Neoplasms

Skin and Connective Tissue Diseases

All Conditions

Breast Neoplasms

Breast Diseases

Skin Diseases

Central Nervous System Depressants

All Drugs and Chemicals

Coagulants

Antineoplastic Agents

Reproductive Control Agents

Anesthetics

Follicle Stimulating Hormone

Hemostatics

Triptorelin Pamoate

Anesthetics, General

Ganirelix

Patients in group 1 will undergo a laparoscopy for an ovarian biopsy from the right ovary. They will then continue with a controlled ovarian stimulation, using a GnRH antagonist protocol. This will be started with Corifollitropin alfa 0.15 mg in the evening. On day six the antagonist, Ganirelix, will be added in the morning. If needed stimulation can be continued after seven days using follitropin beta daily in the evening (dosage ranging from 200-300 IE depending on AMH levels). Agonist trigger Triptorelin 0.2 mg will be administered for ovulation induction. In case of LH levels \<2 IU/L at the start of ovarian stimulation, a dual ovulation strategy will be adapted: Triptorelin 0.2mg and choriongonadotropin 2500 IU (or choriongonadotropin alfa 250 µg) will be given. A transvaginal oocyte retrieval will be planned 36 hours after triggering.

Patients in group 2 will undergo a laparoscopy for an ovarian biopsy from the left ovary. They will then continue with a controlled ovarian stimulation, using a GnRH antagonist protocol. This will be started with Corifollitropin alfa 0.15 mg in the evening. On day six the antagonist, Ganirelix, will be added in the morning. If needed stimulation can be continued after seven days using follitropin beta daily in the evening (dosage ranging from 200-300 IE depending on AMH levels). Agonist trigger Triptorelin 0.2 mg will be administered for ovulation induction. In case of LH levels \<2 IU/L at the start of ovarian stimulation, a dual ovulation strategy will be adapted: Triptorelin 0.2mg and choriongonadotropin 2500 IU (or choriongonadotropin alfa 250 µg) will be given. A transvaginal oocyte retrieval will be planned 36 hours after triggering.

A laparoscopy will be performed to achieve an ovarian cortical biopsy of one of both ovaries. Approximately twenty % of the ovarian volume as initially measured on the baseline ultrasound at the first visit will be removed to be processed in the lab for cortex freezing. The laparoscopic procedure in order to take the ovarian cortex biopsy will be standardised as much as possible. The technique developed by ProFam will be followed and adapted if needed by the surgeon's discretion. A three to four port laparoscopy will be used. The ovarian cortex biopsy will be taken using a curved scissor. Bipolar or unipolar cauterisation will be avoided as much as possible. If necessary for approximation or for hemostatic reasons, the ovarian edges can be stitched or Surgicel ® Absorbable Hemostat can be used.

Ovarian biopsy via laparoscopy

After ovarian stimulation, a transvaginal oocyte retrieval will be performed either under local or general anaesthetics (patient's choice). The oocyte yield between the biopsied and non-biopsied ovary will be evaluated.

Transvaginal oocyte retrieval

Michel De Vos, MD PhD

Elsie Nulens

Michel De Vos, MD

Dominic Stoop, MD PhD

This clinical prospective randomised controlled trial will evaluate the impact of an ovarian biopsy on the oocyte yield after controlled ovarian stimulation before chemotherapy in view of breast cancer. The purpose of this trial is to learn about the possibility to combine these two fertility preservation procedures without decreasing the number of oocytes collected after an ovarian stimulation.

All patients will undergo a biopsy of the ovarian cortex via laparoscopy, after patient eligibility has been established and patient consent has been obtained. The side of the ovarian biopsy will be randomized on the day of the laparoscopy either from the right side (group 1) or from the left side (group 2). The ovarian tissue will be cryopreserved. A small part will also be evaluated by the pathologist to screen for malignant contamination and follicle density. All patients will then continue with a controlled ovarian stimulation.

In both groups, a first blood analysis with hormonal assessment (E2, P, LH, FSH, hCG and AMH) will be performed at first visit, independent of their cycle. At that time a transvaginal ultrasound (frequency ≥ 7 MHz) will be done as well to assess the antral follicle count and the ovarian volume. The antral follicle count will be assessed using real-time 2D-US evaluation, the standard use in clinical practice. The ovarian volume will be measured using the prolate ellipsoid formula (volume = length x width x height x 0.523). If a dominant follicle is noted, choriongonadotropin (Pregnyl ® 5000 IU), choriongonadotropin Alfa (Ovitrelle ® 250 µg) or triptorelin (Gonapeptyl ® or Decapeptyl ® 0.2 mg) will be given to the patient to trigger ovulation. Thereafter, the controlled ovarian stimulation can be initiated in the luteal phase.

