Spontaneous conception in a young woman who had ovarian cortical tissue cryopreserved before chemotherapy and radiotherapy for a Ewing's sarcoma of the pelvis: Case report

L.E. Bath1, G. Tydeman2, H.O.D. Critchley1, R.A. Anderson3, D.T. Baird1 and W.H.B. Wallace1,4

1 Department of Reproductive and Developmental Sciences, University of Edinburgh, 2 Department of Obstetrics and Gynaecology, Fife Acute Hospitals NHS Trust and 3 MRC Human Reproductive Sciences Unit, Edinburgh, UK

4 To whom correspondence should be addressed. Email: hamish.wallace{at}luht.scot.nhs.uk


    Abstract
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 Abstract
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 Case report
 Discussion
 References
 
We report the case of a 14 year old girl who presented with a non-metastatic Ewing's sarcoma involving her superior pubic ramus. She received 14 courses of alkylating agent-based chemotherapy and direct radiation to her hemi-pelvis (55 Gy) and is alive and disease-free 8 years later. Multiple biopsies of ovarian cortical tissue were cryopreserved, with her written consent, before treatment began. Ovarian failure was confirmed on completion of treatment with cessation of menses and persistently elevated serum gonadotrophin and low estradiol levels on repeated measurement over 2 years. HRT was initiated. Irregular vaginal bleeding occurred due to radiation vaginitis. Reimplantation of ovarian cortical tissue was considered at 19 years as fertility was desired, but the decision deferred. A spontaneous conception occurred 1 year later and a healthy boy (birthweight 2.9 kg, 3rd–10th centile) was delivered at term by elective Caesarean section. This is the first case of a spontaneous conception occurring in a young woman with documented ovarian failure in whom ovarian cortical tissue had been cryopreserved. Clinicians should be aware of the possibility of spontaneous conception despite confirmed ovarian failure in young women successfully treated for cancer.

Key words: childhood cancer/ovarian cryopreservation/ovarian failure/pelvic tumour/radiotherapy


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 Abstract
 Introduction
 Case report
 Discussion
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Since the 1960 s the survival rate for children and adolescents with cancer has been steadily increasing. Survival rates are now in excess of 70% and by 2010 it is predicted that one in 715 young adults will be a survivor of childhood cancer (Mertens et al., 2001Go; Campbell et al., 2004Go). The aim of treatment is cure at least cost in terms of long-term morbidity. Treatment with multi-agent chemotherapy and/or radiotherapy is associated with significant late effects (Bath et al., 2002Go). Ovarian damage following treatment of cancer and leukaemia has long been recognized (Himelstein-Braw et al., 1978Go). The human ovary is sensitive to radiotherapy with the LD50 recently estimated to be <2 Gy (Wallace et al., 2003Go). Ovarian failure has been demonstrated in 97% of females following whole abdominal radiation (20–30 Gy) in childhood (Wallace et al., 1989Go), and in 90% of women following total body irradiation (9.2–15.75 Gy) (Sanders et al., 1996Go). Ovarian damage following chemotherapy is both drug and dose dependent (Meirow et al., 2001).

For young people at risk of ovarian failure following chemotherapy or radiotherapy, the options for fertility preservation are limited (Wallace et al., 2004Go). Strategies for preserving reproductive potential include storage of embryos and mature oocytes, which is only possible in post-pubertal women. For the young female, ovarian cortical tissue rich in primordial follicles may be cryopreserved (Poirot et al., 2002Go). Successful return of ovarian function following reimplantation of cortical strips has been reported in ovariectomized sheep with subsequent conception (Gosden et al., 1994Go). Reimplantation and limited return of ovarian activity has been reported in a woman who had received gonadal toxic therapy before ovarian tissue collection (Radford et al., 2001Go). Spontaneous ovulation and pregnancy remain possible in women with premature ovarian failure (Nasir et al., 1997Go; Kalantaridou and Nelson, 2000Go). Ovarian activity and particularly pregnancy following cryopreservation and reimplantation must therefore be carefully documented not to be derived from residual ovarian tissue even after clearly demonstrated ovarian failure. We here report such a case.


