Hot Topics on Fertility Preservation for Women and Girls-Current Research, Knowledge Gaps, and Future Possibilities.

Fertility preservation is a novel clinical discipline aiming to protect the fertility potential of young adults and children at risk of infertility. The field is evolving quickly, enriched by advances in assisted reproductive technologies and cryopreservation methods, in addition to surgical developments. The best-characterized target group for fertility preservation is the patient population diagnosed with cancer at a young age since the bulk of the data indicates that the gonadotoxicity inherent to most cancer treatments induces iatrogenic infertility. Since improvements in cancer therapy have resulted in increasing numbers of long-term survivors, survivorship issues and the negative impact of infertility on the quality of life have come to the front line. These facts are reflected in an increasing number of scientific publications referring to clinical medicine and research in the field of fertility preservation. Cryopreservation of gametes, embryos, and gonadal tissue has achieved quality standards for clinical use, with the retrieval of gonadal tissue for cryopreservation being currently the only method feasible in prepubertal children. Additionally, the indications for fertility preservation beyond cancer are also increasing since a number of benign diseases and chronic conditions either require gonadotoxic treatments or are associated with premature follicle depletion. There are many remaining challenges, and current research encompasses clinical health care and caring sciences, ethics, societal, epidemiological, experimental studies, etc.

The Intentional Differences: A Qualitative Study of the Views and Experiences of Non-peer Mental Health Providers on Working Together with Peer Support Colleagues in Mental Health.

The study reports the results of a qualitative study on the views and experiences of non-peer mental health providers on working together with peer colleagues in mental health. Semi-structured interviews were conducted with 20 providers in different mental health settings. Data were systematic analyzed using thematic analysis and resulted in three overall themes: (1) The relationship and collaboration between the mental health providers and their peer colleagues, (2) The benefits of working with peers, and (3) The challenges of working with peers. In analyzing the data material, the theme of the relationship and collaboration between the non-peer mental health providers and their peer colleagues could be organized into two subthemes on the differences that the providers perceived between themselves and their peer colleagues. One subtheme was on differences when the providers perceived the differences as positive and meaningful. The other subtheme was on differences between themselves and their peer colleagues when the providers perceived the differences as concerning. This study's findings show that the attitudes and experiences of peer support in mental health providers are in general positive, but also that mental health providers in the early phases of peer support implementation could have many concerns and may find the perceived and mainly valued differences between themselves and their peer support colleagues also distressing. The implications for practice include a need to address possible barriers to peer support, including frustration or feelings of injustice among mental health providers, especially as such issues are not easy to pinpoint or address by formal guidelines on peer support.

Reproductive and obstetrical outcomes with the overall survival of fertile-age women treated with fertility-sparing surgery for borderline ovarian tumors in Sweden: a prospective nationwide population-based study.

OBJECTIVE: To assess the efficacy of fertility-sparing surgery (FSS) in terms of reproductive outcomes by following FSS for borderline ovarian tumors (BOTs) and comparing the safety of FSS versus radical surgery (RS). DESIGN: Nationwide cohort study based on prospectively recorded data. SETTING: Sweden. PATIENT (S): All women of reproductive age (18-40 years) treated in Sweden for stage I BOT with the use of FSS or RS from 2008 to 2015, identified in the Swedish Quality Registry for Gynecologic Cancer (SQRGC). INTERVENTIONS (S): FSS or RS. MAIN OUTCOME MEASURE (S): Reproductive outcomes: natural conception, use of assisted reproductive technology (ART), live birth and obstetrical outcomes. Safety outcome: overall survival (OS) rates, comparing women undergoing FSS versus RS. The FSS cohort was linked to the Swedish Medical Birth Register to identify all women who had given birth after FSS and to obtain detailed obstetrical data. For information on ART treatment, the National Quality Registry for Assisted Reproduction was consulted. OS rate comparisons were conducted by means of Kaplan-Meier estimates. RESULT (S): Of the 277 women with BOTs, 213 (77%) underwent FSS, 183 (86%) unilateral salpingo-oophorectomy, and 30 (14%) cystectomy. Following FSS, 50 women gave birth to 62 healthy children, 8% of which were preterm. Only 20 (9%) of the women underwent ART treatment. OS was similar in women treated with FSS and RS. CONCLUSION (S): Natural fertility was maintained after FSS; only 9% required ART treatment. FSS was also deemed to be equivalent to RS regarding survival outcome.

A Swedish Nationwide prospective study of oncological and reproductive outcome following fertility-sparing surgery for treatment of early stage epithelial ovarian cancer in young women.

