59J Gandhara Med Dent Sci
July - September 2025
:
:
SYSTEMATIC REVIEW
BORDERLINE OVARIAN TUMORS AND FERTILITY -PRESERVING SURGERY - A SYSTEMATIC
REVIEW
Sadia Shoukat, 1, Samah Abdalnoor2, Nadia Shoukat3
ABSTRACT
OBJECTIVES
This systematic review evaluates fertility-preserving surgery (FPS) outcomes
in borderline ovarian tumours (BOTs), focusing on reproductive success and
oncologic safety.
METHODOLOGY
We systematically searched PubMed, MEDLINE, ScienceDirect, Google
Scholar, the Cochrane Library, and ResearchGate (through September 14,
2024) using the terms "borderline ovarian tumour," "fertility-preserving
surgery," and "reproductive outcome." From 2,288 initial records, we
identified 10 high-quality (Newcastle-Ottawa Scale score ≥7) retrospective
cohort studies (January 2019- September 2024) that met our eligibility
criteria. The included English-language studies evaluated reproductive-aged
women (14-49 years) with borderline ovarian tumours undergoing fertility-
sparing surgery (cystectomy/USO). After excluding case reports, reviews,
non-peer-reviewed articles, and duplicate publications, two reviewers
independently extracted data, resolving discrepancies through consensus. We
conducted this systematic review in accordance with the PRISMA guidelines,
with registration on Prospero (Id: Crd420251042984).
RESULTS
Among 1051 patients, pooled pregnancy rates ranged from 42.1% to 57.1%.
Live birth rates varied widely (23-67%). Recurrence rates differed
significantly by surgical approach: 24.1–33.3% after cystectomy versus 2.5-
7.7% after USO. High-risk subgroups (advanced-stage/micropapillary
histology) had recurrence rates up to 70.8%. Complete surgical staging
reduced relapse risk by 21%, and ART did not increase recurrence. Bilateral
cystectomy and USO + contralateral cystectomy showed comparable fertility
outcomes. Malignant transformation was rare (0–20%), with no impact on
overall 5-year survival (97–100%).
CONCLUSION
FPS provides reasonable reproductive outcomes but requires careful patient
selection due to higher cystectomy-associated recurrence. Complete staging
and histologic assessment are crucial. Until stronger evidence exists, USO
with complete staging represents the most balanced option. Study limitations
include retrospective designs and heterogeneous follow-up. Prospective trials
with standardised protocols and long-term monitoring (at least 10 years) are
needed.
KEYWORDS: Reproductive Outcomes, Borderline Ovarian Tumours,
Fertility
How to cite this article
Shoukat S, Abdalnoor S, Shoukat N.
Borderline Ovarian Tumors And
Fertility-Preserving Surgery - A
Systematic Review. J Gandhara Med
Date of Submission: 03-03-2025
Date Revised: 27-05-2025
Date Acceptance: 05-06-2025
2Consultant and Senior Registrar
Gynecology and Obstetrics at Hanakiah
General Hospital KSA
3Post-Graduate Resident Liaquat
University, of Medical and Health
Sciences
Correspondence
1Sadia Shoukat, Consultant and Senior
Registrar Gynecology & Obstetrics
Department Suleman Roshan Medical
College Hospital, Tando Adam
+92-334-2041601
nadiashoukat2010@hotmail.com
INTRODUCTION
Borderline ovarian tumours (BOTs) are intermediate
neoplasms accounting for 10-20% of ovarian epithelial
tumours, primarily affecting fertility-age women. While
generally indolent with >95% 10-year survival
(especially in stage I, representing 50-85% of cases),
10-15% demonstrate aggressive behaviour with
malignant potential.1,3 This favourable prognosis
supports fertility-preserving approaches for early-stage
disease. Diagnosing BOTs preoperatively is difficult
since imaging cannot reliably differentiate them from
other ovarian tumours. While intraoperative
examination may suggest BOTs, histological
confirmation remains essential.4 For fertility-preserving
cases, balancing oncologic safety with reproductive
potential poses a key clinical challenge. Fertility-
preserving surgery (FPS) has emerged as the
cornerstone of treatment for young women with BOTs.5
FPS is defined as the preservation of the uterus and
ovarian tissue in one or both ovaries. The two primary
surgical approaches are unilateral ovarian cystectomy
(with or without contralateral ovarian
Dent Sci. 2025;12(3):59-66. https://doi.
