The document discusses fertility preservation options for women with cervical cancer, including radical trachelectomy, which can preserve fertility while managing cancer. It outlines selection criteria, surgical outcomes, risks of recurrence, and obstetric outcomes following the procedure. Additionally, it mentions alternatives for fertility preservation, such as oocyte retrieval and ovarian transposition, emphasizing the need for preoperative counseling and careful patient selection.

1. FERTILITY PRESERVATION
IN CANCER CERVIX

2. Cervical Cancer
• Sexual dysfunction, loss of fertility*
• Reduced autonomic responses- engorgement,
lubrication and orgasm
• Significant dysparaeunia- due to vaginal shortening and
stenosis
* Bergmark K, Avall-Landqvist E, Dickman PW, Henningsohn L,
Steineck G. Vaginal changes and sexuality in women with a history
of cervical cancer. N Eng J Med 1999;340:1383-1389
• Surgical morbidity-
 rarely severe
 short-lived or at least stable
 treatable
 can preserve the ovarian function

3. Radical Trachelectomy
• Initial tendency of small Cx tx to spread laterally into the
parametria and LN, rather than verticaly into uterus/
vagina
• Theoretically possible to resect cervix, parametria and
lymphnodes- preserving uterus, adnexa and vagina
• Like partial nephrectomy/ gastrectomy/ pneumonectomy/
colectomy
• Structures removed-
 Majority of the Cx
 Part of parametria and paracolpos
 Part of uterosacral ligament
 1-2 cm of vaginal cuff
 Descending cervicovaginal branch of uterine artery is ligated
 Permanent encirclage of the cervical stump
 Pelvic lymph nodes
• Done abdominally, vaginally, laparoscopically

4. Abdominal Trachelectomy
Author N Stage
Estimated
blood loss Complications Live
Birth
Recurrence
Smith et al. 1997 1 IB
Rodiguez et al. 2001 3 IAI-IA2 417 1 abscess 1 0
Palfalvi 2003 1 IBI 1
Del Priore et al. 2004 1 IBI Pelvic, 6 mth
Ungar et al. 2005 33 IA2-IB2 6% amenorrhoea 2 0 (47 mth)
Abu-Rustum et al. 2005 2 IBI 0 0
Ungar et al. 2006 91 IA2-IB2 656 4.8% amenorrhoea 6 2.4%
Cibula et al. 2005 3 IA2-IBI 350-3500 1 ileus, 1 bladder atony
Bader et al. 2005 1 IB1 0 1
Abu-Rustum et al. 2006 5 IBI 280
positive margin- needed
completion Sx
0 0

5. Laparoscopically Assisted vaginal
trachelectomy (Dargent Procedure)
• 1987- Dargent described modification of Schauta-
Americh radical hysterectomy to preserve uterine
function*
• 1st laparoscopic complete pelvic lymph node dissection-
then removal of cervix along with proximal portion of
parametrium
* Dargent D. A new future for Schauta's operation through pre-surgical
laparoscopic retroperitoneal pelviscopy. Eur J Gynecol Oncol 1987;8:292
• Plante et al- after 2 decades- oncologic outcomes are
comparable to radical hysterectomy for similar sized
lesions**
** Plante M, Renaud MC, Harel F, et al. Vaginal radical trachelectomy: an
oncologically safe fertility-preserving surgery. An updated series of 72 cases
and review of the literature. Gynecol Oncol 2004;94:614

6. Selection Criteria
Eligibility criteria
• Roy M, Plante M. Pregnancies after radical vaginal trachelectomy for early-stage
cervical cancer. Am J Obstet Gynecol 1998;179(6):1491
1. Desire to preserve fertility
2. No clinical evidence of impaired fertility (relative C/I)
3. Lesion size ≤2.5 cm
4. FIGO stage 1A1 with LVSI, 1A2 and 1B1
5. Sq cell or adeno Ca
6. No involvement of the upper endocervical canal as determined by
colposcopy/ MRI
7. No mets to regional LN
• Can be done in women >40 years (reduced fertility) or those with
completed family
• Experience over 10 years in the Memorial Sloan-Kettering Cancer
Center- 48% of women undergoing radical hysterectomy would
have been candidate for trachelectomy*
* Sonoda Y, Abu-Rustum NR, Gemignani ML, et al. A fertility sparing alternative to
radical hysterectomy: how many patients may be eligible? Gynecol Oncol
2004;95:534-

