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22 The patient with cervical stenosis
Khaldoun Sharif
Fertility Center, Jordan Hospital, Amman, Jordan
Case History 1: A couple was referred for IVF with a 5‐year history of tubal infertility. Previously, an attempt at hysterosalpingography was unsuccessful, as the catheter could not be passed through the cervix. Following that, she had laparoscopy and hysteroscopy. Hysteroscopy was not possible as the scope could not be passed through the cervix, even after attempts at cervical dilatation. Also, no catheter could be inserted to inject dye. Laparoscopy showed moderate to server pelvic adhesions. There was no history of previous cervical surgery.
Case History 2: A 38‐year‐old patient, who underwent radical vaginal trachelectomy at the age of 33 years for early stage (IA2) cervical adenocarcinoma, presented with a 3‐year history of primary infertility due to low sperm count. The couple was referred for ICSI.
Case History 3: A couple was referred for IVF with a 4‐year history of unexplained infertility. Ten oocytes were collected, six fertilized and one good blastocyst was planned for transfer on day 5. However, on attempting the transfer, the catheter could not be passed more than 0.5cm through the cervical canal.
Background
Cervical stenosis is a rare problem, occurring in about 1% of women presenting for embryo transfer (ET) [1]. It has been defined as an external cervical opening of less than 2.5 mm [2], but clinically it manifests as the inability to pass instruments such as dilators and hysterosalpingography (HSG) or ET catheters easily through the cervical canal [3]. Some women with cervical stenosis may have associated dysmenorrhea or even amenorrhea, but most are asymptomatic, so presumably the cervical canal is adequate for the passage of menstrual blood but not instruments [4–7]. Also, it is not just the diameter of the cervical opening but also the tortuosity of the canal as well as the degree of uterine flexion or version that determine the difficulty in inserting instruments [3].
Cervical stenosis could be congenital or acquired. Congenital cases could result from diethylstilbestrol (DES) exposure in utero, while acquired cases could be caused by previous cervical surgery such as cone biopsy, loop excision or trachelectomy [3]. However, many women with cervical stenosis have no such history.
Cervical stenosis is associated with difficult ET [4–7], which in turn is associated with a significantly lower pregnancy rate when compared with easy transfers [8,9].
Management options
Take a precise history
Many women presenting for IVF have had attempts at cervical instrumentation in the past. This includes HSG, hysteroscopy, intrauterine insemination (IUI) or even previous ET. It is important to ask specifically about any history of difficulty in instrumenting the cervix. The woman may have been told about this by her clinician or may recall difficult, painful or prolonged attempts. All these are indicators that there might be cervical stenosis. History of previous cervical surgery is also significant. However, history of dysmenorrhea is very common, rendering it an inaccurate indicator of cervical stenosis.
Mock embryo transfer
In cases referred for IVF (or IUI) where there is suggestion from the history or examination of cervical stenosis (as in Case Histories 1 and 2), a “mock” ET (also called “dummy” or “trial” ET) should be performed [10]. This is when an empty ET catheter is passed through the cervix, thus mimicking what would happen at the actual ET. This should be carried out as an interval procedure before the start of the IVF process, so as to identify women who
