Successful pregnancy after in-vitro fertilization and transmyometrial embryo transfer in a patient with congenital atresia of cervix: case report

Successful management of cervical dysgenesis: Case report and review

Cervical agenesis or dysgenesis is a rare Mullerian anomaly that is usually associated with vaginal aplasia. A literature review revealed reports of 83 cases including ours, of which 57 (68.6%) presented with obstruction of the external OS, 11 (13.2%) had the cervix replaced by a fibrous cord and 5 (6.02%) had a fragmented cervix. A total of 24 (28.9%) were managed by core and drilling technique (CDT), 16(19.2%) patients underwent uterovaginal anastomosis (UVA), 7(8.4%) underwent total abdominal hysterectomy preserving the ovaries and 5 (6.02%) were managed by cervical reconstruction. Unfortunately, 31 failed to return after their clinical and radiological diagnosis was confirmed. Early diagnosis and treatment are necessary to avoid long-term complications.

Functional and Reproductive Outcomes Following Surgical Management of Congenital Anomalies of the Cervix: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to evaluate surgical treatment for malformations of the cervix in terms of short- and long-term postoperative function and relevant reproductive outcomes.

DATA SOURCES

International Prospective Register of Systematic Reviews (ID No CRD42019128899). Electronic databases were searched for eligible studies up to October 2019 on Medline/PubMed (1966-2019), Scopus/Elsevier (1950-2019), and Google Scholar (up to 2019). Search terms included "congenital cervical malformations/anomalies," "uterocervical aplasia/dysgenesis/agenesis," "cervical aplasia/dysgenesis/ agenesis," "müllerian anomalies/dysgenesis/agenesis," "utero-vaginal anastomosis," "cervical reconstruction," "uterocervical reconstruction/canalization," "cervical canalization," "reproductive/pregnancy/functional outcome," "menstruation," "pregnancy," and "regular periods."

METHODS OF STUDY SELECTION

Studies were chosen and included with clear description of preoperative diagnosis via sonography, magnetic resonance imaging, and surgical confirmation; assessment and clear description of gynecologic anatomy and any concomitant anomalies; meticulous description of the operative technique; follow-up of at least 6 weeks postoperatively; and postoperative end points including menstrual and reproductive outcomes. We included randomized controlled trials, case-control studies (both prospective and retrospective), and case reports. Data registries, studies without clearly described primary or secondary outcomes, and studies not in the English language were excluded from the analyses.

TABULATION, INTEGRATION, AND RESULTS

The literature search returned 745 studies; 546 records were initially excluded (397 not related to the topic, 15 not related to humans, 134 non-English language); 111 full-text articles were further excluded (patients underwent hysterectomy or no surgery); 88 studies with a total of 249 patients were suitable for analysis. Almost all patients had preoperative amenorrhea (248/249, 99.6%). Postoperatively, of 249 patients, resolution of menstruation occurred in 228 patients (91.6%), and hysterectomy was performed in 22 patients (8.8%); overall, there were 30 (12.0%) conceptions that resulted in 27 (10.8%) viable and 24 (9.6%) term pregnancies. Indications for hysterectomy were stenosis of the genital tract and sepsis. Coexisting vaginal agenesis and use of full thickness skin graft for creation of neocervix was associated with negative surgical outcomes.

CONCLUSION

This review suggests that conservative surgical approaches result in better clinical and reproductive outcomes than more aggressive reconstructive surgeries for patients with malformations of the cervix.

Laparoscopically Assisted Uterovaginal Canalization and Vaginoplasty for Patients with Congenital Cervical and Vaginal Atresia: A Step-by-step Guide and Long-term Outcomes

STUDY OBJECTIVE

To study the long-term outcomes of laparoscopically assisted uterovaginal canalization and vaginoplasty in patients with congenital cervical and vaginal atresia and to introduce the surgery step by step.

DESIGN

A prospective observational study from January 2016 to September 2019.

SETTING

A tertiary teaching hospital.

PATIENTS

Ten women diagnosed with congenital cervical and vaginal atresia.

INTERVENTIONS

All women underwent laparoscopically assisted uterovaginal canalization and vaginoplasty.

MEASUREMENTS AND MAIN RESULTS

All procedures went smoothly, with no case requiring conversion to laparotomy, and no intraoperative complications occurred. Postoperative febrile morbidity occurred in 1 patient (1/10, 10%). The median (interquartile range) follow-up time was 26.0 (21.3, 48.3) months. All patients resumed menstruation, including 9 patients (9/10, 90%) with regular monthly menstruation. Eight patients (8/10, 80%) experienced mild to moderate dysmenorrhea; the remaining 2 patients (2/10, 20%) had no dysmenorrhea. Cervical restenosis occurred in 1 patient (1/10, 10%) 12 months postoperatively, and cervical dilation was performed. So far, 8 months after the second surgery, no restenosis has been found. The mean postoperative vaginal length was 7.9 ± 1.3-cm at the time of the last follow-up. Only 1 patient attempted to conceive for 2 years, but she had not conceived yet.

