Fertility-Preserving Approaches for PAS

Hope for Fertility Preservation

Being diagnosed with Placenta Accreta Spectrum can feel overwhelming — especially when you are told that the standard treatment is a hysterectomy, a surgery that would end your ability to carry future pregnancies. If you are reading this page, you may be searching for hope. We want you to know: you are not alone, and there are alternatives.

The loss of fertility through hysterectomy is described in the medical literature as "a substantial, life-changing event" that can have profound psychological, social, and cultural impacts.30 We recognize that this decision touches on deeply personal values — your sense of identity, your family plans, your relationships — and we want to give you the most complete picture possible so you and your care team can make the best decision for your situation.

Over the past two decades, pioneering surgeons and researchers in France, the United Kingdom, Argentina, and Vietnam have developed different approaches that aim to treat PAS while preserving the uterus. Hundreds of women have been treated with these techniques, and many have gone on to have successful subsequent pregnancies. Notably, patient interest in uterine-preserving treatment has grown substantially over the last decade, driving more research and broader availability of these options.30

That said, the evidence base for fertility-preserving approaches is growing rapidly. Multiple large studies, including the first randomized controlled trial published in 2024, demonstrate that uterine preservation is feasible in the majority of PAS cases when performed by experienced surgeons. The key is to understand your options, find the right team, and make an informed decision together.

Overview of Fertility-Preserving Approaches

There are three main strategies for preserving the uterus in PAS. Each takes a fundamentally different approach to the problem of a placenta that has grown too deeply into the uterine wall:

Head-to-Head Comparison

Expectant Management (Leave Placenta In Situ)

Pioneered by: Prof. Loïc Sentilhes (Bordeaux University Hospital, France) and the French PACCRETA research network

How It Works

In expectant (also called "conservative") management, the baby is delivered by cesarean section, but the placenta is intentionally left in place. No attempt is made to separate or remove it. The umbilical cord is cut close to the placenta and the uterus is closed with the placenta still attached inside.

Over the following weeks to months, the placenta gradually breaks down and is reabsorbed by the body (a process called "resorption"). The median time for this is approximately 13.5 weeks, but it can range from 4 to 60 weeks. During this period, the patient requires intensive monitoring with regular ultrasounds, blood tests, and clinical visits to watch for complications such as infection, bleeding, or the need for delayed hysterectomy.

• At cesarean delivery, the baby is born but the placenta is left undisturbed
• The uterus is closed with the placenta still inside
• The placenta slowly resorbs over weeks to months
• Regular monitoring for infection, bleeding, and other complications
• Methotrexate was previously used to accelerate resorption, but is no longer recommended (ACOG, FIGO) due to lack of proven benefit and potential side effects

Key Evidence: The PACCRETA Study (2022)

The most important evidence for this approach comes from the PACCRETA study, a large French population-based cohort study spanning 176 hospitals across all of France, capturing 520,114 deliveries. It compared conservative management (n=86) directly with hysterectomy (n=62) in women with PAS.1

Uterine Preservation Rates

Across the available studies, expectant management preserves the uterus in 67–78% of cases. However, 33.2% of women who initially attempted conservative management eventually required a delayed hysterectomy — due to complications such as uncontrolled bleeding, infection, or failure of the placenta to resorb.2

Subsequent Pregnancies

Among women who successfully preserved their uterus:

• 88.9% of women who wanted to become pregnant again succeeded (24 out of 27 women)
• These 24 women had a total of 34 pregnancies
• Mean time to conception: 17.3 months
• 21 third-trimester deliveries, all resulting in healthy babies
• PAS recurred in 28.6% (6 out of 21) of subsequent pregnancies that reached the third trimester3

One-Step Conservative Surgery (Resective-Reconstructive)

Pioneered by: Dr. José Miguel Palacios-Jaraquemada (Buenos Aires, Argentina)

How It Works

This approach takes the opposite philosophy from expectant management: rather than leaving the abnormal tissue behind, the surgeon removes all of it in a single operation and then rebuilds the uterine wall. The key steps are:

1. Classify the PAS by invasion topography — determine exactly where and how deeply the placenta has invaded, guiding the surgical plan
2. Deliver the baby through an upper segmental hysterotomy — the uterine incision is made above the area of placental invasion, avoiding the abnormal blood vessels
3. Ligate newly formed blood vessels — tie off the abnormal neovascularization around the invasion zone to minimize blood loss
4. En bloc resection — remove the invaded portion of the myometrium together with the entire placenta, cutting until healthy, normal tissue is reached on all margins
5. Reconstruct the uterine wall — repair the defect and rebuild the uterus using the remaining healthy tissue

First Randomized Controlled Trial (2024)

In 2024, the first-ever randomized controlled trial (RCT) comparing conservative surgery to hysterectomy for PAS was published. This is a landmark study because RCTs provide the strongest level of medical evidence.4 The 2025 Nature Reviews Disease Primers review highlights this two-centre RCT, noting that it demonstrated comparable blood loss, transfusion rates, and operative time between focal resection-and-repair and hysterectomy — confirming the feasibility of the conservative surgical approach:30

202 Subsequent Pregnancies: The World's Largest Study

Perhaps the most remarkable evidence for this technique comes from the follow-up data on women who became pregnant again after conservative-reconstructive surgery. Dr. Palacios-Jaraquemada and colleagues have documented 202 subsequent pregnancies — the largest series in the world:5

• 90% (162 out of 179) delivered at term (>37 weeks gestation)
• 0% PAS recurrence — because the abnormal tissue was completely removed
• Only 1 hysterectomy in all 202 pregnancies (performed at the patient's own request, not medical necessity)
• Average interpregnancy interval: 15 months for type 1–2 PAS, 18 months for type 3
• Pregnancy outcomes were comparable to those of normal pregnancies

Why Isn't This Technique More Widely Available?

Given the impressive results, you might wonder why this approach is not the standard of care everywhere. A 2021 international survey of 134 PAS centers worldwide found that only about 10% offer uterine-sparing treatment.30 There are several reasons for this gap:

• Steep learning curve — the surgery requires exceptional skill in pelvic anatomy and surgical technique that takes years to develop
• Traditional emphasis on hysterectomy — for decades, hysterectomy has been taught as the "safest" approach, and institutional inertia is difficult to overcome
• Limited training opportunities — there are very few surgeons worldwide who can train others in this technique
• Dr. Palacios-Jaraquemada published a 2025 editorial in the American Journal of Obstetrics & Gynecology asking exactly this question: why are we still defaulting to hysterectomy when the evidence supports uterine preservation?6

However, patient interest in uterine-preserving approaches has grown considerably over the past decade, and more centers are beginning to offer these options.30

For more information about this technique, visit: en.palaciosjaraquemada.com

Triple-P Procedure

Pioneered by: Prof. Eric Jauniaux (University College London) and Prof. Basky Thilaganathan (St George's Hospital, London)

How It Works (The Three P's)

The Triple-P procedure gets its name from three sequential steps, each starting with the letter P:

1. Perioperative Placental Localization — Using ultrasound guidance, the surgeon maps the exact location of the placenta and delivers the baby through an incision above the upper border of the placenta, avoiding the abnormal invasion zone
2. Pelvic Devascularization — The blood supply to the area of invasion is systematically reduced using balloon catheters or surgical ligation, dramatically decreasing the risk of hemorrhage during the next step
3. Placental non-separation with Myometrial excision and reconstruction — Rather than trying to separate the placenta from the uterine wall (which would cause massive bleeding), the surgeon excises the entire area of myometrium where the placenta is attached, then reconstructs the uterine wall

Key Evidence

• Used as a first-line treatment at St George's Hospital since 2010
• More than 80 patients have been treated with excellent results
• Published outcomes of the first 50 patients demonstrate the technique's safety and feasibility7
• Uterine preservation rate of over 80% in experienced hands

Subsequent Pregnancy

The published evidence for pregnancies after the Triple-P procedure is currently limited to a single documented case report, but it is an encouraging one:

