A dedicated team can offer Mayer-Rokitansky-Kuster-Hauser patients the option to perform controlled ovarian stimulation and oocyte cryopreservation at the time of laparoscopic vaginoplasty.
In Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKHS) patients who are scheduled for laparoscopic vaginoplasty and have a desire for biological motherhood, we propose that a concomitant laparoscopic oocyte retrieval for cryopreservation is performed. Oocyte retrieval is pursued at the beginning of the laparoscopy. Right and left 5 mm trocars are positioned, through which a 17 G ovum aspiration needle is used for puncture of the right and left ovaries, respectively. To facilitate exposure of the follicles, the ovaries are mobilized and held with laparoscopic forceps.
When aspirating multiple follicles near each other, the needle tip is retained in the ovary to reduce the number of times that the ovarian cortex is transfixed and due to the inherent risk of bleeding. Subsequent steps are unchanged compared to the Davydov laparoscopic modified technique for vaginoplasty. Prior to surgery, controlled ovarian stimulation is performed with a gonadotropin hormone-releasing hormone (Gn-RH) antagonist protocol, and the concomitant procedure of oocyte retrieval and vaginoplasty is scheduled 36 h after the final follicular maturation trigger. Follicular fluid is collected in the same 10 mL sterile tubes used during transvaginal oocyte retrieval and transferred in a warming block (37 °C) to the assisted reproduction laboratory, where mature (metaphase II) oocytes are vitrified.
In this case, a series of 23 women with MRKH, oocytes were successfully retrieved and cryopreserved in all patients; vaginoplasty was subsequently conducted without modifications, and the inpatient and outpatient postoperative care (day of urinary catheter removal, day of hospital discharge, dilator use, and comfort at follow-up) remained unaffected. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound) and resolved after conservative treatment. Rather than performing surgical vaginoplasty and delaying oocyte retrieval in MRKH patients, this approach combines both procedures in a single laparoscopy, thereby minimizing surgical invasiveness and anesthesiologic risks.
With an incidence of approximately 1 in 4-10,000 women, MRKHS is the cause of 15% of primary amenorrhea cases. MRKHS is characterized by the congenital absence of the upper segment of the vagina and the uterus, whereas urinary tract and skeletal anomalies are associated variably. More specifically, a vaginal vault with a depth of 1-2 cm is usually present, and two rudimental uterine horns may be found1.
In the past, the primary medical interest in MRKHS was to enable normal sexual intercourse, which generally requires the construction of a neovagina by either non-surgical or surgical approaches2. However, advances in reproductive medicine currently allow genetic motherhood in MRKHS patients, by either surrogacy3,4 or-more recently-uterus transplantation5. While uterus transplantation is still an experimental procedure, surrogacy is available in many countries worldwide6, and reported obstetric and psychosocial outcomes are comparable to those of standard in vitro fertilization and oocyte donation7.
Both surrogacy and uterus transplantation require oocyte retrieval and in vitro fertilization, but no consensus exists on how to perform egg collection in patients with MRKHS. A transvaginal approach can be unfeasible because of insufficient vaginal elasticity8 even after vaginoplasty, atypical location of the ovaries9, or excessive distance between the ovaries and the vaginal cuff4,10. In these cases, laparoscopic oocyte retrieval represents the optimal approach in terms of surgical access. However, as most MRKHS patients currently undergo laparoscopic neovaginoplasty, we suggest performing a laparoscopic oocyte retrieval at the time of surgery for vaginoplasty11, followed by oocyte cryopreservation for future use, thus minimizing invasiveness while combining the treatment of the sexual and reproductive function of MRKHS patients.
Demographic data of patients
Twenty-three MRKH patients underwent treatment with this protocol so far. Anamnestic, instrumental, and laboratory findings of patients are summarized in Table 1. Unless specified in Table 1, no associated congenital anomalies were found.
The local ethical committee at the tertiary referral center for MRKHS (IRCCS San Raffaele University Hospital, Milan, Italy) was notified and approved the protocol before its implementation in July 2017. All patients or guardians gave signed informed consent for laparoscopic oocyte retrieval and cryopreservation during vaginoplasty and for the use of anonymized clinical/laboratory data for scientific purposes.
1. Team composition
2. Diagnostic work-up and counseling
3. Scheduling of the surgical procedure and of controlled ovarian stimulation
4. Controlled ovarian stimulation: starting dose, dose adjustments and monitoring, final oocyte maturation triggering
5. Clinical procedure (laparoscopy): oocyte retrieval
6. Clinical procedure (laparoscopy): vaginoplasty
NOTE: Vaginoplasty steps remain unchanged compared to the Davydov's laparoscopic modified technique12.
