence intervals do not rule out no effect of the intervention, and when studies of vasodilators combined with another medication (vitamin E or oestrogen) were excluded, the effects of treatment with vasodilators alone on clinical pregnancy rates were more uncertain.The evidence was of low or moderate quality, and the main limitations were imprecision and lack of clarity about study methods. Risk of publication bias could not be assessed because of the low number of identified studies.

AUTHORS' CONCLUSIONS

Evidence was insufficient to show that vasodilators increased the live birth rate in women undergoing fertility treatment. However, low-quality evidence suggests that vasodilators may increase clinical pregnancy rates in comparison with placebo or no treatment. Evidence was insufficient to show whether any particular vasodilator, administered alone or in combination with other active medications, was superior, and evidence was insufficient to allow the review authors to reach any conclusions regarding adverse effects. Adequately powered studies are needed so that each treatment can be evaluated more accurately.

The impact of uterine radiation on subsequent fertility and pregnancy outcomes

Future fertility is of paramount importance to younger cancer survivors. Advances in assisted reproductive technology mean that young women treated with radiation involving the uterus may require clinical guidance regarding whether to attempt a pregnancy themselves. We performed a review of the literature regarding radiation involving uterus (total body irradiation (TBI) and pelvic radiation), fertility, and pregnancy outcomes to come up with a recommendation for our patients. Limited evidence suggests lower fecundity and an increased incidence of pregnancy complications after uterine radiation. Higher radiation doses and direct uterine radiation both significantly increase the risk of an adverse pregnancy outcome. Uterine radiation doses of <4 Gy do not appear to impair uterine function. Adult TBI data (usually 12 Gy) suggest pregnancy is possible but with lower fecundity and more complications. Although there is no clear data indicating the dose of radiation to the uterus, above which a pregnancy would not be sustainable, we suggest patients receiving >45 Gy during adulthood and >25 Gy in childhood be counselled to avoid attempting pregnancy. There is preliminary evidence that menopausal hormone therapy and a combination of pentoxifylline and tocopherol may improve uterine function following irradiation.

Treating patients with "thin" endometrium - an ongoing challenge

OBJECTIVE

To review the literature regarding inadequate growth ("thin") of the endometrium and to present the hitherto published methods aimed to improve endometrial thickness and the consequent endometrial receptivity.

MATERIALS AND METHODS

A literature review was conducted for all relevant articles assessing the effect of various treatment modalities on "thin" endometrium and the consequent reproductive outcome.

RESULTS

Several treatment modalities have been offered to patients with "thin" endometrium, including hysteroscopic adhesiolysis, hormonal manipulation by estrogen and GnRH-agonist, vasoactive measures such as aspirin, vitamin E, pentoxifylline, l-arginine or sildenafil, intra-uterine infusion of growth factor such as G-CSF and the recent application of regenerative medicine. In spite of the vast diversity of treatment, most of the options accomplish only minor change in the endometrium thickness and subsequent pregnancy rate, and when they fail, patients are usually referred to surrogacy.

CONCLUSIONS

"Thin" endometrium is known to adversely affect reproductive performance. Treatment of "thin endometrium" remains a challenge and future large researches are required to further elucidate and optimal management of patients with "thin" endometrium.

A retrospective cross-sectional study: fresh cycle endometrial thickness is a sensitive predictor of inadequate endometrial thickness in frozen embryo transfer cycles

BACKGROUND

The purpose of this study is to assess predictors of inadequate endometrial cavity thickness (ECT), defined as < 8 mm, in frozen embryo transfer (FET) cycles.

METHODS

This is a retrospective cross-sectional study at an academic fertility center including 274 women who underwent their first endometrial preparation with estradiol for autologous FET in our center from 2001-2009. Multivariable logistic regression was performed to determine predictors of inadequate endometrial development in FET cycles.

RESULTS

Neither age nor duration of estrogen supplementation were associated with FET endometrial thickness. Lower body mass index, nulliparity, previous operative hysteroscopy and thinner fresh cycle endometrial lining were associated with inadequate endometrial thickness in FET cycles. A maximum thickness of 11.5 mm in a fresh cycle was 80% sensitive and 70% specific for inadequate frozen cycle thickness.

CONCLUSIONS

Previous fresh cycle endometrial cavity thickness is associated with subsequent FET cycle endometrial cavity thickness. Women with a fresh cycle thickness of 11.5 mm or less may require additional intervention to achieve adequate endometrial thickness in preparation for a frozen cycle.

