For young female patients who need pelvic radiotherapy, balancing cancer treatment with fertility aspirations is always a clinical challenge. Although pelvic radiotherapy can effectively control pelvic malignancies such as cervical cancer and rectal cancer, it may permanently damage the ovaries and uterus, making the idea of "conceiving offspring" futile. A review published in Obstetrics & Gynecology in 2025 systematically introduced the innovative technology of "uterine transposition", which provides a new possibility for such patients to "control cancer and protect fertility".
The high-energy rays of pelvic radiotherapy will cause a "precise blow" to the reproductive system while killing cancer cells, and the degree of damage is directly related to the radiation dose and the age of the patient: Ovaries: Radiation-sensitive "hardest hit areas" The ovaries are extremely sensitive to radiation, and a dose of only 2 Gy (about 1/20 of a single dose of conventional radiotherapy) will destroy nearly half of the eggs; with age, the threshold for ovarian radiation tolerance will also decrease. The radiation threshold for ovarian failure in 30-year-old women is 14.3 Gy, and 20.3 Gy in the neonatal period Uterine: Fertility function is easily damaged Radiation can damage the basal layer of the endometrium, myometrium and blood vessels: when the dose exceeds 14Gy, the endometrium will become fibrotic and thin, lose embryo receptivity, and cannot support implantation; uterine vascular damage will also increase the risk of placental insufficiency during pregnancy, which may cause miscarriage, premature birth or fetal growth restriction, and in severe cases, the uterus will lose its fertile capacity Traditional fertility protection methods (such as egg freezing and ovarian transposition) can preserve ovarian function, but they cannot protect the uterus. Even if patients can ovulate, they can only rely on surrogacy to achieve fertility, facing multiple obstacles from ethics, law and reality. 2. Uterine transposition:Let the uterus temporarily "escape" from the radiation zone The core idea of uterine transposition is to temporarily transfer the uterus and ovaries to areas that cannot be irradiated before radiotherapy, and then reduce them back to the pelvis after radiotherapy, which does not affect the anti-cancer effect and can protect the function of the uterus and ovaries at the same time. Since its first successful application in 2015, this technology has helped different cancer types such as cervical cancer and rectal cancer, and even prepubescent children at the age of 3 to achieve fertility protection The surgery is mostly performed laparoscopic or robotic-assisted laparoscopy (with higher precision) and is performed in two stages: Step 1: "Move" before radiotherapy The doctor will carefully separate the ligaments around the uterus (round ligament, broad ligament, etc.), ligate the uterine artery (at this time, the uterine blood supply is switched to the ovarian artery to maintain), and then move the uterus and ovary to the upper abdomen (usually the periumbilical area) and fix it with non-absorbable sutures or patches. In order to allow menstruation to pass normally, the cervix and navel will also be anastomosed; if the cervix cannot reach the navel, the patient will be asked to take short-acting contraceptives to temporarily suppress menstruation and avoid menstrual blood retention. Throughout the process, the doctor will use Doppler ultrasound or indocyanine green fluorescence angiography to monitor blood flow in real time to ensure that the uterus and ovaries are not ischemia. The ovarian arteries are the "lifeline" of the uterus after displacement and must be protected throughout the process. Step 2: "Relocation" after radiotherapy 5-6 weeks after the end of pelvic radiotherapy, the uterus and ovaries are returned to their pelvic positions through secondary minimally invasive surgery, and the uterine ligaments are reconnected with the cervix and vagina to restore normal pelvic anatomy. If the patient requires follow-up cancer surgery (such as rectal resection for rectal cancer), it can also be performed simultaneously to reduce the number of surgeries. Figure A (preoperative basic anatomy): show the normal anatomical position of the uterus, cervix, and appendages before pelvic radiotherapy, and clarify the initial relationship between the radiation field (pelvic area) and the reproductive organs; Figure B (pre-radiotherapy displacement): showing the state of the uterus and appendages being free and displaced to the upper abdomen (periumbilical area), marking the anastomosis structure between the cervix and the umbilical cord (for menstrual discharge); Figure C (protection during radiotherapy): shows that when pelvic radiotherapy is performed, the uterus and appendages avoid the radiation field because