Original Article on Intrauterine Adhesion

Page 1 of 7

Diagnosis and treatment of cervical incompetence combined with

intrauterine adhesions
Waixing Li#, Yueran Li#, Xingping Zhao, Chunxia Cheng, Arvind Burjoo, Yimin Yang, Dabao Xu

Department of Obstetrics and Gynecology, The Third Xiangya Hospital of Central South University, Changsha 410013, China
Contributions: (I) Conception and design: D Xu, Y Yang; (II) Administrative support: D Xu; (III) Provision of study materials: Y Li, X Zhao, C Cheng;
(IV) Collection and assembly of data: Y Li, W Li; (V) Data analysis and interpretation: Y Li, W Li; (VI) Manuscript writing: All authors; (VII) Final
approval of manuscript: All authors.
#
These authors contributed equally to this work.
Correspondence to: Dabao Xu; Yimin Yang. Department of Obstetrics and Gynaecology, The Third Xiangya Hospital of Central South University, 138
Tongzipo Road, Changsha 410013, China. Email: [email protected]; [email protected].

Background: Cervical insufficiency (CI) with concomitant intrauterine adhesions (IUAs) is a common
clinical phenomenon among CI patients. But there are neither published reports regarding the difference
in diagnosis and treatment of such patients compared to those with CI only, nor any report about their
prognosis. This study aimed to preliminary the alteration in diagnostic and curative aspects of these patients,
so as to provide a certain reference for the clinical management of such conditions.
Methods: Ten patients with CI combined with moderate to severe IUAs were diagnosed, treated and
followed up at the Third Xiangya Hospital of Central South University from September 2017 to August
2019, their medical records and the pregnancy outcomes were retrospectively analyzed.
Results: All 10 patients had a previous history of typical painless cervical dilatation during the second
trimester. All patients were moderate to severer IUAs, and the mean AFS score of IUAs was 9.80±1.08 (range,
8 to 12). Preoperatively, in 6 patients, the No. 7 Hegar dilator was able to pass through the internal cervical
os before surgery without resistance. In the other 4 patients, the Hegar dilator could not be inserted before
surgery due to the adhesions of the cervical canal and the lower uterine segment; the diagnoses of these
patients were further confirmed at 3 months after hysteroscopic adhesiolysis (HA) when the No. 7 Hegar
dilator was able to pass through the internal cervical os without resistance. There were 9 patients underwent
pre-pregnancy laparoscopic cervical cerclage after HA. The remaining 1 patient exceptionally underwent
laparoscopic cervical cerclage prior to HA, as the cervix was too loose to retain and be treated with an
intrauterine device (IUD) or distended Foley’s catheter balloon; which essentially prevent postoperative
adhesion reformation. The patients were followed-up for 3 months to 2 years. The pregnancy rate was 60%,
and the live birth rate was 100%.
Conclusions: In patients with CI and concomitant cervical or lower uterine segment IUAs, it is necessary
to separate the adhesion prior to evaluating the cervical competency with the No. 7 Hegar dilator, to confirm
the diagnosis. However, when the cervix is too loose, laparoscopic cervical cerclage is exceptionally carried
out first and then IUAs is treated. Pre-pregnancy laparoscopic cervical cerclage has a good prognosis in
patients with CI complicated by moderate to severe IUAs.

Keywords: Cervical incompetence (CI); intrauterine adhesions (IUAs); laparoscopic cervical cerclage; diagnosis;
live birth rate

Submitted Nov 13, 2019. Accepted for publication Dec 26, 2019.
doi: 10.21037/atm.2019.12.148
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© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(4):54 | http://dx.doi.org/10.21037/atm.2019.12.148
Page 2 of 7 Li et al. Diagnosis and treatment of CI with IUAs

