Treatment with the Gonadotropin-Releasinghormone Agonist Buserelin to Protect Spermatogenesis against Cytotoxic Treatment in Young Men/Behandlung zum Schutz der Spermatogenese bei cytotoxischer Therapie mit dem Gonadotropin-Hormon Agonisten Buserelin

Review : Infertility after chemotherapy: A review of the risks and strategies for prevention

Purpose. Infertility as a late complication of cancer chemotherapy, focusing on specific drug-related ef fects, effects observed in the treatment of certain malignancies, and strategies for prevention is re viewed.

Data Sources. A MEDLINE search of articles from 1966 to present was conducted using the terms infertility, antineoplastics, amenorrhea, azospermia, oogenesis, and spermatogenesis. Additional refer ences were identified using review articles and phar macology textbooks.

Study Selection. All human studies reported in English language were included. Animal studies were included when human data were insufficient or un available.

Data Synthesis. Data on the infertility effects of individual antineoplastic agents are difficult to inter pret for several reasons, including small sample sizes, lack of prechemotherapy fertility assessment, inade quate long-term follow-up, and use of regimens in cluding multiple agents. In general, the incidence and severity of antifertility effects are dependent on the total dosage delivered, duration of therapy, and age at exposure. The alkylating agents have the most signif icant effects on fertility. Fertility outcomes have been reported for several different malignancies, especially in patients cured of Hodgkin's disease and testicular cancer. Information on specific antineoplastic agents and cancers are reviewed. Several methods have been employed to decrease gonadotoxic effects, but none have been effective.

Conclusions. Infertility is a common late com plication of cancer chemotherapy that is receiving increasing attention as the number of cancer survi vors increases. Health care professionals should be aware of infertility risks associated with antineoplastic agents and certain malignancies, and patients should be informed of these risks as treatment decisions are made.

GnRH analogue attenuated apoptosis of rat hippocampal neuron after ischemia-reperfusion injury

The expression and new functions of reproductive hormones in organs beyond hypothalamus-pituitary-gonad axis have been reported. So far, there is no report about the protective effects of GnRH analogue to hippocampal neurons suffering from ischemia-reperfusion injury. Middle cerebral artery occlusion model together with TUNEL staining were made in vivo and oxygen-glucose deprivation model together with double staining of Annexin V/PI with flow cytometer were made in vitro to observe the anti-apoptotic effects of GnRH analogue to hippocampal neurons after ischemia-reperfusion injury. The results found that the number of TUNEL positive pyramidal neurons in CA1 region in GnRH analogue experiment group was less than that in control group in vivo; the percentage of apoptotic neurons in GnRH analogue experiment group was less than that in control group in vitro. These findings suggested that pretreatment with certain concentration of GnRH analogue could attenuate apoptosis of hippocampal neurons. GnRH analogue has the protective effects to neurons.

Current status of the approach to assisted reproduction

Assisted reproductive technologies are important tools in the clinical armamentarium used to treat both female and male infertility disorders. Pre-implantation genetic diagnosis offers couples at risk of having children with inheritable disorders the ability to analyze the genetic make-up of embryos before transfer. For patients undergoing treatment of cancer with chemotherapy or radiation therapy, these technologies offer the potential for the preservation of future fertility. As technology evolves, it is likely the clinical applications of assisted reproduction will continue to develop and expand in the future to enhance fertility.

Hormonal strategies for fertility preservation in patients receiving cyclophosphamide to treat glomerulonephritis: a nonrandomized trial and review of the literature

BACKGROUND

Prepubertal patients receiving chemotherapy are relatively resistant to cyclophosphamide-induced germinal cell alterations. We studied the possible protective effect of testosterone and triptorelin to inhibit gonadal activity in men and women receiving cyclophosphamide, respectively.

STUDY DESIGN

Nonrandomized trial.

SETTING & PARTICIPANTS

28 consecutive patients, 11 men and 17 women, from a university medical center with various forms of glomerulonephritis, treated with cyclophosphamide.

INTERVENTION

Men received cyclophosphamide plus testosterone; women were divided into 2 groups: 13 patients (group A) received cyclophosphamide plus triptorelin; 4 (group B) received only cyclophosphamide.

OUTCOMES & MEASUREMENTS

Serum follicle-stimulating hormone (FSH) and serum luteinizing hormone levels and, in addition, sperm counts and testosterone levels in men and estradiol levels in women were measured before and after treatment with cyclophosphamide.

