Читать книгу Assisted Reproduction Techniques - Группа авторов - Страница 200

Natural pregnancy rates of 32–65% have been reported in women with a history of fertility‐preserving surgery for BOTs [1,5,6]. A systematic review found conservative management of early stage BOT resulted in a pooled estimate for natural pregnancy rate of 54%, with a low risk of lethal recurrence (pooled estimate of 0.5%). In patients with advanced stage BOT, the natural pregnancy rate was lower at 34%, with a higher risk of lethal recurrence (pooled estimate of 2%) [7].

For those women who may require ovulation induction or IVF treatment, there is a theoretical concern that ovarian stimulation may be associated with an increased risk of recurrence of BOT or ovarian cancer. Although evidence is sparse, there is no clear evidence to support this association. Two experimental studies showed that estradiol and follicle stimulating hormone (FSH) have no adverse impact on cell proliferation [8,9]. A systematic review of studies of gonadotropin stimulation in women with a history of BOT identified 15 reports, including a total of 62 patients having 152 ovarian stimulation cycles, with a mean follow‐up of 52 months [10]. Live birth rate was 28% per stimulated cycle. The pooled recurrence rate was 19.4%, which is higher than the reported 11% recurrence rate for borderline ovarian tumors [11]. Despite the apparently higher recurrence rate, the survival in this group of women with gonadotropin stimulation is still excellent (100% at a median follow‐up period of 52 months). Notwithstanding these data, there may be a case for limiting the number of ovarian stimulation cycles in women with a history of BOT given the paucity and uncertainty of the available data [1]. Each case should be judged on its own merits.

The optimal time to try to conceive or have fertility treatment after fertility‐sparing surgery is unknown, although successful pregnancies have been achieved as early as 3 months after surgery [12,13]. Before any fertility treatment is initiated, the oncology team should be consulted to obtain clearance to proceed with the treatment. A pelvic ultrasound scan should be arranged to rule out ovarian cysts, which may indicate recurrence of BOT. CA125 has been found to be a useful tumor marker in diagnosing BOT recurrences [14,15], and should therefore be checked before fertility treatment.

After fertility treatment, the oncology multidisciplinary team may consider “completion surgery” to remove the remaining ovarian tissues and the uterus, particularly for those who had cystectomy (as opposed to oophorectomy), advanced stage disease, mucinous tumors or any evidence of peritoneal implants at the time of primary surgery [1].

Although fertility‐sparing surgery may offer the best chance of pregnancy for a woman with BOT, some women may benefit from fertility‐preserving techniques such as oocyte, embryo [16] or ovarian tissue freezing [6] or may require oocyte donation [17] or surrogacy. The role of the antral follicle count and anti‐Müllerian hormone serum levels in patients with BOT remains to be clarified.

A final consideration is whether fertility treatments, such as gonadotropins and clomiphene increase the risk of BOT. Although long‐term outcome data remain limited [18], a review suggested a potentially increased risk of BOT, especially following IVF [19].