The size of the ovarian cortex biopsy will be calculated as 20% of the ovarian volume measured at the initial ultrasound. Immediately after the ovarian biopsy, the objective measurements of the biopsy will be noted in weight (gram) and volume (length x width x height mm³) because the biopsy fragment can be considered a rectangular box. A correction factor will be used afterwards in the statistical analysis if the volume of the ovarian biopsy is not equal to 20%.

The laparoscopic procedure by which the ovarian cortex biopsy will be performed, will be standardised: The technique developed by ProFam will be used and adapted if needed at the surgeon's discretion. A three to four-port laparoscopy will be used. The ovarian cortex biopsy will be performed using a curved scissor. Bipolar or unipolar cauterisation will be avoided as much as possible. If necessary for approximation or for hemostatic reasons, the ovarian edges can be stitched or Surgicel® Absorbable Hemostat can be used.

During the course of the study, there will be a number of blood analyses and ultrasounds, to evaluate follicular growth. This will be arranged at specific time points starting from day 6 of the stimulation and will be performed every other day, until the day of trigger. If necessary and based on clinician's decision, a supplementary blood analysis and/or ultrasound can be scheduled. At the follow-up ultrasounds the follicular growth will be noted for each ovary separately to assess difference in reaction and/or growth after the ovarian biopsy.

The controlled ovarian stimulation will start the day of the laparoscopy. It can start either in basal circumstances, or in the early follicular or luteal phase. A fixed GnRH antagonist protocol will be used. Ovarian stimulation will be started with Corifollitropin alfa 0.15 mg (Elonva®). On day six the antagonist, Ganirelix (Orgalutran®), will be added to prevent a premature LH surge. If needed ovarian stimulation can be continued after seven days using follitropin beta (Puregon®). The dosage of Puregon® is dependent on the AMH level at the first visit. Patients with AMH \> 2 µg/L, will be started with 200-225 IE Puregon® daily. If the initial AMH level is \<2 µg/L, patients will receive 225-300 IE Puregon® daily. Elonva ® and Puregon ® will be administered in the evening, whereas Orgalutran ® will be injected in the morning. Agonist trigger Triptorelin 0.2 mg (Gonapeptyl®) will be ministered as soon as at least three follicles reach a mean diameter of 18 mm or wider, with intermediary follicles 14 mm or wider. In case of LH levels \<2 IU/L at the start of ovarian stimulation, a dual ovulation strategy will be adapted: Triptorelin 0.2mg and hCG 2500 IU (or ovitrelle 250 µg) will be given. Oocyte retrieval will be planned 36 hours after triggering. This will be performed as a transvaginal oocyte pick-up. Oocyte vitrification will be carried out after denudation and assessment of maturity.

All patients will undergo a laparoscopy for an ovarian biopsy (about 20% of the ovarian volume). The side of the ovarian biopsy will be randomized on the day of the laparoscopy either from the right side (group 1) or from the left side (group 2). All patients will then continue with a controlled ovarian stimulation, using corifollitropin alpha and follitropin beta in a GnRH antagonist protocol using ganirelix. The metaphase II oocyte yield will be evaluated between the biopsied versus non-biopsied ovary to proof a non-inferiority (assuming that a difference of 1 metaphase II oocyte yielded from the biopsied ovary compared to the non-biopsied ovary is not clinically relevant).

Combining Interventions of Fertility Preservation to Mitigate Fertility Loss After Breast Cancer

Combining Interventions of Fertility Preservation to Mitigate Fertility Loss After

As this is a multicenter study, we plan to share IPD between the study sites. An electronical case report form (eCRF) will be set up and completed in all sites. Data will be handled in accordance with the general data protection regulation (GDPR).

