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Pavone M, Waeldin L, Seeliger B, Bizzarri N, Mutter D, Jarnet D, Forgione A, Georges N, Akladios C, Scambia G, Marescaux J, Lecointre L, Querleu D. Fertility-sparing uterine displacement for pelvic malignancies: surgical options and radiotherapy dosimetry on a human cadaver. World J Surg Oncol 2024; 22:147. [PMID: 38831328 PMCID: PMC11145884 DOI: 10.1186/s12957-024-03423-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/21/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Radio(chemo)therapy is often required in pelvic malignancies (cancer of the anus, rectum, cervix). Direct irradiation adversely affects ovarian and endometrial function, compromising the fertility of women. While ovarian transposition is an established method to move the ovaries away from the radiation field, surgical procedures to displace the uterus are investigational. This study demonstrates the surgical options for uterine displacement in relation to the radiation dose received. METHODS: The uterine displacement techniques were carried out sequentially in a human female cadaver to demonstrate each procedure step by step and assess the uterine positions with dosimetric CT scans in a hybrid operating room. Two treatment plans (anal and rectal cancer) were simulated on each of the four dosimetric scans (1. anatomical position, 2. uterine suspension of the round ligaments to the abdominal wall 3. ventrofixation of the uterine fundus at the umbilical level, 4. uterine transposition). Treatments were planned on Eclipse® System (Varian Medical Systems®,USA) using Volumetric Modulated Arc Therapy. Data about maximum (Dmax) and mean (Dmean) radiation dose received and the volume receiving 14 Gy (V14Gy) were collected. RESULTS All procedures were completed without technical complications. In the rectal cancer simulation with delivery of 50 Gy to the tumor, Dmax, Dmean and V14Gy to the uterus were respectively 52,8 Gy, 34,3 Gy and 30,5cc (1), 31,8 Gy, 20,2 Gy and 22.0cc (2), 24,4 Gy, 6,8 Gy and 5,5cc (3), 1,8 Gy, 0,6 Gy and 0,0cc (4). For anal cancer, delivering 64 Gy to the tumor respectively 46,7 Gy, 34,8 Gy and 31,3cc (1), 34,3 Gy, 20,0 Gy and 21,5cc (2), 21,8 Gy, 5,9 Gy and 2,6cc (3), 1,4 Gy, 0,7 Gy and 0,0cc (4). CONCLUSIONS The feasibility of several uterine displacement procedures was safely demonstrated. Increasing distance to the radiation field requires more complex surgical interventions to minimize radiation exposure. Surgical strategy needs to be tailored to the multidisciplinary treatment plan, and uterine transposition is the most technically complex with the least dose received.
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Affiliation(s)
- Matteo Pavone
- Institute of Image-Guided Surgery, IHU Strasbourg, 1 place de l'Hôpital, Strasbourg, 67091, France.
- Research Institute against Digestive Cancer, IRCAD, Strasbourg, France.
- UOC Ginecologia Oncologica, Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Laure Waeldin
- Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, Strasbourg, 67200, France
| | - Barbara Seeliger
- Institute of Image-Guided Surgery, IHU Strasbourg, 1 place de l'Hôpital, Strasbourg, 67091, France
- Research Institute against Digestive Cancer, IRCAD, Strasbourg, France
- ICube UMR 7357-Laboratoire des Sciences de l'Ingénieur, de l'Informatique et de l'Imagerie, CNRS, University of Strasbourg, Strasbourg, 67000, France
- Department of Digestive and Endocrine Surgery, University Hospitals of Strasbourg, Strasbourg, 67000, France
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Didier Mutter
- Institute of Image-Guided Surgery, IHU Strasbourg, 1 place de l'Hôpital, Strasbourg, 67091, France
| | - Delphine Jarnet
- Medical Physics Unit, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, Strasbourg, 67200, France
| | | | - Noel Georges
- Radiation Therapy University Department, Institut de Cancérologie Strasbourg Europe (ICANS), 17 rue Albert Calmette, Strasbourg, 67200, France
| | - Cherif Akladios
- Department of Gynecologic Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Jacques Marescaux
- Research Institute against Digestive Cancer, IRCAD, Strasbourg, France
| | - Lise Lecointre
- Institute of Image-Guided Surgery, IHU Strasbourg, 1 place de l'Hôpital, Strasbourg, 67091, France
- ICube UMR 7357-Laboratoire des Sciences de l'Ingénieur, de l'Informatique et de l'Imagerie, CNRS, University of Strasbourg, Strasbourg, 67000, France
- Department of Gynecologic Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Denis Querleu
- Institute of Image-Guided Surgery, IHU Strasbourg, 1 place de l'Hôpital, Strasbourg, 67091, France
- UOC Ginecologia Oncologica, Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
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Łubik-Lejawka D, Gabriel I, Marzec A, Olejek A. Oncofertility as an Essential Part of Comprehensive Cancer Treatment in Patients of Reproductive Age, Adolescents and Children. Cancers (Basel) 2024; 16:1858. [PMID: 38791937 PMCID: PMC11119835 DOI: 10.3390/cancers16101858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024] Open
Abstract
The number of children, adolescents and young adults diagnosed with cancer has been rising recently. Various oncological treatments have a detrimental effect on female fertility, and childbearing becomes a major issue during surveillance after recovery. This review discusses the impact of oncological treatments on the ovarian reserve with a thorough explanation of oncologic treatments' effects and modes of oncofertility procedures. The aim of this review is to help clinicians in making an informed decision about post-treatment fertility in their patients. Ultimately, it may lead to improved overall long-term outcomes among young populations suffering from cancer.
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Affiliation(s)
| | | | | | - Anita Olejek
- Department of Gynaecology, Obstetrics and Oncological Gynaecology in Bytom, Medical University of Silesia, 40-055 Katowice, Poland; (D.Ł.-L.); (I.G.); (A.M.)
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Huber D, Simonson C, Fournier I, Dischl-Antonioni I, Pena Rios FJ, Francey I, Surbone A, Hurni Y. Utero-ovarian transposition before pelvic radiation in a patient with rectal cancer: a case report and systemic literature review. Front Surg 2024; 11:1336047. [PMID: 38468868 PMCID: PMC10925680 DOI: 10.3389/fsurg.2024.1336047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 02/01/2024] [Indexed: 03/13/2024] Open
Abstract
Objective To describe a case of utero-ovarian transposition (UOT) before pelvic radiation in a patient with rectal cancer and provide a systematic literature review on all reported cases of UOT. Methods We performed a prospective collection and revision of clinical, intraoperative, and postoperative data from a patient who underwent UOT. In addition, a systematic review of the literature available to date on all cases of UOT was realized, and 14 patients from 10 articles were included. Results We reported the case of a 28-year-old nulligravida patient who was diagnosed with a low-grade rectal adenocarcinoma and underwent neoadjuvant chemoradiotherapy, followed by transanal total mesorectal excision (TaTME). Before starting neoadjuvant oncological therapies, the patient underwent laparoscopic UOT. The intervention was performed without complications, and the patient received neoadjuvant oncological treatments as planned. TaTME and uterus repositioning were completed six weeks after the end of radiotherapy. No complications were observed during the first 9 postoperative months. Adequate utero-ovarian perfusion was assessed by Doppler ultrasound, cervicovaginal anastomosis appeared to have healed correctly, and the patient experienced menstrual bleeding. Data from the literature review of all reported cases of UOT were presented and discussed. Conclusions UOT represents a valuable option to preserve fertility in patients requiring pelvic radiotherapy. This study provides additional evidence on the feasibility and safety of performing UOT.
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Affiliation(s)
- Daniela Huber
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland
- Department of Pediatrics, Gynecology and Obstetrics, Geneva University Hospitals, Geneva, Switzerland
| | - Colin Simonson
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland
| | - Ian Fournier
- Department of General Surgery, Valais Hospital, Sion, Switzerland
- Department of Visceral Surgery, Geneva University Hospitals, Geneva, Switzerland
| | | | | | - Isaline Francey
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland
| | - Anna Surbone
- Fertility Medicine and Gynaecologic Endocrinology Unit, Department Woman-Mother-Child, Lausanne University Hospital, Lausanne, Switzerland
| | - Yannick Hurni
- Department of Gynecology and Obstetrics, Valais Hospital, Sion, Switzerland
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Salman L, Covens A. Fertility Preservation in Cervical Cancer-Treatment Strategies and Indications. Curr Oncol 2024; 31:296-306. [PMID: 38248104 PMCID: PMC10814061 DOI: 10.3390/curroncol31010019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Abstract
Cervical cancer is frequently diagnosed in women during their reproductive years, and fertility preservation is an essential part of their cancer treatment. In highly selected patients with early stage, low-risk cervical cancer and a tumor size ≤ 2 cm, several treatment strategies can be offered for patients wishing to preserve fertility, including radical/simple trachelectomy or conization with pelvic lymph node assessment. Trachelectomy can be performed through a vaginal, abdominal, or minimally invasive approach and has been shown to have an equivalent oncologic outcome compared to radical hysterectomy. All surgical approaches for radical trachelectomy seem to have excellent survival with comparable oncologic outcomes. Nevertheless, patients undergoing vaginal trachelectomy have better obstetric outcomes compared to the other routes. In patients with larger tumors (2-4 cm), neoadjuvant chemotherapy followed by fertility-sparing surgery is an alternative option. Several chemotherapy regimens have been used for this indication, with a pathologic complete response rate of 17-73%. For locally advanced diseases that require radical hysterectomy or primary chemoradiation, fertility preservation can be performed using oocyte, embryo, or ovarian tissue cryopreservation, as well as ovarian transposition. For these patients, future pregnancy is possible through surrogacy. In addition to fertility preservation, ovarian transposition, where the ovaries are repositioned outside of the radiation field, is performed to maintain ovarian hormonal function and prevent premature ovarian failure. In summary, fertility-preservation treatment strategies for patients with early stage cervical cancer are continuously evolving, and less radical surgeries are becoming more acceptable. Additional and ongoing evidence is helping determine the impact of conservative procedures on oncologic and obstetric outcomes in these patients.
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Affiliation(s)
- Lina Salman
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 2M9, Canada;
| | - Allan Covens
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, University of Toronto, Toronto, ON M5G 2M9, Canada;
- Division of Gynecologic Oncology, Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
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Pavone M, Autorino R, Bizzarri N, Chilorio G, Valentini V, Corrado G, Ferrandina G, Macchia G, Gambacorta MA, Scambia G, Querleu D. Uterine transposition versus uterine ventrofixation before radiotherapy as a fertility sparing option in young women with pelvic malignancies: Systematic review of the literature and dose simulation. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107270. [PMID: 37992415 DOI: 10.1016/j.ejso.2023.107270] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 10/23/2023] [Accepted: 11/10/2023] [Indexed: 11/24/2023]
Abstract
BACKGROUND (Chemo)radiation may be a required treatment in young women with pelvic malignancies. Irradiation may result in ovarian and uterine failure, compromising the fertility of those patients. While ovarian transposition is an established method to move the ovaries away from the irradiation field, similar surgical procedures regarding the uterus remain investigational. The aim of this study was to carry out a systematic review of the literature on uterine displacement techniques (ventrofixation/transposition) and to simulate the radiation dose received by the uterus in different heights place after the procedures. METHODS The systematic review was performed according PRISMA guidelines. PubMed, Scopus, Web of Science and EMBASE were queried to identify included study until March 2023. Retrospectively, a dosimetric study was also performed and Volumetric Modulated Arc Therapy (VMAT) radiotherapy treatment plans were calculated, to assess the dose received by the uterus according to hypothetical different displacement positions taking the case of irradiation for rectal or anal cancer as model. RESULTS A total of 187 studies were included, after the screening 9 studies were selected for synthesis. Data from the dose simulation revealed that the transposition approach was the most protective with a maximum dose of about 3 and 8 Gy for anal and rectal cancer respectively. None of the simulated ventrofixation positions received a Dmean surpassing 14 Gy. CONCLUSION According to the literature review and the simulation results of the present study we may conclude are feasible and safe as fertility sparing approach in young rectal/anal cancer patients.
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Affiliation(s)
- Matteo Pavone
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France; IRCAD, Research Institute Against Digestive Cancer (IRCAD) France, Strasbourg, France; UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Rosa Autorino
- UOC Radioterapia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Nicolò Bizzarri
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy.
| | - Giuditta Chilorio
- UOC Radioterapia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Vincenzo Valentini
- UOC Radioterapia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università cattolica del Sacro Cuore, Rome, Italy
| | - Giacomo Corrado
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
| | - Gabriella Ferrandina
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università cattolica del Sacro Cuore, Rome, Italy
| | - Gabriella Macchia
- Radiation Oncology Unit, Gemelli Molise Hospital-Università Cattolica del Sacro Cuore, Campobasso, Italy
| | - Maria Antonietta Gambacorta
- UOC Radioterapia Oncologica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy; Università cattolica del Sacro Cuore, Rome, Italy
| | - Denis Querleu
- Institute of Image-Guided Surgery, IHU Strasbourg, Strasbourg, France; UOC Ginecologia Oncologica, Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Rome, Italy
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Gerbasi GJ, Deckers P, Kanaguchi G, Pastore CB, Fontes Cintra G, Aparecida Conte Maia M, Lopes A. Pregnancy after sugery and brachytherapy for vaginal cancer. Gynecol Oncol Rep 2023; 48:101208. [PMID: 37408771 PMCID: PMC10319248 DOI: 10.1016/j.gore.2023.101208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 07/07/2023] Open
Abstract
Introduction Primary vaginal cancer is infrequent, corresponding to 1-2% of all female genital tract cancer diagnoses.Treatment for vaginal cancer varies depending on tumor histology, size, location and staging, and may include one or more of the following: surgical excision, radiation therapy and/or chemotherapy. All treatments negatively affect fertility/pregnancy outcomes.Pelvic radiation therapy, even in doses < 2 Gy, may extinguish up to 50% of immature oocytes. In addition, radiotherapy may cause modifications in cervical length, loss of uterine junctional zone anatomy and lead to myometrial atrophy and fibrosis, increasing the risk for adverse pregnancy outcomes. Methods Case report of a patient who carried a pregnancy to term after surgery and brachytherapy for vaginal cancer. Results A 28 year-old woman, presented with a 3 cm right midvagina wall tumor, diagnosed as grade 2, vaginal squamous cell carcinoma - FIGO 2009, stage IB. Computed tomography showed no evidence of lymph node involvement or distant metastasis. The patient underwent surgery followed by 4 fractions of vaginal brachytherapy, once a week, with a dose of 6 Gy at a 5 mm depth, amounting to a total dose of 24 Gy.One year and 9 months after treatment, the patient gave birth to a healthy child at 39 weeks pregnancy. A C-section was needed due functional dystocia during labor. Conclusion This case report recounts a successful pregnancy carried to term after surgery and brachytherapy for squamous cell vaginal cancer.
