Addressing Cervical Stenosis and Uterine Fibroids in IVF: A Case Study on the Effectiveness of TMET.

A 32-year-old woman visited the infertility clinic with her 35-year-old husband with a history of primary infertility for 3 years. The female was referred for fertility work-up and management. Anti-Mullerian hormone (AMH) levels were 1.2 ng/mL, suggestive of lower ovarian reserve, and follicle-stimulating hormone (FSH) was 8.5 mIU/mL, which suggests early signs of ovarian aging. Thyroid-stimulating hormone (TSH) and prolactin levels were within the normal range, thus eliminating thyroid and hormonal derangement as a cause of headache. Ultrasound revealed multiple intramural fibroids, altering the shape of the uterus, though her antral follicle count was moderate. These findings guided the decision to pursue TMET for optimal embryo placement. The male partner underwent semen analysis as a part of fertility evaluation. The semen analysis profile was found within the normal limit with regard to sperm concentration, morphology, and motility, indicating that the fertility problems were primarily due to female reproductive issues. The female and her husband, after going through failed IVF cycles, which resulted from the female partner’s cervical stenosis and intramural fibroids, opted for a unique technique referred to as TMET. This approach bypasses the cervix, which had been a major obstacle during previous ETs. It started with ovarian stimulation that is performed during IVF to induce the growth of multiple eggs. Due to the possibility of the female having slightly lower ovarian reserve based on her AMH and FSH levels, the gonadotropin (FSH and LH) compliance protocol that fitted the plan was used. Her response was followed by transvaginal ultrasound and serial estradiol blood level to assess follicular development. However, after the follicles became mature enough, hCG was given to induce the maturation of the eggs. Then the eggs were collected through oocyte retrieval and were successfully fertilized, which resulted in four high-quality embryos. The embryos were then frozen on two different straws for the frozen ET. Because of the female’s cervical stenosis, the fertility team decided that conventional transcervical ET was not possible. So, they chose TMET, a process in which a needle is inserted in the uterus through the myometrium without passing through the cervix, as shown in Figure 1 . This approach facilitated precise positioning of the embryo in the ideal position within the uterus without further contact with the fibroids. The TMET was performed under ultrasound guidance to ensure the embryo was placed in an unaffected area. After 2 months the frozen ET was done, in which one high-quality embryo was transferred. After the ET, the female was put on progesterone for the purpose of enhancing implantation and supporting the endometrium. Her hormone levels were observed, and changes were made where necessary, to provide the best environment for embryo implantation. She was then instructed to rest for some time at the clinic before being allowed to go home, and was told to come back in 14 days for a beta hCG test. Transmyometrial embryo transfer The female was advised to come for a beta hCG test after 2 weeks of ET, which revealed a positive indication for pregnancy with a beta hCG level of 378 ng/mL. She was then advised for a follow-up ultrasound 3 weeks later to assess for the gestational sac and the early pregnancy. To monitor the progression of pregnancy as well as to prevent complications, blood tests and ultrasounds were conducted frequently in the early stages of the pregnancy.

Infertility is described as “the inability to conceive in 12 months or more of unprotected sexual intercourse in a well-timed manner.”[ 1 ] Ovulatory disorders, endometriosis, adhesions, tubal blockage/abnormalities, and hyperprolactinemia are female factors accounting for 35% while the male factor accounts for 30%, and the combined factors account for only 20%. In 15% the source of infertility remains unidentified, which is classified as idiopathic or unexplained. Infertility rates differ globally and it is estimated that 8–12% of reproductive-age couples experience it.[ 2 ] There are various different causes related to male infertility, which include structural abnormality, increased level of reactive oxygen species, varicocele, an endocrine disease, systemic disease, and inflammation. It also encompasses factors such as hormonal balance, and genetic/epigenetic changes.[ 3 ] Fibroids may account for infertility in up to 2–3% of women. It has been associated with infertility and recurrent miscarriage depending on its size and position in the uterus. Comparing the outcomes with women facing infertility, it was identified that women with fibroids, irrespective of their location had significantly poorer clinical pregnancy rates, implantation rate, ongoing pregnancy, and live birth rates than the control group.[ 4 ] The cervical canal refers to the passage to the uterine cavity. If stenotic, it will hinder the access, therefore failing to accomplish the intended hysteroscopic procedure or complications such as uterine perforation, cervical laceration, or the formation of a false channel. As described earlier, cervical stenosis can be described as the cervix with the obliterated cervical ostium or cervical canal that can be entered only after certain rotations with a hysteroscope to explore the uterine cavity. Cervical stenosis occurs as a consequence of adhesions where the internal wall of the cervical canal is narrowed, distorted, or even absent. The common one is congenital while the other is acquired depending on the procedures done on the cervix. However, congenital cervical stenosis is much scarcer than acquired ones.[ 5 ] A delicate process in infertility treatment is the stage of embryo transfer (ET) in in vitro fertilization (IVF) that may influence the success or failure of the overall IVF procedure; ET may be challenging, which may be due to the anatomical position of the uterus or cervical stenosis. Another method in such a case is the transmyometrial embryo transfer (TMET) using transvaginal ultrasonography (USG). First described in the 1990s and designed by Puneet Rana Arora et al , in this technique, the uterine cavity is accessed through the myometrium, with the embryo being placed in the sub-endometrial zone and exact catheter.[ 6 ]

