Modern radiation therapy and potential fertility preservation strategies in patients with cervical cancer undergoing chemoradiation

Techniques and endocrine-reproductive outcomes of ovarian transposition prior to pelvic radiotherapy in both gynecologic and non-gynecologic cancers: A systematic review and meta-analysis

BACKGROUND

Premature ovarian failure may be a consequence of radiotherapy administered for the treatment of various female oncologic diseases. Before radiotherapy, fertility may be preserved through ovarian transposition (OT), which consists of moving the ovaries away from the radiation field.

OBJECTIVE

To ascertain all types of surgical techniques employed for OT, outline the endocrine and reproductive outcomes of each one, and discover if one works better than the others.

SEARCH STRATEGY

The authors performed a systematic search of the English literature looking for all studies related to OT before radiotherapy published up to June 2023. Nine studies were included.

SELECTION CRITERIA

The eligible studies were assessed based on the presence of a description of the surgical technique employed for OT before pelvic radiotherapy and a report of the endocrine and reproductive outcomes.

DATA COLLECTION AND ANALYSIS

Odds ratios (OR) with 95% confidence intervals were used to compare endocrine and reproductive outcomes The χ2 test was employed for the statistical analysis and a P value less than 0.05 was considered significant.

MAIN RESULTS

A total of 323 female patients aged between 7 and 51 years-198 (61.3%) with non-gynecologic cancer and 125 (38.7%) with gynecologic cancer-underwent OT, either bilateral (221, 68.4%) or unilateral (102, 31.6%), before radiotherapy. Essentially, two types of OT were employed: lateral and medial. A total of 71 (22%) patients underwent medial OT and 252 (78%) patients (127 with non-gynecologic tumors and 125 with gynecologic tumors) had a lateral OT. The latter was used in a similar percentage of cases for gynecologic (50.4%) and non-gynecologic (49.6%) tumors, whereas the medial approach was performed only for non-gynecologic cancers (Hodgkin's lymphoma). The difference between medial OT and lateral OT was not significant regarding the preservation of endocrine function (OR 0.65, P = 0.120). However, midline OT worked better in terms of reproductive outcomes. In fact, the percentage of patients with pregnancy (49.2%) and live births (45%) associated with medial OT was significantly higher than that associated with lateral OT, 6.5% and 13.4%, respectively, and the difference between such data was statistically significant (OR 7.04, P = 0.001 and OR 5.29, P = 0.003, respectively).

CONCLUSIONS

Ovarian transposition is an important method to preserve fertility before radiotherapy, considering the worldwide ongoing use of this treatment for various cancers arising in young women. The surgical method depends on the type of disease, but OT-especially medial OT when feasible-is effective in terms of ovarian function preservation and reproductive outcomes.

To who and by who: Discussions of sexual health, fertility, and premature menopause with women with locally advanced cervical cancer

PURPOSE

To investigate whether gynecologic and radiation oncologists document discussions of chemoradiation treatment's gonadotoxicity for patients with cervical cancer and what patient and physician factors make discussions more likely.

METHODS AND MATERIALS

Women with LACC treated with definitive CRT between 2009 and 2022 were included. Visit notes with gynecologic and radiation oncologists were reviewed for sexual health discussions. Fertility and premature menopause discussions were only evaluated among premenopausal patients. Variables of interest including demographics and staging were collected. Univariate and multivariate analyses were conducted using Rv4.2.1.

RESULTS

A total of 93 women were included (22-91 years old). Most were Stage IIB (32%) or IIIB (34%). Sexual health discussions occurred among 74.2% of patients and did not have a significant relationship with any patient factors. Fertility discussions occurred with 17.5% of the 57 premenopausal patients and were more likely among younger patients (≤31.9, p < 0.001) with fewer children (≤1, p < 0.001). Premature menopause discussions occurred among 73.7% of premenopausal patients and were more likely among younger patients (≤39.0, p = 0.015).

CONCLUSIONS

It is promising to see that oncologists are discussing sexual health and premature menopause with most patients. The limited fertility discussions suggest that oncologists are less likely to discuss fertility as women approach the age of menopause or already have children. Involvement of reproductive endocrinologists and psychologists may provide patients with a more comprehensive understanding of long-term quality of life.

