Preliminary experience of the use of a gonadotrophin-releasing hormone antagonist in ovulation induction/in-vitro fertilization prior to cancer treatment: Case Report

Richard A. Anderson1,3, David Kinniburgh2 and David T. Baird2

1 MRC Reproductive Biology Unit and 2 Department of Obstetrics and Gynaecology, Centre for Reproductive Biology, University of Edinburgh, 37 Chalmers Street, Edinburgh EH3 9ET, UK


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Case reports
 Discussion
 References
 
Therapeutic regimens for the treatment of malignant disease may compromise future fertility. One approach to circumvent this is the cryopreservation of embryos created before treatment for the malignancy. Conventional regimens using gonadotrophin-releasing hormone (GnRH) agonists are time consuming, requiring pituitary down-regulation before gonadotrophin administration, thus the duration of treatment is ~20–30 days. GnRH antagonists, however, do not cause an initial stimulation of gonadotrophin secretion and can thus be administered during the later stages of follicular maturation to prevent premature luteinization and ovulation. The duration of ovulation induction/in-vitro fertilization (IVF) treatment is thus reduced. In this study, case histories are reported of six women with newly diagnosed malignancies who requested ovulation induction/IVF prior to chemotherapy or surgery in which we have used the GnRH antagonist Cetrorelix. Gonadotrophin administration was started in the early follicular phase, and Cetrorelix (0.25 mg s.c. daily) was added from day 6 of treatment. Subsequent to human chorionic gonadotrophin (HCG) administration oocytes were recovered and successful fertilization and embryo cryopreservation was achieved in all cases. The median duration of treatment was 12 days (range 8–13, including induction of luteolysis in two patients). These results illustrate the potential use and advantages of a GnRH antagonist in ovulation induction/IVF when the need for immediate initiation of treatment and its duration are critical factors.

Key words: cancer/GnRH antagonist/IVF/ovulation induction


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Case reports
 Discussion
 References
 
Treatment for malignant disease, whether surgery, chemotherapy or radiotherapy, will often compromise future fertility (Howell and Shalet, 1998Go). As survival rates increase with advances in care, the preservation of fertility becomes increasingly relevant and it is estimated that by the year 2003, 1 in 1000 young adults will be survivors of childhood malignancy. Ovarian tissue cryopreservation has been described, and fertility has been restored to domestic animals following replacement of such tissue (Gosden et al., 1994Go; Newton et al., 1996Go). However re-implantation of the ovarian tissue risks re-introduction of the original malignancy, particularly if the disease is blood-borne rather than a solid tumour (Shaw et al., 1996Go) and guidelines on the use of this approach are currently being prepared by the Royal College of Obstetricians and Gynaecologists. Pregnancy following in-vitro maturation of oocytes from preantral follicles has thus far only been successful in the mouse (Eppig and O'Brien, 1996Go), although human pregnancy following maturation of oocytes from antral follicles has been reported (Barnes et al., 1995Go). Cryopreservation of embryos created by ovulation induction and in-vitro fertilization (IVF) is by contrast a proven technology without risk of re-introducing disease, and can be combined with surrogacy where the treatment of the malignancy involves hysterectomy or radiotherapy to the pelvis (Atkinson et al., 1994Go; Meniru and Craft, 1997Go).

Current ovulation induction techniques involve the use of a gonadotrophin releasing-hormone (GnRH) agonist to down-regulate the hypothalamo-pituitary–ovarian axis prior to gonadotrophin administration. The agonist is commonly administered for 10–14 days starting in the mid-luteal or early follicular phases of the menstrual cycle and is continued during the subsequent administration of gonadotrophins (Filicori et al., 1996Go). If this preliminary down-regulation could be avoided, the duration of ovulation induction treatment would be reduced considerably. This might be of both physical and psychological benefit to those women whose malignant disease necessitates urgent treatment. GnRH antagonists do not stimulate gonadotrophin secretion. Thus they can be administered once follicular development is initiated, preventing premature luteinizing hormone (LH) release while allowing continuing follicular maturation (Diedrich et al., 1994Go; Paulson et al., 1994Go). A further advantage is that less exogenous gonadotrophin is required in ovulation induction protocols (Diedrich et al., 1994Go). We here describe our initial experience with the GnRH antagonist Cetrorelix, administered after starting gonadotrophin treatment, in ovulation induction/IVF with embryo cryopreservation for women with malignant disease.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Case reports
 Discussion
 References
 
