- Email: [email protected]
Ovarian reserve, response to gonadotropins, and oocyte maturity in women with malignancy
FERTILITY PRESERVATION Ovarian reserve, response to gonadotropins, and oocyte maturity in women with malignancy Mausumi Das, M.D., Fady Shehata, M.B.B.Ch., M.Sc., Anwar Moria, M.D., Hananel Holzer, M.D., Weon-Young Son, Ph.D., and Togas Tulandi, M.D., M.H.C.M. Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada
Objective: To study the ovarian reserve, ovarian response to gonadotropins, and oocyte maturity in women with cancer undergoing in vitro fertilization (IVF) before chemotherapy or radiotherapy. Design: Case-control study. Setting: University teaching hospital. Patient(s): We evaluated all women with malignancy who underwent fertility preservation from the year 2003 to 2010. We compared 41 women with cancer undergoing IVF treatment with a control group of 48 age-matched women undergoing IVF for male factor infertility with the same protocol. Intervention(s): In vitro fertilization. Main Outcome Measures(s): Ovarian reserve, ovarian response to gonadotropins, number of oocytes retrieved, and oocyte maturity. Result(s): There were no significant differences in age, antral follicle count, serum FSH, total dose of gonadotropins required for stimulation, duration of stimulation, or peak E2 levels on the day of hCG administration between women with cancer and the control group. No significant differences were observed in the number of retrieved oocytes between the malignancy and control groups. The percentages of mature oocytes in patients with hematologic malignancy (83.3%), gynecologic and intestinal malignancy (94%), and brain cancer (86%) and in the control group (82.1%) were similar, as were the fertilization rates. Conclusion(s): In young women with malignancy, ovarian reserve, response to gonadotropins, oocytes retrieved, and oocyte maturity remain unaltered by the neoplastic process. This is in contrast to the impairment of spermatogenesis before therapy in men with cancer. (Fertil Steril 2011;96:122–5. 2011 by American Society for Reproductive Medicine.) Key Words: Fertility preservation, malignancy, cancer, ovarian reserve, IVF, oocyte maturity
The American Cancer Society estimates that 1,529,560 new cancer cases will have been diagnosed in 2010. Of these, 33,980 cases of lymphoma will occur in women (1). Besides lymphoma, other common cancers in young women include leukemia, breast and cervical cancer, and melanoma (1). There is evidence that fertility is a major issue for many young cancer survivors and that the possibility of becoming pregnant subsequent to cancer is a powerful stimulus for young women to get well (2). This has led the American Society of Clinical Oncology (ASCO) to recommend that reproductive-age women with cancer should be counseled regarding fertility preservation methods (3). To preserve fertility and ovarian function, cryopreservation of oocytes, embryo, or ovarian tissue has been performed (4), and the most established option is embryo cryopreservation (3). However, oocyte cryopreservation is gaining increased recognition as a viable alternative to embryo freezing. It involves freezing mature Received February 9, 2011; revised April 2, 2011; accepted April 14, 2011; published online May 14, 2011. M.D. has nothing to disclose. F.S. has nothing to disclose. A.M. has nothing to disclose. H.H. has nothing to disclose. W.-Y.S. has nothing to disclose. T.T. received a research grant from Ethicon. Reprint requests: Togas Tulandi, M.D., M.H.C.M., Department of Obstetrics and Gynecology, McGill University, 687 Pine Avenue West, Montreal, Quebec, Canada, H3A 1A1 (E-mail: [email protected]).
122
oocytes after ovarian stimulation and may be more attractive to some young women because there is no prerequisite for a partner or sperm donor. Several studies have shown that in male patients affected with a malignancy, especially in those with testicular cancer and lymphoma, sperm count and quality are impaired even before the initiation of treatment (5, 6). This may be due to a direct cytotoxic effect of the cancer on testicular function or via alteration of the immunologic response (6). In female patients however, the effect of malignancy on ovarian function is still unclear (7–9). In addition, the few studies on this subject have shown conflicting results. This could be attributed to several factors. In most studies, the number of cancer patients was small, the baseline antral follicle count (AFC) as a measure of ovarian reserve was not estimated, and the patients studied did not undergo the same stimulation protocol. Patients treated with a particular drug were not compared with similar patients. Furthermore, studies have analyzed data for cancer patients as a whole even though each malignancy may affect ovarian function differently. Our objective was to study the ovarian response to gonadotropins and oocyte maturity among presumably fertile women with cancer before undergoing chemotherapy and/or radiation therapy compared with age-matched women undergoing in vitro fertilization (IVF) with the same stimulation protocol. We particularly aimed to study the effect of cancer on ovarian function in
Fertility and Sterility Vol. 96, No. 1, July 2011 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.04.070
hematologic malignancies, because they have been shown to adversely affect pretherapy sperm quality. These findings would provide valuable information for clinicians to more appropriately counsel young patients with cancer who are seeking fertility preservation treatment.
