The importance of fertility preservation in cancer patients

Arginine Biosynthesis Mediates Wulingzhi Extract Resistance to Busulfan-Induced Male Reproductive Toxicity

Busulfan, an indispensable medicine in cancer treatment, can cause serious reproductive system damage to males as a side effect of its otherwise excellent therapeutic results. Its widespread use has also caused its accumulation in the environment and subsequent ecotoxicology effects. As a Chinese medicine, Wulingzhi (WLZ) has the effects of promoting blood circulation and improving female reproductive function. However, the potential effects of WLZ in male reproduction and in counteracting busulfan-induced testis damage, as well as its probable mechanisms, are still ambiguous. In this study, busulfan was introduced in a mouse model to evaluate its production of the testicular damage. The components of different WLZ extracts were compared using an untargeted metabolome to select extracts with greater efficacy, which were further confirmed in vivo. Here, we demonstrate abnormal spermatogenesis and low sperm quality in busulfan-injured testes. The WLZ extracts showed a strong potential to rehabilitate the male reproductive system; this effect was more prominent in room-temperature extracts. Additionally, both water and ethanol WLZ extracts at room temperature alleviated various busulfan-induced adverse effects. In particular, WLZ recovered spermatogenesis, re-activated arginine biosynthesis, and alleviated the increased oxidative stress and inflammation in the testis, ultimately reversing the busulfan-induced testicular injury. Collectively, these results suggest a promising approach to protecting the male reproductive system from busulfan-induced adverse side effects, as well as those of other similar anti-cancer drugs.

Utilization of sperm cryopreservation in patients with testicular cancer

PURPOSE

We assessed factors that affect the utilization of sperm cryopreservation before 2021, when patients covered expenses, and the influence on quality of life.

METHODS

Between 2011 and 2021, testicular cancer survivors (TCS) at our clinic completed a questionnaire, including EORTC QLQ-TC26, covering sperm cryopreservation, sociodemographic details, post-treatment births, and artificial insemination.

RESULTS

After 5.7 ± 3.0 years, 279 participants (64%) responded to the questionnaire. Among them, 33% (91/279) of testicular cancer survivors chose sperm cryopreservation prior to treatment, with 11% (10/91) using it for insemination. Conversely, 2% (3/188) without cryopreservation reported unfulfilled desire to have children. Univariate analysis showed TCS with cryopreservation were younger (30.6 ± 7.1 (35 (21-59)) vs. 42.4 ± 10.9 (48 (22-81)) years; p = 0.001), had a lower BMI (24.2 ± 3.3 vs. 26.6 ± 4.6 kg/m2; p = 0.009) and a lower Charlson Score (> 3: 36% vs. 60%; p < 0.001). Multivariate analysis revealed older age (≥ 37 years: OR 13.1 (5.5-31.2), p < 0.001) and lower education (middle school or less: OR 3.3 (1.6-6.9), p = 0.001) as independent factors associated with not undergoing cryopreservation. Regarding quality of life, multivariate analysis identified a lower infertility anxiety score (OR 4.3 (2.0-9.0), p < 0.001) and higher age (≥ 44 years: OR 5.4 (2.6-11.3); p < 0.001) as predictors for the absence of prior cryopreservation.

CONCLUSIONS

Age and education seem to impact the choice of undergoing paid sperm cryopreservation. Urologists should inform testicular cancer patients about costs and coverage. Importantly, the occurrence of unmet desires for parenthood is minimal among those who forego cryopreservation.

Oxidative stress-induced apoptosis and autophagy: Balancing the contrary forces in spermatogenesis

Spermatogenesis is a complex process in the testis and is a cornerstone of male infertility. The abundance of unsaturated fatty acid and high cell division rate make male germs cells prone to DNA deterioration. ROS-mediated oxidative stress triggers DNA damage, autophagy, and apoptosis in male germ cells, which are critical causative factors that lead to male infertility. The complex connection and molecular crosstalk between apoptosis and autophagy is seen at multifaceted levels that interconnect the signaling pathways of these two processes. Multilevel interaction between apoptosis and autophagy is a seamless state of survival and death in response to various stressors. Interaction between multiple genes and proteins such as the mTor signaling pathway, Atg12 proteins, and the death adapter proteins, such as Beclin 1, p53, and Bcl-2 family proteins, validates such a link between these two phenomena. Testicular cells being epigenetically different from somatic cells, undergo numerous significant epigenetic transitions, and ROS modulates the epigenetic framework of mature sperm. Epigenetic deregulation of apoptosis and autophagy under oxidative stress conditions can cause sperm cell damage. The current review recapitulates the current role of prevailing stressors that generate oxidative stress leading to the induction of apoptosis and autophagy in the male reproductive system. Considering the pathophysiological consequences of ROS-mediated apoptosis and autophagy, a combinatorial approach, including apoptosis inhibition and autophagy activation, a therapeutic strategy to treat male idiopathic infertility. Understanding the crosslink between apoptosis and autophagy under stress conditions in male germ cells may play an essential role in developing therapeutic strategies to treat infertility.