The ovulation induction regimen involved administration of urinary menopausal gonadotrophins (human menopausal gonadotrophin: HMG, Menogon; Ferring, Feltham, UK), starting in the early follicular phase of the cycle with subsequent additional administration of the GnRH antagonist. The protocol was similar to that used in a phase III study of the use of Cetrorelix conducted by ASTA Medica (Frankfurt, Germany), who supplied both HMG and Cetrorelix for the patients described here on a named-patient basis.

Patients were administered Menogon, 150 IU/day i.m. daily for the duration of ovulation induction, except for patient 6 who was started on a dose of 225 IU/day. Cetrorelix, 0.25 mg s.c. daily was introduced from day 6. When the three leading follicles reached a diameter of >16 mm, HMG and Cetrorelix administration was discontinued and human chorionic gonadotrophin (HCG, Profasi; Serono, Welwyn Garden City, Herts, UK) 10000 IU s.c. was administered. Transvaginal oocyte collection was performed 34 h later.

Spermatozoa were prepared from a fresh ejaculate using a combination of density gradient centrifugation (Sil Select; Microm, Thame, UK) and swim-up, and mixed with oocytes at a concentration of 150 000/4 oocytes in 0.75 ml. Twenty-four hours later, the oocytes were examined for signs of fertilization and those showing two pronuclei were cryopreserved.

Table IGo shows details of ovulation induction treatment, oocyte recovery and fertilization for each patient. Hormonal data from one patient (no. 3) are shown in Figure 1Go.


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Table I. Cycle details for six patients treated with human menopausal gonadotrophin (HMG) with subsequent addition of Cetrorelix from day 6
 


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Figure 1. Plasma concentrations of luteinizing hormone (LH), follicle stimulating hormone (FSH), oestradiol and progesterone in patient 4 during human menopausal gonadotrophin (HMG)/Cetrorelix administration. Abscissa, days relative to start of HMG administration. Cetrorelix (1 mg s.c.) was administered at the first arrow, and at a dose of 0.25 mg s.c. from day 6 daily as indicated by subsequent arrows. HMG was administered on days 1–9 as indicated by the shaded box. Human chorionic gonadotrophin (HCG) (10 000 IU) was administered on day 10 (arrowhead) and oocyte recovery was performed on day 12. Blood samples were taken prior to drug administration each day.

 
Patient details
The patients were referred from Departments of Oncology and Gynaecology. Other than their primary malignant diagnosis, all were otherwise healthy and were not taking hormonal medication or contraception. After initial consultation when the options for preserving fertility were discussed, they and their partners were seen by an independent counsellor specializing in infertility issues prior to starting ovulation induction. Patients were informed that they would need to have at least 2 years free of disease before any embryos would be replaced. Semen analysis was performed prior to or immediately on starting gonadotrophin treatment.


    Case reports
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 Abstract
 Introduction
 Materials and methods
 Case reports
 Discussion
 References
 
Patient 1
This 28 year old patient had had a grade 3 sarcoma resected from her right thigh 4 weeks previously and was about to start chemotherapy. She was nulliparous, single but in a stable relationship, had regular menstrual cycles and was otherwise healthy. When initially seen she was in the luteal phase of her cycle. After discussion of the options, she elected to have both laparoscopic ovarian cortical biopsy with cryopreservation and ovulation induction/IVF with embryo cryopreservation. The laparoscopic procedure was performed without complication a week after her initial consultation. Menses had started 2 days previously, and gonadotrophin administration was started on the day of laparoscopy. Her partner's semen analysis was normal. Following oocyte recovery, she developed moderate ovarian hyperstimulation but did not require admission to hospital and she recovered with conservative management. Chemotherapy (ifosphamide and adriamycin) was started 16 days after oocyte recovery.

