Gonadal function and Fertility issues in Thalassaemia 3

Gonadal function and Fertility issues in Thalassaemia 3 rd Pan-European Conference on Haemoglobinopathies & Rare Anaemias Limassol, 24 – 26 October 2012 Nicos Skordis, MD Makarios Hospital, Nicosia

The Thalassaemia map ? Original sin

stimulated peptin

Antero. Ventral Peri. Ventricular nucleus

Leptin acts on hypothalamic neurons expressing its receptor (Ob-R). Neurons containing POMC and NPY m. RNA also express Ob-R m. RNA, and both POMC and NPY m. RNA are regulated by leptin. Changes in the synthesis and/or release of these or other hypothalamic peptides could then act at Gn. RH neurons to affect Gn. RH release.

Leptin levels in patients with Thalassaemia Del Giudice Br. J Haematology 1999 Vlachopapadopoulou E. Ann Clin Ped Un Ath 2004

Sexual Complications in Thalassaemia 1. Delayed puberty : Lack of pubertal development ( girls by 13 yr, boys 14 yr ) 2. Arrested puberty : Lack of pubertal progression for longer than 12 months with reduced growth velocity 3. Primary Hypogonadism : Total absence of pubertal development by the age of 16 yrs 4. Secondary Hypogonadism : Gonadal failure after puberty has been completed

De Sanctis, 2002 Toumba M, Skordis N. PER 2007

Endocrine events and development of secondary sexual characteristics Endocrine event Sexual maturation Increased Gn. RH increased LH/FSH Increased steroid production Oestrogen secretion Testosterone secretion FSH secretion Adrenal androgen secretion Sex Steroid and GH secretion Oestrogen withdrawal Induction of LH surge ~3 -4 years Breast development Penile and scrotal development Testicular enlargement /follicular development Pubic and axillary hair Growth acceleration Menarche (anovulatory) Ovulatory menstrual cycles

Distribution of body iron at post-mortem in TM in pre-chelation Skeletal muscle Testes Kidney Heart Adrenal Salivary gland Minimum Maximum Thyroid Pancreas Liver Parathyroid 0 2 4 Fe % d. w. 6 TM = thalassaemia major; d. w. = dry weight. Adapted from Modell B, Mathews R. Birth Defects Orig Artic Ser. 1976; 12: 13. 8

Normalization of total body iron load with very intensive combined chelation reverses cardiac and endocrine complications of Thalassaemia major Farmaki K. Br J Haematol. 2010 1. 39 patients with abnormal glucose metabolism, 44% normalized. 2. 18 on thyroxin for hypothyroidism, 10 were able to discontinue, and 4 reduced their thyroxin dose. 7/14 hypogonadal males on testosterone therapy, stopped treatment - one male became father 19 females, who were hypogonadal on DFO monotherapy, six were able to conceive.

Acute effects of blood transfusion on pituitary gonadal axis and sperm parameters in adolescents and young men with Thalassaemia major: a pilot study Soliman A. Fertility Sterility , 2012 • Total sperm count increased significantly from 57. 8 to 166 million/m. L, and rapid progressive sperm motility increased from 20. 6 to 79. 7 % • Blood transfusion is associated with significant acute enhancement ? ? of sperm parameters and increased concentrations of serum T, LH, FSH, and IGF-1

very well known take home message 1

Goddess of Fertility Dionysus Chalcolithic Fertility Goddess Cyprus 3000 -2500 BCE Limestone

Fertility in Cypriot Thalassaemic women Skordis N, Ped Endocr Rev 2004 Endocrine status Normal Menses Number 72 Primary Secondary Αmenorrhea 11 17 Total Number 100 35 % of women older than 20 years Children 161

Outcome of 362 pregnancies in 316 women 53 40 3 266 Singleton 340 Twin 20 Triple 2

