Fertility Preservation: Current Options

Introduction

Indications

1. Oncological - hematological malignancies (leukemia, lymphoma), breast cancer, gynecological cancers (cervical, ovarian, endometrial), sarcomas, CNS tumors requiring craniospinal radiation.
2. Non-oncological medical conditions - systemic lupus erythematosus and other autoimmune diseases requiring cyclophosphamide, bone marrow failure syndromes needing hematopoietic stem cell transplant conditioning, sickle cell disease, gender-affirming hormone therapy/surgery, and benign conditions requiring bilateral oophorectomy or hysterectomy (e.g., severe endometriosis, BRCA-related risk-reducing surgery).
3. Age-related/elective - social oocyte cryopreservation for women delaying childbearing.

Pre-treatment counseling and risk stratification

• Type, dose, and duration of planned chemotherapy/radiotherapy (gonadotoxicity risk: high/intermediate/low)
• Time available before treatment must start
• Age and baseline ovarian reserve (AMH, antral follicle count)
• Partner status, pubertal status (pre- vs post-pubertal), and patient preference
• Feasibility of ovarian stimulation without delaying cancer treatment or worsening hormone-sensitive disease

Current Options in Females

A. Established/standard methods

• The only option for pre-pubertal girls, who cannot undergo ovarian stimulation
• Useful when chemotherapy must start immediately and there is no time for stimulation
• Capable of restoring both fertility and endocrine ovarian function after transplantation

B. Emerging/newer methods

C. Fertility-sparing surgical/medical treatment of the primary disease

• Radical trachelectomy instead of radical hysterectomy for early-stage cervical cancer
• Progestin therapy (e.g., megestrol acetate, levonorgestrel IUS) instead of hysterectomy for early, well-differentiated endometrial cancer in young women desiring fertility
• Unilateral salpingo-oophorectomy with uterine preservation for early-stage, unilateral ovarian tumors (especially germ cell tumors and borderline tumors)

Current Options in Males (for completeness in a couple relationship)

• Sperm cryopreservation remains the standard, simple, and highly effective method, performed prior to any gonadotoxic treatment.
• Testicular sperm extraction (TESE) is now recognized (2025 ASCO update) as a standard-of-care option for men unable to produce an ejaculated sample.
• Testicular tissue cryopreservation for pre-pubertal boys remains experimental, analogous to ovarian tissue cryopreservation in girls.

Special considerations

• Pediatric/pre-pubertal patients: Ovarian and testicular tissue cryopreservation are the only viable options since gonadal stimulation and mature gamete retrieval are not possible.
• Hormone-sensitive cancers (e.g., ER-positive breast cancer): Letrozole or tamoxifen-based stimulation protocols are used to minimize supraphysiological estradiol exposure during oocyte/embryo cryopreservation cycles.
• Time-sensitive cases: Random-start ovarian stimulation, IVM, or ovarian tissue cryopreservation are used when treatment cannot be delayed.
• Survivorship: ASCO 2025 explicitly extends fertility preservation counseling into survivorship, recognizing that many patients were not offered preservation at diagnosis or wish to explore family-building options after remission.

Outcomes and evidence

Barriers to access

Conclusion

WHO Labour Care Guide (LCG) 2021 - Short Notes (MS OBG)

Introduction

Why it replaced the partograph

• The classical partograph used a fixed "alert line" and "action line" (based on 1-cm/hour cervical dilatation from onset of active labour), which is now known to be too rigid - normal labour progress is often slower, especially early in the active phase, and this rigidity led to unnecessary augmentation and caesarean sections.
• The partograph focused almost entirely on cervical dilatation and fetal descent, neglecting maternal wellbeing, pain relief, and companionship.
• Evidence (including the Zhang's guideline vs WHO partograph LaPS trial) showed better labour curves needed to be dynamic, not static.

Key design features

1. No diagonal alert/action lines. Instead, dilatation is plotted against time, and expected time limits for each centimetre of dilatation (based on 95th centile duration in women with normal outcomes) trigger a documented clinical response when exceeded, rather than an automatic diagnosis of "abnormal labour."
2. One-page, single-sheet design starting from 5 cm cervical dilatation (diagnosis of active first stage of labour), used through second stage.
3. Holistic, woman-centred monitoring - integrates maternal and fetal parameters with supportive care indicators on the same chart.

Sections/Parameters monitored (mnemonic-friendly grouping)

• Companion of choice present
• Pain relief method
• Oral fluid/food intake
• Position/mobility
• Vaginal examination consent
• Emotional wellbeing/summary of concerns discussed with woman

• Fetal heart rate (recorded at least every 30 min in first stage)
• FHR decelerations - N (none), E (early), L (late), V (variable)
• Amniotic fluid colour - I (intact), C (clear), M (meconium, graded +/++/+++), B (blood-stained), A (absent)
• Fetal position - occiput anterior (A), posterior (P), transverse (T)
• Caput and moulding

• Cervical dilatation (plotted against time from diagnosis of active labour at 5 cm)
• Descent of fetal head (in fifths palpable per abdomen, or station)
• Uterine contractions - frequency per 10 minutes and duration

• Pulse, blood pressure, temperature
• Urine - protein, acetone, volume
• Oxytocin use (dose, drops/min) if augmented
• Drugs given, IV fluids

Definition of active labour

Clinical response requirement

Advantages over partograph

• Encourages respectful maternity care - continuous companionship, pain relief, nutrition, and emotional support are formally tracked, not just labour mechanics
• Reduces unnecessary augmentation/caesarean delivery driven by rigid alert-action lines
• Single integrated chart improves usability and reduces charting burden
• Applicable across levels of care and resource settings

Implementation challenges

• Requires retraining of existing staff familiar with the partograph
• Staffing shortages and infrastructure gaps in low-resource settings make continuous companionship and 30-minute FHR monitoring difficult
• Recommended gradual, phased rollout with pilot testing, audits, and context-specific adaptation rather than abrupt replacement of the partograph.

