Volkan Turan

Fertility Preservation Success Subsequent to Concurrent Aromatase Inhibitor Treatment and Ovarian Stimulation in Women With Breast Cancer

PURPOSE We have previously reported an approach to ovarian stimulation for the purpose of fertility preservation (FP) in women with breast cancer via embryo freezing with the concurrent use of letrozole. The aim of this study was to provide the pregnancy and FP outcomes when embryos generated with the same protocol are used. PATIENTS AND METHODS In all, 131 women with stage ≤ 3 breast cancer underwent ovarian stimulation and received concurrent letrozole 5 mg per day before receiving adjuvant chemotherapy and cryopreserving embryos. RESULTS Thirty-three of the 131 women underwent 40 attempts to transfer embryos to their own uterus (n = 18) or via the use of a gestational carrier (n = 22) at a mean age of 41.5 ± 4.3 years with a median 5.25 years after embryo cryopreservation. The overall live birth rate per embryo transfer was similar to the US national mean among infertile women of a similar age undergoing in vitro fertilization-embryo transfer (45.0 v 38.2; P = .2). Seven (38.8%) of the 18 pregnancies were twins with no higher-order pregnancies being encountered. No fetal anomalies or malformations were reported in 25 children after a mean follow-up of 40.4 ± 26.4 months. Seventeen of the 33 women attempting pregnancy had at least one child, translating into an FP rate of 51.5% per attempting woman. CONCLUSION Embryo cryopreservation after ovarian stimulation with the letrozole and follicle-stimulating hormone protocol preserves fertility in women with breast cancer and results in pregnancy rates comparable to those expected in a noncancer population undergoing in vitro fertilization.

Safety and feasibility of performing two consecutive ovarian stimulation cycles with the use of letrozole-gonadotropin protocol for fertility preservation in breast cancer patients

OBJECTIVE To investigate the safety and feasibility of performing two consecutive ovarian stimulation cycles with the use of letrozole protocol for fertility preservation in breast cancer patients. DESIGN Retrospective cohort study. SETTING Academic fertility preservation center. PATIENT(S) Seventy-eight women ≤ 45 years, diagnosed with stage ≤ 3 breast cancer, who desired fertility preservation. INTERVENTION(S) Two consecutive cycles versus a single ovarian stimulation cycle with a letrozole-follicle-stimulating hormone (FSH) protocol. MAIN OUTCOME MEASURE(S) Embryo or oocyte cryopreservation outcomes, time interval from surgery to chemotherapy, and breast cancer recurrence rates. RESULT(S) Sixty-one patients underwent single-cycle stimulation and 17 received two stimulation cycles. The mean total number of oocytes harvested (16.1 ± 13.2 vs. 9.1 ± 5.2) and embryos generated (6.4 ± 2.9 vs. 3.7 ± 3.1) were statistically significantly higher in patients who underwent two cycles versus one cycle. The time interval from surgery to chemotherapy was similar between the two-cycle and single-cycle groups (63.7 ± 7.7 vs. 58.0 ± 12.1 days). After a mean follow-up interval of 58.5 ± 13.6 months, the recurrence rates were similar between the two-cycle (0 of 17) and single-cycle (2 of 49) patients. CONCLUSION(S) It appears to be safe and feasible to perform two consecutive ovarian stimulation cycles to increase the oocyte/embryo yield for fertility preservation.

