Fertility sparing surgery

What are fertility sparing operations?

Fertility sparing operations are surgical procedures that preserve the fertility of a patient. In particular, this refers to procedures carried out as part of the treatment of malignant tumors.

According to the guideline of the German Society of Gynecology and Obstetrics regarding fertility preservation in oncological diseases, effective until 2022, approximately 78,000 new cases of cancer are diagnosed every year in Germany in the age group from 0 to 40 years, in which many patients have a desire to have a child now or in the future. This figure is also likely to have increased given that the number of new cancer cases is rising overall.

The guidelines also point out that patients perceive the possibility of future infertility as a result of surgical removal of the testicles, ovaries or uterus, or as a result of chemotherapy or radiotherapy, to be just as distressing as the cancer itself. Therefore, operations to preserve fertility need to be considered for people who have not yet completed family planning.

When is surgery appropriate for preserving fertility?

In principle, surgical procedures aimed at protecting germ cells from damage caused by radiotherapy or chemotherapy can be performed on all patients undergoing radiotherapy or chemotherapy who want to undergo fertility-preserving surgery, as long as the surgical and anaesthetic risks are reasonable. The risk of anesthesia and surgery is significantly increased if, for example, the patient has a serious blood clotting disorder or a severely impaired lung and/or cardiovascular system.

Female patients should, however, be made aware that the preservation of functional germ cells will not always guarantee a subsequent pregnancy. For instance, if the uterus is heavily impaired by the treatment, pregnancy and childbirth are usually impossible. Nevertheless, if the patient's own gametes are preserved, it is possible to give birth to a genetically identical child via surrogacy.

Surgery to treat a tumor in which reproductive organs are spared is also considered a fertility sparing procedure. In cervical cancer, for example, it is possible to remove only a part of the cervix and scrape out the rest of the cervix rather than removing the entire uterus. If a malignant tumor is found on one ovary, the healthy ovary can be left in place on the other side.

Such operations should only be carried out if the cancer is at an early stage and the patient has been carefully informed, because less radical operations are more likely to lead to tumor recurrence, especially in advanced stages, and the preservation of fertility would be achieved by administering a less safe cancer therapy.

What surgical methods are used?

Transposition of the ovaries

To preserve the function of the ovaries during planned radiotherapy of surroundings, it is possible to remove either both ovaries or a single ovary from the uterus and attach it to the abdominal wall with sufficient distance from the radiation field. This surgery is usually performed under general anesthesia using laparoscopy, which is a minimally invasive procedure.

After radiotherapy has been completed, the ovaries can be reimplanted in their original position. Another option is to remove eggs from the ovary that is attached to the abdominal wall and implant them in the uterus after fertilization outside the body.

Cryopreservation of egg cells or ovarian tissue

Egg cells or ovarian tissue can be removed before starting radiotherapy or chemotherapy and then used later for reproduction.

While the collection of eggs does not necessitat surgery, but simply a puncture of the ovary, it requires hormonal stimulation prior to the procedure. This may delay the start of cancer treatment by days or even weeks. The collected eggs can be frozen in an unfertilized state. Patients in a stable partnership can also have part of their eggs artificially fertilized with their partner's sperm before cryopreservation. Once the therapy is complete, the fertilized eggs can be introduced into the uterus. After thawing, unfertilized eggs are artificially inseminated and then implanted.

Cryopreservation of sperm or testicular tissue

Just like egg cells, it is also possible to freeze and preserve sperm, though it is usually easier to obtain them by ejaculation. For 20% of patients, however, ejaculation is no longer possible, frequently because of the cancer, or the number or quality of sperm in the ejaculate is insufficient. In such cases, a microsurgical procedure, usually performed under general anesthesia, can be carried out to remove testicular tissue. This tissue can be used to harvest sperm in many cases, although this only takes place after thawing, since the testicular tissue additionally protects the sperm during freezing and thawing.

Once thawed, the sperm can be used for artificial insemination.

What are the chances of successful fertility-preserving operations?

Due to the lack of a more recent, equally comprehensive guideline, the statistics below are based on the German Society of Gynecology and Obstetrics guideline on fertility preservation in oncological diseases, valid until 2022:

Transposition of the ovaries

• The function of the ovaries can be preserved in 80.8% of cases according to a meta-analysis of 32 studies. This figure may be too high, as trials with poor success rates may have taken place but were not published.

Cryopreservation of egg cells or ovarian tissue

• The number of egg cells collected after stimulation treatment depends on the patient's age, with most being collected between the ages of 31 and 35. This number drops rapidly with increasing age.

• Up to 90% of unfertilized eggs that have been frozen by vitrification can be thawed alive and as many as 83% can be fertilized. Pregnancy is achieved in 44.9% of cases.

• Following transplantation of ovarian tissue, a German study reported a birth rate of 23% and a Danish study reported a birth rate of 31%.

Cryopreservation of sperm or testicular tissue

• Around 50% of sperm is lost during cryopreservation.

• Removal of testicular tissue can provide fertile sperm in 60-70% of patients who were unable to ejaculate.

Which doctors & clinics specialize in fertility sparing operations?

Gynecologists, obstetricians and urologists provide treatment for cancers of the reproductive organs and are your specialists for fertility sparing operations. Fertility centers offer special expertise in fertility.

If you're in need of a doctor, you expect the best medical care possible. So of course patients are curious to find out what clinic to go to. As there is no objective way to answer this question and a legitimate doctor would never claim to be the best, patients must rely on a doctor's experience.

Let us help you find an expert for your condition. All listed doctors and clinics have been reviewed by us for their outstanding specialization in the field of fertility sparing surgery and are looking forward to your inquiry or wish for treatment.