Let me start off by saying that this blog post is going to be different than my usual posts. For starters, I have spent almost a week researching and gathering information for it. I started my rough draft, just bullet point Q&A style draft on November 16th. I have done a lot of reading, and I have looked at more pictures and videos of actual real surgeries than I ever thought I could stomach (that turned out to be about 15 seconds of the video if you were wondering).
Three days after we lost Anika, I got a message from a Facebook friend extending her condolences for our loss and telling me that she had just read an article about a woman who had suffered two late term losses due to incompetent cervix and who had had two healthy babies carried almost to term after a procedure called a transabdominal cerclage. I thanked her for reaching out and let that be that for a few weeks. But it had sparked a little bug of curiosity in my brain, and after a while, I Googled for an article about a mom of two angle babies and two kids on Earth who’d had an incompetent cervix and a transabdominal cerclage. I found a lot more than one!
At our final appointment with Doctor M, I asked her if she knew what a transabdominal cerclage was and what she thought about it as an option if we found out we were pregnant again or if we decided to try again. She explained and said that I’d be a candidate for that procedure if one of those big ifs happened. She also said that she knows of a doctor at MacMaster Hospital who does them. After talking briefly with family about it, I realized that neither myself nor David had a very clear idea about what this procedure was, how it worked or anything about it, really. I decided that I wanted to know for sure what it is so that we could make an informed decision about whether or not it could be a viable option for us.
Don’t get your knickers in a twist! David and I are still not in a position where we want to try again. We have been through a lot in the past two years, and it will be nice to spend some time together without me on crazy hormones or with super anxiety.
I am by no means at all a medical person, and I have to confess that in my research if I didn’t understand what they were trying to say, I didn’t include it. This is especially true in how the procedure is done and in the statistics of success. If you are considering a TAC or are interested in learning more about it, I strongly suggest that you read the articles I link to below. Abbyloopers.org is a fantastic resource, it requires you to register and log in, and your registration must be approved by an admin. They also have a Facebook group which requires admin approval as well.
Important Note About Cost:
In Canada, TACs are commonly paid for by our health care system. In the US there are many insurance companies who will not pay for the procedure considering it to be too risky. Out of pocket costs if it is not covered can be around $7000 USD.
I am not sure how it works in other countries besides Canada and the US. If you are considering a TAC definitely look into what costs you will have to pay out of pocket
Okay, now to the meat and potatoes…
For the ease of writing I am going to use commonly used acronyms for the types of cerclages that will be discussed:
- TAC = Transabdominal Cerclage
- TVC = Transvaginal Cerclage
In my research, I ran into many terms that I didn’t understand, and terms you may not be familiar with, so I turned to Google and figured it out. The first group of links in my list of references is where I got these definitions.
- Internal OS = Internal orifice of the uterus, where the cervix communicates (or connects) with the uterus 1
- External OS = External orifice of the uterus (or ostium), where the cervix communicates (or connects) with the vagina 1
- Laparotomy I’ll be calling this Traditional = abdominal surgery requiring one large incision, associated with longer healing time and complications like scar tissue and infection (cesarean section) 2
- Laparoscopy = small incisions and the use of a camera to see inside the abdomen, associated with shorter healing time, less bleeding, less scarring 3
- D&C = Dilation and Curettage, the cervix is dilated, and the contents of the uterus are removed by scraping or suction 4
- Funneling = Dilation of the cervix starting at the Internal OS, a common sign for Incompetent Cervix 5
What is the difference between a TAC and a TVC?
While the end goal of both are to keep the cervix closed as long as possible, and the names are similar, the procedures are quite different.
A transabdominal cerclage is a suture placed around the cervix through abdominal surgery. It is placed at the top of the cervix at the internal OS to resist the pressure of a growing pregnancy and prevent funneling. Because of its position, the TAC supports the entire length of the cervix. It was first described in 1965 by Benson and Durfee (10) as a way to prevent preterm delivery and late term loss in women with an incompetent cervix. It is often done when TVCs have failed or if there are abnormalities with the cervix.
A transvaginal cerclage is a “purse string” type stitch used to help keep the cervix closed in pregnancy with signs of an incompetent cervix. It is placed at the External OS and can only be placed while a woman is pregnant because it fully closes the cervix. A TVC only supports bottom part of the cervix, approximately ⅓ of the cervical length. Funneling, opening, and tearing of the cervix are possible with it in place. It is often done as a rescue method when funneling, or opening has already happened, or as a preventative measure after a late term loss. TVCs often require bed rest, and there is a risk of infection being wicked into the uterus because of the stitch.
Why are TACs not more widely done?
It is a more invasive procedure than a TVC, and will need follow up surgeries: babies will have to be born by cesarean, and in some cases, another surgery may need to be performed to remove the cerclage. For these reasons it is typically reserved for women who have an incompetent cervix where TVCs (usually at least two) have failed; and/or when a TVC is not possible due to how short the cervix is, scarring, or cervical laceration.
