Monthly Archives: October 2013

Today’s Grief

Grief looked different to me today. Usually I’m sad. I cry, I miss my little girl, I think about what could have been.

But today it looked different. Today I was cranky, moody, and impatient with others. I was tired, and didn’t feel well. Not sick, just not . . . well. I didn’t feel like getting dressed. I didn’t feel like helping people, or trying to make a difference.

Today, on my second Infant and Pregnancy Loss Awareness Day, my grief was ugly, and I didn’t even recognize it. It wasn’t inspirational, it was selfish.

That’s just how grief is sometimes.

My TAC Experience

If you have questions, or would like to contact me privately, please email tac.questions@gmail.com.

Well it turns out that it’s difficult to do things like write blog posts with a new baby. There are people who are much better at it than I am, but the fact is that I’m not very good at it. It’s hard enough to stay on top of the house work when I just want to spend all day cuddling my little boy. I thought my next blog post would be a picture-heavy run-through of William’s first several weeks, but instead it’s going to be about how he got here. No no, not that, get your mind out of the gutter.

If you’ve already lost interest, that’s fine. This is really for all the women who find this blog looking for information about incompetent cervix and the Transabdominal Cerclage (TAC). This is my experience with the TAC surgery and how it’s held up since. But I have to start at the beginning. Feel free to skim – as you know, I’m a talker.

The day that Lucy died, as we were driving home from Bakersfield, David and I looked at each other through our shock and grief and agreed that we’d still like another child. This may not seem like a big deal, but you can’t understand what that decision feels like right after you’ve lost your baby (unless, of course, you’ve lost your baby, in which case I’m so sorry and I’m sure you do understand). But we knew even then that we wanted Lucy to have a little brother or sister, as she would have had she lived. So it didn’t take long – maybe a few weeks – for me to start researching my condition. It was easier for me to start than it is for many women, because the doctor who delivered Lucy had diagnosed me with incompetent cervix. This, unfortunately, is not the case for the majority of women who lose a child to IC. Doctors are reluctant to diagnose IC as it is not a straightforward or easy diagnosis. Sadly, this sometimes means a woman will lose more than one baby before she figures out what the problem is. As I said, this was not the case for me, so a few weeks after Lucy’s memorial service I sat at my computer googling “incompetent cervix.” It didn’t take me long to find the most common solution, which is what my doctors had suggested for next time – the simple TVC (transvaginal cerclage). I then found a group of women who had taken it one step further with the TAC. I won’t get into all the differences and pros and cons here. If you’d like to read about that, I wrote about it here.

After reading the posts of the Abbyloopers (on the web here and on Facebook here) women for a week or so and researching the TAC extensively, David and I decided it was the only way for us to go. If we were going to try to have another baby, we were going to give it the best chance we could. I contacted Dr. Davis in New Jersey and Dr. Haney in Chicago. They, along with Dr. Sumners in Indianapolis are the experts on the TAC in the US, and perform the most surgeries in the US as far as I know (although rumor has it Dr. Davis is nearing his retirement). I discussed my case with both of them (by email and by phone), and they agreed that it sounded like a classic case of IC and suggested I have the TAC surgery. I started checking into insurance coverage for a pre-pregnancy TAC. Then, out of the blue, I found out I was pregnant. I had always had irregular cycles, and it took us so long to get pregnant with Lucy that I didn’t think anything of it when my period was one week late, then two. When I finally took a pregnancy test and got my positive result, I was already 7 weeks pregnant. As in-pregnancy TACs are usually placed between 10 and 14 weeks, I hit full panic mode. How was I supposed to schedule a cross-country trip and clear everything with my insurance that quickly? I originally intended to fly to Chicago to have the TAC placed by Dr. Haney, but after two weeks of trying to get in touch with his assistant she finally told me he would be on vacation during the time I needed to have the surgery. Now I really panicked. Here I was, 9 weeks pregnant and without anything scheduled. Fortunately I was able to get in with Dr. Davis, and we planned our trip from Southern California to New Jersey. And because of Lucy’s time in the NICU, we’d already hit our catastrophic limit with our insurance and didn’t end up paying a thing for the surgery, which was covered without incident (again, many women are not so lucky, so I count myself very fortunate). Dr. Davis is outstanding at getting insurance to cover the procedure, and he usually takes care of everything. If you don’t have insurance, or they won’t cover a TAC, Dr. Davis is the only doctor I know of who offers an out-of-pocket option at cost. It runs about $4500-$6000, I think.

