Incompetent Cervix/IC

What Next?

I think one of the questions I’ve dealt with most in the past week is “What next?” Where do I go from here? What do I do now that I have birthed and lost a child? How do I experience motherhood when I don’t have my children earthside? In what ways can I support Jason in his grief? Will we ever be ready to try again, and what if we somehow can’t have children?

I don’t have all the answers (or maybe any of the answers) at this point but I do know that I am taking it day by day and walking this path in faith. Despite our losses, I have faith that God and the Universe will provide. I can’t know at this point whether Jason and I will be able to have biological children born of my body, but I have faith that we will have a family, one way or another. I’m not sure what I can do to help Jason grieve when my own heart is in pieces, but I have faith that our love is strong, that it has been tested in so many different ways in our four years together, and that we will find healing together as a couple. But my faith doesn’t require me to sit by idle.

Anybody who knows me would tell you that at my core, I am a planner. I tried to plan my path to motherhood, down to the due date, and that didn’t quite work out for me. But I am finding healing in planning for the future. There are so many things about pregnancy that I can never plan or control, and I am slowly learning to give those things to God, but there are a number of things that I can do right now to give our next child the best shot. No, we’re not rushing into trying again, so don’t expect any pregnancy announcements for a year or two at least, but I am educating myself on all the things I can do to make sure we are ready when the time comes.

Treatments for Incompetent Cervix

At this point, I’m doing a lot of research on treatments for my incompetent cervix (IC). I haven’t met with my OBGYN, reproductive endocrinologist, or MFM yet and I am not a medical professional so take all this with a grain of salt and do your own research if you’re also battling IC.

It seems that we have 2 viable options moving forward.

(1) We can wait till we get pregnant, then have a procedure called a preventative transvaginal cerclage (TVC) sometime between 10 and 14 weeks gestation that will supposedly strengthen my cervix. Basically they stitch up the cervix and then remove the stitch around 37 weeks to allow for a vaginal delivery. In theory, I would have to get a new TVC every time I got pregnant. The success rate of preventative TVCs is around 75-80%. Success in the most cited studies seems to be defined as live birth, so these rates don’t account for later neonatal death due to prematurity or associated complications.

(2) Or, we can have a transabdominal cerclage (TAC) placed sometime before our next pregnancy. The TAC is placed higher up in the cervix and is much stronger than traditional TVC, but the TAC is not removed prior to delivery so a C-section would be required for all future pregnancies. The success rate of TAC is anywhere from 90-99%, depending on the doctor and the surgery method. Essentially, they’d only have to place the TAC once and my IC would be “solved.”

Most doctors recommend trying the TVC first, and only resorting to a TAC once you have a TVC that “fails” – essentially where your cervix shortens and dilates despite the stitch, and you either give birth prematurely or lose your child. The reason for this approach is that most OB/MFMs consider the TAC to be an especially aggressive option, only to be used when other methods have failed. But at end of the day, the doctors aren’t the ones who suffer if the TVC fails. They don’t have to leave the hospital empty-handed because their child died, they don’t have to spend months in the NICU fighting for their child’s life, they don’t have to live with the constant what-ifs and self-blame.

Why Go Straight For TAC?

Because I have clearly diagnosed IC, I’d much rather have the procedure that provides the best odds available, regardless of the costs. There are tons of pros and cons to both TVC and TAC, and I highly recommend that you check out the Abbyloopers forum or Facebook page to learn more in addition to speaking to your doctors if you’re in a similar position. Every situation is unique and treatment should be based on individual medical history. The TAC is the best and safest option for me, but there are many situations where a TVC would instead be the best and safest option – this is up to you and your doctor(s).

This diagram shows the placement of the TAC stitch and the three most common TVC stitches (TVCIC, Shirodkar, and McDonald).

I’ll do my best to explain why we plan to bypass the TVC and go straight for a pre-pregnancy TAC.

  1. Safety: Most all TVCs are placed while you are pregnant, and a new one usually has to be placed in each pregnancy. This means major surgery in every pregnancy, with anesthesia, that can put baby at risk. These risks are generally low, but when it comes to our children, we want to take as few risks as possible. A TAC can be placed once, pre-pregnancy, and will usually stay in place for all future pregnancies. The risks to mom seem about the same for either procedure, so I’d rather be in a situation where I can focus on healing myself without worrying about whether my baby is safe.
  2. Lifestyle: Many doctors still recommend bed rest (usually in the 2nd or 3rd trimester) for women with a TVC because the TVC does not protect the entire length of the cervix, so there is still risk of cervical shortening or funneling through the cerclage. Once I start working this fall, I will become the primary source of income for our household. While my job provides maternity leave and benefits, I personally do not want to put myself in a situation where I will need to take additional time off, for every pregnancy, to spend at home or in a hospital on bed rest. Meanwhile, a TAC is placed at the very top of the cervix, with material that can support many times the weight of a term pregnancy, so bed rest is not necessary at any gestational point.
  3. C-Section: A TVC can be removed to allow for a natural birth, while a TAC is usually not removed, so a C-section is required for TAC pregnancies. Don’t get me wrong, it makes me a bit sad to know that I will never be able to deliver another child naturally. That sounds silly but my body birthed Omie beautifully and without any pain medication (I’m shocked too) and it was an amazing experience. But I want to bring my children into this world alive and healthy, even if that means by C-section. For our family, giving up the chance of natural delivery in exchange for safety and peace of mind is worth it. Plus, my bicornuate uterus puts me at a high risk of C-section anyhow so this isn’t a big deal for me.

So what next? We meet with our OBGYN/RE/MFM, we discuss the TAC procedure with the doctors and get the referral, then we schedule a consult with our TAC surgeon of choice, Dr. Atlas, in Baltimore. We manage our grief one day at a time. We find hope and gratitude in each day. And above all, we live in a way that honors our sons’ memories and gives them comfort in heaven.

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