Fer­til­ity in women diag­nosed with bor­der­line ovar­ian tumors can be reduced or lost due to sur­gi­cal treat­ment. Coun­sel­ing regard­ing fer­til­ity preser­va­tion shortly after diag­no­sis can increase the chance of preg­nancy fol­low­ing treatment.

Borderline-low malig­nant poten­tial ovar­ian tumors

The cells in bor­der­line tumors, pro­lif­er­ate more than benign ovar­ian cysts but less than frank malig­nant ovar­ian tumors. Mul­ti­ple lay­ers of these cells are seen on pathol­ogy slides, but they do not invade sur­round­ing tis­sues as in malig­nant tumors. They are diag­nosed in approximately4000 of women each year in the US and are more com­monly encoun­tered in repro­duc­tive age women. These tumors are usu­ally cys­tic, some­times with sur­round­ing implants. Low malig­nant poten­tial tumors are treated sur­gi­cally (removal of cyst, removal of the ovary or some­times removal of both ovaries and the uterus). They gen­er­ally do not require chemother­apy for treat­ment. The major­ity of these tumors are asso­ci­ated with very high sur­vival (10 year sur­vival >90% in stage I and II ), although some may recur or turn malignant.

There is no dif­fer­ence in sur­vival if bor­der­line tumors were treated with removal of the cyst, removal of the ovary or removal of the uterus and both ovaries. Recur­rence may be lower after hys­terec­tomy (5%) com­pared to salp­in­goophorec­tomy (15%) and cyst exci­sion (30%). The high rate for recur­rence after con­ser­v­a­tive surgery indi­cates the need for strict and long term fol­low up (pelvic exams, ultra­sound and tumor mark­ers). Some recur­rences take place years after ini­tial surgery and are some­times malignant.

Fer­til­ity risks in women diag­nosed with bor­der­line tumors

Fer­til­ity risks in women diag­nosed with low malig­nant poten­tial ovar­ian tumors include loss of ovar­ian tis­sue and pelvic scar­ring that can block the fal­lop­ian tubes espe­cially if open approach is used for treat­ment com­pared to laparoscopy (min­i­mal acess surgery). Some loss of ovar­ian tis­sue does occur even dur­ing cyst removal from the ovary. Ovar­ian reserve can be tested after surgery using trans­vagi­nal ultra­sound eval­u­a­tion for ovar­ian vol­ume and num­ber of antral fol­li­cles. Ovar­ian func­tion can also be assessed using day 2 FSH and estra­diol lev­els and antim­ul­ler­ian hormone.

Fer­til­ity preser­va­tion strate­gies in women diag­nosed with bor­der­line ovar­ian tumors

1. Con­ser­v­a­tive surgery

Ovar­ian cys­tec­tomy can be con­sid­ered in repro­duc­tive age women, espe­cially in early dis­ease with favor­able pathol­ogy and absence of implants. Recur­rence is rel­a­tively high but can be man­aged with repeat exci­sion if not malig­nant. If preg­nancy is desired fol­low­ing surgery, fer­til­ity fac­tors; ovu­la­tion, fal­lop­ian tubes and sperm fac­tors should be inves­ti­gated and treated accordingly

2. Embryo and oocyte cryopreservation

Women at risk for dimin­ished fer­til­ity due to surgery, espe­cially if requir­ing removal of the ovaries or repeat exci­sion of cyst, can con­sider ovar­ian stim­u­la­tion, egg retrieval and egg freez­ing or  IVF and embryo freez­ing. There is no evi­dence that ovar­ian stim­u­la­tion and expo­sure to high estro­gen increases the risk for recur­rence. It is not clear if bor­der line cells are sen­si­tive to estro­gen increase dur­ing ovar­ian stim­u­la­tion. Two options are avail­able to reduce estro­gen expo­sure: to per­form IVF in a nat­ural cycle (low egg yield) or to mod­ify the stim­u­la­tion pro­to­col, through adding an aro­matase inhibitor, sim­i­lar to that used for breast can­cer. Alter­na­tively, short stim­u­la­tion fol­lowed by retrieval of imma­ture eggs fol­lowe by in vitro mat­u­ra­tion can be performed.

Women diag­nosed with bor­der­line ovar­ian tumors are at risk for dimin­ished fer­til­ity because of sur­gi­cal treatment(s). This is espe­cially true if repeat sur­gi­cal exci­sion is required. Col­lab­o­ra­tion between a gyne­co­logic oncol­o­gist and a repro­duc­tive endocri­nol­o­gist enable ade­quate sur­gi­cal treat­ment, strict fol­low up and preser­va­tion of future fer­til­ity in repro­duc­tive age women.