I planned for our trip through my morning sickness, which completely disappeared the day before we were scheduled to fly out (hallelujah!). We flew into Philadelphia (PHL) on Wednesday, which is definitely the closest airport to Kennedy Hospital. We got a rental car and settled into our hotel, the Hampton Inn in Turnersville. We got the federal employee rate, and the hotel was nice, clean, had a decent breakfast, and was pretty close to Kennedy Hospital. Next door is a Friendly’s, and there are many other (mostly chain) restaurants very close by. Be warned if you’re not from the area: New Jersey has these really weird left turns called jug handles. You go right and loop around to make a left, and it’s strange to get used to. There’s at least one close to the Hampton Inn, so you’ll probably see what I mean.

The next morning I had a consultation with Dr. Davis, then later met my friend Ruth and her wonderful family for dinner. The morning consultation was easy – a quick vaginal exam to check my cervix, an abdominal ultrasound to check out the baby (then almost 13 weeks and measuring large), and a question and answer session. I had him take me through what would happen during the surgery (he had a handy Powerpoint presentation to show me) and we asked a bunch of questions about safety of the baby and other things. He didn’t rush us at all, and he let us get all of our questions out. He has a dry sense of humor, and he’s easy to get along with. The truth is, Dr. Davis is a bit of a talker too, which is actually nice when you’re used to doctors rushing you out. We also discussed food – I asked him where we should eat, and he had a lot of ideas. We wanted the quintessential New Jersey experience, so he recommended a diner that we enjoyed for lunch. We were there for over an hour and left feeling very reassured. Oh, after we left his office I went down to the lab to do my pre-op bloodwork also.

After dinner with Ruth’s family we went back to our hotel to relax. I wasn’t to eat or drink after midnight, and we had to be at the hospital at 7:00 am to get registered. Both our consultation and the surgery took place at Kennedy, by the way, although Dr. Davis also has offices elsewhere. We got to the hospital, registered, then waited and waited and waited because they were running a little behind. I didn’t mind too much, but I was hungry and thirsty of course. Finally they brought me back to the pre-op room without my husband where I dressed in a gown, met the anesthesiologist, got my IV, briefly met with Dr. Davis, then waited some more. At some point David was allowed to come back and sit with me.

Since I was pregnant and wanted the least medication possible going to my baby, I opted to be awake for the surgery with a spinal, just like for most cesarean sections. I’d had surgery before, but never awake, and that part was a little scary. Finally (after noon by this time – I was starving and so thirsty!) I said goodbye to David and they wheeled me back to the operating room. The anesthesiologist placed the spinal, which was weird and hard for me to deal with (needle issues), but it was actually nice when I felt it moving down my legs because I’d been so cold, and then only my top half was cold. Oh, there was a really nice nurse, a handsome Marine, holding me steady and keeping me calm while the spinal was placed. They then put up the curtain and flipped up my gown. By the way, when you’re awake for a pelvic surgery, you have to just let go of any dignity you thought you had. Actually, just get used to it, because it only gets worse when you actually have the baby. I chose to have the TAC placed with a traditional open incision – the same kind they use for c-sections. They gave me a quick shave where the incision was going to go. I normally might have been pretty embarrassed by that, but when you’re numb from the chest down and you can’t see it, it’s like it’s happening to someone else. Oh, at some point in here they pushed some antibiotics through the IV in my hand, which was incredibly painful. In fact, that was the most painful part of the whole surgery I think. It burned, and it made my wrist feel like it was breaking. The anesthesiologist was really nice though and brought me warm blankets for the top of me that was still cold. I mentioned that it might be cool to watch the surgery on the TV screen they had in there, and they would have let me except I didn’t have my glasses. So if you’d like to watch, ask them to let you bring your glasses back if you need them.