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Affiliation(s)
- Giovana Junqueira Gerbasi
- Department of Gynecology, Instituto Brasileiro de Controle do Cancer - São Camilo, São Paulo, Brazil
| | - Paula Deckers
- Department of Gynecology, Instituto Brasileiro de Controle do Cancer - São Camilo, São Paulo, Brazil
| | - Giuliana Kanaguchi
- Department of Gynecology, Instituto Brasileiro de Controle do Cancer - São Camilo, São Paulo, Brazil
| | - Caroline B.P. Pastore
- Department of Gynecology, Instituto Brasileiro de Controle do Cancer - São Camilo, São Paulo, Brazil
| | - Georgia Fontes Cintra
- Department of Radiotherapy, Instituto Brasileiro de Controle do Cancer - São Camilo, São Paulo, Brazil
| | | | - Andre Lopes
- Department of Gynecology, Instituto Brasileiro de Controle do Cancer - São Camilo, São Paulo, Brazil
- Discipline of Gynecology, Department of Obstetrics and Gynecology, Instituto do Cancer do Estado de Sao Paulo, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Giovannopoulou E, Karakasi MV, Kouroupi M, Giatromanolaki A, Tsikouras P, Pavlidis P. Safety and efficacy of ovarian tissue autotransplantation: A systematic literature review. Folia Med (Plovdiv) 2023; 65:362-370. [PMID: 38351810 DOI: 10.3897/folmed.65.e89198] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 09/30/2022] [Indexed: 02/16/2024] Open
Abstract
Ovarian tissue autotransplantation is an innovative fertility preservation technique that has provoked ongoing investigations. The purpose of the present study was to assess the safety and reproductive performance of ovarian tissue autotransplantation. This review is conducted according to PRISMA guidelines. Seven studies met the inclusion criteria. A total of 3427 patients underwent ovarian tissue cryopreservation and 205 received an autotransplantation. Tissue retrieval was mainly performed by laparoscopy and only one major complication occurred. Transplantations were predominantly performed by open procedures and data on safety were insufficient. A total of 295 autotransplantations were analyzed, resulting in 104 pregnancies. Sixty-five pregnancies led to live births, while nine were ongoing at that time. A pregnancy rate (PR) of 50.7% and a live-birth rate (LBR) of 32.7% were observed. Natural conception accounted for 46.3% of live births. No birth deficits were recorded. Ovarian tissue autotransplantation seems to be a safe procedure with acceptable pregnancy rates.
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Affiliation(s)
| | | | - Maria Kouroupi
- General University Hospital of Alexandroupolis, Alexandroupolis, Greece
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Dittrich R, Lotz L. [Fertility and fertility preservation in women]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00105-023-05170-1. [PMID: 37289206 DOI: 10.1007/s00105-023-05170-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 05/04/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Advances in the treatment of cancer and in reproductive medicine make it possible for many patients to start their family planning even after cytotoxic therapy. Depending on the age of the patient, the planned oncological therapy and its urgency, various methods can be used to preserve the fertility of affected women. OBJECTIVES Presentation of facts about fertility, as well as information about fertility-preserving methods for women, so that they can be discussed with and offered to patients. MATERIALS AND METHODS Presentation and discussion of basic research, clinical data, and expert recommendations on fertility and fertility preservation. RESULTS Well-established fertility-protective techniques now exist for women that offer a realistic chance of subsequent pregnancy. These include transposition of the gonads prior to radiotherapy, gonadal protection with gonadotropin-releasing hormone (GnRH) analogues and cryopreservation of fertilized and unfertilized oocytes, as well as cryopreservation of ovarian tissue. CONCLUSIONS Fertility-protective techniques are an integral part of oncological treatments for prepubertal girls and patients of reproductive age. The various measures must be discussed individually with the patient as part of a multimodal concept. Prompt and timely collaboration with a specialized center is essential.
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Affiliation(s)
- Ralf Dittrich
- Frauenklinik, Uniklinikum Erlangen, Universitätsstr. 21-23, 91054, Erlangen, Deutschland.
| | - Laura Lotz
- Frauenklinik, Uniklinikum Erlangen, Universitätsstr. 21-23, 91054, Erlangen, Deutschland
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Wu X, Zhang W, Liu A, Zhang M. Factors associated with reproductive concerns among young female patients with colorectal cancer: A cross-sectional study. J Clin Nurs 2023. [PMID: 37127929 DOI: 10.1111/jocn.16736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/04/2023] [Accepted: 04/05/2023] [Indexed: 05/03/2023]
Abstract
AIMS AND OBJECTIVES The aim of this study was to describe the prevalence of reproductive concerns among young female patients with colorectal cancer and explore the associated factors. BACKGROUND With the trend of longer survival and younger age at diagnosis of colorectal cancer patients, reproductive concerns have become increasingly prevalent among young female colorectal cancer patients. DESIGN Cross-sectional design. METHODS The study included 150 young female patients with colorectal cancer who completed cancer treatment at 2 hospitals in Guangzhou, China, between November 2020 and December 2021 completed an investigation comprising A general questionnaire, The Reproductive Concerns After Cancer scale, The Family Adaptation and Cohesion Evaluation Scale II and unmet fertility information needs questionnaire. Multivariable linear regression analysis was performed in order to identify factors that influence reproductive concerns. This study was prepared and is reported according to the STROBE checklist. RESULTS The mean (SD) score on the Reproductive Concerns After Cancer scale was 54.78 ± 8.97. The highest score was for the children's health subscale (3.84 ± .92) and the lowest was for acceptance (2.24 ± .70). Multiple regression analysis showed that patients with fewer children, female children, lower education level (less than undergraduate degree), earlier disease stage, lower family function and higher unmet need for fertility information had more reproductive concerns, which explained 26.9% of the total variation of the model. CONCLUSIONS The patients with fewer children, female children, low cultural degree (less than bachelor), early clinical patients, poorer family function and higher unmet fertility information needs had higher reproductive concerns. RELEVANCE TO CLINICAL PRACTICE These findings can guide the development of interventions to mitigate reproductive concerns, including understand and meet their fertility information needs, improve the level of family function. PATIENT OR PUBLIC CONTRIBUTION Survey questionnaires were completed by participants among young female with colorectal cancer in this study.
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Affiliation(s)
- Xiaoyu Wu
- Clinical Nursing Teaching and Research Section, The Second XiangYa Hospital of Central South University, Changsha, China
| | - Wenxia Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Aihong Liu
- Department of Nursing, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Meifen Zhang
- School of Nursing, Sun Yat-sen University, Guangzhou, China
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Reynolds AC, McKenzie LJ. Cancer Treatment-Related Ovarian Dysfunction in Women of Childbearing Potential: Management and Fertility Preservation Options. J Clin Oncol 2023; 41:2281-2292. [PMID: 36888938 PMCID: PMC10115556 DOI: 10.1200/jco.22.01885] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/22/2022] [Accepted: 01/24/2023] [Indexed: 03/10/2023] Open
Abstract
PURPOSE To review the complex concerns of oncofertility created through increased cancer survivorship and the long-term effects of cancer treatment in young adults. DESIGN Review chemotherapy-induced ovarian dysfunction, outline how fertility may be addressed before treatment initiation, and discuss barriers to oncofertility treatment and guidelines for oncologists to provide this care to their patients. CONCLUSION In women of childbearing potential, ovarian dysfunction resulting from cancer therapy has profound short- and long-term implications. Ovarian dysfunction can manifest as menstrual abnormalities, hot flashes, night sweats, impaired fertility, and in the long term, increased cardiovascular risk, bone mineral density loss, and cognitive deficits. The risk of ovarian dysfunction varies between drug classes, number of received lines of therapy, chemotherapy dosage, patient age, and baseline fertility status. Currently, there is no standard clinical practice to evaluate patients for their risk of developing ovarian dysfunction with systemic therapy or means to address hormonal fluctuations during treatment. This review provides a clinical guide to obtain a baseline fertility assessment and facilitate fertility preservation discussions.
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Affiliation(s)
| | - Laurie J. McKenzie
- Baylor College of Medicine Houston, Houston, TX
- The University of Texas MD Anderson Cancer Center, Houston, TX
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Terzic M, Makhadiyeva D, Bila J, Andjic M, Dotlic J, Aimagambetova G, Sarria-Santamera A, Laganà AS, Chiantera V, Vukovic I, Kocijancic Belovic D, Aksam S, Bapayeva G, Terzic S. Reproductive and Obstetric Outcomes after Fertility-Sparing Treatments for Cervical Cancer: Current Approach and Future Directions. J Clin Med 2023; 12:jcm12072614. [PMID: 37048696 PMCID: PMC10095321 DOI: 10.3390/jcm12072614] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
Cervical cancer is one of the leading causes of cancer-related death in women of reproductive age. The established fertility-sparing approaches for the management of early-stage cervical cancer for women who plan pregnancy are associated with a decline in fecundity and an increased risk of pregnancy complications. This article aims to offer an overview of fertility-sparing approaches and the management of potential subfertility and pregnancy complications after these treatments. An extensive search for the available data about infertility and cervical cancer, fertility-sparing techniques in patients with cervical cancer, fertility treatment, obstetrical complications, and pregnancy outcomes in cervical cancer patients was completed. Fertility-preserving procedures such as loop electrosurgical excision procedure (LEEP), cold-knife conization, and trachelectomy in women diagnosed with cervical cancer can be considered as safe and effective treatments that preserve reproductive potential. Current fertility-preserving procedures, based on the balance of the oncological characteristics of patients as well as their desire for reproduction, allow one to obtain acceptable reproductive and obstetric outcomes in women treated for cervical cancer. Nevertheless, careful monitoring of pregnancies obtained after fertility-preserving procedures is recommended, since this cohort of patients should be considered at higher risk compared with a healthy population.
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Affiliation(s)
- Milan Terzic
- Department of Surgery, School of Medicine, Nazarbayev University, Zhanybek-Kerey Khans Street, 5/1, Astana 010000, Kazakhstan
- Clinical Academic Department of Women’s Health, National Research Center for Maternal and Child Health, Corporate Fund “University Medical Center”, Turan Ave. 32, Astana 010000, Kazakhstan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Dinara Makhadiyeva
- School of Medicine, Nazarbayev University, Zhanybek-Kerey Khans Street, 5/1, Astana 010000, Kazakhstan
| | - Jovan Bila
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Mladen Andjic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
| | - Jelena Dotlic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Gulzhanat Aimagambetova
- Department of Surgery, School of Medicine, Nazarbayev University, Zhanybek-Kerey Khans Street, 5/1, Astana 010000, Kazakhstan
- Correspondence:
| | - Antonio Sarria-Santamera
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University, Zhanybek-Kerey Khans Street, 5/1, Astana 010000, Kazakhstan
| | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Vito Chiantera
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy
| | - Ivana Vukovic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Dusica Kocijancic Belovic
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Slavica Aksam
- Clinic of Obstetrics and Gynecology, University Clinical Centre of Serbia, Dr Koste Todorovica 26, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica Starijeg 8, 11000 Belgrade, Serbia
| | - Gauri Bapayeva
- Clinical Academic Department of Women’s Health, National Research Center for Maternal and Child Health, Corporate Fund “University Medical Center”, Turan Ave. 32, Astana 010000, Kazakhstan
| | - Sanja Terzic
- Department of Medicine, School of Medicine, Nazarbayev University, Zhanybek-Kerey Khans Street, 5/1, Astana 010000, Kazakhstan
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Griffiths MJ, Marshall SA, Cousins FL, Alesi LR, Higgins J, Giridharan S, Sarma UC, Menkhorst E, Zhou W, Care AS, Donoghue JF, Holdsworth-Carson SJ, Rogers PA, Dimitriadis E, Gargett CE, Robertson SA, Winship AL, Hutt KJ. Radiotherapy exposure directly damages the uterus and causes pregnancy loss. JCI Insight 2023; 8:163704. [PMID: 36946464 PMCID: PMC10070119 DOI: 10.1172/jci.insight.163704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/01/2023] [Indexed: 03/23/2023] Open
Abstract
Female cancer survivors are significantly more likely to experience infertility than the general population. It is well established that chemotherapy and radiotherapy can damage the ovary and compromise fertility, yet the ability of cancer treatments to induce uterine damage, and the underlying mechanisms, have been understudied. Here, we show that in mice total-body γ-irradiation (TBI) induced extensive DNA damage and apoptosis in uterine cells. We then transferred healthy donor embryos into ovariectomized adolescent female mice that were previously exposed to TBI to study the impacts of radiotherapy on the uterus independent from effects to ovarian endocrine function. Following TBI, embryo attachment and implantation were unaffected, but fetal resorption was evident at midgestation in 100% of dams, suggesting failed placental development. Consistent with this hypothesis, TBI impaired the decidual response in mice and primary human endometrial stromal cells. TBI also caused uterine artery endothelial dysfunction, likely preventing adequate blood vessel remodeling in early pregnancy. Notably, when pro-apoptotic protein Puma-deficient (Puma-/-) mice were exposed to TBI, apoptosis within the uterus was prevented, and decidualization, vascular function, and pregnancy were restored, identifying PUMA-mediated apoptosis as a key mechanism. Collectively, these data show that TBI damages the uterus and compromises pregnancy success, suggesting that optimal fertility preservation during radiotherapy may require protection of both the ovaries and uterus. In this regard, inhibition of PUMA may represent a potential fertility preservation strategy.
