1. FERTILITY PRESERVATION & POST TREATMENT CONCERNS IN HAEMATOLOGY PATIENTS
Joanne McManus
Consultant Gynaecologist
Regional Fertility Centre
Belfast Trust
----- Meeting Notes (12/10/17 19:42) -----
As my specialist areas in gynaecology are fertility & menopause I see a siginficant number of young women & men who have reproductive health problems as a result of haematological & other malignancies. It is therefore encouraging that we can now offer hope not only for men but also for girls by being able to store eggs as well as sperm. While this is described using the umbrella term of fertility preservation it is really only offering them one or maybe 2 chances to conceive using hteir own gametes. Nevertheless it offers some hope & optimism for a future that otherwise may look very bleak
It is

2. FERTILITY SPECIALISTS
QUESTIONS
HAEMATOLOGISTS
WHO should be referred?
WHAT can be done?
What procedures are involved?
How long will it take
Is fertility preservation worthwhile?
FERTILITY SPECIALISTS
WHAT is the disease?
WHAT are the chances of treatment affecting fertility?
What are the chances of survival ?
How much time is there?
Is is Safe to do procedures?
The initial title for this talk that was suggested by Laura was ‘fertility Myth busting’ which suggests that you as haematology nurses & doctors know that you should be referring patients for fertility preservation but probably cant answer the patients questions as to what it involves or if they are suitable candidates for it.
But I can reassure you that you proabably know a lot more about fertility than we as gynaecologists know about haematological disorders. The first patient I ever saw for fertility preservation had myelodysplasia which I dint think I had even heard of.

3. What conditions affect patients of reproductive age?
Hodgkins Lymphoma % <50years
Acute Lymphoblastic Leukaemia 75% < 50years
Acute Myeloid Leukaemia 20% <50years
NHL % <50years
At time of Stem cell transplant
40% allogenic survivors < 40y
25% autologous recipients <40y
The main conditions that affect men & women of reproductive age are Hodgkins & the acute leukaemias
While we have seen lots of men over the years for sperm storage with HL we are now getting young women coming along for egg storage pre chemo. Obviously we don’t see the acute leukaoemia patients as they are too unwell & don’t have time to go through egg harvesting but I see these women after transplants for treamtent of their POF
HL – 80% cure rate, 40-90% for ALL
HCT= haemopoietic stem cell transplant

4. EFFECT ON FERTILITY HIGH DOSE CHEMO OR RADIOTHERAPY – gonadal failure
Lower doses – may not stop periods but will reduce ovarian reserve – accelerate menopause cause a fertility deficit
Risk of ovarian failure increases with age at treatment
Can start off as as less gonadotoxic therapy but change if relapse
MEN – sperm may recover –opposite for women
Although lower dose

5. Effect on Female Fertility
1-2x 106 eggs at birth
25,000 age 37
1000 age 51
Chemotherapy destroys mature ovarian follicles- induces apoptosis in Granulosa cells Also harms dormant primordial follicles – ‘ovarian reserve’ via other mechanisms Radiation directly toxic to oocytes both in dormant primordial & larger antral follicles Dose 2Gy – 50 % reduction in ovarian reserve
Chemo – damages dormant primordial follicles by poorly understood mechanisms
?apoptosis of primordial follicles themselves
? Cause fibrosis of stroma & reduced blood supply to primordial follicles
Depletion of primordial follicles by premature activation triggered by a decrease in granulosa cells(which secrete factors that inhibit primordial cell recruitment
Alison W. Loren Hematology 2015;2015:

6. Fertility Preservation Options
MALE
Post puberty
Sperm banking well established
Pre–pubertal
No options locally (research - Oxford)
FEMALE
IVF & embryo storage - if partner
Egg harvesting & cryopreservation
Pre-pubertal
Ovarian tissue storage not available NI
Can refer to Edinburgh or Oxford
Although still regarded as experimental & research >100 babies have been born worldwide

7. Male Fertility Preservation
Longstanding service in Regional Fertility Centre
Non –invasive but patient must be relatively well
One or more appointments – if time allows
Sperm count often low in haematological malignancies
Stored sperm usually only suitable for IVF/ICSI
Most men don’t use their stored sperm
Storage regulations - labour intensive for clinic

8. Guardian December 2015
Oxford – Dr Sheila Lane
Work in mice has shown sperm production after transplantation of testicular tissue & in vitro maturation