Evaluation of metaphase II oocyte yield between biopsied and non-biopsied ovary

Evaluation of the proportion of follicles that were responsive to FSH and is calculated by dividing the number of preovulatory follicles (16-20 mm) × 100 by the antral follicle count (3-8 mm)

Evaluation of cumulus oophorus complex yield between biopsied and non-biopsied ovary

Evaluation of proportion of metaphase II oocytes within the COC yield between biopsies and non-biopsied ovary

Hopital Antoine Beclere

Universitair Ziekenhuis Brussel

Estradiol

Hormones

Letrozole

Estradiol 17 beta-cypionate

Estradiol 3-benzoate

Polyestradiol phosphate

Cetrorelix

Contraceptive Agents

Contraceptive Agents, Female

Contraceptive Agents, Hormonal

Antineoplastic Agents, Hormonal

Ovarian stimulation will be performed using a fixed antagonist protocol with Follitropin Alfa (daily in the evening) and Ganirelix or Cetrorelix (daily in the morning). Selection of the daily gonadotropin dose will be based on ovarian reserve parameters (AMH and AFC) and BMI. Co-administration of 5 mg of letrozole daily (in the morning) commencing on the first day of gonadotropin administration and continuing throughout the ovarian stimulation will be performed as this reduces oestradiol concentrations. GnRH agonist Triptorelin 3.75 mg Depot form will be used for final oocyte maturation. Ganirelix/Cetrorelix 0.25mg daily (in the morning) will resume for 7 days from the evening of the day of oocyte retrieval onwards. Hormone analysis, analysis of haematology and biochemistry and a pelvic ultrasound scan will be done on days 3, 5 and 7 after oocyte retrieval.

Ovarian stimulation will be performed using a fixed antagonist protocol with Follitropin Alfa (daily in the evening) and Ganirelix/Cetrorelix (daily in the morning). Selection of the daily gonadotropin dose will be based on ovarian reserve parameters (AMH and AFC) and BMI. Co-administration of 5 mg of letrozole daily (in the morning) commencing on the first day of gonadotropin administration and continuing throughout the ovarian stimulation will be performed as this reduces oestradiol concentrations. GnRH agonist Triptorelin 0.2 mg Daily form will be used for final oocyte maturation. Hormone analysis, analysis of haematology and biochemistry and a pelvic ultrasound scan will be done on days 3, 5 and 7 after oocyte retrieval. The first administration of Triptorelin 3.75mg depot will be scheduled on the first day of the menstrual cycle after oocyte retrieval. To prevent the flare-up produced by the GnRH agonist, daily doses of 0.25mg of Ganirelix/Cetrorelix will be given for seven days.

Depot Group (Group A) will receive Triptorelin 3.75mg Depot form for final oocyte maturation.

Triptorelin 3.75 MG Injection

Patients in both groups will undergo a transvaginal oocyte retrieval after ovarian stimulation.

Daily Group (Group B) will receive Triptorelin 0.2mg Daily form for final oocyte maturation.

Triptorelin Injection

Michel De Vos

Sharon Lie Fong, MD PhD

For breast cancer patients who are candidates to receive chemotherapy, concurrent use of temporary ovarian suppression with gonadotropin-releasing hormone agonists (GnRHa) can be offered as ovarian protection.

Because ovarian stimulation for oocyte cryopreservation is usually performed using a GnRH antagonist protocol and typically involves final oocyte maturation triggering with a GnRH agonist, the investigators designed this study to explore the feasibility of combining the final oocyte maturation trigger and the start of ovarian suppression. Short-term cotreatment with GnRH antagonists is needed to induce rapid luteolysis (in view of prevention of ovarian hyperstimulation).

To demonstrate the safety of GnRH agonist depot triggering followed by daily GnRH antagonist luteolysis, this pilot study is set out to analyse the endocrine profile and ovarian morphology of this novel protocol.

For breast cancer patients who are candidates to receive chemotherapy, concurrent use of temporary ovarian suppression with gonadotropin-releasing hormone agonists (GnRHa) can be offered as ovarian protection. A recent meta-analysis of individual patient data from the largest randomised clinical trials in women with early breast cancer indicated beneficial effects of GnRHa ovarian suppression in reducing POI risk and increasing post-chemotherapy pregnancy rates with no negative effect on patients' outcomes. However, it should not be considered as an alternative to cryopreservation strategies in fertility preservation.

Because ovarian stimulation for oocyte cryopreservation is usually performed using a GnRH antagonist protocol and typically involves final oocyte maturation triggering with a GnRH agonist, the investigators designed this study to explore the feasibility of combining the final oocyte maturation trigger and the start of ovarian suppression. Replacement of the 0,2mg triptorelin trigger by a GnRH agonist depot has potential to provide this dual action. However, the protracted action of the GnRH agonist depot will result in prolonged stimulation of multiple corpora lutea, which will lead to enhanced production of steroids (estradiol and progesterone) and growth factors such as vascular endothelial growth factor. Consequently, GnRH agonist-induced stimulation of multiple corpora lutea is potentially unsafe in a patient with breast cancer because of the impact of estradiol and progesterone on breast tumour cells. In addition, VEGF may increase the risk of OHSS, which will lead to postponement of cancer treatment. Therefore, short-term cotreatment with GnRH antagonists is needed to induce rapid luteolysis.

