Service de Gynécologie-Obstétrique, Centre Hospitalier Intercommunal de Créteil, 40, Avenue de Verdun, 94010 Créteil Cedex, France
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Abstract |
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Key words: fertility/pregnancy outcome/uterine cervix atresia/uterine malformation/vagina malformation
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Introduction |
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Materials and methods |
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Patients were assessed postoperatively at 1 and 3 months. Morphological results were obtained from medical records. To assess long-term functional results and reproductive performance, the patients were asked to complete a questionnaire; this took place an average of 54 months after surgical procedure. The questionnaire concerned dysmenorrhoea, dyspareunia, and pregnancies, including their number and results (live birth, early termination, early spontaneous abortion, ectopic pregnancy), gestational age at delivery, and mode of delivery.
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Results |
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All the patients had a medical visit at 1 month. Median vaginal depth at 1 month was 6 cm (range: 49). Menstruation was restored in all patients in a median delay of 1.5 months (range: 15). Three patients were lost to follow-up afterwards. Among women who had follow-up, five (33%) complained of dysmenorrhoea. Finally, the 12 patients who had sexual intercourse were satisfied. A secondary low vaginal stenosis occurred in two cases (11%) far from the utero-vaginal anastomosis. This required a simple section under general anaesthesia followed by wearing of a vaginal mould for 1.5 and 5 months respectively, with good morphological and functional results. In another case, surgery was complicated by a secondary cervical stenosis, leading to dysmenorrhoea, and requiring multiple canalization procedures. Finally, a left pyosalpinx complicated these procedures and led to salpingo-oophorectomy. Because the patient had no desire for pregnancy, ovarian function was blocked with medroxyprogesterone acetate, and the patient was lost to follow-up a few months later.
Ten patients attempted to become pregnant during the study period. Their characteristics are shown in Table II. Six spontaneous pregnancies resulted from four patients (40%). Cervical cerclage was performed in only one case. All pregnancies were delivered by Caesarean section between 36 and 38 weeks gestation (median birth weight 2400 g, range 23502700). Six women were infertile at the time of sending the questionnaire and five of them had an associated complication (Table II
). Two of these patients asked for assisted medical procreation. They were, however, excluded from these procedures because of uterine hypoplasia in one case, and unclear reason in the second case.
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Discussion |
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Conservative surgical treatment of uterine cervical atresia, mainly cervical drilling, has been associated in some cases with deadly peritonitis (Maciulla et al.1978; Niver et al.1980
). Moreover, some authors speculated that chance of subsequent pregnancies were few, (Niver, et al.1980
; Buttram, 1983; Fliegner and Pepperell, 1994
), particularly when associated to vaginal aplasia (Jacob and Griffin, 1989
; Fujimoto et al.1997
). Consequently hysterectomy was recommended as first line treatment by many authors (Niver et al.1980
; Buttram, 1983; Fliegner and Pepperell, 1994
). Some rare cases of successful pregnancies, however, have been recently reported after conservative surgical management of cervical aplasia (Table III
).
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Preserving reproductive performance was the aim of the surgical conservative management. None of our patients had hysterectomy. A total of 40% of the women who attempted to become pregnant had a successful pregnancy. This relatively low fertility rate should be balanced against the significant rate of associated upper genital tract complications (83% of cases in our series), and fertility rate cannot therefore be expected to be as high as in the general population. Infertility, however, may not be related to all the complications cited in Table I. In particular, cervical atresia was complicated by haematometra in 44% of cases, and we have previously demonstrated in women with blind hemivagina, that once the obstruction has been relieved the dilated uterus recovers its normal reproductive function (Haddad et al.1999
). Conversely, four cases of infertility in our series are related to associated upper genital tract lesions such as tube lesions, adhesions, or endometriosis. Of interest, uterine cervix atresia may induce an abnormal endocervical glandular function as evoked by some authors (Geary and Weed, 1973
; Jacob and Griffin, 1989
; Thijssen et al.1990
; Fujimoto et al.1997
) and be also a cause of infertility that has not been analysed in the infertile women of our series. It should be noted, however, that four women had six spontaneous, successful, pregnancies. Finally, assisted medical procreation may help the infertile women to obtain a pregnancy (Thijssen et al.1990
; Fluker et al.1994
; Nargund and Parsons, 1996
; Anttila et al.1999
), provided that the uterus and the ovaries are preserved.
In conclusion, our results show that the diagnosis of uterine cervix atresia should be made as early as possible to avoid genital complications that may lead to aggressive surgery such as adnexectomy or hysterectomy. Utero-vaginal anastomosis appears to be an adequate treatment of uterine cervix atresia with good functional results. By preserving the uterus, this management allows pregnancies that may be obtained spontaneously or by assisted medical procreation procedures.
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Notes |
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References |
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Submitted on December 15, 2000; accepted on April 6, 2001.