Successful Pregnancy Following Treatment of Cervical Stenosis from a Previous Cervical Loop Excision

Introduction

Cervical stenosis as a result of a loop excision procedure is a rare but late complication of this procedure. For women desiring pregnancy, in vitro fertilization (IVF) embryo transfer is very challenging.

Case

A 35-year-old woman para 1001 presented with her husband of 5 years for evaluation of secondary infertility.

Her past obstetric history was significant for a spontaneous pregnancy 2 years prior that had resulted in a normal spontaneous vaginal delivery. A Papanicolaou smear performed during the pregnancy had shown a high-grade squamous intraepithelial lesion, and a colposcopic biopsy performed 6 weeks postpartum had confirmed cervical intraepithelial neoplasia (CIN) II. She had undergone a loop excision procedure of the cervix. Postpartum, she had exclusively breastfed for 9 months and had remained amenorrheic since.

Her past gynecologic history included menarche at 12 years with regular 30-day cycles and she had bled for 5–6 days prior to delivery. After she stopped breastfeeding, her cycles had not resumed. She had a prior history of chlamydia 19 years earlier, which had been treated. She had no significant past medical history and her surgical history included her loop excision procedure.

She denied galactorrhea; hirsuitism; acne; headaches; preference for cold or hot weather; or alcohol, tobacco, or illicit drug use.

On physical examination, the patient was found to be 163 lb, 5 ft 9 in, with a body mass index (BMI) of 24. Her thyroid gland and breasts were normal. Findings from a cardiovascular examination were normal, with a blood pressure of 139/84 mm Hg and normal heart sounds, and her chest was found to be clinically normal on respiratory system examination. On abdominal examination no masses were palpable and her abdomen was soft and not tender.

Pelvic examination revealed normal external genitalia and a cervix that was visualized but flush with the vaginal vault. The external os could not be discerned except for a dimple slightly off center to the patient's left. A Q-tip probe could not gain access into the external os but the uterus was boggy and the adnexa nonpalpable or tender.

A pelvic ultrasound performed showed a uterus 10×5.3 cm with the cavity filled with internal echoes consistent with hematometra, and an enlarged left ovary (5×5.6 cm) with a cyst measuring 3×4.5 cm.

An initial impression of hematometra was made, and the patient was scheduled for an MRI of the pelvis, which confirmed hematometra in a bicornuate uterus. Results of her husband's semen analysis were normal.

The patient underwent vaginal exploration of the upper vagina, exposure of the cervix, placement of a pediatric catheter into the endometrial cavity, and operative laparoscopy. Findings at laparoscopy included a left hematosalpinx, which was drained. On vaginal exploration, the external os could not be discerned. The cervix was shaved with a Mayo scissors, thereby revealing the cervical canal, and a large amount of brawny old blood. The vaginal edge was over-sewn to the ground of the cervix to maintain cervical patency. A pediatric catheter was introduced into the endometrial cavity, insufflated and left in situ. A hysteroscopy could not be performed because of the friable nature of the cervix. The patient was seen 3 weeks postoperatively, after her next normal period and the pediatric catheter was removed. An office visit 3 months later showed reaccumulation of hematometra in the lower uterine segment, and a left endometriotic cyst measuring 5.9×4.5 cm was found on pelvic ultrasound.

The patient underwent a laparoscopy to excise the endometrioma, uterine suspension for a severe retroverted and torted uterus to the right, hysteroscopy and placement of a pediatric catheter, and chromopertubation, which revealed bilateral spillage of dye.

She was seen 2 weeks postoperatively and this time declined to have the pediatric catheter removed. She was commenced on the oral contraceptive pill with the catheter in situ, and then commenced ovulation induction with an IVF cycle.

She underwent a successful IVF transcervical embryo transfer, and a resultant pregnancy ensued. The pediatric catheter was removed once successful pregnancy was noted.

Discussion

Cervical stenosis consists of partial or complete obstruction of the cervical canal, and is considered to be a late complication of laser cone biopsy. ¹ Stenosis of the cervix is characterized by a narrowing of the cervical canal, which prevents the insertion of 2.5 mm Hegar or Pratt dilator. ² The incidence of hematometra secondary to cervical stenosis following laser electrosurgical excision procedure (LEEP) of the cervix is unknown. ³ However, the incidence of cervical stenosis varies from 0 to 25.9%. ⁴ Cervical stenosis is significant with cold-knife conization, and its incidence is quoted to be ∼ 1%. ⁵ LEEP is both diagnostic and therapeutic for CIN management. Cervical stenosis becomes statistically significant for women who had cones >25 mm in size, and is associated with the 1% incidence. ⁶

Radiologic investigations for hematometra include ultrasound and MRI, which our patient had had. Typically, on ultrasound it is depicted as low echoes within the fluid collection. Treatment modalities for cervical stenosis include conservative and surgical options. Conservative measures include gradual blind cervical dilatation, cervical dilatation under ultrasound guidance, use of laminaria stents, with limited success. Suggested placement of cervical stents with sutures immediately after cone biopsy and keeping them in place for 2 weeks for prevention of cervical stenosis is associated with limited success and a high recurrence rate. Surgical options include treatment with colposcopic directed carbon dioxide laser, by removing a central cylinder of the cervix, which has varied success rates between 66 and 80%. Transvaginal uterine cervical dilatation under fluoroscopic guidance using an angioplasty balloon has been reported to have good postoperative results. Hysteroscopic endocervical resection to create a portal of entry to the uterine cavity has been advocated but it requires being able to dilate the cervix. Suggested opening of the external os with multiple radial incisions using a number 11 blade may probably be useful in stenosis of the external os. The combined use of cervical dilatation with sonographic or laparoscopic control is safe and effective. ⁷ Hysteroscopic canalization with or without placement of an indwelling catheter has been described, and a hysterectomy can be a last resort. Pittaway et al. described a vaginal approach under laparoscopic direction, to try to identify the endocervical canal, establish patency, and dilate the canal. An abdominal approach with hysterotomy is necessary only if the vaginal attempts are not successful. ⁸

The approach described here, to create cervical patency by upper vaginal exploration, exposure of the cervical canal by shaving, and over-sewing the vaginal edge to the body of the cervix, is the first ever recorded in the literature. Patency of the cervical canal was maintained with placement of a pediatric catheter.

A successful IVF pregnancy requires a patent cervical canal. There is a positive correlation between the ease of embryo transfer and improved pregnancy rates. ⁹ Several techniques that have been described to overcome cervical stenosis include gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), direct intraperitoneal insemination, and intramyometrial embryo transfer, which is extremely difficult.

Conclusions

Cervical factors account for 5% of all referrals for infertility. Cervical stenosis is a late and rare sequelae of LEEP. A novel procedure to create cervical patency by shaving of the cervix and over-sewing of the vaginal tissue followed up by leaving an indwelling catheter, is reported here.