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Zheng R, Zhou K, Yu C, Rundura M, Dyonne M, Li-xia C, et al. Identification and treatment of a cervical sinus tract in a patient with ten years of infertility. Fertil Steril. In press.
) present a case that also reflects a striking degree of perseverance and resiliency on the part of the patient and her clinicians. They begin their video submission by reviewing the patient’s medical and surgical history, which includes many years of infertility and a 7-year history of documented endometrial cavity fluid. Abdominal myomectomy had been performed in 2007 with resection of a large mass in the posterior wall of the uterus near the cervix, which postoperatively gave rise to symptomatic menstrual changes including intermenstrual spotting. This precipitated what would become 10 years of investigation/treatment with 5 separate hysteroscopic and laparoscopic surgeries and 11 embryo transfers, none of which resulted in a liveborn infant (2Zheng R, Zhou K, Yu C, Rundura M, Dyonne M, Li-xia C, et al. Identification and treatment of a cervical sinus tract in a patient with ten years of infertility. Fertil Steril. In press.
). In April 2020, she presented to the investigators to evaluate an increasing volume of endometrial cavity fluid, which had been present intermittently since 2013.Endometrial cavity fluid (ECF) is the accumulation of mucus, blood, endometrial secretions or tubal fluid within the endometrial cavity (3Impact of endometrial cavity fluid on assisted reproductive technology outcomes.). Causes of ECF are thought to include hydrosalpinges, polycystic ovarian syndrome, subclinical intrauterine infections, and excess fluid generation in response to gonadotropin administration (3Impact of endometrial cavity fluid on assisted reproductive technology outcomes., 4Zhang W.X. Cao L.B. Zhao Y. Li J. Li B.F. Lv J.N. et al.Endometrial cavity fluid is associated with deleterious pregnancy outcomes in patients undergoing in vitro fertilization/intracytoplasmic sperm injection: a retrospective cohort study.). Studies have shown decreased clinical pregnancy rates after in vitro fertilization cycles in patients with ECF compared to those without ECF. Because the likelihood of endometrial implantation and clinical pregnancies is dependent on the volume, timing, and ultimate etiology of the fluid, it is important to explore the cause of ECF before embryo transfer (3Impact of endometrial cavity fluid on assisted reproductive technology outcomes., 4Zhang W.X. Cao L.B. Zhao Y. Li J. Li B.F. Lv J.N. et al.Endometrial cavity fluid is associated with deleterious pregnancy outcomes in patients undergoing in vitro fertilization/intracytoplasmic sperm injection: a retrospective cohort study.). Thus, the clinicians in this case sought to identify the etiology of the fluid with the use of a multimodal approach that allowed for intrauterine and extrauterine visualization and to operate on structures with components inside and outside of the uterus. Through persistence and clever use of injected methylene blue dye, the investigators were able to identify and remove a cystic region connecting to the cervix through the sinus tract identified on hysteroscopy.The investigators present an interesting and compelling theory for the origin of the cystic structure and ECF. Pathology from the surgery confirmed smooth muscle tissue was present in the cyst capsule wall and endometrial tissue was within the capsule. Furthermore, a solid structure was removed from the surface of the right ovary, which was confirmed to be a fibroid. Thus, the investigators posit that following the patient’s 2007 myomectomy, suture failure and the resulting poor wound healing in the lower uterine segment led to the formation of a cervical sinus tract (2Zheng R, Zhou K, Yu C, Rundura M, Dyonne M, Li-xia C, et al. Identification and treatment of a cervical sinus tract in a patient with ten years of infertility. Fertil Steril. In press.
). During subsequent menstrual cycles, menstrual products flowed into the tract, where endometrial tissue deposited and implanted, forming an ectopic endometrial cyst. Thereafter, small amounts of cystic fluid flowed back out into the endometrial cavity, leading to the appearance of intermittent ECF and the patient’s intermenstrual spotting. The investigators lay out evidence for their theory including the timing of onset of symptoms after the myomectomy, the pathology of the specimen, and the anatomic location of the defect in relation to the operation (2Zheng R, Zhou K, Yu C, Rundura M, Dyonne M, Li-xia C, et al. Identification and treatment of a cervical sinus tract in a patient with ten years of infertility. Fertil Steril. In press.