Sphingosine-1-phosphate prevents chemotherapy-induced human primordial follicle death

STUDY QUESTION Can Sphingosine-1-phosphate (S1P), a ceramide-induced death pathway inhibitor, prevent cyclophosphamide (Cy) or doxorubicin (Doxo) induced apoptotic follicle death in human ovarian xenografts? SUMMARY ANSWER S1P can block human apoptotic follicle death induced by both drugs, which have differing mechanisms of cytotoxicity. WHAT IS KNOWN ALREADY S1P has been shown to decrease the impact of chemotherapy and radiation on germinal vesicle oocytes in animal studies but no human translational data exist. STUDY DESIGN, SIZE, DURATION Experimental human ovarian xenografting to test the in vivo protective effect of S1P on primordial follicle survival in the chemotherapy setting. The data were validated by assessing the same protective effect in the ovaries of xenografted mice in parallel. PARTICIPANTS/MATERIALS, SETTING, METHODS Xenografted mice were treated with Cy (75 mg/kg), Cy+S1P (200 μM), Doxo (10 mg/kg), Doxo+S1P or vehicle only (Control). S1P was administered via continuous infusion using a mini-osmotic pump beginning 24 h prior to and ending 72 h post-chemotherapy. Grafts were then recovered and stained with anti-caspase 3 antibody for the detection of apoptosis in primordial follicles. The percentage of apoptotic to total primordial follicles was calculated in each group. MAIN RESULTS AND THE ROLE OF CHANCE Both Cy and Doxo resulted in a significant increase in apoptotic follicle death in human ovarian xenografts compared with controls (62.0 ± 3.9% versus 25.7 ± 7.4%, P < 0.01 and 76.7 ± 7.4% versus 25.7 ± 7.4%, P < 0.01, respectively). This chemotherapy-induced apoptotic death was reduced both in the Cy+S1P (32.7 ± 4.4%, P < 0.01) and the Doxo+S1P group (27.1 ± 7.6%, P < 0.01) compared with Cy and Doxo groups, respectively. In the Doxo+S1P and Cy+S1P groups, the percentages of apoptotic follicles were similar to those of vehicle-treated controls (P > 0.05). The findings from the ovaries of the severe combined immunodeficient mice mirrored the findings with human tissue. LIMITATIONS, REASONS FOR CAUTION The functionality of the rescued human ovarian follicles needs to be evaluated in future studies though the studies in rodents showed that rescued oocytes can result in healthy offspring. In addition, the impact of S1P on cancer cells should be further studied. WIDER IMPLICATIONS OF THE FINDINGS S1P and its future analogs hold promise for preserving fertility by pharmacological means for patients undergoing chemotherapy. STUDY FUNDING/COMPETING INTEREST(S) This research is supported by NIHs NICHD and NCI (5R01HD053112-06 and 5R21HD061259-02) and the Flemish Foundation for Scientific Research (FWO-Vlaanderen, grant number FWO G0.065.11N10). The authors have no conflicts of interest to disclose.

Long-Term Safety of Letrozole and Gonadotropin Stimulation for Fertility Preservation in Women With Breast Cancer

CONTEXT AND OBJECTIVE There has been increased attention to the issue of fertility preservation (FP). We aimed to investigate the long-term safety of FP via controlled ovarian stimulation with letrozole supplementation (COSTLES) prior to breast cancer treatment. DESIGN, SETTING, AND PARTICIPANTS This is a prospective, nonrandomized, controlled study conducted between the years 2002 and 2014. A total of 337 women diagnosed with stage 3 or less invasive breast cancer were enrolled during a FP consultation before chemotherapy. Of those, 120 elected to undergo COSTLES for FP prior to chemotherapy (FP group). The remaining 217 patients did not undergo any FP procedure and served as the controls. MAIN OUTCOME MEASURE The primary end point was cancer recurrence defined as the detection of locoregional tumor (chest wall, regional nodal disease), distant metastases, or contralateral invasive breast cancer. RESULTS The baseline characteristics at enrollment were similar between the FP and control groups except for the less frequent lymph node involvement (P = .02) in the former. The mean follow-up after diagnosis was 5.0 years in the FP group and 6.9 years in the control group. In the FP group, the hazard ratio for recurrence after ovarian stimulation was 0.77 (95% confidence interval 0.28–2.13), and the survival was not compromised compared with controls (P = .61). Neither BRCA gene mutation status (P = .57) nor undergoing FP before or after breast surgery (P = .44) affected survival outcomes in the FP group. Likewise, none of the tumor characteristics including the estrogen receptor status affected the survival rates after the COSTLES. CONCLUSIONS COSTLES is unlikely to cause a substantially increased recurrence risk in breast cancer during the 5 years after diagnosis.

