Ovarian damage from chemotherapy and current approaches to its protection

Does gonadotoxic chemotherapy deplete the ovarian reserve through activation of primordial follicles?

Despite significant advances in fertility preservation, no proven pharmacological options exist to protect ovarian primordial follicle reserve from chemotherapy-induced damage. Developing targeted gonadoprotective treatments will require an improved understanding of the molecular mechanisms underlying chemotherapy-induced primordial follicle depletion. While there is robust evidence that gonadotoxic chemotherapy induces primordial follicle death by causing DNA double-strand breaks which trigger apoptotic death, follicle activation leading to 'burn-out' of the ovarian reserve has been suggested as an alternative mechanism. Here, we critically evaluated whether primordial follicle activation is a significant mechanism of chemotherapy-induced ovarian reserve depletion in humans. We assessed the causal relationship between chemotherapy exposure and primordial follicle activation by applying the Bradford Hill criteria.

Association of pentachlorophenol in urine and follicular fluid with ovarian reserve and reproductive outcomes among women undergoing in vitro fertilization based on a prospective cohort study

Pentachlorophenol (PCP), a persistent organic pollutant, has endocrine disrupting properties and there may be a link between its exposure and reproductive outcomes. In this study, we assessed the relationship of PCP exposure levels with ovarian reserve markers and reproductive health outcomes in women (N = 656) undergoing in vitro fertilization (IVF). PCP concentrations were determined in urine (n = 1968; repeated measures) and follicular fluid samples (n = 603). Generalized linear models or generalized estimating equations were used to analyze adjusted association between PCP exposure and selected outcomes (ovarian reserve and IVF outcomes among the women). The median concentration of PCP in the follicular fluid (1.38 ng/mL) was significantly higher compared with that in the urine (specific gravity-adjusted: 0.79 ng/mL). We observed that the urinary PCP concentrations were significantly associated with increased estradiol levels (12.4%; 95% CI: 0.76, 25.4%) but decreased total oocyte yield (-8.35%; 95% CI: -9.64, -7.04%), mature oocytes (-12.0%; 95% CI: -13.4, -10.6%), and fertilization proportion (-2.98%; 95% CI: -5.51, -0.39%). Moreover, there were significant associations of follicular fluid PCP concentrations with declines in the total oocyte yield (-10.6%; 95% CI: -11.9, -9.26%), mature oocytes (-10.6%; 95% CI: -12.0, -9.09%), and proportions of fertilization (-3.75%; 95% CI: -6.39, -1.03%), blastocyst formation (-8.01%; 95% CI: -16.6, -0.37%), and usable blastocysts (-13.9%; 95% CI: -23.6, -3.03%). Our results revealed that exposure to PCP was related with impaired reproductive outcomes of IVF, while additional research is needed to confirm the findings and clarify the underlying mechanisms.

MSC-EV-transmitted HSPA8 alleviates cisplatin-induced ovotoxicity by regulating the MGARP/PRDX2 axis

Cisplatin (Cis) is among the most widely employed antitumour agents, although its clinical application is limited by self-induced multiple-organ toxicity. Previous studies have demonstrated the essential role of mitochondrial injury in the pathogenesis of Cis-induced ovotoxicity. Notably, mesenchymal stem cell-extracellular vesicles (MSC-EVs), potential cell-free therapeutic agents, exhibit pronounced advantages for the treatment of ovarian dysfunction. However, little is known about which core component contained in MSC-EVs plays a major role in repairing Cis-induced ovarian damage, and further, the potential mechanisms underlying the repair of mitochondrial damage remain unclear. Herein, our study first verified that MSC-EVs effectively ameliorate Cis-induced ovarian dysfunction by upregulating the level of mitochondrion-localized glutamic acid-rich protein (MGARP), after which MGARP repairs mitochondrial damage and inhibits cellular ROS production by combining with and suppressing the degradation of peroxiredoxin 2 (PRDX2) in granulosa cells (GCs). More importantly, our study further showed that heat shock protein family A member 8 (HSPA8) is indispensable for MenSC-EV-mediated improvement of Cis-induced ovotoxicity. This investigation provides novel insights into the molecular mechanisms by which MSCs alleviate Cis-induced ovotoxicity through improving mitochondrial dysfunction.

Preventing chemotherapy-induced ovarian damage through PI3K/AKT and Hippo pathway regulation

Advances in cancer treatment have increased survival rates; however, chemotherapy drugs can impair ovarian reserve via pathways such as PI3K/AKT and Hippo, leading to infertility. Conventional fertility preservation options have limitations. Therefore, agents that prevent or reduce the ovarian side effects of chemotherapy should be investigated. This review explored treatments for preserving ovarian reserve by regulating the PI3K/AKT and Hippo pathways during chemotherapy. When treated with cyclophosphamide and cisplatin, 33 agents in the articles were implicated in the PI3K/AKT and/or Hippo pathways, most of which target the PI3K/AKT pathway. It can be concluded that controlling both the PI3K/AKT and Hippo pathways, but specifically the PI3K/AKT pathway, can help maintain ovarian reserve against these two chemotherapy drugs and provide hope for increased fertility in patients receiving chemotherapy.

Primary mediastinal B-cell lymphoma (PMBCL): The LYSA pragmatic guidelines

Primary mediastinal B-cell lymphoma (PMBCL) is a distinct subtype of large B-cell lymphoma with unique clinical, histopathological, and molecular characteristics. Despite its aggressive nature, PMBCL has a high cure rate when managed appropriately. Advances in the understanding of PMBCL biological characteristics, coupled with improvements in diagnostic tools and therapeutic approaches, have significantly improved patient outcomes in recent years. In this article, we present a set of pragmatic guidelines developed by the Lymphoma Study Association (LYSA) for the management of PMBCL. These guidelines address key aspects of diagnosis, staging, response evaluation, and treatment, integrating the latest evidence from clinical trials, expert consensus, and real-world practice. The aim of the guidelines is to provide clinicians with a clear, practical framework to optimize care for patients with PMBCL, ensuring that the best available evidence is translated into clinical practice.

Intrinsic differences in mTOR activity mediates lineage-specific responses to cyclophosphamide in mouse and human granulosa cells

BACKGROUND

Cyclophosphamide (CTX) often induces oocyte and granulosa cell injury, leading to fertility loss in young female cancer survivors. Deciphering the mechanisms underlying follicular cell injury could offer novel insights into fertility preservation. Granulosa cells represent the most abundant cell type within the follicles and can be generally categorized as cumulus granulosa cells (CGCs) and mural granulosa cells (MGCs). Despite the essential roles of granulosa cells in supporting ovarian function in physiological conditions, their distinct lineage-specific responses to CTX remains elusive.

RESULTS

Here, we performed a genome-wide transcriptome analysis of murine mural and cumulus granulosa cells before and after CTX administration. Compared with MGCs, CGCs exhibited higher basal mammalian target of rapamycin (mTOR) activity and an increased DNA damage response post-injury. Pharmacological mTOR suppression or RNA interference-mediated gene silencing of Raptor, a key component of the mTORC1 complex, significantly reduced DNA damage in granulosa cells induced by 4-HC, an activated form of CTX. Notably, by examining human granulosa cells in response to 4-HC, our results uncovered a conserved role of mTOR inhibition in ovarian protection.

CONCLUSIONS

Taken together, our findings reveal that intrinsic variations in mTOR activity in CGC and MGC lineages determine their differential responses to CTX. Targeting this signaling pathway may prove beneficial in mitigating CTX-induced granulosa cell apoptosis and protecting against ovarian injury.

Restoration of ovarian endocrine function with encapsulated immune isolated human ovarian xenograft in ovariectomized mice

Anti-cancer treatments cause premature depletion of the non-renewable ovarian reserve of follicles, the source of key steroid hormones, leading to premature ovarian insufficiency (POI) in 50% of pediatric cancer survivors. Patients with POI, especially at the onset of pubertal development, experience significant endocrine complications, including delayed growth, elevated risks of obesity and diabetes, and accelerated cardiovascular, musculoskeletal and neurological disorders as adults. The only approved pharmacological treatment for POI is an off-label prescribed hormone replacement therapy, which does not replace physiologically functioning ovaries. To restore production of ovarian hormones and protect against immune-mediated injury, we developed a hydrogel-based capsule for implantation of donor ovarian tissue. We evaluated the restoration of ovarian endocrine function in ovariectomized immunodeficient (NOD scid gamma, NSG) mice implanted with encapsulated xenografts over 20 weeks through daily vaginal cytology, hormone measurements and histological analysis of explanted human xenografts. The encapsulated xenografts integrated into the murine hypothalamus-pituitary-gonad (HPG) axis responding to circulating murine gonadotropins and restoring ovarian endocrine function. As controls, we implanted non encapsulated human ovarian xenografts comparable in size. Without the need for exogeneous stimulation, the estrous cyclicity resumed in both groups of mice 12 weeks post implantation and all mice regularly cycled experiencing between 3 to 8 estrous cycles in 20 weeks. The levels of estradiol gradually increased reaching on average 50pg/mL 20 weeks post implantation. Morphological analysis of the encapsulated grafts revealed presence of large antral follicles, ∼3mm in diameter, consistent with regular cyclicity and measurable levels of circulating hormones. This work demonstrates that endocrine function of encapsulated human ovarian tissue was not affected by the encapsulation and integrated with the host physiology similarly to the non-encapsulated controls.

Is there a relationship between tumour aggressiveness and ovarian stimulation outcomes in adolescent and young adult patients with lymphoma?

