Assisted Reproduction Techniques. Группа авторов

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oophorectomy could be considered once childbearing is completed.

      For those women who may require ovulation induction or IVF treatment, there is a theoretical concern that ovarian stimulation may be associated with an increased risk of recurrence of BOT or ovarian cancer. Although evidence is sparse, there is no clear evidence to support this association. Two experimental studies showed that estradiol and follicle stimulating hormone (FSH) have no adverse impact on cell proliferation [8,9]. A systematic review of studies of gonadotropin stimulation in women with a history of BOT identified 15 reports, including a total of 62 patients having 152 ovarian stimulation cycles, with a mean follow‐up of 52 months [10]. Live birth rate was 28% per stimulated cycle. The pooled recurrence rate was 19.4%, which is higher than the reported 11% recurrence rate for borderline ovarian tumors [11]. Despite the apparently higher recurrence rate, the survival in this group of women with gonadotropin stimulation is still excellent (100% at a median follow‐up period of 52 months). Notwithstanding these data, there may be a case for limiting the number of ovarian stimulation cycles in women with a history of BOT given the paucity and uncertainty of the available data [1]. Each case should be judged on its own merits.

      The optimal time to try to conceive or have fertility treatment after fertility‐sparing surgery is unknown, although successful pregnancies have been achieved as early as 3 months after surgery [12,13]. Before any fertility treatment is initiated, the oncology team should be consulted to obtain clearance to proceed with the treatment. A pelvic ultrasound scan should be arranged to rule out ovarian cysts, which may indicate recurrence of BOT. CA125 has been found to be a useful tumor marker in diagnosing BOT recurrences [14,15], and should therefore be checked before fertility treatment.

      After fertility treatment, the oncology multidisciplinary team may consider “completion surgery” to remove the remaining ovarian tissues and the uterus, particularly for those who had cystectomy (as opposed to oophorectomy), advanced stage disease, mucinous tumors or any evidence of peritoneal implants at the time of primary surgery [1].

      Although fertility‐sparing surgery may offer the best chance of pregnancy for a woman with BOT, some women may benefit from fertility‐preserving techniques such as oocyte, embryo [16] or ovarian tissue freezing [6] or may require oocyte donation [17] or surrogacy. The role of the antral follicle count and anti‐Müllerian hormone serum levels in patients with BOT remains to be clarified.

      A final consideration is whether fertility treatments, such as gonadotropins and clomiphene increase the risk of BOT. Although long‐term outcome data remain limited [18], a review suggested a potentially increased risk of BOT, especially following IVF [19].

      Key points

      Challenge: ART in a patient with a previous borderline ovarian tumor (BOT).

       Background:

       BOTs account for 10–20% of all ovarian tumors; approximately one‐third of these occur in women of reproductive age.

       They have low malignancy potential.

       Preservation of fertility is an important issue in the management of BOTs.

       BOTs are bilateral in 25–50% of cases.

       Fertility‐sparing surgery involves preservation of at least part of one ovary, and the uterus.

       The recurrence risk (after conservative fertility‐sparing surgery) is reported to be around 10%. In women who have gonadotropin stimulation, the recurrence rate may be doubled, although causation has not been firmly established.

       Almost all recurrences are again borderline ovarian tumors, with excellent survival prospects.

       Management options:

       Liaise with the gynecologic oncology team.

       Pelvic ultrasound to rule out ovarian cysts before fertility treatment.

       Serum marker: CA125

       Aim to reduce the number of ART cycles as ovarian stimulation may increase recurrence.

       Once fertility treatment is completed, the oncology team may consider “completion surgery,” particularly in women who had cystectomy (as opposed to oophorectomy), advanced stage disease, mucinous tumors and any evidence of peritoneal implants.

      Answers to questions patients ask

      1  Q1 What is a borderline ovarian tumor (BOT)? A1.A1. Borderline ovarian tumors result from the development of abnormal cells in the ovary. They are not cancerous, but are said to have low malignant potential, meaning they could possibility become cancerous in the long run. Approximately 10–20% of ovarian tumors are borderline, and they more commonly affect women of child‐bearing age.A small number of women who have been diagnosed with a BOT will be diagnosed at a more advanced stage where the disease has spread either to both ovaries or to the peritoneum (a layer of tissue covering the organs in the abdomen). These seedlings can be successfully removed surgically, but occasionally they may remain on this surface layer, for which you will be closely monitored by your consultant.

      2  Q2 How are BOTs treated? A2.A2. As borderline ovarian tumors are slow growing, many of them are diagnosed at an early stage and can be cured by surgery. The best surgery for you will be agreed together with your oncologist and for a lot of women this will include important discussions about the fertility options.Most young women will have fertility sparing surgery, which will usually involve removal of one ovary or only the cyst. In about 1 in 20 women (5%), the tumor will come back (recurrence). Some women may be advised to have more definitive surgery following pregnancy based upon the type of disease and risk of recurrence. Most recurrent tumors can be easily cured by surgery with no impact on survival.For women who have completed their family or have more advanced disease, surgical removal of the womb, both tubes and ovaries may be advised. During surgery, the surgeon will closely look at the inside of the pelvis and abdomen and take small biopsies (small samples of tissue) from different areas.

      3  Q3 Will I be able to get pregnant in future? A3.A4. Young women with early stage BOTs who have fertility sparing surgery have good chances of future natural pregnancy. Some women may require fertility treatment, such as IVF; the timing and safety of this will be planned together with the oncology doctor. Some women may benefit from fertility‐preservation, such as embryo freezing, which should be discussed when preparing for any surgery to treat BOTs.

      1 1 Morice P. Borderline tumours of the ovary and fertility. Eur J Cancer. 2006; 42(2):149–58.

      2 2 Morice P, Camatte S, Wicart‐Poque F, Atallah D, Rouzier R, Pautier P, et al. Results of conservative management of epithelial malignant and borderline ovarian tumours. Hum Reprod Update. 2003; 9(2):185–92.

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