I remember wondering when they were going to start, and then I smelled burning. I wondered what it was for a second, then realized oh, hey, that’s my burning flesh as they cauterize the incision. It was a bit weird feeling a lot of pulling and tugging and not knowing what was going on – I kind of wish they’d say “ok, this is what we’re doing now.” But Dr. Davis was just chatting with everyone in the room, and at one point started quizzing people: “how many cups in a pint?” and “how many feet in a mile?” Then he asked “how many two cent pieces in a dozen?” Trick question of course, and his assistant surgeon fell for it: “umm, 6?” “Nope. Anyone?” Nobody answered, so finally I said “12. There are always 12 in a dozen.” Everybody stopped, then Dr. Davis leaned over the curtain to look at me and said “Yes, Jill is correct.” Haha. Anyway, the surgery was progressing fine, and it didn’t hurt at all, but it did feel like they were trying to pull my lungs out through my belly. Partway through they put me into a steep Trendelenburg position, which means that they tip you head down. I had to lay like that the whole time I was in labor with Lucy, but this was a steeper angle and they did it so quickly it felt like I was going to slide off the operating table. When he was finished placing the TAC he did an ultrasound directly on my uterus, and I got to see my healthy squirmy little baby looking fantastic.

After what felt like kind of a long time, they finished up and cleared out really quickly, wrapped my torso up tightly with a binder, then I was wheeled back to recovery. They brought David back to see me, and he told me he’d received texts letting him know the surgery was going fine. I thought that was a nice touch. After a little while (not sure how long) they took me to my regular hospital room. I was happy and awake and felt pretty great. They gave me Duramorph – a morphine injection – through my spinal that lasted most of the next two days, and I didn’t need any other pain medication until I left the hospital. I was on a liquid diet (bummer) until the next morning, and I also had the catheter until the next morning. I HATE the catheter, but it wasn’t a big deal. After they took it out, they wanted me to get up to use the bathroom. It was a little tricky at first, but I managed fine and just held a pillow against my incision while I walked. The next morning they took off the binder and said my incision was all the way closed after 12 hours, and I could shower after 24 hours. (I showered back in the hotel before we left.)

Just an aside, and probably TMI, but this is a concern for many women having this surgery. Many, many women had trouble with constipation and painful bowel movements after the surgery. This was NOT a problem for me, but I think I’m in the minority. They give you Colace stool softener in the hospital, and you should definitely take it, but you should probably start it a few days before the surgery if you think you might have any trouble. Also try to eat foods high in fiber, and you should be fine.

The most important thing (as everyone will tell you) after the surgery for your recovery is to get walking as soon as possible. Right after the surgery, it will help your body get rid of extra gas caused by the surgery. This is a problem for every surgery, but is even worse for laparoscopic procedures, so keep that in mind. It’s scary, but walk as much as you comfortably can. Your incision will probably burn at first, but the more you move the better it will feel. Don’t overdo it, of course. In the long run it’s even more important to walk a lot right off the bat. If you don’t, you’re more likely to develop scar tissue, and I can tell you that it is not pleasant. As my pregnancy progressed it became apparent that I had some scar tissue (confirmed by ultrasound), and it was incredibly painful as the baby pressed against it. One of the most painful things I have EVER experienced, in fact. So walk. Just do it. This is probably even more important if you’re already pregnant when you get your TAC, especially if there’s any chance that you’ll end up on bed rest like I did. You want to be as active as possible while you can, and if you have a complicated or difficult pregnancy, you might have trouble with it later.

I was discharged from the hospital the next morning, less than 24 hours later (so it was an outpatient procedure, not requiring pre-authorization from our insurance). They took me in a wheelchair down to the car, and we drove straight to the pharmacy. I took other women’s advice and filled the pain-medicine prescription at a Walgreens near there. I’ve heard that you can’t fill it out of state (although that doesn’t make sense to me, so I don’t know), and that the hospital pharmacy takes a long time. Anyway, we picked up my Percocet and I took one since I knew I’d be moving more. We drove back to our hotel and hung out there the rest of the day (Saturday by now, surgery was on Friday). I slept a lot, and David went and got dinner and brought it back, then we got a sundae from Friendly’s. I took the Percocet the rest of that day and mostly stopped it by Sunday. On Sunday David and I took a drive out to the Pine Barrens to explore. On Monday we went back to Dr. Davis’ office. He removed the staples (he uses staples instead of dissolving stitches), which didn’t hurt at all. I couldn’t even feel it really. He covered the incision with steri-strips. He also did a vaginal ultrasound to check the TAC and take pictures to send to my OB. We saw the baby again, then sat with him while he wrote a letter to my OB. We thanked him and left the hospital, driving straight to the airport. Oh, not quite, we stopped for bagels.