RESEARCH QUESTION

Does the aggressiveness of Hodgkin lymphoma impact the oocyte cohort after ovarian stimulation for fertility preservation?

DESIGN

A retrospective analysis of prospectively collected data was undertaken. Seventy-seven chemo-naive women with newly diagnosed Hodgkin lymphoma were enrolled prospectively at the Observatory and Fertility Preservation Centre, Lille University Hospital, France between 2012 and 2021. Seventy-eight ovarian stimulation cycles were performed. Oocyte cohort characteristics were compared between patients with early and intermediate stage disease [German Hodgkin Study Group (GHSG) I + II] and patients with advanced stage disease (GHSG III). Among the GHSG III patients, the influence of the Hasenclever score on fertility preservation outcomes was analysed. The primary endpoint was the number of metaphase II oocytes (MII) retrieved.

RESULTS

The groups were comparable except for body mass index (BMI). Overall, a median of seven (interquartile range 4-11) MII oocytes were retrieved. Before and after adjustment for BMI, age, pre-treatment anti-Müllerian hormone concentration, and total dose of gonadotrophin, GHSG status did not have a significant impact on the number of MII oocytes retrieved [relative risk 0.96, 95% confidence interval 0.68-1.34; P = 0.79] or the other ovarian stimulation outcomes. The Hasenclever score was not significantly associated with the number of MII oocytes retrieved.

CONCLUSION

Tumour aggressiveness was not found to have a significant influence on the number of MII oocytes retrieved in young women with Hodgkin lymphoma. These results suggest that fertility preservation should be proposed systematically, regardless of the stage of Hodgkin disease, in young women.

The Protective Effect of GnRH Agonist Triptorelin on the Histomorphometric Parameters of the Utero-ovarian Tissue in the Doxorubicin- and Cyclophosphamide-treated Mice

One of the common side effects of chemotherapy drugs is ovarian failure and uterine dysfunction, which can occur after the administration of doxorubicin and/or cyclophosphamide. In clinics, gonadotropin-releasing hormone agonists (GnRHa) are used to modulate the toxic effect of chemotherapy and intercept infertility with some controversy and limited histological knowledge. This study aimed to evaluate the serological and histological features of protective effects of triptorelin, (GnRHa), on utero-ovarian tissue in the mice treated with cyclophosphamide and/or doxorubicin. Forty-eight female BALB/c mice were randomly divided into 8 groups as follows: Group I: normal saline; Group II: triptorelin; Group III: cyclophosphamide; Group IV: doxorubicin; Group V: cyclophosphamide + doxorubicin; and Groups VI, VII, and VIII: after injection of cyclophosphamide, doxorubicin, or cyclophosphamide + doxorubicin, administration of triptorelin (1 mg/kg; intraperitoneally) for 15 consecutive days, respectively. On the 21st day, the ovaries and uterine horns were dissected and weighed. Then, tissue processing and staining were performed for further histological and stereological studies. Triptorelin treatment in the damaged groups significantly increased the number of primordial and pre-antral follicles and granulosa cells. It decreased the number of atretic follicles compared to cyclophosphamide and/or doxorubicin-treated groups (P < 0.05). Triptorelin also significantly improved the volume of the ovary, cortex, medulla, oocytes in the primordial and antral follicles, uterus, endometrium, myometrium, uterine glands, and endometrial blood vessels in the damaged groups (P < 0.05). Triptorelin treatment prevents the destructive effects of cyclophosphamide and/or doxorubicin on utero-ovarian tissue.

Fertility Sparing Medical Management Options in Gynecologic Cancers

OPINION STATEMENT

There is an increasing use of medical management for gynecologic cancers given the rise in neoadjuvant therapies, delayed childbearing, and use of assisted reproductive technology. Chemotherapy, albeit broadly used in most gynecologic cancers, lacks long term data with respect to its associated gonadotoxicity and potential adverse pregnancy outcomes. Immunotherapy and other targeted therapies that have demonstrated promising responses in other tumor types are increasingly being studied in gynecologic malignancies. These therapies may offer opportunities for enhanced treatment response in an effort to minimize more toxic, invasive, or surgical management approaches that could have significant negative implications on fertility. Given that some of these therapies do not represent the standard of care and currently only exist in the experimental setting, detailed counseling and careful selection of patients for fertility sparing treatment remains critical. It is reasonable for patients with early stage, low-risk endometrial cancers to attempt conservative management while establishing clear treatment objectives. Early involvement of fertility specialists is necessary in order to optimize these patients' pregnancy goals. An emphasis on lifestyle changes and in particular weight loss should also be discussed with these patients. Neoadjuvant chemotherapy followed by fertility sparing surgery in cervix cancer patients with low-risk, small tumors shows promising results that suggest this can be a safe treatment option. Patients with advanced stage disease of any primary tumor or aggressive histology such as in many cases of ovarian cancer are not appropriate candidates for prioritization of fertility sparing treatment options. Ongoing and future studies will help to better identify appropriate patients and maximize medical management options in early-stage gynecologic cancers.

Humanin alone and in combination with GnRHa therapy attenuates ovarian dysfunction induced by prepubertal cyclophosphamide chemotherapy in female mice

Prepubertal chemotherapy induced ovarian damage poses a significant threat to female fertility, particularly following cyclophosphamide (CP) treatment. Humanin (HNG), a small molecule polypeptide encoded by mitochondrial DNA, has a variety of effects, this study aimed to investigate the protective effects of HNG and its combination with conventional Gonadotropin Releasing Hormone Agonist (GnRHa) on ovarian function in a CP-induced damage model. The 21-day-old C57BL/6 J female mice were randomly assigned to six groups: Control, CP model, HNG, HNG+CP, GnRHa+CP, and HNG+GnRHa+CP. Reproductive related parameters were assessed through histopathological examination, follicle counts, serum sex hormone levels, estrous cycle monitoring, and oxidative stress evaluation. Results indicated that CP treatment led to significant reproductive dysfunction especially ovarian dysfunction, evidenced by reduced follicles, hormonal imbalances, prolonged estrous cycles, reduced body weight, and diminished ovarian and uterine weights, alongside pathological alterations. Notably, HNG treatment, both alone and in conjunction with GnRHa, significantly mitigated these adverse effects, however the combination did not provide additional benefits over HNG alone regarding follicles preservation and antioxidant capacity. Transcriptomic analysis revealed significant enrichment in inflammation and immune response pathways following HNG treatment. In conclusion, HNG demonstrates potential as a therapeutic agent to protect against CP-induced ovarian damage, offering insights for future strategies aimed at preserving female fertility during chemotherapy.

AMH protects the ovary from doxorubicin by regulating cell fate and the response to DNA damage

Anti-Müllerian hormone (AMH) protects the ovarian reserve from chemotherapy, and this effect is most pronounced with Doxorubicin (DOX). However, DOX toxicity and AMH rescue mechanisms in the ovary have remained unclear. Herein, we characterize the consequences of these treatments in ovarian cell types using scRNAseq. DOX-induced DNA damage activates Tp53 class mediators across ovarian cell types. In the mesenchyme, cotreatment with AMH halts theca progenitor differentiation and reduces apoptotic gene expression. In preantral granulosa cells, DOX upregulates the cell cycle inhibitor Cdkn1a and dysregulates Wnt signaling, which are ameliorated by AMH cotreatment. Finally, AMH induces Id3, a gene involved in DNA repair, which is necessary to prevent the accumulation of DNA lesions marked by γ-H2AX. Altogether these mechanisms of AMH protection contribute to sustained fertility in mice, offering promising broad avenues for fertility preservation in cancer patients undergoing chemotherapy.

Parental occupational exposure to anticancer drugs and radiation: Risk of fetal loss and physical abnormalities in The Japan Environment and Children's Study

BACKGROUND

Many studies have indicated an association between maternal occupational exposure to hazardous agents, such as anticancer drugs and ionizing radiation, and an increased risk of adverse pregnancy outcomes, including stillbirths or miscarriages and physical abnormalities in offspring. However, the effects of recent advancements in protective measures to reduce these risks have not been clarified. Aim To investigate the current impact of parental occupational exposure to anticancer drugs and ionizing radiation on stillbirths or miscarriages as well as physical abnormalities under the circumstances of the developed safety protocols.

METHODS

This cohort study utilized The Japan Environment and Children's Study dataset, which included 96,606 fetuses born between January 2011 and March 2014. This study focused on the association between occupational exposure to these agents during pregnancy and the incidence of stillbirths or miscarriages and physical abnormalities in offspring, employing Poisson regression models for adjusted relative risk.

RESULTS

From the study population, 471 cases of stillbirths or miscarriages and 4493 infants with physical abnormalities were identified. Fisher's exact tests indicated no significant differences in fetal loss or physical abnormalities between the exposure groups. A multivariable analysis also found no significant association between maternal exposure to anticancer drugs and ionizing radiation and these adverse outcomes.

CONCLUSION

Under improved safety measures, maternal occupational exposure to anticancer drugs and ionizing radiation does not significantly affect the occurrence of stillbirths or miscarriages and physical abnormalities in offspring. These findings highlight the critical role of current safety practices and indicate lower reproductive risks with proper precautions.

Pathways to motherhood: A single-center retrospective study on fertility preservation and reproductive outcomes in patients with breast cancer

BACKGROUND

Breast cancer treatments often have negative effects on fertility, which pose challenges among patients who want to be parents in the future. This study aimed to examine the efficacy of oocyte cryopreservation, embryo cryopreservation, and ovarian tissue cryopreservation in patients with breast cancer.

