Preservation Of Ovarian Function Research Articles

Treatment concepts for premature ovarian failure

Treatment concepts for premature ovarian failure concern restoration, preservation, and substitution of ovarian function. To date, there is no effective treatment to restore ovarian function. Preservation of ovarian function using cryopreservation and auto- or xenotransplantation will be possible in the near future. Regulation of the dynamics of the oocyte pool through GDF9 or AMH is not envisaged in the near future. Developments in estrogen receptor research may change treatment concepts in hormone replacement therapy.

Ovarian transposition for patients with cervical carcinoma treated by radiosurgical combination

Objective: To assess the indications, effectiveness, and complications of ovarian transposition before pelvic irradiation for cervical cancer. Design: Prospective study. Setting: Gynecologic oncology department at a French cancer center. Patient(s): One hundred seven patients treated for cervical cancer. Intervention(s): Ovarian transposition to the paracolic gutters with radical hysterectomy and lymphadenectomy. Main Outcome Measure(s): Clinical and laboratory follow-up tests for ovarian function. Result(s): Bilateral ovarian transposition was achieved in 104 patients (98%). Twelve patients were lost to follow-up or excluded because of evolution of the disease. Preservation of ovarian function was achieved in 83% of the patients having follow-up. The rates of ovarian preservation were 100% for patients treated exclusively by surgery, 90% for patients treated by postoperative vaginal brachytherapy, and 60% for patients treated by postoperative external radiation therapy and vaginal brachytherapy. The main risk for ovarian failure was found in patients treated by external radiation therapy. Conclusion(s): Ovarian transposition is a safe and effective procedure for preserving ovarian function in patients treated by a radiosurgical combination. This procedure should be performed in patients <40 years of age with a small invasive cervical carcinoma (<3 cm) treated by initial surgery. In such selected cases, the risk of ovarian metastasis is low.

Rectus abdominis endometrioma

A 31-year-old woman presented with complaints of increasingly severe right lower quadrant discomfort that had occurred for several days each month over the course of the previous 6 months. A tender mass of the abdominal wall was palpated on physical examination, and subsequent ultrasonography and magnetic resonance imaging disclosed a discrete mass of the body of the right rectus abdominis muscle which was confirmed as endometrial tissue on biopsy. Rectus abdominis endometrioma is a relatively rare cause of abdominal pain which may mimic an acute abdomen. Clinical clues to the diagnosis include previous uterine or gynecological surgery/invasive procedure (with preservation of ovarian function), cyclical nature of the discomfort, and the presence of a palpable mass with or without associated skin color changes.

Preservation of fertility and ovarian function and minimizing chemotherapy-induced gonadotoxicity in young women.

After the improved long-term survival in young women with lymphoma and leukemia undergoing chemotherapy, the preservation of future fertility has been the focus of recent interest. Three major topics are reviewed. They include the following: (1) the role of chemotherapy in the treatment of malignant and nonmalignant disease in young women, the types of chemotherapy and their gonadal effects (differing between ovaries and testes) in both human and other species, and the reasons for differences in the outcomes of various studies; (2) the human experience with GnRH-agonist therapy for minimizing chemotherapy-associated gonadotoxicity; and (3) inhibin measurements in young women treated by chemotherapy and in perimenopausal patients and those with impending premature ovarian failure (POF). Whereas egg retrieval for in vitro fertilization (IVF) and embryo cryopreservation is a valid assisted reproductive technology (ART) for married couples, it may be unacceptable for the young single woman. The investigational endeavors of ovarian cryopreservation awaits the clinical experience of in vitro maturation of thawed primordial follicles, their IVF, and embryo transfer. Although promising, this experience is not yet available. Moreover, the risk of possible reimplantation of malignant stem cells with the thawed cryopreserved ovary has been raised after animal observations. Therefore, until these innovative endeavors prove successful, and in parallel with them, an attempt was made to minimize the gonadotoxic effect of chemotherapy by the cotreatment with a GnRH agonistic analogue (GnRH-a) to induce a temporary prepubertal milieu, because prepubertal ovaries were found more resistant to alkylating agents' effect than the ovaries of older women. To characterize the correlation with ovarian function after gonadotoxic chemotherapy for Hodgkin or non-Hodgkin lymphoma in young women, the immunoreactive inhibin-A concentrations in the sera of these patients were measured before, during, and after the gonadotoxic chemotherapy. The GnRH-a cotreatment should be considered in every woman in the reproductive age receiving chemotherapy, in addition to ART and the investigational attempts of ovarian cryopreservation for future in vitro maturation or reimplantation. If these preliminary data are confirmed in a larger group of patients, inhibin-A concentrations may serve as a prognostic factor for predicting the resumption of ovarian function in addition to the levels of FSH, LH, and estradiol.

