fertility preservation in cancer patients
TRANSCRIPT
Fertility Preservationin Cancer Patient
Marwan Al-Halabi MD. PhDProfessor in Faculty of Medicine Damascus - University
And
Medical DirectorOrient Hospital assisted Reproduction center Damascus – Syria
Introduction
Increase incidence of cancer during the reproductive age.
Survival and cure rates of cancer are improving.
One in 1000 adults is a survivor of childhood cancer.
Better attention has been paid to prevention of reproductive failure.
Increasing demand for fertility preserving interventions.
Childhood CA Survival Rate
Factors to Consider
Desire of patient to retain fertility potential
Age, obstetrical history, family history, history of
infertility
Extent of the patient’s cancer
Optimal cancer therapy should always supersede
fertility preservation
Six distinct issues should be considered
The risk of sterility with the proposed treatment program
The overall prognosis for the patient
The potential risks of delaying chemotherapy
The impact of any future pregnancy upon the risk of tumor recurrence
The impact of any required hormonal manipulation on tumor itself
The possibility of tumor contamination of the harvested tissue
The Forgotten Female?
Studies suggest that only
about half of oncologists
discuss fertility preservation
with their patients
ASRM Guidelines
The ASRM report therefore offers guidelines
to cancer and fertility specialists to assist
them in preserving fertility in cancer
patients and in facilitating reproduction
after treatment.
Cancer specialists should inform patients about
these options
refer them to fertility specialists.
counseling by a qualified geneticist
ASRM Guidelines
should not deny cancer patients assistance with reproduction??.
An Expected Shortened Life
Cancer Treatment&
Fertility
Chemo – Therapy
Fallicular destruaction .
Ovarian Fibrosis .
Premature Ovarian Failure
Reduced E2 and P4 Levels
13
Temporal intervals in folliculogenesis
Ovulation
Differential sensitivity of different cellular components of the ovary
Impaire follicular maturation.
Deplete primordial follicles.
Effects of cancer treatment onmale fertility
Agents Effect on sperm•Radiation to the testes, Chlorambucil, Cyclophosphamide, Procarbazine, Melphalan, Cisplatin
Prolonged azoospermia
•BCNU, CCNU Azoospermia in adulthood after treatment before puberty
•Busulfan, Ifosfamide, BCNU, Nitrogen Mustard, Actinomycin D
Azoospermia likely, but always given with other highly sterilizing agents
•Carboplatin Prolonged azoospermia not often observed at indicated dose
•Doxorubicin, Thiotepe, Cytosine arabinoside, Vinblastine, Vincristine
Can be additive with above agents in causing prolonged azoospermia, but cause only temporary reductions in counts when used alone
•Amacrine, Bleomycine, Dacarbazine, Daunorubicin, Epirubicin, Etoposide, Fludarabine, 5-Fluorouracil, 6-Mercaptopurine, Methotrexate, Mitoxantrone, Thioguanine
Only temporary reductions in counts at doses used in conventional regimens, but additive effects are possible
•Newer agents ?
Lee et al. JCO, 2006
Degree of Risk Treatment
High risk(>80%)
•Hematopoietic stem cell transplantation with cyclophosphamide/total body irradiation or cyclophosphmide/busulfan•External beam radiation to a field that includes the ovaries•CMF, CEF, CAF x 6 cycles in women age 40 and older
Intermediate risk •CMF, CEF, CAF x 6 cycles in women age 30-39•AC x 4 in women age 40 and older
Lower risk (<20%)
•CHOP X 4-6 cycles•CVP•AML therapy (anthracycline/cytarabine)•ALL therapy (multi-agent)•CMF, CEF, CAF x 6 cycles in women age less than 30
Very low or no risk
•Vincristine•Methotrexate•5-fluorouracil
?•Taxanes•Oxaliplatin•Irinotecan•Monoclonal antibodies•Tyrosine kinase inhibitors
Risks of Permanent POF after Chemotherapy & Radiotherapy
Lee et al. JCO, 2006
Factors affecting the extent of radiotherapy induced gonadotoxicity
1. Patient’s age.
2. Dose of radiation (Breaking point 300cGy).
3. Extent.
4. Type of radiation (abdominal, pelvic external beam, brachytherapy).
5. Fractionation of the total dose.
Effect of radiation dose and age on ovarian function
Ovarian dose (cGy) Risk of ovarian failure
60 No deleterious effect 150 No deleterious effect in young
women ; some risk for sterilization in women older than 40
250-500 In women aged 15-40, 60%permanently sterilized; remainder may suffer temporary amenorrhea. In women older than 40, 100%permanently sterilized
500-800 In women aged 15-40, 60%-70%permanently sterilized; remaindermay experience temporary amenorrhea. No data available for women over 40 .
