About Christopher Bryant, M.D., FACOG
Dr. Bryant is a gynecologic oncologist specializing in surgery, treatment, and research for female conditions, including reproductive cancers (ovarian, endometrial, cervical, and others), and robotic surgery. His special interests include oncofertility and helping with education and management of women’s health issues and impact on family planning.
Dr. Bryant is board certified by the American Board of Obstetrics and Gynecology. He is also a member of the American Congress of Obstetricians and Gynecologists, the Society of Gynecologic Oncology, the American Society of Clinical Oncology, the American Medical Association and the Florida Society of Clinical Oncology.
Dr. Bryant received his undergraduate degree from Arkansas State University and his Doctor of Medicine from the University of Arkansas for Medical Sciences. He completed his residency in obstetrics and gynecology at St. John’s Hospital and Medical Center and completed a fellowship in gynecologic oncology at Wayne State University Karmanos Cancer Institute.
About Mark P. Trolice, M.D.
Mark P. Trolice, M.D., FACOG, FACS, FACE, is Director of Fertility CARE: The IVF Center in Winter Park, Florida and Associate Professor of Obstetrics & Gynecology (OB/GYN) at the University of Central Florida College of Medicine in Orlando responsible for the medical education of OB/GYN residents and medical students as well as Medical Endocrinology fellows. He is past President of the Florida Society of Reproductive Endocrinology & Infertility (REI) and past Division Director of REI at Winnie Palmer Hospital, part of Orlando Health.
His current book, The Fertility Doctor’s Guide to Overcoming Infertility: Discovering Your Reproductive Potential and Maximizing Your Odds of Having a Baby, is now available for pre-order on Amazon.com.
He is double board certified in REI and OB/GYN, maintains annual recertification, and has been awarded the American Medical Association’s “Physicians’ Recognition Award” annually. He holds the unique distinction of being a Fellow in all three American Colleges of OB/GYN, of Surgeons, and of Endocrinology. His colleagues select him as Top Doctor in America® annually, one among the top 5% of doctors in the U.S. In 2018, he was awarded the “Social Responsibility Award” by the National Polycystic Ovary Syndrome Association. For ten years his foundation, Fertile Dreams, organized seminars to increase fertility awareness and granted national scholarships for those unable to afford in vitro fertilization (IVF) treatment.
Dr. Trolice serves on committees for the American Society for Reproductive Medicine and the Society for Assisted Reproductive Technology as well as the editorial advisory board of Ob.Gyn.News. He has conducted scientific studies with resultant numerous publications and been appointed a reviewer in many leading medical journals and textbooks. He has lectured at numerous physician and patient seminars around the country. In addition, he is interviewed regularly on TV news/talk shows, radio, podcasts, print/online magazines and newspapers on reproductive health topics.
Speaker 1: Thanks for tuning in to the Fertility Health Podcast, hosted by renowned fertility specialist, Mark Trolice, MD. Each episode features firsthand advice and potential treatment news tips and strategies listeners can use on their fertility journey. And now here’s your host, Dr. Trolice.
Mark: Hi and welcome to the Fertility Health Podcast. I’m your host, Dr. Mark Trolice, and I wanted to talk today about the cervix. A woman get screened with pap smears for cervix and screens for cancer obviously. So you may be thinking, what does this have to do with fertility? Well, pregnancy health is really based on how healthy you are prior to pregnancy and unless you are optimal before you get pregnant, you can have more complications during pregnancy that would affect you and baby.
Mark: So I thought we would talk about some things with your cervix to ensure that you are getting proper screening and also what we can do to optimize your fertility and protect your fertility if you do get cervical disease. I could think of no other person to talk about that better than Dr. Christopher Bryant. Chris is here in Orlando and he’s a gynecologic oncology and surgeon for more than 15 years.
Mark: He’s specially trained at National Cancer Institute, a designated Karmanos Cancer Institute in Michigan, and his special interests are in onco fertility, helping with education and management of women’s health issues and impact on the family planning. Chris has helped us with our patients and he’s an outstanding clinician and advocate for women’s health. Chris, thanks for joining us on the Fertility Health Podcast.
