Fertility Sparing Research Articles

Fertility sparing treatment in patients with endometrial cancer (FERT-ENC): a multicentric retrospective study from the Spanish Investigational Network Gynecologic Oncology Group (SPAIN-GOG).

The primary objective was to evaluate the response rate of conservative treatment for endometrial cancer, and the secondary objective was to assess oncological, fertility and obstetric outcomes in patients who underwent fertility preservation treatment. This multicentre, observational, retrospective study evaluated endometrial cancer patients who underwent fertility-sparing treatment in Spanish centres between January 2010 and January 2020. Seventy-three patients with stage IA endometrioid adenocarcinoma of the uterus were included in the study. The levonorgestrel intrauterine device (LNG-IUD) was the most common fertility-sparing treatment (53.4%), followed by megestrol acetate (20.5%) and medroxyprogesterone acetate (16.4%). During the 24-month follow-up period, the rate of complete response to fertility-sparing management was 74% (n = 54), and 8.2% (n = 6) of patients presented a partial response. Additionally, 13 (17.8%) patients presented with persistent disease and six (8.2%) relapsed after response. The LNG-IUD was associated with a higher complete response rate than the other methods (87.2 vs. 58.8%; p = 0.01). Surgical treatment (at least hysterectomy) was performed in 44 (60.3%) patients as the end of fertility-sparing treatment. Four (5.5%) patients presented relapse after surgery, associated with final FIGO stage III (p = 0.036), myometrial invasion > 50% (p = 0.018) and final tumour grade 2-3 (p = 0.018). The mean follow-up period was 57.8 (range 6-159) months. The 5-year relapse-free survival and overall survival rates were 92.6% [95% CI (81.3, 97.2)] and 93.5% [95% CI (80.7, 97.9)], respectively. During follow-up, three patients (4.1%) died of the disease after completion of surgical treatment. Up to 50.7% of patients included in the study attempted to get pregnant. Of these, the rate of pregnancy was 81.1% (n = 30/37), and reproductive techniques were used for this purpose in 78.4% of cases. Fertility-sparing management presented a high response rate in patients with endometrial cancer. LNG-IUD was associated with a better response rate compared to the other treatment options. Moreover, in patients using this management method, pregnancy could be achieved using reproductive techniques.

Conservative and Fertility Sparing Surgery for Treating Endometriosis

Conservative and Fertility Sparing Surgery for Treating Endometriosis

Short and long-term outcomes of endometrial cancer and atypical endometrial hyperplasia management in young women

Objecitve: The incidence of endometrial cancer in young women is increasing. Since survival after management is in most cases excellent, the focus on long-term patient reported outcomes (PROs) is crucial. Herein we examine the characteristics and oncological and reproductive outcomes of young women with endometrial cancer. Methods: We have identified all women under 45 years of age treated at the University Medical Centre Maribor between the years 2008–2020. Women were contacted to evaluate the endometrial cancer specific PROs using the EORTC QLQ-EN24 questionnaire. Results: Endometrial cancer and atypical endometrial hyperplasia were diagnosed in women younger than 45 years in 5.1% women and in 5.3% women respectively. Fourteen women (44%) under 45 years were eligible for fertility sparing procedures and only 6 of them (43%) opted for this approach. Women who opted for fertility sparing procedures were significantly younger (p < 0.001) with a median age of 31.0 (29–35) versus 42.5 years (34–45) in women opting for standard treatment. A significant proportion of women opting for fertility sparing treatment (67%) were nulliparous (p < 0.014) at time of diagnosis. Considering PROs, a high level of reported back/pelvic pain and tingling/numbness in the limbs was reported in our group of women. Conclusions: Young women with endometrial cancer should be offered counselling on the possibility of fertility sparing procedures. Future research should focus on long term PROs and mechanisms of improving them.

A case with repeat of hemorrhagic shock caused by retained products of conception, and fertility sparing uterine conservation using transcatheter arterial embolization and methotrexate

A case with repeat of hemorrhagic shock caused by retained products of conception, and fertility sparing uterine conservation using transcatheter arterial embolization and methotrexate

Spontaneous Pregnancy and Live Birth After Fertility Sparing Treatment For a Yolk Sac Tumor: Case Report

The Anatolian Journal of Family Medicine is an international periodical on family medicine and primary health care, published three times a year on independent, unbiased, double-blinded and peer-review principles.