RESULTS

All 10 men became azoospermic or severely oligospermic during treatment; after 12 months, all except 1 had a normal sperm count and FSH levels were normal. In women during cyclophosphamide therapy, amenorrhea occurred in all patients. After cessation of therapy, all women in group A started to menstruate regularly, and at the end of follow-up, ovulatory cycles were demonstrated in all women. Hormone levels showed no significant changes throughout the observation period. Six women conceived, and the pregnancies were brought to term successfully without complications. In group B, all 4 women developed sustained amenorrhea; serum FSH and luteinizing hormone levels at the end of therapy and follow-up were significantly higher with respect to baseline; estradiol levels at the end of follow-up were significantly lower compared with baseline and corresponding values in group A.

LIMITATIONS

The substudy in men is uncontrolled, the substudy in women is nonrandomized.

CONCLUSIONS

The study suggests a protective effect of testosterone and triptorelin against cyclophosphamide-induced gonadal damage in men and women with various forms of kidney disease, respectively.

Ischemia-reperfusion injury effects a change in expression of GnRH and its receptor in CA1 neurons in rat hippocampus

Many researches on the change and protective effects of estrogen and its receptor in hippocampus with ischemia-reperfusion injury have been done in recent years; the study on the change of GnRH and its receptor in hippocampus with ischemia-reperfusion injury has not been seen yet. This study used immunohistochemistry and in situ hybridization method, together with an image analysis system to observe the change in expression of GnRH and its receptor in hippocampus with ischemia-reperfusion injury. The study found that the expression of GnRH and GnRH mRNA and the number of positive cells decreased with time after damage. Expression of GnRH receptor and GnRH receptor mRNA in single positive cell early increased and later decreased after injury; the number of positive cells decreased with time after injury. Three days after injury, rare GnRH, GnRHR immunoreactive positive cells and cells with GnRH mRNA, GnRHR mRNA hybridization signal could be found in the stratum pyramida of CA1 region, many cells with weak GnRH, GnRH receptor immunoreactivity and weak GnRH mRNA, GnRH receptor mRNA hybridization signal appeared at stratum oriens and stratum radiatum. These suggested that GnRH may participate in the regulation of ischemia-reperfusion injury in CA1 region and repair of brain tissue.

Fertility preservation in female cancer patients: current developments and future directions

OBJECTIVE

To review the current advances in fertility preservation strategies and to discuss future directions with an emphasis on ovarian tissue cryobanking.

DESIGN

The publications related to fertility preservation in cancer patients were identified through Medline and other bibliographic databases, focusing on the most recent developments.

CONCLUSION(S)

There are several options for fertility preservation in cancer patients. Even though most of them are still experimental and their efficacy and reliability have not been determined, the future of fertility preservation in women with cancer is promising. In particular, the recent report of a live birth after transplantation of human ovarian tissue has reinforced the clinical potential of ovarian tissue banking for fertility preservation. Many exciting studies are underway to improve the efficacy and solve the problems with current fertility preservation strategies. It is inevitable that we will see the emergence of more complex ethical problems with the application of new technologies to humans. However, continuous efforts to improve current strategies and to develop new strategies will benefit many women and children who are facing premature ovarian failure and sterility.

[Medical preservation of ovarian function before and during radiochemotherapy]

Intensive use of radiochemotherapy has greatly improved the prognosis associated with cancer in young women patients. However, improvement of the vital prognosis is frequently associated with impairment of fertility and premature ovarian failure. Cryopreservation of ovarian tissues has been developed but effective secondary use of cryopreserved tissue by means of autograft or through in vitro follicular maturation need yet to be clarified even though first success seemed to be recently obtained. Infant ovaries have been considered to be less sensitive than adult ovaries, which has suggested that hypophysal blockage could protect adult ovaries against fertility impairment before and during radiochemotherapy. Non-randomized studies using LHRH agonists support such a hypothesis. However what we know about physiopathology of follicular destruction involving exaggerated apoptosis and several animal models do not fit with these results. By consequence randomized studies need to be performed to verify the benefit, which one could expect from such a systematic clinical use.

Ovarian function preservation in the cancer patient

OBJECTIVE

To review the clinical modalities that are available to women receiving potentially sterilizing cancer therapy.

DESIGN

The MEDLINE database was reviewed for all publications on medication, surgery, or assisted reproductive technology that could potentially preserve fertility in women who are receiving cancer therapy.

CONCLUSION(S)

There are many options available to a patient undergoing a treatment that will negatively impact her fertility. Many procedures and medical interventions have been proven successful both in terms of ovarian function and pregnancy rates. Other techniques have great potential but do not have long-term clinical data. It is important that the patient's primary care physician understand the methods available to preserve fertility in cancer patients and communicate this information to the patient.