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Affiliation(s)
- Meaghan J Griffiths
- Department of Anatomy and Developmental Biology, Development and Stem Cells Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Gynaecology Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Sarah A Marshall
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Fiona L Cousins
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Lauren R Alesi
- Department of Anatomy and Developmental Biology, Development and Stem Cells Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Jordan Higgins
- Department of Anatomy and Developmental Biology, Development and Stem Cells Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Saranya Giridharan
- Department of Anatomy and Developmental Biology, Development and Stem Cells Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Urooza C Sarma
- Department of Anatomy and Developmental Biology, Development and Stem Cells Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Ellen Menkhorst
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Gynaecology Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Wei Zhou
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Gynaecology Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Alison S Care
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Jacqueline F Donoghue
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Gynaecology Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Sarah J Holdsworth-Carson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Gynaecology Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Peter Aw Rogers
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Gynaecology Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Evdokia Dimitriadis
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Gynaecology Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia
| | - Caroline E Gargett
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Sarah A Robertson
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Amy L Winship
- Department of Anatomy and Developmental Biology, Development and Stem Cells Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Karla J Hutt
- Department of Anatomy and Developmental Biology, Development and Stem Cells Program, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
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Mitrogiannis I, Evangelou E, Efthymiou A, Kanavos T, Birbas E, Makrydimas G, Papatheodorou S. Risk factors for preterm labor: An Umbrella Review of meta-analyses of observational studies. RESEARCH SQUARE 2023:rs.3.rs-2639005. [PMID: 36993288 PMCID: PMC10055511 DOI: 10.21203/rs.3.rs-2639005/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Preterm birth defined as delivery before 37 gestational weeks, is a leading cause of neonatal and infant morbidity and mortality. Understanding its multifactorial nature may improve prediction, prevention and the clinical management. We performed an umbrella review to summarize the evidence from meta-analyses of observational studies on risks factors associated with PTB, evaluate whether there are indications of biases in this literature and identify which of the previously reported associations are supported by robust evidence. We included 1511 primary studies providing data on 170 associations, covering a wide range of comorbid diseases, obstetric and medical history, drugs, exposure to environmental agents, infections and vaccines. Only seven risk factors provided robust evidence. The results from synthesis of observational studies suggests that sleep quality and mental health, risk factors with robust evidence should be routinely screened in clinical practice, should be tested in large randomized trial. Identification of risk factors with robust evidence will promote the development and training of prediction models that could improve public health, in a way that offers new perspectives in health professionals.
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Heemelaar JC, Heemelaar S, Hertel SN, Jukema JW, Sueters M, Louwerens M, Antoni ML. Cardiac and obstetric outcomes of pregnancies for women after cardiotoxic therapy in childhood: a single center observational study. BMC Cancer 2023; 23:115. [PMID: 36732710 PMCID: PMC9893596 DOI: 10.1186/s12885-023-10578-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/11/2023] [Accepted: 01/24/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Childhood cancer survivors (CCS) are at increased risk of cardiomyopathy during pregnancy if they have prior cardiotoxic exposure. Currently, there is no consensus on the necessity, timing and modality of cardiac monitoring during and after pregnancy. Therefore, we examined cardiac function using contemporary echocardiographic parameters during pregnancy in CCS with cardiotoxic treatment exposure, and we observed obstetric outcomes in CCS, including in women without previous cardiotoxic treatment exposure. METHOD A single-center retrospective cohort study was conducted among 39 women enrolled in our institution's cancer survivorship outpatient clinic. Information on potential cardiotoxic exposure in childhood, cancer diagnosis and outcomes of all pregnancies were collected through interviews and review of health records. Echocardiographic exams before and during pregnancy were retrospectively analyzed for left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) if available. The primary outcomes were (i) left ventricular dysfunction (LVD) during pregnancy, defined as LVEF < 50% or a decline of ≥ 10% in LVEF below normal (< 54%), and (ii) symptomatic heart failure (HF). Rate of obstetric and fetal complications was compared to the general population through the national perinatal registry (PERINED). RESULTS All pregnancies (91) of 39 women were included in this study. The most common malignancy was leukemia (N = 17, 43.6%). In 22 patients, echocardiograms were retrospectively analyzed. LVEFbaseline was 55.4 ± 1.2% and pre-existing subnormal LVEF was common (7/22, 31.8/%). The minimum value of LVEF during pregnancy was 3.8% lower than baseline (p = 0.002). LVD occurred in 9/22 (40.9%) patients and HF was not observed. When GLS was normal at baseline (< -18.0%; N = 12), none of the women developed LVD. Nine of out ten women with abnormal GLS at baseline developed LVD later in pregnancy. In our cohort, the obstetric outcomes seemed comparable with the general population unless patients underwent abdominal irradiation (N = 5), where high rates of preterm birth (only 5/18 born at term) and miscarriage (6/18 pregnancies) were observed. CONCLUSION Our study suggests that women with prior cardiotoxic treatment have a low risk of LVD during pregnancy if GLS at baseline was normal. Pregnancy outcomes are similar to the healthy population except when patients underwent abdominal irradiation.
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Affiliation(s)
- Julius C. Heemelaar
- grid.10419.3d0000000089452978Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - Steffie Heemelaar
- grid.10419.3d0000000089452978Department of Obstetrics and Gynaecology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Svenja N. Hertel
- grid.10419.3d0000000089452978Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
| | - J. Wouter Jukema
- grid.10419.3d0000000089452978Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands ,grid.411737.7Netherlands Heart Institute, Moreelsepark 1, 3511 EP Utrecht, The Netherlands
| | - Marieke Sueters
- grid.10419.3d0000000089452978Department of Obstetrics and Gynaecology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Marloes Louwerens
- grid.10419.3d0000000089452978Department of Internal Medicine, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - M. Louisa Antoni
- grid.10419.3d0000000089452978Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, the Netherlands
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15
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Cancer in pregnancy: treatment effects. ABDOMINAL RADIOLOGY (NEW YORK) 2023; 48:1774-1783. [PMID: 36639533 DOI: 10.1007/s00261-022-03787-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023]
Abstract
PURPOSE Pregnant patients present a unique challenge to cancer therapy. Due to the potential catastrophic implications related to teratogenic effects or pregnancy loss, oncologic management of this vulnerable patient group must be strategic and personalized. METHODS This article will discuss the unique treatment approach to the pregnant cancer patient. This includes discussion of the role of imaging during staging, treatment, and follow-up with an emphasis on avoiding ionizing radiation when possible. RESULTS AND CONCLUSION Specific considerations and modifications to standard cancer treatments, including surgery and systemic therapies such as chemotherapy, immunotherapy, targeted and hormone therapies are crucial components of providing oncologic care to minimize negative effects to the mother and developing fetus. Radiation and proton therapy are also options that may be employed in specific circumstances. Finally, this article will address the long-term treatment effects of these therapies on future fertility.
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16
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Dickstein DR, Buckstein M. What Rectal Cancer Patients May Be Able to Safely Avoid Radiation? CURRENT COLORECTAL CANCER REPORTS 2023. [DOI: 10.1007/s11888-022-00480-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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17
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Tanaka IB, Nakahira R, Komura JI, Tanaka S. Life Span, Cause of Death and Neoplasia in B6C3F1 Mice Exposed In Utero to Low- and Medium-Dose-Rate Gamma Rays. Radiat Res 2022; 198:553-572. [PMID: 36223164 DOI: 10.1667/rade-22-00131.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/22/2022] [Indexed: 11/07/2022]
Abstract
Previously, we reported that while low-dose-rate (LDR) gamma-ray exposure to 20 mGy/day for the entire gestation period (gestation days 0-18) did not result in any significant effect in B6C3F1 pups up to 10 weeks of age when compared to the non-irradiated controls, exposure to medium-dose-rates (MDR, 200 and 400 mGy/day) resulted in growth retardation and gonadal hypoplasia, in addition to delayed ossification (only at 400 mGy/day). In the present work, we investigated the late effects of continuous in utero exposure to gamma rays at LDRs (0.05, 1.0 and 20 mGy/day) and at an MDR of 400 mGy/day, on life span, causes of death, neoplastic and non-neoplastic disease incidences in B6C3F1 mice. Reproductive parameters such as litter size and weaning rates was not significantly different among the LDR groups, but was significantly decreased in the MDR group, when compared to the non-irradiated controls. Mean life spans were not significantly different among the LDR exposed groups compared to the non-irradiated controls, whereas the life spans of those exposed to the MDR were significantly shorter than the non-irradiated controls. There was no significant difference in tumor spectra between the non-irradiated and LDR nor MDR irradiated groups. In mice exposed to MDR in utero, the over-all incidence rates shifted with increased incidences in the number of neoplasms of liver (both sexes) and endocrine (adrenals, pituitary and ovaries in females) origin with corresponding decreases in the incidence of malignant lymphomas (both sexes) and lung neoplasms (males). Multiple primary neoplasms were significantly increased only in females exposed to MDR. Results show that B6C3F1 mice exposed to gamma-rays in utero at LDRs of 0.05, 1 and 20 mGy/day for the entire gestation period (18 days) does not significantly alter lifespan, cause of death, neoplasm incidence rates and tumor spectra.
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Affiliation(s)
- Ignacia B Tanaka
- Department of Radiobiology, Institute for Environmental Sciences. 1-7, Ienomae, Obuchi, Rokkasho-mura, Kamikita-gun, Aomori 039-3212, Japan
| | - Rei Nakahira
- Department of Radiobiology, Institute for Environmental Sciences. 1-7, Ienomae, Obuchi, Rokkasho-mura, Kamikita-gun, Aomori 039-3212, Japan
| | - Jun-Ichiro Komura
- Department of Radiobiology, Institute for Environmental Sciences. 1-7, Ienomae, Obuchi, Rokkasho-mura, Kamikita-gun, Aomori 039-3212, Japan
| | - Satoshi Tanaka
- Department of Radiobiology, Institute for Environmental Sciences. 1-7, Ienomae, Obuchi, Rokkasho-mura, Kamikita-gun, Aomori 039-3212, Japan
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18
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Colmorn LB, Pedersen AT, Larsen EC, Hansen AS, Rosendahl M, Andersen CY, Kristensen SG, Macklon KT. Reproductive and Endocrine Outcomes in a Cohort of Danish Women following Auto-Transplantation of Frozen/Thawed Ovarian Tissue from a Single Center. Cancers (Basel) 2022; 14:cancers14235873. [PMID: 36497354 PMCID: PMC9740843 DOI: 10.3390/cancers14235873] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/19/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Ovarian tissue cryopreservation (OTC) is a method of fertility preservation in girls and young women prior to gonadotoxic treatment. It is a safe and promising method to restore fertility. The initial recovery of endocrine function is high, but the longevity of the grafted tissue varies. In this single-center, combined retro- and prospective cohort study, we report the reproductive outcome and hormonal recovery following ovarian tissue transplantation (OTT) and evaluate possible predictors of the chance of pregnancy. The study includes 40 women from eastern Denmark undergoing 53 OTTs between 2003 and 2021. Permission to obtain retrospective data was given by the Danish Patient Safety Authorities and prospective data-collection by informed consent. Initial recovery of endocrine function was seen in 18/19 women with POI, and ongoing function of the grafted tissue in 7/14 two years from OTT. Live birth rate (LBR) was 41%, with 20 children to 39 women trying to conceive. Women who conceived had higher AFC at the time of OTC than women who did not (p ± 0.04). Repeated transplantations were not successful in terms of delivery. Half of all pregnancies were achieved by ART, but PRs were lower after ART than by spontaneous conception. LBRs after OTT are encouraging. Chance of pregnancy after OTT is correlated to ovarian reserve at OTC. Repeated transplantations were not successful in terms of unfulfilled pregnancy wish.
