The trans positioning of ovaries out of the radiation field has been recognized as one of the oldest fertility preservation options when radiation is considered to the pelvic area. This procedure is usually performed via laparoscopy or as an open procedure at the time of cancer surgery.  Yet, the procedure is still underutilized 1

A 28-year-old single nulliparous patient was referred by the radiation oncologist. She had two consecutive surgical procedures performed for a soft tissue sarcoma in the lower anterior abdominal wall. The surgical margins remained positive, and it was decided to proceed with radiation in this field. The radiation field was mapped (Fig. 1) and a radiation dose of 4 Gy was planned. On examination, the patient had clinical features of polycystic ovarian syndrome with an AMH= 12 ng/ml. Due to the high dose of radiation and the deleterious effect radiation has on the oocyte reserve, the patient was offered fertility preservation. The options considered were oocyte cryopreservation or transposition of the ovaries. Her medical aid was prepared to cover the surgical option.

Ovarian transposition involved moving both ovaries out of the pelvis and away from the radiation field. The procedure involves the dissection of the ovarian vascular pedicles and the creation of a retroperitoneal tunnel for these pedicles to run through. In this case, both ovaries were fixated with non-absorbable sutures to the anterior abdominal wall, at the level of the iliac crest. Radio-opaque clips were placed to locate the exact position of the ovaries during radiation. The procedure and the postoperative course were uneventful.

The success of ovarian transposition, in preserving ovarian function has been reported in a follow-up trial. In the ovarian transposition Group 60,3 % showed ovarian function as compared to 0% in the control group after a 5-year follow-up period 2. A meta-analysis has also reported superior ovarian function survival rates in the transposition group as compared to the control group 3

The patient presented 5 years later with the request that she wanted to start a family. She had a regular menstrual cycle.  Her Antral Follicle count and AMH had decreased significantly. The AMH is reported now as 1,2 ng/ml. She had a normal-sized uterus with an endometrial lining of 9 mm. Her husband’s semen analysis was within the normal range.

As the pelvic anatomy has been distorted the patient was counselled for IVF. Abdominal scans were performed to monitor the follicular growth. After 10 days of stimulation, the patient was triggered. Five follicles were aspirated via the abdominal route retrieving 4 oocytes, of which all fertilized. On day 5 a single embryo transfer was performed of a 3 AB embryo. One day 5 embryo was vitrified.

The patient conceived and at 9 weeks was referred to her obstetrician. The pregnancy is regarded as high-risk due to the potential radiation effects on the uterus. Evidence has shown that pelvic radiation can cause fibrosis of the musculature and vasculature of the uterus, complicating pregnancies by premature birth, miscarriage, growth impairment and stillbirth. The gestation needs to be monitored carefully to identify for this potential side effects.

1. Woodruff TK et al. Oncofertility: a grand collaboration between reproductive medicine and oncology. Reproduction. 2015;150:S1-S10.

2. Hoekman et al. Ovarian survival after pelvic radiation: transposition until the age of 35 years. Arch Gynecol Obstet 2018;298:1001–7.

3. Hoekman et al. Ovarian function after ovarian transposition and additional pelvic radiotherapy: a systematic review. Eur J Surg Oncol 2019;45:1328–40.

Figure 1