{"paper_id":"4ef95515-e964-4929-b1a8-bd7f2e2523e4","body_text":"Gynecol Surg (2007) 4: 45 –48\nDOI 10.1007/s10397-006-0204-2\nCASE REPORT\nYücel Karaman . Banu Bingol . Ziya Günenc\nLaparoscopic transabdominal isthmic cerclage in a case\nof cervical agenesis and a successful pregnancy with ICSI\nReceived: 8 March 2006 / Accepted: 6 May 2006 / Published online: 27 July 2006\n# Springer-V erlag Berlin / Heidelberg 2006\nAbstract The objective was to construct a laparoscopic\ntransabdominal isthmic cerclage in a patient with cervical\nagenesis at Kadir Has University, Metropolitan Florence\nNightingale Hospital. A 39-year-old woman diagnosed\nwith primary infertility due to cervical agenesis was\nadmitted to our hospital because of recurrent assisted\nreproductive technique (ART) failures. She underwent\nthree operations for acute abdominal pain due to endome-\ntriosis and pyometra. There was a tiny fistula-like opening\nat the level of the isthmus, through which menstrual blood\npassed. Three intracytoplasmic sperm injection (ICSI)\nattempts with transmyometrial transfer had failed at three\ndifferent IVF centres. We performed a laparoscopic\ntransabdominal isthmic cerclage to prevent a miscarriage\ndue to a clinical condition similar to cervical insufficiency\nand then an ICSI procedure was performed. We delivered a\nhealthy baby weighing 3,200 g by Caesarean section. We\nleft the cerclage in place for subsequent pregnancies. To the\nbest of our knowledge, this is the first report of\nlaparoscopic isthmic cerclage for the prevention of a\nclinical condition similar to cervical insufficiency in\ncervical agenesis that has resulted in a term pregnancy\nafter ICSI.\nKeywords Laparoscopic cerclage . Abdominal cerclage .\nCervical agenesis . Cervical insufficiency . ICSI\nIntroduction\nCervical incompetence has been acknowledged as a\nsignificant entity predisposing patients to second trimester\nmiscarriage. V arious surgical techniques have been used to\nprolong pregnancy and improve prenatal outcome. These\ninclude transvaginal and transabdominal cervical cerclage\napplied preconceptionally or during pregnancy.\nHere we report a case of 39-year-old-woman with\ncervical agenesis and infertility, in which laparoscopic\nisthmic placement of cerclage was performed before\nembryo transfer, resulting in a successful pregnancy.\nCase report\nA 39-year-old woman was admitted to our hospital with the\ndiagnosis of primary infertility. When she was 15 years old,\nshe consulted a gynaecologist because of acute abdominal\npain. In her gynaecological examination, the cervix uteri\ncould not be visualised and in the ultrasonographic\nexamination bilateral endometriomas and haematometra\nwere seen. A laparotomic cystectomy was performed and\nan incision was made at the level of the isthmus to let\nmenstrual bleeding occur. During her reproductive period,\nshe suffered from acute abdominal pain and she underwent\nthree operations for pyometra and haematometra, and the\nincision was repeated for patency of the blocked passage.\nShe had been married for 20 years and was unable to\nachieve a spontaneous pregnancy. In 1999, the couple\nattended an infertility clinic and her husband ’s spermio-\ngram revealed severe oligospermia. In her gynaecologic\nexamination, the cervix could not be visualised and it was\nnoted that the vaginal cuff had a post-hysterectomy\nappearance. A diagnostic laparoscopy was carried out\nand severe adhesions were reported because of endome-\ntriosis and laparotomies. Three cycles of intracytoplasmic\nsperm injection (ICSI) and transmyometrial embryo trans-\nfer were performed. Although three or four embryos of\ngood quality were transferred at every attempt, pregnancy\nwas not achieved. In a university hospital, it was concluded\nthat the couple could never have a baby because of\ncervical agenesis.\nThe patient was evaluated at our centre in January 2004.\nWe performed a gynaecologic examination, but were\nunable to see the cervix. We invited the patient to be re-\nexamined at the beginning of her menstrual period in order\nY . Karaman . B. Bingol ( *) . Z. Günenc\nKadir Has University,\nMetropolitan Florence Nightingale Hospital,\nCemil Aslan Guder Sok No: 8,\nGayrettepe, Istanbul, Turkey\ne-mail: banubingol1975@yahoo.com\n\nto see where the blood was going. She had severe\ndysmenorrhoea because of the narrow opening at the\nright side of the vaginal end. The fistula-like opening\nprobably occurred because of the repeated incisions at the\nlevel of the isthmus. We decided to place an isthmic\ncerclage before IVF for a successful outcome.