Therapeutic management of intestinal fibrosis induced by radiation therapy: from molecular profiling to new intervention strategies et vice et versa

Chronic toxicities of locoregional and systemic oncological treatments commonly develop in long-term cancer survivors. Amongst these toxicities, post-radiotherapeutic complications alter patient's quality of life. Reduction of exposure of normal tissues can be achieved by optimization of radiotherapy. Furthermore, understanding of the fibrogenic mechanisms has provided targets to prevent, mitigate, and reverse late radiation-induced damages. This mini-review shows how (i) global molecular studies using gene profiling can provide tools to develop new intervention strategies and (ii) how successful clinical trials, conducted in particular with combined pentoxifylline-vitamin E, can take benefice of biological and molecular evidences to improve our understanding of fibrogenic mechanisms, enhance the robustness of proposed treatments, and lead ultimately to better treatments for patient's benefice.

Optimizing hormone therapy for future reproductive performance in women with premature ovarian failure

With increasing success in treatment of childhood cancer there is a growing population of women with premature ovarian failure (POF) seeking fertility treatment. Various preparations of estrogen and progestogen are prescribed for young women with POF. While the dose and duration of hormone therapy (HT) is usually adjusted according to the patient's height and the Tanner's stage of development for young pre-pubertal women, the optimal effective HT regimen to maximise the reproductive potential for young as well as for the older age group remains unclear. Furthermore, there is a paucity of evidence to support the preferential effectiveness of the different regimens used. Assisted reproduction using donated gametes or embryos remains the only realistic option to enable women with POF to conceive. Successful outcomes are primarily dependant on successful implantation and placentation. Consequently, the success of assisted reproduction is determined by uterine and endometrial development, which is largely influenced by the modality of HT as well as the age at which it is commenced. In this review, we critically appraise the current practices and published data for management of women with POF. We aim to focus on the effect of HT on uterine development in women with primary and irreversible POF.

Breast pseudotumoral radionecrosis as a late radiation-induced injury: a case report

Introduction

New therapies and treatment protocols have led to improved survival rates in many cancers. The improved rates are such that patients are now living long enough to experience some negative long-term side effects of the initial therapy.

Case presentation

We report the case of a 65-year-old Caucasian woman who presented with a rare case of pseudotumoral radionecrosis, a late radiation-induced injury, after combined surgical and cobalt radiation therapy for the treatment of adenocarcinoma of the right breast. The patient underwent resection of this benign, yet progressively growing and painful tumor. A cosmetically satisfying result was achieved by reconstruction of the thoracic wall with a polypropylene mesh and a latissimus dorsi muscle flap.

Conclusion

With improved overall survival, new management strategies for late side effects of therapy are becoming of crucial importance for affected patients. In the future, improving toxicity-free survival will be as important as achieving disease-free survival or local tumor control.

DNA damage in cultured skin microvascular endothelial cells exposed to gamma rays and treated by the combination pentoxifylline and α-tocopherol

PURPOSE

This in vitro study aims at evaluating the effect of the combination of pentoxifylline (PTX) and trolox (Tx), the water-soluble analogue of alpha-tocopherol, on the oxidative state and DNA damage in dermal microvascular endothelial cells exposed to doses up to 10 Gy of ionizing radiation.

MATERIALS AND METHODS

Confluent primary cultures of dermal endothelial cells were gamma irradiated at 3 and 10 Gy, and 0.5 mM of both drugs, PTX and Tx, was added either before (15 min) or after (30 min or 24 h) irradiation. Reactive oxygen species (ROS), measured by the dichlorodihydrofluorescein diacetate assay, and DNA damage, assessed by the comet and micronucleus assays, were measured at different times after exposure (0 - 21 days).

RESULTS

The PTX/Tx treatment decreased the early and delayed peak of ROS production by a factor of 2.8 in 10 Gy-irradiated cells immediately after irradiation and the basal level by a factor of 2 in non-irradiated control cells. Moreover, the level of DNA strand breaks, as measured by the comet assay, was shown to be reduced by half immediately after irradiation when the PTX/Tx treatment was added 15 min before irradiation. However, unexpectedly, it was decreased to a similar extent when the drugs were added 30 min after radiation exposure. This reduction was accompanied by a 2.2- and 3.6-fold higher yield in the micronuclei (MN) frequency observed on days 10 and 14 post-irradiation, respectively.

CONCLUSION

These results suggest that oxidative stress and DNA damage induced in dermal microvascular endothelial cells by radiation can be modulated by early PTX/Tx treatment. These drugs acted not only as radical scavengers, but they were also responsible for the increased MN frequency in 10 Gy-irradiated cells. Thus, these drugs may cause a possible interference with DNA repair processes.

