fertililty sparing surgeries in gynecological cancers

1. `
PRESENTER :DR SREELASYA K
SRI SIDDHARTHA MEDICAL COLLEGE & RESEARCH HOSPITAL , TUMKUR

2. • Fertility is a key aspect for quality of life for cancer patients of
childbearing age.
• Preservation of fertility is defined as the application of medical,
surgical and laboratory procedures to preserve the potential of
genetic parenthood in adults and children at risk of sterility before the
end of natural reproductive lifespan (Gosden 2009).

3. • Decrease or loss of fertility can take place due to exposure to
medication (chemotherapy), radiation or surgery (e.g. Removal of the
ovaries).
• The American Cancer Society estimates that cancer affects one in
each 3 women living in the United States.
• Modern cancer treatment commonly involve exposure to
chemotherapy and sometimes pelvic radiation.

4. • Advances in the management of gynecological cancers have resulted
in an ever increasing number of women cured of their disease.
• It is estimated that 15-21% of women diagnosed with female genital
tract malignancy are < 40 years of age at the time of diagnosis.

5. List of gynaecological cancers for fertility
sparing surgeries
CERVIX : squamous or adenocarcinoma1A1, 1A2, 1B1
OVARY: epithelial ovarian tumours
borderline ovarian tumours
ENDOMETRIUM: endometrioid

6. CERVICAL CANCER

7. • Cervical cancer is the second most common cancer among women in
developing countries and 7thmost common cancer in developed world.
• More than 5,00,000 new cases of invasive cervical cancers are diagnosed
every year.
• 83% of these occur in developing countries.
• India accounts for estimated 1,26,000 new cases per year with 72,000
deaths.
• More than 25 per cent of women with cervical cancer are under the age of
40 years with an increasing number of them being nulliparous in developed
countries.

8. Transformation zone

9. • Countries with established cervical cancer screening programs have
beer able to markedly reduce incidence of invasive cervical cancer.
• The Pap test has been successful in reducing the incidence of
cervical cancer by 79% and the mortality by 70%.

11. FIGO STAGING OF CARCINOMA CERVIX
• Stage 1 : carcinoma is strictly confined to cervix (extension to the
corpus would be disregarded)
1A : Invasive carcinoma which can be diagnosed only by microscopy,
with deepest invasion ≤ 5mm and largest extension ≤ 7mm
1A1 : measured stromal invasion of ≤ 3mm in depth and extension of ≤
7mm
1A2 : measured stromal invasion of ≥ 3mm and not > 5mm with an
extension of not >7mm

12. • 1B : clinically visible lesions limited to the cervix or preclinical cancers > 1A
• 1B1 : clinically visible lesion ≤ 4 cm in greatest dimension
• 1B2 : clinically visible lesion >4 cm in greatest dimension
• Stage II :
• Invades beyond uterus, but not to the pelvic wall or to the lower third of
the vagina.
• IIA : without parametrial invasion
• IIA1: clinically visible lesion ≤ 4 cm in greatest dimension
• IIA2 : clinically visible lesion >4 cm in greatest dimension
• IIB: without obvious parametrial invasion.

13. • Stage III: extends to the pelvic wall or to the lower third of the vagina
and or causes hydronephrosis or non functioning kidney.
• IIIA: involves lower third of vagina, with no extension to the pelvic wall.
• IIIB : extension to the pelvic wall and or hydronephrosis or non
functioning kidney.
• Stage IV: extended beyond the true pelvis or has involved (biopsy
proven) mucosa of the bladder or rectum.
• IVA: spread of the growth to adjacent organs
• IVB : spread to distant organs.

14. • Till recent past standard surgical treatment for early stage cervical
cancer was radical hysterectomy.
• Advance cases (stage IIb onwards) are managed by chemoradiation.
• However, some of these young patients with early stage cancer (Stage
Ia1, Ia2 and Ib1) are candidates for fertility preserving surgery.

