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Paediatric Integrated Cancer Service, VIC, Australia
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Cytotoxic chemotherapies have been a mainstay of cancer treatment but are associated with numerous systemic adverse effects, including impacts on fertility and endocrine health. Irreversible ovarian damage and follicle depletion are the side effects of chemotherapy that can lead to infertility and premature menopause, both being major concerns of young cancer patients. Notably, many women will proceed with fertility preservation, but unfortunately existing strategies do not entirely solve the problem. Most significantly, oocyte and embryo freezing do not prevent cancer treatment-induced ovarian damage from occurring, which may result in the impairment of long-term hormone production. Unfortunately, loss of endogenous endocrine function is not fully restored by hormone replacement therapy. Additionally, while GnRH agonists are standard care for patients receiving alkylating chemotherapy to lessen the risk of premature menopause, their efficacy is incomplete. The lack of more broadly effective options stems, in part, from our poor understanding of how different treatments damage the ovary. Here, we summarise the impacts of two commonly utilised chemotherapies – cyclophosphamide and cis-diamminedichloroplatinum(II) (cisplatin) – on ovarian function and fertility and discuss the mechanisms underpinning this damage. Additionally, we critically analyse current research avenues in the development of novel fertility preservation strategies, with a focus on ferto-protective agents.
Lay summary
Over the past few decades, advances in the detection and treatment of cancer have dramatically improved survival rates in young women. This means that ensuring patients have a high quality of life after cancer treatment has become a new priority. Therefore, it is important to understand and prevent any long-term negative side effects of cancer treatments, with infertility and early-onset menopause being major concerns for women receiving chemotherapy. The current fertility preservation options available to young women have significant limitations. Therefore, the identification of new approaches to protect fertility has been an intense topic of research in recent years. In this review, we provide information on the negative side effects of two commonly used chemotherapy drugs – cyclophosphamide and cis-diamminedichloroplatinum(II) (cisplatin) – on fertility, and discuss how they cause damage to the ovaries. We also critically analyse recent preclinical studies related to the development of new fertility preservation techniques.
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Graphical abstract
Abstract
In laboratory mice, sperm quality is usually assessed in spermatozoa collected from the cauda epididymidis of freshly sacrificed males. Percutaneous epididymal sperm aspiration (PESA) is a non-terminal alternative that would allow repeated sperm collection for sperm quality assessment in living males. To test whether PESA is a suitable method to assess sperm quality, we compared sperm traits between samples collected by PESA vs the commonly applied terminal cauda epididymidis dissection. The collected sperm samples were analyzed using computer-assisted sperm analysis and various parameters, including sperm motility, swimming velocity and morphology, were determined. We were able to retrieve motile sperm from all mice using PESA and the terminal cauda epididymidis dissection. Based on computer-assisted sperm analysis, however, sperm motility and swimming velocity were significantly lower after PESA compared to samples obtained by cauda epididymidis dissection. In addition, we found significantly more morphological abnormalities in PESA samples, probably induced as a side effect of the sampling technique. Although sperm samples collected by PESA are successfully used for in vitro fertilization, we cannot recommend PESA as a suitable method to assess sperm quality in mice, since the procedure seems to impair various sperm traits.
Lay summary
In mice, sperm quality is usually assessed in sperm collected from the epididymis (organ where ripe sperm is stored) of euthanized males. However, there is one non-terminal and minimal invasive alternative to collect sperm, called percutaneous epididymal sperm aspiration (PESA), which allows repeated sample collections from the same individual. Given that individual sperm quality is variable and can change according to various factors, PESA could allow to track sperm quality over time and would be highly appreciated in different research fields. Here, we tested the suitability of PESA to determine sperm quality by comparing sperm samples collected by PESA vs the commonly applied terminal epididymis dissection. We used computer-assisted sperm analysis to determine various sperm quality traits. Surprisingly, we found that sperm collected by PESA showed significantly reduced motility, swimming velocity and more morphological abnormalities compared to sperm samples collected by epididymis dissection. Thus, we cannot recommend PESA as a suitable method to determine sperm quality traits as the procedure itself seems to affect collected sperm cells.
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Females are born with a finite number of oocytes, collectively termed the ovarian reserve, established within the developing fetal ovary. Consequently, maternal exposure to reproductive toxicants can have harmful effects on the future fertility of her unborn female fetus. The chemical benzo[a]pyrene (B[a]P) is a prominent component of cigarette smoke. Despite it being a known ovotoxicant, around 8% of women in Europe smoke during pregnancy.