Intensity-Modulated Radiation Therapy for Uterine Cervical Cancer to Reduce Toxicity and Enhance Efficacy - an Option or a Must?: A Narrative Review

Radiotherapy (RT) is a fundamental modality in treatment of cervical cancer. With advancement of technology, conventional RT used for external beam radiotherapy (EBRT) for over half a century has been rapidly replaced with intensity-modulated radiation therapy (IMRT) especially during the last decade. This newer technique is able to differentiate the intensity of radiation within the same field, thus reduces the inevitable exposure of radiation to normal organs and enables better dose delivery to tumors. Recently, the American Society for Radiation Oncology has released a guideline for RT in cervical cancer. Although a section of the guideline recommends IMRT for the purpose of toxicity reduction, a thorough review of the literature is necessary to understand the current status of IMRT in cervical cancer. This narrative review updates the recent high-level evidences regarding the efficacy and toxicity of IMRT and provides a better understanding of the most innovative techniques currently available for EBRT enabled by IMRT.

Uterine transposition versus uterine ventrofixation before radiotherapy as a fertility sparing option in young women with pelvic malignancies: Systematic review of the literature and dose simulation

BACKGROUND

(Chemo)radiation may be a required treatment in young women with pelvic malignancies. Irradiation may result in ovarian and uterine failure, compromising the fertility of those patients. While ovarian transposition is an established method to move the ovaries away from the irradiation field, similar surgical procedures regarding the uterus remain investigational. The aim of this study was to carry out a systematic review of the literature on uterine displacement techniques (ventrofixation/transposition) and to simulate the radiation dose received by the uterus in different heights place after the procedures.

METHODS

The systematic review was performed according PRISMA guidelines. PubMed, Scopus, Web of Science and EMBASE were queried to identify included study until March 2023. Retrospectively, a dosimetric study was also performed and Volumetric Modulated Arc Therapy (VMAT) radiotherapy treatment plans were calculated, to assess the dose received by the uterus according to hypothetical different displacement positions taking the case of irradiation for rectal or anal cancer as model.

RESULTS

A total of 187 studies were included, after the screening 9 studies were selected for synthesis. Data from the dose simulation revealed that the transposition approach was the most protective with a maximum dose of about 3 and 8 Gy for anal and rectal cancer respectively. None of the simulated ventrofixation positions received a Dmean surpassing 14 Gy.

CONCLUSION

According to the literature review and the simulation results of the present study we may conclude are feasible and safe as fertility sparing approach in young rectal/anal cancer patients.

Radiation therapy of cancer in the adolescent and young adult (AYA) generation

Cancer of the adolescent and young adult (AYA) generation has received increasing attention in recent years, however, there were few reports on radiotherapy for this area. As for pediatric cancer, many cancer of the AYA generation were treated with radiation therapy as the multidisciplinary treatment. In this article, we will review reproductive complications, which are considered to be particularly important complications of radiation therapy for AYA generation, and describe investigation of radiation therapy for cancers of the AYA generations at the Hyogo Cancer Center and the Hyogo Ion Beam Medical Center Kobe Proton Center. Germ cells are highly radiosensitive, and even low doses of radiation can cause infertility. Therefore, patients should be treated with sufficient knowledge to prevent fertility. Proton beam therapy for cancer of the AYA generation was useful therapy as pediatric cancer. However, proton beam therapy used less frequently. Insurance coverage, publicity, and access to facilities were considered issues for future study.

