Spontaneous pregnancy and normal delivery after repeated autologous bone marrow transplantation and GnRH agonist treatment

Autologous hematopoietic stem cell transplantation of patients with aggressive relapsing-remitting multiple sclerosis: Danish nation-wide experience

BACKGROUND

Autologous hematopoietic stem cell treatment (AHSCT) is considered an effective treatment option for patients with aggressive relapsing-remitting multiple sclerosis (RRMS). Still there are few randomized and controlled studies of AHSCT to shed light on the safety and efficacy of the treatment, and therefore experiences from single centers are important.

AIM

To describe the Danish experience with AHSCT regarding patient characteristics, safety, and efficacy.

METHOD

Nationwide retrospective single center study of patients with multiple sclerosis (MS) treated with AHSCT.

RESULTS

A total of 32 patients were treated with AHSCT from May 2011 to May 2021. Seven were treated with carmustine, etoposide, cytarabine arabinoside, and melphalan (BEAM) as well as antithymocyte globulin (ATG). Twenty-five patients were treated with cyclophosphamide (CY) and ATG. In the whole cohort, relapse-free survival (RFS) was 77% (95% CI: 64-94%), worsening-free survival (WFS) was 79% (95% CI: 66-96%), MRI event-free survival (MFS) was 93% (95% CI: 85-100%), and no evidence of disease (NEDA-3) was 69% (95% CI: 54-89%) at the end of year two post-AHSCT. We had no treatment related mortality and only few severe adverse events (AEs).

CONCLUSION

AHSCT of patients with aggressive RRMS was an effective and relatively safe treatment with few serious AEs and no mortality in Danish patients.

Fertility Preservation in Female Pediatric Patients With Cancer: A Clinical and Regulatory Issue

Fertility preservation represents one important goal of cancer patients’ management due to the high impact on health and quality of life of survivors. The available preventive measures cannot be performed in all patients and are not feasible in all health-care facilities. Therefore, the pharmacological treatment with GnRHa has become a valuable non-invasive and well-tolerated alternative, especially in those who cannot access to cryopreservation options due to clinical and/or logistic issues. Supporting data demonstrate a significant advantage for the survivors who received GnRHa in the long-term maintenance of ovarian function and preservation of fertility. The prevention of the risk of ovarian failure with GnRHa is a typical off-label use, defined as the administration of a medicinal product not in accordance with the authorized product information. Italy has officially recognized the off-label use of GnRHa in adult women at risk of premature and permanent menopause following chemotherapy. However, fertility preservation still represents an unmet medical need in adolescents who cannot access to other treatment options.

Fertility preservation in gynecological cancers

For cancers of reproductive system in women, fertility preservation is complex. Fertility is also affected by therapies, however prevention is possible. Radiotherapy affects gonads, uterus, and subsequent pregnancy outcomes in all ages. However, degree and damage depend on dose, irradiation field, and age at the time of exposure. Ovarian transposition is considered if ovarian involvement is unlikely. Gonadotoxic effects of chemotherapy are related to agent's type, cumulative doses, age, and ovarian reserve. Some agents are highly toxic. Rendering follicular development quiescent by suppression of gonadotropins does reduce the ovarian damage. Simple or radical trachelectomy can be used in early cervical cancer. Fertility saving surgery is possible only in early stage low grade epithelial cancers of the ovary, however, in germ cell tumors even in advanced stages it may be possible to preserve fertility. There are no standard recommendations for endometrial cancer. Embryo, oocyte, and ovarian tissue cryopreservation are possible. The human embryo is very resistant to damage. In view of these possibilities, it is advocated that attention to long term health and quality of life in gonadotoxic therapy must be incorporated into plans as early as possible.

Randomized trial using gonadotropin-releasing hormone agonist triptorelin for the preservation of ovarian function during (neo)adjuvant chemotherapy for breast cancer

PURPOSE

Chemotherapy-induced amenorrhea is a serious concern for women undergoing cancer therapy. This prospective randomized trial evaluated the use of gonadotropin-releasing hormone (GnRH) analog triptorelin to preserve ovarian function in women treated with chemotherapy for early-stage breast cancer.

PATIENTS AND METHODS

Premenopausal women age 44 years or younger were randomly assigned to receive either triptorelin or no triptorelin during (neo)adjuvant chemotherapy and were further stratified by age (< 35, 35 to 39, > 39 years), estrogen receptor status, and chemotherapy regimen. Objectives included the resumption of menses and serial monitoring of follicle-stimulating hormone (FSH) and inhibin A and B levels.

RESULTS

Targeted for 124 patients with a planned 5-year follow-up, the trial was stopped for futility after 49 patients were enrolled (median age, 39 years; range, 21 to 43 years); 47 patients were treated according to assigned groups with four cycles of adriamycin plus cyclophosphamide alone or followed by four cycles of paclitaxel or six cycles of fluorouracil, epirubicin, and cyclophosphamide. Menstruation resumed in 19 (90%) of 21 patients in the control group and in 23 (88%) of 26 in the triptorelin group (P= .36). Menses returned after a median of 5.8 months (range, 1 to 19 months) after completion of chemotherapy in the triptorelin versus 5.0 months (range, 0 to 28 months) in the control arm (P= .58). Two patients (age 26 and 35 years at random assignment) in the control group had spontaneous pregnancies with term deliveries. FSH and inhibin B levels correlated with menstrual status.

CONCLUSION

When stratified for age, estrogen receptor status, and treatment regimen, amenorrhea rates on triptorelin were comparable to those seen in the control group.