org/10.37762/jgmds.12-3.699
60 J Gandhara Med Dent Sci
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Borderline Ovarian Tumors and Fertility - Preserving Surgery
biopsy/cystectomy) and unilateral salpingo-
oophorectomy (USO). In contrast, radical surgery
involves hysterectomy and bilateral salpingo-
oophorectomy (BSO). Since ovarian cystectomy
removes less ovarian tissue than adnexectomy, it offers
a higher likelihood of preserving fertility. However,
some studies suggest that bilateral cystectomy may be
associated with an increased recurrence rate due to the
potential presence of residual tumour cells. A
prospective randomised controlled trial by Palomba et
al. (2007) found no significant difference in outcomes
between bilateral cystectomy and USO with
contralateral cystectomy.6,8 FPS aims to reduce
recurrence while optimising pregnancy chances;
however, its effects on conception rates and live births
remain under investigation.9 Recurrence risks and their
impact on long-term fertility also warrant careful
consideration.10 Over the past decade, advancements in
surgical techniques, including laparoscopy and
improved perioperative care, have refined FPS
approaches for patients with BOT.11 Concurrently, there
has been growing interest in the role of assisted
reproductive technologies (ART) in optimising fertility
outcomes in this population.12 Despite these
developments, the literature on reproductive outcomes
following FPS for BOTs remains heterogeneous, with
varying definitions of fertility success and inconsistent
long-term follow-up data.13 Previous systematic reviews
have focused on recurrence rates, conservative
surgeries, and prognosis.5,14,26 Subsequently, more
recent reviews have addressed updates in laparoscopic
surgery, molecular advances, and the role of ultrasound
in BOT diagnosis.17,18,19 However, due to outdated
evidence and a lack of ART outcome data, an updated
systematic review is warranted to assess the role of FPS
in light of evolving surgical and reproductive
technologies. This systematic review aims to synthesise
recent evidence regarding reproductive outcomes
following FPS for BOTs, with a particular focus on
pregnancy success, live birth rates, ART utilisation, and
oncologic safety, by critically evaluating contemporary
data. This paper seeks to provide updated guidance for
clinical decision-making and identify key areas for
future research in this evolving field.
METHODOLOGY
This systematic review followed the PRISMA
(Preferred Reporting Items for Systematic Reviews and
Meta-Analyses) 2020 guidelines 20 and was
prospectively registered in the PROSPERO
international prospective register (Registration ID:
CRD420251042984). The relevant studies were
searched in electronic research literature databases and
research engines, including PubMed, PMC, the Medical
Literature Analysis and Retrieval System Online
(MEDLINE), ScienceDirect, Google Scholar, the
Multidisciplinary Digital Publishing Institute (MDPI),
the Cochrane Library, and ResearchGate. A
combination of keywords: Borderline ovarian tumour,
Fertility-preserving surgery, and Reproductive
outcome. For MEDLINE, PubMed, and PubMed
Central, the integrated Mesh (Medical Subject
Headings ) approach applied is as follows: ((Borderline
ovarian tumour OR borderline ovarian neoplasm OR
borderline ovarian cancer OR epithelial ovarian cancer
OR borderline serous ovarian cancer OR borderline
mucinous ovarian cancer OR ( "Ovarian
Neoplasms/classification"[Majr] OR "Ovarian
Neoplasms/complications"[Majr] OR "Ovarian
Neoplasms/surgery"[Majr] )) AND (Fertility-preserving
surgery OR fertility-preserving surgery OR fertility-
conserving surgery OR unilateral salpingo-
oophorectomy OR ovarian cystectomy OR "Salpingo-
oophorectomy/adverse effects"[Majr])) AND
(Reproductive outcome OR fertility outcome OR live
birth rate OR pregnancy outcome OR oncofertility OR
childbirth OR "Pregnancy Rate/trends"[Majr]). The
databases and keywords used, along with the papers
retrieved from each database, are presented in Table 1.
Figure 1: PRISMA flow chart.
