Cancer Treatment and the Ovary: Clinical and Laboratory Analysis of Ovarian Toxicity provides the reader with a basic understanding on how the ovary is adversely impacted by cancer treatment, an essential foundational knowledge for this rapidly-developing field.
The book describes both the clinical and laboratory approaches to discovering the potentially adverse effects of cancer treatment on the ovary, also laying out possible preventative approaches and future directions for the field.
Clinicians working in the field of reproductive biology and oncology will find an essential reference that provides the necessary tools to assess the reproductive toxicological effects of cancer treatments.
- Brings together an international group of experts to address the current state of the science of ovarian toxicity caused by cancer treatment
- Provides scientific, clinical, and preclinical approaches to assessing this toxicity
- Describes current techniques and future strategies to protect the ovary
- Ideal reference for the further study of ovarian toxicity, oncofertility, cancer treatment, and reproductive toxicology
Ovarian Follicle Biology and the Basis for Gonadotoxicity
Marilia Henriques Cordeiro, So-Youn Kim and Teresa K. Woodruff, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
Normal ovarian function requires tight control of germ cell meiosis and the quantitative activation or loss of ovarian follicles from the primordial follicle pool over the reproductive lifespan. The mechanisms controlling the activation of specific subsets of primordial follicles during this lengthy time are complex, involving coordination of what we now understand to be multiple molecular cues. In this chapter we review ovarian follicle development from initial formation in the embryo to activation, growth and endocrine regulation during the normal reproductive lifespan. We discuss how the unique features of primordial follicle biology relate to their vulnerability to chemotherapy and radiation treatment, emphasizing the importance of preserving the ovarian reserve to ensure normal ovarian function and the endocrine health of the individual.
endocrine system; follicle; follicle activation; follicle death; folliculogenesis; ovarian hormones; ovarian reserve; ovary
1.1 Overview of Ovarian Function
The ovary serves two roles - the production of hormones necessary to support the endocrine health of the individual and the generation of mature oocytes that are able to be fertilized and contribute half of the genetic makeup of a new organism. The ovarian follicle is the functional unit of the ovary that carries out both of these goals.1,2 The ovarian follicles within an adult ovary produce steroid and protein hormones in cyclical patterns in response to tropic factors from the hypothalamus and pituitary (Figure 1.1). These hormones then act locally to support follicle and oocyte growth and development, as well as systemically to support reproductive health, bone health and cardiovascular function.3 Interruption of the endocrine hormones at the level of the brain or gonad due to cancer treatment can result in loss of cyclicity and diminished endocrine health for short periods of time or can render an individual sterile due to loss of ovarian follicles. Figure 1.1 Ovarian endocrine control of reproductive cyclicity and female systemic health.
(A) Ovarian-derived hormones are important to maintain normal homeostasis of peripheral organs, including brain, heart, mammary glands, bones, reproductive tract, etc. Therefore, systemic health complications are associated with interruption of ovarian function at menopause or due to anticancer treatment-induced premature ovarian failure (POF). The hypothalamus-pituitary-ovary axis is represented in blue. (B) Normal ovarian function and cyclicity are regulated by a complex hormonal feedback loop between the organs of the hypothalamus-pituitary-ovary axis. Hypothalamic gonadotropin-releasing hormone (GnRH) pulses control pituitary gonadotropin (luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) release, which regulates follicle growth and production of steroid and peptide hormones (oestrogen, inhibins and progesterone). These gonadal hormones then exert a negative feedback on the pituitary and hypothalamus. (C) Hormonal regulation of the women's menstrual cycle. The frequency of GnRH pulses determines FSH and LH release, stimulating follicle development. During follicular growth oestrogen and inhibin are produced, causing negative feedback in the hypothalamus and pituitary. Increased frequency of GnRH pulses induces LH release, triggering ovulation. The residual follicle structure forms the corpus luteum and produces progesterone, which is responsible for preparing the endometrium (uterine wall) for implantation and pregnancy. If pregnancy is not achieved, the uterine wall disintegrates causing the menses, at a time when a new group of gonadotropin-responsive follicles will start to grow, initiating a new cycle. The hormonal levels and fluctuations have been simplified to better represent the overall secretion pattern throughout the menstrual cycle.