Chris: Dr. Trolice, I appreciate being invited to be here with you.
Mark: Oh my pleasure, completely. So, Chris, the issues of pap smears screening have changed over the years, certainly since we’d been trained. So what could you advise a woman who’s trying to conceive for good cervical health?
Chris: Well, you’re correct in that since we did our initial training, things have changed drastically. And the two things that have happened most are the way the pap smears are collected and processed, as well as something that’s called cotesting, where we use actual tests for DNA that looks for a virus that is largely involved with people that have abnormal precancer or cancerous changes at the cervix.
Chris: Since the populations of people that are trying to become pregnant or start their family planning is a wide range of people, it actually encompasses those people that are under the age of 21, because some couples choose to start very early in their pregnancy and their attempts of obtaining family planning and those that go further out into their 40s even that have had other obstacles, either career or not opportunities to start their family planning until later.
Chris: And because of that wide range of age groups, we sort of cross a significant continuum of screening guidelines. Used to, we were taught that your cervical cancer screening with pap smears should start at a very early age and that was based on both sexual activity and age. Since then, we have noticed and learned through our research that those women that are under the age of 21 have a very low risk of developing cervical cancer, and therefore, starting your initial screening really shouldn’t occur, regardless of your sexual activity until the age of 21.
Chris: So I think there would be a small group of women before the age of 21 that if they were starting their family planning and moving forward that there would still be a catch point that we would be able to evaluate them to make sure that they were at optimal health. That optimal health is most women’s prenatal visit at the very first visit allows them to have a pap smear performed to ensure that their environment for the pregnancy is as healthy as possible.
Chris: Then when we get into that age group of 21 to 29, we see that we can use the pap smear test alone without using the virus testing as a way to screen women for those changes that make us concerned for precancer changes.
Mark: I’m sorry, because I may just jump in for a second because a lot of information, I just want to make sure our audience is staying with us. So the initial screening after age 21, irrespective of sexual activity, how often should women be getting a screen?
Chris: Well, so as we look at those three age group categories would be under 21, 21 and 29, and then 30 through menopausal age. They vary based on those age groups. So when you reach that reproductive years of 21 to 29, the recommendation is that every three years they received their pap smear testing. For that age group older than 29, which would be 30 and above, they use the HPV testing plus the pap smear and that’s done typically every five years.
Mark: Okay. So HPV for our audience is the human papillomavirus. And this is the one that has been most commonly associated with cervical cancer, particularly the different types of HPV. Was it 16 and 18 I believe, correct?
Chris: That’s correct. That’s the most common types that we watch for for precancerous and cancerous changes.
Mark: So if a woman has a normal pap smear and is tested positive for HPV, should that influence her reproductive choices?
Chris: I don’t believe so, unless there are scenarios that resulted in further diagnostic tests or treatment based on the results. For example, you and I both know that in those women that we do find precancerous change too. Sometimes they need a larger biopsy or a portion of it cervix to be evaluated, and there’s a lot of concern that that in itself can result in some loss of fertility or difficulty with becoming pregnant or maintaining a pregnancy.
Mark: Okay. All right. Very good. So what a lot of women may not be aware is that if they do have an abnormal pap smear, a lot of times they’ll go to the next step of having a microscopic or magnified view of their cervix to see if there’s any changes on the cervix. And this is done while you’re awake in the gynecologist’s office and maybe biopsies are performed as well, and this is called a colposcopy. Now, based on the colposcopy, Chris, there are treatments for cervical disease that are not very invasive. And can you just walk us through a couple of those?
Chris: Yeah, so you’re right, I described the colposcopy the same way, basically as a magnifying glass that lets us have a closer look at the skin or the tissue at the cervix. It’s very similar to what dermatologists do and lots of people understand dermatology exams. There are multiple treatments you can do based on the risk or the scale of the precancerous change or the abnormal changes. And you’ll see things all the way from observation, which is different from when you and I first started.
