Incompetent Cervix Facts

Thanks to rlajambe for writing this very informative and helpful blog post!!!

What is incompetent Cervix (IC)?
Incompetent cervix (IC) is essential a weak cervix.  Mainly occurring in the 2nd trimester, the weight of the baby causes the cervix to dilate prematurely and this can result in premature labour (PTL).  IC is characterized by dilation in the absence of contractions.
What is cervical insufficiency?
Cervical insufficiency is having little to no cervix.  Some women are born with little to no cervix due to a congenital anomaly.  Surgery can also be a main reason for cervical insufficiency.  A cone biopsy or a cervical surgery for cancer can result in part of the cervix being compromised and cervical insufficiency.
How is it diagnosed?
Unfortunately, unless dilation is detected during a routine ultrasound, IC is very hard to diagnose.  Some women lose multiple babies in the 2nd trimester without a reason.  Generally, three losses in the 2nd trimester with premature labour are deemed to be IC.  However, doctors have started to perform more cervical monitoring for women with suspected IC.
What treatment options are there for IC?
Cervical cerclage (aka cervical stitches) – stitches are placed to hold the cervix closed and prevent cervical shortening.  There are two main types:
Preventative cerclage – placed at around the 12-13th week of gestation.  When a diagnosis of IC has been made during a previous pregnancy, your OB will likely recommend a cerclage at the end of the 1st trimester.  The success rate is about 90-95%.
Emergent cerclage – placed during the 2nd trimester after dilation has already started.  This type is usually due to the discovery of IC that was not known.  The success rate is lower (40-60%) than the preventative cerclage, but many women are successful with this technique.  Also, most doctors will not perform an emergent cerclage after 23 weeks due to the risk of premature rupture of membranes and possible infection.
Bed rest – By placing the women on bed rest, the baby’s weight is taken off the cervix and the cervix is less likely to dilate.  The bed rest period will vary from one women to another usually depending on cervical length through the course of the pregnancy.
Progesterone –Some women experience contractions even after the cerclage is placed. Progesterone gels or P17 injections (17 alpha-hydroxyprogesterone caproate) are intended to prevent the onset of PTL.  
Cervical length monitoring – The length of the cervix will be measured and examined to check for shortening and/or funneling.  Transvaginal ultrasound generally gives more reliable measurements than transabdominal ultrasound.
Your doctor may recommend one or all of these treatments depending on your specific situation.   
Dr. Google told me that there are different methods of cerclage.  What is the difference between them?
There are two main methods of cerclage.  Each has advantages and disadvantages.
Transvaginal Cerclage (TVC) – This method is the most common.  It is essentially placing sutures onto the cervix to hold it closed.  There are several techniques of how the stitches are placed (McDonald’s, Shiradkor, etc.); however, all have approximately the same success rate.  Different doctors have preferences for specific techniques.
Advantages 
  • the sutures can removed from the cervix and allow for a vaginal delivery
  • no incisions are needed as the sutures are placed through the vaginal opening
Disadvantages 
  • not suitable for women with cervical insufficiency
Transabdominal Cerclage (TAC)- This method is usually reserved for women with a failed transvaginal cerclage or those with cerclage insufficiency.  Sutures and surgical mesh are placed internally (inside the abdomen) to close the cervical opening.
Advantages 
  • higher success rate than transvaginal
Disadvantages 
  • makes vaginal delivery impossible, you must have a C-section
  • requires laproscopic surgeries during pregnancy to be placed
  • often not available unless a TVC has already failed
Why doesn’t my OB place the cerclage as soon as I get a BFP?
Viability.  You OB will want to ensure that the pregnancy is viable before placing the cerclage.  Otherwise, they will have to perform two surgeries (placement and removal).  Unfortunately, women with IC still have same risk of a 1st trimester loss as any other woman does.
I had IC with my twins. Will it happen again with another pregnancy?
Not necessarily.  Some women who have IC with multiples go on to have normal pregnancies with singletons.  However, there is no way to know for sure.  Some doctors will take the “wait and see” approach, but this can be risky.  Finding a doctor that will perform the cerclage preventatively can be difficult, but is highly recommended.
What can I do while we’re TTC?
Get the right doctor – The right OB will make all the difference in having a successful pregnancy.  Find an OB with experience with IC and cerclage.  You will need to have your doctor in place before you get pregnant, as you will need to start your appointments sooner than most women.  Discuss your plan with your OB before you get pregnant.  Be clear about what restrictions will be in place during the pregnancy.  
For those who live in more rural areas, you may have look to a major city to find the right doctor.  You want someone who performs cerclages on at least a semi-regular basis, not the OB that does one cerclage a year or less.
Get the right insurance and get your finances in order – You know that you will be high-risk next time out, make sure you have the financial resources to cover all the possible expenses that may arise.  Bed rest (with no income) and extra doctor visits are not cheap.  
Get in shape physically – You can’t make your cervix any stronger, but you can get everything else stronger.  Being in shape physically will help to prevent any other complications, like gestational diabetes or high blood pressure.  You have enough to manage with IC.
Consider talking to a therapist – Your loss can be very difficult to process.  Therapy can help you work through all the emotional issues of your loss and a subsequent pregnancy.  