7. IVF laboratory: the day before the oocyte retrieval
8. IVF laboratory: oocyte retrieval procedure
9. Oocyte denudation
10. Oocyte vitrification
11. Inpatient postoperative care
12. Outpatient postoperative care
13. Follow-up
Table 2 includes ovarian stimulation data of the patients, whereas main surgical and functional outcomes are described in Table 3. The concomitant laparoscopic procedures of oocyte retrieval and vaginoplasty were combined successfully in all patients. An average of 11.4 ± 5.4 (mean ± SD) oocytes were retrieved, and 9.6 ± 4.3 MII oocytes were cryopreserved (Table 3). In our experience with oocyte cryopreservation in patients undergoing ART, postwarming oocyte survival rate following this vitrification protocol-defined as the proportion of morphologically intact oocytes at the time of intracytoplasmic sperm injection-was 84.5 ± 19.3. The total average operative time was 114 ± 17 min, intraoperative blood loss was insignificant (<50 mL) in all patients, and no intraoperative adverse events were observed. The urinary catheter and vaginal gauze were removed on day 2 after surgery in all patients. On day 3 post surgery, the patients began daily dilator use and were discharged on day 6.0 ± 1.0. One postoperative complication occurred in one patient (fever developing on day 5 post surgery and intraperitoneal fluid detection on transabdominal ultrasound). The patient was treated successfully with orally administered antibiotics and discharged on day 9 post surgery. Follow-up after surgery confirmed anatomical and functional success of the procedure. None of the patients reported any limitation to their daily life activities, any pain, or urinary symptom.
Figure 1: Oocyte vitrification protocol. Schematic showing the various steps of vitrification workflow of oocytes. Oocytes are first placed in a drop of WS1 (A), and then in a drop of WS2 (B). Mix the drop of ES1 into WS2 and after 2 min of incubation, merge the drop of ES2 to the previously merged drops (B). After 2 min, a third drop of ES3 is merged (B). After 1 min, place oocytes in a drop of ES4 incubating for 10 min (C). Then, oocytes are moved sequentially into the three drops of VS for 60 s (D). Please click here to view a larger version of this figure.
Characteristic | Mean ± SD or n (%) | |
Age at diagnosis, years | 13.8 ± 1.5 | |
46 XX karyotype | 23 | |
Age at surgery, years | 20.3 ± 3.4 | |
Antral Follicle Count (AFC), n | 13.2 ± 4.1 | |
Relevant findings (instrumental/laboratory) | ||
Horseshoe kidney | 2 (8.7) | |
Extra pelvic ovary/ovaries | 3 (13.0) | |
Unilateral renal agenesis | 2 (8.7) | |
Dilative cardiomyopathy | 1 (4.3) | |
Mesocardia | 1 (4.3) | |
Vater Syndrome | 1 (4.3) | |
Sensorineural hearing loss | 1 (4.3) | |
Congenital clubfoot | 1 (4.3) | |
Scoliosis | 1 (4.3) | |
Celiac disease | 1 (4.3) | |
Type 1 Diabetes | 1 (4.3) | |
Autoimmune Hypothyroidism | 1 (4.3) |
Table 1: Demographic, anamnestic, and clinical data of the 23 patients treated so far.
Mean ± SD | |
FSH starting dose, IU | 196 ± 44 |
FSH total dose, IU | 2,174 ± 506 |
Days of stimulation, n | 12.1 ± 0.4 |
E2 levels at triggering, pg/mL | 4,330 ± 2,007 |
P levels at triggering, ng/mL | 1.06 ± 0.95 |
Table 2: Controlled ovarian stimulation data of the 23 patients treated so far. Abbreviations: FSH = follicle-stimulating hormone; E2 = estradiol; P = progesterone.
Mean ± SD or n (%) | |
Operative time, min | 114 ± 17 |
Hospital stay, days | 6.0 ± 1.0 |
Blood loss, mL | insignificant |
Retrieved oocytes, n | 11.4 ± 5.4 |
Mature oocytes (vitrified), n | 9.6 ± 4.3 |
Complications | |
None | 22 (95.6) |
Postoperative fever and intraperitoneal fluid detection | 1 (4.3) |
Table 3: Outcomes of the combined laparoscopic procedure of oocyte retrieval and vaginoplasty in the 23 patients treated so far.
This protocol reduces the invasiveness in the treatment of MRKHS by combining the procedures of vaginoplasty and oocyte retrieval. To this purpose, it is crucial that a dedicated team is designated to ensure that the timing of COS, the surgical procedure, and oocyte vitrification are scheduled efficiently.
MRKHS patients for whom this combined laparoscopic method is expected to be most beneficial are those in whom a transvaginal retrieval would be considered technically challenging or unfeasible due to extrapelvic ovaries located laterally along the pelvic walls14 or in proximity of organs such as the liver and gallbladder9, or due to the presence of pelvic kidneys. In these patients, a transabdominal approach could be hypothesized and has been reported in the literature: nonetheless, a mean number of 4.92 ± 1.7 oocytes was collected15, suggesting a suboptimal retrieval due to technical limitations. In addition, a transabdominal approach might be difficult or impossible in some cases, such as in patients with marked abdominal wall thickness or poor visibility of ovaries due to overlying loops of bowel16.