Back at the airport in Philadelphia we got a wheelchair escort. I could have walked very slowly, but we were running a little late, and I knew I had a long day ahead of me. I’m a little paranoid about the full-body scans, so I opted out of that and the TSA agent very gently patted me down. The escort left me at our gate, and I realized I needed to use the restroom before we left, so I set out to find one. It took forever, it was way back out of the terminal. When I finally got back, people were asking David if I was going to be okay. It was nice that people were so concerned; you don’t normally think of strangers being that worried about you. The flight attendants offered to let me board first, and I did very gratefully. We had booked a nonstop flight, thinking it would be easier not to have to transfer. I had an aisle seat (definitely recommend to my fellow TAC mamas) because you need to get up and move during the flight. Unfortunately, it was a very turbulent flight, so the seatbelt light was on most of the time. I got up when I could, and was fine. Oh, you should also be drinking a LOT, and therefore will probably pee a lot. Try to get a seat near the bathroom if you can. I took the Percocet at regular intervals all day Monday, more because I wanted to stay on top of the pain than because I was actually in pain. We got back to LAX, where I didn’t use a wheelchair. We just walked slowly and took the shuttle back to our car. We had a 3 hour drive home still so we set off immediately. We stopped once to stretch and use the bathroom and got home pretty late.

I think I only took one Percocet after we got home because I felt fine really. I stayed mostly in bed for a couple of days and took a shower after a few days. The steri-strips mostly just fell off, and my incision healed really nicely. In fact, my OB used the same incision for my c-section, and 6 weeks post-op it is still just a thin, flat red line. David took really good care of me. Dr. Davis hadn’t given me any restrictions. He said I could do anything that felt okay whenever it felt okay. I asked about swimming and he said it was one of the best things I could do. He said sex was fine whenever we felt up to it. I was swimming very gentle laps a week after the surgery, driving myself to the dentist ten days after surgery, and feeling pretty much completely back to normal a week and a half after surgery. Again, probably TMI, but sex did happen pretty shortly after surgery and it was perfectly fine.

So that was my experience of the surgery. I had other complications of my pregnancy, and they may or may not have been related to the TAC. I will write about that at some point, but here’s the most important thing: the TAC held strong until I was full term (39 weeks) and had reached my scheduled c-section date. I have a delicious, wonderful, beautiful, perfectly healthy baby boy because of Dr. Davis and the TAC. I only wish I had known enough to have it done when I was pregnant with Lucy, because then I’d have my sweet little girl with me. Of course, if that had happened I never would have had William (he was conceived before Lucy’s due date).

Okay, I hope this is informational for women thinking of or planning on having the surgery.

A Step in the Right Direction

Update: If you’d like to read the specifics of my surgery and recovery, see this post. If you have questions, or would like to contact me privately, please email tac.questions@gmail.com.

Okay, I was waiting until everything was planned to really discuss this, but now that everything’s been arranged, I’ve had a hard time working myself up to it. I want to explain the next step we’re taking to make sure that what happened to Lucy won’t happen to any of our other babies in the future. I also want this post to be a source of information for any women out there looking for an idea of what they should do next, because I know it can be hard to find. So before I really start, let me say that I am clearly not a doctor, and this is just my attempt to assemble the relevant information I’ve been able to gather. I’m not going to cite sources, although I may come back in the future and do that. Also, this post is going to be LONG and discuss lady parts in great detail and with diagrams, so that’s just a warning.

Before I get to the nitty-gritty, though, let me just break it down really simply for those who don’t want to know the details. David and I have decided that we’re going to do everything in our power to prevent my stupid dysfunctional cervix from hurting any more of our babies. Neither of us thinks we could live through another experience like we had with Lucy. What I’m doing is flying to New Jersey to have a surgery that will essentially permanently prevent my cervix from dilating. Technically, it’s reversible, but it’s meant to be left in place, and it will mean that I will be required to have a cesarean delivery for any future pregnancy. Not only that, but due to certain risks, I’m not even supposed to labor, so the C-section will be scheduled a little early. That’s the basic idea, and I know it sounds extreme (especially for someone who always wanted a natural delivery), but read on if you want to know more.

