Ovarian reserve and oocyte maturity in cancer patients

17 05 2011

To the Editor:

With great interest we read the article on ovarian reserve and oocyte maturity in cancer patients undergoing in vitro maturation treatment (IVM) by Moria et al. (1). Detailed information concerning this topic is of great value to doctors counselling cancer patients with regard to their wish to conceive in the (near) future.

The authors studied ovarian reserve and oocyte maturity in cancer patients in comparison to infertile patients (1). We wonder whether it is correct to compare cancer patients to infertile patients. Ideally, one would like to compare to healthy subjects to investigate the effect of cancer on fertility. We are aware that it would be ethically impossible to acquire these parameters on a group of fertile individuals as they would have to undergo unnecessary IVM. However, a viable solution to this problem would be to compare cancer patients with couples who are infertile due to an andrological factor.

Furthermore, the authors fail to further specify the infertile control group. Besides the described subgroup of polycystic ovary syndrome patients, the control group could contain infertile patients due to endometriosis or tubal factor infertility and it is known that these groups have different ovarian reserve (2).

A recent study by Anderson et al. reported that measurement of AMH at cancer diagnosis predicts long-term ovarian function after chemotherapy (3). It would therefore have been interesting if AMH was measured in the group of breast cancer patients in the authors’ study. This would make it possible to predict which patients would have to undergo IVM before chemotherapy treatment and which patients would not.

We highly appreciate the authors’ 7-year effort on this study and we acknowledge that it is hard to collect a large group of different cancer patients treated with IVM. However with the small number of patients in the subgroup of other cancers, it is impossible to draw solid conclusions on ovarian reserve and oocyte maturity in cancer patients other than breast cancer patients.

Lobke Bastings, M.D.
Angèle Oei, M.D, Ph.D.
Catharina C.M. Beerendonk, M.D., Ph.D.
Department of Obstetrics and Gynaecology
Radboud University Nijmegen Medical Centre
Nijmegen, The Netherlands

References
1. Moria A, Das M, Shehata F, Holzer H, Son WY, Tulandi T. Ovarian reserve and oocyte maturity in women with malignancy undergoing in vitro maturation treatment. Fertil Steril 2011;95:1621-3.

2. Aboulghar MA, Mansour RT, Serour GI, Al-Inany HG, Aboulghar MM. The outcome of in vitro fertilization in advanced endometriosis with previous surgery: a case-controlled study. Am J Obstet Gynecol 2003;188:371-5.

3. Anderson RA Cameron DA. Pretreatment serum anti-mullerian hormone predicts long-term ovarian function and bone mass after chemotherapy for early breast cancer. J Clin Endocrinol Metab 2011;96:1336-43.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.05.043

The Authors Respond:

We appreciate the interest of Bastings and colleagues in our article (1) . Indeed, women with normal fertility would not be expected to undergo assisted conception. In our unit, IVM is mainly performed for women with PCO to avoid the risk of ovarian hyperstimulation. It is an established and viable treatment option for this group of patients (2). Women with PCO undergoing IVM therefore comprised a large proportion of the control group of patients in our study and were likewise compared to cancer patients with PCO (1).

The non-PCO control group consisted mainly of patients with male factor infertility (n: 20) and unexplained infertility (n: 16). In addition, there were four women with tubal factor infertility who preferred to undergo IVM treatment instead of IVF. Whether tubal disease has an impact on ovarian reserve is unclear and there is no good evidence to suggest that it impairs ovarian reserve. As a matter of fact, women with tubal factor infertility have been used as a control group for patients with cancer in published studies (3). There were no patients with endometriosis or endometrioma. In fact, we previously reported that the presence of ovarian endometrioma is associated with decreased antral follicle count (4).

We concur with Bastings et al. that serum AMH level would be helpful to evaluate ovarian reserve. However, we do not agree that measuring serum AMH would help to predict which patients should undergo IVM before chemotherapy. It is well known that pelvic radiation and chemotherapy can result in premature ovarian failure and infertility (5). We routinely measure serum FSH and antral follicle count as well established parameters of ovarian reserve.

We are aware of the relatively small number of cases with different types of malignancy in our study. As we stated in our article, multi-center studies with a large number of cases are required to clarify this matter (1).

Mausumi Das, M.D.
Anwar Moria, M.D.
Fady Shehata, M.B.B.Ch.,
Hananel Holzer, M.D.
Weon-Young Son, Ph.D.
Togas Tulandi, M.D., M.H.C.M.
McGill University
Montreal, Quebec, Canada

References
1. Moria A, Das M, Shehata F, Holzer H, Son WY, Tulandi T. Ovarian reserve and oocyte maturity in women with malignancy undergoing in vitro maturation treatment. Fertil Steril 2011;95:1621-3.

2. Chian RC, Huang JY, Gilbert L, Son WY, Holzer H, Cui SJ, et al. Obstetric outcomes following vitrification of in vitro and in vivo matured oocytes. Fertil Steril 2009;91:2391-8.

3. Pal L, Leykin L, Schifren JL, Isaacson KB, Chang YC, Nikruil N, et al. Malignancy may adversely influence the quality and behaviour of oocytes. Hum Reprod 1998;13:1837-40.

4. Almog B, Shehata F, Sheizaf B, Tulandi T. Effects of Different Types of Ovarian Cyst on Antral Follicles Count. Fertil Steril 2010;94:2338-9.

5. Meirow D, Nugent D. The effects of radiotherapy and chemotherapy on female reproduction. Hum Reprod Update. 2001;7:535-43.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2011.05.044

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