Fertility preservation in uterine cancer

Most people with uterine cancer will have surgery as the primary treatment. Typically, surgery for uterine cancer includes removal of the uterus (a hysterectomy) and removal of the fallopian tubes and ovaries (a bilateral salpingo-oophrectomy). After having a hysterectomy, with or without a bilateral salpingo-oophrectomy, a person is no longer able to conceive (get pregnant) and carry a pregnancy to term.

Fertility preservation may be offered to people diagnosed with uterine cancer who wish to have children in the future. Fertility-preservation techniques try to prevent damage to, or the loss of, a person’s reproductive system that may be caused by some treatments for uterine cancer. Following treatment for uterine cancer, you may be able to get pregnant naturally or conceive through assisted reproduction (such as in vitro fertilization, or IVF) or through a surrogate (someone who becomes pregnant and gives birth to a child for someone else).

Taking steps to preserve your fertility before cancer treatment starts gives you the best chance of conceiving when you are ready. Which type of fertility preservation is available to you depends on factors about you and the cancer, including your age, the type of uterine cancer, which parts of your reproductive system are affected and the grade of cancer.

Speak to your healthcare team and fertility specialist about the best options for you.

Fertility-sparing treatment for uterine cancer mainly uses hormone therapy instead of surgery. If you have low-grade, stage 1A endometrial carcinoma that is only in the endometrium, your healthcare team may offer fertility-sparing treatment if you wish to get pregnant in the future.

To confirm you can have fertility-sparing treatment, a pathologist must look at a sample of tissues, collected from a uterine biopsy, to give the cancer a stage and grade. A biopsy before fertility-sparing treatment is done by a procedure called dilation and curettage (D&C) or through a hysteroscopy. An MRI or a transvaginal ultrasound is also done to confirm there is no cancer outside of the endometrium.

If tests confirm you can have fertility-sparing treatment, you’ll be given a type of hormone therapy called progestin. Progestins are drugs that act like progesterone in the body to control cancer cell growth. The most common progestin used as fertility-sparing treatment is a levonorgestrel intrauterine device (Mirena, Kyleena), sometimes called a hormonal IUD. Other progestin drugs that may be given instead include:

• megestrol
• medroxyprogesterone (Provera)

The hormonal (levonorgestrel) IUD is a small device made of flexible plastic that is inserted into the uterus. It remains there and releases progestin into the body until you are ready to try to get pregnant. Megestrol and medroxyprogesterone are taken daily by mouth as a pill.

You’ll have a biopsy of the uterus every 3 to 6 months while you have hormone therapy to see how the cancer is responding to treatment. If the cancer responds to the progestin treatment, you and your healthcare team will decide when to stop hormone therapy so that you can try to conceive. When you are done having children, you will have a hysterectomy. If the cancer doesn’t respond to treatment with progestin, or if it progresses at any point during treatment, you’ll stop hormone therapy and have a hysterectomy as soon as possible. In that case, your healthcare team may suggest other types of fertility preservation.

Fertility-sparing treatment isn’t a standard treatment for uterine cancer. The risk of cancer coming back (recurring) is greater in people who have fertility-sparing treatment than in those who have surgery. Your doctor will talk to you about the risks of fertility-sparing treatment.

Uterine-sparing surgery removes only the parts of the uterus that are affected by cancer. By leaving part of the uterus and at least 1 ovary, uterine-sparing surgery allows you to try to get pregnant after cancer treatment. Uterine-sparing surgery may be done through laparoscopy or hysteroscopy. It is a type of fertility-sparing treatment, sometimes called fertility-sparing surgery or a local tumour excision.

You may be offered uterine-sparing surgery for low-grade, stage 1 endometrial stromal sarcoma (a type of uterine sarcoma) that is only in the endometrium if you wish to get pregnant in the future. Very few people will have uterine-sparing surgery to treat uterine sarcoma.

Like with fertility-sparing treatment for endometrial carcinoma, a pathologist must look at a sample of tissues collected from a uterine biopsy to give the cancer a stage and grade, and to confirm you can have uterine-sparing surgery. A biopsy is done through dilation and curettage or hysteroscopy.

Hormone therapy is sometimes offered after uterine-sparing surgery as adjuvant therapy to reduce the risk of cancer recurring. Medroxyprogesterone is the most common hormone therapy used.

After uterine-sparing surgery and adjuvant therapy is done, you will have the chance to try to conceive. You’ll have follow-up tests every 3 months to look for signs the cancer has recurred. A hysterectomy will be done when you are done having children. If the cancer recurs, a hysterectomy will be done as soon as possible. In that case, your healthcare team may suggest other types of fertility preservation.

Uterine-sparing surgery is not a standard treatment for uterine sarcoma. The risk of cancer recurring is greater in people who have fertility-sparing treatment than in those who have a total hysterectomy (removal of the uterus and the cervix) and bilateral salpingo-oophrectomy (removal of both fallopian tubes and both ovaries). If you’re trying to conceive, your doctor will talk to you about the risks of choosing a non-standard treatment like uterine-sparing surgery for uterine cancer.

Egg freezing is the process of removing mature eggs from your ovaries and freezing and storing them to be used to create an embryo in the future. When you’re ready to have a child, your eggs can be thawed and fertilized with sperm in the lab (called in vitro fertilization, or IVF) to create an embryo. Egg freezing is also called egg cryopreservation or oocyte cryopreservation.

You’ll be given hormone injections to increase the number of mature eggs that develop in your ovaries. After about 10 to 14 days, mature eggs are collected using a needle through the vagina to the ovary.

You may choose to do egg freezing if you can’t have or don’t want fertility-sparing treatment or surgery for uterine cancer. If you have a hysterectomy as part of treatment for uterine cancer, you will need a surrogate to become pregnant with and carry any embryos you create from eggs you freeze.

Egg freezing is done at specialized fertility clinics and may not be available at all cancer centres or hospitals. The cost of egg freezing may not be covered by all provincial and territorial health plans. Talk to your doctor about your options if you are considering egg freezing.

Embryo freezing removes mature eggs from your ovaries and fertilizes them with sperm in the lab (IVF) to create an embryo. The embryos are frozen and stored until you are ready to have a child. Embryo freezing is also called embryo banking or embryo cryopreservation.

You may choose to do embryo freezing if you can’t have or don’t want fertility-sparing treatment or surgery for uterine cancer. If you have a hysterectomy as part of treatment for uterine cancer, you will need a surrogate to become pregnant with and carry any embryos you create from eggs you freeze.

A partner who has contributed sperm to the embryos has legal rights to the embryos. This means that if you and a partner create and freeze embryos, you both have to agree about when the embryos are used or donated to others. If you create embryos using sperm from an anonymous donor, the embryos are your responsibility.

Embryo freezing is done at specialized fertility clinics and may not be available at all cancer centres or hospitals. The cost of embryo freezing may not be covered by all provincial and territorial health plans. Talk to your doctor about your options if you are considering embryo freezing.