>800 100% permanently sterilized
Break point for radiation is around 300cGy
11-13% had POF <300cGy.
60-63% had POF >300cGy.
>6Gy irreversible ovarian failure.
< 2Gy 50% of the oocyte population is destroyed.
Factors affecting the extent of chemotherapyinduced gonadotoxicity.
Type, duration, dose.Gonatotoxicity induced by chemotherapy is almost irreversible.
(• decreased number of follicles to absent follicles)(• fibrosis )
Amenorrhea ranges 0-100 %– younger age group 21 -71%– older age group 49 - 100%
The risk of gonadal damage increases with age (lower number of oocytes).Temporary amenorrhea or permanent.
Effect of age on risk of premature ovarian failure
indicator of ovarian damage
The best biochemical indicator of ovarian damage and failure
is :
FSH
E2
Inhibin – B
AMH
Fertility
Preservation
Options for preserving fertility
Fertility – sparing surgical procedures
Pharmacological protection ( GnRHa )
Embryo cryopreservation
Oocyte cryopreservation
Ovarian transposition
Ovarian tissue cryopreservation
In vitro oocyte maturation
Stem Cells Therapy
Ovarian Cancer
3-17% of ovarian cancer patients are < 407-8% of all stage I epithelial ovarian cancers occur in women < 35Possible candidates for fertility-sparing treatment– Malignant germ cell tumors– Sex cord – stromal tumors – Borderline tumors– Stage IA invasive epithelial ovarian cancer
Duska, L et al. Epithelial ovarian cancer in the reproductive age group. Cancer 1999, 85: 2623-2629.
Fertility-Sparing Surgical Procedures
Ovarian cystectomy
Unilateral salpingo-oophorectomy
Bilateral salpingo-oophorectomy
All should be performed with comprehensive
surgical staging
Pharmacological protection
GnRH – Agonist
GnRH – Antagonist : under investigation , no result
to date .
Oral Contraceptives : not work .
Progesterones : not works .
Apoptosis inhibitors : Mice only .
Sphingosinc -1- Phosphate
GnRH agonist
The concept is to
induce
hypogonadism
before starting
chemotherapy,
GnRH agonists
– Premenarchal gonads appear to be least sensitive to cytotoxic drugs.
– By suppressing gonadotrophin.
– No protection effect of radiation therapy.
– No protetive effect on male gonads.
GnRHa for protection of ovary and preservation of fertility during C/T
-a preliminary report(I) pereyra, Gynecologic Oncology 81, 371-7
Method: the patients were divided into three groups:
– Group A: premenarchal Pt, age 3~7.5(n=5), GnRHa(-).
– Group B: postmenarchal Pt,age: 14~20(n=12),GnRH(+)
– Group C: postmenarchal Pt,age: 15~20(n=4),GnRH(-)
– All Pt, received PCT regimens for Tx lymphoma, leukemia
or thymoma. In group B, leuprolide acetate inhibition was obtained with a deport injection administered each months
before and during treatment.
–
GnRHa for protection of ovary and preservation of fertility during C/T -a preliminary report(II)
Result:
– Group A:spontaneous menarche between 12~17.9y/o. followed by normal menstruction and ovulatory cycles.
– Group B: After withdrawal GnRHa, continue normal ovulatory cycles. 2 Pt became preg.
– Group C: hypergonadotrophic hypoestreogenic amenorrhea
GnRHa for protection of ovary and preservation of fertility during C/T
-a preliminary report(III)
Conclusion:
– Polychemotherapy(PCT) administered at early age, when ovarian follicles have not reached maturation, produces less damage.
