1
|
Roof KA, Andre KE, Modesitt SC, Schirmer DA. Maximizing ovarian function and fertility following chemotherapy in premenopausal patients: Is there a role for ovarian suppression? Gynecol Oncol Rep 2024; 53:101383. [PMID: 38633671 PMCID: PMC11021951 DOI: 10.1016/j.gore.2024.101383] [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: 02/28/2024] [Revised: 03/28/2024] [Accepted: 03/29/2024] [Indexed: 04/19/2024] Open
Abstract
As more premenopausal patients undergo fertility preserving cancer treatments, there is an increased need for fertility counseling and ovarian sparing strategies. Many patients receive gonadotoxic chemotherapeutic agents which can put them at risk of primary ovarian insufficiency or profoundly diminished ovarian reserve. Traditionally, estradiol and follicle stimulating hormone (FSH) values have been used to evaluate ovarian function but more recently, reproductive endocrinologists have been proponents of anti-mullerian hormone (AMH) as a validated measure of ovarian potential. While the gold standard for fertility preservation remains oocyte cryopreservation, data suggest there may be additional interventions that can mitigate the gonadotoxic effects of chemotherapeutic agents. The main objectives of this focused review were to quantify the risk of primary ovarian failure associated with the most common chemotherapies used in treatment of gynecologic cancers and to evaluate and recommend potential interventions to mitigate toxic effects on ovarian function. Chemotherapeutic agents can cause direct loss of oocytes and primordial follicles as well as stromal and vascular atrophy and the extent is dependent upon mechanism of action and age of the patient. The risk of ovarian failure is the highest with alkylating agents (42.2 %), anthracyclines (<10-34 % in patients under 40 years versus 98 % in patients aged 40-49), taxanes (57.1 %) and platinum agents (50 %). Multiple trials demonstrate that gonadotropin releasing hormone (GnRH) agonists, when administered concurrently with chemotherapy, may have protective effects, with more patients experiencing resumption of a regular menstruation pattern and recovering ovarian function more quickly post-treatment. Premenopausal patients receiving chemotherapy for the treatment of gynecologic cancers should receive adequate counseling on the potential adverse effects on their fertility. Although oocyte cryopreservation remains the gold standard for fertility preservation, there is some evidence to suggest that GNRH agonists could help maintain and preserve ovarian function and should be considered.
Collapse
Affiliation(s)
- Kelsey A. Roof
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Kerri E. Andre
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | - Susan C. Modesitt
- Division of Gynecologic Oncology, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| | - D. Austin Schirmer
- Division of Reproductive Endocrinology, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, United States
| |
Collapse
|
2
|
Kabirian R, Franzoi MA, Havas J, Coutant C, Tredan O, Levy C, Cottu P, Dhaini Mérimèche A, Guillermet S, Ferrero JM, Giacchetti S, Petit T, Dalenc F, Rouanet P, Everhard S, Martin AL, Pistilli B, Lambertini M, Vaz-Luis I, Di Meglio A. Chemotherapy-Related Amenorrhea and Quality of Life Among Premenopausal Women With Breast Cancer. JAMA Netw Open 2023; 6:e2343910. [PMID: 37971739 PMCID: PMC10654794 DOI: 10.1001/jamanetworkopen.2023.43910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/28/2023] [Indexed: 11/19/2023] Open
Abstract
Importance Younger survivors of breast cancer frequently report more treatment-related symptoms, mostly related to the menopausal transition. Objective To assess factors associated with chemotherapy-related amenorrhea (CRA) and to evaluate its association with long-term quality of life (QOL). Design, Setting, and Participants The prospective, longitudinal Cancer Toxicities Study, a multicenter French cohort study, includes women with a diagnosis of stage I to III breast cancer and collects data approximately yearly after diagnosis. The current study reports outcomes up to 4 years after diagnosis for participants enrolled from 2012 to 2017. Participants included premenopausal women younger than 50 years treated with chemotherapy and not receiving adjuvant ovarian function suppression. Data analysis was performed from September 2021 to June 2023. Exposures Clinical, socioeconomic, tumor, and treatment characteristics assessed at diagnosis (for the analysis of factors associated with CRA) and persistent CRA (for the QOL analysis). Main Outcomes and Measures The main outcome of interest was CRA at year 1 (Y1), year 2 (Y2), and year 4 (Y4) after diagnosis. Generalized