Key reference points for exam

• WHO Labour Care Guide: user's manual, WHO, Geneva (2020/2021)
• Based on WHO recommendations: Intrapartum care for a positive childbirth experience (2018)
• FIGO (2024/25) has endorsed LCG as the new global standard for monitoring childbirth, while acknowledging that it retains the core principle of tracking cervical dilatation and descent, but with dynamic, evidence-based time limits instead of static alert/action lines.

Fluid Management in Labour - MS OBG Short Notes

Introduction

Physiological rationale

• Labour is energy-intensive; prolonged fasting can cause maternal ketosis, dehydration, and exhaustion, which may prolong labour.
• Traditional restriction of oral intake arose from fear of pulmonary aspiration (Mendelson syndrome) if general anaesthesia were needed - now less relevant given modern regional anaesthesia use and airway management.
• Both under-hydration (ketosis, longer labour) and over-hydration (maternal/neonatal hyponatremia, fluid overload) carry risk - fluid balance must be actively monitored, not just liberally given.

Oral fluids

• WHO and most current bodies advise against routine restriction of oral fluids/light food in low-risk labouring women; restriction has no proven benefit on labour outcomes and can cause dehydration/exhaustion.
• Women should be encouraged to drink and eat light food as desired if at low risk of needing general anaesthesia.
• Women should record their own oral intake and voiding at least every 4 hours (per NICE NG235 recommendations on fluid balance).

Intravenous fluids

• Induction/augmentation of labour (oxytocin infusion requires IV access)
• Epidural/regional analgesia (co-loading to prevent hypotension)
• Prolonged labour, ketosis, or inability to tolerate oral intake
• High-risk labour (anticipated hemorrhage, operative delivery, pre-eclampsia)
• Poor oral intake, vomiting, or clinical dehydration

• Commonly used rate in oral-restricted patients: 125 mL/hr vs 250 mL/hr - a 2024 systematic review/meta-analysis (PMID 37855398) compared these rates in nulliparas; higher rate (250 mL/hr) has been associated with shorter duration of labour in several RCTs, though effect on Cesarean rate is less consistent.
• Dextrose-containing isotonic fluids (e.g., 5% dextrose in normal saline or Ringer's lactate with dextrose) are often preferred over plain non-dextrose crystalloids to reduce ketosis, though excess free water/dextrose solutions increase hyponatremia risk if given in large volumes.
• Avoid large volumes of hypotonic fluids (e.g., large amounts of 5% dextrose in water) - linked to maternal and neonatal hyponatremia.

Complications of fluid mismanagement

• Occurs with excessive IV fluid administration (especially hypotonic or large-volume dextrose solutions) combined with oxytocin (which has an antidiuretic effect at high doses).
• Can cause maternal seizures, cerebral oedema, and neonatal hyponatremia/seizures.
• NICE NG235 (2025 update) specifically addresses peripartum fluid balance and hyponatremia prevention - recommends fluid balance charting, monitoring oral and IV intake plus output (urine, vomitus), and vigilance for women drinking excessive fluid even in absence of thirst.

• Risk increases with prolonged oxytocin infusion, pre-eclampsia, or cardiac disease - cumulative fluid balance should be tracked especially in high-risk women.

• From prolonged fasting or inadequate replacement - associated with maternal exhaustion and possibly longer labour.

Practical monitoring recommendations (NICE NG235-aligned)

1. Explain the importance of fluid balance monitoring to all labouring women.
2. Maintain a fluid balance chart, especially during induction/augmentation with oxytocin.
3. Encourage women to record their own oral intake and urine output at least 4-hourly.
4. Measure and record other losses (vomiting, blood loss).
5. Escalate fluid balance monitoring if there is any concern about intake or output (nausea, vomiting, diarrhea, inability to void).
6. Use isotonic, dextrose-containing solutions in preference to large volumes of hypotonic fluid when IV hydration is needed.

Special situations

• Induction of labour: A 2022 RCT (PMID 35114186) and a 2024 pilot RCT (PMID 38780492) examined liberal vs restricted IV fluid regimens during induction; findings suggest fluid regimen can influence time to delivery, but restriction/liberalization must be balanced against hyponatremia risk - no single universally adopted protocol yet.
• Epidural analgesia: routine large-volume IV pre-loading is no longer mandatory before every epidural; used selectively to prevent hypotension.
• Pre-eclampsia/cardiac disease: strict fluid restriction and hourly input-output charting mandatory due to risk of pulmonary oedema.

Conclusion