18- Fertility preservation

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Questions and Answers

What condition should be excluded before considering the continuation of a pregnancy in cases of complete hydatidiform mole with a coexistent fetus?

Preeclampsia

Maternal obesity

Gestational diabetes

Fetal anomalies and abnormal karyotype (correct)

What is the primary role of hysterectomy in women with low-risk nonmetastatic GTN?

To provide palliative care

As a part of primary treatment for those desiring future fertility

As a part of primary treatment for those with no desire for future fertility (correct)

To prevent pregnancy

What should be documented in the medical record regarding fertility preservation discussions?

Patient's future family planning goals

The specific fertility methods suggested

Any doubts the patient expresses

All fertility preservation discussions (correct)

Which fertility preservation method is not adequately supported by current evidence?

Ovarian suppression using gonadotropin-releasing hormone analogs Signup and view all the answers

What is one potential impact of cancer treatment on the ovaries?

Follicle depletion Signup and view all the answers

How should fertility preservation options be presented to adult females?

Present both embryo and oocyte cryopreservation as established methods Signup and view all the answers

What is recommended for children regarding fertility preservation when applicable?

Utilize established methods with parent or guardian consent Signup and view all the answers

According to current recommendations, when should discussions about fertility preservation be addressed with patients?

As early as possible, before treatment starts Signup and view all the answers

Why should patients experiencing distress about potential infertility be referred to psychosocial providers?

To address emotional and psychological support Signup and view all the answers

What has growing evidence supported regarding female gamete vitrification?

It is now considered a standard practice according to multiple organizations Signup and view all the answers

What characteristic defines FIGO stage Ia1 cervical cancer?

Stromal invasion up to 3 mm in depth Signup and view all the answers

Which of these is a fertility-preserving option for patients with early-staged cervical cancer?

Conization with clear surgical margins Signup and view all the answers

Which patients are considered candidates for radical trachelectomy?

Patients with FIGO stage Ib lesions smaller than 2 cm Signup and view all the answers

What percentage of ovarian cancer patients are typically younger than 40 years of age?

3% to 17% Signup and view all the answers

In the context of germ cell tumors, what is a common therapeutic consideration for younger patients?

Conservative therapy with fertility preservation Signup and view all the answers

What treatment is often sufficient for stage Ia dysgerminoma?

Unilateral salpingooophorectomy Signup and view all the answers

Which of the following is a traditional management option for ovarian carcinoma?

Operative treatment Signup and view all the answers

What guideline indicates candidates for conservative management in cervical cancer?

Patient's importance placed on childbearing Signup and view all the answers

What is a key factor that may allow conservative therapy for ovarian cancer?

Desire to preserve some ovarian tissue Signup and view all the answers

Which of the following describes the typical age demographic for patients with dysgerminomas?

85% are younger than 30 years Signup and view all the answers

What surgical procedure may be associated with minimal increased risk of recurrence in young women with stage IA ovarian cancer desiring further childbearing?

Unilateral salpingo-oophorectomy Signup and view all the answers

In cases of clear cell or carcinosarcoma, what is generally advised concerning conservative surgery?

It is not recommended. Signup and view all the answers

What is the preferred surgical procedure for endometrioid adenocarcinomas associated with pregnancy?

Total hysterectomy with bilateral salpingo-oophorectomy Signup and view all the answers

For invasive vulvar cancer diagnosed during the first trimester, what is the typical management?

Treatment as indicated in nonpregnant patients after the 18th week Signup and view all the answers

What is the correct course of action for women treated for vulvar cancer during pregnancy with respect to delivery?

Vaginal delivery is allowed if wounds are well healed. Signup and view all the answers

What is typically the standard surgical procedure for the treatment of fallopian tube cancer?

Total abdominal hysterectomy with bilateral salpingo-oophorectomy Signup and view all the answers

What is the recommended management strategy for primary invasive vaginal tumors diagnosed early in pregnancy?

Prioritize immediate surgery Signup and view all the answers

Which specific type of tumor is typically not suitable for conservative surgical management when outside the ovaries?

Clear cell tumor Signup and view all the answers

What approach has improved management of germ cell malignancies in women desiring fertility preservation?

Adjuvant chemotherapy Signup and view all the answers

What must be rigorously adhered to when determining candidacy for fertility preservation in ovarian cancer?

Carefully devised and rigorously adhered criteria Signup and view all the answers

Which factor does NOT influence the extent of ovarian damage after chemotherapy?

Duration of cancer diagnosis Signup and view all the answers

What is NOT a fertility preservation method listed in the content?

In-vivo fertilization Signup and view all the answers

Which approach is likely to be influenced by the presence of a male partner in fertility preservation?

Oocyte and embryo cryopreservation Signup and view all the answers

What outcome is associated with a delay in chemotherapy initiation for breast cancer patients?

Decreased overall survival by 15% for every 4-week delay Signup and view all the answers

What is a hypothetical fertility preservation approach mentioned in the content?

Ovarian suppression with gonadotropin-releasing hormone analogues Signup and view all the answers

Which of the following is NOT part of emerging technologies for fertility preservation?

Cytogenetic analysis Signup and view all the answers

Which factor is least likely to affect the fertility preservation approach chosen?

Family background Signup and view all the answers

Which option is unlikely to be used to avoid a delay in chemotherapy?

Intrauterine insemination Signup and view all the answers

Which element does NOT play a role in deciding fertility preservation strategies?

Patient's nutritional status Signup and view all the answers

What is a recognized impact of a 4-week delay in chemotherapy initiation?

15% decrease in overall survival Signup and view all the answers

Study Notes

Fertility-Sparing Therapies in Gynecologic Cancers

Advances in cancer treatment have extended life expectancy.
Fertility-preserving approaches are becoming more important for young patients.