Premature ovarian failure: etiology and possible prevention

Premature ovarian failure (POF) is defined as premature menopause in women younger than 40 years of age. This heterogeneous disorder (occurring in 1% of women younger than 40 of age and 0.1% of those younger than 30 years of age), is associated with many and different etiologies, such as chromosomal, genetic, enzymatic, iatrogenic, metabolic and infectious causes. Only in less than half of cases can the etiologic cause be identified. In the last decade, many genetic abnormalities were identified in association with POF, mainly owing to the transgenic mice models, which enabled the study of phenotype in these null mice. Iatrogenic POF after chemotherapy has gained worldwide interest owing to significantly improved survival in the last three decades and the ability to preserve future fertility and ovarian function in many young women who are survivors of young-age malignancy. The attempts of in vitro fertilization-assisted reproductive technology and embryo or unfertilized ova cryopreservation, combined with ovarian tissue cryopreservation and coadministration of gonadotrophin-releasing hormone agonists in parallel with chemotherapy may maximize future fertility and minimize long-term POF in these women.

GnRH-agonists in fertility preservation

PURPOSE OF REVIEW

Description of the recent progress in fertility preservation despite gonadotoxic chemotherapy, using gonadotropin-releasing hormone (GnRH)-agonists (GnRH-a).

RECENT FINDINGS

Most groups of investigators have found a beneficial effect of the administered GnRH-a on minimizing the chemotherapy-associated gonadotoxic effect, in both hematologic diseases, mainly Hodgkin lymphoma and in young breast cancer patients. The GnRH-a cotreatment may also prevent premature ovarian failure in patients with nonmalignant, autoimmune diseases, such as systemic lupus erythematosus, exposed to cyclophosphamide pulsatile therapy. Moreover, GnRH-a coadministration proved to prevent the menometrorrhagia of young women during chemotherapy-induced thrombocytopenia more effectively than gestagens.

SUMMARY

GnRH-a cotreatment appears to minimize ovarian damage. If these preliminary results are consistent in a larger group of patients and proven in a prospective randomized study, the GnRH-a cotreatment should be considered as a clinical routine in every woman in the reproductive age exposed to gonadotoxic chemotherapy, in addition to assisted reproductive technology, and to the investigational attempts of ova, follicles, or ovarian cryopreservation for future in-vitro maturation of primordial follicles, and ovarian autotransplantation or xenotransplantation.

GnRH-analogues and oral contraceptives for fertility preservation in women during chemotherapy

BACKGROUND

For preserving fertility in women during chemotherapy, the character of invasive techniques, such as ovarian cryopreservation and other techniques, await further experience. Meanwhile, non-invasive techniques have attempted to minimize the gonadotoxic effect of chemotherapy, by using gonadotrophin-releasing hormone-analogues (GnRH-a) or oral contraceptives (OC).

METHODS

We performed a computerized MEDLINE search to identify articles published on fertility preservation using GnRH-a or OCs.

RESULTS

Nine human-controlled studies reported the use of GnRH-a and four reported the use of OCs in parallel to chemotherapy. All nine studies analysing the effect of GnRH-a found lower rates of premature ovarian failure (POF) in patients receiving GnRH-a compared with the controls. Summarizing the studies resulted in 11.1% incidence of POF in patients who received GnRH-a compared with 55.5% incidence in the controls. Evidence using the fertility preserving effect of OC is limited. Two studies showed lower POF rates in OC-treated patients. The summarized data revealed a POF rate of 13.2% in patients who received OCs compared with that of 29.8% in the controls.

CONCLUSIONS

The published clinical studies provide evidence, but do not prove statistically, that GnRH-a co-treatment reduces gonadotoxicity. Owing to the retrospective and non-randomized nature of most of the studies, definite conclusions concerning the reduction of POF by GnRH-a can still not be unequivocally drawn. As GnRH-a and OC have no serious side effects and as GnRH-a can even reduce chemotherapy-induced complications, such as severe menometrorrhagia, GnRH-a are considered by many clinicians as a clinically useful co-treatment in chemotherapy. The published clinical studies on OC also suggest a possible effect on the reduction of POF under certain conditions.

Therapy Insight: preserving fertility in cyclophosphamide-treated patients with rheumatic disease

Cyclophosphamide remains a necessary treatment for severe rheumatic diseases, despite the continued search for alternative therapies with less gonadal toxicity. The risk of premature gonadal failure and sterility might lead young patients to delay treatment with cyclophosphamide. The patient's age at treatment and the cumulative dose received remain important risk factors for cyclophosphamide-induced gonadal failure in both males and females. Estrogen-containing oral contraceptives for females and testosterone for males are suggested to reduce the gonadal toxicity of cyclophosphamide, although few studies support these interventions. Owing to increased side effects, hormonal therapy is often avoided in patients with edema, hypertension, nephrotic syndrome or antiphospholipid antibodies. Agonists and antagonists of gonadotropin receptors are under study. Gonadotropin-receptor agonists might have beneficial effects in addition to suppression of sex-hormone production. The outcome of attempted cryopreservation of eggs, embryos or ovaries remains uncertain for women seeking to preserve their reproductive potential. Storing male gametes before chemotherapy is widely practiced and technically successful. As recovery of menses or production of testosterone does not predict individual fertility, identification of biomarkers of gonadal function and reserve, including serum levels of several hormones, ultrasonographic measurements of ovarian volume and antral follicle count, are necessary.