Tag Archives: cerclage

TAC Variations

When you think of a procedure like the TAC (transabdominal cerclage), you may think that it is a standardized operation. In fact, each surgeon has his or her own techniques, informed by their teachers and developed over their years of experience. So while there are some basics that are common to all TACs, the procedure itself can actually vary quite a bit.

So what are the defining characteristics of a TAC? What makes a TAC a TAC? Technically, there’s only one:

A TAC must be placed via an abdominal incision. If a surgeon tells you a TAC can be placed vaginally, he/she is either misleading you or very much mistaken. Either way, steer clear. A TAC is a transABDOMINAL cerclage, and can only be placed through an abdominal incision.

For the record, when I say “TAC” throughout this blog, I mean a cerclage that is placed via an abdominal incision and tied as a band around the internal os of the cervix at the cervicoisthmic junction. This has been proven to be the most effective form of TAC so far, although any cerclage that is placed through an abdominal incision is technically a TAC.

There are several areas where TACs differ:

Incision

Remember, this incision is NOT on your uterus, only on the outside. We’ve established that all TACs must be placed abdominally. Traditionally, this has meant through an open incision in the abdomen (laparotomy). Most of the time the incision is a low transverse incision — a horizontal line at about the level of your pubic hairline. Sometimes, however, there might be a reason for a vertical incision. If a surgeon does all of his placements vertically by default, I personally might consider seeing somebody else, as that type of incision makes recovery more difficult (in addition to creating a nasty scar). Sometimes a Pfannenstiel type incision has been used, but that is not as popular these days. Alternately, many surgeons now place TACs laparoscopically, or via several tiny incisions in the abdomen. This can be done with or without the DaVinci robot, but the incisions should be about the same regardless.

Here are a few examples of incisions:

Jill Donald Davis in-preg traditional almost 3 yrs

This is my scar, on my soft, stretch-marked 3 pregnancy belly. Dr. Davis in-pregnancy traditional TAC, September 2012. This scar has been used for TAC placement and 2 c-sections. 3 years post-TAC, 2.5 years post c-section #1, and 6 months post c-section #2.

Haney pre preg almost 2 months

This is a Dr. Haney traditional pre-pregnancy TAC at about 2 months post-op.

Haney 4 weeks

This is a traditional Dr. Haney TAC at 4 weeks post-op. Dr. Haney is able to make a very small incision for pre-pregnancy TACs and TACs on smaller women, but keep in mind that your OB will very likely use the same incision for your c-section, so it will be bigger anyway.

Davis pre preg traditional 1 month

This is a traditional Dr. Davis TAC at 1 month post-op.

Paraiso RoboTAC 3 months

This is a Dr. Paraiso RoboTAC, 3 months post-op. She has older scars as well; the arrows point to the TAC scars.

Scibetta in-preg lap TAC 3 yrs

Dr. Scibetta lap TAC, 3 years post-op. After 3 years and 2 c-sections, she says this scar on her right side is the only incision you can still see.

Material

There are three possibilities here:

    • 5 mm mersilene tape. This is probably the most common option. Mersilene is a nonabsorbable braided polyester suture. It is sterile, inert, and nonreactive, so it should be able to stay in your body indefinitely without causing any problems. It’s incredibly strong, and could essentially support the weight of a grown man jumping on it.
Mersilene Tape In Situ

5 mm mersilene tape in situ. From http://www.kjkhospital.com/CaseStudyDetails.aspx?nid=24

    • Neonatal/IV tubing. I only know of this being used in Australia. Tubing — either neonatal tubing or IV tubing — is used the same way as mersilene tape. As far as I know, success rates are similar.
Dr. Alexander Neonatal Tubing TAC

A TAC placed by Dr. Alexander in Brisbane using neonatal tubing.

  • Nylon suture material. This is not recommended. It is strong, but much more likely to erode into the tissue of your cervix.

Suture Type/ Knot Placement

Some surgeons use curved needles to thread the band behind the cervix, but some prefer to use a more blunt instrument like clamps. Most surgeons placing a TAC traditionally tie the knot posteriorly (behind the cervix), I believe, to avoid problems with bladder adhesions and irritation. (One paper I read said tying the knot posteriorly allows the TAC to be removed, theoretically, through the vagina in a procedure called a culdotomy, in which the vaginal wall is cut in order to access the knot via the rectouterine pouch. I have never heard of this being done.) However, the knot is sometimes anterior (in front of the cervix) when placed laparoscopically without the DaVinci robot. The knot is usually a square knot, but surgeons may have their own variations.

