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
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Abstract |
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Key words: cancer/GnRH antagonist/IVF/ovulation induction
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Introduction |
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Current ovulation induction techniques involve the use of a gonadotrophin releasing-hormone (GnRH) agonist to down-regulate the hypothalamo-pituitaryovarian axis prior to gonadotrophin administration. The agonist is commonly administered for 1014 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., 1996). 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., 1994
; Paulson et al., 1994
). A further advantage is that less exogenous gonadotrophin is required in ovulation induction protocols (Diedrich et al., 1994
). 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.
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Materials and methods |
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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 I shows details of ovulation induction treatment, oocyte recovery and fertilization for each patient. Hormonal data from one patient (no. 3) are shown in Figure 1
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Case reports |
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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 1), 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 1
), 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 46
These three women aged 2829 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.
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Discussion |
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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., 1994) 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., 1994
; Fraser and Bouchard, 1994
). 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., 1994
).
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., 1996; Felberbaum et al., 1996
). That luteolysis indeed occurred was confirmed by a rapid fall in progesterone concentration, followed by menses 24 days later. Administration of the GnRH antagonist in the late follicular phase results in follicular regression (Leroy et al., 1994
), 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., 1995), 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., 1987
; Blumenfeld and Haim, 1997
): however, results are inconsistent. While CMF is not a particularly gonadotoxic therapy, all chemotherapeutic agents will advance follicular loss (Howell and Shalet, 1998
).
The duration of gonadotrophin administration was 813 days; thus the total dose of HMG was 1639 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., 1994). 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., 1997
). 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, 1996), are acknowledged and are not reduced by the use of a GnRH antagonist.
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Acknowledgments |
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Notes |
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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.
Bahadur, G. (1996) Posthumous assisted reproduction (PAR): cancer patients, potential cases, counselling and consent. Hum. Reprod., 11, 25732575.[ISI][Medline]
Barnes, F.L., Crombie, A., Gardner, D.K. et al. (1995) Blastocyst development and birth after in-vitro maturation of human primary oocytes, intracytoplasmic sperm injection and assisted hatching. Hum. Reprod., 10, 32433247.[Abstract]
Blumenfeld, Z. and Haim, N. (1997) Prevention of gonadal damage during cytotoxic therapy. Ann. Med., 29, 199206.[ISI][Medline]
Diedrich, K., Diedrich, C., Santos, E. et al. (1994) Suppression of the endogenous luteinizing hormone surge by the gonadotrophin-releasing hormone antagonist Cetrorelix during ovarian stimulation. Hum. Reprod., 9, 788791.[Abstract]
Eppig, J.J. and O'Brien, M.J. (1996) Development in vitro of mouse oocytes from primordial follicles. Biol. Reprod., 54, 197207.[Abstract]
Felberbaum, R., Reissmann, T., Kupker, W. et al. (1996) Hormone profiles under ovarian stimulation with human menopausal gonadotrophin (HMG) and concomitant administration of the gonadotrophin releasing hormone (GnRH)-antagonist Cetrorelix at different dosages. J. Assist. Reprod. Genet., 13, 216222.[ISI][Medline]
Filicori, M., Cognigni, G.E., Arnone, R. et al. (1996) Role of different GnRH agonist regimens in pituitary suppression and the outcome of controlled ovarian hyperstimulation. Hum. Reprod., 11, 123132.
Fraser, H.M. and Bouchard, P. (1994) Control of the preovulatory luteinizing hormone surge by gonadotrophin-releasing hormone antagonists: prospects for clinical application. Trends Endocrinol. Metab., 5, 8793.[ISI]
Gonzalez-Barcena, D., Vadillo Buenfil, M., Garcia Procel, E. et al. (1994) Inhibition of luteinizing hormone, follicle-stimulating hormone and sex steroid levels in men and women with a potent antagonist of luteinizing hormone-releasing hormone, Cetrorelix (SB-75). Eur. J. Endocrinol., 131, 286292.[ISI][Medline]
Gosden, R.G., Baird, D.T., Wade, J.C. and Webb, R. (1994) Restoration of fertility to oophorectomized sheep by ovarian autografts stored at 196°C. Hum. Reprod., 9, 597603.[Abstract]
Howell, S. and Shalet, S. (1998) Gonadal damage from chemotherapy and radiotherapy. Endocrinol. Metab. Clin. N. Am., 27, 927943.[ISI][Medline]
Human Fertilisation and Embryology Authority (1997) Annual Report. HFEA, London.
Leroy, I., d'Acermont, M.F., Brailly-Tabard, S. et al. (1994) A single injection of a gonadotrophin-releasing hormone (GnRH) antagonist (Cetrorelix) postpones the luteinizing hormone (LH) surge: further evidence for the role of GnRH during the LH surge. Fertil. Steril., 62, 461467.[ISI][Medline]
Meniru, G.I. and Craft, I. (1997) Assisted conception options for patients with good-prognosis cervical cancer. Lancet, 349, 542.
Newton, H., Aubard, Y., Rutherford, A. et al. (1996) Low temperature storage and grafting of human ovarian tissue. Hum. Reprod., 11, 14871491.
Paulson, R.J., Sauer, M.V. and Lobo, R.A. (1994) Addition of a gonadotropin releasing hormone (GnRH) antagonist and exogenous gonadotrophins to unstimulated in vitro fertilization (IVF) cycles: physiologic observations and preliminary experience. J. Assist. Reprod. Genet., 11, 2832.[ISI][Medline]
Sauer, M.V., Paulson, R.J. and Lobo, R.A. (1997) Comparing the clinical utility of GnRH antagonist to GnRH agonist in an oocyte donation program. Gynaecol. Obstet. Invest., 42, 215218.
Shaw, J.M., Bowles, J., Koopman, P. et al. (1996) Fresh and cryopreserved ovarian tissue samples from donors with lymphoma transmit the cancer to graft recipients. Hum. Reprod., 11, 16681673.[Abstract]
Waxman, J.H., Ahmed, R., Smith, D. et al. (1987) Failure to preserve fertility in patients with Hodgkin's disease. Cancer Chemother. Pharmacol., 19, 159162.[ISI][Medline]
Submitted on April 16, 1999; accepted on July 8, 1999.