The radical trachelectomy procedure is now recognized as a “standard of care” option for young women with early-stage cervical cancer who wish to preserve fertility. However, the oncologic safety of this approach has mostly been validated for small lesions measuring <2 cm. The optimal management for patients with larger lesions who wish to preserve fertility remains unsettled and there is currently no standard of care. There are essentially two alternatives: either to proceed with upfront radical trachelectomy or neo-adjuvant chemotherapy (NACT) followed by fertility-sparing surgery (FSS). The balance between oncologic outcomes and surgical morbidity versus fertility and obstetrical outcomes need to be carefully balanced and addressed. We wish to present to the readers with arguments for and against both options in the hopes that it will help clinicians decide which is the best option for their individual patients.