Appraising the Biological Evidence for and Against the Utility of GnRHa for Preservation of Fertility in Patients With Cancer
A partir des données d'un essai randomisé européen incluant 129 patientes atteintes d'un lymphome traité par chimiothérapie (durée de suivi : 5 ans), cette étude évalue l'efficacité d'un traitement par antagonistes de l'hormone libérant la gonadotropine pour préserver la fonction ovarienne et la fertilité
Tremendous advances have been made within the past 15 years in the field of fertility preservation.1 Although embryo cryopreservation was an already available standard technique, new ovarian stimulation techniques with aromatase inhibitors2,3 to reduce estrogen exposure in patients with breast cancer and random-start strategies4 to shorten the delay to chemotherapy have increased the acceptability of this approach in patients with cancer. Oocyte cryopreservation emerged as an established technique for single women who did not wish to use donor sperm, and success rates justified its removal from the experimental category.5 Ovarian cryopreservation has also shown a giant leap since its first successful use to restore ovarian endocrine function in 1999,6 as live birth rates have exceeded 30% in those who undergo ovarian transplantation,7,8 though it is still considered experimental by the American Society of Reproductive Medicine. Given that the recent advances in cryopreservation and transplantation techniques7 may improve the longevity of ovarian transplants with cryopreserved tissue, and given that the number of live births is increasing exponentially, it may not be too long before ovarian cryopreservation is also added to the list of established fertility preservation procedures.
In the area of medical preservation of ovarian function, however, we have seemingly continued to spin our wheels without apparent progress. The initial idea of gonadotropin-releasing hormone analogs (GnRHa) to preserve fertility during cancer treatments came from misinterpreted observations that children are less likely to develop ovarian failure after chemotherapy. On the basis of that thought, simulation of a prepubertal hormonal milieu by pituitary suppression was proposed, to possibly guard the ovary against chemotherapy agents. This led to a number of retrospective and inadequately controlled studies, which suggested some benefit of ovarian suppression in the preservation of menstrual function during chemotherapy. In fact, recent studies with long-term follow-up showed that children are also equally vulnerable to chemotherapy-induced ovarian reserve loss; however, because of their larger ovarian reserves at the time of chemotherapy, this vulnerability is not immediately apparent in short-term follow-up(...)
Journal of Clinical Oncology , éditorial, 2016