Intraoperative Ketorolac and Outcomes after Ovarian Cancer Surgery.

INTRODUCTION: Surgery is the cornerstone of ovarian cancer treatment. However, surgery and perioperative inflammation have been described as potentially pro-metastagenic. In various animal models and other human cancers, intraoperative administration of non-steroidal anti-inflammatory drugs (NSAIDs) appears to have a positive impact on patient outcomes. MATERIALS AND METHODS: In this unicentric retrospective study, we provide an exploratory analysis of the safety and potential benefit of intraoperative administration of ketorolac on the outcome of patients undergoing surgery for ovarian cancer. The study population included all patients who were given a diagnosis of ovarian, fallopian tube or peritoneal cancer by the multidisciplinary oncology committee (MOC) of the Cliniques universitaires Saint-Luc between 2015 and 2020. RESULTS: We included 166 patients in our analyses, with a median follow-up of 21.8 months. Both progression-free survival and overall survival were superior in patients who received an intraoperative injection of ketorolac (34.4 months of progression-free survival in the ketorolac group versus 21.5 months in the non-ketorolac group (p = 0.002), and median overall survival was not reached in either group but there was significantly higher survival in the ketorolac group (p = 0.004)). We also performed subgroup analyses to minimise bias due to imbalance between groups on factors that could influence patient survival, and the group of patients receiving ketorolac systematically showed a better outcome. Uni- and multivariate analyses confirmed that administration of ketorolac intraoperatively was associated with better progression-free survival (HR = 0.47 on univariate analysis and 0.43 on multivariate analysis, p = 0.003 and 0.023, respectively). In terms of complications, there were no differences between the two groups, either intraoperatively or postoperatively. CONCLUSION: Our study has shown a favourable association between the use of ketorolac during surgery and the postoperative progression of ovarian cancer in a group of 166 patients, without any rise in intra- or postoperative complications. These encouraging results point to the need for a prospective study to confirm the benefit of intraoperative administration of ketorolac in ovarian cancer surgery.

Centralizing surgery for ovarian cancer in a 'non-centralizing' country (Belgium): the UNGO (UCLouvain Network of Gynaecological Oncology) experience.

OBJECTIVE: In Belgium there is no centralization of surgery for ovarian cancer, with more than 100 centers treating around 800 cases per year. In 2017 a network with several collaborating hospitals was established to centralize surgery for ovarian cancer (UCLouvain Network of Gynecological Oncology; UNGO) following publication of the European Society of Gynecological Oncology (ESGO) recommendations and quality criteria for surgery of advanced ovarian cancer. We obtained ESGO accreditation in 2019. METHODS: We retrospectively collected data associated with patients undergoing surgery in our institution from 2007 to 2016, before the creation of the network (cohort 1) and, following the establishment of UNGO (2017-2021), patients undergoing surgery were prospectively registered in a REDCap database (cohort 2). The outcomes of the two cohorts were compared. RESULTS: A total of 314 patients underwent surgery in our institution from 2007 and 2021: 7.5 patients/year in cohort 1 (retrospective, 2007-2016) and 40.8 patients/year in cohort 2 (after network creation, 2017-2021). Median disease-free survival was increased from 16.5 months (range 13.2-20.4) in cohort 1 to 27.1 months (range 21.5-33.2) in cohort 2 (p=0.0004). In cohort 2, the rate of patients with residual disease at the end of the surgery was significantly less (18.7% vs 8.8%, p=0.023), although more patients in cohort 1 received neoadjuvant chemotherapy (89% vs 54%, p<0.001). However, there was a higher rate of complications in the patients in cohort 2 (18.8% vs 30%, p=0.041). CONCLUSION: Our study shows that, with the help of ESGO and its recommendations, we have been able to create an efficient advanced ovarian cancer centralized network and this may provide an improvement in the quality of care.

Are lower levels of apoptosis and autophagy behind adenomyotic lesion survival?

