Reproductive outcomes after radical abdominal trachelectomy for cervical cancer

Objective: Some patients who have undergone radical trachelectomy require in vitro fertilization-embryo transfer. We examine the reproductive problems in patients with cervical cancer after radical abdominal trachelectomy. Methods: A retrospective single-center study of the fertility treatment for the cervical cancer patients who received radical abdominal trachelectomy was performed in 17 cases. One patient had stage IA1 disease with lymph-vascular involvement, 4 had stage IA2 disease, and 12 had stage IB1 disease. Histologically, there were 9 squamous cell carcinomas and 8 adenocarcinomas. Six patients received adjuvant chemotherapy. No deaths due to disease were observed. Results: The median age and length of follow-up were 36 years old and 71 months, respectively. Among the 12 patients desirous of pregnancy, 9 received in vitro fertilization (IVF), and 8 pregnancies were confirmed in 6 patients. Seven patients had cervical stenosis, and 4 of them needed transmyometrial embryo transfer. Two cases showed spontaneous abortion in the first trimester, and five resulted in births. The remaining case is in her 17th gestational week with no abnormal findings. One case had a fetomaternal transfusion syndrome, and another had partial placenta previa and preterm premature rupture of the membranes. Conclusions: In this small series of cases, the pregnancy rate after radical abdominal trachelectomy was 50%; most patients received transmyometrial embryo transfer was used for cervical stenosis.

Cervical stenosis; Complication; Radical trachelectomy; Reproductive outcomes; Transmyometrial embryo transfer; Fertility treatment

[1] Zhang Q, Li W, Kanis MJ, Qi G, Li M, Yang X, et al. Oncologic and obstetrical outcomes with fertility-sparing treatment of cervical cancer: a systematic review and meta-analysis. Oncotarget. 2017; 8: 46580–46592.

[2] Nezhat C, Roman RA, Rambhatla A, Nezhat F. Reproductive and oncologic outcomes after fertility-sparing surgery for early stage cervical cancer: a systematic review. Fertility and Sterility. 2020; 113: 685–703.

[3] Wu C, Chang W, Chen C, Chen C, Huang S, Sheu B. Radical trachelectomy for early stage cervical cancer: a case series and literature review. Taiwanese Journal of Obstetrics & Gynecology. 2017; 56: 143–146.

[4] Okugawa K, Kobayashi H, Sonoda K, Kaneki E, Kawano Y, Hidaka N, et al. Oncologic and obstetric outcomes and complications during pregnancy after fertility-sparing abdominal trachelectomy for cervical cancer: a retrospective review. International Journal of Clinical Oncology. 2017; 22: 340–346.

[5] Nishio H, Fujii T, Sugiyama J, Kuji N, Tanaka M, Hamatani T, et al. Reproductive and obstetric outcomes after radical abdominal trachelectomy for early-stage cervical cancer in a series of 31 pregnancies. Human Reproduction. 2013; 28: 1793–1798.

[6] Kim CH, Abu-Rustum NR, Chi DS, Gardner GJ, Leitao MM, Jr., Carter J, et al. Reproductive outcomes of patients undergoing radical trachelectomy for early-stage cervical cancer. Gynecologic Oncology. 2012; 125: 585–588.

[7] Kato O, Takatsuka R, Asch RH. Transvaginal-transmyometrial embryo transfer: the Towako method; experiences of 104 cases. Fertility and Sterility. 1993; 59: 51–53.

[8] Plante M, Gregoire J, Renaud M, Roy M. The vaginal radical trachelectomy: an update of a series of 125 cases and 106 pregnancies. Gynecologic Oncology. 2011; 121: 290–297.

[9] Carter J, Raviv L, Sonoda Y, Chi DS, Abu-Rustum NR. Recovery issues of fertility-preserving surgery in patients with early-stage cervical cancer and a model for survivorship: the physician checklist. International Journal of Gynecological Cancer. 2011; 21: 106–116.

[10] Bentivegna E, Maulard A, Pautier P, Chargari C, Gouy S, Morice P. Fertility results and pregnancy outcomes after conservative treatment of cervical cancer: a systematic review of the literature. Fertility and Sterility. 2016; 106: 1195–1211.e5.

[11] Fanfani F, Landoni F, Gagliardi ML, Fagotti A, Preti E, Moruzzi MC, et al. Sexual and reproductive outcomes in early stage cervical cancer patients after excisional cone as a fertility-sparing surgery: an Italian experience. Journal of Reproduction & Infertility. 2014; 15: 29–34.

[12] van Meurs H, Visser O, Buist MR, ten Kate FJW, van der Velden J. Frequency of pelvic lymph node metastases and parametrial involvement in stage IA2 cervical cancer: a population-based study and literature review. International Journal of Gynecologic Cancer. 2009; 19: 21–26.

[13] Shim SH, Lim MC, Kim HJ, Lee M, Nam EJ, Lee JY, et al. Can simple trachelectomy or conization show comparable survival rate compared with radical trachelectomy in IA1 cervical cancer patients with lymphovascular space invasion who wish to save fertility? A systematic review and guideline recommendation. PLoS ONE. 2018; 13: e0189847.

[14] Shah JS, Jooya ND, Woodard TL, Ramirez PT, Fleming ND, Frumovitz M. Reproductive counseling and pregnancy outcomes after radical trachelectomy for early stage cervical cancer. Journal of Gynecologic Oncology. 2019; 30: e45.

[15] Noyes N, Abu-Rustum NR, Ramirez PT, Plante M. Options in the management of fertility-related issues after radical trachelectomy in patients with early cervical cancer. Gynecologic Oncology. 2009; 114: 117–120.

[16] Khairy M, Shah H, Rajkhowa M. Transmyometrial versus very difficult transcervical embryo transfer: efficacy and safety. Repro-ductive Biomedicine Online. 2016; 32: 513–517.

[17] Sullivan-Pyke CS, Kort DH, Sauer MV, Douglas NC. Successful pregnancy following assisted reproduction and transmyometrial embryo transfer in a patient with anatomical distortion of the cervical canal. Systems Biology in Reproductive Medicine. 2014; 60: 234–238.

[18] Sharif K, Afnan M, Lenton W, Bilalis D, Hunjan M, Khalaf Y. Transmyometrial embryo transfer after difficult immediate mock transcervical transfer. Fertility and Sterility. 1996; 65: 1071–1074.

[19] Vandermolen BI, Hezelgrave NL, Smout EM, Abbott DS, Seed PT, Shennan AH. Quantitative fetal fibronectin and cervical length to predict preterm birth in asymptomatic women with previous cervical surgery. American Journal of Obstetrics and Gynecology. 2016; 215: 480.e1–480.e10.

[20] Committee on Practice Bulletins—Obstetrics, The American College of Obstetricians and Gynecologists. Practice bulletin no. 171 summary: management of preterm labor. Obstetrics & Gynecology. 2016; 128: 931–933.

[21] Šimják P, Cibula D, Pařízek A, Sláma J. Management of pregnancy after fertility-paring surgery for cervical cancer. Acta Obstetricia et Gynecologica Scandinavica. 2020; 99: 830–838.