Fertility Sparing in Gynecological Cancers Fırat Ortaç, MD Güven Hospital Güven Hospital Department of Obstetrics and Gynecology Department of Obstetrics

Fertility SparingFertility Sparing in in

Gynecological Cancers Gynecological Cancers

Fertility SparingFertility Sparing in in

Gynecological Cancers Gynecological Cancers Fırat Ortaç, MDFırat Ortaç, MD Güven HospitalGüven Hospital

Department of Obstetrics and Department of Obstetrics and Gynecology Gynecology

Cancer TreatmentCancer Treatment

ObjectiveObjective

CureCure

Adverse EffectsAdverse Effects Psychological effectsPsychological effects Cosmetic problemsCosmetic problems Loss of organ functionLoss of organ function Sexual and reproductive Sexual and reproductive

dysfunctiondysfunction

Fertility sparing surgeryFertility sparing surgery

Goals of Fertility-SparingGoals of Fertility-Sparing Surgery(FSS)Surgery(FSS)Goals of Fertility-SparingGoals of Fertility-Sparing Surgery(FSS)Surgery(FSS)

Preservation of reproductive potential

Preservation of hormonal function

Preservation of healthy body image

No compromise in curability

FSS ObjectivesFSS ObjectivesFSS ObjectivesFSS Objectives

Similiar oncologic outcomes to standard therapy

Favorable obstetric outcome

Benefits > risksLow morbidity

Defining prognostic factorsDefining prognostic factors

Evidence-based DataEvidence-based Data

Fertility Sparing SurgeryFertility Sparing Surgery

PhysicianPhysician

Fertility-Sparing Fertility-Sparing in in

Gynecologic OncologyGynecologic Oncology


Gynecologic OncologyGynecologic Oncology

The patient and family must be:The patient and family must be:aware of the problemaware of the probleminvolved in the final decisioninvolved in the final decision

Once Once the the fertility fertility has been has been completed, demolitive procedure completed, demolitive procedure should be consideredshould be considered


GynGyneecologic Oncologycologic Oncology


GynGyneecologic Oncologycologic Oncology

AgeAgeDesire to preserve Desire to preserve fertilityfertility Tumor factorsTumor factors

HHistologic type, grade, othersistologic type, grade, othersStage of diseaseStage of disease

Principles in Treatment of Early-Principles in Treatment of Early-Stage Cervical CancerStage Cervical Cancer

Principles in Treatment of Early-Principles in Treatment of Early-Stage Cervical CancerStage Cervical Cancer

PaPatient’s general statustient’s general status

Desire of fertilityDesire of fertility

Tumor factorsTumor factorsDepth and width of invasionDepth and width of invasionSize of cervical lesion Size of cervical lesion LVSILVSI

TTraditional treatment of early stage raditional treatment of early stage

cervical cancer beyond cervical cancer beyond

micro-invasionmicro-invasion

Radical hysterectomyRadical hysterectomy++

PPLNDPPLND

LLoss of fertilityoss of fertility

LVSILVSI

Pelvik lenf nodu Pelvik lenf nodu metastazımetastazı

Pelvik rekürensPelvik rekürens

Lenfadenektomi – Radikal cerrahiLenfadenektomi – Radikal cerrahi

Spread of Cervical CancerSpread of Cervical CancerSpread of Cervical CancerSpread of Cervical Cancer

Laterally (Dominant) Laterally (Dominant) Parametrium Parametrium

Vertically (rare)Vertically (rare)Stage Ib and IIa Stage Ib and IIa 0% 0%Stage IIb Stage IIb 20% 20%

FFertility Sparing Surgery ertility Sparing Surgery inin

Early-Stage Cervical CancerEarly-Stage Cervical Cancer


Early-Stage Cervical CancerEarly-Stage Cervical Cancer

ID<3 mmID<3 mmLVSI(-)LVSI(-)

MARGIN (-)MARGIN (-)

CONIZATIONCONIZATION

FOLLOW-UPFOLLOW-UP

Cold Conization

CONIZATIONCONIZATION < 10 mm < 10 mmCONIZATIONCONIZATION < 10 mm < 10 mm

Does not affect Does not affect fertility potentialfertility potential

Clin. Exp.Clin. Exp. Obstet. Gynecol, 1992: 19(1):40-2Obstet. Gynecol, 1992: 19(1):40-2

