Detailed inform­a­tion and a list of ref­er­ences can be found in Chapter 2.3 of the Fer­ti­PRO­TEKT book, “Indic­a­tions and fertility pre­ser­va­tion methods for onco­lo­gic­al and non-onco­lo­gic­al disorders”, which can be down­loaded free of charge.

Ovarian tumours can be varied in nature. So-called bor­der­line tumours make up 31%, epi­theli­al tumours 50% and malignant germ cell tumours 19% of ovarian tumours in repro­duct­ive age, each of which has a different prognosis.

prognosis

  • Bor­der­line ovarian tumours are mostly dis­covered in the early stages and therefore usually have a good chance of cure.
  • Epi­theli­al ovarian car­cino­mas are unfor­tu­nately usually not dis­covered until a late stage, and then only have a 5‑year survival rate of 42%. With early detection (FIGO stage I), however, it is over 90% and is therefore excellent.
  •  Malignant germ cell and sex cord tumours have a much better chance of cure than epi­theli­al carcinoma.

fertility pre­ser­va­tion problems due to treatment

+ BORDERLINE OVARIAN TUMOURS

Despite very good cure rates, the removal of the affected ovaries and fallopian tubes and removal of tissue in the abdomen is the recom­men­ded treatment, since the post­oper­at­ive residual tumour is also the most important survival factor here. If the patient does not wish to have children, both ovaries should be removed. If the patients wishes to maintain her fertility, the unaf­fected ovary or in the case of bilateral disease, part of the ovary and the uterus can be retained.

+ EARLY OVARIAN CANCER

The adequate surgical treatment of ovarian cancer (also early stage) includes the bilateral removal of the ovaries, the fallopian tubes, the uterus, the caecum and targeted biopsy removal and lymph node removal in the abdomen. One exception is uni­lat­er­al ovarian carcinoma (FIGO IA G1) with a con­cur­rent wish to conceive, where the uterus and the unaf­fected ovary can be tem­por­ar­ily retained after con­sid­er­ing the risks. Fur­ther­more, no chemo­ther­apy is required. Chemo­ther­apy is recom­men­ded for higher tumour stages (later discovery). Depending on the situation, this consists of car­boplat­in for 6 cycles with or without pac­l­it­axel. Addi­tion­al treatment with anti­bod­ies (beva­ci­zu­mab) may be also recommended.

+ MALIGNANT GERM CELL TUMOURS

Only the affected ovary and tissue samples are removed from the abdominal cavity if possible when treating a malignant germ cell tumour. Com­bin­a­tion chemo­ther­apy follows, depending on the stage. Despite surgery and sub­sequent chemo­ther­apy, regular menstrual bleeding returns in 70% of cases with good chances of preserved fertility.

+ MALIGNANT SEX CORD STROMAL TUMOURS

Addi­tion­al endo­metri­al cancer should be ruled by a hys­ter­o­scopy and curettage in patients with a sex cord stromal tumour. Chemo­ther­apy is only recom­men­ded from FIGO stage IC and later and for residual tumours.

The chance of pre­serving the woman’s fertility here generally depends on her age and the existing ovarian reserve.

risks of fertility preservation

hormonal stim­u­la­tion

It needs to be debated whether hormonal stim­u­la­tion with egg col­lec­tion can be con­sidered with a bor­der­line tumour or not, since it is still unclear whether this increases the risk of a relapse.

cryo­con­ser­va­tion of ovarian tissue

Freezing of ovarian tissue is not currently recom­men­ded for ovarian tumours since re-trans­plant­a­tion is dis­cour­aged because of possible tumour cell dis­place­ment. Only when exper­i­ment­al tech­niques for obtaining oocytes from ovarian tissue in a test tube or the trans­plant­a­tion of tissue in other species (e.g. a mouse) become possible, would a pregnancy using frozen tissue be conceivable.

GNRH-AGONISTs

If chemo­ther­apy is planned after pre­serving an ovary, then GnRH agonists should be con­sidered. Impair­ment of the effect­ive­ness of chemo­ther­apy by GnRH agonists has been discussed in the case of hormone-sensitive tumours; however this is rather unlikely.

special aspect of BRCA1 / 2 MUTATIONS

A special aspect in the coun­selling of women with ovarian cancer and fertility is a proven BRCA1 / 2 mutation. After com­ple­tion of family planning, you will be advised to undergo pro­phy­lact­ic removal of both fallopian tubes and ovaries. The indi­vidu­ally increased risk from retaining the ovaries and the risk of passing on the hered­it­ary disorder to your children should be addressed in the consultation.

practical approach if fertility pre­ser­va­tion is considered

After careful selection and good risk coun­selling, fertility pre­serving surgery can also be performed in women with malignant ovarian tumours. Fertility pre­serving surgery with complete staging appears to be sensible and onco­lo­gic­ally safe only in women under 40 years of age who wish to conceive and who have uni­lat­er­al epi­theli­al ovarian cancer (FIGO IA G1) or a bor­der­line tumour.

A stage-adapted approach in com­bin­a­tion with chemo­ther­apy should be con­sidered for malignant germ cell tumours. Ovarian pro­tec­tion with GnRH agonists can be used alongside chemo­ther­apy in these women.

All women should be advised that final­iz­a­tion surgery should be performed when family planning is complete.