Ovarian damage from chemotherapy and current approaches to its protection.

BACKGROUND: Anti-cancer therapy is often a cause of premature ovarian insufficiency and infertility since the ovarian follicle reserve is extremely sensitive to the effects of chemotherapy and radiotherapy. While oocyte, embryo and ovarian cortex cryopreservation can help some women with cancer-induced infertility achieve pregnancy, the development of effective methods to protect ovarian function during chemotherapy would be a significant advantage. OBJECTIVE AND RATIONALE: This paper critically discusses the different damaging effects of the most common chemotherapeutic compounds on the ovary, in particular, the ovarian follicles and the molecular pathways that lead to that damage. The mechanisms through which fertility-protective agents might prevent chemotherapy drug-induced follicle loss are then reviewed. SEARCH METHODS: Articles published in English were searched on PubMed up to March 2019 using the following terms: ovary, fertility preservation, chemotherapy, follicle death, adjuvant therapy, cyclophosphamide, cisplatin, doxorubicin. Inclusion and exclusion criteria were applied to the analysis of the protective agents. OUTCOMES: Recent studies reveal how chemotherapeutic drugs can affect the different cellular components of the ovary, causing rapid depletion of the ovarian follicular reserve. The three most commonly used drugs, cyclophosphamide, cisplatin and doxorubicin, cause premature ovarian insufficiency by inducing death and/or accelerated activation of primordial follicles and increased atresia of growing follicles. They also cause an increase in damage to blood vessels and the stromal compartment and increment inflammation. In the past 20 years, many compounds have been investigated as potential protective agents to counteract these adverse effects. The interactions of recently described fertility-protective agents with these damage pathways are discussed. WIDER IMPLICATIONS: Understanding the mechanisms underlying the action of chemotherapy compounds on the various components of the ovary is essential for the development of efficient and targeted pharmacological therapies that could protect and prolong female fertility. While there are increasing preclinical investigations of potential fertility preserving adjuvants, there remains a lack of approaches that are being developed and tested clinically.

Preantral ovarian follicles in serum-free culture: suppression of apoptosis after activation of the cyclic guanosine 3',5'-monophosphate pathway and stimulation of growth and differentiation by follicle-stimulating hormone.

Progression of preantral follicle development is essential to further follicle maturation and ovulation, but there are few models for studying the regulation of preantral follicle survival and growth. We have evaluated preantral follicle survival in vivo and in vitro, and have developed a serum-free rat follicle culture system that can be used to characterize the regulation of preantral follicle growth and differentiation. Analysis of ovarian cell DNA fragmentation during the first wave of follicle growth in the infantile rat indicated negligible apoptosis up to day 16 of age. However, a major increase in apoptosis was found by day 18, a time point associated with the appearance of large antral follicles. In situ analysis confirmed that apoptotic DNA fragments were limited to antral follicles. Culture of individual preantral follicles mechanically dissected from ovaries of 12- or 14-day-old rats in serum-free conditions led to major increases in follicle cell apoptosis, similar to that seen in cultures of antral and preovulatory follicles. In contrast to antral and preovulatory follicles, treatment of preantral follicles with gonadotropins or cAMP analogs did not prevent apoptosis. However, treatment with 8-bromo-cGMP or 10% serum suppressed apoptosis by 75% in cultured preantral follicles. In situ analysis identified granulosa cells as the cell type susceptible to apoptosis regulation. Taking advantage of the ability of the cGMP analog to suppress apoptosis, we evaluated the potential of FSH as a growth factor. In the absence of serum, FSH treatment for 48 h did not affect follicle size compared to controls; however, treatment with the cGMP analog together with FSH increased follicle diameter (13%; P < 0.01) and viable cells (2.4-fold; P < 0.01) compared to control values. Immunoblot analysis further indicated that the inhibin-alpha content of the cultured follicles was increased by treatment with the combination of FSH and 8-bromo-cGMP, demonstrating the induction of follicle cell differentiation during culture. Therefore, we demonstrated that activation of the cGMP pathway promotes the survival of cultured preantral follicles and that in the presence of alpha cGMP analog, FSH is a growth and differentiation factor for preantral follicles. The present serum-free follicle culture model system will be useful in further evaluation of the regulation of growth and differentiation of preantral follicles.

Clozapine treatment in polydipsia and intermittent hyponatremia.