Effect of Con on Pregnancy Outcome

< 18 mm

< 15 mm NO EFFECT

> 18 mm

25% PRETERM LABOR 18% PROM

Sadler L. Et al., Am J Med Ass, 2004

Frencezy A, 1995Haffenden DK, 1993Tan L, 2004

> 15 mm

FFertility Sparing Surgeryertility Sparing Surgery inin Early-Stage Early-Stage Cervical CancerCervical Cancer

Stage IStage Iaa11 (LVS +) (LVS +)

Stage IaStage Ia22 (LVS (LVS ))

Stage Ib-IIa (Stage Ib-IIa (2cm)2cm)

FFertility Sparing Surgeryertility Sparing Surgery inin Early-Stage Early-Stage Cervical CancerCervical Cancer

Stage IStage Iaa11 (LVS +) (LVS +)

Stage IaStage Ia22 (LVS (LVS ))

Stage Ib-IIa (Stage Ib-IIa (2cm)2cm)

Desire of fertilityDesire of fertility

LymphLymph Node Dissection Node Dissection

(L/S, L/T)(L/S, L/T)

Node (-)Node (-) Node (+)Node (+)

RVTRVT RTRTSentinel Lymph NodeSentinel Lymph Node

RRAATT

Sentinel lymph nodeSentinel lymph nodeSentinel lymph nodeSentinel lymph node

Radical TrachelectomyRadical TrachelectomyRadical TrachelectomyRadical Trachelectomy

1994 1994 DargentDargent

Vaginal Radical Trachelectomy (VRT)Vaginal Radical Trachelectomy (VRT)inin

Early-Stage Cervical CancarEarly-Stage Cervical Cancar

Vaginal Radical Trachelectomy (VRT)Vaginal Radical Trachelectomy (VRT)inin

Early-Stage Cervical CancarEarly-Stage Cervical Cancar

by Dargent in Lyon, Franceby Dargent in Lyon, FranceModification of the Schauta-Stoeckel Modification of the Schauta-Stoeckel technique of vaginal radical hysterectomytechnique of vaginal radical hysterectomy

L/SL/S

Pelvic Pelvic lymphadenectomylymphadenectomy

Preservation ofPreservation ofthe upper endocervixthe upper endocervixand uterine corpusand uterine corpus

Radical TrachelectomyRadical Trachelectomy(RT)(RT)Radical TrachelectomyRadical Trachelectomy(RT)(RT)

VRVRT-AbRTT-AbRTVRVRT-AbRTT-AbRT

IndicationsIndicationsPatient who desires preservation of Patient who desires preservation of

fertilityfertility

FIGO Stage IaFIGO Stage Ia11 (+ (+LLVSI), Ia2, Ib1VSI), Ia2, Ib1

Lesions Lesions 2 cm in diameter 2 cm in diameterLimited endocervical involvement Limited endocervical involvement

- - MRI and colposcopyMRI and colposcopy

Lymph node dissection(Sentinel lymph node)Lymph node dissection(Sentinel lymph node)

ParametrectomyParametrectomy

Trachelectomy (FS analyse- free margin 5-8 mm)Trachelectomy (FS analyse- free margin 5-8 mm)

Cervical circlageCervical circlage

Surgıcal procedure Surgıcal procedure

RTRTRTRT

FeasibilityFeasibilityNo evidence of lymph node metastasis No evidence of lymph node metastasis

(Frozen section at L/S)(Frozen section at L/S)(ultrastaging)(ultrastaging)

Upper endocervical margins free of Upper endocervical margins free of tumor (Frozen section)tumor (Frozen section)

VRTVRTVRTVRT

ResultsResults Dargent (Lyon)Dargent (Lyon) 8282 Plante and Roy (Quebec)Plante and Roy (Quebec) 4444 Covens (Toronto) Covens (Toronto) 5858 Shepherd (London, UK) Shepherd (London, UK) 4040 TotalTotal

224224

VRTVRTVRTVRT

Oncologic Outcome (N:24)Oncologic Outcome (N:24)

FFollow-up (months)ollow-up (months) 3030RecurrencesRecurrences 7(3.1%)7(3.1%)

Parametrium Parametrium 33 Pelvic side wallPelvic side wall 11 DDistant istant 33