METHODS

This retrospective review evaluated 42 patients with breast cancer who underwent fertility preservation at our center from January 2012 to December 2022. This review encompassed the demographic characteristics of the patients, cancer stages, treatment details, and types of fertility preservation procedures and their outcomes.

RESULTS

The average age at disease diagnosis was 33.4 years. Approximately 90.4% of patients presented with early-stage cancer (≤2). Of 42 patients, 26 underwent oocyte cryopreservation; 17, embryo cryopreservation; and 2, ovarian tissue cryopreservation. Further, three patients received mixed treatment. The overall live birth rate was 63.2%. There are more live births in embryo cryopreservation group. The successful pregnancy group was significantly younger and had a remarkably higher quantity of preserved oocytes/embryos than the nonsuccessful pregnancy group. The oocyte and embryo utilization rates in cryopreservation were 7.69% and 52.94%, respectively. These findings underscored the importance of prompt, informed discussions about fertility preservation options.

CONCLUSION

Fertility preservation in patients with breast cancer have promising reproductive outcomes, with embryo cryopreservation being particularly effective. Prompt counseling and individualized fertility preservation strategies are important for improving the likelihood of posttreatment pregnancy. Nevertheless, future research on the long-term psychological and emotional effects of different fertility preservation methods must be performed.

Current status of fertility preservation procedures in gynecologic oncology: from a Chinese perspective

BACKGROUND

The "Healthy China" initiative, along with advancements in technology for cancer diagnosis and treatment, has significantly enhanced outcomes for patients with gynecologic tumors. The trends of late marriage and delayed childbirth have led to an increasing number of women diagnosed with gynecologic cancers who are seeking fertility preservation in China. This issue is critical yet often overlooked in clinical practice. This review aims to synthesize the existing research on fertility preservation within the field of gynecologic oncology, emphasizing both clinical explorations and expert guidelines.

METHODS

We conducted a comprehensive literature review on fertility preservation in the context of gynecologic tumors, examining treatment approaches, commonly employed tumor management technologies, and specific techniques for preserving fertility.

RESULTS

This extensive review highlights the importance of integrating fertility preservation strategies into treatment plans for gynecologic tumors. It explores various methods to safeguard fertility during chemotherapy, radiation therapy, and surgical interventions. For patients with early-stage cervical cancer, surgical options are available; however, these may result in obstetric complications. Neoadjuvant chemotherapy is currently under investigation as an alternative approach. Endometrial cancer can be managed through hysteroscopic resection combined with hormonal therapy. The feasibility of fertility preservation in ovarian cancer varies based on tumor type and patient age. In cases of vulvar and vaginal cancers, partial excision may be considered following a thorough evaluation. Chemotherapy for gestational trophoblastic tumors has proven effective and typically preserves fertility despite potential decreases in AMH levels.

CONCLUSION

This review provides a comprehensive and current synthesis of the latest evidence and clinical practice guidelines regarding fertility preservation in gynecologic cancers. Its aim is to assist clinicians and researchers in addressing the urgent and increasing demand for effective fertility preservation strategies for their patients.

Exploration of the mechanism and therapy of ovarian aging by targeting cellular senescence

The ovary is a crucial gonadal organ that supports female reproductive and endocrine functions. Ovarian aging can result in decreased fertility and dysfunction across multiple organs. Research has demonstrated that cellular senescence in various cell types within the ovary can trigger a decline in ovarian function through distinct stress responses, resulting in ovarian aging. This review explores how cellular senescence may contribute to ovarian aging and reproductive failure. Additionally, we discuss the factors that cause ovarian cellular senescence, including the accumulation of advanced glycation end products, oxidative stress, mitochondrial dysfunction, DNA damage, telomere shortening, and exposure to chemotherapy. Furthermore, we discuss senescence in six distinct cell types, including oocytes, granulosa cells, ovarian theca cells, immune cells, ovarian surface epithelium, and ovarian endothelial cells, inside the ovary and explore their contribution to the accelerated ovarian aging. Lastly, we describe potential senotherapeutics for the treatment of ovarian aging and offer novel strategies for ovarian longevity.

Icariin inhibits cisplatin-induced ovarian toxicity via modulating NF-κB and PTEN/AKT/mTOR/AMPK axis

Cisplatin (CP) is a highly effective broad-spectrum chemotherapeutic agent for several solid tumors. However, its clinical use is associated with ovarian toxicity. Icariin (ICA) is a bioactive flavonoid of Epimedium brevicornum with reported protective activities against inflammation, oxidative stress and ovarian failure. This study aimed to explore the protective effects of ICA against CP-associated ovarian toxicity in rats. Rats were randomized into five groups and treated for 17 days: control, ICA (10 mg/kg/day, for 17 days. p.o.), CP (6 mg/kg, i.p. on days 7 and 14), CP + ICA (CP 6 mg/kg i.p. on days 7 and 14 and ICA 5 mg/kg p.o. daily), and CP + ICA (CP 6 mg/kg i.p. on days 7 and 14 and ICA 10 mg/kg p.o. daily). Our results indicated that ICA effectively improved ovarian reserve as indicated by attenuating CP-induced histolopathological changes and enhancing serum anti-müllerian hormone (AMH). Furthermore, co-administration of ICA with CP showed restoration of the oxidant-anti-oxidant balance in ovarian tissues, evidenced by decreased malondialdehyde (MDA) concentrations and elevated superoxide dismutase (SOD) and catalase (CAT) activities. Also, ICA suppressed ovarian inflammation as evidenced by down-regulation of the expression of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α) and nuclear factor kappa B (NF-κB). ICA inhibited ovarian apoptosis in CP-treated rats by down-regulation of CASP3 and Bax and up-regulation of Bcl-2 mRNA expression. Further, ICA enhanced PTEN, p-AKT, p-mTOR, and p-AMPKα expression. In conclusion, ICA possesses a protective activity against CP-induced ovarian toxicity in rats by exhibiting antioxidant, antiinflammatory, anti-apoptotic activities and modulating NF-κB expression and PTEN/AKT/mTOR/AMPK axis in ovarian tissues.

Impact of a Nurse Navigator Program on Referral Rates and Use of Fertility Preservation Among Female Cancer Patients: A 14-Year Retrospective Cohort Study

INTRODUCTION

Given the known detrimental impact of cancer treatment on fertility, fertility preservation (FP) is recommended for reproductive age patients who are newly diagnosed with cancer. However, the rate of referral to fertility specialists remains suboptimal. The objective of this study was to determine the impact of a dedicated Nurse Navigator Program (NNP) on the rate of referrals and utilization of FP services.

METHODS

A retrospective cohort study of all women ≥ 18 years old referred for FP consultation with a known cancer diagnosis from 2007 to 2021 at a single, large academic center was conducted. FP referrals for non-cancer indications were excluded. Descriptive statistics were performed including comparing referrals received per 30 days and FP utilization rates pre-NNP (October 2007-September 2013) to post-NNP (October 2013-December 2021).

RESULTS

A total of 176 patients were included pre-NNP and 990 patients post-NNP. Overall, the mean age at the time of referral was 31.5 ± 6.9 years. The referral rates post-NNP were higher among those without prior exposure to chemotherapy/radiation (0.33 pre-NNP vs. 2.75 post-NNP per 30 days, p < 0.01) and lower among those with prior exposure to chemotherapy/radiation (1.26 pre-NNP vs. 0.70 post-NNP per 30 days, p < 0.01).

CONCLUSIONS

After the launch of a dedicated fertility preservation nurse navigation program at our institution, we observed a higher number of referrals for FP as well as greater use of FP overall. While not the only variable that changed during this period, this program has optimized patient care and clinical workflow at our institution and serves as a model for such improvement.

Prioritising gynaecological care in post-haematopoietic stem cell transplant patients

An adolescent girl with acute myeloid leukaemia underwent chemotherapy followed by haematopoietic stem cell transplantation (HSCT). Post-HSCT, she developed oral chronic graft-versus-host disease (cGvHD), which was successfully treated. Twenty months later, she was referred to the gynaecology department for evaluation of secondary amenorrhoea. Hormonal assessment led to a diagnosis of primary ovarian insufficiency due to chemotherapy. She was prescribed hormone replacement therapy (HRT), but the absence of withdrawal bleeding prompted vaginal examinations, which revealed vaginal adhesions. A sonogram confirmed haematocolpos and haematometra resulting from silent genital cGvHD. The patient was managed surgically, followed by treatment with topical oestrogen and vaginal moulds. HRT was restarted, and she resumed regular menstruation. Over a routine 20-month follow-up period, no recurrence of symptoms was observed. This case highlights gynaecologic complications of cGvHD and emphasises the importance of gynaecological monitoring in post-transplant care to proactively identify and address genital cGvHD, preventing its irreversible complications.

Chemotherapy-induced diminished murine ovarian reserve model and impact of low-dose chemotherapy on fertility

OBJECTIVE

To establish a murine model of chemotherapy-induced diminished ovarian reserve (DOR) and investigate residual fertility after chemotherapy exposure.

DESIGN

Two different chemotherapy protocols were tested to establish a valid DOR model by comparing follicle densities in mice given either protocol or physiological solution. An ovarian stimulation protocol was then selected from among different gonadotropins by counting the number of day 2 embryos obtained from normal mice. Finally, DOR mice were stimulated 5 and 8 weeks after chemotherapy with the chosen gonadotropin protocols, and day 2 embryos were recovered after mating, as was ovarian tissue for further immunohistologic analyses.

