Fertility Preservation in cancer patients ASCO recommendation

1
Fertility Preservation in cancer patients ASCO
recommendation

• Rama Suresh MD.

2
Faculty disclosure

• Dr. Rama Suresh has no financial conflict of
  interest to disclose.

3
Infertility in cancer patients

• Type of drug
• Location of radiation field/dose/doseintensity
• Disease
• Age
• Pretreatment fertility

4
Male infertility

• Disease itself
• Anatomic problems
• Primary or secondary hormonal insufficiency
• Damage or depletion of germinal stem cells
• Measurable effects sperm, motility, DNA
  integrity and morphology

5
Female infertility

• Decrease in primordial follicles
• Hormonal balance
• Interfering with function of reproductive organs
• Fertility maybe compromised despite maintainence
  or resumption of menses
• Premature menopause

6
(No Transcript)
7
(No Transcript)
8
Questions

• Are cancer patients interested in interventions
  to preserve fertility?
• What is the quality of evidence supporting
  current and forthcoming options for fertility
  preservation in males?
• What is the quality of evidence supporting
  current and forthcoming options for fertility
  preservation in females?
• What is the role of oncologist in advising
  patients about fertility preservation options?

9

• What is the quality of evidence supporting
  current and forthcoming options for fertility
  preservation in males?

10
(No Transcript)
11
LHRH agonist with chemo in men

• 6 men (5HD, 1LL)
• LHRH agonist 50mcg/d sq started before chemo and
  ended 1 week post chemo
• Testosetrone levels decreased and all patients
  were oligospermic/azoospermic within 8 weeks of
  chemo
• Post chemo testosterone/LH/FSH normalized but
  only one patient recovered spermatogenesis at 84
  weeks post chemo

Johnson DH et. Al.Blood 65(4) 832-836, 1985
12
Buserelin in Hodgkin's disease patients

• 30 men and 18 women with Hodgkin's disease
• randomized to Buserelin starting before chemo
  till after chemo vs. control
• LH suppressed
• After 3 years
• Buserelin arm all men oligospermic and 4 of 8
  women amenorrhoeic
• Control all men oligospermic and 6 of nine
  females amenorrhoeic

Waxman JH et.al. Cancer Chemother Pharmacol
19(2)159-162, 1987
13
Lupron and irradiation

• 12 men with seminoma got Lupron during XRT
• 8 men with seminoma were control
• LH and testosterone were low before XRT
• 18 month f/u all patients reached normal
  testosterone, LH levels and motile spermatozoa
  levels in the treatment and the control group

Brennemann W et. al. Clin Investig 72(11)
838-42, 1994
14
Lupron and PVB chemo

• Post orchiectomy 2 cycles of PVB chemo
• 6 patients received Lupron and 8 patients control
• Lupron patients had their hormone levels
  suppressed before chemo
• Post chemo all patients (study and control) had
  elevated FSH and azoospermia. They normalised
  within 24 months

Kreuser ED et. Al. Horm Metab Res 22 494-98, 1990
15

• What is the quality of evidence supporting
  current and forthcoming options for fertility
  preservation in females?

16
(No Transcript)
17
(No Transcript)
18
Ovarian protection Lupron

• 18 patients (13 HL, 5 NHL)
• Monthly depot Lupron x 6months starting 7 days
  before chemo
• 15 pts got MOPP/ABV(D)
• Control 18 patients of which 14 pts got same
  regimen
• 2 patients died in each group.
• 16 patients in the GnRH agonist arm and 7 pts in
  the control arm resumed menses within 3-8 months
  of chemo

Hum Reprod 11 1620-1626, 1996
19
Ovarian protection with Lupron

• 24 patients
• Ages 23-42 with early stage breast cancer
• ACx4 (n12), ACx4T(n10), CAF (n1), ATCMF(n1)
• Lupron 5 to 14 days before cycle 1 and and then
  day 1 of each subsequent cycle
• Amennorhea by cycle 3 and resumed menses in 23 of
  24 pts within 12 months of chemo
• 6 pregnancies in 5 patients 3 miscarriages, 1
  Downs syndrome terminated, one live birth,one
  ongoing pregnancy.
• 3 patients unsuccessful despite fertility
  treatment

Proc Am Soc Clin Oncol 22 13, 2003 (abstr 50)
20
Ovarian protection with Goserelin

• 64 pts with early stage breast cancer received
  3.6mg Goserelin q 28 days for one year
• Ages 27-50
• 44 ER, 56 ER neg
• CMF (n18) , Anthracylcine (n46), ABMT (n9)
• ER got tamoxifen for 5 yrs
• F/U 55 months
• 86 resumed menses, 1 patient was pregnant with
  normal childbirth

Anticancer drugs 13 417-424, 2002
21
Ovarian preservation with OC pills

• 1994 to 1998 Hodgkin's Lymphoma patients surveyed
• 405 women aged lt 40 yrs of 3186 patients answered
• F/U 3.2 yrs
• 51 patients who got dose escalated had
  amenorrhea
• Advanced stage, age gt30, women who did not take
  OC pills correlated with increased risk

J Clin Oncol 23 7555-7564, 2005
22
Ovarian follicle preservation with OC pills

• 6 women with Hodgkins disease
• Ages 18 to 31 f/u for 26 months
• MVPP x 6 cycles and OC pills at the beginning of
  chemo
• Pregnancy in one woman and regular menses in 3
  women, 2 had amenorrhea before establishing
  regular menses and one patient continued OC pills
• Pre chemo ovarian biopsy 18-55 follicles, post
  chemo with OC pills 22 follicles and one gt1000
  follicles (post chemo with no OC pills 0-4
  follicles)

Blood 58 849-851, 1981
23

• What is the role of oncologist in advising
  patients about fertility preservation options?

24
(No Transcript)
25
(No Transcript)