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Carem conceived naturally after conserving her reproductive organs through uterine transposition surgery
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- Author, Bruna Alves
- Rolle, from São Paulo for BBC News Brazil
7 hours ago
Cancer is not a disease that causes infertility unless it has specifically affected the reproductive organs. However, treatment with radiation therapy can cause the eggs to die or damage other parts of the region which can lead to infertility.
Against this background, in the experimental phase, the researcher and oncological surgeon at the Institute of Robotic Surgery of Paraná, Reitan Ribeiro, developed the technique that has become known worldwide as uterine transposition.
The aim is to preserve the fertility of women undergoing radiation therapy for cancer treatment.
The method, carried out as part of a research protocol, consists in moving the reproductive organs to the upper part of the abdomen in order to keep them intact during therapies. At the end of the treatment, the uterus, fallopian tubes and ovaries are returned to their original position.
One of the beneficiaries of the implementation was 33yearold makeup artist Carem dos Santos.
In June 2018, she discovered a liposarcoma (a rare tumor that starts in the body’s fatty tissue) in her pelvis and as part of the treatment, in addition to surgery, radiation therapy sessions were required to treat the cancer cells. However, the radiation would affect your uterus and prevent future pregnancy.
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At the age of 28, Carem underwent an organ transplant after discovering pelvic cancer and requiring radiation therapy sessions.
“I didn’t have a boyfriend or children, but when I turned 30 I thought about starting a family. So this news was very sad and the radiation therapist gave me some time to see what I could do,” he recalls.
During this time, she learned the technique of uterine transposition, an ongoing study being conducted in Curitiba with the goal of preserving the organ for later pregnancy.
“The doctor was very sincere in saying that it was still a study and no woman had ever gotten pregnant so he couldn’t guarantee I would get pregnant later, but I listened to myself and had the surgery,” says the makeup artist.
Carem remembers that the postoperative phase was quite painful for the first fifteen days, but otherwise there were no complications. Then, three months after the radiation therapy sessions, the organs were moved to their proper place.
She later discovered two other types of cancer, one in the pleura and one in the lungs, and underwent the appropriate treatments. “I met my husband in 2021 and upon completing those processes, I found out I was pregnant,” she says.
“Today I look back and I’m like, my god, that was the right decision I made in my whole life because I fell in love with motherhood. Courage and faith were very important to me and we need to talk about it because it’s a dream for many women,” she concludes.
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Carem was the first woman to have a child after the uterine transposition experiment; Nicholas was born in January 2022
cervical cancer
In 2020, 33yearold newly married hairstylist Angelica Hodecker Azambuja was diagnosed with cervical cancer through routine exams.
“The doctor’s first option was to remove the uterus, ovaries and fallopian tubes, but since my cancer was only in the cervix, these organs were not affected. And yet I got around to thinking about the hypothesis,” he recalls.
At first, Angélica says, it was very difficult to process the news that not only was she ill, but that her dream of motherhood would not come true in the future.
“I was devastated because a woman might not even want to be a mother, and that’s fine, but when someone says you can’t have children, that you don’t have a choice, it really upsets us,” she says.
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Angélica says the uterine transposition was the best decision she could have made
She underwent surgery to remove part of her cervix, and then she made the difficult decision. “Either I stopped treatment to get pregnant or I lost the chance to have children because I had to undergo radiation therapy,” she says.
However, she was not satisfied with the options offered and went in search of an alternative. There he learned about transposition of the uterus. “At first I was unsure because it was a very new study and I wasn’t sure if it would work,” she says.
Nevertheless, Angélica completed the transposition and, after fifteen days, underwent treatment with chemotherapy and radiotherapy.
“A week after I finished chemotherapy and radiotherapy, I underwent transposition surgery again in March and I’ve been doing really well, having a smooth recovery,” comments the hairstylist.
Already in October 2021, she was diagnosed with remission of the disease and decided that it was time to dare to have children. To her surprise, she became pregnant the following year.
“The uterine transposition was the best option I had and the best decision we (she and her husband) made,” says Angélica, mother of fivemonthold Isabel.
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Angélica thought that due to her type of cancer it would not be possible to conceive naturally, but she managed and her baby was born on December 24th
How does uterine transposition work?
It is a minimally invasive surgery performed using robotic technology, in which the uterus, fallopian tubes and ovaries are removed from their original location and temporarily repositioned in the upper part of the abdomen to preserve them during radiation therapy treatment. The operation is performed in the pelvic area.