BRCA Mutations, DNA Repair Deficiency and Ovarian Aging

ABSTRACT Oocyte aging has a significant impact on reproductive outcomes both quantitatively and qualitatively. However, the molecular mechanisms underlying the age-related decline in reproductive success have not been fully addressed. BRCA is known to be involved in homologous DNA recombination and plays an essential role in double-strand DNA break repair. Given the growing body of laboratory and clinical evidence, we performed a systematic review on the current understanding of the role of DNA repair in human reproduction. We find that BRCA mutations negatively affect ovarian reserve based on convincing evidence from in vitro and in vivo results and prospective studies. Because decline in the function of the intact gene occurs at an earlier age, women with BRCA1 mutations exhibit accelerated ovarian aging, unlike those with BRCA2 mutations. However, because of the still robust function of the intact allele in younger women and because of the masking of most severe cases by prophylactic oophorectomy or cancer, it is less likely one would see an effect of BRCA mutations on fertility until later in reproductive age. The impact of BRCA2 mutations on reproductive function may be less visible because of the delayed decline in the function of normal BRCA2 allele. BRCA1 function and ataxia-telangiectasia-mutated (ATM)-mediated DNA repair may also be important in the pathogenesis of age-induced increase in aneuploidy. BRCA1 is required for meiotic spindle assembly, and cohesion function between sister chromatids is also regulated by ATM family member proteins. Taken together, these findings strongly suggest the implication of BRCA and DNA repair malfunction in ovarian aging.

Age-Related Decline in DNA Repair Function Explains Diminished Ovarian Reserve, Earlier Menopause, and Possible Oocyte Vulnerability to Chemotherapy in Women With BRCA Mutations

United States are projected to increase by 27% based on population changes alone; if the cost of the initial and terminal years of care increase by 2% annually, this estimate increases to 39%. There are growing concerns among many—ranging from patients and their families to providers to payers and to policymakers—regarding these trends, their sustainability, and their ramifications. The high cost of newer anticancer drugs is certainly a contributor, but there are many other cost drivers as well. To effectively and durably address these cost issues will require attention to many factors and a comprehensive approach. Battley et al provide suggestions that offer potential costsaving opportunities. These savings may not require an actual decrease in the drug unit price. That being said, the spirit of their comments clearly highlights the need for a more value-based system in determining the cost of cancer drugs, as noted in the article by Kantarjian et al and the accompanying editorial. In addition, we congratulate Battley et al as oncologists looking to be part of the solution, the importance of which was emphasized in the editorial, and we encourage other oncologists to do the same.

Utility of GnRH-agonists for Fertility Preservation in Women With Operable Breast Cancer: Is It Protective?

Breast cancer is the most common type of malignancy in reproductive-age women. Breast cancer chemotherapy is associated with premature ovarian failure, infertility, and negative psychosocial effects related to these reproductive changes. As a result of this, fertility preservation becomes highly critical in this group of women. Besides the fertility preservation methods that utilize assisted reproductive technologies such as embryo, oocyte, and ovarian tissue cryopreservation, another suggested strategy for fertility preservation is suppression of ovarian ovulatory function by gonadotropin-releasing hormone agonist (GnRHa) administration before and during chemotherapy. However, both the efficacy and safety of GnRH agonists for prevention of ovarian damage are unproven and the preponderance of evidence indicates that this is an ineffective strategy. This review details the most recent information and studies on this controversial topic.

Oogonial Precursor Cell-Derived Autologous Mitochondria Injection to Improve Outcomes in Women With Multiple IVF Failures Due to Low Oocyte Quality: A Clinical Translation.