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Affiliation(s)
- Lotte B Colmorn
- The Fertility Clinic, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
| | - Anette T Pedersen
- Gynecological Department, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
| | - Elisabeth C Larsen
- The Fertility Clinic, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
| | - Alexandra S Hansen
- The Fertility Clinic, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
| | - Mikkel Rosendahl
- Gynecological Department, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
| | - Claus Yding Andersen
- Laboratory for Reproductive Biology, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
| | - Stine G Kristensen
- Laboratory for Reproductive Biology, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
| | - Kirsten T Macklon
- The Fertility Clinic, Rigshospitalet, University Hospital of Copenhagen, 2100 Copenhagen, Denmark
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Lotz L, Bender-Liebenthron J, Dittrich R, Häberle L, Beckmann MW, Germeyer A, Korell M, Sänger N, Kruessel JS, von Wolff M. Determinants of transplantation success with cryopreserved ovarian tissue: data from 196 women of the FertiPROTEKT network. Hum Reprod 2022; 37:2787-2796. [PMID: 36272106 DOI: 10.1093/humrep/deac225] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 09/19/2022] [Indexed: 12/14/2022] Open
Abstract
STUDY QUESTION What are the pregnancy and live birth rates for ovarian tissue transplantation and which factors are associated with the success rate? SUMMARY ANSWER Pregnancy and live birth rates per transplanted woman are 32.7% and 26.5% and success rate is associated with female age and first versus repeated transplantation. WHAT IS KNOWN ALREADY Live birth rates after ovarian tissue transplantations have been reported to be between around 24% and 41% per patient. Success rates seem to be negatively associated with increasing female age at the time of tissue cryopreservation and with pelvic radiation. Success rates are apparently not reduced after overnight transportation of ovarian tissue before freezing. STUDY DESIGN, SIZE, DURATION Registry analysis of 244 transplantations in 196 women, performed by 26 FertiPROTEKT network centres from 2007 to 2019 with follow-up till December 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS Orthotopic ovarian tissue transplantations were performed in 196 women, 191 with previous malignant and 5 with previous non-malignant diseases. Size of transplanting centres varied between 1 and 100 transplantations per centre (median: 2). Factors possibly associated with success rate such as female age, first and repeated transplantation, experience of the transplanting centre and overnight transportation of the ovarian tissue before freezing were analysed. MAIN RESULTS AND THE ROLE OF CHANCE Average age of all 196 transplanted women was 31.3 years (SD 5.2; range 17-44) at the time of cryopreservation of tissue and 35.9 years (SD 4.8; range 23-47) at the time of transplantation. Pregnancy rate was 30.6% (95% CI, 24.2-37.6%) per first transplantation and 32.7% (95% CI, 26.1-39.7%) per patient. Pregnancy rate was higher after first transplantation (30.6% (95% CI, 24.2-37.6%)) compared to second and subsequent transplantations (11.8% (95% CI, 3.3-27.5%)). Live birth rate per first transplantation was 25.0% (95% CI, 19.1-31.7%) and per patient 26.5% (95% CI, 20.5-33.3%). Success rate decreased with increasing age at the time of ovarian tissue freezing. Live birth rate was 28.2% (95% CI, 20.9-36.3%) in women <35 years and 16.7% (95% CI, 7.9-29.3%) in women >35 years. Pregnancy rates after first transplantation were higher in centres who had performed ≥10 transplantations (35.1%) compared to centres with <10 transplantation (25.4%) (P = 0.12). Corresponding live birth rates were 27.0% and 18.6%. Success rates were not different in women with and without overnight transportation of tissue before cryopreservation. LIMITATIONS, REASONS FOR CAUTION The data were drawn from a registry analysis. Data such as ovarian reserve and premature ovarian insufficiency were not available for all women. Data might be influenced by different follow-up policies of the centres. WIDER IMPLICATIONS OF THE FINDINGS The study reveals the high potential of ovarian tissue freezing and transplantation, but only if freezing is performed in younger women. The study suggests focus should be placed on the first and not on repeated transplantations. It also opens the discussion of whether transplantation should rather be performed by experienced centres. STUDY FUNDING/COMPETING INTEREST(S) No funding. No competing interests. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- L Lotz
- Department of Obstetrics and Gynaecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - J Bender-Liebenthron
- UniCareD, University Cryobank for Assisted Reproductive Medicine and Fertility Protection at UniKiD, University Women's Hospital Duesseldorf, Duesseldorf, Germany
| | - R Dittrich
- Department of Obstetrics and Gynaecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - L Häberle
- Department of Obstetrics and Gynaecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
- Biostatistics Unit, Department of Gynaecology and Obstetrics, Erlangen University Hospital, Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - M W Beckmann
- Department of Obstetrics and Gynaecology, Erlangen University Hospital, Friedrich-Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - A Germeyer
- Department of Gynaecological Endocrinology and Fertility Disorders, University Women's Hospital Heidelberg, Heidelberg, Germany
| | - M Korell
- Department of Obstetrics and Gynaecology, Johanna-Etienne-Hospital Neuss, Neuss, Germany
| | - N Sänger
- Department of Gynaecological Endocrinology and Reproductive Medicine, University Hospital of Bonn, Bonn, Germany
| | - J S Kruessel
- Department of Obstetrics/Gynecology and Reproductive Endocrinology and Infertility, UniKiD, University Women's Hospital Duesseldorf, Duesseldorf, Germany
| | - M von Wolff
- Division of Gynaecological Endocrinology and Reproductive Medicine, University Women's Hospital, Inselspital, Bern, Switzerland
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Transplantation of Refrozen Ovarian Cortical Strips Retrieved from a Cryopreserved Whole Ovary: Proof of Feasibility. J Clin Med 2022; 11:jcm11174942. [PMID: 36078872 PMCID: PMC9456442 DOI: 10.3390/jcm11174942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/11/2022] [Accepted: 08/20/2022] [Indexed: 11/17/2022] Open
Abstract
We report successful clinical outcomes after transplantation of refrozen-rethawed cortical strips from a cryopreserved whole ovary in a patient diagnosed with stage IIIb rectal adenocarcinoma. Whole ovary cryopreservation was proposed as a fertility preservation strategy in 2006 prior to radiotherapy, chemotherapy and oncological surgery. To allow for minimal residual disease screening before ovarian reimplantation, the whole ovary was thawed and dissected into cortical strips. While awaiting the results, the majority of the cortical strips were refrozen. These refrozen-rethawed cortical strips were laparoscopically grafted to 2 sites: the previously irradiated pelvic cavity and the non-irradiated extrapelvic cavity. Ovarian function resumption was assessed by recovery of menses, hormone levels, ultrasound and oocyte pick-up following controlled ovarian stimulation (COS). Restoration of ovarian function occurred 6 months after reimplantation, with recovery of menses and estradiol secretion. A total of 12 cycles were followed by the IVF department. A second reimplantation was performed 1.5 years later, since the grafts were found to have stopped functioning for >3 consecutive months. Overall, 3 fertilizable oocytes were retrieved transabdominally from the extrapelvic graft following COS, yielding 2 embryos and culminating in one fresh embryo transfer, but no pregnancy. Concerning the reimplantation site, no ovarian activity was detected in the graft placed in the previously irradiated pelvic cavity. Indeed, only fibrotic-looking tissue was observed in the pelvic site at second laparoscopy 1.5 years later, while ovarian activity was noted in the extrapelvic graft, showing a large antral follicle. All in all, transplantation of refrozen-rethawed cortical strips from a cryopreserved whole ovary can lead to ovarian function resumption and embryo development if grafted to a non-irradiated field.
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21
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Arapaki A, Christopoulos P, Kalampokas E, Triantafyllidou O, Matsas A, Vlahos NF. Ovarian Tissue Cryopreservation in Children and Adolescents. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1256. [PMID: 36010146 PMCID: PMC9406615 DOI: 10.3390/children9081256] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 07/29/2022] [Accepted: 08/12/2022] [Indexed: 11/16/2022]
Abstract
Cancer during childhood and adolescence remains a major public health issue, affecting a significant portion of this age group. Although newer anti-cancer treatments have improved survival rates, this comes at a cost in terms of gonadotoxic effects. As a result, the preservation of fertility is important. Ovarian tissue cryopreservation, one of the newest methods, has some advantages, especially for prepubertal patients: no need for ovarian stimulation, thus, no further risk for estrogen-sensitive cancer types, and preservation of more and better-quality primordial follicles of the ovarian cortex. The most frequent indications include treatment with alkylating agents, ovarian-focused radiotherapy, leukemias, lymphomas, brain and neurological tumors, as well as Turner syndrome and benign hemoglobinopathies. An expected survival exceeding 5 years, the absence of systematic disease and an overall risk of premature ovarian insufficiency over 50% are among the criteria that need to be fulfilled in order for a patient to undertake this method. Orthotopic transplantation is more frequently used, since it can allow both live birth and the recovery of endocrine function. Reimplantation of malignant cells is always a major risk and should always be taken into consideration. Histological analysis, as well as immunohistochemical and molecular methods, are needed in order to improve the search for malignant cells before transplantation. Ovarian tissue cryopreservation appears to be a method with specific benefits, indications and risks which can be an important tool in terms of preserving fertility in younger women.
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Affiliation(s)
| | - Panagiotis Christopoulos
- Second Department of Obstetrics and Gynecology, “Aretaieion” Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
| | | | | | | | - Nikolaos F. Vlahos
- Second Department of Obstetrics and Gynecology, “Aretaieion” Hospital, Faculty of Medicine, National and Kapodistrian University of Athens, 11528 Athens, Greece
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22
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Martin A, Suff N, Shennan A. Successful term pregnancy following cervical cerclage for uterine atrophy secondary to childhood radiotherapy. BMJ Case Rep 2022; 15:e249452. [PMID: 35914799 PMCID: PMC9344985 DOI: 10.1136/bcr-2022-249452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/03/2022] Open
Abstract
Pelvic radiotherapy can lead to scarring and atrophy of reproductive organs including the uterus. This may lead to complications, such as preterm birth, during pregnancy. The mechanism by which preterm birth is associated with pelvic radiation is believed to be due to inefficient uterine stretch or a deficient cervix. We report a case of cervical shortening during the second trimester in a pregnant woman with a history of pelvic radiotherapy in childhood. Ultrasound surveillance and cervical cerclage inserted in the shortening cervix successfully prevented preterm labour in this case. Cerclage insertion led to a longer cervix and lower fibronectin. Although cervical cerclage does not influence uterine stretch, it may be able to prevent cervical dilatation and therefore prevent ascending infections and subsequent inflammatory sequelae which results in preterm labour. We recommend cervical surveillance and targeted cerclage interventions to prevent preterm labour in women with prior childhood pelvic radiotherapy.
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Affiliation(s)
- Anastasia Martin
- Department of Women and Children's Health, King's College London, London, UK
| | - Natalie Suff
- Department of Women and Children's Health, King's College London, London, UK
| | - Andrew Shennan
- Department of Women and Children's Health, King's College London, London, UK
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23
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Khattak H, Malhas R, Craciunas L, Afifi Y, Amorim CA, Fishel S, Silber S, Gook D, Demeestere I, Bystrova O, Lisyanskaya A, Manikhas G, Lotz L, Dittrich R, Colmorn LB, Macklon KT, Hjorth IMD, Kristensen SG, Gallos I, Coomarasamy A. Fresh and cryopreserved ovarian tissue transplantation for preserving reproductive and endocrine function: a systematic review and individual patient data meta-analysis. Hum Reprod Update 2022; 28:400-416. [PMID: 35199164 PMCID: PMC9733829 DOI: 10.1093/humupd/dmac003] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 12/29/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Ovarian tissue cryopreservation involves freezing and storing of surgically retrieved ovarian tissue in liquid or vapour nitrogen below -190°C. The tissue can be thawed and transplanted back with the aim of restoring fertility or ovarian endocrine function. The techniques for human ovarian tissue freezing and transplantation have evolved over the last 20 years, particularly in the context of fertility preservation in pre-pubertal cancer patients. Fresh ovarian tissue transplantation, using an autograft or donor tissue, is a more recent development; it has the potential to preserve fertility and hormonal function in women who have their ovaries removed for benign gynaecological conditions. The techniques of ovarian tissue cryopreservation and transplantation have progressed rapidly since inception; however, the evidence on the success of this intervention is largely based on case reports and case series. OBJECTIVE AND RATIONALE The aim of this study was to systematically review the current evidence by incorporating study-level and individual patient-level meta-analyses of women who received ovarian transplants, including frozen-thawed transplant, fresh or donor graft. SEARCH METHODS The review protocol was registered with PROSPERO (CRD42018115233). A comprehensive literature search was performed using MEDLINE, EMBASE, CINAHL and Cochrane Central Register of Controlled Trials from database inception to October 2020. Authors were also contacted for individual patient data if relevant outcomes were not reported in the published manuscripts. Meta-analysis was performed using inverse-variance weighting to calculate summary estimates using a fixed-effects model. OUTCOMES The review included 87 studies (735 women). Twenty studies reported on ≥5 cases of ovarian transplants and were included in the meta-analysis (568 women). Fertility outcomes included pregnancy, live birth and miscarriage rates, and endocrine outcomes included oestrogen, FSH and LH levels. The pooled rates were 37% (95% CI: 32-43%) for pregnancy, 28% (95% CI: 24-34%) for live birth and 37% (95% CI: 30-46%) for miscarriage following frozen ovarian tissue transplantation. Pooled mean for pre-transplant oestrogen was 101.6 pmol/l (95% CI: 47.9-155.3), which increased post-transplant to 522.4 pmol/l (95% CI: 315.4-729; mean difference: 228.24; 95% CI: 180.5-276). Pooled mean of pre-transplant FSH was 66.4 IU/l (95% CI: 52.8-84), which decreased post-transplant to 14.1 IU/l (95% CI: 10.9-17.3; mean difference 61.8; 95% CI: 57-66.6). The median time to return of FSH to a value <25 IU/l was 19 weeks (interquartile range: 15-26 weeks; range: 0.4-208 weeks). The median duration of graft function was 2.5 years (interquartile range: 1.4-3.4 years; range: 0.7-5 years). The analysis demonstrated that ovarian tissue cryopreservation and transplantation could restore reproductive and hormonal functions in women. Further studies with larger samples of well-characterized populations are required to define the optimal retrieval, cryopreservation and transplantation processes. WIDER IMPLICATIONS Ovarian tissue cryopreservation and transplantation may not only be effective in restoring fertility but also the return of reproductive endocrine function. Although this technology was developed as a fertility preservation option, it may have the scope to be considered for endocrine function preservation.