Most variations here are minor and don’t make a lot of difference. There are a couple, though, that potentially make a big difference.

  • I have heard of surgeons tying the band lateral to the uterine arteries, instead of medial to them, but that is a mistake (as opposed to a preference), and can lead to erosion into the arteries and bleeding.
  • Some surgeons don’t tie a band around the cervix at all, but instead stitch through the cervix. One example is a surgeon who makes an abdominal incision and places a modified Shirodkar stitch at the internal os. This, in my opinion, should not be done, as it is more susceptible to problems with erosion and more likely to cause damage to the cervix, and ultimately, more likely to fail. If you’re going to undergo major surgery, you might as well have the best, safest solution, which is a band tied around the internal os of your cervix.

Method

This encompasses all the other variations that might exist between surgeons. Some prefer only in-pregnancy, while some only do pre-pregnancy. Some have a strong preference for traditional, laparoscopic, or robotic laparoscopic. There are a lot of different approaches to anesthesia and pain management. Some doctors prefer spinal anesthesia in pregnancy, some always place the TAC under general anesthesia. Some prescribe ibuprofen for pain management, while others tell you never to take ibuprofen in pregnancy. There isn’t a clearly right way to do most of these things, and very experienced, very successful doctors have different opinions. Do your own research and decide who you want to trust based on that.

A Note About TAC Surgeons

When you start looking into a TAC, you will quickly realize that there are a few surgeons who are much more frequently mentioned than others. In the US, those are Dr. Haney, Dr. Davis, and Dr. Sumners (see The Big Three for contact info). When I got my TAC in 2012, all three were equally popular. Since then, Dr. Davis has semi-retired, and more women are seeing Dr. Haney, so the commentary is very much skewed toward Dr. Haney at the moment. While these three doctors have some differing opinions, they are all essentially equally experienced, and all have the same very high success rates. As far as the Big Three go, you’re in good hands all around, but I’ve been hearing some disturbing comments to the effect that Dr. Davis (or Dr. Sumners, or any other doctor) does it “wrong,” and therefore their TACs fail more often. That’s pure nonsense, so if you hear such a thing, don’t let it worry you.

My real point here is that there is no “right” or “best” surgeon, only the best one for you. If you have time, shop around. See who your insurance covers, and figure out if you can or want to travel. There are a lot of things to consider when you choose your surgeon. Here are a few:

  • How far are you willing to travel?
  • Does he or she accept your insurance?
  • How much experience does he or she have?
  • Does he or she prefer laparoscopic, traditional, or robotic assisted laparoscopic? (If you have a preference.)
  • What type of material does he or she prefer to use?
  • What are his or her stats? Success rate?
  • How comfortable are you with him or her?
  • Will he or she be available to answer questions after surgery/during pregnancy? Will he or she consult with your OB/MFM/perinatologist?
  • Does he or she offer an out-of-pocket rate? (if your insurance will not cover the procedure, you may save money by traveling cross country or even out of country to a doctor who offers an at-cost option)

These are all questions you’ll need to ask yourself and your doctor. As far as experience goes, you’ll have to remember that not all doctors can have 20+ years of experience placing TACs. Some of them will be less experienced, and that’s okay. With several of our beloved TAC doctors nearing retirement, more and more women will have to see these less experienced surgeons, which, of course, is how they gain experience. Also, no two doctors do any procedure the exact same way. They each put their own spin on it, and are constantly trying to improve their own performance. Some use mersilene, some use neonatal tubing. Some place one band, some place more. There are a hundred variations, and no “right” version. We all want the very best doctor when our baby’s lives are at risk, but placing a TAC is actually a relatively simple procedure. If you find yourself in a situation where it makes sense to you to see a surgeon with less experience, there might be some additional things to think about. Personally, if I were going to have my TAC placed by a newer surgeon, I would want 1) a traditional open placement, and 2) an in-pregnancy placement. Here’s my reasoning: 1) a traditional placement allows an inexperienced surgeon a more open field and better visualization. He or she can feel the tension of the band and the knot. 2) This one seems counter-intuitive, but according to at least one study, it’s more difficult to get the correct tension on the band when placing it on a non-pregnant cervix. Since the cervix swells during pregnancy, placing it in-pregnancy means that you already know what size it will be. Placing it before than can lead to the band being too loose or too tight, both of which can cause the TAC to fail. These are probably more cautious than necessary, and if your convenient local doctor only does pre-pregnancy lap-TACs, you will do just fine. Going with the method your doctor feels most comfortable performing is probably more important than any specific type of placement. If you have any questions, please feel free to email me (Jill) at tac.questions@gmail.com.

