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Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis
Vol. 67, No. 6, June 1997
FERTILMY AND STERILIT@ Copyright o 1997 American Society for ReproductiveMedicine
Printed on acid-free paper in U. 5’.A.
Published by Elsevier Science Inc.
Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis
Isaac Z. Glatstein, M.D.* Samuel C. Pang, M.D. Patricia M. McShane, M.D. Reproductive
Science
Center of Boston, Deaconess-Waltham
Hospital,
Waltham,
Massachusetts
Objective: To determine whether laminaria tents are a safe and effective method of cervical dilatation in patients with a history of cervical stenosis and difficult ET. Design: Case reports describing two patients. Setting: Tertiary care, assisted reproduction practice. Patient(s): Two patients with cervical stenosis and a history of multiple failed cycles of IVF. Intervention(s): Laminaria tents were placed intracervically before ET. Main Outcome Measure(s): Presence of a gestational sac and fetal heartbeat on ultrasound. Result(s): Successful clinical pregnancies occurred in both patients after laminaria placement and ET. Conclusion(s): Laminaria tent cervical dilatation appears to be a safe and effective option to assist ET in patients with a history of cervical stenosis. (Fertil Steril@ 1997;67:1172-4. 0 1997 by American Society for Reproductive Medicine.) Key Words: Laminaria tents, cervical stenosis, embryo transfer
It is well known that a critical limiting factor in determining the success of IV@’cycles is obtaining implantation after ET (1). It has been reported that the ease of the ET procedure itself does influence the success of the cycle (2). A variety of techniques have been proposed to facilitate ET. These include the use of a full bladder to straighten out the uterine axis, the use of an ultrasound (U&guided transfer technique to visualize catheter placement on US, the use of a mock ET before the actual transfer to determine the length and position of the uterus, the use of soft and flexible transfer catheters, and the use of a tenaculum to straighten the uterocervical ang1e.t Although the practicing reproductive endocrinologist has a variety of these techniques at his or her Received January 6, 1997; revised and accepted February 5, 1997. * Reprint requests: Isaac Z. Glatstein, M.D., Deaconess-Waltham Hospital, Hope Avenue, Waltham, Massachusetts 02254 (FAX:
617-647-6323).
t References describing these techniques are available from the author.
1172
disposal, there does exist a small subset of patients in whom it is extremely difficult, if not impossible, to use the usual maneuvers to enter the uterine cavity atraumatically with the embryos. These cases are often difficult to manage and frustrating, especially when good-quality embryos are involved. Although one option would be an intratubal transfer of either eggs or embryos, this is not possible in all patients, especially those with a history of tubal disease or pelvic adhesions. Kato et al. (3) described a novel transmyometrial technique, the Towako method, although this may be technically demanding and is not widely available in all centers. In this preliminary report, we described the use of laminaria tents to facilitate ET in two patients with a history of cervical stenosis. MATERIALS AND METHODS Patient 1
The patient was a 28-year-old woman, gravida 0, para 0, with bilateral tubal occlusion who was re00150282/97/$17.00 PI1 SOOlS-0282(97)00053-8
ferred to us after three cycles of IVF with implantation failure. Her history was notable for severe ovarian hyperstimulation resulting in acute renal failure with her most recent attempt at IVF. In addition, she had a history of Crohn’s disease and had an ileostomy placed with a large-bowel and rectum resection. Upon review of her previous cycles, we noted that she had a history of extremely difficult transfers necessitating the use of a cervical tenaculum, dilators, and intracervical lidocaine anesthesia. In addition, the patient recalled that the transfers were extremely painful and difficult. We decided to perform a mock ET at our facility in the cycle before IVF. On pelvic examination, the cervix was very posterior, and the initial attempt to cannulate the cervical OSwas unsuccessful with a variety of ET catheters. After local anesthesia was given and a tenaculum and dilators were used, the cavity eventually was entered. The cavity measured 8.0 cm but was noted to be “corkscrew” along its entire length. At this point, after a discussion with the patient, it was agreed to perform cervical dilatation at the time of oocyte retrieval, followed by placement of a mediumsized laminaria tent to facilitate the ET. After a leuprolide acetate (LA) down-regulated cycle with gonadotropin stimulation, a total of nine oocytes were obtained, with fertilization in seven. After egg retrieval under IV sedation, the patient underwent gentle dilatation with Hanks dilators followed by placement of a medium-sized laminaria tent (laminaria japonica; Milex Inc., Chicago, IL). She received