Background: Mitochondrial dysfunction has been suggested as a major cause of age-induced decline in oocyte quality. In the past, donor oocyte cytoplasmic transfer showed some success but was abandoned due to the concerns with heteroplasmy. Recent studies indicated presence of oogonial precursor cells (OPCs) in the human ovary, which could be an autologous source of “healthy mitochondria.” We sought to investigate the clinical efficacy of OPC-derived autologous mitochondrial injection (AMI) to improve oocyte quality in women with multiple in vitro fertilization (IVF) failures. Methods: The OPCs were isolated from laparoscopically obtained ovarian cortical pieces by cell sorting using a monoclonal anti-vasa homolog (anti-DDX) antibody. They were then disrupted and mitochondria were isolated. Reconstituted mitochondria were injected into each oocyte during intracytoplasmic sperm injection. Paired comparisons were made between the first failed cycles and the post-AMI cycles. Results: Of the 15 women undergoing ovarian stimulation, 2 were canceled and 3 decided to pool oocytes for later AMI. In remaining 10 (mean age 34.7 ± 4.1), AMI significantly improved fertilization rates (49.7 ± 31.3 vs 78.3 ± 18.9; P = .03) with a trend for better embryo grades (2.3 ± 0.3 vs 3.1 ± 0.7; P = .08). Four of 10 women conceived after single frozen embryo transfer and 3 after confirmation of diploidy via array comparative genomic hybridization (aCGH) (clinical pregnancy/embryo transfer = 4/10). Conclusion: These data show encouraging results for AMI in comparison to previous failed IVF cycles.

Failure of Ovarian Suppression With Gonadotropin-Releasing Hormone Analogs to Preserve Fertility An Assessment Based on the Quality of Evidence

