out of the irradiation field can preserve ovarian function and should be considered in women of reproductive age with pelvic malignancies or before pelvic lymph node irradiation. This can be unilateral or bilateral and carried out via laparotomy or laparoscopy. The proper location to fix the transposed ovaries depends on the planned irradiation field. For cervical cancer the ovaries are transposed high and lateral above the pelvic brim, while for pelvic lymph node irradiation (as in Hodgkin’s lymphoma) the ovaries can be medially or laterally transposed. Complications of the procedure are rare but include chronic pelvic pain, vascular injury, fallopian tube infarction and ovarian migration. For patients with external pelvic (45 Gy) irradiation with or without para‐aortic nodal irradiation (45 Gy), the amount of radiation received by the ovaries with lateral transposition (mean distance 14.4cm) was calculated to be 1.26Gy for intracavitary radiation, whereas for external pelvic with or without para‐aortic nodal irradiation the dose was 1.35–1.90 and 2.30–3.10 Gy, respectively [10]. Ovarian function preservation rates with a median follow up of 31 months were 100% for patients treated exclusively by surgery, 90% for those treated with vaginal brachytherapy and surgery, and 60% for those treated with pelvic irradiation and vaginal brachytherapy.
Fertility preservation techniques (see chapter 10)
Other methods of fertility preservation include gonadal shielding, laparoscopic uterine fixation [11], embryo cryopreservation, oocyte cryopreservation, ovarian tissue cryopreservation and autotransplantation of the ovary to the upper extremity with creation of vascular anastomosis [12].
Key points
Challenge: Fertility in a patient with previous pelvic irradiation.
Background:
With improved RT and chemotherapy techniques there is a significant increase in childhood cancer survival rates.
The impact of radiation therapy on fertility depends on radiation dosage, age at the time of radiation exposure and extent of radiation field treatment.
Ovarian dysfunction can manifest as premature ovarian failure or diminished ovarian reserve.
Uterine dysfunction can present as reduction in uterine volume, endometrial thickness, uterine blood flow or distensibility.
Pelvic irradiation increases the risk of pregnancy‐related complications, including spontaneous miscarriages, preterm labor and delivery, low birth weight infants and placental abnormalities (placenta accreta and percreta).
Prevention and management options:
Ovarian transposition and other fertility preservation techniques such as gonadal shielding, donor oocytes and gestational surrogacy, embryo, oocyte or ovarian tissue cryopreservation may be useful.
There have been no live births reported in patients with prepubertal pelvic irradiation. Postpubertal pelvic irradiation patients have had live births.
Answers to questions patients ask
1 Q1 As a cancer survivor, can I get pregnant?A1. In many cancer survivors, pregnancy is now possible, but it depends on a number of factors. You should speak to your cancer specialist regarding this and, generally, the cancer should be “cured” before you attempt pregnancy.
2 Q2 How does my radiation treatment affect my ovaries?A2. The radiation treatment causes direct damage to your eggs. This can result in a decrease in your ovaries’ ability to release female hormones and can lead to early menopause. The dose of radiation used, your age at time of radiation treatment and the area of your body that is radiated are some of the factors that determine the extent of damage to your eggs.
3 Q3 Can I get pregnant with my own eggs after radiation treatment?A3. If you are still getting regular periods, it may be possible for you to get pregnant with your own eggs. Your fertility specialist will do an ultrasound to measure your ovarian volume (at least 3 cc) and measure your antral follicle count (small follicles in your ovaries measuring 2–5 mm in diameter). Other tests include measuring your follicle stimulating hormone (FSH) level (should be less than 10 mIU/mL) and anti‐Müllerian hormone (AMH) level (should be more than 1 ng/mL). If you are not getting regular periods, you may be in premature menopause. In that case, you can get pregnant using an egg donor.
4 Q4 Will my pregnancy be complicated?A4. There is an increased chance of miscarriage in patients with a history of pelvic radiation. Other complications include preterm delivery, low birth weight babies, increased rate of C‐section and placental complications.
References
1 1 Rodriguez‐Wallberg KA, Olofsson JI. Future fertility in survivors of childhood cancer—examining the impact of cancer treatment on uterus function. Fertil Steril. 2019; 111(2):262–3.
2 2 Wo JY, Viswanathan AN. Impact of radiotherapy on fertility, pregnancy and neonatal outcomes in female cancer patients. Int J Radiat Oncol Biol Phys. 2009; 73(5):1304–12.
3 3 Schover LR, Rybicki LA, Martin BA, Bringelsen KA. Having children after cancer: a pilot survey of survivors’ attitudes and experiences. Cancer. 1999; 86(4):697–709.
4 4 Wallace WH, Thomson AB, Kelsey TW. The radiosensitivity of the human oocyte. Hum Reprod. 2003; 18:117–21.
5 5 Wallace WH, Thomson AB, Saran F, Kelsey TW. Predicting age of ovarian failure after radiation to a field that includes the ovaries. Int J Radiat Oncol Biol Phys. 2005; 62(3):738–44.
6 6 Larsen EC, Muller J, Schmieglow K, Rechnitzer C, Andersen AN. Reduced ovarian function in long‐term survivors of radiation‐ and chemotherapy‐treated child‐ hood cancer. J Clin Endocrinol Metab. 2003; 88:5307–14.
7 7 Bath LE, Wallace WH, Critchley HO. Late effects of the treatment of childhood cancer on the female reproductive system and the potential for fertility preservation. BJOG. 2002; 109(2):107–14.
8 8 Sanders JE, Hawley J, Levy W, Gooley T, Buckner CD, Deeg HJ, et al. Pregnancies following high‐dose cyclophosphamide with or without high‐dose busulfan or total‐body irradiation and bone marrow transplantation. Blood. 1996; 87(7):3045–52.
9 9 Van de Loo LE, Van den Berg MH, Overbeek A, Van Dijk M, Damen L, Lambalk CB, et al. Uterine function, pregnancy complications, and pregnancy outcomes among female childhood cancer survivors. Fertil Steril. 2019; 11(2):372–80.
10 10 Covens AL, van der Putten HW, Fyles AW, Leung PM, O’Brien PF, Murphy KJ, et al. Laparoscopic ovarian transposition. Eur J Gynaecol Oncol. 1996; 17(3):177–82.
11 11 Azais H, Canova C‐H, Vesale E, Simon J‐M, Canlorbe G, Usan C. Laparoscopic uterine fixation to spare fertility before pelvic radiation therapy. Fertil Steril. 2018; 110(5):974–5.
12 12 Schmidt KT, Larsen EC, Andersen CY, Andersen AN. Risk of ovarian failure and fertility preserving methods in girls and adolescents with a malignant disease. BJOG. 2010; 117:163–74.
18 Female fertility after chemotherapy
Nivedita Reddy