The purpose of this research was to examine the effect of B[a]P on the developing ovary, using the mouse as a model and with experiments carried out in vitro. B[a]P-exposure to the fetal ovary prior to follicle formation reduced the number of germ cells and subsequently, the number of healthy primordial follicles, by up to 76%; however, while proliferation of germ cells was not affected, the germ cells contained higher levels of DNA double-strand breaks. Exposure to B[a]P also affected the proportion of oocytes progressing through prophase I of meiosis. B[a]P exposure to neonatal mouse ovaries, after follicle formation, resulted in an 85% reduction in the number of healthy follicles, with a corresponding increase in apoptotic cell death and reduction in somatic cell proliferation. Although there was a trend towards a higher level of oxidative stress in B[a]P-exposed ovaries, this was not statistically significant; likewise, the antioxidant melatonin failed to protect against the B[a]P-induced ovarian damage. Together, the results here demonstrate that B[a]P-exposure damages the developing ovary, both before and shortly after follicle formation, an effect that could lead to a subsequent decrease in fertility.
Lay summary
Cigarette smoking during pregnancy can affect the fertility of the offspring, yet in Europe around 1 in 12 children born have been exposed to cigarette smoke before birth due to their mother smoking. Benzo[a]pyrene (B[a]P), one of the main chemicals found in cigarette smoke, can have damaging effects on the ovary as it develops in the fetus during the time that the population of future eggs, known as ovarian germ cells also develop. In this research, ovaries from mouse fetuses at stages of development, equivalent to the second and third trimesters of a human pregnancy, were cultured with or without B[a]P. Fetal mouse ovaries exposed to B[a]P had fewer germ cells and larger numbers of cells did not survive. Overall, the results suggest that development of the ovary of a fetus could be affected if the mother is exposed to B[a]P, whether that is through cigarette smoke, or other types of exposure.
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Department for Health, University of Bath Honorary Research Fellow, Bath Spa University, UK
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In vitro fertilisation (IVF) add-ons are techniques, medicines, or procedures used in addition to standard IVF with the aim of improving the chance of success. The United Kingdom’s IVF regulator, the Human Fertilisation Embryology Authority (HFEA) developed a traffic light system to categorise add-ons as either green, amber, or red, based on results of randomised controlled trials. We undertook qualitative interviews to explore understanding and views of the HFEA traffic light system among IVF clinicians, embryologists, and IVF patients across Australia and the United Kingdom (n = 73). Overall, participants were supportive of the intention of the traffic light system; however, many limitations were raised. It was widely recognised that a simple traffic light system necessarily omits information which may be important to understanding the evidence. In particular, the red category was used in scenarios that patients viewed as having different implications for their decision-making, including ‘no evidence’ and ‘evidesssnce of harm’. Patients were surprised at the absence of any green add-ons and questioned the value of a traffic light system in this context. Many participants considered the website a helpful starting point, but desired more detail, including the contributing studies, results specific to patient demographics (e.g. <35 years and >35 years), and inclusion of more options (e.g. acupuncture). Overall, participants believed the website to be reliable and trustworthy, particularly due to the Government affiliation, and despite some concerns regarding transparency and an overly cautious regulator. The limitations of the traffic light system could be considered in any future updates to the HFEA website and others developing similar decision support tools.
Lay summary
In vitro fertilisation (IVF) add-ons are medical procedures or technologies that may be used in addition to standard IVF. They are usually used with the aim of increasing the chance of pregnancy and live birth. However, most add-ons have not been studied in high-quality clinical trials so it is uncertain whether they are beneficial. The UK’s IVF regulator developed a traffic light system for add-ons. They label them red, amber, or green, depending on whether there is evidence the add-on increases the chance of having a baby from IVF. We interviewed IVF patients, IVF doctors, and embryologists about the traffic light system. Overall, many people thought it was a reliable and trustworthy resource – however, many problems were identified. People generally thought the system was too simple and didn’t give enough information, it had limited detail about the number and types of studies included, and some important add-ons were missing, such as acupuncture.