• Cauldwell case report (2018): A 30-year-old woman with 4 prior cesarean sections and posterior percreta (the most severe form, in a challenging location) was treated with the Triple-P procedure8
• Despite being advised against future pregnancy due to her complex history, she conceived again
• She delivered successfully with a good outcome for both mother and baby
• Estimated PAS recurrence risk after Triple-P: approximately 30% in future pregnancies

Other Innovative Techniques

Beyond the three principal approaches, several other centers around the world have developed their own fertility-preserving techniques:

MOSCUS — Tu Du Hospital, Vietnam

The Modified One-Step Conservative Uterine Surgery (MOSCUS) technique was developed at Tu Du Hospital in Ho Chi Minh City, one of the highest-volume obstetric centers in the world:

• Total series: 619 patients; 217 managed with MOSCUS
• Uterine preservation rate: 88.9%
• Compared to hysterectomy: less operative time, less blood loss, lower transfusion rates9

Segmental Resection — Various Centers

Segmental resection involves removing only the portion of the lower uterine segment that is affected by PAS, then repairing the uterus:

• A 21-patient study showed 100% successful treatment without complete hysterectomy
• A large Chinese study of 210 cases reported: 0% total hysterectomy, 15% partial hysterectomy10

TURIP Procedure — Japan

The TURIP (Tourniquet, Uterus Inversion, and Placental Dissection) procedure was developed for a specific subset of PAS — cases without placenta previa (where the placenta is not covering the cervix):

• The uterus is temporarily inverted to allow direct visualization and careful placental dissection
• A tourniquet is used to control blood supply during the procedure
• Particularly useful for posterior PAS cases11

All Techniques: Preservation Rates at a Glance

Leading Specialists Worldwide

Fertility-preserving PAS care is highly specialized. The following clinicians and centers have published the most significant evidence and are recognized leaders in the field:

Am I a Candidate for Fertility Preservation?

Whether fertility-preserving treatment is possible in your case depends on a combination of factors that must be evaluated by a multidisciplinary team at an experienced PAS center. These factors include the depth and location of placental invasion, the availability of specialized surgical expertise, and your overall health. No two cases of PAS are identical, and candidacy must be determined individually.

PAS Severity and Candidacy

The depth of placental invasion is one of the most important factors in determining whether conservative management is possible:

• Accreta (Grade 1) — The placenta attaches to the surface of the uterine muscle but does not penetrate deeply. These patients are the best candidates for conservative management, with success rates of approximately 78–80%.18
• Increta (Grade 2) — The placenta grows into the uterine muscle. Conservative management is feasible in many cases, particularly with one-step conservative surgery techniques that can resect and reconstruct the affected area.20
• Percreta (Grade 3) — The placenta penetrates through the full thickness of the uterine wall and may invade neighboring organs. Conservative management has significantly lower success rates, with 56% maternal morbidity reported with conservative approaches. Deep pelvic invasion is generally considered a contraindication for uterine preservation.1820

Location of Invasion (Topographic Classification)

Where the placenta has invaded matters as much as how deeply. Dr. Palacios-Jaraquemada's topographic classification system categorizes PAS by the location of invasion, which directly determines surgical approach and feasibility:20

Key rule: PAS located above the bladder trigone (the triangular area at the base of the bladder) is potentially suitable for conservative surgery. PAS below the bladder trigone is generally excluded due to the difficulty of achieving safe resection and repair in that anatomic space.

TUPAS Ultrasound Scoring System

The TUPAS (Topography-focused Ultrasound for Placenta Accreta Spectrum) scoring system is a validated tool that helps clinicians assess PAS severity using ultrasound. It scores three domains on a scale of 0–3 each, for a total score of 0–9:19

1. Uterine wall defect (0–3): How much of the uterine wall has been disrupted
2. Arterial vascularity at defect (0–3): The degree of abnormal blood vessel formation at the invasion site
3. Cervical involvement (0–3): Whether and how much the cervix is involved

Ask your MFM specialist whether TUPAS scoring has been applied to your imaging studies. This can provide a more objective basis for discussing your management options.

