Ovarian Transposition: A Vital Fertility Preservation Technique for Surgeons

Introduction to Ovarian Transposition

Ovarian transposition, also known as oophoropexy, is a surgical procedure designed to preserve ovarian function in women undergoing pelvic radiation therapy. This intervention is particularly vital for young women who wish to maintain fertility and hormonal function after cancer treatment. The technique involves relocating the ovaries outside the radiation field, thereby minimizing the exposure to harmful radiation.

Indications for Ovarian Transposition

Ovarian transposition is primarily indicated for women of reproductive age who are scheduled to undergo pelvic irradiation, which could otherwise lead to ovarian failure and infertility. Common conditions that necessitate pelvic radiation include cervical cancer, rectal cancer, and Hodgkin’s lymphoma. The procedure is also considered in cases where high doses of radiation are anticipated, and the ovaries are at risk of being compromised.

Preoperative Evaluation

Before performing ovarian transposition, a thorough preoperative evaluation is essential. This includes:

1. Assessment of Fertility Goals: The patient’s desire for future fertility plays a significant role in deciding whether to proceed with the surgery. Fertility preservation counseling should be provided, and options such as egg or embryo freezing should be discussed.

2. Imaging Studies: Pelvic imaging, typically using MRI or CT scans, is performed to assess the anatomy and plan the surgical approach. The imaging helps in determining the optimal location for ovarian transposition.

3. Ovarian Reserve Testing: Blood tests, such as anti-Müllerian hormone (AMH) levels and antral follicle count (AFC), provide insight into the ovarian reserve. These tests help in predicting the potential success of the transposition in preserving ovarian function.

4. Evaluation of General Health: A complete medical history, physical examination, and assessment of comorbidities are crucial to ensure the patient is fit for surgery.

Contraindications

While ovarian transposition is a valuable technique for preserving fertility, certain contraindications must be considered:

1. Advanced Cancer Stages: In cases of advanced-stage cancer where the disease has metastasized to the ovaries, transposition may not be feasible.

2. Pelvic Adhesions: Extensive pelvic adhesions, often due to previous surgeries or inflammatory conditions, may complicate the procedure.

3. Severe Comorbidities: Patients with severe comorbidities that increase the risk of surgery may not be suitable candidates.

4. Poor Ovarian Reserve: Women with significantly diminished ovarian reserve may derive limited benefit from the procedure.

Surgical Techniques and Steps

Ovarian transposition can be performed using various surgical approaches, including open surgery, laparoscopic surgery, and robotic-assisted surgery. The choice of technique depends on the surgeon’s expertise, the patient’s anatomy, and the extent of the disease. Here’s a detailed overview of the surgical steps:

1. Anesthesia and Positioning: The patient is placed under general anesthesia, and the position is adjusted to allow optimal access to the pelvis. Typically, a lithotomy position is used.

2. Incision and Access: Depending on the approach, a midline or Pfannenstiel incision is made for open surgery, while laparoscopic and robotic approaches involve small trocar incisions.

3. Mobilization of the Ovaries: The ovaries are carefully mobilized from their attachments. This involves dissecting the ovarian ligaments while preserving the blood supply from the ovarian arteries.

4. Relocation of the Ovaries: The ovaries are then transposed to a higher location outside the radiation field. Common sites include the paracolic gutters or the lateral abdominal wall.

5. Fixation: The ovaries are fixed in their new position using non-absorbable sutures. The fixation ensures that the ovaries remain in place during subsequent radiation therapy.

6. Closure: The incisions are closed in layers, ensuring hemostasis and minimizing the risk of postoperative complications.

Postoperative Care

Postoperative care is crucial to ensure the success of the transposition and the patient’s recovery. Key aspects include:

1. Pain Management: Adequate pain relief is essential. Non-opioid analgesics are preferred to avoid the side effects of opioids, but stronger pain relief may be necessary in some cases.