Preservation of Fertility and Ovarian Function and Minimizing Chemotherapy-Induced Gonadotoxicity in Young Women

Preservation of Fertility and Ovarian Function and Minimizing Chemotherapy-Induced Gonadotoxicity in Young Women

Laparoscopic lateral ovarian transposition before radiation treatment of Hodgkin disease

More than one-half of women treated with pelvic radiation therapy for malignant disease experience premature ovarian failure. Preservation of ovarian function by repositioning the ovaries out of the irradiation field is suggested in all women of reproductive age. This repositioning generally is done by moving the ovaries either medially so they are posterior to the uterus, or laterally so they are in the paracolic gutters. Laparoscopic medial transposition has been reported, with mixed results. A woman underwent successful laparoscopic lateral transposition before irradiation for stage Illa Hodgkin disease. A review of published cases suggests that this is preferable to medial transposition.

Treatment of bilateral multiple primary ovarian leiomyomas during pregnancy by way of conservative surgery: a case report

Primary ovarian leiomyoma is a rare, unilateral and solitary, benign tumour. We report a unique case of bilateral, multiple, primary ovarian leiomyomas diagnosed incidentally during caesarean section. As opposed to previously reported cases, conservative surgery was performed which resulted in preservation of ovarian function and anatomy.

Subcutaneous transposition of the ovary following hysterectomy

Objectives: Preservation of ovarian function at hysterectomy in pre-menopausal women is desirable. A possibly malignant tumor from retained ovary is a concern. We demonstrate a new technique for exteriorization of the ovaries. Method: In 27 patients, the infundibulopelvic ligament was mobilized. The retroperitoneal space was then widely opened. The ovary was gently pulled through a fascial incision and fixed on the fascia followed by skin closure. Results: Cystic formation was common (66.7%). Four patients had extreme enlargement of the transposed ovary. A needle puncture revealed intra-ovarian hematomas or fluid retention. One had puncture of the translocated ovary for in vitro fertilization more than two years following transposition. Conclusions: Possible advantages are (1) early detection and diagnosis of ovarian cysts, (2) easy surgical access to remove ovarian cysts, (3) transposition of ovaries outside the radiation field and (4) in vitro fertilization is facilitated. Comparative study for ovarian function is ongoing.

Lateral ovarian transposition before radiation treatment of Hodgkin disease

Preservation of ovarian function by repositioning the ovaries out of the irradiation field is suggested in women of reproductive age before pelvic radiotherapy for cervical cancer or Hodgkin disease. In women with Hodgkin disease this is usually done at the time of staging laparotomy. A 21-year-old woman with stage IIIa Hodgkin disease underwent repositioning of the ovaries during staging laparotomy, but before planned irradiation therapy it was noted that the ovaries were back in their normal anatomic position. Outpatient laparoscopic lateral transposition of the ovaries was performed without complication. Five years after pelvic irradiation she still has normal ovarian function. In selected women with malignancy and planned irradiation therapy, laparoscopy is an alternative to laparotomy to preserve ovarian function by lateral ovarian transposition.

Laparoscopic lateral ovarian transposition

To determine if the new technique laparoscopic lateral transposition of the ovaries before pelvic radiotherapy for anal canal carcinoma prevents radiation-related ovarian failure. A case report. The operating room of a Canadian teaching hospital. A single patient with anal canal carcinoma, requiring pelvic radiotherapy, who desired preservation of ovarian function. Laparoscopic ovarian transposition to the level of the pelvic brim. Follow-up clinical and laboratory evidence of ovarian failure. Initially ovarian failure was confirmed with the appearance of postmenopausal symptoms and the elevation of serum gonadotropins. These symptoms resolved by 8 months after radiotherapy, normal menstrual cycles resumed, and normal FSH levels were detected at that time. The laparoscopic, lateral transposition of this patient's ovaries was effective at preventing radiation-related ovarian failure.