PRISMA: Preferred Reporting Items for Systematic Reviews and
Meta-Analyses
The included studies involved female patients of
reproductive age (14-49 years) with histologically
confirmed borderline ovarian tumours who underwent
fertility-preserving surgery (either unilateral salpingo-
oophorectomy or ovarian cystectomy). The review was
limited to English-language publications from January
2019 to September 2024 due to both the need for
updated evidence synthesis (as previous systematic
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Borderline Ovarian Tumors and Fertility - Preserving Surgery
reviews lacked recent studies) and limited resources for
professional translation. In this study, mixed-methods
observational studies were included; however, no
randomised controlled trials or prospective studies that
met the criteria were identified during the search period.
The excluded papers were the following types of
publications to ensure methodological rigour: Review
articles, grey literature, and preprints (as these non-
peer-reviewed sources typically lack standardised
quality control mechanisms essential for reliable
evidence synthesis), Case reports and case series
(considered lower levels of evidence) and those Articles
whose full text could not be retrieved. A comprehensive
search was conducted across multiple electronic
databases, including PubMed, MDPI, ScienceDirect,
the Cochrane Library, and Google Scholar. While
Google Scholar was included to maximise search
sensitivity for emerging evidence, we restricted final
inclusion to peer-reviewed studies meeting our
predefined quality criteria, thereby ensuring reliable
results while minimising bias. The final search was
completed on September 14, 2024. supplemented these
database searches with a manual search of Research
Gate to identify additional relevant studies. Our search
strategy employed Boolean operators (AND/OR) to
optimise results. All retrieved records were imported
into EndNote software for systematic duplicate
removal, followed by manual screening to ensure the
complete elimination of redundant publications.
Figure 2: Quality Appraisal Using the Newcastle- Ottawa Scale for Retrospective Cohort Studies
Kumar
i S, et
al [22]
Lađević
I, et
al[23]
Ko M-
E, et
al[24]
Cang
W, et
al[25]
Kurt S,
et a[26]
Jia S-Z,
et al[27]
Ozenne
A, et
al[28]
Sobicze
wski P,
et al [29]
Johanse
n G, et
al[30]
Wang L,
et al[31]
Selection
Representativeness of the
exposed cohort
1 1 1 1 1 1 1 1 1 1
Selection of the non-
exposed cohort
0 0 0 0 0 0 0 0 0 0
Ascertainment of
exposure
1 1 1 1 1 1 1 1 1 1
Demonstration that
outcome of interest was
not present at the start of
the study
1 1 1 1 1 1 1 1 1 1
Comparability
Study controls for age 1 1 1 1 1 1 1 1 1 1
The study controls for
other factor
1 1 1 1 1 1 1 1 1 1
Outcome
Assessment of outcome 1 1 1 1 1 1 1 1 1 1
Was follow-up long
enough for outcomes to
occur
1 1 1 1 1 1 1 1 1 1
Adequacy of follow-up of
cohorts
1 1 1 1 1 1 1 1 1 1
Total 8 8 8 8 8 8 8 8 8 8
To ensure methodological quality and minimise bias,
critically appraised all included studies using the
Newcastle-Ottawa Scale for retrospective cohort
studies.21 Only medium- and high-quality studies were
selected for final analysis. Two independent reviewers
conducted study screening, data extraction, and
interpretation. Any discrepancies in eligibility
judgments or findings were resolved through
consensus-based discussion.
A total of 2,288 articles were identified from the
following databases: 389 from PubMed, PubMed
Central, and MEDLINE; 567 from Science Direct;
1,330 from Google Scholar; and one article each from
MDPI and the Cochrane Library. After removing 158
duplicates, the remaining 2,130 papers were screened.
Using automated filters (limiting to English-language
articles published within the last five years, human
studies, and original research), 1,658 papers were
excluded. Manual title screening excluded an additional
420 articles. Of the 52 papers that met the initial
eligibility criteria, 21 were excluded as irrelevant after
reviewing the abstracts, and the full text could not be
retrieved for 29 others. Through manual hand
searching, two additional articles were identified and
included from ResearchGate. Reapplying the eligibility
criteria to the remaining 25 articles resulted in the
each study, as determined by the Newcastle-Ottawa
quality assessment scale for retrospective cohort
studies, are listed below in Figure 2.
exclusion of 15 papers: four preprints, four case reports,
one case series, four conference presentations or
posters, and two that failed to meet the inclusion
criteria. Following the PRISMA 2020 guidelines, the
final selection comprised 10 retrospective cohort
studies, all of which demonstrated strong quality
appraisal scores on the Newcastle-Ottawa scale for
retrospective cohort studies. The specific scores for
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Borderline Ovarian Tumors and Fertility - Preserving Surgery
The analysis incorporated 10 retrospective studies with
cohort sizes ranging from 32 to 213 patients. The
geographic distribution included 6 Asian studies (India,
China, Taiwan, and Turkey) and 4 European studies
(Serbia, France, Poland, and Sweden). Populations
covered early-stage (7 studies), advanced-stage (2
studies), and bilateral/recurrent tumours (3 studies).
