Case study conducted by Dr Tony Rodriquez

Onco-Fertility Case Presentation: Carcinoma of cervix, fertility preservation, radical trachelectomy and trans-myometrial embryo transfer with a successful ongoing pregnancy.

Clinical History

The patient Miss CP is a 29-year female presenting a previous diagnosis of squamous carcinoma of the cervix with a cervical cone biopsy having been performed showing a FIGO stage 1B1 tumour with involvement of stromal margins.

The decision was that the oncology treatment of choice is a radical trachelectomy with hitching of the ovaries above the pelvic brim, in view of the possible need for radiotherapy.

The patient was referred to Medfem Fertility Clinic (MFC) for consideration regarding the options available for preserving her fertility. Her baseline Blood tests were all normal and her AMH level was 2.34 ng/ml. Ms CP was engaged to be married ( Mr J S). After counselling, it was decided that we would carry out an IVF program with Embryo preservation. The semen analysis was normal. Importantly the couple opted to not have PGT.

IVF cycle 1:  Luteal phase stimulation, Cetrotide for 4 days, Menopur 3amps ( 9 days ) daily plus Femara  2,5mg daily x 5 days. A total of 8 follicles developed. Only 3 oocytes were harvested. The sperm on the day had a very low HBA ( 54% ) and therefore ICSI was performed. 2 blastocysts were frozen.

IVF cycle 2: A repeat cycle of IVF was immediately started on day 3 of her next menstruation. The stimulation was changed to Pergoveris 300 IU ( 8 days ) plus Provera 10mg daily. On 1-05-2021 13 oocytes were retrieved and fertilized by ICSI. Six high morphological-grade embryos were frozen on day 5.

The Provera was continued for 7 days, a withdrawal bleed occurred and her definitive operation was carried out on 17-05-2021.


Radical Trachelectomy, laparotomy biopsy of right and left lymph nodes and an intra-abdominal cerclage were placed.

Histology: Radical Trachelectomy with extended endocervical margins and lymp nodes resection.

No evidence of residual invasive malignancy was found.

Ms CP presented to MFC in January 2022. She had been cleared by her Gynae-oncologist to continue with an embryo transfer.

However, her clinical vaginal speculum examination revealed no obvious cervical opening. A repeat examination during her menses also did not identify an opening. A EUA was performed but this was also unsuccessful.

Ms CP was referred back to her Gynaeoncologist. Unfortunately, the cervical canal could not be identified during his attempt to open up the tissue over the cervix.

The patient was offered the option of a transvaginal ultrasound-guided embryo transfer using the Kitazoto catheter and the Towako Method. This is achieved by accessing the endometrium by piercing the myometrium with a needle,  loading the embryo transfer catheter and transferring the embryo ( SET ) directly into the endometrium cavity via the needle channel.

This was a new technique for the Medfem team.

A few important operative touch points deserve mentioning:

  1.  The accurate placement of the needle is essential, making sure the tip was in the middle of the endometrial cavity. We achieved this by ensuring the cavity was seen at its maximum longitudinal extent, then traversing the myometrium anteriorly and placing the needle in the middle of the endometrial cavity.
  2. There is a distinct change in the resistance between the myometrium and entering the uterine cavity.
  3. The embryo was loaded at the same time as the needle was been placed.

The Uterine Preparation for Embryo Transfer was by using a Natural Cycle for uterine  Estrogen preparation, triggering with Ovitrelle and adding cyclogest 1  bd, prednisone 10mg daily, Ecotrin and 2 weekly subcutaneous Beriglobin.

We carried out 3 consecutive trans-myometrial embryo transfers before achieving a positive pregnancy test. The first trimester of pregnancy was uneventful. The NIPT was normal as well as the patient’s fetal medicine assessment.