Prognostic Factors of Granulosa Cell Tumors: A Retrospective Study in a Tertiary Care Cancer Centre of Eastern India.

Bhagyalaxmi NayakBackground and Aims The main objective of this study was to analyze the clinicopathological profile and prognostic factors of granulosa cell tumor (GCT). Method All the cases of ovarian cancer which were seen at our institute between January 2000 and December 2017 were reviewed. Data were analyzed with failure-free survival (FFS) as the primary end point. Results GCTs consisted of 2.66% of all ovarian cancers at our institute. The median age was 43 years. Majority of the patients (62.5%) were unstaged. Six patients (25%) had a fertility-preserving procedure. Forty two percent of the patients received adjuvant chemotherapy. Thirty eight percent of the patients developed recurrence. Considering tumor-related prognostic factors, there was a statistically significant decrease in FFS with the presence of hemorrhage ( p = < 0.001), larger tumors ( p = 0.042), and juvenile variant ( p = 0.002). On the contrary, when treatment-related factors were considered, there was no statistically significant improvement in FFS with the performance of lymphadenectomy ( p = 0.218), omentectomy ( p = 0.453), fertility sparing surgery ( p = 0.152), or administration of adjuvant chemotherapy ( p = 0.45). Conclusion Inherent tumor-related biological factors tend to play a more important role compared with treatment-related factors in GCTs. Hence, the traditional practice of performance of extensive staging procedures and routine adjuvant chemotherapy should be reviewed. Fertility-preserving surgery appears safe to be offered in early stages when desired. Although it is common knowledge that GCTs tend to be hemorrhagic tumors, this factor has not been well recognized as a prognostic indicator till date. Our study sheds some light on this aspect. Since these tumors have a tendency toward late recurrences, a long follow-up is prudent.

Long term oncologic and reproductive outcomes after robot-assisted radical trachelectomy for early-stage cervical cancer. An international multicenter study

ObjectivesLong term outcomes following fertility sparing robot-assisted radical trachelectomy (RRT). MethodsA retrospective study of consecutive women selected for RRT between 2007 and 2019 at five referral centres. Generally used selection criteria for fertility-sparing surgery were applied. Oncologic, reproductive and long-term clinical data were analysed. ResultsOf the 166 included women, 149 completed a RRT. Median tumor size was 9 mm (range 3-20 mm), 111 women (75%) had FIGO 2009 stage IB1 cancer and 4.8% were node positive. At a median follow up of 58 months, 12 of all women (7.2%) and 9 of 149 women (6%) who underwent completed RRT with fertility preservation had recurred and two had died. 70 of 88 women (80%) who attempted to conceive succeeded, resulting in 81 pregnancies that progressed beyond the first trimester and 76 live births of which 54 (70%) were delivered at term and 65 (86%) delivered after gestational week 32. A short postoperative cervical length was associated with impaired fertility. A late secondary hysterectomy was necessary in four women due to persistent bleeding (n = 2), hematometra due to a cervical stenosis (n = 1) and recurrent dysplasia (n = 1). ConclusionIn this long-term follow-up of RRT the recurrence rate is comparable to larger individual studies of minimally invasive or vaginal radical trachelectomy with similar risk profile and follow up. The high pregnancy rate and low rate of premature delivery before 32 weeks GA may promote the use of robot-assisted approach.

Clinical Characteristics and Survival in Non-Epithelial Ovarian Cancer

Ovarian cancer is often asymptomatic, grows rapidly and most diagnosed at advanced stage. Till now there is no method for early detection. Its incidence and mortality rate are increasing. Actually, non-epithelial type of ovarian cancer most found in young women and has better prognosis with adequate therapy. The main therapy for non-epithelial ovarian cancer is surgery, both radical and conservative (fertility sparing). Postoperative chemotherapy depends on the type and stage, although platinum-based chemotherapy regimens are used in almost all cases because of their chemosensitivity. The first-line regimens used are bleomycin, etoposide and cisplatin. Some clinical characteristics could affect prognosis including recurrence and survival rate. They include patient?s age, cancer stage, tumor size, tumor marker, post-operative tumor residue, histopathological type of cancer, and chemotherapy. Better knowledge of those prognostic factor will lead to better management of patients with non-epithelial ovarian cancer and increase survival rate.