Introduction Methods

Cervical incompetence (CI) is one of the main causes of General information

premature birth or miscarriage in the second trimester.
The clinical information of 10 patients with CI combined
According to statistics, 8% of miscarriages in the second
with moderate to severe IUAs who were treated at the
trimester and premature births are due to CI (1). If a
Third Xiangya Hospital of the Central South University
patient has a history of typical painless cervical dilation
from September 2017 to August 2019 were retrospectively
during the second trimester, and a No. 7 Hegar dilator can
analyzed. Among them, 9 patients underwent HA and
pass through the internal cervical os without resistance
IUD and intrauterine balloon placement first and upon
during the nonpregnancy period, the diagnosis of CI can
restoration of a normal uterine cavity morphology, pre-
be confirmed (2). The surgical treatment of CI is cervical
pregnancy laparoscopic cervical cerclage was performed.
cerclage which refers to a variety of procedures that use
After counselling, the remaining 1 patient underwent pre-
sutures or synthetic tape to reinforce the cervix. Cervical
pregnancy laparoscopic cervical cerclage prior to HA
cerclage can be done through the vagina (transvaginal as the use of IUD and intrauterine balloon (to prevent
cervical cerclage) or, less commonly, through the abdomen postoperative adhesion) were hampered by an excessively
(transabdominal or laparoscopic cervical cerclage). The loose cervix. The mean patient age was 31.20±2.57 years
prophylactic cervical cerclage should preferably be (range, 28 to 36 years). Before the laparoscopic cervical
performed before or in the early period of pregnancy. Both cerclage,the mean number of pregnancies were 3.70±1.80
approaches have their own advantages and disadvantages. (2 to 8) and the mean number of adverse pregnancies
Currently, the most commonly used method is the were 1.80±0.63 (1 to 3). Four patients had a history of
transvaginal approach, but upon its failure, laparoscopic previous cervical surgery or injury. Among them, 2 patients
cervical cerclage is recommended. underwent transvaginal cervical cerclage during the second
Intrauterine adhesions (IUAs) encompass adhesions and trimester, but premature delivery or miscarriage during the
atresia of the uterine cavity and cervical canal secondary second trimester still occurred, 1 patient had a previous
to damage of the endometrial basal layer caused by cervical loop electrosurgical excision procedure (LEEP),
intrauterine operations, infections, and other factors (3). and 1 experienced cervical laceration during a previous
CI is the main cause of recurrent abortions which usually delivery.
resort to curettage. In turn, curettage is the most common
etiological factor for IUAs, and that explains the co-
existence of CI & IUAs. At present, hysteroscopy is the Inclusion criteria
gold standard for the diagnosis and treatment of IUAs. Patients diagnosed with moderate to severe IUAs combined
There are some differences in the diagnosis and treatment with CI and who had a fertility desire were included.
between the CI combined with IUAs and only CI. There (I) The American Fertility Society (AFS) scoring system
are two main problems. On the one hand, for patients with for IUAs (4): a score of 1 to 4 points is classified as
adhesions of the cervical canal or the lower uterine segment, mild, 5 to 8 as moderate, and 9 to 12 as severe.
a Hegar dilatator is often unable to enter the uterine cavity (II) Diagnostic criteria of CI (2): (i) multiple spontaneous
or it enters with difficulty, which can easily lead to a missed miscarriages during the second trimester, (ii) loose
diagnosis of CI and increase the risk of uterine perforation. cervical canal during nonpregnancy, as reflected by
On the other hand, when the cervix is too loose, more the No. 7 Hegar dilator passing through without
difficulties are encountered in HA and in the postoperative resistance. CI is diagnosed if either (or both) of the
prevention of adhesion reformation. Currently, studies on above 2 criteria is satisfied.
the diagnosis, treatment, and prognosis of such patients
have not been published. This study preliminary the
Exclusion criteria
diagnosis and treatment modalities of such patients and
followed up the pregnancy outcomes after treatment, so as Acute inflammation of the internal genitalia or systemic
to provide a certain reference for future clinical treatment acute inflammation, severe pelvic adhesion that is not
of such conditions. suitable for laparoscopic surgery, age older than 40 years,