TABLE 1 Type of malignancy in women undergoing IVF for fertility preservation. Type of cancer
MATERIALS AND METHODS Patients We evaluated the medical records of all women with malignancy who underwent IVF for the purpose of fertility preservation from 2003 to 2010 at McGill University Health Centre, Montreal. The study was approved by the Research and Ethics Board of the McGill University Health Centre. During the study period, 51 women who had recently been diagnosed with cancer underwent IVF for fertility preservation before undergoing treatment with gonadotoxic agents. None of these women had a history of infertility. Patients who had received earlier chemotherapy or radiotherapy (n ¼ 7) were excluded from the analysis. Age-matched control groups were selected among women undergoing IVF for male factor infertility. This control group was chosen so that they would be similar to the cancer patients regarding their fertility status before the diagnosis of malignancy. Only patients undergoing their first IVF cycle were included in the analysis. Patients who received aromatase inhibitors or antiestrogen therapy (n ¼ 3) were excluded to avoid confounding variables. Women presenting for fertility preservation underwent intracytoplasmic sperm injection (ICSI) to avoid the risk of fertilization failure with IVF. Patients in the control group underwent ICSI for male factor infertility. Patients with autoimmune conditions who presented for fertility preservation before chemotherapy were also excluded. All patients underwent serum measurements of basal FSH as well as transvaginal ultrasound examination for AFC to estimate ovarian reserve. All investigations, imaging procedures, and IVF cycles were performed before the initiation of chemotherapy or radiation.
Stimulation Protocol All patients and the control group underwent controlled ovarian stimulation with the GnRH antagonist protocol. GnRH antagonist (0.25 mg/d) was commenced when the diameter of the leading follicle was 14 mm and continued until the day of hCG administration. Transvaginal ultrasound and serum E2 measurements were performed throughout the stimulation period and on the day of hCG administration. An hCG trigger was administered when two follicles reached 17 mm in diameter, and ultrasound-guided oocyte retrieval was performed 36 hours later. Mature oocytes were either vitrified or fertilized with the use of ICSI and preserved as vitrified embryos (10). Normal fertilization was documented by the presence of two pronuclei (2PN).
Statistical Analysis We used the Shapiro-Wilks test to evaluate the distribution of the data. Comparisons were analyzed with the use of Student t test or Mann-Whitney U test when appropriate. Proportions were compared with chi-square test or Fisher
No. of patients
Hematologic malignancy Hodgkin lymphoma Non-Hodgkin lymphoma Acute myeloid leukemia Acute lymphocytic leukemia Gynecologic malignancy Cervical cancer Ovarian cancer Vaginal cancer Gastrointestinal malignancy Colon cancer Brain malignancy Astrocytoma High grade glioma Bone malignancies Osteosarcoma Ewing sarcoma Synovial sarcoma Desmoid bone tumor Breast cancer Estrogen receptor–negative breast cancer Other malignancies Melanoma
12 4 2 1 3 3 1 3 4 1 2 1 1 1 1
1
Das. Ovarian stimulation in malignancy. Fertil Steril 2011.
exact test. A P value of < .05 was considered to be significant. Primary outcome measures included the total dose of gonadotropins required to achieve stimulation, the peak serum E2 level on the day of hCG administration, number of oocytes retrieved, and number of mature oocytes. Secondary outcome measures included the baseline FSH and the number of days of stimulation.
RESULTS Patients diagnosed with cancer who underwent controlled ovarian stimulation with the GnRH antagonist protocol (n ¼ 41) were compared with age-matched control patients (n ¼ 48). Table 1 presents the types of malignancy. Hematologic malignancies were predominant (19/41, 46.3%) and consisted mainly of stage 1A and 2A lymphoma. Those with colon cancer had stage 3 disease. There were no significant differences in age, FSH, or AFC between women with malignancies and the control group (Table 2).
TABLE 2 Profile of women with malignancy who underwent IVF for fertility preservation.
Clinical profile No. of patients Age (y) AFC Baseline FSH (IU/L)
Hematologic cancer
Gynecologic and gastrointestinal cancer
Brain cancer
Bone cancer
Control group
19 27.5 1.2 18.6 2.4 6.2 0.5
10 29 2.3 14.3 3.3 6.9 1
5 29.4 0.8 19.8 1.9 7.4 0.5
5 29.5 2.8 21.8 6.4 6.9 1.3
48 30.7 0.3 17.4 1.4 6.8 0.3
Note: Values are mean SEM. There were no statistically significant differences in any of the parameters between the malignancy and control groups. AFC ¼ antral follicle count. Das. Ovarian stimulation in malignancy. Fertil Steril 2011.
Fertility and Sterility
123
48 2,487 229.5 8 0.3 5,440 (2,708–8,017) 12 (7–16) 82.1 (68–93.7) 82.1 (68–93.7) 75 (66.7–89.5) 5 1,850 292.8 8 0.3 3,787 (2,810–6,015) 14 (12–19) 73 (66.7–83) 82 (73.7–94.1) 87.5 (75–100)
Das. Ovarian stimulation in malignancy. Fertil Steril 2011.
