Surgical methods to preserve fertility can be divided into attempts to surgically preserve a female reproductive organ affected by a tumor and operations to protect the internal genitals from radiation damage.
If a female reproductive organ is to be preserved when it is affected by a tumor, it is absolutely necessary to carry out a careful risk-benefit analysis and to provide extensive information to the patient.
In this context, there are limited data on trachelectomy for cervical cancer (Covens et al. Cancer 1999, 86:2273-2279; Bernardini et al. Am J Obstet Gynecol 2003, 189:1378-1382), unilateral adnexectomy for malignant germ cell tumors, borderline tumors and early stages of ovarian cancer (Ayhan et al. Eur J Gynaecol Oncol 2003, 24:223-232) as well as for progestin treatment for corpus carcinoma in the stage FIGO Ia and a low degree of proliferation (Kimmig et al. Gynecol Oncol, 1995, 58:255-257; Wang et al. Cancer 2002, 94:2192-2198; Gotlieb et al. Obstet Gynecol 2003, 102:718-725).
If the small pelvis is to be irradiated, the ovaries may be transposed to protect them from radiation since a dose of about 10 Gy or more applied to the pelvis is associated with a high risk of secondary amenorrhea. In a study by Thibaud et al. (J Pediatr, 1992, 121: 880-4), the radiation dose could be reduced to below 9 Gy, which caused ovarian damage in only 2 out of 18 women. However, even much lower doses can lead to ovarian damage which does not cause amenorrhoea immediately but becomes evident only later in the form of premature ovarian failure. Wallace et al. (Hum Reprod, 2003, 18: 117-21) calculated that 50% of the oocytes are destroyed by a radiation dose of < 2 Gray.
As the ovaries are very radiosensitive, it is necessary to luxate the ovaries a long distance away from the radiation field so that any damage from scattered radiation is minimised. This can be done laparotomically or laparoscopically. Apart from the general operation risks, the frequency of the patients developing ovarian cysts is about 25% (Chambers et al. Gynecol Oncol 1990, 39:155-159). The risk of ovarian ischaemia, which led to non-radiation-induced amorrhoea in 4% of patients (Chambers et al. 1990) should be seen as less significant relative to the benefit of the therapy.
FertiPROTEKT favours the laparoscopic transposition of one or both ovaries above the pelvic inlet towards the diaphragm. Once in that position, the ovaries are fixed and marked with a titanium clip for easier subsequent localisation. After the radiotherapy, the ovary is reposed into the pelvis laparoscopically. However, the tubes must be severed for such a transposition, so that a subsequent pregnancy can only be achieved by in vitro fertilisation (IVF). Studies are therefore under way in the FertiPROTEKT network to see whether transposition is also possible without severing the tubes.
Transposition of the ovaries far above the pelvic inlet is a surgical technique only mastered by experienced endoscopic surgeons. In the framework of FertiPROTEKT, therefore, the patients are referred to experienced centers (contacts) when a transposition becomes necessary.