الفهرس 
Gestational Trophoblastic NeoplasiaOnly 14 pages are availabe for public view
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Abstract
C
ancer treatment can threaten a woman’s ovarian reserve, resulting in infertility and premature ovarian insufficiency. In young women exposed to gonadotoxic therapy, menstrual pattern, follicular stimulating hormone (FSH), anti-Mullerian hormone (AMH), and antral follicular count (AFC) appear to be the most sensitive indicators of the ovarian reserve. Menstrual pattern remains the standard outcome, but cancer survivors may recover menstrual cycling after significant lengths of amenorrhea.
Gestational trophoblastic neoplasia (GTN) may threaten the life and health of the patient if not properly treated. The majority of patients with GTN are successfully treated with chemotherapy using a single anticancer drug. Therefore, in patients with low-risk GTN, reproductive capacity is not considered to be significantly affected by chemotherapy. On the other hand, patients with high-risk GTN, who are at greater risk of rapid disease development, require treatment with multi-agent chemotherapy, which might affect the post-treatment ovarian function.
In the current study, we analyzed 70 patients who underwent chemotherapy to treat GTN at Ain Shams University Maternity Hospital. Blood samples for assaying AMH obtained before receiving chemotherapy and 6 weeks after responding to chemotherapy.
Our study excluded patients with history of previous ovarian surgery or with evidence of any endocrine disorders, including thyroid dysfunction, hyperprolactinemia, or Cushing’s syndrome.
In the current study there was significant statistical difference between AMH level before and after chemotherapy received in all GTN patient with mean difference 2.29 after 6 weeks.
In our study the multiregresion analysis after adjustment of different variables showed that there was statistical significance in percentage of AMH level reduction after chemotherapeutic treatment.
Our study included74.3% of patients with low risk category who received single agent chemotherapy and 25.7% of patients with high risk category who received combined chemotherapy. There is significant statistical difference in age group between patients of low risk and high risk category with mean of age 26.7 and 32 respectively. This might be associated with the significant difference in AMH level before chemotherapy treatment in patient with low risk and high risk category with mean of AMH level 4.78 and 3.28 of two groups respectively.
In the low risk group AMH level was reduced by 42.3 % after receiving single agent chemotherapy and this group of patient received methotrexate as treatment.While the high risk group AMH level was reduced by 77.8 % after receiving combined chemotherapy which include etoposide based regimen.The type of chemotherapy agent (multi-agent or single-agent) may influence the decrease of the ovarian reserve. Alkylating agents, such as cyclophosphamide are known to be highly gonadotoxic.
In the current study, we found a significant difference in serum AMH levels between patients receiving etoposide-negative regimens and those receiving etoposide-positive regimens. ETP has been considered to be a key agent for high-risk GTN.
ETP prevents re-ligation of DNA strands, and thereby inhibits DNA synthesis. Therefore, the gonadotoxicity of etoposide is not negligible, similar to the effects of alkylating agents that cause DNA crosslinks.
Although treatment with MTX or ACD did not show any correlation between doses and post-chemotherapy AMH levels in this study, our results indicate that all patients receiving regimens with MTX and/or ACD have lower AMH levels than levels before receiving chemotherapy.
Our study was done immediately after treatment with chemotherapy and revealed decrease in ovarian reserve.
Our results suggest that treatment with ETP causes the ovarian reserve to decrease, and even treatment with MTX and/or ACD affects ovarian reserve in patients with low-risk GTN. Our results may be helpful for counseling of GTN patients who are concerned about their ovarian reserve. Further studies to evaluate pre- and postchemotherapy serum AMH levels in GTN patients would provide detailed information regarding ovarian reserve.