BACKGROUND: Epithelial ovarian cancer (EOC) is rare in women of reproductive age and fertility-sparing surgery (FSS) may be applied in early stages. The purpose of this study was to investigate the safety and efficacy of FSS for treatment of EOC. METHODS: The Swedish nationwide population-based Quality Register for Gynecological Cancer was used to identify all women 18-40 years of age diagnosed with stage I EOC between 2008 and 2015. Detailed data on surgery, staging, histopathology, and follow-up were extracted and reviewed. Cross-linking of individuals to population-based registries allowed retrieval of data on obstetrical and reproductive outcomes after FSS. Disease-free survival (DFS) and overall survival (OS) rates were compared (Kaplan-Meier method) between women who underwent FSS vs. radical surgery (RS). RESULTS: In total 83 women were identified; 36 who had FSS performed and 47 RS. The 5-year OS rate was 92% and no statistical differences between DFS or OS were found between women treated by FSS or RS. The recurrence rate after RS was 13% compared to 6% after FSS. Recurrences were more frequently found in women with stage IC tumor or with histologic subtypes with more aggressive behavior. In the FSS cohort, nine women gave birth to 12 healthy children, all delivered at fullterm. Only one women had received assisted reproductive technology treatment. CONCLUSION: In this nationwide population-based cohort study natural fertility was maintained after FSS. Specific histologic subtypes showed greater prognostic impact on the oncological outcome than the use of FSS. Recurrences occurred after FSS, but none in the uterus, which questions the need of hysterectomy in young women with EOC. TRIAL REGISTRATION: This article reports the results of a healthcare intervention using the data prospectively registered in the Swedish population-based registries including the Quality Register for Gynecological Cancer, the National Death Register, the Swedish Medical Birth Register, and the National Quality Register for Assisted Reproduction.

Fertility-sparing surgery for treatment of non-epithelial ovarian cancer: Oncological and reproductive outcomes in a prospective nationwide population-based cohort study.

OBJECTIVE: To compare the oncologic outcome of women who underwent fertility-sparing surgery (FSS) vs. radical surgery (RS) for treatment of NEOC in a prospective, nationwide, population-based study and report on the reproductive outcomes in women after FSS. METHODS: Using the Swedish Quality Register for Gynecological Cancer, we identified all women ages 18-40 treated with either FSS or RS for stage I NEOC between 2008 and 2015. Progression-free survival (PFS) and overall survival (OS) rates were compared using the Kaplan-Meier method. Data on use of assisted reproductive technology (ART) treatments and obstetrical outcomes after FSS were extracted from the National Quality Register for Assisted Reproduction (Q-IVF) and the Swedish Medical Birth Register. RESULTS: During the study period, 73 women ages 18-40 received a stage I NEOC diagnosis. The majority, 78% (n = 57), underwent FSS. The 5-year OS rate, regardless of surgical approach, was 98%. There were no statistical differences between OS and PFS rates in women treated with FSS, compared to RS. Recurrences were more common after RS than FSS: 12.5% (2/16) vs. 3.5% (2/57), respectively. Following FSS, 11 women gave birth to 13 healthy children (all conceived naturally). Additionally, 12% of the women in the cohort developed infertility and received ART treatment (n = 7). CONCLUSION: FSS is not associated with worse oncologic outcomes than RS in young women with early stage NEOC. The prognosis was excellent in both groups, with an OS of 98%. Natural fertility was maintained in women treated with FSS, only 12% required ART treatment.

Two Cases of True Uterine Artery Aneurysms Diagnosed during Pregnancy.

We report 2 cases of true uterine artery aneurysms diagnosed during pregnancy. Both cases presented with nonspecific symptoms such as urethral obstruction, minimal vaginal bleeding and lower abdominal pain in the 2nd trimester. Both aneurysms were diagnosed by color Doppler ultrasound. In the first case labor was induced at 37 + 4 weeks of gestation. However, due to sudden fetal distress and maternal abdominal pain, an emergency Caesarean section was performed during labor, and 3 liters of intra-peritoneal blood were encountered upon laparotomy, secondary to a ruptured uterine artery aneurysm. In the second case, an elective Caesarean section was scheduled at 38 + 3 weeks of gestation, and the delivery and postpartum period were uncomplicated. Albeit a rare condition, a uterine artery aneurysm should be among the differential diagnosis considered in pregnant women who present with pelvic and vaginal masses, vague bladder symptoms or radiating pelvic pain. The diagnosis is readily made by color Doppler imaging. Elective Caesarean section should be the preferred mode of delivery to avoid rupture of the aneurysm during labor.

Reproductive and oncologic outcome following robot-assisted laparoscopic radical trachelectomy for early stage cervical cancer.

OBJECTIVE: To investigate the reproductive and oncologic outcome following robotic radical trachelectomy for early stage cervical cancer. METHODS: All women with early stage cervical cancer planned for fertility-sparing robotic trachelectomy between December 2007 and April 2015 at two tertiary referral centers in Sweden were identified. Perioperative- and follow-up data was retrieved from prospective databases used for all robotic procedures at the respective institution and an additional review of computerized patient files was performed. Reproductive outcome evaluation was restricted to women with ≥12months follow-up and an active wish to conceive. Oncological outcome was evaluated for all patients. RESULTS: Fifty-six women (3 stage IA1, 14 stage IA2 and 39 stage IB1) were included. The median age was 29years (range 23-41). Median follow-up was 24months (range 1-89). Seven trachelectomies were aborted in favor of a radical hysterectomy and/or chemoradiation due to nodal metastases or insufficient margins; two distant recurrences occurred in these women. A local recurrence was seen in two of the 49 women (4%) in whom the procedure was completed as planned. Seventeen of the 21 women (81%) in the reproductive follow-up group conceived - 16 naturally and one following IVF. Sixteen women (94%) delivered in the third trimester, 12 women (71%) in gestational week ≥36. One (6%) second trimester delivery occurred. CONCLUSION: The high fertility rate, low rate of premature deliveries and an acceptable rate of recurrence support the feasibility of robotic fertility-sparing radical trachelectomy in women with early stage cervical cancer.