prophylactic antibiotic coverage with doxycycline at a dose of 100 mg orally twice a day for 6 doses. Twenty-four hours after insertion, the laminaria was removed and the uterus was sounded easily using a Monash ET catheter (Cook Urological, Inc., Spencer, IN). On the third day after egg retrieval, the patient underwent an uneventful ET of three good-quality embryos with a Monash transfer catheter using a full-bladder technique. The patient’s first P-hCG level 12 days after ET was positive at 168 mIU/mL (conversion factor to SI unit, 1.00). Subsequent P-hCG levels rose appropriately. A US scan performed at 6 weeks showed an intrauterine gestational sac with a fetal pole and cardiac activity. The patient currently has an ongoing singleton pregnancy. Patient 2
The patient was a 39-year-old woman, gravida 0, para 0, with a 2.5-year history of unexplained infertility. During her work-up, she underwent an office hysteroscopy, which was reported as technically difficult because of cervical stenosis; the procedure reVol. 67, No. 6, June 1997
quired a tenaculum, dilators, and intracervical lidoCaine to gain access to the cavity. Subsequently, she underwent an LA down-regulated GIFT cycle in which 30 oocytes were retrieved and four oocytes were transferred to her left fallopian tube. It was noted at the time of the GIFT procedure that the right fallopian tube was dilated and the left fallopian tube had a phimotic fimbriated end, although cannulation was possible through the left fallopian tube. She subsequently developed an ectopic pregnancy in the left tube, which was treated with IM methotrexate. As a result of this GIFT cycle, a total of 11 cryopreserved embryos were available for subsequent frozen ET cycles. With her initial attempt at a frozen ET, 3 embryos were thawed uneventfully. However, at the time of ET, the clinician was unable to cannulate the internal OSdespite multiple maneuvers, including the use of several catheter types and plastic OS finders. In addition, bleeding was noted from the cervical OS.After a discussion with the patient, it was decided to place an intracervical laminaria tent and to attempt transcervical ET again the following day. The patient was given doxycycline prophylaxis as well. The 3 embryos were cultured overnight in the incubator but, unfortunately, did not survive. As was previously agreed, 3 additional cryopreserved embryos were thawed and these were transferred the following day, 4 hours after removal of the laminaria. At the time of ET, the cervix was described as having slight stenosis, although the transfer was performed uneventfully, A ,8-hCG level performed 12 days after ET was positive at 54 mIU/mL, and US performed at 6 gestational weeks demonstrated a singleton intrauterine pregnancy with positive fetal cardiac motion. The patient currently has an ongoing pregnancy. DISCUSSION
In this preliminary report, we present two patients who underwent ET with histories of cervical stenosis refractory to the usual methods of gaining entry to the uterine cavity. We have used laminaria tents to gently facilitate cervical dilatation before the ET procedure. In each of these cases, antibiotic prophylaxis was used to prevent intrauterine infection. The use of laminaria does introduce a theoretical risk of contamination of the uterine cavity. An elegant Scandinavian study evaluated the use of cervical laminaria tents before suction dilatation and curettage and the rate of subsequent postabortal pelvic inflammatory disease. Jonasson et al. (4) showed that among patients randomized prospectively into a laminaria group and a control group, the rate of Glatstein
et al.
Techniques
and instrumentation
1173
pelvic inflammatory disease was significantly lower after pretreatment with laminaria tents. It was concluded that pretreatment with laminaria tents significantly reduced the rate of postabortal pelvic inflammatory disease. Fortunately, neither of our patients developed any signs or symptoms of infection, and both pregnancies are proceeding normally. To our knowledge, this is the first report on the use of laminaria tents to achieve cervical dilatation before ET in patients with refractory cervical stenosis and of subsequent successful pregnancies. Frishman (5) described the use of a stem pessary to facilitate ET. In this study, however, no patients were successful in maintaining a pregnancy. The possible adverse impact of an indwelling device that is sutured into the cervix probably represents a much higher risk for uterine contamination. The advantage of the laminaria is that it can be placed easily without significant discomfort and may be removed in 24 hours after facilitating cervical dilatation in a slow, controlled fashion. In summary, in patients with a history of difficult ETs and cervical stenosis, one may consider the use of laminaria tents to facilitate cervical dilatation and allow a technically easier ET. Laminaria are commercially available in a variety of sizes and are generally well tolerated by patients. In such cases, we
1174
Glatatein et al.
