The Medical Minute: Preservation of fertility -- gynecologic cancer
In recent years, several new innovations have been employed in the treatment for women with gynecologic cancer in an effort to preserve fertility. These innovations consist of conservative ovarian staging, embryo/oocyte cryopreservation, hormonal treatment of endometrial cancer, and fertility-sparing radical hysterectomy for women with cervical cancer.
Ovarian cancer is the most common cancer to present with advanced disease. However, approximately 30 percent of ovarian cancer is limited to the ovaries or the pelvis. In women with early ovarian cancer limited to one ovary who desire further childbearing, conservative ovarian staging can be performed. This staging consists of removing the affected ovary and tube, the omentum, the surrounding lymph nodes and multiple biopsies and washings. The opposite normal ovary and uterus are conserved, allowing future fertility.
In women requiring significant chemotherapy or radiation, which may sterilize the ovary, pretreatment embryo/oocyte cryopreservation (freezing of embryos or eggs) is possible. Before radiation or chemotherapy, the women’s ovaries are stimulated with hormones and eggs are retrieved. The eggs can be fertilized and the embryos frozen or the eggs can be directly frozen. At a later date, in vitro fertilization (IVF) can be performed.
Approximately 90 percent of endometrial cancers occur in women who are in their sixties and beyond childbearing age. However, a small percentage of endometrial cancer occurs in young women with a gynecologic disorder called polycystic ovarian disease. These young women can develop endometrial cancer in their twenties or thirties. The standard treatment for endometrial cancer is laparoscopic hysterectomy (removal of the uterus), oophorectomy (removal of an ovary or ovaries) and lymphadenectomy (removal of lymph nodes). However, these young women who wish to have children in the future can be treated with high-dose progesterone hormones for approximately six months. After six months these women undergo a D&C -- a procedure that involves expanding or enlarging the entrance of a woman’s uterus so that a thin, sharp instrument can scrape or suction away the lining and take tissue samples -- and approximately 50 percent will have no residual cancer. If there is no residual cancer, they can be treated by reproductive endocrinology experts in an attempt to achieve a pregnancy.
Women with early cancer of the cervix require an extended type of hysterectomy termed a radical hysterectomy. In the last several years, fertility-conserving radical hysterectomy has been performed. During this procedure, lymphadenectomy and radical removal of the cervix is performed. However, unlike the standard radical hysterectomy, the top part of the uterus is conserved. The top part of the uterus is then sutured to the vagina and these patients are then referred to reproductive endocrinologists for attempted pregnancy.