).Zheng et al. (2Zheng R, Zhou K, Yu C, Rundura M, Dyonne M, Li-xia C, et al. Identification and treatment of a cervical sinus tract in a patient with ten years of infertility. Fertil Steril. In press.
) remind us of the importance of good closure of surgical myometrial defects. Among reproductive-aged women, uterine fibroids are the most common benign tumors of the pelvis and are known to contribute to pelvic pain and pressure, abnormal uterine bleeding, and decreased fertility (5Clinical practice. Uterine fibroids.). For women who desire preservation (or improvement) of fertility, surgical management via myomectomy often is undertaken and remains the standard of care for this population in whom subsequent pregnancy is desired. The specific techniques of laparoscopic, robot-assisted, vaginal, or abdominal, and the type of closure (for example, single layer, multiple layer, barbed suture) are still debated. However, the import of tissue reapproximation is reinforced not only in the myomectomy setting, but also in the setting of cesarean sections with resultant isthmoceles. Certainly, the process of aligning myometrial tissue for the best wound healing possible is the ultimate objective. In this case, Zheng et al. (2Zheng R, Zhou K, Yu C, Rundura M, Dyonne M, Li-xia C, et al. Identification and treatment of a cervical sinus tract in a patient with ten years of infertility. Fertil Steril. In press.
) demonstrate how they effectively closed the uterine scar with a layer of interrupted suture, oversewn by a layer of continuous suture. Hysteroscopy at the end of the case revealed that the sinus tract was repaired.The NASA Perseverance mission demonstrated persistence in the face of global challenges in the search for signs of extraterrestrial life. One could argue that the patient in this case, who underwent a decade of treatment for infertility, also demonstrated perseverance in the pursuit of life. Both missions remind us that a clear focus on objectives, thoughtful approaches to new challenges, and equipping oneself with the right tools, whether in the operating room or outer space, can lead to remarkable progress. Though we do not yet know whether this patient has been able to achieve a pregnancy, at 6 months postoperatively, her abnormal uterine bleeding had resolved and the endometrial fluid/pelvic cystic area was no longer present on pelvic ultrasound.
While we continue to grapple with the current and future implications of the global coronavirus pandemic, we can reconsider the role of perseverance in our own day-to-day lives. Whether at the workplace or at home, all of us have faced extraordinary challenges and our resiliency often is tested. However, time and time again, these challenges have been met with admirable resolve and dogged problem solving. As we all work in our own ways toward the betterment of society, perseverance will remain key to achieving our goals and the goals of those for whom we provide care.
ReferencesNASA Jet Propulsion LaboratoryMars 2020 Perseverance Landing Press Kit.
()Zheng R, Zhou K, Yu C, Rundura M, Dyonne M, Li-xia C, et al. Identification and treatment of a cervical sinus tract in a patient with ten years of infertility. Fertil Steril. In press.
Impact of endometrial cavity fluid on assisted reproductive technology outcomes.
Int J Gynecol Obstet. 132: 278-283Zhang W.X. Cao L.B. Zhao Y. Li J. Li B.F. Lv J.N. et al.Endometrial cavity fluid is associated with deleterious pregnancy outcomes in patients undergoing in vitro fertilization/intracytoplasmic sperm injection: a retrospective cohort study.
Ann Transl Med. 9: 9Clinical practice. Uterine fibroids.
N Engl J Med. 372: 1646-1655Article InfoPublication HistoryPublished online: July 07, 2021
Publication stageIn Press Corrected ProofFootnotesYou can discuss this article with its authors and other readers at https://www.fertstertdialog.com/posts/33165
IdentificationDOI: https://doi.org/10.1016/j.fertnstert.2021.06.003
Copyright©2021 American Society for Reproductive Medicine, Published by Elsevier Inc.
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