Since the cervix will not stay closed in patients with IC (incompetent cervix), treatment is to close it via intervention. This is referred to as a cerclage. There are many types of cerclages, all varying by method and height of placement. I am going to discuss only the two main ones here with a mention to a third one. This is a picture drawn by Dr. Davis to illustrate the different levels of cerclages. (Picture courtesy of Amy H., one of Dr. Davis’s TVCIC patients. Thanks, Amy!)
Transvaginal Cerclage (TVC): a stitch (suture) which is placed through the vagina, within and around the cervix, much like a “purse string”. This is placed at the bottom of the cervix or “as high up” as the doctor can get. The method of placement is vaginal and the patient is given a spinal. A TVC may be placed anytime from 12 weeks on. Sometimes it is placed preventively before a problem seems to arise (aka a prophylactic cerclage). Other times it is placed after the “wait-and-see” has demonstrated a problem with the cervix. These are called a rescue or emergency cerclage.
A TVC requires pelvic rest, has an increased risk of infection as the stitch material itself can wick up vaginal bacteria, and is currently considered successful about 80% of the time. Be sure you ask your doctor what the definition of success is! Often times in discussing a TVC, their definition of success is a “live birth” regardless of prematurity.
The TVC is removed around 37 weeks to allow for a normal vaginal delivery.
Transabdominal Cerclage (TAC): a band is placed around the OUTSIDE of the cervix and tied in place to disallow dilation. This is placed at the very top of the cervix/bottom of the uterus. It is placed via abdominal incision or laparoscopically. The TAC may be placed prior to pregnancy or during pregnancy (around 12 weeks). The TAC does not make the cervix smaller, it simply allows it from dilating. So, blood, sperm, catheters/fertility instruments can still enter and exit the uterus.
A TAC is considered the absolute medical solution for IC. Once a patient has a TAC, she can cross IC off her list of potential problems. No bed rest or pelvic rest is required due to IC with a TAC. It has a success rate of greater than 95% for a TERM delivery. (The success rate varies on the particular surgeon. For example, Dr. Haney currently has a success rate of greater than 99% for a TERM delivery)
The TAC is permanent and requires delivery via c-section.
Transvaginal cervico-isthmic cerclage (TVCIC): The TVCIC is placed above the cardinal ligaments but isn’t quite as high as the TAC. It closes the cervix about 1/2 cm below the internal os. Dr. Michael Katz in San Francisco is doing a lot of these. Dr. George Davis in New Jersey performs these as well. More recently, Dr. James Sumners learned how to place a TVCIC. It is NOT the same as the TAC. It is placed vaginally and can be removed for vaginal delivery or left in place for future use if a c-section is required.
See “TVCIC” for more information.
Explore this journal article by Dr. Katz (It’s a .pdf):