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Affiliation(s)
- Hajra Khattak
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and
Systems Research, University of Birmingham, Birmingham, UK
| | - Rosamund Malhas
- Birmingham Women’s and Children’s NHS Foundation Trust,
Birmingham, UK
| | - Laurentiu Craciunas
- Population Health Sciences Institute, Newcastle University, Newcastle upon
Tyne, UK
| | - Yousri Afifi
- Birmingham Women’s and Children’s NHS Foundation Trust,
Birmingham, UK
| | - Christiani A Amorim
- Pôle de Recherche en Gynécologie, Institut de Recherche Expérimentale et
Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Simon Fishel
- CARE Fertility Group, Nottingham, UK
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores
University, Liverpool, UK
| | | | - Debra Gook
- Reproductive Services/Melbourne IVF, The Royal Women’s Hospital,
Parkville, VIC, Australia
| | - Isabelle Demeestere
- Research Laboratory on Human Reproduction, Faculty of Medicine, Université
Libre de Bruxelles (ULB), Brussels, Belgium
| | - Olga Bystrova
- AVA-PETER Fertility Clinic, Saint-Petersburg, Russia
| | - Alla Lisyanskaya
- Division of Gynecologic Oncology, Saint-Petersburg City Oncology
Clinic, Saint-Petersburg, Russia
| | - Georgy Manikhas
- Department of Oncology of the First Pavlov State Medical University of
Saint-Petersburg, Saint-Petersburg, Russia
| | - Laura Lotz
- Department of Obstetrics and Gynecology, Erlangen University Hospital,
Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Ralf Dittrich
- Department of Obstetrics and Gynecology, Erlangen University Hospital,
Friedrich Alexander University of Erlangen-Nuremberg, Erlangen, Germany
| | - Lotte Berdiin Colmorn
- The Fertility Clinic, University Hospital of Copenhagen,
Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Tryde Macklon
- The Fertility Clinic, University Hospital of Copenhagen,
Rigshospitalet, Copenhagen, Denmark
| | | | - Stine Gry Kristensen
- Laboratory of Reproductive Biology, The Juliane Marie Centre for Women,
Children and Reproduction, University Hospital of Copenhagen,
Rigshospitalet, Copenhagen, Denmark
| | - Ioannis Gallos
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and
Systems Research, University of Birmingham, Birmingham, UK
| | - Arri Coomarasamy
- Tommy’s National Centre for Miscarriage Research, Institute of Metabolism and
Systems Research, University of Birmingham, Birmingham, UK
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24
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Nickel RS, Maher JY, Hsieh MH, Davis MF, Hsieh MM, Pecker LH. Fertility after Curative Therapy for Sickle Cell Disease: A Comprehensive Review to Guide Care. J Clin Med 2022; 11:2318. [PMID: 35566443 PMCID: PMC9105328 DOI: 10.3390/jcm11092318] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/07/2022] [Accepted: 04/12/2022] [Indexed: 12/30/2022] Open
Abstract
Curative therapy for sickle cell disease (SCD) currently requires gonadotoxic conditioning that can impair future fertility. Fertility outcomes after curative therapy are likely affected by pre-transplant ovarian reserve or semen analysis parameters that may already be abnormal from SCD-related damage or hydroxyurea treatment. Outcomes are also likely affected by the conditioning regimen. Conditioning with myeloablative busulfan and cyclophosphamide causes serious gonadotoxicity particularly among post-pubertal females. Reduced-intensity and non-myeloablative conditioning may be acutely less gonadotoxic, but more short and long-term fertility outcome data after these approaches is needed. Fertility preservation including oocyte/embryo, ovarian tissue, sperm, and experimental testicular tissue cryopreservation should be offered to patients with SCD pursing curative therapy. Regardless of HSCT outcome, longitudinal post-HSCT fertility care is required.
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Affiliation(s)
- Robert Sheppard Nickel
- Children’s National Hospital, Division of Hematology, Washington, DC 20001, USA;
- Children’s National Hospital, Division of Blood and Marrow Transplantation, Washington, DC 20001, USA
- School of Medicine and Health Sciences, The George Washington University, Washington, DC 20001, USA;
| | - Jacqueline Y. Maher
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Pediatric and Adolescent Gynecology, National Institutes of Health, Bethesda, MD 20810, USA;
- Children’s National Hospital, Pediatric and Adolescent Gynecology Program, Washington, DC 20001, USA
| | - Michael H. Hsieh
- School of Medicine and Health Sciences, The George Washington University, Washington, DC 20001, USA;
- Children’s National Hospital, Division of Urology, Washington, DC 20001, USA
| | - Meghan F. Davis
- Department of Urology, MedStar Georgetown University Hospital, Washington, DC 20001, USA;
| | - Matthew M. Hsieh
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20810, USA;
| | - Lydia H. Pecker
- Division of Hematology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD 20810, USA
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25
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Rose BI. Female astronauts: Impact of space radiation on menopause. Eur J Obstet Gynecol Reprod Biol 2022; 271:210-213. [PMID: 35228092 DOI: 10.1016/j.ejogrb.2022.02.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 01/28/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022]
Abstract
Space travel has different effects on the reproductive capacity of women compared to men. The radiation exposure intrinsic to deep space travel causes destruction of some of a woman's primordial follicles. Data suggests that a typical Mars mission may reduce a women's ovarian reserve by about 50%. This has consequences to a woman's reproductive capacity and, more significantly, decreases the time interval to her menopause. A reduced time interval to menopause is associated with earlier mortality. Estrogen replacement therapy and cryopreservation of a female astronaut's oocytes may be used to address these issues. However, cortical tissue freezing provides advantages to more directly compensate for these workplace complications. Cortical tissue freezing especially provides advantages if there are plans to reproduce in an extraterrestrial location.
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Affiliation(s)
- Bruce I Rose
- Department of Obstetrics and Gynecology, University of Vermont Medical Center, 111 Colchester Avenue, Burlington, VT 05401, USA; Department of Obstetrics and Gynecology, University of Central Florida, Orlando, FL 32816, USA.
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26
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Chung RK, Salari S, Findley J, Richards EG, Flyckt RLR. Uterine Transplantation: Recipient Patient Populations. Clin Obstet Gynecol 2022; 65:15-23. [PMID: 35045021 DOI: 10.1097/grf.0000000000000672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Uterine transplantation is an emerging treatment for patients with uterine factor infertility (UFI). In order to determine patient candidacy for transplant, it is imperative to understand how to identify, counsel and treat uterine transplant recipients. In this article, we focus on patient populations with UFI, whether congenital or acquired, including Mayer-Rokitansky-Kuster-Hauser, complete androgen insensitivity syndrome, hysterectomy, and other causes of nonabsolute UFI. Complete preoperative screening of recipients should be required to assess the candidacy of each individual prior to undergoing this extensive treatment option.
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Affiliation(s)
- Rebecca K Chung
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
| | - Salomeh Salari
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
| | - Joseph Findley
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
| | | | - Rebecca L R Flyckt
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Beachwood
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27
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Abstract
Dose constraints are essential for performing dosimetry, especially for intensity modulation and for radiotherapy under stereotaxic conditions. We present the update of the recommendations of the French society of oncological radiotherapy for the use of these doses in classical current practice but also for reirradiation.
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Affiliation(s)
- G Noël
- Département de radiothérapie-oncologie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France.
| | - D Antoni
- Département de radiothérapie-oncologie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
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28
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Mehedintu C, Frincu F, Carp-Veliscu A, Barac R, Badiu DC, Zgura A, Cirstoiu M, Bratila E, Plotogea M. A Warning Call for Fertility Preservation Methods for Women Undergoing Gonadotoxic Cancer Treatment. Medicina (B Aires) 2021; 57:medicina57121340. [PMID: 34946285 PMCID: PMC8709408 DOI: 10.3390/medicina57121340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/25/2021] [Accepted: 12/02/2021] [Indexed: 11/30/2022] Open
Abstract
Malignant hematological conditions have recognized an increased incidence and require aggressive treatments. Targeted chemotherapy, accompanied or not by radiotherapy, raises the chance of defeating the disease, yet cancer protocols often associate long-term gonadal consequences, for instance, diminished or damaged ovarian reserve. The negative effect is directly proportional to the types, doses, time of administration of chemotherapy, and irradiation. Additionally, follicle damage depends on characteristics of the disease and patient, such as age, concomitant diseases, previous gynecological conditions, and ovarian reserve. Patients should be adequately informed when proceeding to gonadotoxic therapies; hence, fertility preservation should be eventually regarded as a first-intention procedure. This procedure is most beneficial when performed before the onset of cancer treatment, with the recommendation for embryos or oocytes’ cryopreservation. If not feasible or acceptable, several options can be available during or after the cancer treatment. Although not approved by medical practice, promising results after in vitro studies increase the chances of future patients to protect their fertility. This review aims to emphasize the mechanism of action and impact of chemotherapy, especially the one proven to be gonadotoxic, upon ovarian reserve and future fertility. Reduced fertility or infertility, as long-term consequences of chemotherapy and, particularly, following bone marrow transplantation, is often associated with a negative impact of recovery, social and personal life, as well as highly decreased quality of life.
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Affiliation(s)
- Claudia Mehedintu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
- Department of Obstetrics and Gynecology, “Nicolae Malaxa” Clinical Hospital, 022441 Bucharest, Romania;
| | - Francesca Frincu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
- Department of Obstetrics and Gynecology, “Nicolae Malaxa” Clinical Hospital, 022441 Bucharest, Romania;
| | - Andreea Carp-Veliscu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
| | - Ramona Barac
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
| | - Dumitru-Cristinel Badiu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
- Correspondence: ; Tel.: +40-723226346
| | - Anca Zgura
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
| | - Monica Cirstoiu
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
| | - Elvira Bratila
- “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania; (C.M.); (F.F.); (A.C.-V.), (R.B.); (A.Z.); (M.C.); (E.B.)
| | - Mihaela Plotogea
- Department of Obstetrics and Gynecology, “Nicolae Malaxa” Clinical Hospital, 022441 Bucharest, Romania;
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29
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Ovarian tissue and oocyte cryopreservation prior to iatrogenic premature ovarian insufficiency. Best Pract Res Clin Obstet Gynaecol 2021; 81:119-133. [PMID: 34887172 DOI: 10.1016/j.bpobgyn.2021.09.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 11/21/2022]
Abstract
Gonadotoxic treatments like chemotherapy or radiotherapy and ovarian surgery may result in an accelerated depletion of the ovarian reserve and subsequent premature ovarian insufficiency. Important determinants of this severe risk that require fertility preservation strategies are patient age, ovarian reserve, type of treatment, and administered dose. Oocytes and ovarian tissue can both be cryopreserved, with encouraging results in terms of pregnancy and live birth rates according to recent publications. Moreover, since ovarian tissue transplantation also results in long-term endocrine resumption, it represents a potential future therapeutic option for complete ovarian function restoration in patients with premature ovarian insufficiency.
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30
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Dolmans MM, Hossay C, Nguyen TYT, Poirot C. Fertility Preservation: How to Preserve Ovarian Function in Children, Adolescents and Adults. J Clin Med 2021; 10:jcm10225247. [PMID: 34830528 PMCID: PMC8621487 DOI: 10.3390/jcm10225247] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 01/15/2023] Open
Abstract
Chemotherapy, pelvic radiotherapy and ovarian surgery have known gonadotoxic effects that can lead to endocrine dysfunction, cessation of ovarian endocrine activity and early depletion of the ovarian reserve, causing a risk for future fertility problems, even in children. Important determinants of this risk are the patient’s age and ovarian reserve, type of treatment and dose. When the risk of premature ovarian insufficiency is high, fertility preservation strategies must be offered to the patient. Furthermore, fertility preservation may sometimes be needed in conditions other than cancer, such as in non-malignant diseases or in patients seeking fertility preservation for personal reasons. Oocyte and/or embryo vitrification and ovarian tissue cryopreservation are the two methods currently endorsed by the American Society for Reproductive Medicine, yielding encouraging results in terms of pregnancy and live birth rates. The choice of one technique above the other depends mostly on the age and pubertal status of the patient, and personal and medical circumstances. This review focuses on the available fertility preservation techniques, their appropriateness according to patient age and their efficacy in terms of pregnancy and live birth rates.
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Affiliation(s)
- Marie-Madeleine Dolmans
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Av. Mounier 52, 1200 Brussels, Belgium; (C.H.); (T.Y.T.N.)
- Department of Gynecology, Cliniques Universitaires Saint-Luc, Av. Hippocrate 10, 1200 Brussels, Belgium
- Correspondence:
| | - Camille Hossay
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Av. Mounier 52, 1200 Brussels, Belgium; (C.H.); (T.Y.T.N.)
| | - Thu Yen Thi Nguyen
- Gynecology Research Unit, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Av. Mounier 52, 1200 Brussels, Belgium; (C.H.); (T.Y.T.N.)
| | - Catherine Poirot
- Department of Hematology, AYA Unit, Saint Louis Hospital AP-HP, 1 Avenue Claude Vellefaux, 75010 Paris, France;
- Médecine Sorbonne Université, Site Pitié Salpêtrière, 91 Bd de l’Hôpital, 75013 Paris, France
- Department of Reproductive Biology, Cochin Hospital AP-HP, 123 Bd de Port Royal, 75014 Paris, France
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31
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Abstract
The delineation of organs at risk is the basis of radiotherapy oncologists' work. Indeed, the knowledge of this delineation enables to better identify the target volumes and to optimize dose distribution, involving the prognosis of the patients but also their future. The learning of this delineation must continue throughout the clinician's career. Some contour changes have appeared with better imaging, some volumes are now required due to development of knowledge of side effects. In addition, the increasing survival time of patients requires to be more systematic and precise in the delineations, both to avoid complications until now exceptional but also because re-irradiations are becoming more and more frequent. We present the update of the recommendations of the French Society for Radiation Oncology (SFRO) on new findings or adaptations to volumes at risk.
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Affiliation(s)
- G Noël
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France.
| | - C Le Fèvre
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
| | - D Antoni
- Department of Radiation Oncology, Institut de Cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, BP 23025, 67033 Strasbourg, France
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32
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A case of placenta previa with increta with a history of pelvic radiation. Gynecol Oncol Rep 2021; 37:100800. [PMID: 34150975 PMCID: PMC8192561 DOI: 10.1016/j.gore.2021.100800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/23/2021] [Accepted: 05/27/2021] [Indexed: 11/23/2022] Open
Abstract
No documented pregnancy has occurred with history of pelvic radiation > 45 Gy prior to this case report. Severe pregnancy complications that can occur after pelvic radiation. Detailed counseling teams to be available to patients considering conception with history of pelvic radiation.
Background Prior pelvic radiation increases risks of pregnancy complications that can be life threatening. No documented pregnancy has successfully occurred with pelvic radiation dosing of >45 Gy. This case report describes a successful conception after receiving 54 Gy with subsequent severe pregnancy complications. Case 34 yo G4P2012 with a history of pelvic radiation who presented with painless vaginal bleeding at 12w6d gestation resulting from a donor egg embryo transfer. She was subsequently diagnosed with a subchorionic hemorrhage, complete placenta previa, and placenta increta leading to a gravid hysterectomy at 23w0d due to concern for hemodynamic instability. Conclusion History of pelvic radiation increases risk of severe life-threatening pregnancy complications. This case report details the complications that can arise to provide assistance for counseling and management for future providers.