Successful human ovarian autotransplantation to the upper arm

In young patients with cervical carcinoma, the standard surgical treatment is often followed by postoperative radiotherapy. This treatment strategy, although resulting in a significant increase in cure rates, often causes infertility and premature ovarian failure. Ovarian autotransplantation outside the field of radiotherapy is a new technique to preserve gonadal function. One ovary was transplanted to the left upper arm during the surgical treatment for cervical carcinoma. Vascular anastomoses were performed by microsurgery. After transplantation, the ovary showed adequate arterial and venous blood flow. By clinical examination and ultrasound monitoring, the ovarian cycles remained regular and follicle growth occurred normally for > 1 year. Heterotopic autotransplantation of the ovary to the upper arm is a promising surgical technique to maintain the ovarian function in women who become menopausal due to cancer treatment regimens.

Fertility after treatment for Hodgkin's disease

BACKGROUND

The investigational endeavors of ovarian cryopreservation await the clinical experience of auto- or xenotransplantation, in vitro maturation of thawed primordial follicles, their in vitro fertilization and embryo transfer. Although promising, this experience is not yet available. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryoperserved ovary has been raised following experimental animal observations. Therefore, until these innovative endeavors prove successful, we have attempted to minimize the gonadotoxic effect of chemotherapy by the co-treatment with a gonadotropin-releasing hormone agonistic analog (GnRH-a) to induce a temporary prepubertal milieu. The immunoreactive inhibin-A and -B in these patients was measured before, during and following the gonadotoxic chemotherapy.

METHODS

A prospective clinical protocol was undertaken in 60 women aged 15-40 years with lymphoma, 10 with leukemia and 10 undergoing chemotherapeutic treatments for non-malignant diseases such as systemic lupus erythematosus or other autoimmune diseases. A monthly injection of depot D-TRP(6)-GnRH-a was administered from before starting the chemotherapy until its conclusion, up to a maximum of 6 months. Hormonal profile [follicle-stimulating hormone (FSH), luteinizing hormone (LH), E2, T, P4, insulin-like growth factor (IGF)-1, IGF-BP3 and prolactin) was taken before starting the GnRH-a/chemotherapy co-treatment, and monthly thereafter until resumtion of spontaneous ovulation. This group was compared with a control group of 60 women who have been treated with similar chemotherapy.

RESULTS

Whereas all but three (40, 36 and 34 year old) of the surviving patients within the GnRH-a/ chemotherapy co-treatment group resumed spontaneous ovulation and menses within 12 months, less than half of the patients in the 'control' group (chemotherapy without GnRH-a co-treatment) resumed ovarian function and regular cyclic activity (P <0.05). The remaining 55% experienced premature ovarian failure (POF). Temporarily increased FSH concentrations were experienced by about one-third of the patients resuming cyclic ovarian function, suggesting reversible ovarian damage in a larger proportion of women than those experiencing POF. Inhibin-A and -B decreased during the GnRH-a/ chemotherapy co-treatment but increased to normal levels in patients who resumed regular ovarian cyclicity, and/or spontaneously conceived, as compared with low levels in those who developed POF.

CONCLUSIONS

If these preliminary data are consisent in a larger group of patients, GnRH-a co-treatment should be considered in every woman of reproductive age receiving chemotherapy, in addition to assisted reproductive technologies and the investigation into ovarian cryopreservation for future in vitro maturation, autotransplantation or xenotransplantation.

Preservation of fertility and ovarian function and minimalization of chemotherapy associated gonadotoxicity and premature ovarian failure: the role of inhibin-A and -B as markers

BACKGROUND

Following the improved long term survival in young women with lymphoma and leukemia undergoing chemotherapy, the preservation of future fertility has been the focus of recent interest. The investigational endeavors of ovarian cryopreservation awaits the clinical experience of in-vitro maturation of thawed primordial follicles, their in-vitro fertilization and ET. Although promising, this experience is not available yet. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryopreserved ovary has been raised, following experimental animal observations. Therefore, until these innovative endeavors prove successful, and in parallel to them we attempted to minimize the gonadotoxic effect of chemotherapy by the co-treatment with a GnRH agonistic analogue to induce a temporary prepubertal milieu. Whereas, inhibin-B concentrations in serum may reflect the ovarian granulosa cell compartment, inhibin-A reflects luteal function. The immunoreactive inhibin-A and -B in these patients, before, during, and following the gonadotoxic chemotherapy were measured.