And When I Die: Theory of Planned Behavior as Applied to Sperm Cryopreservation

The present study investigates fertility intentions of men, aged 18-59, as expressed in willingness to cryopreserve sperm for future use in procreation. An economic stated-preference framework is combined with the Theory of Planned Behavior (TPB) to investigate which attributes are important in the decision to cryopreserve sperm, what is the Willingness to Pay (WTP) for cryopreservation, and which attributes influence it. A structured, two-part questionnaire was used, based on WTP and Conjoint analysis (CA) applied in tandem to elicit respondents' preferences in evaluating utility. Findings show which attributes are important in the decision to cryopreserve sperm among them Risk of Infertility, Personal monthly income, Chance of pregnancy from frozen semen, Age and what are significant predictor variables for the WTP which are Personal monthly income, Importance of the risk of infertility, Initial registration fee to sperm bank and cryopreservation, and Degree of religious observance. The findings further demonstrate that respondents value sperm cryopreservation and have a positive WTP for it as it seems to contribute to improving well-being. As a result of these findings, governments should consider state funding for cryopreservation as part of national health policy.

Human placental mesenchymal stem cells ameliorate chemotherapy-induced damage in the testis by reducing apoptosis/oxidative stress and promoting autophagy

Background

The side effects of busulfan on male reproduction are serious, so fertility preservation in children undergoing busulfan treatment is a major worldwide concern. Human placental mesenchymal stem cells (hPMSCs) have advantages such as stable proliferation and lower immunogenicity that make them an ideal material for stimulating tissue repair, especially restoring spermatogenesis. The protective effects of hPMSCs in busulfan-induced Sertoli cells and in busulfan-treated mouse testes have not been determined. Our study aimed to elaborate the protective effect and potential mechanisms of hPMSCs in busulfan-treated testes and Sertoli cells.

Methods

First, we developed a mouse model of busulfan-induced testicular toxicity in vivo and a mouse Sertoli cell line treated with busulfan in vitro to assess the protective effect and mechanisms of hPMSC treatment on spermatogenesis. Then, the length, width, and weight of the testes were monitored using Vernier calipers. Furthermore, at 1 week and 4 weeks after the transplantation of hPMSCs, histological sections of testes were stained with hematoxylin-eosin, and the seminiferous tubules with fluid-filled cavities were counted. Through ELISA analysis, testosterone levels and MDA, SOD, LDH, and CAT activities, which are associated with ROS, were detected. Markers of ROS, proliferation (Ki67), and apoptosis (Annexin V) were evaluated by FACS. Next, the fluorescence intensity of proliferation markers (BrdU and SCP3), an antioxidant marker (SIRT1), a spermatogenesis marker (PLZF), and autophagy-related genes (P62 and LC3AB) were detected by fluorescence microscopy. The mRNA expression of γ-H2AX, BRCA1, PARP1, PCNA, Ki67, P62, and LC3 was determined by qRT-PCR.

Results

hPMSCs restored disrupted spermatogenesis, promoted improved semen parameters, and increased testosterone levels, testis size, and autophagy in the testis toxicity mouse model induced by busulfan. hPMSCs suppressed the apoptosis of Sertoli cells and enhanced their rate of proliferation in vitro. Additionally, hPMSCs protected against oxidative stress and decreased oxidative damage in the testis toxicity mouse model induced by busulfan. Furthermore, hPMSCs increased the expression of proliferation genes (PCNA and KI67) and decreased the mRNA levels of apoptotic genes such as γ-H2AX, BRCA1, and PARP1.

Conclusions

This research showed that hPMSC injection ameliorated busulfan-induced damage in the testis by reducing apoptosis/oxidative stress and promoting autophagy. The present study offers an idea for a new method for clinical treatment of chemotherapy-induced spermatogenesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02275-z.