– GnRHa provide a powerful protection of ovarian follicle during C/T.
– We suggested GnRHa in all adolescents with maligancies prior and during C/T.
Embryo Cryopreservation
Embryo Cryopreservation
15 – 40 % success rates.
Survival rates of embryos between 35 and 90%.
8 – 30% implantation rates.
Not acceptable to prepubertal, adolescent and
women without a partner.
Need IVF.
Ovarian stimulation protocols in estrogen–sensitive cancers.
Short flare – up protocol.Natural cycle IVF.Tamoxifen ( Anti–estrogen)Letrozole suppresses plasma ostradiol, estrone
and estrone sulphate levels.
Oocyte Cryopreservation
Oocyte Cryopreservation.
for single women, ethically accepted.Oocytes are more sensitive to freezing–thawing
procedures than embryos.Results are still very low.Alternative strategy is to freeze immature oocytes
( primordial follicle).Other alternative is vitrification .
Pregnancy Rate 2 – 11 %
Oocyte Freezing
68% Survival
48% Fertilization
21% Pregnancy Rate
Oocyte Cryopreservation.
Oocyte Vitrification
In vitro Oocyte Maturation (IVM)
Harvesting immature follicles (they may become atretic).More oocytes became available for clinical treatment.No large doses of gonadotropic hormones for stimulation.Eliminates risks of ovarian stimulation
Ovarian
Transposition
Ovarian Transposition
Ovaries(one) surgically moved away from the radiation field to minimize exposure and damage.
available before or after puberty as an outpatient surgical procedure.
TechniqueTechniques for ovarian transposition using a laparoscopic approach vary according to the radiation field shape, size, and location
Ovarian Transposition
Ovarian Transposition
Pregnancy rates are approximately 50 – 75 %
Spontoneouselly.
11% Conceived with IVF
Benefit :
Prevention of premature menopause .
Preservation of fertility ?? !
Complications of Ovarian Transposition
Fallopian tube infarction.Chronic ovarian pain.Ovarian cyst formation.Migration of ovaries back to their originalposition.Ovarian metastasis (No increased risk).
Ovarian Tissue Freezing and transplantation
Ovarian cortical freezing
24 year-old patient with Hodgkin’s disease, pre-SCT
Case report
Belgian day-old baby Tamara Bouanati nestles in the arms of her mother Ouarda Touirat, 32. Touirat beat cancer and gave birth after an ovarian tissue transplant
It is still a Hope
Stem cells Therapy
Conclusion.
GnRH analogues are the only available medical protection for chemotherapy.Laparoscopic ovarian transposition is a good option if radiotherapy is to be used.Oocyte cryopreservation is gaining popularity.Embryo cryopreservation is the most successful
fertility preservation.
Slow-freeze protocol for ovarian tissue preservation
1) Equilibrate cortical slices in cryoprotectant for 30 min at 0o C
2) Cool at 2o C/min to -9o C
3) Soak for 10 min and seed
4) Continue at -0.3o C/min to -40o C
5) 10o C to -140o C
6) Transfer to liquid nitrogen (-196o C)
Risk of ovarian involvement in cryopreservation candidates
Low risk Moderate risk High risk
Wilms’ tumor Stage IV breast cancer Leukemia
LymphomasStage I–III lobular
breast cancer Neuroblastoma
Stage I-III breast cancer
(infiltrating ductal)
Adenocancer of the cervix
Stage IV lobular breast cancer
Non-genital-rhabdonyosarcoma Colorectal cancer
Osteogenic sarcoma
Squamous cell cancer of the cervix
Ewing’s sarcoma
Screening of ovarian tissue
Best screening is light microscopy
Molecular markers can be used in rare cancers
Test tissue before freezing and after thawing
Transplantation
High rate of follicle loss after transplantation
5% of primordial
follicles lost during
freezing and thawing
65% of primordial
follicles lost during
revascularization
(xenografting)
Whole ovary cryopreservation as an attempt to improve follicle
survival
Successful in micePartial success in sheep– 3/11 patent after 8–10 days1
– Long-term function with new freezing technology2
Whole ovary freezing by directional freezing in sheep
8 sheep ovaries frozen with MTG technology