CONCLUSION

Laparoscopically assisted uterovaginal canalization and vaginoplasty is an easy, safe, and promising management option for correcting congenital cervical and vaginal atresia.

Transmyometrial embryo transfer as a useful method to overcome difficult embryo transfers - a single-center retrospective study

OBJECTIVE

Pregnancy after an embryo transfer depends largely on embryo quality, endometrial receptivity, and the technique used in the embryo transfer. Embryo transfers have been reported as inevitably traumatic and difficult for 5-7% of patients in assisted reproduction treatment. In these cases, transmyometrial embryo transfer should be considered as a suitable method to overcome difficult embryo transfers. The aim of this study was to report our experience with this technique and analyze its causes, results and complications.

METHODS

Since 1993, 39 women (40 cycles of assisted reproductive technology treatment) were submitted to transmyometrial embryo transfers in our center. The procedures were carried out as described by the Towako group.

RESULTS

The enrolled female patients had a mean age of 34 years and a mean baseline FSH level of 6.89 IU/mL. The median number of retrieved oocytes was 7.50 and a mean of 2.63 embryos were transferred. Implantation rate was 9.5%. With respect to clinical results, pregnancy and miscarriage rates were 25% and 30%, respectively. Since there were two twin pregnancies, the live birth rate was 22.5% (9/40). No major complications were reported.

CONCLUSION

Transmyometrial embryo transfer can and should be an option in cases of difficult/impossible transcervical embryo transfer.

Outcomes in patients undergoing robotic reconstructive uterovaginal anastomosis of congenital cervical and vaginal atresia

Objective

To introduce our experience of robotic surgery of reconstructive uterovaginal anastomosis and operative outcomes in congenital cervical and vaginal atresia patients.

Methods

Clinical observation and follow‐up of four patients with congenital cervical and vaginal atresia who underwent robotic reconstruction of cervix and vagina by SIS (small intestinal submucosa, SIS) graft.

Results

Average patient age was 13.8 ± 2.2. Patients complained of severe periodic abdominal pain. Diagnosis was made according to clinical characteristics, physical examination, MRI and classified by ESHRE/ESGE system. All patients underwent reconstruction of cervix and vagina by uterovaginal anastomosis by SIS graft. Average operation time was 232.5 ± 89.2 min, average blood loss was 225.0 ± 95.7 mL. After surgery, all patients have regular menstruation without pain. Average follow up was 12 months, average vagina length was 8.9 ± 0.3 cm, average vagina width was 2.9 ± 0.1 cm.

Conclusion

Robotic assisted reconstruction of cervix and vagina is feasible from our experience, enlarged cases and additional studies are required.

Cervicovaginal atresia with hematometra: restoring menstrual and sexual function by utero-coloneovaginoplasty

BACKGROUND

Cervicovaginal atresia is a rare Mullerian anomaly. The management of cervicovaginal atresia has evolved from historical recommendations of hysterectomy to various reconstructive procedures more recently. The latter carries a risk of significant morbidity and unknown fertility. We present our experience in the management of this complex anomaly.

METHODS

Twenty patients with cervicovaginal atresia were operated in our hospital from January 2004 through December 2013. The details of their anatomical variations and functional outcomes were analyzed.

RESULTS

Eighteen out of twenty patients had cervical agenesis. Two patients had cervical hypoplasia. All patients underwent utero-coloneovaginoplasty. Post operatively, all patients have regular menstrual cycles. One patient is married, sexually active and has satisfactory coital function. One patient had a bowel anastomotic leak that required a diversion ileostomy. Two patients developed mild stenosis. One patient has mild neovaginal mucosal prolapse. No patient has developed pyometra.

CONCLUSION

Patients with cervicovaginal atresia need to be counselled about the various reconstructive options available and the potential risks. Social and economic factor play a significant role in determining the plan of management. For patients from conservative societies, utero-coloneovaginoplasty provides a safe conduit for the passage of menstrual flow and coitus, at the cost of permanent infertility.