Key cohorts included Wei Cang’s advanced serous
BOTs and Wang’s second fertility-sparing
interventions. Two studies mandated complete staging
[14,29], one flagged micropapillary histology as high-
risk [29], and the Francogyn multicenter study
enhanced generalizability despite most studies being
single-centre.
BOT:Borderline Ovarian Tumor,FPS: Fertility-Preserving Surgery, RS: Radical Surgery (Hysterectomy + Bilateral Salpingo-oophorectomy),
Study
(Author,
Year)
Countr
y
Sample Size Age
Range
(Years)
Type of FPS Pregnancy Rate Recurrence Rate Follow-up
Duration
Kumari et al.
2021
India 75 Median:
32
Cystectomy,
Oophorectomy
42.1% (8/19) 9.3% (higher with
cystectomy: 33.3%)
Median: 36
months
Lađević et al.
2022
Serbia 52 <40 USOE (57.8%),
Cystectomy
44.8% (13/29) 7.7% (FPS group
only)
Median: 68.5
months
Mu-EnKo et al .
Taiwan 71
(BOT)
18-45 USO (57.8%),
Cystectomy
57.1% (20/35) 11.3% (BOT) Median: 36.3
months
Cang et al.
2023
China 65 ≤45 USO + CC (31),
Bilatera Cystectomy(25)
48.6% (17/35) 70.8% (advanced-
stage SBOT)
Median DFS:
22.8 months
Kurt et al.
2024
Turkey 58 (FSS
group)
NR Cystectomy, USO 36% (21/58: 18
spontaneous, 3 ART)
24.1% (vs. 2.5%
in non-FSS)
NR
Jia et al.
2020
China 110 NR UAC (unilateral
adnexectomy +
cystectomy), BOC
47% (24
spontaneous, 3 IVF)
65% (highest in
UAC: 84%)
Median: 64
months
Ozenne et al.
2022
France 175 NR NR 67% (majority
spontaneous)
20% (higher if age
<35,MP component
Median: 29.5
months to
recurrence
Sobiczewski
et al. 2022
Poland 110 Reprodu
ctive age
Laparoscopy/laparo
tomy.(Cystectomy/a
dnexectomy)
50.9% (56/110) PFS: 78.2% at 5
years
NR
Johansen et al.
2021
Swede
n
213 Fertile
age
USOE (86%),
Cystectomy (14%)
23% (50/213; 84%
spontaneous)
NR Mean: 58–76
months
Wang et al.
2022
China 32
(attempted
conception)
NR USO,
Oophorocystectomy
46.9% (15/32) 31.9% (vs. 6.5%
after RS)
Median: 18
months to
pregnancy
2023
RESULTS
Table 1: Summary of characteristics of each study.
Table 2: Reproductive and Oncologic Outcomes of FPS for BOTs.
Author Year of Study Reproductive outcome Oncologic Outcome
Kumari et al.
2021
Pregnancy rate: 42.1% (8/19)
- Median time to menses: 1 month
Recurrence rate: 9.3% (higher after cystectomy: 33.3%)
- OS: 98.7%
Lađević et al.
2022
- Pregnancy rate: 44.8% (13/29)
- 93.7% spontaneous pregnancies
Recurrence rate: 7.7% (FSS only)
- OS: 100%
Mu-EnKo et al.
2023
Pregnancy rate (BOT): 57.1% (20/35)
- Median time to conception: 39 months
Recurrence rate (BOT): 11.3%
- Malignant transformation: 1 case
Cang et al.
2023
Pregnancy rate: 48.6% (17/35)
- 5 ART live births
Recurrence rate: 70.8% (advanced-stage SBOT)
- 5-yr OS: 97%
Kurt et al.
