18- Fertility preservation

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.

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.