April 23, 1999

"By working collaboratively, we are able to help our cervical cancer patients deal with the issues and pursue avenues of fertility preservation that may not be available at other hospitals."

Thomas Toth, MD

What happens when a woman in her childbearing years discovers she has cervical cancer before she's had children? Not only must she deal with the shock of a cancer diagnosis, she also must confront the possibly traumatic news that she may never be able to have children.

In an effort to expand fertility options for women, a trio of physicians at the MGH Vincent Memorial Obstetrics/Gynecology Service has offered women with early cervical cancer the possibility of having their own children through in vitro fertilization (IVF), a standard infertility procedure. It is the first time in the United States that the use of IVF for cervical cancer patients has been reported in a medical journal.

In the article published in Obstetrics & Gynecology in December 1998, gynecologic oncologists Linda Duska, MD, and Annekathyrn Goodman, MD, and infertility specialist Thomas Toth, MD, presented two examples, as well as technical and ethical issues. As they outlined, in more than 50 percent of the cases of cervical cancer, the tumors are small – less than a quarter of an inch – and appear only on the cervix. The standard therapy of a radical hysterectomy, which involves removing the uterus and cervix but not the ovaries, cures more than 80 percent of patients. Yet 10 to 15 percent of women diagnosed with the disease are in their childbearing years. "It's heartbreaking to tell a woman she has cancer, and that the cure requires that we remove her uterus," says Duska.

Taking advantage of the opportunity offered by the Vincent team, two women with cervical cancer chose to undergo the IVF procedure. First their ovaries were stimulated to produce multiple eggs. After the retrieved eggs were mixed with sperm, the embryos were frozen and each woman then underwent a radical hysterectomy. In one case, some of the embryos were implanted in the woman's twin sister, who had offered her uterus as a surrogate womb. She conceived but later miscarried. In the second case, a 28-year-old woman without a partner, the egg retrieval was successful and the embryos remain frozen.

Though using IVF techniques postpones cancer therapy for two to three months, the delay appears to be safe for most women with cervical cancer. "The treatment, however, may not be appropriate for all patients," says Goodman. "We don't think using hormones to stimulate the ovaries spreads cancer of the cervix, a contrast to breast and uterine cancers, which are exacerbated by hormone use."

In addition to informing other gynecologists and gynecological oncologists of the technique, the Vincent physicians published the article because they wanted to present a host of issues to the medical community: Should the treatment be offered only to women with no children? Should it be offered to women in their late 30s or older? To women who are HIV positive? To a woman with cervical cancer who has no partner? Should the therapy be available when a couple has no surrogate womb available? And if a couple never finds a woman to carry the embryo, what happens to the frozen embryos? If the patient dies, but her embryos survive, what should happen to the embryos? Which criteria should the medical community use to determine appropriate candidates? And because IVF is an expensive procedure, in which circumstances should insurance companies be paying for the treatment?

While the issues for physicians are numerous and complex, "for patients they can be overwhelming," says Toth. "It requires close teamwork among the cancer physician, reproductive endocrinologist, nurse and social worker to counsel the patient. By working collaboratively, we are able to help our cervical cancer patients deal with the issues and pursue avenues of fertility preservation that may not be available at other hospitals."