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Overcoming the Challenging Cervix

Identification and Techniques to Access the Uterine Cavity

Wood, Michelle A., DO*†; Kerrigan, Katherine L., MD; Burns, Megan K., MD, MA§∥; Glenn, Tanya L., MD‡¶; Ludwin, Artur, MD#**††; Christianson, Mindy S., MD‡‡; Bhagavath, Bala, MD§§; Lindheim, Steven R., MD, MMM∥∥

Obstetrical & Gynecological Survey: November 2018 - Volume 73 - Issue 11 - p 641–649
doi: 10.1097/OGX.0000000000000614

Importance Cervical stenosis is a challenging clinical entity that requires prompt identification and management in order to avoid iatrogenic injury at the time of endocervical canal cannulation.

Objective The aim of this study was to identify cervical stenosis and discuss associated etiologies, risk factors, and review medical and surgical approaches for overcoming cervical stenosis.

Evidence Acquisition Computerized searches of MEDLINE and PubMed were conducted using the key words “cervix”, “cervical stenosis,” “embryo transfer,” “hysteroscopy complications,” “misoprostol,” and “ultrasound.” References from identified sources were manually searched to allow for a thorough review. Data from relevant sources were compiled to create this review.

Results Transcervical access to the uterine cavity is frequently required for procedures such as hysteroscopy, dilation and curettage, endometrial biopsy, sonohysterogram, hysterosalpingogram, intrauterine insemination, embryo transfer in those undergoing in vitro fertilization, and insertion of intrauterine devices. These procedures can become complicated when difficult cannulation of the endocervical canal is encountered. Management strategies include preprocedural use of cervical-ripening agents or osmotic dilators, ultrasound guidance, no-touch vaginoscopy, manual dilatation, and hysteroscopic resection of the obstructed endocervical canal.

Conclusions and Relevance Cervical stenosis is associated with iatrogenic complications that can result in significant patient morbidity. In patients undergoing in vitro fertilization, difficult embryo transfer is associated with lower pregnancy rates. The clinician should carefully consider the patient's menopausal status, risk factors, and symptoms in order to anticipate difficult navigation of the endocervical canal. Various medical and surgical management strategies, including hysteroscopic resection, can be used to overcome the stenotic cervix.

Target Audience Obstetricians and gynecologists, family physicians.

Learning Objectives After participating in this activity, the provider should be better able to diagnose cervical stenosis; distinguish associated etiologies and risk factors; and assess appropriate medical and surgical approaches.

*Resident Physician, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, OH;

Clinical Research Fellow, Camran Nezhat Institute, Palo Alto, CA;

Resident Physician, Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH;

§Surgical Fellow, Camran Nezhat Institute, Palo Alto, CA;

Surgical Fellow, Stanford University Medical Center, Palo Alto, CA;

Resident Physician,Wright-Patterson Medical Center, Department of Obstetrics and Gynecology, Wright-Patterson Air Force Base, Dayton, OH;

#Associate Professor of Gynecology, Department of Gynecology and Oncology, Jagiellonian University, Kraków, Poland;

**Associate Professor of Gynecology, Ludwin and Ludwin Gynecology, Kraków, Poland;

††Associate Professor of Gynecology, Centermed, Kraków, Poland;

‡‡Assistant Professor of Gynecology and Obstetrics, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD;

§§Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY; and

∥∥Professor of Obstetrics and Gynecology, Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH

All authors, faculty, and staff in a position to control the content of this CME activity and their spouses/life partners (if any) have disclosed that they have no financial relationships with, or financial interests in, any commercial organizations relevant to this educational activity.

Correspondence requests to: Steven R. Lindheim, MD, MMM, 128 Apple St, Suite 3800 Weber CHE, Dayton, OH 45409. E-mail:

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