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Lv Q, Wang L, Luo X, Chen X. Adult stem cells in endometrial regeneration: Molecular insights and clinical applications. Mol Reprod Dev 2021; 88:379-394. [PMID: 34014590 PMCID: PMC8362170 DOI: 10.1002/mrd.23476] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 03/23/2021] [Accepted: 04/22/2021] [Indexed: 02/06/2023]
Abstract
Endometrial damage is an important cause of female reproductive problems, manifested as menstrual abnormalities, infertility, recurrent pregnancy loss, and other complications. These conditions are collectively termed "Asherman syndrome" (AS) and are typically associated with recurrent induced pregnancy terminations, repeated diagnostic curettage and intrauterine infections. Cancer treatment also has unexpected detrimental side effects on endometrial function in survivors independently of ovarian effects. Endometrial stem cells act in the regeneration of the endometrium and in repair through direct differentiation or paracrine effects. Nonendometrial adult stem cells, such as bone marrow-derived mesenchymal stem cells and umbilical cord-derived mesenchymal stem cells, with autologous and allogenic applications, can also repair injured endometrial tissue in animal models of AS and in human studies. However, there remains a lack of research on the repair of the damaged endometrium after the reversal of tumors, especially endometrial cancers. Here, we review the biological mechanisms of endometrial regeneration, and research progress and challenges for adult stem cell therapy for damaged endometrium, and discuss the potential applications of their use for endometrial repair after cancer remission, especially in endometrial cancers. Successful application of such cells will improve reproductive parameters in patients with AS or cancer. Significance: The endometrium is the fertile ground for embryos, but damage to the endometrium will greatly impair female fertility. Adult stem cells combined with tissue engineering scaffold materials or not have made great progress in repairing the injured endometrium due to benign lesions. However, due to the lack of research on the repair of the damaged endometrium caused by malignant tumors or tumor therapies, the safety and effectiveness of such stem cell-based therapies need to be further explored. This review focuses on the molecular insights and clinical application potential of adult stem cells in endometrial regeneration and discusses the possible challenges or difficulties that need to be overcome in stem cell-based therapies for tumor survivors. The development of adult stem cell-related new programs will help repair damaged endometrium safely and effectively and meet fertility needs in tumor survivors.
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Affiliation(s)
- Qiaoying Lv
- Department of GynecologyObstetrics and Gynecology Hospital of Fudan UniversityShanghaiChina
| | - Lulu Wang
- Department of GynecologyObstetrics and Gynecology Hospital of Fudan UniversityShanghaiChina
| | - Xuezhen Luo
- Department of GynecologyObstetrics and Gynecology Hospital of Fudan UniversityShanghaiChina
| | - Xiaojun Chen
- Department of GynecologyObstetrics and Gynecology Hospital of Fudan UniversityShanghaiChina
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Oonsiri P, Vannavijit C, Wimolnoch M, Suriyapee S, Saksornchai K. Estimated radiation doses to ovarian and uterine organs in breast cancer irradiation using radio-photoluminescent glass dosimeters (RPLDs). J Med Radiat Sci 2021; 68:167-174. [PMID: 33078910 PMCID: PMC8168059 DOI: 10.1002/jmrs.445] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 09/04/2020] [Accepted: 09/30/2020] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The well-being of breast cancer patients is essential, especially fertility in patients of reproductive age. The objective of this study was to estimate the radiation doses to the ovaries and uterus for different treatment techniques of breast cancer irradiation using radio-photoluminescent glass dosimeters (RPLDs). METHODS A Farmer-type ionisation chamber (IBA FC-65G) and RPLDs were used to measure in- and out-of-field radiation doses in a solid water phantom. The field sizes were set to 10 × 10 cm2 and 8 × 17 cm2 with the central axis at out-of-field measurement distances of 30 or 50 cm. The Rando phantom's left breast was planned using four different techniques: two tangential standard fields with and without electronic tissue compensator (E-comp) techniques, intensity-modulated radiation therapy (IMRT) and volumetric modulated arc therapy (VMAT). The radiation doses in the ipsilateral ovary, contralateral ovary and uterus were measured using RPLDs. RESULTS The percentage ratio of out of field to in field was affected by distance from the central axis to the point of measurement, in addition to the field sizes associated with collimator scatter. Advanced techniques such as IMRT and VMAT produced higher doses to the ovaries and uterus. The estimated results of the worst-case scenario for the ipsilateral ovary, contralateral ovary and uterus were 0.84% (42 cGy), 0.62% (31 cGy) and 0.76% (38 cGy), respectively, for a 5000 cGy prescription dose. CONCLUSION The lowest to highest out-of-field radiation doses to the ovarian and uterine organs from breast irradiation were the two tangential field techniques, VMAT and IMRT. These advanced techniques yielded higher radiation leakage, which potentially contributed to the out-of-field radiation dose.
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Affiliation(s)
- Puntiwa Oonsiri
- Radiation Oncology DivisionRadiology DepartmentKing Chulalongkorn Memorial HospitalThe Thai Red Cross SocietyBangkokThailand
| | - Chulee Vannavijit
- Radiation Oncology DivisionRadiology DepartmentKing Chulalongkorn Memorial HospitalThe Thai Red Cross SocietyBangkokThailand
| | - Mananchaya Wimolnoch
- Radiation Oncology DivisionRadiology DepartmentKing Chulalongkorn Memorial HospitalThe Thai Red Cross SocietyBangkokThailand
| | - Sivalee Suriyapee
- Radiation Oncology DivisionRadiology DepartmentFaculty of MedicineChulalongkorn UniversityBangkokThailand
| | - Kitwadee Saksornchai
- Radiation Oncology DivisionRadiology DepartmentKing Chulalongkorn Memorial HospitalThe Thai Red Cross SocietyBangkokThailand
- Radiation Oncology DivisionRadiology DepartmentFaculty of MedicineChulalongkorn UniversityBangkokThailand
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Rosenbrock J, Vásquez-Torres A, Mueller H, Behringer K, Zerth M, Celik E, Fan J, Trommer M, Linde P, Fuchs M, Borchmann P, Engert A, Marnitz S, Baues C. Involved Site Radiotherapy Extends Time to Premature Menopause in Infra-Diaphragmatic Female Hodgkin Lymphoma Patients - An Analysis of GHSG HD14- and HD17-Patients. Front Oncol 2021; 11:658358. [PMID: 34113567 PMCID: PMC8185193 DOI: 10.3389/fonc.2021.658358] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/06/2021] [Indexed: 12/28/2022] Open
Abstract
Introduction Consolidation radiotherapy in intermediate stage Hodgkin´s lymphoma (HL) has been the standard of care for many years as involved field radiotherapy (IFRT) after chemotherapy. It included initially involved region(s). Based on randomized studies, radiation volumes could be reduced and involved site radiation therapy (ISRT) became the new standard. ISRT includes the initially affected lymph nodes. In young adults suffering from HL, infertility and hypogonadism are major concerns. With regard to these questions, we analyzed the influence of modern radiotherapy concepts such as consolidating ISRT in infradiaphragmatic involvement of HL after polychemotherapy. Patients and Methods Five hundred twelve patients treated within German Hodgkin Study Group (GHSG) HD14 and HD17 trials were evaluated. We analyzed log-adjusted follicle-stimulating-hormone (FSH)- and luteinizing-hormone (LH)-levels of HD14-patients with infradiaphragmatic radiotherapy (IDRT) in comparison with HD14-patients, who had a supradiaphragmatic radiotherapy (SDRT). In a second step, we compared IFRT with ISRT of female HD17 patients regarding the effects on ovarian function and premature menopause. Results We analyzed FSH- and LH-levels of 258 female and 241 male patients, all treated with IFRT. Of these 499 patients, 478 patients had SDRT and 21 patients had IDRT. In a multiple regression model, we could show that log-adjusted FSH (p=0.0006) and LH values (p=0.0127) were significantly higher after IDRT than after SDRT. The effect of IDRT on gonadal function was comparable to two cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPPesc). We compared the effect of IFRT with ISRT in thirteen female HD17 patients with infradiaphragmatic (ID) involvement. The mean ovarian dose after ISRT was significantly lower than after IFRT. The calculated proportion of surviving non-growing follicles (NGFs) increased significantly from 11.87% to 24.48% in ISRT compared to IFRT, resulting in a significantly longer calculated time to menopause. The younger the age at therapy, the greater the absolute time gain until menopause. Conclusion Infradiaphragmatic IFRT impairs gonadal function to a similar extent as two cycles of BEACOPPesc. In comparison, the use of ISRT target volume definition significantly reduced radiation dose to the ovaries and significantly extends the time interval from treatment to premature menopause.
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Affiliation(s)
- Johannes Rosenbrock
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andrés Vásquez-Torres
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Horst Mueller
- German Hodgkin Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Karolin Behringer
- German Hodgkin Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Department of Hematology and Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Matthias Zerth
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Eren Celik
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jiaqi Fan
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Maike Trommer
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Philipp Linde
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael Fuchs
- German Hodgkin Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Department of Hematology and Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Peter Borchmann
- German Hodgkin Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Department of Hematology and Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Andreas Engert
- German Hodgkin Study Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Department of Hematology and Oncology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Simone Marnitz
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christian Baues
- Department of Radiation Oncology, CyberKnife and Radiation Therapy, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Radiation Therapy Reference Center of the German Hodgkin Study Group (GHSG), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Transplantation of cryopreserved ovarian tissue in a series of 285 women: a review of five leading European centers. Fertil Steril 2021; 115:1102-1115. [DOI: 10.1016/j.fertnstert.2021.03.008] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/19/2021] [Accepted: 03/04/2021] [Indexed: 01/18/2023]
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Qu J, Li Y, Liao S, Yan J. The Effects of Negative Elements in Environment and Cancer on Female Reproductive System. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1300:283-313. [PMID: 33523439 DOI: 10.1007/978-981-33-4187-6_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
With the development of human society, factors that contribute to the impairment of female fertility is accumulating. Lifestyle-related risk factors, occupational risk factors, and iatrogenic factors, including cancer and anti-cancer treatments, have been recognized with their negative effects on the function of female reproductive system. However, the exact influences and their possible mechanism have not been elucidated yet. It is impossible to accurately estimate the indexes of female fertility, but many researchers have put forward that the general fertility has inclined through the past decades. Thus the demand for fertility preservation has increased more and more dramatically. Here we described some of the factors which may influence female reproductive system and methods for fertility preservation in response to female infertility.
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Affiliation(s)
- Jiangxue Qu
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Yuehan Li
- Department of Gynaecology and Obstetrics, Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shujie Liao
- Department of Gynaecology and Obstetrics, Cancer Biology Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China.
| | - Jie Yan
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
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Counseling and surveillance of obstetrical risks for female childhood, adolescent, and young adult cancer survivors: recommendations from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Am J Obstet Gynecol 2021; 224:3-15. [PMID: 32502557 DOI: 10.1016/j.ajog.2020.05.058] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 05/07/2020] [Accepted: 05/29/2020] [Indexed: 02/03/2023]
Abstract
Female childhood, adolescent, and young adult cancer survivors have an increased risk of adverse pregnancy outcomes related to their cancer- or treatment-associated sequelae. Optimal care for childhood, adolescent, and young adult cancer survivors can be facilitated by clinical practice guidelines that identify specific adverse pregnancy outcomes and the clinical characteristics of at-risk subgroups. However, national guidelines are scarce and vary in content. Here, the International Late Effects of Childhood Cancer Guideline Harmonization Group offers recommendations for the counseling and surveillance of obstetrical risks of childhood, adolescent, and young adult survivors. A systematic literature search in MEDLINE database (through PubMed) to identify all available evidence published between January 1990 and December 2018. Published articles on pregnancy and perinatal or congenital risks in female cancer survivors were screened for eligibility. Study designs with a sample size larger than 40 pregnancies in childhood, adolescent, and young adult cancer survivors (diagnosed before the age of 25 years, not pregnant at that time) were eligible. This guideline from the International Late Effects of Childhood Cancer Guideline Harmonization Group systematically appraised the quality of available evidence for adverse obstetrical outcomes in childhood, adolescent, and young adult cancer survivors using Grading of Recommendations Assessment, Development, and Evaluation methodology and formulated recommendations to enhance evidence-based obstetrical care and preconception counseling of female childhood, adolescent, and young adult cancer survivors. Healthcare providers should discuss the risk of adverse obstetrical outcomes based on cancer treatment exposures with all female childhood, adolescent, and young adult cancer survivors of reproductive age, before conception. Healthcare providers should be aware that there is no evidence to support an increased risk of giving birth to a child with congenital anomalies (high-quality evidence). Survivors treated with radiotherapy to volumes exposing the uterus and their healthcare providers should be aware of the risk of adverse obstetrical outcomes such as miscarriage (moderate-quality evidence), premature birth (high-quality evidence), and low birthweight (high-quality evidence); therefore, high-risk obstetrical surveillance is recommended. Cardiomyopathy surveillance is reasonable before pregnancy or in the first trimester for all female survivors treated with anthracyclines and chest radiation. Female cancer survivors have increased risks of premature delivery and low birthweight associated with radiotherapy targeting the lower body and thereby exposing the uterus, which warrant high-risk pregnancy surveillance.
