Sterilitätsbehandlung, ovarielle Stimulation und Malignome

L. Wildt

Klinik für Gynäkologische Endokrinologie und Reproduktionsmedizin

Department für FrauenheilkundeMedizinische Universität Innsbruck

Ovarielle Stimulation und Malignome

Prädisponierende Faktoren und Malignome

Case reports

Studienlage und Probleme

Ovarielle Stimulation und Malignome – Probleme I

• Änderungen der Stimulationsprotokolle• Änderungen der Präparate (Clomid,

GnRH-Agonisten und Antagonisten ,rekombinante /urinäre Präparate

• Kontrollgruppe (ist Infertilität per se ein Malignomrisiko?)

Ovarielle Stimulation und Malignome – Probleme II

• Art der Sterilitätsbehandlung (ivF-IUI-VZO)• Erfolg der Sterilitätsbehandlung• Ursache der Sterilität?• Qualität der Abklärung ?• Male Factor ?

Ovarielle Stimulation und Malignome

Prädisponierende Faktoren und Malignome

Case reports

Studienlage und Probleme

• Mammakarzinom

• Ovarialkarzinom

• Bordeline Ovarialtumore

• Endometriumkarzinom

• Sonstige: Zervixkarzinom, Melanom, Kolonkarzinom; SD - Karzinom

SchlussfolgerungDie ovarielle Stimulation mit Clomid und /oder Gonadotropinen erhöht das Mamma-Ca- Rsiko offenbar nicht

Is endometriosis a risk factor of Is endometriosis a risk factor of cancer, and what is the effect of cancer, and what is the effect of

IVF on that risk?IVF on that risk?

MEGA

Endometriose

OR 1,73 95% CI, 1,10 – 2,71 Ness et al, Am J Epidemiol 2002

The possibility that ovulation induction increases the risk of ovarian cancer remains unproven. However, recent studies suggest that both infertility and endometriosis may be independent risk factors.

Burmeister L, Healy DL Ann Med 1998

Environmental factors and medical conditions that increased risk included talc use, endometriosis, ovarian cysts, and hyperthyroidism.

Ness et al, Epidemiol 2000

The synchronous occurrence of endometriosis with endometrioid, clear cell, and mixed subtypes of ovarian cancers suggests transformation of endometriosis constituents into tumor cells.

Ness et al, AM J Obstet Gynecol 2003

Ovarielle Stimulation und Malignome

Prädisponierende Faktoren und Malignome

Case reports

Studienlage und Probleme

Conclusion 1:Conclusion 1:

• No increased risk for breast cancer in comparison No increased risk for breast cancer in comparison with the general population and the control groupwith the general population and the control group

• Increased risk of endometrial cancer in both the Increased risk of endometrial cancer in both the IVF group and control group.IVF group and control group.

• Since the increase in risk of endometrial cancer was Since the increase in risk of endometrial cancer was observed in both IVF and Control groups, an effect of observed in both IVF and Control groups, an effect of subfertility itself is likely subfertility itself is likely

Conclusions 2: • There is NOT a significant and increased risk of There is NOT a significant and increased risk of ovarian cancer after IVFovarian cancer after IVF

• There is an increased risk of BTO in the IVF group There is an increased risk of BTO in the IVF group within one, and after 5 yrs within one, and after 5 yrs (although the number of cases in the (although the number of cases in the control group is low)control group is low)

• The risk appears to correlated with the IVF procedureThe risk appears to correlated with the IVF procedure

• Endometriosis is a risk factor of ovarian cancer and Endometriosis is a risk factor of ovarian cancer and is is NOT correlated with IVF NOT correlated with IVF (RR 4.9 ( CI 1.0-14.0 )(RR 4.9 ( CI 1.0-14.0 )

Ovarielle Stimulation und Malignome

Prädisponierende Faktoren und Malignome

Case reports

Case report I 37a Patientin, Kiwu seit 18a, prim Sterilitas, BMI 23 App. perforata als Kind 1992 Lap auswärts: Adhäsiolyse, Ovarialcyste 1998 op. HSK: subendometrialer Cyste

(Histo: Endometríose ?) HSG: Hydrosalpinx li, re ? 8x IVF: (5x long, 1x Anta; 7x HMG,

1x FSH) zuletzt 10/03 09/06: Vorstellung wegen seit 6

Monaten vag. Fluor (z.T. fleischwasserfarben)

CT kl. Becken 06/06: Verdacht auf Hydrosalpinx li DD Pseudocyste

CEA, CA 125: 0,7/15,5

Case report I 11/06 Lap.: Dg.:

Adhäsiones permagna, Hydrosalpinx re, Hämatosalpinx li Op.:

Adhäsiolyse,Tubektomie bil Histo:Tubenkarzinom li G III

12/06 Re Lap: He + Ovarektomie bil pelv. Lymphonodektomie Hemicolektomie Histo:

pT1a, GIII, N0 weitere Ko: oB

Case report II 35a Patientin, Kiwu seit 3a, sek. Sterilitas, BMI

25 05/05 op LASK:Adhäsiolyse, Neostomie re 01/06 Sono IVF: cyst/solider Tu li 02/06 CT/NMR: Befund idem CA 125: 17,6 05/06 op LASK:2x Cystenexstirpation li Ovar

(SS), multiple PE`s Histo (SS): Teratom, Cystadenofribrom

Histo (revidiert): borderline Tu, Figo IIa

Case report II 07/06: long protocol (Suprecur/rFSH) ad

ICSI 9EZ, 5BZ → Kryo! 09/06 Lap: Adenexektomie li (SS)

Tubektomie dext, Ovarialteilresktion re, Adhäsiolyse, Omentumresektion, AE, Implantresektion

Histo: Figo II a, Omentum, App.+Zyto: neg 01/07: CT/NMR: oB, CA 125: oB 01/04//07: 2x TET (2BZ) → neg 09/07: Stimulation ad ICSI, CA 125: 7,8

(AMH: 5,02 → 0,84) Geplant: falls neg. → Re LASK