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(4):54 | http://dx.doi.org/10.21037/atm.2019.12.148
Annals of Translational Medicine, Vol 8, No 4 February 2020 Page 3 of 7

with a 5.4 mm outer diameter and a 5-Fr working channel

was used to enter the cervical canal in order to prevent
a misdiagnosis of CI caused by IUAs. After a confirmed
diagnosis of IUAs, HA was carried out using 5-Fr double
action forceps and single action scissors (5,6). After
adhesiolysis a suitable sized IUD (Figure 1) was placed
into the intrauterine cavity and whether the size and
position of the IUD was suitable was verified right after its
placement via hysteroscopy. Estradiol valerate at 3 mg/Bid
was administered starting on the 5th day of the menstrual
period for 21 consecutive days, and progesterone at 200 mg
q.n. was added starting on the 16th day of the 21 days for 6
Figure 1 Uterine-shaped loop IUD. IUD, intrauterine device. consecutive days. Following up hysteroscopy was carried out
1 month and 4 months after the initial HA. If the follow-up
hysteroscopy showed adhesions, they were separated again.
The cervical cerclage was performed until the AFS score
was less than 5. The IUD of one patient moved down to the
cervical canal and the balloon (Figure 2) fell off within one
day after HA due to the very loose cervix. The patient was
reviewed one month after initial HA. Hysteroscopy showed
a recurrent IUAs with an AFS score of 7 and cervical
cerclage was performed followed by HA at the same time.
Laparoscopic cervical cerclage: the vesicouterine
peritoneum is opened using the monopolar L-hook
electrode and dissected off the lower uterine segment,
exposing the uterine vessels anteriorly on both sides. A
5-mm nonabsorbable Mersilene polyester suture (Johnson
and Johnson company), with adjacent straightened blunt
needles was introduced through the laparoscopic port into
the abdominal cavity. The stitch was placed by passing each
needle between the uterine vessels and the uterine isthmus
from anterior to posterior, at the level of the internal
cervical os bilaterally. The needles were then cut off and
Figure 2 Foley’s catheter balloon, with the top catheter portion removed, and the Mersilene suture was then tied tightly
beyond the balloon removed. around the cervix with four knots using intracorporeal knot
tying. The ends of the stitch were trimmed. No suture
penetration was detected by hysteroscopy. The cervix
decreased ovarian reserve function [follicle stimulating accommodated up to the No. 6 Hegar dilator without
hormone (FSH) ≥10 IU/L], and fetal abnormalities or resistance but cannot through the No. 8 Hegar dilator.
other adverse reproductive outcomes history. Patients
with the above conditions were advised to perform
Evaluation indexes of the treatment effect
cerclage during pregnancy after screening at 14 weeks of
pregnancy. Pregnancy status after treatment: The pregnancy rate,
miscarriage rate, live birth rate, incidence of preterm
premature rupture of membranes, full-term delivery rate,
Surgical methods and postoperative management
blood loss during cesarean section, and placental adhesions
Hysteroscopic adhesiolysis (HA): Bettocchi hysteroscope were assessed.

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(4):54 | http://dx.doi.org/10.21037/atm.2019.12.148
Page 4 of 7 Li et al. Diagnosis and treatment of CI with IUAs