2024
Pregnancy rate: 36% (21/58)
- 12 live births
Recurrence rate: 24.1% (vs. 2.5% in non-FPS)
- Higher after cystectomy
Jia et al.
2020
Pregnancy rate: 47% (24 spontaneous + 3 IVF)
- 19 live births
Recurrence rate: 65% (highest after UAC: 84%)
- Invasive recurrence: 15%
Ozenne et al.
2022
Pregnancy rate: 67% (majority spontaneous)
- 51% live births
Recurrence rate: 20%
- Risk factors: age <35, MP component, advanced stage
Sobiczewski et al.
2022
Pregnancy rate: 50.9% (56/110)
- 83 children born
PFS: 78.2% at 5 yrs
- All recurrences borderline (no invasive)
Johansen et al.
2021
Live birth rate: 23% (50/213)
- 84% spontaneous
5-yr OS: 98% (FPS)
- 3 deaths (mucinous BOT with malignant recurrence)
Wang et al.
2022
Pregnancy rate: 46.9% (15/32)
- Live birth rate: 81.3%
Recurrence rate: 31.9% (vs. 6.5% after RS)
- USO safer than cystectomy
USO/USOE: Unilateral Salpingo-oophorectomy, CC: Contralateral Cystectomy, BOC: Bilateral Ovarian Cystectomy, UAC: Unilateral
Adnexectomy + Contralateral Cystectomy
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Borderline Ovarian Tumors and Fertility - Preserving Surgery
DISCUSSION
The systematic review of reproductive outcomes in
patients with BOTs undergoing FPS highlights several
critical aspects, including oncologic safety, recurrence
rates, and reproductive success. The included studies
collectively provide a comprehensive overview of the
outcomes, enabling a detailed comparison across
different populations, surgical approaches, and follow-
up durations.
Recurrence Rates:
Recurrence rates in BOTs demonstrate considerable
variability, which can be attributed to differences in
study design, patient demographics, surgical
approaches, and follow-up durations. While some
studies report relatively low recurrence rates, others
indicate significantly higher risks, particularly in
specific subgroups. Kumari et al. (2023) observed a
recurrence rate of 9.3%, with a stark contrast between
cystectomy (33.3%) and oophorectomy (6.2%).32 This
discrepancy raises important questions about the
appropriateness of cystectomy in patients desiring
fertility preservation, as the substantially higher
recurrence risk may outweigh its benefits. Similarly,
Lađević et al. (2022) reported a 7.7% recurrence rate in
fertility-preserving surgery (FPS) cases, with no
recurrences in radical surgery groups.23 These findings
suggest that while FPS is feasible, it may compromise
Author and
year of
study
Study
period
and
country
Age of
patients
Sample
size
Tumor
stage and
recurrence
Type of fertility-
preserving surgery
Tried for
pregnancy
Live
birth
Abortion Use of
art
Mu-EnKo et
al.
2023
2007 -
2022
Taiwan
19–44
years
Total
sample
size (244)
patients
with BOT
(71)
IA to IC
11%
Unilateral salpingo-
oophorectomy
35 23 3 1
Kumari et
al.
2021
2014-
2019
India
18–45
years
120
patients
I to III
Recurrence
rate: 9.3%
Cystectomy, Unilateral
salpingo-
oophorectomy
42 23 5 3
Cang et al.
2023
1999-
2021
china
<_45
years
65 II – III
Unilateral salpingo-
oophorectomy and
contralateral
cystectomy
35 15 1
12
Ozenne et
al.
2022
1997-
2020
France
>_18
years
BOT 175 I to IV
17.7 %
Unilateral cystectomy,
Unilateral
ovariectomy, Bilateral
cystectomy,
Cystectomy +
contralateral
ovariectomy
45 23 0 5
Sobiczewski
et al.
2022
1994-
2010
Poland
17 – 40
years
110 Stage I–III;
Recurrence
rate: Not
specified
Cystectomy,
Cystectomy +
contralateral
adnexectomy
83 62 10 20
Wang et al.
2022
2009 –
2020
China
18–45
years
BOT (78) Stage I–III;
Recurrence
rate: Not
specified
Unilateral salpingo-
oophorectomy
32 20 3 6
Jia et al.
