Even radical reproductive surgery need not mean the end of fertility and motherhood

Published 27 October 2020

An online Campus meeting held in October considered the outcomes of uterine transplantation for fertility restoration and radical surgery to treat genital tract malformations. The conclusions were positive but cautious.

Motherhood is possible for women having radical surgery to preserve fertility after cancer or to treat genital tract malformations. This was the positive, albeit cautious, message from presentations at an online Campus meeting in October, which was organised by the SIG Reproductive Surgery and considered uterine transplants, cervico-neovagina anastomosis and abdominal radical trachelectomy.

Using quality-of-life survey data spanning more than two decades, Laszlo Ungar described how patients having abdominal radical trachelectomy for invasive cervical cancer go on to enjoy high self-esteem, a satisfactory sex life and continued working lives. Moreover, of those patients wanting to conceive (22% of 370 in his series), more than one in ten (12%) did become pregnant. A technique rediscovered by Ungar and colleagues in the 1990s, abdominal radical trachelectomy is now used widely and adjusted to suit different indications. It has helped women benefit from fertility-sparing surgery for what is one of the most common cancers. Laszlo described the results as ‘beyond our expectations’. However, there are downsides, including loss of bladder sensation and some night-time incontinence.

Uterine transplantation is still a relatively new approach for restoring or creating uterine function for the purpose of pregnancy, with the first baby born from a live donor in 2014 in Sweden. The world’s first laparoscopic assisted retrieval of a uterus for transplant was performed in 2017 by Shailesh Puntambekar, medical director of Galaxy Care hospital in India, who detailed the steps behind the procedure which resulted in the birth of a 1.45 kg healthy girl.(1) However, not everything has been straightforward, said Puntambekar, who now has more than 200 patients on his waiting-list. One major setback was his first transplant recipient, who miscarried at week six; other challenges along the way included the risk of transplant rejection by the recipient, which has to be managed by immunosuppressants until uterus removal. Based on his experience, Puntambekar now recommends the consideration of embryo transfer six months post-transplantation and planning for a c-section (between 32 to 34 weeks). The benefits of uterus transplant, he says, include legal and genetic motherhood, which surrogacy and adoption cannot provide. ‘Patients have a craving for motherhoodm’ he said. ‘It gives a feeling of being a mother and a woman.’

The incidence of female genital tract anomalies is small in the general population but much greater in women with infertility, although true figures are unknown. Maria Isabel Acien, SIG Reproductive Surgery co-ordinator, focused her presentation on anomalies relating to the mesonephric duct and on isolated Mullerian anomalies, such as congenital cervical atresia and cervico-vaginal agenesis. The most common presentation, she explained, is combined cervicovaginal atresia which involves two stage surgery for neovagina creation and cervical resection. Although success conceiving is limited in cases of female genital tract anomalies, Acien noted case reports of patients who became pregnant spontaneously following surgery, which included McIndoe vaginoplasty and cervico-isthmic resection.(2)

1. Puntambekar S, Telang M, Kulkarni P, et al. Laparoscopic-assisted uterus retrieval from live organ donors for uterine transplant. J Minim Invasive Gynecol 2018; 25; 571-572. doi: 10.1016/j.jmig.2017.11.001
2. Acién P, Acién MI, Quereda F, Santoyo T. Cervicovaginal agenesis: spontaneous gestation at term after previous reimplantation of the uterine corpus in a neovagina: Case Report. Hum Reprod 2008; 23; 548-553.

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