Note: There were no statistically significant differences in any of the parameters between the cancer and control groups. a Mean SEM. b Median and interquartile range.
10 2,857 428 9 0.6 3,663 (2,441–7,088) 11 (6–19) 94 (70–100) 94 (90–100) 71.4 (47–83) 19 2,484 313 8 0.5 4,034 (3,202–8,572) 13 (6–16) 75 (60.6–85) 83 (73.3–100) 71.7 (64–100) No. of patients Total dose of gonadotropinsa (IU) No. of days of stimulationa Peak E2 on day of hCG (pg/mL)b No. of oocytes retrievedb MII oocytes on day of oocyte retrieval (%)b Percentage of total MII oocytes (%)b Fertilization rate (%)b
Das et al.
DISCUSSION
5 1,760 222 8 1.4 3,409 (2,849–10,077) 18 (14–25) 78 (70–86) 86 (70.4–88.9) 87.5 (37.5–100)
Control group Bone cancer Brain cancer Gynecologic and gastrointestinal cancer Hematologic cancer Characteristic
of total MII oocytes, and fertilization rate of women with malignancy and control women.
Gonadotropin dose, duration of stimulation, peak E2 level, number of retrieved oocytes, percentage of mature (metaphase II [MII]) oocytes on day of oocyte retrieval, percentage
TABLE 3 124
The total dose of gonadotropins and the duration of stimulation also were similar (Table 3). No significant difference was observed in the median peak E2 level on the day of hCG administration between the malignancy and control groups. There was no instance of ovarian hyperstimulation in either the cancer or the control group. The numbers of retrieved oocytes, the percentages of mature (metaphase II [MII]) oocytes on the day of oocyte retrieval, and the percentages of mature (MII) oocytes vitrified also were similar. In the malignancy group, 18 women opted for oocyte cryopreservation. Of these, 10 women had hematologic malignancies. The fertilization rates in the malignancy and control groups were similar.
Ovarian stimulation in malignancy
Malignancy, especially testicular cancer and lymphomas have been shown to affect sperm count and quality even before treatment (5, 6). Whether lymphomas have a similar effect on ovarian function is unclear. The present study demonstrates that ovarian reserve, response to gonadotropins, number of oocytes retrieved and oocyte maturity are not affected by hematologic and other types of malignancy. These findings are reassuring and could be attributed to the fact that unlike sperm cells, oocytes are mature cells that are arrested in the diplotene stage of the first meiotic division until ovulation and might behave differently from spermatozoa. The results of this study are consistent with and advance the findings of Knopman et al. (8), who showed that the baseline FSH, dose of gonadotropins required for stimulation, peak E2 levels on the day of hCG administration, and the number of oocytes retrieved in cancer patients did not differ from patients undergoing IVF for male factor infertility. However, the number of hematologic malignancies in their series was small and they were not compared separately from the rest of the group. We also observed that the percentages of mature oocytes and fertilization rates in patients with hematologic and other types of cancer were similar to patients without cancer undergoing IVF. In addition, we estimated the AFC in all patients. Indeed, AFC seems to be the most reliable determinant of ovarian response to gonadotropins and number of oocytes retrieved (11). In contrast to our results, Pal et al. (7), in a case series of five patients, observed that although a similar number of oocytes were retrieved in cancer patients, the peak E2 level on the day of hCG, percentage of mature oocytes, and fertilization rate were significantly lower compared with a control group of tubal factor patients. However, the baseline serum FSH level was available for only two patients, both of whom had FSH levels of >10 IU/L. AFC was not recorded. The baseline ovarian reserve therefore may not have been similar to that of the control group. None of the cancer patients had a hematologic malignancy, which comprised the major cancer type in the present study. The similar fertilization rates in our study and more recent studies can also be attributed to the improvement in laboratory techniques over the last decade. In agreement with our findings, Robertson et al. (9) did not observe a significant difference in the amount of gonadotropins needed to stimulate follicular development or in the number of oocytes retrieved in 38 women with cancer or autoimmune disease compared with age-matched controls. In contrast, they noted that the peak E2 levels were significantly lower for women seeking fertility preservation. This could be attributed to the use of letrozole in some cycles. Moreover, all of the patients in the control group did not undergo the same stimulation protocol as the patients with cancer and autoimmune disease. Unlike our findings, Quintero et al. (12) observed that patients with cancer had a longer duration of stimulation (10.5 vs. 9.0 days) Vol. 96, No. 1, July 2011