2020
1999-
2019
China
<_40
years
old
BOT 94 I to III
Recurrence
UAC 84%
BOC 67%
Unilateral
adnexectomy +
contralateral
cystectomy (UAC),
Bilateral ovarian
cystectomy (BOC)
UAC: 31
patients,
BOC: 48
patients
UAC:
15 live
births,
BOC:
28 live
births
UAC: 5
abortions,
BOC: 14
abortions
UAC:
3 Patien
ts, BOC:
3 Patien
ts used
ART
Kurt et al.
2024
2001 –
2020
turkey
18–45
years
80 Stage I–III;
Recurrence
rate: 24.1%
Cystectomy, Unilateral
salpingo-
oophorectomy
32 18 4 5
Lađević et
al.
2022
2010-
2019
Serbia
18-40
years
52
FPS 45
Stage I
Recurrence
7.7%
Unilateral
salpingooophrectomy
29 16 2 1
Johansen et
al.
2021
2008-
2015
Sweden
18-
40years
277
FPS 213
Stage I -III;
Recurrence
rate: Not
specified
Unilateral salpingo-
oophorectomy 183
cystectomy 30
62 40 5 15
Table 3: Summary and comparison of each study
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Borderline Ovarian Tumors and Fertility - Preserving Surgery
excellent (97-100%) across all studies.23,25,31,32
Pregnancy Rates:
Fertility-preserving surgery for borderline ovarian
tumours shows variable pregnancy rates (42.1-57.1%)
across studies. Kumari et al. reported a pregnancy rate
of 42.1%, while Lađević et al. observed a slightly
higher rate of 44.8%.23,32 Ko et al. found that 57.1% of
BOT patients achieved pregnancy, with higher rates in
those without prior childbirth (82.4%).24 Cang et al.
reported a pregnancy rate of 48.6% in patients with
advanced-stage serous BOTs, with 12 patients
achieving pregnancy through assisted reproductive
technology (ART).25 Sobiczewski et al. noted a
successful pregnancy rate of 50.9%, with the majority
of pregnancies occurring spontaneously.30 While these
results are encouraging, they should not be viewed in
isolation, as they are subject to significant variability
across studies and must be balanced against the
elevated recurrence risks associated with micropapillary
and advanced-stage disease.
Impact of Surgical Approach
The choice of fertility-preserving procedure
significantly affected both oncologic and reproductive
outcomes. Consistent with previous findings,
cystectomy demonstrated higher recurrence rates than
oophorectomy.27,32 Notably, Jia et al. reported a 67%
relapse rate for bilateral ovarian cystectomy (BOC)
versus 84% for unilateral adnexectomy with
contralateral cystectomy (UAC), though pregnancy
rates were similar between approaches.28 For recurrent
cases requiring a second FPS, unilateral salpingo-
oophorectomy (USO) has shown superior oncologic
safety and fertility preservation compared to
oophorocystectomy.32
Role of Assisted Reproductive Technology (ART)
ART played a significant role in achieving pregnancy in
several studies. Ko et al. reported that only one BOT
patient and three EOC patients required assisted
reproductive technology (ART), while Cang et al. noted
that 12 patients achieved pregnancy through ART.24,25.
Sobiczewski et al. observed that only one patient
achieved pregnancy through ART, suggesting that
spontaneous conception is the primary mode of
achieving pregnancy after FPS.30 These findings
highlight the potential role of ART in supporting
fertility preservation, particularly in patients with
persistent infertility.
Long-Term Follow-Up
Studies consistently highlighted late recurrence risks,
necessitating long-term follow-up. Kumari et al.
reported median recurrence at 35 months (some >5
years), while Lađević et al. found most recurrences
within 3 years.32,23 In contrast, Cang et al. reported a
median disease-free survival (DFS) of 22.8 months,
with recurrences occurring beyond 3 years.25 Our
review confirms Wang and Fang‘s findings of lower
recurrence rates with salpingo-oophorectomy while
adding new ART outcome data (5-20% pregnancy
rates) and showing that complete surgical staging
reduces relapse by 21%, thereby strengthening the
evidence for fertility-preserving approaches.14
long-term oncologic safety, necessitating thorough
patient counselling.