If you don’t know me, and you got to this post while searching for information about incompetent cervix/cervical insufficiency, then you’ve probably experienced a loss (or losses) like we did. I’m so sorry. I know the pain you’re feeling, the confusion, the anger, and the frustration with your body. I’m so terribly sorry you’ve had to go through this. If you’re like so many of us, your doctors have told you that your loss was a fluke, or maybe they are pretty sure it was IC. My case was pretty clear, although many times it’s difficult to diagnose IC. Other things can cause preterm labor – infection, problems with the baby, problems with the placenta or cord, etc. So if you have any of those things, it’s hard to know: did one of those things cause labor, which then caused your cervix to dilate, or did your cervix dilate first, causing labor to begin? In my case, there was no infection, nothing wrong, just a 3 cm dilated cervix, bulging bag of waters, and contractions. Anyway, my point is that some doctors are reluctant to diagnose IC. My advice to you, if you’re not sure, is to get enough opinions about your case that you feel comfortable in your own mind that you know what happened to you. Sometimes you just can’t know, and no doctor will be able to help you. You’ll just have to do your research and follow your heart.

The day that my sweet Lucy was born, while she was very much alive down the hall in the NICU, two different OBs told me what we were going to do next time. That’s how they say it. They say “here’s what we’re going to do,” and it is inferred that it will work. People trust their doctors, and when their doctors give them one option, and tell them it will work, they mostly put their faith in them. Doctors are, in general, wonderful knowledgeable people, whom I respect greatly. But they’re also people, and I’ve always thought it was my job as a patient to make sure I was well-informed about any course of treatment. That’s what started me doing research about this, and I assume that’s why you’re reading this. What my doctors told me was that I had an incompetent cervix, and that during my next pregnancy, we’d do a prophylactic TVC (trans-vaginal cerclage) at 11 weeks and I’d have progesterone shots starting at about 16 weeks. My guess is that, if you’ve had a loss, you’ve heard something similar from your doctor. The problem is, that’s all they say. There is a lot more information that they don’t give you, and you really need to have all that information to make an informed decision.

So, now to the diagrams, as I try to explain my understanding of the available procedures. There are essentially three types*:

1) TVC – transvaginal cerclage

a) Shirodkar stitch
b) McDonald stitch

2) TVCIC – transvaginal cervico-isthmic cerclage
3) TAC – transabdominal cerclage

a) Traditional open approach (laparotomy)
b) Laparascopy (through 5 small holes usually)
c) Robotic laparascopy (via da Vinci robot)

*It’s important to note that different doctors (and doctors in different parts of the world) may call these procedures different things. For example, a traditional Shirodkar stitch is somewhat complicated and placed high on the cervix. However, most doctors performing “Shirodkar” cerclages these days are really doing some variation, a modified Shirodkar. Similarly, any cerclage placed through an incision in the abdomen is technically a TAC (transabdominal cerclage). However, some surgeons placing a “TAC” are actually doing a modified McDonald or Shirodkar stitch through the top of the cervix via an abdominal incision. This is NOT recommended and is more likely to cause damage to the cervix and uterus during a normal pregnancy and any contractions. Make sure your doctor explains the procedure he or she plans to perform.

You’ve probably seen this before, but this is what the female reproductive system looks like:

uterus
This image is from MedlinePlus.

However, I’m simplifying it. Please forgive my extremely crude diagram. The important part for this discussion is that part of the cervix lies above the vagina, connecting to the uterus at the internal os, and the rest protrudes into the vagina, ending at the external os. Normally, and during a normal pregnancy, the cervix is long and closed (during pregnancy, you develop a mucous plug that prevents bacteria from entering your uterus). During labor, the cervix thins and opens (effaces and dilates), allowing the baby to pass through.

basic

So, what happens in a TVC is the doctor goes in through the vagina, reaches as high as they can on the visible part of the cervix, and stitches around the flesh of the cervix, pulling it tight like a purse-string. There are two main stitches used, although there are variants on each: the Shirodkar and the McDonald.