Reproductive and Obstetric Outcomes after Fertility-Sparing Treatments for Cervical Cancer: Current Approach and Future Directions

Cervical cancer is one of the leading causes of cancer-related death in women of reproductive age. The established fertility-sparing approaches for the management of early-stage cervical cancer for women who plan pregnancy are associated with a decline in fecundity and an increased risk of pregnancy complications. This article aims to offer an overview of fertility-sparing approaches and the management of potential subfertility and pregnancy complications after these treatments. An extensive search for the available data about infertility and cervical cancer, fertility-sparing techniques in patients with cervical cancer, fertility treatment, obstetrical complications, and pregnancy outcomes in cervical cancer patients was completed. Fertility-preserving procedures such as loop electrosurgical excision procedure (LEEP), cold-knife conization, and trachelectomy in women diagnosed with cervical cancer can be considered as safe and effective treatments that preserve reproductive potential. Current fertility-preserving procedures, based on the balance of the oncological characteristics of patients as well as their desire for reproduction, allow one to obtain acceptable reproductive and obstetric outcomes in women treated for cervical cancer. Nevertheless, careful monitoring of pregnancies obtained after fertility-preserving procedures is recommended, since this cohort of patients should be considered at higher risk compared with a healthy population.

Fertility-sparing options for cancer patients

Fertility preservation is becoming an integral part of cancer care among women of reproductive age. Despite advances in the treatment of pelvic malignancies, all the currently available treatment approaches, including radiotherapy, chemotherapy, and surgery, place women at high risk for future fertility impairment. With improved long-term survival rates associated with cancer, expanding the reproductive options available is of high priority. Several fertility preservation options are available today for women with gynecologic and non-gynecologic malignancies. Depending on the underlying oncological entity, these can include the following procedures whether alone or in combination: oocyte cryopreservation, embryo cryopreservation, ovarian tissue cryopreservation, ovarian transposition, and trachelectomy. The purpose of this review is to provide the most up-to-date information on the aforementioned fertility-preserving approaches and highlight the current challenges, drawbacks, and areas of research where more data are still very necessary to optimize outcomes in young female oncological patients desiring pregnancy in the future.

Synovial sarcoma of the vulva: A case report and literature review with discussion on fertility sparing approaches

•Vulvar synovial sarcoma is a rare malignancy with unclear treatment guidelines but usually includes surgical resection.•Our literature review demonstrates additional survival benefit from addition of radiotherapy to surgical resection.•There is no specific guidance in the literature for the addition of systemic agents to treat vulvovaginal disease.•Our patient received wide surgical excision and IMRT radiotherapy with no signs of recurrence 2 years from treatment.•She conceived after treatment. This has only been documented once before with different, less accessible treatments.

Outcomes of ovarian transposition in cervical cancer; an updated meta-analysis

Background

Cervical cancer is the most common indication for ovarian transposition in reproductive-age women. Ovarian transposition should be performed in premenopausal women undergoing pelvic irradiation to preserve ovarian function, and prevent early menopause. As women become more knowledgeable about their fertility options, it is still unclear who will benefit from the intervention. We updated our previous meta-analysis of ovarian function preservation, symptomatic ovarian cysts, and metastases to the transposed ovaries following ovarian transposition in cervical cancer patients to further guide current clinical practice.

Methods

A systematic search of Medline, Embase, Web of Science, and The Cochrane Library databases, dating from January 1980 to July 2021, was conducted. We computed the summary proportions of women who had ovarian function preservation, non-ovarian cyst formation and metastases to the transposed ovaries following ovarian transposition by random-effects meta-analysis and we explored study heterogeneity by type of radiotherapy.

Results

There were 29 publications reporting on 1160 women with cervical cancer who underwent ovarian transposition. In the group that underwent surgery alone, 91% of the women had preserved ovarian function (95% CI 83–100), 89% (95% CI 80–99) of women who did not develop ovarian cysts, and 99% (95% CI 1–5) of women who did not suffer metastases to the transposed ovaries. In the surgery ± brachytherapy (BR) group, the proportion of women with the preserved ovarian function was 93% (95% CI 76–113), 84% (95% CI 69–103) of women who did not develop ovarian cysts, and 99% (95% CI 82–120) of women who did not suffer metastases to the transposed ovaries. In the external beam pelvic radiotherapy (EBRT) ± BR ± surgery group, the proportion of women with the preserved ovarian function was 61% (95% CI 55–69), and 95% (95% CI 85–107) of women who developed ovarian cysts. There were no metastases to the transposed ovaries in that group.