7. * Abdominal radical trachelectomy
Oncologic Outcome
Authors Number Recurrences Deaths
Plante and Roy 100 2 (2.0%) 1 (1.0%)
Covens and
Steeed
121 7 (5.8%) 4 (3.3%)
Shepherd et al. 112 3 (2.7%) 2 (1.8%)
Hertel et al. 100 4 (4.0%) 2 (2.0%)
Dargent and
Mathever
95 4 (4.2%) 3(3.1%)
Ungar et al.* 91 2 (2.2%) 0
Total 619 22 (3.5%) 12 (1.9%)

8. Recurrences
• Unusual recurrences- Vesico-vaginal septum and bladder- needs
very meticuous surgical technique and dissection in proper plane to
prevent dissemination of Tx cells *
* Morice P, Dargent D, Haie-Meder C, Duvillard P, Castaigne D. First case of a centropelvic
recurrence after radical trachelectomy: literature review and implications for the preoperative
selection of patients. Gynecol Oncol 2004;92:1002-1005
• Recurrence in Cx itself- 2 cases
1. Bali- 7 yrs follow up (Recurrence or new primary-?)
2. Bader- 6 mnth FU- detected by Pap smear
• 2 recurrences after Abd trachelectomy- both having bulky Cx (3.8
cm, 5 cm respectively) **
• Role of abd trachelectomy in bulky Cx ?
** Ungar L, Plafalvi L, Smith JR, et al. Update on and long term follow up of 91 abdominal radical
trachelectomies. Gynecol Oncol 2006;101:S20(abst).
• Alternative- Neo-adjuvant chemotherapy to reduce the size of the
lesions- then radical trachelectomy
• Experience in 3 cases- all had complete response to chemo and
none had residual ds- still experimental
• Plante M, Lau S, Brydon L, et al. Neoadjuvant chemotherapy followed by vaginal radical
trachelectomy in bulky stage 1B1 cervical cancer: case report. Gynecol Oncol 2006;101:367

9. Follow up
• Shepherd JH, Mould T, Oram DH. Radical trachelectomy in the early stage carcinoma of the
cervix: outcome as judged by recurrence and fertility rates. BJOG 2001;108(8):882
• Every 3-4 months for 1st 2-3 years
• Then every 6 months for next 2 years
• Then every year
• Colposcopy, cytology and RV examination
• Colposcopy and cytology- frequently unsatisfactory because SCJ is
not often visualized and cytology often meets only squamous cells
• Atypical glandular cells from lower uterine segment is often picked
up by cyto- false +ve results
• Singh et al- 200 smears- most unsatisfactory, 2% atypical gladular
cells (suspicious), only 2 cases true recurrence- abnormality long
before clinical features*
* Singh N, Titmuss E, Aleong JC, et al. A review of post-trachelectomy isthmic and vaginal smear
cytology. Cytopathology 2004;15:97
• Shepherd- use of endoCx cytobrush for cytology and MRI 6, 12, 24
mth
• Needs expert radiologists to interprete MRI**
** Sahdev A, Jones J, Shepherd JH, et al. MR imaging appearances of the female
pelvis after trachelectomy. Radiographics 2005;25:41