they are in the upper abdomen, clearly distinguishing between the "radiation area" and the "position of the displaced organ"; Figure D (reduction after radiotherapy): shows the normal anatomical recovery of the uterus and appendages after the uterus and appendages are returned to their pelvic position, the cervix and vagina are re-anastomosed, and the uterine ligament is repaired. This technology is still experimental and requires strict screening of patients: Age < 40 years old, with a clear intention to have children, and the reproductive organs are not directly invaded by the tumor; The scope of pelvic radiotherapy is limited to the lower abdomen or pelvis, and the upper abdomen is not in the radiation area (if the radiation needs to cover the liver, stomach and other areas, the uterus will still be exposed to radiation when it is "moved", which is not applicable); Normal ovarian reserve (assessed by anti-Müllerian hormone, antral follicle count) and uterine structure intact(No serious fibroids, adenomyosis and other problems affecting displacement); Normal blood supply to the ovarian artery without serious vascular disease. Patients with distant tumor metastasis, requiring radiotherapy of the uterus itself, or serious underlying diseases (such as heart disease, coagulation disorders) are not suitable for this surgery. 3. Real effect: The menstrual recovery rate is 100%, and some patients have successfully given birth As of publication, 47 cases of uterine transposition have been reported worldwide, with a median age of 29 years, mainly in cervical cancer (55.6%) and rectal cancer (35.6%), with encouraging short-term results: Good reproductive function protection Among the patients who survived surgery and completed reduction, 100% of the patients returned to regular menstruation after puberty, and 100% retained ovarian function. Even if one ovary enters the radiation zone or ischemic necrosis due to displacement in two patients, the other ovary can still maintain normal hormone levels. Successful pregnancy is not a dream 4 patients have become pregnant naturally and successfully gave birth to healthy babies (1 case planned cesarean section at 38 weeks, 3 cases were born prematurely at 36 weeks due to complications such as gestational hypertension and premature rupture of membranes), and the newborn was followed up for 6 months without abnormalities. However, there were also 2 patients who failed to try IVF after surgery, which may be related to insufficient endometrial receptivity (such as the endometrium is still thin after estrogen stimulation). Safety is controllable Among the 43 patients with complete follow-up data, 93% successfully completed the "moving" and "relocation"; Complications are mostly mild, such as cervical ischemia and stenosis (6 cases, which can be repaired by surgery), only 1 case of uterine necrosis needs to be removed, and 1 case dies due to tumor progression. Despite the initial results, uterine transposition still needs to be improved: Long-term effect is unknown: At present, the median follow-up of patients is only 21.5 months, and it is unclear whether the function of the uterus and ovaries will decline after 10 or 20 years, and there is a lack of long-term health data on offspring; Hidden dangers of vascular blood supply: After displacement, the uterus only relies on the ovarian artery to supply blood (normally, it relies on the uterus artery + ovarian artery to supply blood), which may lead to insufficient placental blood supply during pregnancy and increase the risk of fetal growth restriction (1 case has been reported); Technology is not standardized: surgical details (such as fixed position, suture selection) vary depending on the experience of the surgeon, and there is a lack of unified standards. For young pelvic cancer patients, uterine transposition is a "dawn". For the first time, it has achieved the goal of "curing cancer while preserving the ability to conceive", allowing patients to have the opportunity to conceive children in person after successfully fighting cancer. At present, this technology is still improving, and in the future, with the accumulation of more cases and long-term follow-up, it is expected to become an important choice for fertility protection for young patients. If you or someone around you is diagnosed with pelvic cancer and has the intention to have children, it is recommended to cooperate with gynecological oncologists and reproductive specialists as soon as possible to evaluate the desire to have children so that the desire to have children will not be "stolen" by cancer. ● References 1. Yue X, Pruemer JM, Hincapie AL, Almalki ZS, Guo JJ. Economic burden and treatment patterns of gynecologic cancers in the United States: evidence from the medical expenditure panel survey 2007-2014. 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