Chris: Everybody, even with mild changes that are really not a big deal, would receive some of treatment. Nowadays the people with mild changes, they just many times get watched for some times as long as two years because they know it may resolve on its own and then those people that go further into the more higher changes either moderate or severe. When we see those changes, we start talking about procedures that remove the abnormal cells from the skin to allow the healthy cells to grow in.
Chris: And physicians have a huge list of tools to do that with, not only freezing the area but removing that area with a very simple biopsy-like procedure and some docs even still use laser as a way to treat those abnormal skin areas of the cervix.
Mark: So, a lot of women do hear about a LEEP or a cone, which is excising were removing a part of the cervix that’s diseased. Now without having to really distinguish between the two, it is removing a portion of the cervix, and obviously for reproductive purposes we’re always concerned about is that going to cause any problems with subsequent fertility? Because the cervix does secrete mucus to facilitate sperm transport to go up through the cervix into the uterine cavity and eventually the Fallopian tubes to fertilize the egg.
Mark: So if the cervix is affected, are we reducing pregnancy rates as a result of affecting cervical mucus, number one. And number two, are we increasing our risk of miscarriage or preterm labor if we are removing such a large amount of the cervix based on the extent of disease?
Chris: Yeah. So there’s been a lot of interest, especially for LEEP colonizations or any colonizations, and we’ll just refer that to as a LEEP because that’s the most common term I think our patients hear. It has been a procedure that’s been around for many years and decades, and therefore we’ve gathered a lot of information from it. And if you watch people that have a LEEP performed, the things that they worry about are after the LEEP, will there be a barrier like you’re talking about to cervical mucus or the opening of the cervix to the wound that results in cervical stenosis, which may result in a barrier of the reproductive male and reproductive female reproductive parts being able to join together to allow for fertilization.
Chris: Then the other part would be is there a role for what we call a cervix not being strong enough to hold a pregnancy or resulting in miscarriages. They seem to be extremely uncommon to occur. Women that have had multiple, extensive procedures appear to be at risk for having more complications related to the LEEPs. So fortunately, we don’t see a high risk related to being able to become pregnant or carry a healthy pregnancy and it seems to be only in a rare few that that occurs. But it’s definitely something and each provider should work with their patients to minimize that risk as much as possible.
Mark: What about further and, oh by the way, when you mentioned stenosis, just for the listeners, that’s a narrowing of the canal of an area that we’re looking at. So cervical stenosis means that the area from the outside of the cervix up into the uterus can get very, very, very narrow. Rarely, it can be closed off and prevent menstrual flow if I’m passing, and obviously we’d be concerned about fertility issues of sperm traveling up into the uterine cavity.
Mark: But while we talked about miscarriage, Chris, what about cervical shortening? You hear a lot about this from our colleagues in high risk obstetrics, and they will measure by ultrasound the length of a pregnant woman’s cervix to predict preterm labor and possibly delivery. Are you seeing any increasing risks with a LEEP, removing that portion of the cervix, and preterm labor because of cervical shortening?
Chris: So, it kind of falls into all of those areas. As we do more procedures and this particular case leaves, we do increase that risk of it occurring. Although that risk is still small, but well, we’ve sure come a long way with helping women with maintaining a healthy pregnancy. As you know, our technology of ultrasounds, which most women now are very familiar with ultrasounds, and it’s like the stethoscope of the OB/GYN.
Chris: It’s really our main tool that helps us see what’s going on with the mom and the pregnancies, and they’ve developed algorithms that, like you said, the high risk docs will use actual measurements of that to determine if someone is starting to come into a high risk group for either the cervix not holding onto the pregnancy or something that would be at risk for preterm delivery or a miscarriage. So yeah, so definitely people with a history of those changes from precancerous or cancerous changes from the cervix. Those that need to be monitored because of their previous procedures have hopefully and happily we have high risk docs that are able to help us with that.
