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PRESENTER :DR SREELASYA KSRI SIDDHARTHA MEDICAL COLLEGE & RESEARCH HOSPITAL , TUMKUR

FERTILITY PRESERVING SURGERIES IN GYNECOLOGICAL CANCERS

• Fertility is a key aspect for quality of life for cancer patients of childbearing age.

• Preservation of fertility is defined as the application of medical, surgical and laboratory procedures to preserve the potential of genetic parenthood in adults and children at risk of sterility before the end of natural reproductive lifespan (Gosden 2009).

• Decrease or loss of fertility can take place due to exposure to medication (chemotherapy), radiation or surgery (e.g. Removal of the ovaries). • The American Cancer Society estimates that cancer affects one in

each 3 women living in the United States. • Modern cancer treatment commonly involve exposure to

chemotherapy and sometimes pelvic radiation.

• Advances in the management of gynecological cancers have resulted in an ever increasing number of women cured of their disease.

• It is estimated that 15-21% of women diagnosed with female genital tract malignancy are < 40 years of age at the time of diagnosis.

List of gynaecological cancers for fertilitysparing surgeries

CERVIX : squamous or adenocarcinoma1A1, 1A2, 1B1OVARY: epithelial ovarian tumours

borderline ovarian tumours

ENDOMETRIUM: endometrioid

CERVICAL CANCER

• Cervical cancer is the second most common cancer among women in developing countries and 7thmost common cancer in developed world.• More than 5,00,000 new cases of invasive cervical cancers are

diagnosed every year.• 83% of these occur in developing countries. • India accounts for estimated 1,26,000 new cases per year with 72,000

deaths. • More than 25 per cent of women with cervical cancer are under the age

of 40 years with an increasing number of them being nulliparous in developed countries.

Transformation zone

• Countries with established cervical cancer screening programs have beer able to markedly reduce incidence of invasive cervical cancer.

• The Pap test has been successful in reducing the incidence of cervical cancer by 79% and the mortality by 70%.

FIGO STAGING OF CARCINOMA CERVIX• Stage 1 : carcinoma is strictly confined to cervix (extension to the

corpus would be disregarded)1A : Invasive carcinoma which can be diagnosed only by microscopy, with deepest invasion ≤ 5mm and largest extension ≤ 7mm 1A1 : measured stromal invasion of ≤ 3mm in depth and extension of ≤ 7mm 1A2 : measured stromal invasion of ≥ 3mm and not > 5mm with an extension of not >7mm

• 1B : clinically visible lesions limited to the cervix or preclinical cancers > 1A• 1B1 : clinically visible lesion ≤ 4 cm in greatest dimension• 1B2 : clinically visible lesion >4 cm in greatest dimension

• Stage II :• Invades beyond uterus, but not to the pelvic wall or to the lower third of

the vagina.• IIA : without parametrial invasion• IIA1: clinically visible lesion ≤ 4 cm in greatest dimension• IIA2 : clinically visible lesion >4 cm in greatest dimension• IIB: without obvious parametrial invasion.

• Stage III: extends to the pelvic wall or to the lower third of the vagina and or causes hydronephrosis or non functioning kidney.• IIIA: involves lower third of vagina, with no extension to the pelvic wall.• IIIB : extension to the pelvic wall and or hydronephrosis or non

functioning kidney.

• Stage IV: extended beyond the true pelvis or has involved (biopsy proven) mucosa of the bladder or rectum.• IVA: spread of the growth to adjacent organs• IVB : spread to distant organs.

• Till recent past standard surgical treatment for early stage cervical cancer was radical hysterectomy. • Advance cases (stage IIb onwards) are managed by chemoradiation. • However, some of these young patients with early stage cancer (Stage

Ia1, Ia2 and Ib1) are candidates for fertility preserving surgery.

•STAGEWISE CONSERVATIVE SURGICAL PROCEDURE FOR CANCER CERVIX

STAGEWISE CONSERVATIVE SURGICAL PROCEDURE FOR CANCER CERVIXStage la (1)

• Microinvasive carcinoma cervix with <3 mm of stromal invasion is associated with a very low-risk of lymph node metastasis in the absence of lymph-vascular invasion (0.8% risk of lymph node metastasis). • Cervi cal conisation or large loop excision of transformation zone

(LEETZ) may be the treatment in young patients.