METHODS

A prospective clinical protocol was undertaken in 55 women with lymphoma, aged 15-40 years, ten with leukemia and eight undergoing chemotherapeutic treatments for non malignant diseases such as systemic lupus erythematosus (SLE) or other autoimmune diseases. A monthly injection of depot D-TRP6-GnRH-a was administered from before starting the chemotherapy until its conclusion, up to a maximum of 6 months. Hormonal profile (FSH, LH, E2, T, P4, IGF-1, IGF-BP3, and PRL) was taken before starting the GnRH-a/chemotherapy co-treatment, and monthly thereafter, until resuming spontaneous ovulation. This group was compared with a control group of 55 women who have been treated with similar chemotherapy. Inhibin-A and -B immunoactivity was measured by an ELISA commercial kit (Serotec).

RESULTS

Whereas, all but three (40- and 36-year-old) of the surviving patients with GnRH-a/chemotherapy co-treatment group resumed spontaneous ovulation and menses within 12 months, less than half of the patients in the control group (chemotherapy without GnRH-a co-treatment) resumed ovarian function and regular cyclic activity (P<0.05). The remaining 56% experienced premature ovarian failure (POF). Temporary increased FSH concentrations were experienced by about a third of the patients resuming cyclic ovarian function, suggesting a reversible ovarian damage in a larger proportion of women than those experiencing POF. Inhibin-A and -B decreased during the GnRH-a/chemotherapy co-treatment but increased to normal levels in patients who resumed regular ovarian cyclicity, and/or spontaneously conceived, as compared with low levels in those who developed POF.

CONCLUSIONS

If these preliminary data are consistent in a larger group of patients, inhibin-A or -B concentrations may serve as prognostic factors for predicting the resumption of ovarian function, in addition to the levels of FSH, LH and E2. The GnRH-a co-treatment should be considered in every woman in the reproductive age receiving chemotherapy, in addition to ART, and to the investigational attempts of ovarian cryopreservation for future in-vitro maturation, autotransplantation, or xenotransplantation.

Inhibin A concentrations in the sera of young women during and after chemotherapy for lymphoma: correlation with ovarian toxicity

PROBLEM

Inhibin A concentrations in serum may reflect the ovarian granulosa cell compartment. To characterize the correlation between ovarian function after gonadotoxic chemotherapy for Hodgkin's or non-Hodgkin's lymphoma in young women, the immunoreactive inhibin A concentrations in the sera of these patients was measured before, during, and after the gonadotoxic chemotherapy.

METHOD OF STUDY

A prospective clinical protocol was undertaken in 20 cycling women with lymphoma, aged 15-40 years. A monthly injection of depot D-TRP6-GnRH-a (Decapeptyl CR, Ferring) was administered from before starting the chemotherapy until its conclusion, up to a maximum of six monthly injections. Most of the patients were treated with the mustargen-oncovin-procarbazine-prednisone (MOPP)/actinomycin D-bleomycin-vincristine (ABV) chemotherapy combination; 13 with and 7 without radiotherapy. A hormonal profile [follicle-stimulating hormone (FSH), luteinizing hormone (LH), 17-beta-estradiol (E2), testosterone (T), progesterone (P4), insulin-like growth factor (IGF)-1, IGF-BP3, and prolactin (PRL)] was taken before starting the gonadotropin-releasing hormone agonist (GnRH-a)/chemotherapy co-treatment and monthly thereafter until resuming spontaneous ovulation and menstrual cyclicity. This group of prospectively treated lymphoma patients was compared with a control group of 22 regularly cycling women who had been treated with chemotherapy (mostly MOPP/ABV) with or without radiotherapy for Hodgkin's or non-Hodgkin's lymphoma. Inhibin A immunoactivity developed by Nigel Groome was measured by an enzyme-linked immunoadsorbent assay (ELISA) commercial kit (Serotec).

RESULTS

Whereas all but one (40 years of age) of the surviving patients in the GnRH-a/chemotherapy co-treatment group resumed spontaneous ovulation and menses within 6 months, only one half of the patients in the "control" group (chemotherapy without GnRH-a co-treatment) resumed ovarian function and regular cyclic activity (P < 0.05). The remaining 50% experienced premature ovarian failure (POF). Temporarily increased FSH concentrations were experienced by approximately one third of the patients resuming cyclic ovarian function, suggesting a reversible ovarian damage in a larger proportion of women than those experiencing POF. The inhibin A immunoactive concentrations decreased during the GnRH-a/chemotherapy co-treatment but increased to normal levels in patients who resumed regular ovarian cyclicity, and/or spontaneously conceived, as compared to low levels in menopausal women and those who had developed POF.