Conclusions

In women with cervical cancer, ovarian transposition offers a significant preservation of the ovarian function. Despite an expected incidence of ovarian cyst formation, it carries almost no risk for metastases to the transposed ovaries.

Practical Prediction Model for Ovarian Insufficiency after Radiation

OBJECTIVE

 The present study aimed to develop a useful mathematical model that predicts the age at which premature ovarian insufficiency might occur after teletherapy radiation. A diagnosis of premature or early menopause has physical and psychological consequences, so women may need support and long-term medical follow-up.

METHODS

 To correlate ovarian radiation dose with ovarian function, we used the formula described by Wallace et al.: √g(z) = 10^(2-0,15z), where "g(z)" and "z" represent oocyte survival rate and the radiation dose (in Gray), respectively. By simulating different ages and doses, we observed a pattern that could be used to simplify the relationship between radiation dose and remaining time of ovarian function.

RESULTS

 We obtained a linear function between ovarian radiation dose and loss of ovarian function (LOF) that is the percentage of decrease in the time to the ovarian failure compared with the time expected for a woman at the same age without irradiation exposition. For patients < 40 years old and with ovarian radiation doses < 5 Gy, the equation LOF = 2.70 + (11.08 x Dose) can be applied to estimate the decrease in time to premature ovarian insufficiency.

CONCLUSION

 The present study reports a practicable theoretical method to estimate the loss of ovarian function. These findings can potentially improve the management and counseling of young women patients submitted to radiotherapy during their reproductive years.

Comparison of melatonin, oxytetracycline, and N-acetylcysteine pre-treatments in autologous intraperitoneal ovarian transplantation in rats

This study was aimed at investigating the effects of melatonin, oxytetracycline and N-acetylcysteine on the ovarian follicle reserves and surface epithelium in autologous intraperitoneal ovarian transplantation in rats. Thirty adult female Wistar Albino were selected and randomly divided into six groups (n = 5). Group 1, which was the control group, only had their abdomens opened and closed while Group 2 underwent ovarian transplantation. Group 3, 4, 5 and 6 received 20 μg/kg/IM melatonin, 10 mg/kg/IM oxytetracycline, 150 mg/kg/IP N-Asetil sistein (NAC) and 1% ethanol respectively 15 min before the ovarian transplantation. Vaginal cytology was performed to monitor the estrus phase and the follicle reserve and changes in the surface epithelium were histopathologically evaluated during the preparations. Moreover, cellular apoptosis in tissues was evaluated with immunofluorescence staining of Bcl-2 and Bax. The Bax/Bcl-2 ratio was then calculated as the mean fluorescence intensity (MFI) of Bax and Bcl-2 MFI. Dysplastic change was found only significantly higher in the transplantation group (G2) (p < 0.01). Histopathologically, it was found that the follicle reserve was preserved significantly in the oxytetracycline and melatonin treated group (G3, G4) (p < 0.01). It was also observed that the oxytetracycline treated group (G4) were able to show better preventive effects against dysplastic changes of the surface epithelium. Moreover, the melatonin treated group depicted a low Bax/Bcl-2 ratio compared to the group that only underwent transplantation (G2) (p < 0.01). This study indicated that oxytetracycline and melatonin might be more effective than N-acetylcysteine in protecting against oxidative stress during ovarian transplantation.

Radiotherapy dose limit for uterus fertility sparing in curative chemoradiotherapy for rectal cancer

AIMS

Curative sphincter sparing radiotherapy is a treatment option for early rectal cancer. There are many methods developed for fertility preservation in young patients treated with pelvic radiotherapy. Pregnancy rates after radiotherapy are dependent on the radiation dose to ovaries and uterus. Data on outcomes of total body irradiation suggest a pregnancy is possible following 12-14 Gy TBI, despite elevated rates of preterm deliveries and other complications.

METHODS

We report a case of full-term delivery of twins after curative chemoradiotherapy for anorectal adenocarcinoma T2 N0 M0 with the total dose 58.6 Gy. The patient underwent laparoscopic laterocranial ovarian transposition before radiotherapy.

