Cervical cancer, a type of cancer that begins in the cervix, can raise questions about fertility and the ability to carry a pregnancy. While a diagnosis can be concerning, advancements in medical treatment offer various possibilities for individuals hoping to conceive or continue a pregnancy.
Impact of Cervical Cancer During Pregnancy
A diagnosis of cervical cancer during pregnancy presents unique complexities. It is rare, with an estimated incidence of 0.1–12.0 cases per 10,000 pregnancies. The incidence is increasing, possibly due to the trend of delayed childbearing.
Managing cervical cancer during pregnancy requires careful consideration of both maternal health and fetal well-being. A multidisciplinary team, including obstetricians, gynecologic oncologists, and neonatologists, makes individualized treatment decisions. The stage and type of cancer, along with the gestational age, significantly influence these choices.
Pregnant individuals diagnosed with cervical cancer face increased maternal health risks, including a higher likelihood of preterm births and cesarean sections. While maternal risks are elevated, neonatal outcomes generally remain stable, with no major differences in birth outcomes between affected mothers and others. Spontaneous regression rates of cervical intraepithelial neoplasia (CIN) are high in pregnant patients, and progression to malignancy is low.
Treatment decisions often involve delaying definitive treatment until after delivery, particularly if fetal maturity is approaching, typically after 34 weeks of gestation. For high-grade lesions or adenocarcinoma in situ (AIS) diagnosed during pregnancy, surveillance via colposcopy and age-based testing (cytology/HPV) is recommended every 12-24 weeks. Excision is only recommended if cancer is suspected.
Fertility-Sparing Treatment Options
For early-stage cervical cancer patients desiring fertility preservation, fertility-sparing surgeries remove cancerous tissue while preserving the ability to conceive. These options are suitable for early-stage disease where the cancer is small and confined to the cervix.
One common fertility-sparing procedure is conization, also known as a cone biopsy. This outpatient procedure removes a cone-shaped piece of tissue from the cervix, including the cancerous growth and a border of surrounding healthy tissue. Conization is typically performed for stage IA1 cases without lymphovascular space invasion (LVSI).
Another option is a radical trachelectomy, which involves removing the cervix and some surrounding tissue, along with a small portion of the upper vagina and nearby lymph nodes, while leaving the uterus, ovaries, and fallopian tubes intact. Recommended for early-stage cervical cancer (stages IA2 to IB1) with tumors under 2 centimeters and no lymph node spread, it suits premenopausal patients desiring reproductive potential, especially for squamous cell carcinoma or adenocarcinoma.
Conceiving and Carrying a Pregnancy After Treatment
The ability to conceive and carry a pregnancy after cervical cancer treatment varies significantly by treatment type. Many individuals can still become pregnant, particularly after fertility-sparing surgeries.
After fertility-sparing treatments like a radical trachelectomy, pregnancies are possible, with reported rates ranging from 41-79%. However, any pregnancy after such treatment is considered high-risk due to complications, including preterm birth (25-39% of cases) and preterm premature rupture of membranes (PPROM), which can lead to infection. The shortened cervix after trachelectomy may lack mechanical support and a cervical mucus plug, increasing the risk of premature labor.
A cervical cerclage, a reinforcing stitch, is often performed during the trachelectomy or in the second trimester of pregnancy to help maintain pregnancy and reduce preterm birth risk. Close obstetric monitoring, including regular ultrasound surveillance of cervical length, is recommended every two weeks from 12 weeks gestation. Progesterone support and prophylactic antibiotics may also be considered. Delivery is typically via cesarean section, often between 34 and 37 weeks, due to the altered cervical structure and the permanent stitch.
In contrast, treatments that are not fertility-sparing, such as a hysterectomy, prevent natural pregnancy. For those undergoing hysterectomy or radiation therapy, which can damage the uterus and ovaries, assisted reproductive technologies offer alternative paths to parenthood. These options include egg or embryo freezing (often before treatment), followed by in vitro fertilization with a gestational carrier (surrogate).
Pelvic radiation can damage ovaries, potentially leading to infertility or early menopause. While rare, successful pregnancies after radiation occur, often due to ovarian displacement. However, the uterus itself can be permanently damaged by pelvic radiation, making pregnancy difficult or impossible. Chemotherapy can also damage reproductive organs, increasing early menopause risk and affecting fertility. Pre-conception counseling with a multidisciplinary team (oncologist, high-risk obstetrician) is highly recommended to discuss treatment implications, risks, and family-building options.