This is because the side effect of radiation therapy, even if not aimed directly at the uterus, is harmful to the ova and leads to infertility or an early menopause.
According to Ribeiro, the Brazilian surgeon responsible for developing the technique, the surgery is lowrisk and patients are typically discharged a day or two after the procedure and may experience pain or discomfort in the postoperative period, “but generally are they … lead relatively normal lives, even if the uterus is temporarily in an abnormal position.”
Of note, even with repositioning, the uterus continues to function normally, as does ovarian function. And at the end of the sessions, the reproductive organs are moved to their proper place.
Transposition may be indicated in patients who require radiation therapy to treat tumors in the rectum, colon, bladder, vagina, vulva (among others) and for sarcomas, which are malignant tumors in soft tissues such as muscle, fat, and tendon Just a few radiation sessions would be enough to induce infertility.
According to Renato Moretti Marques, coordinator of the Robotic Surgery in Gynecology program at the Israelita Albert Einstein Hospital, there are contraindications to transposition.
“It is important that the disease has not affected the uterus, fallopian tubes and ovaries. And if this patient doesn’t have functioning ovaries, it’s not possible to move the uterus because there would be no way to feed her, and if she’s already had pelvic radiation, it’s not possible to do that surgery either,” says Sie Marques, who is also the coordinator of the Department of Gynecology and Oncology at the Hospital Municipal Vila Santa Catarina.
quality of life of patients
Ribeiro emphasizes that the purpose of oncology today is not only to cure the patient, but also to ensure that he has the same quality of life as before the treatment. This was his main motivation for studying transposition surgery.
“Ten years ago we tried at all costs to cure cancer, even committing excesses. Today we don’t just want to heal a cancer patient, we want to heal her and give her a normal life. “For example, if you have a tumor in your leg, we don’t want to amputate the limb, we want it to heal and for the person to be able to move on,” the researcher describes, adding that this is now a very important concept in oncology.
For the coordinator of the “Robotic Surgery in Gynecology” program at Hospital Israelita Einstein, there are other reproductive alternatives, such as in vitro fertilization techniques, “but perhaps this is the most physiological that it is possible, the physiology of the inner part the uterus, which is called the endometrium, and the physiology of the ovary, which allows the patient to have a spontaneous pregnancy. So that might be the best way.”
Uterine transposition in the experimental phase
Although several surgeries have been performed, uterine transposition is still an experimental study.
The technique was presented at an international congress for gynecological oncology in 2016 and the study is currently in the publication phase.
The first operation was performed in Brazil by doctor and researcher Reitan Ribeiro in October 2015 and has since been used in several countries including Germany, Russia, Argentina, Colombia, the United States and Israel.
Dozens of patients have already undergone uterine transplantation, twenty of them in Brazil alone.
However, there have been unsuccessful cases in the past where the uterus has died after a blood clot has blocked the artery, leaving the patient’s organ unable to receive nourishment.
Marques says that “she was going to lose it anyway because of the radiation therapy, so this is a chance for the patient to preserve the reproductive organ.”
This is an experimental phase 3 study that will be carried out with the patients themselves over the long term.
“There are two surgeries that serve as a base, and combining them ultimately gives this third surgery, and now we’re in phase 3 of the trials, with a large number of patients that need to be studied longterm because there are patients who do that “I haven’t even tried to conceive because they’re very young,” Ribeiro explains.
The technology is not yet available in the SUS (Unified Health System).
“To be included in the SUS, we must submit an application to Conitec (National Commission for the Integration of Technologies into the Unified Health System), who is responsible for evaluating the application, checking whether it is economically viable and whether the literature this justifies. Then they set a price and finally authorize. This process can take one to two years and maybe even longer,” Ribeiro estimates.
According to Ribeiro, four hospitals in Brazil are authorized by the Conep (National Commission on Research Ethics) to perform this operation. These are: Hospital Erasto Gaertner, Hospital Israelita Albert Einstein, ACCamargo Cancer Center and Instituto de Câncer de Manaus.
“It is good to make it clear that it is an operation that will be carried out with the consent of Conep and in reference hospitals, because people may wonder if I can really do it, and yes I can,” notes Ribeiro clear.
To perform the procedure, women of childbearing potential who have been diagnosed with pelvic cancer and who are interested in performing the uterine transposition technique may ask their physician for a referral form to Erasto Gaertner Hospital (PR) and an evaluation for inclusion in the study apply for .
The medical team will assess the case to verify that it actually corresponds to the indications of the research that has been carried out free of charge for patients since 2017 and, if selected, will initiate the care protocol.