estimating equations assessed associations of exposure variables with CRA. In the QOL analysis, QOL at Y4 (assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaires C30 and BR23) was the outcome of interest. Multivariable random-effect mixed models assessed the association of persistent CRA (ie, never recovering menses after treatment) with QOL. Results Among 1636 women, the mean (SD) age at diagnosis was 42.2 (5.6) years. Overall, 1242 of 1497 women (83.0%) reported CRA at Y1, 959 of 1323 women (72.5%) reported it at Y2, and 599 of 906 women (66.1%) reported it at Y4. Older age vs 18 to 34 years (adjusted odds ratio [OR] for 35 to 39 years, 1.84 [95% CI, 1.32 to 2.56]; adjusted OR for 40 to 44 years, 5.90 [95% CI, 4.23 to 8.24]; and adjusted OR for ≥45 years, 21.29 [95% CI, 14.34 to 31.61]) and receipt of adjuvant tamoxifen (adjusted OR, 1.97 [95% CI, 1.53 to 2.53]) were associated with higher likelihood of CRA. In the QOL analysis, 416 of 729 women (57.1%) had persistent CRA. However, late menses recovery among women aged 18 to 34 years with no menses at Y2 were reported by 11 of 21 women (52.4%) between Y2 and Y4. Persistent CRA was associated with worse insomnia (mean difference vs recovery at any time, 9.9 points [95% CI, 3.2 to 16.5 points]; P = .004), systemic therapy-related adverse effects (mean difference, 3.0 points [95% CI, 0.2 to 5.8 points]; P = .04), and sexual functioning (mean difference, -9.2 points [95% CI, -14.3 to -4.1 points]; P < .001) at Y4. Conclusions and Relevance In this cohort study of premenopausal women with breast cancer, persistent CRA was common, although some women recovered menses late, and was associated with worse long-term QOL. This study can help inform risk communication, personalized counseling, and early supportive care referrals for such patients.
Collapse
Affiliation(s)
- Rayan Kabirian
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
- Sorbonne Université, Paris, France
| | - Maria Alice Franzoi
- INSERM Unit 981, Molecular Predictors and New Targets in Oncology, Gustave Roussy, Villejuif, France
| | - Julie Havas
- INSERM Unit 981, Molecular Predictors and New Targets in Oncology, Gustave Roussy, Villejuif, France
| | | | | | | | | | - Asma Dhaini Mérimèche
- Institut de Cancérologie de Lorraine–Alexis Vautrin, Vandœuvre-lès-Nancy, France
- Now with Centre Hospitalier de Lunéville-Ghemm, Pôle Mère-Enfant, Lunéville, France
| | | | | | | | - Thierry Petit
- Centre Paul Strauss Centre de Lutte Contre le Cancer, Strasbourg, France
| | | | | | | | | | - Barbara Pistilli
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
| | - Matteo Lambertini
- Department of Internal Medicine and Medical Specialties, School of Medicine University of Genova, Genova, Italy
- Department of Medical Oncology, UO Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Ines Vaz-Luis
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
- INSERM Unit 981, Molecular Predictors and New Targets in Oncology, Gustave Roussy, Villejuif, France
- Département Interdisciplinaire d’Organisation des Parcours Patients, Gustave Roussy, Villejuif, France
| | - Antonio Di Meglio
- Department of Medical Oncology, Gustave Roussy, Villejuif, France
- INSERM Unit 981, Molecular Predictors and New Targets in Oncology, Gustave Roussy, Villejuif, France
| |
Collapse
|
3
|
Zhao P, Guo C, Du H, Xiao Y, Su J, Wang X, Yeung WSB, Li G, Wang T. Chemotherapy-induced ovarian damage and protective strategies. HUM FERTIL 2023; 26:887-900. [PMID: 38054300 DOI: 10.1080/14647273.2023.2275764] [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: 03/01/2023] [Accepted: 10/14/2023] [Indexed: 12/07/2023]
Abstract
More than 9.2 million women worldwide suffer from cancer, and about 5% of them are at reproductive age. Chemotherapy-induced impairment of fertility affects the quality of life of these women. Several chemotherapeutic agents have been proven to cause apoptosis and autophagy by inducing DNA damage and cellular stress. Injuries to the ovarian stroma and micro-vessel network are also considered as pivotal factors resulting in ovarian dysfunction induced by chemotherapeutic agents. Primordial follicle pool over-activation may also be the mechanism inducing damage to the ovarian reserve. Although many studies have explored the mechanisms involved in chemotherapy-induced reproductive toxicity, the exact molecular mechanisms have not been elucidated. It is essential to understand the mechanisms involved in ovarian damage, in order to develop potential protective treatments to preserve fertility. In this article, we reviewed the current knowledge on the mechanism of chemotherapy-induced ovarian damage and possible protective strategies that prevent the ovary from such damages.
