I often see patients for an initial consult and while reviewing their gynecological history, they tell me they had an abnormal pap smear. The next question from me is what did the doctor do about it and have you had follow up pap smears? Most all patients have been followed up and many are now getting the thin prep pap as well as an HPV test. This is the most up to date recommendation. By detecting and treating early stage cervical dysplasia (abnormal cells), cervical cancer can be greatly reduced. Recent studies show an 80 percent reduction in cancer rates.
Most of the treatments are successful in terms of eradicating the cervical disease, but they may cause problems or damage to the cervix that could translate into infertility or premature delivery.
It is important for you to know what was done to your cervix. You may recognize your procedure from the following list, but you may need to get old medical records to make sure that you know what was done.
1. Excisional procedures (removing part of the cervix)
- Trachelectomy- removal of the entire cervix. This is a major surgery and usually done for cancer, not just precursors to cancer.
- Cone (Laser or Cold-knife). This is also a surgery, most often done in an operating room, with a laser and/ or scapel. A cone shaped portion of the cervix is removed, since that part of the cervix contained abnormal cells and is more sensitive to cancer formation. This is sent to pathology for a careful exam. This can weaken the cervix and remove the glands that produce the mucus. The mucus helps the sperm get to the egg.
- LEEP/LOOP. This is a procedure where an electrical current is passed through a wire and cuts out the abnormal cervical lesion. It can be a small amount or a large amount. The amount removed determines the remaining cervical strength and the mucus production.
2. Ablative procedures (the tissue stays in place but is “killed” through burning or freezing)
- Laser. A laser zaps the abnormal tissue, burning it.
- Cryotherapy. A freezing metal ball is using to freeze the abnormal tissue and then it will no longer divide.
- Electrocautery. The lesion is burned with a metal ball.
Fertility after the procedure
Most studies show no association between ablative procedures and infertility. Low birth rate and a possible risk of perinatal mortality were seen with the electrocautery in some studies. While infertility may not be hampered in most patients, there can be significant cervical mucus changes in some. If this is coupled with low sperm volume, spermicidal lubricants, or poor sperm quality, it may increase the time to conception. Most infertility doctors no longer do post-coital tests (as studies show little benefit from this awkward test). Instead, undergoing an insemination of sperm rather than timed intercourse may be helpful. The use of clomid also diminishes cervical mucus in most patients and may have an additive effect on the ablative therapy.
In regards to the excisional procedures, data is conflicting. Problems may be caused by some patients getting pregnant too soon after the therapy (it must not cause infertility for them!) and this may result in cervical incompetence or preterm delivery. Cerclages (a stitch placed around the cervix) may be needed to help keep the cervix from prematurely dilating. This is often done at 12 weeks of pregnancy or even before conception in some women. The opposite can also occur and cervical stenosis can cause labor to be abnormal more painful than it already is, or impossible to deliver vaginally. A meta-analysis in 2006 showed that fertility is not impaired after a LEEP. Cold knife cone has been shown to increase second trimester miscarriages by 7 times (1982 study), but newer studies have shown no increase risk. A recent meta-analysis by Arbyn in 2008 showed an increase in preterm labor and pregnancies complications.
Recent studies have also looked at progesterone injections to prevent preterm labor. This does not appear to be successful in the group of patients who are predisposed due to cervical surgery. Using the ultrasound to monitor the cervical length before and during early pregnancy may help but identifying the patients most at risk of cervical incompetence.
While more studies are needed to better understand the effect of cervical disease treatment on fertility, it is clear there are some risks. Being informed about your options and about the potential complications and risks is essential in taking charge of your fertility.