5/8 grafts survived but only 2/8 had long-term cyclical function (24–36 months)
Oocyte retrieval in 2Parthenogenic activation
Whole ovary freezing is challenging in humans
Human ovary is larger– 4 x 2 x 0.8 cm (20–35 gm)
vs 2.5 x 1.5 x 0.5 (3–8 gm) Need to optimize the protocol for germ cells and somatic cellsWhole ovary cryopreservation not yet technically possible in humans
Orthotopic(pelvic)
transplant
Heterotopic(subcutaneous)
transplant
Resumptionof ovarian functions
Spontaneousconception
IVF
Embryo transfer
Ovarian transplantation techniques
Orthotopic(pelvic)
transplant
Heterotopic(forearm)transplant
Resumptionof ovarian functions
Spontaneousconception
IVF
Embryo transfer
Ovarian transplantation techniques
“Successful” cases of orthotopic ovarian transplantation
Author Outcome
Oktay & KarlikayaN Engl J Med 2000;342:1919
Ovulation, endocrine function for 9 months
Radford et al. Lancet 2001;357:1172–5
Follicle development and endocrine function up to 9 months
Donnez et al. Lancet 2004;364:1405–10
Spontaneous pregnancy and live birth
Meirow et al.N Engl J Med 2005;353:318–21
Live birth after IVF
Pelvic ovarian transplantation
0
20
40
60
80
100
0 5 10 15 20 25 30Days after follicle seen
Estra
diol
(pg/
mL)
Prog
este
rone
(ng/
mL) hCG injections
First orthotopic ovarian transplant with frozen ovarian tissue
First pregnancy after ovarian transplant?
Ovarian biopsies frozen in 1997 at age 25Received MOPP for Hodgkin’s diseaseBirth control pills after chemotherapyTransplant in 2003Spontaneous conception & delivery in 2004
Questions with Donnez et al. report
Risk of ovarian failure relatively low– 20% at ≤ 25 years of age
– 50% chance of pregnancy1
Both ovaries remainThree ovulations from the right (intact) ovaryNo hormonal or ultrasound monitoring of ovulation from the transplant
Live birth following transplantation of cryopreserved ovarian tissue
after chemotherapy-induced ovarian failure
Comparison of two orthotopic transplant techniques
Ovarian function &pregnancy via IVF
No ovarian function
Orthotopic(pelvic)
transplant
Heterotopic(subcutaneous)
transplant
Resumptionof ovarian functions
Spontaneousconception
IVF
Embryo transfer
Ovarian transplantation techniques
Advantages of heterotopic transplant
Non-invasive
Repeated procedures feasible
Can inject agents directly in the graft
Easy monitoring (risk of recurrence)
Easy removalSuitable after pelvic radiation
“Successful” cases of heterotopic ovarian transplantation
Author Outcome
Oktay et al. JAMA 2001;286:1490–3
Follicle development and endocrine function for 3 years
Oktay et al. JAMA 2001;286:1490–3
Ovulation, endocrine function for 3 years
Oktay et al. Lancet 2004
Folliculogenesis, endocrine function for > 2½ years; embryo development
Oktay Hum Reprod 2006;21:1345–8
Live birth?
Patient A
Patient B
Patient A
Patient B
Estradiol output from heterotopic transplant
RCV estradiol
0100020003000400050006000
1 5 13 15 20 22 28 32 33 34 36 39 40Cycle day (arbitrary)
pg/m
L
RH estradiol
0
50
100
150
200
250
1 5 13 15 20 22 28 32 33 34 36 39 40Cycle day (arbitrary)
pg/m
L
RH
RCV
Ovarian transplant in a patient with breast cancer
36-year-old patientOvary cryopreserved before chemotherapyHigh-dose chemotherapy before bone marrow transplantIn menopause for 6 years
Follicle development in a frozen-thawed transplant
Percutaneous oocyte retrieval
First embryo after ovarian transplant
24 hours
18 hours24 hours
Embryo #3: 1 PN after ICSI
16h post-ICSI 24h post-ICSI
6/03/04z
PGD: Female pronucleus, partially decondensed sperm DNA
“Normal” embryo yield
22 oocytes
9 suitable for IVF (8 ICSI)
2 abnormal embryos
1 grade 1/2, 4-cell embryo
Yield: 4.5%
Follicle maturity is achieved at a smaller follicle diameter
Follicle stage GV M-I Mature
Mean follicle size (range)
8.7 mm(6.4–10.9)
10.4 mm(7.6–13.1)
11.5 mm(9.9–12.8)
Average number of stimulation days similar to controls (10.8 days, range 8–13)
Is Pregnancy Possibleafter heterotopic transplantation?
