Cancer is not a disease that causes infertility, unless it has specifically affected the reproductive organs. However, radiation therapy treatment can cause eggs to die or damage other parts of the region, which can lead to infertility.
With this in mind, ReitanRibeiro, a researcher and oncology surgeon at the Institute of Robotic Surgery in Paraná (Brazil), has developed the technique, in the experimental phase, which has become known worldwide as uterine transposition. The objective is to preserve fertility in women who undergo radiotherapy sessions in cancer treatment.
The method, carried out within a research protocol, consists of transferring the reproductive organs to the upper part of the abdomen, to keep them intact during the therapies. At the end of the treatment, the uterus, fallopian tubes, and ovaries return to their original location.
One of the beneficiaries of the transposition was the make-up artist Carem dos Santos (33 years old). In June 2018, she was discovered to have a liposarcoma (a rare tumor that originates in fatty tissue in the body) in her pelvis and, as part of her treatment, would require radiation therapy to treat the cancer cells.
However, the radiation would affect her uterus, preventing a future pregnancy. “I did not have a boyfriend or children, but I was planning to start a family after I was 30. So this news was very sad and the radiation therapy doctor gave me some time to see what I could do”, she recalls.
During this period, she learned about the uterine transposition technique, a study being carried out in Curitiba that aimed to preserve the organ for a subsequent pregnancy. “The doctor was very honest in saying that it was still a study and that no women had gotten pregnant, so he could not guarantee that I would get pregnant later, but I listened to myself and had surgery”, says the makeup artist.
Carem remembers that the postoperative period was quite painful during the first 15 days. Otherwise, there were no complications. Within 3 months after the radiotherapy sessions, the organs were replaced in their proper place.
Over time, she was discovered 2 more cancers, one in the pleura and the other in the lung, and she underwent the respective treatments. “I met my husband in 2021 and, when he was finishing these processes, I found out that she was pregnant”, she says. “Today I look at it and think: my God, it was the best decision I made in my life, because I fell in love with motherhood. Courage and faith were very important to me and we have to talk about it, because it is the dream of many women”, she concludes.
Cervical cancer
In 2020, AngélicaHodeckerAzambuja, a 33-year-old newlywed hairdresser, was diagnosed with cervical cancer through routine examinations. “The doctor’s first option was to remove the uterus, ovaries and fallopian tubes, but since my cancer was only in the cervix, it had not affected these organs. Still, I hypothesized”, she recalls.
At first, says Angélica, it was very difficult to assimilate the news that, in addition to being sick, she would not fulfill her dream of being a mother in the future. “I was devastated, because a woman may not even want to be a mother, and that’s fine, but when someone tells you that you are not going to be able to have children, that you have no choice, it really affects you”, she says.
They operated on her to remove part of her cervix and then came her difficult decision. “Either I interrupted the treatment to get pregnant, or I lost the opportunity to have children, because I had to undergo radiation therapy”, she says. However, she was not satisfied with the options presented to her and she went in search of an alternative. It was then that she was introduced to uterine transposition. “At first I was unsure because it was a very new study and I didn’t know if it would work”, she says.
Even so, Angélica underwent the transposition, and 15 days later she underwent chemotherapy and radiotherapy treatment. “A week after finishing the chemo and the radio, in March, I had the transposition operation again and it was super good, I had a quiet recovery”, says the hairdresser.
In October 2021, she received the diagnosis of remission of the disease and then decided that it was time to try to have a child. To her surprise, she became pregnant naturally the following year. “Uterine transposition was the best option I had and the best decision we (her and her husband) made”, says Angélica, mother of Isabel, who is only 5 months old.
How does uterine transposition work?
It is a minimally invasive surgery performed with robotic technology that removes the uterus, fallopian tubes, and ovaries from their original location and repositions them in the upper abdomen, temporarily, to preserve them during the radiotherapy treatment that is performed in the pelvic region. This is because, even if it is not directed at the uterus, the side effect of radiation therapy is harmful to the eggs, causing infertility or early menopause.
According to Ribeiro, the Brazilian surgeon responsible for the development of the technique, the surgery is low risk and patients are usually discharged one or two days after the procedure. They may feel pain or discomfort postoperatively, “but, in general, they have a normal life, even with the uterus temporarily in an abnormal position”, he says. The uterus continues to function normally, even when it is repositioned, as well as ovarian function. And, at the end of the sessions, the reproductive organs are put back in their place.
Transposition may be indicated for patients who need radiation therapy to treat tumors in the rectum, intestine, bladder, vagina, vulva (among others) and cases of sarcomas, which are malignant tumors in soft tissues, such as muscle, fat, and tendons, in which that a few radiation sessions would be enough to cause infertility.
According to Renato Moretti Marques, coordinator of the Robotic Surgery Program in Gynecology at the Albert Einstein Israelite Hospital, there are contraindications for transposition. “It is essential that the disease has not compromised the uterus, fallopian tubes and ovaries. And if this patient does not have functional ovaries, it is not possible to move the uterus, because there would be no way to nourish it, and if she has already received pelvic radiotherapy, it is not possible to perform this surgery either”, explains Marques, who is also coordinator of the Department of Gynecological Oncology of the Vila Santa Catarina Municipal Hospital.
Uterine transposition is already in the experimental phase
Although several surgeries have already been performed, uterine transposition remains an experimental study. The technique was already presented at an international gynecologic oncology congress in 2016 and the study is in the publication phase.
The first surgery was performed in October 2015 in Brazil by the doctor and researcher ReitanRibeiro and, since then, it has been adopted in several countries, such as Germany, Russia, Argentina, Colombia, the United States, Israel, among others. Dozens of patients have already undergone uterine transposition, 20 out of them in Brazil alone. However, there is a history of failed cases in which the uterus became necrotic after a clot obstructed the artery, preventing the nutrition of the patient’s organ.
Marques states that “she would lose it anyway due to the radiotherapy treatment, so this is an opportunity for the patient to preserve the reproductive organ”. This is still a long-term phase 3 experimental study, conducted with the patients themselves. “We are now in phase 3 of the studies, with a large number of patients to evaluate in the long term, because there are patients who have not even tried to get pregnant yet, because they are very young”, explains Ribeiro.
The Brazilian surgeon stresses that today the objective of oncology is not only to cure the patient, but to ensure that she has the same quality of life as before undergoing treatment. This was his main motivation for studying transposition surgery. “About 10 years ago, we tried to cure cancer at all costs and even sinned excessively. Today, we not only want to cure a cancer patient, we want to cure him and have a normal life”.
