This blog post was originally published on Dr Simon West’s website, 20 February 2025, and is co-authored by Dr Simon West and Dr Kath Whitton. For more information about (Brisbane-based) Dr Simon West, visit his website or follow his Instagram.

This week's blog is co-authored by Dr. Kath Whitton, a RANZCOG board-certified fertility specialist (CREI). She shares valuable insights into the fertility options available to Australian patients, providing expert guidance on their reproductive choices.

Gynaecological cancers can occur in young women of reproductive age and occasionally, even earlier. Being diagnosed with cancer at such a young age can be overwhelming, especially when combined with the fear of losing fertility. This time can be incredibly challenging for both patients and their families. It’s important to understand that all hope is not lost. There are many options available that can preserve fertility without compromising the treatment of the primary disease or affecting survival rates.

In this post, we will discuss various treatment options for gynaecological cancers and how they impact fertility. Followed by the options currently available to patients in Australia.

Surgical Treatments

Oophorectomy (Removal of a single Ovary)

• Removing a single ovary does not eliminate natural fertility as an option. However, if issues arise with the remaining ovary during surveillance, future surgery may have an impact.

• The adjacent fallopian tube should be removed along with the affected ovary.

• Unilateral Oophorectomy is commonly performed for germ cell tumours, borderline tumours, and certain epithelial tumours of the ovary.

Bilateral Oophorectomy (Removal of Both Ovaries)

• Removing both ovaries leads to menopause and removes the possibility of natural fertility.

• However, before the removal, oocytes (eggs) or embryos can sometimes be collected for future use.

• If the uterus is not removed as part of the procedure, embryos may be implanted after the completion of treatment (surgery or chemotherapy, rarely post radiation).

• Bilateral oophorectomy may be necessary when managing metastatic epithelial tumours or sex cord stromal tumours.

Hysterectomy (Removal of the Uterus)

• This procedure is typically performed for endometrial, cervical, or occasionally vaginal cancers.

• While the removal of the uterus means a patient can no longer carry a pregnancy, oocyte collection is still possible for surrogacy if the ovaries are preserved.

Trachelectomy (Removal of the Cervix)

• Often performed alongside lymph node dissection for early-stage cervical cancers.

• The uterus, tubes, and ovaries remain intact, allowing for the possibility of natural fertility, although assisted reproductive technology (ART) may be required.

• Pregnancy following this procedure carries inherent risks, particularly for mid-trimester loss or preterm birth.

Pelvic Clearance – Total Hysterectomy and Bilateral Salpingo-Oophorectomy

• Pelvic clearance is often standard for many uterine and ovarian cancers when fertility is no longer desired. For those still wishing to preserve fertility, this procedure is typically considered a last resort when survival depends on removing all reproductive organs.

• In certain cases, ovarian tissue cryopreservation may be an option for fertility preservation.

Chemotherapy

Various chemotherapy regimens are used in the treatment of gynaecological cancers. Below are the three most used regimens:

Carboplatin/Paclitaxel

• The first-line standard of care for most epithelial ovarian cancers.

• This regimen generally will often have spontaneous return of ovulation, and natural fertility can occur after completing treatment.

EMA-CO (Etoposide, Methotrexate, Actinomycin, Cyclophosphamide, and Vincristine)

• Standard care for high-risk gestational trophoblastic neoplasia.

• Natural fertility is possible after treatment, with spontaneous resumption of ovulation expected.

• There is a slight risk of earlier menopause (by about 3 years), though it is not associated with pregnancy complications.

BEP (Bleomycin, Etoposide, and Cisplatin)

• Standard care for germ cell cancers of the ovary requiring chemotherapy.

• Most patients will resume normal ovulation and reproductive capacity after treatment.

Radiotherapy

Radiation therapy is an effective treatment for some gynaecological cancers but often results in the loss of natural fertility. Radiation treatment to the pelvis has two primary concerns: it can render the ovaries nonfunctional and make pregnancy impossible due to damage to the uterus.

External Beam Radiation Therapy (EBRT)

• This radiation is administered to the whole pelvis, with targeted doses directed at the primary tumour. Surrounding organs are also affected.

• EBRT is often used to treat cervical, vaginal, and sometimes vulval cancers, and commonly in endometrial cancers occasionally as a primary treatment, and commonly as adjuvant therapy following hysterectomy.

Brachytherapy (Interstitial Radiation)

• This method involves delivering high doses of radiation directly to the primary tumour site using a probe, with some surrounding tissue also affected.

• Brachytherapy is typically used as a boost after EBRT or occasionally as the sole treatment for cervical, vaginal, or vulval cancers.

Hormonal Therapy

In some cases, hormonal therapy is used as a frontline or maintenance treatment for gynaecological cancers, especially when fertility is a concern.

Progesterone Therapy

• This treatment is used for early-stage, hormone receptor-positive endometrial cancer, with the goal of reversing the disease. It may be followed by assisted reproductive technology (ART) to help the patient carry a pregnancy.

Anti-Oestrogen Therapy

• This therapy is given in the maintenance of metastatic low-grade serous ovarian cancer after surgical management. In this case, the patient may have retained their uterus for fertility preservation but would have had both ovaries removed.

Fertility Preservation

Your doctor will discuss the fertility preservation options available to you. This will depend on the type of malignancy you have, planned treatment and safety.

Oocyte (egg) freezing

• Allows the patient to freeze unfertilised oocytes, and provides an opportunity to create embryos in the future

• Involves around 2 weeks of injections to stimulate growth of multiple follicles, followed by an egg retrieval

• Depending on the laboratory that the eggs are frozen, around 80-90% of eggs should survive the warming process, and once they have warmed, we can expect similar fertilisation and embryo development rates as fresh eggs

Embryo freezing

• Allows the patient to collect eggs and fertilise them with sperm (usually from their partner).

• An embryo can be transferred into a healthy uterus in the future, when the patient is ready for pregnancy.

• Live birth rates from frozen embryos are very similar to those from fresh embryos, and depend largely on the patients age at which the eggs were collected

Ovarian tissue cryopreservation

• This is the only fertility preservation option for some patients, including prepubescent girls, and people needing to commence treatment urgently.

• Involves removing ovarian tissue via laparoscopy and cryopreserving it, for grafting back into the patient’s body in the future when they are healthy.

• Spontaneous pregnancy from the grafted tissue is possible but very rare, and usually the patient requires multiple rounds of ovarian stimulation, similar to IVF, to grow and collect eggs.

Zoladex

• Gonadatropin-releasing hormone (GnRH) agonists such as Zoladex may be advised to help protect the ovary from the effect of gonadotoxic therapy.

• Zoladex is an implant that suppresses ovarian function placing the ovary into an artificial prepubertal state.

• Evidence for effectiveness is mixed, but it may result in less damage from chemotherapeutic agents and protect against early menopause.

Transposition of the ovaries

• Also known as oophoropexy, this process involves a laparoscopy to elevate the ovaries out of the pelvis, out of the field of radiation.

• Fertility preservation is not an option for some patients, due to the nature and severity of their disease and treatment. There are many pathways to parenthood however, and speaking with a fertility specialist can help to clarify these options.

Conclusion

While a diagnosis of gynaecological cancer can be overwhelming, there are multiple options available to preserve fertility, depending on the specific circumstances and type of cancer. It is crucial to have open discussions with a fertility specialist to explore potential fertility preservation options before beginning cancer treatment. Each case is unique, and a personalised approach can help strike the right balance between managing cancer effectively and preserving fertility, giving patients hope for the future.