Conization• Conization of the cervix plays an important role in the management of CIN. • Conization is both a diagnostic and therapeutic procedure and has the

advantage over ablative therapies of providing tissue for further evaluation to rule out invasive cancer.• TYPES:• COLD KNIFE CONIZATION• LASER CONIZATION• LLETZ• LEEP• NETZ

indications1. limits of lesion not visible(extending >1.5cm into endocervical

canal)2. Squamo columnar junction not seen colposcopically3. endocervical curettage positive for CIN 2 or 34. discrepency in cytology,biopsy & colposcopy findings5. suspicion of microinvasion on cytology,colposcopy or biopsy6. suspicion of endocervical glandular atypia

procedure• can be cold knife cone or using laser or electro surgical wire• done in ot under GA• size & shape of cone varies depending on location of lesion• to reduce blood loss, cx is injected with a vasoconstrictive agent• cx stained with lugol’s iodine to outline lesion• some prefer ligating descending cervical arteries by 2 lateral

sutures at 3 & 9’o clock positions• then cone is taken with scalpel or electrosurgical wire• cone should be symmetrical around the endocervical canal with

apex in the canal but below the internal os

• it is desirable to remove the cone intact in one piece & mark it with a suture at 12’o clock position• endocervical curettage is performed above apex of cone to screen

for residual d/s distal to excised specimen• any bleeding,arrested with cautery,hemostatic sutures• if margins of cone are free of CIN, conisation is adequate rx,but if

nothysterectomy may be necessaryCOMPLICATIONSa. intra & post op hemorrhageb. cervical stenosisc. recurrent miscariage, preterm labour, pprom

LARGE LOOP EXCISIONOF THE TRANFORMATION ZONE(LLETZ)

• uses low voltage diathermy• loop is advanced into cx, lateral to lesion until the reqd depth is

reached.loop is then taken across to the opposite side & a cone of tissue removed• loop size <2cm gives better cone than larger one• low cost,harmless to technician• requires lesser time to perform than laser• similar success rates to laser• prefered over laser

LOOP ELECTROSURGICAL EXCISION PROCEDURE (LEEP)• simpler than LLETZ,applicable anywhere in the lower

genital tract unlike LLETZ• now, the most commonly used technique for treatment

of CIN• >95% cure rate• simple & safe procedure, done in OPD under Local

anaesthesia,• the procedure of choice in CIN 2 & 3 (where colposcopy

is satisfactory)• most important advantage of leep over cryotherapy is

that tissue is available for HPE study no chance of missing an invasive cancer.

Cone biopsy alone

• In microscopic tumours (stage 1A1) the incidence of metastatic nodal or parametrial disease is extremely small and therefore a simple cone biopsy has been used for cure for many years. • Lymphadenectomy is not required and fertility outcomes are

excellent. • Recent meta-analysis demonstrates that even in these cases there is

an increased premature delivery rate which is related to the proportion of the cervix that is removed with delivery before 37 weeks of gestation in approximately 11% in comparison to 7% in untreated controls.

• A database study from United States National Cancer (n=1409) did not find a significant difference in five year survival between those who underwent conisation (98%) versus hyster ectomy (99%) for microinvasive cancer cervix. • Cold knife conisation is associated with a small risk of obstetric

complications in subsequent preg nancy such as preterm delivery (RR 2.59), low birth weight (RR 2.53) and cesarean section (RR 3.17).

• Risk of recurrence has been estimated to increase from 3.2 to 9.7% with presence of lymphovascular invasion."• For conservative management of stage Ia(l) adenocarcinoma data is

limited. • In a retrospective review of 16 cases of cervical microinvasive

adenocarcinoma managed by conisation, Bisseling et al found no recurrence over 72 months period. • Satisfactory tumor-free margin following conisation seems to be the

most significant marker among microinvasive adenocarcinoma managed by conisation."

Stage la(2)

• Microinvasive carcinoma with depth of invasion 3-7 mm is associated with a higher chances of lymph node metastasis. • Risk of lymph node metastasis is estimated to be 7%.• Surgical management of stage la2 includes pelvic lymphadenectomy. • A radical hysterectomy with bilateral pelvic lymphadenectomy has been

the treatment for this stage till recent past. • However, in younger patients desirous of preserving fertility a radi cal

trachelectomy is the treatment. • This includes removal of cervix along with surrounding parametrium" and

upper 1-2 cm of vagina combined with pelvic lymph node dissection.