15. •STAGEWISE CONSERVATIVE SURGICAL
PROCEDURE FOR CANCER CERVIX

16. STAGEWISE CONSERVATIVE SURGICAL PROCEDURE
FOR CANCER CERVIX
Stage la (1)
• Microinvasive carcinoma cervix with <3 mm of stromal invasion is
associated with a very low-risk of lymph node metastasis in the
absence of lymph-vascular invasion (0.8% risk of lymph node
metastasis).
• Cervical conisation or large loop excision of transformation zone
(LEETZ) may be the treatment in young patients.

17. Conization
• Conization of the cervix plays an important role in the management of CIN.
• Conization is both a diagnostic and therapeutic procedure and has the
advantage over ablative therapies of providing tissue for further
evaluation to rule out invasive cancer.
• TYPES:
• COLD KNIFE CONIZATION
• LASER CONIZATION
• LLETZ
• LEEP
• NETZ

18. indications
1. limits of lesion not visible(extending >1.5cm into endocervical
canal)
2. Squamo columnar junction not seen colposcopically
3. endocervical curettage positive for CIN 2 or 3
4. discrepency in cytology,biopsy & colposcopy findings
5. suspicion of microinvasion on cytology,colposcopy or biopsy
6. suspicion of endocervical glandular atypia

20. procedure
• can be cold knife cone or using laser or electro surgical wire
• done in ot under GA
• size & shape of cone varies depending on location of lesion
• to reduce blood loss, cx is injected with a vasoconstrictive agent
• cx stained with lugol’s iodine to outline lesion
• some prefer ligating descending cervical arteries by 2 lateral
sutures at 3 & 9’o clock positions
• then cone is taken with scalpel or electrosurgical wire
• cone should be symmetrical around the endocervical canal with
apex in the canal but below the internal os

21. • it is desirable to remove the cone intact in one piece & mark it with
a suture at 12’o clock position
• endocervical curettage is performed above apex of cone to screen
for residual d/s distal to excised specimen
• any bleeding,arrested with cautery,hemostatic sutures
• if margins of cone are free of CIN, conisation is adequate rx,but if
nothysterectomy may be necessary
COMPLICATIONS
a. intra & post op hemorrhage
b. cervical stenosis
c. recurrent miscariage, preterm labour, pprom

22. LARGE LOOP EXCISIONOF THE TRANFORMATION ZONE(LLETZ)
• uses low voltage diathermy
• loop is advanced into cx, lateral to lesion until the reqd depth is
reached.loop is then taken across to the opposite side & a cone of tissue
removed
• loop size <2cm gives better cone than larger one
• low cost,harmless to technician
• requires lesser time to perform than laser
• similar success rates to laser
• prefered over laser

24. LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP)
• simpler than LLETZ,applicable anywhere in the lower
genital tract unlike LLETZ
• now, the most commonly used technique for treatment
of CIN
• >95% cure rate
• simple & safe procedure, done in OPD under Local
anaesthesia,
• the procedure of choice in CIN 2 & 3 (where colposcopy
is satisfactory)
• most important advantage of leep over cryotherapy is
that tissue is available for HPE study no chance of
missing an invasive cancer.

26. Cone biopsy alone
• In microscopic tumours (stage 1A1) the incidence of metastatic nodal
or parametrial disease is extremely small and therefore a simple cone
biopsy has been used for cure for many years.
• Lymphadenectomy is not required and fertility outcomes are
excellent.
• Recent meta-analysis demonstrates that even in these cases there is
an increased premature delivery rate which is related to the
proportion of the cervix that is removed with delivery before 37
weeks of gestation in approximately 11% in comparison to 7% in
untreated controls.

27. • A database study from United States National Cancer (n=1409) did
not find a significant difference in five year survival between those
who underwent conisation (98%) versus hysterectomy (99%) for
microinvasive cancer cervix.
• Cold knife conisation is associated with a small risk of obstetric
complications in subsequent pregnancy such as preterm delivery (RR
2.59), low birth weight (RR 2.53) and cesarean section (RR 3.17).