Techniques and instrumentation
recommend the use of prophylactic antibiotics to reduce the chance of contamination of the endometrial cavity with endogenous pelvic flora. The use of laminaria should provide yet another tool in the armamentarium of the physician for dealing with the clinical problem of difficult ETs. Acknowledgment. We gratefully acknowledge the assistance of Ms. Claudette Constant in coordinating this study. REFERENCES 1. Paulson FLJ,Sauer MV, Lobo RA. Factors affecting embryo implantation after human in-vitro fertilization: an hypothesis. Am J Obstet Gynecol 1990; 163:2020-3. 2. Visser DS, Fourie FLR, Kruger HF. Multiple attempts at embryo transfer: effect on pregnancy outcome in an in-vitro fertilization and embryo transfer program. J Assist Reprod Genet 1993; 10:37-43. 3. Kato 0, Takatsuka R, Asch RH. Transvaginal-transmyometrial embryo transfer: the Towako method; experiences of 104 cases. Fertil Steril 1993;59:51-3. 4. Jonasson A, Larsson B, Bygdeman S, Forsum U. The influence of cervical dilatation by laminaria tent and with Hegar dilators on the intrauterine microflora and the rate of postabortal pelvic inflammatory disease. Acta Obstet Gynecol Stand 1989;68:405-10. 5. Frishman GN. The use of the stem pessary to facilitate transcervical embryo transfer in women with cervical stenosis. J Assist Reprod Genet 1994; 11:225-8.
Fertility and Sterility@
FERTILMY AND STERILIT@ Copyright o 1997 American Society for ReproductiveMedicine
Printed on acid-free paper in U. 5’.A.
Published by Elsevier Science Inc.
Successful pregnancies with the use of laminaria tents before embryo transfer for refractory cervical stenosis
Isaac Z. Glatstein, M.D.* Samuel C. Pang, M.D. Patricia M. McShane, M.D. Reproductive
Science
Center of Boston, Deaconess-Waltham
Hospital,
Waltham,
Massachusetts
Objective: To determine whether laminaria tents are a safe and effective method of cervical dilatation in patients with a history of cervical stenosis and difficult ET. Design: Case reports describing two patients. Setting: Tertiary care, assisted reproduction practice. Patient(s): Two patients with cervical stenosis and a history of multiple failed cycles of IVF. Intervention(s): Laminaria tents were placed intracervically before ET. Main Outcome Measure(s): Presence of a gestational sac and fetal heartbeat on ultrasound. Result(s): Successful clinical pregnancies occurred in both patients after laminaria placement and ET. Conclusion(s): Laminaria tent cervical dilatation appears to be a safe and effective option to assist ET in patients with a history of cervical stenosis. (Fertil Steril@ 1997;67:1172-4. 0 1997 by American Society for Reproductive Medicine.) Key Words: Laminaria tents, cervical stenosis, embryo transfer
It is well known that a critical limiting factor in determining the success of IV@’cycles is obtaining implantation after ET (1). It has been reported that the ease of the ET procedure itself does influence the success of the cycle (2). A variety of techniques have been proposed to facilitate ET. These include the use of a full bladder to straighten out the uterine axis, the use of an ultrasound (U&guided transfer technique to visualize catheter placement on US, the use of a mock ET before the actual transfer to determine the length and position of the uterus, the use of soft and flexible transfer catheters, and the use of a tenaculum to straighten the uterocervical ang1e.t Although the practicing reproductive endocrinologist has a variety of these techniques at his or her Received January 6, 1997; revised and accepted February 5, 1997. * Reprint requests: Isaac Z. Glatstein, M.D., Deaconess-Waltham Hospital, Hope Avenue, Waltham, Massachusetts 02254 (FAX:
617-647-6323).
t References describing these techniques are available from the author.