RESULTS

Long term complete remission was achieved after treatment. Although a spontaneous conception was not successful, the patient underwent an in vitro fertilisation procedure with donor eggs and conceived twins 10 years after the radiotherapy treatment. The mean dose to the uterus was 16 Gy and to the uterine cervix 35 Gy. She reached a full-term pregnancy and delivered two healthy babies by caesarean section at a gestational age of 38 weeks, weighing 2420 g and 2220 g.

CONCLUSION

This is the first case report of the successful pregnancy following sphincter sparing curative pelvic radiotherapy for rectal cancer. Furthermore it allows us to propose an increased limit dose to the uterus enabling fertility sparing beyond the limits achieved from total body irradiation series with 12-14 Gy and accept 16 Gy as uterine body (35 Gy for uterine cervix) limit for IMRT treatment planning in young patients asking for maintaining fertility potential.

Fertility preservation in gynecologic cancers

An increasing number of women in modern societies are delaying childbearing beyond the age of 35, and gynecologic cancers affect a significant proportion of reproductive age women who wish to preserve fertility for a future chance of childbearing. As a result, providing treatment options for fertility preservation in women with gynecologic cancer has become a crucial component of cancer survivorship care. In this review article, we discussed the current knowledge on fertility-sparing surgical approaches, as well as assisted reproductive technologies that can be utilized to preserve reproductive potential in women with cervical, endometrial, and ovarian cancer. A brief section on fertility preservation in pediatric gynecologic malignancies is also provided.

Diagnosis, Therapy and Follow-up of Vaginal Cancer and Its Precursors. Guideline of the DGGG and the DKG (S2k-Level, AWMF Registry No. 032/042, October 2018)

Purpose This is an official guideline, published and coordinated by the Gynecological Oncology Working Group (AGO) of the German Cancer Society (DKG) and the German Society for Gynecology and Obstetrics (DGGG). Vaginal cancers are rare tumors, which is why there is very little evidence on these tumors. Knowledge about the optimal clinical management is limited. This first German S2k guideline on vaginal cancer has aimed to compile the most current expert knowledge and offer new recommendations on the appropriate treatment as well as providing pointers about individually adapted therapies with lower morbidity rates than were previously generally available. The purpose of this guideline is also to set up a register to record data on treatment data and the course of disease as a means of obtaining evidence in future. Methods The present S2k guideline was developed by members of the Vulvar und Vaginal Tumors Commission of the AGO in an independently moderated, structured, formal consensus process and the contents were agreed with the mandate holders of the participating scientific societies and organizations. Recommendations To optimize the daily care of patients with vaginal cancer: 1. Monitor the spread pattern; 2. Follow the step-by-step diagnostic workup based on initial stage at detection; 3. As part of individualized clinical therapeutic management of vaginal cancer, follow the sentinel lymph node protocol described here, where possible; 4. Participate in the register study on vaginal cancer.

Error analysis of applicator position for combined internal/external radiation therapy in cervical cancer

The aim of this study was to analyze the error variation in the applicator placement during the first and second radiotherapy session for cervical cancer. We recruited 22 patients with cervical cancer treated with radiotherapy. According to the image output in the first and second CT-Sim inspection, we conducted comparative analysis of image fusion to accurately measure the errors in applicator position in the horizontal (X-), longitudinal (Y-) and vertical (Z)-axes. The calibration processing was implemented in accordance with the data error measured and the location parameters, such as the angle and depth of the applicator. Electronic portal imaging technology (EPID) was used to calibrate posture change amplitude for the extracorporeal irradiation of patients, and dynamic measurement with applicator position was used to describe the error of the parameters. Finally, the data from two measurements in CT-Sim, digital reconstruction radiography (DRR) and EPID were compared. After calibration, the mean value of error of the applicator were significantly smaller. Image registration planning for error parameter calibration of applicator position can effectively reduce the applied horizontal spatial position error in radiotherapy treatment, and improve the accuracy and effectiveness during treatment.