• Late Professor Daniel Dargent carried out fertility sparing procedure for invasive cervical cancer in 1986 and reported results in 1994. • This procedure later became popular by the name 'Radical Vaginal

Trache-lectomy'.• Procedure comprised of laparoscopic pelvic lymphadenectomy

followed by vaginal excision of cervix, upper vagina and parametrium and placement of a cervical cerclage suture at isthmus and approximation of edges of vagina and isthmus.

• Removed lymph nodes and endocervical margins are submitted for frozen section to decide need for radical hys terectomy. • Approximately 550 cases of cervical cancer managed by radi cal

vaginal trachelectomy have been reported in literature. • Subsequently a number of modification have been described to this

procedure these include radical abdominal trachelectomy, laparoscopic radical trachelec tomy and robotic radical trachelectomy.

Vaginal Radical Trachelectomy (VRT)

The procedure was described by Daniel Dargent from Lyon, France in 1994. Following selection criteria was used.

Selection Criteria for Vaginal Radical Trachelectomy1. Stage Ia1 with vascular invasion, stage Ia(2) and stage Ib(l).2. Desire to preserve fertility3. Age < 40 years4. Lesion < 2-2.5 cm with limited endocervical extension5. Squamous cell carcinoma or adenocarcinoma6. No evidence of widespread lymphovascular invasion7. No evidence of lymph node metastasis8. Absence of other histologies.

Steps of Surgery

1. Laparoscopic pelvic lymph node dissection: Submit lymph nodes for frozen section.

2. Vaginal radical trachelectomya. Circumcision in upper vagina to remove upper 2 cm of vaginab. Mobilization of bladderC. dIvision of bladder pillars, avoid injury to uretersd. Opening of pouch of Douglase. Excision of cervix with vagina just below isthmusf. placing cerclage suture In Isthmus using polypropylene or ethibond suture.

POSTOPERATIVE COMPLICATIONS FOLLOWING VRT• DYSMENORRHEA• HEMATOMETRA• HEMATOSALPINX• ENDOMETRIOSIS• 10-15% Cases have been reported to have cervical stenosis

CANCER RECURRENCE• 40% Occur in the parametrium or pelvic side wall indicating

insufficient excision.• Lymph node recurrences account for 25 percent Oi recurrences ifter

vaginal radical trachelectomy, these include pelvic & para aortic and supraclavicular lymph node metastasis.

• A study by Eskander has reported 23 (3.9%) recurrences among 582 cases of VRT pooled from 10 reported series.

RISK FACTORS FOR RECURRENCE• lesion size more than 2 cm,• presence of lymphovascular space involvement • and nonsqua-mous histology.

• Patients with neuroendocrine histology have much higher risk of recurrences due to aggressive behavior, • However, adenocarcinoma and adenosquamous histology has not

been associated with increase recurrence rates.

Pregnancy following VRT• Eskander et al have reported 257 pregnancies among 582 patients from 10

reported series of vaginal radical trachelectomy with 164 live births.

PROBLEMS ASSOCIATED :• Second trimester abortions• Preterm labour.MODE OF DELIVERY:• Cesarean section is advocated for delivery after vaginal radical trachelec

tomy in view of cervical cerclage suture and a possibility of lateral cervical laceration.

Abdominal Radical TrachelectomyAn abdominal approach to radical trachelectomy was described by Smith et al in 1997.Steps include:a. Vertical midline incisionb. Bilateral pelvic lymphadenectomyc. Division of round ligamentsd. Ligation and division of uterine arteries near their origin form internal iliac Arterye. Complete ureteric dissection from ureteric tunnelf. Cul-de-sac is opened and uterosacral ligaments are dividedg. Incision is made in vagina 1-2cm below the level of cervix

h. Proximal incision is made in cervix 5 mm below internal OS i. Trachelectomy specimen is separated and submitted for Frozen section j. A permanent cerclage is put at the level of isthmus using prolene or mersilene tape.k. Edges of vagina and isthmus are approximated using interrupted sutures with absorbable suture material.

Advantages of Abdominal Approach for Radical Trachelectomy• Shorter learning curve• In nulliparous patients with narrow vagina abdominal approach makes the procedure easier.

Disadvantages• Abdominal incision• Greater blood loss• Longer hospital stay• Ligation of uterine artery.