Uterine tumor resembling ovarian sex-cord tumor: a case report of recurrence after conservative management and review of the literature

Background: Uterine tumor resembling ovarian sex-cord tumor is an extremely rare uterine mesenchymal neoplasm. Less than 100 cases have been described in literature and only eleven cases were treated with a fertility sparing approach. Three patients treated with preservation of reproductive function presented a local relapse; among these, two patients were treated conservatively and one had a second relapse with peritoneal carcinomatosis.

Quality of life and long-term clinical outcome following robot-assisted radical trachelectomy

Quality of Life and long-term clinical outcome following robot-assisted radical trachelectomy. ObjectivesTo evaluate quality of life (QoL) and long-term clinical outcome following robot-assisted radical trachelectomy (RRT).Study Design:Prospectively retrieved clinical data were rereviewed on all women planned for a fertility sparing RRT for early stage cervical cancer at Skåne University Hospital, Sweden between 2007 and 2020. QoL was assessed using the validated questionnaires EORTC QLQ-C30, QLQ-CX24 and the Swedish LYMQOL. ResultsData was analyzed from 49 women, 42 with a finalised RRT and seven with an aborted RRT due to nodal metastases (n = 3) or insufficient margins (n = 4). At a median follow-up time of 54 months one recurrence (2%) occurred (aborted RRT). According to QLQ-C30 the median global health status score was 75. The disease specific QLQ-C24 showed an impact on symptoms related to sexual function where sexual/vaginal functioning had a median score of 25 and 48% of patients reported worry that sex would cause physical pain. Despite this the functional items sexual activity and sexual enjoyment both had a median score of 66.7. Lymphoedema was reported in 45%, where 9% reported severe symptom with an impact on their QoL. No intraoperative complications and no postoperative complications ≥ Clavien Dindo grade III were observed. Twenty-two of 28 (79%) women who attempted to conceive were successful. A metronidazole/no intercourse regimen was applied between GW 15 + 0–21 + 6 in 26 of 28 pregnancies beyond first trimester resulting in a 92% term (≥GW 36 + 0) delivery rate. ConclusionsAlthough robot-assisted radical trachelectomy in this cohort was associated with a low recurrence rate, a high fertility rate and an exceptionally high term delivery rate, women’s quality of life was affected postoperatively, particularly with regards to their sexual well-being and lymphatic side-effects.

Fertility Sparing Treatments in Endometrial Cancer Patients: The Potential Role of the New Molecular Classification.

Endometrial cancer is the most frequent gynecological malignancy, and, although epidemiologically it mainly affects advanced age women, it can also affect young patients who want children and who have not yet completed their procreative project. Fertility sparing treatments are the subject of many studies and research in continuous evolution, and represent a light of hope for young cancer patients who find themselves having to face an oncological path before fulfilling their desire for motherhood. The advances in molecular biology and the more precise clinical and prognostic classification of endometrial cancer based on the 2013 The Cancer Genome Atlas classification allow for the selection of patients who can be submitted to fertility sparing treatments with increasing oncological safety. It would also be possible to predict the response to hormonal treatment by investigating the state of the genes of the mismatch repair.

