Fertility preservation in patients undergoing gonadotoxic treatments: a Canadian Fertility and Andrology Society clinical practice guideline.

The management of young patients with cancer presents several unique challenges. In general, these patients are ill prepared for the diagnosis and the impact on their fertility. With the improved survival for all tumour types and stages, the need for adequate fertility counselling and a multidisciplinary approach in the reproductive care of these patients is paramount. Recent advances in cryopreservation techniques allow for the banking of spermatozoa, oocytes, embryos and ovarian tissue without compromising survival. This Canadian Fertility and Andrology Society (CFAS) guideline outlines the current understanding of social and medical issues associated with oncofertility, and the medical and surgical technologies available to optimize future fertility.

Integrin beta-4 signaling plays a key role in mouse embryogenesis.

Integrins, by signaling between extracellular matrix and cell nucleus, serve critical roles in cell proliferation and survival. A knock-in mice was developed by a targeted deletion of the C-terminal segment of the cytoplasmic tail of beta 4-integrin (beta 4-1355T). The beta 4-1355T mice had a longer gestational length, smaller litter sizes, lower fecundity rate, and higher frequency of early pregnancy loss. beta 4-1355T embryos demonstrated a high degree of fragmentation and asymmetry, with fewer surviving to either a morula or blastocyst stage. In wild-type oocytes and embryos, beta1, beta 4, and laminin-5 signals colocalized at the opposing surfaces of blastomeres and between the polar bodies and oocytes. Blastomeres within the beta 4-1355T embryos were less cohesive, with a more diffuse expression of beta 4 and laminin-5 compared with wild type. The alpha 6 beta 4_laminin-5 interaction appears to be vital for maintaining the cohesiveness between the cells of the embryo. Deciphering the role of integrins such as beta 4 in embryogenesis may help explain in vitro fertilization failures.

Fertility preservation: a comprehensive approach to the young woman with cancer.

Modern treatments for cancers of the reproductive age are yielding ever-higher cure rates, but more often than not, the price paid for survival is the loss of reproductive function from gonadal toxicity. Alkylating agents and ionizing radiation have well-recognized deleterious effects within the testes and ovary and cause sterility in a high proportion of patients exposed to these treatments. Preservation of fertility for men simply involves the banking of sperm before treatment, but for women, the storage of gametes is technically very complex and has limited success. Even when faced with the diagnosis of cancer, many reproductive-aged women are burdened by the possibility of never conceiving a child with their own eggs. Fertility preservation for the reproductive-age women with cancer is emerging as a challenging, but rewarding, application of assisted reproductive technologies such as in vitro fertilization. With recent advances in cryopreservation techniques, oocytes, embryos, and ovarian tissue can be banked from these patients before exposure to sterilizing chemotherapy and radiotherapy, providing future fertility options without compromising survival.

Taking a basal follicle-stimulating hormone history is essential before initiating in vitro fertilization.

OBJECTIVE: To analyze IVF outcomes in patients with a history of one or more elevations in basal FSH who have a normal basal FSH at the start of their IVF cycle, compared with the general IVF population. DESIGN: Retrospective clinical study. SETTING: University hospital. PATIENT(S): General IVF patient population. INTERVENTION(S): Patients received standard IVF gonadotropin protocols, oocyte retrieval, and embryo transfer. MAIN OUTCOME MEASURE(S): Oocyte yield, fertilization, implantation, clinical pregnancy, and cancellation rate. RESULT(S): Oocyte yields were lower in patients with a history of elevated basal FSH, for all age groups, and showed an age-dependent decline in all patients. Over the age of 40 years, both implantation and clinical pregnancy rates were lower in these patients, with no significant difference observed in patients under the age of 40 years. No pregnancies were observed in patients with a history of three or more elevated FSH levels, regardless of age. CONCLUSION(S): A history of elevated basal FSH levels in patients under the age of 40 years predicts a lower oocyte yield in IVF cycles with normal basal FSH levels but does not translate to either lower pregnancy or implantation rates. Patients aged >40 years with prior elevations in basal FSH levels have both compromised ovarian response and compromised embryo quality relative to those with normal FSH levels, as illustrated by lower oocyte yield, higher cancellation rates, and lower implantation and pregnancy rates.

Spontaneous ovarian hyperstimulation caused by a follicle-stimulating hormone-secreting pituitary adenoma.

OBJECTIVE: To report a case of spontaneous ovarian hyperstimulation resulting from an FSH-secreting pituitary adenoma. DESIGN: Case report. SETTING: University hospital. PATIENT(S): A 29-year-old previously healthy, nulligravid woman. INTERVENTION(S): Transphenoidal resection of the adenoma. MAIN OUTCOME MEASURE(S): Clinical remission. RESULT(S): After transphenoidal resection of the adenoma, the patient had an uneventful postoperative recovery with complete resolution of ovarian hyperstimulation and associated symptoms. Postoperative magnetic resonance imaging demonstrated residual tumor within the cavernous sinus. CONCLUSION(S): Follicle-stimulating hormone-secreting pituitary adenoma may present as acute spontaneous ovarian hyperstimulation.

Maternal serum vascular endothelial growth factor levels in early ectopic and intrauterine pregnancies after in vitro fertilization treatment.

OBJECTIVE: To determine whether serum levels of vascular endothelial growth factor (VEGF) 11 days after a day-3 embryo transfer were predictive of outcome, in women with normal intrauterine pregnancy (IUP), first-trimester miscarriage (SAB), biochemical (BC), and ectopic pregnancy (EP) after IVF therapy. DESIGN: Retrospective analysis. SETTING: University hospital IVF unit. PATIENT(S): One hundred eight women who underwent IVF therapy and who were subsequently diagnosed with EP, BC, SAB, or a normal IUP (27 in each category). INTERVENTION(S): Serum samples were obtained at 11 days after a day-3 embryo transfer. MAIN OUTCOME MEASURE(S): Serum concentrations of VEGF, P, and beta-hCG. RESULT(S): Serum concentrations of VEGF were similar in women with BC and EP and higher than in women with normal IUP and SAB (571.8 +/- 61.8, 604.4 +/- 73.4 vs. 448.9 +/- 39.9, 461.8 +/- 39.2 pg/mL, respectively). Also, serum beta-hCG and P levels were significantly higher in women with a normal IUP and SAB. Using a cutoff concentration of >700 pg/mL for VEGF, an EP could be distinguished from an IUP (normal and SAB), with a positive predictive value of 64% and a negative predictive value of 71%. CONCLUSION(S): Elevated maternal serum levels of VEGF, as early as 11 days after embryo transfer, are associated with ectopic pregnancies after IVF.