Abstract
Fertility preservation, especially in women of reproductive age undergoing gonadotoxic treatment, has become an important part of our practice. This is reflected in the increasing number of publications on the subject. A recent PubMed search yields 518 articles on fertility preservation published in the time period of 1980–2000 and 4,288 others between 2000 and 2017. Today, failure to discuss fertility preservation with young women scheduled to undergo radiotherapy or chemotherapy could be considered as malpractice.
Fertility preservation, especially in women of reproductive age undergoing gonadotoxic treatment, has become an important part of our practice. This is reflected in the increasing number of publications on the subject. A recent PubMed search yields 518 articles on fertility preservation published in the time period of 1980–2000 and 4,288 others between 2000 and 2017. Today, failure to discuss fertility preservation with young women scheduled to undergo radiotherapy or chemotherapy could be considered as malpractice.
There are many options to preserve fertility [1–6]. They include medical treatment with gonadotropin releasing hormone agonist (GnRHa) and cryopreservation of embryos, oocytes, or ovarian tissue. In addition, those who are undergoing pelvic irradiation for low abdominal malignancy could be offered ovarian transposition relocating them outside the radiation field. The purpose is to preserve fertility as well as the ovarian function including its metabolic, skeletal, and cardiovascular effects.
Although embryo cryopreservation is generally associated with good fertility rates, it is not always possible. The patient might be single or too young to have a partner or to facilitate the process of sperm donor. The ovary has numerous important roles in the well-being of women including endocrine, metabolic, skeletal, and cardiovascular functions. In our institution, we offer all types of fertility preservation. However, the choice depends on many factors including patient’s age, types of malignancy, marital status, planned treatment, and preferences. It is crucial to conduct a thorough consultation with the patient and her family.
Radiation
Pelvic irradiation with or without chemotherapy is commonly used for gynecologic malignancies as well as for genitourinary and low intestinal cancers. The treatment results in excellent results among selected population and disease states. An important side effect in reproductive age women is decreased or loss of ovarian function. The amount of radiation to eliminate a half of the ovarian follicles is estimated to be 2–4 Gy. Radiation of 20 Gy would lead to a complete ovarian failure [7–12].
Studying abdominal pelvic irradiation for childhood malignancies, Chiarelli et al. reported that the risks are proportional to the administrated dose. The relative risk for premature ovarian failure was 1.02 with <20 Gy, 1.37 with 20–35 Gy, and 3.27 with over 35 Gy [12].
Ovarian Transposition
The ovaries can be transposed to a variety of locations, from the base of the round ligament, abdominal wall peritoneum, paracolic gutters, and up to the level of lower kidney pole. The traditional ovarian transposition was medial transposition where the ovaries were sutured to the posterior wall of the uterus. Although radiotherapy is performed by protecting the lower abdomen with a lead shield [7, 13], most of the medially transposed ovaries are still affected by radiation.
Today, the preferred method and location for ovarian transposition is the lateral transposition, where the ovaries are relocated above the pelvic brim and fixated as lateral as possible [14].
Technique
Ovarian transposition can be done at the completion of an oncologic procedure or as a semi-emergency procedure before the initiation of radiation treatments. We perform interval ovarian transposition by laparoscopy. To facilitate the procedure, the primary trocar is inserted 2 cm above the umbilicus and two secondary trocars at the same level. After a thorough abdominal examination, the course of the ureter is followed. The ovarian ligament is coagulated and transected. Dissection is continued on the mesovarium until the level of the infundibulopelvic ligament. The vascular pedicle inside the ligament is left intact (Figure 16.1).
Figure 16.1 Laparoscopic ovarian suspension. The ovarian ligament is coagulated and divided (1). Dissection on the mesovarium until the infundibulopelvic ligament (2). If mobilization is inadequate, perform a relaxing incision on the peritoneum inferior to the ovary (3). In this illustration, the integrity of Fallopian tube is preserved
The ovary is then mobilized superior and laterally to a new location above the pelvic brim. If mobilization is insufficient, a relaxing incision on the peritoneum inferior to the ovary is performed. The proximal Fallopian tube can also be transected in order to facilitate more mobility (Figure 16.2). Due to the possibility of spontaneous conception, we do not always divide the Fallopian tube. The ovaries are sutured to the peritoneum with two sutures of 3–0 polydioxanone (Figure 16.3). A metal hemostatic clip is applied on the lower border of the ovary to facilitate future location of the ovaries by imaging.
Figure 16.2 Both the Fallopian tubes and ovaries have been separated from the uterus
Figure 16.3 The ovary has been transposed
In our institution, we also excise one-third to a half of the ovarian tissue for ovarian cryopreservation (Figure 16.4). Oocytes could be retrieved at the time of laparoscopy or from the excised ovarian tissue in the embryology laboratory for oocyte cryopreservation. Accordingly, we perform oocyte and ovarian cryopreservation at the same setting as ovarian transposition. The frozen-thawed ovarian tissue could be transplanted at future date if needed.
Figure 16.4 One-third of the ovary has been excised for cryopreservation
Results
Many authors have published the results of their experience with this method and most report excellent results with preservation of ovarian function, continuation of menses, and pregnancy achievement [14–29; Table 16.1].
Table 16.1 Results of laparoscopic ovarian transposition
| Author/s | Study type | No. of patients | Population | Intervention | Resumption of menstrual cycle | Pregnancy rate of those who attempted to conceive |
|---|---|---|---|---|---|---|
| Gubbala et al. (2014) | Meta-analysis | 892 | Gynecologic cancers | Radiotherapy, brachytherapy and external Radiation |
| − |
| Huang et al. (2007) | Retrospective | 14 | Gynecologic cancers | Pelvic irradiation | 13/14 (85%) | − |
| Kuohung et al. (2008) | Retrospective | 15 | Pediatric brain tumor | Spinal irradiation | 13/15 [87%] | − |
| Williams et al. (1999) | Retrospective | 10 | Hodgkin lymphoma | Total Node irradiation | 5/10 [50%] | 4/10 [40%] |
| Pahisa et al. (2007) | Retrospective | 12 | Cervical Cancer | Pelvic radiotherapy | 8/12 [66%] | |
| Terenziani et al. (2009) | Retrospective | 11 | Hodgkin Lymphoma | Inverted Y irradiation, radio + chemotherapy, non- pelvic radiotherapy + chemotherapy | − | 14 pregnancies; 12 live births 3 miscarriages |
| Hwang et al. (2012) | Retrospective |
| Cervical cancer | Whole pelvic external beam radiotherapy and high-dose brachytherapy | 10/31 [32%]* | − |
| Morice et al. (1998) | Retrospective |
| Clear cell vaginal adenoca and/or the cervix, ovarian dysgerminoma, para-uterine soft tissue sarcoma | External beam irradiation | − | 12/37 [32%]** |
| Bisharah & Tulandi (2003) | Review | 46 | Various | Various | 39/44 (88.6%) | − |
| Covens et al. (1996) | Prospective | 3 | Cervical Cancer | Intracavitary Radiation | 2/3 (66%) | − |
*Stratification according to age and not by surgical approach.
**Stratification not according to surgical approach.
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