Safety is a noteworthy strength of this approach. In addition to the advantages of optimal visualization and access described above, combining two procedures into a single one reduces anesthesiologic risks. Of note, a similar operative time is maintained compared to that of Davydov laparoscopic vaginoplasty alone, for which a mean duration of 125 min was reported in the literature12. Moreover, the fact that patients undergo COS at a very young age rather than later in life does not imply an increased risk of ovarian hyperstimulation syndrome for them, as this complication is efficiently avoided by triggering final follicular maturation with a Gn-RH analog.
Current guidelines for MRKHS require clinicians to address future options for having children with patients and parents at the time of diagnosis as a means to help them cope with the disease and its implications1. Adoption, surrogacy, or uterine transplant are the available solutions, with both options for biological motherhood requiring oocyte retrieval17. This combined laparoscopic approach might thus also be particularly beneficial in those MRKHS patients expressing major distress about their diagnosis of infertility18. In fact, surveys have shown that infertility can be one of the most challenging conditions to accept for patients receiving the diagnosis of MRKHS19. Early cryopreservation of oocytes in patients with a desire for future genetic offspring might alleviate their psychological distress, compared to delaying this necessary invasive intervention to an undefined date in the future.
However, as the main limitation to this approach, not all patients who opt for oocyte cryopreservation as early as at the time of vaginoplasty will eventually pursue their desire for genetic motherhood in their later adulthood years. For this reason, the team should also obtain and record the patient's decision regarding the use of her oocytes in the event of her ceasing to renovate cryopreservation (i.e., elimination, donation for research purposes, donation, or sell for heterologous reproduction where legal).
As a possible modification of this technique, we foresee the use of laparoscopic ultrasound probes, which could assist the infertility expert in puncturing the follicles that are located far from the ovarian surface. Lastly, we envisage that building expertise in laparoscopic oocyte retrieval for fertility preservation at the time of other procedures might allow the availability of this option. As an example, patients undergoing other laparoscopic procedures such as myomectomy and showing an indication to fertility preservation might benefit from this approach.
The authors have nothing to disclose.
No specific funding was received for this work.
Oocyte retrieval procedure | |||
Equipment | |||
CO2 O2 Incubator | Sanyo | ||
Incubator | Thermo Scientific | ||
Laminar Flow Hood | Cooper Surgical | ||
Portable incubator | Cooper Surgical | ||
Stereomicroscope | Nikon | ||
Consumables | |||
14 mL Polystyrene Round-Bottom Tube | Falcon | 352057 | |
4-well dish | Nunc | 144444 | |
60 mm Petri dish | Nunc | FA9150270 | |
90 mm Petri dish | Nunc | FA9150360 | |
Human Serum Albumin 100 mg/ml in Normal Saline (5%) | Origio | 3001 | |
Mineral oil for embryo culture | Origio | 4008 | |
One Well Dish | Oosafe | OOPW-CW05 | |
Quinn’s Advantage Fertilization medium SAGE | Origio | 1020 | |
Quinn’s Advantage medium with HEPES | Origio | 1024 | |
Sterile glass pasteur pipettes | |||
Oocyte denudation | |||
Equipment | |||
CO2 O2 Incubator | Sanyo | ||
Flexipet adjustable handle set | Cook | G18674 | |
Incubator | Thermo Scientific | ||
Laminar Flow Hood | Cooper Surgical | ||
Stereomicroscope | Nikon | ||
Consumables | |||
4-well dish | Nunc | 144444 | |
CSCM (Continuos single culture) medium | Fujifilm irvine Scientific | 90165 | |
Human Albumin 100 mg/mL in Normal Saline (5%) | Origio | 3001 | |
Hyaluronidase | Fujifilm Irvine Scientific | 90101 | |
IVF culture 60 mm petri dish | Nunc | FA9150270 | |
Mineral oil for embryo culture | Origio | 4008 | |
One Well Dish | Oosafe | OOPW-CW05 | |
Quinn’s Advantage medium with HEPES | Origio | 1024 | |
Serum Substitute Supplement | Fujifilm irvine Scientific | 99193 | |
Sterile glass pasteur pipettes | |||
Stripping pipette tips (140 μm) | Cook | K-FPIP-1140-10BS-5 | |
Stripping pipette tips (170 μm) | Cook | K-FPIP-1170-10BS-5 | |
Oocyte vitrification | |||
35 mm Petri dish | NUNC | 150255 | |
60 mm Petri dish | NUNC | 150270 | |
90 mm Petri dish | NUNC | 150360 | |
Container for Cooling rack | Kitazato | ||
Cryodevice/cryotop | Kitazato | 81111 | |
Electronic timer | |||
Flexipet | COOK | K- 1000 | |
Gilson Pipetman | Gilson | F123601 | |
Lab Printer LabXpert | Brady | XSL-86-461 | |
Tips 20-200 µL | Thermo Scientific | 2160G | |
Tips 2-20 µL | Thermo Scientific | 2139-HR | |
Visotubes | Cryo Bio System | 20 | |
Vitrification Freeze Kit | Fujifilm Irvine Scientific | 90133-SO | |
Vitrification Thaw kit | Fujifilm Irvine Scientific | 90137-SO |