Conception, cerclage, and clinical counseling

Abstract

Procreative specialists have unique opportunities for primary prevention. The Barker hypothesis (1Barker D.J. Osmond C. Infant mortality, childhood nutrition, and ischaemic heart disease in England and Wales.Lancet. 1986; 1: 1077-1081Abstract PubMed Scopus (1892) Google Scholar), where the intrauterine environment results in epigenetic influences beyond those contributed by maternal and paternal DNA, has important implications for preconception and antepartum care. Accordingly, reproductive endocrinologists counsel mothers-to-be regarding weight optimization, hypertensive control, diabetic management, and more because these can yield lifetime benefits for the future embryo and fetus. The Barker hypothesis reminds us of the birth mother’s importance for donor egg and gestational carrier scenarios. For all the relevance of broader maternal wellness, inherent genetic risks remain. Reproductive endocrinologists increasingly turn to preimplantation genetic testing for aneuploidy to reduce markedly Down syndrome and miscarriages. Moreover, preimplantation genetic testing for monogenic disease can reduce transmission of spinal muscular atrophy, cystic fibrosis, BRCA-associated breast cancer, sickle cell disease, and more. With fertility practice often weighted toward office care and embryology, reproductive endocrinologists can gravitate toward counseling that emphasizes these domains. However, if the goal is best outcomes for the mother and her future child, surgical aspects of primary prevention remain important as well. Women with a history of cervical insufficiency have meaningful risk with a future pregnancy, sometimes best managed through prophylactic cerclage. Appropriate cerclage placement reduces prematurity, which has numerous negative effects, such as respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, and more. Almost 70 years after Shirodkar’s publication on the technique (2Shirodkar V.N. A new method of operative treatment for habitual abortions in the second trimester of pregnancy.Antiseptic. 1955; 52: 299-300Google Scholar), for patients with insufficient benefit from vaginal cerclage, laparoscopic and robotic approaches have become the least invasive route for transabdominal cerclage. A recent review in Fertility and Sterility by Clark and Einarsson (3Clark N.V. Einarsson J.I. Laparoscopic abdominal cerclage: a highly effective option for refractory cervical insufficiency.Fertil Steril. 2020; 113: 717-722Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar) cited data for improved neonatal survival from laparoscopic relative to open abdominal cerclage. Of note, part of this benefit likely derives from confounding by indication, where the majority of laparoscopic cerclages are placed prior to conception, whereas open abdominal cerclages were often placed during pregnancy (71% preconception vs. 19% preconception) (3Clark N.V. Einarsson J.I. Laparoscopic abdominal cerclage: a highly effective option for refractory cervical insufficiency.Fertil Steril. 2020; 113: 717-722Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar). If preconception abdominal cerclage results in better outcomes than those postconception, then fertility experts have a greater burden for addressing this difference through counseling and treatment prior to procreative therapy. In this issue of Fertility and Sterility, a video submission by Dr. Heiden and colleagues (4Heiden A.L. Kashi P.K. Rose G.S. Dengler K.L. A four step strategy for robot assisted abdominal cerclage placement prior to pregnancy.Fertil Steril. 2020; 114: 902-904Scopus (1) Google Scholar) demonstrates a technique for robot-assisted laparoscopic cerclage in a manner where many reproductive surgeons, even if not having performed previously this specific procedure (with or without robotic assistance), can do so with reasonable efficacy and safety. High-resolution, labeling of appropriate anatomy, and stepwise instruction enhance clear communication through the video. The techniques involved so clearly derive from existing reproductive surgical principles that gynecologic surgeons who have not previously offered laparoscopic cerclage may consider expanding services after watching the video from Dr. Heiden and colleagues, given the meaningful benefits for appropriate patients. Even if not personally planning to perform laparoscopic cervical cerclage, for those not familiar with the technique, a single viewing of the video by Dr. Heiden and colleagues can provide perspective on core aspects for the approach and guide patient counseling prior to referral. The civil rights activist Marian Wright Edelman noted, “You can’t be what you can’t see.” Unfamiliar concepts often must germinate first in our own minds before we can help fully our patients conceive. Hopefully viewing this video enhances growing our own perspectives leading to better growth for many future pregnancies. A four step strategy for robot assisted abdominal cerclage placement prior to pregnancyFertility and SterilityVol. 114Issue 4PreviewTo demonstrate a simple, stepwise strategy for robot-assisted abdominal cerclage placement before pregnancy. Full-Text PDF