Collapse
Affiliation(s)
- Peikun Zhao
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Chenxi Guo
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Huijia Du
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Yuan Xiao
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Jiaping Su
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Xiaohui Wang
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Willian S B Yeung
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| | - Guangxin Li
- Department of Breast and Thyroid Surgery, Peking University Shenzhen Hospital, Shenzhen, PR China
| | - Tianren Wang
- Shenzhen Key Laboratory of Fertility Regulation, Reproductive Medicine Center, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China
| |
Collapse
|
4
|
Hong YH, Park C, Paik H, Lee KH, Lee JR, Han W, Park S, Chung S, Kim HJ. Fertility Preservation in Young Women With Breast Cancer: A Review. J Breast Cancer 2023; 26:221-242. [PMID: 37387349 DOI: 10.4048/jbc.2023.26.e28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 07/01/2023] Open
Abstract
Fertility preservation is a major concern in young patients diagnosed with breast cancer and planning to receive multimodality treatment, including gonadotoxic chemotherapy with or without age-related decline through long-term endocrine therapy. Most breast cancer patients undergo multimodality treatments; many short-term and long-term side effects arise during these therapies. One of the most detrimental side effects is reduced fertility due to gonadotoxic treatments with resultant psychosocial stress. Cryopreservation of oocytes, embryos, and ovarian tissue are currently available fertility preservation methods for these patients. As an adjunct to these methods, in vitro maturation or gonadotropin-releasing hormone agonist could also be considered. It is also essential to communicate well with patients in the decision-making process on fertility preservation. It is essential to refer patients diagnosed with breast cancer on time to fertility specialists for individualized treatment, which may lead to desirable outcomes. To do so, a multimodal team-based approach and in-depth discussion on the treatment of breast cancer and fertility preservation is crucial. This review aims to summarize infertility risk related to currently available breast cancer treatment, options for fertility preservation and its details, barriers to oncofertility counseling, and psychosocial issues.
Collapse
Affiliation(s)
- Yeon Hee Hong
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Changhee Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Haerin Paik
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Hun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
| | - Jung Ryeol Lee
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Wonshik Han
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seho Park
- Division of Breast Surgery, Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Seockhoon Chung
- Department of Psychiatry, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Hee Jeong Kim
- Division of Breast Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| |
Collapse
|
5
|
Levi M, Shalgi R, Ben-Aharon I. Pretreatment with gonadotropin-releasing hormone antagonist protects against chemotherapy-induced testicular damage 'in mice. Ther Adv Med Oncol 2022; 14:17588359221113274. [PMID: 36225594 PMCID: PMC9549199 DOI: 10.1177/17588359221113274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/27/2022] [Indexed: 11/15/2022] Open
Abstract
Background Testicular toxicity following chemotherapy is of increasing importance with the continuous improvement of survival rates. Gonadotropin-releasing hormone (GnRH) was suggested to protect testis against such toxicity; however, its suppressive quality and mechanism of action are still unclear. We examined whether and how pretreatment with GnRH antagonist protects against the testicular damage caused by chemotherapy. Methods Mature male mice were injected subcutaneously eight times in 2-day intervals with either saline or GnRH antagonist (Cetrotide; 1 g/mg), followed by an intraperitoneal injection with either saline or cyclophosphamide (CTX;100 mg/kg BW) and sacrificed 2 weeks or 3 months later. Testicular weight, epididymis weight, epididymal sperm count and sperm motility were measured. Serum anti-Müllerian hormone (AMH) was measured by enzyme-linked immunosorbent assay. Immunohistochemistry (Ki-67), immunofluorescence (PCNA, CD34), terminal transferase-mediated deoxyuridine 5-triphosphate nick-end labeling (TUNEL) and computerized analysis were performed to examine testicular proliferation, apoptosis and vascularization. Quantitative real-time PCR was used to assess the amount of spermatogonial reserve (Id4 and Gfra1 mRNAs). Results Pretreatment with GnRH antagonist transiently reduced testicular weight, epididymal weight, germinal proliferation and sperm count; it also abolished the permanent long-term effect of CTX on these parameters and prevented cyclophosphamide-induced testicular toxicity characterized by apoptosis and serum AMH increase and irreversible loss of spermatogonial reserve. Conclusions Our findings imply that pretreatment with GnRH antagonist temporarily reduces spermatogenesis and may be used as pretreatment for reducing chemotherapeutic testicular toxicity.