\nUnder general anaesthesia, the patient was placed in the\ndorsal lithotomy position, and a Foley catheter was\ninserted. The anterior vaginal wall neighbouring this\nnarrow passage was grasped with a tenaculum and the\npassage was dilated with an 8-mm Hegar bougie under\nultrasound and laparoscopic guidance. The Hegar bougie\nwas placed and secured with a tenaculum and was not\nremoved during the operation (Fig. 1). Then a laparoscopy\nwas performed with three puncture sites, using the\numbilical one for the laparoscope. The second and third\nones were made in the suprapubic area. At the beginning of\nthe surgical procedure, the adhesions were lysed using a\nCO\n2 laser and then the uterovesical peritoneum was incised\ntransversely again with the laser, where the reflection of the\nbladder was seen. A non-absorbable prolene suture (No 2,\nEthicon; Johnson & Johnson, Istanbul, Turkey) was used.\nWhen the vesico-uterine space was opened, the bladder\nwas pushed down. The ligature was passed through from\nthe anterior and towards the posterior parts of the isthmus,\nand it was knotted at the level of the sacro-uterine\nligaments.\nAfter confirming that the ligature was in an appropriate\nplace at the isthmus, the ends of the ligature were knotted.\nThe peritoneum was sutured over the knot and the\nlaparoscopy was finalised following haemostasis. The\nsuture was left in place for subsequent pregnancies.\nTwo months later, we started controlled ovarian stimu-\nlation with recombinant follicle stimulating hormone (FSH;\nPuregon; Organon, Altunizade, Turkey) at 200 IU/day.\nWe obtained 20 oocytes and 14 of them were metaphase II.\nWe transferred two embryos on the 3rd day; both of them\nwere reported to be Grade 1. The beta human chorionic\ngonadotrophin (HCG) level on the 11th day of embryo\ntransfer was 223 mIU/ml. During pregnancy, in the 32nd\nFig. 1 The steps of laparo-\nscopic transabdominal isthmic\ncerclage\n46\n\ngestational week, there was a risk of pre-term labour, after\nwhich only bed rest was recommended. The antenatal\nfollow-up showed no abnormality and she delivered a\nhealthy male baby weighing 3,200 g in the 38th\ngestational week by Caesarean section.\nDiscussion\nCervical incompetence is a premature dilatation of the\ncervix leading to recurrent mid-trimester pregnancy loss or\nearly premature labour. It is thought that the condition is\ncaused by a defect in the strength of the cervical tissue\neither congenitally or acquired, resulting in the inability to\nmaintain a pregnancy [1]. The treatment consists of placing\na purse string suture around the cervix. The conventional\nmethod is placing the sutures vaginally, but it might not be\npossible in extremely short, deformed and scarred cervices\nor in the absence of a cervix. Abdominal cerclage has been\nadvocated by several authors to overcome this problem.\nThe indications for abdominal cerclage are as follows:\ncongenitally short cervix, extensively amputated cervix,\nmarked scarring of the cervix, deep and jagged multiple\ncervical defects, and previously failed vaginal cerclage [ 2].\nThere are no studies in the literature showing that cervical\nagenesis always results in cervical insufficiency; however,\nan endoscopic cerclage operation was performed in our\npatient, since she had undergone several operations for\nhaematometra and there was irregular fistula formation at\nthe level of the isthmus, which could be a reason for a\nsecond trimester miscarriage. A review of the literature is\nshown in Table 1.\nIn 1965, Benson and Durfee first described the transab-\ndominal cervico-isthmic cerclage by laparotomy in a group\nof women with cervical incompetence in whom a\nconventional transvaginal procedure was impossible [ 3].\nSince then, these operations have been performed during\npregnancy or before conception to prevent cervical insuf-\nficiency [ 4, 5]. A less invasive approach is laparoscopic\nabdominal cerclage, which has the advantages of a\nlaparoscopic procedure including no hospitalisation, less\npostoperative pain, and faster recovery [ 2].