9. Oocyte Cryopreservation (egg freezing/ vitrification)
Funding for 12 cases per year in RFC (1st case 2013)
Conditions requiring surgery/chemo-radio- therapy likely to affect fertility
Unlikley to be beneficial >37-38 years old
Need approx 20 eggs to achieve a live birth
Possible for any post- pubertal girl – how young??
Published case of 13 year old pre-menarchal girl with Myleodysplasia – 18 mature eggs stored (Cornell)
Fertility & Sterility 2012;98:1225-8
EGG FREEZING HAS REALLY ONLY BECOME SUCCESSFULA OVER THE LAST DECADE WITH THE DEVELOPMNT OF VITRIFICATION AS A TECHNIQUE FOR FREEZING - SIGNIFICANT ADVANCE IN FERTILITY PRESERVATION AS WOMEN & GIRLS WHO DON’T HAVE A PARTNER NOW HAVE A REALTIVELY EASY MEANS OF PRESERVING some FERTILITY OR AT LEAST HAVING A CHANCE OF HAVING THEIR OWN CHILD IN THE FUTURE

10. EGG FREEZING Time needed = 2-+weeks
Ovarian stimulation - gonadotrophin injections usually days
GnRH Antagonist – prevents premature ovulation
Ultrasound follicle tracking – ideally transvaginal
Serum oestradiol measurements
Transvaginal egg retrieval – GA in younger girls
Egg freezing has become very

11. OVARIAN STIMULATION & EGG RETRIEVAL
RISKS
INFECTION
BLEEDING
NEEDLE INJURY – BOWEL, BLADDER, VASCULAR
OVARIAN HYPERSTIMULATION SYNDROME
POOR RESPONSE – NO EGGS OR LOW NUMBERS

12. Leah Age 15 Diagnosed with High Risk Myleodysplasia March 2013
Seen by adult & Paediatric Haematology
Recommended treatment allogenic BMT - 13yr old brother
Likely to induce ovarian failure – conditioning chemo & radiotherapy
Mother enquired about fertility preservation

13. Leah Attended RFC with Mum 8th May 2013
Discussed the option of egg harvesting & freezing
Leah understood that her treatment was likely to result in ovarian failure & infertility
Processes involved in ovarian stimulation and egg collection explained
Urgency of BMT discussed with Bristol who felt that there was time for egg freezing
RISKS – BLEEDING, INFECTION

14. Oocyte Cryopreservation
Monitoring by abdominal ultrasound & blood tests
Straightforward trans-vaginal egg collection - GA
Prophylactic ciprofloxacin 500mg twice daily & Fluconazole 100mg once daily x 5 days– commenced 48h before egg collection
21 eggs, 18 mature eggs vitrified
Future chance of live birth ?
25year old, 6 eggs injected – 37% chance of a live birth
Fertil Steril 2013;100,492-9
Tragically Leah died 7 months later

15. EGG FREEZING 5/6/13- 02/10/17 Date Age Eggs Diagnosis Alive / Deceased
05/06/13 15 18
Myleodysplasia
D Jan ‘14
30/10/13 22 12
Adenoca. cervix
D Oct ‘14
11/11/13 24 11
Hodgkins
Alive
10/07/14 17 31
AML relapse (TBI)
Alive (GvH)
01/09/14 16
Ewings + ALL
D March ‘16
23/06/15 20
09/07/15 36 2
Hodgkins 4B
26/08/15 30 4
Metastatic SB ca.
D May ‘17
12/10/15 23 8
Yolk sac tumour
09/11/15 19 6
2/11/16 21 9
Ovary teratoma
21/11/6 37
Breast cancer
22/05/17 25
Adenosquamous cx
19/07/17 10
Hodgkins 4a
20/07/2017 34
3 embryos
20 MDS (ALL)
31/08/2017 38
7 embryos
Breast ca
02/10/2017 29 13
Hodgkins 2a 27
Glioma
16 patients have had egg freezing - A THIRD OF OUR EGG STORAGE PATIENTS HAVE HL
4 out of 16 have died = 25%

16. Hodgkins Lymphoma LD age 29, single, no children
Hodgkins Lymphoma neck & Mediastinum Gd 2a
ABVD – low risk to fertility
If relapse -further treatment would result in ovarian failure
Less eggs likely to be obtained for freezing after initial chemo
Anti- Mullerian (AMH) Hormone = 12.3pmol/l (average ovarian reserve)
Swerdlow et al J Natl Cancer Inst 2014;106

17. Patient LD
Screening for Hepatitis B, C & HIV carried out in advance of appointment
Started ovarian stimulation on the same day attended RFC 20th September – day 5 of cycle
Egg collection 2/10/17
13 eggs vitrified
Vitrification (rather than slow rate freezing) has improved the success of egg freezing