No cervico-uterine recurrenceNo cervico-uterine recurrence

Pregnancy Results after VRTPregnancy Results after VRTPregnancy Results after VRTPregnancy Results after VRT

n FertilityDesire

No.of Pregn/ Patient

Livebirth

96 42 56/33 3472 42 48/31 2893 39 22/18 1830 13 14/8 919 4 4/3 210 4 4/4 2

315 144 148/97 93

Fertil Steril 2005;84:156

VRTVRTVRTVRT

ConclusionsConclusionsAbdominal way is possibleAbdominal way is possibleThe risk of recurrence is unchangedThe risk of recurrence is unchangedFertility is preservedFertility is preservedBut pregnancies are at high riskBut pregnancies are at high riskAn international study is An international study is requiredrequired to to

confirm indications and limits of this confirm indications and limits of this conservative techniqueconservative technique

Preserving Fertility in Endometrial Preserving Fertility in Endometrial Cancer Cancer

Preserving Fertility in Endometrial Preserving Fertility in Endometrial Cancer Cancer

2% -14 % of endometrial 2% -14 % of endometrial cancercancer

40 years40 years

Up to 25% Up to 25% PCOSPCOS

GG11 Early stageEarly stage

Respond to Respond to progestin progestin treatment treatment

Stage Ia, GStage Ia, G11

Standart treatmentStandart treatment

TAH + BSOTAH + BSO

Preserving Fertility in Endometrial Preserving Fertility in Endometrial CancerCancer


Endometrial Cancer Endometrial Cancer

Fertility DesireFertility Desire

Pretreatment Evaluation Pretreatment Evaluation

Tumor Tumor GradeGrade

Depth Depth of MIof MI

Tumor Tumor SizeSize

Hormone Hormone receptor statusreceptor status

Flow cytometric Flow cytometric analysisanalysis

FavorableFavorable prognosisprognosis



Inclusion CriteriaInclusion Criteria

Age < 40 yearsAge < 40 years Nulliparous statusNulliparous status Endometrioid Carcinoma Endometrioid Carcinoma G1G1 Presence of PgRPresence of PgR Normal serum levels of CA 125 (<35 u/mL) and CEA Normal serum levels of CA 125 (<35 u/mL) and CEA

(< 5 ng/mL)(< 5 ng/mL) Tumor DNA index < 1.3 Tumor DNA index < 1.3 Absence of MI or extrauterine spread (by vaginal USG Absence of MI or extrauterine spread (by vaginal USG

and MRI) ,surgıcal stagingand MRI) ,surgıcal staging



Pretreatment EvaluationPretreatment Evaluation Pretreatment EvaluationPretreatment Evaluation History (infertility...)Physicial ExaminationTVUSGD&CAbdominopelvic/ endovajinal coil

MRICa-125Laparoscopic evaluation

Staging Laparotomy

Response to Progesteroneor

Explain the patient the risk of conservative treatmentExplain the patient the risk of conservative treatment

Evaluate the patient for prognosisEvaluate the patient for prognosis

Medical treatment (Megestrol acetate 40-160 mg/d , MPA 30 Medical treatment (Megestrol acetate 40-160 mg/d , MPA 30

mg/d mg/d Tamoxifen 30 mg/d or GnRHa) Tamoxifen 30 mg/d or GnRHa)

Repeated D&C; hysteroscopy (+tubal blockage)Repeated D&C; hysteroscopy (+tubal blockage)

No residual diseaseNo residual disease

Assisted reproductionAssisted reproduction

Elective hysterectomy when the patient no longer desires to Elective hysterectomy when the patient no longer desires to

maintain fertilitymaintain fertility



Progestogenic AgentsProgestogenic AgentsProgestogenic AgentsProgestogenic Agents MPA 30/mg/ day Megace 40-160 /mg/day IUD / Prog Response Rate Hyperplasia with Atypia %83-94 End. Ca %57-75.6 Duration of Treatment Range 3-6 months Median 9 months Recurrens Hyperplasia with Atypia % 13 End. Ca % 11-50

There is no consensusThere is no consensusThere is no consensusThere is no consensus

Which progesterone formulation to use What schedule to use What dose to use How long to treat How often to resample

72 cases in literature72 cases in literature



Positive responsePositive response histologically documented histologically documented

55 cases (76%)55 cases (76%)

Endometrial CancerEndometrial CancerEndometrial CancerEndometrial CancerLiterature Overview (1966-2006)

No pts.= 53 80% were nulliparousIn 96% of them the tumor was well

differentiatedAt least 36 pregn. were obtained by ART70% of pts. Underwent a hysterectomy

after completing gestation

DiagnosisDiagnosisPre-operative?Pre-operative?Intra-operative frozen section?Intra-operative frozen section?Histopathological evaluation ofHistopathological evaluation of

hysterectomy or myomectomyhysterectomy or myomectomy

specimen.specimen.

