Fertility Risk Assessment and Preservation in Male and Female Prepubertal and Adolescent Cancer Patients

Aiming for patient safety indicators in radiation oncology - Results from a systematic literature review as part of the PaSaGeRO study

BACKGROUND

Patient Safety Indicators (PSIs) allow the evaluation of safety levels in healthcare settings. Despite their use in various medical fields, a specific and comprehensive PSI catalogue for radiation oncology (RO) is lacking. The Patient Safety in German Radiation Oncology (PaSaGeRO) study aims for the development of a specific PSI catalogue in radiation oncology.

OBJECTIVES

The primary objective of this systematic literature review as part of the PaSaGeRO study is to identify, formulate, and categorize PSIs specific to RO to bridge existing gaps in comprehensive patient safety evaluation.

METHODS

An electronic search in PubMed included studies from 1989 onwards, in English or German, focusing on safety and quality indicators in RO, patient safety measures, or risk analyses. Exclusions were non-transferable, country-specific measures, techniques exclusive to specific departments, and legally mandated procedures. Additional sources were identified through reference tracking and professional society websites. Two experts independently extracted PSIs from the included references.

RESULTS

Out of 157 included publications and nine secondary sources, we identified and formulated 145 PSIs. These were categorized into patient-specific processes (82, 56%), quality and risk management (42, 28%), human resources (15, 10%), and institutional culture (13, 9%).

CONCLUSION

The hereby developed PSIs provides a base for professionals to systematically evaluate and improve safety practices, addressing previously unmet needs in this field. By offering clear guidance on safety assessment, the catalogue has the potential to drive significant improvements in patient care and safety outcomes in RO. Funded by Deutsche Krebshilfe. Registered in the German Clinical Trials Register (DRKS00034690).

Alkylating agents-induced gonadotoxicity in prepubertal males: Insights on the clinical and preclinical front

Rising cure rates in pediatric cancer patients warrants an increased attention toward the long-term consequences of the diagnosis and treatment in survivors. Chemotherapeutic agents can be gonadotoxic, rendering them at risk for infertility post-survival. While semen cryopreservation is an option that can be provided for most (post)pubertal boys before treatment, this is unfortunately not an option prepubertal in age, simply due to the lack of spermatogenesis. Over the last couple of years, studies have thus focused on better understanding the testis niche in response to various chemotherapeutic agents that are commonly administered and their direct and indirect impact on the germ cell populations. These are generally compounds that have a high risk of infertility and have been classified into risk categories in curated fertility guidelines. However, with it comes the lack of evidence and the challenge of using informative models and conditions most reflective of the physiological scenario, in short, the appropriate study designs for clinically relevant outcomes. Besides, the exact mechanism(s) of action for many of these "risk" compounds as well as other agents is unclear. Understanding their behavior and effect on the testis niche will pave the way for incorporating new strategies to ultimately combat infertility. Of the various drug classes, alkylating agents pose the highest risk of gonadotoxicity as per previously established studies as well as risk stratification guidelines. Therefore, this review will summarize the findings in the field of male fertility concerning gonadotoxicity of akylating agents as a result of chemotherapy exposure.

Fertility status in childhood cancer survivors of hematological malignancies: a systematic review

Stunning advances in treatment modalities implemented in children with hematological malignancies have led to 5-year overall survival rates exceeding 85%. However, this growing population of long-term survivors has raised significant concerns about their fertility status throughout adulthood, while specific treatment- and non-treatment-related factors appear to possibly affect fertility through distinct mechanisms. We aimed to comprehensively review the published literature on the association between treatment-related factors and risk of impaired fertility in childhood hematological cancer survivors. We searched PubMed up to March 2021 to identify eligible studies published during the last two decades. A narrative synthesis of the results was performed, although no meta-analysis was feasible due to the small number of studies and the large heterogeneity of evidence. Five studies on 2020 survivors of childhood leukemia were deemed eligible. The qualitative data synthesis showed significant fertility deficits in survivors treated with cranial radiotherapy and chemotherapy for childhood leukemia. Two studies examined biochemical measures of reduced ovarian reserve, providing some evidence that the levels of anti-Müllerian hormone can be used as a proxy for diminished ovarian reserve. The current findings should facilitate the delivery of age- and gender-appropriate interventions to optimize reproductive outcomes in childhood hematological cancer survivors.