Contraindications for Conservative Management

The following conditions are generally considered contraindications for fertility-preserving approaches. If one or more apply to your case, hysterectomy may be the safer option:

Questions to Ask Your MFM About Candidacy

If you are considering fertility preservation, bring these specific questions to your consultation with a maternal-fetal medicine specialist:

1. What grade/depth of PAS do my imaging studies suggest?
2. Where is the invasion located? Above or below the bladder trigone?
3. What is my TUPAS or ultrasound score?
4. Would MRI provide additional useful information?
5. Does your center have a multidisciplinary PAS team with conservative surgery experience?
6. How many conservative PAS cases has your team performed? What are your success rates?
7. What is the realistic probability of uterine preservation in my specific case?
8. If conservative management fails, what is the backup plan?
9. What are the recurrence risks if I become pregnant again?
10. Am I a candidate for one-step conservative surgery or would expectant management be more appropriate?

Informed Consent: What You Must Understand

US-Based PAS Centers & Fertility Preservation

In the United States, the standard of care for confirmed PAS is planned cesarean hysterectomy (removal of the uterus at the time of cesarean delivery). ACOG considers conservative management "investigational." However, a growing number of US academic centers are offering fertility-preserving options for select patients, and the evidence base is expanding rapidly.

Tier 1: US Centers with Published Fertility-Preservation Experience

These centers have published research specifically on conservative (fertility-preserving) PAS management and have documented case series or are running clinical trials:

Tier 2: Major US PAS Centers with Fertility-Preservation Capabilities

These are major academic PAS centers with multidisciplinary teams that may offer conservative management as part of their practice:

Tier 3: Other Notable US PAS Programs

Cincinnati Area: PAS Specialists & Resources

If you are in the Cincinnati, Ohio area and have been diagnosed with PAS, the following information will help you understand the local resources available to you. Cincinnati has strong maternal-fetal medicine expertise through its academic medical center.

Other Cincinnati-Area Resources

Insurance Coverage for PAS Care at Specialty Centers

Overview

PAS delivery is one of the most expensive obstetric events in modern medicine, with hospital charges often ranging from $200,000 to $350,000 or more depending on the complexity of the case, length of stay, ICU time, blood products, and surgical procedures involved. However, if you have health insurance, your out-of-pocket costs are capped by your plan's annual out-of-pocket maximum — which for most employer-sponsored plans is in the range of $3,000–$8,000 for an individual.

Getting care at a specialized PAS center is critically important for outcomes, but it also requires planning ahead to ensure your insurance will cover treatment there. Below is what we have been able to determine about Aetna coverage at major Tier 1 PAS centers.

Aetna Coverage at Tier 1 Centers

Aetna Fertility Preservation Policy

Aetna Clinical Policy Bulletin 0327 covers fertility preservation (egg and/or embryo cryopreservation) when surgery could cause iatrogenic infertility — meaning infertility caused by a medical treatment. This directly applies to PAS patients who face possible hysterectomy, as egg or embryo freezing before surgery may be covered. See: Aetna CPB 0327 — Fertility Preservation29

Precertification Checklist

To maximize your chance of smooth coverage for PAS care at a specialty center, follow these steps as early as possible (ideally weeks before your planned delivery):

1. Call Aetna Member Services (1-800-704-7287) to verify in-network status of the specific hospital and all physicians involved in your care.
2. Have your MFM write a medical necessity letter documenting your PAS diagnosis, the need for specialized surgical care, and why that specific center is medically appropriate.
3. Request precertification for: extended inpatient stay, cesarean delivery, possible hysterectomy, possible ICU admission, interventional radiology procedures, and blood products/transfusion.
4. Get everything in writing with authorization numbers. Phone approvals can be disputed later; written authorization is much harder to reverse.
5. Ask the PAS center's financial counselor to run a full benefits verification on your behalf. Most large academic centers have dedicated staff for this.
6. Confirm ALL physicians are in-network — not just the lead surgeon, but the anesthesiologist, neonatologist, and interventional radiologist as well. This is important to avoid surprise billing from out-of-network providers.