and needed a higher total dose of gonadotropins, although the numbers of mature oocytes retrieved and fertilization rates were similar. However, they used tamoxifen and letrozole in some of the cancer cycles. In addition, although 46 of the 50 cancer patients underwent ovarian stimulation with the GnRH antagonist protocol, only 20 patients in the control group did so. The AFC, which was similar in both groups in our study, was not estimated in Quintero et al.’s study. Several young women faced with cancer in our study opted for oocyte cryopreservation before undergoing chemotherapy or radiotherapy. Although earlier results in this field were disappointing regarding fertilization and pregnancy rates (13), in recent years success rates have improved with improvement in laboratory techniques, such as vitrification, which decreases the risk of ice crystal formation compared with slow cooling (10, 14). This has led the American Society of Reproductive Medicine to endorse oocyte cryopreservation as a fertility preservation strategy for women with cancer and other illnesses requiring treatments that pose a serious threat to their future fertility (15). Chemotherapy and radiotherapy-induced damage can result in premature ovarian failure and infertility, thereby denying many young women the chance of raising a family of their own (16). Even though menstruation can recommence after chemotherapy, ultrasound assessments frequently demonstrate reduced follicle num-
bers as well as change in markers of ovarian reserve, such as FSH, antimullerian hormone, and inhibin B (17). There are many conditions that require treatment with gonadotoxic agents. For example, non-Hodgkin lymphoma is commonly treated with highly gonadotoxic alkylating agents, such as cyclophosphamide (18). Rectal cancer and Hodgkin disease are usually treated with irradiation (16). Bone-marrow transplant, which is frequently used for many hematologic malignancies, including Hodgkin lymphoma, usually requires pretreatment with high-dose chemotherapy and radiotherapy, resulting in a high incidence of permanent gonadal failure (16). In light of our findings, early referral for fertility preservation before gonadotoxic treatment may allow young women to take advantage of the small window of opportunity that is available to them. In conclusion, the present study shows that in young women with malignancy, including lymphomas, ovarian reserve, response to gonadotropins, number of oocytes retrieved, and oocyte maturity remain unaffected by the neoplastic process. This is in contrast to the pretherapy impairment of spermatogenesis in men with Hodgkin and non-Hodgkin lymphoma. These results are encouraging and will assist clinicians to make appropriate management decisions and help in counseling young patients with cancer who are seeking fertility preservation before gonadotoxic treatment.
REFERENCES 1. American Cancer Society. Cancer facts & figures 2010. Atlanta: American Cancer Society; 2010. 2. Dow KH. Having children after breast cancer. Cancer Pract 1994;2:407–13. 3. Lee SJ, Schover LR, Partridge AH, Patrizio P, Wallace WH, Hagerty K, et al. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 2006;24:2917–31. 4. Tulandi T, Huang JY, Tan SL. Preservation of female fertility: an essential progress. Obstet Gynecol 2008;112:1160–72. 5. van Casteren NJ, Boellaard WP, Romijn JC, Dohle GR. Gonadal dysfunction in male cancer patients before cytotoxic treatment. Int J Androl 2010;33:73–9. 6. Rueffer U, Breuer K, Josting A, Lathan B, Sieber M, Manzke O, et al. Male gonadal dysfunction in patients with Hodgkin’s disease prior to treatment. Ann Oncol 2001;12:1307–11. 7. Pal L, Leykin L, Schifren JL, Isaacson KB, Chang YC, Nikruil N, et al. Malignancy may adversely influence the quality and behaviour of oocytes. Hum Reprod 1998;13:1837–40.
Fertility and Sterility
8. Knopman JM, Noyes N, Talebian S, Krey LC, Grifo JA, Licciardi F. Women with cancer undergoing ART for fertility preservation: a cohort study of their response to exogenous gonadotropins. Fertil Steril 2009;91:1476–8. 9. Robertson AD, Missmer SA, Ginsburg ES. Embryo yield after in vitro fertilization in women undergoing embryo banking for fertility preservation before chemotherapy. Fertil Steril 2011;95:588–91. 10. Chian RC, Huang JY, Gilbert L, Son WY, Holzer H, Cui SJ, et al. Obstetric outcomes following vitrification of in vitro and in vivo matured oocytes. Fertil Steril 2009;91:2391–8. 11. Hsu A, Arny M, Knee AB, Bell C, Cook E, Novak AL, et al. Antral follicle count in clinical practice: analyzing clinical relevance. Fertility and sterility 2011;95:474–9. 12. Quintero RB, Helmer A, Huang JQ, Westphal LM. Ovarian stimulation for fertility preservation in patients with cancer. Fertil Steril 2010;93:865–8. 13. Oktay K, Cil AP, Bang H. Efficiency of oocyte cryopreservation: a meta-analysis. Fertil Steril 2006;86: 70–80.
14. Katayama KP, Stehlik J, Kuwayama M, Kato O, Stehlik E. High survival rate of vitrified human oocytes results in clinical pregnancy. Fertil Steril 2003;80:223–4. 15. ASRM Practice Committee. Response to Rybak and Lieman: elective self-donation of oocytes. Fertil Steril 2009;92:1513–4. 16. Meirow D, Nugent D. The effects of radiotherapy and chemotherapy on female reproduction. Hum Reprod Update 2001;7:535–43. 17. Bath LE, Wallace WH, Shaw MP, Fitzpatrick C, Anderson RA. Depletion of ovarian reserve in young women after treatment for cancer in childhood: detection by anti-mullerian hormone, inhibin B and ovarian ultrasound. Hum Reprod 2003;18:2368–74. 18. Fisher RI, Gaynor ER, Dahlberg S, Oken MM, Grogan TM, Mize EM, et al. Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-Hodgkin’s lymphoma. N Engl J Med 1993;328:1002–6.
