Fertility-sparing treatment in gynaecological cancer

Standard treatment for gynaecological cancer often removes the womb, cervix or both ovaries, which ends the ability to carry or conceive a pregnancy. Fertility-sparing treatment modifies this for people with small, early cancers who still hope to have children. It is not a lesser form of treatment, but a different balance in which a small extra risk of recurrence is accepted in return for keeping reproductive organs.

Macmillan says doctors and nurses should discuss fertility preservation if treatment might affect fertility, and that you do not need to be in a relationship or a certain age, gender or sexual orientation to ask. The conversation ideally happens before treatment starts.

Macmillan describes LLETZ or cone biopsy as sufficient for the earliest stage 1A1 disease, which preserves the womb. For slightly larger early cancers, trachelectomy removes the cervix and upper part of the vagina, leaves the womb and places a stitch at the lower womb to support a later pregnancy. Cancer Research UK says it may preserve fertility.

Macmillan notes that pregnancies after trachelectomy need caesarean delivery and that miscarriage risk is increased. Pelvic lymph nodes are usually assessed, and if they contain cancer the plan can switch to chemoradiotherapy, which ends fertility. Radical trachelectomy has its own dedicated page in this series.

The NHS states that early-stage ovarian cancer can be treated by removing one or both ovaries with the tubes or by hysterectomy, and that specialists discuss fertility preservation before treatment. In selected cases, removing the affected ovary and tube while keeping the womb and opposite ovary is possible. Staging checks are done at the same operation, including biopsies from the pelvis and abdomen.

Eligibility rests on cell type. Early-stage low-grade tumours, borderline tumours and germ cell tumours are the settings in which conservative surgery is used most often. Higher-grade or high-grade serous disease generally calls for fuller surgery, since the risk of leaving cancer behind is greater.

The NHS lists hormone therapy within womb cancer treatment, mainly for advanced cases or people unfit for surgery. In a small group of younger people with early, low-grade disease and no sign of spread on MRI, specialist centres may offer progestogen-based hormone treatment with repeated biopsies, as a bridge to pregnancy.

This is an off-pathway approach that needs frequent monitoring, and hysterectomy is generally advised after childbearing is complete or if the treatment does not work. Atypical endometrial hyperplasia, a pre-cancer, is managed in a similar way in some people.

Macmillan lists egg freezing, embryo freezing and ovarian tissue preservation as the options for women. Which are possible depends on how urgently treatment must start, because egg stimulation takes time, and on whether the cancer is hormone sensitive.

If chemotherapy or pelvic radiotherapy is needed, ovarian function may fall. Cancer Research UK states that radiotherapy to the cervix stops the ovaries working, leaving a woman infertile and unable to have children naturally. Your team may refer you to a fertility service, and advice on contraception during and after treatment is part of the plan.

Macmillan says research suggests pregnancy generally does not increase the risk of cancer recurring, though history and treatment shape individual risks. Waiting periods are sometimes advised, and some treatments bring menopause forward and narrow the window.

After fertility-sparing surgery, pregnancy is usually under the care of an obstetric team with experience of high-risk cases, with extra scans and a planned birth. Your oncology team should agree when it is safe to try.