Overcoming Cervical Stenosis: A Case Study of Transmyometrial Embryo Transfer in Infertility Treatment.

A 36-year-old woman and a 40-year-old man from Wardha, with primary infertility for four years, presented with complaints of severe cervical stenosis, which had complicated three previous IVF attempts. The male partner’s semen analysis showed normal results, indicating strong fertility prospects. Medical and surgical history—male partner had no significant medical comorbidities or chronic illnesses, but the female had a surgical history which included a diagnostic uterine sound instrument that confirmed severe cervical stenosis. Physical examination—the patient was observed with hormone-induced symptoms, increased vaginal discharge, hormonal effects, bloating, and breast changes. Primary investigations included endometrial receptivity assessment, hormonal profile including estradiol, progesterone, beta-human chorionic gonadotropin (B-hCG), ultrasound imaging, hysteroscopy, blood test consisting complete blood count, infectious disease screening, like HIV, hepatitis B, etc., as shown in Table 1 . Hormonal profile of female The patient’s previous IVF attempts involved controlled ovarian stimulation and retrieval of high-quality oocytes, but embryo transfer remained difficult. In her most recent cycle, a transcervical embryo transfer was performed, but it led to significant bleeding, likely caused by trauma to the stenotic cervix. This complication not only made the procedure challenging but also negatively impacted the uterine environment, resulting in implantation failure. As a result, the decision was made to proceed with a transmyometrial embryo transfer. Firstly patient had given ovarian stimulation 48 hours prior to ovum pickup. Prior to ovum pickup procedure, the patient was administered with anesthetic agent. Ovum pickup was done by transabdominal access due to cervical stenosis. After that retrieved oocytes were fertilized using intracytoplasmic sperm injection (ICSI). On day 5 after fertilization, a well-developed embryo (blastocyst stage) was chosen for embryo transfer. After that under the ultrasound guidance, specialized needle was inserted through the uterine wall bypassing the cervix as shown in Figure 1 . The embryo was carefully placed in the optimal location within the uterus, ensuring minimal trauma. The patient was advised to rest for 24 hours following the procedure and commenced luteal phase support with intravaginal progesterone. After eight days, patients were diagnosed with increase in the level of β-hCG that results in the positive clinical pregnancy outcome. Transmyometrial embryo transfer Visits and ultrasounds were scheduled to monitor the embryo’s development and ensure the progression of a healthy pregnancy. Medicines were prescribed, heavy lifting of weights was not allowed, and in case of any bleeding and severe abdominal pain, the patient was told to visit the hospital immediately.

Infertility is defined as a couple’s inability to conceive after a year of regular, unprotected intercourse.[ 1 ] This issue can arise from a variety of factors that may affect either the male partner, the female partner, or both. Infertility is generally divided into two categories: primary infertility, where a couple has never achieved pregnancy, and secondary infertility, where a couple has been able to conceive in the past but is now facing difficulties.[ 2 ] One common cause of infertility is cervical stenosis, which happens when the cervical canal, the passage connecting the uterus to the vagina, becomes narrowed or blocked. This condition can lead to significant reproductive and gynecological challenges. Cervical stenosis can be congenital (present from birth, though it is rare) or acquired later in life. This often causes no symptoms. It may cause menstrual abnormalities or, rarely in premenopausal women, infertility. The acquired form of cervical stenosis is more common and may result from scarring caused by surgical procedures, such as cone biopsy, or dilation and curettage, as well as from radiation therapy to the pelvic area or chronic infections.[ 3 ] One of the additional factors which contribute to this is menopause, which causes cervical tissues to shrink, and reduces estrogen levels and conditions, such as endometriosis, which can also lead to cervical stenosis. Endometriosis is an often-painful condition in which tissue that is similar to the inner lining of the uterus grows outside the uterus. Endometriosis most commonly affects the ovaries, Fallopian tubes, and pelvic tissue, though lesions can also appear in rare extra-pelvic locations, like the pleura or central nervous system. This condition significantly impacts fertility, complicating treatments, such as in vitro fertilization (IVF). The etiology of endometriosis is complex, with retrograde menstruation being the most widely accepted theory. Emerging evidence suggests that endometrial stem cells, transported via retrograde menstruation, play a role in lesion formation and disease progression. Endometriosis is a chronic, inflammatory, hormone-dependent condition characterized by ectopic endometrial growth outside the uterus, affecting approximately 10% of reproductive-age individuals. It is a leading cause of infertility and pelvic pain, with its diagnosis often requiring laparoscopic surgery and histopathological analysis. The etiology remains unclear, with theories suggesting retrograde menstruation or peritoneal stem cells as the source of lesions. Factors, like hormonal imbalances, inflammation, oxidative stress, and genetic predisposition, contribute to disease progression.[ 4 ] These complexities complicate treatment and highlight the need for novel approaches, including integrating artificial intelligence and advanced models to improve understanding and refine fertility treatments, like IVF.

This case study shows the significance of using transmyometrial transfer of embryo in case of cervical stenosis. The patient had faced many complications during the conventional process of IVF, including cervical bleeding, severe contractions along with multiple IVF failure. To overcome this, transmyometrial transfer of embryo was done that was successful with positive clinical pregnancy outcome. This technique stated useful for the patients as it became easier and possible pregnancy for the patients who were suffering from severe cervical stenosis and women infertility. This technique demonstrates the success of artificial reproductive technique and overcoming infertility providing further more scope of research, leading to successful pregnancy. There are no conflicts of interest.

The challenges of embryo transfer, particularly in cases of very difficult transcervical embryo transfer (vdTCET), highlight the importance of exploring alternatives, like transmyometrial embryo transfer (TMET). While concerns about trauma and uterine contractions exist, TMET offers a viable option with reported success rates, aligning with my study’s focus on optimizing noninvasive, AI-assisted embryo selection and transfer outcomes.[ 5 ] The Towako method of TMET showed 36.5% clinical pregnancy rate, while frozen-thawed cycles were notably successful at 70.8%. This provides evidence for TMET in problematic TCET conditions, which is directly in line with the aim of my study regarding the improvement of embryo transfer using advanced, noninvasive AI-driven selection and placement techniques.[ 6 ] This adds to the reputation of safety for the procedure. However, the flexibility of TMET is somewhat limited since it relies on the Towako catheter set, which is specialized and therefore crucial for the procedure.[ 7 ] Aside from TMET, there are other techniques available for dealing with tough ET situations, such as hysteroscopic canal shaving, hysteroscopic-guided ET, cervical dilation, and the use of Malecot catheters. While these methods can be helpful, most of the supporting evidence comes from case reports and retrospective studies, which makes it hard to directly compare their effectiveness.[ 8 ] Moreover, the absence of a standardized grading system for ET difficulty complicates the assessment of these methods, limiting their use in various clinical environments.[ 6 ] Looking ahead, there is a clear need for extensive, multi-center, prospective studies to evaluate and compare how well different approaches work for managing difficult ET cases.[ 5 ] Such research could pave the way for standardized protocols, better outcomes, and enhanced clinical decision-making. TMET emerges as a valuable choice for patients dealing with anatomical obstacles or failed mock transfers. Its combination of high success rates and a good safety profile keeps it relevant in the realm of assisted reproductive technologies. Ongoing research will be essential to refine TMET techniques, investigate alternative tools, and create consensus guidelines that can improve patient care and success rates in challenging ET scenarios.