Static magnetic field halves cryoinjuries of vitrified mouse COCs, improves their functions and modulates pluripotency of derived blastocysts

This study was performed with the aim of evaluating the influence of static magnetic field (SMF) of 60 mT on mouse Cumulus Oocytes Complexes (COCs) vitrification. The COCs were vitrified in the presence (Vit_SMF⁺) and absence of SMF (Vit_SMF^-). Along with these groups, non-vitrified or fresh COCS, which exposed (nVit_SMF⁺) and non-exposed (nVit_SMF^-) to magnetic field, were also considered. Survival and viability rates and mitochondrial activity as well as ultrastructure of oocytes were examined by trypan blue Staining (TBS), Annexin-PI Staining, JC1 staining and transition electron microscopy, respectively. Following in vitro fertilization (IVF) and embryo development, gene expression was carried out through qRT-PCR at blastocyst (BL) stage. The survival rate in Vit_SMF⁺ and Vit_SMF^- decreased meaningfully in comparison with nVit_SMF^- (P < 0.05), but there was no significant difference between SMF⁺ and SMF^- groups. The mitochondrial activity in Vit_SMF^- was significantly reduced compared to the nVit_SMF^- group (P < 0.05), however its value in Vit_SMF⁺ returned to the control level. Ultrastructural study demonstrated that SMF could protect the COCs from cryoinjuries and reduced damaged features in ooplasm of the vitrified oocytes. There was no significant difference in fertilization rate. Although, BL formation was the highest rate in the Vit_SMF⁺ group, it was just substantially higher than the non-vitrified groups (P < 0.05). The significant changes of Oct4, Cdx2 and Nanog genes expression due to vitrification (Vit_SMF^-) or SMF (nVit_SMF⁺) treatments (P < 0.05) as compared to control (nVit_SMF^-), returned to the natural level after using SMF in vitrified derived blastocysts (Vit_SMF⁺). Totally based on the results, it is clear that static magnetic field improves mitochondrial potential activity and ultrastructure of mouse vitrified COCs. In addition, SMF enhances the embryo cleavage rate to blastocyst stage and modulates pluripotency in blastocyst embryos derived from vitrified COCs.

Measuring the Multidimensional Reproductive Concerns of Young Adult Male Cancer Survivors

Purpose: The aims of this study were to adapt the multidimensional Reproductive Concerns After Cancer (RCAC) scale for use with young adult (YA) male cancer survivors, defined as current age 18-35 years and at least 1 year postdiagnosis, and to examine the factor structure, reliability, and validity of the newly adapted RCAC-Male (RCAC-M) scale. Methods: We conducted cognitive interviews with 10 YA male cancer survivors to inform modifications to RCAC item wording. Online surveys were then completed by 170 YA male cancer survivors. We used confirmatory factor analysis to examine structural models of the RCAC-M scale, and assessed reliability and construct validity. Results: The oblique six-factor model of the RCAC-M scale provided the best model fit. Omega total and Revelle's omega total estimates for all six three-item subscales were in the nearly satisfactory to good range (0.69-0.88). As hypothesized, men who wanted to have a baby and men who believed that having a biological child was very important scored higher on at least one RCAC-M subscale. We observed correlations in the expected directions between the RCAC-M and measures of depression and health-related quality of life. Conclusion: The RCAC-M scale is a multidimensional scale that is best represented as a profile of subscale scores. This scale demonstrated good reliability and construct validity and can be used to inform tailored interventions to more effectively address men's reproductive concerns.

Alginate oligosaccharides improve germ cell development and testicular microenvironment to rescue busulfan disrupted spermatogenesis

Rationale: Busulfan is currently an indispensable anti-cancer drug, particularly for children, but the side effects on male reproduction are so serious that critical drug management is needed to minimize any negative impact. Meanwhile, alginate oligosaccharides (AOS) are natural products with many consequent advantages, that have attracted a great deal of pharmaceutical attention. In the current investigation, we performed single-cell RNA sequencing on murine testes treated with busulfan and/or AOS to define the mitigating effects of AOS on spermatogenesis at the single cell level.

Methods: Testicular cells (in vivo) were examined by single cell RNA sequencing analysis, histopathological analysis, immunofluorescence staining, and Western blotting. Testes samples (ex vivo) underwent RNA sequencing analysis. Blood and testicular metabolomes were determined by liquid chromatography-mass spectrometry (LC/MS).