Each ovarian follicle consists of one oocyte surrounded by supporting somatic cells, the granulosa and theca cells,4 and the follicle structure is embedded in an ovarian stroma that provides additional critical signals that determine follicle fate.5 Follicle development starts with selection of follicles from a pool of dormant primordial follicles - the ovarian reserve. The recruited follicles are activated and undergo a series of changes in morphology and size, developing through primary and secondary stages before acquiring a fluid-filled antral cavity.4 Although multiple follicles are selected to begin growing and eventually reach the antral stage, many are lost to atresia and only one (or a few depending on the species) reaches the Graffian follicle stage.1,6 Ovulation occurs in response to a timed surge of pituitary gonadotropins (see Figure 1.1) that triggers the release of a mature oocyte from the surface of the ovary into the fallopian tube, where it can be fertilized. The residual follicle unit (the remaining theca and mural granulosa cells) undergoes transformation to become the corpus luteum.
Ovarian follicle development is a carefully orchestrated event that is directed by both endocrine signalling within the hypothalamic-pituitary-ovarian axis as well as paracrine signalling occurring within and between follicles in the ovary.7 Hormone-regulated follicular development involves the integration of feedback loops between oestrogen, progesterone, inhibin A and inhibin B from the ovary; follicle-stimulating hormone (FSH) and luteinizing hormone (LH) from the pituitary; and hypothalamic gonadotropin-releasing hormone (GnRH) to direct follicle and oocyte development (see Figure 1.1).8 On the other hand, early follicle development is driven by intrinsic ovarian factors9 that regulate oocytic and follicular development before the follicles acquire FSH responsiveness.10-13 These locally acting factors and their roles in maintaining the dormant follicle pool, activating selected primordial follicles and supporting the earliest stages of follicle development are less well understood and of intense interest in the reproductive field. Understanding the early signalling events associated with maintaining a health-quiescent follicle pool may provide insights into gonadotoxicity and how to mitigate this effect.
1.2 Ovarian Development
The mammalian gonad is formed during embryonic development (Figure 1.2) after migration of primordial germ cells (PGCs) from the hindgut into the genital ridge between 9 to 10.5 days post coitum (dpc) in the mouse and at 6 weeks of gestation in humans.14-16 During this process, PGCs undergo mitotic divisions17 with incomplete cytokinesis resulting in cysts where germ cells remain connected by cytoplasmic bridges.18 At this stage, the gonad is bipotent. In the presence of a Y chromosome, the expression of the Sry gene (sex-determining region on the Y chromosome) directs male development through a process called sex determination.19 In contrast, sex determination in females requires the activity of several genes, such as Wnt4, Rspo1, ß-Catenin, Foxl2 and Fst. Loss of these genes during development causes various degrees of female-to-male sex reversal.20,21 Figure 1.2 Life cycle of the female germ cell.
The primordial follicles originate from primordial germ cells (PGCs) after their migration into the genital ridge, proliferation, sex determination, meiosis and individual follicle assembly. Individual primordial oocytes are recruited to grow and produce mature oocytes through the process of folliculogenesis. The oocyte increases in size as the number and complexity of the granulosa and theca cell layers expand. When the follicle reaches the antral stage, it forms a fluid-filled cavity, the antrum, causing differentiation of the granulosa cell layers into mural and cumulus cells. Following the luteinizing hormone (LH) surge, the oocyte resumes meiosis becoming arrested at metaphase II (MII), while cumulus cells expand and the follicle wall is prepared for ovulation. The MII oocyte is then released from the follicle cavity, ovulated, and if fertilized by available sperm, becomes a zygote and initiates embryogenesis. The embryo then travels through the fallopian tube and arrives at the uterus where implantation takes place. During embryogenesis, the presumptive germ cells are established and ultimately move to the developing bipotent gonad where the oogonia life cycle begins again. The initial and cyclic waves of follicular growth are also represented. Embryonic germ cell loss by attrition and follicular degeneration by atresia are represented by dark purple and dark green, respectively. The timing of events is approximated and represented in embryonic days (E) for mouse (green) and weeks of gestation (W) for human (blue), with E19.5 and W40 being the day of birth, respectively.
Following female-specific gene activation, the early ovary develops distinct structural features, including the formation of ovigerous cords by interaction of the germ cell clusters with surrounding pregranulosa cells.22,23 Around 13.5 dpc, mouse germ cells enter meiosis in an anterior-to-posterior gradient believed to be driven by retinoic acid (RA)24-27; in...