10. Risk of recurrence
• Size ≥2 cm*
• LVSI*
• Adeno Ca**
*Plante M, Renaud M-C, Francois H, Roy M, Vaginal radical trachelectomy:
an oncologic safe fertility preserving surgery. An updated series of 72 cases
and review of the literature. Gynecol Oncol 2004;94:614-623
**Hertel H, Kohler C, Hillemanns P, et al. Radical vaginal trachelectomy
(RVT) combined with laparoscopic pelvic lymphadenectomy: prospective
multicenter study of 100 patients with early cervical cancer. Gynecol Oncol
2006:103;506-511

11. Obstetric outcomes
Author Pregnancy
1st
trimester
loss
Therapeutic
abortions
2nd
trimester
loss
3rd
trimester
delivery
Delivery
<32 wks
Delivery
>32 wks
Plante and
Roy
59 10 (16%) 3 (4%) 2 (5%) 44 (75%) 3 (7%) 41 (93%)
Dargent
and
Mathevet
56 11 (18%) 3 (5%) 8 (14%) 34 (61%) 5 (15%) 29 (85%)
Shepherd
et al.
52 15 (29%) 2 (4%) 7 (13%) 28 (54%) 7 (25%) 21 (75%)
covens
and
Bernardini
45 8 (16%) 0 3 (7%) 34 (77%) 6 (18%) 28 (82%)
Hertel et
al.
14 1 (7%) 2 (14%) 0 11 (78%) 3 (27%) 8 (73%)
Ungar et
al.
10 4 (40%) 0 0 6 (60%) 1 (17%) 5 (83%)
Total 236
49
(20%)
10 (4%)
20
(8%)
157
(66%)
25
(15%)
132
(85%)

12. Obstetric Outcomes (Contd.)
• 1st trimester loss- not higher than that in general
population
• 2nd trimester loss- significantly higher
• Prematurity <32 wk- 15%
• Prematurity <28 wk (↑ morbidity) - <10%
• Majority deliver at term
• Prematurity rate particularly higher after multiple
pregnancy in post-trachelectomy- needs special
consideration before IVF-ET
• Birth weight- Not significantly different as vasculat flow to
uterine artery is preserved (Klemm et al. 2005)
• Abdominal trachelectomy- Obst outcome similar but
chance of ligating uterine arteries higher- risk of IUGR

13. Eitiology of pregnancy loss
• Mechanical - uterus enlarges→ short Cx
cannot offer much support to LUS→ Cx
more likely to dilate prematurely
• Infective- main eitiology →short Cx cannot
form effective protective mucus plug
between vagina and the membranes→
subclinical chorioamnionitis → PPROM
and preterm labour

14. Obstetric Management
• Consultation with specialist in fetal-maternal medicine
• Prophylactic antibiotics and steroid to accelerate fetal
lung maturity- unclear but strongly recommended by
Shepherd*
* Shepherd JH, Mould T, Oram DH. radical trachelectomy in early
stage carcinoma of the cervix: outcome as judjed by recurrence and
fertility rates. Br J Obstet Gynaecol 2001;108:882-885
• Needs USG assessment of neo-cervix (length, diameter,
funneling) regularly**
** Petignat P, Stan C, Megevand E, Dergent D. Pregnancy after
trachelectomy: a high risk condition of preterm delivery. Report of a
case and review of the literature. Gynecol Oncol 2004;94:575-577
• Delivery should be planned at 38-39 weeks by elective
CS due to permanent encerclage

15. Decision for trachelectomy
• Many women, even after choosing such
Sx, decide not to attempt pregnancy
• Uncertain long-term survival results
• There are considerable challenges to
overcome
• Needs pre-op counseling
• In case of recurrence- total radical Sx/ RT

16. Conisation
• 1A1- LEEP, Cold knife/ Laseconisation
• Lymphatic spread extremely low (<1%)- no need
of lymphadenectomy
• Entire cone should be blocked- to prepare
adequate number of sections
• Needs careful colposcopic exam of vagina- as
most recurrences occur from this area
• 5-year survival with optimal care >95%*
* Gadducci A, Sartori E, Maggino T et al. The clinical outcome of
patients with stage 1a1 and 1a2 squamous cell carcinoma of the
uterine cervix: a Cooperation Task Force (CTF) study. cancer J
2003;24:513-516

