What precautions should be taken for a woman of reproductive age with a history of atypical hyperplasia of the endometrium and a Mirena (levonorgestrel-releasing intrauterine system) in place, now seeking infertility treatment?

Management of Atypical Endometrial Hyperplasia with Mirena IUD Prior to Infertility Treatment

Before proceeding with infertility treatment in this patient with a history of atypical hyperplasia treated with Mirena IUD, you must first confirm complete disease regression through repeat endometrial sampling by D&C with hysteroscopy, reviewed by a specialist gynaecopathologist, and obtain pelvic MRI to exclude myometrial invasion. 1, 2

Mandatory Pre-Infertility Treatment Evaluation

Histological Confirmation of Disease Status

• Perform D&C with or without hysteroscopy to obtain adequate tissue for pathological assessment, as this is superior to pipelle biopsy for accurate evaluation 2
• Specialist gynaecopathologist review is essential to confirm complete regression and exclude concurrent carcinoma, which occurs in up to 50% of atypical hyperplasia cases 2
• If any residual atypical hyperplasia or progression to carcinoma is detected, infertility treatment must be deferred 1, 2

Imaging Assessment

• Obtain contrast-enhanced pelvic MRI to exclude myometrial invasion and adnexal involvement before proceeding with fertility treatment 1, 2
• Transvaginal ultrasound should be performed to assess current endometrial thickness and characteristics 1, 3

Critical Counseling Requirements

Informed Consent Discussion

• Explicitly inform the patient that fertility-sparing treatment for atypical hyperplasia is non-standard therapy with significant oncologic risks 1, 2
• Discuss the 50% risk of concurrent endometrial cancer at initial diagnosis of atypical hyperplasia 2
• Explain the 35-40% recurrence rate even after complete response to progestin therapy 2
• Document that the patient accepts close surveillance requirements 1, 2

Post-Pregnancy Planning

• Counsel that hysterectomy with bilateral salpingo-oophorectomy is strongly recommended after completion of childbearing to eliminate future cancer risk 1, 2
• This definitive surgery should be performed even if complete regression was achieved 2

Surveillance Protocol During and After Infertility Treatment

Monitoring Frequency

• Endometrial sampling must be performed every 3 months during any period without pregnancy 2, 3
• More frequent sampling (every 3 months rather than 6 months) is specifically required for atypical hyperplasia compared to non-atypical disease 2

Management of Mirena IUD

• The levonorgestrel-releasing IUD is an acceptable treatment option for atypical hyperplasia per guidelines 1, 2
• However, be aware that case reports document progression to adenocarcinoma despite Mirena treatment 4
• The IUD will need to be removed for conception attempts, requiring alternative surveillance strategies during this period 5

Response Assessment

• If hyperplasia persists or progresses after 6-12 months of treatment, proceed immediately to hysterectomy 2
• Treatment should continue until no pathological changes are observed in two consecutive endometrial biopsies before attempting conception 3

Fertility Treatment Considerations

Timing of Conception Attempts

• Patients with fully regressed disease who wish to become pregnant should be advised to seek assistance through assisted reproductive technologies 3
• Do not delay conception attempts unnecessarily once complete regression is confirmed, as prolonged time increases recurrence risk 2

Specialized Center Requirement

• This patient must be managed at a specialized center with expertise in both reproductive endocrinology and gynecologic oncology 1, 2
• Coordination between fertility specialists and gynecologic oncologists is mandatory 2

Common Pitfalls to Avoid

Inadequate Follow-up

• Failure to perform endometrial sampling every 3 months leads to undetected progression to carcinoma 2
• Do not rely solely on ultrasound monitoring; histological assessment is mandatory 2, 3

Assuming Complete Response

• Even with Mirena in place, do not assume the atypical hyperplasia has regressed without histological confirmation 4
• One case series showed only 72% complete remission rate with levonorgestrel IUD plus GnRH agonist for grade 1 cancer, and 92% for atypical hyperplasia 5

Proceeding Without MRI

• Never proceed with fertility treatment without pelvic MRI to exclude myometrial invasion, as this would indicate progression to invasive cancer requiring immediate hysterectomy 1, 2

Ignoring Contraindications

• Verify no contraindications to continued progestin therapy exist, including history of breast cancer, stroke, myocardial infarction, pulmonary embolism, deep vein thrombosis, or active smoking 2