Laparoscopic ovarian transposition prior to pelvic radiation for gynecologic cancer

This study evaluates a novel technique of laparoscopic ovarian transposition performed by Gynecologic Oncologists prior to pelvic radiation for gynecologic cancer. A retrospective review was completed of all patients that underwent laparoscopic ovarian transposition from February 2007 to June 2017 at one tertiary care cancer. The technique involves salpingectomy, followed by retroperitoneal dissection to move the ovaries lateral to the hepatic and splenic flexures of the colon. Normal ovarian function was defined by the absence of vasomotor symptoms, FSH and menstrual history (if menstruating). The radiation dose to the ovary was calculated through dose volume histograms from three-dimensional image planning. Ten patients had laparoscopic ovarian transposition, of which, eight patients received post-operative external beam radiation to the pelvis (45–59.4 Gy). Four had additional brachytherapy (35.5–40 Gy). Median age and follow up were 29 years (18–37), and 20 months (6–103). Nine patients had cervical and one had vaginal cancer. Four patients were treated with primary radiation, three had radical trachelectomy with adjuvant radiation, and three had radical hysterectomy with one of three receiving adjuvant radiation. No patients developed vasomotor symptoms (0/8 (95% CI 0–19%)). FSH was normal in 2/2 patients. Menses continued post-radiation in 5/7 women who retained their uterus. The median radiation dose to the right and left ovary was 0.51 (0.23–1.1) Gy and 0.53 (0.23–1.1) Gy, respectively. Laparoscopic ovarian transposition with mobilization to the hepatic and splenic flexures of the colon achieves preservation of ovarian function in women prior to pelvic radiation.

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Ovarian transposition lateral to the hepatic and splenic flexure

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Median radiation dose to the ovary was 0.51 Gy (right) and 0.53 Gy (left).

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Preservation of ovarian function all women after pelvic radiation

In vitro maturation of human immature oocytes for fertility preservation and research material

Aim

In recent years, the importance of fertility preservation (FP) has increased. In vitro maturation (IVM), an important technique in FP, has started to be used in the clinic, but controversies persist regarding this technique. Here, a survey of IVM for FP is provided.

Methods

Based on a literature review, the applications of FP, methods of FP, IVM of oocytes that had been collected in vivo and ex vivo, maturation of oocytes after IVM for FP, cryopreservation of oocytes for FP, explanation of the procedures to patients, and recent research on FP using IVM were investigated.

Results

Although IVM for FP remains controversial, the application of FP is expected to expand. Depending on the age and disease status of the patient, various methods of oocyte collection and ovarian stimulation, as well as various needle types and aspiration pressures, have been reported. The maturation rate of IVM in FP ranges widely and requires optimization in the future. In regard to cryopreservation for matured oocytes, the vitrification method is currently recommended.

Conclusion

Regarding FP for patients with cancer, the treatment of cancer is prioritized; thus, the time and use of medicines are often constrained. As several key points regarding IVM remain unclear, well‐designed and specific counseling for patients is necessary.

Oncofertility for women with gynecologic malignancies

The emerging field of oncofertility addresses fertility and the reproductive health needs for cancer patients, a key topic in cancer survivorship. Given that the standard treatment for gynecologic malignancies involves removal of reproductive organs, pelvic radiation, or chemotherapy, the effect of such treatment on fertility and options for fertility preservation are even more relevant than for other malignancies. In young women with new diagnoses of cervical, endometrial, or ovarian cancers, viable strategies for fertility preservation without compromising oncological outcome exist and should be considered. We present here a comprehensive review of the literature as it pertains to gynecologic malignancies on 1) the effects of radiation and chemotherapy on fertility, 2) fertility-sparing surgeries and the role of assisted reproductive technology, and 3) fertility preservation in adolescent girls and women with BRCA germline mutations.

