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CASE HISTORY

Case History

image A 25-year-old nulliparous woman with no relevant past medical or surgical history presented with a lump in the neck, high grade fever and night sweats. Clinical examination confirmed a 1.5 cm painless, firm, left cervical lymph node. An excisional biopsy of the cervical mass was performed showing lymphoproliferative disorder with presence of Reed-Sternberg cells consistent with Hodgkin’s lymphoma (HL). The clinical staging including positron emission tomography (PET)/computer tomography (CT) scan was negative for disease outside the cervical area. Treatment with ABVD (Doxorubicin, Bleomycin, Vinblastine, and Dacarbazine) for six cycles was planned.

Prior to initiation of chemotherapy, she was referred to a reproductive medicine specialist to discuss the risks of the chemotherapy regimen on her fertility. Oocyte/embryo cryopreservation and ovarian tissue cryopreservation (OTC) were discussed for fertility preservation (FP). She had no partner at the time of diagnosis and had regular menses every 28 days. A transvaginal ultrasound showed adequate ovarian reserve with an antral follicle count (AFC) of 18 and an anti-müllerian hormone (AMH) of 17.8 pmol/l.

The initial chemotherapy treatment had limited gonadotoxic effect and posed only limited risk of infertility. After a long discussion, she opted not to go for oocyte cryopreservation as deemed at low risk for ovarian damage. During ABVD treatment her disease progressed. Her treatment was escalated to a gonadotoxic chemotherapy regimen consisting of BEACOPP (Bleomycin, Etoposide, Doxorubicin, Cyclophosphamide, Vincristine, Procarbazine, Prednisolone). Because of the risk of premature ovarian insufficiency (POI) due to the gonadotoxic alkylating agent, she requested a second fertility consultation to consider her FP options before proceeding with second-line chemotherapy. She was offered ovarian tissue preservation.

What is the fertility risk following ABVD treatment compared to other regimens?

Should she have considered FP even in the setting of a regimen with a low gonadotoxic effect?

Why oocyte/embryo cryopreservation is not an option after recent chemotherapy?

What are the available options for FP at the time of chemotherapy?

Is post chemotherapy OTC as effective and safe as pre chemotherapy?

What is the fertility risk following ABVD treatment compared to other regimens?

The degree to which ovarian function is compromised depends on the type of chemotherapy. The ABVD regimen is associated with less than 10% risk of long-term infertility in female HL survivors. Conversely, combination protocols containing alkylating agents such as BEACOPP have 50–65% risk of continuous amenorrhea with significant decline in ovarian reserve markers.1,2 Based on a large cohort of 5-year survivors of HL, the risk of POI is 12-fold higher in patients receiving a procarbazine-based regimen, with a cumulative risk of 48% at the age of 40.1

In refractory or relapsing lymphoma, second-line chemotherapy including ICE (ifosfamide, carboplatin, etoposide) and/or DHAP (dexamethasone, high-dose cytarabine, cisplatin) before haematopoietic cell transplantation are the most damaging with an infertility rate of up to 81%.3 The menstrual status after HL therapy was evaluated by the German Hodgkin’s Lymphoma ...

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