Methods of Protecting Ovaries from Radiation Therapy

Preservation of ovarian function is both safe and feasible in many young women with pelvic malignancies. Of the methods used to preserve ovarian function after radiation, only surgically transposing the ovary from its site within (or close to) the radiated field to a distant site has withstood the test of time. Despite transpositioning and the use of blocks, the ovaries are still subject to the following sources of radiation; head leakage, the collimator assembly, air scattering, and internal scattering (the most significant). Ovarian failure secondary to radiation is dependent not only on the dose of radiation received, but also the age at exposure, and the use of concomitant chemotherapy.Sites of ovarian transposition are midline and lateral. Although midline transpositions are technically easier to perform and require no further intervention for pregnancy to occur, they are associated with a low rate of efficacy (0 to 67% in Hodgkin’s patients), and are contra-indicated in patients requiring whole pelvic radiation. Lateral ovarian transpositions have been associated with modest success rates in cervical cancer patients (15 to 50%) . Despite preservation of ovarian tissue, studies in cervical cancer patients have found only 30 to 60 percent of patients have continued long term ovarian function after transposition alone, and 15 to 50 percent after transposition and external pelvic radiation. Furthermore, up to 25 percent of non-irradiated patients experience complications from the retained ovarian tissue later in life.Laparoscopy appears to be an ideal method for performing ovarian transpositions as its preliminary morbidity is low, and it can be combined with other staging, diagnostic, and therapeutic interventions including pelvic and para-aortic lymphadenectomy. With more experience and longer follow-up confirming its safety and efficacy in comparison to laparotomy, it will likely replace laparotomy as the predominant method of ovarian transposition in the future.Despite the above innovations, ovarian transposition is at best fair in preventing radiation induced menopause (after external pelvic radiation), and is associated with a potential for an increase in ovarian complications. Future efforts should be directed towards improving patient selection, while increasing the efficacy and decreasing the long-term morbidity associated with this procedure.

Fine-needle aspiration cytology in the management of gynecologic oncology patients.

Fine-needle aspiration cytology has received little attention by physicians involved in the care of gynecologic oncology patients. Concerns over diagnostic accuracy and complications such as rupture of cystic ovarian tumors with resultant tumor dissemination have limited the technique's utilization. Recent studies have shown the method to have a diagnostic accuracy (percent of neoplasms correctly categorized as benign or malignant) of approximately 95% for ovarian tumors [2-8]. The method is generally free of major complication when patients are properly selected, but severe pelvic infections have followed transvaginal or transrectal puncture of cystic ovarian neoplasms, resulting in a complication rate of about 1.6% [28]. Presently, FNA of ovarian tumors has a role in the workup of cystic lesions in young women where epithelial malignancies are unlikely and preservation of ovarian function is highly desirable. In peri- or postmenopausal women with adnexal masses, operative intervention is appropriate in most cases. Sevin and colleagues defined four clinical situations where FNA is useful [16]. These are 1) workup of primary neoplasms, 2) biopsy of superficial masses in patients with known prior disease, 3) follow-up of irradiated patients, and 4) follow-up of patients undergoing chemotherapy. From the available data, FNA has an accuracy of approximately 90% [10,18] and a low complication rate. The technique is an excellent method for the detection of recurrent or metastatic disease in patients being followed for gynecologic malignancies. When FNA is used for the investigation of newly discovered adnexal masses, patient selection is critical. FNA is helpful in carefully selected young women with cystic ovarian masses. However, its utility is limited in peri- or postmenopausal women with solid and solid-cystic adnexal masses, because these should be investigated by operative intervention.

Radiotherapy after ovarian transposition: Ovarian function and fertility preservation

The outcome of ovarian function preservation and fertility after ovarian transposition was examined in women treated for cancer. Of 134 patients, 126 were treated with radiotherapy and 72 with chemotherapy. In a multivariate analysis, three factors appeared to be prognostic of ovarian castration: the age over 25, MOPP chemotherapy and a total dose to the ovaries higher than 5 Gy. The incidence of birth was lower than in the general population but no abnormality was observed.

