What are the treatment options for a female with high-grade dysplasia who wants to have children and has been recommended a Loop Electrosurgical Excision Procedure (LEEP)?

Treatment Options for High-Grade Cervical Dysplasia in Women Desiring Future Fertility

For women with high-grade cervical dysplasia who desire future fertility, fertility-sparing procedures should be prioritized, with LEEP being an acceptable option when performed with proper technique to minimize cervical damage. 1

Understanding Treatment Options

Fertility-Sparing Options:

• Cone biopsy (preferred for fertility preservation):
  • Cold knife conization (CKC): Preferred approach for women desiring fertility as it provides adequate margins, proper orientation, and non-fragmented specimens without electrosurgical artifact 2
  • LEEP (Loop Electrosurgical Excision Procedure): Acceptable alternative if adequate margins, proper orientation, and a non-fragmented specimen can be obtained 2
  • Laser conization: Associated with lower recurrence rates (4% at 5 years) compared to LEEP (8.1% at 5 years) 3

Key Considerations:

1. Margin Status:

   • Negative margins are crucial for successful treatment
   • Positive margins significantly increase recurrence risk (39% vs 15% with negative margins) 4
   • Women with positive margins who wish to remain fertile should undergo reexcision to attain negative margins 2

2. Follow-up Protocol:

   • After successful treatment with negative margins: cervical cytology at 6 and 12 months or HPV DNA testing at 12 months 1
   • Continue follow-up at 4-6 month intervals until at least 3 consecutive negative cytology results 1
   • Any result of ASC-US or greater during follow-up warrants referral for colposcopy 1

Special Considerations During Pregnancy

If the patient is currently pregnant:

• Colposcopy and cervical biopsy for high-grade lesions should be performed only when high-grade neoplasia or invasive cancer is suspected 2
• Treatment for CIN (any grade) should be delayed until after pregnancy 2
• Diagnostic limited excisional procedure is recommended only if invasion is suspected 2

Long-Term Management

• Fertility outcomes after LEEP appear promising, with studies showing no significant detrimental effect on future fertility 5
• After childbearing is complete, hysterectomy should be strongly considered, especially for women with adenocarcinoma in situ (AIS) 2, 1
• HPV persistence is the most significant factor associated with recurrence after either laser conization or LEEP 3

Pitfalls to Avoid

• Performing hysterectomy as primary treatment for CIN without other indications is not recommended for women desiring fertility 1
• Inadequate follow-up after treatment increases risk of undetected recurrence 1
• Overreliance on a single positive HPV test without corroborating findings should be avoided when making decisions about repeat procedures 1

For women with high-grade cervical dysplasia who want children, fertility-sparing procedures with appropriate margins and thorough follow-up provide the best balance between treating the dysplasia and preserving fertility potential.