FERTILITY AND STERILITYt

VOL. 70, NO. 2, AUGUST 1998

Copyright ©1998 American Society for Reproductive Medicine
Published by Elsevier Science Inc.
Printed on acid-free paper in U.S.A.

Laparoscopic ovarian suspension before

irradiation
Togas Tulandi, M.D., and Sundus Al-Took, M.D.
Department of Obstetrics and Gynecology, McGill University, Montreal, Quebec, Canada

Objective: To evaluate a technique of lateral ovarian transposition by laparoscopy.

Design: Case report.
Setting: Tertiary care center.
Patient(s): A 34-year-old woman with rectal carcinoma.
Intervention(s): Laparoscopic ovarian transposition.
Main Outcome Measure(s): Return of normal menstruation after irradiation.
Result(s): Lateral ovarian transposition could be done by laparoscopy. However, division of the ovarian ligament was
needed. The location of the ovaries after surgery was outside the radiation field.
Conclusion(s): Lateral ovarian transposition can be done by laparoscopy. Contrary to a previous report, division of the
ovarian ligament is required. (Fertil Sterilt 1998;70:381–3. ©1998 by American Society for Reproductive Medicine.)
Key Words: Laparoscopy, ovarian transposition, rectal cancer, radiation

Radiation therapy is one of the treatment but not into the muscularis propria, with resec-
modalities used in the management of patients tion margins free of carcinoma. There was in-
with cancer. Depending on the site and the vasion of several small veins inside the submu-
extent of the disease, radiation can be admin- cosa. Computerized tomography scan of the
istered locally or to a larger area. In some abdomen and pelvis revealed no invasion of
women with genitourinary or low intestinal perirectal fat and no lymphadenopathy or liver
tumors, pelvic irradiation may be indicated. It metastasis. She was offered pelvic irradiation
is highly effective in patients with early stage and was referred to us for possible preservation
cancers, but it results in the loss of ovarian of her fertility.
function. We discussed the alternatives of lateral
In an attempt to protect the ovaries from ovarian transposition, cryopreservation of
radiation, ovarian transposition to an extrapel- ovarian tissue, and autograph of the ovarian
vic site out of the field of radiation has been tissue to a distant extra-abdominal site. Be-
advocated. In general, this is done by laparot- cause of the seriousness of the situation, IVF
omy either as a part of surgical staging or as a and embryo cryopreservation was not consid-
separate procedure (1– 8). We describe laparo- ered. The patient consented to ovarian transpo-
scopic ovarian transposition in a young woman sition and cryopreservation of ovarian tissue.
Received December 1, Because the procedure has been done by lapa-
1997; revised and
with rectal cancer.
accepted March 1, 1998. rotomy, institutional review board approval to
Reprint requests: Togas perform the same procedure by laparoscopy in
Tulandi, M.D.,
CASE REPORT this patient was not obtained. Before surgery,
Reproductive Center, the field of radiation was outlined by a radia-
McGill University, 687 Pine A 34-year-old woman whose condition re-
Avenue West, Montreal, cently was diagnosed as T1, N0, M0, grade 2 tion oncologist.
Quebec, Canada, H3A 1A1 adenocarcinoma of the rectum (Duke’s A, T1) On September 29, 1997, the patient under-
(FAX: 514-843-1496; E-
mail: TOGAS@RVHOB2 presented to the hospital. A transanal resection went a laparoscopy. We used three trocars. The
.MCGILL.LAN.CA). of the tumor was done on July 24, 1997. The primary trocar was inserted through a 10-mm
pathologic diagnosis revealed moderately dif- incision above the umbilicus, and two second-
0015-0282/98/$19.00
PII S0015-0282(98)00155-1 ferentiated adenocarcinoma with extension to ary trocars were inserted at the same level

