NOVEL CASE OF TRANSVAGINAL OOCYTE RETRIEVAL FOLLOWING OVARIAN TRANSPOSITION AND REVERSAL IN A PATIENT WITH RECURRENT RECTAL CANCER.

Ovarian transposition is a common procedure for reproductive age women prior to pelvic radiation. For women who seek in vitro fertilization following ovarian transposition, abdominal retrieval is required for egg retrieval. However, many reported cases utilizing abdominal retrieval for fertility preservation report low oocyte yield. Yet, reversal of ovarian transposition is not typically performed and it is unclear if there are additional safety concerns with transvaginal oocyte retrieval once the ovarian pedicles have been mobilized for transposition. Herein, we report a novel case of oocyte retrieval following ovarian transposition and reversal in an oncofertility patient. Case report of a 37-year-old G0P0 with recurrent rectal adenocarcinoma and history of bilateral salpingectomy, and ovarian transposition who desires egg banking for fertility preservation prior to chemotherapy, robotic left anterior rectum resection and loop ileostomy. She had no prior radiation exposure. Her transposed ovaries were not visible on transvaginal ultrasound. Abdominal imaging showed the right ovary in lateral position above the right iliac crest with an antral follicle count (AFC) of 6 and the left ovary medial and inferior to the iliac spine with an AFC of 2. Her AMH was 3.228. The patient was counseled regarding possibility of low oocyte yield due to her current medical condition, suboptimal view of the ovaries transabdominally with lower-than-expected AFC for her AMH. She elected to have her ovaries released robotically from the abdominal wall by gynecologic oncology at the time of debulking surgery for her recurrent rectal cancer. The released ovaries were sutured bilaterally to the pelvic side wall peritoneum to ensure ovarian stability. The patient proceeded with ovarian stimulation five weeks following her ovarian transposition release procedure using straight start with antagonist protocol and 250 IU of Gonal-F to start. Transvaginal ultrasound following surgery demonstrated excellent visualization of the ovaries in the pelvis. AFC was 18 at the beginning of ovarian stimulation. Ovarian stimulation required 11 days and the patient required a total of 2750 IU of Gonal-F and 450 IU of Menopur. She was triggered with Lupron and 1000 IU of hCG with 18 follicles between 12 mm to 21 mm. A total of 15 oocytes were retrieved, 12 were MII and cryopreserved. The remaining three oocytes included one MI, one germinal vesicle, and one empty cumulus. The patient did well post operatively and did not have any complications. One concern with release of the ovarian pedicles during transposition reversal is hypermobility of the ovaries precluding safe transvaginal oocyte retrieval. We demonstrate that this procedure can be done safely with attention to suturing of the ovaries to the pelvic side wall at the time of reversal that resulted in a good outcome for this patient.