Characteristics and outcomes analysis of ovarian Sertoli\u2013Leydig cell tumors (SLCTs): analysis of 15 patients

IntroductionBecause of limited information of Sertoli–Leydig cell tumors (SLCTs), the objective aimed to describe clinical parameters, management and treatment results of SLCTs.Material and methodsWe retrospectively reviewed 15 cases with SLCTs, who were treated in the Affiliated Hospital of Qingdao University between 2009 and 2020. Data of clinical parameters and treatment was studied.ResultsThe age ranged 25–69 years. Elevated testosterone was observed in 4 patients. FIGO-stage: 14 were at Ia(10 moderately differentiated, 3 poorly differentiated, 5 retiform pattern).1 was at Ic. Patients with retiform pattern were more likely to exhibit endocrine function (p = 0.019, w = 0.61) and tumor diameter was significantly bigger in no endocrine function (p = 0.012, d = 1.52). All patients received surgical treatment. 8 received postoperative chemotherapy. The median follow-up was 66 months (20–112 months). 1 patient relapsed within 36 months and received cytoreductive surgery. She survived without disease after recurrence treatment. Of 5 patients who performed fertility sparing surgeries with the desire of childbirth, 3 had full-term pregnancy and 1 experienced a miscarriage. Another one has not tried to conceive.ConclusionThe prognosis of SLCTs is good. Our data showed patients with retiform pattern were more likely to exhibit endocrine function. The diameter of tumor was significantly bigger in no endocrine function. Conservative surgery is the preferred option for patients with the desire of fertility at stage Ia. Postoperative chemotherapy is advised to cases with high-risk factors, but the most effective chemotherapy regimen is still uncertain.

Unexplained uterine atrophy following neoadjuvant chemotherapy in fertility sparing management of cervical cancer

A 31-year-old nulliparous woman attended our hospital for treatment of squamous cell carcinoma of the cervix. She had previously presented with vaginal bleeding and a 28 mm lesion had been found on clinical examination and shown on MRI. We aimed to adopt a fertility sparing strategy—neoadjuvant chemotherapy followed by conservative surgery of the body of the uterus—since biopsy samples of both pelvic sentinel lymph nodes showed no signs of metastatic spread.

Fertility Sparing Treatment in Gastric-Type Endocervical Carcinoma.

Simple SummaryDue to a trend toward late childbearing, fertility preservation has become a major issue in young patients with gynecological cancer. Surgical fertility sparing management is universally acknowledged as an acceptable option in eligible patients with cervical cancer. Excisional cone biopsy or trachelectomy are now standard surgical procedures offered to selected patients with gynecological malignancies who wish to preserve their fertility. Neoadjuvant chemotherapy followed by surgery is another therapeutic option studied currently in numerous clinical trials. However, fertility preserving treatment is generally not recommended in rare histological types of cervical cancer, including clinically aggressive gastric-type endocervical carcinoma. Due to controversies in this emerging topic, a review of literature and international database was carried out, in search of solid evidence on fertility sparing management in gastric-type endocervical carcinoma.Fertility sparing management of cancer is one of the main components of quality-of-life issues. Early-stage cervical cancer, frequently diagnosed in women of reproductive age, can potentially be treated conservatively. However, some rare histological types of cervical cancer present with aggressive clinical behavior. Particularly, in the newly introduced concept of gastric-type endocervical carcinoma, fertility sparing management is ‘a priori’ not recommended. Even so, this issue remains undocumented. For this reason, a selected review of the current literature on gastric type endocervical carcinoma was carried out through PubMed. The keywords included “gastric-type cervical cancer”, “gastric-type endocervical carcinoma”, “conservative surgery”, “conservative treatment”, “fertility sparing surgery”, “radical trachelectomy”, “laparoscopic trachelectomy”, “robotic trachelectomy”, “laparotomic trachelectomy”, “abdominal trachelectomy”, “trachelectomy”, “neoadjuvant chemotherapy”, “conisation”, and “cone resection”. A search in the European Network on Cancer, Infertility and Pregnancy (INCIP) database was performed. The rarity of gastric-type endocervical carcinoma does not allow for conclusions on fertility sparing management with solid evidence. However, diffuse character of the disease and aggressive clinical behavior contraindicate a conservative treatment in young women with gastric type cervical cancer.

