Fertilitätserhaltende Andrologie bei Tumorerkrankungen

Increasing survival rates and increasing numbers of cancerous diseases have led to increased awareness of the quality of life after surviving the disease. A long-term consequence of oncological therapy can be permanent infertility in male patients. Although in recent years protective treatment strategies have shown a reduction in testicular damage and associated loss of fertility, it is still often difficult to estimate the degree of damage before treatment. For this reason for male cancer patients who still have family plans, the possibility to become a father should be preserved by timely protection of fertility. An established method of choice for realization of the desire to become a father for postpuberty men is cryoconservation of spermatozoa. More recent techniques for preserving fertility, such as removal of testicular tissue for later germ cell transplantation or autotransplantation are in the developmental stage. Due to the expected clinical establishment of these methods which are currently in the research stage, the possibility of later fatherhood could be preserved by pre-emptive removal of testicular tissue for cryoconservation and long-term storage, particularly for prepuberty male patients.     

Fertilitätserhaltende Operationen bei Uterus myomatosus und Endometriose

Background

Uterine leiomyoma and endometriosis are among the most common benign diseases in gynecological practice. Both are currently subject to laparoscopic treatment.

Aim

The aim of this article was to summarize the current importance of fertility-preserving and minimally invasive surgery for treatment of uterine leiomyoma and endometriosis and to assess the evidence for laparoscopic treatment.

Material and methods

A search of the current literature was carried out in PubMed and the articles were examined for relevance. Furthermore, guidelines of medical societies were taken into account.

Results

Laparoscopic approaches can further improve the therapy of these diseases in terms of symptom relief and also in terms of fertility.

Conclusion

The comprehensive implementation of laparoscopic procedures for the treatment of uterine leiomyoma and endometriosis means that many patients who have often endured a great deal of suffering can now be helped not only efficiently but also protectively and last but not least with an optimal cosmetic result.     

Fertilit?tsprotektion bei Krebspatientinnen

Impaired fertility is a common consequence of cancer treatment. Actions to protect fertility taken in the crucial moment would therefore be of utmost importance for future quality of life in young cancer survivors. The decision for or against any procedure to preserve fertility, however, signifies an additional burden for all parties involved. The narrow timeframe between the diagnosis of cancer and the start of cancer treatment implies that the decision must be taken under considerable time pressure and is often associated with emotional chaos, alternating between fear of death and hope or euphoria. If patients, however, are not offered these options the psychological burden resulting from loss of fertility may persist lifelong. Based on the results of current research, psychological aspects in the context of fertility preservation in young female cancer patients will be presented and discussed with a special focus on the significance of fertility, the attitude towards fertility preserving techniques, the decisional conflict and the strategies to provide support.     

Fertilit?tsprotektion bei Frauen

The improvement in survival of young cancer patients in recent years has led to an increasing interest for treatment aimed at increasing the quality of life during and after chemotherapy and radiotherapy. Thus new reports on the progress in fertility preservation techniques have led to the establishment of the German-speaking network FertiPROTEKT (http://www.fertiprotekt.eu) in 2006. Decisions on the type of fertility preservation technique offered to the patient need to be made after careful discussion by reproductive specialists and oncologists according to the cancer disease, the prognosis, the age of the patient and the available time frame until the onset of cytotoxic therapy. The different techniques, such as ovarian stimulation followed by cryopreservation of fertilized or unfertilized oocytes, cryopreservation of ovarian tissue and the use of gonadotropin-releasing hormone agonists are critically analyzed in this paper.     

Hormonelle Therapien zur Fertilitätsprotektion

Advances in oncology have led to an increase in long-term survivors of cancer and preservation of fertility in young patients has increasingly gained importance because one of the devastating side effects of chemotherapy is a reduction or loss of fertility. Most fertility protection techniques are invasive and only the administration of gonadotropin-releasing hormone agonists (GnRH-a) additional to chemotherapy provides a non-invasive possibility of fertility preservation. Different pathophysiological mechanisms are discussed for protection of the follicles by the administration of GnRH-a, including the influence of the blood flow to the ovaries and the creation of a prepubertal hormonal milieu. The data on the efficacy of GnRH-a administration are not uniform but in the meta-analyses a positive effect of reducing the risk for premature ovarian failure is currently seen. For definitive confirmation of the protective effect of GnRH-a administration further prospective randomized studies are necessary. Primary outcome parameter should be the anti-Mullerian hormone as it is currently the best marker for measuring the ovarian reserve.     

