PII: S0015-0282(07)01463-X

Abstract

Reply of the Authors: We appreciate the response of Gudipudi et al. to our case report (1Grund D. Kohler C. Krauel H. Schneider A. A new approach to preserve fertility by using a coated nitinol stent in a patient with recurrent cervical stenosis.Fertil Steril. 2007; 87: 1213-1216Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar). However, we have a different perspective on the issue. In general, barrier materials are intended for and used to prevent peritoneal adhesions in the abdominal cavity by separating peritoneal surfaces mechanically, but without exerting any mechanical force. Cervical adhesions are primarily formed of fibrinogen being transformed into fibrin, which eventually results in occlusion of the cervical channel with loss of function. The main problem of recurrent cervical stenosis, however, seems to be based on fibrotic shrinking of the remnants of the wall of the cervical channel itself rather than on primary luminal occlusion originating from adhesive processes (2Luesley D.M. Redman C.W. Buxton E.J. Lawton F.G. Williams D.R. Prevention of post-cone biopsy cervical stenosis using a temporary cervical stent.Br J Obstet Gynaecol. 1990; 97: 334-337Crossref PubMed Scopus (24) Google Scholar). The well-known tendency for recurrence of such stenoses after successful mechanical dilatation can be overcome effectively only by mechanical force until the formation of fibrotic tissue has been completed (i.e., 3 to 6 weeks, or less than 8 weeks) (1Grund D. Kohler C. Krauel H. Schneider A. A new approach to preserve fertility by using a coated nitinol stent in a patient with recurrent cervical stenosis.Fertil Steril. 2007; 87: 1213-1216Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 3Pabuccu R. Ceyhan S.T. Onalan G. Goktolga U. Ercan C.M. Selam B. Successful treatment of cervical stenosis with hysteroscopic canalization before embryo transfer in patients undergoing IVF: a case series.J Minim Invasive Gynecol. 2005; 12: 436-438Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar). Reports of recurring fibrotic stenoses in the gastrointestinal tract have confirmed these pathophysiologic considerations (4Conigliaro R. Battaglia G. Repici A. De Pretis G. Ghezzo L. Bittinger M. et al.Polyflex stents for malignant oesophageal and esophagogastric stricture: a prospective, multicentric study.Eur J Gastroenterol Hepatol. 2007; 19: 195-203Crossref PubMed Scopus (69) Google Scholar). In our cases of real stenosis with scar tissue in patients who wished to preserve fertility, the permanent dilatative force—optimally exerted in an elastic manner over 8 to 9 months—proved to be the only therapy with a long-term effect. Only an elastic and flexible device such as a self-expanding stent made of a memory alloy (e.g., nitinol) fulfilled these demands. Our method seems to be very successful, as the clinical course in our patient showed: The patient gave birth to a healthy child 2 weeks ago. Alternative approaches to cervical stenosisFertility and SterilityVol. 88Issue 3PreviewTo the Editor: Full-Text PDF