[Views of each member of an Assisted Reproductive Technologies centre on the embryo transfer procedure]

The embryo transfer (ET) is probably the key step of Assisted Reproductive Technologies (ART), end point of the collaboration of a multidisciplinary clinical team and an infertile couple. Thus, a perfect knowledge of available data regarding ET is required to optimize the results of ART. Indeed, numerous published studies demonstrate the impact of defined parameters onto the effectiveness of ET procedure. The aim of this study is to provide views of physicians dealing with ART, i.e. endocrinologist, ultrasound scan specialist, surgeon and biologist to put in perspective questions and answers about ET.

[Post-operative fibrosis: pathophysiological aspects and therapeutical perspectives]

Postoperative fibrosis (POF) is a rare, localized, and irreversible delayed effect of surgery, described in numerous tissues and organs. Is this fibrotic process amenable to therapeutic intervention? A synthesis of various clinical and histopathological aspects, and of cellular and molecular process regulation is described. In summary, there exists a prefibrotic chronic inflammatory phase, a constituted and cellular phase, and lastly a matricial densification and remodelling phase. The respective phases and the roles played over time by the main protagonists, namely myofibroblasts, extracellular matrix and growth factor (TGFbeta1) are clarified. Understanding the mechanism of POF leads logically to treatments derived from our knowledge of the treatment of radiation-induced fibrosis: anti-inflammatory drugs help in the prefibrotic phase, pentoxifylline-tocopherol combination (PE) in the organized fibrotic phase, and pentoclo (PE-clodronate) in the late fibronecrotic phase. Randomized trials are necessary to validate the preliminary results of phase II trials.

Pentoxifylline to treat radiation proctitis: a small and inconclusive randomised trial

This prospective randomised controlled study of 40 patients could not show a statistically significant advantage with 6 months of pentoxifylline compared with standard measures for late radiation-induced rectal bleeding. However, a modest benefit cannot be excluded and larger randomised placebo-controlled trials with longer durations of pentoxifylline treatment may be justified.

Do antioxidants interfere with radiation therapy for cancer?

Despite recent comprehensive review articles concluding that supplemental antioxidants do not undermine the effectiveness of cytotoxic therapies, the use of antioxidants during cancer treatment remains controversial. Many oncologists take the position that antioxidants by their nature undermine the free radical mechanism of chemotherapy and radiotherapy and should therefore generally be avoided during treatment. For their part, many integrative practitioners believe that antioxidants taken during cancer treatment not only alleviate some of the adverse effects of that treatment but also enhance the efficacy of cancer therapy. Until recently, research attention has focused primarily on the interaction of antioxidants with chemotherapy; relatively little attention has been paid to the interaction of antioxidants with radiotherapy. This article reviews the clinical literature that has addressed whether antioxidants do in fact interfere with radiation therapy. Studies have variously investigated the use of alpha-tocopherol for the amelioration of radiation-induced mucositis; pentoxifylline and vitamin E to correct the adverse effects of radiotherapy; melatonin alongside radiotherapy in the treatment of brain cancer; retinol palmitate as a treatment for radiation-induced proctopathy; a combination of antioxidants (and other naturopathic treatments) and external beam radiation therapy as definitive treatment for prostate cancer; and the use of synthetic antioxidants, amifostine, dexrazoxane, and mesna as radioprotectants. With few exceptions, most of the studies draw positive conclusions about the interaction of antioxidants and radiotherapy. Although further studies are needed, the preponderance of evidence supports a provisional conclusion that dietary antioxidants do not conflict with the use of radiotherapy in the treatment of a wide variety of cancers and may significantly mitigate the adverse effects of that treatment.

[Current practices of oocyte donation in France and Europe]

This review aims to evaluate, in France, oocyte donation, an assisted reproductive technique (ART), for which 25 years of experience have shown its efficacy for the palliative treatment of infertility caused by ovarian exocrine failure. Its indications have since been expanded to cover certain genetic diseases and document failures of other ART attempts. Oocyte donation is performed within the framework of French legislation - bioethics laws 94-653 and 94-654 of 29 July 1994, and the revised bioethics law 2004-800 of 6 August 2004. Its main fundamental principles are: voluntary, free, anonymous donation, for which regulated confidentiality is assured and now - judicial decree 2004-606 of 24 June 2004 - and the synchronization of donor-recipient cycles with fresh embryo transfer in accordance with established safety procedures. According to the 2004 results of the French Group for the Study of Oocyte Donation (GEDO) for French centers actively involved in ART, the chance of pregnancy was increased to 43.4% for synchronized cycles with fresh embryo transfers versus 18.7% for deferred cycles with frozen-thawed embryos (P<0.01). In addition, follow-up studies reported the excellent family relationships and physical and psychological development of these children. The major difficulties encountered in the daily practice of oocyte donation concern the recruitment and management of donors, but also, and above all, the lack of optimal means to exercise this medical specialty, due to the lack of recognition of the organizational duties incurred, which are the cornerstone of the character-specific functioning of this type of ART. In comparison, we foresee that the discrepancies of this ART practice in Europe, with it differential facets, will lead to medical nomadism for those couples financially able to do so, when national conditions of access fail because of prohibitions but also as a consequence of insufficient means to perform the inherent tasks. Today, it seems essential to provide information on the particularity and practice of oocyte donation required for the comprehension of its obligations for the different players with the aim of obtaining the means necessary for the perpetuation of its practice.

