On Saturday night, we admitted a patient at only 19 weeks’ gestation with advanced cervical dilation, occasional contractions, and fetal membranes ballooning through the cervix into the vagina – a history consistent with severe cervical incompetence. Although she is only 26 years’ old, she had an 8 year-long history of primary infertility and this, her first pregnancy, was the result of ovulation induction and in vitro fertilization (IVF).
As in so many of these patients, there were multiple factors contributing to her infertility. She had been diagnosed with mild endometriosis in the past and had laparoscopic laser ablation for the same. She had had a small fibroid in the uterine cavity that was resected using hysteroscopy. Probably more significant with regard to her current problem, she was moderately obese, did not ovulate regularly, and had “insulin resistance” associated with glucose intolerance, elevated androgens (‘male hormones’), mildly elevated prolactin, and hirsutism (male pattern hair distribution). In addition to these factors, her husband had repeatedly had “low sperm counts.” Using drugs to induce ovulation and to reduce her insulin resistance, she had conceived with her first cycle of IVF. Although she worked as a nurse, the cost of her infertility care and the IVF had run more than $50,000 over the years and most of that was not covered by insurance.
I have learned that problems women have with infertility don’t go away with conception, and often contribute to complications during pregnancy. For example, the patient above was at increased risk for gestational diabetes and hypertensive disorders during pregnancy because of her hormonal ‘imbalances’ and ‘insulin resistance.’ Furthermore, patients who require ovulation induction and assisted reproductive technologies have a 3.5-fold risk of delivery less than 37 weeks, a 1.5-fold risk of having a low birth weight baby (less than 2500 g), and 1.8-2.6-fold risk of having a very low birth weight (VLBW) baby ( less than 1500 g). They have higher rates for these outcomes in both singleton and multiple gestations. In 2001, 57% of twins and 92% of triplets were born at less than 37 weeks; and, 10% of twins, 35% triplets, and more than 70% of higher order multiples resulted in VLBW babies with 80% of the triplets and higher order multiples resulting from interventions for infertility.
Reasons for these early deliveries and low birth weight babies are often written off as a consequence of multiple gestations or the medical complications these patients develop during pregnancy. But, many practitioners, including the infertility specialists who help these patients conceive, are not aware of the fact that such patients are also at extraordinarily high risk for cervical incompetence. The reason for this is not entirely clear to me. It could be the result of the underlying metabolic defects that lead to their insulin resistance, the insulin resistance itself, or some other unknown association that deleteriously affects the composition of cervical connective tissue. It also could be the result of the previous surgical procedures many of these patients undergo as part of their infertility evaluation and management that might compromise the integrity of the internal cervical os. Personally, I believe the ‘metabolic’ defect is the more significant but, regardless, when given the opportunity to counsel these patients preconceptionally, or in early pregnancy, I outline a course of management that includes ultrasound evaluation of the cervix during midtrimester to look, specifically, for evidence of cervical incompetence.
Unfortunately, the problem our patient encountered occurred even earlier than usual for this group of ‘at risk’ patients. Most of these individuals do not exhibit this degree of cervical change before 20 weeks’ during their first pregnancies. Even more unfortunately, there was nothing that could be done for her because of the advanced cervical dilation and the membranes stretched and bathed in the unsterile environment of the vagina at the time of her transfer to our service. We have a relatively good track record with ‘rescue cerclages’ prior to complete prolapse of the membranes, but once that occurs, delivery is usually inevitable and, even if a cerclage can be placed, this is almost always followed by infection and spontaneous rupture of membranes necessitating delivery of the pregnancy. Although we provided her with counseling and educated her to the fact that she has an incompetent cervix that will require cerclage placement early in a subsequent pregnancy, that is little consolation for the disappointing loss of a baby for which she had invested so much time, emotion, and resources in conceiving and carrying.