Ovarian transposition before pelvic radiation
- Togas Tulandi, MD, MHCM
Togas Tulandi, MD, MHCM
- Professor of Obstetrics and Gynecology
- Milton Leong Chair in Reproductive Medicine
- McGill University, Canada
Oocytes are uniquely sensitive to radiation injury. A mathematical model predicted 16 gray (Gy) of radiation would deplete the ovarian oocyte pool at age 20 years and 10 Gy of radiation would deplete the ovarian oocyte pool at age 45 years . One method of protecting the ovaries from radiation injury is to transpose them out of the radiation field (ie, ovarian transposition, also known as ovarian suspension, oophoropexy, or ovariopexy) [2,3]. The vascular pedicle remains intact in ovarian transposition, which distinguishes this procedure from ovarian transplantation.
Historically, the ovaries were relocated medially by suturing them to the posterior uterus, and protected during radiation therapy with a lead shield placed centrally on the abdomen . However, medially placed ovaries still absorb radiation from scatter and some transmission through the shield, reducing the efficacy of the procedure [5-7]. In one report of medial ovarian transposition by positioning the ovaries behind the uterus in 11 girls with Hodgkin lymphoma, the authors reported 14 pregnancies approximately 15 years later . Contemporary procedures transpose the ovaries above the pelvic brim and as lateral as possible, which minimizes the ovarian dose of radiation and improves efficacy compared with medial approaches. Various lateral locations have been used, including the base of the round ligament , the level of lower kidney pole , and the paracolic gutters [11-13].
Ovarian transposition is performed to preserve fertility or prevent early menopause in reproductive aged women who are undergoing pelvic or low abdominal radiation therapy and who will be treated with chemotherapy with low probability of gonadotoxicity (table 1). In our institution, the most common cancers in adults treated with low abdominal radiation are rectal and anal. These cancers are usually also treated with 5-fluorouracil (5FU) or mitomycin, which are not gonadotoxic, thus these patients are candidates for ovarian transposition. In children, Hodgkin or non-Hodgkin lymphoma, vaginal or uterine tumors, pelvic Ewing's sarcoma, and spinal tumors are more common reasons for referral for the procedure [14-16].
The decision to perform ovarian transposition depends on a combination of factors including the patient’s age, ovarian reserve, desire for future pregnancy, personal preferences (eg, willingness to take hormone therapy for premature menopause), medical condition, and prognosis. The patient’s medical team (medical and radiation oncologists, reproductive endocrinologist, and surgeon who will perform the transposition) should help the patient weigh the risks and benefits of ovarian transposition based on her specific clinical situation.
The potential benefit of the procedure is lower in older women and women at increased risk of ovarian metastases:
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