Patient education: Fertility preservation in women with early-stage cervical cancer (Beyond the Basics)
- Marie Plante, MD
Marie Plante, MD
- Full Professor of Gynecologic Oncology
- Department of Obstetrics and Gynecology
- Division of Gynecologic Oncology
- L'Hôtel-Dieu de Québec
- Centre Hospitalier Universitaire de Québec
- Laval University
CERVICAL CANCER OVERVIEW
More than 11,000 American women develop cancer of the uterine cervix (cervical cancer) each year. Cervical cancer is a treatable condition, and there is a good chance of cure if it is found and treated in the early or precancerous stages.
Many women with cervical cancer are in their reproductive years. Advice regarding options for fertility preservation for women with early-stage cervical cancer is available from clinicians who are experts in reproductive endocrinology and infertility, in conjunction with a gynecologic oncologist.
This topic review discusses the diagnosis and treatment of women with the earliest stages of localized cervical cancer who wish to preserve their ability to become pregnant in the future. Separate topic reviews discuss screening for cervical cancer and the standard treatment of all early-stage cervical cancers (which usually includes hysterectomy). (See "Patient education: Cervical cancer screening (Beyond the Basics)" and "Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)".)
CERVICAL CANCER TREATMENT DECISIONS REGARDING FERTILITY
A woman with cervical cancer who wishes to preserve her fertility may feel that she has to choose between doing what seems best for her own life and what might be best for preserving fertility. Every woman's circumstances are different, and every decision must be individualized based upon the woman's situation. Advice regarding options for fertility preservation is available from clinicians who are experts in reproductive endocrinology and infertility, in conjunction with a gynecologic oncologist.
CERVICAL CANCER FERTILITY-SPARING TREATMENT OPTIONS
Early-stage cervical cancer refers to stage IA1, IA2, IB1, and some small IIA1 tumors. Options for preservation of fertility are usually limited to women with stages IA1, IA2, or IB1 cervical cancer. Factors such as tumor size, tumor cell type, lymphovascular space invasion, and lymph node metastases may also affect the ability to receive fertility-sparing treatment.
Options for treatment of early-stage cervical cancer include cone biopsy, hysterectomy, and chemoradiation. Future pregnancies are not possible after hysterectomy or radiation therapy. Some women with early-stage cervical cancer with no spread to other organs or lymph nodes who wish to carry a pregnancy after cervical cancer treatment are eligible for less aggressive forms of treatment. Treatments that allow a woman to carry a pregnancy at a later time include the following:
●Conization – Large biopsy of the cervix
●Simple trachelectomy – More extensive removal of the cervix
●Radical trachelectomy – Removal of the cervix and surrounding tissues, but not the uterus
In addition, removal of the lymph nodes in the pelvis is performed except in women with stage IA1 disease without cancer cells in the lymphatic channels.
Sentinel node biopsy is increasingly performed to reduce the extent of and complications associated with extensive lymph node dissection. However, this procedure is not yet considered "standard of care" but it can be considered and performed by surgeons experienced with the technique.
Cervical conization — Cervical conization is the surgical removal of a cone-shaped portion of the cervix, including the cancerous area (figure 1). It is an acceptable option only for the earliest stages of cervical cancer (ie, stage IA1 and IA2).
Conization is usually performed in the operating room after the woman receives anesthesia. Conization is performed through the vagina. Most women can go home the same day.
Following conization, most gynecologic oncologists recommend that the woman avoid sexual intercourse, not place anything in the vagina, and not take a bath or swim for a few weeks (showers are fine); these activities could potentially interfere with healing. Some bleeding is expected, although it should not be heavy. If bleeding becomes heavy (eg, soaks a pad in less than an hour) or continues for more than one week, the woman should contact her health care provider.
After conization, follow-up examinations are recommended to ensure that there is no evidence of cervical cancer. (See "Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)", section on 'Monitoring'.)
