Fertility preservation in young females with non-gynaecologic malignancy: an emerging speciality.

BACKGROUND: As new treatment and research advances continue to improve the prognosis of cancer patients, oncologists and surgeons are increasingly faced with the issue of fertility protection and preservation. Cancer patients are frequently exposed to gonadotoxic chemotherapy and radiation therapy as a component of their treatment regimens. There are currently various anticipatory techniques available to women who wish to retain future reproductive ability, the most successful of which involves oocyte retrieval followed by in vitro fertilisation and embryo cryopreservation. Innovative methods include oocyte cryopreservation, ovarian follicle cryopreservation and oophoropexy. AIM: The aim of this study was to examine our combined experiences at Mayo General Hospital of treating female patients (<30 years) with non-gynaecologic malignancy and requiring referral to the HARI Unit during a 6-year period (2007-2012). Emphasis was placed on reviewing the fertility-preservation options available. METHODS: The hospital inpatient enquiry system was inspected for all cases of non-gynaecologic malignancy referred for fertility preservation from 2007 to 2012. RESULTS: Three cases of non-gynaecologic malignancy in young females, with an intention to protect and preserve future fertility were identified. The primary treatment plan did not initially incorporate input from a gynaecology or fertility specialist. It was after concerted inquiry and reflection by both physician and patient that oncofertility consultation was sought. CONCLUSION: The responsibility is on both physicians and surgeons to consider a more holistic approach to cancer care in young female patients, which focuses not only on the elimination of malignancy but also on preservation of fertility and quality of life.

Specific targeting of activated endothelium in rat adjuvant arthritis with a 99mTc-radiolabeled E-selectin-binding peptide.

OBJECTIVE: To determine the potential of an E-selectin-binding peptide (ESbp) to specifically bind activated endothelium in rheumatoid arthritis (RA) animal models. METHODS: ESbp (KYDGDITWDQLWDLMK; 2,027 daltons) was labeled with biotin and 99mTc. The affinity of ESbp derivatives for E-selectin was measured by enzyme-linked immunosorbent assay. The binding of biotin-ESbp was compared with that of an anti-E-selectin antibody, by immunohistochemical analyses of human synovial sections and sections from the Mycoplasma pulmonis MRL-lpr/lpr mouse arthritis model. 99mTc-ESbp was sequentially imaged in vivo with a gamma camera in the rat adjuvant-induced arthritis model. RESULTS: E-selectin expression was detected in human RA synovium and mouse arthritic synovium using biotin-ESbp. Both biotin-ESbp and 99mTc-labeled ESbp had high affinity for E-selectin (dissociation constant 2-5 nM). In vivo imaging showed specific binding of 99mTc-ESbp to the rat ankle joint prior to clinical manifestations of inflammation. CONCLUSION: These results demonstrate that activated endothelium can be targeted with 99mTc-ESbp. The specificity of targeting can be used to evaluate up-regulation of E-selectin in RA models, and to follow changes in this up-regulation during treatment trials.

Decline in basic fibroblast growth factor (FGF-2) mRNA expression in female rat hypothalamus at puberty.

There is a growing acceptance of the importance of hypothalamic growth factors in the control of sexual maturation. Basic fibroblast growth factor (bFGF, FGF-2), a potent mitogen and neurotropic factor for brain cells in vitro, including hypothalamic cells, is widely expressed in the post-natal CNS but its physiological functions there are largely unknown. Previously, studies of FGF-2 mRNA regulation in vivo have been hampered by the low levels of FGF-2 mRNA present in post-natal tissues. We have applied a sensitive semi-quantitative procedure based on reverse transcription followed by polymerase chain reaction amplification (RT-PCR) to detect and estimate relative amounts of mRNAs encoding FGF-2 and its receptor in the hypothalamic-hypophyseal axis in individual female rats undergoing sexual maturation. FGF receptor and FGF-2 mRNAs were detectable in all brain regions examined. Injections of the glutamate agonist N-methyl-D-aspartic acid (NMDA) or pregnant mare's serum gonadotropin (PMSG) were used to advance the onset of puberty in immature female rats, and the levels of FGF-2 and FGF receptor mRNA in MBH and cortex were examined. Daily injections of NMDA (20 mg/kg) from day 24-28 resulted in advancement of first ovulation and vaginal opening (VO) in 5 of 9 treated rats. None (0/4) of the saline treated controls achieved first ovulation during the course of the experiment. Expression of FGF-2 mRNA in the medial-basal hypothalamus of the NMDA-treated VO animals, but not nonVO animals, was significantly (P<0.05) reduced by 50% vs saline-treated nonVO controls. There was no effect of NMDA on FGF-2 expression in cerebral cortex of VO Vs nonVO animals. FGF receptor mRNA levels were unaffected by NMDA treatment. To assess the possibility that the decline in hypothalamic FGF-2 mRNA levels was related to puberty and not just to an effect of NMDA, pregnant mare's serum gonadotropin was used to induce first ovulation and vaginal opening. Injection of PMSG to immature female rats on day 26 resulted in precocious first ovulation on day 29. This was accompanied by a significant 40% reduction in the steady-state level of FGF-2 mRNA in the medial basal hypothalamus compared to saline treated controls. As with NMDA treatment, PMSG did not affect FGF-2 mRNA abundance in the cortex, nor the FGF receptor mRNA in MBH or cortex. Immunohistochemical detection of FGF-2 protein in the arcuate nucleus revealed that FGF-2 immunoreactivity was also significantly modified in peri-ovulatory NMDA-treated animals. FGF-2 immunoreactivity in NMDA treated rats was significantly elevated at day 29 (the day of ovulation), but significantly inhibited by day 33. These findings suggest that alterations in the level of FGF-2 mRNA in the hypothalamus may be associated with first ovulation and the onset of sexual maturation in the female rat.