Brenda: first primate pregnancyafter ovarian transplant
Latest case of heterotopic ovarian transplant
Hodgkin’s disease at age 28: receives ABVD + RT to chest & spleenOvarian tissue cryopreserved at age 29 prior to SCT due to relapseAmenorrhea and elevated FSH for 2.5 years (45–95 IU/L) after receiving preconditioning chemotherapySubcutaneous ovarian transplant performed on 12 August 2004
Subcutaneous transplantation in a menopausal woman
post-stem cell transplantation
15 pieces thawed5 x 5 x 1 – 15 x 5 x 2 mm
Suture pull-through technique
Ovarian function after heterotopic ovarian transplant
Felt follicle growth 7 weeks post-transplant10 weeks post-transplant– E2: 250 pg/mL– P4: 14 ng/mL
Transvaginal ultrasound performed 11 weeks post-transplant
Pregnancy after heterotopic transplant
Corpus luteum in menopausal ovary?
Spontaneous recurrent pregnancies after heterotopic ovarian transplant
D&C performed as no FH detectedCytogenetics of POC revealed trisomy 16Patient felt follicle growth 3 weeks after D&C and menstruated a week laterHad intercourse on the day of ovulationand conceived again!
Long-term follow-up
Resumed follicular activity in graft 3 months postpartumOvulation in graft? and “menopausal” ovary a week agoAttempted pregnancyB-hCG pending
Spontaneous pregnancy after heterotopic ovarian transplant
What is the true source of pregnancies after ovarian transplants?
How did the two conceptions occur in a menopausal women contemporaneouslywith follicle growth in the graft?
Evidence for germline stem cells in adult human female bone marrow
Analysis of human female bone marrow (BM) reveals expression of
germline marker genes
1 BM collected from donors between 24–36 years of age2 Ut1 and Ut2: adult human uterus used as a negative
control
Ovariectomy causes a near-complete elimination of Mvh expression in BM. Replacement of estrogen, norgesterone, or both does not alter BM Mvh levels in
ovariectomized females
Ovariectomy abolishes Mvhexpression in the bone marrow
Impact of chemotherapy on stromal function
Ovarian graft
Germ cell
Signal for induction of germ stem cell production in bone marrow or other sites
Bone marrow
Migration to the menopausal ovary
Ovulation
Fertilization
Summary
Ovarian transplantation is an emerging experimental technique that can be offered for fertility preservation if studied under IRB-approved protocols
Germ stem cell story intriguing
– needs confirmation
Cryopreservation and transplantation of ovarian tissue.
Still experimental procedure.Limited studies.Primordial follicles should have better survival rates.In vitro – growth of primordial follicles.(after immune deficient animal host).trans–species viral infections.
Transplanted back into patient, (Cancer nidus).
after cryopreservation.
Ovarian Cancer and Infertility
Ovulation is associated with an increased risk of epithelial ovarian cancer. (epithelia proliferation, inclusion cyst formation).Oncogenes HER-2/meu
K-rasc-mycmutations P53 tumor-suppressor gene.
S. AL SAMAWI MD. Gyn. Obs.A. TAHA MD. Gyn. Obs.M. ABDUL WAHED MD. Gyn. Obs.J. SHARIF Senior BiologistN. ABO HASSAN AndrolgistF. RAHMEH AndrolgistS. MATOUK Executive SecretaryF. HAMAD Administration ManagerA. ALKHATEB M.D Micro BiologistR. ALKHATEB MD. Gyn. Obs. Ph. D.
Acknowledgement
Thank You