[Congenital cervical agenesis: pregnancy after transmyometrial embryo transfer]

Cervical agenesis is a rare congenital pathology linked to an anomaly of development of the Mullerian system. We described a case report about a 22-year old woman, consulting for infertility, who had a complete cervical agenesis. The first evaluation suggested a 46 XX karyotype and a normal ovarian reserve. The surgical examination confirmed the absence of cervix with impossibility of catheterization. She became pregnant thanks to an in vitro fertilization (IVF) with transmyometrial embryo transfer. Caesarean was decided at 36 weeks of gestation (WG) due to spontaneous uterine contractions. An injection of medroxyprogesterone was made after the placenta delivery in order to warning the partum hemorrhage. The ultrasound examination, realized 15 days after caesarean, underlined a good uterine involution. The surgery by cervico-vaginal anastomosis can be offered to patients because it offers chances of spontaneous pregnancies. But this surgery exposes women to a risk of failure, and of severe complications such as pain or infection, and might end in a hysterectomy. By choosing the transmyometrial transfer by vaginal way, the patient was exposed to the risk of spontaneous miscarriage. It was raising the problem of the uterine evacuation. This delivery after 34 WG is encouraging for the infertility by cervical agenesis.

Successful pregnancy following assisted reproduction and transmyometrial embryo transfer in a patient with anatomical distortion of the cervical canal

Abstract Presented is the case report of a patient noted to have gross distortion of the internal cervical canal during her attempt at embryo transfer following an in vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) procedure. Multiple attempts at cervical dilation were unsuccessful and the patient was ultimately treated by transmyometrial embryo transfer also known as the Towako method. She successfully achieved a singleton pregnancy and delivered at 41 weeks by primary cesarean section because of arrest of cervical dilation. Transmyometrial embryo transfer represents a viable option for patients with cervical stenosis refractory to conventional methods of navigation or severe anatomical distortion of the internal cervical canal.

Clinical characteristics of congenital cervical atresia based on anatomy and ultrasound: a retrospective study of 32 cases

Background

To explore the clinical characteristics of congenital cervical atresia.

Methods

This retrospective analysis included 32 cases of congenital cervical atresia treated from March 1984 to September 2010. The anatomic location, ultrasonic features, surgical treatments, and outcomes were recorded.

Results

Based on clinical characteristics observed during preoperative ultrasound and intraoperative exploration, congenital cervical atresia was divided into four types. Type I (n?=?22/32, 68.8%) is incomplete cervical atresia. Type II (n?=?5/32, 15.6%) defines a short and solid cervix with a round end; the structure lacked uterosacral and cardinal ligament attachments to the lower uterine body. Type III (n?=?2/32, 6.3%) is complete cervical atresia, in which the lowest region of the uterus exhibited a long and solid cervix. Type IV (n?=?3/32, 9.4%) defines the absence of a uterine isthmus, in which no internal os was detected, and a blind lumen was found under the uterus.

Conclusions

Observations of clinical characteristics of congenital cervical atresia based on the anatomy and ultrasound may inform diagnosis and treatment strategy.

Uteroneovaginal cannulation using Pezzer catheter in patients with vaginal agenesis and functional uterus

AIM

The aim of this study was to introduce a method for uterus preservation in patients with vaginal agenesia and functional uterus.

MATERIAL AND METHODS

Six patients with vaginal agenesia and one patient with cervicovaginal agenesis with functional uterus were enrolled in the study. Laparoscopy, vaginal reconstruction, laparatomy, hematocolpos evacuation and cannulation were carried out between atretic cervix and neovagina using a Pezzer catheter. No sutures or grafts were used. Patients were trained to use a vaginal mold regularly. Pezzer catheter remained in place for 6 months to maintain menstrual drainage and avoid orifice obstruction.

RESULTS

The surgical procedure was successful in all cases. Menses returned and abdominal pain was relieved in all patients. Three patients faced stenosis and two cases suffered from infection. One patient became pregnant and delivered at term. Self-image and quality of life were improved in all cases.

CONCLUSIONS

Uteroneovaginal cannulation using a Pezzer catheter relieves pain, restores regular menses and fertility and reduces symptoms related to retrograde menstruation in patients with vaginal agenesis and functional uterus.

Pregnancy with cervical dysgenesis

OBJECTIVE

To report a case of cervical dysgenesis in a patient who became pregnant through IVF and transmyometrial ET.

DESIGN

Case report.

SETTING

King Fahad Medical City.

PATIENT(S)

A 28-year-old nulligravida with cervical dysgenesis who underwent IVF and transmyometrial ET.

INTERVENTION(S)

Controlled ovarian hyperstimulation, IVF, and transmyometrial ET.

MAIN OUTCOME MEASURE(S)

Successful intrauterine pregnancy.

RESULT(S)

Single intrauterine pregnancy was achieved 30 days after transmyometrial ET.

CONCLUSION(S)

Successful pregnancy is possible in similar patients, eliminating the need for reconstructive surgery.

