of transformation zone (LLETZ) or cold knife cone, had a higher preterm birth rate than those undergoing ablative treatments. However, these results should be interpreted with caution due to the low quality of the included studies [4].
Management options
Good practice would be to ensure all patients referred to fertility clinics are up to date with their local cervical screening program, and if they are not, they should be encouraged to take up this opportunity to have the screening. This also includes couples in same sex female relationships. This should ideally have been done in primary care prior to referring the patient, but if it has not been done, this should again be encouraged to be undertaken before undergoing fertility investigations and treatment. All patients should be strongly encouraged to stop smoking, as those who persist with smoking are less likely to find their precancerous cells resolve.
Women who are attending for consideration for assisted reproduction techniques (ART) are often stressed because of their fertility issues. Any additional issues will only compound this. Women with abnormal cervical cytology, who are referred for colposcopy, are also at increased stress, often comparable to levels seen prior to major surgery. There are currently no national recommendations for clinical situations where the cervical sample shows an abnormality and the woman is considering treatment for infertility.
Women should be seen and assessed but not necessarily treated. To avoid overtreatment, women should not be seen on a “see and treat” basis. In women being considered for ART, it would be prudent to undertake immediate colposcopy. The advantage of this approach is that if the colposcopic assessment is normal, then no further action needs to take place apart from repeating the cervical sample in 6 months.
Low‐grade lesions
HRHPV positive result with low‐grade dyskaryosis (as in Case History 1) warrants referral to the colposcopy clinic with the aim of the patient being seen within 6 weeks. If the colposcopy is deemed to be low grade changes on colposcopic impression alone, or on biopsy of cervical intraepithelial neoplasia (CIN) 1 at most, the patient would be returned to the primary care setting for a cervical screening sample to be repeated in 12 months. If this low‐grade abnormality persists for more than 2 years, then consideration of treatment should be offered.
A low‐grade abnormity alone with reassuring colposcopic features should not delay fertility investigations or treatment, with the proviso that should the patient develop symptoms which raise the suspicion of cervical cancer such as post coital or intermenstrual bleeding, she should be reviewed in an appropriate clinical setting.
High‐grade lesions
On the other hand, severe dyskaryosis (as in Case History 2) warrants an urgent referral to colposcopy. This patient should be seen within 2 weeks. A colposcopic examination should be performed with the aim of establishing a diagnosis. Careful counseling should be offered to the patient with a discussion around the option of see and treat (excisional LLETZ) versus punch biopsy with the options of observation alone, or treatment once the diagnosis has been established. Treatment options include excisional LLETZ or ablative treatments such as cold coagulation, acknowledging the increasing preterm birth rates associated with deeper excisions. If CIN 1–2 is diagnosed it is reasonable to have these cases reviewed, both histology and cytology at the local colposcopy multidisciplinary team (MDT) meeting with the option of conservative management in the form of 6 monthly colposcopy attendance and cervical screening, progressing to treatment should the patient develop symptoms suspicious of cancer or the CIN rises to CIN 3 or 2 years have elapsed with no cytological resolution.
If CIN 3 is detected along with any suggestion of a glandular abnormality or cancer, then excisional rather than ablative treatment should be offered promptly.
In those with CIN, the aim is to keep the depth of excision to >7 mm but <10 mm where possible. All patients with CIN should be offered HPV test of cure testing with their general practitioner 6 months following treatment, and ideally fertility treatment should be deferred until this result is known.
Glandular abnormalities
Glandular abnormalities (as in Case History 3) warrant a prompt direct referral to colposcopy and should be seen within 2 weeks [2]. There is a high prevalence of invasive adenocarcinoma, cervical glandular intraepithelial neoplasia (CGIN) and CIN in this population of patients [2]. Cervical biopsy alone in this setting lacks adequate sensitivity and excisional treatment such as a LLETZ is preferable to establish a reliable diagnosis of high‐grade CGIN. Distinction from invasive adenocarcinoma can only be achieved by histopathology, and an excisional biopsy including the endocervical canal is required for this purpose [2]. The excisional treatment needs to include the entire transformation zone and extend at least 1cm above the squamocolumnar junction [2], although this may increase the risk of preterm birth. All glandular cytology and histology samples should be discussed at the local colposcopy MDT meeting.
Those with complete excision should be offered HPV test of cure sampling 6‐ and 18‐months posttreatment and return to normal recall if both samples are normal [2]. In health systems without HPV test of cure, cytological follow up at 6 months and then annually for 10 years should be followed.
Those that are incomplete should consider a repeat LLETZ, accepting a further increased risk of preterm birth, or colposcopy and screening 6 months after treatment, and then annually for 10 years [2], whilst accepting that incomplete removal further increases the risk of recurrence of cervical disease which could lead to cancer in the future.
Key points
Challenge: abnormal cervical screening test in women undergoing infertility investigations or treatment.
Background:
Approximately 4% of women will have abnormal cervical screening, with the peak age group coinciding with the peak age group of infertility patients.
Untreated cervical abnormalities can progress to cancer for some, but can regress naturally for others.
Cervical treatment, particularly at depths greater than 10mm increase the preterm birth rate.
Those with abnormal cervical screening even without treatment have a higher preterm birth rate compared to those with normal screening histories.
Management options:
If minor cytologic abnormality is being managed by repeat cervical sample, then proceed with fertility treatment.
If low‐grade changes, then continue cytologic/colposcopic surveillance, but proceed with fertility treatment.
If high‐grade changes, then treat. Ideally, wait for reversion to normal with cervical sample +/− colposcopy. In exceptional circumstances, proceed with fertility management early following local treatment.
Prevention:
Encourage uptake of HPV vaccination.
Encourage women to take up the offer of HPV screening.
Encourage all women that smoke to stop.
Answers to questions patients ask
1 Q1 Why should I have a smear test? I am worried that the test results may delay my IVF treatment.A1. The cervical smear test is done to discover if there are any abnormalities in the cells covering the cervix. Some of these abnormalities, if not treated, may progress to cancer over time. So, the smear test reduces the chances of patients developing cervical cancer and saves lives. Also, it is better to be reassured before you start your IVF treatment and hopefully get pregnant. If any abnormality is discovered, then it is definitely much easier to sort out before