18. Y T - attends HRT Clinic Age 36, Premature Ovarian failure
HL diagnosed 2008
Age 27, married, 1st child 15mths old
Relapse during 2nd pregnancy (2010)
Treatment started when 2nd child 5 weeks old
No periods after treatment for relapse
Married – could have been referred for IVF & embryo freezing

19. Jane AML age 16 4 courses chemo Relapse June 2014 – referred to RFC
Ovarian reserve (AMH) excellent
Offered egg harvesting & storage
31 eggs stored
Myeloablative chemo & sibling SCT
Acute leukaemia – so no time for egg storage
4TH patient we stored eggs for in RFC

20. Jane Ovarian failure - referred to HRT clinic
Graft v Host Disease including vagina
Hormone replacement therapy – combined contraceptive pill
Future fertility Options?
Use frozen eggs
? Periods on Qlaira
? Dose of radiation

21. TOTAL BODY IRRADIATION
12GY – increased risk of
Miscarriage
Pre-term labour
Low birth weight babies
Very low chance of natural conception
IVF – cryopreserved eggs, donor eggs

23. EDINBURGH OVARIAN CRYOPRESERVATION
MRC study – 1st patient 1993
PROVISIONAL CRITERIA
≤ 30 years old
No existing children
Reasonable chance of surviving 5 years
>50% chance of having ovarian function destroyed by the therapy
If age >15: no previous chemo/radiotherapy
If age <15: eligible if previous ‘mild’ chemotherapy
90 PATIENTS SO FAR – TISSUE REPLACED IN 3
50% <16 YEARS
YOUNGEST 1.3

24. RISK OF MALIGNANT CONTAMINATION
Ovary from ALL patients tested with PCR transplanted into mice showed malignant transformation in ovarian tissue if positive with PCR but not if negative.
Gold standard should be transplantation of ovarain tissue into host mice for 20 weeks first.
No risk of transmission if cryopreservation carried out after complete remission
J Assist Reprod Genet Jan; 30(1): 11–24

25. POST TREATMENT FERTILITY CONCERNS
Young adults referred from Late Effects clinic to Fertility Clinic or Adolescent Gynae clinic
MALES Semen Analysis
FEMALES
Can have assessment of ovarian reserve
AMH measurement & ultrasound scan of ovaries
Reasssuring if good result
If AMH low may cause unnecessary distress

26. Patient ZF Junior doctor age 26 ALL age 14
Concerned re irregular periods – no period for 5 months
Worried that chemo had caused premature menopause
Going to Australia
Wanted to discuss possibility of egg freezing.

27. Patient ZF Pelvic ultrasound
Ovaries looked polycystic – lots of antral follicles
Dominant follicle – imminent ovulation
Hormone levels were ‘ovulatory’
Anti Mullerian Hormone – 64.1pmol/l – in keeping with excellent ovarian reserve & PCOS

28. POST TREATMENT - FEMALES
May have reduced ovarian reserve & shorter reproductive window
IF EARLY menopause – refer to SPECIALIST HRT CLINIC
Need Hormone Replacement - optimised
G v H can affect vagina
If ovarian failure & no eggs or embryos stored can have donor eggs – refer to FERTILITY CLINIC
HRT CLINIC MATER HOSPITAL, REGIONAL FERTILITY CENTRE - RVH

29. POST TREATMENT -MALES Childhood Cancer
Often have anxiety re fertility
May have very low sperm count or no sperm
Adolescents /adults should have had sperm stored
If low sperm count will need IVF/ICSI
If need IVF/ICSI for male – or female – problem
? Use stored or fresh sperm
High rate of aneuploidy & DNA damage in sperm after chemotherapy – but no increase in congenital abnormalities
Concern that ICSI maybe bypass natural selection

30. Post Chemotherapy MEN – 2 YEARS – but what if female partner is 38+?
How long to wait before trying for a pregnancy?
MEN – 2 YEARS – but what if female partner is 38+?
could consider using stored sperm?
WOMEN MONTHS
? longer because of risk of relapse
But may not have time if reduced ovarian reserve
IVF SUCCESS AFTER CHEMO
No evidence of reduced success – but women may have reduced ovarian reserve & hence less eggs
Increased abnormalities – aneuploidy & DNA damage has been found in sperm of men post chemotherapy – many years later.
But no increase in congenital abnormalities in babies – probably as ‘normal’ sperm naturally selected. Concern re ICSI bypassing natural selection hence some suggest using stored sperm