Fertility-sparing management in cervical cancer: balancing oncologic outcomes with reproductive success

BACKGROUND

Cervical cancer is the fourth most common cancer among women worldwide, many of who are still within their reproductive lifespan. Advances in screening and treatment have increased the 5-year survival for early stage disease to over 90 % in developed countries. The focus is now shifting to reducing morbidity and improving fertility outcomes for cervical cancer patients. Radical trachelectomy with lymph node assessment became the standard of care for selected women with lesions <2 cm who desire fertility preservation. However, several questions still remain regarding the degree of surgical radicality required for tumors <2 cm, and fertility-sparing options for women with early-stage disesase ≥2 cm, and those with more advanced disease. Here, we compile a narrative review of the evidence for oncologic and pregnancy outcomes following radical trachelectomy, non-radical fertility-sparing surgery, and the use of neoadjuvant chemotherapy prior to surgery for larger lesions. We also review the literature for assisted reproductive technologies in women with more advanced disease.

FINDINGS

Available literature suggests that the crude recurrence and mortality rates after radical trachelectomy are <5 and <2 %, respectively (approx. 11 and 4 % for tumors ≥ 2 cm). Among 1238 patients who underwent fertility-sparing surgery for early cervical cancer there were 469 pregnancies with a 67 % live birth rate. Among 134 cases with lesions ≥ 2 cm, there were ten conceptions with a live birth rate of 70 %. Outcomes after non-radical surgery (simple trachelectomy or cervical conization) are similar, although only applicable among a highly selected patient population. For patients ineligible for fertility-preserving surgery or who require adjuvant radiation therapy, current options include ovarian transposition and cryopreservation of oocytes or embryos but other techniques are under investigation.

CONCLUSION

Today, many cervical cancer survivors have successful pregnancies. For those with early-stage disease, minimally invasive and fertility sparing techniques have resulted in improved obstetrical outcomes without compromising oncologic safety. Results from three ongoing trials on non-radical surgery for low-risk tumors <2 cm will further inform the need for radical surgery in such patients. For those in whom natural childbearing is unachievable, advances in assisted reproductive technologies provide reproductive options. Despite our advances, the effects of cervical cancer survivorship on quality of life are not fully elucidated.

Fertility preservation in women with cervical, endometrial or ovarian cancers

Background

Although cancer in general affects an aged population, a significant number of women develop cancer at childbearing age. Long-term survival rates after gynecological cancer, especially in young patients are increasing and all quality-of-life aspects, including preservation of fertility have become of major relevance.

Outcomes

Surgical techniques aimed at sparing reproductive organs and preserving fertility have been developed for women presenting with gynecological cancer found at early stages. Indications for fertility-sparing surgery are in general restricted to women presenting with a well-differentiated low-grade tumor in its early stages or with low malignant potential. Up to now, use of fertility-sparing techniques in well-selected patients has not been shown to affect overall survival negatively and fertility outcomes reported have been favorable. Still larger amounts of data and longer follow-up periods are needed. Several current fertility-sparing cancer treatments may result in sub-fertility and in those cases assisted reproductive techniques are indicated. Overall quality of life has been satisfactory in cancer patients after fertility-sparing surgery.

Conclusions

Fertility-sparing surgery is a viable tool to enable gynecological cancer patients of young age to fulfill their family building without impairment of oncological outcome. Cancer patients of reproductive age should undergo fertility counseling to analyze this sensitive subject. Further studies are needed to investigate the role of fertility-sparing treatment and combined adjuvant therapy in higher-grade cancers.

Histomorphometric Evaluation of Superovulation Effect on Follicular Development after Autologous Ovarian Transplantation in Mice

The effect of superovulation by pregnant mare serum gonadotropin (PMSG) on autologous transplanted ovaries in the lumbar muscles of mice was histomorphometrically evaluated using the indices of number and volume of different kind of follicles and volume of corpora lutea, ovary, and stroma. Angiogenesis was observed after mouse ovarian transplantation on days 14 and 21 after ovarian grafting. After transplantation, the total number and volume of primary and secondary follicles reduced, while PMSG superovulation increased the total number and total volume of tertiary follicles and also the ovarian volume after transplantation. Transplantation increased the average size of primary, secondary, and tertiary follicles. Therefore, primary and secondary follicles can survive after autologous transplantation but their reservations diminished by increasing the time of transplantation. However, number of tertiary follicles and their response to superovulation increased over time after transplantation.