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

miRNA-149 targets PARP-2 in endometrial epithelial and stromal cells to regulate the trophoblast attachment process

Embryo implantation is a highly complex process involving many regulatory factors, including several micro RNAs (miRNAs/miRs). One miRNA present in the stromal cells of normal endometrium is miR-149, which targets poly (ADP-ribose) polymerase 2 (PARP-2), a gene involved in endometrial receptivity for trophoblast implantation. However, the precise role of miR-149 in the endometrial receptivity during blastocyst implantation is still unknown. We studied miR-149-dependent PARP-2 regulation during trophoblast attachment to endometrial epithelial cells. Using FISH, we found that miR-149 is expressed in mouse endometrial epithelial and stromal cells at implantation and inter-implantation sites. Endometrial receptivity for embryo implantation and attachment is inhibited by the upregulation of miR-149 in the endometrium. Our RT-PCR analysis revealed downregulation of miR-149 in the implantation region of the uterus during the receptive stage (Day 5, 0500 h, p.c.) in the mouse. Under in-vitro conditions, miR-149 overexpression in human endometrial epithelial cells (hEECs) abrogated the human trophoblastic cells spheroid and mouse blastocyst attachment. Subsequently, miR-149 also regulates transformed human endometrial stromal cell (T-hESCs) decidualization by downregulating PARP-2 and upregulating caspase-8 proteins. Overexpression of miR-149 in hEECs and downregulated PARP-2 protein expression, reconfirming that PARP-2 is a downstream target of miR-149 in endometrial cells as well. miR-149 is also able to alter the expression of caspase-8, another PARP-2 regulator. In conclusion, our data indicate that miR-149 is one of the regulators of endometrial receptivity and decidualization for trophoblast implantation, and it exerts the effects by acting on the downstream targets PARP-2 and caspase-8.

Ovarian function after cancer treatment in young women affected by Hodgkin disease (HD)

We have evaluated the best method to assess the ovarian reserve and the ovarian protective effect of GnRH-analog (GnRH-a), in 29 women with Hodgkin's disease (HD) treated with chemotherapy (CHT). The ovarian reserve was studied by measuring the serum levels of follicle stimulating hormone (FSH), luteinizing hormone (LH), inhibin B, antimullerian hormone (AMH) and the ultrasound antral follicular count (AFC). The patients were randomly treated with or without GnRH-a. At the time of study menstrual function was normal in 21 cases (72.4%), but absent in 8 (27.5%). Mean basal values of FSH, LH, AMH, inhibin B and AFC were normal in patients less than 30 years old and in the group treated four years or less before observation. AFC appeared to be the best marker of reduced ovarian reserve and a combination of AFC-AMH or inhibin B appeared the best predictor. In the GnRH-a group, no women had amenorrhoea, although ovarian reserve assessment was not significantly different from those who were not treated. The time-interval from CHT was the only significant predictor of ovarian function in GnRH-a treated patients. In conclusion, ovarian reserve evaluation, in young patients treated by CHT, can be performed by AFC. GnRH-a treatment does not have a protective effect, but could delay the development of ovarian failure.

Lentivirus-mediated bcl-2 gene therapy improves function and structure of chemotherapy-damaged ovaries in wistar rats

OBJECTIVE

This study aimed to explore the roles and mechanisms of lentivirus-mediated bcl-2 gene therapy in repairing the function and structure of chemotherapy-damaged ovaries in rats.

METHOD OF STUDY

The lentivirus vector carrying the bcl-2 gene (pGC-FU -EGFP-bcl-2) was constructed and condensed at a high titer. Wistar rats were divided into seven groups based on the treatment they were given: no treatment [the normal control (NC) group]; intraperitoneal injection of cyclophosphamide (the CTX group); bilateral ovarian injection of pGC-FU-EGFP-bcl-2 (the bcl-2 group) or empty vector pGC-FU-EGFP (the enhanced green fluorescent protein (EGFP) group); bilateral ovarian injection of normal saline (the NS + CTX group), pGC-FU-EGFP (the EGFP + CTX group), or pGC-FU-EGFP-bcl-2 (the bcl-2 + CTX group) followed by intraperitoneal injection of CTX. At 15, 30, 45, and 60 days after injection, the rats were killed, serum levels of estradiol (E₂) and follicle-stimulating hormone (FSH) were detected by radioimmunoassay; ovarian structure and follicles were observed under a microscope, the apoptosis of granulosa cells was detected by terminal deoxynucleotidyide transferase-mediated biotin-dUTP biotin nick-end labeling, and the expression of Bcl-2 in the ovaries was detected by Western blotting.