Key Phone Numbers

Subsequent Pregnancy Data Summary

One of the most important questions for women considering fertility-preserving treatment is: "If my uterus is saved, can I actually have another baby, and will it be safe?" The answer, based on current evidence, is cautiously optimistic — but the outcomes depend heavily on which technique was used.

Latest Research (2024–2025)

Several important studies published in 2024–2025 add to our understanding of what happens after conservative PAS management:

Chen et al. (2025) published a cohort study of 40 patients who attempted pregnancy after conservative PAS management:24

• 60% achieved successful delivery
• 33.3% had PAS recurrence in the subsequent pregnancy
• Median time to return of menstruation: 4.5 months
• Mean interpregnancy interval: 3.3 years

Psychological impact is an increasingly recognized aspect of PAS care:

• Freitas et al. (2024) found that 36% of PAS patients had PTSD risk scores, highlighting the significant psychological toll of a PAS diagnosis and treatment.25
• Einerson et al. (2021) documented the emotional burden, fear, and loss of autonomy experienced by PAS patients through qualitative interviews, finding that women described feelings of grief, loss of control over their birth experience, and anxiety about future pregnancies.26

Questions to Ask Your Doctor

If you have been diagnosed with PAS and want to explore fertility-preserving options, the following questions can help guide a productive conversation with your healthcare team. You may wish to print this list or save it on your phone to bring to your appointment.

1. Am I a candidate for fertility-preserving treatment? — Not all PAS cases can be managed conservatively. Your doctor needs to assess whether your specific situation makes it feasible.
2. What type of PAS do I have? — Is it Grade 1 (accreta), Grade 2 (increta), or Grade 3 (percreta)? The grade affects which approaches may be possible.
3. Where exactly is the placenta invading? — The location of the invasion (anterior, posterior, lateral, near the bladder) affects surgical options and risks.
4. Do you have experience with conservative PAS management? — The surgeon's experience is one of the single most important factors in outcomes. Ask how many cases they have managed.
5. Can you refer me to a center that specializes in fertility-preserving PAS care? — If your current team does not have expertise in these techniques, ask for a referral. Many patients travel to specialized centers.
6. What are the risks of uterine preservation versus hysterectomy in my specific case? — The risk-benefit balance is different for every patient. Insist on a personalized discussion, not just general statistics.
7. If we try to preserve my uterus, what is the backup plan? — Ask about the plan if conservative management fails or complications arise. Knowing the contingency plan can provide reassurance.
8. What monitoring will I need after delivery? — Understand the follow-up requirements, which may involve weeks or months of monitoring depending on the approach used.
9. How long should I wait before trying to get pregnant again? — Interpregnancy intervals vary by technique: typically 15–18 months after resective surgery.
10. What are the risks in a subsequent pregnancy? — Understand the recurrence risk, the monitoring that will be required, and whether you would need to deliver at a specialized center again.
11. Does my insurance cover care at your center? — Ask what specific steps you should take to get preauthorization, and whether the center's financial counselor can help verify benefits.
12. Are there any clinical trials I might be eligible for? — Ask about ongoing research studies, such as the Penn Medicine trial (NCT06512181) or others that may be recruiting.
13. If I'm not a candidate for conservative management, can we discuss egg or embryo cryopreservation before my surgery? — Fertility preservation through egg or embryo freezing before hysterectomy is a well-established option that may be covered by insurance (see Aetna CPB 0327).
14. What psychological support services are available for PAS patients? — Research shows 36% of PAS patients have PTSD risk scores. Ask about perinatal mental health counselors and support groups.

Sequential and Combined Approaches

A natural question many patients ask is: "Can I start with expectant management (leaving the placenta in situ) and then, if it doesn't fully resolve, switch to a fertility-preserving surgery later?" This idea of a stepwise or "double method" approach — combining the safety of watchful waiting with the definitive tissue removal of conservative surgery — is intuitively appealing. Here is what the research shows.

The Two-Step Surgical Approach

The closest documented stepwise strategy is the two-step surgical approach, studied by Bolla et al. in a 2024 paper published in the Journal of Clinical Medicine.31 In this approach, the placenta is left in situ (in its place) at the time of cesarean delivery, and then a planned second operation is performed days to weeks later.