TVC copy

This is the procedure that most doctors recommend. Sometimes they will wait and watch your cervix for signs of funneling (when it starts to open at the top) or shortening. If it begins to funnel or shorten, they will then do an emergency/salvage/rescue TVC. Other times, they will do a prophylactic cerclage late in the first trimester or early in the second, then monitor the situation. The stitch is usually done with a spinal in place for anesthesia. When the pregnant woman reaches term, the stitch is cut and removed, allowing a vaginal delivery.

A TVCIC is relatively uncommon, although possibly becoming more common. (My doctor had never heard of it and accused me of using “chat room lingo.” As I said, doctors don’t know everything.) A TVCIC is an attempt to place a band made of mersilene (a very tough woven polyester fiber – you want it to be 5 mm) as high on the cervix as possible, still accessing it through the vagina. This is done by making two small cuts in the lining of the vagina in front of and behind the cervix. Then the band is inserted through the cuts, then tied around the cervix as high as possible. A TVCIC is usually placed during pregnancy (unless it is intended to be permanent), and can be done under general anesthesia or spinal, I believe. I have read some studies that report that a TVCIC should be intended to be permanent, but at least one doctor I’ve spoken with does it a little differently. He leaves the knot inside the vagina (instead of tucked away above) so that it can be snipped and removed to allow a vaginal delivery.

TVCIC copy

A TAC is a full-blown abdominal surgery. The surgeon places the woman under general anesthesia (often, although in my case, since I was pregnant, my doctor felt it would be better for the baby if I was awake using just a spinal block) and makes a bikini cut at the bottom of the abdomen (just like in a C-section). They then carefully move the bladder (which is in the way of the cervix). Spacers are placed in the cervix to make sure the mersilene band is not fitted too tightly. (Edit: No spacers were used in my surgery. Dr. Davis told us that during pregnancy, the cervix is swollen, so he ties the band as tightly as possible. Then, after delivery, the swelling goes down and leaves a functional cervical canal.) The band is then tied around the very top of the cervix, just below the internal os. If it is placed correctly, there is enough room left for all normal functions of the cervix (enough room for semen, menstrual blood, even enough room to have a D&C if that is necessary). The band simply prevents the cervix from dilating beyond its normal state. The TAC is always meant to be permanent, and can be used through multiple pregnancies without being redone. Also, a TAC can be placed laparoscopically, either by hand or by DaVinci robot. Outcomes vary from doctor to doctor, but in general, laparoscopic TACs have had slightly worse outcomes. The surgeons with whom I’ve spoken feel that that is because it’s hard to see and feel the exact place and the correct tension in the band. I think the DaVinci robot, in skilled hands, improves outcomes, but it still hasn’t been as well-tested as the traditional open placement. I will be having a traditional TAC, but here is a very succint discussion of the laparoscopic approach: Prophylactic laparoscopic abdominal cerclage: Tips for success

TAC copy

So those are your three basic options.

TAC, TVC, TVCIC copy

Edit: Dr. Davis, my surgeon, drew a much better diagram and has given me permission to share it here:

Dr. D

Pros and Cons

I think it’s pretty obvious how I’ve come down on this issue, but let me just lay out some of the basics.

My doctors didn’t give me any statistics about the TVC, so I went searching on my own. Statistics vary of course, but what I found is that they have a 75-85% chance of success. Sounds pretty good, right? But there are a few problems. The first is that those numbers very possibly include a lot of women who never would have had a problem a second time. Say you lost a baby in the second trimester because you developed an infection. That infection could have been caused by an opening cervix, or it could have been a complete fluke. If it was a fluke, you may very well not have any problems in the future, but you may receive a TVC nonetheless. The second, and much bigger, problem is that success for a TVC means getting a woman to viability, or 24 weeks. That’s right, let that sink in. So basically, if you really do have an incompetent cervix, your doctors are aiming for 24 weeks (or more, obviously, but 24 weeks is a success, remember), and you have a 3-in-4 or a 4-in-5 chance of getting there. I am here to tell you, having a baby at 24 weeks is NOT a successful pregnancy. Lucy was born at 23 weeks, but her case would not have been substantially different if she’d made it to 24. A baby is not meant to be born at 24 weeks. In the very best case, you’re looking at months in the NICU with the very real possibility of cerebral palsy, vision problems, breathing problems, and developmental delays. But that’s the BEST case at 24 weeks. Viability is no guarantee. Even with all the amazing medicine happening in NICUs, a 24 week baby has less than a 50% chance of living.