Learning Objectives

Patient selection
Fertility-preserving approaches

Invasive Cervical Cancer

Conservative management of early-stage cervical cancer in young women should be considered if childbearing is important.
Stage Ia1 cancers have stromal invasion up to 3 mm in depth and no greater than 7 mm.
Stage Ia2 cancers have stromal invasion between 3 and 5 mm in depth and no greater than 7 mm.
Patients with FIGO stage Ia1 and SGO criteria for microinvasion can be treated conservatively with simple hysterectomy or conization only (if fertility desired), provided surgical margins are free of cancer.
In addition, patients with FIGO stage Ib lesions smaller than 2 cm with limited endocervical involvement and no lymph node metastases may be candidates for radical trachelectomy.

Adnexal Masses

Operative treatment is the traditional approach to ovarian carcinoma.
Some patients with ovarian cancer (3%–17% under 40) may consider fertility preservation options.
Conservative therapy (preserving some ovarian tissue) appears safe, though no prospective trials have compared it with bilateral salpingo-oophorectomy.

Optimal Requirements for Conservative Management in Stage Ia Epithelial Ovarian Cancer

Well-differentiated tumor
Young woman of low parity
Otherwise normal pelvis
Encapsulated and free of adhesions
No invasion of capsule, lymphatics, or mesovarium
Negative peritoneal washings
Adequate evaluation of opposite ovary and omental biopsy result
Close follow-up probable
Excision of residual ovary after completion of childbearing

Germ Cell, Stromal, and Other Ovarian Tumors

85% of dysgerminoma patients are under 30, so fertility preservation is important.
In some cases (stage la dysgerminoma and stage la grade I immature teratoma), unilateral salpingo-oophorectomy is curative.

Epithelial Ovarian Cancer

Unilateral salpingo-oophorectomy for stage IA disease and desire for future childbearing has a minimal increased risk of recurrence.
Conservative surgery is generally not recommended for clear cell or carcinosarcoma grade III tumors and when disease is present outside the ovaries.

Cancer in Pregnancy

Vulvar Cancer

Invasive vulvar malignant disease diagnosed during the first, second, and early third trimesters is usually treated like non-pregnant patients after the 18th week.
Women may attempt vaginal delivery if vulvar wounds are healed and no further therapy is needed.

Primary Invasive Vaginal Tumors

If the diagnosis is made during early pregnancy (first or early second trimester), the pregnancy may be disregarded.
Decisions about intervention in later pregnancy depend on patient preference and oncologist advice.

Endometrial Cancer

Endometrial carcinoma during pregnancy is rare.
Recommended therapy for endometrioid adenocarcinomas is total hysterectomy with bilateral salpingo-oophorectomy and adjuvant radiotherapy when indicated.

Fallopian Tube Cancer

Diagnosis is typically made via laparotomy.
Treatment often involves total abdominal hysterectomy with bilateral salpingo-oophorectomy and postoperative radiotherapy or chemotherapy.
Criteria for fertility preservation candidacy must be carefully determined.

Complete Hydatidiform Mole With Coexistent Fetus

If fetal abnormalities and abnormal karyotyping are excluded, pregnancy can be continued if there's no pre-eclampsia and the patient desires.
Primary hysterectomy is part of treatment for women with low-risk non-metastatic GTN who do not want future fertility.

Fertility After Treatment for Gestational Trophoblastic Neoplasia

89% of patients desired fertility.
Infertility rate: 57%
Pregnancy rate: 43%
79% normal infants, 12% spontaneous abortion, 5% therapeutic abortion, and 4% mole.

Emerging Technologies

Oocyte and embryo cryopreservation
Ovarian transposition (oophoropexy)
Ovarian suppression with gonadotropin-releasing hormone analogs (hypothetical)
Ovarian cortex cryopreservation (experimental)

The Effect of Cancer Treatment on the Ovary

Chemotherapy and radiotherapy can cause follicle depletion, stromal fibrosis, and vascular injury.
Survivors who maintain ovarian function might experience a shorter fertility window.
Damage extent depends on chemotherapy and radiotherapy type, dose, fractionation, irradiation field, and ovarian reserve before treatment.

Fertility Preservation Approaches

Approaches depend on patient age, cancer type, type of treatment, presence of a male partner, patient preference for donor sperm, time available, and likelihood of ovarian metastasis.

Fertility Preservation Methods

Oocyte and embryo cryopreservation
Ovarian transposition (oophoropexy)
Ovarian suppression with gonadotropin-releasing hormone analogs (hypothetical)
Ovarian cortex cryopreservation (experimental)

Delay in Chemotherapy

No published randomized controlled trials have investigated the association between chemotherapy delay and breast cancer survival.
Seven studies suggest that overall survival decreases by 15% for every 4-week delay in chemotherapy initiation.

Avoiding Chemotherapy Delay

Oocyte in-vitro maturation
Ovarian cortex transplantation
Cryopreservation of ovarian tissue
Primordial and preantral follicle culture

Existing and Emerging Technologies

Diagram showing methods for oocyte and embryo cryopreservation
Shows methods for ovarian follicle isolation and transplantation.

Key Recommendations

Discuss fertility preservation with all reproductive-age patients and their parents/guardians.
Refer patients interested/ambivalent in fertility preservation to reproductive specialists.
Document fertility preservation discussions.
Answer questions about impact on cancer success.
Refer patients experiencing distress to psychosocial providers.
Encourage patients to participate in registries and clinical studies.

Studying That Suits You

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Description

This quiz explores fertility-preserving approaches in the treatment of gynecologic cancers, particularly for young women. It covers the criteria and management strategies for various stages of invasive cervical cancer, emphasizing the importance of patient selection and treatment options that maintain fertility. Understanding these therapies can provide essential knowledge for those involved in oncology and women's health.