Neoadjuvant chemotherapy and cone biopsy• In an attempt to reduce morbidity and the radicality of surgery, some

investigators have recommended the use of neoadjuvant chemotherapy followed by a simple cone biopsy and pelvic lymphadenectomy.• In the largest series of 21 patients there were no recurrences after a median

follow up of 69 months. • During this follow up period, 6 patients conceived a total of 10 pregnancies.

This option may be worth investigating further and might allow tumours above 2 cm to be treated in a way that allows a good prognosis. • However, chemotherapy will have a damaging effect on ovarian function.

Whether this is partial or complete will depend on the woman’s pre-existing fertility status, the type of chemotherapy and the dose.

Ovarian transposition• If irradiating the pelvis becomes essential in the management of

cervical cancer, for example, in the presence of pelvic nodal metastasis or parametrial invasion, ovarian transposition may be considered.• Ovaries can be hitched up and sutured to the mid abdominal sidewall

whilst their blood supply is preserved. • They need to be transposed well above the level of the pelvic brim if

they are to be excluded from the radiation field. • This procedure may prevent early menopause and ovaries may be

used at a later date for oocyte retrieval, in vitro fertilisation (IVF) and achieving pregnancy through surrogacy if appropriate..

• However there is still a high risk of ovarian failure and oocyte retrieval should therefore be considered prior to administration of radiotherapy. • This does not necessarily result in significant delay in treatment

OVARIAN CARCINOMA

• Of all the gynecologic cancers, ovarian malignancies represent the greatest clinical challenge. • According to estimates in United States there will be 21,880 new cases of

ovarian cancer in the year 2010 with 13,850 deaths.

• Epithelial cancers are the most common ovarian malignancies, and because they• are usually asymptomatic until they have metastasized, patients have

advanced disease at• diagnosis in more than two thirds of the cases

EPITHELIAL OVARIAN CANCER

• Although majority of women tend to be more than 45 years but as many as 12 % cases of epithelial ovarian cancer occur in women younger than 45 years of age.• Younger patients are likely to have localized disease. • 5 year survival rates are higher among early stage disease and may be

80 % in younger population.

Technique for Surgical Staging• In patients whose preoperative evaluation suggests a probable malignancy, a

midline or paramedian abdominal incision is recommended to allow adequate access to theupper abdomen. • When a malignancy is unexpectedly discovered in a patient who has a lower

transverse incision, the rectus muscles can be either divided or detached from the symphysis pubis to allow better access to the upper abdomen. • If this is not sufficient, the incision can be extended on one side to create a “J”

incision.• The ovarian tumor should be removed intact, if possible, and a frozen

histologicsection should be obtained. • If ovarian malignancy is present and the tumor is apparentlyconfined to the

ovaries or the pelvis, thorough surgical staging should be performed.

Steps • Any free fluid, especially in the pelvic cul-de-sac, should be

submitted for cytologic evaluation.

• If no free fluid is present, peritoneal washings should be performed by instilling and recovering 50 to 100 mL of saline from the pelvic cul-de-sac, each paracolic gutter, and beneath each hemidiaphragm.

• systematic exploration of all the intra-abdominal surfaces and viscera is performed, proceeding in a clockwise fashion from the cecum cephalad along the paracolic gutter and the ascending colon to the right kidney, the liver and gallbladder, the right hemidiaphragm, • the entrance to the lesser sac at the para-aortic area, across the

transverse colon to the left hemidiaphragm, down the left gutter and the descending colon to the rectosigmoid colon.• The small intestine and its mesentery from the Treitz ligament to

thececum should be inspected.

• Any suspicious areas or adhesions on the peritoneal surfaces should be biopsied. If there is no evidence of disease, multiple intraperitoneal biopsies should be performed. • Tissue from the peritoneum of the pelvic cul-de-sac, both paracolic gutters,

the peritoneum over the bladder, and the intestinal mesenteries should be taken for biopsy.• The diaphragm should be sampled either by biopsy or by scraping with a

tongue depressor and obtaining a sample for cytologic assessment. • Biopsies of any irregularities on the surface of the diaphragm can be

facilitated by use of the laparoscope and the associated biopsy instrument.