Extremely Active Nano-formulation of Resveratrol (XAR™) attenuates and reverses chemotherapy-induced damage in mice ovaries and testes

BACKGROUND

Fertility preservation and restoration in cancer patients/survivors is the need of present times when increased numbers of patients get cured of cancer but face infertility as a serious side effect. Resveratrol has beneficial effects on chemoablated ovaries and testes in mice but has failed to enter the clinics because of extremely poor bioavailability. The present study was undertaken to evaluate the protective and curative effects of Extremely active Resveratrol (XAR™)- a nano-formulation of resveratrol with significantly improved bioavailability- on mouse ovary and testis after chemotherapy. Effects of XAR™ and FSH were compared on stimulation of follicle growth in adult mice ovaries. XAR™ (25 mg/kg) was administered for two days prior to chemotherapy to study the protective effects on the mouse gonads. XAR™ was also administered for 14 days post chemoablation to study the regenerative effects. Besides effect on numbers of primordial and growing follicles and spermatogenesis, the effect of XAR™ was also evaluated on the transcripts specific for ovarian/testicular stem/progenitor/germ cells, their proliferation, differentiation, meiosis, and the antioxidant indices.

RESULTS

Similar to FSH, XAR™ increased the numbers of primordial follicles (PF) as well as growing follicles. It protected the gonads from the adverse effects of chemotherapy and showed the ability to regenerate non-functional, chemoablated gonads. Besides stimulating follicle growth in adult ovaries similar to FSH, XAR™ also protected the testes from the adverse effects of chemotherapy and improved spermatogenesis. This was accompanied by improved anti-oxidant indices.

CONCLUSIONS

The results of the present study potentiate the use of XAR™ in pilot clinical studies to protect gonadal function during oncotherapy and also regenerate non-functional gonads in cancer survivors by improving antioxidant indices and stem cell-based tissue regeneration.

A Descriptive Study Exploring Semen Quality Among Indian Cancer Patients

Purpose: To descriptively explore semen quality among Indian men with various types of malignancies. We evaluated semen parameters of male patients referred to our hospital before commencing their cancer treatment. Methods: Four hundred sixty-one male patients who were within the age range of 15-50 years were recruited with diagnosed malignancies. Pre-treatment semen analyses were performed on these patients to collect data on the volume, sperm concentration, motility, and normal forms (morphology). These semen parameters were compared between cancer groups (testicular cancer, hematological cancer, and other cancers). Further comparisons were also drawn to World Health Organization (WHO) semen parameter levels (2010, fifth edition) for normal outcomes. Results: There were no notable variations observed in semen volume (mL) and progressive motility (%) between cancer groups. These parameters were within the WHO normal semen criteria. Differences in normal forms (%) between cancer groups were not observed either; however, they were marginally lower compared with the WHO criteria. Sperm concentration was evidently lower in testicular cancer 34 × 10⁶/mL (IQR: 10.1-60 × 10⁶/mL) compared with hematological cancers 66 × 10⁶/mL (IQR: 23-84.21 × 10⁶/mL) and other cancers (IQR: 27-86.3 × 10⁶/mL). Testicular cancer patients also presented with the largest semen disorder diagnosis (Asthenozoospermia, Oligoasthenozoospermia, Oligozoospermia, and Azoospermia) compared with two other groups. Conclusion: Males with testicular cancer have shown to have lower semen quality between cancer groups and compared with WHO criteria, increasing their likelihood of them being infertile. This study further allows us to understand these outcomes, particularly in the Indian subpopulation, propagating changes in guidelines in oncofertility and medical counseling. Clinical Trials Registry-India number: CTRI/2020/09/027720.

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.

Reproductive Care of Childhood and Adolescent Cancer Survivors: A 12-Year Evaluation

Background: Reproductive complications for cancer survivors are identified as one of the top unmet needs in the survivorship period. However, current models of cancer care do not routinely incorporate reproductive follow-up for pediatric or adolescent cancer patients. The Kids Cancer Centre has had a one-stop survivorship clinic that includes the attendance of a gynecologist and fertility specialist for the last 12 years. Methodology: To inform the future development of our reproductive survivorship care, we reviewed the reproductive care our survivorship clinic has provided over a 12-year period, specifically reviewing the electronic and patient records to collect information on the demographics of the patients who used the service and their gonadotoxic risk and associated fertility treatment, their documented reproductive needs and concerns, and information provided on preventative reproductive advice and screening. Main Results: Two hundred seventy-eight patients were seen (397 consultations) for advice and management of reproductive issues, including 189 female patients (68.0%). Survivors' median age at follow-up was 25.0 years (range = 6-50), on average 19.2 years from their primary diagnosis (range = 3-46). The reviewed data had five overarching themes (fertility care, hormone dysfunction, sexual dysfunction, fertility-related psychological distress due to reproductive concerns, and preventative health care), although each theme had a number of components. Patients had on average 2.5 reproductive concerns documented per consultation (range 1-5). The three most commonly documented symptoms or concerns at the initial consultation related to fertility status (43.9%), endocrine dysfunction (35.3%), and contraception advice (32.4%). In patients younger than 25 years, documented discussions were predominately about endocrine dysfunction, fertility status, and contraception, while dominant themes for 26-35-year olds were fertility status, reproductive-related health prevention strategies, contraception, and endocrine dysfunction. Survivors 36-45 years of age prioritized fertility status, pregnancy, and contraception. Fertility preservation (FP) (p = 0.05), preventative health strategies (p = 0.001), and contraception advice (p < 0.001) were more commonly discussed by females than males. Conclusion: Young cancer survivors have multiple ongoing reproductive concerns that change over time. Assessing survivors' reproductive potential following cancer treatment is important as it gives patients who have not completed their family planning an opportunity to explore a possible window to FP or Assisted Reproductive Treatment. Our data can assist in informing the model of care for a reproductive survivorship clinic.