Table 1 Pregnancy and pregnancy outcomes patients were pregnant [5 with natural conception and
1 who underwent in vitro fertilization/embryo transfer
Variables Outcomes
(IVF/ET)]. The occurrence time of the pregnancy
Postoperative pregnancy (pregnancy rate) 6 (60%)
was 1 to 2 months after treatment, with an average of
Live birth rate 100% 1.2±0.4 months. Four patients were not pregnant (2 patients
Gestation week at delivery (weeks) 37.2±1.17 each actively prepared for pregnancy for 3 and 9 months
after surgery, but were still not pregnant. The other 2
<37 1 (16.7%)
patients underwent IVF-ET 1 month after surgery, but
≥37 5 (83.3%) both had failed conceptions due to a lack of “implantation
Miscarriage rate 0 of embryo”).
Premature rupture of membranes 0 Pregnancy outcomes: the mean delivery gestational
age was 37.2±1.17 weeks (range, 35 to 38). One patient
Placental adhesion 2 (33.3%)
underwent cesarean section due to preterm labor at
Blood loss during cesarean section (mL) 283±263 35 weeks of pregnancy without premature rupture of
membranes; the remaining 5 patients underwent elective
cesarean sections at 37 to 38 weeks. six patients who
Results underwent cesarean section experienced no serious
surgical complications. The intraoperative blood loss was
Diagnosis and treatment of CI: all 10 patients had a
100–800 mL, with an average of 283±263 mL.
previous history of typical painless cervical dilation during
Four patients had intact placentas and membranes
the second trimester before surgery, and in 6 patients, the
during cesarean delivery. The placental adhesions were
No. 7 Hegar dilator could pass through the internal cervical
identified during cesarean section in 2 patients, and manual
os before surgery without resistance. In the other 4 patients,
detachment of the placenta was performed.
the cervical dilator could not be inserted before surgery
due to adhesions of the cervical canal and the lower uterine
segment; the diagnoses of these patients were further Discussion
confirmed 3 months after the HA when the No. 7 Hegar CI is defined as the inability of the uterine cervix to retain a
dilator was able to pass through the internal cervical os pregnancy in the second trimester in the absence of clinical
without resistance. There were 9 patients who underwent contractions, labor, or both (2). IUAs refers to the disease
pre-pregnancy laparoscopic cervical cerclage after HA. caused by trauma or inflammation of the endometrium. It is
The remaining 1 patient underwent laparoscopic cervical most often secondary to endometrial basal layer injury, such
cerclage prior second HA, as the cervix was too loose to as curettage, cesarean section, abdominal myomectomy
retain and be treated with an IUD or distended Foley’s and/or hysteroscopic myomectomy, polypectomy or
catheter balloon (Figures 1,2) which essentially prevent incision of the uterine septum (7,8). As CI patients usually
postoperative adhesion reformation. Ten patients underwent undergo multiple uterine operations, they are prone to
laparoscopic cervical cerclage with an intraoperative develop IUAs and this explains the co-existence of these
blood loss of 10–50 mL, with an average blood loss of 27± two conditions. Accurate diagnosis while avoiding missed
16.16 mL. diagnosis is a necessary first step in managing these patients
Diagnosis and treatment of IUAs: all 10 patients were and eventually improving their prognosis.
diagnosed with IUAs by hysteroscopy. The mean AFS score According to the American College of Obstetricians
of the initial IUAs was 9.80±1.08 (range, 8 to 12) and the and Gynecologists (ACOG) guidelines (2), the diagnostic
mean number of HA was 2.8±1.03 (2 to 5). At the end of criteria for simple CI are based on 3 aspects: medical
treatment of IUAs, the mean AFS score was 2.70±1.00. history, ultrasound indicators, and a tentative diagnosis
during the nonpregnancy period. Among them, the
medical history is the most important for the diagnosis of
Pregnancy and pregnancy outcomes after the treatment of
CI, and a history of miscarriage in the second trimester
CI concomitant with IUAs (see Table 1)
or premature birth caused by repeated painless cervical
Pregnancy: in all, 10 patients were followed-up. Six dilatation is the direct basis for the diagnosis of CI. At the

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Annals of Translational Medicine, Vol 8, No 4 February 2020 Page 5 of 7

