Preserving fertility in female patients with hematological malignancies: a multidisciplinary oncofertility approach

Abstract

Oncofertility is a new interdisciplinary field at the intersection of oncology and reproductive medicine that expands fertility options for young cancer patients. The most common forms of hematological malignancies that occur in girls and young women and therefore necessitate oncofertility care are acute lymphocytic leukemia, acute myeloid leukemia, non-Hodgkin's lymphoma, and Hodgkin's lymphoma. Aggressive gonadotoxic anticancer regimens including alkylating chemotherapy and total body irradiation are used often in treating girls and young women with hematological malignancies. The risks of gonadotoxicity and subsequent iatrogenic premature ovarian insufficiency and fertility loss depend mainly on the type and stage of the disease, dose of anticancer therapy as well as the age of the patient at the beginning of treatment. To avoid or at least mitigate the devastating complications of anticancer therapy-induced gonadotoxicity, effective and comprehensive strategies that integrate different options for preserving and restoring fertility ranging from established to experimental strategies should be offered before, during, and after chemotherapy or radiotherapy. A multidisciplinary approach that involves strong coordination and collaboration between hemato-oncologists, gynecologists, reproductive biologists, research scientists, and patient navigators is essential to guarantee high standard of care.

Advances in the Treatment and Prevention of Chemotherapy-Induced Ovarian Toxicity

“…Figure 1 and Table 1 show the most common cancers and the risk of chemotherapy-induced ovarian toxicity in women according to chemotherapy protocol and age [ 3 , 20 , 21 ]. Notice that the course of chemotherapy and its related risks of gonadotoxicity can be unpredictable and variable due to treatment response and disease prognosis, i.e., refractory or recurrent cases [ 13 , 22 ]. In order to prevent POI due to chemotherapy and subsequent complications, effective and comprehensive oncofertility strategies should be undertaken to preserve fertility in young reproductive age women before initiation of cancer treatment [ 17 , 23 , 24 , 25 , 26 ].…”

“…After cancer remission is achieved, frozen ovarian sections are thawed and implanted on the surface of the remaining ovary or on the peritoneum [ 100 ]. In most cases, frozen–thawed ovarian tissue is orthotopically transplanted, but if orthotopic transplantation is not possible, it can be heterotopically transplanted to other areas, such as the subcutaneous space of the abdominal wall or forearm [ 13 ].…”

“…According to data from published research, since the first pregnancy was reported using this technique in 2004, the number of live births after ovarian tissue slow freezing and orthotopic auto-transplantation has exceeded 120 [ 13 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 ]. According to data from five major centers, the pregnancy and live birth rates were 29% and 23%, respectively [ 108 ].…”

“…Although ovarian tissue cryopreservation may be feasible in patients with aggressive cancer requiring immediate chemotherapy, possible contamination of ovarian tissue with malignant cells is a major concern associated with this technique [ 13 , 110 ]. Low levels of malignant cells have been detected in ovarian tissue and can lead to recurrence of disease after transplantation in both mouse and human models with hematologic malignancies [ 111 , 112 , 113 ].…”

“…Currently, embryo and oocyte cryopreservation are the only established methods for fertility preservation [ 12 ]. However, there is accumulating evidence for other experimental techniques including ovarian tissue cryopreservation, artificial ovaries, and in vitro maturation [ 13 ].…”