However, the most alarming recurrence rates were
reported by Cang et al. (2021), with 70.8% in
advanced-stage serous BOTs.25 This exceptionally high
rate challenges the conventional perception of BOTs as
indolent tumours, particularly in advanced stages. The
study underscores the aggressive potential of certain
histologic subtypes (e.g., micropapillary patterns) and
reinforces the need for tailored surgical strategies in
high-risk cases. Kurt et al. (2020) further supported this
notion, demonstrating a significantly higher recurrence
rate in FPS groups (24.1%) compared to non-FPS
groups (2.5%).27 Collectively, these findings highlight a
critical trade-off between fertility preservation and
oncologic outcomes, emphasising the necessity of
individualised risk assessment.
Several risk factors for recurrence were consistently
identified, including younger age (<35 years),
nulliparity, advanced FIGO stage, micropapillary
histology, and incomplete surgical staging.23,25,29,32 The
study by Ozenne et al. (2021) provided compelling
evidence that initial complete peritoneal staging (ICPS)
significantly reduces the recurrence risk (25% in the
ICPS group vs. 46% in the non-ICPS group).29 This
reinforces the argument that comprehensive surgical
staging should be prioritised, even in presumed early-
stage disease, to minimise recurrence risk.
Malignant Transformation:
Malignant transformation was rare but clinically
significant. While Kumari et al. reported no cases, Cang
et al.32 observed invasive recurrence in 20% of patients
(including low-grade serous ovarian carcinoma).25
Johansen et al. documented three fatal mucinous cancer
recurrences post-FPS, underscoring mucinous histology
risks.31 Notably, overall survival rates remained
Clinical Recommendations
Based on this review, we propose the following:
Patient Selection:
FPS is suitable for FIGO I BOTs in fertility-desiring
patients (pregnancy rates: 23–67%) and avoids high-
risk cases (micropapillary histology, FIGO II–III,
mucinous subtypes) due to increased
recurrence/malignant transformation
Surgical Approach:
Preferred: USO for unilateral tumours (recurrence: 7.7–
24.1%). Alternative: Cystectomy if
bilateral/conservation needed (higher recurrence: 28.5–
84%) and Staging reduces recurrence (7.7% vs 46%)
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Borderline Ovarian Tumors and Fertility - Preserving Surgery
ART & Recurrence:
ART is safe post-FPS. For recurrences: Repeat FPS
achieves 46.9% pregnancy rates (USO preferred)
Follow Up:
Monitor ≥10 years (peak recurrence risk: first 3 years)
LIMITATIONS
No randomised controlled trials were identified on this
topic, and the full texts of many potentially relevant
articles could not be retrieved, leading to their
exclusion. All included studies were retrospective in
design, increasing the risk of bias. The potential for
self-reporting and publication bias should also not be
disregarded. Furthermore, only English-language
articles were included. The studies in this review had
several limitations, including retrospective designs,
small sample sizes, variable follow-up durations, and
inconsistent definitions of surgical techniques. These
factors may introduce selection bias and limit the
generalizability of the findings. Additionally, some
studies used marital status as a proxy for pregnancy
desire [19,24], which may not accurately reflect
patients' actual attempts to conceive. Given these
limitations, the results should be interpreted with
caution, and further high-quality prospective research is
needed.
CONCLUSIONS
This systematic review highlights key trade-offs in FPS
for BOTs. While pregnancy rates range from 42.1% to
67%, outcomes vary substantially by approach:
unilateral salpingo-oophorectomy (USO) demonstrates
lower recurrence rates (7.7-24.1%) compared to
cystectomy (28.5-84%), with bilateral cystectomy
offering intermediate results. Complete surgical staging
halves recurrence risk (7.7% vs 46%), and
micropapillary/advanced-stage disease carries
particularly high relapse rates (70.8%). Three research
priorities emerge: RCTs comparing USO and
cystectomy techniques, Long-term (>10-year)
reproductive and oncologic registries, and Biomarker
studies for recurrence prediction. Until stronger
evidence exists, USO with complete staging represents
the most balanced option, requiring thorough
counselling about residual uncertainties.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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Sadia Shoukat - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Critical
Revision; Supervision; Final Approval
Samah Abdalnoor - Concept & Design; Data Acquisition;
Data Analysis/Interpretation; Drafting Manuscript; Final
Nadia Shoukat - Concept & Design; Data Acquisition;
Approval
Drafting Manuscript; Final Approval
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