RESULTS

After the injection of pGC-FU-EGFP-bcl-2, the serum level of E₂ was elevated, whereas that of FSH was dropped, follicles were increased, the CTX-induced apoptosis of granulosa cells was inhibited, and the expression of Bcl-2 was up-regulated.

CONCLUSION

The lentivirus-mediated bcl-2 gene therapy can improve ovarian function and structure damaged by chemotherapy and, therefore, might be a potential method to treat CTX-induced pre-mature ovarian failure.

Effects of cancer treatment on ovarian function

Causes of primary ovarian failure are reviewed, focusing specifically on cancer treatment-related modalities. Strategies and future directions for protection of the ovaries during cancer therapy, including ovarian transposition, and conformal radiation techniques are presented.

A pilot study of predictive markers of chemotherapy-related amenorrhea among premenopausal women with early stage breast cancer

BACKGROUND

Premenopausal women treated for early stage breast cancer (ESBC) are at risk for chemotherapy-related amenorrhea (CRA). Prospectively-validated, predictive markers of CRA are needed.

PATIENTS AND METHODS

Premenopausal women with ESBC and planned chemotherapy (>/= 25% risk of amenorrhea) were evaluated. Follicle stimulating hormone (FSH), estradiol, Inhibin A and B, anti-Müllerian hormone (AMH), and quality of life (QOL) were prospectively evaluated pre-, post-, 6 months and 1 year post-chemotherapy and correlated with age and menstrual status. CRA was defined as absence of menses 1 year post-chemotherapy.

RESULTS

Forty-four women were evaluated at the time of analysis. Median age at diagnosis and FSH 1 year post-chemotherapy were higher among women with CRA (44 yrs [33-51] vs. 40 yrs [31-43]; p = 0.03; 39.8 vs. 5.0 mLU/mL, p = 0.0058, respectively). Median estradiol 1 year post-chemotherapy was higher among women who resumed menses (108.3 vs. 41.3 pg/mL, p = 0.01). Pre-chemotherapy median Inhibin B and AMH were lower among women with CRA (33.2 vs. 108.8 pg/mL; p = 0.03; 0.16 vs. 1.09 ng/mL, p = 0.02, respectively). The risk of CRA was increased among women with lower pre-chemotherapy Inhibin B (RR = 1.67, p = 0.15) and AMH (RR = 1.83, p = 0.05). Amongst women whose pre-chemotherapy Inhibin B and AMH values were below the median, the incidence of CRA was 87.5%.

CONCLUSIONS

RESULTS indicate that pre-chemotherapy Inhibin B and AMH are lower among women experiencing CRA and may be predictive of CRA among premenopausal women facing chemotherapy for ESBC.

Gonadotropin-releasing hormone agonist decreases chemotherapy-induced gonadotoxicity and premature ovarian failure in young female patients with Hodgkin lymphoma

OBJECTIVE

To minimize the gonadotoxic effect of chemotherapy by the cotreatment with a GnRH agonistic analogue (GnRH-a).

DESIGN

Prospective nonrandomized study with concurrent and historical controls.

SETTING

University medical center.

PATIENT(S)

One hundred fifteen female patients with Hodgkin lymphoma (HL).

INTERVENTION(S)

Sixty-five patients received a monthly injection of GnRH-a, administered before starting chemotherapy until its conclusion, up to a maximum of 6 months. Thirty-five patients were treated with ABVD and 76 with a procarbazine-containing regimen. This group was compared with a control group of 46 women who were treated concurrently with similar chemotherapy (n = 26) without GnRH-a or were historical controls (n = 20).

MAIN OUTCOME MEASURE(S)

Cyclic ovarian function (COF) versus premature ovarian failure (POF).

RESULT(S)

The ovarian function could be determined in 111 patients. In the GnRH-a/chemotherapy group, 63 out of 65 patients resumed ovulation and regular menses (96.9 %), compared with 63% of the 46 control subjects. Twenty of the 22 patients in the BEACOPP/escalated BEACOPP/GnRH-a cotreatment resumed cyclic ovarian function versus 9 of the 14 in the chemotherapy-only group. All 17 MOPP/ABV/GnRH-a cotreated patients resumed COF versus 11 of the 22 in the chemotherapy-only group. There was no significant effect of the GnRH-a cotreatment regarding COF in the ABVD group. There were no significant differences in the cumulative doses of the various alkylating agents between the two groups.

