Innovations in Fertility Preservation: Uterine Transposition

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic podcast for medical professionals exploring the latest innovative research and clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shephard, a medical oncologist here at Cleveland Clinic directing the Taussig Early Cancer Therapeutics program and co-directing the Cleveland Clinic Sarcoma program. Today I'm very happy to be joined by Dr. Mindy Christianson, Section Chief of Reproductive Endocrinology and Infertility and Practice Director of Cleveland Clinic's Fertility Center. She's here today to talk to us about uterine-focused fertility preservation with uterine transposition. So welcome.

Mindy Christianson, MD, MBA: Great. Thank you so much for having me.

Dale Shepard, MD, PhD: Absolutely. So, I gave your title, but give us a little bit of an idea. What do you do here at Cleveland Clinic?

Mindy Christianson, MD, MBA: So, I just started about five months ago. I'm the section head for reproductive endocrinology, but my clinical and research focus has always been on fertility preservation. And so, one of the things that attracted me to the Cleveland Clinic was the opportunity to really grow the fertility preservation program. And then when I came here, I realized that there was already a lot of work being done and so we actually have a very large fertility preservation program here.

Dale Shepard, MD, PhD: Excellent. So, let's start out with the big picture. When we talk about fertility preservation in women, what are we primarily talking about in terms of ways to do that?

Mindy Christianson, MD, MBA: So, fertility preservation for women includes freezing embryos, freezing eggs. And then for younger females and or females who may not have time, freezing ovarian tissue. Those are the three main options we offer today.

Dale Shepard, MD, PhD: All right. And so specifically when we think about women who are going to get pelvic radiation, that's what we'll kind of focus on, what are examples of cases, like when would women be getting pelvic radiation? What kind of cancers are we dealing with?

Mindy Christianson, MD, MBA: So, I see a lot of patients, young females with colorectal cancer or patients with pelvic lymphoma or patients with cervical cancer are requiring pelvic radiation. And unfortunately, radiation is extremely damaging, more damaging than chemotherapy for the ovaries, which are very sensitive, which is why we've developed surgical techniques to move the ovaries out of the pelvis. But unfortunately, it also is highly damaging to the uterus.

Dale Shepard, MD, PhD: And what kind of damage are we looking at? Is this long-term damage? Short-term damage?

Mindy Christianson, MD, MBA: Well, no one's really looked at it. Most of the focus for years has been on the ovaries because we know that females are born with a limited number of eggs and the number of eggs goes down over time. And so, we've always worried about eggs. So, we've frozen embryos and frozen eggs for women, but then when they try to get pregnant in the future, unfortunately the uterine lining doesn't develop to carry a pregnancy. So, it's very damaging to the inside of the uterus where an embryo would implant the muscle of the uterus. It really compromises greatly the ability for a woman to carry a pregnancy.

Dale Shepard, MD, PhD: And is that something that scarring, things like that, that doesn't really improve over time? So once there's damage, is it kind of damage?

Mindy Christianson, MD, MBA: Unfortunately, there has not been a way to restore the uterus back to its pre radiation condition. So unfortunately, the only option these women have would be to use a gestational carrier or potentially uterine transplant.

Dale Shepard, MD, PhD: All right. When we think about difficulties, uterine damage, scope of the problem, is this pretty much any woman who gets pelvic radiation has a very high risk? Is this something that some women have risk? What do we normally look at in terms of success rates for pregnancy?

Mindy Christianson, MD, MBA: When you review the literature, there's very few reported live births in women who've had pelvic radiation. Those that we do see are women who've had pelvic lymphoma, and that radiation can actually be less focused on the uterus. But I have personally never had a patient able to conceive after pelvic radiation for rectal cancer. And I don't know of any existing successful cases either.

Dale Shepard, MD, PhD: Excellent. So uterine transposition, a lot of different people listening in a lot of different backgrounds. What is that?

Mindy Christianson, MD, MBA: So, what it is simply described is it's moving the uterus out of the radiation field. If you look at MRI pictures where they're planning radiation for women with rectal cancer, the radiation will be directly targeting the tumor, but unfortunately the uterus is right in that field as well. And so, what uterine transposition is, it's moving the uterus out of that direct target of the radiation. And there's several ways to do it, more complicated ways, or else just simply attaching the uterus to the anterior abdominal wall for a short period of time.

Dale Shepard, MD, PhD: And so, I guess maybe a little bit about that. What exactly does that entail? Is this a long procedure in most cases? What is the most promising way to do that? You mentioned that short-term abdominal reattachment.

Mindy Christianson, MD, MBA: So, when you look at the techniques described in the literature, and really there are a series of case reports in some case series, there's a variety of different ways that are reported to do it. Some are very complicated where they actually attach the cervix to the woman's umbilicus so she can have menstrual cycles out of her umbilicus. Others are a little simpler. At my prior institution where we did start a uterine transposition program, we worked closely with the G1 oncologists to really move the uterus out the radiation field. So, it is actually a more complicated surgical procedure, but it's done laparoscopically, and we did at the same time that we moved the ovaries out of the radiation field. So, it wasn't an additional surgery for the patient.

Dale Shepard, MD, PhD: All right. When we think about uterine transposition, people have also heard about uterine transplants. Where would a transplant come into play here?

Mindy Christianson, MD, MBA: So uterine transplants, that would be another person's complete uterus being transplanted, which would be a much, much more complicated procedure. It would be a procedure for both the donor as well as the patient. And the patient would need to take anti-transplant medications to prevent rejection. With uterine transposition, it's really just suspending or lifting the uterus out of the radiation field, so it's much less invasive.