Whew, gotta catch my breath. There are benefits to TVCs, of course. They are the least invasive option – one quick outpatient procedure, and you’re done. Also important is that they are easily removed for a vaginal delivery. They do have to be redone for each pregnancy, but no big deal there. Overall, the biggest benefit is that they’re not very invasive. See here to read about the different types of TVC, and to see the difference between the Shirodkar and McDonald stitches. Also see here.

There are other important cons to consider about a TVC, though. Due to their placement in the part of the cervix inside the vagina, some believe that they can have a wicking effect, actually causing ascending infections that endanger a pregnancy. Also, for how simple the procedure, TVCs require a lot of a woman afterward. For example, my doctors wanted to place my prophylactic TVC at 11 weeks. Thereafter, I was to be on complete bed rest. Yep, you read that right. Complete bed rest from 11 weeks until I have the baby. IF I were to make it full-term, that means 29 weeks in bed. That wreaks complete havoc on your body, and I’m not sure why doctors don’t take that into account. I’m already overweight and at higher risk for embolisms and blood clots, and bed rest makes that risk so much higher. So that is definitely something I considered. Complete bed rest isn’t good for anybody.

But I truly believe that I wouldn’t make it full term with a TVC. As I said, success is measured by getting to 24 weeks, and you have a 75-85% chance of that. But one study I read suggested that you actually only have a 20% chance of carrying to term. Those are not good odds. As far as I can tell, this is because the cerclage is too low on the cervix. This means that if you have IC, your cervix can still funnel open from the top to the stitch. That means the baby, the amniotic sac, the umbilical cord – whatever – can sink down into the cervix, putting pressure on the cerclage. This is a problem for two reasons: 1) it makes your cervix functionally shorter, so you are more likely to lose your mucous plug and get an infection, and 2) the pressure, an infection, or a problem with the baby (say an umbilical cord prolapse, where the cord is pushed out ahead of the baby) can cause you to go into labor anyway. Once you’re in labor, it either has to be stopped or you have to deliver. In many cases I’ve read about, women with TVCs went into labor early, their stitch was not removed quickly enough, and the baby was delivered through the stitch. If this happens, it is very likely to tear or otherwise damage the cervix, making it even less likely to work in the future. Also, I know of at least one instance where a baby was delivered through a stitch and suffered severe head trauma because of it. These are real worries. I can’t count how many women I’ve talked to who have had failed TVCs that resulted in the loss of a baby and usually some damage to their bodies. And according to one surgeon I talked to, if you have true IC, it’s not a matter of if your cervix will funnel to the stitch, but when it will funnel, regardless of bed rest.

Now, the TVCIC. This one is tricky, as it’s not often done. The goal with a TVCIC is to get the band as close to the level of a TAC as possible while still going through the vagina for minimum invasiveness. If I understand it correctly, though, it’s otherwise like a TAC and not a TVC, in that the band is placed around the cervix, rather than a stitch being placed through the flesh of the cervix. I spoke with one well-known surgeon who thinks the TVCIC is not really an option. He thinks it is impossible to get the band as high on the cervix as the TAC. This is important because, as I mentioned above, the cervix will still funnel as much as it can. Any funneling at all can cause problems, although the less, the better. He also pointed out that during a TVCIC, the surgeon goes in blind essentially, and there are important things going on in that area (like your urethra and big blood vessels). So you would definitely want to make sure you were in the hands of a very skilled and experienced surgeon. That criticism makes sense to me, but it would be much less of an ordeal if the procedure could be done through the vagina (rather than through the abdomen, like a TAC). It would also be fantastic if it could be removed for a vaginal delivery, although this would mean that it would have to be redone for each subsequent pregnancy. The critical surgeon I talked to did not think it should be removed, but I spoke to another well-known surgeon who has done the procedure very successfully and who does think it’s a valid option. According to the somewhat limited data available on TVCIC, women with proven IC were able to carry their babies to term with the TVCIC about 90% of the time. That is a much better figure than for TVCs.