SUBJECTS

Seventy-two Naval Medical Research Institute mice.

EXPOSURE

Two different chemotherapy protocols.

MAIN OUTCOME MEASURES

This study compared day 2 embryo counts in both normal and chemotherapy-induced DOR mice. Ovarian histology and morphology were also investigated by follicle counting and classification, as was immunostaining for apoptosis (cleaved caspase-3), activation (phospho-Akt), and proliferation (Ki67).

RESULTS

A dose of 12 mg/kg of busulfan (Bu) + 120 mg/kg of cyclophosphamide (Cy) was chosen to establish the DOR model as it significantly reduced the ovarian reserve compared to both control mice (physiological solution) and the 1.2 mg/kg of Bu + 12 mg/kg of Cy protocol, without depleting it completely. When stimulated with 3.75 IU of Menopur, normal mice produced significantly more embryos than DOR mice given 12 mg/kg of Bu + 120 mg/kg of Cy (41.40 ± 14.74 vs. 23.67 ± 15.55 day 2 embryos). Although the follicle count was statistically diminished after single-dose chemotherapy administration, the remaining follicles did not display any difference in terms of apoptosis, activation, or proliferation rates.

CONCLUSION

We successfully established a chemotherapy-induced DOR model using 12 mg/kg of Bu + 120 mg/kg of Cy, as evidenced by lower, but not completely depleted, follicle numbers and fewer retrieved embryos. Histologic study of ovarian tissue exposed to DOR-inducing chemotherapy revealed that surviving follicles were of the similar quality as tissue not exposed to chemotherapy.

Uptake of gonadotrophin-releasing hormone agonists for prevention of premature ovarian insufficiency in women undergoing chemotherapy: an Australian single-centre study

BACKGROUND

Treatment-related premature ovarian insufficiency (POI) can result in early-onset menopause and infertility.

AIMS

To assess the prevalence of goserelin use for POI prevention in women with cancer since it was listed by the Australian Pharmaceutical Benefits Scheme in 2018 for this indication.

METHODS

This retrospective study included women aged 18-45 years who received curative-intent alkylating chemotherapy for a malignancy between August 2020 and December 2022 at the Peter MacCallum Cancer Centre. The co-primary end-points were (i) documentation of a discussion with the patient regarding goserelin for POI prevention and (ii) prescription of goserelin for POI prevention prior to chemotherapy commencement.

RESULTS

Sixty-six patients were eligible. Fifty patients (76%) had a documented discussion regarding goserelin for POI prevention and 53 patients (80%) were prescribed goserelin for POI prevention. Nulliparous women were more likely to have a discussion regarding goserelin (P = 0.004). Younger women, nulliparous women and those referred to a fertility service were more likely to have been prescribed goserelin for POI prevention (P = 0.003, P = 0.001 and P = 0.002 respectively). Twenty-one of 53 patients (40%) who received goserelin had the first dose administered ≥7 days before chemotherapy commencement.

CONCLUSION

One-quarter of eligible patients did not have a documented discussion regarding goserelin, despite the negative consequences of POI. Efforts are needed to increase the discussion and use of goserelin in all premenopausal women regardless of their fertility interests and to ensure timely administration in those who choose to receive it.

Single-cell and bulk transcriptional profiling of mouse ovaries reveals novel genes and pathways associated with DNA damage response in oocytes

Immature oocytes enclosed in primordial follicles stored in female ovaries are under constant threat of DNA damage induced by endogenous and exogenous factors. Checkpoint kinase 2 (CHEK2) is a key mediator of the DNA damage response (DDR) in all cells. Genetic studies have shown that CHEK2 and its downstream targets, p53, and TAp63, regulate primordial follicle elimination in response to DNA damage. However, the mechanism leading to their demise is still poorly characterized. Single-cell and bulk RNA sequencing were used to determine the DDR in wild-type and Chek2-deficient ovaries. A low but oocyte-lethal dose of ionizing radiation induces ovarian DDR that is solely dependent on CHEK2. DNA damage activates multiple response pathways related to apoptosis, p53, interferon signaling, inflammation, cell adhesion, and intercellular communication. These pathways are differentially employed by different ovarian cell types, with oocytes disproportionately affected by radiation. Novel genes and pathways are induced by radiation specifically in oocytes, shedding light on their sensitivity to DNA damage, and implicating a coordinated response between oocytes and pregranulosa cells within the follicle. These findings provide a foundation for future studies on the specific mechanisms regulating oocyte survival in the context of aging, therapeutic and environmental genotoxic exposures.

Comparison of large single and small multiple doses of cyclophosphamide exposure in mice during early prepubertal age on fertility outcome

Cyclophosphamide (CY) exposure is known to affect the ovary and impair fertility. Clinically, treatment is generally given over multiple doses, but research models have generally used single doses. The relative effects of administering multiple small doses of CY in the prepubertal period are not elucidated. Two-week-old early-prepubertal Swiss albino female mice were administered with either large single (200 mg/Kg x 1; CY200X1) or small multiple (75 mg/Kg x 4; CY75X4) CY doses, thus a 50% higher total dose. Surviving females were assessed for estrous cyclicity, ovarian follicle reserve, oocyte functional competence, and postnatal assessment of first-generation (F1) pups. Exposure to CY75X4 reduced the loss of ovarian follicles (p < 0.05), and body weight (p < 0.001), and resulted in a larger population of cycling females (p < 0.01) with higher oocyte yield (p < 0.05) compared to CY200X1. Although CY200X1 exposed cycling females had comparable oocyte quality, and fertility index, the postnatal mortality was higher in F1 pups (p < 0.05) in comparison to the CY75X4 group. Although both strategies affect oocyte quality and functional competence similarly, CY75X4, despite the higher overall dose, results in reduced follicle loss, produces higher oocyte/blastocyst yield, and exhibits lower postnatal mortality rates, suggesting a potential advantage over CY200X1 for later fertility and offspring health. The differences in effects of the two treatment models show the need for designing animal model studies that more closely mimic the clinical administration of gonadotoxic therapies such as cyclophosphamide.

Metformin protects prepubertal mice ovarian reserve against cyclophosphamide via regulation of the PI3K/Akt/mTOR signaling pathway and Yap-1

BACKGROUND

Cyclophosphamide is a widely utilized chemotherapeutic agent for pediatric cancers, known to elicit adverse effects, including perturbation of the PI3K/Akt/mTOR and Hippo signaling pathways, thereby diminishing ovarian reserve and fertility potential in females. Consequently, this investigation delves into the mitigative effects of metformin on cyclophosphamide-induced ovarian impairment in prepubertal mice.

METHODS

Twenty-four 14-day-old NMRI female mice were distributed into four groups: Control (Cont), Cyclophosphamide (Cyc), Metformin (Met), and Metformin plus Cyclophosphamide (Met-Cyc). The Met-Cyc group was given daily doses of 150 mg/kg metformin for 11 consecutive days and in parallel 3 intermittent doses of 65 mg/kg cyclophosphamide once every three days. The Met and Cyc groups were given identical doses of Met or Cyc alone. The control group received normal saline treatment. On the 12th day, mice were sacrificed for analysis. Stereological methods were employed to measure the overall volume of the ovaries, including the medulla, cortex, and follicles, along with measuring anti-Müllerian hormone (AMH) levels using an ELISA kit. Furthermore, qRT-PCR was utilized to quantify the expression levels of genes, including P53, Bax, Bcl-2, Rad-51, Pten, Mtor, and Yap-1.

RESULTS

The findings demonstrate that metformin ameliorates cyclophosphamide-induced ovarian toxicity by increasing AMH levels and attenuating the excessive activation of primordial follicles, the ratio of growing to quiescent follicles, and follicular atresia. This protective effect is mediated by the downregulation of apoptosis-related genes, upregulation of the gene involved in a reparative pathway, and modulation of the PI3K/Akt/mTOR pathway evidenced by increased expression of Pten, Mtor and Hippo pathway by Yap-1 expression.

CONCLUSIONS

Our results advocate for the potential of metformin as a viable therapeutic option for preserving ovarian function in cyclophosphamide-treated adolescent girls, given its favorable side effect profile and ability to improve cyclophosphamide-induced ovarian damage.

Low doses of alkylating agents do not harm human ovarian tissue destined for cryopreservation

OBJECTIVE

To investigate the impact of nongonadotoxic doses of alkylating agents on human ovarian cortex.

DESIGN

Retrospective study.

SETTING

Academic research center.

PATIENTS

Biopsies from 78 patients who had undergone ovarian tissue cryopreservation were retrieved and analyzed. Among them, 42 had previously been treated with chemotherapy (alkylating agents, dose <3,400 mg/m2), making up the chemotherapy group, whereas 36 had not been given any chemotherapy, constituting the control group.

MEAN OUTCOME MEASURES

Follicle count and classification, morphology study, immunostaining for apoptosis (cleaved caspase-3), immunostaining for activation (phospho-Akt), fibrosis (Masson's trichrome), and vascularization (von Willebrand factor and smooth muscle actin).

