Fertility-Preserving Surgery

For young women with early-stage cervical cancer (FIGO Stage IA2–IB1, tumour ≤2 cm), a radical trachelectomy offers a fertility preserving alternative to radical hysterectomy. This procedure removes the cervix and surrounding parametrial tissue but preserves the uterine body, fallopian tubes, and ovaries.

After trachelectomy, a cerclage (stitch) is placed at the internal os to support future pregnancies. Pregnancy is possible via natural conception or IVF, though deliveries must be by planned caesarean section. Oncological outcomes for appropriately selected patients are comparable to radical hysterectomy.

Strict selection criteria apply:

• Tumour size ≤2 cm on MRI
• Squamous cell carcinoma, adenocarcinoma, or adenosquamous histology
• No lymphovascular space invasion (LVSI) on biopsy (relative criterion)
• Negative pelvic lymph nodes (confirmed intraoperatively via sentinel lymph node mapping)
• No evidence of spread beyond the cervix on imaging

Radical trachelectomy can be performed via open, laparoscopic, or robotic-assisted approaches depending on tumour characteristics and surgeon expertise.

In apparent Stage IA ovarian cancer (confined to one ovary, intact capsule, favourable histology), it may be possible to remove only the affected ovary and fallopian tube while preserving the uterus and contralateral ovary. This is called fertility preserving staging surgery.

Candidates must meet strict criteria:

• FIGO Stage IA (unilateral, capsule intact, no surface involvement)
• Favourable histology — low-grade serous, mucinous, or endometrioid
• Comprehensive surgical staging (peritoneal biopsies, omentectomy, pelvic washings, lymph node assessment)
• Normal contralateral ovary on imaging and intraoperative inspection

Comprehensive surgical staging is essential — if the cancer is understaged, the decision to preserve fertility may have been based on incomplete information, potentially compromising survival. This is why fertility preserving surgery for ovarian cancer must be performed by a gynaecological oncologist with expertise in oncological staging.

After completion of childbearing, definitive surgery (removal of the remaining ovary and uterus) is recommended in most cases.

For young women with Grade 1 endometrioid endometrial cancer or complex atypical hyperplasia who wish to preserve fertility, conservative hormonal management with high-dose progestogens may be considered as a temporizing measure. Options include oral medroxyprogesterone acetate, megestrol acetate, or a levonorgestrel-releasing intrauterine device (Mirena).

This approach requires:

• MRI confirming no myometrial invasion
• Grade 1 endometrioid histology confirmed on hysteroscopic biopsy
• Regular endometrial surveillance with repeat biopsy every 3–6 months
• Close monitoring by a gynaecological oncologist
• Definitive surgery after completion of childbearing

Response rates are approximately 70–80%, but recurrence risk is significant (30–40% even after initial complete response). This is a temporizing strategy, not a cure — and patients must understand that definitive hysterectomy remains necessary after childbearing is complete.

When fertility preserving surgery is not possible — or when adjuvant chemotherapy or radiation may compromise ovarian function — oncofertility counselling should be offered before treatment begins. Depending on the clinical urgency, options include:

• Oocyte (egg) freezing — stimulation and retrieval of eggs before treatment begins. Can often be completed within 2 weeks.
• Embryo cryopreservation — eggs are fertilised with partner or donor sperm before freezing. Offers the highest success rates for future pregnancy.
• Ovarian tissue cryopreservation — ovarian cortex is surgically removed and frozen for future reimplantation. Used when there is no time for egg retrieval.
• GnRH agonist ovarian suppression — during chemotherapy, to reduce ovarian damage. Evidence is strongest for breast cancer; role in gynaecological cancers is still evolving.

These procedures are coordinated with reproductive medicine specialists. In most cases, oncofertility interventions can be completed without delaying cancer treatment.

Candidacy depends on cancer type, stage, histological grade, and the patient’s reproductive goals. General principles:

• Cervical cancer: Stage IA2–IB1, tumour ≤2 cm, no LVSI, negative nodes
• Ovarian cancer: Stage IA, favourable histology, intact capsule, comprehensive staging
• Endometrial cancer: Grade 1 endometrioid, no myometrial invasion on MRI, willingness to accept close surveillance

Patients with high-grade histology, advanced stage, lymphovascular space invasion, or nodal involvement are generally not candidates for fertility preservation — the oncological risk is too high. Honest discussion of these limitations is essential.

Dr. Nishtha Tripathi Patel offers fertility preserving surgical options at Sterling Hospitals, KD Hospital, and Welcare Speciality Hospital in Ahmedabad. Her practice provides:

• Radical trachelectomy (open and minimally invasive) for eligible cervical cancer patients
• Fertility-sparing staging surgery for early ovarian cancer
• Progestogen-based management with close endometrial surveillance for Grade 1 endometrial cancer
• Coordination with reproductive medicine specialists for oncofertility interventions

Patients from across Gujarat — including Surat, Vadodara, and Gandhinagar — as well as from neighbouring states regularly consult for fertility preserving cancer surgery in Ahmedabad. No GP referral is required.

Fertility preserving decisions in cancer require accurate staging, understanding of tumour biology, honest discussion of oncological risk, and coordination with reproductive medicine. A general gynaecologist may not have the training to assess whether fertility preservation is safe in a given case — and an error in this assessment can have fatal consequences.

A gynaecological oncologist ensures that fertility is considered within the treatment plan — without compromising the primary goal of curing the cancer. The first surgery determines the patient’s prognosis; getting it right from the start is non-negotiable.