125
Objective: To study the ovarian reserve, ovarian response to gonadotropins, and oocyte maturity in women with cancer undergoing in vitro fertilization (IVF) before chemotherapy or radiotherapy. Design: Case-control study. Setting: University teaching hospital. Patient(s): We evaluated all women with malignancy who underwent fertility preservation from the year 2003 to 2010. We compared 41 women with cancer undergoing IVF treatment with a control group of 48 age-matched women undergoing IVF for male factor infertility with the same protocol. Intervention(s): In vitro fertilization. Main Outcome Measures(s): Ovarian reserve, ovarian response to gonadotropins, number of oocytes retrieved, and oocyte maturity. Result(s): There were no significant differences in age, antral follicle count, serum FSH, total dose of gonadotropins required for stimulation, duration of stimulation, or peak E2 levels on the day of hCG administration between women with cancer and the control group. No significant differences were observed in the number of retrieved oocytes between the malignancy and control groups. The percentages of mature oocytes in patients with hematologic malignancy (83.3%), gynecologic and intestinal malignancy (94%), and brain cancer (86%) and in the control group (82.1%) were similar, as were the fertilization rates. Conclusion(s): In young women with malignancy, ovarian reserve, response to gonadotropins, oocytes retrieved, and oocyte maturity remain unaltered by the neoplastic process. This is in contrast to the impairment of spermatogenesis before therapy in men with cancer. (Fertil Steril 2011;96:122–5. 2011 by American Society for Reproductive Medicine.) Key Words: Fertility preservation, malignancy, cancer, ovarian reserve, IVF, oocyte maturity
The American Cancer Society estimates that 1,529,560 new cancer cases will have been diagnosed in 2010. Of these, 33,980 cases of lymphoma will occur in women (1). Besides lymphoma, other common cancers in young women include leukemia, breast and cervical cancer, and melanoma (1). There is evidence that fertility is a major issue for many young cancer survivors and that the possibility of becoming pregnant subsequent to cancer is a powerful stimulus for young women to get well (2). This has led the American Society of Clinical Oncology (ASCO) to recommend that reproductive-age women with cancer should be counseled regarding fertility preservation methods (3). To preserve fertility and ovarian function, cryopreservation of oocytes, embryo, or ovarian tissue has been performed (4), and the most established option is embryo cryopreservation (3). However, oocyte cryopreservation is gaining increased recognition as a viable alternative to embryo freezing. It involves freezing mature Received February 9, 2011; revised April 2, 2011; accepted April 14, 2011; published online May 14, 2011. M.D. has nothing to disclose. F.S. has nothing to disclose. A.M. has nothing to disclose. H.H. has nothing to disclose. W.-Y.S. has nothing to disclose. T.T. received a research grant from Ethicon. Reprint requests: Togas Tulandi, M.D., M.H.C.M., Department of Obstetrics and Gynecology, McGill University, 687 Pine Avenue West, Montreal, Quebec, Canada, H3A 1A1 (E-mail: [email protected]).
122
oocytes after ovarian stimulation and may be more attractive to some young women because there is no prerequisite for a partner or sperm donor. Several studies have shown that in male patients affected with a malignancy, especially in those with testicular cancer and lymphoma, sperm count and quality are impaired even before the initiation of treatment (5, 6). This may be due to a direct cytotoxic effect of the cancer on testicular function or via alteration of the immunologic response (6). In female patients however, the effect of malignancy on ovarian function is still unclear (7–9). In addition, the few studies on this subject have shown conflicting results. This could be attributed to several factors. In most studies, the number of cancer patients was small, the baseline antral follicle count (AFC) as a measure of ovarian reserve was not estimated, and the patients studied did not undergo the same stimulation protocol. Patients treated with a particular drug were not compared with similar patients. Furthermore, studies have analyzed data for cancer patients as a whole even though each malignancy may affect ovarian function differently. Our objective was to study the ovarian response to gonadotropins and oocyte maturity among presumably fertile women with cancer before undergoing chemotherapy and/or radiation therapy compared with age-matched women undergoing in vitro fertilization (IVF) with the same stimulation protocol. We particularly aimed to study the effect of cancer on ovarian function in
Fertility and Sterility Vol. 96, No. 1, July 2011 Copyright ª2011 American Society for Reproductive Medicine, Published by Elsevier Inc.
0015-0282/$36.00 doi:10.1016/j.fertnstert.2011.04.070
hematologic malignancies, because they have been shown to adversely affect pretherapy sperm quality. These findings would provide valuable information for clinicians to more appropriately counsel young patients with cancer who are seeking fertility preservation treatment.
