O'Connor Sarah K, Ryley David A, Obasiolu Charles W, Esselen Katharine M, Skiadas Christine C, Kuohung Wendy
Department of Obstetrics & Gynecology, Boston Medical Center, Boston, MA USA.
Harvard Medical School, Boston IVF, Waltham, MA USA.
Fertil Res Pract. 2020 Sep 2;6:16. doi: 10.1186/s40738-020-00085-0. eCollection 2020.
Vaginal cuff dehiscence (VCD) is a rare but potentially serious complication following hysterectomy with an estimated incidence of 0.14-1.4%. There is a wide range of risk factors thought to contribute to VCD, but due to its rare occurrence, much still remains to be learned about the true impact of risk factors leading to dehiscence. We present here the second known report of VCD to occur in a patient undergoing transvaginal oocyte retrieval during her fertility treatment. This case highlights what may become a more common clinical scenario as more premenopausal women are diagnosed with reproductive tract cancers and access assisted reproductive therapies to preserve fertility.
Our patient is a 35-year-old G1 P0 A1 who had undergone ovary-sparing total laparoscopic hysterectomy (TLH) following diagnosis of endometrial adenocarcinoma. She underwent two in-vitro fertilization (IVF) cycles after TLH to bank frozen blastocysts, the first vaginal oocyte retrieval (VOR) taking place 12 weeks following hysterectomy. She experienced VCD during her second VOR that occurred 17 weeks after TLH, the second case of VCD to be reported in the literature during fertility preservation treatment following hysterectomy. The patient underwent an emergent and uncomplicated repair of the defect vaginally the same day.
Currently there are no guidelines in place for women who have undergone hysterectomy with regard to when they can begin fertility treatment in the post-operative period. Based on now two case reports, it is worth considering extension of the typical 6-week timeline of avoidance of vaginal procedures to allow for full cuff healing. Infertility providers should also be mindful of limiting transvaginal ultrasounds where possible to reduce force along the cuff.
阴道残端裂开（VCD）是子宫切除术后一种罕见但可能严重的并发症，估计发生率为0.14 - 1.4%。有多种危险因素被认为与VCD的发生有关，但由于其罕见性，关于导致裂开的危险因素的真正影响仍有许多有待了解。我们在此呈现第二例已知的在生育治疗期间接受经阴道取卵的患者发生VCD的报告。随着更多绝经前女性被诊断出生殖道癌症并接受辅助生殖治疗以保留生育能力，这个病例凸显了一种可能变得更为常见的临床情况。
我们的患者是一名35岁、孕1产0、流产1次的女性，在被诊断为子宫内膜腺癌后接受了保留卵巢的全腹腔镜子宫切除术（TLH）。TLH术后她进行了两个体外受精（IVF）周期以储存冷冻囊胚，第一次经阴道取卵（VOR）在子宫切除术后12周进行。她在TLH术后17周进行第二次VOR时发生了VCD，这是文献中报道的子宫切除术后生育保留治疗期间发生VCD的第二例。患者于同日紧急且顺利地经阴道修复了缺损。
目前对于接受子宫切除术的女性在术后何时可以开始生育治疗尚无指南。基于现在的两例病例报告，值得考虑将避免阴道操作的典型6周时间延长，以使残端完全愈合。不孕不育治疗人员还应注意尽可能限制经阴道超声检查，以减少对残端的压力。