RESULTS

In the prepubertal group, 271 follicles/mm3 were detected in control patients and 501 follicles/mm3 in chemotherapy-exposed subjects. In the adult group, 4,916 follicles/mm3 were found in control patients and 6,570 follicles/mm3 in chemotherapy-exposed patients. No difference in follicle density was observed between the 2 groups in any age category. Neither did we encounter any significant difference in follicle viability according to chemotherapy exposure or age. Proportions of nongrowing follicles were >76% in all age groups, irrespective of chemotherapy exposure, and higher, although not significantly, in the chemotherapy group compared with the control group. There were significantly fewer secondary follicles in the adult chemotherapy group than in the adult control group. Concerning apoptosis, no significant difference was observed between control and chemotherapy subjects in any age groups. Numbers of activated follicles were systematically higher in all age categories in the chemotherapy group than the control group. Areas of atypical follicles were noted in 4 out of 14 prepubertal patients in the chemotherapy group. In these areas, follicle density was 84,570 ± 8,837 follicles/mm3 and all follicles appeared nonviable but showed no sign of apoptosis.

CONCLUSION

Low-dose chemotherapy had no major impact on ovarian tissue, suggesting that ovarian tissue exposed to some chemotherapy before cryopreservation is comparable with ovarian tissue free of any chemotherapy, as clinically demonstrated by high pregnancy rates after ovarian tissue transplantation in women exposed to chemotherapy. Previous chemotherapy should therefore no longer be a contraindication to ovarian tissue cryopreservation.

Overview of the evaluation of the destructive effect of procarbazine on the ovarian reserve in the apoptotic, inflammatory, and oxidative pathways

The use of chemotherapeutic agents during childhood, adolescence, and early adulthood has a detrimental effect on ovarian functions, leading to a decrease in ovarian reserves, thus adversely affecting fertility. Alkylating agents are one of the most frequently used groups of chemotherapeutics in this age group. An important and effective chemotherapeutic drug, procarbazine is used to treat brain tumors and Hodgkin lymphoma in children, adolescents, and young adults. This agent is also an indispensable component of combination-type chemotherapy. Procarbazine has a detrimental impact on ovarian reserve by directly targeting the oocyte or indirectly through somatic cell destruction. Evidence gathered thus far indicates that procarbazine's mode of action in the ovaries may involve apoptosis, inflammation, and oxidative stress. This review seeks to clarify the processes by which procarbazine might induce apoptosis, inflammation, and oxidative stress, hence affecting ovarian reserve and functioning.

An overview of different methods to establish a murine premature ovarian failure model

Premature ovarian failure (POF)is defined as the loss of normal ovarian function before the age of 40 and is characterized by increased gonadotropin levels and decreased estradiol levels and ovarian reserve, often leading to infertility. The incomplete understanding of the pathogenesis of POF is a major impediment to the development of effective treatments for this disease, so the use of animal models is a promising option for investigating and identifying the molecular mechanisms involved in POF patients and developing therapeutic agents. As mice and rats are the most commonly used models in animal research, this review article considers studies that used murine POF models. In this review based on the most recent studies, first, we introduce 10 different methods for inducing murine POF models, then we demonstrate the advantages and disadvantages of each one, and finally, we suggest the most practical method for inducing a POF model in these animals. This may help researchers find the method of creating a POF model that is most appropriate for their type of study and suits the purpose of their research.

Systematic Review of the Gonadotoxicity and Risk of Infertility of Soft Tissue Sarcoma Chemotherapies in Pre- and Postpubertal Females and Males

Increasing awareness of gonadotoxicity in cancer treatments and infertility risk is essential for counseling young cancer patients. While fertility preservation options are available in many countries, limited data on gonadotoxicity hinder recommendations, especially for soft tissue cancers. This review, part of the FertiTOX project (www.fertitox.com), organized by FertiPROTEKT (www.fertiprotekt.com), aims to address this knowledge gap to improve fertility preservation guidance. We performed a systematic literature search on gonadotoxicity in soft tissue sarcoma (STS) cancer treatments. Only patients without metastases or recurrent disease were considered. "Suspected infertility" was defined based on low ovarian reserve parameters, low inhibin B levels, high gonadotropin concentration, gonadal dysfunction, amenorrhea, oligomenorrhea, azoospermia, or oligozoospermia due to limited infertility data. The study quality was assessed using the Newcastle-Ottawa Scale. The search yielded 3309 abstracts, with 138 undergoing full-text analysis. Eight studies on STS were included. Suspected infertility was observed in 20 of 28 females (71.4%, range 0-100%) and 38 of 63 males (60.3%, range 34.8-100%) with STS. Six of the eight studies received high-quality scores on the NOS, while two received a fair score. Our data suggest a high risk of infertility from chemotherapy in pre- and postpubertal STS survivors. This underscores the importance of considering fertility preservation measures when counseling these patients.

A Case of Severe Lupus and Refractory Anemia

Systemic lupus erythematosus (SLE) is a multisystemic connective tissue disease with a wide range of clinical and laboratory manifestations. The diagnosis of SLE is often challenging due to the great variability in its presentation, and treatment should be individualized according to the patient's manifestations and affected organs. We present the clinical case of a 25-year-old female who developed SLE with severe hematological and renal involvement as first manifestations, including hemolytic anemia, thrombocytopenia, and nephrotic syndrome. Diagnosis of SLE was confirmed after positive high titers of ANA and anti-dsDNA antibodies. A kidney biopsy confirmed lupus nephritis class II.  Despite successive treatment with corticosteroids, hydroxychloroquine, intravenous immunoglobulin, and mycophenolate mofetil, there was no hematological improvement, and rituximab was administered, resulting in partial response, with resolution of thrombocytopenia and stabilization of kidney function. However, anemia remained refractory, and subsequent tests indicated a non-hemolytic cause, most likely due to iatrogenic bone marrow suppression. After discontinuing potentially myelotoxic agents, the patient's hemoglobin levels normalized. This case highlights the intricate challenges associated with managing SLE. It underscores the critical importance of ongoing reassessment of therapeutic strategies, particularly in situations where the treatment response is inadequate. This approach enables the optimization of interventions to improve clinical outcomes and address the unique needs of each patient.

Advances in understanding cisplatin-induced toxicity: Molecular mechanisms and protective strategies

Cisplatin, a widely used chemotherapeutic agent, has proven efficacy against various malignancies. However, its clinical utility is hampered by its dose-limiting toxicities, including nephrotoxicity, ototoxicity, neurotoxicity, and myelosuppression. This review aims to provide a comprehensive overview of cisplatin toxicity, encompassing its underlying mechanisms, risk factors, and emerging therapeutic strategies. The mechanisms of cisplatin toxicity are multifactorial and involve oxidative stress, inflammation, DNA damage, and cellular apoptosis. Various risk factors contribute to the interindividual variability in susceptibility to cisplatin toxicity. The risk of developing cisplatin-induced toxicity could be related to pre-existing conditions, including kidney disease, hearing impairment, neuropathy, impaired liver function, and other comorbidities. Additionally, this review highlights the emerging therapeutic strategies that could be applied to minimize cisplatin-induced toxicities and aid in optimizing cisplatin treatment regimens, improving patient outcomes, and enhancing the overall quality of cancer care.

Effect and mechanisms of cyclophosphamide-induced ovarian toxicity on the quality of primordial follicles with respect to age at treatment initiation

Chemotherapy-induced ovarian toxicity in patients with cancer significantly affects future fertility depending on the age of initiation of treatment. However, the mechanisms underlying the age-related depletion of the ovarian reserve are not well understood. We investigated the effects of chemotherapy on pre- and postpubertal ovarian reserves in a mouse model. Juvenile (3-week-old) and adult (8-week-old) mice were injected with vehicle or cyclophosphamide (CPA;100 mg/kg). We assessed the short-term effects at 24 h and 72 h after injection and the long-term effects at 10 and 12 weeks of age by counting the follicles. The number of primordial follicles in the juvenile group was significantly reduced by CPA treatment compared with that in the adult group. To elucidate the mechanisms of this depletion, we performed immunostaining for γH2AX, cleaved PARP1, and FOXO3 at 24 h post-treatment. CPA-treated juvenile mice had a significantly higher proportion of γH2AX-positive primordial follicles, indicating double-strand DNA breaks. By contrast, 4-hydroperoxy CPA, an activated analog of CPA, induced γH2AX-positive primordial follicles in both groups in vitro, suggesting age-dependent differences in humoral ovarian microenvironment. Moreover, the level of cleaved PARP1 was specifically elevated in CPA-treated juvenile mice. However, primordial follicle activation was unaffected in the CPA-treated groups, as assessed by FOXO3 translocation. In conclusion, our findings suggest that ovaries in juveniles are more susceptible to DNA damage and subsequent apoptosis, leading to a higher rate of primordial follicle depletion. Therefore, it is crucial to recognize that cancer treatment, especially in children, can exert a substantial influence on future fertility.

Serum androgen dynamics in young women aged 18-40 treated with chemotherapy for breast cancer: an observational, multicentric, prospective study in France

Although the deleterious impact of chemotherapy regimen used to treat women of reproductive age with breast cancer on ovarian reserve has been extensively studied, hardly anything has been reported on the effect of these protocols on theca cell function and ovarian androgen secretion. The aim of this prospective multicentric cohort study was to describe serum levels of total testosterone and androstenedione during chemotherapy and 24-month follow-up in 250 patients <40 years treated for breast cancer. Mean basal levels of androstenedione and total testosterone at diagnosis were 1.68 ng/mL and 0.20 ng/mL respectively. No correlation with age was found. Serum levels of androstenedione and total testosterone rapidly decreased after chemotherapy completion, before slowly increasing and almost returning to basal levels in all patients during 2-year follow-up. In conclusion our study demonstrates a chemotherapy-induced alteration of ovarian thecal function, resulting in a significant decrease in serum androgen levels. This alteration of theca cell function adds to the well-known alteration of granulosa cell function, resulting in a global, but partly transient, ovarian failure in young women treated for breast cancer. These data bring new insight into ovarian physiology and emphasize the need for pre and post-treatment ovarian follow-up. Trial registration: ClinicalTrial.gov identifier NCT01114464.