\nIn 1998, Scibetta and colleagues described the first case\nof the successful use of an interval laparoscopic technique\nfor transabdominal cerclage placement, so as to avoid the\nneed to resort to a laparotomy during the pregnant or non-\npregnant state [ 6], but this case and all subsequent cases\nhad normal cervical anatomy.\nGallot and colleagues reported the use of laparoscopic\ntransabdominal cerclage in three women with a history of\nrecurrent miscarriages and failed cerclage. All procedures\nwere successful and two of them became pregnant within\n4 months, delivering by Caesarean section at 38 weeks ’\ngestation [ 7].\nConclusion\nIn the case presented, the failure of previous assisted\nreproductive technique (ART) cycles can be attributed to\ntransmyometrial transfer, which caused bleeding. We\ncreated an artificial cervical canal through which we\ncarried out the transfer of the embryos. There is only one\nstudy in the literature reporting transvaginal cerclage being\nperformed in cases of severe cervical hypoplasia under\nultrasound guidance [8]. To the best of our knowledge, this\nis the first report of transabdominal laparoscopic isthmic\ncerclage performed for cervical agenesis that has\nresulted in a successful pregnancy and a healthy baby\nfollowing ICSI.\nTable 1 Reproductive outcomes after laparoscopic abdominal cerclage\nAuthors Number of\nCases\nAge\n(years)\nCerclage in\npregnancy\nIndication Pregnancy outcome\nAl-Fadhli and\nTulandi [ 2]\n2 36, 38 No Failed cerclages One term pregnancy, one not\npregnant\nDarwish and\nHassan [ 9]\n1 31 Yes Eight failed cervical cerclages Live birth, 37 weeks\nGallot et al [ 7] 3 26, 35,\n29\nNo Failed cervical cerclages Two live births at 38 weeks; one\nnot pregnant\nHenricus et al.\n[10]\n1 34 No Short cervix after wide excision followed by\nimmature delivery\nLive baby with intrauterine growth\nrestriction, 37 weeks\nInd and Mason\n[11]\n1 33 No Two failed cervical cerclages Not reported\nLessor et al [ 12] 1 40 Yes Failed cerclage, diethylstilbestrol exposed, and\nmid-trimester miscarriage\nLive birth, 35 weeks\nMingione et al.\n[4]\n11 22 –39 No Absent or short cervix or failed cervical\ncerclages\nTen term live births, one elective\ndelivery at 34.5 weeks\nScibetta et al. [ 6] 1 37 Yes Absence of exocervix following cone biopsy Live birth, 38.5 weeks\nPresent case 1 39 No Cervical agenesis Live birth, 38.5 weeks\n47\n\nAcknowledgement We thank Russell Fraser for checking the\nEnglish of this manuscript.\nReferences\n1. Ludmir J (1998) Sonographic detection of cervical incompe-\ntence. Clin Obstet Gynecol 31:101 –109\n2. Al-Fadhli R, Tulandi T (2004) Laparoscopic abdominal\ncerclage. Obstet Gynecol Clin North Am 31:497 –504\n3. Benson RC, Durfee RB (1965) Transabdominal cervicouterine\ncerclage during pregnancy for the treatment of cervical\nincompetency. Obstet Gynecol 25:145 –155\n4. Mingione MJ, Scibetta JJ, Sanko SR, Phipps WR (2003)\nClinical outcomes following interval laparoscopic transabdom-\ninal cervico-isthmic cerclage placement: case series. Hum\nReprod 18:1716 –1719\n5. Groom KM, Jones BA, Edmonds DK, Bennett PR (2004)\nPreconception transabdominal cervicoisthmic cerclage. Am J\nObstet Gynecol 191:230 –234\n6. Scibetta JJ, Sanko SR, Phipps WR (1998) Laparoscopic\ntransabdominal cervicoisthmic cerclage. Fertil Steril 69:161 –\n163\n7. Gallot D, Savary D, Laurichesse H, Bournazeau JA, Amblard J,\nLemery D (2003) Experience with three cases of laparoscopic\ntransabdominal cervico-isthmic cerclage and two subsequent\npregnancies. BJOG 110:696 –700\n8. Ludmir J, Jackson GM, Samuels P (1991) Transvaginal\ncerclage under ultrasound guidance in cases of severe cervical\nhypoplasia. Obstet Gynecol 78:1067 –1072\n9. Darwish A, Hassan Z (2002) Feasibility of laparoscopic\nabdominal cerclage in the second trimester. Gynaecol Endosc\n11:327–329\n10. Brölmann HAM, Oei SG (2000) The laparoscopic approach of\ntransabdominal cerclage of the uterine cervix in case of cervical\nincompetence. Gynaecol Endosc 9:191 –194\n11. Ind T, Mason P (2000) Endoscopic trans-abdominal cervical\ncerclage. Gynaecol Endosc 9:199 –200\n12. Lessor KB, Childers JM, Surwit EA (1998) Transabdominal\ncerclage: a laparoscopic approach. Obstet Gynecol 91:855 –856\n48","source_license":"CC0","license_restricted":false}