Results: We found that AOS increased murine sperm concentration and motility, and rescued busulfan disrupted spermatogenesis through improving (i) the proportion of germ cells, (ii) gene expression important for spermatogenesis, and (iii) transcriptional factors in vivo. Furthermore, AOS promoted the ex vivo expression of genes important for spermatogenesis. Finally, our results showed that AOS improved blood and testis metabolomes as well as the gut microbiota to support the recovery of spermatogenesis.

Conclusions: AOS could be used to improve fertility in patients undergoing chemotherapy and to combat other factors that induce infertility in humans.

Folliculogenesis-Associated Genes Expression in Human Vitrified Ovarian Tissue after Xenotransplantation in γ-Irradiated Mice

Objective

Autograft transplantation of vitrified cortical ovarian tissue is an acceptable clinical technique for fertility preservation in women. Xenograft transplantation into animal models could be useful for evaluating the safety of human vitrified ovarian tissue. This study targeted to evaluate impact of vitrification on expression of the genes associated with folliculogenesis after xenograft transplantation of human vitrified ovarian tissue to γ-irradiated mice.

Materials and Methods

In this experimental study, ovarian biopsies were gathered from six transsexual persons. The cortical section of ovarian biopsies was separated and chopped into small pieces. These pieces were randomly divided into vitrified and non-vitrified groups. In each group some pieces were considered as non-transplanted tissues and the others were transplanted to γ-irradiated female National Medical Research Institute (NMRI) mice. Before and after two weeks of xenograft transplantation, histological assessment and evaluation of the expression of folliculogenesis- associated genes (FIGLA, GDF-9, KL and FSHR) were performed in both vitrified and non-vitrified groups.

Results

Percentage of the normal follicles and expression of the all examined genes from transplanted and non- transplanted tissue were similar in both vitrified and non-vitrified groups (P>0.05). After transplantation, the normal follicle rate was significantly decreased and among the folliculogenesis-associated genes, expression of GDF-9 gene was significantly increased, rather than before transplantation in vitrified and non-vitrified tissues (P<0.05).

Conclusion

The vitrification method using dimethyl solphoxide and ethylene glycol (EG) had no remarkable effect on the normal follicular rate and expression of folliculogenesis-associated genes after two weeks human ovarian tissue xenografting. In addition, transplantation process can cause a significant decrease in normal follicular rate and expression of GDF-9 gene.

Testicular Tissue Cryopreservation and Ethical Considerations: A Scoping Review

Testicular tissue cryopreservation (TTCP) aims to preserve the future option of genetic reproduction for prepubescent cancer patients who are at risk of infertility as a result of their cancer therapies. This technology is experimental and currently only offered in the research context. As TTCP moves towards becoming more widely available, it is imperative that healthcare providers recognize the complex ethical issues surrounding this technology. This scoping review study identifies and assesses the range and depth of ethical concerns related to this testicular tissue cryopreservation technology. At present, no such scoping review of ethical concerns exists in the TTCP literature. The forty-three full-text articles included in this study yielded twenty-two different ethical considerations discussed in relation to TTCP. It was observed that these ethical considerations fit within a mainstream Principlism approach to bioethics. Accordingly, there are ethical gaps in the TTCP literature that can be identified with alternative moral lenses. In particular, it was found that ethical concerns related to context and relational aspects of identity were absent in nearly all ethical examinations of TTCP. Furthermore, only 9 per cent of articles reviewed in this study focused primarily on the ethics of TTCP, thus demonstrating a need for further in depth ethical analyses of this technology. The results of this study are important for supporting the ethical provision of TTCP and can contribute to policy and guideline development. The findings of this study demonstrate the need for greater depth and diversity in analyses of ethical considerations related to this technology.

Knowledge and awareness of long-term and late treatment consequences amongst colorectal cancer survivors: A qualitative study

PURPOSE

To describe patient knowledge and awareness of long-term and late onset treatment consequences amongst colorectal cancer survivors.

METHODS

Semi-structured qualitative interviews were conducted with 19 colorectal cancer survivors at least 12 months post-treatment. Interviews were audio-recorded, transcribed into NVivo 10 software and analysed using the framework method.

RESULTS

Participants were aware of disease recurrence but not many other treatment consequences; change in bowel habit and impact on diet were common and had significant impact, yet many felt they had not received 'warning', considering it a gap in both information and support. Participants expressed preference to know about possible consequences early on and were willing to engage in education and support if offered. Information overload, timing of information provision and unequipped health care professionals were considered barriers to awareness.

