Fertility-Preserving Surgeries in Gynecologic Oncology
For young women with gynecologic malignancies, unilateral salpingo-oophorectomy with surgical staging is the recommended fertility-sparing surgical approach for early-stage ovarian cancer, while radical trachelectomy is appropriate for early-stage cervical cancer (stage IA2-IB, ≤2 cm diameter, ≤10 mm invasion), and these patients must be managed in specialized oncofertility clinics. 1
Ovarian Cancer: Surgical Options
Unilateral salpingo-oophorectomy with complete surgical staging is the standard fertility-sparing procedure for appropriately selected patients 1. This approach is safe for:
- Borderline tumors (all stages)
- Non-epithelial tumors (germ cell, sex cord-stromal)
- Stage IA low-grade epithelial cancers (serous, endometrioid, or mucinous expansile subtype)
- Selected IC1 stage disease
The procedure preserves the uterus and contralateral ovary while removing the affected adnexa. Do not biopsy the unaffected ovary unless there is visible suspicion of involvement 1. Minimally invasive surgery is acceptable if tumor rupture can be avoided 1.
Critical exclusion criteria: High-grade serous carcinoma, clear cell carcinoma, high-grade endometrioid carcinoma, and infiltrative mucinous subtypes require complete surgical resection including hysterectomy and bilateral salpingo-oophorectomy 1.
Cervical Cancer: Surgical Options
Radical trachelectomy (surgical removal of the cervix while preserving the uterus) should be restricted to 2:
- Stage IA2 to IB disease
- Tumor diameter ≤2 cm
- Invasion depth ≤10 mm
- Negative lymph nodes (pelvic node dissection required first)
- No lymphovascular space invasion (relative contraindication)
The procedure can be performed vaginally with laparoscopic assistance or abdominally (laparotomy, laparoscopy, or robotic-assisted) 3. Simple conization may be sufficient for smaller lesions meeting strict criteria.
Important caveat: Radical trachelectomy carries increased risk of mid-trimester pregnancy loss and preterm birth. Cervical stenosis may require assisted reproductive technology for conception 4.
Endometrial Cancer: Conservative Management
For early-stage, low-grade endometrial cancer, fertility-sparing treatment involves:
- Hysteroscopic resection or dilation and curettage
- High-dose progestin therapy (not surgical, but part of conservative approach)
Strict MRI criteria required: Tumor confined to endometrium without myometrial invasion, no cervical stromal invasion, no evidence of metastasis 5.
Ovarian Transposition (Oophoropexy)
When pelvic radiation is planned, ovarian transposition can be offered 2:
- Surgically relocate ovaries outside the radiation field
- Perform as close to radiation treatment as possible (risk of remigration)
- Success rate approximately 50% for preserving ovarian function
- Radiation scatter may still affect transposed ovaries
Limitation: If IVF is later needed, oocyte retrieval becomes technically challenging and may require surgical repositioning 4.
Gamete Preservation: Preferred Over Tissue
Cryopreservation of oocytes or embryos is preferred over ovarian tissue cryopreservation in patients who can undergo ovarian stimulation 1. The 2024 ESGO-ESMO-ESP consensus specifically recommends gamete cryopreservation rather than ovarian tissue when feasible 1.
Timing considerations: Modern flexible ovarian stimulation protocols no longer depend on menstrual cycle timing, allowing cycle day-independent scheduling 2. For estrogen-sensitive cancers, aromatase inhibitor-based protocols (letrozole) can be used 2, 6.
Essential Management Framework
All patients must be managed in oncofertility clinics with multidisciplinary teams including gynecologic oncologists and reproductive specialists 1. This is a Grade A recommendation with 97% consensus.
Pre-surgical assessment requirements:
- Ultrasound expert evaluation or IOTA ADNEX model with CA-125 1
- MRI for tumor characterization and extent 5
- Comprehensive surgical staging at time of fertility-sparing procedure
- Frozen section analysis when appropriate
Critical pitfall: Fertility-sparing surgery is only appropriate for early-stage disease with favorable prognostic factors. Tumor size >2 cm, lymphovascular space invasion, and higher-stage disease significantly increase recurrence risk and are relative or absolute contraindications 7, 8.
What NOT to Rely On
GnRH agonists should NOT be relied upon for fertility preservation 2. While the 2018 ASCO update suggests GnRHa may be offered when proven methods aren't feasible (specifically in young women with breast cancer), this remains controversial and should not replace established fertility preservation methods 6.
Ovarian tissue cryopreservation remains experimental in most contexts, though increasingly accepted. It's primarily reserved for prepubertal patients or when immediate cancer treatment is required without time for ovarian stimulation 2, 9.