Assisted conception following radical trachelectomy.

BACKGROUND: Radical trachelectomy (RT) has been established as a valuable fertility-preserving treatment in women with early stage cervical cancer. A number of these women will require assisted conception which may bring certain challenges to those managing treatment. An awareness of those challenges is essential to maximize outcome in terms of live birth rates. METHODS: All women who had undergone assisted conception following RT were assessed with respect to treatment management and pregnancy outcome. RESULTS: Pregnancy rates were good, with nine pregnancies in seven women treated. Difficulties in treatment were essentially related to isthmic stenosis. There was a clear need for trial embryo transfer (ET) prior to treatment and dilatation of the isthmus where necessary. The premature delivery rate was high (75% at <37 weeks), highlighting the importance of single ET to avoid multiple pregnancy. CONCLUSIONS: Assisted conception following RT is associated with a good pregnancy rate, although there is a high miscarriage and premature delivery rate. Treatment outcome should be maximized by careful patient preparation in terms of assessing the need for isthmic dilatation, and ET should be performed by an experienced operator.

The normal menstrual cycle in women.

The menstrual cycle in women is characterised by high variability in cycle length (26-35 days), 5-day menses, a fertile phase from 5 days before to the day of ovulation, and low fertility which is dependent on cycle length and age. All women show an FSH rise at the luteal-follicular transition, stimulating a cohort of follicular growth and inhibin B secretion in the early follicular phase. The ovulatory dominant follicle (DF) is selected in the mid-follicular phase, and as this DF grows it increasingly secretes oestradiol and inhibin A for a week before ovulation. Gonadotrophin responsiveness, IGF binding protein expression and degradation, and vascularisation have been identified to be crucial for DF selection and progression. Two-thirds of women show two follicle waves and 1/3 show 3 follicle waves per cycle. Three-wave women have longer cycles, and a later oestradiol rise and LH surge. The corpus luteum secretes progesterone, oestradiol and inhibin A in response to LH pulses, and reaches its peak in terms of size, secretions, and vascularization 6-7 days after ovulation. Luteal regression is passive and independent of the uterus, but can be prevented by hCG, the luteotrophic signal from the trophoblast, from 8 days after conception. Reductions in systemic steroid and protein hormone concentrations may be responsible for the FSH rise characteristic of premenopausal women. The functional layer of the endometrium shows steroid hormone-dependent proliferation, differentiation, and shedding in the absence of the trophoblast. Menstruation is initiated by progesterone responsive decidual cells, and executed by PGE and PGF2α, vasoconstriction and matrix metalloprotease secretion by leukocytes. Ovarian function and also hormone fluctuations during the menstrual cycle are similar to oestrous cycles of cows and mares, justifying research into comparative aspects of menstrual and oestrous cycles in monovulatory species.