Simple trachelectomy — Some data suggest that "radical" trachelectomy may not always be necessary in patients with small lesions as the risk of cancer spread to the tissues next to the uterus and cervix (parametrium) is extremely low. The simple trachelectomy is similar to the radical trachelectomy in that it involves the "en bloc" removal of most of the cervix but it does not include the removal of the parametrial tissue. It is, however, more extensive than a conization. It is an acceptable option for stage IA1, IA2, and small IB1 lesions measuring <2 cm. It is performed in the operating room, through the vagina, and is usually a day surgery like a conization. A cerclage is not necessarily placed after the simple trachelectomy. It depends on the amount of cervical tissue remaining after the procedure. A laparoscopy for removal of the lymph nodes is performed prior to the trachelectomy to make sure cancer cells have not spread to the lymph nodes .
Radical trachelectomy — Radical trachelectomy is defined as partial or complete surgical removal of the cervix and parametrium (connective tissues next to the uterus and cervix). Radical trachelectomy removes much more of the cervix compared to cervical conization (figure 2). It also involves the removal of lymph nodes in the pelvis.
The procedure is performed in the operating room after the woman receives anesthesia. Trachelectomy may be done through the vagina or through an incision on the abdomen, depending upon the surgeon's preference. The procedure may also be performed using laparoscopy or robotic surgery. The cervix and upper portion of the vagina may be completely or partially removed, depending upon the size and depth of the cancer. A permanent purse-string suture (cerclage) is usually placed at the lower end of the uterus or remaining cervix (figure 2).
Before trachelectomy begins, surgical removal of lymph nodes within the pelvis is performed to be sure that the cancer has not spread; this is called lymphadenectomy (figure 3). The nodes may be removed through an incision in the abdomen (if an abdominal incision is made for the trachelectomy), which allows the clinician to see the nodes directly. Alternately, the nodes are removed with the assistance of a laparoscope if the trachelectomy is done vaginally, laparoscopically, or robotically.
After removal, the lymph nodes are examined under a microscope during the operation to preliminarily confirm that cervical cancer cells are absent (frozen section analysis). If any nodes are found to contain cancer cells, trachelectomy is not performed, and more aggressive therapy (radical hysterectomy or chemoradiotherapy) is usually recommended. (See "Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)".)
Following trachelectomy, most gynecologic oncologists recommend that the woman avoid sexual intercourse, not place anything in the vagina, and not take a bath or swim for four to six weeks (showers are fine); these activities could potentially interfere with healing. Some bleeding is expected for approximately one week, although it should not be heavy. If bleeding becomes heavy (eg, soaks a pad in less than an hour) or continues for more than one week, the woman should contact her health care provider.
After trachelectomy, follow-up examinations and testing are recommended to ensure that there is no evidence of cervical cancer. (See "Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)", section on 'Monitoring'.)
Need for further treatment — Further surgery may be required if abnormal or cancerous cells are found at the margins (edges) of the area that is surgically removed during conization or trachelectomy. For a woman who had conization, this could mean a second conization, radical trachelectomy, or hysterectomy. For a woman who had radical trachelectomy, this usually means a radical hysterectomy (see "Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)"). Additional chemoradiation may be necessary if cancer cells are identified in the lymph nodes on final pathology or if other risk factors are identified on the trachelectomy specimen.
PREGNANCY AFTER CERVICAL CANCER TREATMENT
Most women are advised to wait 6 to 12 months after conization or trachelectomy before attempting to become pregnant to allow the tissue to heal fully. Even if a woman waits to attempt pregnancy, there is a risk of pregnancy complications and/or infertility after cervical cancer treatment.
Infertility — There is an increased risk of difficulty in becoming pregnant if the cervix or lower uterus becomes scarred or narrowed as a result of the conization or radical trachelectomy. This could potentially prevent sperm from entering the uterus. This can usually be overcome with an infertility treatment, such as intrauterine insemination (IUI), following attempts at dilating the cervical opening. With IUI, a small catheter is used to deliver sperm directly into the uterus. If dilating the cervical opening is impossible or if IUI fails, in vitro fertilization with embryo transfer can be attempted.
Cervical insufficiency — Cervical insufficiency occurs when the cervix opens or thins earlier than normal during pregnancy. This can lead to miscarriage or preterm delivery (when delivery occurs before 37 weeks of pregnancy). Women who have had cervical conization or radical trachelectomy may be at an increased risk of cervical insufficiency.
For these reasons, women who undergo treatment for cervical cancer are followed closely during pregnancy. This generally involves regular monitoring of the length and opening (dilation) of the cervix. (See "Patient education: Preterm labor (Beyond the Basics)", section on 'Cervical length'.)