TABLE 1 Type of malignancy in women undergoing IVF for fertility preservation. Type of cancer
MATERIALS AND METHODS Patients We evaluated the medical records of all women with malignancy who underwent IVF for the purpose of fertility preservation from 2003 to 2010 at McGill University Health Centre, Montreal. The study was approved by the Research and Ethics Board of the McGill University Health Centre. During the study period, 51 women who had recently been diagnosed with cancer underwent IVF for fertility preservation before undergoing treatment with gonadotoxic agents. None of these women had a history of infertility. Patients who had received earlier chemotherapy or radiotherapy (n ¼ 7) were excluded from the analysis. Age-matched control groups were selected among women undergoing IVF for male factor infertility. This control group was chosen so that they would be similar to the cancer patients regarding their fertility status before the diagnosis of malignancy. Only patients undergoing their first IVF cycle were included in the analysis. Patients who received aromatase inhibitors or antiestrogen therapy (n ¼ 3) were excluded to avoid confounding variables. Women presenting for fertility preservation underwent intracytoplasmic sperm injection (ICSI) to avoid the risk of fertilization failure with IVF. Patients in the control group underwent ICSI for male factor infertility. Patients with autoimmune conditions who presented for fertility preservation before chemotherapy were also excluded. All patients underwent serum measurements of basal FSH as well as transvaginal ultrasound examination for AFC to estimate ovarian reserve. All investigations, imaging procedures, and IVF cycles were performed before the initiation of chemotherapy or radiation.
Stimulation Protocol All patients and the control group underwent controlled ovarian stimulation with the GnRH antagonist protocol. GnRH antagonist (0.25 mg/d) was commenced when the diameter of the leading follicle was 14 mm and continued until the day of hCG administration. Transvaginal ultrasound and serum E2 measurements were performed throughout the stimulation period and on the day of hCG administration. An hCG trigger was administered when two follicles reached 17 mm in diameter, and ultrasound-guided oocyte retrieval was performed 36 hours later. Mature oocytes were either vitrified or fertilized with the use of ICSI and preserved as vitrified embryos (10). Normal fertilization was documented by the presence of two pronuclei (2PN).
Statistical Analysis We used the Shapiro-Wilks test to evaluate the distribution of the data. Comparisons were analyzed with the use of Student t test or Mann-Whitney U test when appropriate. Proportions were compared with chi-square test or Fisher
No. of patients
Hematologic malignancy Hodgkin lymphoma Non-Hodgkin lymphoma Acute myeloid leukemia Acute lymphocytic leukemia Gynecologic malignancy Cervical cancer Ovarian cancer Vaginal cancer Gastrointestinal malignancy Colon cancer Brain malignancy Astrocytoma High grade glioma Bone malignancies Osteosarcoma Ewing sarcoma Synovial sarcoma Desmoid bone tumor Breast cancer Estrogen receptor–negative breast cancer Other malignancies Melanoma
12 4 2 1 3 3 1 3 4 1 2 1 1 1 1
1
Das. Ovarian stimulation in malignancy. Fertil Steril 2011.
exact test. A P value of < .05 was considered to be significant. Primary outcome measures included the total dose of gonadotropins required to achieve stimulation, the peak serum E2 level on the day of hCG administration, number of oocytes retrieved, and number of mature oocytes. Secondary outcome measures included the baseline FSH and the number of days of stimulation.
RESULTS Patients diagnosed with cancer who underwent controlled ovarian stimulation with the GnRH antagonist protocol (n ¼ 41) were compared with age-matched control patients (n ¼ 48). Table 1 presents the types of malignancy. Hematologic malignancies were predominant (19/41, 46.3%) and consisted mainly of stage 1A and 2A lymphoma. Those with colon cancer had stage 3 disease. There were no significant differences in age, FSH, or AFC between women with malignancies and the control group (Table 2).
TABLE 2 Profile of women with malignancy who underwent IVF for fertility preservation.
Clinical profile No. of patients Age (y) AFC Baseline FSH (IU/L)
Hematologic cancer
Gynecologic and gastrointestinal cancer
Brain cancer
Bone cancer
Control group
19 27.5 1.2 18.6 2.4 6.2 0.5
10 29 2.3 14.3 3.3 6.9 1
5 29.4 0.8 19.8 1.9 7.4 0.5
5 29.5 2.8 21.8 6.4 6.9 1.3
48 30.7 0.3 17.4 1.4 6.8 0.3
Note: Values are mean SEM. There were no statistically significant differences in any of the parameters between the malignancy and control groups. AFC ¼ antral follicle count. Das. Ovarian stimulation in malignancy. Fertil Steril 2011.
Fertility and Sterility
123
48 2,487 229.5 8 0.3 5,440 (2,708–8,017) 12 (7–16) 82.1 (68–93.7) 82.1 (68–93.7) 75 (66.7–89.5) 5 1,850 292.8 8 0.3 3,787 (2,810–6,015) 14 (12–19) 73 (66.7–83) 82 (73.7–94.1) 87.5 (75–100)
Das. Ovarian stimulation in malignancy. Fertil Steril 2011.
Note: There were no statistically significant differences in any of the parameters between the cancer and control groups. a Mean SEM. b Median and interquartile range.