28. • Risk of recurrence has been estimated to increase from 3.2 to 9.7%
with presence of lymphovascular invasion."
• For conservative management of stage Ia(l) adenocarcinoma data is
limited.
• In a retrospective review of 16 cases of cervical microinvasive
adenocarcinoma managed by conisation, Bisseling et al found no
recurrence over 72 months period.
• Satisfactory tumor-free margin following conisation seems to be the
most significant marker among microinvasive adenocarcinoma
managed by conisation."

29. Stage la(2)
• Microinvasive carcinoma with depth of invasion 3-7 mm is associated with
a higher chances of lymph node metastasis.
• Risk of lymph node metastasis is estimated to be 7%.
• Surgical management of stage la2 includes pelvic lymphadenectomy.
• A radical hysterectomy with bilateral pelvic lymphadenectomy has been
the treatment for this stage till recent past.
• However, in younger patients desirous of preserving fertility a radical
trachelectomy is the treatment.
• This includes removal of cervix along with surrounding parametrium" and
upper 1-2 cm of vagina combined with pelvic lymph node dissection.

30. • Late Professor Daniel Dargent carried out fertility sparing procedure
for invasive cervical cancer in 1986 and reported results in 1994.
• This procedure later became popular by the name 'Radical Vaginal
Trache-lectomy'.
• Procedure comprised of laparoscopic pelvic lymphadenectomy
followed by vaginal excision of cervix, upper vagina and parametrium
and placement of a cervical cerclage suture at isthmus and
approximation of edges of vagina and isthmus.

32. • Removed lymph nodes and endocervical margins are submitted for
frozen section to decide need for radical hysterectomy.
• Approximately 550 cases of cervical cancer managed by radical
vaginal trachelectomy have been reported in literature.
• Subsequently a number of modification have been described to this
procedure these include radical abdominal trachelectomy,
laparoscopic radical trachelectomy and robotic radical trachelectomy.

33. Vaginal Radical Trachelectomy (VRT)
The procedure was described by Daniel Dargent from Lyon, France in 1994.
Following selection criteria was used.
Selection Criteria for Vaginal Radical Trachelectomy
1. Stage Ia1 with vascular invasion, stage Ia(2) and stage Ib(l).
2. Desire to preserve fertility
3. Age < 40 years
4. Lesion < 2-2.5 cm with limited endocervical extension
5. Squamous cell carcinoma or adenocarcinoma
6. No evidence of widespread lymphovascular invasion
7. No evidence of lymph node metastasis
8. Absence of other histologies.

34. Steps of Surgery
1. Laparoscopic pelvic lymph node dissection: Submit lymph nodes for frozen
section.
2. Vaginal radical trachelectomy
a. Circumcision in upper vagina to remove upper 2 cm of vagina
b. Mobilization of bladder
C. dIvision of bladder pillars, avoid injury to ureters
d. Opening of pouch of Douglas
e. Excision of cervix with vagina just below isthmus
f. placing cerclage suture In Isthmus using polypropylene or ethibond suture.

36. POSTOPERATIVE COMPLICATIONS
FOLLOWING VRT
• DYSMENORRHEA
• HEMATOMETRA
• HEMATOSALPINX
• ENDOMETRIOSIS
• 10-15% Cases have been reported to have cervical stenosis

37. CANCER RECURRENCE
• 40% Occur in the parametrium or pelvic side wall indicating
insufficient excision.
• Lymph node recurrences account for 25 percent Oi recurrences ifter
vaginal radical trachelectomy, these include pelvic & para aortic and
supraclavicular lymph node metastasis.
• A study by Eskander has reported 23 (3.9%) recurrences among 582
cases of VRT pooled from 10 reported series.

38. RISK FACTORS FOR RECURRENCE
• lesion size more than 2 cm,
• presence of lymphovascular space involvement
• and nonsqua-mous histology.
• Patients with neuroendocrine histology have much higher risk of
recurrences due to aggressive behavior,
• However, adenocarcinoma and adenosquamous histology has not
been associated with increase recurrence rates.

39. Pregnancy following VRT
• Eskander et al have reported 257 pregnancies among 582 patients from 10
reported series of vaginal radical trachelectomy with 164 live births.
PROBLEMS ASSOCIATED :
• Second trimester abortions
• Preterm labour.
MODE OF DELIVERY:
• Cesarean section is advocated for delivery after vaginal radical trachelec-
tomy in view of cervical cerclage suture and a possibility of lateral cervical
laceration.

40. Abdominal Radical Trachelectomy
An abdominal approach to radical trachelectomy was described by Smith et
al in 1997.
Steps include:
a. Vertical midline incision
b. Bilateral pelvic lymphadenectomy
c. Division of round ligaments
d. Ligation and division of uterine arteries near their origin form internal
iliac Artery
e. Complete ureteric dissection from ureteric tunnel
f. Cul-de-sac is opened and uterosacral ligaments are divided
g. Incision is made in vagina 1-2cm below the level of cervix

41. h. Proximal incision is made in cervix 5 mm below internal OS
i. Trachelectomy specimen is separated and submitted for Frozen
section j. A permanent cerclage is put at the level of isthmus using
prolene or mersilene tape.
k. Edges of vagina and isthmus are approximated using interrupted
sutures with absorbable suture material.

42. Advantages of Abdominal Approach for Radical Trachelectomy
• Shorter learning curve
• In nulliparous patients with narrow vagina abdominal approach makes
the procedure easier.
Disadvantages
• Abdominal incision
• Greater blood loss
• Longer hospital stay
• Ligation of uterine artery.

43. Neoadjuvant chemotherapy and cone biopsy
• In an attempt to reduce morbidity and the radicality of surgery, some
investigators have recommended the use of neoadjuvant chemotherapy
followed by a simple cone biopsy and pelvic lymphadenectomy.
• In the largest series of 21 patients there were no recurrences after a
median follow up of 69 months.
• During this follow up period, 6 patients conceived a total of 10
pregnancies. This option may be worth investigating further and might
allow tumours above 2 cm to be treated in a way that allows a good
prognosis.
• However, chemotherapy will have a damaging effect on ovarian function.
Whether this is partial or complete will depend on the woman’s pre-
existing fertility status, the type of chemotherapy and the dose.

44. Ovarian transposition
• If irradiating the pelvis becomes essential in the management of
cervical cancer, for example, in the presence of pelvic nodal
metastasis or parametrial invasion, ovarian transposition may be
considered.
• Ovaries can be hitched up and sutured to the mid abdominal sidewall
whilst their blood supply is preserved.
• They need to be transposed well above the level of the pelvic brim if
they are to be excluded from the radiation field.
• This procedure may prevent early menopause and ovaries may be
used at a later date for oocyte retrieval, in vitro fertilisation (IVF) and
achieving pregnancy through surrogacy if appropriate..

45. • However there is still a high risk of ovarian failure and oocyte
retrieval should therefore be considered prior to administration of
radiotherapy.
• This does not necessarily result in significant delay in treatment

46. OVARIAN CARCINOMA

47. • Of all the gynecologic cancers, ovarian malignancies represent the
greatest clinical challenge.
• According to estimates in United States there will be 21,880 new
cases of ovarian cancer in the year 2010 with 13,850 deaths.
• Epithelial cancers are the most common ovarian malignancies, and
because they
• are usually asymptomatic until they have metastasized, patients have
advanced disease at
• diagnosis in more than two thirds of the cases

49. EPITHELIAL OVARIAN CANCER

50. • Although majority of women tend to be more than 45 years but as
many as 12 % cases of epithelial ovarian cancer occur in women
younger than 45 years of age.
• Younger patients are likely to have localized disease.
• 5 year survival rates are higher among early stage disease and may be
80 % in younger population.

52. Technique for Surgical Staging
• In patients whose preoperative evaluation suggests a probable
malignancy, a midline or paramedian abdominal incision is recommended
to allow adequate access to theupper abdomen.
• When a malignancy is unexpectedly discovered in a patient who has a
lower transverse incision, the rectus muscles can be either divided or
detached from the symphysis pubis to allow better access to the upper
abdomen.
• If this is not sufficient, the incision can be extended on one side to create a
“J” incision.
• The ovarian tumor should be removed intact, if possible, and a frozen
histologicsection should be obtained.
• If ovarian malignancy is present and the tumor is apparentlyconfined to the
ovaries or the pelvis, thorough surgical staging should be performed.

53. Steps
• Any free fluid, especially in the pelvic cul-de-sac, should be
submitted for cytologic evaluation.
• If no free fluid is present, peritoneal washings should be performed
by instilling and recovering 50 to 100 mL of saline from the pelvic
cul-de-sac, each paracolic gutter, and beneath each hemidiaphragm.

54. • systematic exploration of all the intra-abdominal surfaces and
viscera is performed, proceeding in a clockwise fashion from the
cecum cephalad along the paracolic gutter and the ascending colon
to the right kidney, the liver and gallbladder, the right
hemidiaphragm,
• the entrance to the lesser sac at the para-aortic area, across the
transverse colon to the left hemidiaphragm, down the left gutter and
the descending colon to the rectosigmoid colon.
• The small intestine and its mesentery from the Treitz ligament to
thececum should be inspected.

55. • Any suspicious areas or adhesions on the peritoneal surfaces should be
biopsied. If there is no evidence of disease, multiple intraperitoneal
biopsies should be performed.
• Tissue from the peritoneum of the pelvic cul-de-sac, both paracolic gutters,
the peritoneum over the bladder, and the intestinal mesenteries should be
taken for biopsy.
• The diaphragm should be sampled either by biopsy or by scraping with a
tongue depressor and obtaining a sample for cytologic assessment.
• Biopsies of any irregularities on the surface of the diaphragm can be
facilitated by use of the laparoscope and the associated biopsy instrument.

56. • The omentum should be resected from the transverse colon, a
procedure called an infracolic omentectomy.
• The retroperitoneal spaces should be explored to evaluate the pelvic
and paraaortic lymph nodes.
• Any enlarged lymph nodes should be resected and submitted for
frozen section. If no metastases are present, a formal pelvic
lymphadenectomy should be performed. The paraaortic area should
be explored

57. FIGO STAGING OF CARCINOMA
OVARY

58. •STAGE 1 : Tumour confined to the ovaries
• 1A – Tumour limited to one ovary, capsule intact, no tumour
on surface, negative washings
• 1B – Tumour involves both ovaries otherwise like 1A
• 1C – Tumour limited to one or both ovaries
• 1C1 - Surgical spill
• 1C2 - Capsule rupture before surgery or the tumour is on the
ovarian surface
• 1C3 – Malignant cells in the ascites or peritoneal washings

59. •STAGE II : Tumour involves one or both ovaries with
pelvic extension [below pelvic brim] or primary
peritoneal cancer
• IIA – Extension and/or implant on uterus and/or fallopian tubes
• IIB – Extension to other pelvic intraperitoneal tissues

60. • STAGE III : Tumour involves one or both ovaries with cytologically or
histologically confirmed spread to the peritoneum outside the pelvis
and/or metastasis to the retroperitoneal lymph nodes
• IIIA [Positive retroperitoneal lymph nodes and/or microscopic
metastasis beyond the pelvis]
• IIIA1 - Positive retroperitoneal lymph nodes only
• IIIA1(i) – Metastasis ≤ 10mm
• IIIA1(ii) – Metastasis > 10mm
• IIIA2 - Microscopic, extrapelvic [above the brim] and peritoneal
involvement +/-
positive retroperitoneal lymph nodes

61. • IIIB - Macroscopic, extrapelvic, peritoneal metastasis ≤ 2cm +/-
positive retro peritoneal lymph nodes.
Includes extension to capsule of liver or spleen.
• IIIC - Macroscopic, extrapelvic, peritoneal metastasis > 2cm +/-
positive retro peritoneal lymph nodes.
Includes extension to capsule of liver and spleen.