Combined retropubic balloon vaginoplasty and laparoscopic canalization: a novel blend of techniques provides a minimally invasive treatment for cervicovaginal aplasia

We studied the operative and functional outcomes of combined retropubic balloon vaginoplasty and laparoscopic canalization (RBV-LC) for treatment of cervicovaginal aplasia. The RBV-LC procedure was performed successfully in 4 cases of cervicovaginal aplasia within 35-40 minutes primary operative time. Cystoscopy was performed to ensure bladder and urethral integrity. Endoscopically monitored canalization with laparoscopic canalization is a feasible, effective, less invasive way for management of cervicovaginal aplasia.

Transmyometrial oocyte retrieval and pregnancy rates

OBJECTIVE

To determine whether transvaginal, ultrasound-guided oocyte retrieval performed through the myometrium has a negative impact on IVF pregnancy rates.

DESIGN

Retrospective cohort study.

SETTING

Academic hospital and research center.

PATIENT(S)

A total of 5,115 IVF cycles performed at the Brigham and Women's Hospital between 1998 and 2001 were evaluated. In 85 cycles (1.7%), the oocyte retrieval needle passed through the myometrium because of ovarian position during retrieval. Each of these cases was matched to a control cycle by age, attempt number, and date of retrieval.

INTERVENTION(S)

Transmyometrial oocyte retrieval.

MAIN OUTCOME MEASURE(S)

Pregnancy rates.

RESULT(S)

There were no statistically significant differences in pregnancy rates between cases and controls. Cases were more likely than controls to have underlying tubal disease and adhesions as the primary cause of infertility. The groups did not differ significantly in terms of age, attempt number, estradiol level, follicle number, days stimulated, ampules of gonadotropins administered, number of eggs, number of embryos, or quality of embryos.

CONCLUSION(S)

Transmyometrial oocyte retrieval is an uncommon event. Clinicians and patients can be reassured that transmyometrial oocyte retrieval does not seem to decrease IVF pregnancy rates; however, a larger study with greater power might reveal a statistically significant difference.

Intrauterine pregnancy following low-dose gonadotropin ovulation induction and direct intraperitoneal insemination for severe cervical stenosis

BACKGROUND: We present a case of primary infertility related to extreme cervical stenosis, a subset of cervical factor infertility which accounts for approximately 5% of all clinical infertility referrals. CASE PRESENTATION: A 37 year-old nulligravida was successfully treated with ovulation induction via recombinant follicle stimulating hormone (FSH) and direct intraperitoneal insemination (IPI). Anticipating controlled ovarian hyperstimulation with in vitro fertilization/embryo transfer (IVF), the patient underwent hysteroscopy and cervical recanalization, but safe intrauterine access was not possible due to severe proximal cervical stricture. Hysterosalpingogram established bilateral tubal patency and confirmed an irregular cervical contour. Since the cervical canal could not be traversed, neither standard intrauterine insemination nor transcervical embryo transfer could be offered. Prepared spermatozoa were therefore placed intraperitoneally at both tubal fimbria under real-time transvaginal sonographic guidance using a 17 gage single-lumen IVF needle. Supplementary progesterone was administered as 200 mg/d lozenge (troche) plus 200 mg/d rectal suppository, maintained from the day following IPI to the 8th gestational week. A singleton intrauterine pregnancy was achieved after the second ovulation induction attempt. CONCLUSIONS: In this report, we outline the relevance of cervical factor infertility to reproductive medicine practice. Additionally, our andrology evaluation, ovulation induction approach, spermatozoa preparation, and insemination technique in such cases are described.

Management of missed abortion in a patient with congenital cervical atresia

OBJECTIVE

To describe a patient with congenital cervical atresia who became pregnant through IVF and thawed transmyometrial ET and then experienced a missed abortion.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A patient with congenital cervical atresia who underwent reconstructive surgery at 23 years of age and underwent IVF twice at 28 and 30 years of age.

INTERVENTION(S)

Abortion management.

MAIN OUTCOME MEASURE(S)

Medical follow-up of IVF-ET, resultant pregnancy, and abortion.

RESULT(S)

After the second cycle of IVF with frozen-thawed transmyometrial ET, the patient became pregnant but then experienced a missed abortion. Serum beta-hCG levels decreased, the two gestational sacs disappeared, and genital bleeding without signs of infection occurred 14 weeks after diagnosis of the abortion. The abortion was managed conservatively.

CONCLUSION(S)

When assisted reproductive techniques are used in patients with congenital cervical atresia, the risks (including those relating to the management of an abortion) should be explained in detail to the couple and sufficient informed consent should be obtained before starting IVF-ET procedures.