Treatment of ovarian damage induced by chemotherapeutic drugs in female rats with G-CSF and platelet-rich plasma(PRP): an immunohistochemical study correlation with novel marker INSL-3

OBJECTIVE

To assess the impacts of Platelet-Rich Plasma(PRP) and Granulocyte Colony-Stimulating Factor(G-CSF) on a rat model with induced ovarian follicular damage caused by cyclophosphamide(Cy).

MATERIALS AND METHODS

Forty-two Sprague-Dawley rats were randomly allocated into seven distinct groups as; Group 1(control): NaCl intraperitoneal (IP) injection was administered on days D1, D7, and D14. Group 2(Cy):Cy IP injection on D1 + NaCl IP injection on D7 and D14 were administered. Group 3(PRP): PRP IP injection on D1,D7 and D14 were administered. Group 4(Cy + PRP):Cy IP injection on D1 and PRP IP injection on D1, D7 and D14 were administered. Group 5(G-CSF): G-CSF IP injection on D1, D7 and D14 were administered. Group 6(Cy + G-CSF):Cy IP injection on D1+ G-CSF IP injection on D1, D7 and D14 were administered. Group 7(Cy + PRP + G-CSF):Cy IP injection on D1+ PRP IP injection on D1,D7 and D14+ G-CSF IP injection on D1,D7 and D14 were administered. Follicular number, histological scores of AMH and INSL3 stained follicles at different stages of follicular development, and serum Anti-Müllerian hormone(AMH) were evaluated.

RESULTS

The primary, secondary, and antral follicle intensity scores for AMH-positive staining were most prominent in Groups 3 and 5. There was no significant difference between groups 4, 6 and 7 compared to group 1 in terms of follicule counts and AMH staining. The intensity scores of AMH-positive staining follicles were notably reduced in group 2 compared to groups 4, 6, and 7, with a significant difference (p < .01). Among the groups, group 2 exhibited the least intense antral follicle staining for INSL3, displaying a significant difference(p < .01) compared to the remaining groups.

CONCLUSIONS

Autologous PRP and G-CSF might protect ovarian function in the face of ovarian damage caused by Cy-induced effects.

Carnitine traffic and human fertility

Carnitine is a vital molecule in human metabolism, prominently involved in fatty acid β-oxidation within mitochondria. Predominantly sourced from dietary intake, carnitine also derives from endogenous synthesis. This review delves into the complex network of carnitine transport and distribution, emphasizing its pivotal role in human fertility. Together with its role in fatty acid oxidation, carnitine modulates the acety-CoA/CoA ratio, influencing carbohydrate metabolism, lipid biosynthesis, and gene expression. The intricate regulation of carnitine homeostasis involves a network of membrane transporters, notably OCTN2, which is central in its absorption, reabsorption, and distribution. OCTN2 dysfunction, results in Primary Carnitine Deficiency (PCD), characterized by systemic carnitine depletion and severe clinical manifestations, including fertility issues. In the male reproductive system, carnitine is crucial for sperm maturation and motility. In the female reproductive system, carnitine supports mitochondrial function necessary for oocyte quality, folliculogenesis, and embryonic development. Indeed, deficiencies in carnitine or its transporters have been linked to asthenozoospermia, reduced sperm quality, and suboptimal fertility outcomes in couples. Moreover, the antioxidant properties of carnitine protect spermatozoa from oxidative stress and help in managing conditions like polycystic ovary syndrome (PCOS) and endometriosis, enhancing sperm viability and fertilization potential of oocytes. This review summarizes the key role of membrane transporters in guaranteeing carnitine homeostasis with a special focus on the implications in fertility and possible treatments of infertility and other related disorders.

The melatonin-FTO-ATF4 signaling pathway protects granulosa cells from cisplatin-induced chemotherapeutic toxicity by suppressing ferroptosis

PURPOSE

In cisplatin-induced premature ovarian failure (POF) mice, granulosa cells showed a high level of ferroptosis. Previous research has indicated that the fat mass and obesity-associated protein/activating transcription factor 4 (FTO/ATF4) axis was involved in the regulation of ferroptosis. The purpose of this study was to explore the role of the FTO/ATF4 axis in cisplatin-induced ferroptosis in granulosa cell.

METHODS

The extent of ferroptosis was assessed by transmission electron microscopy (TEM) and ROS, GPX, GSH, and MDA assays. Western blotting was used to evaluate the protein expression levels of ferroptosis-related molecules. Ferroptosis activator and inhibitor were also used.

RESULTS

We found that ferroptosis increased in a concentration-dependent manner in cisplatin-induced injured granulosa cells, accompanied by the downregulation of FTO. In addition, gain- and loss-of-function studies showed that FTO affects ferroptosis in injured cells by regulating ATF4 expression. Ferrostatin-1 inhibited the effect of FTO downregulation on injured granulosa cells ferroptosis, and erastin reversed the protective effect of FTO on ferroptosis in injured granulosa cells. Finally, melatonin was used, and we found that melatonin reduced ferroptosis in cisplatin-induced injured granulosa cells by upregulating FTO expression.

CONCLUSION

Our study demonstrated that cisplatin induced granulosa cell ferroptosis by downregulating the expression of FTO. ATF4 was identified as a downstream target of FTO, and overexpression of ATF4 reversed the effects of decreased FTO on ferroptosis. Additionally, melatonin mitigates the cytotoxic effects of cisplatin by upregulating FTO expression. The melatonin-FTO-ATF4 signaling pathway plays a vital role in the treatment of cisplatin-induced POF.

Autoimmune Disease is Increased in Women with Primary Ovarian Insufficiency

CONTEXT

Autoimmune disease is common in women with primary ovarian insufficiency (POI) and the genetic etiology of autoimmune disease suggests that it could be hereditary in families of women with POI.

OBJECTIVE

We hypothesized that a subset of women with POI and their family members would have increased risk for autoimmune disorders.

DESIGN

Population-based study using electronic health records from 1995-2022.

SETTING

Two major Utah healthcare systems serving 85% of the state.

SUBJECTS

Women with POI (n=610) were identified using ICD codes and chart reviewed for accuracy. First-, second-, and third-degree relatives were identified using genealogy data in the Utah Population Database.

INTERVENTION

Autoimmune diagnoses were identified using ICD codes.

MAIN OUTCOME MEASURES

The relative risk of autoimmune disease in women with POI and relatives was estimated by comparison to population rates.

RESULTS

At least one autoimmune disease was identified in 25% of women with POI. The relative risk of autoimmune hypothyroidism (OR [95%CI] 6.88 [5.71, 8.22]; p<0.001), adrenal insufficiency (4.72 [1.73, 10.28]; p=0.0020), type 1 diabetes (4.13 [2.14, 7.22]; p=5.25X10-5), rheumatoid arthritis (5.66 [3.10, 9.50]; p=3.70X10-7), vitiligo (15.33 [6.16, 31.58]; p=5.25X10-7), celiac disease (7.58 [3.47, 14.39]; p=4.47X10-6), psoriasis (3.90 [2.01, 6.81]; p=9.04X10-5) and systemic lupus erythematosus (4.43 [1.63, 9.64]; p=0.0027) were increased in women with POI compared to population rates. There was no increased risk of autoimmune disease in family members.

CONCLUSIONS

Data confirm increased autoimmune disease in women with POI. The increased risk is largely related to autoimmune polyglandular syndrome types 1 through 4 and autoimmune hypothyroidism. The absence of risk in family members may result from differences in environmental influences or hormone milieu.

Nicotinamide mononucleotide improves the ovarian reserve of POI by inhibiting NLRP3-mediated pyroptosis of ovarian granulosa cells

BACKGROUND

Premature ovarian insufficiency (POI) is a common clinical problem, but there is currently no effective treatment. NLRP3 inflammasome-induced pyroptosis is thought to be a possible mechanism of POI. Nicotinamide mononucleotide (NMN) has a certain anti-inflammatory effect, providing a promising approach for the treatment of POI.

METHODS

Thirty female Sprague Dawley rats were randomly divided into a control group (n = 10) and a POI group (n = 20). Cyclophosphamide (CTX) was administered for 2 weeks to induce POI. Then the POI group was divided into two groups: the CTX-POI group (n = 10), which was given saline; and the CTX-POI + NMN group (n = 10), which was given NMN at a dose of 500 mg/kg/day for 21 consecutive days. At the end of the study, the serum hormone concentrations of each group were determined, and each group was subjected to biochemical, histopathological, and immunohistochemical analyses. In the in vitro experiment, cell pyroptosis was simulated by using lipopolysaccharide (LPS) and nigricin (Nig), and then KGN cells were treated with NMN, MCC950, and AGK2, and the levels of Nicotinamide adenine dinucleotide (NAD+) and inflammatory factors Interleukin-18(IL-18) and Interleukin-1β(IL-1β) in the cell supernatants were detected, and the levels of pyroptosis-related factors in the cells were determined.