RESEARCH QUESTION: How are markers of cell death, invasiveness and progesterone signalling expressed in endometrium and ectopic lesions from adenomyosis patients? DESIGN: Formalin-fixed paraffin-embedded tissue was collected from 15 control and 15 adenomyosis participants . To assess cell survival capacity, caspase 3 and microtubule-associated proteins 1A/1B light chain 3B (LC3B) were immunolabelled as markers of apoptosis and autophagy respectively. Matrix metalloproteinase 9 (MMP9) expression served as a marker of extracellular matrix degradation and invasion activity. Progesterone receptors were immunostained to detect evidence of progesterone resistance. RESULTS: Caspase 3 expression was significantly lower in the stromal (P = 0.0013) and epithelial (P = 0.0157) compartments of adenomyotic lesions than in healthy endometrial tissue. In the stroma, caspase 3 expression was significantly weaker in lesions than in corresponding eutopic endometrium (P = 0.0006). LC3B immunostaining was significantly decreased in adenomyotic stroma compared with corresponding eutopic endometrium (P = 0.0349). A significantly higher expression of MMP9 was detected in eutopic stroma from adenomyosis patients than in healthy tissue (P = 0.0295). Progesterone receptor immunostaining was found to be significantly weaker in the stroma of endometrium and ectopic lesions from adenomyosis patients than disease-free women (P = 0.0001; P = 0.0021). CONCLUSIONS: Adenomyotic lesions show lower levels of apoptosis and autophagy, suggesting that aberrant cell survival may be involved in disease pathogenesis. MMP9 appears to contribute to endometrial invasiveness in adenomyosis, as its expression is more pronounced in endometrium from these women than women without the disease. Evidence of progesterone resistance can be found in endometrium and ectopic lesions from adenomyosis patients, and may drive disease development and account for the failure of certain patients to respond to progestogens.

Hysteroscopic management of molar pregnancy: A series of 36 cases.

Background: Hydatidiform Mole (HM) is the most common form of gestational trophoblastic disease. Dilatation and curettage is the classical treatment of this affection. Hysteroscopic resection (HsR) is an alternative for the treatment of intra-uterine pathology. Objective: To describe the feasibility of HsR for the management of HM. Result: Case series of patients who had a complete or partial HM confirmed by histological examination of the trophoblastic tissue resected by operative hysteroscopy between 2007 and 2019. After approval of our ethics committee, we evaluated 36 patients who underwent hysteroscopic resection for molar pregnancy. Histological analysis showed partial HM in 28 patients (77.8%) and complete HM in 8 (22.2%). Main surgical complications were uterine perforation in one patient and glycine resorption in 10 patients with two cases of hyponatremia corrected by standard treatment. We performed an ultrasound control 1 month after the intervention in 19 patients (52.8%) as they had slow decrease of HCG or bleeding complaints and found retained product of conception (RPOC) in six patients (16.7%). Conclusion: This first report on a small number of patients demonstrate that hysteroscopic resection is a feasible procedure for the management of molar pregnancy. Direct visualization of the procedure helps the surgeon to control the resection. Further studies are mandatory to compare this technique with D&C in term of RPOC and fertility outcomes as it remains the standard treatment.

Outcomes after Laparoscopic Excision of Bladder Endometriosis Using a CO2 Laser: A Review of 207 Cases in a Single Center.