The study compared 43 PAS patients:

• Two-step group: Placenta left in situ at cesarean, followed by a delayed second operation. Median blood loss: 2,000 mL.
• One-step group: Everything done in a single surgery. Median blood loss: 2,800 mL.

However, it is important to note that the second step in this approach was typically a delayed hysterectomy (removal of the uterus), not a fertility-preserving conservative surgery. The two-step approach was designed to reduce bleeding and improve surgical safety — not to preserve the uterus.

When Expectant Management Doesn't Fully Resolve: Salvage Options

In about one-third of expectant management cases, the placenta does not fully resorb on its own. When this happens, a "salvage" intervention is needed. The published literature documents the following outcomes:

• Hysterectomy (uterus removal) remains the most common salvage procedure. Duzyj Buniak et al. reported in a 2022 review in Medicina that 33.2% of expectant management cases required hysterectomy within 12 months.32
• Hysteroscopic resection (a minimally invasive procedure using a small camera and instruments passed through the cervix) is the closest documented fertility-preserving salvage option. Legendre et al. reported in a 2014 study in the Journal of Minimally Invasive Gynecology on 12 patients with persistent retained placental tissue after expectant management. Complete removal was achieved in 11 of 12 patients, and 4 subsequent pregnancies occurred in follow-up.33
• No documented cases exist of one-step conservative surgery (the Palacios-Jaraquemada resective-reconstructive technique) being used as a salvage procedure after failed expectant management.

Why the Exact Sequential Approach Has Not Been Studied

There are sound clinical reasons why the combination of expectant management followed by one-step conservative surgery has not been documented:

1. One-step conservative surgery is designed as a primary procedure. The resective-reconstructive technique developed by Palacios-Jaraquemada is performed at the time of cesarean delivery, when the surgical anatomy is well-defined and the tissue planes are fresh and identifiable.
2. Weeks of expectant management changes the surgical field. After the placenta has been left in situ for weeks or months, the tissue undergoes inflammation (the body's immune response), develops adhesions (scar-like tissue bands that form between organs), and may become infected. These changes can make the precise dissection required for resective-reconstructive surgery significantly more difficult or potentially not feasible.
3. Different clinical contexts. Patients who begin with expectant management are typically at centers that specialize in that approach, while one-step conservative surgery requires a different set of specialized surgical skills and infrastructure. The transition between these two approaches would require coordination between teams with very different expertise.

Fertility Outcomes After Conservative Management (All Methods)

Regardless of which specific conservative method is used, the research on subsequent fertility is encouraging for many patients:

• Sentilhes et al. reported in Human Reproduction (2010) that among women who successfully preserved their uterus through expectant management and later desired pregnancy, 88.9% achieved a subsequent pregnancy.34
• Palacios-Jaraquemada et al. reported in the Journal of Maternal-Fetal & Neonatal Medicine (2022) on 202 subsequent pregnancies after resective-reconstructive surgery, with 90% reaching term delivery.35
• PAS recurrence risk: This is a critical consideration. Studies report a recurrence rate of 22–29% in subsequent pregnancies after expectant management, meaning that roughly 1 in 4 future pregnancies may develop PAS again. After resective-reconstructive surgery, reported recurrence rates have been lower, though long-term data is still being collected.

Important Caveats

We have presented the evidence for fertility-preserving approaches as clearly and honestly as we can. Before making any decisions, please keep the following in mind:

References

1. Sananès N, Schuller E, Fritz G, et al. Conservative management versus hysterectomy for placenta accreta spectrum: a population-based study (PACCRETA). American Journal of Obstetrics & Gynecology. 2022;226(1):S364–S365. doi:10.1016/j.ajog.2021.11.603
2. Sentilhes L, Ambroselli C, Kayem G, et al. Maternal outcome after conservative treatment of placenta accreta. Obstetrics & Gynecology. 2010;115(3):526–534. doi:10.1097/AOG.0b013e3181d066d4
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