Protective effect of alpha-lipoic acid and omega-3 fatty acids against cyclophosphamide-induced ovarian toxicity in rats

Background and Aim:

Cyclophosphamide therapy is known to be associated with the risk of female infertility as a result of ovarian toxicity. Alpha-lipoic acid (LA) and omega-3 fatty acids are known for their antioxidant and anti-inflammatory activities. The present study investigated the potential protective effect of alpha-LA, omega-3 fatty acids, and its combination against cyclophosphamide-induced ovarian toxicity in rats.

Materials and Methods:

Thirty rats were equally divided into Groups I, II, III, IV, and V. Group I was normal control, wherein the rats were fed with normal feed and water ad libitum. Group II served as cyclophosphamide-induced group, wherein the rats were injected with cyclophosphamide at 75 mg/kg through intraperitoneal route once a week to induce ovarian toxicity. Groups III and IV were treated with alpha-LA at the rate of 25 mg/kg and omega-3 fatty acids at the rate of 400 mg/kg, respectively, in parallel to cyclophosphamide induction as in Group II. Group V animals were coadministered with alpha-LA (25 mg/kg) and omega-3 fatty acids (400 mg/kg) along with cyclophosphamide induction as in Group II. The respective treatments were administered daily through oral route for a period of 30 days. Regularity of estrous cycle was evaluated by vaginal cytology. Post-treatment period, the animals were humanely sacrificed, and the blood samples were subjected to the estimation of follicle-stimulating hormone (FSH) and estrogen. The ovarian tissue was weighed and subjected to histopathology, transmission electron microscopy, estimation of decreased glutathione (GSH), and tumor necrosis factor (TNF)-alpha.

Results:

Rats treated with cyclophosphamide alone manifested irregularity in estrous cycle, increased FSH, and reduced estrogen levels. The ovaries showed decreased GSH and increased TNF-alpha concentrations. Histopathological and transmission electron microscopic analysis of the ovarian follicles revealed degenerative changes. Administration of alpha-LA and omega-3 fatty acids as well as the combination of both the treatments demonstrated significant normalization of the estrous cycle and antioxidant defense mechanism as well as ameliorated the hormonal profile and histological architecture of the ovarian follicles. However, appreciable synergistic efficacy of the combination therapy (alpha-LA+omega-3 fatty acids) with respect to the monotherapies was not observed in the present study.

Conclusion:

The efficacy of alpha-LA and omega-3 fatty acids against cyclophosphamide-induced ovarian toxicity could be attributed to its antioxidant and anti-inflammatory activities that prevented the oxidative damage to the ovaries caused by cyclophosphamide. Hence, our findings suggest that dietary supplementation of alpha-LA and omega-3 fatty acids in women receiving cyclophosphamide therapy could carry potential benefits in preventing cyclophosphamide-induced infertility in childbearing women.

Fluvastatin attenuates doxorubicin-induced testicular toxicity in rats by reducing oxidative stress and regulating the blood–testis barrier via mTOR signaling pathway

