Domestic and international surrogacy laws: implications for cancer survivors

Fertility Sparing Treatment in Gastric-Type Endocervical Carcinoma

Simple Summary

Due to a trend toward late childbearing, fertility preservation has become a major issue in young patients with gynecological cancer. Surgical fertility sparing management is universally acknowledged as an acceptable option in eligible patients with cervical cancer. Excisional cone biopsy or trachelectomy are now standard surgical procedures offered to selected patients with gynecological malignancies who wish to preserve their fertility. Neoadjuvant chemotherapy followed by surgery is another therapeutic option studied currently in numerous clinical trials. However, fertility preserving treatment is generally not recommended in rare histological types of cervical cancer, including clinically aggressive gastric-type endocervical carcinoma. Due to controversies in this emerging topic, a review of literature and international database was carried out, in search of solid evidence on fertility sparing management in gastric-type endocervical carcinoma.

Abstract

Fertility sparing management of cancer is one of the main components of quality-of-life issues. Early-stage cervical cancer, frequently diagnosed in women of reproductive age, can potentially be treated conservatively. However, some rare histological types of cervical cancer present with aggressive clinical behavior. Particularly, in the newly introduced concept of gastric-type endocervical carcinoma, fertility sparing management is ‘a priori’ not recommended. Even so, this issue remains undocumented. For this reason, a selected review of the current literature on gastric type endocervical carcinoma was carried out through PubMed. The keywords included “gastric-type cervical cancer”, “gastric-type endocervical carcinoma”, “conservative surgery”, “conservative treatment”, “fertility sparing surgery”, “radical trachelectomy”, “laparoscopic trachelectomy”, “robotic trachelectomy”, “laparotomic trachelectomy”, “abdominal trachelectomy”, “trachelectomy”, “neoadjuvant chemotherapy”, “conisation”, and “cone resection”. A search in the European Network on Cancer, Infertility and Pregnancy (INCIP) database was performed. The rarity of gastric-type endocervical carcinoma does not allow for conclusions on fertility sparing management with solid evidence. However, diffuse character of the disease and aggressive clinical behavior contraindicate a conservative treatment in young women with gastric type cervical cancer.

Oocyte Retrieval during Laparoscopic Vaginoplasty to Reduce Invasiveness in the Treatment of Mayer-Rokitansky-Küster-Hauser Syndrome

STUDY OBJECTIVE

To evaluate the treatment of patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome with a combination of oocyte retrieval and surgical vaginoplasty in a single laparoscopic procedure.

DESIGN

A case series.

SETTING

The study was conducted at 2 tertiary referral facilities for MRKH syndrome in Milan, Italy, between July 2017 and September 2018.

PATIENTS

Eleven patients presented with MRKH and required surgical vaginoplasty while expressing a desire for future fertility.

INTERVENTIONS

Two experienced surgeons and an expert in assisted reproductive technology performed concomitant vaginoplasty according to the modified technique of Davydov and laparoscopic oocyte retrieval for gamete cryopreservation.

MEASUREMENTS AND MAIN RESULTS

Before the procedure, patients underwent extensive counseling and gave written consent. At the start of surgery, 10.4 ± 4.4 (mean ± standard deviation [SD]) oocytes were retrieved laparoscopically, and 8.8 ± 3.1 (SD) mean mature oocytes were cryopreserved. After oocyte retrieval, the steps of the modified Davydov technique were followed. The total operative time was 116 ± 16 minutes (mean ± SD), and no intraoperative/postoperative complications were observed.

CONCLUSION

This is the first report of combined oocyte retrieval and vaginoplasty for patients with MRKH syndrome. The approach was found to be feasible in patients with a desire for future fertility. It is our belief that physicians treating patients with MRKH should refer patients to centers with expertise in both vaginoplasty and assisted reproductive technology.

Cross border reproductive care (CBRC): a growing global phenomenon with multidimensional implications (a systematic and critical review)

PURPOSE

Many people travel abroad to access fertility treatments. This growing phenomenon is known as cross border reproductive care (CBRC) or fertility tourism. Due to its complex nature and implications worldwide, CBRC has become an emerging dilemma deserving more attention on the global healthcare agenda.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English during the past 18 years to explore CBRC phenomenon in the new millennium.

RESULTS

Little is known about the accurate magnitude and scope of CBRC around the globe. In this systematic and critical review, we identify three major dimensions of CBRC: legal, economic, and ethical. We analyze each of these dimensions from clinical and practical perspectives.

CONCLUSION

CBRC is a growing reality worldwide with potential benefits and risks. Therefore, it is very crucial to regulate the global market of CBRC on legal, economic, and ethical bases in order to increase harmonization and reduce any forms of exploitation. Establishment of accurate international statistics and a global registry will help diminish the current information gap surrounding the CBRC phenomenon.

Uterus transplantation: ethical and regulatory challenges

Moving forward rapidly in the clinical research phase, uterus transplantation may be a future treatment option for women with uterine factor infertility, which accounts for three per cent of all infertility in women. This new method of treatment would allow women, who currently rely on gestational surrogacy or adoption, to gestate and birth their own genetic offspring. Since uterus transplantation carries significant risk when compared with surrogacy and adoption as well as when compared with other organ transplants, it requires greater justification because its goals are quality of life, not life-saving, in their scope. It is important to address questions regarding the physical, psychosocial and ethical risks and benefits of uterus transplantation for all three parties involved--the patient, the donor and the potential child--as well as discuss the regulatory implications as research on uterus transplantations moves forward.

Sexual and reproductive health in cancer survivors

As patients live longer after cancer diagnosis and treatment, attention to symptoms and quality of life (QoL) are of increasing importance both during treatment and throughout survivorship. Two complications of multi-modal cancer treatment that can profoundly affect both men and women are sexual dysfunction and infertility. Survivors at highest risk for treatment-related sexual dysfunction are those with tumors that involve the sexual or pelvic organs and those whose treatment affects the hormonal systems mediating sexual function. Sexual dysfunction may not abate without appropriate intervention. Therefore, early identification and treatment strategies are essential. Likewise, multiple factors contribute to the risk of infertility from cancer treatment and many cancer patients of reproductive age would prefer to maintain their fertility, if possible. Fortunately, advances in reproductive technology have created options for young newly diagnosed patients to preserve their ability to have a biologic child. This paper will focus on the sexual and reproductive problems encountered by cancer survivors and discuss some treatment options.