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Danish National Genome Center, Ørestads Boulevard, København, Denmark
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Bambino Gesù Children’s Hospital, Piazza di Sant'Onofrio, Roma, Italia
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Testicular samples obtained for fertility preservation often need to be transported between clinics. This study aimed to mimic this short-term hypothermic storage (4–8°C) and explore the impact of these conditions and the transport medium composition on prepubertal rat testicular tissue samples. Testicular tissue samples obtained from 7 days post-partum rats were transferred to six compositionally different basal culture media and a balanced salt solution, which had been kept at 4–8°C prior to transfer. The samples were preserved for either 12 or 24 h in these hypothermic conditions. The potential effects of the short-term storage were evaluated by assessing the morphology, measuring the testosterone levels by radioimmunoassay and analysing 96 genes with TaqMan Low-Density Arrays. Levels of gene expression related to energy, apoptosis, and angiogenesis pathways were altered after hypothermic storage for 12 and especially 24 h. We observed only minor differences in gene expression profiles for germ and testicular somatic cells and no differences in tissue morphology and testosterone production levels. Short-term hypothermic storage of testicular tissue with a maximum duration of 24 h does not affect the overall expression profile of testicular cell-specific genes; however, in a minor way, it affects the expression of specific cellular genes.
Lay summary
Male fertility depends on the proper functioning of cells which develop into reproductive cells. Due to an increasing number of childhood cancer survivors suffering from treatment-related fertility problems, as well as recent reports showing a dramatic decrease in sperm counts over the last decades, male fertility preservation has become an important research topic. To date, there is no method to restore fertility for men who are not able to produce sperm. One promising method to preserve the potential fertility of these patients is freezing tissue or cells from the testicles for future fertility treatments. A critical phase in freezing testicular tissue or cells is the time between removing the tissue from the testicles and freezing it. To better understand the impact of this phase on the quality of the testicular tissue, we used the testes of rats as a model for our research. We found that cooling testis tissue has only minor effects on the expression of genes that are important for testis function.
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Androgens are essential in normal ovarian function and follicle health, but hyperandrogenism, as seen in polycystic ovary syndrome, is associated with disordered follicle development. There are few data on the effect of long-term exposure to high levels of testosterone as found in transgender men receiving gender-affirming endocrine therapy. In this study, we investigate the effect of testosterone on the development, morphological health and DNA damage and repair capacity of human ovarian follicles in vivo and their survival in vitro. Whole ovaries were obtained from transgender men (mean age: 27.6 ± 1.7 years; range: 20–34 years, n = 8) at oophorectomy taking pre-operative testosterone therapy. This was compared to cortical biopsies from age-matched healthy women obtained at caesarean section (mean age: 31.8 ± 1.5 years; range: 25–35 years, n = 8). Cortical tissues were dissected into fragments and either immediately fixed for histological analysis or cultured for 6 days and subsequently fixed. Follicle classification and morphological health were evaluated from histological sections stained with hematoxylin and eosin and expression of γH2AX as a marker of DNA damage by immunohistochemistry (IHC). In uncultured tissue, testosterone exposure was associated with reduced follicle growth activation, poor follicle health and increased DNA damage. After 6 days of culture, there was enhanced follicle activation compared to the control with further deterioration in morphological health and increased DNA damage. These data indicate that high circulating concentrations of testosterone have effects on the primordial and small-growing follicles of the ovary. These results may have implications for transgender men receiving gender-affirming therapy prior to considering pregnancy or fertility preservation measures.
Lay summary
As part of gender transitioning, transgender men take testosterone therapy. While androgens like testosterone are essential to maintain ovarian health, the effects of long-term testosterone treatment on the ovary are unclear. This study examines whether testosterone impacts ovarian follicle growth activation, follicle health and whether it causes DNA damage. It also looks at how well these follicles grow in tissue culture. The results showed there was a higher proportion of non-growing ovarian follicles in the ovaries of trans men, they appeared less healthy and there were higher levels of DNA damage. After 6 days of tissue culture, there were more growing follicles in transgender ovaries compared to control, but follicle health further deteriorated and there are increased levels of DNA damage. These results identify new effects of testosterone on the ovary and highlight the importance of discussing fertility preservation options prior to starting testosterone.
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Royal Hospital for Women, Randwick, New South Wales, Australia
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Royal Hospital for Women, Randwick, New South Wales, Australia
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A prospective longitudinal cohort study aimed to longitudinally examine the kinetics of anti-Müllerian hormone (AMH) during the first two trimesters of pregnancy. Pregnant women with stored first-trimester serum samples were recruited at 24–28 weeks gestation during their gestational diabetes testing, where they provided an additional serum sample. The samples were analysed for AMH, oestradiol and progesterone concentrations. A decrease in serum AMH was observed in 40 out of 45 (88.9%) (95% CI: 75.9–96.3%) of the participants in this study. The median serum AMH concentration was 10.9 pmol/L in the first trimester and 6.5 pmol/L during the second trimester, with a significantly different distribution of the values between the first-trimester and the second-trimester AMH samples (P < 0.001). The median percentage of AMH difference of −39.8%. This study demonstrated a significant decrease in serum AMH levels from the first to the second trimester of pregnancy. The absolute decrease in AMH levels seems to be positively associated with first-trimester AMH levels, whereas the percentage of AMH difference is not. Further studies are required to elucidate the potential physiological mechanisms of this finding.
