# Oncological and Reproductive Outcomes of a Standardized Hysteroscopic Approach for the Fertility-Sparing Treatment of Atypical Endometrial Hyperplasia and Early-Stage Endometrial Cancer

## TL;DR

A standardized hysteroscopic approach combined with progestin therapy effectively treats early-stage endometrial cancer and hyperplasia while preserving fertility.

## Contribution

This study introduces a standardized hysteroscopic fertility-sparing treatment protocol with demonstrated oncological and reproductive efficacy.

## Key findings

- High complete response rates (94.9% AEH, 98.2% EC) were achieved with the standardized hysteroscopic approach.
- Age ≥ 35 years was the main factor associated with reduced treatment response and increased relapse risk.
- Live birth rates exceeded 50% among patients who conceived, showing favorable reproductive outcomes.

## Abstract

Fertility-sparing treatment (FST) is increasingly offered to young women with atypical endometrial hyperplasia (AEH) and early-stage endometrial cancer (EC) who wish to preserve their reproductive potential. However, the surgical approach to the conservative management of these patients has historically lacked standardization. In this study, we evaluated oncological and reproductive outcomes of women who underwent tailored hysteroscopic treatment, combined with progestin therapy. We found high rates of disease regression and favorable pregnancy outcomes in both AEH and early-stage EC, without significant differences between groups. Age emerged as the main factor influencing treatment response and recurrence, whereas lesion severity did not affect outcomes when hysteroscopic removal was adequately performed. These findings support the central role of adequate and standardized hysteroscopic surgery as a key element of FST and highlight its potential to preserve fertility without compromising oncologic safety when applied in specialized centers.

Background/Objectives: Fertility-sparing treatment (FST) is an accepted option for selected women with atypical endometrial hyperplasia (AEH) and early-stage endometrioid endometrial cancer (EC). While combined progestin therapy and hysteroscopic approaches yield the best outcomes, the surgical component has long lacked standardization. This study aimed to evaluate oncological and reproductive outcomes following a standardized hysteroscopic fertility-sparing approach. Methods: This retrospective single-center study included women of reproductive age diagnosed with AEH or grade 1–2 endometrioid EC between 2021 and 2024 at the Digital Hysteroscopic Clinic CLASS Hysteroscopy, Fondazione Policlinico A. Gemelli IRCCS, Rome. All patients were treated using a standardized hysteroscopic approach based on lesion type and disease extension, combined with progestin therapy. Oncological outcomes included complete response (CR), time to CR and recurrence. Reproductive outcomes included the clinical pregnancy rate (CPR), live birth rate (LBR), and miscarriage rate (MR). Multivariate analysis was performed to identify factors associated with CR and relapse. Results: A total of 138 patients were included (79 AEH, 59 EC). CR rates were high and comparable between AEH (94.9%) and EC (98.2%), with a median time to response of 6 months. Recurrence rates did not differ significantly between groups (16.7% AEH vs. 26.8% EC). CPR was similar (47.5% AEH vs. 54.8% EC), with LBR exceeding 50% among women who conceived. Multivariate analysis identified age ≥ 35 years as the only factor associated with reduced response and increased relapse risk. Conclusions: A standardized hysteroscopic fertility-sparing approach combined with progestin therapy provides excellent oncologic control and favorable reproductive outcomes. Lesion severity did not affect outcomes when hysteroscopic removal was adequately performed, while patient age remains a key determinant of outcomes.