STUDY OBJECTIVE: Assess efficacy, safety, fertility outcomes and recurrence after laparoscopic resection of bladder endometriosis (BE) using a CO2 laser. DESIGN: Retrospective cohort study. SETTINGS: University gynecologic surgery unit, referral center for endometriosis. PATIENTS: A total of 207 women having undergone laparoscopic BE excision between January 1998 and January 2019. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Intra- and postoperative complication rates. Disease recurrence and fertility outcomes in patients with a minimum 1-year follow-up (n = 176) for "isolated" and "non-isolated" BE groups. RESULTS: Forty-three patients presented with isolated BE. Bladder "shaving" without mucosae opening was performed in 50.7% cases. No intraoperative complications were noted. One postoperative grade 3 complication was related to BE excision: a bladder breach requiring closure by repeat laparoscopy. Mean (± SD) follow-up was 7.05 (± 4.65) years. In patients wishing to conceive (n = 132), the total pregnancy rate (PR) was 75% (48.5% spontaneous), 76.19% in the isolated BE group (56.3% spontaneous). Among the 94 patients with previous infertility, 74.5% conceived, 50% spontaneously. No statistical difference was found in PR and need for in vitro fertilization between isolated and nonisolated BE groups. BE recurrence rate was 3.4%. No difference was observed between groups with full-thickness bladder resection (4/88) and shaving (2/88) (p = .406). Age at surgery (hazard ratio 0.91 [0.84-0.98], p = .016) and postoperative pregnancy (hazard ratio 0.07 [0.01-0.91], p = .042) showed influence on disease recurrence. CONCLUSIONS: The study demonstrates that laparoscopic BE removal is feasible with very low complications rates and was associated with high PR (both spontaneous and in vitro fertilization), even in patients with previous infertility. BE recurrence is lower than for other endometriosis locations. Bladder endometriosis; Laparoscopy; Deep infiltrating endometriosis; Fertility; Partial bladder resection.

Diagnosis and Treatment of Vulvo-Perineal Endometriosis: A Systematic Review.

Objective: To describe the available knowledge on vulvo-perineal endometriosis including its diagnosis, clinical management and recurrence rate. Methods: We followed the PRISMA guidelines for Systematic Reviews and our study was prospectively registered with PROSPERO (CRD42020202441). The terms "Endometriosis" and "Perineum" or "Vulva" were used as keywords. Cochrane Library, Medline/Pubmed, Embase and Clinicaltrials.gov were searched. Papers in English, Spanish, Portuguese, French or Italian from inception to July 30, 2020 were considered. Reference lists of included articles and other literature source such as Google Scholar were also manually scrutinized in order to identify other relevant studies. Two independent reviewers screened potentially eligible studies according to inclusion criteria. Results: Out of 539 reports, 90 studies were eligible including a total of 283 patients. Their mean age was 32.7 ± 7.6 years. Two hundred sixty-three (95.3%) presenting with vulvo-perineal endometriosis have undergone either episiotomy, perineal trauma or vaginal injury or surgery. Only 13 patients (4.7%) developed vulvo-vaginal endometriosis spontaneously i.e., without any apparent condition favoring it. The reasons that motivated the patients to take medical advice were vulvo-perineal cyclical pain increasing during menstruations (98.2% of the patients, n = 278). Out of the 281 patients for whom a clinical examination was described, 274 patients (97.5%) showed a vulvo-perineal nodule, mass or swelling while six presented with bluish cutaneous lesions (2.1%) and 1 with bilateral polyps of the labia minora (0.4%). All but one patients underwent surgical excision of their lesions but only 88 patients (28.1%) received additional hormonal therapy. The recurrence rate was 10.2% (29 patients) considering a median follow-up period of 10 months (based on 61 studies). Conclusion: In conclusion, vulvo-perineal endometriosis is a rare entity with approximately 300 cases reported in the literature since 1923. With the available knowledge shown in this systematic review, we encourage all practitioners to think about perineal endometriosis in case of perineal cyclical pain with or without previous perineal damage. Diagnosis should be done with clinical exam, perineal ultrasound and pelvic MRI when available. In case of anal sphincter involvement, perianal ultrasound should be performed. Surgical excision of the lesion should be realized in order to remove the lesion and to confirm the diagnosis histologically. Hormonal treatment could be proposed to attempt to decrease the size of a large lesion before surgery or to avoid recurrence of the lesion. As evidence-based approach to the diagnosis, treatment and recurrence rate of affected patients remains a challenge given its low prevalence, the variations in management found in the articles included and the limited quality of available studies, we suggest that a prospective database on vulvo-perineal endometriosis should be generated to increase knowledge but also awareness among healthcare professionals and optimize patients' care. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/, identifier: CRD42020202441.