To demonstrate the safety of GnRH agonist depot triggering followed by daily GnRH antagonist luteolysis, this pilot study is set out to analyse the endocrine profile and ovarian morphology of this novel protocol.

Patients will be randomized before start of stimulation to either DEPOT group (group A) or control group (group B), only after patient eligibility has been established and patient consent has been obtained.

Patients will be randomized before start of ovarian stimulation to either DEPOT group (group A) or control group (group B), only after patient eligibility has been established and patient consent has been obtained.

Group A will receive the GnRH agonist Depot form for final oocyte maturation followed by daily GnRH antagonist injections for 1 week.

Group B will receive the GnRH agonist daily form for final oocyte maturation. After one week the Depot form combined with daily GnRH antagonist injections for 7 days, will be administered in view of ovarian protection during chemotherapy.

Blood analysis and ultrasounds will be organised on day 3, 5 and 7 after oocyte pick-up in both groups.

DEPO-Trigger Trial: GnRH Agonist DEPOt TRIGGER for Final Oocyte Maturation

DEPO-Trigger Trial: GnRH Agonist DEPOt TRIGGER for Final Oocyte Maturation in Breast Cancer Patients Undergoing Fertility Preservation: a Pilot Study

As this is a multicenter study, we plan to share IPD between the study sites. An electronically case report form (eCRF) will be set up and completed in all sites. Data will be handled in accordance with the general data protection regulation (GDPR).

A transvaginal ultrasound will be performed to measure the ovarian volume according to the formula 'length x width x height x 0.523' mm³.

In the assumption of safety ovarian volume should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate hematocrit (%). In the assumption of safety hematocrit levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate hemoglobine (g/dL). In the assumption of safety hemoglobine levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate White Blood cell Count (X10³/mm³). In the assumption of safety White Blood cell Count should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate Platelet Count (X10³/mm³). In the assumption of safety Platelet Count should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate eGFR (mL/min/1.73m²). In the assumption of safety eGFR levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate Creatinine (mg/dL). In the assumption of safety creatinine levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate Albumin (g/L). In the assumption of safety Albumin levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate liver function (AST U/L, ALT U/L, Gamma-GT U/L, bilirubine mg/dL, LDH U/L).

In the assumption of safety liver function levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate Oestradiol (ng/L). In the assumption of safety Oestradiol levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate Progesteron (mcg/L). In the assumption of safety Progesteron levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate FSH (IU/L). In the assumption of safety FSH levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

A blood sample will be taken to evaluate LH (IU/L). In the assumption of safety LH levels should be similar to that in the control group and there should be no events of ovarian hyperstimulation syndrome.

Evaluation of the number of cumulus-oocyte complexes between the Depot Group and Daily Group

Evaluation of the number of Metaphase II oocytes between the Depot group and Daily group

Assessment of MENQOL (The Menopause-Specific Quality of Life) Questionnaire

Universitaire Ziekenhuizen KU Leuven

Bone Density Conservation Agents

Tamoxifen

Tamoxifen given at a fixed dose for invasive breast cancer adjuvant hormonotherapy or for breast cancer prophylaxis.

Oocyte retrieval

César Diaz-Garcia, MD

Ainhoa Romero, MD

Ainhoa Romero Espinós, MD

Alicia Marzal Escrivá, MD

Antonio Pellicer, MD

Natalia Fischer, MD

Daniella Galliano, MD

Ignacio Iniesta, BSc

Irene Peinado, BSc

Survival in young patients with cancer has increased and also have increased the adverse long-term side effects of chemotherapy, there is a large number of women who experience loss of ovarian function without accomplishing their reproductive desire due to gonadotoxic treatment. The ovarian reserve determine the response to controlled ovarian hyperstimulation in fertility preservation treatments as well as in assisted reproduction techniques. Improving this reserve by avoiding its depletion during the process could result in increase fertility rates after cancer treatment.

Collecting follicles during tamoxifen treatment would increase the number of cryopreserved oocytes and thus rise the potential ovarian reserve in these patients, which is reduced due to age, chemotherapy and length of treatments.