Doxorubicin (DOX) is an anthracycline derivative antibiotic that still frequently used in the treatment of solid tumors and hematological malignancies. The clinical use of DOX is largely restricted due to acute and chronic renal, cardiac, hematological, and testicular toxicities. Previous studies have indicated that oxidative stress, lipid peroxidation, and apoptosis in germ cells are the main factors in DOX-induced testicular toxicity, but the entire molecular mechanisms that responsible for DOX-induced testicular damage are not yet fully understood. Fluvastatin is a cholesterol-lowering agent that acts by inhibiting hydroxylmethyl glutaryl coenzyme A, the key enzyme for cholesterol biosynthesis. In addition to its cholesterol-lowering effect, fluvastatin showed an antioxidant effect by cleaning hydroxyl and superoxide radicals and this drug could have a protective effect by acting on the mammalian target of rapamycin (mTOR) signal pathway in testicular damage caused by obesity. This study aimed to investigate the possible protective and therapeutic effects of fluvastatin on the DOX-induced testicular toxicity model by histochemical, immunohistochemical, biochemical, and real-time polymerase chain reaction analyses. The present study indicates that fluvastatin may have a protective and therapeutic effect by removing reactive oxygen species and by regulating the mTOR, connexin 43, and matrix metalloproteinase 9 protein and messenger ribonucleic acid expressions, which play an important role in regulating the blood–testis barrier. On the other hand, the use of fluvastatin as a protective/prophylactic agent was found to be more effective than the use of this drug for treatment. In light of this information, fluvastatin may be a candidate agent that can be used to prevent testicular toxicity observed in men receiving DOX treatment.

The role of flavonoid antioxidant, morin in improving procarbazine-induced oxidative stress on testicular function in rat

BACKGROUND

Procarbazine (PCZ) is an effective chemotherapeutic drug used in the treatment of lymphoma; however, oxidative stress-mediated testicular toxicity is a major side effect. Recently, therapeutic intervention using flavonoids against oxidative stress-related pathologies is gaining more attention. Morin (MOR) is a natural flavonoid with proven antioxidant activity. This study was designed therefore to evaluate the potential role of MOR in ameliorating PCZ-induced testicular oxidative stress and altered sperm quality in rat model.

METHODS

A total of 24 male Wistar rats (170-180 g) were randomly assigned into 4 treatment groups: I, control; II, PCZ (2 mg/kg b.w.); III, PCZ (2 mg/kg b.w.) + MOR (100 mg/kg b.w.) simultaneously administered and IV, MOR (100 mg/kg b.w.), and all treatments lasted 14 days.

RESULTS

PCZ treatment displayed significant reduction in sperm number, sperm motility, percentage normal sperm cells, and daily sperm production rate. Meanwhile the activities of testicular enzymes: gamma-glutamyl transferase, acid phosphatase, and lactate dehydrogenase were significantly altered in the PCZ group compared to control. Furthermore, PCZ caused a significant reduction in levels of glutathione and ascorbic acid as well as activities superoxide dismutase, catalase, glutathione peroxidase, and glutathione S-transferase in the testes of PCZ-treated rats. A significant increase in testicular malondialdehyde level was also observed in the PCZ group. MOR treatment, however, significantly restored the altered sperm parameters and biochemical markers in the testis.

CONCLUSIONS

Our data suggest that MOR administration protected against PCZ-induced testicular and spermatotoxicity in rat, by improving testicular antioxidant system.

Naringenin palliates cisplatin and doxorubicin gonadal toxicity in male rats

Cisplatin (CP) and doxorubicin (DX) can cause testicular injury by inducing oxidative/nitrosative stress, inflammation, and apoptosis, Naringenin (NG) has antioxidant, antinitrative, anti-inflammatory, and anti-apoptotic effects. This study investigated the potential ability of NG to block gonadotoxicity induced CP and DX in male rats. The rats received one injection of either CP (10 mg/kg, i.p.) or DX (15 mg/kg, i.p.), and treated with NG (50 mg/kg/day, p.o.) for 10 days beginning 6 days prior to CP and DX administration. NG significantly prevented the decreases of serum testosterone and inhibin B in rats received CP and DX. Additionally, NG significantly decreased the elevated testicular malondialdehyde, tumor necrosis factor-α/interleukin-10 ratio, and caspase-3 in CP- and DX-treated rats. NG also significantly raised the decreased testicular Bcl-2/Bax ratio, and total antioxidant status in CP- and DX-challenged rats. In addition, NG significantly increased P-glycoprotein level in testes of rats received CP and DX. Moreover, NG significantly decreased the testicular histopathological injury, and immunohistochemical expression of inducible nitric oxide synthase induced by CP and DX in rat testes. It was concluded that NG impeded gonadotoxicity of CP and DX in male rats by mitigating oxidative stress, nitrosative stress, inflammation, and apoptosis.

Triptorelin for Fertility Preservation in Adolescents Treated With Chemotherapy for Cancer

BACKGROUND

Triptorelin, a gonadotropin releasing hormone analogue, can be administered to postpubertal female individuals with cancer who receive chemotherapy to obtain menstrual suppression and decrease the risk of hemorrhage caused by thrombocytopenia. Our goal was to assess whether triptorelin also has a protective role against the gonadotoxicity of chemotherapy.