1172
disposal, there does exist a small subset of patients in whom it is extremely difficult, if not impossible, to use the usual maneuvers to enter the uterine cavity atraumatically with the embryos. These cases are often difficult to manage and frustrating, especially when good-quality embryos are involved. Although one option would be an intratubal transfer of either eggs or embryos, this is not possible in all patients, especially those with a history of tubal disease or pelvic adhesions. Kato et al. (3) described a novel transmyometrial technique, the Towako method, although this may be technically demanding and is not widely available in all centers. In this preliminary report, we described the use of laminaria tents to facilitate ET in two patients with a history of cervical stenosis. MATERIALS AND METHODS Patient 1
The patient was a 28-year-old woman, gravida 0, para 0, with bilateral tubal occlusion who was re00150282/97/$17.00 PI1 SOOlS-0282(97)00053-8
ferred to us after three cycles of IVF with implantation failure. Her history was notable for severe ovarian hyperstimulation resulting in acute renal failure with her most recent attempt at IVF. In addition, she had a history of Crohn’s disease and had an ileostomy placed with a large-bowel and rectum resection. Upon review of her previous cycles, we noted that she had a history of extremely difficult transfers necessitating the use of a cervical tenaculum, dilators, and intracervical lidocaine anesthesia. In addition, the patient recalled that the transfers were extremely painful and difficult. We decided to perform a mock ET at our facility in the cycle before IVF. On pelvic examination, the cervix was very posterior, and the initial attempt to cannulate the cervical OSwas unsuccessful with a variety of ET catheters. After local anesthesia was given and a tenaculum and dilators were used, the cavity eventually was entered. The cavity measured 8.0 cm but was noted to be “corkscrew” along its entire length. At this point, after a discussion with the patient, it was agreed to perform cervical dilatation at the time of oocyte retrieval, followed by placement of a mediumsized laminaria tent to facilitate the ET. After a leuprolide acetate (LA) down-regulated cycle with gonadotropin stimulation, a total of nine oocytes were obtained, with fertilization in seven. After egg retrieval under IV sedation, the patient underwent gentle dilatation with Hanks dilators followed by placement of a medium-sized laminaria tent (laminaria japonica; Milex Inc., Chicago, IL). She received prophylactic antibiotic coverage with doxycycline at a dose of 100 mg orally twice a day for 6 doses. Twenty-four hours after insertion, the laminaria was removed and the uterus was sounded easily using a Monash ET catheter (Cook Urological, Inc., Spencer, IN). On the third day after egg retrieval, the patient underwent an uneventful ET of three good-quality embryos with a Monash transfer catheter using a full-bladder technique. The patient’s first P-hCG level 12 days after ET was positive at 168 mIU/mL (conversion factor to SI unit, 1.00). Subsequent P-hCG levels rose appropriately. A US scan performed at 6 weeks showed an intrauterine gestational sac with a fetal pole and cardiac activity. The patient currently has an ongoing singleton pregnancy. Patient 2
The patient was a 39-year-old woman, gravida 0, para 0, with a 2.5-year history of unexplained infertility. During her work-up, she underwent an office hysteroscopy, which was reported as technically difficult because of cervical stenosis; the procedure reVol. 67, No. 6, June 1997
quired a tenaculum, dilators, and intracervical lidoCaine to gain access to the cavity. Subsequently, she underwent an LA down-regulated GIFT cycle in which 30 oocytes were retrieved and four oocytes were transferred to her left fallopian tube. It was noted at the time of the GIFT procedure that the right fallopian tube was dilated and the left fallopian tube had a phimotic fimbriated end, although cannulation was possible through the left fallopian tube. She subsequently developed an ectopic pregnancy in the left tube, which was treated with IM methotrexate. As a result of this GIFT cycle, a total of 11 cryopreserved embryos were available for subsequent frozen ET cycles. With her initial attempt at a frozen ET, 3 embryos were thawed uneventfully. However, at the time of ET, the clinician was unable to cannulate the internal OSdespite multiple maneuvers, including the use of several