Progesterone and TTC

We often hear about low progesterone levels, or women taking progesterone supplements. What exactly is progesterone, though, and how does it affect a pregnancy? Check out tons of information in the below article from JustMommies.com:

Signs of Low Progesterone
By Rebecca Pillar

The body is an amazing miracle in action. Every second, millions of reactions are taking place to maintain a perfect balance. People spend years of their lives studying how the body functions and they still don’t know everything there is to know about human life. One aspect of humanity is reproduction. For some women, becoming pregnant seems as easy as simply thinking about a baby. For others, becoming pregnant and maintaining a pregnancy is a very frustrating experience. The hormone progesterone is responsible for several reactions that must take place for a healthy pregnancy to occur. If progesterone is not present in the body at a proper amount, a woman is most likely going to be dealing with infertility and pregnancy loss.

The female menstrual cycle is a complicated “dance” that takes place within the female body. Each cycle varies from woman to woman with an average length of 28 days. Hormones secreted by the pituitary gland in the brain stimulate the ovaries to secrete the hormones estrogen and progesterone at different intervals. Of course, this process is much more complex than described here.
Progesterone is an important hormone as it is responsible for preparing the lining of the uterus for implantation. Progesterone is also responsible for maintaining a pregnancy. Progesterone is secreted from the ovary after ovulation by a mass called a “corpus luteum.”  The corpus luteum is maintained by the hormone hCG until the placenta is capable of taking over progesterone production. HCG is the hormone detected in blood and urine in a pregnancy test. If pregnancy does not occur, the corpus luteum begins to die, progesterone levels plummet and a woman starts her menstrual cycle over again with menstruation. It is easy to see how important progesterone is and why it is commonly referred to as “the pregnancy hormone.”

Low progesterone symptoms:

The problem with progesterone imbalances is the symptoms typically mimic those of other disorders. Besides infertility and pregnancy loss, low progesterone symptoms can include:
Mood swings
Depression
Insomnia
Appetite changes
Weight changes
Irritability
Lack of concentration
Anxiety
Fatigue
Frequent menstruation
Irregular menstruation
Low sex drive
Migraines
PCOS (Polycystic Ovarian Syndrome)
Vaginal dryness
Painful intercourse

Causes of low progesterone:

Low progesterone levels can be caused by several known factors or unknown factors.  Due to the complexity of hormones, some women may have no difficulty getting pregnant but for some reason, the placenta does not create the proper levels when it should.  Researchers believe that high levels of stress, poor nutrition and lack of exercise can contribute to low progesterone levels. Certain medications can also interfere with the body’s ability to produce progesterone.

Treatment for low progesterone:

Diagnosing low progesterone can be done by a blood test that measures your level after ovulation and by ovulation charting. Progesterone is responsible for the spike in body temperature after ovulation. If there is no increase in body temperature, progesterone levels may be low. Women should never attempt to self diagnose or self treat a suspected hormonal imbalance as low progesterone symptoms mimic symptoms of other disorders.

Progesterone creams, shots and vaginal suppositories are available once a diagnosis is made. Generally, a progesterone supplement is taken right after ovulation to boost progesterone levels. Many times, when a woman is supplemented with progesterone, it is taken until 12 weeks or so but sometimes, is taken for the duration of the pregnancy.

The most important thing to remember is talk to your doctor about your fertility and pregnancy loss concerns. There are many reasons why couples may have difficulty becoming pregnant or maintaining a pregnancy aside from progesterone. If are concerned that you have low progesterone talk to your doctor.