Experience With Medical Treatment of Cesarean Scar Ectopic Pregnancy (CSEP) With Local Ultrasound-Guided Injection of Methotrexate.

Objective: Ectopic pregnancy within Cesarean section scars is a rare condition. Late diagnosis carries significant risk of bleeding with poor prognosis for survival. There is no consensus on the management of this type of pregnancy. Historically, our facility offered an intra-muscular injection of methotrexate that resulted in a significant failure rate and later need for surgery. We hypothesized that injecting methotrexate directly into the gestational sac would improve the success rate of the treatment. Patients and Methods: This retrospective, uni-centric study examined nine patients aged between 33 and 42 years (mean age = 36.5 years) with Cesarean scar ectopic pregnancy (CSEP) between 2010 and 2018. CSEP was diagnosed by transvaginal ultrasound at a mean gestational age of 8w0/7. CSEP was treated under general anesthetic by ultrasound-guided methotrexate injection directly into the gestational sac. HCG levels and subsequent childbearing were monitored post-treatment. Results: Half of the patients were asymptomatic at the time of diagnosis. All patients tolerated treatment well and all ectopic pregnancies were successfully removed. HCG levels returned to negative within 3 months without additional medical or surgical intervention. The post-treatment pregnancy rate was 50%. Discussions/Conclusions: Our findings indicate that local ultrasound-guided injection of methotrexate into the gestational sac is a safe and effective therapeutic approach when performed by a trained team on a hemodynamically stable patient in the early stages of CSEP.

Hysteroscopic Resection for Missed Abortion: Feasibility, Operative Technique and Potential Benefit Compared to Curettage.

Objective: To evaluate the feasibility of hysteroscopic resection (HsR) for primary surgical management of missed abortion. Reproductive outcomes and potential benefit of this technique will be compared to traditional dilatation and curettage (D&C). Design: Retrospective cohort study in two Departments (Gynecology and Obstetrics) of a tertiary medical care center (Canadian Task Force classification II-2). Patients: Women with first trimester missed abortion. Intervention: Two techniques were used for the management of missed abortion: ultrasound-guided dilatation and curettage (D&C) and hysteroscopic resection (HsR). Results: We evaluated 358 patients who underwent primary surgical removal of missed abortion. Hundred seventy three patients have been treated by D&C and 185 underwent HsR. In the HsR group, 110 patients (59.5%) have obtained their pregnancy with in vitro fertilization (IVF) vs. 7 patients (4.0%) in the D&C group which make the HsR population hypofertile in comparison to the D&C population. The intra- and post-operative complication rates are low and comparable. Intrauterine anomalies were diagnosed during the HsR in 10 patients (5.4%) and could be investigated after the intervention as a possible cause of miscarriage. Because of the difference in term of fertility, the reproductive outcomes have been analyzed by multivariate analysis. The hazard ratio of pregnancy at 6 months, adjusted to the factor IVF for D&C compared to HsR is 0.69 [0.49-0.96] (p = 0.026). That could represent a significant benefit in the particular population followed in IVF, but regarding the retrospective analysis, and the very different population in the two groups, it doesn't allow us to draw any evidence based conclusion. Conclusion: Hysteroscopic resection is a feasible and safe procedure for the management of missed abortion that could increase the diagnosis of uterine abnormalities. With all the limitation of the design of our study, our data seems to show a trend to a potential benefit in term of reproductive outcomes for hypofertile patient undergoing IVF treatment.

Fertility Sparing Treatment in Patients With Early Stage Endometrial Cancer, Using a Combination of Surgery and GnRH Agonist: A Monocentric Retrospective Study and Review of the Literature.