BACKGROUND: Recent case reports indicate that clozapine treatment diminishes excessive diurnal weight gain and alleviates hyponatremia observed in some chronically psychotic patients. We examined the influence of clozapine on sodium metabolism and water regulation across a group of patients with the syndrome of polydipsia and intermittent hyponatremia. METHOD: Eleven patients with treatment-resistant DSM-III-R schizophrenia or schizoaffective disorder were studied. Each had a history of repeated diurnal weight gains of greater than 10% with at least one documented bout of hyponatremia in the 6 months before clozapine treatment. We utilized a target weight protocol and serial laboratory measures to compare changes in sodium metabolism and water regulation during 26 weeks of standard antipsychotic medication and 26 weeks of clozapine treatment. RESULTS: Across patients, we found significant improvement in routinely monitored 6 a.m. and 4 p.m. serum sodium, reflecting normalization of sodium metabolism. We also found that the frequency (as reflected by diurnal weight gain), severity (lowest serum sodium), and estimated quantity (calculated urine volume) of polydipsia improved across patients. Improvement in polydipsia and hyponatremia was associated with decreased necessity for monitoring and restrictive interventions, and tended to be associated with psychiatric improvement. CONCLUSION: We found a corrective and stabilizing effect of clozapine on polydipsia and intermittent hyponatremia. Future studies need to examine the relationship of psychiatric improvement and alterations in the regulation of sodium and water physiology to our findings.

Follicular development in vitro.

There has been tremendous interest in recent years in the culture of oocytes and follicles. Although much of the research using follicle culture aims to increase understanding of the regulation of follicle development, an important goal has been to develop a method that will eventually allow maturation of human oocytes from the primordial follicle to the mature Graafian stage. We are still some way from this at present, although it has now been achieved in the mouse. In this article, we consider various methods of follicle culture for primordial, preantral, and antral follicles. In vitro development of primordial follicles has used primarily whole ovaries or ovarian fragments as a source of follicles. Culture of later stages of follicle development uses mainly isolated follicular units, either whole (with an intact basement membrane and, in some cases, attached thecal cells) or nonintact (oocyte-somatic cell complexes, which may or may not have remnants of basement membranes and/or thecal cells attached).

Long day lengths enhance myelination of midbrain and hindbrain regions of developing meadow voles.

Rates of brain growth differed in meadow voles maintained in long (LP) or short (SP) photoperiods postnatally. At 35 days of age, brain weight was greater by 6.6% in LP males and by 4.7% in LP females as compared to their SP counterparts. Whole brain galactolipid content, an index of brain myelin, was greater by 15.6% in LP as compared to SP males. At 70 days of age, brains of LP males were 4% heavier than those of SP males. Differences attributable to photoperiod were most pronounced in midbrain and hindbrain (8% and 14%, respectively). DNA and galactolipid contents were greater by 11% and 15%, respectively, in hindbrain of LP males. Photoperiod did not affect any of these measures in diencephalon, striatum, or cerebellum. Short day lengths reduce myelination in meadow voles, presumably by decreasing proliferation rates of oligodendroglia. This is one facet of a general delay in somatic development associated with being born at the end of the normal breeding season when day lengths are decreasing or below a critical threshold.

Long day lengths promote brain growth in meadow voles.

Male meadow voles kept in a long photoperiod (LP) from birth to 70 days of age have heavier brains than those kept in a short photoperiod (SP). Brain weights of male voles kept in the LP first exceeded those of SP animals at 20 days of age; differences were greatest at 35 days (5.8%) and persisted through 140 days of age (2%), although the magnitude of the difference declined progressively. Accelerated compensatory increases in brain weight were observed in voles transferred from the SP to the LP at 70 days of age. Total brain DNA content, an index of cell number, was not significantly affected by initial or final photoperiod, although it increased 7.8% within 70 days after voles were transferred from the SP to the LP. Brain weights (but not DNA content) of males exceeded those of females, but this sex difference was present only in the LP. We suggest that short day lengths retard brain development by reducing rates of myelination and possibly reducing cell size as well; this is part of a general retardation of somatic growth associated with a delayed onset of puberty that can be reversed by a stimulatory LP but, ordinarily, occurs spontaneously as voles become refractory to short day lengths.

How do chemotherapeutic agents damage the ovary?

