Infertility is a well-recognized short- and long-term consequence of cancer treatment. For young patients, particularly women diagnosed with gynecological malignancies, the ability to preserve fertility is of paramount importance. Beyond medical outcomes, fertility preservation directly impacts psychosocial wellbeing, as most patients express a strong preference for biological parenthood over alternatives such as adoption or surrogacy.
At a recent seminar at KCTRI, Hubli, organised by Fertility Preservation Society of India (FPSI) Dr. Pavan Kumar C G addressed the principles, techniques, and clinical evidence behind fertility-sparing surgeries (FSS) in gynecological cancers, underscoring their role in balancing oncologic safety with reproductive potential.
Cervical Cancer and Fertility Preservation
Cervical cancer remains one of the most common gynecological malignancies in women under 40 years of age.
Standard Treatment: Radical hysterectomy with systematic pelvic dissection.
Fertility-Sparing Options:
- Cold Knife Conization: Excision of the transformation zone and part of the endocervical canal, preferred for stage IA1 without LVSI.
- Simple Trachelectomy: Supravaginal amputation of the cervix in cases where conization is not feasible.
- Radical Trachelectomy: Vaginal, abdominal, laparoscopic, or robotic approach for stage IA2–IB1 (<2 cm).
Key Considerations
Oncologic selection criteria: Tumor size ≤2 cm, absence of LVSI, and negative nodes.
Neoadjuvant Chemotherapy (NACT): In investigational settings, NACT may downstage larger tumors (2–4 cm) to make them amenable to fertility-sparing surgery.
Fertility Outcomes: Patients undergoing trachelectomy may achieve successful pregnancies, though prematurity and infertility remain concerns.
Ovarian Cancer: FSS in Early-Stage Disease
For ovarian malignancies, fertility preservation is primarily considered in stage I tumors confined to one ovary with low-grade histology.
Epithelial Ovarian Cancer: FSS can be considered if comprehensive staging is performed.
Borderline Ovarian Tumors: Fertility-sparing management is widely accepted, given their indolent behavior.
Non-Epithelial Tumors: Germ cell and sex-cord stromal tumors are particularly amenable to fertility-sparing surgery due to favorable oncologic outcomes.
Outcomes
Most women retain normal menstruation and ovulation after unilateral oophorectomy.
Conception rates range between 50–70%, often spontaneously, though assisted reproduction may be needed in some cases.
Obstetric outcomes are generally favorable, with no increased miscarriage risk attributable to surgery.
Endometrial Cancer: Emerging Fertility-Sparing Strategies
Traditionally managed with hysterectomy, select early-stage endometrial cancers in young women may be treated with conservative approaches.
Hormonal Therapy: Progestin therapy alone or in combination with hysteroscopic resection.
Response Rates: Up to 70% complete remission at 6 months, with live birth rates exceeding 65% in reported series.
Limitations: Non-response or progression mandates early hysterectomy.
Innovative Approaches: Uterine Transposition
For patients requiring pelvic radiotherapy, uterine and ovarian transposition has been explored.
The uterus is surgically mobilized and relocated to the upper abdomen during radiation therapy.
Post-treatment, it may be repositioned in the pelvis and reattached to the vagina.
Early feasibility studies show encouraging outcomes, though long-term oncological safety remains under evaluation.
Conclusion
Fertility-sparing surgery represents a paradigm shift in the management of gynecological cancers—prioritizing oncologic safety while addressing reproductive aspirations.
Careful patient selection, multidisciplinary evaluation, and long-term follow-up are critical.
Minimally invasive and robotic techniques further enhance safety and recovery.
With growing evidence and technological advances, fertility preservation is no longer an exception but an integral component of modern oncologic care.
Seminar by Dr. Pavan Kumar C G, Consultant Surgical Oncologist, SDM Dharwad
Venue: Karnataka Cancer Therapy & Research Institute (KCTRI), Hubli