Uterine LeiomyosarcomaUterine Leiomyosarcoma (LMS) (LMS)Uterine LeiomyosarcomaUterine Leiomyosarcoma (LMS) (LMS)

IncidenceIncidence

Uterine LUterine LMSMSUterine LUterine LMSMS

patients operated for patients operated for presumed leiomyomapresumed leiomyoma

0.1-0.3%0.1-0.3%

Safe margin: 3-5 mm. Safe margin: 3-5 mm. ??

<10 mitoses/per 10 HPF<10 mitoses/per 10 HPF

Solitary pedinculated massSolitary pedinculated mass


LMSLMS


LMSLMS

Accurately restage the patientsAccurately restage the patients

Color doppler USGColor doppler USGHysteroscopyHysteroscopyChest X-rayChest X-rayMRI or CT scanMRI or CT scan


LMSLMS


LMSLMS

Cesarean sectionCesarean sectionMultiple uterine biopsies Multiple uterine biopsies

should be taken.should be taken.

FFertility Sparing Surgeryertility Sparing Surgery inin

LMSLMS


LMSLMS•DeliveryDelivery

Lissoni A (Gynecol Oncol 70(3): 348-50 (1998)Lissoni A (Gynecol Oncol 70(3): 348-50 (1998)

Between 1982-1996 (8 patients)Between 1982-1996 (8 patients) Median age: 29Median age: 29 All nulliparousAll nulliparous Tumor was confined to myomaTumor was confined to myoma Mean mitotic count 6 per 10 HPFMean mitotic count 6 per 10 HPF 3 pregnancies3 pregnancies Median follow-up 42 monthsMedian follow-up 42 months 7 patients alive7 patients alive One patient died (26 months after diagnosis).One patient died (26 months after diagnosis).


LMSLMS


LMSLMS

FFertility Sparingertility Sparing in in

Epithelial Ovarian Cancer Epithelial Ovarian Cancer and Borderline Tumorsand Borderline Tumors

FFertility Sparingertility Sparing in in

Epithelial Ovarian Cancer Epithelial Ovarian Cancer and Borderline Tumorsand Borderline Tumors

Optimal Staging:Optimal Staging: USO or cystectomy (in BOT)USO or cystectomy (in BOT) Peritoneal washing and cytologyPeritoneal washing and cytology Inspection of the contralateral ovarian Inspection of the contralateral ovarian

surface, biopsies of any suspicious lesionssurface, biopsies of any suspicious lesionsWedge resection of the opposite ovary?Wedge resection of the opposite ovary?

Staging biopsies of the peritoneal cavityStaging biopsies of the peritoneal cavity Sampling of retroperitoneal lymph nodes or Sampling of retroperitoneal lymph nodes or

radical lymphadenectomy since 1990radical lymphadenectomy since 1990 Omentectomy, appendectomy.Omentectomy, appendectomy.

FFertility Sparing Surgeryertility Sparing Surgery in Epithelial in Epithelial Ovarian Cancer and Borderline TumorsOvarian Cancer and Borderline TumorsFFertility Sparing Surgeryertility Sparing Surgery in Epithelial in Epithelial

Ovarian Cancer and Borderline TumorsOvarian Cancer and Borderline Tumors

Recurrence rate in the patients Recurrence rate in the patients underwent conservative surgery underwent conservative surgery for border-line tumors is %7for border-line tumors is %7

Gynecol Oncol 55;552-6, 1994.Gynecol Oncol 55;552-6, 1994.

FFertility Sparing Surgeryertility Sparing Surgery in in

Borderline Tumors Borderline Tumors

FFertility Sparing Surgeryertility Sparing Surgery in in

Borderline Tumors Borderline Tumors

Retrospective reviewRetrospective review82 patients82 patients39 patients underwent conservative 39 patients underwent conservative

managementmanagementThree patients had a contralateral Three patients had a contralateral

recurrence (7%)recurrence (7%)22 pregnancies were achieved.22 pregnancies were achieved.