10 2,857 428 9 0.6 3,663 (2,441–7,088) 11 (6–19) 94 (70–100) 94 (90–100) 71.4 (47–83) 19 2,484 313 8 0.5 4,034 (3,202–8,572) 13 (6–16) 75 (60.6–85) 83 (73.3–100) 71.7 (64–100) No. of patients Total dose of gonadotropinsa (IU) No. of days of stimulationa Peak E2 on day of hCG (pg/mL)b No. of oocytes retrievedb MII oocytes on day of oocyte retrieval (%)b Percentage of total MII oocytes (%)b Fertilization rate (%)b
Das et al.
DISCUSSION
5 1,760 222 8 1.4 3,409 (2,849–10,077) 18 (14–25) 78 (70–86) 86 (70.4–88.9) 87.5 (37.5–100)
Control group Bone cancer Brain cancer Gynecologic and gastrointestinal cancer Hematologic cancer Characteristic
of total MII oocytes, and fertilization rate of women with malignancy and control women.
Gonadotropin dose, duration of stimulation, peak E2 level, number of retrieved oocytes, percentage of mature (metaphase II [MII]) oocytes on day of oocyte retrieval, percentage
TABLE 3 124
The total dose of gonadotropins and the duration of stimulation also were similar (Table 3). No significant difference was observed in the median peak E2 level on the day of hCG administration between the malignancy and control groups. There was no instance of ovarian hyperstimulation in either the cancer or the control group. The numbers of retrieved oocytes, the percentages of mature (metaphase II [MII]) oocytes on the day of oocyte retrieval, and the percentages of mature (MII) oocytes vitrified also were similar. In the malignancy group, 18 women opted for oocyte cryopreservation. Of these, 10 women had hematologic malignancies. The fertilization rates in the malignancy and control groups were similar.
Ovarian stimulation in malignancy
Malignancy, especially testicular cancer and lymphomas have been shown to affect sperm count and quality even before treatment (5, 6). Whether lymphomas have a similar effect on ovarian function is unclear. The present study demonstrates that ovarian reserve, response to gonadotropins, number of oocytes retrieved and oocyte maturity are not affected by hematologic and other types of malignancy. These findings are reassuring and could be attributed to the fact that unlike sperm cells, oocytes are mature cells that are arrested in the diplotene stage of the first meiotic division until ovulation and might behave differently from spermatozoa. The results of this study are consistent with and advance the findings of Knopman et al. (8), who showed that the baseline FSH, dose of gonadotropins required for stimulation, peak E2 levels on the day of hCG administration, and the number of oocytes retrieved in cancer patients did not differ from patients undergoing IVF for male factor infertility. However, the number of hematologic malignancies in their series was small and they were not compared separately from the rest of the group. We also observed that the percentages of mature oocytes and fertilization rates in patients with hematologic and other types of cancer were similar to patients without cancer undergoing IVF. In addition, we estimated the AFC in all patients. Indeed, AFC seems to be the most reliable determinant of ovarian response to gonadotropins and number of oocytes retrieved (11). In contrast to our results, Pal et al. (7), in a case series of five patients, observed that although a similar number of oocytes were retrieved in cancer patients, the peak E2 level on the day of hCG, percentage of mature oocytes, and fertilization rate were significantly lower compared with a control group of tubal factor patients. However, the baseline serum FSH level was available for only two patients, both of whom had FSH levels of >10 IU/L. AFC was not recorded. The baseline ovarian reserve therefore may not have been similar to that of the control group. None of the cancer patients had a hematologic malignancy, which comprised the major cancer type in the present study. The similar fertilization rates in our study and more recent studies can also be attributed to the improvement in laboratory techniques over the last decade. In agreement with our findings, Robertson et al. (9) did not observe a significant difference in the amount of gonadotropins needed to stimulate follicular development or in the number of oocytes retrieved in 38 women with cancer or autoimmune disease compared with age-matched controls. In contrast, they noted that the peak E2 levels were significantly lower for women seeking fertility preservation. This could be attributed to the use of letrozole in some cycles. Moreover, all of the patients in the control group did not undergo the same stimulation protocol as the patients with cancer and autoimmune disease. Unlike our findings, Quintero et al. (12) observed that patients with cancer had a longer duration of stimulation (10.5 vs. 9.0 days) Vol. 96, No. 1, July 2011
