Efficacy and Safety of Controlled Ovarian Stimulation With or Without Letrozole Co-administration for Fertility Preservation: A Systematic Review and Meta-Analysis

Abstract

Background: The co-administration of letrozole during controlled ovarian stimulation (COS) with gonadotropins is used to limit the potentially harmful effects of a supra-physiological rise in estrogen levels on hormone-sensitive cancers. However, the efficacy and safety of adding letrozole to COS remain debated. Methods: This is a systematic review and meta-analysis of published studies that compared the efficacy and safety of COS with co-administration of letrozole vs. COS without letrozole in all patient populations. A secondary analysis was done including only the studies in breast cancer patients. The primary efficacy endpoint was the number of retrieved mature Metaphase II (MII) oocytes. Secondary efficacy and safety endpoints were total number of oocytes, maturation rate, fertilization rate, number of cryopreserved embryos, peak estradiol levels, progesterone levels, and total gonadotropin dose. Data for each endpoint were reported and analyzed thorough mean ratio (MR) with 95% confidence interval (CI). Results: A total of 11 records were selected including 2,121 patients (990 patients underwent COS with letrozole and 1,131 COS without letrozole). The addition of letrozole to COS did not have any negative effect on the number of mature oocytes collected (MR = 1.00, 95% CI = 0.87-1.16; P = 0.967) and the other efficacy endpoints. COS with letrozole was associated with significantly decreased peak estradiol levels (MR = 0.28, 95% CI = 0.24-0.32; P < 0.001). Similar results were observed in the secondary analysis including only breast cancer patients. Bonardi et al. Letrozole for Controlled Ovarian Stimulation Conclusions: These findings are reassuring on the efficacy and safety of COS with gonadotropins and letrozole and are particularly important for fertility preservation in women with hormone-sensitive cancers.

Letrozole for Female Infertility

“…Compared with the standard COS regimen, letrozole combined with FSH in COS (LE-FSH-COS) significantly decreased plasma E 2 peak concentration ( 69 ). A systematic review and meta-analysis including 2,121 hormone-sensitive cancer patients, compared the efficacy and safety of COS with letrozole vs. COS without letrozole, it showed the addition of letrozole did not have any negative effect on the number of mature oocytes collected and the other efficacy endpoints ( 70 ).…”

Abnormal Elevation of Anti-Mullerian Hormone and Androgen Levels Presenting as Granulosa Cell Tumor

“…In this ovarian stimulation protocol, letrozole was administered based on a micro-stimulation protocol. Letrozole is an aromatase inhibitor with the ability to suppress endogenous estrogen production and was recommended for fertility preservation in women with hormone-sensitive cancers ( 19 ). Considering the risk of blastocyst culture, all three frozen embryos were day 3 embryos, and their quality was rated as grade 1.…”

Reproductive issues in carriers of germline pathogenic variants in the BRCA1/2 genes: an expert meeting

“…As for BC patients, modified protocols using letrozole in estrogen-sensitive tumors are recommended to reduce estrogen serum concentration by more than 50%, without affecting the number of mature oocytes retrieved or their fertilization capacity and cancer prognosis [57,[83][84][85][86]. In a recent survey, 42% of the interviewed BC oncologists were unsure about the safety of COS in BRCAmutated BC patients [7].…”