Border-line Tumors of the Ovary Border-line Tumors of the Ovary Conservative Management and Conservative Management and

Pregnancy OutcomePregnancy Outcome

Border-line Tumors of the Ovary Border-line Tumors of the Ovary Conservative Management and Conservative Management and

Pregnancy OutcomePregnancy OutcomeCancer 1998 Jan, 1;82(1):141-6Cancer 1998 Jan, 1;82(1):141-6

Stage IaStage IaG1 and Border-lineG1 and Border-line

No further treatment

Stage IaStage IaG2, G3G2, G3

Chemotherapy

Stage Ic-IIIStage Ic-III• Selected cases• Requested by

patients herself• Preliminary reports.

FROZENFROZEN

Invasive Epithelial Ovarian CancerInvasive Epithelial Ovarian Cancer

and Border-Line Tumorsand Border-Line Tumors

Desire for fertility

Endometrial biopsy

Optimal Staging

Can conservative surgical approach be used in Can conservative surgical approach be used in selected young patients with ovarian cancer who selected young patients with ovarian cancer who would usually undergo radical operations.would usually undergo radical operations.

Cancer 1998 Jan, 1;82(1):141-6Cancer 1998 Jan, 1;82(1):141-6

Retrospective study between 1980-1994Retrospective study between 1980-1994 10 patients with high grade or limited 10 patients with high grade or limited

extraovarian diseaseextraovarian disease• Stage Ia G3Stage Ia G3 22• Stage IcStage Ic 22• Stage IIIaStage IIIa 22• Stage IIIcStage IIIc 44

All patients were given adjuvant CTAll patients were given adjuvant CT All patients were alive median follow-up 70 All patients were alive median follow-up 70

monthsmonths 9 patients were menstruating regularly9 patients were menstruating regularly Three had became pregnant.Three had became pregnant.

Ovarian Cancer Treatment Ovarian Cancer Treatment with Fertility-Sparing Therapy with Fertility-Sparing Therapy Ovarian Cancer Treatment Ovarian Cancer Treatment with Fertility-Sparing Therapy with Fertility-Sparing Therapy Stage IA and IC epithelial ovarian cancerStage IA and IC epithelial ovarian cancer 1965 to 2000, n=521965 to 2000, n=52 20 (%38) received chemotherapy20 (%38) received chemotherapy 9 (17%) eventual TAH9 (17%) eventual TAH 5(10%) recurred, 2 died5(10%) recurred, 2 died 24 (46%) attempted, 17 (33%) conceived 24 (46%) attempted, 17 (33%) conceived

26 term, 5 SAb26 term, 5 SAb 33% take home baby33% take home baby

Schilder et al., Gynecol Oncol, 2002Schilder et al., Gynecol Oncol, 2002

FFertility Sparing Surgeryertility Sparing Surgery in Epithelial in Epithelial Ovarian Cancer and Borderline TumorsOvarian Cancer and Borderline TumorsFFertility Sparing Surgeryertility Sparing Surgery in Epithelial in Epithelial

Ovarian Cancer and Borderline TumorsOvarian Cancer and Borderline Tumors

CONCLUSIONSCONCLUSIONSFor more advanced stages, additional For more advanced stages, additional

investigation is needed.investigation is needed.After completion of fertility, residual After completion of fertility, residual

ovary should be taken out.ovary should be taken out. Incidence of ovarian cancer gets Incidence of ovarian cancer gets

higher with age.higher with age. Screening method are unreliable.Screening method are unreliable.

Germ Cell TumorGerm Cell Tumorss of the Ovary of the OvaryGerm Cell TumorGerm Cell Tumorss of the Ovary of the Ovary

Incidence: less than %5 of all Incidence: less than %5 of all ovarian neoplasm.ovarian neoplasm.