and needed a higher total dose of gonadotropins, although the numbers of mature oocytes retrieved and fertilization rates were similar. However, they used tamoxifen and letrozole in some of the cancer cycles. In addition, although 46 of the 50 cancer patients underwent ovarian stimulation with the GnRH antagonist protocol, only 20 patients in the control group did so. The AFC, which was similar in both groups in our study, was not estimated in Quintero et al.’s study. Several young women faced with cancer in our study opted for oocyte cryopreservation before undergoing chemotherapy or radiotherapy. Although earlier results in this field were disappointing regarding fertilization and pregnancy rates (13), in recent years success rates have improved with improvement in laboratory techniques, such as vitrification, which decreases the risk of ice crystal formation compared with slow cooling (10, 14). This has led the American Society of Reproductive Medicine to endorse oocyte cryopreservation as a fertility preservation strategy for women with cancer and other illnesses requiring treatments that pose a serious threat to their future fertility (15). Chemotherapy and radiotherapy-induced damage can result in premature ovarian failure and infertility, thereby denying many young women the chance of raising a family of their own (16). Even though menstruation can recommence after chemotherapy, ultrasound assessments frequently demonstrate reduced follicle num-
bers as well as change in markers of ovarian reserve, such as FSH, antimullerian hormone, and inhibin B (17). There are many conditions that require treatment with gonadotoxic agents. For example, non-Hodgkin lymphoma is commonly treated with highly gonadotoxic alkylating agents, such as cyclophosphamide (18). Rectal cancer and Hodgkin disease are usually treated with irradiation (16). Bone-marrow transplant, which is frequently used for many hematologic malignancies, including Hodgkin lymphoma, usually requires pretreatment with high-dose chemotherapy and radiotherapy, resulting in a high incidence of permanent gonadal failure (16). In light of our findings, early referral for fertility preservation before gonadotoxic treatment may allow young women to take advantage of the small window of opportunity that is available to them. In conclusion, the present study shows that in young women with malignancy, including lymphomas, ovarian reserve, response to gonadotropins, number of oocytes retrieved, and oocyte maturity remain unaffected by the neoplastic process. This is in contrast to the pretherapy impairment of spermatogenesis in men with Hodgkin and non-Hodgkin lymphoma. These results are encouraging and will assist clinicians to make appropriate management decisions and help in counseling young patients with cancer who are seeking fertility preservation before gonadotoxic treatment.
REFERENCES 1. American Cancer Society. Cancer facts & figures 2010. Atlanta: American Cancer Society; 2010. 2. Dow KH. Having children after breast cancer. Cancer Pract 1994;2:407–13. 3. Lee SJ, Schover LR, Partridge AH, Patrizio P, Wallace WH, Hagerty K, et al. American Society of Clinical Oncology recommendations on fertility preservation in cancer patients. J Clin Oncol 2006;24:2917–31. 4. Tulandi T, Huang JY, Tan SL. Preservation of female fertility: an essential progress. Obstet Gynecol 2008;112:1160–72. 5. van Casteren NJ, Boellaard WP, Romijn JC, Dohle GR. Gonadal dysfunction in male cancer patients before cytotoxic treatment. Int J Androl 2010;33:73–9. 6. Rueffer U, Breuer K, Josting A, Lathan B, Sieber M, Manzke O, et al. Male gonadal dysfunction in patients with Hodgkin’s disease prior to treatment. Ann Oncol 2001;12:1307–11. 7. Pal L, Leykin L, Schifren JL, Isaacson KB, Chang YC, Nikruil N, et al. Malignancy may adversely influence the quality and behaviour of oocytes. Hum Reprod 1998;13:1837–40.
Fertility and Sterility
8. Knopman JM, Noyes N, Talebian S, Krey LC, Grifo JA, Licciardi F. Women with cancer undergoing ART for fertility preservation: a cohort study of their response to exogenous gonadotropins. Fertil Steril 2009;91:1476–8. 9. Robertson AD, Missmer SA, Ginsburg ES. Embryo yield after in vitro fertilization in women undergoing embryo banking for fertility preservation before chemotherapy. Fertil Steril 2011;95:588–91. 10. Chian RC, Huang JY, Gilbert L, Son WY, Holzer H, Cui SJ, et al. Obstetric outcomes following vitrification of in vitro and in vivo matured oocytes. Fertil Steril 2009;91:2391–8. 11. Hsu A, Arny M, Knee AB, Bell C, Cook E, Novak AL, et al. Antral follicle count in clinical practice: analyzing clinical relevance. Fertility and sterility 2011;95:474–9. 12. Quintero RB, Helmer A, Huang JQ, Westphal LM. Ovarian stimulation for fertility preservation in patients with cancer. Fertil Steril 2010;93:865–8. 13. Oktay K, Cil AP, Bang H. Efficiency of oocyte cryopreservation: a meta-analysis. Fertil Steril 2006;86: 70–80.
14. Katayama KP, Stehlik J, Kuwayama M, Kato O, Stehlik E. High survival rate of vitrified human oocytes results in clinical pregnancy. Fertil Steril 2003;80:223–4. 15. ASRM Practice Committee. Response to Rybak and Lieman: elective self-donation of oocytes. Fertil Steril 2009;92:1513–4. 16. Meirow D, Nugent D. The effects of radiotherapy and chemotherapy on female reproduction. Hum Reprod Update 2001;7:535–43. 17. Bath LE, Wallace WH, Shaw MP, Fitzpatrick C, Anderson RA. Depletion of ovarian reserve in young women after treatment for cancer in childhood: detection by anti-mullerian hormone, inhibin B and ovarian ultrasound. Hum Reprod 2003;18:2368–74. 18. Fisher RI, Gaynor ER, Dahlberg S, Oken MM, Grogan TM, Mize EM, et al. Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-Hodgkin’s lymphoma. N Engl J Med 1993;328:1002–6.
125