Patient 2
This patient, aged 30 years, had been found to have a poorly differentiated adenosquamous carcinoma of the cervix and was scheduled to have a Wertheim's hysterectomy with ovarian preservation. The tumour was subsequently found to be stage 1B, with no evidence of lymphatic involvement. She was nulliparous and unmarried but in a stable relationship and had stopped oral contraception 5 months previously with a view to conception. Her partner's initial semen analysis showed reduced progressive motility (35%) with normal density and morphology, but subsequent analysis was normal. At the time of diagnosis and referral she was in the luteal phase of a cycle and menses commenced 9 days after diagnosis. Gonadotrophin treatment was started that day. In view of the future requirement for surrogacy, viral screening [hepatitis B and C, human immunodeficiency virus (HIV)] of both the patient and her partner was performed pretreatment following appropriate counselling. Cetrorelix was continued for 7 days after oocyte recovery to enhance ovarian regression and she subsequently underwent hysterectomy 9 days after oocyte recovery. This was 14 days later than the operation had originally been planned before the possibility of ovulation induction/IVF was raised.

Patient 3
This 25 year old women had breast cancer and had undergone a bilateral mastectomy. This had been at her request as she had a strong family history of breast cancer. Her tumour staging was T1N0M0 and she was due to start chemotherapy (CMF: cyclophosphamide, methotrexate and fluorouracil). She was married and the couple had been attempting to conceive. She was para 0+2, having had two miscarriages, the more recent 4 months previously. She was in the luteal phase of her cycle at presentation, and was administered 1 mg Cetrorelix s.c. to induce luteolysis. Plasma progesterone concentration fell rapidly (Figure 1Go), menses started 4 days later and she commenced HMG the following day. On day 6 of HMG, 0.25 mg Cetrorelix s.c. was added. Plasma LH was found to be 16.2 IU/l with progesterone concentration 1.90 ng/ml on that day, indicating a premature LH surge. The following day LH had dropped to 3.1 IU/l and remained suppressed for the duration of treatment (Figure 1Go), while follicular growth continued. Partner's semen analysis initially showed reduced normal morphology (33%) at initial assessment, which improved to 57% on subsequent analysis.

Patients 4–6
These three women aged 28–29 years also all had breast cancer and had undergone lumpectomy or mastectomy and axillary clearance. Patients 4 and 5 were staged T2N0M0, patient 3 was T2N1M0. The tumours were all grade 3 and oestrogen receptor negative, and adjuvant chemotherapy with CMF was scheduled. Patients 5 and 6 also received local radiotherapy. All were married or in stable relationships, one had been trying to conceive at the time of diagnosis and the other two were using the combined contraceptive pill. Patients 5 and 6 had each had one previous pregnancy, which had been an ectopic gestation treated by salpingostomy the previous year and electively terminated respectively. All partner's semen analyses were normal. Patient 4 presented in the mid-luteal phase of a cycle, and as with patient 3 was given a single injection of Cetrorelix 1 mg s.c. to induce luteal regression: menses started 2 days later. Patients 5 and 6 presented premenstrually and commenced HMG on day 2 of the subsequent cycle. Patient 4 continued on Cetrorelix for 7 days after oocyte collection, and chemotherapy was started the day following oocyte collection: chemotherapy was started within 2 weeks in the other two patients.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Case reports
 Discussion
 References
 
Cryopreservation of embryos has been routine clinical practice for many years with implantation rates similar to those obtained with fresh embryos (Human Fertilization and Embryology Authority, 1997). It therefore offers women a realistic chance of conception using their own oocytes should the treatment for their malignant disease result in ovarian failure. The six women described here were all in stable relationships, and in fact two were actively pursuing pregnancy.

The purpose of this report, however, is to address the practical problem of minimizing any delay in initiating definitive treatment for the malignancy as a result of undergoing ovulation induction/IVF by the use of a GnRH antagonist. Cetrorelix is a potent GnRH antagonist (Gonzalez-Barcena et al., 1994Go) which has recently completed phase III clinical trials. GnRH antagonist administration does not result in the initial stimulation of gonadotrophin secretion characteristic of the widely used GnRH agonists, allowing administration to be delayed until after follicular development has been initiated while still preventing premature luteinization (Diedrich et al., 1994Go; Fraser and Bouchard, 1994Go). The absence of preliminary suppression of the hypothalamo-pituitary-ovarian axis also results in both a lower total dose of gonadotrophin and a shorter duration of gonadotrophin administration (Diedrich et al., 1994Go).