S2k-Leitlinie: Fertilitätserhaltende Maßnahmen bei onkologischen Erkrankungen

Oncological and nononcological diseases can affect current or future fertility, either through the disease itself or through necessary surgery, hormonal and/or gonadotoxic treatments. They therefore require an adequate fertility-protective approach—i.?e. counselling is essential and, if the prerequisites are met, an appropriate fertility-protective therapy. Cryopreservation of oocytes is usually the first-choice method for postpubertal women. Metaphase II oocyte cryopreservation by vitrification is the preferred and recommended option. However, cumulative evidence of restoration of ovarian endocrine function and resulting spontaneous pregnancies and births, or after the use of assisted reproductive techniques, after orthotopic transplantation of cryopreserved ovarian tissue also advocates this method as an open clinical application, especially in prepubertal girls who are no less affected by germ cell-damaging treatments than adolescent or adult patients of reproductive age and for whom no other possible option for fertility preservation is currently available.     

Fertilit?tsprotektion bei M?nnern

Cryopreservation of sperm obtained from ejaculates or testicular tissue is a suitable procedure to establish a fertility reserve in tumor survivors facing infertility as a consequence of exposure to gonadotoxic site effects from intensive oncological chemotherapy and radiotherapy. Due to the absence of mature germ cells, cryopreservation of sperm from prepubertal patients is not an option. Preclinical studies on testicular stem cells have improved the understanding of gonadotoxic site effects and revealed novel procedures for conservation, culture and transplantation of germ line stem cells which provide interesting novel concepts for male fertility but also created exciting options for fertility preservation. This review depicts the physiology of male germ cell production, analyzes the clinically relevant problems and presents novel experimental methods which could provide future stem cell-based options for fertility preservation.     

Fertilit?tsprotektion bei rheumatologischen Erkrankungen

Cytotoxic therapy which can harm ovarian function is not only used for malignant diseases but also for severe autoimmune diseases (AID) using mainly the immunosuppressive agent cyclophosphamide. Young women during childbearing age are frequently affected by AID. Due to the significantly improved long-term survival of these patients, preservation of ovarian function is a very important issue. Disease-specific risks must be taken into consideration when counselling patients with AID for fertility preservation. Systemic lupus erythematosus (SLE) is one of the more common forms of AID and the only AID with existing data on fertility preservation. Therefore the available techniques will be discussed on the basis of SLE. Gonadotropin releasing hormone (GnRH) analogue treatment during cyclophosphamide therapy has been shown to be effective in patients with AID and can be recommended in almost all situations. Cryopreservation of ovarian tissue is still an experimental approach but seems to be very promising. The risk of the necessary laparoscopic surgery and the delay are justifiable. A stimulation therapy for cryopreservation of oocytes has the risk of an exacerbation of the underlying disease and of thromboembolic complications. Therefore this option should only be recommended in isolated cases and under close monitoring of disease activity by an interdisciplinary team of gynecologists and rheumatologists. Treatment with GnRH analogues and cryopreservation of ovarian tissue seems to be a reasonable combination.     

Fertilitätserhalt bei Krebs

Survival rates of female cancer patients are improving steadily. Clinicians are increasingly confronted with the long-term effects of chemotherapy and radiotherapy on the fertility of young women. Premature ovarian failure in women who wish to become pregnant is devastating both for the patient and her partner. In the case of predictable loss of gonadal function due to a planned cancer treatment fertility preservation options should be offered to the patient. Current methods of fertility preservation include conventional reproductive techniques as well as GnRH analogue treatment, cryopreservation of oocytes and cryopreservation of ovarian tissue. Most of these techniques are still experimental and should only be decided after individual and patient-specific informed consent as well as interdisciplinary counselling.     

Bedeutung der Fertilitätschirurgie bei Kinderwunsch

Gynäkologische Endokrinologie - Die Bedeutung der Fertilitätschirurgie bei Kinderwunsch kann vielfach aufgrund fehlender eigener Erfahrung während der Facharztweiterbildung nicht...     

Fertilitätserhalt bei Borderline-Tumoren des Ovars

According to the German guidelines, patients with borderline ovarian tumors require bilateral salpingo-oophorectomy, which leads to loss of fertility. Cohort studies and case reports demonstrate that fertility-sparing surgery (unilateral salpingo-oophorectomy or cystectomy) is an option in these patients. In addition, modern fertility-preservation measures could be offered to these patients, including controlled ovarian stimulation with cryopreservation of oocytes as well as cryopreservation of ovarian tissue. All patients with a (prospective) desire to have children must be provided with detailed information on the possible options for fertility preservation as well as on the possible risks. After completion of family planning, subsequent removal of the remnant ovarian tissue to minimize the risk of recurrence should be discussed.     