CONCLUSIONS

If these preliminary data are consistent in a larger group of patients, inhibin A concentration may serve as a prognostic factor for predicting the resumption of ovarian function, in addition to the levels of FSH, LH, and E2.

Prevention of gonadal damage during cytotoxic therapy

Infertility represents one of the main remote sequelae of cytotoxic chemotherapy given for various malignant diseases. The impairment of gonadal function after cytotoxic chemotherapy is more frequent in the male than in the female. Because dividing cells are more sensitive to the cytotoxic effects of alkylating agents than are cells at rest, it has been hypothesized that inhibition of the pituitary-gonadal axis by gonadotropin-releasing hormone (GnRH) agonists would render the germinal epithelium less susceptible to the cytotoxic effects of chemotherapy. This hypothesis has not been thoroughly clinically tested until recently, although several investigators have demonstrated that GnRH-agonistic analogues (GnRH-a) inhibit chemotherapy-induced ovarian follicular depletion in the rat and Rhesus monkeys. Based on this rationale, we have undertaken a prospective evaluation to determine whether GnRH-a administration during combination chemotherapy for Hodgkin's and non-Hodgkin's lymphoma could prevent posttreatment ovarian damage in women by inducing a temporary prepubertal hormonal milieu. While over 93% of the surviving patients in the GnRH-a and chemotherapy group resumed spontaneous ovulation and menses, less than 40% of the women in the control group of chemotherapy without the GnRH-a cotreatment resumed normal ovarian cyclic activity. More than 60% of the women experienced premature ovarian failure (POF) in the chemotherapy alone group. Our preliminary results suggest that GnRH-a cotreatment protects against POF during cytotoxic chemotherapy. The GnRH-a and chemotherapy cotreatment may be also suggested for young women treated by cyclophosphamide pulse therapy or other gonadotoxic treatments for systemic lupus erythematosus, organ transplantation and other autoimmune diseases. The technology of cryopreservation of human ova for future fertility in these patients awaits clinical validation and substantiation. This review discusses possibilities to prevent gonadal damage induced by cytotoxic therapy and presents the clinical data currently available.

Protection of the germinal epithelium in the rat from the cytotoxic effects of chemotherapy by a luteinizing hormone-releasing hormone agonist and antiandrogen therapy

OBJECTIVES

The protection of spermatogenesis during chemotherapy using an antiandrogen and a luteinizing hormone-releasing hormone (LHRH) agonist was examined in the rat. Previous studies using LHRH agonists alone have been inconclusive, as both protective and deleterious effects on the germinal epithelium have been reported. Flutamide has not previously been used in this manner but theoretically should protect the germinal epithelium, since flutamide rapidly blocks testosterone at the cellular level and also minimizes the testosterone "flare" when LHRH agonist therapy is initiated.

METHODS

Mature Sprague-Dawley rats were pretreated with flutamide, sustained-release goserelin acetate (Zoladex), or a combination of flutamide and sustained-release goserelin acetate for 14 days before 4 weekly doses of procarbazine were initiated. The seminiferous tubules were evaluated histologically after a 90-day regeneration period using the stem cell assay test.

RESULTS

After treatment with procarbazine alone, only 43% of the seminiferous tubules were active; however, 80% were active if protected with flutamide, 91% if protected with sustained-release goserelin acetate, and 95% if protected with both flutamide and goserelin acetate.

CONCLUSION

Flutamide, sustained-release goserelin acetate, and a combination of these agents were effective in protecting the germinal epithelium of the rat during chemotherapy. A combination of flutamide and goserelin acetate provided the best protection. This study demonstrates for the first time the protective effect of flutamide and flutamide with goserelin acetate on the germinal epithelium during chemotherapy.

Dyspermia in men with localized Hodgkin's disease. A potentially reversible, immune-mediated disorder

Localized Hodgkin's disease (HD) is curable in the great majority of patients. However, common programs of chemotherapy for this disease render most men permanently azoospermic. In studies of seminal cryopreservation prior to treatment, it has been recognized that many men with HD are dyspermic at diagnosis. It is hypothesized that this abnormality reflects a change in the cellular regulation of spermatogenesis; specifically an alteration in the balance between distinct sub-populations of lymphocytes which normally either inhibit or stimulate the production of sperm. This change in regulation within the testes is believed to be part of a systemic perturbation which is unrelated to the extent of HD but is potentially reversible with effective treatment of the primary disease. Recognizing the distinction between sperm analyses and fertility status, it is proposed that radiotherapy of localized HD, delivered in a manner that is not toxic to the male gonad, will restore useful spermatogenesis in patients who are dyspermic (and probably subfertile) before treatment is initiated.