Ovarian Transposition an Option for Fertility Preservation for Some Cervical Cancer Patients

January 06, 2023

For young women with cervical cancer, the possibility of losing the ability to have children can be a particularly challenging part of their diagnosis. Those who desire to have children after treatment may want to know if there are options for fertility preservation.

There are evolving data in some early cancers about patients who may be safe with a surgery that preserves either their ovaries, uterus or both. Standard treatments for most cervical cancers may involve giving radiation to the pelvis, even when the uterus is removed. Because the ovaries are in the pelvis, they will lose hormone function and the ability to generate egg cells when the radiation is delivered. However, ovarian transposition has become a more widely accepted fertility-sparing method that may give patients the chance to preserve normal ovarian function and have children.

Current Cervical Cancer Standard of Care

The current standard treatment recommendation for many cervical cancers may include pelvic radiation therapy, often used concurrently with chemotherapy.

Depending on each patient's type and stage of cervical cancer, radiation therapy can include brachytherapy (radiation delivered internally right next to the tumor) and external beam therapy (radiation delivered from outside the body) as part of a personalized treatment plan. However, radiation can lead to premature ovarian failure. Decreased or failed ovarian function results in early menopause symptoms and the inability to conceive or carry a pregnancy, but may also cause cardiovascular disease, osteoporosis and genitourinary atrophy.

Because of these concerning adverse effects, gynecologic oncologists may recommend fertility-sparing treatments for some patients, especially those under 40, such as egg freezing or ovarian transposition prior to radiotherapy.

The current standard practice for fertility preservation is egg or embryo freezing or ovarian tissue cryopreservation, which enables patients to have children later but does not preserve ovarian function and hormone secretion. Further, the need for timely initiation of cancer therapy may not provide the time needed for egg and embryo harvesting. Ovarian transposition can often preserve function and hormone secretion thus avoiding the need for hormone replacement therapy.

While ovarian transportation has become an established method of reproductive preservation, it's still a widely underused procedure. Less than half of cervical cancer patients are referred to fertility specialists to discuss fertility-sparing methods prior to radiation, and many fertility specialists don't offer ovarian transportation.

At Moffitt, our gynecologic oncologists perform this minimally invasive ovarian transposition procedure that has the potential to spare fertility and preserve hormone function for many women under 40 who are diagnosed with cervical cancer each year.

Ovarian Transposition: How It Works

For cervical cancer patients who are recommended ovarian transposition, the procedure is performed laparoscopically, allowing patients to get back to normal function and start radiation quickly. For some women who must have an open radical hysterectomy as part of their treatment plan, this procedure can be performed at the same time as that procedure so that the ovaries may be spared if radiation is needed later.

During an ovarian transposition procedure, also known as ovarian suspension, oophoropexy, or ovariopexy, the gynecologic oncologist makes a small anterior incision and places a small laparoscope with a camera into the incision. Using gas to create room in the abdomen to work, the gynecologic oncologist makes other small incisions to move the ovaries and fallopian tubes as far away from the radiation area as possible, securing them in place with sutures.

The gynecologic oncologist relocates the ovaries as lateral as possible above the pelvic brim, at least 4 cm outside the radiation field or 1.5 cm above the iliac crest, typically using the paracolic gutters as a location. The vascular pedicle remains intact, distinguishing the procedure from transplantation.

While removing the ovaries from their anatomical position and as far away from the radiation field is the goal so that cancer metastasis to ovaries is rare, extreme care is necessary to avoid compromising blood supply by overstretching or twisting the suspensory ligaments of the ovaries. Additionally, to maintain ovary function adequately, a limited dose of radiotherapy and younger patient selection is key.

Ovarian Transposition Benefits

Clinicians should consider recommending ovarian transposition for cervical cancer patients under 40 and/or those who desire to have children later for several benefits, including:

Reduced Radiation to Ovaries

If ovaries are transposed laterally, the ovarian dose after transposition is reduced to just 5-10% of the radiation dose that non-transposed ovaries would receive.

Decreased Likelihood of Ovarian Dysfunction in Premenopausal Patients

Laparoscopic ovarian transposition is 44-85% effective at preserving ovarian function.
In one 2019 study, 41 out of 105 patients who had limited radiation doses to the ovaries preserved normal ovarian function. Patients under 38 were most likely to keep normal function.
In another study, 41% of ovarian function was preserved after radiation therapy for an average period of 43 months.

Low Likelihood of Ovarian Metastasis

There is a small risk of metastases to ovaries, but the risk for metastases to transposed ovaries is very low, with reports of around 0-1.2%.

Having Children After Treatment

Because most women who have an ovarian transposition will have had their uterus removed or had full-dose radiation to the uterus, they will need to have a surrogate to carry their genetic child. Ovarian transposition may preserve ovary function to increase the potential to harvest your eggs later.

Adoption and Standards

At Moffitt, we recommend ovary transposition to qualified cervical cancer patients to preserve fertility and ovarian function. Our cervical cancer survival rates exceed 1.5 times the national average, with the greatest improvement of outcomes seen among advanced-stage patients.

Fertility preservation is now an important conversation to have with patients prior to cervical cancer treatment, and we believe ovarian transportation should be considered as a method of fertility preservation prior to pelvic radiation, but not all cancer centers offer this procedure. All of Moffitt’s gynecologic oncologists can perform this procedure, ensuring that any patient who’s the right candidate and wants the procedure has access to it.

As the ovarian transposition procedure becomes more commonly practiced, more treatment plans should start to look like Cammie’s, who was 28 and in good health when she was diagnosed with stage 2 cervical cancer. Her personalized treatment plan, created by Dr. Robert Wenham, Chair of the Gynecologic Oncology Department at Moffitt, focused on her quality of life and included ovarian transposition before radiation to preserve her ovarian function.

"It's important to think about cancer, not as a cancer treatment but as patient treatment," explains Dr. Wenham. "Patients have desires. Patients have hopes. Patients have dreams. A lot of those will change because of cancer they have, so to call it cancer treatment is somewhat of a misnomer. We really must think about it as treating the whole patient."

Ovarian transposition is a procedure that considers the whole patient and their goals beyond their cancer diagnosis, allowing them to maintain normal reproductive function and potentially have children after treatment.

If you'd like to refer a patient to Moffitt Cancer Center, complete our online form or contact a physician liaison for assistance. As part of our efforts to shorten referral times as much as possible, online referrals are typically responded to within 24 - 48 hours.