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Zapardiel I, Cruz M, Diestro MD, Requena A, Garcia-Velasco JA. Assisted reproductive techniques after fertility-sparing treatments in gynaecological cancers. Hum Reprod Update 2016; 22:281-305. [PMID: 26759231 DOI: 10.1093/humupd/dmv066] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 12/18/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The trend toward late childbearing has made fertility preservation a major issue for women who face gynecological cancer. New techniques in assisted reproductive medicine enable conception after primary treatment of these cancers. Here, we aimed to review the efficacy and safety of assisted reproductive techniques (ART) after fertility-preserving treatment of gynaecological cancers. METHODS We conducted a systematic literature review of both prospective and retrospective studies in the PubMed, EMBASE, CENTRAL and SciSearch databases. In the retrieved studies, we evaluated live births, clinical pregnancies, overall survival and disease-free survival. RESULTS We identified many prospective and retrospective studies on this topic, but no relevant randomized clinical trials. Fertility-sparing treatments with safe oncological outcomes are feasible in endometrial, cervical and ovarian cancer cases. After cancer treatment, ART seem safe and show variable obstetrical outcomes. CONCLUSIONS After fertility-preserving treatment for gynaecological cancers, ART can enable pregnancy to be achieved with apparent oncological safety. The success of such procedures should directly impact clinical practice and management of those patients who require fertility-sparing treatment.
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Affiliation(s)
- Ignacio Zapardiel
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
| | | | - Maria D Diestro
- Gynaecologic Oncology Unit, La Paz University Hospital - IdiPAZ, Madrid, Spain
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Kalogera E, Dowdy SC, Bakkum-Gamez JN. Preserving fertility in young patients with endometrial cancer: current perspectives. Int J Womens Health 2014; 6:691-701. [PMID: 25114594 PMCID: PMC4122529 DOI: 10.2147/ijwh.s47232] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries and affects predominantly postmenopausal women. It is estimated, however, that 15%–25% of women will be diagnosed before menopause. As more women choose to defer childbearing until later in life, the feasibility and safety of fertility-sparing EC management have been increasingly studied. Definitive treatment of total hysterectomy and bilateral salpingo-oophorectomy precludes future fertility and may thus be undesirable by women who wish to maintain their reproductive potential. However, the consideration of conservative management carries the oncologic risks of unstaged EC and the risk of missing a synchronous ovarian cancer. It is further complicated by the lack of consensus regarding the initial assessment, treatment, and surveillance. Conservative treatment with progestins has been shown to be a feasible and safe fertility-sparing approach for women with low grade, early stage EC with no myometrial invasion. The two most commonly adopted regimens are medroxyprogesterone acetate at 500–600 mg daily and megestrol acetate at 160 mg daily for a minimum of 6–9 months, with initial response rates commonly reported between 60% and 80% and recurrence rates between 25% and 40%. Photodynamic therapy and hysteroscopic EC excision have recently been reported as alternative approaches to progestin therapy alone. However, limited efficacy and safety data exist. Live birth rates after progestin therapy have typically been reported around 30%; however, when focusing only on those who do pursue fertility after successful treatment, the live birth rates were found to be higher than 60%. Assisted reproductive technology has been associated with a higher live birth rate compared with spontaneous conception, most likely reflecting the presence of infertility at baseline. Close follow-up is of paramount importance, and definitive treatment after completion of childbearing is advised.
