Surgical Fertility Preservation Before Pelvic Radiation: Time to Replace Oophoropexy with Uterine Transposition?

COMMENTARY Radiotherapy is an essential treatment for some low abdominal malignancies including cervical and endometrial cancer as well as rectal, anal, and bladder malignancies. Radiation, however, affects the ovarian function leading to a reduction in the ovarian reserve, infertility, or premature ovarian failure (POF). Oocytes are indeed very sensitive to radiation injury. To minimize radiation injury to the ovaries, transposing the ovaries (ovarian transposition, ovarian suspension, and oophoropexy) outside the radiation field, especially in reproductive-aged patients has been a standard procedure for a few decades. The effects of radiation to the ovaries depend on a few factors including the amount of radiation, type of radiation, and age. At 20 years old, the estimated dose leading to POF is 16.5 Gy at 20 years old and at 30 years old is 14.3 Gy.[1] Half of the oocytes would be eliminated with 2–4 Gy of radiation.[1] To preserve ovarian function, a few methods have been performed. These include cryopreservation of oocytes, embryos, or ovarian tissue and ovarian transposition.[2] Instead of by laparotomy, today we perform oophoropexy by laparoscopy. Preservation of ovarian function has been reported in over 80% of cases.[3] On a smaller scale and despite advancement in radiation technology and uterine protection by a radiation shield, scattered radiation could still affect the uterine function. This includes damage to the uterine vasculature leading to reduced uterine blood supply, endometrial damage (thinning or scarring), and myometrial fibrosis. Pediatric patients who received direct uterine irradiation had a significant reduction in uterine volume, decreased in endometrial thickness, or uterine artery blood flow without improvement with high-dose estrogen replacement therapy.[4,5] Besides the widespread use of oophoropexy, there is a paucity of information about live births after this procedure. In addition, there has been report of infertility, miscarriages, preterm deliveries, intrauterine growth restriction, and placenta accreta. Although rare, radiation-induced malignancy of the uterus or ovaries can also occur. To minimize radiation injury to the uterus, Ribeiro et al.[6] advocated uterine transposition. Instead of just the ovaries, the uterus and the attached adnexas are transposed to the upper abdomen [Figure 1]. In a prospective study of 8 cases,[7] the technique proved to be feasible and capable of achieving spontaneous pregnancies and successful deliveries, after pelvic radiation for nongynecological cancers.Figure 1: (a) Transposed uterus to the upper abdomen with transparietal suspension sutures pulling the round ligaments by the end of the first procedure. (b) Uterus and adnexa were observed with a suprapubic camera at the start of the repositioning surgery, showing adhesions that keep these structures attached to the anterior abdominal wallWhile ovarian transposition is a simpler procedure to preserve ovarian function, most patients submitted to pelvic radiation with the uterus in situ will have infertility due to uterine factors. In addition, they have a high risk of miscarriages and other obstetrics complications.[8,9] Uterine transposition is a more complex procedure, yet it offers a better chance of spontaneous pregnancy and successful birth. If needed, the patients can still undergo oocyte retrieval and in vitro fertilization (IVF). The procedure could be performed with conventional laparoscopy or robotic-assisted laparoscopy. We call for fertility specialists to consider uterine transposition as one of the tools to help reproductive-aged patients to have spontaneous pregnancy and live births after pelvic radiotherapy, especially if they are prepubertal or have limited access to IVF. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Author contributions RR and TT contributed to conceptualization, writing, editing, and finalizing of the manuscript. All authors have read and agreed to the final version of the manuscript. Data availability statement The datasets generated during and/or analyzed during the current study are publicly available. Financial support and sponsorship Nil. Conflicts of interest Prof. Togas Tulandi , an editorial board member at Gynecology and Minimally Invasive Therapy, had no role in the peer review process of or decision to publish this article. The two authors authors declared no conflicts of interest in writing this paper.

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