What precautions should a provider take when treating infertility in a young to middle-aged adult female with a history of laparotomy (surgical incision into the abdominal cavity) with pancreatic duodenectomy (removal of the pancreas and duodenum) and splenectomy (removal of the spleen) due to a solid pseudo-papillary neoplasm (a type of pancreatic tumor)?

Precautions for Infertility Treatment in a Patient with History of Pancreatic Duodenectomy and Splenectomy for Solid Pseudopapillary Neoplasm

The provider must prioritize infection prophylaxis due to asplenia, assess for pancreatic insufficiency and diabetes, evaluate fertility preservation options given prior abdominal surgery, and ensure oncologic surveillance is maintained during fertility treatment. 1

Critical Infection Prevention Measures

Vaccination Requirements

• Verify completion of trivalent vaccination (pneumococcus, haemophilus influenzae b, meningococcus) that should have been administered preoperatively. 1, 2 If not previously given, administer immediately before initiating fertility treatment.
• Ensure annual influenza vaccination and consider COVID-19 vaccination to minimize infection risk during potential pregnancy. 1

Antibiotic Prophylaxis

• Counsel the patient on lifelong risk of overwhelming post-splenectomy infection (OPSI), particularly during pregnancy when immune function is altered. 1
• Establish a protocol for immediate antibiotic treatment at first signs of fever or infection during fertility treatment and potential pregnancy.

Metabolic and Endocrine Assessment

Pancreatic Function Evaluation

• Assess for exocrine pancreatic insufficiency with fecal elastase testing, as pancreatic duodenectomy significantly impairs digestive enzyme production. 1
• Screen for diabetes mellitus or impaired glucose tolerance, which commonly develops after pancreatic resection and can affect fertility and pregnancy outcomes. 1
• Optimize pancreatic enzyme replacement therapy and glycemic control before initiating fertility treatment to improve conception rates and pregnancy outcomes.

Nutritional Status

• Evaluate for fat-soluble vitamin deficiencies (A, D, E, K) secondary to pancreatic insufficiency, as these affect reproductive health. 1
• Assess nutritional status including BMI, as malabsorption may impact fertility and pregnancy outcomes.

Fertility-Specific Considerations

Ovarian Reserve Assessment

• Evaluate ovarian reserve with anti-Müllerian hormone (AMH), antral follicle count, and day 3 FSH/estradiol, as prior abdominal surgery and potential adhesions may have affected ovarian blood supply. 1
• Consider the patient's age and time elapsed since surgery when counseling on fertility treatment urgency. 1

Surgical History Impact

• Document extent of adhesions from prior laparotomy, as these may complicate oocyte retrieval procedures or increase risk during pregnancy. 3, 4
• If in vitro fertilization (IVF) is planned, coordinate with reproductive endocrinologist regarding potential technical challenges with transvaginal oocyte retrieval due to adhesions.
• Consider pelvic ultrasound to assess accessibility of ovaries for potential oocyte retrieval. 1

Fertility Treatment Options

• Embryo or oocyte cryopreservation remains the standard fertility preservation approach if the patient desires to delay pregnancy. 1
• Ovarian stimulation protocols using gonadotropins with letrozole or tamoxifen can be safely employed. 1
• Avoid GnRH agonists as primary fertility preservation method, as evidence for ovarian protection is insufficient. 1

Oncologic Surveillance During Fertility Treatment

Recurrence Monitoring

• Maintain surveillance imaging (CT or MRI) every 6-12 months, as solid pseudopapillary neoplasms can recur despite complete resection, though this is rare. 3, 4, 5
• Do not delay oncologic surveillance during fertility treatment, as recurrence typically occurs within 3-5 years post-resection. 3
• Coordinate imaging timing to avoid radiation exposure during potential early pregnancy (use MRI preferentially during fertility treatment cycles). 3, 5

Prognosis Counseling

• Reassure the patient that solid pseudopapillary neoplasms have excellent prognosis with 5-year survival rates approaching 95-100% after complete resection. 4, 6, 5
• Pregnancy is not contraindicated after treatment for solid pseudopapillary neoplasm, as these are low-grade malignancies with minimal recurrence risk after R0 resection. 3, 5

Pregnancy Planning Considerations

Timing of Conception

• Recommend waiting at least 6-12 months post-surgery before attempting conception to allow adequate healing and metabolic stabilization. 1
• Ensure at least 2 years of disease-free surveillance before pregnancy if there were any high-risk features (lymphovascular invasion, positive margins). 3

Contraception During Treatment Optimization

• Prescribe effective contraception (barrier methods or IUDs preferred) while optimizing metabolic status and completing initial oncologic surveillance. 1
• Avoid hormonal contraception if concerns exist about pancreatic endocrine function.

High-Risk Pregnancy Designation

• Counsel that future pregnancy will be considered high-risk requiring multidisciplinary care including maternal-fetal medicine, endocrinology, and surgical oncology. 1
• Establish care coordination between reproductive endocrinology, high-risk obstetrics, and surgical oncology before initiating fertility treatment. 1

Medication Review

Avoid Teratogenic Agents

• Verify the patient is not on any chemotherapy or targeted therapy, though this is unlikely given the benign nature of solid pseudopapillary neoplasms. 1
• Review all medications for pregnancy safety, particularly pancreatic enzyme supplements and diabetes medications if present.

Thromboembolism Risk

• Assess baseline thromboembolism risk, as both asplenia and fertility treatments (particularly ovarian stimulation) increase thrombotic risk. 7
• Consider prophylactic anticoagulation during ovarian stimulation cycles if additional risk factors present. 7

Documentation and Coordination

• Obtain complete operative and pathology reports to confirm R0 resection status and absence of malignant features. 3, 5
• Establish clear communication pathway between fertility specialist, primary oncologist, and primary care provider for coordinated care. 1
• Document informed consent discussion regarding potential pregnancy complications related to surgical history and asplenia. 1