Update on fertility in Thalassaemia major 359 successful pregnancies - Skordis N. PER 2004 • Absence of any deleterious effect on the course of Thalassaemia • Safety of the pregnancy • Spontaneous fertility can occur in well chelated and transfused patients • Ovarian function is well preserved in women suffering primary or secondary amenorrhea as they become able to conceive following a closely monitored stimulation therapy

Fertility and Pregnancy in Thalassemia Major SUSAN M. TUCK, JAN 2006 Over the last 15 years, 22 women with TM have completed 29 pregnancies The major pre-pregnancy issues, medications, and pregnancy care reviewed Experience suggests that, with proper care and guidance, pregnancies among women with Thalassaemia major are practical and can have successful outcomes.

Current perspectives of fertility and pregnancy in Thalassaemia. Bajoria R, Chatterjee R Hemoglobin. 2009 Pregnancies following ART in 11 TM women Pregnancy is feasible and safe in women with TM with normal resting cardiac performance and optimized iron overload in specialist centers under a multi disciplinary team

Pregnancy and beta-thalassemia: an Italian multicenter experience. Origa R, Haematologica. 2010 46 women with TM (58 pregnancies) 11 women with TI (17 pregnancies) Pregnancy was safe in most women with TM or TI However, women with TI who had never previously been transfused or who had received only minimal transfusion therapy were at risk of severe alloimmune anemia if blood transfusions were required during pregnancy

Cardiac monitoring during pregnancy in 44 pregnancies in 35 women with TM from 1997 to 2009 Echocardiograms were performed before pregnancy, at first, second, third trimester and after labour Kypris L et al. 2011 No significant cardiac complications were encountered Pregnancy can be safe for cardiac function in women with TM provided they have started early on proper treatment and have a normal resting cardiac performance

1. Pregnancy is safe 2. No severe obstetric complications 3. No deleterious effects of pregnancy on the course of Thalassaemia 4. Women with Primary or Secondary Amenorrhea preserve their Ovarian function and therefore Induction of Ovulation can be easily achieved 5. ? The incidence of preterm labour and growth restriction take home message 2

Issues • Medical history • Emotional dilemmas • Legal issues • Ethical issues

Evaluation of Eligibility 1. Cardiac function: ECG, Echo 2. Liver function tests, Ultrasound 3. Vessels: Clotting factors, Doppler 4. Endocrine: Hypothalamic – Pituitary – Gonadal axis Thyroid, Calcium - OGTT 5. Viral infections: HBV, HCV, HIV 6. Iron status 7. Genetic counseling – Partner’s carrier status and fertility

Management during pregnancy 1. Maintenance of Hb level at 10 gr/dl 2. Frequent low volume blood transfusions 3. Serial Ultrasound to monitor fetal growth 4. Regular cardiac monitoring 5. Assessment of endocrine function, OGTT Multidisciplinary approach by all specialist involved in the medical care of Thalassaemic women

stated simply 1. The desire of Thalassaemic women to achieve motherhood should be recognized, respected and approached with special caution and sensitivity by all physicians involved in their medical care 2. Ambitions of this sort pose numerous medico legal and ethical issues that need to be addressed prudently if the patients' quality of life is to be optimized 3. Should balance improvement in the quality of life of the woman and the safety of her life

Induction of ovulation • Primary Amenorrhea • Secondary Amenorrhea • Oligomenorrhea • Normal Menstrual function who fail to conceive • Planned pregnancy where both partners are Thalassaemics

two significant risks • Powerful drugs - growth of two or more follicles, with risk of twin or triplet pregnancy • Ovarian Hyperstimulation Syndrome – enlarged ovaries - fluid retention with bloating, breathlessness and nausea. Although uncommon , serious cases require hospitalization and would be particularly complicated to manage in a patient already unwell with Thalassaemia.