• The omentum should be resected from the transverse colon, a procedure called an infracolic omentectomy.• The retroperitoneal spaces should be explored to evaluate the pelvic

and paraaortic lymph nodes.• Any enlarged lymph nodes should be resected and submitted for

frozen section. If no metastases are present, a formal pelvic lymphadenectomy should be performed. The paraaortic area should be explored

FIGO STAGING OF CARCINOMA OVARY

•STAGE 1 : Tumour confined to the ovaries

• 1A – Tumour limited to one ovary, capsule intact, no tumour on surface, negative washings• 1B – Tumour involves both ovaries otherwise like 1A• 1C – Tumour limited to one or both ovaries• 1C1 - Surgical spill• 1C2 - Capsule rupture before surgery or the tumour is on the

ovarian surface• 1C3 – Malignant cells in the ascites or peritoneal washings

•STAGE II : Tumour involves one or both ovaries with pelvic extension [below pelvic brim] or primary peritoneal cancer

• IIA – Extension and/or implant on uterus and/or fallopian tubes

• IIB – Extension to other pelvic intraperitoneal tissues

• STAGE III : Tumour involves one or both ovaries with cytologically or histologically confirmed spread to the peritoneum outside the pelvis and/or metastasis to the retroperitoneal lymph nodes

• IIIA [Positive retroperitoneal lymph nodes and/or microscopic metastasis beyond the pelvis]

• IIIA1 - Positive retroperitoneal lymph nodes only• IIIA1(i) – Metastasis ≤ 10mm• IIIA1(ii) – Metastasis > 10mm

• IIIA2 - Microscopic, extrapelvic [above the brim] and peritoneal involvement +/-

positive retroperitoneal lymph nodes

• IIIB - Macroscopic, extrapelvic, peritoneal metastasis ≤ 2cm +/- positive retro peritoneal lymph nodes.

Includes extension to capsule of liver or spleen.

• IIIC - Macroscopic, extrapelvic, peritoneal metastasis > 2cm +/- positive retro peritoneal lymph nodes. Includes extension to capsule of liver and spleen.

•STAGE IV : Distant metastasis excluding peritoneal metastasis

• IVA - Pleural effusion with positive cytology• IVB - Hepatic and/or splenic parenchymal metastasis,

metastasis to extra abdominal organs [including inguinal lymph nodes and lymph nodes outside the abdominal cavity.]

• Majority of women suffering from ovarian carcinoma are managed by total abdominal hysterectomy, bilateral salpingo-oophorectomy, infra-colic omnectomy, pelvic +/- para-aortic lymphadenectomy and multiple peritoneal biopsies. • However, cases of stage la and Ic are candidates for conservative

surgery in the form of unilateral salpingo-oophorectomy with adequate surgical staging.

• Studies on conservative management of epithelial ovarian cancer are limited.• Eskander et al (2011) have published combined results of 8 series

reported in literature with fertility sparing surgery in patients with inva sive epithelial ovarian cancer. • Among a total of 328 cases there were 119 pregnancies, 104 live

births and 42 recurrences with 20 deaths."

BORDERLINE OVARIAN TUMOURS

• Borderline ovarian rumors are subset of epithelial ovarian tumors charac terized by abnormal epithelial proliferation but lack of stromal invasion. • They comprise 10-15 percent of ovarian cancers.• Most borderline ovar ian tumors tend to be serous or mucinous in histology. • Median age at diagnosis is 45 with 34 percent of patients being less than 40

years of age. • In majority of patients with stage I borderline ovarian tumor 10 years

survival is as high as 90 percent.

• Given the low recurrence rates, patients with borderline ovarian tumor are suitable candidates for conservative surgery in the form of unilateral salpingo-oophorectomy combined surgi cal staging.

• Ovarian cystectomy can also be undertaken, however, recur rence rates from 36 % have been noted among borderline ovarian tumors managed by conservative surgery.32

• Eskander et al (2011) in a 1 meta analysis of 10 published series of borderline ovarian tumor managed by fertility preserving surgery noted 185 pregnancies, 107 live births, 111 recurrences and one death among 626 subjects.

GERM CELL TUMOURS

• Malignant germ cell tumors of ovary are a class of tumor with biological behavior quite different from epithelial ovarian cancers. • They comprise 5 percent of all ovarian malignancies. They mostly

occur in young adoles cent or teenage girls. • It is uncommon to see germ cell tumors in women older than 25 years

of age

• most of germ cell tumors of ovary tend to be unilateral except dysgerminoma which may be bilateral in 15 percent of cases.• These tumor secrete tumor markers such as alpha-fetoprotein,

human chorionic gonadotropin, lactic dehydrogenase making diagnosis easy and also help in follow-up. • They show excellent response to chemotherapy, cure rates reach

almost 100 percent in early stage disease and 75 percent for those with advance disease.

