DO NOT FORGET GONADAL FUNCTION... In patients with glomerular diseases, irreversible infertility may occur after treatment with alkylating agents, such as oral or intravenous cyclophosphamide and chlorambucil.
Here is a short summary
of available recommendations for maintenance of fertility in patients needing
alkylating drugs.
Female sex
Serologic parameters of ovarian reserve include FSH,
LH, and estradiol measured at the follicular phase on days 1–3 of the menstrual
cycle, and progesterone measured at the luteal phase 7 days before the next
menstruation to confirm ovulation.
In the postpubertal female, options for gonad
preservation include hormonal contraceptives, GRH agonists, and embryo and
oocyte cryopreservation.
Therapy with GRH agonists or analogs shows the most
promising results for ovarian protection. The GRH agonists or analogs inhibit
the pituitary–gonadal axis and subsequently, the complete ovarian suppression
reduces the rate of oocyte maturation. Women develop amenorrhea at 3–8 weeks of
treatment with GRH agonists or analogs, and menses generally return 6–10 weeks
after withdrawal of GRH agonists or analogs.
Commercially available options include:
- leuprolide
3.75 mg intramuscular every 4 weeks,
- triptorelin
3.75 mg IM every 4 weeks, or
- buserelin 200 mg 3 times a day intranasal
- buserelin 200 mg 3 times a day intranasal
Ovarian
protection with GRH agonists or analogs for 6 consecutive months during
treatment with cytotoxic agents has been reported in patients with autoimmune
diseases. The main adverse events associated with GRH agonist or analog therapy
include injection site reactions (3–8%), hot flash, dry vagina, and irregular vaginal
bleeding. Menopausal symptoms disappear generally 6–10 weeks after GRH agonist
or analog withdrawal. The most serious side effect is loss of bone density. Concomitant
calcium and vitamin D supplementation., bisphosphonate therapy, or transdermal estrogen
supplementation are therefore necessary. Lupus flares may be induced by the
increase of estrogen that is observed in the first two weeks of the start of GRH
agonist or analog therapy. Anticoagulation in patients with SLE and/or the antiphospholipid
syndrome for the first 3 weeks of GRH agonist or analog treatment seems
prudent.
Male sex
Cryopreservation
of spermatogonial stem cells for future autologous intratesticular
transplantation is a preferable method for prepubertal boys, whereas sperm
cryopreservation for future ARTs are options for postpubertal males. Importantly,
regarding hormonal therapy for testicular preservation, several studies did not
show a beneficial effect from hormonal treatment.
Cryopreservation of semen and
subsequent IVF is the only standard available option.
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