This case illustrates the successful use of TMET in overcoming infertility caused by severe cervical stenosis and intramural fibroids, conditions that complicated traditional ET methods. Despite earlier unsuccessful implantation attempts in IVF, TMET provided a technical and efficient application in avoiding the cervical barrier and ensuring proper positioning of the embryos in the uterus. The individualized treatment including ovarian stimulation, administration of progesterone, and close monitoring contributed to a successful pregnancy. This case shows the necessity of an individual approach to fertility treatments and proves that new methods such as TMET can add a ray of hope to every infertile patient who has faced numerous reproductive problems. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. There are no conflicts of interest.

This study deals with the difficulties and ultimate strategies applicable while addressing infertility caused due to structural problems such as an immensely constricted cervical canal, often referred to as cervical stenosis and intramural fibroids, which made the conventional procedure of transcervical ET a real trouble. Even after four failed IVF cycles, TMET was an effective option for treating cervical stenosis as it gave an opportunity to place the embryo in the correct location in the uterus. TMET can be an acceptable plan in circumstances where standard ET is not possible because cervical or uterine anatomy presents some major challenges. Indeed, the decision to proceed with TMET was influenced by the patients’ hormonal assays being normal while anatomically limiting factors. However, TMET allowed the doctor to avoid cervical passage and place an embryo directly in the uterus such that even fibroid distortions did not affect implantation. The positive outcome also underscores the need to attain high levels of regional specialization with regard to cases where reproductive anatomy can make routine procedures difficult to perform. Compared to traditional ET, TMET is more invasive; however, it served as a successful solution with a confirmed pregnancy. This illustrates how monitoring, follow-up blood tests together with early ultrasound made sure that the pregnancy was on course. This case highlights the concept of personalized fertility treatment, whereby even the most complex situation can be resolved through a unique method or approach and the right plan. In a study by Rubina Izhar et al. ,[ 7 ] it was stated that cervical stenosis can be another cause of cervical factor that goes unnoticed in the normal evaluation for infertility. Cervical stenosis is of two types – the congenital and the acquired. This may cause hematometra, pyometra, or subfertility. Failed ETs are among the common reasons given for low clinical pregnancy rates among IVF cycles. Emma E Don et al. ,[ 8 ] in their study, concluded that the endometrial cavities which are distorted by submucosal or intramural fibroids affect fertility and pregnancy, implantation, and delivery outcomes in women receiving IVF than infertile women without fibroids. Ou YC et al .[ 9 ] stated that the use of outpatient hysteroscopy (OH) may be useful in detecting cervical lesions, which could complicate ET in women undergoing their first IVF or ICSI cycle. In cervical stenosis, the patient’s cervical dilatation and mock ET (using or without a tenaculum) help for easier, ultrasound-guided ET at a later time. TMET can serve as a final option for difficult transcervical ET. According to T Kothari, TMET can be indicated when the transcervical approach to the uterus is not possible because of the complex cervical anatomy, stenotic cervix that resists dilation, and prior cervical surgery.[ 10 ] Similarly, due to cervical stenosis, a standard ET was not feasible in our case. Consequently, the decision to perform TMET was made, in which the embryo was placed directly into the uterine lining.