When can a TAC procedure be done?
A TAC can be performed either before pregnancy occurs or early in the pregnancy.
A TAC placed before pregnancy allows for optimum exposure for placement, and reduces the risks for bleeding and harm to the baby. For that reason, some surgeons feel that this is the most optimal time to place the TAC. Other’s argue that one risk of placing the TAC pre-pregnancy is the possibility of making it too tight and making it harder to conceive. However, risk of this is less than 5%.
If a TAC is being placed after a loss it is best to give the cervix time to return to its normal size. If it’s placed too soon after pregnancy, it will be too loose when the cervix returns to normal size, upping the risk of failure. While the general consensus is to wait, some doctors suggest waiting 90 days, others say 4-6 weeks, while still others say to wait for 2 menstrual cycles.
If a TAC is placed during pregnancy, it’s better if it’s performed in the first trimester as the growing uterus will make the procedure more difficult, upping the potential for complications. That said, many surgeons would choose to do the surgery after the 11-week mark when the risk of miscarriage is lower. While most suggest that it be done before 15 weeks, because the bigger the uterus is the harder the TAC is to place properly. Some surgeons will place a TAC up to 20 weeks gestation. If cervical funneling has already started before the TAC is placed, then it’s more likely the TAC will fail regardless of gestation at the time of the procedure.
How is a TAC surgery done?
There are different methods of surgery. It can be done with a traditional laparotomy, or through laparoscopy. Laparoscopic procedures have only been done for about 10 years and were first done only pre-pregnancy. However, current success rates of both procedures are about the same.
Traditional TACs can be placed either under local or general anesthetic and is up to the doctor and patient’s discretion. Laparoscopic TACs are usually done under general because of the gas used to inflate the abdomen in order to be able to see can make it hard for the patient to breathe.
A suture made of strong, flexible, non-absorbant, non-elastic synthetic material which is about 5mm thick is placed around the cervix at or near the Internal OS, and tied snugly enough to stop the cervix from opening but not tight enough to completely seal the cervix, allowing proper blood flow and mimicking the support of a regular cervix during pregnancy.
It is usually an outpatient procedure with few limitations after surgery, such as no driving for 7 days. Recovery from the laparoscopic method tends to be easier because of smaller incisions and less trauma to the abdomen. Full recovery from a pre-pregnancy laparoscopic can take as little as 1-2 weeks; traditional can take about 4 weeks. Though some patients still experience pain up to 6 weeks after either type. Pregnant women may take a few days longer to recover as anesthesia can make morning sickness worse and all that heaving can hurt the abdomen. Though some doctors keep pregnant patients in the hospital for a few days to monitor for complications.
What are the benefits of this procedure?
It allows a suture to be placed higher up near or at the level of the internal OS, because of this there is less chance of suture migration. Unlike with a TVC, there is not a foreign object in the vagina which could wick infection into the uterus. The TAC also provides a greater barrier to ascending infections by nature of its placement. The TAC can be left in for future pregnancies, a TVC cannot.
As long as the pregnancy progresses properly, no modifications to activity or bed rest are needed. Unlike with the TVC, pelvic rest is not necessary because the entirety of the cervical mucous column is intact, though some doctors recommend the use of a condom because of chemicals in semen that soften the cervix and can stimulate contractions. If there are severe concerns in the pregnancy like preterm contractions or shortening of the cervix bed rest or other modifications may be necessary.
Overall, a properly placed TAC can significantly lower the likelihood of a late term loss. It is genuinely hard to compare these numbers to those of a TVC, and I’ll get into more detail of why in the section about success rates.
What are the drawbacks?
It is an invasive medical procedure, and as such it comes with risks such as bleeding, and infection as well as a longer recovery. It also requires further surgeries to deliver the baby, or remove the cerclage.
Pregnancies are high risk and must be closely monitored as contractions that are not properly dealt with could lead to severe complications for mother and child such as cervical tearing or rupture of the uterus.
What are possible complications?
According to one site the potential complications for a TAC are similar to those for a TVC**:
- The amniotic sack (membranes) slipping into the vagina
- Infection in the uterus – including but not limited to infection of the placenta, membranes or amniotic fluid
- PPROM – when the water breaks pre-term
- Late term loss
** From all of my reading it seems to me these risks are far less with a TAC than with a TVC though because the TAC keeps the full length of the cervix closed and mimics the behaviour of a healthy cervix.
When the TAC is placed too tightly pre-pregnancy some women experience painful periods (dysmenorrhea), secondary infertility, or have the TAC interfere in dealing with first trimester complications. There are also possible complications specific to a TAC placed during pregnancy, the procedure itself holds a higher risk of blood loss or fetal complications such as miscarriage.