• Most girls managed by conservative surgery and effective chemotherapy (Bleomycin-Etopocide-Cisplatin) resume there menses and achieve pregnancies following complete treatment.

• Such a good outcome following treatment makes girls with malignant germ cell tumors of ovary ideal candidate for conservative surgical pro cedure. • Unilateral salpingo-oophorectomy with adequate surgical stag ing comprising

of infracolic omnectomy, ipsilateral pelvic and para-aortic lymphadenectomy offers excellent hope for return of reproductive func tion. • Most patients are treated by adjuvant chemotherapy comprising of bleomycin,

etopocide and cisplatin (BEP).

• Only cases of stage la dysger minoma or stage la malignant teratoma with Norris class I can be treated by surgery alone and avoiding chemotherapy.• For bilateral germ cell tumors of ovary also fertility preservation is possible

and should be attempted. • It comprises of saving normal looking portion of the ovary on the side with

smaller tumor while removing the ovary with larger tumor. • Uterus should be retained in all cases, IVF with ovum donation can offer hope

of pregnancy to those where both ovaries need to be removed.• Eskander et al11 in a review has reported 185 pregnancies, 148 live births, 46

recurrences and 17 deaths among 453 patients pooled form 7 reported series.

• Sex Cord Stromal Tumors of Ovary• Sex cord stromal tumors generally occurs in postmenopausal women. • However, granulosa cell tumor, Sertoli-Leydig cell tumors can been

seen in young patients and women in reproductive age group. • Granulosa cell tumor is the most common sex cord tumor seen in

women of reproductive age. • Histologically two varieties are seen, adult type or juvenile type of

granulosa cell tumors with different biological behaviors.

• Up to 95 percent of granulosa cell tumors are unilateral and 95 percent are stage I.• Fertil ity preserving surgery is possible in young patients with

granulosa cell tumor. • Patients with advance stage disease need cisplatin based chemo

therapy.• Pregnancies have been reported in case reports following suc cessful

treatment of sex cord stromal tumors

• Cryopreservation of oocyte, embryos, and whole ovarian tissue prior to chemotherapy or radiation therapy has been investigated as fertility preserving method in women with cancer.

ENDOMETRIAL CANCER

• Six percent of endometrial cancers are diagnosed in women under the age of 50 years• 29Hysterectomy and bilateral salpingooophorectomy plus or minus lymph node

dissection is the standard surgical treatment for endometrial cancer.• Progesterone treatment• Stage IA endometrial cancer• There have been reports of the use of progestogens as conservative treatment in the

management ofvery early-stage endometrial cancer in young women as a fertility-preserving treatment.• Kaku et al.31 assessed the outcome of nine women with stage IA (tumour confined

within the endometrium), grade 1 endometrial cancer treated with megestrol acetate, tamoxifen and gonadotrophin-releasing hormone analogue.• Eight of the nine women achieved complete remission following treatment

• Another important factor is the high recurrence rate following conservative treatment for endometrial cancer. • A recent study by Ushijima et al.assessed 28 women with presumed

stage IA endometrial cancer and 17 women with atypical hyperplasia. • The women were given 600 mg medroxyprogesterone acetate daily

for 26 weeks. A complete response was reported in 55% of the women with endometrial carcinoma and 82% of the women with atypical hyperplasia. A recurrence rate of 47% was documented.• Other studies have also demonstrated high recurrence rates, of 25%.

• Successful pregnancy has occurred in women treated conservatively with progesterones. • In the paper by Ushijima et al.,38 12 pregnancies and 7 normal

deliveries were achieved in 28 women during a 3-year follow-up period.

STORAGE OF OOCYTES AND EMBRYOS

• Where fertility sparing surgery is not appropriate, it may occasionally be feasible to offer ovarian tissue retrieval and cryopreservation, ovarian stimulation and oocyte retrieval and/or IVF and embryo cryopreservation. • Surrogacy will be required to achieve a pregnancy if the uterus is

removed. • Assisted conception techniques would usually be undertaken in the

window between primary surgery and the start of chemotherapy or radiotherapy

`• only carries a 3–5% chance of resulting in a successful pregnancy per

frozen egg.• Embryo cryopreservation following IVF is a routine procedure in

fertility clinics; however, there are few data on its success rates in the context of fertility preservation in women with gynaecological cancers.

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