Objectives: To evaluate the efficacy and safety of gonadotropin-releasing hormone (GnRH) agonist after endometrial resection in women suffering early stage endometrial carcinoma (EC) and/or endometrial intra-epithelial neoplasia (EIN). Design: A retrospective review of clinical files between January 1999 and December 2016. Setting: University hospital. Patients: Eighteen women younger than 41 years with grade 1 endometrial carcinoma (G1EC) and/or Endometrial intra-epithelial neoplasia (EIN). INTERVENTIONS: All patients received GnRH agonist for 3 months after an endometrial resection combined with a laparoscopy to exclude concomitant ovarian tumor and/or other extra-uterine disease. The patient underwent a follow-up of 3 months interval with endometrial sampling by hysteroscopy. Main Outcome Measure(s): The recurrence rate and the pregnancy rate after fertility sparing treatment. Results: We identified 9 patients with EIN (50%), 7 patients with G1EC (38.9%), 1 with combined histology (5.5%), and 1 with G2EC (5.5%). After a median follow-up of 40.7 months, 12 patients conserved their uterus (66.7%), and 8 (53.3%) patients were pregnant with a total of 14 pregnancies among those who tried to become pregnant. We observed a complete response rate in 12 patients (66.7%) but 3 of these patients relapsed (25%). We also found a stable disease in 6 patients (33.3%). Conclusions: Compared with other fertility sparing treatments, GnRH agonist after surgery is an effective fertility-sparing strategy for women with EIN and/or G1EC. We recommend hysterectomy once a family has been completed even if the literature does not clearly lead to radical surgery.

Survival and growth of human preantral follicles after cryopreservation of ovarian tissue, follicle isolation and short-term xenografting.

In women, chemotherapy and radiotherapy can be harmful to the ovaries, causing loss of endocrine and reproductive functions. When gonadotoxic treatment cannot be delayed, ovarian tissue cryobanking is the only way of preserving fertility. This technique, however, is not advisable for patients with certain types of cancer, because of the risk of reintroducing malignant cells present in the cryopreserved tissue. Our objective is therefore to develop a transplantable artificial ovary. To this end, cryopreserved human preantral follicles were isolated and embedded in fibrin formulations prepared with 50 mg/ml fibrinogen and 10 IU/ml thrombin supplemented or not with 3% hyaluronic acid, and respectively xenografted to specially created right and left peritoneal pockets in eight nude mice. On days 0 and 7, the animals were killed and the matrices retrieved. On day 7, no difference was observed in the recovery rate of follicles embedded in fibrin alone (23.4%) or fibrin-hyaluronic acid (20.5%). Ki67 staining confirmed growth of the grafted follicles and terminal deoxynucleotidyl transferase)-mediated dUDP nick-end labelling assay revealed 100% of the follicles to be viable in both groups on day 7. In conclusion, fibrin seems to be a promising material for creation of an artificial ovary, supporting follicle survival and development.

First series of 18 pregnancies after ulipristal acetate treatment for uterine fibroids.

OBJECTIVE: To study the pregnancy rate after ulipristal acetate (UPA) therapy for fibroids. DESIGN: Retrospective analysis of a series of 52 patients prospectively included in the PGL4001 (ulipristal acetate) Efficacy Assessment in Reduction of Symptoms Due to Uterine Leiomyomata (PEARL) II and III trials. SETTING: Academic hospital. PATIENT(S): Among the 52 patients, 21 wished to conceive upon treatment completion. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Pregnancy rate and live birth rate. RESULT(S): Twenty-one patients attempted to get pregnant, among whom 15 (71%) succeeded, totaling 18 pregnancies. Among these 18 pregnancies, 12 resulted in the birth of 13 healthy babies and 6 ended in early miscarriage. No regrowth of fibroids was observed during pregnancy. CONCLUSION(S): We report the first series of pregnancies achieved after UPA treatment. Our data confirm a sustained long-term effect after UPA therapy.

Evaluation of cryopreserved ovarian tissue from prepubertal patients after long-term xenografting and exogenous stimulation.

