How Gynaecological Cancer Affects Fertility and the Importance of Early Preservation Counselling - Dr Sindhu V A

Gynaecological cancer directly affects fertility, as treatment consists of surgical removal of the reproductive system and/or exposure to gonadotoxic agents.

International guidelines recommend that physicians discuss, as early as possible, with all patients of reproductive age, their risk of infertility from the disease and/or treatment and their interest in having children after cancer, and help with informed fertility preservation decisions.

As recommended by the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), sperm cryopreservation and embryo/oocyte cryopreservation are standard strategies for fertility preservation in male and female patients, respectively.

Interest in fertility preservation has increased in recent decades, both because of late pregnancies and because of the higher incidence of cancer in young people. The incidence rate of all cancers increased by 29% between 1973 and 2015 in adolescents and young adults of both sexes. Cervical cancer in women aged 20-29 years increased annually by an average of 10.3% between 2000 and 2009.

Onco-fertility counselling should be individualized, discussing both the absolute benefits and risks for each individual based on age, comorbidities, ovarian reserve in women and the sterilizing potential of the treatment proposed. The multidisciplinary discussion with clinical oncologist, radiotherapist, pathologist and psychologist is important for therapeutic planning and follow-up. In early stages, conservative surgeries are the first fertility-sparing options. However, it may be necessary to add fertility preservation techniques that include oocyte, embryo or ovarian tissue cryopreservation.

Cervical Cancer

It affects young women and has high incidence and mortality rates. Women with early-stage (IA1-IB1) cervical cancer may be candidates for fertility-sparing cervical conization, simple trachelectomy, or radical trachelectomy.

Conization: In stage IA1 without LVSI, conization or trachelectomy with surgical margins free of tumour and free of HSIL serves as diagnosis and treatment in women who wish to preserve the uterus.

Radical trachelectomy with pelvic lymphadenectomy: The preferred treatment in stages IA1 with LVSI, IA2 and IB1 with or without LVSI.

The criteria include reproductive age, desire to preserve fertility, tumours of up to 2 cm, squamous, adenocarcinoma and adenosquamous histological types, absence of parametrial invasion, lymph node metastasis and infertility. Other histological types, such as neuroendocrine and non-human papillomavirus (HPV)-associated adenocarcinoma are contraindicated for conservative treatment. MRI is the best imaging method to assess the preoperative extent of the neoplasm, lymph node metastasis, and parametrial invasion.

Sentinel lymph node mapping is recommended for the identification of low-volume metastases (isolated tumour cells and micrometastases). Intraoperative frozen section has the advantage of contraindicating surgery, in addition to allowing ovarian transposition in the same surgery. The disadvantage is the risk of not identifying low-volume metastases. In patients with tumours larger than 2 cm, neoadjuvant chemotherapy is an option.

Recurrence rates following fertility sparing surgery were associated with tumour size greater than 2 cm and LVSI.

Follow up is every 3-4 months in the first two years, every six months from the third to the fifth year, and annually thereafter. In addition to physical examination, cervicovaginal cytology is recommended annually. A follow-up period of 6-12 months is advised for pregnancy. There is no indication of radical treatment after pregnancy.

Endometrical Cancer

It mainly affects postmenopausal women, even though 4% occur before the age of 40 years and 6.4% between 20 and 44 years of age. In these age groups, tumours are generally well differentiated. Fertility preservation is limited to the well-differentiated endometrioid histological type (G1), stage IA without myometrial infiltration.

MRI is the imaging method that best defines myometrial invasion, cervical invasion, and lymph node metastasis. The preferred conservative treatment is hormonal with oral systemic progestogen, such as medroxyprogesterone acetate (MPA) or megestrol acetate (MA), or with an intrauterine levonorgestrel device (LNG-IUD).

The risk of recurrence or persistent disease is greater with conservative treatment compared to hysterectomy, and surgical staging is indicated after pregnancy. Even at a presumed early stage, the risk of synchronous ovarian cancer is 4-25% in women younger than 45 years.

Ovarian Cancer

Suspicious ovarian lesions are managed in two steps in patients who wish to maintain fertility, awaiting the definitive histopathology for decision-making. Fertility-sparing surgery provides for preservation of the uterus with or without preservation of the contralateral adnexa. It is acceptable in young patients with low-grade stage IA epithelial histology (G1 and G2), non-epithelial germ cell and sex cord stromal histology stage IA/IC and low malignant potential (borderline) tumours.

In stage I, survival rates reach 99%, and unilateral salpingo- oophorectomy associated with collection of peritoneal lavage, omentectomy and biopsy of any peritoneal alteration is the conservative treatment option. Considering that the definitive histologic diagnosis may change the therapeutic plan, oocyte or embryo cryopreservation is advised in patients with an ovarian tumour suspected of malignancy.

Criteria for patient selection for fertility-sparing therapy are not well-defined, thus patients and providers must carefully discuss potential risks and benefits. In general, in carefully selected patients, survival outcomes do not appear to differ significantly between radical and fertility-sparing approaches.

Preconception counselling with high-risk obstetric specialists is important to optimize health before a woman attempts to conceive. Identifying appropriate candidates for fertility-sparing treatments, assessing fertility potential, and helping women conceive after cancer treatment is best accomplished through multidisciplinary collaboration between gynaecologic oncologists and fertility specialists.