title: Non-growing follicle density is increased following adriamycin, bleomycin, vinblastine and dacarbazine (ABVD) chemotherapy in the adult human ovary.
abstract: Do the chemotherapeutic regimens of ABVD (adriamycin, bleomycin, vinblastine and dacarbazine) or OEPA-COPDAC (combined vincristine, etoposide, prednisone, doxorubicin (OEPA) and cyclophosphamide, vincristine, prednisone, dacarbazine (COPDAC)) used to treat Hodgkin lymphoma (HL), affect the density, morphology and in vitro developmental potential of human ovarian follicles?
  
  
  
  Ovarian tissue from women treated with ABVD contained a higher density of non-growing follicles (NGFs) per cubic millimetre and increased numbers of multiovular follicles but showed reduced in vitro growth compared with patients with lymphoma who had not received chemotherapy, patients treated with OEPA-COPDAC, age-matched healthy women and age-related model-predicted values.
  
  
  
  Chemotherapy regimens can cause a loss of follicles within the ovary, which depends on the drugs given. Early stage HL is commonly treated by ABVD, a non-alkylating regimen that apparently has ovarian sparing qualities; thus it is important to investigate the histological appearance and distribution of follicles within ABVD-treated ovarian tissue.
  
  
  
  Thirteen ovarian biopsies were obtained from HL patients (six adolescents and seven adults) and one biopsy from a non-HL patient. Two HL patients and the non-HL patient had received no treatment prior to biopsy collection. The remaining 11 HL patients received one of two regimens: ABVD or OEPA-COPDAC. Tissue was analysed histologically and compared to biopsies from healthy women, and in a subgroup of patients, tissue was cultured for 6 days in vitro.
  
  
  
  Ovarian biopsies were obtained from patients undergoing ovarian cryopreservation for fertility preservation and from healthy women at the time of Caesarian section ('obstetric tissue'). Follicle number and maturity were evaluated in sections of ovarian cortical tissue, and compared to an age-related model of mean follicle density and to age-matched contemporaneous biopsies. The developmental potential of follicles was investigated after 6 days of tissue culture.
  
  
  
  A total of 6877 follicles were analysed. ABVD-treated tissue contained a higher density of NGFs per cubic millimetre (230 ± 17) (mean ± SEM) than untreated (110 ± 54), OEPA-COPDAC-treated (50 ± 27) and obstetric (20 ± 4) tissue (P < 0.01), with follicle density 9-21 SD higher than predicted by an age-related model. Biovular and binucleated NGFs occurred frequently in ABVD-treated and in adolescent-untreated tissue but were not observed in OEPA-COPDAC-treated or obstetric tissue, although OEPA-COPDAC-treated tissue contained a high proportion of morphologically abnormal oocytes (52% versus 23% in untreated, 22% in ABVD-treated and 25% in obstetric tissue; P < 0.001). Activation of follicle growth in vitro occurred in all groups, but in ABVD-treated samples there was very limited development to the secondary stage, whereas in untreated samples from lymphoma patients growth was similar to that observed in obstetric tissue (untreated; P < 0.01 versus ABVD-treated, NS versus obstetric).
  
  
  
  N/A LIMITATIONS, REASONS FOR CAUTION: Although a large number of follicles were analysed, these data were derived from a small number of biopsies. The mechanisms underpinning these observations have yet to be determined and it is unclear how they relate to future fertility.
  
  
  
  This study confirms that the number of NGFs is not depleted following ABVD treatment, consistent with clinical data that female fertility is preserved. Our findings demonstrate that immature follicle density can increase as well as decrease following at least one chemotherapy treatment. This is the first report of morphological and follicle developmental similarities between ABVD-treated tissue and the immature human ovary. Further experiments will investigate the basis for the marked increase in follicle density in ABVD-treated tissue.
  
  
  
  Funded by UK Medical Research Council Grants G0901839 and MR/L00299X/1. The authors have no competing interests.
authors.affiliation: Centre for Integrative Physiology, University of Edinburgh, Edinburgh EH8 9XD, UK.|Institute of Cell Biology, University of Edinburgh, Edinburgh EH9 3BF, UK.
authors.forename: M
authors.initials: M
authors.lastname: McLaughlin
authors.affiliation: School of Computer Science, University of St. Andrews, St. Andrews KY16 9SX, UK.
authors.forename: T W
authors.initials: TW
authors.lastname: Kelsey
authors.affiliation: Department of Haematology/Oncology, Royal Hospital for Sick Children, Edinburgh EH9 1LF, UK.
authors.forename: W H B
authors.initials: WH
authors.lastname: Wallace
authors.affiliation: MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh EH16 4TJ, UK.
authors.forename: R A
authors.initials: RA
authors.lastname: Anderson
authors.affiliation: Centre for Integrative Physiology, University of Edinburgh, Edinburgh EH8 9XD, UK Evelyn.Telfer@ed.ac.uk.|Institute of Cell Biology, University of Edinburgh, Edinburgh EH9 3BF, UK.
authors.forename: E E
authors.initials: EE
authors.lastname: Telfer
mesh_terms: D000293:Adolescent; D000328:Adult; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage* / Q000627:therapeutic use; D001761:Bleomycin / Q000008:administration & dosage / Q000627:therapeutic use; D002648:Child; D003606:Dacarbazine / Q000008:administration & dosage / Q000627:therapeutic use; D004317:Doxorubicin / Q000008:administration & dosage / Q000627:therapeutic use; D005260:Female; D006689:Hodgkin Disease / Q000188:drug therapy*; D006801:Humans; D006080:Ovarian Follicle / Q000187:drug effects* / Q000254:growth & development; D010053:Ovary / Q000187:drug effects* / Q000254:growth & development; D014747:Vinblastine / Q000008:administration & dosage / Q000627:therapeutic use; D055815:Young Adult
chemical_list: D001761:Bleomycin; D014747:Vinblastine; D003606:Dacarbazine; D004317:Doxorubicin
keywords: ABVD; chemotherapy; follicle; lymphoma; modelling; oocyte; ovary; primordial; regeneration