All six patients reported here were initially seen in the luteal phase of a spontaneous cycle. In four, gonadotrophin administration was started with next spontaneous menses. In two who were estimated to be in the mid-luteal phase, confirmed in patient 3 by plasma progesterone measurement, a single dose of Cetrorelix was used to induce luteolysis. A larger dose was used than during the follicular phase, in the absence of any previous data, to ensure adequate LH suppression but a lower dose may well have sufficed (Albano et al., 1996Go; Felberbaum et al., 1996Go). That luteolysis indeed occurred was confirmed by a rapid fall in progesterone concentration, followed by menses 2–4 days later. Administration of the GnRH antagonist in the late follicular phase results in follicular regression (Leroy et al., 1994Go), allowing rapid commencement of gonadotrophin administration and avoidance of an LH surge: this effect was seen in patient 3, who was found in retrospect to have initiated an LH surge at the time Cetrorelix administration was started. As the state of the endometrium was of no consequence as all embryos were cryopreserved, for the clinical situation described here the stage of the cycle when gonadotrophin treatment was started was of less importance than if embryos were to be replaced. Avoidance of the mid-late follicular phase would, however, avoid the detrimental effect of a spontaneous LH surge before Cetrorelix was started. While there is no compelling reason not to start HMG administration in the luteal phase, endogenous gonadotrophin secretion will be at its nadir at this time, thus reducing the benefit of the absence of GnRH agonist-induced pituitary suppression.

The majority of patients had a diagnosis of breast cancer and were scheduled to have chemotherapy. All tumours were oestrogen-receptor negative, thus reducing the risk of tumour stimulation from the elevated oestradiol concentrations resulting from ovulation induction and also reducing the risk from subsequent pregnancy. This complication could be avoided by aspiration of immature oocytes without administration of gonadotrophins (Barnes et al., 1995Go), but this technique is not widely available. An alternative approach using GnRH agonist administration to prevent the adverse reproductive effects of chemotherapy has been described (Waxman et al., 1987Go; Blumenfeld and Haim, 1997Go): however, results are inconsistent. While CMF is not a particularly gonadotoxic therapy, all chemotherapeutic agents will advance follicular loss (Howell and Shalet, 1998Go).

The duration of gonadotrophin administration was 8–13 days; thus the total dose of HMG was 16–39 ampoules. While the small number of patients involved precludes detailed analysis, the present results are consistent with there being a reduction in HMG dose and duration of administration with Cetrorelix (Diedrich et al., 1994Go). The total duration of treatment in these four cases was therefore a maximum of 2 weeks, which included laparoscopy for ovarian biopsy and cryopreservation in one case. This is consistent with studies comparing GnRH antagonist with agonist regimens (Sauer et al., 1997Go). The delay in initiating treatment for the malignancy was therefore reduced by the availability of the GnRH antagonist compared to using a GnRH agonist in a standard down-regulation protocol. This also required good communication with the oncologists, and no difficulties were experienced in this regard as the referring physicians had been previously informed of the practicalities of a rapid referral service. In all six cycles oocytes were successfully recovered, fertilized, and embryos cryopreserved. Fertilization rates were within the normal range. It was noted, however, that the preliminary semen analyses was abnormal in two cases in that sperm motility or percentage normal morphology were low. It is possible that this resulted from a prolonged period of sexual abstinence, a further potential complication of the management of couples recently diagnosed with malignant disease.

This report illustrates a further indication for the use of GnRH antagonists. While the minimizing of delay in initiating ovulation induction may be of benefit, it allows less time for counselling and reflection by the couple. The ethical difficulties of this treatment at such a time, which include issues of the provision of consent from the male partner and posthumous use or disposal of the embryos (Bahadur, 1996Go), are acknowledged and are not reduced by the use of a GnRH antagonist.


    Acknowledgments
 
We are grateful to ASTA Medica AG for the supply of Cetrorelix and Menogon for these patients.


    Notes
 
3 To whom correspondence should be addressed Back


    References
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 Abstract
 Introduction
 Materials and methods
 Case reports
 Discussion
 References
 
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Atkinson, H.G., Apperley, J.F., Dawson, K. et al. (1994) Successful pregnancy after embryo cryopreservation after BMT for CML. Lancet, 344, 199.

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Submitted on April 16, 1999; accepted on July 8, 1999.