Age: the first and second decadeAge: the first and second decade

Usually unilateralUsually unilateral

1978 Forney first reported a case of successful pregnancy in a 18 year-old with EST of ovary.

Obstet Gynecol 52, 360-62 (1978)Obstet Gynecol 52, 360-62 (1978)1985 Gershenson at the MD Anderson

Hospital.48 patients with malignant germ cell

tumorsFull-term pregnancies in 6 cases

Cancer 56, 2756-2761 (1985)Cancer 56, 2756-2761 (1985)

FFSS SS in Germ Cell Tumors of the Ovaryin Germ Cell Tumors of the OvaryFFSS SS in Germ Cell Tumors of the Ovaryin Germ Cell Tumors of the Ovary

FFSS SS in Germ Cell Tumors of the Ovaryin Germ Cell Tumors of the OvaryFFSS SS in Germ Cell Tumors of the Ovaryin Germ Cell Tumors of the Ovary

RationalesRationalesUnilaterality of tumorUnilaterality of tumorImprovement of prognosis by Improvement of prognosis by

modern combination chemotherapymodern combination chemotherapy

1970s the 1970s the VAC regimenVAC regimen

1980s the 1980s the PVB regimenPVB regimen POMP/ACE.POMP/ACE.

A Report of 28 Cases / Cancer 42, 1152-1160 (1978)A Report of 28 Cases / Cancer 42, 1152-1160 (1978)

Tumor was confined to one ovary in all Tumor was confined to one ovary in all cases.cases.

All patients were taken chemotherapy All patients were taken chemotherapy except two with stage I immature except two with stage I immature teratoma.teratoma.

More than 5 years survival in 13 cases More than 5 years survival in 13 cases (59.1%)(59.1%)

7 of 12 married patients, became pregnant, 7 of 12 married patients, became pregnant, all had term delivery.all had term delivery.

Treatment of Malignant Ovarian Germ Treatment of Malignant Ovarian Germ Cell Tumors With Preservation of FertilityCell Tumors With Preservation of Fertility

Treatment of Malignant Ovarian Germ Treatment of Malignant Ovarian Germ Cell Tumors With Preservation of FertilityCell Tumors With Preservation of Fertility

ObstetricObstetricObstetricObstetric

Author % Pregnancy Term Delivery

Abort. Ektopic Anomaly

Gershenson 1988

100 (12/16) 22 0 0 0

Perrin1999

------ 8 -- -- 0

Low 2000

95 (19/20) 16 -- -- 0

Zanetta 2001

80 (16/20) 26 9 -- 3

Tangir 2003 76 (25/33) 38 2 -- 0

Toplam 87.75 (72/89)

110 11 0 3

Outcome in GCTOutcome in GCT

ConclusionConclusion RRegardless of the stage is a safe egardless of the stage is a safe

and practicable procedure in the and practicable procedure in the absence of involvement of absence of involvement of CONTRALATERAL OVARY CONTRALATERAL OVARY AND UTERUSAND UTERUS

FFertility Sparing Surgery ertility Sparing Surgery in Germ Cell in Germ Cell Tumors of the OvaryTumors of the Ovary

FFertility Sparing Surgery ertility Sparing Surgery in Germ Cell in Germ Cell Tumors of the OvaryTumors of the Ovary

History of ARTHistory of ARTHistory of ARTHistory of ART

The new millenium:The new millenium:2001 Clinic Specific Success 2001 Clinic Specific Success

about 28% per cycle overallabout 28% per cycle overallOocyte and ovarian slice Oocyte and ovarian slice

cryopreservation with function cryopreservation with function (Oktay)(Oktay)

İnvitro maturation maturesİnvitro maturation matures

Lancet, Lancet, March March 13, 2004 13, 2004

Fertility Preservation StrategiesFertility Preservation StrategiesFertility Preservation StrategiesFertility Preservation Strategies

As we discover what As we discover what can be done, we need to can be done, we need to learn what should done learn what should done

Thank you…Thank you…Thank you…Thank you…

Fertility-Preserving Fertility-Preserving Treatment in Endometrial Treatment in Endometrial

AdenocarcinomaAdenocarcinoma

Fertility-Preserving Fertility-Preserving Treatment in Endometrial Treatment in Endometrial

AdenocarcinomaAdenocarcinoma Stage IA, grade 1, 1991-9Stage IA, grade 1, 1991-9 N=9, average 32 yearsN=9, average 32 years Megace, tamoxifen, +GnRHaMegace, tamoxifen, +GnRHa 8 CR, 1 TAH8 CR, 1 TAH 4 pregnant4 pregnant

2 term after ART, 2 ectopic2 term after ART, 2 ectopic %22 take home baby%22 take home baby

Wang et al., Cancer, 2002Wang et al., Cancer, 2002

Documents

Fertility Sparing in Gynecological Cancers Fırat Ortaç, MD Güven Hospital Güven Hospital Department of Obstetrics and Gynecology Department of Obstetrics