Abstract
Objective: to evaluate the desire for parenthood and
reproductive outcomes following fertility-sparing treatment for invasive
cervical cancer including Vaginal Radical Trachelectomy (VRT), Radical
Hysterectomy (RH) and chemoradiotherapy.
Design Retrospective cohort study
Setting Tertiary referral center in the Netherlands
Population patients <45 years with invasive cervical
cancer desiring to maintain reproductive potential.
Methods Clinicopathologic and reproductive outcomes were
retrieved from medical files and postal questionnaires for patients
treated between 2009 – 2020.
Main outcome measures Survival, recurrences, fertility and
pregnancy outcomes
Results : 75 patients were identified of whom 34 underwent VRT,
9 RH and 32 had (chemo)radiotherapy. 26 patients started fertility
preservation (FP) procedures of whom 23 (88.5%) successfully preserved
fertility. After a median follow-up of 49 months, 5 patients developed
recurrent disease and died. Reproductive outcomes were available for 58
patients of whom 89.6% maintained their desire for parenthood.
Following VRT, 15 patients conceived 21 pregnancies which resulted in 15
live-births, yielding a pregnancy rate of 61.9% and live-birth rate of
75.0%. Following RH or (chemo)radiotherapy, 3 surrogate pregnancies
were established (21.4%) using frozen-thawed oocytes (n=2) and ovarian
tissue fragments (n=1) with good neonatal outcomes.
Conclusions Many cervical cancer patients maintain the desire
to become parents after cancer treatment. Vaginal Radical Trachelectomy
and Fertility Preservation enable young women with invasive cervical
cancer to become a parent after cancer treatment. Structural and timely
fertility counseling is of the essence when attempting fertility-sparing
treatment and should be available to all.
Keywords cervical cancer / oncofertility / trachelectomy /
fertility preservation / surrogacyIntroduction
Cervical cancer is the fourth most common cancer among women worldwide
and affects women at a significantly younger age than most other
malignancies. Approximately 42% of the women diagnosed with cervical
cancer is ≤ 45 years 1, 2. Combined with a trend
towards delayed childbearing, many of these women may not have completed
their desire for parenthood at time of cancer diagnosis. Recent studies
on the effects of treatment-associated infertility and quality of life
among young cancer survivors have quantified the impact of
treatment-induced infertility, resulting in long-lasting emotional and
physical distress 3, 4. Together with the improved
survival rates for cervical cancer, fertility-sparing treatment options
are becoming increasingly for these women 5.
Standard treatment for invasive cervical cancer includes radical
hysterectomy (RH) with pelvic lymphadenectomy for early-stage disease
and chemoradiotherapy for advanced stage-disease. Both with obvious
implications for fertility 6. The past two decades,
fertility-sparing treatment options have been introduced in the
management of invasive cervical cancer. These include Vaginal Radical
Trachelectomy (VRT) and fertility preservation (FP) for more advanced
disease. Studies showed that VRT is an oncologically safe treatment
alternative in carefully selected patients with overall good obstetric
and neonatal outcomes 7, 8. When requiring RH or
chemoradiotherapy, biological parenthood is feasible through fertility
preservation (FP) and a surrogate. While all these treatment options
enable patients to have a biological offspring after cancer treatment,
well-known complications following VRT include infertility and
prematurity9 . Furthermore, little is known about
reproductive outcomes following FP and gestational surrogacy pregnancies
due to the experimental nature of these procedures.
To date no studies have addressed the desire for parenthood after cancer
treatment among cervical cancer survivors nor did they address
reproductive outcomes for all patients with invasive cervical cancer
including both fertility-sparing surgery and fertility preservation.
The aim of this study is to evaluate fertility-sparing management for
invasive cervical cancer as a whole, addressing the desire for
parenthood and reproductive outcomes of patients who underwent either
fertility-sparing surgery or fertility preservation. These data will
provide both patients and clinicians with realistic expectations
regarding reproductive intentions and outcomes in cervical cancer
treatment and therefore improve counseling in newly diagnosed cervical
cancer patients.