Cervical Stenosis from a Cone or LEEP

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Hello Once More,

Today we are going to talk more about blockage of the cervical canal: Cervical Stenosis. We will concentrate on the most common causes of cervical stenosis; scaring that results from the treatment of an abnormal pap smear.

Please refer back to the previous post on the cervix to get some background for this blog.

Treatment of an abnormal pap can cause scarring of the lower part of the cervix, the external os. This type of scar is a problem for 2 reasons. First, it reduces the number of mucus producing cells, sometimes lowering natural fertility. Second, it may make fertility procedures, such as insemination or embryo transfer, more difficult.

Most cases of cervical stenosis occur as a result of improper healing from a surgical procedure. It may not be that the procedure was done improperly; it’s just that the healing did not cooperate

It is cells in the area of the external os that are tested during a pap smear. When these cells look abnormal, we need to remove them before they progress to cervical cancer. We treat the abnormal cells by either by destroying them or removing them: both processes can cause scarring. Examples of destroying the tissue include cauterization (basically burning away with electricity or a laser) and Cryo.

Cautery just basically fries the cells away, some abnormal and some normal tissue. Cryo literally freezes off some of the tissue of the external os, removing abnormally growing cells and some normal tissue. Cryo and Cautery are not popular because they do not give you any tissue to send to the lab.

Rather than destroying cervical tissue, there are other procedures that remove a small piece. Examples of tissue removal include a cone biopsy or a LEEP (Loop Electrosurgical Excision Procedure). The cone procedure and LEEP are basically the same thing, however if necessary the LEEP can be a little more precise and remove a smaller amount of normal tissue. The LEEP and the cone biopsy cut away pieces of tissue that can be further evaluated under the microscope.

A cone involves and old fashioned scalpel, and takes away a larger piece in the shape of a cone (pictures to follow). The LEEP uses a thin wire loop that scoops out a little piece. However, sometimes using a LEEP the doctor needs to take a larger area as if a cone were being performed. Today, most procedures are LEEP procedures because the biopsy can be directed; in other words, only a small area can be removed if necessary. In addition, the LEEP can be performed in the office as opposed to the hospital. Finally, there is a lower chance of bleeding with a LEEP.

No matter which of these procedures is performed, a small percentage of people can have post-op scarring that leads to cervical stenosis. The more tissue removed or destroyed, the greater the chance of a scar.

Why do some people scar an others not? Some people are just more prone to it. Scaring is the normal way we heal. For some women, the scarring is more robust and progresses enough to cover over the cervical canal. Certainly, if any of these procedures are followed by infection, scarring will be more likely.

Let’s go through the pictures.

Here is our uterine drawing showing the uterus and cervix.

The next picture is a drawing of what your doctor sees when she puts in the speculum. It’s the cervix, actually the very bottom of the cervix.

Let’s say your pap comes back abnormal. This usually means that there are some cells around the external os that are abnormal. Depending on the severity of the pap, these cells may need to be removed. Using some special techniques, you doctor would look very carefully at your cervix under magnification to try to determine the extent and location of the abnormality.
This picture is an example of abnormal cells in a very small area.

Here, the doctor does not need to remove much tissue, and this is not likely to lead to scarring. The doctor will probably use the LEEP procedure, but only a small amount of cervix needs to be removed. This picture shows a cervix with a small abnormality and a small LEEP.

This picture shows a case where there is a larger amount abnormal cells and they take up a larger area on the cervix.

In this case, the abnormal cells are all around the external os. Here, the doctor needs to take away much more tissue.

You can see that the shape of the removed tissue is in the shape of a cone, thus the term cone biopsy. A larger LEEP will also make a cone shaped biopsy. While the odds of scaring remain low, if it does happen, it is more likely to come from taking more tissue. The next picture shows a post-LEEP scar.

The good news is that in most cases, scarring at the external os is the easiest to deal with. Unlike scar tissue that forms higher up in the cervix, scarring at the external os can be seen with a speculum and the scar is usually shallow. The scar is usually on the thin side and can be easily opened, usually in the office.

After opening, the scar may have a tendency to return, but re-opening is not that difficult. In the case of fertility treatments such as insemination and embryo transfer, the scar can be opened just prior to these procedures without much difficulty. Unfortunately some women can have more serious scarring after these procedures that is not so easy to deal with. Additionally, some women need to have multiple biopsies, and this will increase the scar risk.

More on Cervical Stenosis next time.

Thanks for reading and please read disclaimer 5.17.06.

Dr. Licciardi

References:

  • Noyes N, Licciardi F, Grifo J, Krey L, Berkeley A. In vitro fertilization outcome relative to embryo transfer difficulty: a novel approach to the forbidding cervix. Fertil Steril. 1999 Aug;72(2):261-5.
  • Baldauf JJ, Dreyfus M, Ritter J, Meyer P, Philippe E. Risk of cervical stenosis after large loop excision or laser conization. Obstet Gynecol. 1996 Dec;88(6):933-8.
  • D.M. Luesley, C.W. Redman, E.J. Buxton, F.G. Lawton, D.R. Williams. Prevention of post-cone biopsy cervical stenosis using a temporary cervical stent. Br J Obstet Gynaecol, 97 (1990), pp. 334–337.
  • Houlard S, Perrotin F, Fourquet F, Marret H, Lansac J, Body G. