Seminars in Reproductive Medicine

After Radical Trachelectomy: Reproductive and Obstetrical Outcomes of Fertility-Sparing Surgery for Cervical Cancer

AbstractRadical trachelectomy has become an accepted fertility-sparing treatment for patients with early-stage cervical cancer. Despite its oncological safety, radical trachelectomy is associated with persistent sexual dysfunction and voiding issues, complicating long-term quality of life. Fertility outcomes demonstrate overall pregnancy rates ranging from 25.7-73%, with less radical procedures such as conization and simple trachelectomy reporting higher pregnancy rates compared with radical trachelectomy. Assisted reproductive treatments might be necessary due to complications such as cervical stenosis. During pregnancy, there is an elevated risk of miscarriage, preterm delivery, and premature rupture of membranes due to cervical shortening. However, less radical fertility-sparing procedures such as conization and simple trachelectomy demonstrate lower preterm delivery rates. Prophylactic cerclage, as well as close monitoring of cervical length during pregnancy, is essential, and cesarean section remains the recommended method of delivery. Recent studies suggest that less radical fertility-sparing procedures may provide comparable oncological safety while reducing complications, highlighting the need to reevaluate surgical approaches. This review provides an overview of reproductive and obstetrical outcomes in patients after treatment for early-stage cervical cancer with trachelectomy. This review additionally emphasizes the need for further research to refine fertility-sparing strategies.

Fertility Preservation in Women with Cervical Cancer

AbstractCervical cancer (CC) is one of the most common malignancies affecting young women of childbearing age, making fertility preservation (FP) a pivotal consideration in its management. The feasibility of FP techniques depends on the cancer stage and oncological treatments. In early-stage CC, fertility-sparing surgery can be offered for young patients wishing to preserve fertility without compromising oncological safety. Neoadjuvant chemotherapy followed by fertility-sparing surgery is an alternative for patients with nonmetastatic locally advanced disease and negative lymph node status. Nevertheless, for patients with locally advanced disease requiring radical hysterectomy or pelvic radiotherapy, FP can be performed using oocyte, embryo, or ovarian tissue cryopreservation. For these patients, future pregnancy is possible through surrogacy. Recently, uterine transposition has been proposed as an alternative to preserve uterine anatomy to prevent uterine radio-induced damage and avoid surrogacy. This review provides a comprehensive overview of the FP options available for young patients with CC.

Fertility Challenges Facing Women with Early-Stage Endometrial Cancer

AbstractYoung women diagnosed with endometrial cancer may have a fertility wish and may, under certain conditions, be offered fertility-sparing treatment. However, they may also have underlying infertility issues, as anovulation, obesity, polycystic ovary syndrome, and advanced maternal age are often found in women with endometrial cancer or atypical hyperplasia. These fertility issues may hinder pregnancy or prolong the time to pregnancy, in a situation where not much time is allowed to try for a pregnancy. Referral to a reproductive specialist is recommended as early as possible to detect any possible underlying infertility issues that might require assisted reproductive technology once a pregnancy is allowed or may even contradict fertility-sparing treatment. Ovarian reserve testing is a tool used to assess a woman's ovarian reserve, although it cannot, as such, be used to predict the chance of pregnancy. In case of obesity, weight loss is recommended as soon as possible.

Fertility Following Fertility-Sparing Surgery for Borderline Ovarian Tumors

AbstractBorderline ovarian tumors (BOTs) are commonly diagnosed in women of reproductive age, raising concerns about the impact of surgical management on fertility. This review explores the role of fertility-sparing surgery (FSS) and fertility preservation (FP) strategies in young women diagnosed with BOTs. While FSS carries a slightly higher risk of recurrence compared to bilateral salpingo-oophorectomy, there is growing evidence supporting the safety of FSS, with no adverse effects on 10-year overall survival. In light of this, recent multidisciplinary guidelines recommend FSS for BOT at all stages. A significant proportion of women with BOTs report infertility prior to diagnosis, suggesting a possible pathophysiological link between reduced reproductive fitness and the development of BOT. The potential association between ovarian stimulation (OS) and an increased risk of BOT remains controversial, with current evidence failing to establish a definitive causal link. For women with recurrent stage I BOT and no evidence of peritoneal disease on imaging, OS followed by oocyte retrieval is a viable option before definitive surgery. Notably, a history of BOT does not significantly affect pregnancy outcomes following IVF. FP counseling is essential to tailor treatment plans that address both oncological and reproductive needs in patients undergoing FSS for BOT.