PATIENTS AND METHODS

This retrospective observational study includes all postmenarchal female patients who presented to our Unit from 2000 to 2015 and received chemotherapy for cancer. They were administered depot triptorelin. We evaluated long-term ovarian function in order to detect clinical signs of ovarian damage, miscarriages, and pregnancies. Laboratory follow-up consisted in dosing serum follicle stimulating hormone, luteinizing hormone, prolactin, estradiol, and progesterone. Ultrasound of the ovaries was performed as well.

RESULTS

Of 36 evaluable patients, 9 received hematopoietic stem cell transplantation (HSCT). The remaining 27 patients maintained normal ovarian function at clinical, laboratory, and ultrasound assessment. Five of them achieved spontaneous physiological pregnancy. Four of the 9 patients who underwent HSCT developed premature ovarian failure.

CONCLUSION

Our study suggests that gonadotropin releasing hormone-a administered during chemotherapy can prevent premature ovarian failure in patients treated without HSCT and that it is not enough to preserve the ovarian function during HSCT. Hence, a prospective randomized trial with a larger population would be recommended.

Fertility Preservation in Pediatric Oncology Patients: New Perspectives

Over the past 30 years, advances in antineoplastic treatment led to a significant increase in the survival of patients with childhood cancer. In Europe and the United States, 82% of children, adolescents, and young adults survive 5 years from the cancer diagnosis and the majority achieves long-term survival into adulthood. The impact of cancer therapy on fertility is related to the age of the patient and to the duration, dose/intensity, and type of treatment. Exposure to chemotherapy or to radiation to gonads or pituitary brings long-term complications of cancer-directed therapies that include effects on reproductive capacity. Different methods to preserve fertility can be offered. In prepubertal women, ovarian tissue freezing, in vitro maturation, and surgical movement of ovaries outside the field of irradiation are still experimental. In pubertal and postpubertal women, oocyte-embryo freezing is an established option. In men, the options are sperm cryopreservation, gonadal transposition, and testicular tissue or spermatogonial cryopreservation and reimplantation. Fertility risks and provision of strategies to minimize cancer treatment impact fertility include discussion of the tail of the option before cancer treatment. Having to make a decision in a limited time, while still coming to terms with a potentially life-threatening diagnosis, can cause patients to feel overwhelmed. To date, there are no uniform guidelines on how to approach this problem, so it is important to be aware of it for proper clinical practice.

The antineoplastic busulphan impairs peritubular and Leydig cells, and vitamin B12 stimulates spermatogonia proliferation and prevents busulphan-induced germ cell death

Busulphan (Bu), an alkylating agent used for bone marrow and spermatogonial stem cell transplantation (SSCT), impairs Sertoli (SC) cells, which are necessary for the spermatogonial stem cell (SSC) homing during transplantation. As Leydig (LC) and peritubular myoid (PMC) cells are essential for SC support and maintenance of spermatogonial niche, we evaluated the impact of Bu on the LC and PMC structural integrity. Vitamin B₁₂ (B₁₂) has demonstrated beneficial effects against drug-induced testicular changes; thus, we also examined whether this vitamin is able to stimulate spermatogonia mitotic activity and prevent Bu-induced germ cell death. Rats received 10mg/kg of Bu in the 1st and 4th days, and daily B₁₂ supplementation during Bu treatment and for 6days after the last injection of Bu (Bu-6d), totaling 10days of treatment. Other animals received the same treatment as Bu-6d, and B₁₂ supplementation (Bu+7dB₁₂) or saline (Bu+7dS) for 7 more days, totaling 17days of treatment. Serum testosterone levels were measured. In the historesin-embedded testis sections, the seminiferous tubule and epithelial areas were measured, and the number of spermatogonia and PMC was quantified. Actin and 17β-HSD6 immunofluorescence was detected, and the number of TUNEL-positive LC and germ cells was computed. In Bu-6d, PMC number reduced, and a weak actin immunoexpression and death in these cells was observed. The testosterone levels reduced, and the interstitial tissue showed a weak 17β-HSD6 immunoexpression and increased number of TUNEL-positive LC. In Bu+7dB₁₂, the number of spermatogonia was higher than in Bu-6d and Bu+7dS, and the number of TUNEL-positive germ cells was significantly lower than in Bu+7dS. Bu exerts a harmful impact on PMC and LC, reducing the testosterone levels. Vitamin B₁₂ prevents significantly Bu-induced germ cell death and stimulates spermatogonia proliferation, being a useful strategy for the enrichment of SSC in vitro and an adjuvant therapy for spermatogenesis recovery in oncologic patients.