Neonatal hypothalamic c-fos expression in an excitotoxicity-induced model of precocious puberty.

We have used immunocytochemical detection of c-fos expression (FOS-like immunoreactivity, FLI) to establish the site of action of monosodium glutamate (MSG) in neonatal rats in a model of lesion-induced precocious puberty. The primary target appears to be the hypothalamic arcuate nucleus (ARC) but other circumventricular organs (CVO) are also affected (e.g. subfornical organ). Single injections of MSG (1-4 mg/g single dose, postnatal day 2 (P2)) which result in precocious puberty induce an area of edema, surrounded by a ring of FLI in the basal hypothalamus. In contrast, a maximal sub-lethal dose of NMDA (N-methyl-D-aspartate; 3 mg/kg) which produces a different pattern of ARC FLI, without edema, has no effect on puberty. Multiple doses of MSG (4 mg/g P2, P4, P6, P8), consistent with severe ARC damage and resultant sterility, markedly attenuates the FLI response by P8, with no visible edematous reaction following the final injection. In efforts to block the effect of MSG, pretreatment with the NMDA receptor-specific antagonist MK-801 (dizocilpine maleate) prevented the appearance of edema, as well as the onset of precocious puberty. However, MK-801 did not completely eliminate the FLI, but transformed the pattern of staining so that the original edematous area now contained many FOS-positive cells. This remaining MSG-induced FLI could not be eliminated by higher doses of MK-801 or by the non-NMDA antagonist DNQX (6,7-dinitroquinoxaline-2,3-dione). The combination of MK-801 and DNQX was also ineffective. MK-801 or DNQX had no effect on FLI when injected alone (i.e., without MSG) or in combination. The receptor which mediates MSG-induced c-fos expression, in the presence of MK-801 or DNQX, needs to be identified. We conclude, in conjunction with our previous work, that MSG induces precocious sexual maturation via an MK-801-sensitive mechanism associated with an edematous response of the basal hypothalamus. Whether the appearance of edema is indicative of an excitotoxic action of MSG, resulting in the removal of neurons inhibitory to sexual maturation, remains to be established.

A critical period for glutamate receptor-mediated induction of precocious puberty in female rats.

The excitatory amino acid glutamate and especially its NMDA subtype receptor are important components of the neural system that regulates sexual maturation. It is known that multiple daily injections of immature rats and monkeys with NMDA will induce precocious puberty. We have previously reported that a single daily injection of NMDA administered from 27 days of age to the day of vaginal opening (VO) is sufficient to synchronize and slightly accelerate (1-2 days) first ovulation in female rats. We have now optimized this treatment schedule and show that a higher dose of NMDA (20 mg/kg), or the racemic mixture N-methyl-D,L-aspartate (NMA; 30 mg/kg), initiated earlier in development (24 days to VO) significantly advances first ovulation (4 days). Rats induced to ovulate prematurely had normal estrous cycles. We also report that the same degree of precocity can be obtained when injections are discontinued well before first ovulation occurs. For example, NMA administered from day 21 to 25 or from day 24 to 28 accelerates sexual maturation to the same degree as if injections were continued until VO was observed. It is clear that the hypothalamic-pituitary-ovarian (H-P-O) axis is stimulated by daily NMDA treatment as shown by the dose-related luteinizing hormone (LH) release and by an estrogen-dependent rise in uterine weight. However, stimulation of the P-O axis with daily injections of GnRH (5 ng/100 g), which elicits an LH response slightly greater than NMDA (20 mg/kg), does not advance puberty. This suggests that NMDA induces some change in hypothalamic control which is not directly related to LH secretion. Interestingly, there also seems to be a critical period of NMDA effectiveness because daily injections of NMA (30 mg/kg) from day 16 to 20 do not induce precocious puberty. Since the ovaries respond with increased estrogen production (increased uterine weight) to gonadotrophin stimulation at this early age (16 days) we conclude that the hypothalamus may be relatively unresponsive to stimulation with NMDA. Paradoxically the hypothalamus is also hyporesponsive to NMDA in the period preceding spontaneous first ovulation. We now show that an LH dose-response curve for NMDA at age 28 days demonstrates that in NMDA-treated rats the LH response to NMDA is less than in the control group. Further, the hyporesponsiveness is not due to pituitary desensitization since an LH dose-response curve for GnRH at age 28 days is identical in the NMDA-treated and control groups.(ABSTRACT TRUNCATED AT 400 WORDS)