We’ve opted to go with the traditional TAC. The surgery can be done either during pregnancy or before pregnancy (something neither my OB nor my RE – reproductive endocrinologist – were aware of). Some surgeons will only do it during pregnancy, but the most experienced surgeons in the country (both of whom I’ve talked to by email and by phone) prefer to do it pre-pregnancy if at all possible, because there is no risk to the baby (as there is no baby, of course), it requires a smaller incision, and the recovery is faster. However, some insurance companies will not cover it prior to pregnancy (ugh, the insurance is another issue entirely – some insurances will not cover a TAC unless you’ve had TWO or MORE failed TVCs, meaning you’ve lost at least two babies.) Anyway, when the TAC is performed prior to pregnancy, it does not interfere with any attempts to get pregnant, or with IUI or IVF. As far as I know, the surgeons say you can start trying to conceive as soon as you’ve had one period.

Pros:

  • It’s permanent, and you should never have to worry about your cervix opening up again (although you will anyway). It shouldn’t get in the way of anything else, so even when you’re done having kids, you shouldn’t have to worry about it.
  • No bed rest is required by the surgeons, although your particular case may warrant some degree of bed rest. They do recommend taking it easy.
  • No pelvic rest necessary, unlike a TVC, unless your situation warrants. Have as much sex as you want, or don’t.
  • Since the TAC is placed just at the cervico-isthmic junction just below the internal os, if it is placed correctly, your cervix can’t really funnel at all.
  • If you are prone to premature labor for reasons other than IC (as many women with IC are), the TAC improves your chances regardless by improving the functionality of your cervix.
  • Again, statistics vary, and some doctors are better than others. But with a well-placed TAC, you have a 95-98% chance of carrying to term. I like those odds.

Cons:

  • It’s definitely a surgery. It’s pretty straightforward as surgeries go, but it has all the same risks as any other abdominal surgery: adhesions, blood loss, mistakes, etc.
  • If you have the TAC while you’re pregnant, there is a small risk to the baby. The surgeons I’ve talked with haven’t really had any losses to speak of, but there is something like a 1-2% chance of loss. It’s hard to determine what might be caused by the surgery and what might have been a first trimester miscarriage anyway.
  • Longer recovery.
  • Required C-section. The cut is made through the same incision (unless you’ve had your TAC placed laparoscopically, in which case you’ll have several small incisions, and a new larger one for the C-section).
  • No labor/chance of uterine/cervical rupture. If you are allowed to labor hard for a long time, there is a chance that your uterus or cervix could rupture. Some might see the fact that you aren’t allowed to labor as a pro, I guess. This small risk is the reason they usually schedule the C-section a week or two early.
  • You may have issues getting your insurance to cover the procedure. I didn’t, but if your insurance isn’t that great, you might have to fight them for it.
  • The TAC can be placed incorrectly, in which case it could fail. Research your doctor carefully.
  • Not that many doctors do it, and your OB may very well not support your decision.
  • It’s not a 100% guarantee. Women have lost babies with TACs in place, either because they had a badly placed TAC or because they had some other, unrelated problem. If you do go into labor early with the TAC, and the labor can’t be stopped, you will probably have to have an emergency C-section to deliver.

I feel like I’m forgetting a lot of stuff, so I may come back and add more information, but I think I’ve hit the main points. I’m really not looking forward to having the surgery. I’ve had surgery a couple times before, and it’s no fun. But losing my little girl was the worst thing that’s ever happened to me, and I could not bear a repeat of that. I listed more cons than pros for the TAC, but it’s the 95-98% chance of carrying to term that outweighs all the cons for me.

Again, I’m not a doctor. If you’re considering these options, I advise you to do your own research. The important thing is that you feel comfortable about your decision and you know why you made it. Don’t let doctors push you into any particular course of action, because they get it wrong, and the stakes just aren’t as high for them. You have to be an advocate for yourself, your baby, and your family. If you’d like to learn more, or hear from the doctors doing the TAC, or talk to a lot of women who have suffered losses like this (and have or would like to have a TAC), I’d suggest you head over to Abbyloopers for more info.