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Anderson RA, Amant F, Braat D, D'Angelo A, Chuva de Sousa Lopes SM, Demeestere I, Dwek S, Frith L, Lambertini M, Maslin C, Moura-Ramos M, Nogueira D, Rodriguez-Wallberg K, Vermeulen N. ESHRE guideline: female fertility preservation. Hum Reprod Open 2020; 2020:hoaa052. [PMID: 33225079 PMCID: PMC7666361 DOI: 10.1093/hropen/hoaa052] [Citation(s) in RCA: 262] [Impact Index Per Article: 65.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 10/02/2020] [Indexed: 12/15/2022] Open
Abstract
STUDY QUESTION What is the recommended management for women and transgender men with regards to fertility preservation (FP), based on the best available evidence in the literature? SUMMARY ANSWER The ESHRE Guideline on Female Fertility Preservation makes 78 recommendations on organization of care, information provision and support, pre-FP assessment, FP interventions and after treatment care. Ongoing developments in FP are also discussed. WHAT IS KNOWN ALREADY The field of FP has grown hugely in the last two decades, driven by the increasing recognition of the importance of potential loss of fertility as a significant effect of the treatment of cancer and other serious diseases, and the development of the enabling technologies of oocyte vitrification and ovarian tissue cryopreservation (OTC) for subsequent autografting. This has led to the widespread, though uneven, provision of FP for young women. STUDY DESIGN SIZE DURATION The guideline was developed according to the structured methodology for development of ESHRE guidelines. After formulation of key questions by a group of experts, literature searches and assessments were performed. Papers published up to 1 November 2019 and written in English were included in the review. PARTICIPANTS/MATERIALS SETTING METHODS Based on the collected evidence, recommendations were formulated and discussed until consensus was reached within the guideline group. A stakeholder review was organized after finalization of the draft. The final version was approved by the guideline group and the ESHRE Executive Committee. MAIN RESULTS AND THE ROLE OF CHANCE This guideline aims to help providers meet a growing demand for FP options by diverse groups of patients, including those diagnosed with cancer undergoing gonadotoxic treatments, with benign diseases undergoing gonadotoxic treatments or those with a genetic condition predisposing to premature ovarian insufficiency, transgender men (assigned female at birth), and women requesting oocyte cryopreservation for age-related fertility loss.The guideline makes 78 recommendations on information provision and support, pre-FP assessment, FP interventions and after treatment care, including 50 evidence-based recommendations-of which 31 were formulated as strong recommendations and 19 as weak-25 good practice points and 3 research only recommendations. Of the evidence-based recommendations, 1 was supported by high-quality evidence, 3 by moderate-quality evidence, 17 by low-quality evidence and 29 by very low-quality evidence. To support future research in the field of female FP, a list of research recommendations is provided. LIMITATIONS REASONS FOR CAUTION Most interventions included are not well studied in FP patients. As some interventions, e.g. oocyte and embryo cryopreservation, are well established for treatment of infertility, technical aspects, feasibility and outcomes can be extrapolated. For other interventions, such as OTC and IVM, more evidence is required, specifically pregnancy outcomes after applying these techniques for FP patients. Such future studies may require the current recommendations to be revised. WIDER IMPLICATIONS OF THE FINDINGS The guideline provides clinicians with clear advice on best practice in female FP, based on the best evidence currently available. In addition, a list of research recommendations is provided to stimulate further studies in FP. STUDY FUNDING/COMPETING INTERESTS The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, with the literature searches and with the dissemination of the guideline. The guideline group members did not receive payment. R.A.A. reports personal fees and non-financial support from Roche Diagnostics, personal fees from Ferring Pharmaceuticals, IBSA and Merck Serono, outside the submitted work; D.B. reports grants from Merck Serono and Goodlife, outside the submitted work; I.D. reports consulting fees from Roche and speaker's fees from Novartis; M.L. reports personal fees from Roche, Novartis, Pfizer, Lilly, Takeda, and Theramex, outside the submitted work. The other authors have no conflicts of interest to declare. DISCLAIMER This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose. (Full disclaimer available at www.eshre.eu/guidelines.) †ESHRE Pages content is not externally peer reviewed. The manuscript has been approved by the Executive Committee of ESHRE.
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Affiliation(s)
| | - Richard A Anderson
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Frédéric Amant
- Department of Gynaecological Oncology, Academic Medical Centres Amsterdam, Amsterdam, The Netherlands.,Department of Gynaecology, Antoni van Leeuwenhoek-Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Oncology, Catholic University Leuven, Leuven, Belgium
| | - Didi Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Arianna D'Angelo
- Wales Fertility Institute, Swansea Bay Health Board, University Hospital of Wales, Cardiff University, Cardiff, UK
| | | | - Isabelle Demeestere
- Fertility Clinic, CUB-Hôpital Erasme and Research Laboratory on Human Reproduction, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Lucy Frith
- Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Matteo Lambertini
- Department of Medical Oncology, U.O.C Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy.,Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
| | | | - Mariana Moura-Ramos
- Reprodutive Medicine Unit, Unit of Clinical Psychology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,University of Coimbra, Center for Research in Neuropsychology and Cognitive and Behavioral Intervention, Coimbra, Portugal
| | - Daniela Nogueira
- Laboratory of Reproductive Biology, INOVIE Fertilité Clinique Croix du Sud, Toulouse, France
| | - Kenny Rodriguez-Wallberg
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden.,Division of Gynaecology and Reproduction, Department of Reproductive Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Nathalie Vermeulen
- European Society of Human Reproduction and Embryology, Central Office, Grimbergen, Belgium
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Impact and Timing of Breast Cancer Radiation Therapy and Fertility Preservation. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00394-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Rozen G, Rogers P, Chander S, Anderson R, McNally O, Umstad M, Winship A, Hutt K, Teh WT, Dobrotwir A, Hart R, Ledger W, Stern K. Clinical summary guide: reproduction in women with previous abdominopelvic radiotherapy or total body irradiation. Hum Reprod Open 2020; 2020:hoaa045. [PMID: 33134561 PMCID: PMC7585646 DOI: 10.1093/hropen/hoaa045] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/13/2020] [Indexed: 11/13/2022] Open
Abstract
STUDY QUESTION What is the evidence to guide the management of women who wish to conceive following abdominopelvic radiotherapy (AP RT) or total body irradiation (TBI)? SUMMARY ANSWER Pregnancy is possible, even following higher doses of post-pubertal uterine radiation exposure; however, it is associated with adverse reproductive sequelae and pregnancies must be managed in a high-risk obstetric unit. WHAT IS KNOWN ALREADY In addition to primary ovarian insufficiency, female survivors who are treated with AP RT and TBI are at risk of damage to the uterus. This may impact on its function and manifest as adverse reproductive sequelae. STUDY DESIGN SIZE DURATION A review of the literature was carried out and a multidisciplinary working group provided expert opinion regarding assessment of the uterus and obstetric management. PARTICIPANTS/MATERIALS SETTING METHODS Reproductive outcomes for postpubertal women with uterine radiation exposure in the form of AP RT or TBI were reviewed. This included Pubmed listed peer-reviewed publications from 1990 to 2019, and limited to English language.. MAIN RESULTS AND THE ROLE OF CHANCE The prepubertal uterus is much more vulnerable to the effects of radiation than after puberty. Almost all available information about the impact of radiation on the uterus comes from studies of radiation exposure during childhood or adolescence.An uncomplicated pregnancy is possible, even with doses as high as 54 Gy. Therefore, tumour treatment doses alone cannot at present be used to accurately predict uterine damage. LIMITATIONS REASONS FOR CAUTION Much of the data cannot be readily extrapolated to adult women who have had uterine radiation and the publications concerning adult women treated with AP RT are largely limited to case reports. WIDER IMPLICATIONS OF THE FINDINGS This analysis offers clinical guidance and assists with patient counselling. It is important to include patients who have undergone AP RT or TBI in prospective studies to provide further evidence regarding uterine function, pregnancy outcomes and correlation of imaging with clinical outcomes. STUDY FUNDING/COMPETING INTERESTS This study received no funding and there are no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- G Rozen
- Reproductive Services, Royal Women's Hospital, Parkville, VIC, Australia.,Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne and Gynaecology Research Centre, Parkville, VIC, Australia.,Melbourne IVF, East Melbourne, VIC, Australia
| | - P Rogers
- Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne and Gynaecology Research Centre, Parkville, VIC, Australia
| | - S Chander
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - R Anderson
- University of Edinburgh, MRC Centre for Reproductive Health Queens Medical Research Institute, Edinburgh, UK
| | - O McNally
- Royal Women's Hospital, Gynae-Oncology Unit, Parkville, VIC, Australia
| | - M Umstad
- Department of Maternal Fetal Medicine, Royal Women's Hospital, Parkville, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne School of BioSciences, Melbourne, VIC, Australia
| | - A Winship
- Development and Stem Cells Program, Monash University Monash Biomedicine Discovery Institute, Clayton, VIC, Australia.,Department of Anatomy and Developmental Biology, Monash University, Clayton, VIC, Australia
| | - K Hutt
- Development and Stem Cells Program, Monash University Monash Biomedicine Discovery Institute, Clayton, VIC, Australia
| | - W T Teh
- Reproductive Services, Royal Women's Hospital, Parkville, VIC, Australia.,Department of Obstetrics and Gynaecology, Royal Women's Hospital, University of Melbourne and Gynaecology Research Centre, Parkville, VIC, Australia.,Melbourne IVF, East Melbourne, VIC, Australia
| | - A Dobrotwir
- Royal Women's Hospital, Radiology, Parkville, VIC, Australia
| | - R Hart
- University of Western Australia, School of Womens and Infants Health University of Western Australia King Edward Memorial Hospital Subiaco, Perth, WA, Australia
| | - W Ledger
- University of New South Wales, School of Womens and Childrens Health Level 1, Royal Hospital for Women, Sydney, NSW, Australia
| | - K Stern
- Reproductive Services, Royal Women's Hospital, Parkville, VIC, Australia.,Melbourne IVF, East Melbourne, VIC, Australia
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42
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Verhaeghe C, Decanter C, Sudour H, Defachelles AS, Escande A, Grabarz A, Garabedian C, Debarge V. Pregnancy after chemoradiotherapy in childhood: Complications and recommendations - about one case. J Gynecol Obstet Hum Reprod 2020; 50:101947. [PMID: 33069913 DOI: 10.1016/j.jogoh.2020.101947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/07/2020] [Accepted: 10/12/2020] [Indexed: 10/23/2022]
Abstract
The question of pregnancy prognosis after radio chemotherapy is unaddressed. We report here the case of three successive spontaneous pregnancies 17 years after the management of a thigh rhabdomyosarcoma treated by radiochemotherapy. In 2018 the patient aged 22 presented with a spontaneous miscarriage. In 2019, she obtained a new spontaneous pregnancy. At 21 W G, she presented with threatened late miscarriage and gave birth to a live girl who would die. Three months after delivery, she had spontaneous pregnancy. At 18 W G, emergency cervical cerclage was performed. At 35 W G the ultrasound found severe intrauterine growth retardation. Cesarean section was performed allowing the birth of a girl in good health status. Childbirth was complicated by 1L8 postpartum hemorrhage secondary to uterine atony, controlled after surgical revision. To conclude, pregnancy in a patient with a history of pelvic irradiation in childhood must be considered high-risk pregnancy and its management must be multidisciplinary.
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Affiliation(s)
- C Verhaeghe
- Angers University Hospital Center, Mother-Child Unit, 49000, Angers, France.
| | - C Decanter
- Mother-Child Unit, Assisted Reproductive Techniques Department, Lille University Hospital Center, Avenue Eugène Avinée, 59037, Lille cedex, France
| | - H Sudour
- Pediatric and Young Adults Oncology Department, Centre Oscar Lambret, 59000, Lille, France
| | - A-S Defachelles
- Pediatric and Young Adults Oncology Department, Centre Oscar Lambret, 59000, Lille, France
| | - A Escande
- Radiotherapy Department, Centre Oscar Lambret, 59000, Lille, France
| | - A Grabarz
- Lille University Hospital Center, Mother-Child Unit, 59000, Lille, France; Medical School Henri Warembourg, Université Lille Nord de France, ULR, 2694, Metrics, France
| | - C Garabedian
- Lille University Hospital Center, Mother-Child Unit, 59000, Lille, France; Medical School Henri Warembourg, Université Lille Nord de France, ULR, 2694, Metrics, France
| | - V Debarge
- Lille University Hospital Center, Mother-Child Unit, 59000, Lille, France; Medical School Henri Warembourg, Université Lille Nord de France, ULR, 2694, Metrics, France
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43
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Lohynska R, Jirkovska M, Novakova-Jiresova A, Mazana E, Vambersky K, Veselsky T, Kindlova A, Stankusova H, Malinova B. Radiotherapy dose limit for uterus fertility sparing in curative chemoradiotherapy for rectal cancer. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 165:99-101. [PMID: 32975243 DOI: 10.5507/bp.2020.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/04/2020] [Indexed: 11/23/2022] Open
Abstract
AIMS Curative sphincter sparing radiotherapy is a treatment option for early rectal cancer. There are many methods developed for fertility preservation in young patients treated with pelvic radiotherapy. Pregnancy rates after radiotherapy are dependent on the radiation dose to ovaries and uterus. Data on outcomes of total body irradiation suggest a pregnancy is possible following 12-14 Gy TBI, despite elevated rates of preterm deliveries and other complications. METHODS We report a case of full-term delivery of twins after curative chemoradiotherapy for anorectal adenocarcinoma T2 N0 M0 with the total dose 58.6 Gy. The patient underwent laparoscopic laterocranial ovarian transposition before radiotherapy. RESULTS Long term complete remission was achieved after treatment. Although a spontaneous conception was not successful, the patient underwent an in vitro fertilisation procedure with donor eggs and conceived twins 10 years after the radiotherapy treatment. The mean dose to the uterus was 16 Gy and to the uterine cervix 35 Gy. She reached a full-term pregnancy and delivered two healthy babies by caesarean section at a gestational age of 38 weeks, weighing 2420 g and 2220 g. CONCLUSION This is the first case report of the successful pregnancy following sphincter sparing curative pelvic radiotherapy for rectal cancer. Furthermore it allows us to propose an increased limit dose to the uterus enabling fertility sparing beyond the limits achieved from total body irradiation series with 12-14 Gy and accept 16 Gy as uterine body (35 Gy for uterine cervix) limit for IMRT treatment planning in young patients asking for maintaining fertility potential.