Lay summary
Anti-Müllerian hormone, also known as AMH, is produced by developing ovarian follicles in the ovary. The concentration of AMH in the serum is used as a marker of ovarian reserve. This marker has been shown to vary throughout the menstrual cycle and in women using hormonal contraception. This study examined this marker in women in the first and second trimesters of pregnancy to determine if it is variable throughout pregnancy. The study found that there was a significant decrease from the first to second trimester, with a larger decrease seen in women who had a higher first-trimester concentration of this marker. Further research is required to determine the physiological mechanism which causes the reduction of AMH in pregnancy.
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Graphical abstract
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An ectopic pregnancy occurs when an embryo implants outside of the uterus, usually in a fallopian tube. When detected early, treatment is often with a medication called methotrexate. When methotrexate does not work, surgery is required. A recent clinical trial of ectopic pregnancy treatment (called GEM3) found that adding a drug called gefitinib to methotrexate did not reduce the need for surgery. We have used data from the GEM3 trial, combined with data collected 12 months after the trial finished, to investigate post-methotrexate pregnancy outcomes. We found no difference in pregnancy rates, pregnancy loss rates and recurrent ectopic pregnancy rates between those treated medically only and those who subsequently also needed surgery. The surgical technique used also did not affect pregnancy rates. This research provides reassurance that women with ectopic pregnancies treated medically who need surgery have similar post-treatment pregnancy outcomes to those treated successfully medically.
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Wellcome Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
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Maternal and Fetal Health Research Centre, Saint Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
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Maternal and Fetal Health Research Centre, Saint Mary’s Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Sciences Centre, Manchester, UK
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Obesity is a rapidly growing public health issue among women of reproductive age associated with decreased reproductive function including implantation failure. This can result from a myriad of factors including impaired gametes and endometrial dysfunction. The mechanisms of how obesity-related hyperinsulinaemia disrupts endometrial function are poorly understood. We investigated potential mechanisms by which insulin alters endometrial transcript expression. Ishikawa cells were seeded into a microfluidics device attached to a syringe pump to deliver a constant flow rate of 1 µL/min of the following: (i) control (ii) vehicle control (acidified PBS), or (iii) insulin (10 ng/mL) for 24 h (n = 3 biological replicates). Insulin-induced transcriptomic response of endometrial epithelial cells was determined via RNA sequencing, and DAVID and Webgestalt to identify Gene Ontology (GO) terms and signalling pathways. A total of 29 transcripts showed differential expression levels across two comparison groups (control vs vehicle control; vehicle control vs insulin). Nine transcripts were differentially expressed in vehicle control vs insulin comparison (P < 0.05). Functional annotation analysis of transcripts altered by insulin (n = 9) identified three significantly enriched GO terms: SRP-dependent co-translational protein targeting to membrane, poly(A) binding, and RNA binding (P < 0.05). The overrepresentation analysis found three significantly enriched signalling pathways relating to insulin-induced transcriptomic response: protein export, glutathione metabolism, and ribosome pathways (P < 0.05). Transfection of siRNA for RAPSN successfully knocked down expression (P < 0.05), but this did not have any effect on cellular morphology. Insulin-induced dysregulation of biological functions and pathways highlights potential mechanisms by which high insulin concentrations within maternal circulation may perturb endometrial receptivity.
Lay summary
Changes in components of blood associated with obesity in women of reproductive age can have consequences for pregnancy success. These changes to circulating molecules associated with obesity can alter the ability of the endometrium (the innermost lining of the womb/uterus) to be receptive to an embryo to implant – a key stage of successful pregnancy. Understanding which molecules contribute to this is difficult and one in particular, insulin, can change the role of the endometrium. Studying this is limited to static culture, that is, the cells are not exposed to sustained and high concentrations of Insulin that could occur in the mother. In this study, we use a new laboratory-based approach (microfluidics) that allows us to mimic maternal circulation. We have determined that exposure of these endometrial cells to insulin changes the expression of specific genes that may lead to the inability of the endometrium to support implantation and early pregnancy.
