P–339 Fertility treatment and live birth are still possible following the unexpected diagnosis of endometrial carcinoma/complex hyperplasia - provided that there is careful multidisciplinary team involvement
Authors: Roche D , Martyn F , Wingfield M 
Published: August 2021

Abstract

Study question
Is it safe for young women to delay hysterectomy for endometrial carcinoma or complex hyperplasia, have fertility treatment and carry a pregnancy to term?

Summary answer
Fertility treatment and livebirth are possible after a diagnosis of endometrial carcinoma or complex hyperplasia but close co-operation between fertility and gynae-oncology services is key.

What is known already
While predominantly a disease of postmenopausal women, 7% of cases of endometrial adenocarcinoma or complex hyperplasia occur in women under 40 years. The standard surgical treatment is hysterectomy, which is curative in the majority of cases. In younger women wishing to preserve fertility, conservative treatment may be considered. The fertility outcomes in this population are not well reported, possibly because fertility preservation is not always discussed or considered when faced with the devastating diagnosis of cancer or pre-cancer in the younger woman or because of concerns regarding the impact of pregnancy or ovarian stimulation on a predominantly oestrogen sensitive tumour.

Study design, size, duration
This case series retrospectively evaluated the outcomes of 6 women with endometrial adenocarcinoma or complex hyperplasia who attended Merrion Fertility Clinic, Dublin from 2013 to 2020 and who were managed conservatively. These women initially presented with a history of infertility for which they underwent routine ultrasonography, which then led to hysteroscopy and endometrial biopsy. The histopathology of all 6 women showed an incidental finding of endometrial adenocarcinoma or complex hyperplasia.

Participants/materials, setting, methods
Patient files and a fertility clinic online database were reviewed to identify those with a diagnosis of endometrial carcinoma or complex hyperplasia. Their treatment course and reproductive outcomes were followed up, as was there eventual definitive surgical treatment.

Main results and the role of chance
Six women attending our service over a 7 year period were found to have endometrial adenocarcinoma or hyperplasia. They ranged in age from 34 to 46(mean 39). All were nulliparous. Four of the women had adenocarcinoma and 2 had complex hyperplasia. One woman, aged 41, with grade II endometrial adencocarcinoma was deemed unsuitable for conservative management by the gynaecological oncology team. She underwent urgent total abdominal hysterectomy and is well. The remaining 5 women proceeded with conservative management with oral or local progesterone therapy for 6 to 12 months. This resulted in an inactive endometrium on follow-up endometrial biopsy. Once disease regression was achieved, assisted reproduction in the form of in-vitro fertilization (IVF) was advised to ensure minimal time to pregnancy. Two of the women conceived using own egg IVF and two with donor eggs. All were successful in achieving at least one live birth. One had twins and one had 2 singletons, from a fresh and a frozen embryo transfer. The 6th woman has embryos frozen but has not yet had embryo transfer. Two of the 6 women ultimately had a hysterectomy, while 4 continue to be followed up with 6 monthly endometrial biopsies and progesterone therapy.

Limitations, reasons for caution
This study is limited by the small sample size. However, this paper reports on a niche subset of the population and finding larger sample sizes would be difficult to obtain.
Wider implications of the findings: This case series illustrates the favourable outcome of pregnancy with IVF after either systemic or local progesterone therapy in early stage endometrial adenocarcinoma or complex hyperplasia. Early involvement of a fertility specialist may prove highly valuable in cases of fertility sparing treatment to increase each patient’s potential for pregnancy.

Trial registration number
Not applicable