CONCLUSION

Improvement in information provision, management of expectations and support around bowel function would facilitate patient self-empowerment and could improve holistic management of health and well-being after cancer.

Fertility preservation in men with cancer

During the past decade, advances in cancer treatment have increased survival rates of both boys and men. However, cancer treatment itself can compromise fertility, especially exposure to alkylating agents and whole body irradiation, which cause substantial germ cell loss. Children and adolescents with testicular cancer, leukaemia, and Ewing sarcomas are at the highest risk of developing permanent sterility from cancer treatment. Consequently, various strategies to preserve fertility are necessary. Sperm cryopreservation is an effective but underused method to safeguard spermatozoa. In the past few years, large advances have been made in prepubertal germ cell storage aimed at subsequent transplantation of testicular tissue and associated stem cells. Although still experimental, these approaches offer hope to many men in whom germ cell loss is associated with sterility. The derivation of male gametes from stem cells also holds much promise; however, data are only available in animals, and the use of this method in human beings is probably many years away.

Assisted reproductive outcomes of male cancer survivors

PURPOSE

The objective of our study was to evaluate the reproductive outcome of male cancer survivors treated with intracytoplasmic sperm injection (ICSI) using cryopreserved sperm and compare it with the same treatment in non-cancer males.

METHODS

We retrospectively analyzed database derived from cancer and non-cancer patients undergoing sperm cryopreservation from August 2008 to August 2012 at a university-based center. We evaluated the reproductive outcome of those cancer and non-cancer patients that had frozen sperm and returned subsequently to the clinic for assisted reproduction.

RESULTS

We studied 272 males with cancer and 296 infertile males. The most prevalent types of cancer in our cohort were lymphoma (25.3 %), testicular cancer (19.2 %), leukemia (7.3 %), and other malignancies including sarcoma, gastrointestinal, and central nervous system malignancies (48.2 %). The use rate of cryopreserved sperm was 10.7 % for cancer patients and 30.7 % for non-cancer patients. The mean age of males with cancer who returned to the clinic for fertility treatment was 36.7 ± 6 years, and the diagnoses were testis cancer (43.4 %), lymphoma (36.9 %), leukemia (13 %), and other malignancies (6.7 %). Live birth rate of the cancer cohort was 62.1 %, which was higher than that of the normospermic non-cancer population (p < 0.0047).

CONCLUSIONS

The use rate of cryopreserved sperm from oncofertility preservation cases is at around 10 %. The live birth rate using assisted reproductive technologies among these patients is at least comparable to that of the non-cancer population.

IMPLICATIONS FOR CANCER SURVIVORS

To our knowledge, this was the first comparative study of male cancer survivors treated with ICSI using cryopreserved sperm, which were compared to non-cancer males undergoing the same treatment. Male fertility preservation is a highly valued service that should be strongly encouraged prior to beginning cytotoxic cancer treatment. These results can help healthcare professionals in oncology to improve the quality of counseling on fertility preservation when managing young men with newly diagnosed cancer that require gonadotoxic treatment.

Sexual dysfunction and infertility as late effects of cancer treatment

Sexual dysfunction is a common consequence of cancer treatment, affecting at least half of men and women treated for pelvic malignancies and over a quarter of people with other types of cancer. Problems are usually linked to damage to nerves, blood vessels, and hormones that underlie normal sexual function. Sexual dysfunction also may be associated with depression, anxiety, relationship conflict, and loss of self-esteem. Innovations in cancer treatment such as robotic surgery or more targeted radiation therapy have not had the anticipated result of reducing sexual dysfunction. Some new and effective cancer treatments, including aromatase inhibitors for breast cancer or chemoradiation for anal cancer also have very severe sexual morbidity. Cancer-related infertility is an issue for younger patients, who comprise a much smaller percentage of total cancer survivors. However, the long-term emotional impact of being unable to have a child after cancer can be extremely distressing. Advances in knowledge about how cancer treatments may damage fertility, as well as newer techniques to preserve fertility, offer hope to patients who have not completed their childbearing at cancer diagnosis. Unfortunately, surveys in industrialised nations confirm that many cancer patients are still not informed about potential changes to their sexual function or fertility, and all modalities of fertility preservation remain underutilised. After cancer treatment, many patients continue to have unmet needs for information about restoring sexual function or becoming a parent. Although more research is needed on optimal clinical practice, current studies suggest a multidisciplinary approach, including both medical and psychosocial treatment options.