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Affiliation(s)
| | - Sean C Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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Bakkum-Gamez JN, Kalogera E, Keeney GL, Mariani A, Podratz KC, Dowdy SC. Conservative Management of Atypical Hyperplasia and Grade I Endometrial Carcinoma: Review of the Literature and Presentation of a Series. J Gynecol Surg 2012. [DOI: 10.1089/gyn.2012.0011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | | | - Gary L. Keeney
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Andrea Mariani
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Karl C. Podratz
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sean C. Dowdy
- Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota
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Gunderson CC, Fader AN, Carson KA, Bristow RE. Oncologic and reproductive outcomes with progestin therapy in women with endometrial hyperplasia and grade 1 adenocarcinoma: a systematic review. Gynecol Oncol 2012; 125:477-82. [PMID: 22245711 DOI: 10.1016/j.ygyno.2012.01.003] [Citation(s) in RCA: 269] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 12/31/2011] [Accepted: 01/04/2012] [Indexed: 01/08/2023]
Abstract
OBJECTIVE The objective of this review was to analyze published contemporary oncologic and reproductive outcomes in women with endometrial hyperplasia or cancer undergoing medical management with progestin therapy. METHODS A systematic review of oncologic and pregnancy outcomes in women with complex atypical hyperplasia or grade 1 adenocarcinoma was performed using a comprehensive search of the MEDLINE literature. English language studies published from 2004 to 2011 which utilized hormonal therapy were identified using key words endometrial hyperplasia, endometrial cancer, fertility preservation, hormone and progestin therapy. Fisher's exact test was used to calculate statistical differences. RESULTS Forty-five studies with 391 study subjects were identified. The median age was 31.7 years. Therapies included medroxyprogesterone (49%), megestrol acetate (25%), levonorgestrel intrauterine device (19%), hydroxyprogesterone caproate (0.8%), and unspecified/miscellaneous progestins (13.5%). Overall, 344 women (77.7%) demonstrated a response to hormonal therapy. After a median follow up period of 39 months, a durable complete response was noted in 53.2%. The complete response rate was significantly higher for those with hyperplasia than for women with carcinoma (65.8% vs. 48.2%, p=.002). The median time to complete response was 6 months (range, 1-18 months). Recurrence after an initial response was noted in 23.2% with hyperplasia and 35.4% with carcinoma during the study periods (p=.03). Persistent disease was observed in 14.4% of women with hyperplasia and 25.4% of women with carcinoma (p=.02). During the respective study periods, 41.2% of those with hyperplasia and 34.8% with a history of carcinoma became pregnant (p=.39), with 117 live births reported. CONCLUSION Based on this systematic review of the contemporary literature, endometrial hyperplasia has a significantly higher likelihood of response (66%) to hormonal therapy than grade 1 endometrial carcinoma (48%). Disease persistence is more common in women with carcinoma (25%) compared to hyperplasia (14%). Reproductive outcomes do not seem to differ between the cohorts.
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Affiliation(s)
- Camille C Gunderson
- Johns Hopkins Hospital, Department of Gynecology and Obstetrics, 600 North Wolfe Street, Phipps 279, Baltimore, MD 21287, USA.
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Lavery S, Ng C, Kyrgiou M, Farthing A. Gestational surrogacy after intra-operative oocyte collection in a hysterectomised woman diagnosed with endometrial cancer. BJOG 2011; 118:1669-71. [PMID: 21967041 DOI: 10.1111/j.1471-0528.2011.03145.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- S Lavery
- Reproductive Medicine Unit, Hammersmith Hospital, London, UK
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Erkanli S, Ayhan A. Fertility-Sparing Therapy in Young Women With Endometrial Cancer. Int J Gynecol Cancer 2010; 20:1170-87. [DOI: 10.1111/igc.0b013e3181e94f5a] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Controversies in the management of endometrial carcinoma. Obstet Gynecol Int 2010; 2010:862908. [PMID: 20613958 PMCID: PMC2896852 DOI: 10.1155/2010/862908] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Revised: 12/01/2009] [Accepted: 04/13/2010] [Indexed: 01/03/2023] Open
Abstract
Endometrial carcinoma is the most common type of female genital tract malignancy. Although endometrial carcinoma is a low grade curable malignancy, the condition of the disease can range from excellent prognosis with high curability to aggressive disease with poor outcome. During the last 10 years many researches have provided some new valuable data of optimal treatments for endometrial carcinoma. Progression in diagnostic imaging, radiation delivery systems, and systemic therapies potentially can improve outcomes while minimizing morbidity. Firstly, total hysterectomy and bilateral salphingo-oophorectomy is the primary operative procedure. Pelvic lymhadenectomy is performed in most centers on therapeutic and prognostic grounds and to individualize adjuvant treatment. Women with endometrial carcinoma can be readily segregated intraoperatively into “low-risk” and “high-risk” groups to better identify those women who will most likely benefit from thorough lymphadenectomy. Secondly, adjuvant therapies have been proposed for women with endometrial carcinoma postoperatively. Postoperative irradiation is used to reduce pelvic and vaginal recurrences in high risk cases. Chemotherapy is emerging as an important treatment modality in advanced endometrial carcinoma. Meanwhile the availability of new hormonal and biological agents presents new opportunities for therapy.