Stories of Strength: Tanesha’s Story

Tanesha’s story is so sadly familiar. After losing three beautiful babies, she’s got her TAC and is ready to try again. Thanks for sharing your experience, Tanesha.

If you’d like to share your story, please send it and any pictures to tac.questions@gmail.com.

I’m about 2 days post-op from my Dr. Davis pre-pregnancy TAC and decided to share my journey up to this point. I have not given up hope and I hope that you will not either. I’m 35 years old and I have 2 children from a prior marriage – a 16 year old daughter and 12 year old son. My husband and I married in January 2010. We conceived twin boys January 2013 on our 3 year wedding trip to NYC and were on top of the moon.

Vacation

Tanesha and her husband on vacation, when the twins were conceived.

At my 20 week anatomy scan it was discovered that my cervix was open and I had to be rushed to L&D. Long story short, I had an emergent cerclage, and since my membranes were already bulging, they then ruptured. After Pprom (preterm premature rupture of membranes) of baby A’s waters and 3.5 weeks on hospital bed rest, I had to deliver them due to infection and they were born too soon. After meeting with specialists and all, it was decided that due to my history, my issue was more related to the fact that I had twins and not my cervix. No one thought that I’d need a preventative cerclage and that it was more risky since it could cause infection. I would only have p17 (progesterone) shots and weekly cervical length checks.

Angels Tyler and Taylor

Tanesha’s beautiful boys, Tyler and Taylor. Photo by NowILayMeDownToSleep photographers.

Taylor and Tyler feet

Taylor’s and Tyler’s perfect tiny feet. Photo by NowILayMeDownToSleep photographers.

It didn’t take me long to get pregnant and I did so 4 months after my loss in October 2013, the same month my twin boys were due. I was so excited and thankful for another chance. I stayed positive. Had affirmations that I posted daily. I started a journal. I tried to drown out my fears with faith and hope. February 17th, I went and did a little shopping. When I got home I noticed some brown spotting. I was 17 weeks and had just had my first p17 injection about 5 days prior and my cervical length at that time was 5 cm. I decided to go to L&D as a precaution even though I felt that I was overreacting. Of course, as soon as I was checked out, the sonographer told me that my cervix was open and she could already see my baby girl’s hand. Heartbreak all over again! I had my baby girl within 24 hours and started the process of grief and disbelief all over again.

I started researching and found Dr. Davis and Dr. Haney. Since Dr. D was less than 2 hours away from me and I had such a good feeling about him I called, did a phone consult, and scheduled my appointment for a little more than 6 weeks from my loss. My husband had this week off already because my stepson is attending Duke this fall and on Monday we had to go down for Duke Blue Devil days in NC. Thankfully Dr. D had the same week open for my TAC. We went down on Thursday for pre-op. It took less than 2 hours and we checked into our hotel, the Hampton Inn on Blackhorse Road, before heading to his office since we were so early. The hospital rate for our stay was $99 and it was nice, clean, and in a good busy area with lots of restaurants. The hospital was about 5 minutes away and easy to find. Dr. D didn’t think we would get GPS coverage in our area, but we did and found it quickly. We used free valet parking and headed up to the 3rd floor for our appointment. We waited about 20 minutes and filled out some paperwork and Dr. D came and got us. We chatted, admired his collection of sodas, and I cracked up at his dry humor and multitasking skills. He asked me what I was going to have for my “last meal.” SMH. That didn’t help my nerves but it still cracked me up. He then walked us down to show us where to come in for surgery the next day. No food or drink after midnight. He gave us some restaurant suggestions and then we were free to go.

