Journal of Reproductive Medicine Gynaecology & Obstetrics Category: Medical Type: Editorial
Fully Embedded Prophylactic Cervical Cerclage for Twin Pregnancies Achieved Following Fertility Treatment
- Leonidas Mamas1*, Eudoxia Mamas1
- 1 Neogenesis Ivf Centre, 3 Kifissias Ave, 151 23 Marousi, Athens, Greece
*Corresponding Author:Leonidas Mamas
Neogenesis Ivf Centre, 3 Kifissias Ave, 151 23 Marousi, Athens, Greece
Fax:+30 210 6836090
Received Date: May 25, 2020 Accepted Date: May 29, 2020 Published Date: Jun 05, 2020
Assisted Reproductive Technology (ART) has offered hope to a great number of couples in the past few decades. The rate of multiple pregnancies has increased after the use of ART; 19.6% of ART conceived infants were twins in 2015 according to the Centre of Disease Control (CDC) . It is well known that multiple pregnancies are considered high risk due to the associated increased risk of maternal and neonatal complications . Twin neonates show a higher incidence of prematurity, low birth weight, cerebral palsy  and need for Neonatal Intensive Care Unit (NICU). Furthermore, it has been estimated that in the US, preterm deliveries following ART cost approximately one billion US dollars every year . One may argue that Single Embryo Transfer (SET) may offer a solution to the problem of multiple pregnancies achieved through IVF and ICSI. We have to bear in mind however, that SET is usually applied to younger women and there is still a 1.56% chance of a twin pregnancy due to zygotic splitting . Furthermore, no such solution is available for couples undergoing Intrauterine Insemination (IUI) or Controlled Ovarian Stimulation (COS).
Numerous different strategies have been applied throughout the years in an attempt to minimise the rate of prematurity in multiple pregnancies and its associated risks. Vaginal progesterone has not been shown to prevent preterm delivery in twin pregnancies [6,7]. Bed rest (either inpatient or outpatient) shows no improvement in premature deliveries  and has been associated with a higher rate of maternal depression . The efficacy of the Arabin pessary is under continuous investigation. In a recent randomised controlled trial, the routine use of pessaries in twin pregnancies did not show a reduction in the rate of early preterm birth .
Vaginal cervical cerclage was first introduced in the 1950s; a suture was used in order to reinforce the cervix, increase mechanical stretch thus avoiding cervical dilatation and premature delivery [11,12]. The beneficial effect of the application of a prophylactic vaginal cervical cerclage in multiple pregnancies was first described in 1999 by Elimian et al., who reported a lower rate of extremely low birth weight neonates in triplet pregnancies with a cerclage . In 2016, a randomised controlled trial assessed the effect of a prophylactic vaginal cerclage in 120 ICSI twin pregnancies . Once again, the cerclage group showed greater mean gestational age at delivery and neonatal delivery weight.
In a recently published article , our team presented the promising results of the use of a prophylactic modified Shirodkar vaginal cervical cerclage. The cerclage was applied in pregnancies achieved through fertility treatment in our Centre. The main difference between the classic Shirodkar cerclage and our modified type is the fact that the suture and the knot of the suture are embedded under the vaginal mucosa in order to minimise the complications associated with infection such as chorioamnionitis and premature rupture of the membranes. Our team investigated the effect of the cerclage in the following end points: gestational age at delivery, neonatal delivery rate, rate of admission and length of stay in the NICU.
The prophylactic modified vaginal cerclage was applied in 43 women with twin gestations achieved through ART treatments following local institutional review board approval. The operation was performed at 13 to 14 weeks gestation after the nuchal translucency scan as well as blood and vaginal tests to exclude infection. The operation has been previously described in detail by the authors . The women were discharged following an overnight hospital stay; follow up included monthly CRP and white blood count measurement and routine obstetric ultrasounds. In an attempt to avoid obstetric and perinatal complications associated with vaginal deliveries of twin pregnancies all women delivered by elective Caesarean Section (CS) following the administration of antenatal corticosteroids. The suture was removed following the CS.
During our study period, 86 twin neonates were delivered. The results were very promising; the mean neonatal delivery weight was 2,238 ± 329 grams and the mean gestational age at delivery 35+4 weeks. 49 neonates (55.8%) required admission to NICU and the average length of stay was 7 day; that is 12 days less than the average length of stay reported from Pinborg et al., . No significant differences were noted when comparing the type of ART treatment used or between neonatal sexes.
Is prematurity in twin pregnancies so frequent after ART? The data are clear. In 2014, according to the European IVF Monitoring Consortium, 17% of the deliveries from IVF and ICSI embryo transfers were twins, and the risk of extreme and very preterm birth (<32 weeks gestation) was 4.1% and 15.5% respectively . In the US, the rate of very preterm birth was 10.5% in 2015 . If we combine the above data and given the fact that annually about 500,000 neonates conceived through ART are born, one can estimate that approximately 30,000 twin pregnancies will be premature; this number may double if we add pregnancies conceived through IUI and COS. One must not forget the high incidence of cerebral palsy encountered in preterm deliveries reaching up to 20% in neonates delivered <32 weeks gestation .