The proximate cause of menopause, whether natural or induced, is ovarian primordial follicle oocyte reserve depletion. This reserve is established inutero and cannot be replenished. Specific chemotherapeutics, particularly alkylatingagents and topoisomerase inhibitors, induce DNA double strand breaks in primordial follicle oocytes, thereby triggering apoptotic death.1 It is by this reduction of the ovarian folliclereservethatthereproductive life span is shortened andmenopause is facilitated. Ovarian failure is the last manifestation of chemotherapy-induced infertility. Hence, ovarian follicle depletion and infertility due to cancer treatments are not independent processes. In the meta-analysis by Munhoz et al,2 the authors conclude that gonadotropin-releasing hormone analog (GnRHa) suppression preserves menstruation but not fertility in premenopausalwomenwithearly-stagebreast cancer.Howdowe explain this contradiction?As the authors indicate,menstruation is not a surrogate of fertility. In fact, the commonly accepteddefinitionof premature ovarian failure (POF) is irregular periods or amenorrhea with 2 serum follicle-stimulating hormone (FSH) values greater than 40mIU/mL (to convert to IU/L,multiplyby1.0).Prior studies incorrectlyapplied thedefinition of natural menopause (ie, a retrospective absence of menses for 12months inwomen>40years) to chemotherapyinduced POF.2 Irregular menstruation is more common than amenorrhea inwomenexperiencingearlymenopause. In a recent 18-month longitudinal follow-up of women with breast cancer receiving chemotherapy, we found that approximately one-third of women with severely diminished and/or undetectable ovarian reserves by serum antimullerian hormone (AMH) levels were still menstruating.3 This brings up a major weakness of all studies that show some benefit in preserving menstruation by GnRHa. Each used different criteria and none reported on the frequency of periods and whether theprechemotherapymenstrualpatternwaspreserved.Moreover, many included women close to menopausal age. Given that at least one-third ofwomen in early POFmay bemisclassified as having normal ovarian function, the use of resumptionof periods afterGnRHa treatments as a gaugeof effectiveness of ovarian suppression is questionable. Furthermore, tamoxifen isanovarianstimulantandcanaltermenstrual functionandcause amenorrhea.Only 3 studies, 2withnegative results, excludedwomen receiving tamoxifen. Studiesmeasuring menstrual regularity postchemotherapy did not find a benefit of GnRHa in ovarian protection.4 In addition,no trial usedblindingand/orplacebo.Theparticipantswho are aware of theGnRHa treatmentmaybemore likely to report anybleeding asmenstruation. Ideally, short of using long-term fertility rates, theovariannormalcy shouldbe assessed by quantitative biomarkers. Some studies randomly measured serumFSHandestradiol, and this is not reliableunless performed on cycle days 2 to 3 as the FSH and estradiol serum values fluctuate throughout the cycle. Antral follicle count (AFC) is amore reliablemeasure,which is likewisecycledaydependent. Finally, serumAMH is thought to be themost reliableand lesscycle-dayspecificmarkerbecauseofbeingproduced from early-stage follicles. Only 2 randomized studies employed ovarian reserve markers appropriately. Demeestere et al5 used the widely accepted criterion of FSH level greater than 40 mIU/mL to determine POF in GnRHa-treated women with lymphomas after 12months. Elgindy et al,4 in addition to regularmenstrual status, followed women with breast cancer measuring AFCs andAMHlevels forup to 12months.Neither study foundabenefit from GnRHa treatments. The currentmeta-analysiswas limited to premenopausal women with early-stage breast cancer only.2 Given that the mechanismof ovarian damage by gonadotoxic agents is similar regardless of theunderlyingmalignancy type, a diagnosisbased segregation is not needed to assess the efficacy of GnRHa. The prospective studies in women with hematological malignancies, which were left out from the current metaanalysis, found ovarian suppression to be ineffective in preserving ovarian function.4 Ameta-analysis doesnot remove flaws, andas the authors indicated, amajority of patients originated from3studieswith the aforementioned inherent weaknesses. In the study by Badawy et al,6 receptor status, tamoxifen use, and the definition for resumption of menses were not mentioned. Whether this studywasactually randomizedwasalsoquestioned.7 Inanotherstudy,8authorsobservedhigherpregnancyrateswithGnRHa, thoughthiswasnot theprimaryoutcomemeasure.When recalculated based on those who were attempting pregnancy and not the total number of women in each group, there was nostatisticaldifference.Moreover, attesting to thepositivebias amongwomen receivingGnRHa, there appeared to be a trend, though not statistically significant, for a higher number of women attempting pregnancy in the GnRHa group (P = .13). In a recent meta-analysis5 that included 10 eligible trials and907womenwith theprimaryoutcomedefinedas theproportion of women with resumed ovarian function at the longest follow-upafter the endof chemotherapy,GnRHa cotreatment did not favor ovarian function resumption (320/468 Related article page 65

Sexual and fertility adverse effects associated with chemotherapy treatment in women

Introduction: Earlier diagnosis and novel chemotherapy strategies have resulted in a considerable improvement in cancer survival, but the quality of that survival is influenced by late effects of chemotherapy. Premature ovarian failure is a common consequence of chemotherapy in reproductive-aged women, and, as a result, fertility issues and sexual dysfunction occur frequently in women who have undergone chemotherapy. Areas covered: This article reviews what is known about the effects of chemotherapy on fertility and sexuality. We also discuss risk factors for premature ovarian failure, fertility preservation options in patients willing to have a child after treatment, and sexual changes associated with estrogen withdrawal and psychological factors. Expert opinion: Chemotherapy-induced ovarian failure in young women is associated with poorer quality of life, decreased sexual functioning, psychosocial distress related to fertility concerns, and infertility. Fertility preservation options should be considered in women at risk of premature ovarian failure caused by chemotherapy. Sexual dysfunction associated with estrogen withdrawal and psychological stress is common in cancer survivors. Women who suffer from sexual dysfunction may benefit from brief counseling and targeted intervention.