If labour contractions are ignored, it could lead to tearing of the cervix or uterine rupture. With timely intervention, mother and baby can both have positive outcomes and uterine rupture rarely occurs.
What happens if the pregnancy proves non-viable?
First Trimester – Since the TAC does not seal the cervix/birth canal closed a first term loss can exit the body naturally or by way of a D&C.
Second Trimester – A loss after 12-14 weeks often requires a small c-section type procedure called a hysterotomy to remove the baby and to leave the TAC in place.
-A laparoscopic procedure, or an incision though the vagina to the rear of the cervix could also be done at this point to remove the TAC and then do a D&C.
Past the Point of Viability – often a C-section is performed, and the TAC stays in place.
What are the success rates?
Because the TAC tends (at least historically) to be reserved for more severe cases where there have been multiple losses and/or TVC failure and because TVCs are often done without a sure diagnosis of cervical incompetence it is hard to directly compare their success rates. So you can look at these numbers as the success rates for the roughly 10% who would be childless if TVCs were the only option.
No random trials have been done to directly compare the likelihood of successful outcomes from a TAC placed before or during pregnancy, but a review of 14 studies performed between 1990 and 2013 on 678 different patients showed no real difference in live birth rates of TACs placed before or during pregnancy.
A study done in 2002 looked at women who had experienced preterm birth (before 34 weeks) or mid term loss and who had gotten pregnant again. It compared the likelihood of birth before 24 weeks or fetal death in the time directly before or after birth for women with repeat TVC versus TAC. TVC had a 12.5% likelihood, and TAC had 6%
Some estimated success rates for TACs are higher than 90%. All but one of the doctors whose Q&As I read on Abbyloopers give the success rate to be in the 90% range or higher for women with Incompetent Cervix based on the results of their practices. The one who did not linked to this study, which I had also found here:
- A 2011 meta-analysis of 31 studies was done it found that delivery of a viable baby at or past 34 weeks gestation was 78.5% for laparoscopic TVCs and 84.8% for traditional. The rate for second-trimester loss was 8.1% for laparoscopic and 7.8% for traditional. And no third-trimester losses were reported.**
**I’d say that’s a success rate of 91.9% for the laparoscopic and 92.2% for the traditional.
Doctor Haney is a well-known TAC surgeon based out of Chicago, who has been performing traditional TACs for over 30 years and does over 200 per year. He wrote in his Q&A section of the abbyloopers website that there is a 98% success rate with a TAC and stated that other complications are what lead to late term losses when a TAC is used.
He lists the following factors:
- The surgeon’s experience
- The surgical technique
- Individual patient factors:
- Placing a TAC after funneling has begun
- Cervix previously shortened by a surgical procedure
- Previous obstetrical cervical tear
- Fibroids or other pelvic pathology or previous surgery close to the cervix
- Loss of cervical integrity due to surgical injury
- Cysts within the cervix
- Connective tissue disorders (11)
Major surgery is never something to walk into blindly, especially elective major surgery. I told myself that I was going to do this research and write this post with as little bias as possible, but I definitely have a bias about this procedure after learning all I could about it.
While I’m not ready to run to the doctor right now and demand a transabdominal cerclage, I can’t help but feel like I wish I had known about it sooner. I can’t say for certain that I would have opted for the TAC over the TVC with Anika, but I do wish I’d had the opportunity to consider it.
I hope my research can help someone else who is dealing with an incompetent cervix to know what options are out there so that she can make the best decisions possible for herself and her family. Again, I recommend reading through the links below and signing up at Abbyloopers if you are considering a transabdominal cerclage.
If you would like to follow my personal TAC story as it continues, you may click here to read more about my experiences.
Abbyloopers is a closed facebook group for women around the world who have or are considering getting a transabdominal cerclage to prevent future loss. If you are considering the TAC I recommend you join this group
Abby-sisters of Canada is a closed group specifically for Canadian women who have or are considering getting a TAC. If you are Canadian and considering getting a transabdominal cerclage I recommend you join this group as well as Abbyloopers.
- 1.) Wikipedia – Cervical Canal
- 2.) Better Health – Laparotomy
- 3.) NHS Laparoscopy Introduction
- 4.) American Pregnancy – D-and-C After Miscarriage
- 5.) Radiopaedia – Funneling of the Internal Cervical OS
- Up to Date – Transabdominal Cervical Cerclage
- Up to Date – TCC – Sources
- Better Health – Laparotomy
- OBGYN.net – LAC Excellent Option
- Desert Womens Care
- Modern Medicine – Prophylactic Laparoscopic Abdominal Cerclage
- AbbyLoopers Dr Arthur Haney
- AbbyLoopers Dr Arthur Haney
- AbbyLoopers Dr Robert Debbs
- AbbyLoopers Dr Richard Demir
- AbbyLoopers Dr James Sumners
- AbbyLoopers Dr George Davis
- AbbyLoopers Dr Roy Farquharson