P–339 Fertility treatment and live birth are still possible following the unexpected diagnosis of endometrial carcinoma/complex hyperplasia - provided that there is careful multidisciplinary team involvement

Study question

Is it safe for young women to delay hysterectomy for endometrial carcinoma or complex hyperplasia, have fertility treatment and carry a pregnancy to term?

Summary answer

Fertility treatment and livebirth are possible after a diagnosis of endometrial carcinoma or complex hyperplasia but close co-operation between fertility and gynae-oncology services is key.

What is known already

While predominantly a disease of postmenopausal women, 7% of cases of endometrial adenocarcinoma or complex hyperplasia occur in women under 40 years. The standard surgical treatment is hysterectomy, which is curative in the majority of cases. In younger women wishing to preserve fertility, conservative treatment may be considered. The fertility outcomes in this population are not well reported, possibly because fertility preservation is not always discussed or considered when faced with the devastating diagnosis of cancer or pre-cancer in the younger woman or because of concerns regarding the impact of pregnancy or ovarian stimulation on a predominantly oestrogen sensitive tumour.

Study design, size, duration

This case series retrospectively evaluated the outcomes of 6 women with endometrial adenocarcinoma or complex hyperplasia who attended Merrion Fertility Clinic, Dublin from 2013 to 2020 and who were managed conservatively. These women initially presented with a history of infertility for which they underwent routine ultrasonography, which then led to hysteroscopy and endometrial biopsy. The histopathology of all 6 women showed an incidental finding of endometrial adenocarcinoma or complex hyperplasia.

Participants/materials, setting, methods

Patient files and a fertility clinic online database were reviewed to identify those with a diagnosis of endometrial carcinoma or complex hyperplasia. Their treatment course and reproductive outcomes were followed up, as was there eventual definitive surgical treatment.

Main results and the role of chance

Six women attending our service over a 7 year period were found to have endometrial adenocarcinoma or hyperplasia. They ranged in age from 34 to 46(mean 39). All were nulliparous. Four of the women had adenocarcinoma and 2 had complex hyperplasia. One woman, aged 41, with grade II endometrial adencocarcinoma was deemed unsuitable for conservative management by the gynaecological oncology team. She underwent urgent total abdominal hysterectomy and is well. The remaining 5 women proceeded with conservative management with oral or local progesterone therapy for 6 to 12 months. This resulted in an inactive endometrium on follow-up endometrial biopsy. Once disease regression was achieved, assisted reproduction in the form of in-vitro fertilization (IVF) was advised to ensure minimal time to pregnancy. Two of the women conceived using own egg IVF and two with donor eggs. All were successful in achieving at least one live birth. One had twins and one had 2 singletons, from a fresh and a frozen embryo transfer. The 6th woman has embryos frozen but has not yet had embryo transfer. Two of the 6 women ultimately had a hysterectomy, while 4 continue to be followed up with 6 monthly endometrial biopsies and progesterone therapy.

Limitations, reasons for caution

This study is limited by the small sample size. However, this paper reports on a niche subset of the population and finding larger sample sizes would be difficult to obtain.

Wider implications of the findings: This case series illustrates the favourable outcome of pregnancy with IVF after either systemic or local progesterone therapy in early stage endometrial adenocarcinoma or complex hyperplasia. Early involvement of a fertility specialist may prove highly valuable in cases of fertility sparing treatment to increase each patient’s potential for pregnancy.

Trial registration number

Not applicable

CA125 measured during menstruation can be misleading

The aim of these case reports and literature review is to report the importance of cyclical variation of serum CA-125 levels in two patients with endometriosis. Two case reports and a literature review of cyclical variation in serum CA-125 levels are discussed. There was significant variation in serum CA-125 levels taken during menses and mid-cycle in these two cases. Serum CA-125 levels increase dramatically during menstruation in women with endometriosis. This is important when assessing disease status.

The role of the cervix in fertility: is it time for a reappraisal?

Knowledge regarding the role of the cervix in fertility has expanded considerably over the past 20 years and in this article, we propose that it is now time for its function to be reappraised. First, we review the anatomy of the cervix and the vaginal ecosystem that it inhabits. Then, we examine the physiology and the role of the cervical mucus. The ongoing mystery of the exact mechanism of the sperm-cervical mucus interaction is reviewed and the key players that may unlock this mystery in the future are discussed. The soluble and cellular biomarkers of the lower female genital tract which are slowly being defined by contemporary research are reviewed. Attempts to standardize these markers, in this milieu, are hindered by the changes that may be attributed to endogenous or exogenous factors such as: age, hormonal changes during the menstrual cycle, ectropion, infection, smoking and exposure to semen during sexual intercourse. We review what is known about the immunology of the cervix. With the widespread use of large loop excision of the transformation zone (LLETZ) for treatment of cervical intraepithelial neoplasia, the anatomy of the cervix is changing for many women. While LLETZ surgery has had very positive effects in the fight against cervical cancer, we debate the impact it could have on a woman's fertility.

Hepatitis C: is there a case for universal screening in pregnancy?

Hepatitis C (HCV) is not routinely screened for antenatally in all maternity hospitals. Most hospitals adopt a policy of targeted screening. The policy in the Coombe Women and Infants University Hospital in Dublin changed from targeted screening in 2006 to universal screening in 2007. We audited the two consecutive years. The prevalence of HCV in our antenatal population was 1.4% for 2006 (67/4666) when targeted screening applied and in 2007--0.71% (66/9222) when universal screening came into affect. One woman in 2007 would not have been detected by targeted screening--1.49% (1/67). Fifty five percent (37/67) of women were HCV-RNA positive in 2006 and 57.5% (38/66) were positive in 2007. We conclude that there were similar detection rates for HCV in 2006 and 2007 and that universal screening is not required if inclusive criteria for selective screening are employed but is of use in research context.

Written consent for intimate examinations undertaken by medical students in the operating theatre--time for national guidelines?

The teaching of pelvic examinations to medical students is a challenge faced by most Obstetricians and Gynaecologists. It is an embarrassing and potentially painful procedure for the woman while she is awake. Elective gynaecological procedures under general anaesthesia are often seen as an ideal opportunity to teach pelvic examinations with least disturbance to the patient. Patients are aware that medical students need to learn and are often quiet willing to assist doctors in this teaching process. In our audit we found that 26% of women did not consent to a pelvic examination by a student while asleep. We also highlight the fact that only five other units in Ireland actually have a dedicated written consent form for patients undergoing intimate examinations under anaesthetic. A significant percentage of women will not agree to such an intimate examination and thus there is an urgent need for a national guideline regarding consent in these circumstances and full compliance.

The management of ectopic pregnancy

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