Developing an Algorithm for Ovarian Preservation

Saving Mary’s Ovary

The sharp abdominal pain Mary* felt didn’t compare to anything she had experienced with her monthly periods. At the time Mary was admitted to Nationwide Children’s, she had worsening symptoms of sharp abdominal pain and vomiting.

A computed tomography (CT) scan suggested appendicitis and ovarian masses, suggestive of benign dermoid cysts on both ovaries. The problem wasn’t her appendix, however. When the surgeons took her into surgery, they discovered that her right fallopian tube and ovary were twisted, or torsed, blocking the blood supply and causing both to be markedly enlarged. Her appendix and left fallopian tube and ovary were normal.

In surgery, the surgeons were able to untwist her right ovary and fallopian tube, but the ovary was so inflamed and enlarged that the masses could not immediately be removed. A second surgery was scheduled.

Because of the number of cysts and their size, Mary’s mother, Amy*, worried her 16-year-old daughter might lose the ovary. “Remember, those are my future grandchildren in there,” she said to hospital staff before the second surgery.

Amy’s concern for her daughter’s future fertility is shared by the surgeons at Nationwide Children's.

“My personal goal is that fewer ovaries are removed in this hospital because of benign disease,” says Dr. Hewitt. “In our department, we’re dedicated to improving lives and reproductive outcomes for girls and young women, and ovarian preservation is part of that.”

*names have been changed to protect the patient’s privacy

Developing an Algorithm for Ovarian Preservation

Fueled by her passion, Dr. Hewitt, in collaboration with co-directors of the Surgical Oncology Clinic Jennifer H. Aldrink, MD, pediatric surgeon, and Mark A. Ranalli, MD, oncologist, developed an algorithm for ovary preservation. This algorithm is in place hospital-wide as a way to provide a protocol for preoperative assessment of risk of malignancy.

The algorithm has been implemented as part of a quality improvement project, and the results are currently being tracked.

“In some circumstances, the ovary would have been removed immediately in that first surgery,” says Dr. Hewitt. “Because we worked so closely with pediatric surgery, we were able to work collaboratively when the intraoperative findings were different than what was anticipated — together we were able to address the acute surgical emergency by untwisting the tube and ovary, saving both of them.”

Additionally, at the second operation, the surgeons were able to perform ovarian sparing surgery to remove the three dermoid cysts and leave intact the healthy remaining ovary and fallopian tube. Today, the patient has her full complement of reproductive organs she was born with, minus of course, the three dermoid cysts.

"Research has shown that ovarian preservation is higher in institutions with a department of gynecology. This initiative is likely one example of why this is true. We have experts from three departments working together to develop and implement an algorithm to save the fertility of young girls. This is a venture we can be proud of." - R. Lawrence Moss, MD, Surgeon-in-Chief

Ovarian cysts are not unusual, but the size and number of cysts in Mary’s ovary were. And although the surgery to remove the cysts was complicated by how extensive the cysts were, in the end, the ovary was preserved.

“It’s [Mary’s] future and her ability to have children,” Amy said weeks after the second surgery. “I don’t think at this age, you want to limit those likelihoods.”