Pregnancy options after radical hysterectomy or radiation — It is not usually possible to become pregnant or carry a pregnancy after treatment with radical hysterectomy and/or chemoradiation therapy. However, advances in assisted reproductive technology may offer a way for women to have a biologically related child after this type of treatment.
Embryo cryopreservation is a technique that has been available for many years for fertility preservation. Embryo cryopreservation requires that radical surgery, chemotherapy, or radiotherapy is delayed for several weeks, and that a partner's or donor's sperm is available. Thus, it may not be an option for all women. To use embryo cryopreservation, a woman must use fertility medications and undergo a surgical procedure to harvest her oocytes (eggs). The oocyte is then combined with a partner's or donor's sperm to create an embryo. The embryo is then frozen for use at a later time.
Another option is oocyte cryopreservation (freezing the egg before it is fertilized with sperm). Ovarian cryopreservation (freezing the ovary) is under investigation; further study is needed before this technique is available to the general public.
Since the uterus has been removed or damaged by cancer treatment, all of these techniques, including embryo cryopreservation, would require a gestational carrier to carry the pregnancy. (See "Surrogate pregnancy".)
Progress in treating cervical cancer requires that better treatments be identified through clinical trials, which are conducted all over the world. A clinical trial is a carefully controlled way to study the effectiveness of new treatments or new combinations of known therapies. Ask for more information about clinical trials, or read about clinical trials at:
Videos addressing common questions about clinical trials are available from the American Society of Clinical Oncology (http://www.cancer.net/pre-act).
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Follow-up of low-grade abnormal Pap tests (Beyond the Basics)
Patient education: Follow-up of high-grade abnormal Pap tests (Beyond the Basics)
Patient education: Cervical cancer screening (Beyond the Basics)
Patient education: Cervical cancer treatment; early stage cancer (Beyond the Basics)
Patient education: Genital warts in women (Beyond the Basics)
Patient education: Management of a cervical biopsy with precancerous cells (Beyond the Basics)
Patient education: Vaginal hysterectomy (Beyond the Basics)
Patient education: Preterm labor (Beyond the Basics)
Patient education: Miscarriage (Beyond the Basics)
Patient education: Sexual problems in women (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Cervical intraepithelial neoplasia: Terminology, incidence, pathogenesis, and prevention
Human papillomavirus infections: Epidemiology and disease associations
Invasive cervical cancer: Epidemiology, risk factors, clinical manifestations, and diagnosis
Management of early-stage cervical cancer
Management of locally advanced cervical cancer
Invasive cervical cancer: Staging and evaluation of lymph nodes
Management of recurrent or metastatic cervical cancer
HIV infection and malignancy: Epidemiology and pathogenesis
Preventive care in adults: Recommendations
Preinvasive and invasive cervical neoplasia in HIV-infected women
Human papillomavirus vaccination
Virology of human papillomavirus infections and the link to cancer
Invasive cervical adenocarcinoma
Small cell neuroendocrine carcinoma of the cervix
The following organizations also provide reliable health information.
●American Society of Clinical Oncology
●Society for Gynecologic Oncology
●National Comprehensive Cancer Network
●Gynecologic Oncology Group
●National Cancer Institute
●American Cancer Society
●The National Cervical Cancer Coalition
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- Green J, Kirwan J, Tierney J, et al. Concomitant chemotherapy and radiation therapy for cancer of the uterine cervix. Cochrane Database Syst Rev 2005; :CD002225.
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- Wethington SL, Cibula D, Duska LR, et al. An international series on abdominal radical trachelectomy: 101 patients and 28 pregnancies. Int J Gynecol Cancer 2012; 22:1251.
- Roman LD. Pregnancy after radical vaginal trachelectomy: maybe not such a risky undertaking after all. Gynecol Oncol 2005; 98:1.
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- Kasuga Y, Nishio H, Miyakoshi K, et al. Pregnancy Outcomes After Abdominal Radical Trachelectomy for Early-Stage Cervical Cancer: A 13-Year Experience in a Single Tertiary-Care Center. Int J Gynecol Cancer 2016; 26:163.
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All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.