[What are at present the real hopes of pregnancy after ovarian cryopreservation?]

Survival rates for cancers that occur in childhood and adolescence have improved over the last decades, and preservation of future fertility in these patients has become a relevant issue. Premature ovarian failure is a consequence of exposing women to chemotherapeutic drugs and ionizing radiation. Ovarian cryopreservation is an alternative to cryopreservation of embryos or oocytes for theses patients. Ovarian cryopreservation aims to reimplant ovarian tissue after complete remission into the pelvic cavity (orthotopique site) or a heterotopic site like the abdominal wall or the forearm. In vitro folliculogenesis, that aims at the maturation of ovarian cortex primordial follicles cryopreserved for a FIV, is still in an experimental research stage. In this review, the objective was to evaluate the real hopes of pregnancy after ovarian cryopreservation. Indeed, many teams offer ovarian cryopreservation at present time, although only two pregnancies have been achieved to date. In both cases, it can be discussed whether the fertilized oocyte originated from the transplant or from the native ovary. Furthermore, the potential for reintroduction of cancerous cells may limit this technique in cancers that are known to have a risk of ovarian dissemination. The hopes engendered by ovarian cryopreservation, but also its limits, must be explained to the patients before an ovarian surgery for cryopreservation.

Significance of endothelial dysfunction in the pathogenesis of early and delayed radiation enteropathy

This review summarizes the current state of knowledge regarding the role of endothelial dysfunction in the pathogenesis of early and delayed intestinal radiation toxicity and discusses various endothelial-oriented interventions aimed at reducing the risk of radiation enteropathy. Studies published in the biomedical literature during the past four decades and cited in PubMed, as well as clinical and laboratory data from our own research program are reviewed. The risk of injury to normal tissues limits the cancer cure rates that can be achieved with radiation therapy. During treatment of abdominal and pelvic tumors, the intestine is frequently a major dose-limiting factor. Microvascular injury is a prominent feature of both early (inflammatory), as well as delayed (fibroproliferative) radiation injuries in the intestine and in many other normal tissues. Evidence from our and other laboratories suggests that endothelial dysfunction, notably a deficiency of endothelial thrombomodulin, plays a key role in the pathogenesis of these radiation responses. Deficient levels of thrombomodulin cause loss of vascular thromboresistance, excessive activation of cellular thrombin receptors by thrombin, and insufficient activation of protein C, a plasma protein with anticoagulant, anti-inflammatory, and cytoprotective properties. These changes are presumed to be critically involved in many aspects of early intestinal radiation toxicity and may sustain the fibroproliferative processes that lead to delayed intestinal dysfunction, fibrosis, and clinical complications. In conclusion, injury of vascular endothelium is important in the pathogenesis of the intestinal radiation response. Endothelial-oriented interventions are appealing strategies to prevent or treat normal tissue toxicity associated with radiation treatment of cancer.

Current Management for Late Normal Tissue Injury: Radiation-Induced Fibrosis and Necrosis

Radiation-induced fibrosis (RIF) and radionecrosis (RN) are late complications that are usually considered irreversible. Usual management strategy includes eliminating local and general aggravating factors and controlling acute and chronic inflammation with steroids. Thanks to progress in understanding the pathophysiology of these lesions, several lines of treatment have been developed in clinical practice. However, results of clinical studies are difficult to compare because of variations in severity of RIF, method of RIF assessment, availability of efficient therapeutic drugs, treatment duration, and quality of trial design. For moderate established RIF, current management strategy mainly includes (1) anti-inflammatory treatment with corticosteroids or interferon gamma; (2) vascular therapy with pentoxifylline (PTX) or hyperbaric oxygen (HBO); and (3) antioxidant treatment with superoxide dismutase, tocopherol (vitamin E), and, most successfully, with a PTX-vitamin E combination. On the basis of etiology, RN can be managed by (1) anti-inflammatory treatment with corticosteroids and possibly clodronate, (2) vascular therapy with HBO and PTX, (3) antioxidant treatment with a PTX-vitamin E combination, and (4) a PTX-vitamin E-clodronate combination. Controlled randomized trials are now necessary to identify the best treatment at each step of RIF. In the future, these treatments of fibrosis and necrosis should include targeted drugs (such as growth factors) to take organ specificities into account.