The Safety of Hormone Replacement Therapy in Gynecological Cancer Survivors

AbstractTreatment of gynecological cancers often induces a premature menopause. Plus advancing treatments mean more gynecological cancer survivors are living to physiological menopause. Hormone replacement therapy (HRT) has proven substantial long-term benefits in physiological menopause and premature menopause particularly. We aimed to evaluate the current evidence on the safety of HRT in gynecological cancer survivors to help clinicians counsel these patients. HRT is not contraindicated in most gynecological cancer survivors, as evidence available often shows safety or even benefit with HRT use. However, HRT is contraindicated in a few cancers—in low-grade serous ovarian carcinoma, high-risk endometrial carcinoma, and some uterine sarcomas. Caution is advised in high-grade serous, late-stage endometrioid, and granulosa ovarian carcinomas when there is substandard evidence demonstrating safety, but also a theoretical harm present. Due to deficient large randomized controlled trials and methodological biases being present in most studies, HRT use needs to be individualized in most cancers—ovarian carcinomas, endometrial carcinomas, and cervical adenocarcinomas. Justification for HRT use is strong, and HRT is not contraindicated in most gynecological cancers due to largely reassuring evidence. More robust long-term data are needed for further reliable guidance for clinicians and patients.

Fertility-Sparing Treatment in Young Women Diagnosed with Endometrial Cancer: Review of Safety, Pregnancy Outcomes, and Current Recommendations

AbstractWith the rising incidence of endometrial cancer, including among young women, and the trend of increasing age among first-time mothers, the need for safe and effective fertility-sparing treatments for endometrial cancer and atypical endometrial hyperplasia has become crucial. Focusing on studies from the past decade, this review synthesizes findings on the safety and outcomes of fertility-sparing treatments for endometrial cancer and atypical endometrial hyperplasia and provides an overview of current treatment recommendations. Fertility-sparing treatment, including hysteroscopic tumor resection followed by hormonal therapy with oral progestins and/or the insertion of a levonorgestrel-releasing intrauterine device, can be offered to a selected group of women of reproductive age who wish to preserve their ability to become pregnant in the future. The safety of conservative treatment for women diagnosed with Stage 1A, Grade 1 endometrial cancer without myometrial invasion is high; however, current evidence on the safety of this treatment for women with Grade 1, Stage 2 endometrial cancer is limited. Even though the success rate in terms of pregnancies and deliveries is high, it is not as high as in the general population, and women should be informed of the potential need for assisted reproductive technology.

Candidates for Fertility-Sparing Surgery in Case of Ovarian Cancer

AbstractOvarian cancer, a leading cause of gynecological cancer mortality, often affects women of reproductive age. Fertility-sparing surgery (FSS) has emerged as a viable option for selected patients with early-stage ovarian cancer who wish to preserve fertility. Patient and tumor selection criteria focus on preserving ovarian function and reproductive potential without compromising oncological safety. Optimal candidates are young, premenopausal women with disease confined to one ovary and favorable prognostic factors such as early FIGO stage, specific histologic subtypes, and good overall health. FSS typically involves unilateral salpingo-oophorectomy while preserving the uterus and contralateral ovary, achieving survival outcomes comparable to radical surgery in early-stage low-grade tumors. However, its application in higher-risk cases requires cautious evaluation. Multidisciplinary management, involving gynecologic oncologists and reproductive specialists, is essential for successful implementation of FSS, ensuring both oncological safety and preservation of reproductive potential. Long-term follow-up is critical to monitor recurrence and assess reproductive outcomes. Pregnancy after FSS is feasible, with timing guided by cancer type, stage, and individual circumstances. This review summarizes the current knowledge on FSS in ovarian cancer, emphasizing its relevance and the need for further research to refine patient selection and ensure optimal outcomes.