Options in the management of fertility-related issues after radical trachelectomy in patients with early cervical cancer.

摘要

It is estimated that more than 40% of cervical cancer cases diagnosed in the United States occur in women of reproductive age [1 ]. Due to the fact that many young women diagnosed with cervical cancer desire childbearing, treatment options for early-stage (IA2 and IB1) disease now include the fertility-sparing radical trachelectomy in lieu of radical hysterectomy in well-selected patients. This newer procedure can be performed vaginally or abdominally, laparoscopi-cally, and, more recently, by robotic surgery [2-6] (see Fig. 1). Accumulating data suggest that disease-free and overall survival after radical trachelectomy in carefully selected patients is similar to that of radical hysterectomy [7,8]. It is estimated that nearly half the women diagnosed with early-stage cervical cancer under the age of 40 may be eligible for the fertility-sparing option [9]. As of 2008, at least 906 radical trachelectomies had been performed; 790 vaginally and 116 abdominally [10]. Multiple reports document successful pregnancy outcome following trachelectomy, although not without the potential for obstetrical risk [11-17]. Coincident cerclage placement is optional and varies among practices performing trachelectomy procedures. Regarding infertility, in the three largest published series totaling 247 post-trachelectomy patients, 120 (48.6%) attempted conception, and of these, 35 (29.2%) patients were noted to have fertility-related issues [11-13]. Plante [11 ] and Bernadini [12] cumulatively reported on 23 infertile women post-trachelectomy; 15 (65.2%) cases were attributed to cervical issues while the other 8 were felt to be caused by traditional infertility problems, including 5 with ovulatory dysfunction, 1 with low semen parameters plus endometriosis, and 2 with unexplained infertility. Eleven (48%) of these infertile women conceived, all through the use of fertility-enhancing treatments (IUI or 1VF). Of the 15 cases attributed to cervical insufficiency, 7 (47%) became pregnant using IUI or IVF.