Ovarian Reserve Testing (the capacity of the ovary to provide eggs that are capable of fertilization resulting in a healthy and successful pregnancy) is based on indirect measures to evaluate the size of the residual ovarian follicle pool

Antral follicle count (AFC ) reflects the pool of primordial follicles , those follicles that decline with age

Reproductive aging is directly related to the decline in the pool of these follicles

AMH : Earliest marker of change with age and has very little intercycle and intracycle variability AMH prevents recruitment of non-dominant follicles

very well known take home message 3

Paternity in Cypriot Thalassaemics Skordis N, Ped Endocr Rev 2004 Endocrine Status Normal Hypogonadism Number 54 4 Total number 58 20% of all men > 20 years Children 96

Abnormal sperm concentrations , quality , motility and morphology in males with TM De. Sanctis in Fert Ster; 50: 969, 1988 Induction of spermatogenesis with h. CG and h. MG

Endocrine complications Cryopreservation - preserved by freezing - of ejaculated semen, which can be used for insemination or ICSI whenever pregnancy is desired

one sperm is sufficient

Oxidative stress and Infertility • Induced by Reactive Oxygen Species – ROS • Normal levels of ROS are required for sperm physiology but excessive levels can negatively affect sperm quality • Contributing factor in 30 – 80 % of all cases • The generation of ROS can be exacerbated by environmental, infectious and life style factors • Oxidative stress can be measured

F Hypothesis suggesting one of the mechanisms by which DNA damage in human spermatozoa can increase the mutational load subsequently carried by the embryo Aitken R J et al. Reproduction 2011; 141: 139 -150 © 2011 Society for Reproduction and Fertility

Spermatozoal DNA damage in patients with β- thalassaemia syndromes. - 28 patients with TM and TI De Sanctis V Pediatr Endocrinol Rev. 2008 1. Significantly more sperm DNA damage (mean TUNEL=18. 5%, SCSA=0. 28) than controls (mean TUNEL=11. 4%, mean SCSA=0. 18) 2. Negative correlation between itchromatin structure damage and sperm concentration (r 2=0. 3, p<0. 006). 3. There was a significant negative correlation between serum ferritin levels and abnormal sperm morphology - Possible detrimental effect on spermatogenesis by the iron chelator DFX

Sperm DNA damage in potentially fertile homozygous βthalassaemia patients with iron overload Doreen Perera Results 1. TM patients (median ferritin: 2251 μg/l) had more sperm DNA damage 2. The sperm DNA damage by SCSA and TUNEL were positively correlated 3. The age of onset of chelation and sperm DNA damage were positively associated with both SCSA and TUNEL 4. No other biochemical or clinical data were associated with sperm DNA damage.

Sperm DNA damage in potentially fertile homozygous βthalassaemia patients with iron overload Doreen Perera Conclusions 1. The increase in sperm DNA damage and the negative correlation between sperm motility and DNA damage suggest that iron overload predisposes sperm to oxidative injury. 2. This finding has important implications in ART – ICSI where there is increased risk of transmitting defective DNA to the offspring

Therapeutic management of Oxidative Stress take home message 4

Sperm concentartion 106/m. L Semen quality North America Europe

Mother, don’t kill my sperm ! take home message 5

Vitamin D

Hormone (Vitamin ) D and Reproduction • Steroidogenesis in healthy women • Higher clinical pregnancy rates in IVF • Endometriosis • Polycystic Ovary Syndrome • Semen Quality • Androgen status - Testosterone levels

Spermatozoal DNA damage in patients with β- thalassaemia syndromes. - 28 patients with TM and TI De Sanctis V Pediatr Endocrinol Rev. 2008 1. Thalassaemic patients with low sperm concentrations were more likely to have a higher degree of defective chromatin packaging. 2. Possible detrimental effect on spermatogenesis by the iron chelator desferrioxamine 3. Thalassaemic patients especially those being considered for assisted conception procedures should be counselled accordingly

take home message 6

Use of laptop computers connected to internet through Wi-Fi decreases human sperm motility and increases sperm DNA fragmentation Conrado Avenda Fertility and Sterility, 2012

take home message 7

take home message 8

thank you

this is not a take home message epilogue

to be continued