381
lateral to the rectus muscle. A thorough examination of the
abdominal cavity, including the liver and diaphragm, re- FIGURE 1
vealed normal abdominal organs. Peritoneal lavage for cy- Laparoscopic lateral ovarian transposition. The ovarian liga-
tologic examination was done. For the purpose of cryo- ments (1-see arrow) and the mesovarium (2) are divided. If
preservation of the ovary, a wedge resection of the left ovary mobility is inadequate, a relaxing incision on the peritoneum
was performed. To prevent thermal damage to the ovarian inferior to the ovary (3) may be needed. The final location of
follicles, this was done only with a laparoscopic scissors. the ovary is shown in the illustration and the photograph.
The specimen immediately was placed in Leibovitz L-15
media (Sigma Chemical Co., St. Louis, MO) on ice for
processing.
The course of both ureters was followed and the ovarian
ligament was electrocoagulated and divided. The same pro-
cedure was performed on the mesovarium. The dissection
was continued to the infundibulopelvic ligament, but the
vascular pedicle inside the ligament was left intact. The left
ovary could be mobilized to the level of the anterior-superior
iliac spines. Because of inadequate mobilization on the right
side, a relaxing incision was made on the peritoneum inferior
to the right ovary. This allowed mobilization of the right
ovary to the same level as the left ovary.
Of interest, both ovaries could be transposed to this level
without transecting the fallopian tubes. The ovary was an-
chored to the peritoneum with two sutures of 4-0 polydiox-
anone (Fig. 1). The inferior border of the ovary was marked
with a vascular metal hemoclip bilaterally. Blood loss was
negligible.
The operation and the postoperative course were unevent-
ful. From October 6, 1997, until December 7, 1997, the
patient was treated with pelvic irradiation. She received a
dose of 45 Gy given in 25 fractions to the pelvis and a
combined mixed beam of 15- and 6-megavolt photons with
a three-field technique (one posterior and two lateral). The
treatment was completed with intrarectal brachytherapy. Flat
plates of the abdomen (anterior-posterior and lateral views)
revealed that the ovaries were located outside the field of
radiation (Fig. 2). The patient’s menstrual cycles were never
interrupted and she continued to menstruate regularly every
28 days.

DISCUSSION
transplantation (8). In this procedure, vascular anastomosis
Many procedures that previously required a laparotomy is performed and the ovary is implanted on the inner face of
now are done by laparoscopy. This includes lateral ovarian the arm. A recent case report of accidental retention of
suspension before irradiation. Lateral ovarian transposition functional ovarian tissue in the subcutaneous tissue of the
by laparotomy is associated with preservation of ovarian trocar site suggests the feasibility of ovarian autograft with-
function in 83% of patients after pelvic irradiation (4). This out vascular anastomosis (9). An ovary or a portion of
technique is more effective than transposing the ovaries ovarian tissue potentially can be separated from its blood
behind the uterus and protecting them with a lead block (6). supply and grafted under the skin distant from the radiation
Further, the lead block also may shield affected nodes. field. The efficacy of this technique remains to be deter-
Another method is exteriorization of the ovaries under the mined.
skin through an opening in the flank. This approach, how- Ovarian transposition by laparotomy is associated with a
ever, is not used widely and has been associated with ovarian large abdominal incision, a long hospital stay, and an in-
cyst formation (7). creased risk of adhesion formation with subsequent intestinal
A more complicated technique is heterotopic ovarian obstruction. The findings in our case report support a previ-

382 Tulandi and Al-Took Techniques and instrumentation Vol. 70, No. 2, August 1998
 In addition to ovarian transposition, we also cryopre-
FIGURE 2 served a portion of the left ovary. It has been demonstrated
The transposed ovaries as indicated by the metal hemoclips
that primordial follicles can be isolated from cryopreserved
(arrows) were located outside the radiation field (flat plate of human ovarian tissue and retain high viability rates (12).
abdomen: anterior-posterior view). Because our patient potentially could conceive spontane-
ously, it is possible that she may not require her cryopre-
served tissue. The urgency of the situation led us not to
consider IVF and embryo cryopreservation. Further, an en-
larged ovary after ovarian stimulation with gonadotropin
might not be easy to maneuver. Our report demonstrates that
ovarian transposition can be done by laparoscopy. Contrary
to a previous report, division of the ovarian ligament is
required.

Acknowledgments: The authors thank Sarkis H. Meterissian, M.D. for

referring the patient, Te Vuong, M.D., and Ted Roman, M.D. for their
expertise in radiation therapy, and Seang Lin Tan, M.D., and the staff of McGill
Reproductive Center for their assistance in cryopreservation of the ovary.

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FERTILITY & STERILITYt 383