17. • Cone biopsy- Both diagnostic and Risk of residual disease *
therapeutic
• No LVSI, both endocervical
margins and curettage -ve for
Ca/ dysplasia
• Roman LD, Felix JC, Muderspach LI, et al. Risk of residual invasive disease in women with
microinvasive squamous cancer in a conisation specimen. Obstet Gynecol. 1997;90:759
• Hopkins MP. Adenocarcinoma in situ of the cervix: the margins must be clear. Gynecol Oncol.
2000;79:4-5
Conisation (Contd.)
Sq Cell Ca Adeno Ca
Both endocx
curette and
margin -ve
4% 3%
Only
endocx
margin +ve
22%
7%
Both +ve 33%

18. Management of Stage IA2
• May be individualized using non-FIGO
information to stratify the patients as per H/P
features
 LVSI (presence/ Absence)
 Degree of differentiation
 Type of Tx (Adeno-/ Squamous Ca)
 Tx volume (higher risk at upper limit of 1A2)
• Low risk- like 1A1
• High risk- conisation + LN dissection
• Radical trachelectomy + LN dissection

19. Ovarian Transposition
• Transposing ovaries out of the planned RT field- if RT is
required
• 1st described ovarian transposition to keep the ovaries
outside the radiation field*
• No case of iatrogenic menopause in that series (4 cases)
* Lemevel A, Bourdin S, Harousseau J, et al. Ovarian transposition by laparoscopy
before radiotherapy in the treatment of Hodgkin's disease. cancer 1998;83:1420
• Bisharah and Tulandi- recommends transection of the
ovarian lig and transposition of the ovaries without
affecting fallopian tubes- positioning ovaries antero-
laterally at the level of ASIS**
** Bisharah M, Tulandi T. Laparoscopic preservation of ovarian function: an underused
procedure. Am J Obstet Gynecol 2003;188:367
• Ovarian reserve may be tested- ovarian volume, AFC,
AMH, Inhibin B

20. Results
• Normal ovarian function seen in <50% cases*
* Fenny DD, Moore DH, Look KY, et al. The fate of the ovaries after radical hysterectomy and ovarian transposition.
Gynaecol Oncol. 1995;56:3
* Anderson B, LaPolla J, Turner D, et al. Ovarian transposition in cervical cancer. Gynecol Oncol. 1993;49:206
• Risk of ovarian mets- 0.5% (sq cell Ca) and 1.7%
(adenoca)- thus incurs a small risk**
** Sutton GP, Bundy BN, Delgado G, et al. Ovarian metastasis in stage IB carcinoma of the cervix: a
Gynecologic Oncology Group (GOG) study. Am J Obstet Gynecol.1992;166:50
• In a series of 37 consecutive cases- clear cell adenoCa
of vagina and Cx, ovarian dysgerminoma and sarcoma
• Pregnancy rates in women trying for conception- 15%
(4/27) for clear cell Ca of vagina/ Cx, 80% (8/10) in
ovarian Tx ***
***Morice P, Thiam-Ba R, Castaige D, et al. Fertility results after ovarian transposition for
pelvic malignancies treated by external irradiation and brachytherapy. Hum Reprod
1998;13:660

21. Alternatives
• Oocyte retrieval
• IVF and cryopreservation (ART procedure)
• Cryopreservation of unfertilized oocytes- under research- low fertility
rates
• Autologous orthotoptic/ heterotopic transplantation after
cryopreservation- can restore fertility
• Ovarian tissue can tolerate ischaemia for at least 3 hours
• Success depends on post-grafting ischaemia time after effective
revascularization techniques
• Ethics Committee of ASRM- the physician should inform
the cancer survivors of the alternatives before initiation
of therapy*
* American Society for Reproductive Medicine. Fertility preservtion and reproduction in
cancer patients. Fertil Steril 2005;83(6):1622