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 Abstract
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 Case report
 Discussion
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We here report the case of a 14.9 year old girl who presented with a 2 year history of left groin pain. Radiological investigation demonstrated a bony mass, 110 ml in volume, arising from left superior pubic ramus that, on biopsy, was confirmed to be a Ewing's sarcoma. She was considered to be at high risk of developing ovarian failure as a result of the planned treatment with chemotherapy and local pelvic radiotherapy. After detailed discussion, informed consent was obtained from the girl and her parents for laparoscopic collection of ovarian cortical biopsies. These were stored in Leibovitz medium with cryoprotectant at –176°C. Treatment was commenced in accordance with the EICESS 1992 protocol; 14 courses of chemotherapy, with a total dose of ifosfamide of 86.4 g/m2, and 55 Gy to her left pelvis. The treatment was completed aged 15.8 years.

Ovarian function was monitored during and after treatment. After completion of radiotherapy aged 15.3 years, she developed symptoms and biochemical evidence of ovarian failure with hot flushes, elevated gonadotrophins and undetectable inhibin B concentrations in serum (see Table I). Sex steroid replacement in the form of the combined oral contraceptive pill, Loestrin 20 (ethinyl estradiol 20 µg and norethisterone acetate 1 mg) was commenced and continued until completion of chemotherapy. There was intermittent vaginal spotting and HRT was discontinued for 3 months on completion of treatment. Re-evaluation of her biochemical data confirmed ovarian failure with significant elevation of serum gonadotrophins and undetectable inhibin B with absent menses (Table I). HRT was restarted but persistent vaginal bleeding continued. A variety of preparations was administered, as detailed in Figure 1. Aged 16.7 years, while on HRT, a transabdominal ultrasound scan of her pelvis demonstrated a uterine length of 5.9 cm (AP 2.6 cm, transverse 3 cm) with an endometrial echo. Wave forms were obtained from both uterine arteries: the left had a pulsatility index of 2.72 and the right 2.87. The left ovarian volume was 2.2 ml and the right 4.2 ml. No follicles were seen and no Doppler signals were obtained from either ovary. HRT was discontinued for 3 weeks, after which gonadotrophin levels indicated ovarian failure (see Figure 1). Continuous transdermal estradiol with oral progesterone every 2 weeks for 14 days was then recommenced. Further evaluation of the persistent vaginal bleeding, on the above regimen, at the age of 18.5 years included an examination under anaesthesia, a cervical smear, a biopsy of vaginal wall, a hysteroscopy and an endometrial biopsy. Examination revealed an atrophic lower vaginal tract. Biopsy of the vaginal wall showed chronic inflammation and ulceration consistent with a post-radiation effect. The uterine cavity appeared normal and the endometrial biopsy showed normal early secretory phase endometrium. Radiation damage to the lower vaginal tract was found to be the cause for the bleeding and topical vaginal estrogen was prescribed in addition to transdermal estradiol. The intermittent vaginal bleeding improved.


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Table I. Biochemical profile in relation to age, HRT and spontaneous menstrual cycles

 


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Figure 1. FSH concentration, details of HRT and specific events over time.

 
At the age of 19.7 years, she and her partner presented to discuss their fertility prospects. There was no dyspareunia or vaginal bleeding. Consideration was given to reimplantation of cortical biopsies and consultation was organized with the Gynaecology Department, but after discussion the decision for reimplantation was deferred for personal reasons and HRT continued.

An ultrasound scan carried out when she was 20.2 years, following a history of abdominal pain and vaginal bleeding, demonstrated an early intrauterine pregnancy. The bleeding resolved and the pregnancy progressed. Cardiac assessment was carried out to exclude anthracycline cardiomyopathy. Pelvic assessment was required to consider optimum mode of delivery in view of previous pelvic mass and radiotherapy. Regular fetal growth assessments were performed in view of concern of potential effect of radiotherapy on uterine function. Fetal growth progressed normally.

The history of pelvic radiotherapy suggested that vaginal delivery might be difficult and a decision was made to proceed to elective Caesarean section. At 38 weeks gestation, a healthy baby boy was delivered weighing 2940 g (3rd–10th centile). Intraoperative examination of the pelvic structures revealed apparently normal ovaries and pelvic bones with no macroscopic evidence of radiation damage.

After delivery there was spontaneous return of menses. Menses have remained regular over the subsequent 15 months, without any HRT. Early follicular gonadotrophin levels were initially normal but more recently have indicated impaired ovarian function, with plasma inhibin B remaining undetectable (see Table I). A pelvic ultrasound scan 15 months after delivery showed uterine length to be 7.3 cm (AP 3.7 cm, transverse 5.3 cm). The uterine artery blood flow was normal. The left ovary was not seen. The right ovary measured 1.9 x 1.8 x 1.5 cm (volume 2.3 ml).