Preservation of ovarian function by ovarian transposition performed before pelvic irradiation during childhood

Ovarian transposition in adults has been shown to protect ovarian function in about 60% of cases by reducing ovarian exposure to less than 4 to 7 Gy. We therefore evaluated the effect of ovarian transposition during childhood or adolescence. Eighteen girls had ovarian transposition performed at a mean (+/- SEM) age of 9.4 +/- 1.2 years (range, 1.2 to 16 years). Twelve were prepubertal and six had menstruated at the time of ovarian transposition. The initial abnormalities were Hodgkin disease (5 cases), iliac Ewing sarcoma (3), medulloblastoma (2), ovarian seminoma (1), and vaginal or uterine tumor (7). The irradiation was external in 11 cases and local by vaginal curietherapy in 7 cases. Fifteen girls received chemotherapy. The ovarian transposition was bilateral in 15 patients and unilateral in 3 cases; in the latter the other ovary had been destroyed by the tumor or by abdominal irradiation. Ovaries were placed just below the iliac crest (15 cases) or posterolateral to the uterus (3); thus, the calculated ovarian radiation dose was up to 9.5 Gy. At the time of evaluation (8.6 +/- 0.9 years after ovarian transposition), 16 girls had menstruated and 2 remained amenorrheic because of major lesions of the vagina and uterus caused by the vaginal curietherapy. Basal plasma gonadotropin values were normal. Ovulation was documented in seven cases. Two pregnancies occurred. Complications of ovarian transposition were present in four patients: intestinal occlusion, dyspareunia, functional ovarian cysts, and pelvic adhesions with tubal obstruction. We conclude that ovarian transposition, performed before abdominopelvic irradiation during childhood, can preserve ovarian function. Longer follow-up is required to assess the risk of ovarian dystrophy because of vascular lesions or chemotherapy.

Preservation of ovarian function in patients with cervical cancer treated with radiation therapy

Preservation of ovarian function in patients with cervical cancer treated with radiation therapy

Clinical presentation and management of stage I cervical adenocarcinoma: A 25 year experience

In this study, we review the clinical presentation, treatment, and prognosis of 89 patients with stage I cervical adenocarcinoma treated at Strong Memorial Hospital over the past 25 years. In the past decade, the mean age of patients with stage I cervical adenocarcinoma was 44 years, in contrast to a mean of 58 years in the prior interval ( P < 0.001). Prior to 1980 only 4% of patients were of childbearing age, whereas in the past decade 27% were under 35 years old ( P = 0.02). The difference in age at presentation cannot be explained by earlier detection, as the fraction of stage I patients, the mean tumor size, and the percentage of clinically occult tumors have not changed. There were no ovarian metastases in 41 patients who underwent oophorectomy. Adenosquamous tumors did not differ in prognosis from pure adenocarcinoma. Grade and lymph node status were significant predictors of outcome. Treatment results have not improved over the past 25 years, and combined therapy with radiation and surgery offered no advantage over radiation alone. Because this tumor is more frequently seen in younger patients, the management of occult adenocarcinoma with early stromal invasion has become problematic. Ovarian conservation has been questioned, and the lack of generally accepted criteria for microinvasive adenocarcinoma has led to radical therapy in patients who might have been adequately treated with local excision. Further study is necessary to guide our recommendations regarding preservation of ovarian function or even childbearing potential in young women.

Sequelae of lateral ovarian transposition in irradiated cervical cancer patients

Lateral ovarian transposition (LOT) is a useful technique for preserving ovarian function in “high-risk” premenopausal Stage I cervix cancer patients who undergo hysterectomy and subsequent postoperative whole pelvic radiation therapy. From 1978 to 1988, 38 FIGO Stage I cervical cancer patients underwent LOT as part of their initial operative procedure and 14 of these patients (37%) subsequently received pelvic radiation therapy (LOT + RT) because of pathological findings such as metastatic pelvic lymph node involvement or positive surgical margins(13 patients) or recurrent disease (1 patient). Ten (71%) of the 14 (LOT + RT) patients have maintained ovarian function with a median follow-up of 35 months. Preservation of ovarian function was directly related to the estimated scatter dose to the ovaries. For patients whose estimated ovarian dose was 300 cGy or less, only 1 of 9 patients (11%) underwent menopause, whereas 3 of 5 patients (60%) became menopausal if the ovarian dose was more than 300 cGy. The placement of the ovaries was also crucial for preservation of ovarian function, with 100% of the patients developing menopause if the ovaries were placed below the iliac crest. A major side effect of LOT was the development of symptomatic ovarian cysts in 7 (18%) of the 38 Stage I patients who underwent LOT. In the 24 patients who underwent LOT alone without RT, the incidence of symptomatic ovarian cysts was 25% compared to only 7% of the patients who underwent LOT + RT, although this difference was not statistically significant ( p = .18).