RESULTS

In POI rats, NMN treatments can improve blood hormone levels and partially improve the number of follicles, enhance ovarian reserve function and ovarian index.The evidence is that the increase in NAD+ levels and the activation of SIRT2 expression can reduce the expression of NLRP3, Gasdermin D (GSDMD), Caspase-1, IL-18, and IL-1β in the ovary.

CONCLUSION

NMN improves CTX-induced POI by inhibiting NLRP3-mediated pyroptosis, providing a new therapeutic strategy and drug target for clinical POI patients.

Premature ovarian insufficiency in pediatric cancer patients: a 10 year Rady Children's Hospital experience

OBJECTIVES

To highlight the occurrence of premature ovarian insufficiency in pediatric cancer patients and determine which patient characteristics or treatment modalities are associated with ovarian failure and recovery.

METHODS

Between August 2011-August 2021, 36 of 2,661 patients with cancer were identified to have subsequent ovarian failure. Data collected included cancer type, diagnosis age, types of chemotherapy, bone marrow transplant or radiation treatment, peak follicle-stimulating hormone (FSH), peak anti-Mullerian hormone (AMH), gonadotropin releasing hormone agonist (GnRHa) treatment, type of hormone replacement therapy, and if ovarian function recovery occurred.

RESULTS

The most common cancer type identified was ALL. The mean age of diagnosis was 8.5±4.3 years and mean age of peak FSH value was 12.6±2.8 years. Most patients (97.2 %) were treated with alkylating agents and 72.2 % received radiation. Most patients (72.2 %) received hormone therapy, and 15.8 % of patients received GnRHa Lupron. Ten patients (27.8 %) had ovarian function recovery. Diagnosis age and treatment type were recovery predictors in multivariate regression modeling. Each year older in age was associated with a 30 % decrease in odds of recovery (OR: 0.7, CI: 0.5-0.95, p=0.035), and alkylating agent treatment without transplant was associated with a 3-fold increase in odds of recovery (OR: 3, CI: 2.7-564, p=0.007).

CONCLUSIONS

This retrospective review demonstrates that POI can occur in pediatric cancer survivors, emphasizing the importance of educating patients on potential long-term effects of cancer treatment and importance of routine surveillance. This study confirmed that recovery of ovarian function is possible, especially when diagnosed at a younger age, making continued monitoring essential.

The Role of lncRNAs in the Protective Action of Tamoxifen on the Ovaries of Tumor-Bearing Rats Receiving Cyclophosphamide

Infertility due to ovarian toxicity is a common side effect of cancer treatment in premenopausal women. Tamoxifen (TAM) is a selective estrogen receptor modulator that prevented radiation- and chemotherapy-induced ovarian failure in preclinical studies. In the current study, we examined the potential regulatory role of long noncoding RNAs (lncRNAs) in the mechanism of action of TAM in the ovaries of tumor-bearing rats receiving cyclophosphamide (CPA) as cancer therapy. We identified 166 lncRNAs, among which 49 were demonstrated to be differentially expressed (DELs) in the ovaries of rats receiving TAM and CPA compared to those receiving only CPA. A total of 24 DELs were upregulated and 25 downregulated by tamoxifen. The identified DELs shared the characteristics of noncoding RNAs described in other reproductive tissues. Eleven of the identified DELs displayed divergent modes of action, regulating target transcripts via both cis- and trans-acting pathways. Functional enrichment analysis revealed that, among target genes ascribed to the identified DELs, the majority were involved in apoptosis, cell adhesion, immune response, and ovarian aging. The presented data suggest that the molecular mechanisms behind tamoxifen's protective effects in the ovaries may involve lncRNA-dependent regulation of critical signaling pathways related to inhibition of follicular transition and ovarian aging, along with the suppression of apoptosis and regulation of cell adhesion. Employing a tumor-bearing animal model undergoing chemotherapy, which accurately reflects the conditions of mammary cancer, reinforces the obtained results. Given that tamoxifen remains a key player in the management and prevention of breast cancer, understanding its ovarian-specific actions in cancer patients is crucial and requires detailed functional studies to clarify the underlying molecular mechanisms.

HDAC-driven mechanisms in anticancer resistance: epigenetics and beyond

The emergence of drug resistance leading to cancer recurrence is one of the challenges in the treatment of cancer patients. Several mechanisms can lead to drug resistance, including epigenetic changes. Histone deacetylases (HDACs) play a key role in chromatin regulation through epigenetic mechanisms and are also involved in drug resistance. The control of histone acetylation and the accessibility of regulatory DNA sequences such as promoters, enhancers, and super-enhancers are known mechanisms by which HDACs influence gene expression. Other targets of HDACs that are not histones can also contribute to resistance. This review describes the contribution of HDACs to the mechanisms that, in some cases, may determine resistance to chemotherapy or other cancer treatments.

Bufalin: A promising therapeutic drug against the cisplatin-resistance of ovarian cancer by targeting the USP36/c-Myc axis

Cisplatin (DPP) resistance is a severe obstacle to ovarian cancer (OC) treatment. Our research aims to uncover the therapeutic effect and the underlying mechanism of Bufalin against DDP resistance. The cell viability, proliferation capacity, γH2AX expression, and apoptosis ratio were quantified via CCK8 assay, colony formation assay, immunofluorescence, and flow cytometry analysis respectively. Xenografting experiment was performed to detect the tumor growth. Molecular docking was applied to mimic the combination of Bufalin and USP36 protein, and Western blotting was conducted to measure the Bax, Bcl-2, γH2AX, USP36, and c-Myc expression. The c-Myc ubiquitination and half-life were detected via ubiquitination assay and cycloheximide chasing assay. Bufalin treatment notably suppressed the cell viability and colony numbers, and increased the apoptosis ratio and γH2AX level in the DDP treatment group. Bufalin therapy also notably inhibited tumor growth, Bax, Bcl-2, and γH2AX expression in vivo. Moreover, the Bufalin application remarkedly reduced the c-Myc expression and half-life and increased the c-Myc ubiquitination via interaction and subsequent down-regulation of USP36. Knockdown of USP36 reversed the antiproliferative effect and proapoptotic capacity of Bufalin therapy in the DDP treatment group. In conclusion, Bufalin can overcome the DDP resistance in vitro and in vivo via the USP36/c-Myc axis, which innovatively suggests the therapeutic potential of Bufalin against DDP resistance ovarian cancer.

MSCs-derived EVs protect against chemotherapy-induced ovarian toxicity: role of PI3K/AKT/mTOR axis

Chemotherapy detrimentally impacts fertility via depletion of follicular reserves in the ovaries leading to ovarian failure (OF) and development of estrogen deficiency-related complications. The currently proposed options to preserve fertility such as Oocyte or ovarian cortex cryopreservation are faced with many technical obstacles that limit their effective implementation. Therefore, developing new modalities to protect ovarian function remains a pending target. Exosomes are nano-sized cell-derived extracellular vesicles (EVs) with documented efficacy in the field of regenerative medicine. The current study sought to determine the potential beneficial effects of mesenchymal stem cells (MSCs)-derived EVs in experimentally induced OF. Female albino rats were randomly allocated to four groups: control, OF group, OF + MSCs-EVs group, OF + Rapamycin (mTOR inhibitor) group, and OF + Quercetin (PI3K/AKT inhibitor) group. Follicular development was assessed via histopathological and immunohistochemical examination, and ovarian function was evaluated by hormonal assay. PI3K/Akt/mTOR signaling pathway as a key modulator of ovarian follicular activation was also assessed. MSCs-EVs administration to OF rats resulted in restored serum hormonal levels, preserved primordial follicles and oocytes, suppressed ovarian PI3K/AKT axis and downstream effectors (mTOR and FOXO3), modulated miRNA that target this axis, decreased expression of ovarian apoptotic markers (BAX, BCl2) and increased expression of proliferation marker Ki67. The present study validated the effectiveness of MSCs-EVs therapy in preventing ovarian insufficiency induced by chemotherapy. Concomitant MSCs-EVs treatment during chemotherapy could significantly preserve ovarian function and fertility by suppressing the PI3K/Akt axis, preventing follicular overactivation, maintaining normal ovarian cellular proliferation, and inhibiting granulosa cell apoptosis.

Fertility protective effects of Brillantaisia patula leaf extract against cyclophosphamide-induced ovarian damage in Wistar rats

BACKGROUND

The primary indication of infertility is the incapacity to conceive, and in females, the majority of instances of female infertility stem from ovulation disorders. This study evaluated the female fertility-enhancing effects and safety of aqueous leaf extract of Brillantaisia patula (ALEBP) in a cyclophosphamide (CYP) model of sterility in Wistar rats.

METHOD

Sixty-six female rats randomly allotted to six groups (n = 11) were administered with the appropriate regimen for 21 days and then mated with male rats. Group 1 (control) received distilled water. Groups 2-6 were treated with a single dose (200 mgkg- 1 body weight) of cyclophosphamide intraperitoneally and, in addition, received the same volume (0.5 mL) of distilled water, 18, 36, 72 mgkg- 1 body weight of ALEBP and 200 mg per body weight of vitamin C orally. Mating lasted 11 days; on day 20, the female Wistar rats were sacrificed. Data were analysed using One-way Analysis of Variance (ANOVA) followed by Dunett's posthoc analysis, and GraphPad (at p < 0.05).