Effect of inhibin immunoneutralization on steroidogenesis in rat ovarian follicles in vitro.

Inhibin is a putative gonadal paracrine factor produced by FSH-stimulated granulosa cells. To assess the paracrine function of inhibin further, preantral follicles (approx. 240 microns) with attached thecal cells were isolated mechanically from immature rat ovaries and cultured individually in vitro for 5 days in medium containing homologous serum and FSH. After 5 days, follicles had grown to preovulatory size (approx. 470 microns) with a commensurate increase in oestradiol secretion but not progesterone. Immunoneutralization of endogenous inhibin resulted in a significant decrease in oestradiol secretion and an increase in progesterone accumulation. When antiserum-treated follicles were supplemented with exogenous inhibin, oestradiol secretion was restored and progesterone accumulation was reduced. Aromatase substrate (androstenedione) levels were too low to measure, regardless of antiserum treatment. However, follicles treated with inhibin antiserum in the presence of exogenous androstenedione also exhibited oestradiol levels similar to untreated controls while progesterone accumulation remained elevated. We interpret these data as evidence that inhibin secreted by FSH-stimulated granulosa cells exerts a physiologically significant paracrine function in the follicle wall. Based on previous observations that inhibin stimulates androgen synthesis by isolated thecal/interstitial cells, it is proposed that granulosa-derived inhibin promotes thecal androgen synthesis and hence oestrogen synthesis during preovulatory follicle development. The antiserum-induced increase in progesterone accumulation is most probably explained by reduced metabolism of C21 steroid substrate to androgen in thecal/interstitial cells deprived of inhibin. It is concluded that inhibin is a physiological modulator of follicular steroidogenesis which exerts its effect at the level of thecal cell androgen synthesis.

Development-related effects of recombinant activin on steroid synthesis in rat granulosa cells.

Activin is structurally related to polypeptide growth factors such as transforming-growth factor-beta, which may have paracrine and/or autocrine functions in the ovaries. We have investigated the action of activin on granulosa cell steroidogenesis in vitro in relation to preovulatory follicular development in vivo. Estrogen-primed immature female rats received no other treatment (nondifferentiated granulosa cells), treatment with ovine (o) FSH (differentiated granulosa cells), or treatment with oFSH followed by human (h) CG (preovulatory granulosa cells) to stimulate preovulatory follicular development. Granulosa cells were isolated and cultured in the presence and absence of recombinant human activin-A using serum-free medium supplemented with 1.0 microM testosterone as an aromatase substrate and hFSH, hLH, forskolin, or 8-bromo-cAMP to stimulate steroid synthesis in vitro. After 48 h, medium was collected for measurement of estradiol (aromatase activity), progesterone, and cAMP. Basal steroid synthesis in nondifferentiated granulosa cells was unaffected by activin, but both aromatase activity and progesterone production induced by treatment with FSH in vitro were dosedependently enhanced up to 10-fold by the presence of activin. FSH-stimulated cAMP production was not measurably altered by activin; however, steroidogenesis induced by forskolin or 8-bromo-cAMP was significantly enhanced by the factor. Thus the effect of activin on steroidogenesis includes action at a subcellular level(s) distal to the production of cAMP. After gonadotropin treatment in vivo, granulosa cell aromatase activity and progesterone production showed divergent responses to activin in vitro. Basal-, FSH-, and LH-stimulated aromatase activity were all enhanced by activin in cultures of differentiated and preovulatory granulosa cells. However, whereas basal progesterone production was stimulated by activin in cultures of differentiated granulosa cells, in preovulatory granulosa cells it was inhibited. Moreover, in vitro stimulation of progesterone production by treatment of both differentiated and preovulatory granulosa cells with FSH or LH was suppressed by the presence of activin. Thus rat granulosa cells display development-related steroidogenic responses to activin, aromatase production becoming enhanced and progesterone production suppressed as follicular maturation progresses. These results further implicate activin as a local modulator of granulosa cell steroid synthesis in the ovaries, although its functional significance has yet to be established.