62. •STAGE IV : Distant metastasis excluding peritoneal
metastasis
•IVA - Pleural effusion with positive cytology
•IVB - Hepatic and/or splenic parenchymal
metastasis, metastasis to extra abdominal organs
[including inguinal lymph nodes and lymph nodes
outside the abdominal cavity.]

63. • Majority of women suffering from ovarian carcinoma are managed by
total abdominal hysterectomy, bilateral salpingo-oophorectomy, infra-
colic omnectomy, pelvic +/- para-aortic lymphadenectomy and
multiple peritoneal biopsies.
• However, cases of stage la and Ic are candidates for conservative
surgery in the form of unilateral salpingo-oophorectomy with
adequate surgical staging.

64. • Studies on conservative management of epithelial ovarian cancer are
limited.
• Eskander et al (2011) have published combined results of 8 series
reported in literature with fertility sparing surgery in patients with
invasive epithelial ovarian cancer.
• Among a total of 328 cases there were 119 pregnancies, 104 live
births and 42 recurrences with 20 deaths."

65. BORDERLINE OVARIAN TUMOURS

66. • Borderline ovarian rumors are subset of epithelial ovarian tumors charac-
terized by abnormal epithelial proliferation but lack of stromal invasion.
• They comprise 10-15 percent of ovarian cancers.
• Most borderline ovarian tumors tend to be serous or mucinous in
histology.
• Median age at diagnosis is 45 with 34 percent of patients being less than
40 years of age.
• In majority of patients with stage I borderline ovarian tumor 10 years
survival is as high as 90 percent.

67. • Given the low recurrence rates, patients with borderline ovarian
tumor are suitable candidates for conservative surgery in the form
of unilateral salpingo-oophorectomy combined surgical staging.
• Ovarian cystectomy can also be undertaken, however, recurrence
rates from 36 % have been noted among borderline ovarian tumors
managed by conservative surgery.32

68. • Eskander et al (2011) in a 1 meta analysis of 10 published series of
borderline ovarian tumor managed by fertility preserving surgery
noted 185 pregnancies, 107 live births, 111 recurrences and one
death among 626 subjects.

69. GERM CELL TUMOURS

70. • Malignant germ cell tumors of ovary are a class of tumor with
biological behavior quite different from epithelial ovarian cancers.
• They comprise 5 percent of all ovarian malignancies. They mostly
occur in young adolescent or teenage girls.
• It is uncommon to see germ cell tumors in women older than 25 years
of age

72. • most of germ cell tumors of ovary tend to be unilateral except
dysgerminoma which may be bilateral in 15 percent of cases.
• These tumor secrete tumor markers such as alpha-fetoprotein,
human chorionic gonadotropin, lactic dehydrogenase making
diagnosis easy and also help in follow-up.
• They show excellent response to chemotherapy, cure rates reach
almost 100 percent in early stage disease and 75 percent for those
with advance disease.

73. • Most girls managed by conservative surgery and effective chemotherapy
(Bleomycin-Etopocide-Cisplatin) resume there menses and achieve
pregnancies following complete treatment.
• Such a good outcome following treatment makes girls with malignant germ
cell tumors of ovary ideal candidate for conservative surgical procedure.
• Unilateral salpingo-oophorectomy with adequate surgical staging
comprising of infracolic omnectomy, ipsilateral pelvic and para-aortic
lymphadenectomy offers excellent hope for return of reproductive func-
tion.
• Most patients are treated by adjuvant chemotherapy comprising of
bleomycin, etopocide and cisplatin (BEP).