OBJECTIVE: To assess follicular development after long-term xenotransplantation and exogenous stimulation of cryopreserved prepubertal ovarian tissue. DESIGN: Pilot study. SETTING: Gynecology research unit in a university hospital. PATIENT(S): Cryopreserved ovarian fragments were obtained from five prepubertal patients aged 7.2-12.2 years. INTERVENTION(S): Xenografting of frozen-thawed prepubertal ovarian fragments to SCID mice for 5 months and exogenous stimulation. MAIN OUTCOME MEASURE(S): Follicular density, morphology, proliferation, development. RESULT(S): Follicular density varied between 1.05 and 47.89 follicles/mm(2) in frozen-thawed ovarian tissue and 0.48 and 32.74 follicles/mm(2) in grafted prepubertal ovarian tissue. Growing follicles at the last stage of follicular development were observed at significantly higher proportions after grafting. No statistical difference was evidenced in the number of primordial follicles, representing the largest proportion of the follicle pool (99.51% before grafting and 92.46% after grafting). Ki67 and antimüllerian hormone expression were observed in these growing follicles. CONCLUSION(S): This is the first description of transplantation of human cryopreserved prepubertal ovarian tissue to mice, demonstrating that a very high number of follicles survive after transplantation and a large pool of primordial follicles remains dormant. Growing follicles were observed, proving the responsiveness of prepubertal ovarian tissue to gonadotropins.

A review of 15 years of ovarian tissue bank activities.

PURPOSE: To review 15 years of activities in ovarian tissue cryobanking from medical database files, including patient indications, histological evaluation and clinical characteristics. METHODS: Retrospective longitudinal analysis of data from an ovarian tissue bank in an academic hospital. Five hundred and eighty-two patients had their ovarian tissue cryobanked between April 1997 and January 2012. Analysis of cryobanking database: precryopreservation patient characteristics, indications and safety issues, laboratory files and postcryopreservation clinical data. RESULTS: Of the 582 patients who had their ovarian tissue cryopreserved, 106 patients donated for research purposes and 476 patients for fertility preservation and long-term cryopreservation. Clinical data analysis of the 476 patients revealed a mean age at the time of cryopreservation of 23 ± 8.5 years (range: 9 months - 39 years), with 96.2 % of subjects aged ≤35 years (n = 458). Among 391 cases of malignant disease, hematological malignancies (39.9 %, n = 156) and breast cancer (21.7 %, n = 85) were the two main indications. At histology, malignant cells were found in ovarian tissue from leukemia patients (n = 3) and non-Hodgkin's lymphoma patients (n = 2). Eleven patients underwent autotransplantation, resulting in 5 live births and 1 ongoing pregnancy. CONCLUSION: This is the largest and most comprehensive study to describe and analyze indications and clinical patient characteristics before and after ovarian tissue cryopreservation. The procedure is safe, easy and promising. The database concept is a useful tool in patient selection for autotransplantation.

Laparoscopic repair of post-cesarean section uterine scar defects diagnosed in nonpregnant women.

Herein we describe laparoscopic repair of uterine scar defects after cesarean section and pregnancy outcomes in a series of 13 patients. Defects and the residual anterior uterine wall were evaluated using ultrasound and magnetic resonance imaging (MRI). Patients' clinical symptoms were recorded. Pregnancy outcomes were investigated after laparoscopic surgical repair. Intervention included laparoscopic repair of the defect, including excision of fibrotic tissue and laparoscopic closure of the anterior uterine wall. The defect was completely corrected using this technique in all 13 patients. Four patients became pregnant spontaneously, 3 delivered via cesarean section between 38 and 39 weeks, and 1 is currently pregnant. Evaluation of uterine scar defects after cesarean section can be performed using ultrasound and MRI, and the defect can be repaired via laparoscopy, with reproducible postoperative anatomic and functional outcomes.

Surgical treatment of ovarian endometriomas: state of the art?