Laparoscopic Resection of Deep Infiltrative Endometriosis of the Bowel and Bladder

<h3>Study Objective</h3> To show a systematic approach to perform resection of deep infiltrating endometriosis of the bowel and bladder in the setting of posterior cul-de-sac obliteration and intentional cystotomy creation. <h3>Design</h3> Step-by-step video demonstration of the technique. <h3>Setting</h3> A university tertiary care hospital. <h3>Patients or Participants</h3> A 28-year-old gravida 0 with a history of several years of severe dysmenorrhea, pelvic pain, and dyspareunia. She had been managed with hormonal medical therapy and physical therapy with little improvement in her symptoms. Pelvic ultrasound and MRI was significant for 0.8 × 1 cm rectal nodule located between the posterior wall of the uterus and anterior wall of the rectum, suggestive of deep infiltrating endometriosis. <h3>Interventions</h3> Studies have shown that surgery can improve pain in the context of deep infiltrating endometriosis. Moreover, deep infiltrating endometriosis has been associated with infertility with retrospective and prospective nonrandomized studies showing that resection improves spontaneous conception rates. Laparoscopy with resection of deep infiltrating endometriosis is performed using a conservative fertility sparing endometriosis surgery with bowel discoid resection. Deep infiltrating endometriosis of the bladder is performed with repair of therapeutic cystotomy. <h3>Measurements and Main Results</h3> We describe three phases of deep endometriosis nodule excision. First, opening pelvic avascular spaces, restoring anatomy, and identifying important anatomical structures. Second, resection of deep infiltrative endometriosis lesions with relevant vital structures properly identified and lateralized. Third, ensure integrity of our repair and hemostasis. At postoperative follow up, the patient reported improvement in pain symptoms. She had no bowel or bladder dysfunction postoperatively. <h3>Conclusion</h3> Management of deep infiltrating endometriosis begins in the preoperative period and continues beyond the immediate postoperative period. Appropriate preoperative evaluation, systematic and skilled intra-operative surgical technique, and appropriate postoperative follow up are important steps necessary to perform safe and effective fertility sparing endometriosis surgery.

Robotic-Assisted Laparoscopic Fertility Sparing Surgery for Treatment of Early-Stage Cervical Cancer

<h3>Study Objective</h3> To explore the safety, feasibility and pregnancy outcome of da Vinci robotic-assisted laparoscopic fertility-sparing surgery for early-stage cervical cancer. <h3>Design</h3> Retrospectively review clinical data of 10 patients who underwent robotic-assisted radical trachelectomy with bilateral lymphadenectomy between January 2018 and February 2020 in our center. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> The mean age of the 10 patients was 29.6±3.0 years old and the mean BMI was 23.9±3.7 kg/m². Among them, 1 patient was in stage IA1 with lymph-vascular space invasion, 2 patients in stage IA2 and 7 patients in stage IB1. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> The average operative time was 295±21 min. The average estimated amount of intraoperative blood loss was 65±18 ml, and the average number of lymph nodes removed was 28.6±3.5. The length of parametrial tissue removed on the left side was 34.3±1.6 mm and 33.9±1.5 mm on the right side. No intraoperative complications occurred. Postoperatively, the length of cervix (measured by transvaginal ultrasound) was 7.1±1.7 mm. The average length of hospital stay was 7.7±2.0 days. The median follow-up was 23.9 months. One patient had lymphocele 2 months after the operation. No recurrence happened during the follow-up period. Three patients achieved pregnancy, including 2 natural pregnancy and 1 assisted-reproductive pregnancy. One woman with natural pregnancy 11 months postoperatively delivered a healthy female infant at 38⁺¹ weeks. <h3>Conclusion</h3> Robotic-assisted radical trachelectomy is a safe and feasible alternative for cervical cancer patients who desire fertility preservation. Its long-term oncologic outcome and pregnancy outcome require further investigation.

