Fertility Outcome Following Transvaginal Cervicoisthmic Cerclage Using a Polypropylene Sling

Abstract

Transabdominal cervicoisthmic cerclage is beneficial in most women with cervical incompetence, for whom a conventional transvaginal procedure is inadequate or would be impossible. A large number of studies have reported that the fetal survival rate after the procedure increases from 70% to 95%. The high morbidity, however, associated with transabdominal cervicoisthmic cerclage limits its use. Recent studies have shown that a new procedure for transvaginal cervicoisthmic cerclage, using a macroporous monofilament polypropylene sling, may be an effective minimally-invasive alternative to transabdominal cervicoisthmic cerclage in women who present with a previous cerclage failure. This study evaluated the effect of the new procedure on the fertility and subsequent pregnancy outcomes among 57 women who underwent prophylactic transvaginal cervicoisthmic cerclage in a previous (reference) pregnancy, because of a high risk for preterm delivery. At 12 months or more after the reference pregnancy, telephone interviews were conducted to assess each patient's subsequent fertility. Of the 57 women interviewed, 8 had an inadequate follow-up of less than 12 months, 13 were lost to follow-up, 2 women required removal of the sling after cesarean delivery, and 1 needed a hemostatic peripartum hysterectomy. Among the other 33 women interviewed, 14 desired a subsequent pregnancy and 19 did not. One of the 14 women wanting a subsequent pregnancy had previously known tubal infertility and did not undergo in vitro fertilization. A total of 7 (54%) of the 13 subsequently became pregnant with the following outcomes: 1 had a spontaneous abortion at 11 weeks of pregnancy; 1 delivered at 22 weeks after spontaneous premature membrane rupture; 1 had a cesarean delivery at 25 weeks; and 4 had a term cesarean delivery at a median duration of 37 weeks (interquartile range = 37-38 weeks). The median birth weight of the 4 neonates was 3040 gm (interquartile range = 2500-3250 g). The investigators concluded from these findings that, subsequent successful pregnancy is possible when a transvaginal cervicoisthmic cerclage (specifically a polypropylene sling) is in place.