Dale Shepard, MD, PhD: So essentially, if women that might not have had a uterine transposition, they have damage to the uterus, that's where a transplant would come in?

Mindy Christianson, MD, MBA: Correct. If they have the access to have a uterine transplant.

Dale Shepard, MD, PhD: Correct. So, tell us a little bit about the successes from this procedure.

Mindy Christianson, MD, MBA: So, I know that there are at least two live births from uterine transposition or uterine suspension procedures. One of them is out of Brazil. I just recently read that report. I don't know of any in the United States yet, but I do know that we're starting a program here at the Cleveland Clinic. We're really excited. We have several of our G1 oncologists that have actually already kind of practiced the procedure in the lab, in the cadaver lab. And so, we would potentially be ready to go very shortly.

Dale Shepard, MD, PhD: From a patient selection standpoint, how do you choose the right patient for a procedure like this?

Mindy Christianson, MD, MBA: So, I think it's really important to look at the patient individually because oftentimes we'll look at all of the fertility preservation procedures. For instance, the patient that I was involved in, her uterine transposition, we actually froze her eggs first. And after we froze her eggs, we did the procedure where we moved her ovaries out of the radiation field and her uterus. And so, for some patients, she may have the opportunity to do that. Some patients may not have the time, the two weeks required to harvest eggs. And so, I think it's really looking at the appropriate patient. But in general, it would be a patient who is under the age of 40 probably who future reproduction is very important for.

Dale Shepard, MD, PhD: Makes sense. You mentioned a couple of cases of live birth so far, so certainly promising. How common is the procedure at this point?

Mindy Christianson, MD, MBA: I don't think it's very common. I only know of the one center where I previously worked where we did the procedure. I don't know of any other programs in the US that are doing it, but I am excited to do it here. And I know that they've done it in France as well as in Brazil.

Dale Shepard, MD, PhD: And in terms of the center, you said you have a number of people who are sort of coming together to help out with this multidisciplinary sort of team. Who is all involved? You mentioned the gynecologic surgeons. Who else?

Mindy Christianson, MD, MBA: So, what we're starting is the Cleveland Clinic Center for Fertility Preservation and Restoration. It's really a multidisciplinary approach for fertility preservation. So obviously, we would work closely with oncologists, we would work with geneticists if a patient had a genetic condition, G1 oncology, reproductive surgery. So really being able to provide for the patient all of the experts that she needs to make that decision so she can build her family in the future.

Dale Shepard, MD, PhD: And I guess when we think about the success of the program, what do you think that's going to look like? How many procedures? How often are we going to be able to do this?

Mindy Christianson, MD, MBA: Well, I think that we already are doing a large volume of fertility preservation, and we have a lot of systems in place at the Cleveland Clinic to support it. So, I think success really looks like having a website so a patient has a resource to learn about it so we can really have access. Having quick access to care is really one of the most important things when we look at oncofertility. So being able to see these patients within 48 hours and having them seen by the right people as soon as possible.

Dale Shepard, MD, PhD: Again, back to the, on that time aspect, this is a relatively quick procedure, recovery time. How soon can people start radiation after the procedure? What kind of timeframe are we looking at for these kinds of procedures?

Mindy Christianson, MD, MBA: Well, it's a laparoscopic procedure. And in general, I would defer to the radiation oncologist for how long it would be, but I don't think there's a huge delay in doing the procedure and being able to undergo radiation.

Dale Shepard, MD, PhD: One thing that seems to always come up when we talk about fertility preservation, freezing eggs, things like that is cost and insurance coverage and things like that. Since this is a surgical procedure, is it more likely to be covered for preservation technique, or no?

Mindy Christianson, MD, MBA: I am so glad you brought that up because this is a really, really important point for multiple reasons. Unfortunately, Ohio does not have a state mandate for fertility preservation treatment. I previously practiced in a state that did. So, one of my goals is also to really have people come together so we can have a state mandate for fertility preservation treatment in Ohio for our patients. But as far as the treatment, most of the time ovarian transposition is covered. And so, I'm hoping that if a patient was having that procedure done, that this procedure could be covered at the same time.

Dale Shepard, MD, PhD: Excellent. What do you think are going to be the biggest barriers to make this more of a common procedure for patients?

Mindy Christianson, MD, MBA: Well, I think anytime you start out a new surgical technique, it's just kind of deciding as a team what technique we'll use, have monitor the patient afterwards, and having a system in place and a protocol. But I think that we already have a great team of talented surgeons and people who are very enthusiastic about fertility preservation, and so just bringing the team together.

Dale Shepard, MD, PhD: One thing that is always seemingly a problem is getting people to you and your colleagues to talk about fertility preservation in the first place. How do we make that better? I think it's something that in the haste to get started on treatments and things too often gets dropped.

Mindy Christianson, MD, MBA: Yeah. So what I find has worked in the past well, which I'm planning to initiate here, is reaching out to all of the different subspecialties for oncology and other types of medical conditions such as sickle cell disease where patients would require fertility preservation and sharing my personal information and having people know that they can even reach out to me directly by email. But we also have, within our electronic medical records system, a referral system for oncofertility and we have a navigator who can get people in very soon.

Dale Shepard, MD, PhD:That's excellent. So, sounds like you're well on your way to getting a center set up for a very important problem with an interesting solution. So, thanks for being with us today.

Mindy Christianson, MD, MBA: Great. Thank you for having me.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You'll receive a confirmation once the appointment is scheduled.

This concludes this episode of Cancer Advances. For more podcast episodes, visit our website, clevelandclinic.org/canceradvancespodcast. Subscribe on Apple Podcasts, Spotify, or wherever you listen to podcasts. Don't forget, you can access real time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer.

Thank you for listening. Please join us again soon.