CONCLUSION(S)

Cotreatment with GnRH-a may reduce ovarian damage significantly in female patients treated for HL and should be considered in addition to assisted reproduction for women in reproductive age receiving gonadotoxic chemotherapy.

How to preserve fertility in young women exposed to chemotherapy? The role of GnRH agonist cotreatment in addition to cryopreservation of embrya, oocytes, or ovaries

The possibilities to preserve fertility in women exposed to chemotherapy are: in vitro fertilization plus embryo cryopreservation, ovarian cryopreservation, unfertilized ova cryopreservation, and the administration of a gonadotropin-releasing hormone (GnRH) agonist. Because none of these methods is ideal, combination of several methods should be considered. Because the chances of preserving gonadal function following combined-modality treatment are significantly better for girls than for boys, simulation of a prepubertal milieu was applied only to women of reproductive age. The administration of GnRH agonists to women with Hodgkin's disease, breast cancer, and other malignancies, or to patients with lupus nephropathy, in parallel with chemotherapy, by others and by us, has demonstrated a significantly lower rate of premature ovarian failure in survivors than in nonrandomized controls. Several prospective, randomized studies are ongoing. A recent meta-analysis found that the administration of a GnRH agonist, in addition to chemotherapy, to patients with breast cancer was associated with less recurrence and superior survival. Several possibilities to explain the beneficial effect of GnRH agonists to minimize chemotherapy-associated gonadotoxicity are suggested: (a) The hypogonadotropic milieu decreases the number of primordial follicles entering the differentiation stage, which is more vulnerable to chemotherapy; (b) The hypoestrogenic state decreases ovarian perfusion and delivery of chemotherapy to the ovaries; (c) A direct effect of the GnRH agonist on the ovary occurs independently of the gonadotropin level; (d) GnRH agonists may upregulate an intragonadal antiapoptotic molecule such as sphingosine-1-phosphate; (e) The GnRH agonist may protect ovarian germline stem cells.

[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.

Gynaecologic concerns for young women exposed to gonadotoxic chemotherapy

PURPOSE OF REVIEW

Due to the improved long-term survival of adolescents and young women with systemic malignancies such as lymphomas and leukaemia undergoing gonadotoxic chemotherapy, preservation of future fertility has been the focus of recent ubiquitous interest. This review summarizes, in brief, the recent progress in the various attempts to prevent premature ovarian failure in these young women with unconsumed fertility potential.

RECENT FINDINGS

The investigational endeavours of ovarian cryopreservation await the clinical experience of auto- or xenotransplantation, or in-vitro maturation of thawed primordial follicles, and in-vitro fertilization. Although promising, this procedure is not available yet. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryopreserved ovary has been highlighted following experimental animal observations. The gonadotropin-releasing hormone agonist has been efficient in primates in a prospective study, and in young women in several nonrandomized series. The disruption of the acid sphingomyelinase gene, or sphingosine-1-phosphate, in rodents can prevent follicle destruction by ionizing radiation, possibly indicating in-vivo protection in cancer patients at risk of iatrogenic sterilization.

SUMMARY

The recent enormous scientific advance lends hope that the future may hold answers to the questions regarding safety and efficiency of oocyte, follicle, or ovarian tissue cryopreservation, and the most efficient means of using the thawed tissue - auto-, hetero-, or xenotransplantation versus IVM on the one hand, and in-vivo pharmacological attempts to minimize follicle depletion by gonadotropin-releasing hormone agonist or other modalities on the other hand. Until then, a combination of all the clinically available modalities should be offered to these young women with unconsumed fertility potential who face gonadotoxic therapy.

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.

Restoration of menstruation after chemotherapy-induced amenorrhoea in a patient with ovarian immature teratoma

We described a rare case of a 20-year-old woman with an ovarian immature teratoma who resumed regular spontaneous menses after more than 5 years of chemotherapy-induced amenorrhoea. Efforts to reverse chemotherapy-induced ovarian failure can be continued even after persistent menstrual dysfunction of 5 or more years.