Fertility preservation in uterine cancer

Endometrial cancer is the second most common malignancy among women in Bulgaria. It is mainly detected during menopause, but it is also possible to diagnose it in women of reproductive age.

The standard treatment includes surgical removal of the uterus with or without the ovaries, as well as various types of radiotherapy and chemotherapy according to medical indications. The removal of the uterus makes it impossible to carry a future pregnancy.

If you are a woman of reproductive age who has been diagnosed with endometrial cancer, and you wish to have a child, KEEP HOPE ALIVE! Uterine preservation is sometimes possible, and we have done it in 3 cases (fertility-sparing treatment). 

This approach is only possible for the endometrioid subtype, which is also the most common one, having the most favorable prognosis.

Additionally, the tumor should not have penetrated deep into the uterine wall or cervix. With a good ultrasound examination and MRI this could be assessed accurately. The cells should resemble normal cells as much as possible, which is reflected on the histopathological result as a G1, or the so-called well/highly differentiated carcinoma.

This is largely assessed by the pathologist evaluating your histological slides, and no matter what a good specialist he or she is, to avoid a subjective assessment, ask for a second opinion with immunohistochemistry.

This is the point where we must clarify that the fertility-sparing approach is not the standard of care but is accepted worldwide as an option for women desiring pregnancy. It should be performed in sites in possession of high-level expertise and opportunity for close collaboration between reproductive specialists, oncologists, and pathologists.

How is this done? With a surgical procedure called hysteroscopy, the uterus is entered through the vagina and the entire endometrium is cut out using an electric loop. This is the so-called  three-step resection technique, which we have performed many times. The procedure is performed under intravenous anesthesia and you can leave the hospital the same day.  

The disappearance of cancer cells is also associated with strict hormone therapy, which lasts for six months. Hysteroscopy is repeated the first month, after three months and at the sixth month after the first manipulation.

The procedure is performed in the presence of a pathologist, with a biopsy is taken from each suspicious site separately. During this time, you will not experience a menstrual period.

With us, the main focus of treatment is your complete safety and the full restoration of a healthy uterus.

Frequently asked questions and common situations you may run into

Are there contraindications to the fertility-sparing approach?

Relative contraindications to any hormonal therapy are old myocardial infarction, pulmonary thromboembolism, or deep vein thrombosis. Do not hesitate to contact us to discuss your case and find the best solution.

What happens after giving birth?

After a successfully carried pregnancy, it is recommended that the uterus be removed.

Should I have other tests?

The reproductive specialist may recommend genetic counseling. The reason for this is that in some cases endometrial carcinoma may be a manifestation of a genetic syndrome predisposing to a variety of malignancies, e.g. Li-Fraumeni syndrome.

My doctor said the surgery should be done immediately.I'm afraid consultation can take a long time.

You should not be worried! Cancer patients interested in fertility preservation are given priority at Nadezhda Hospital. Call us and you will have your consultation take place not later than 1-2 days afterwards.

How can I be sure that endometrial biopsy examination during hormone treatment is a biopsy from the exact right place?

In our hospital we use the Hysteroscopy method (a small camera is used to view the uterine cavity) in the presence of a pathologist, who indicates the biopsy site.


Remember that...

A diagnosis of endometrial cancer requires a high level of expert evaluation, and always requires a second opinion.

Before the cells become cancerous, they undergo the so-called hyperplastic changes. A diagnosis of atypical hyperplasia is a precancerous condition, but not yet cancer. This diagnosis does not require removal of the uterus. It may be misinterpreted or taken by your gynecologist as an indication for removal of the uterus.

Our advice is to seek an appointment with us for a second opinion, and to take your histology slides with you.

If cancerous cells would be established in a removed polypus and you are offered to undergo radical surgery, don't rush to agree!

A polypus is a small, isolated part of the endometrium, and this does not mean cancer of the whole uterus. Finding out what the condition really is requires another consultation and a very carefully considered approach. Get in touch with us!

We now come to the conclusion – if you have read the above lines carefully, you are no longer asking yourself ‘I have endometrial cancer, why do I have to read this?'

Yes, options exist, and you should check all of them before opting in to make a radical decision. Options do exist!


Fertility preservation options

In contemporary practice, a fertility-sparing approach can be applied to women seeking pregnancy; it should be conducted in centers with experience and capacity for teamwork between reproductive specialists, oncologists and pathologists. Ovarian transposition is a procedure used to preserve ovarian function when radiotherapy is required. 

Fertility preservation options

Frequency of application and success rate of the approach

Fertility-sparing treatment ★★★  
Transposition of the ovaries  

★★★ - most commonly used approach, highest success rate  ★★ - less frequently used approach, lower success rate - rarely used approach