Fertility preservation in uterine cancer and endometrial hyperplasia

The endometrium is the inner lining of the uterus. Changes in the endometrium can take place with prolonged exposure to estrogen, unopposed by progesterone. This can take place in women who do not ovulate regularly. Changes usually start as excessive proliferation-cell division- and then may progress to cancer. Endometrial hyperplasia and cancer are problems encountered in older women. During reproductive years, they are encountered in women diagnosed with polycystic ovary syndrome-PCOS. It is recommended that women with PCOS should prevent these changes either using progesterone treatment if they are not trying to get pregnant or induction of ovulation if they are trying to conceive.

The definitive treatment for endometrial hyperplasia and cancer involves a hysterectomy-surgical removal of the uterus. Although fertility in women depends on the number and quality of eggs in the ovaries, removal of the uterus markedly complicates a woman’s reproductive capacity. There are multiple options available for women diagnosed with hyperplasia or cancer.

Avoiding hysterectomy after diagnosis with endometrial hyperplasia. Progesterone or synthetic substitute can reverse endometrial hyperplasia to normal endometrium. The medicine can be taken orally or usinf an intrauterine device loaded with progestin. It is important that the physician check the lining of the uterus periodically to assure regression to normal status. This treatment is effective in regressing hyperplasia in about 80% of women.

Preservation of fertility in women diagnosed with endometrial cancer. When uterine cancer is diagnosed the usual treatment is surgery. The aim of surgery is to evaluate the extent of the disease. This is achieved by removing the uterus and sometimes the ovaries and submitting them for pathological examination. One of two options can be used to protect future fertility;

1. Progesterone or synthetic progestin to induce regression of cancer. The caveat to this method is that the extent of the disease is not evaluated. In 20% of women, the disease maybe more widespread e.g. to the cervix or the ovary, than originally thought.

2. Ovarian stimulation, egg retrieval and embryo freezing followed by definitive surgical treatment. Pregnancy is then achieved by transferring the embryos to a gestational carrier-surrogate. Although a more complex treatment, it allows for adequate evaluation of the extent of the disease and definitive surgery. I use a modified regimen, similar to that used for breast cancer, to stimulate the ovaries to prevent the rise in estrogen during stimulation. Estrogen rise can increase cancer cell proliferation. The eggs can be retrieved just before surgery through the vagina or during surgery directly from the ovary. When the woman or couple want to use the embryos, the lining of the uterus of the gestational carrier is prepared then the embryos are thawed and transferred to her uterus.

So even if the uterus is involved with a disease process, its possible to tailor implement a fertility preservation plan to enable a woman to conceive a biological child.

Posted on