Fertility sparing treatment for cervical cancer - Volume 75 multiple choice answers

Fertility sparing treatment for cervical cancer - Volume 75 multiple choice answers

Cystectomy of Ovarian Borderline and Malignant Tumors for Fertility Sparing: Outcome of Seventeen Cases

Background: Here we present a retrospective study of 17 cases in which the ovary on the affected side was spared in fertility-sparing surgery (FSS) during treatment for ovarian borderline malignant or malignant tumor. We determine that cystectomy is a suitable treatment for ovarian borderline tumors. Methods: A retrospective observation study was conducted at Saiseikai Fukuoka General Hospital in Japan between April 2009 and September 2020. Our hospital experienced 89 cases of FSS during treatment for ovarian borderline or malignant tumor. Of those, there were 17 cases in which the ovary on the affected side was spared. We examined recurrent and pregnant cases by stage, preoperative diagnosis, intraoperative pathological diagnosis, postoperative pathological diagnosis, and adjuvant therapy. Result: Of the 17, 12 cases were borderline malignant tumor, 4 were immature teratoma grade 1 (G1), and 1 case was endometrioid adenocarcinoma G1. Rapid intraoperative pathological diagnosis was conducted in 9 of the cases, and there were 6 in which surgical method was chosen based on the aforementioned results. Laparoscopic surgery was performed in 2 cases in which tumors were deemed benign via preoperative diagnosis, 2 cases of mature teratoma, and 2 in which borderline ovarian tumor was suspected. One (1) case of paraovarian cystecomy in a patient with history of multiple cesarean sections turned out to be serous borderline tumor. Postoperative treatment took place in only 1 case: endometrioid adenocarcinoma. There were 2 cases of recurrence, and 4 cases were eventually able to become pregnant naturally post-surgery. These pregnant cases included 1 in which serous borderline tumor recurred and we performed both cystectomy and lymphadenectomy, and one in which chemotherapy was performed after cyst enucleation for endometrioid adenocarcinoma G1. Conclusion: At present, there is no clear policy for FSS in cases such as stage Ib in which there are bilateral tumors. Accordingly, in the current study a radiologist was consulted for preoperative diagnosis, and surgical method was chosen with a view towards possible borderline malignancy or malignancy. In cases where fertility preservation of the affected ovary is a high priority, it is crucial to clearly explain the possibility of recurrence to the patient. We also stress the importance of detailed consultation among the surgical team during rapid intraoperal frozen section pathological examination for making the appropriate decision to ensure fertility preservation mid-surgery.

Fertility sparing treatment for cervical cancer - Volume 75 multiple choice questions

Fertility sparing treatment for cervical cancer - Volume 75 multiple choice questions

Risk factors for occurrence of placenta accrete spectrum following primary cesarean delivery

Background: Many maternal and fetal complications werereported during delivery for patients diagnosed to have placenta accrete spectrum (PAS). Cesarean delivery (CD) isconsidered to be the most common risk factor for developing PAS disorders during pregnancy specially with increasing rate of CD in developing countries.Methods: A cross- sectional study over 12 months in a tertiary care obstetric unit between January 2020 and January2021.Results: 47 pregnant females having history of previousone CD were divided into 2 groups after ultrasonic and intraoperative evaluation of placenta site and invasion to theuterine wall.14 cases were in the low risk group ad 33 caseswere in the high-risk group. The mean ages of patients were(27.6 ± 4.6 & 27.6 ± 4.6, p value =0.961) respectively. Themedian gravidity was (3 & 2) in both groups. We found that36.4 % of case in the high-risk group had unreliable indications of the primary CD. Emergency caesarean deliverieswere done in about 18 % of cases in the high-risk group either due to failure to progress in labour or foetal distress.We reported successful conservative management in bothgroups using either cervico-isthmic compression sutureor step wise approach. There was statistically significantin the mean amount of intraoperative blood loss (1000 ml(850-1200) &1600 ml (850-2500), p < 0.001) in the low andhigh-risk groups respectively. We reported 3 cases of intraoperative pulmonary embolism, urinary bladder injury and HELLP (hemolysis, elevated liver enzymesand low platelet count) syndrome among patients in the high-risk group. There was statistically significant longer hospital stay durationamong patients in the high-risk group rangingfrom 2 days up to 21 days. On the other hand,there were no serious complications reportedin the low risk group.Conclusion: Decreasing rate of primary CDand optimizing obstetric care are mandatoryto prevent maternal of fetal complication thatcould happen due to having future PAS. Fertility sparing surgery is feasible during surgical management of PAS disorders.