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.
- 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
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.
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.