To define the role of surgery in the treatment of endometriomas, we review the literature available via PubMed and cross-reference the published data. We analyze the arguments in favor of and against surgical treatment of endometriomas and compare surgical techniques. Pain relief and pregnancy rates of more than 50% after surgery are the most important arguments in favor of surgery. Histologic and biologic markers of ovarian reserve show a risk of decreased ovarian reserve that should be taken into consideration, especially in cases of repeated surgery. Considerable surgical expertise is required, and the lack of comparative studies yields no conclusions on the best surgical technique. Despite the risk of decreased ovarian reserve due to the surgical procedure, surgery has an important role in the treatment of ovarian endometriomas, and more studies are required to define the most appropriate surgical technique.

Live birth after transplantation of frozen-thawed ovarian tissue after bilateral oophorectomy for benign disease.

OBJECTIVE: To report the restoration of ovarian function and pregnancy in a woman after bilateral oophorectomy for benign disease after autotransplantation of cryopreserved ovarian cortex. DESIGN: Case report. SETTING: Gynecology research unit in a university hospital. PATIENT(S): A 28-year-old woman who underwent bilateral adnexectomy for ovarian abscesses at the age of 18 years. INTERVENTION(S): We performed ovarian cortex autotransplantation to a peritoneal pocket in the broad ligament. MAIN OUTCOME MEASURE(S): Restoration of ovarian activity and pregnancy. RESULT(S): Restoration of ovarian function began at 20 weeks and was achieved 24 weeks after transplantation. After the fifth stimulation attempt, two mature oocytes were obtained and microinjected. One embryo (seven cells) was obtained and transferred, leading to a normal pregnancy. The patient delivered a healthy baby boy weighing 2,370 g at 38 weeks of gestation. CONCLUSION(S): Ovarian cortex cryopreservation can be performed at the time of surgery for benign diseases when fertility is impaired. We report the first pregnancy to occur after ovarian tissue cryopreservation for benign ovarian pathology after bilateral oophorectomy.

Fertility considerations in young women with hematological malignancies.

The need for practice guidelines for fertility preservation in young women with hematological malignancies has been increased. To develop recommendations, publications relevant to fertility preservation and hematological cancers were identified through a PubMed database search and reviewed systematically, focusing on the effects of oncological treatments on fertility as well as on the efficacy, feasibility and risks of existing fertility preservation methods.

How does bone marrow transplantation affect ovarian function and fertility?

PURPOSE OF REVIEW: This article sets out to review the literature on gonadal toxicity of bone marrow transplantation (BMT) in women, and preventive and curative actions available for girls and women facing BMT and infertility. FINDINGS: The real incidence of ovarian damage after BMT is difficult to assess. Series reporting ovarian function and pregnancies after BMT vary greatly in terms of endpoints, number of patients included, age at and indications for BMT, conditioning regimens and duration of follow-up. The risk of premature ovarian failure (POF) is very high, however, and increases with age and in case of BMT conditioning treatment with total body irradiation. Embryo, oocyte and ovarian cortex cryopreservation are effective fertility preservation methods that should be discussed with all girls and young women requiring BMT. SUMMARY: Despite a lack of literature on long-term follow-up of fertility after BMT in large populations, it is clear that the risk of ovarian damage and POF is very high. Fertility preservation options should therefore be discussed with all patients having to undergo BMT.

Fertility preservation in women with ovarian endometriosis.

Endometriosis is one of the most frequently encountered benign diseases in gynecology. Complete resolution of endometriosis is not yet possible, but therapy has essentially three main objectives: (1) to preserve and improve fertility, (2) to reduce pain, and (3) to delay recurrence for as long as possible. The aim of this paper is to focus on fertility preservation in women with severe endometriosis. In moderate and severe endometriosis, a medico-surgical approach remains the gold standard, but more and more papers are reporting a low ovarian reserve after laparoscopic cystectomy for endometriomas. Indeed, very frequently, normal ovarian tissue is excised together with the endometrioma wall. Ovarian surgery in endometriosis patients should therefore be performed by experienced surgeons in order to both preserve and improve fertility. Preservation of ovarian tissue should be considered in all patients at serious risk of future fertility impairment, particularly before any treatment likely to result in ovarian endometriosis recurrence and/or premature ovarian failure.