    Discussion
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
We report a case of a girl who had a spontaneous conception following a history of clinical and biochemical evidence of ovarian failure after treatment with chemotherapy and local radiotherapy for a pelvic Ewing's sarcoma. Before treatment she had consented to collection of ovarian cortical tissue. There was clinical and biochemical evidence of ovarian failure on completion of treatment with elevated FSH levels and undetectable serum inhibin B concentrations. The left ovary received the full dose of radiation (55 Gy), but it is harder to estimate the dose received by the right ovary. The best estimate is that the right ovary received <30% of the total dose (<16.5 Gy), which will be associated with significant depletion of primordial oocytes (Wallace et al., 2003Go). The effect of the chemotherapy is harder to determine. There are no good data regarding gonadal toxic doses of ifosfamide. Cyclophosphamide, an analogue of ifosfamide, is associated with gonadal toxicity. Doses of >200 mg/kg are associated with ovarian failure (Sanders et al., 1991). The development of ovarian failure in our patient is likely to be a consequence of both radiotherapy and chemotherapy. After delivery there was spontaneous return of menses, with circulating gonadotrophin levels within the normal range. However, at 15 months post delivery there was evidence of incipient ovarian failure with elevated FSH concentrations and small ovarian volume (2.3 ml), consistent with a decreased primordial follicle pool, as a consequence of the previous therapy.

The risk of ovarian failure should be assessed before potentially gonadal toxic treatment begins and discussed with the patient and family. Exact prediction is not possible as this case demonstrates, but fertility preservation should be discussed with those deemed at high risk of ovarian failure. For pre-pubertal girls, and the majority of young women, preservation of fertility remains experimental and harvesting and storage of gonadal tissue before commencing cancer therapy is the most promising option (Grundy et al., 2001Go; Multidisciplinary Working Group, 2003Go).

Incipient ovarian failure may be detected by early follicular biochemical assessment of serum gonadotrophin and inhibin B concentrations (Creus et al., 2000Go). Recently anti-Müllerian hormone has been shown to be a potential marker of ovarian reserve (de Vet et al., 2002Go; Bath et al., 2003Go). Radiological assessment of ovarian volume may also be a potential predictor of reserve, with ovarian volume correlating with number of remaining follicles (Syrop et al., 1999Go; Larsen et al., 2003Go, Wallace et al., 2004Go).

Return of ovarian function and conception years after gonadal toxic chemotherapy and biochemical evidence of ovarian failure has been reported previously (Nasir et al., 1997Go). There are few reports of return of ovarian function after radiation-induced ovarian failure (Chao et al., 1998Go). Early data from autopsy specimens of children with leukaemia demonstrated a reduction in antral follicle number following chemotherapy (Himmelstein-Braw et al., 1978). Return of ovarian activity several months after completion of therapy and after documented biochemical ovarian failure is well recognized and reflects the duration of follicular growth from the primordial stage (Gougeon, 1996Go). The basis for return of ovarian activity years after documented evidence of ovarian failure is unclear. Women with premature ovarian failure after gonadal toxic therapy should be aware of the small but possible chance of return of function and therefore conception.

Collection of ovarian tissue as a potential method of preserving reproductive potential is available in some centres, and there is increasing evidence for the potential for partial restoration of ovarian function by heterotopic (Lee et al., 2004Go; Oktay et al., 2004Go) and orthotopic (Oktay and Karlikaya, 2001; Radford et al., 2001Go; Tryde Schmidt et al., 2004Go) transplantation. Recently, a spontaneous pregnancy after orthotopic ovarian transplantation in a Hodgkin survivor was also reported (Donnez et al., 2004). In these cases, consideration had been given to reimplantation as fertility was not thought possible, given the clinical and biochemical evidence of ovarian failure. However, in the case of orthotopic transplantation, the spontaneous conception could have then been erroneously attributed to successful re-engraftment and function of the stored cortical tissue. This case report thus clearly illustrates the need for precise analysis of the possible functional activity of any reimplanted ovarian tissue, particularly when reimplanted adjacent to or on existing ovary.


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Submitted on April 5, 2004; resubmitted on July 12, 2004; accepted on July 21, 2004.