74. • Only cases of stage la dysgerminoma or stage la malignant teratoma with
Norris class I can be treated by surgery alone and avoiding chemotherapy.
• For bilateral germ cell tumors of ovary also fertility preservation is possible
and should be attempted.
• It comprises of saving normal looking portion of the ovary on the side with
smaller tumor while removing the ovary with larger tumor.
• Uterus should be retained in all cases, IVF with ovum donation can offer
hope of pregnancy to those where both ovaries need to be removed.
• Eskander et al11 in a review has reported 185 pregnancies, 148 live births,
46 recurrences and 17 deaths among 453 patients pooled form 7 reported
series.

78. • Sex Cord Stromal Tumors of Ovary
• Sex cord stromal tumors generally occurs in postmenopausal women.
• However, granulosa cell tumor, Sertoli-Leydig cell tumors can been
seen in young patients and women in reproductive age group.
• Granulosa cell tumor is the most common sex cord tumor seen in
women of reproductive age.
• Histologically two varieties are seen, adult type or juvenile type of
granulosa cell tumors with different biological behaviors.

79. • Up to 95 percent of granulosa cell tumors are unilateral and 95
percent are stage I.
• Fertility preserving surgery is possible in young patients with
granulosa cell tumor.
• Patients with advance stage disease need cisplatin based chemo-
therapy.
• Pregnancies have been reported in case reports following successful
treatment of sex cord stromal tumors

80. • Cryopreservation of oocyte, embryos, and whole ovarian tissue prior
to chemotherapy or radiation therapy has been investigated as
fertility preserving method in women with cancer.

81. ENDOMETRIAL CANCER

82. • Six percent of endometrial cancers are diagnosed in women under the age
of 50 years
• 29Hysterectomy and bilateral salpingooophorectomy plus or minus lymph
node dissection is the standard surgical treatment for endometrial cancer.
• Progesterone treatment
• Stage IA endometrial cancer
• There have been reports of the use of progestogens as conservative
treatment in the management ofvery early-stage endometrial cancer in
young women as a fertility-preserving treatment.
• Kaku et al.31 assessed the outcome of nine women with stage IA (tumour
confined within the endometrium), grade 1 endometrial cancer treated
with megestrol acetate, tamoxifen and gonadotrophin-releasing hormone
analogue.
• Eight of the nine women achieved complete remission following treatment

83. • Another important factor is the high recurrence rate following
conservative treatment for endometrial cancer.
• A recent study by Ushijima et al.assessed 28 women with presumed
stage IA endometrial cancer and 17 women with atypical hyperplasia.
• The women were given 600 mg medroxyprogesterone acetate daily
for 26 weeks. A complete response was reported in 55% of the
women with endometrial carcinoma and 82% of the women with
atypical hyperplasia. A recurrence rate of 47% was documented.
• Other studies have also demonstrated high recurrence rates, of 25%.

84. • Successful pregnancy has occurred in women treated conservatively
with progesterones.
• In the paper by Ushijima et al.,38 12 pregnancies and 7 normal
deliveries were achieved in 28 women during a 3-year follow-up
period.

85. STORAGE OF OOCYTES AND
EMBRYOS

86. • Where fertility sparing surgery is not appropriate, it may occasionally
be feasible to offer ovarian tissue retrieval and cryopreservation,
ovarian stimulation and oocyte retrieval and/or IVF and embryo
cryopreservation.
• Surrogacy will be required to achieve a pregnancy if the uterus is
removed.
• Assisted conception techniques would usually be undertaken in the
window between primary surgery and the start of chemotherapy or
radiotherapy

87. `
• only carries a 3–5% chance of resulting in a successful pregnancy per
frozen egg.
• Embryo cryopreservation following IVF is a routine procedure in
fertility clinics; however, there are few data on its success rates in the
context of fertility preservation in women with gynaecological
cancers.