Advances in fertility-preservation surgery: navigating new frontiers

Abstract

For female patients facing fertility-impairing treatment for select cancers and other medical conditions, fertility-preserving surgeries have evolved to meet the needs of those who desire fertility preservation. Over the last 70 years, advances in surgical options for fertility preservation have vastly increased in scope and availability. Major breakthroughs in fertility-preservation surgeries include the development of ovarian transposition procedures as well as uterine fixation; both procedures move these vital reproductive organs away from radiation fields to help protect and preserve future fertility. Since the first transplantation of thawed cryopreserved ovarian tissue 20 years ago, there have been major advances in techniques to optimize outcomes. Additionally, surgeries specific for gynecologic malignancies, including radical trachelectomy, have allowed for the preservation of vital reproductive organs. This juncture between innovation and technology resulting in fertility-sparing surgical options for cancer patients illustrates both surgical creativity and continued commitment to develop new techniques, while improving those already in practice. This review explores current advancements in fertility-preserving reproductive surgery, highlighting significant historical landmarks and recent major developments. (Fertil Steril Ò 2019;112:438-45. Ó2019 by American Society for Reproductive Medicine.

An update on fertility preservation strategies for women with cancer

“…For this technique, the vascular pedicles between the uterus and ovary (1 or both) are divided, then the ovarian artery and vein isolated, and the ovary is positioned outside of the radiation field and attached to the abdominal sidewall; though there is variation in where the ovaries are transposed, the ideal position is above the pelvic brim, as lateral as possible, to ensure they are out of the field for most radiation treatment plans [13]. After completion of cancer treatment, COH and oocyte retrieval can be performed using a transabdominal approach if the ovary remains above the pelvic brim [13]. Additionally, transposition of one ovary along with cryopreservation of ovarian tissue from the contralateral ovary can be considered.…”

“…Additionally, transposition of one ovary along with cryopreservation of ovarian tissue from the contralateral ovary can be considered. Failures in transposition may still occure either due to scattered radiation above the pelvis or impairment of blood supply to the ovary that ultimately depletes ovarian reserve [13]. It is also possible for the ovaries to migrate back into the field of radiation as evidenced on follow up laparoscopy [14].…”

“…A recent study showed that pregnancy rates approached 30% and live birth rates 23%; other studies confirm rates of 30e40% [22]. Since the initial OTC surgery, approximately 130 live births have been reported after re-implantation of ovarian tissue [13]. Currently, whole ovary transplantation after cryopreservation is not clinically feasible, but may be in the future [13].…”

“…Since the initial OTC surgery, approximately 130 live births have been reported after re-implantation of ovarian tissue [13]. Currently, whole ovary transplantation after cryopreservation is not clinically feasible, but may be in the future [13]. Similarly, isolation and in vitro maturation of primordial follicles from frozen tissue may help avoid the need for re-implantation, reducing potential risk of reintroducing malignancy [23].…”

Fertility-sparing Surgery for Patients with Cervical, Endometrial, and Ovarian Cancers

“…2 Thus, any young woman diagnosed with a gynecologic malignancy should promptly be offered referral to a reproductive endocrinologist and infertility (REI) specialist to discuss options such as oocyte cryopreservation, embryo cryopreservation, or ovarian tissue cryopreservation with future transplantation. 3,4 In addition, patients should be referred to a gynecologic oncologist who is comfortable providing fertility-sparing medical and surgical treatment.…”