Ovarfunktion und Fertilit?t

The main task of the ovaries is to periodically provide a mature oocyte for fertilization. In addition the ovaries provide nidation of the fertilized oocyte by developing a competent and receptive endometrium thus forming the basis of female fertility. The ovarian follicle pool, out of which only few oocytes reach selection and ovulation stages in the course of the reproductive phase, is already formed early in embryogenesis. The sensitive interaction between the hypothalamus, pituitary gland and ovaries can easily be disturbed by several factors potentially resulting in constraint of ovarian function and overall fertility. The age-related depletion of the ovarian reserve is characterized in particular by a high level of follicle atresia and degenerative effects. The anti-Müllerian hormone (AMH) is widely deemed the best marker of the ovarian reserve. Beyond that the follicle-stimulating hormone (FSH) level and antral follicle count (AFC) also represent useful indicators of ovarian function and reserve.     

Fertilit?tsprotektion in der Onkologie

To date the treatment of various cancer types has become much more effective in young patients and fortunately has significantly increased survival rates. Due to these achievements fertility preservation prior to chemotherapy or radiation therapy becomes an important issue. Severe side effects, such as sterility need to be explained to the patient in advance by the physician; however, not all cancer patients are treated in gynecology and many young patients suffering from cancer are treated in medical oncology. Therefore, these colleagues need to be involved in counseling the patients in advance of forthcoming therapy. In this context, the attending doctor needs to inform patients of the possibility of fertility preservation. Thus, contact can be made to a fertility clinic to offer the patient immediate consultation and treatment. Information about the therapy and the side effects on fertility must be given to the patient and the informed consent consultation should include a close person or family member in order to give support. Treatment options should be outlined even those forms of treatment with an experimental character. Options are conventional assisted reproductive techniques, administration of GnRH analogues, oocyte or ovarian tissue cryopreservation and in vitro maturation.     

Fertilität bei Männern über 40 Jahren

Background

Parenting in later life is perceived by many as advantageous because more stable living conditions are often possible. In addition, this gives men the option to have a second family. Therefore, biological aspects of becoming a father later in life have become the focus of scientific and clinical research.

Age-dependent factors influencing male fertility

Age affects male fertility by a number of factors that are not yet completely understood. Generally, the amount of produced spermatozoa as well as their motility decrease with advancing age, and testicular histological architecture deteriorates. This results in decreased fecundity and also an increased risk for difficult pregnancies with advancing paternal age. Some rare autosomal dominant diseases are associated with paternal age.

Epigenetic effects

Dysbalanced patterns of epigenetics and gene expression in aging sperm seem to affect a range of neurocognitive disorders across generations. A man’s age older than 40 years is viewed as a biological factor which may, however, be —at least partially—compensated by a younger female partner. Nevertheless, counseling of older fathers-to-be must be patient-oriented and statistical probabilities must be weighed against individual wishes and life-planning.     

Adipositas und Fertilit?t der Frau aus gyn?kologischer Sicht

Obesity and co-morbidities represent a global epidemic problem. As a result, many issues arise concerning overweight/obese females during the reproductive phase. From a gynaecological point of view androgenized patients are at the focus of scientific and clinical interest. Three major groups of overweight/obese androgenized patients are distinguished: largely healthy women with cutaneous androgenization showing no significant systemic dysfunctions [functional cutaneous androgenization (FCA)]; patients with endocrine-metabolic disorders and enlarged polyfollicular ovaries (functional androgenizing syndrome, FAS?III); and patients with anthropometric and metabolic disorders similar to those seen in FAS?III patients, but who, in contrast, present with small oligofollicular ovaries (FAS?IV). Lifestyle modifications form the basis of any treatment, the beneficial impact of which may be supported by metformin. In the case of infertility the varying sensitivity of the ovaries to hormone stimulation among the three groups should be taken into account. Although to a lesser extent for the first group, the risk of gestational diabetes mellitus needs to be recognized in FAS?III and IV, thereby necessitating a possible changeover to insulin treatment and intensive intra- and postpartal care.     

Endometriose und Fertilitätsprotektion – sinnvoll oder nicht?

Gynäkologische Endokrinologie - Endometriose ist eine der häufigsten gynäkologischen Erkrankungen. Sie ist per se mit dem Risiko der Subfertilität behaftet. Entzündliche...