2. Monitoring for Complications: The patient is closely monitored for signs of infection, bleeding, or ovarian torsion—a rare but serious complication where the ovary twists on its pedicle, cutting off its blood supply.

3. Follow-up Imaging: Postoperative imaging is often performed to confirm the position of the ovaries and to ensure that they are outside the radiation field.

4. Hormonal Monitoring: Regular monitoring of ovarian function through hormonal assays may be indicated, especially if the patient wishes to conceive in the future.

Possible Complications

As with any surgical procedure, ovarian transposition carries potential risks and complications:

1. Ovarian Torsion: This is a rare but serious complication that can occur postoperatively, leading to acute abdominal pain and potentially requiring emergency surgery.

2. Infection: Surgical site infections can occur, although they are relatively uncommon with proper aseptic techniques.

3. Hemorrhage: Intraoperative or postoperative bleeding can occur, necessitating careful surgical technique and postoperative monitoring.

4. Loss of Ovarian Function: Despite successful transposition, there is a risk of reduced or complete loss of ovarian function due to compromised blood supply or inadvertent radiation exposure.

5. Adhesions: Postoperative adhesions may develop, leading to chronic pelvic pain or infertility.

Different Techniques

Ovarian transposition can be performed using various techniques depending on the patient’s individual circumstances:

1. Medial Transposition: The ovaries are relocated medially, often towards the uterine fundus. This technique is suitable when the radiation field is confined to the lower pelvis.

2. Lateral Transposition: The ovaries are moved laterally to the paracolic gutters, which is preferred when the radiation field extends more superiorly.

3. Abdominal Wall Fixation: In some cases, the ovaries are fixed to the anterior abdominal wall. This technique is considered when maximal distance from the radiation field is required.

Prognosis and Outcome

The success of ovarian transposition largely depends on various factors, including the patient’s age, ovarian reserve, and the radiation dose. Studies have shown that ovarian transposition can preserve ovarian function in approximately 50-90% of cases. The likelihood of preserving fertility is higher in younger women with good ovarian reserve.

For women who retain ovarian function post-transposition, the chances of spontaneous conception are favorable. However, some may require assisted reproductive technologies (ART) such as in vitro fertilization (IVF) to achieve pregnancy.

Alternative Options

For women who are not candidates for ovarian transposition or for whom the procedure may not be successful, alternative fertility preservation options should be considered:

1. Cryopreservation of Oocytes or Embryos: This is the most established method of fertility preservation. It involves the retrieval of eggs or embryos before cancer treatment, which are then frozen for future use.

2. Ovarian Tissue Cryopreservation: This experimental technique involves the removal and freezing of ovarian tissue before radiation therapy, with the aim of reimplanting it after treatment.

3. Use of Gonadotropin-Releasing Hormone (GnRH) Agonists: These medications may protect the ovaries during chemotherapy or radiation by temporarily suppressing ovarian function.

Average Cost

The cost of ovarian transposition varies widely depending on the country, healthcare setting, and whether the procedure is performed as part of cancer treatment. In the United States, the cost can range from $5,000 to $15,000, depending on the surgical approach and associated hospital fees. Insurance coverage for the procedure may also vary, so patients should consult with their providers regarding financial aspects.

Recent Advances

Recent advances in ovarian transposition focus on improving surgical techniques and maximizing the preservation of ovarian function. Robotic-assisted surgery offers enhanced precision and minimally invasive options, reducing recovery time and postoperative pain. Additionally, research is ongoing into optimizing the timing of ovarian transposition relative to cancer treatment to maximize outcomes.

Another area of development is the integration of ovarian transposition with other fertility-preserving techniques, such as concurrent egg retrieval for cryopreservation during the same surgical procedure.

Conclusion

Ovarian transposition remains a critical intervention for preserving fertility and hormonal function in young women undergoing pelvic radiation therapy. With proper patient selection, meticulous surgical technique, and comprehensive postoperative care, the procedure offers significant benefits in terms of long-term reproductive health.