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Affiliation(s)
- Radka Lohynska
- Department of Oncology, First Faculty of Medicine, Charles University in Prague and Thomayer Hospital Prague, Czech Republic
| | - Michaela Jirkovska
- Department of Oncology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol Hospital, Prague, Czech Republic
| | - Alena Novakova-Jiresova
- Department of Oncology, First Faculty of Medicine, Charles University in Prague and Thomayer Hospital Prague, Czech Republic
| | - Eva Mazana
- Department of Oncology, First Faculty of Medicine, Charles University in Prague and Thomayer Hospital Prague, Czech Republic
| | - Kamil Vambersky
- Department of Medical Physics, University Hospital Motol, Prague, Czech Republic
| | - Tomas Veselsky
- Department of Medical Physics, University Hospital Motol, Prague, Czech Republic
| | - Anna Kindlova
- Department of Medical Physics, University Hospital Motol, Prague, Czech Republic
| | - Hana Stankusova
- Department of Oncology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol Hospital, Prague, Czech Republic
| | - Bela Malinova
- Department of Oncology, Second Faculty of Medicine, Charles University in Prague and University Hospital Motol Hospital, Prague, Czech Republic
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44
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Somigliana E, Mangili G, Martinelli F, Noli S, Filippi F, Bergamini A, Bocciolone L, Buonomo B, Peccatori F. Fertility preservation in women with cervical cancer. Crit Rev Oncol Hematol 2020; 154:103092. [PMID: 32896752 DOI: 10.1016/j.critrevonc.2020.103092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/15/2020] [Accepted: 08/17/2020] [Indexed: 12/16/2022] Open
Abstract
Fertility preservation in women with cervical cancer is a demanding but evolving issue. Some remarkable achievements have been reached, in particular the improvement of primary and secondary prevention and the broadening of the indications for conservative surgery up to FIGO 2018 stage IB2. Natural pregnancy rate and the rate of obstetrics complications following conservative approach is satisfactory even if not optimal. On the other hand, the use of classic strategies for fertility preservation such as oocytes or ovarian cortex freezing is extremely limited, being the uterus compromised by treatment in a high proportion of cases. In fact, the availability of uterine surrogacy can play a role in the counseling and the decision-making process. The recent advent of uterus transplantation is fascinating but, at present, cannot be viewed as a realistic solution.
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Affiliation(s)
- Edgardo Somigliana
- Dept of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Obstet-Gynecol Dept, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
| | - Giorgia Mangili
- Obstet-Gynecol Dept, San Raffaele Scientific Institute, IRCCS Milan, Italy
| | - Fabio Martinelli
- Gynecologic Oncology Unit, Fondazione IRCCS National Cancer Institute, Milan, Italy
| | - Stefania Noli
- Dept of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy; Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Francesca Filippi
- Obstet-Gynecol Dept, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alice Bergamini
- Obstet-Gynecol Dept, San Raffaele Scientific Institute, IRCCS Milan, Italy
| | - Luca Bocciolone
- Obstet-Gynecol Dept, San Raffaele Scientific Institute, IRCCS Milan, Italy
| | - Barbara Buonomo
- Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Fedro Peccatori
- Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
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45
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Huang W, Sundquist K, Sundquist J, Ji J. Risk of Being Born Preterm in Offspring of Cancer Survivors: A National Cohort Study. Front Oncol 2020; 10:1352. [PMID: 32850432 PMCID: PMC7418466 DOI: 10.3389/fonc.2020.01352] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/29/2020] [Indexed: 12/03/2022] Open
Abstract
Background: With the increased number of cancer survivors, it is necessary to explore the effect of cancer and its treatments on pregnancy outcomes, such as preterm birth, which seriously endangers the health of offspring. We aimed to explore the risk of being born preterm among offspring of cancer survivors. Materials and Methods: This is a retrospective cohort study. All singleton live births between 1973 and 2014 in Sweden with information of birth outcomes were retrieved from the Swedish Medical Birth Register. By linking to several Swedish registers, we identified all parents of children and parental cancer diagnosis. Logistic regression was used to estimate odds ratios and 95% confidence intervals. Results: As compared to the children without parental cancer, the risk of being born preterm was significantly higher among children of overall female cancer survivors born after cancer diagnosis with an adjusted OR of 1.48 (95 CI% = 1.39–1.59), in particular those diagnosed with childhood cancer and cancer in female genital organs. Besides, the risk might continuously decline with time at the first 8 years after maternal diagnosis. A higher risk of being born preterm was found among offspring of male survivors diagnosed with central nervous system cancer (Adjusted OR = 1.26, 95% CI = 1.04–1.53). Conclusions: Our study provides evidence for a higher risk of being born preterm among children of female cancer survivors and male survivors with central nervous system tumor, as well as indicates that the effect on female reproductive system from cancer and related-treatments might decline with time.
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Affiliation(s)
- Wuqing Huang
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Kristina Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden.,Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Department of Functional Pathology, Center for Community-Based Healthcare Research and Education (CoHRE), School of Medicine, Shimane University, Matsue, Japan
| | - Jan Sundquist
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden.,Department of Family Medicine and Community Health, Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States.,Department of Functional Pathology, Center for Community-Based Healthcare Research and Education (CoHRE), School of Medicine, Shimane University, Matsue, Japan
| | - Jianguang Ji
- Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
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46
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Buonomo B, Orecchia R, Tomao F, Pup LD, Garcia-Faura A, Peccatori FA. Uterine irradiation as a determinant of infertility and pregnancy losses in young cancer survivors. Ecancermedicalscience 2020; 14:1032. [PMID: 32419844 PMCID: PMC7221126 DOI: 10.3332/ecancer.2020.1032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Indexed: 11/23/2022] Open
Abstract
Several concerns exist regarding the impact of anticancer treatments on fertility and pregnancy outcome. The detrimental effects of both chemotherapy and radiotherapy on the ovaries are well reported in the available literature. Fewer data are focused on the importance of a functioning uterus to conceive and carry on a healthy pregnancy. The aim of this paper is to provide a narrative review of the current literature to assess the role of uterine irradiation as a potential determinant of infertility and poor obstetrical outcomes. This review addresses the need for multidisciplinary counselling in order to face the poor reproductive and obstetrical outcomes of women who had uterine radiation, according to the different backgrounds (radiotherapy during adulthood versus childhood; total body irradiation versus pituitary, spinal and/or abdominal-pelvic irradiation).
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Affiliation(s)
- Barbara Buonomo
- Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Tomao
- Department of Gynaecologic Oncology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Lino Del Pup
- University Sanitary Agency Friuli Central (ASU FC) Italy; Board Italian Society of Third Age Gynaecology (SIGiTE), Italy
| | | | - Fedro A Peccatori
- Fertility and Procreation Unit, Division of Gynaecologic Oncology, European Institute of Oncology IRCCS, Milan, Italy
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47
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Looking beyond the ovary for oncofertility care in women: uterine injury as a potential target for fertility-preserving treatments. J Assist Reprod Genet 2020; 37:1467-1476. [PMID: 32342270 PMCID: PMC7311602 DOI: 10.1007/s10815-020-01792-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/22/2020] [Indexed: 10/24/2022] Open
Abstract
Treatment for cancer has the potential to significantly diminish fertility and, further, to negatively impact the obstetrical outcomes of pregnancies that do occur. Cancer survivors have decreased rates of fertility and increased rates of pregnancy complications, such as preterm birth and low birth weight, after exposure to chemotherapy. To date, research on the impact of chemotherapy and radiotherapy on fertility and pregnancy outcomes has focused largely on the gonadotoxic effect of cancer treatments on ovaries, while the uterus and endometrium have not been extensively studied. It is intuitive, however, that decreased fertility and poorer obstetrical outcomes may be substantially mediated through injury to a highly mitotic tissue like the endometrium, which is also central to embryo implantation and utero-placental exchange. Pregnancy complications in cancer survivors might be due to compromised blood supply to the endometrium and myometrium affecting placentation or altered remodeling of the pregnant uterus secondary to radiation fibrosis. Alterations in endometrial receptivity at the molecular level could affect pregnancy implantation and early pregnancy loss, but later complications also can occur. This review focuses on understanding the unintended effects of chemotherapy and radiotherapy on uterine function in female cancer survivors and the impact on pregnancy, and summarizes mechanisms to protect and treat the uterus before and after cancer chemotherapy and radiotherapy.
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48
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van Dijk M, van Leeuwen FE, Overbeek A, Lambalk CB, van den Heuvel-Eibrink MM, van Dorp W, Tissing WJ, Kremer LC, Loonen JJ, Versluys B, Bresters D, Ronckers CM, van der Pal HJ, Beerendonk CCM, Kaspers GJL, van Dulmen-den Broeder E, van den Berg MH. Pregnancy, time to pregnancy and obstetric outcomes among female childhood cancer survivors: results of the DCOG LATER-VEVO study. J Cancer Res Clin Oncol 2020; 146:1451-1462. [PMID: 32221745 PMCID: PMC7230041 DOI: 10.1007/s00432-020-03193-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/20/2020] [Indexed: 12/02/2022]
Abstract
Purpose To evaluate pregnancy rates, time to pregnancy (TTP) and obstetric outcomes in female childhood cancer survivors (CCSs) and to identify specific diagnosis- and treatment-related factors associated with these outcomes. Methods The study is part of the DCOG LATER-VEVO study, a nationwide multicenter cohort study evaluating fertility among long-term Dutch female CCSs. Data were collected by questionnaire. The current study included 1095 CCSs and 812 controls, consisting of sisters of CCSs and a random sample of women from the general population. Results Among the subgroup of women who ever had the desire to become pregnant, the chance of becoming pregnant was significantly lower for CCSs than controls (OR 0.5, 95%CI 0.4–0.8). Moreover, TTP was 1.1 times longer for CCSs compared to controls (p = 0.09) and was significantly longer in survivors of CNS and renal tumours. Overall, no differences were found between CCSs and controls regarding the probability of ever having had a miscarriage, still birth, or induced abortion. However, CCSs had a significantly increased risk of delivering preterm (OR 2.2, 95%CI 1.3–3.7) and delivering via caesarean section (OR 1.8, 95%CI 1.2–2.6). Treatment with lower abdominal/pelvic radiotherapy was strongly associated with several adverse obstetric outcomes. Conclusion CCSs are less likely to have ever been pregnant. Among those who do become pregnant, certain subgroups of CCSs are at increased risk of longer TTP. Moreover, as pregnant CCSs, especially those treated with lower abdominal/pelvic radiotherapy, are more likely to develop various adverse obstetric outcomes, appropriate obstetric care is highly advocated. Electronic supplementary material The online version of this article (10.1007/s00432-020-03193-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- M van Dijk
- Department of Paediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - F E van Leeuwen
- Department of Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - A Overbeek
- Department of Paediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - C B Lambalk
- Department of Obstetrics and Gynaecology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | | | - W van Dorp
- Department of Gynaecology and Obstetrics, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - W J Tissing
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - L C Kremer
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - J J Loonen
- Department of Haematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - B Versluys
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - D Bresters
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - C M Ronckers
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - H J van der Pal
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - C C M Beerendonk
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G J L Kaspers
- Department of Paediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - E van Dulmen-den Broeder
- Department of Paediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - M H van den Berg
- Department of Paediatric Oncology, Emma Children's Hospital, Amsterdam UMC, Vrije Universiteit Amsterdam, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
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49
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Pais AS, Guerra N, Couto D, Sousa AP, Almeida-Santos T. Fertility preservation with successful pregnancy outcome in a patient with transplanted heart and non-Hodgkin's lymphoma - a case report. BMC Pregnancy Childbirth 2019; 19:421. [PMID: 31744460 PMCID: PMC6862739 DOI: 10.1186/s12884-019-2587-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 11/08/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Fertility preservation must be discussed with reproductive age women before cancer treatment. Heart transplantation raises complex issues in pregnancy. Pregnancy in a heart transplant woman after pelvic irradiation involves close multidisciplinary follow-up to avoid complications in the mother and the foetus. We report the first live birth in a heart transplant woman after pelvic irradiation, chemotherapy and fertility preservation. CASE PRESENTATION A 36-year-old heart transplant woman with pelvic non-Hodgkin lymphoma spared her fertility, with cryopreservation of oocytes and embryos, before chemotherapy and pelvic irradiation. After multidisciplinary discussion and pre-conception evaluation, pregnancy was achieved. A close follow-up by a multidisciplinary team allowed a normal pregnancy without maternal or foetal complications and the delivery of a healthy infant. CONCLUSIONS Achieving pregnancy in heart transplant women with iatrogenic ovarian failure after oncologic treatment including pelvic irradiation is possible and can be successful. Careful and close surveillance by a multidisciplinary team is mandatory due to increased risk of maternal and foetal complications.
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Affiliation(s)
- Ana Sofia Pais
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
- Obstetrics A Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Nuno Guerra
- Obstetrics A Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Daniela Couto
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
| | - Ana Paula Sousa
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
- Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
| | - Teresa Almeida-Santos
- Reproductive Medicine Unit, Centro Hospitalar e Universitário de Coimbra (CHUC), Praceta Prof. Mota Pinto, 3000-075 Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- Center for Neuroscience and Cell Biology, University of Coimbra, Coimbra, Portugal
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50
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Prasad SK, Bose A, Bhattacharjee A, Banerjee O, Singh S, Mukherjee S, Pal S. Radioprotective effect of ethanolic extract of Alocasia indica on γ-irradiation-induced reproductive alterations in ovary and uterus. Int J Radiat Biol 2019; 95:1529-1542. [DOI: 10.1080/09553002.2019.1642545] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
| | - Ananya Bose
- Department of Physiology, Serampore College, Hooghly, India
| | | | - Oly Banerjee
- Department of Physiology, Serampore College, Hooghly, India
| | | | | | - Swagata Pal
- Department of Physiology, Raja Peary Mohan College, Hooghly, India
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