same time, a cervical canal width >0.6 cm at the internal the special population of patients with IUAs combined with
cervical os under ultrasound examination can also assist in CI, the benefits of laparoscopic cervical cerclage outweigh
the diagnosis. Other diagnostic modalities of CI include: its drawbacks as it is primordial in ensuring increased live
hysterosalpingography (HSG) and imaging of balloon birth rate. Patients with IUAs are prone to miscarriages, and
traction on the cervix radiographically, assessment of those who also have CI are more likely to have miscarriages
the patulous cervix with Hegar or Pratt dilators, balloon during the second and third trimester or premature
elastance test, and graduated cervical dilators which are labor when compared cervical cerclage transvaginally to
used to calculate the cervical resistance index based on the laparoscopically. If curettage is performed again due to
functional anatomy of the internal os in the non-pregnant miscarriage, damage to the uterine cavity may lead to
state. In this study, CI was diagnosed upon easy passage of irreversible chances to reproduction as the uterine cavity
the No. 7 Hegar dilator through the intracervical canal. and the endometrium had already been severely damaged
The diagnosis of CI combined with IUAs should be previously. Therefore, for patients with moderate to severe
carried out with diligence as the inability or difficulty in IUAs combined with CI, we recommend pre-pregnancy
introducing the Hegar dilator may lead to missed diagnosis, laparoscopic cervical cerclage to maximally reduce the
creation of false passage and even cause uterine perforation. risk of miscarriage or premature birth. Many studies have
we were unable to introduce the Hegar dilator into the demonstrated that compared with emergency cervical
cervical canal in 4 of them due to the adhesion. However, cerclage treatment, elective cervical cerclage treatment
after HA, diagnosis of CI was confirmed as the No. 7 Hegar for CI can significantly prolong the gestation weeks,
dilator accessed the cervical canal without any resistance. shorten the hospitalization time, and improve neonatal
Therefore, for patients with CI, complicated with moderate prognosis (14). In addition, pre-pregnancy laparoscopic
to severe IUAs, especially of the cervix and lower uterine cervical cerclage not only can prevent miscarriage but
segment, it is recommended to insert the cervical dilator also won't limit conception or assisted reproductive
again after the uterine cavity morphology returns to normal technology (13). Of the 10 patients we treated, 6 (60%)
or 3 months after the initial HA; as it is more safe and were pregnant 1–2 months after surgery. Among them,
reliable postoperatively and it effectively avoids missed one patient had a previous cervical LEEP, and 1 patient
diagnosis. had 2 previous failed transvaginal cervical cerclages. The
Cervical cerclage is the mainstay of surgical treatment laparoscopic cervical cerclage is simple and minimally
for CI and the approaches include transvaginal and invasive. In our study, the average amount of blood loss
transabdominal cervical cerclage (9). The most effective during pre-pregnancy laparoscopic cervical cerclage
method is laparoscopic cervical cerclage through surgery was very small (27±16.16 mL) and there was no
transabdominal approach. For patients with simple surgical complication. After the treatment of CI and IUAs,
CI, transvaginal cervical cerclage is currently the most the average gestational age was 37 weeks, and the full-
commonly performed procedure. However, studies show term delivery rate was 83%. Only 1 patient delivered at
that 11–53% of patients who underwent transvaginal 35 weeks by cesarean section due to preterm labor. The
cervical cerclage still experienced miscarriage, and patients prognosis of the newborns was good. No patient had
who had failed transvaginal cervical cerclage underwent midterm miscarriage, premature rupture of membranes,
transabdominal cerclage and achieved a live birth rate of chorioamnionitis, etc. One-third of the patients (2 patients)
more than 90% (10-13). This finding is due to the relatively had placental adhesions, and thus manual placental
low cerclage position in transvaginal cervical cerclage. detachment was performed with an average intraoperative
Moreover, transvaginal cerclage is more likely to fail for blood loss of 283±263 mL. In our study, pre-pregnancy
patients who underwent LEEP or with the short cervix. laparoscopic cervical cerclage for moderate to severe IUAs
The laparoscopic cervical cerclage site is close to the concomitant with CI has a relatively good prognosis.
internal cervical os, which can greatly reduce the possibility The order of treatment of CI and IUAs should be
of surgical failure caused by low cerclage position (10). decided according to the specific circumstances. Generally,
Compared with transvaginal cervical cerclage, laparoscopic it is recommended to treat IUAs first and then to treat
cervical cerclage is more complicated, the cerclage band CI. The reasons are as follows: (I) the treatment of IUAs
can only be removed by cesarean section, and there is an does not surely have a good prognosis, especially for a
increased risk of pelvic adhesion and bladder injury. But for totally destroyed uterine cavity; (II) to avoid cerclage band

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Page 6 of 7 Li et al. Diagnosis and treatment of CI with IUAs

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Cite this article as: Li W, Li Y, Zhao X, Cheng C, Burjoo A,

Ya n g Y, X u D . D i a g n o s i s a n d t r e a t m e n t o f c e r v i c a l
incompetence combined with intrauterine adhesions. Ann
Transl Med 2020;8(4):54. doi: 10.21037/atm.2019.12.148

© Annals of Translational Medicine. All rights reserved. Ann Transl Med 2020;8(4):54 | http://dx.doi.org/10.21037/atm.2019.12.148