The ovaries

The standard surgical treatment for epithelial ovarian cancer is a total abdominal hysterectomy and bilateral salpingo-oophorectomy. These will cause permanent infertility. In women who have ovarian tumours that are not of epithelial origin or are a very low grade (ie borderline ovarian tumours), preserving fertility is a possible option with conservative surgery.(31) This is an accepted standard treatment but would need to be decided on an individual basis. It involves leaving the uterus and one ovary behind. Although this potentially also leaves behind areas where recurrence is possible, the risk of this appears to be small.(31)

The cervix

Current treatment for cervical cancer is either a radical hysterectomy or radiotherapy causing permanent infertility. Since the mid 1990s a procedure called a radical trachelectomy (the removal of the cervix but not the uterus) has been developed for women with early stage cancer. This procedure appears to offer adequate treatment of small cervical lesions in women who wish to maintain their fertility.(32) The recurrence rates after radical trachelectomy appear to be similar to those for hysterectomy. However, there is no randomised data as yet. Also there is an increased risk of miscarriage and premature birth.(10) Radical trachelectomy is a specialist procedure, and the woman may have to travel to a gynaecological cancer centre that offers this surgery to have it done.

A recent systematic review by Kyrgiou et al (2006), looked at obstetric outcomes following conservative treatment for intraepithelial cervical lesions. It found that cold knife conisation was significantly associated with pre-term delivery, low birth weight and caesarian section. Large loop excision of the transformation zone was significantly associated with pre-term delivery, low birth weight and premature rupture of the membranes. No significantly increased obstetric risks were found after laser ablation. The conclusion of this review is that “all excisional procedures to treat cervical intraepithelial neoplasia present similar pregnancy related morbidity without apparent neonatal morbidity”.(33)

The uterus

Although endometrial cancer is much more common in older women, younger women of reproductive age can be affected.

For women with stage 1 disease who wish to preserve their fertility, there is some evidence to support conservative management (using progestin therapy) as a short term alternative to surgery.(34) This approach throws up a number of issues. For example, there are no definitive recommendations regarding; patient selection; dosage and duration of therapy; the need for maintenance therapy after treatment and methods of surveillance after treatment.

Furthermore, the possible risk of recurrence has led some doctors to recommend hysterectomy once child bearing is complete.

These considerations highlight the need for a randomised trial of fertility preserving treatment for young women with endometrial cancer.(34)

The testes

Orchidectomy involves the surgical removal of the testicle. If only one testicle is removed fertility should not be affected. However the man may already have sub optimal fertility in the other testicle.

Removing both testicles leads to infertility. Hormone therapy is needed to replace the lack of testosterone and although this means that erections and ejaculations are possible, no sperm will be produced.(35)

In some men with testicular cancer a biopsy is taken from the other testicle to look for pre-malignant changes which might later progress to a second cancer. This can be treated with radiotherapy but will also stop sperm production. In this case sperm banking may be done beforehand.

Sometimes an operation to remove the lymph nodes in the abdomen is carried out as well as the orchidectomy. This can have potentially permanent side effects including failure of ejaculation and infertility. Impotence does not occur unless surgery extends deep into the pelvis (which is very rare).

The prostate

Radical prostatectomy involves the removal of the prostate, seminal vesicles, distal vasa and ejaculatory ducts as well as the prostatic urethra.(36)

Radical prostatectomy is associated with ejaculatory disturbance although the sensation of orgasm can usually be preserved. When the entire prostate and seminal vesicles have been removed, however, no semen is produced, causing infertility in men who have had this surgery.(37)

Radical surgery also carries with it the risk of side effects such as incontinence and erectile dysfunction although this may be minimised by the use of nerve sparing surgery. But this type of surgery may only be suitable in certain cases. Erectile function can sometimes return after nerve sparing surgery depending on the technique used.(36)

Several factors have been shown to influence post-operative sexual function these include: age, clinical and pathological stage and surgical technique. Reported frequencies of impotence range from 20% to 80%. Incontinence is a significant problem for many men after radical prostatectomy. Reported incidences of incontinence range from 4–21% for mild or stress incontinence and from 0–7% for total incontinence 18 months post-operatively.(38)

The bladder

Radical cystectomy (removal of the bladder) can damage the nerves of the prostate causing erectile dysfunction. In some men a nerve sparing technique that can maintain erectile function can be performed. However, fertility is impaired because the prostate and seminal vesicles are removed therefore no semen can be produced.

The rectum

Surgery for rectal cancer can cause impotence due to damage to the parasympathetic pelvic nerves.(39)