BACKGROUND: Chemotherapy treatment in premenopausal women is associated with an increased risk of premature ovarian failure (POF) but the exact mechanism through which this occurs is uncertain. In this review we examine the current evidence for the direct action of chemotherapeutic agents on the ovary and discuss possible molecular pathways through which follicle loss may occur. METHODS: A systemic search of the databases, PubMed and Google Scholar, was made for all English language articles through to 2011 in each subject area discussed. RESULTS: POF results from the loss of primordial follicles but this is not necessarily a direct effect of the chemotherapeutic agents. Instead, the disappearance of primordial follicles could be due to an increased rate of growth initiation to replace damaged developing follicles. Likewise, the loss of oocytes need not necessarily be a direct result of damage: evidence suggests that chemotherapy drugs can also induce oocyte death indirectly via damage to somatic cells. Specific molecular mechanisms and likely ovarian targets are discussed for some of the anti-cancer drugs most commonly used to treat premenopausal women. Finally, we consider current and prospective methods of preserving fertility. CONCLUSIONS: It is likely that different chemotherapeutic drugs act through a range of mechanisms and on different target cells. More research into the cellular mechanisms underpinning chemotherapy-induced follicle loss could lead to the generation of treatments specifically designed to prevent POF.

Genomic imprinting and reproduction.

Genomic imprinting is the parent-of-origin specific gene expression which is a vital mechanism through both development and adult life. One of the key elements of the imprinting mechanism is DNA methylation, controlled by DNA methyltransferase enzymes. Germ cells undergo reprogramming to ensure that sex-specific genomic imprinting is initiated, thus allowing normal embryo development to progress after fertilisation. In some cases, errors in genomic imprinting are embryo lethal while in others they lead to developmental disorders and disease. Recent studies have suggested a link between the use of assisted reproductive techniques and an increase in normally rare imprinting disorders. A greater understanding of the mechanisms of genomic imprinting and the factors that influence them are important in assessing the safety of these techniques.

Programmed cell death in the reproductive system.

The reproductive system presents some of the best examples of programmed cell death, which is to be expected considering the dramatic cycles of tissue growth and regression in females. Hormones from the pituitary gland, gonads and uterus are responsible for coordinating cycles in which the preservation of cell survival and inhibition of apoptosis are important. In the ovary, atresia regulates the size of the follicle cohort for ovulation and is an archetype of apoptosis as induced by hormone withdrawal. The fate of an antral follicle--growth or atresia--is determined by circulating levels of gonadotrophins, and follicle-stimulating hormone (FSH) in particular. At the end of a menstrual cycle or pregnancy or lactation, hormone withdrawal triggers cell death and tissue remodelling and initiates a fresh cycle. In the endometrium, breast and prostate gland, steroid hormones are the principal survival factors and castration triggers regression of responsive tissues, which is sometimes decisive in the fight against disease. But while the primary trigger of cell death varies between tissues, underlying cellular mechanisms are more conservative and cell death/survival genes, such as bcl-2, bax and others that are expressed in other tissues, play important roles in the reproductive system too.

Comparison of the gonadal response of wild and laboratory field voles (Microtus agrestis) to different photoperiods.

Weanling male and female field voles from laboratory stock and from the F1 generation of wild-caught animals were placed in a long (16L:8D) or short (6L:18D) photoperiod for 28 or 56 days. Both types of field vole showed the well-established effect of photoperiod upon sexual maturation, with animals in the long photoperiod having larger and more active gonads than animals in the short photoperiod. After 28 and 56 days laboratory stock females were more mature, sexually, and had a higher growth rate than did Wild F1 females. There was no difference between the two types of males at 28 days, but by 56 days laboratory stock males were more sexually mature and had a higher growth rate than did Wild F1 males. These differences between the two types occurred in the long and short photoperiods. There was no interaction between photoperiod and type of vole. The use of laboratory stock animals in experiments could lead to an incorrect assessment of the effect of photoperiod in the control of seasonal breeding in wild populations.

Effect of male presence and of photoperiod on the sexual maturation of the field vole (Microtus agrestis).

The effect of mature males on the sexual development of young female and male field voles, reared in either long (stimulating) or short (inhibiting) photoperiods, was examined. Females reared in the presence of a mature male had a more advanced state of sexual maturation (as indicated by uterine weight) than did females reared in isolation from males, in long and short photoperiods (P less than 0.01). No interaction between photoperiod and male presence was found. Augmented uterine growth occurred not only when young females were separated from mature males by a wire mesh or solid metal screen but also when they were merely exposed to bedding previously used by mature males. Castrated males had no effect on the sexual development of females. The effect of mature males on the sexual development of young males was less clear, although there was some indication that the presence of adult males inhibited their sexual development in long and short photoperiods. For males and females, growth rate was stimulated by long photoperiod, but no effect of male presence on growth rate was found.