catheter types and plastic OS finders. In addition, bleeding was noted from the cervical OS.After a discussion with the patient, it was decided to place an intracervical laminaria tent and to attempt transcervical ET again the following day. The patient was given doxycycline prophylaxis as well. The 3 embryos were cultured overnight in the incubator but, unfortunately, did not survive. As was previously agreed, 3 additional cryopreserved embryos were thawed and these were transferred the following day, 4 hours after removal of the laminaria. At the time of ET, the cervix was described as having slight stenosis, although the transfer was performed uneventfully, A ,8-hCG level performed 12 days after ET was positive at 54 mIU/mL, and US performed at 6 gestational weeks demonstrated a singleton intrauterine pregnancy with positive fetal cardiac motion. The patient currently has an ongoing pregnancy. DISCUSSION
In this preliminary report, we present two patients who underwent ET with histories of cervical stenosis refractory to the usual methods of gaining entry to the uterine cavity. We have used laminaria tents to gently facilitate cervical dilatation before the ET procedure. In each of these cases, antibiotic prophylaxis was used to prevent intrauterine infection. The use of laminaria does introduce a theoretical risk of contamination of the uterine cavity. An elegant Scandinavian study evaluated the use of cervical laminaria tents before suction dilatation and curettage and the rate of subsequent postabortal pelvic inflammatory disease. Jonasson et al. (4) showed that among patients randomized prospectively into a laminaria group and a control group, the rate of Glatstein
et al.
Techniques
and instrumentation
1173
pelvic inflammatory disease was significantly lower after pretreatment with laminaria tents. It was concluded that pretreatment with laminaria tents significantly reduced the rate of postabortal pelvic inflammatory disease. Fortunately, neither of our patients developed any signs or symptoms of infection, and both pregnancies are proceeding normally. To our knowledge, this is the first report on the use of laminaria tents to achieve cervical dilatation before ET in patients with refractory cervical stenosis and of subsequent successful pregnancies. Frishman (5) described the use of a stem pessary to facilitate ET. In this study, however, no patients were successful in maintaining a pregnancy. The possible adverse impact of an indwelling device that is sutured into the cervix probably represents a much higher risk for uterine contamination. The advantage of the laminaria is that it can be placed easily without significant discomfort and may be removed in 24 hours after facilitating cervical dilatation in a slow, controlled fashion. In summary, in patients with a history of difficult ETs and cervical stenosis, one may consider the use of laminaria tents to facilitate cervical dilatation and allow a technically easier ET. Laminaria are commercially available in a variety of sizes and are generally well tolerated by patients. In such cases, we
1174
Glatatein et al.
Techniques and instrumentation
recommend the use of prophylactic antibiotics to reduce the chance of contamination of the endometrial cavity with endogenous pelvic flora. The use of laminaria should provide yet another tool in the armamentarium of the physician for dealing with the clinical problem of difficult ETs. Acknowledgment. We gratefully acknowledge the assistance of Ms. Claudette Constant in coordinating this study. REFERENCES 1. Paulson FLJ,Sauer MV, Lobo RA. Factors affecting embryo implantation after human in-vitro fertilization: an hypothesis. Am J Obstet Gynecol 1990; 163:2020-3. 2. Visser DS, Fourie FLR, Kruger HF. Multiple attempts at embryo transfer: effect on pregnancy outcome in an in-vitro fertilization and embryo transfer program. J Assist Reprod Genet 1993; 10:37-43. 3. Kato 0, Takatsuka R, Asch RH. Transvaginal-transmyometrial embryo transfer: the Towako method; experiences of 104 cases. Fertil Steril 1993;59:51-3. 4. Jonasson A, Larsson B, Bygdeman S, Forsum U. The influence of cervical dilatation by laminaria tent and with Hegar dilators on the intrauterine microflora and the rate of postabortal pelvic inflammatory disease. Acta Obstet Gynecol Stand 1989;68:405-10. 5. Frishman GN. The use of the stem pessary to facilitate transcervical embryo transfer in women with cervical stenosis. J Assist Reprod Genet 1994; 11:225-8.
Fertility and Sterility@