It must be considered that prematurity related with multiple pregnancies, apart from the associated neonatal health risks is also associated with increased financial cost and most importantly social and psychological cost. In conclusion, based on the above data and our promising results, the modified prophylactic vaginal cervical cerclage may prove a very important tool to avoid prematurity in twin pregnancies achieved through ART treatment.
- Sunderam S, Kissin DM, Crawford SB, Folger SG, Boulet SL, et al. (2018) Assisted Reproductive Technology Surveillance - United States, 2015. MMWR Surveill Summ 67: 1- 28.
- Santolaya J, Faro R (2012) Twins--twice More Trouble? Clin Obstet Gynecol 55: 296- 306.
- Himpens E, Van den Broeck C, Oostra A, Calders P, Vanhaesebrouck P (2008) Prevalence, Type, Distribution, and Severity of Cerebral Palsy in Relation to Gestational Age: A Meta-Analytic Review. Dev Med Child Neurol 50: 334-340.
- Bromer JG, Ata B, Seli M, Locdwood CJ, Seli E (2011) Preterm Deliveries That Result From Multiple Pregnancies Associated With Assisted Reproductive Technologies in the USA: A Cost Analysis. Curr Opin Obstet Gynecol 23: 168-173.
- Ikemoto Y, Kyroda K, Ochiai A, Yamashita S, Ikuma S, et al. (2018) Prevalence and Risk Factors of Zygotic Splitting After 937 848 Single Embryo Transfer Cycles. Hum Reprod 33: 1984-1991.
- Hernandez WR, Francisco RPV, Bittar RE, Gomez UT, Zugaib M, et al. (2017) Effect of Vaginal Progesterone in Tocolytic Therapy During Preterm Labor in Twin Pregnancies: Secondary Analysis of a Placebo-Controlled Randomized Trial. J Obstet Gynaecol Res 43: 1536-1542.
- Dodd JM, Grivell RM, O’Brien CM, Dowswell T, Deussen AR (2017) Prenatal Administration of Progestogens for Preventing Spontaneous Preterm Birth in Women With a Multiple Pregnancy. Cochrane Database System Rev 10: CD012024.
- da Silva Lopes K, Takemoto Y, Ota E, Tanigaki S, Mori R (2017) Bed Rest With and Without Hospitalisation in Multiple Pregnancy for Improving Perinatal Outcomes. Cochrane Database Syst Rev 3: CD012031.
- Maloni JA, Margevicious SP, Damato EG (2006) Multiple Gestation: Side Effects of Antepartum Bed Rest. Biol Res Nurs 8: 115-128.
- Nicolaides KH, Syngelaki A, Poon LC, de Paco Matallana C, Plasencia W, et al. (2016) Cervical Pessary Placement for Prevention of Preterm Birth in Unselected Twin Pregnancies: A Randomized Controlled Trial. Am J Obstet Gynecol 214: 1-9.
- Shirodkar JN (1955) A new method for operative treatment of habitual abortions in the second trimester of pregnancy. Antiseptic 52: 299.
- McDonald IA (1957) Suture of the Cervix for Inevitable Miscarriage. J Obstet Gynecol Br Emp 64: 346-350.
- Elimian A, Figueroa R, Nigam S, Verma U, Tejani N, et al. (1999) Perinatal Outcome of Triplet Gestation: Does Prophylactic Cerclage Make a Difference? J Matern Fetal Med 8: 119-122.
- Ayman S, Hesham MB, Naglaa H, Maher AH (2016) Prophylactic Cerclage in ICSI Twins: To Do or Not to Do? A Randomized Controlled Study. Women’s Health & Gynecology 2: 042.
- Mamas L, Mamas E (2020) Prophylactic cervical cerclage, fully embedded, for twin pregnancies following fertility treatment. CEOG 47: 238-242.
- Pinborg A, Loft A, Rasmussen S, Schmidt L, Langhoff-Roos J, et al. (2004) Neonatal Outcome in a Danish National Cohort of 3438 IVF/ICSI and 10,362 non-IVF/ICSI Twins Born Between 1995 and 2000. Hum Reprod 19: 435-441.
- De Geyter C, Calhaz-Jorge C, Kupka MS, Wyns C, Mocanu E, et al. (2018) European IVF-monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE): “ART in Europe, 2014: results generated from European registries by ESHRE: The European IVF-monitoring Consortium (EIM) for the European Society of Human Reproduction and Embryology (ESHRE). Hum Reprod 33: 1586-1601.
Citation:Mamas L, Mamas E (2020) Fully Embedded Prophylactic Cervical Cerclage for Twin Pregnancies Achieved Following Fertility Treatment. J Reprod Med Gynecol Obstet 5: 050.
Copyright: © 2020 Leonidas Mamas, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.