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Gadducci A, Spirito N, Baroni E, Tana R, Genazzani AR. The fertility-sparing treatment in patients with endometrial atypical hyperplasia and early endometrial cancer: a debated therapeutic option. Gynecol Endocrinol 2009; 25:683-91. [PMID: 19562604 DOI: 10.1080/09513590902733733] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Fertility-sparing treatment may represent a realist option for accurately selected young patients with endometrial atypical hyperplasia or well differentiated, early endometrial cancer. Oral progestins, and especially medroxyprogesterone acetate (MPA) and megestrol acetate with different doses and schedules, represent the most commonly used hormone agents in this clinical setting. Approximately three fourths of the women achieve a histologically documented complete response, with an mean response time of 12 weeks, but about one third of these subsequently developed a recurrence after a mean time of 20 months. The expression of receptor for progesterone receptor (PR), PTEN gene, DNA mismatch repair gene MLH1 and phospho-AKT on tissue specimens may be useful for selecting patients fit for a conservative management. Several successful pregnancies have occurred after a fertility-sparing treatment of endometrial atypical hyperplasia or endometrial cancer, more frequently with assisted reproductive technologies. The implementation of in vitro fertilisation techniques not only increases the chance of conception, but it may also decrease the interval to conception. The opportunity of a demolitive surgery after delivery or after childbearing being no longer required is a still debated issue. Large multicenter trials are strongly warranted to better define the selection criteria for a conservative treatment, endocrine regimen of choice, the optimal dosing, the duration of treatment and follow-up protocols. In any case, the patient should be accurately informed about the relatively high recurrence rates after complete response to hormone treatment and expectations for pregnancy.
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Affiliation(s)
- Angiolo Gadducci
- Department of Procreative Medicine, Division of Gynecology and Obstetrics, University of Pisa, via Roma 56, Pisa 56127, Italy.
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Sodano M, Bogliatto F, Morero S, Mosso L, Torchio B, Leidi L. Successful IVF programme after conservatively treated endometrial cancer. Reprod Biomed Online 2009; 18:578-81. [DOI: 10.1016/s1472-6483(10)60137-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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ICSI outcome following conservative fertility sparing management of endometrial cancer. Reprod Biomed Online 2009; 18:416-20. [DOI: 10.1016/s1472-6483(10)60102-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Pregnancy and Assisted Reproduction Techniques in Men and Women after Cancer Treatment. Placenta 2008; 29 Suppl B:152-9. [DOI: 10.1016/j.placenta.2008.07.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 07/15/2008] [Accepted: 07/17/2008] [Indexed: 01/15/2023]
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Preserving fertility before assisted reproduction in women with endometrial carcinoma: case report and literature review. Reprod Biomed Online 2007; 15:561-5. [DOI: 10.1016/s1472-6483(10)60389-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Bocca S, Stadtmauer L, Oehninger S. Current status of robotically assisted laparoscopic surgery in reproductive medicine and gynaecology. Reprod Biomed Online 2007; 14:765-72. [PMID: 17579994 DOI: 10.1016/s1472-6483(10)60680-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Laparoscopic techniques have revolutionized the concept of minimally invasive surgery. Robotically assisted surgery is one of the latest innovations in this field and many operative laparoscopic procedures have been performed in urology, cardiac and general surgery. More recently, the use of robotically assisted techniques have been introduced in gynaecology, and most available studies have shown it to be a safe and effective alternative to conventional laparoscopic surgery. However, whether or not to approach the management of certain gynaecological pathologies with a laparotomy or laparoscopy (conventional or with robotic aid) continues to be a point of debate. This article reviews recent developments in the endoscopic management of reproductive (tubal reanastomosis and myomectomies) and other gynaecological surgical conditions (hysterectomies, pelvic organ prolapse, repair of vesicovaginal fistulas and staging for gynaecological malignancies). Ongoing controversies associated with this technology, such as cost, learning curve, conversion rate to laparotomy, post-surgical fertility and complications, are briefly addressed. Long-term analysis of outcomes is ongoing.
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Affiliation(s)
- Silvina Bocca
- The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley Avenue, Norfolk, VA 23507, USA.
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Bibliography. Current world literature. Minimally invasive gynecologic procedures. Curr Opin Obstet Gynecol 2006; 18:464-7. [PMID: 16794430 DOI: 10.1097/01.gco.0000233944.74672.e0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Bibliography. Current world literature. Fertility. Curr Opin Obstet Gynecol 2006; 18:344-53. [PMID: 16735837 DOI: 10.1097/01.gco.0000193023.28556.e2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Current awareness in prenatal diagnosis. Prenat Diagn 2005. [DOI: 10.1002/pd.1026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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