31. The Pain of Infertility
Letter from patient’s mother
Conor
ALL 1979, age 3y 8mths. Relapse chemo finished 1984

32. Ist ICSI June 2007 SELF - FUNDED 11 eggs very few sperm
10 injected only 2 fertilised
2 good quality embryos - but not pregnant
Sperm storage suggested for next treatment
3 x SAs Sept & Oct ‘07 – NO SPERM
2 samples stored Oct /Nov (10-30 sperm only)

33. 2nd ICSI February 2008
NHS FUNDED 20 eggs, 15 injected, 3 fertilised 2 reasonable quality embryos transferred Clare admitted with Ovarian hyperstimulation Pregnant - baby boy 8/11/2008, 40 weeks gestation

34. ETHICAL ISSUES EQUALITY What is available ? where? to whom?
FUNDING ASSISTED CONCEPTION
WHO MAKES DECISIONS FOR CHILDREN/ADOLESCENTS ?
Should funding for assisted conception for cancer survivors be separated from what might be considered less medical causes of infertility.
Currently in NI there is the same allocation of one stimulated cycle & another embryo transfer if there are frozen embryos – for all couples. This is the same for a couple who have had 2 children naturally and fancy a 3rd but it isnt happening as it is for a young couple who need IVF because they have to use stored sperm or the man has a very low sperm count after chemo therapy

36. SUMMARY Low risk of ovarian failure with initial chemo for HL
Treatment for relapse likley to induce ovarian failure & infertility
‘Egg Freezing’ should be considered for women of reproductive age (<38) especially if no children
Lower egg yield even after ‘mild’ chemo – but still worth considering especially if young
Male sperm storage easy & should be routine
Women with ovarian failure need specialist HRT advice & can have fertility treatment with egg donation

38. Cytotoxic agents according to degree of toxicity
High risk
Intermediate risk
Low risk
Cyclophosphamide
Doxorubicin
Methotrexate
Busulphan
Cisplatin
Bleomycin
Melphalan
Carboplatin
5-Fluorouracil
Dacarbazine
Actinomycin-D
Procarbazine
Mercaptopurine
Ifosfamide
Vincristine
Thiotepa
The ovaries are every sensitive to cytotoxic treatment, especially to alkylating agent eg cycle / ifos / busulphan / melphalan which are classified as high risk for gonadal dysfunction.
Cyclophospahmide is the agent most commonly implicated in causing damage to oocytes and granulosa cells in a dose-dependent manner [meirow 1999].
Follicular destruction induced by alkylating agents generally results in loss of both endocrine and reproductive function depending on th edose and age of the patient.
Indeed Larsen et al [JCEM 2003] reported a fourfold increased risk of POF in teenagers treated for cancer, and a risk increased by a factor of 27 in women aged 21-25yrs.
This is a dose and dependent phenomena. For example, complete amenorrhoea (absence of periods) was reported after a dose of 5g of cyclo in women over 40yrs, and after doses of 9 and 20g in women and respectively [Shalet 1980]. A combination of chemotherapy agents increases risk. MOPP/ABVD – amenorrhoea developed in 89% and 20% over and under 25yrs at the age of treatment.
Procarbazine has recently been described as high risk for inducing premature menopause [de bruin 2008]. 10yrs after treatment – 84% after high cumulative doses, compared to 15% after low dose (<=4.2g/m2)

39. Anti-Mullerian Hormone (AMH)
AMH is a product of the granulosa cells in the pre antral & small antral follicles. It regulates folliculogenesis by inhibiting recruitment of resting follicles from the resting pool in order to select the dominant follicle

40. OVARIAN TISSUE TRANSPLANTATION
>100 births worldwide
several case series
Van en Ver et al 2016 – 95 transplants in 74 women
Average age 30y at cryopreservation, 34y at transplant
Most common diagnosis – Breast ca & Hodgkins
1 year post transplant 62.5% - ovarian activity pregnancy rate = 27.5%, delivery 22.5%
Mostly natural conception, some IVF
CONCERN RE RISK OF MALIGNANT CONTAMINATION – OVARIAN TISSUE CAN BE BIOPSIED PRE STORAGE BUT CANT BIOPSY TISSUE ACTUALLY GOING BACK.
CONCERN particularly in leukaemias
Solid tumours – assumption that ovary should be free if no metastases

41. Age at ovarian cryopreservation: Edinburgh experience since 1993
Median age 18.4yr
50% aged 16 or less
90 patients so far, ovarian tissue replaced in 3

42. Ovarian or Oocyte preservation ? OR BOTH?
EGG FREEZING
OVARIAN FREEZING
2-4 week window required
Puberty
Lots of babies born
Only one or 2 chances of conception – COST!
Invasive procedure
Limited centres
Risk of disease transmission
Success rates unknown
? Cure for menopause
natural conception may avoid cost of IVF