Fast forward to Friday. We checked in in the general same day surgery area around 11 am. Be prepared to wait an hour or 2 to actually go back for this part. I paid $100 copay and finally went back. The nurses were awesome in prepping me. They were really sweet and talked to me a lot. They were sweet even though my veins gave them problems (they give everyone problems). They went and got my husband and explained how everything would work, and then I finally went back around 2:30 or so for the surgery. I did not see Dr. D beforehand and I was knocked out almost immediately from general anesthesia. When I woke up, they wheeled me to recovery and I felt pretty good. I was not really loopy after getting to my room. I was a little hungry but not starving and I was on a liquid diet for 24 hours. My husband said that Dr. D came up to him and told him, “Piece of cake” and shook his hand. That was his post-surgery report in true Dr. D fashion. Lol. The next day after having the catheter removed I did some walking around, had a post-surgical ultrasound, and Dr. D gave me a summary of his reports and helped me with aftercare instructions. We then hit the road and came back home.

Post op selfie

Tanesha’s post-op selfie.

I am feeling a lot better than I thought I would. Besides having D&Cs after each loss, I had never had major surgery so I was pretty freaked out and worried. I felt in good hands and I am glad about my decision. I still have worries about conceiving after the TAC, etc., but I feel like this was necessary to move on. I’m 35 now and I would like to have to my rainbow as soon as possible. Dr. D gave us no restrictions. We can start TTC (trying to conceive) as soon as we feel up to it. I was actually ovulating when he did my ultrasound the day before the surgery (which I already knew) so hopefully things will stay intact and I will bounce back to my normal schedule soon. Sorry that this post was so long but I wanted to share my experience. Wish us luck on our new journey of TTC with the TAC and remember to stay strong and never give up on your dreams!

Thank you to Dr. D

Tanesha saying thank-you to Dr. Davis post-op.

Stories of Strength: Brittany’s Story

Brittany, whose cervical insufficiency was compounded by treatments for precancerous cells on her cervix, had her TAC placed as an emergency procedure late in her pregnancy. Unfortunately, the damage was already done. This is one way that a TAC can fail, and one option for how to proceed when it does. Thank you for sharing your story, Brittany. You’re a strong mama, and we wish you the very best.

If you’d like to share your story, please send it and any pictures to tac.questions@gmail.com.

My name is Brittany and this is my story. I was 19 when I found out I was pregnant and while I was happy to find out I was carrying twins, I also had found out I had pre-cancerous cells in my cervix. Due to a weak cervix, I had my twin boys at the gestational age of 24.5 weeks and they had to stay in the NICU for four months. I had to have two surgeries on my cervix and was only left with 9mm functional cervix and was told I am lucky to already have my kids.

Fast forward to 2013, my husband and I wanted to try for another baby because our kiddos are now 5. Remembering what the other doctors said about my cervix, I told my new doctor I would need a cerclage done. I was about 6-8 weeks pregnant when I started to have some bleeding on and off but my cervix was still shut. But I kept insisting bleeding is not normal and my cervix is barely there . . . Unfortunately, at 15 weeks I went into full on labor and that’s when the military doctors FINALLY believed me and my cervical issues. So they rushed me to a hospital in Savannah, GA. I stayed there over night and all contractions stopped. We were referred to Dr. Davis but had to drive up to NJ to be seen for the TAC (trans-abdominal cerclage). Two other doctors said I was too far along to have it done, but Dr. Davis had hope as long as we could get there.

We made it up there and had an amazing surgery. I got to see my baby, got the TAC, and Dr. Davis was amazed at how well it had gone. I went from 9mm to 3cm. He told me it looked great but we weren’t out of the woods yet. Mind you I had been bleeding and while Dr. Davis was doing my TAC, he couldn’t see why I was bleeding/clotting. Sadly, at 18 weeks my waters ruptured which is known as PPROM (preterm premature rupture of the membranes). The TAC did not fail – my cervix never opened – but since I was bleeding, the blood was like sandpaper and tore my membranes. I was told to abort our baby, but I had faith and had heard so many stories of fellow ladies going through the same thing, so I chose to be on strict bed rest. But, on week 19+6 I went into labor and had to go to the hospital. Since my daughter was not at a gestational age where she could survive, Dr. Davis told my doctor to just go in and cut the TAC instead of having a c-section since a c-section would further damage my uterus. I delivered the next day at 20 weeks. The nylon “string” he used is still around my cervix. I am currently trying to see Dr. Davis again to have it removed and get a pre-pregnancy TAC to eventually try again one day for our rainbow baby. It is not a guaranteed fix but I know it will hopefully help get me to a gestational age of a healthy baby. I hope my story can help in some way or give information on some questions you may have. Thank you for reading my story. Please keep your fingers crossed for us that everything goes well in the future and we get our rainbow we so desperately want.

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.