Random-start controlled ovarian hyperstimulation for emergency fertility preservation in letrozole cycles

Purpose Chemotherapeutic agents have a known gonadotoxic effect; however, it is difficult to predict the impact they may have on ovarian stimulation. The objective of this study was to evaluate response to ovarian stimulation in patients exposed to chemotherapy compared with patients who were chemotherapy-naïve. Methods A retrospective cohort study of 130 patients with cancer or autoimmune disease was performed. Demographics, ovarian reserve, ovarian response and stimulation parameters, and oocyte data were compared between patients who were pre-and post-chemotherapy. Logistic regression modeling was performed to identify risk factors for cancellation and low oocyte yield, adjusting for confounders as appropriate. Results Antral follicle count (AFC) was significantly lower in post-chemo patients (9 vs. 17, p<0.001). Post-chemotherapy patients were more likely to be cancelled during stimulation (23 vs. 4 %, p=0.003). Among those that went to retrieval, there was no difference in total number of oocytes (10 vs. 10, p=0.31) or mature oocytes retrieved (8 vs. 8, p=0.38), despite higher starting (300 vs. 450 IU, p<0.001) and total gonadotropin (3075 vs. 4612.5 IU, p=0.008) doses in post-chemotherapy patients. Low AFC (≤6) was associated with cycle cancellation (OR 7.7, 95 % CI 1.8-33.2) and low oocyte yield (<6) (OR 5.4, 95 % CI 1.6-17.7). Conclusions Patients post-chemotherapy have lower AFC compared with the chemotherapy-naïve and have higher cancellation rates. Among those who underwent oocyte retrieval, oocyte yield was similar in both groups. Low AFC was most strongly associated with cycle cancellation and oocyte yield. Post-chemotherapy patients had higher rates of cycle cancellation but did equally well as pre-chemotherapy patients if they reached retrieval.

Section: Discussionmentioning

confidence: 70%

Outcomes of ovarian stimulation after treatment with chemotherapy

Chan

Johnson

Efymow

et al. 2015

“…Eight of the qualitative studies were excluded due to the lack of a control group or due to a sample size of only one subject [8,10,28,32,[35][36][37][38].…”

Section: Quantitative Analysismentioning

confidence: 99%

“…Sonmezer et al followed with a case series documenting success with random-start ovarian stimulation in three women with newly diagnosed breast cancer [8]. Likewise, Nayak and Wakim demonstrated that with luteal phase stimulation, four women were able to complete ovarian stimulation and embryo cryopreservation and begin cancer treatments within 17 days of presentation [9].…”

Section: Introductionmentioning

confidence: 99%

Ovarian stimulation in the luteal phase: systematic review and meta-analysis

Boots

Meister

Cooper

et al. 2016

Purpose The purpose of this study was to evaluate whether outcomes are different if controlled ovarian stimulation (COS) is started in the luteal phase rather than the follicular phase. Methods A systematic review and meta-analysis was performed. Sixteen studies were included in the qualitative analysis, and eight studies with a total of 338 women were included in the quantitative analysis. Results Cycles initiated in the luteal phase were slightly longer (WMD 1.1 days, 95 % CI 0.39-1.9) and utilized more total gonadotropins (WMD 817 IU, 95 % CI 489-1144). However, no differences were noted in peak estradiol levels (WMD −411 pg/ml, 95 % CI −906-84.7) or in the total number of oocytes retrieved (WMD 0.52 oocytes, 95 % CI −0.74-1.7). There were slightly more mature oocytes retrieved in the luteal phase (WMD 0.77 oocytes, 95 % CI 0.21-1.3), and fertilization rates were significantly higher (WMD 10 %, 95 % CI 0.03-0.18). While only three studies reported pregnancy outcomes, no difference was noted in the FET pregnancy rates after COS in the luteal versus follicular phase (RR 0.95, 95 % CI 0.56-1.7).A post hoc power analysis revealed that a sample of this size was sufficient to detect a clinically meaningful difference of 2 oocytes retrieved with 93 % power.Conclusion Although initiating COS in the luteal phase requires a longer stimulation and a higher dose of total gonadotropin, these differences are not clinically significant. Furthermore, COS initiated in the luteal phase does not compromise the quantity or quality of oocytes retrieved compared to outcomes of traditional stimulation in the follicular phase.

“…Traditional ovarian stimulation protocols require women to be at the start of their menstrual cycle. The use of 'random start cycles' avoids this requirement and minimise the delays in initiating fertility preservation treatment [28] and ultimately ensures the prompt onset of essential cancer therapy. There is evidence to suggest that cancer survival rates were only reduced when the time from surgery to chemotherapy exceeded 12 weeks [20].…”

Section: Discussionmentioning

confidence: 99%

Fifteen year follow-up of embryos cryopreserved in cancer patients for fertility preservation

Barcroft

Dayoub

Thong

2013

Purpose Determine the outcome of embryo cryopreservation in female oncology patients Methods The outcomes of IVF/ICSI cycles in oncology patients over 15 years in a University Teaching Hospital. Results Forty-two oncology patients (mean 31.9±3.9 years) underwent embryo cryopreservation treatment (n=33 IVF, n=6 ICSI). Controlled ovarian stimulation with GnRH antagonist protocol (n=34; 81 %) yielded fewer oocytes than GnRH agonist protocol (n=8; 19 %) (9.4±6.3 vs. 15.3±8.9; p=0.04) respectively. There was no significant difference in mean (±SD) duration of ovarian stimulation (11.6±2.6 vs.10.6±2.7), median gonadotrophin dose (1950( vs. 1670, median day 5-6 oestradiol level (1124 vs.1129 pmol/l) or embryo yield (6.2±4.1 vs. 8.8± 4.3; p=0.07) between GnRH antagonist and agonist treatment cycles respectively. Thirty-nine patients cryopreserved embryos and three had their cycle cancelled. During this study period, of those who cryopreserved embryos, 5 patients underwent 9 frozen-thaw cycles (13 %), resulting in 2 live births (1 twin, 1 singleton, live birth rate 22 %). Six patients died (15 %), 3 conceived naturally (8 %) and 2 couples separated (5 %). Fourteen patients discarded their embryos (36 %). Twenty-two patients' (56 %) have embryos remaining in storage. Conclusions This study demonstrates that embryo cryopreservation in female oncology patients gives a satisfactory live birth rate. However, there are concerns regarding costeffectiveness, resulting from high disposal/non-usage of embryos, and further studies are required.