Mark: Thanks for tuning in to the Fertility Health Podcast. I’m your host, Dr. Mark Trolice and I wanted to take a few seconds and share some exciting news with you. My new book, The Fertility Doctor’s Guide to Overcoming Infertility: Discovering Your Reproductive Potential and Maximizing Your Odds of Having a Baby is now available for preorder on Amazon. It’s a long title, but I assure you that’s because there is so much great information and insight packed within the only general guide to infertility written by a medical doctor who specializes in the subject. That’s me.
Mark: This book has been a labor of love and I can’t wait to share it with you all. So give yourself the best possible odds for getting pregnant and having a baby with this concise and encouraging companion available on Amazon for preorder today. Now back to the episode.
Mark: Moving on now to disease, that becomes much more serious, and this is the carcinoma in situ, which is the limited disease to the cervix. Okay, it hasn’t spread. It’s the cancer that’s very, very limited to the cervix. And then of course cervical cancer, that’s a little bit more invasive. Those are opportunities still for fertility preservation, whether it was sparing the woman’s uterus to be able to subsequently conceive, correct? And could you walk us through that a little bit?
Chris: Yeah, so those people, we still are lucky to have a continuum there and like you said, the term we use is carcinoma in situ or stages zero cervix cancer. It technically hasn’t reached the cancerous stage itself, but those are still amenable to treatments either with colonization or that LEEP procedure. And in that you get to preserve the normal portions of the cervix to participate with a sperm transfer and fertilization and holding and maintaining a pregnancy.
Chris: And then even up to those people that may have an actual cancerous lesion or spot. Some of those women are able to have a larger portion of the cervix removed, even removed from the lower part of the uterus to able to still maintain the ability to not only have their own pregnancy but carry their own pregnancy. And then fortunately those conditions that create a risky environment for a woman related to their cervix and uterus, the chances of cervix cancers involving or being spread to the ovary, because all of this worry about cancer spread if we’re given a diagnosis of cancer.
Chris: It is so low that even with those women that unfortunately have to have their complete cervix and uterus removed, usually we are able to preserve or keep the ovaries so that we can use techniques like you do with our reproductive specialists with their IVF and use of surrogate mothers to still be able to build their family.
Mark: Yeah. So someone with a localized cancer to the cervix, and you mentioned you’re removing the cervix, so that’s the trachelectomy, correct? So we’re sparing the uterus, but removing the neck, if you will, the neck of the uterus, which is the cervix. So what fertility opportunities there are if you’re able to move the cervix, so the woman is able to still have periods if you create an opening in the lower part of the uterus, correct?
Chris: That’s correct. We still try to maintain that canal or lower uterine opening so that there could be natural fertilization. Although most of those patients, we work with an onco fertility specialists like yourself to assist or aid in the fertilization process. But still be able to either transfer or offer fertilization further into the uterus, away from the surgery area.
Mark: So for our fertility patients listening, the typical way for a reproductive specialist, fertility specialist, to help you conceive is either through intrauterine insemination, IUI, or in vitro fertilization with embryo transfer. And both of these involve the cervix. So we put a catheter through the outside of the cervix, passing through the cervical canal up into the uterine cavity. So if we’re doing this, and then the embryo transfer the same way, of course. So if we’re doing this and the cervix is removed, we may be able to get through the opening up into the uterine cavity. But how would these patients deliver, Chris, if they fortunately can conceive?
Chris: Well, for those of the women that are thinking, well, this doesn’t make sense, you remove part of the uterus and we’re worried about incompetence, but then you tell me you remove all of the cervix, and now I’m not worried about incompetence. There are then procedures that we’ve used for decades as a way to help women carry their own pregnancy when they’re at risk for early pregnancy loss, miscarriages and preterm labor. And those are called cerclages.
Chris: And the cerclage is actually a term that describes basically a tourniquet and a tourniquet that holds that area permanently together in a fashion that allows you to still do those procedures that you just talked about. But then at the same time, small enough and tight enough that it allows the pregnancy to develop and do the normal growth and the size of the uterus without growing in that particular area to result in pregnancy loss.