RESULTS

Results herein showed that ALEBP significantly (p < 0.05) increased the diminution in activities/levels of glutathione peroxidase (GPx), reduced glutathione (GSH), total antioxidant capacity (TAC), cholesterol, alkaline phosphatase (ALP), acid phosphatase (ACP), estrogen (ES), and luteinising hormone (LH) induced by cyclophosphamide. ALEBP further reversed the increased level of malondialdehyde (MDA), tumour necrosis factor-α (TNFα), interleukin 8 (IL-8), and follicle-stimulating hormone (FSH) caused by cyclophosphamide (p < 0.05). In addition, ALEBP, while it significantly increased the cyclophosphamide-induced reduction in the number of implantations in each animal, the total number of viable fetuses, the total number of corpora lutea, and the fertility index, also significantly reduced the number of fetal resorptions in each animal and pre-implantation loss that was increased by cyclophosphamide. Moreover, the cyclophosphamide-induced degenerative and necrotic changes in the ovarian cells and uterus were reversed by ALEBP.

CONCLUSIONS

Considered as a whole, the aqueous leaf extract of Brillantaisia patula reversed oxidative stress and inflammatory side effects of cyclophosphamide, preserving ovarian function and fertility in the rats. This may suggest its exploration as a safe agent against toxic side effects of chemotherapy and fertility-related disorders of the uterus and ovary.

Human umbilical cord mesenchymal stem cells restore chemotherapy-induced premature ovarian failure by inhibiting ferroptosis in vitro ovarian culture system

BACKGROUND

Mesenchymal stem cells (MSCs) have shown potential in repairing chemotherapy-induced premature ovarian failure (POF). However, challenges such as stem cell loss and immune phagocytosis post-transplantation hinder their application. Due to easy and safe handling, in vitro ovarian culture is widely available for drug screening, pathophysiological research, and in vitro fertilization. MSCs could exhibit therapeutic capacity for ovarian injury, and avoid stem cell loss and immune phagocytosis in vitro tissue culture system. Therefore, this study utilizes an in vitro ovarian culture system to investigate the reparative potential of human umbilical cord mesenchymal stem cells (hUCMSCs) and their mechanism.

METHODS

In this study, a chemotherapy-induced POF model was established by introducing cisplatin in vitro ovarian culture system. The reparative effects of hUCMSCs on damaged ovarian tissue were validated through Transwell chambers. Tissue histology examination, immunohistochemical staining, Western blotting, and RT-PCR were employed to evaluate the expression effects of hUCMSCs on ferroptosis and fibrosis-related genes during the process of repairing cisplatin-induced POF.

RESULTS

Cisplatin was found to activate ovarian follicles in vitro POF model. Transcriptomic sequencing analysis revealed that cisplatin could activate genes associated with ferroptosis. hUCMSCs alleviated cisplatin-induced POF by suppressing the expression of ferroptosis. Moreover, inhibiting ferroptosis by hUCMSCs also ameliorated ovarian hormone levels and reduced the expression of fibrosis-related factors α-SMA and COL-I in the ovaries.

CONCLUSIONS

This study confirms that cisplatin-induced ovarian damage via ferroptosis in vitro POF model, and hUCMSCs repair ovarian injury by inhibiting the ferroptosis pathway and suppressing fibrosis. This research contributes to evaluating the effectiveness of hUCMSCs in treating chemotherapy-induced POF by inhibiting ferroptosis in an in vitro ovarian culture system and provides a potential therapeutic strategy for chemotherapy-induced POF.

Oocyte death is triggered by the stabilization of TAp63α dimers in response to cisplatin

The TAp63α protein is highly expressed in primordial follicle oocytes, where it typically exists in an inactive dimeric form. Upon DNA damage, TAp63α undergoes hyperphosphorylation, transitioning from a dimeric to a tetrameric structure, which initiates oocyte apoptosis by upregulating pro-apoptotic gene. Our results demonstrate that cisplatin, an alkylating anti-cancer agent, predominantly produced the TAp63α dimer rather than the tetramer. We further observed that TAp63α protein accumulation occurred in primordial follicle oocytes following cisplatin treatment, and this accumulation was significantly reduced by cycloheximide, a protein synthesis inhibitor. These findings suggest that TAp63α accumulation is driven primarily by de novo protein synthesis in response to DNA damage. Notably, cycloheximide protected oocytes from cisplatin-induced apoptosis, as evidenced by reduced levels of both PUMA, a known pro-apoptotic target gene of TAp63α, and TAp63α itself. Additionally, TAp63α turnover appears to be regulated by ubiquitination and proteasome degradation, as evidenced by TAp63α accumulation without oocyte death when treated with PYR-41, a pharmacological inhibitor. However, when TAp63α was stabilized by PYR-41 and subsequently activated by cisplatin, oocyte death occurred, marked by increased γH2AX and Cleaved PARP. Moreover, the Casein kinase 1 inhibitor PF-670462 effectively blocked cisplatin-induced oocyte death, indicating that CK1-mediated phosphorylation is essential for TAp63α activation, even in the absence of tetramer formation. The ATR inhibitor BEZ235 prevented cisplatin-induced TAp63α accumulation, suggesting that TAp63α accumulation precedes its phosphorylation-driven activation. Collectively, our study reveals a novel mechanism of cisplatin-induced apoptosis in primordial follicle oocyte through TAp63α stabilization and accumulation, independent of tetramerization.

Hydrogel Strategies for Female Reproduction Dysfunction

Infertility is an important issue for human reproductive health, with over half of all cases of infertility associated with female factors. Dysfunction of the complex female reproductive system may cause infertility. In clinical practice, female infertility is often treated with oral medications and/or surgical procedures, and ultimately with assisted reproductive technologies. Owing to their excellent biocompatibility, low immunogenicity, and adjustable mechanical properties, hydrogels are emerging as valuable tools in the reconstruction of organ function, supplemented by tissue engineering techniques to increase their structure and functionality. Hydrogel-based female reproductive reconstruction strategies targeting the pathological mechanisms of female infertility may provide alternatives for the treatment of ovarian, endometrium/uterine, and fallopian tube dysfunction. In this review, we provide a general introduction to the basic physiology and pathology of the female reproductive system, the limitations of current infertility treatments, and the lack of translation from animal models to human reproductive physiology. We further provide an overview of the current and future potential applications of hydrogels in the treatment of female reproductive system dysfunction, highlighting the great prospects of hydrogel-based strategies in the field of translational medicine, along with the significant challenges to be overcome.

Live birth and maternity outcome in childhood and adolescent cancer survivors under 18 years at diagnosis: a 40-year population-based cohort study

BACKGROUND

Survival from childhood and adolescent cancer has increased, but the chance of a livebirth in female survivors under 18 years at diagnosis may be reduced.

METHODS

We performed a national population-based analysis, including all female cancer survivors diagnosed in Scotland before the age of 18 years between 1981 and 2012. Scottish Cancer Registry records were linked to Scottish maternity records. Females from the exposed group with no pregnancies before cancer diagnosis (n = 2118) were compared with three general population controls matched for age and year of diagnosis.

FINDINGS

The cumulative incidence of a livebirth for all diagnoses was reduced to 37% (95% CI 33-40%) for cancer survivors at 30 years of age vs 58% (57-60%) for controls. The deficit varying by diagnosis: for lymphoid leukaemia, the cumulative incidence at 30 years was 29% (23-36%) vs 57% (52-61%) for controls with similar deficits in CNS tumours and retinoblastoma. There was a steady improvement in the chance of livebirth in those diagnosed more recently.

INTERPRETATION

We have shown a reduced chance of livebirth in female survivors of cancer diagnosed before age 18. The deficit is present for all diagnoses.

Sleep Deprivation Triggers the Excessive Activation of Ovarian Primordial Follicles via β2 Adrenergic Receptor Signaling

Sleep deprivation (SD) is observed to adversely affect the reproductive health of women. However, its precise physiological mechanisms remain largely elusive. In this study, using a mouse model of SD, it is demonstrated that SD induces the depletion of ovarian primordial follicles, a phenomenon not attributed to immune-mediated attacks or sympathetic nervous system activation. Rather, the excessive secretion of stress hormones, namely norepinephrine (NE) and epinephrine (E), by overactive adrenal glands, has emerged as a key mediator. The communication pathway mediated by the KIT ligand (KITL)-KIT between granulosa cells and oocytes plays a pivotal role in primordial follicle activation. SD heightened the levels of NE/E that stimulates the activation of the KITL-KIT/PI3K and mTOR signaling cascade in an β2 adrenergic receptor (ADRB2)-dependent manner, thereby promoting primordial follicle activation and consequent primordial follicle loss in vivo. In vitro experiments further corroborate these observations, revealing that ADRB2 upregulates KITL expression in granulosa cells via the activation of the downstream cAMP/PKA pathway. Together, these results reveal the significant involvement of ADRB2 signaling in the depletion of ovarian primordial follicles under sleep-deprived conditions. Additionally, ADRB2 antagonists are proposed for the treatment or prevention of excessive activation of primordial follicles induced by SD.

Hormone Receptor Positive Breast Cancer in Young Women: A Review

The global incidence of hormone-positive breast cancer (HR+ BC) in young women is rising, though the underlying reasons remain unclear. HR+ disease in younger women appears to represent a distinct clinical entity compared to that in older women, exhibiting distinct clinicopathological characteristics, outcomes and responses to treatment. Despite these differences, there is a paucity of large-volume data focusing on young women with HR+ in contemporary literature. Hormone receptor positive breast cancer in young women is associated with poorer prognoses compared to older women. Additionally, early age onset breast cancer presents unique challenges, including concerns related to fertility, the toxic effects of therapeutic agents, and specific surgical considerations. The purpose of this review is to report the existing literature on HR+ disease in young women.