Impact of Cervical Cancer Treatment on Fertility and Advances in Fertility Preservation

Abstract

Cervical cancer is one of the most common malignant cancers, predominantly affecting women in their reproductive ages. This is a distressing issue to the majority of the women affected by cervical cancer as their fertility becomes threatened during cervical cancer treatments. Previously, radical hysterectomy was the gold standard treatment method for cervical cancer. While simple and radical hysterectomy are still standard treatment methods, there is a shift towards less radical approaches such as trachelectomy and cervical excision procedures to treat cervical cancer while also sparing fertility. Since the introduction of radical trachelectomy with laparoscopic pelvic lymph node dissection by Daniel Dargent in 1987, it has come a long way and evolved into a technique that has offered a lot of promise to many women. Regardless of the several options available today for cervical cancer treatment, an individualized approach must be taken when selecting the optimal treatment method for the patient. Factors like tumour size, tumour stage, its histology, lymphovascular space invasion and patient's strong expressed desire for fertility preservation must be taken into account to ensure the best desired results for the patient.

Hysterectomy, radiotherapy and chemotherapy do not offer chances to spare fertility in most cases unless assisted reproductive techniques such as oocyte or embryo cryopreservation have been utilized for use in future surrogacy before carrying out these procedures. Trachelectomy and cervical excision procedures are optimal for women in early stages of their cancer, as these procedures have produced good oncological outcomes as well as obstetric outcomes with some reported complications such as cervical insufficiency and premature rupture of membranes. For patients with early-stage cervical cancer but with certain high-risk features such as having tumours > 2cm, neoadjuvant chemotherapy combined with a fertility-sparing approach has proven to reduce recurrence rates and improve pregnancy and live birth rates but this approach currently has limited data and requires more research. This combination is also linked with increased preterm birth rates.

Embryo and oocyte cryopreservation are two well-established fertility preservation methods but they cannot be used for women who cannot delay their treatments as they both require ovarian hyperstimulation. In vitro maturation, ovarian tissue cryopreservation and artificial ovaries are newer techniques. For women who require urgent treatment as well as fertility preservation, in vitro maturation or ovarian tissue cryopreservation can be utilized as they do not require ovarian hyperstimulation. However, in vitro maturation has limited evidence of success while ovarian tissue cryopreservation has a slight risk of malignant spread as with oocyte cryopreservation. Artificial ovaries currently lack data on human trials. This paper aims to make an in-depth review of all of the information here.