Sequelae of lateral ovarian transposition in unirradiated cervical cancer patients

The sequelae of lateral ovarian transposition (LOT) in cervical cancer patients has been examined only in the light of the effect of pelvic radiation therapy on ovarian preservation. Preservation of ovarian function has not been examined in the absence of radiation therapy, and symptomatic ovarian cyst formation in tranposed ovaries with the need for subsequent surgery has not been addressed in either radiated or unirradiated cervical cancer patients. We studied 84 premenopausal FIGO stage IA or IB cervical cancer patients treated by primary radical hysterectomy between the years 1978 and 1988. None of these patients received adjuvant radiation therapy. Fifty-nine of eight-four patients had radical hysterectomy (RH) without LOT. These patients were compared to 25 of 84 patients who had LOT in addition to RH. The incidence of symptomatic ovarian cysts, the majority requiring operative intervention, was 24% in the ovarian transposition patients as compared to 7.4% in those who had RH alone. This threefold increase in symptomatic benign ovarian cyst formation in the translocated ovary was significant ( P = .048). On the other hand, LOT in these RH patients does not appear to increase the incidence of early menopause ( P > 0.05). On follow-up of those patients who did not incur additional surgery or radiation, 4.3% became menopausal, as compared to 4.1% of those patients undergoing RH alone, with the mean ages of the two groups being comparable.

Preservation of ovarian function and reproductive ability in patients with malignant ovarian tumors

In a study designed to determine the merit of preserving ovarian function and childbearing capability in women with unilateral malignant ovarian tumors, the results of radical surgery ( n = 86) and conservative surgery ( n = 106) were compared. The mean length of survival was slightly but not significantly shorter following conservative surgery. There were 15 recurrences (14%) and 11 deaths among the conservative surgery group. The incidence of metastasis to the preserved ovary was high. In the most cases restoration of normal menses was fairly rapid after initial treatment, but this appeared to depend on whether or not chemotherapy was given postoperatively, the specific agents used, and the duration of their administration. Hypergonadotropic hypogonadism was the most common finding among the anovulatory patients. Sixteen women experienced a total of 27 pregnancies and 18 normal infants were born. Abortion was induced when conception occurred during a course of chemotherapy. These findings are encouraging in terms of the feasibility of preserving childbearing capability in ovarian cancer patients. However, they also underscore the necessity for close, long-term follow-up, which will be improved as new technologies become available.

Ovariopexy: Clinical and radiologic correlation

Computerized tomography (CT) scans and sonograms of the pelvis were performed in 17 young female patients (13 postpubertal and 4 prepubertal), whose ovaries had been fixed either to the uterus or the pelvic wall to move them away from the field of radiation. These patients were given radiation therapy for the treatment of Hodgkin's disease (n = 15) or rhabdomyosarcoma (n = 2). The mean age of the postpubertal girls was 16.5 years (range 12–21) and the CT scans were done 2–7 years following radiation therapy. Ovarian function was determined based upon the patient reporting normal menstrual function and normal levels of follicle-stimulating hormone (FSH). FSH levels in the postpubertal girls were elevated in 5 patients and normal in 8. The ovaries could not be seen on CT scans of the 9 patients with elevated FSH and clinical signs of estrogen deficiency, while of the 8 patients with normal FSH levels, 7 had ovaries visualized by CT. Thus, visualization of the ovaries of adolescent girls correlated with the preservation of ovarian function in the majority of patients. Lack of detectable ovarian function correlated with lack of ability to visualize ovarian tissue on the sonograms or CT radiographs. Estrogen replacement is recommended to limit the consequences of therapy-induced ovarian failure.