Collapse
Affiliation(s)
- Mattan Levi
- Department of Cell and Developmental Biology,
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- IVF Lab Director, IVF unit, Meir Medical
Center, 59 Tchernichovsky st. Kfar Saba 4428163, Israel
| | - Ruth Shalgi
- Department of Cell and Developmental Biology,
Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Ben-Aharon
- Division of Oncology, Rambam Health Care
Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa,
Israel
| |
Collapse
|
6
|
Rosario R, Cui W, Anderson RA. Potential ovarian toxicity and infertility risk following targeted anti-cancer therapies. REPRODUCTION AND FERTILITY 2022; 3:R147-R162. [PMID: 35928672 PMCID: PMC9346327 DOI: 10.1530/raf-22-0020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Unlike traditional chemotherapy agents which are generally cytotoxic to all cells, targeted anti-cancer therapies are designed to specifically target proliferation mechanisms in cancer cells but spare normal cells, resulting in high potency and reduced toxicity. There has therefore been a rapid increase in their development and use in clinical settings, including in curative-intent treatment regimens. However, the targets of some of these drugs including kinases, epigenetic regulatory proteins, DNA damage repair enzymes and proteasomes, have fundamental roles in governing normal ovarian physiology. Inhibiting their action could have significant consequences for ovarian function, with potentially long-lasting adverse effects which persist after cessation of treatment, but there is limited evidence of their effects on reproductive function. In this review, we will use literature that examines these pathways to infer the potential toxicity of targeted anti-cancer drugs on the ovary. Lay summary Compared to traditional chemotherapy agents, anti-cancer therapies are thought to be highly effective at targeting cancer cells but sparing normal cells, resulting in reduced drug side effects. However, many of processes within the cells that these drugs affect are also important for the ovary to work normally, so suppressing them in this way could have long-lasting implications for female fertility. This review examines the potential toxicity of anti-cancer therapies on the ovary.
Collapse
Affiliation(s)
- Roseanne Rosario
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Wanyuan Cui
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,The Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Richard A Anderson
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
7
|
Lambertini M, Marrocco C, Spinaci S, Demeestere I, Anderson RA. Risk of gonadotoxicity with immunotherapy and targeted agents remains an unsolved but crucial issue. Eur J Clin Invest 2022; 52:e13779. [PMID: 35342940 DOI: 10.1111/eci.13779] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/15/2022] [Accepted: 03/26/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Matteo Lambertini
- Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genova, Italy
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Camilla Marrocco
- Department of Medical Oncology, U.O. Clinica di Oncologia Medica, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Stefano Spinaci
- Division of Breast Surgery, Ospedale Villa Scassi, Genova, Italy
| | - Isabelle Demeestere
- Fertility clinic, CUB-Erasme Hospital, Université Libre de Bruxelles (U.L.B.), Brussels, Belgium
| | - Richard A Anderson
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
| |
Collapse
|
8
|
Levi M, Ben-Aharon I, Shalgi R. Irinotecan (CPT-11) Treatment Induces Mild Gonadotoxicity. FRONTIERS IN REPRODUCTIVE HEALTH 2022; 4:812053. [PMID: 36303648 PMCID: PMC9580821 DOI: 10.3389/frph.2022.812053] [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: 11/09/2021] [Accepted: 02/15/2022] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Gonadal toxicity following chemotherapy is an important issue among the population of young cancer survivors. The inhibitor of DNA topoisomerase I, irinotecan (CPT-11), is widely used for several cancer types. However, little is known about the effect of irinotecan on the fertility of both genders. Thus, the aim of the present study was to evaluate irinotecan gonadotoxicity, using a mouse model. METHODS Mature male and female mice were injected intraperitoneally with either saline (), irinotecan (100 mg/kg) or cyclophosphamide (100 mg/kg); and sacrificed one week or three months later for an acute or long-term toxicity assessment, respectively. We used thorough and advanced fertility assessment by already established methods: Gonadal and epididymal weights, as well as sperm count and sperm motility were determined; serum anti-Müllerian hormone (AMH) was measured by ELISA. Immunohistochemistry (Ki-67), immunofluorescence (PCNA, CD34), terminal transferase-mediated deoxyuridine 5-triphosphate nick-end labeling (TUNEL) and computerized analysis were performed to examine gonadal proliferation, apoptosis and vascularization. qPCR was used to assess the amount of testicular spermatogonia (Id4 and Gafra1 mRNA) and ovarian primordial oocytes reserves (Sohlh2, Nobox and Figla mRNA). RESULTS Females: Irinotecan administration induced acute ovarian apoptosis and decreased vascularity, as well as a mild, statistically significant, long-term decrease in the number of growing follicles, ovarian weight, and ovarian reserve. Males: Irinotecan administration caused an acute testicular apoptosis and reduced testicular spermatogenesis, but had no effect on vascularity. Irinotecan induced long-term decrease of testicular weight, sperm count and testicular spermatogonia and caused elevated serum AMH. CONCLUSION Our findings imply a mild, though irreversible effect of irinotecan on mice gonads.
Collapse
Affiliation(s)
- Mattan Levi
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- IVF Unit, Meir Medical Center, Kfar Saba, Israel
| | - Irit Ben-Aharon
- Division of Oncology, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ruth Shalgi
- Department of Cell and Developmental Biology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|