The aim of this study is to retrieve viable mature oocytes during adjuvancy with tamoxifen in breast cancer patients to improve the probability of subsequent pregnancy.

New chemotherapy regimens and management options developed during the last 20 years have yielded increased survival rates in cancer patients but they also cause side effects such as premature ovarian failure and infertility due to their gonadotoxicity. Hormone therapy also increases survival rates in breast cancer patients; tamoxifen, a selective estrogen receptor modulator, has been proven to reduce the risk of recurrence and mortality due to breast cancer when administered during 10 years.

The risk of premature ovarian failure depends not only on the gonadotoxicity of chemotherapy but also on the age of the patient, therefore although tamoxifen is not gonadotoxic itself, it can compromise fertility because of the long length of treatment and the subsequent delay in childbearing.

On the other hand, tamoxifen is a drug that can be used in assisted reproduction techniques to induce ovarian stimulation, therefore, the tamoxifen treatment followed by breast cancer patients represent somehow a way of continuous ovarian stimulation. If viable oocytes could be retrieved during the long-term hormonal treatment with tamoxifen, there will be an option to use them to restore fertility afterwards.

STUDY DESIGN:

Patients included in the study who have normal menstrual periods will be monitored by sonography (antral follicle count) and serum hormonal levels: E2 (oestradiol), P4 (progesterone), FSH (follicle stimulating hormone) and LH (luteinizing hormone) from the second day of their cycle. Patients without spontaneous menstruations will perform periodic visits every 15 days until images corresponding with antral follicle definition will be seen, this will be considered day 2 of the cycle.

Follow-up of the antral follicles will be done with sonography and serum hormonal levels according to the protocols of the investigators in vitro fertilization unit. When a follicle of more than 18 mm is seen, 250 µg of hCG (human chorionic gonadotropin) will be administered and 36 hours after, transvaginal oocyte retrieval will be performed. Oocyte and embryo quality assessment will be performed according to morphological ASEBIR (association for the study of reproduction biology) classification on day +2 and +3. Grade 1 and 2 embryos on day +3 will be cryopreserved.

Patients requiring assisted reproduction technologies to get pregnant after completion of their oncologic treatment will have their embryos thawed and subsequently transferred.

FOLLOW-UP:

During the time oocytes retrieved are being used or until the end of gestation in case the patient become pregnant.

Bearing in mind that most of the patients in our center undergo 5 year of tamoxifen treatment, it will be assumed a maximum follow-up of 6 years.

Oocyte Recovery During Tamoxifen Adjuvant Therapy

Tamoxifen as Adjuvant Treatment in Breast Cancer and Its Impact on Ovarian Function

pregnancy rates after the use of frozen embryos generated during tamoxifen treatment

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Combining Interventions of Fertility Preservation to Mitigate Fertility Loss After Breast Cancer	NCT04586686	Breast Cancer F...	Ovarian biopsy ... Transvaginal oo...	18 Years - 35 Years	Universitair Ziekenhuis Brussel
DEPO-Trigger Trial: GnRH Agonist DEPOt TRIGGER for Final Oocyte Maturation	NCT04616729	Breast Cancer F...	Triptorelin 3.7... Transvaginal oo... Triptorelin Inj...	18 Years - 35 Years	Universitair Ziekenhuis Brussel
Combining Interventions of Fertility Preservation to Mitigate Fertility Loss After Breast Cancer	NCT04586686	Breast Cancer F...	Ovarian biopsy ... Transvaginal oo...	18 Years - 35 Years	Universitair Ziekenhuis Brussel
Oocyte Recovery During Tamoxifen Adjuvant Therapy	NCT02355600	Breast Cancer	Oocyte retrieva...	18 Years - 35 Years	Instituto de Investigacion Sanitaria La Fe
DEPO-Trigger Trial: GnRH Agonist DEPOt TRIGGER for Final Oocyte Maturation	NCT04616729	Breast Cancer F...	Triptorelin 3.7... Transvaginal oo... Triptorelin Inj...	18 Years - 35 Years	Universitair Ziekenhuis Brussel
DEPO-Trigger Trial: GnRH Agonist DEPOt TRIGGER for Final Oocyte Maturation	NCT04616729	Breast Cancer F...	Triptorelin 3.7... Transvaginal oo... Triptorelin Inj...	18 Years - 35 Years	Universitair Ziekenhuis Brussel

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