Mark: Interesting. So they would then have a scheduled C-section at the time of delivery and, yes, mm-hmm (affirmative). So, there is no ability for the, I’m just curious, for the ability for the lower uterus to expand, to allow baby to pass, if you’re able to remove that cerclage. But typically the cerclages are not placed through the vagina. There would be abdominal placements. So more complicated, correct?
Chris: That’s right. So the cerclages are done two different ways. For women that have a cervix in place, typically a high risk pregnancy physician will play cerclages around the cervix itself. Those are commonly removed at the time of labor to allow for a normal vaginal delivery. For those women that have been burdened with cervical cancer, that they’ve undergone the removal of the cervix or that trachelectomy and then the reproductive specialist to aid in helping with obtaining a pregnancy.
Chris: Prior to that pregnancy, and usually at the time of the removal of the cervix, an abdominal cerclage is placed, meaning that it is inside the abdomen. Although behind all the special normal structures, it’s in a place that is not able to be removed, nor is it advised to be removed to allow for a vaginal delivery.
Mark: Interesting, very, very good. So to take it one step further, if we have significant advanced disease and the uterus is required to be removed, for our listeners, if we’re able to just maintain one ovary, then we can still potentially get eggs. Or, of course if your ovaries needs to be removed at the time of a surgery, we could get eggs before the removal of the ovaries and then use a gestational carrier to still use your eggs. Chris, is it common to remove the ovaries with cervical cancer or are you just displaced them if you have to do radiation?
Chris: Yeah, that’s a good question. So unfortunately, like with all cancer patients, we’re always worried do they need more than just surgery? Do they need chemotherapy or do they need radiation? And unfortunately in those women that need radiation, we know that that can result in what we call premature early failure of the ovaries. And that failure we’re talking about is not only hormonal function, but also the reproductive function, the loss of a production of eggs.
Chris: So in women that have a very early cervix cancer and minimal to no chance of needing chemotherapy or radiation, the ovaries typically are left down in an area close to the vagina so that those reproductive specialists like yourself that are helping families build their families larger. They’re in a place that you know technically allow you to reach them after you’ve used your special techniques to produce the eggs.
Chris: But fortunately, you and I’ve had a few cases where in those patients we’re worried that they may need more treatment than the surgery alone. The ovaries are able to be placed into different area just a little bit outside the pelvis with their normal attachments and blood supply to the body, but still gives us an opportunity to stimulate those ovaries or achieve those eggs and use a gestational carrier.
Mark: Yeah, I’ve seen it. I was at the American Society of Reproductive Medicine. I was moderating or video session and they were showing the return of the ovaries that were transposed or displaced out of the pelvis to not be affected by the radiation beam, the extra radiation beam, and then put back into the pelvis. So it’s difficult to retrieve those eggs through the vagina when they are displaced and transposed, but I hope this is as exciting to the listeners as it is to me, because what we’re doing now for fertility preservation and early detection of cancer is amazing.
Mark: So Chris, before we actually close, I just wanted to emphasize the fact to our listeners that for everything that you can do, it’s always better to do for your health before pregnancy, because every treatment of a problem gets more complicated once we are pregnant with baby involved. So then we have to think about how to do that and also maintain an optimal pregnancy. So Chris, before we go, if you could just review how often women should be getting screening for pap smears and evaluations of their cervix.
Chris: That sounds great. And remember we’re talking about reproductive age women that go from early years after starting their cycles all the way up until menopause, and those screening guidelines change across those age groups. So those women under the age of 21, they can wait and worry about their screening either at the time of a pregnancy, which is a part of their prenatal visit. But their routine screening technically doesn’t start until 21.
Chris: Those women between the age of 21 and 29 will receive a pap test only and that pap test only has done every three years as long as it stays normal. Once we reached the age 30 til the menopausal age is when you will see what we call, like we talked about earlier, the co-testing with the HPV as well as the pap smear, and as long as those are normal women can sometimes space their pap smears out as long as five years during those times.
Mark: Yeah, that’s great, wonderful information, Chris, you’re always a wealth of knowledge and a great resource for me and I want to thank you so much for being part of the Fertility Health Podcast today.
Chris: That’s great. Thanks for having me.
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