Gynecological disorders present a wide variety of diagnostic and treatment challenges, particularly among younger women of reproductive age. Conditions like cervical or ovarian cancers, uterine fibroids, endometriosis and polycystic ovarian syndrome (PCOS) may require treatments ranging from surgery to chemotherapy or radiation. For many, fertility preservation becomes a top priority alongside achieving better health.
Discussing fertility-sparing surgery with your patients should be a natural part of the treatment planning process. As a trusted healthcare provider, it's important to share the facts about fertility preservation while staying realistic about the possibility of achieving pregnancy.
Candidates for Fertility Preservation
Fertility-sparing surgery isn't an appropriate choice for every woman, and selecting ideal candidates for this type of procedure increases the likelihood of successful outcomes. In general, you should review the patient's complete medical history, along with results of any physical examinations or diagnostic tests, before making a recommendation.
Information about a patient's specific gynecological condition, such as cancer, may be used to predict whether pregnancy would even be possible after treatment ends. Fertility preservation is typically most successful among patients with early-stage conditions or those who are least likely to experience disease recurrence.
Fertility Preservation Options
The method of fertility preservation a provider should recommend depends on the health of the patient and the gynecological condition being treated. According to Clinical and Experimental Reproductive Medicine, fertility-sparing surgery options may include:
- Cervical conization: A cone-shaped portion of the cervix is removed. The base of the cone includes a portion of the ectocervix, and the apex is approximately one centimeter from the internal os.
- Ovarian cystectomy: Performed laparoscopically, this surgical procedure precisely removes ovarian cysts with little to no damage to surrounding ovarian tissue.
- Radical trachelectomy: The cervix, medial parametrium and upper two centimeters of the vaginal cuff are removed. This technique preserves the uterus and ovaries.
- Unilateral salpingo-oophorectomy: Only one ovary and fallopian tube are surgically removed in this procedure.
Ovarian transposition may also be a viable option. In this procedure, one or both ovaries together with the fallopian tubes are separated from the uterus. These tissues are surgically attached to the abdominal wall to prevent exposure to harmful therapies like radiation.
Some conditions, such as early-stage endometrial cancer, may be treated using a combination of different medications and close monitoring to promptly identify disease progression.
For a select few young women, high doses of progesterone or gonadotropin-releasing hormone (GnRH) analogs can effectively manage cancer. However, these patients need frequent monitoring since a significant portion of patients relapse after treatment. Transvaginal ultrasound is a safe and efficient method of measuring the thickness of the endometrium, which can be used to determine a patient's response to treatment.
Discussing Fertility-Sparing Surgery With Your Patient
A discussion of fertility preservation options may provide hope for your patient, but it's also important to be realistic about success rates and side effects. The decision to preserve the uterus and ovaries may expose the patient to increased risk for negative outcomes from the gynecological condition itself. It is critical to help your patient weigh the benefits and risks of fertility preservation, especially if the disease is advanced or likely to recur.
Additionally, research on the success rates of various fertility-sparing options is limited. Your patients should understand they may need to use assistive reproductive technologies to achieve pregnancy. Several rounds of in vitro fertilization may be necessary to become pregnant, which can be a difficult experience for the patient.
It's up to the clinician to determine which patients might benefit from fertility-sparing surgery. These procedures aren't a viable option for many, but for others, they offer a chance to become pregnant after a serious gynecological condition. Through an informed discussion about their underlying condition, as well as fertility preservation options and their potential risks, your patient will be empowered to make the best treatment decision for them.
