Gynecological cancer in a woman of reproductive age is devastating news. Many women facing cancer treatment are interested in maintaining fertility. Fortunately, fertility-sparing treatment options are increasingly available and successful pregnancies have been reported.
These pregnancies present unique challenges to optimizing care of the mother and the fetus. In this article, we review the literature on pregnancies after successful treatment of ovarian, cervical, and endometrial cancer, and gestational trophoblastic disease.
For young women diagnosed with ovarian cancer, the question of fertility preservation is often paramount. The American Society for Reproductive Medicine and the American Society of Clinical Oncology have published guidelines endorsing embryo and oocyte cryopreservation as viable strategies for maintaining fertility ( J. Clin. Oncol. 2013;31:2500-10 / Fertil. Steril. 2013;100:1224-31 ).
Particularly with non–epithelial cell (germ cell) and borderline tumors, innovations in cryopreservation have become more widely available. Cryopreservation of immature oocytes in young girls is still considered investigational and should be undertaken as part of a research protocol. In a study of 62 women with epithelial ovarian cancer who underwent oocyte cryopreservation, there were 19 conceptions and 22 deliveries – all at term with no anomalies ( Gynecol. Oncol. 2008;110:345-53 ).
However, pregnancies resulting from in vitro fertilization are at increased risk for anomalies and a targeted ultrasound and fetal echocardiogram are recommended.
In the United States, 43% of women diagnosed with cervical cancer are under age 45. For women with early-stage cancer with radiographically negative lymph nodes, tumors less than 2 cm, and no deep stromal invasion, fertility-sparing procedures include radical trachelectomy and simple vaginal trachelectomy.
Trachelectomy for appropriately selected patients is safe with recurrence rates of 2%-3% and death rates of 2%-5%. While experimental, for women with bulky disease (greater than 2 cm), neoadjuvant chemotherapy and subsequent trachelectomy has been reported ( Gynecol. Oncol. 2014;135:213-6 ). While there is no consensus, most experts recommend 6 months to 1 year after surgery to attempt conception.
Conception rates after trachelectomy are promising with 60%-80% able to conceive. Approximately 10%-15% of these women will experience cervical stenosis, often attributed to the cerclage, resulting in menstrual or fertility issues ( Gynecol. Oncol. 2005;99:S152-6 / Gyncol. Oncol. 2013;131:77-82 ). Placement of an intrauterine cannula (Smith sleeve) at the time of trachelectomy decreases the rate of stenosis ( Gynecol. Oncol. 2012;124:276-80 ).
Pregnancy outcomes in several case series after trachelectomy have demonstrated a rate of first trimester loss of 13%-20%, second trimester loss of 5%-8%, and preterm delivery of 27%-51%, mostly secondary to preterm premature rupture of membranes (PPROM) and/or chorioamnionitis. Both preterm deliveries and midtrimester losses are thought to be secondary to cervical insufficiency, decreased cervical mucus, and ascending infection.
Women who have undergone fertility-sparing treatment for cervical cancer should be counseled about the challenges of pregnancy, including decreased fertility, risk of early and late miscarriage, and preterm delivery. Practitioners should consider cervical length surveillance, especially for those without a cerclage, and vaginal progesterone. The potential utility of preemptive antibiotics in this population is unclear, though early treatment of urinary or genital tract infections is prudent.
As a consequence of the obesity epidemic, younger women are being diagnosed with endometrial hyperplasia and cancer. Approximately 25% of early stage endometrial cancers are diagnosed in premenopausal women, and 5% in women under age 40.
While hysterectomy is standard, fertility-sparing treatment with progestin for well-differentiated grade 1 stage 1A endometrial cancer has been successful and is not associated with any increase in disease progression and/or death ( Obstet. Gynecol. 2013; 121:136-42 ).
Nearly two-thirds of the successfully treated women will require fertility medications and/or assisted reproductive technology (ART). Among those who conceive, 25% will miscarry. Following childbearing, definitive hysterectomy is recommended given the high recurrence rate ( Gynecol. Oncol. 2014;133:229-33 ).
Gestational trophoblastic disease
Women with a history of complete and partial molar pregnancies and persistent gestational trophoblastic neoplasia (GTN) often pursue subsequent pregnancy. In a large cohort of more than 2,400 pregnancies after GTN, pregnancy outcomes were similar to those of the general population ( J. Reprod. Med. 2014;59:188-94 ).
Among women with a history of a complete or partial mole, 1.7% had a subsequent pregnancy complicated by another molar pregnancy. Women who received chemotherapy for GTN may have a slightly higher risk of stillbirth (1.3%) and higher rates of anxiety in subsequent pregnancies ( BJOG 2003;110:560-6 ).
Young women experiencing gynecologic malignancies are often concerned about the safety of pregnancy. In appropriately selected patients, fertility preservation is safe and pregnancy outcomes overall are favorable, although women should be counseled regarding reduced fertility, the need for ART, and the risks of prematurity and stillbirth.
Pregnant women with a history of cancer or gestational trophoblastic disease are also at high risk for depression and anxiety. Women with a personal history of gynecologic cancer or GTD should be followed by a multidisciplinary team that can address the obstetrical, oncological, and psychological aspects of pregnancy.
Dr. Smid is a second-year fellow in maternal-fetal medicine at the University of North Carolina at Chapel Hill. Dr. Ivester is an associate professor of maternal-fetal medicine and an associate professor of maternal child health at UNC-Chapel Hill. The authors reported having no financial disclosures.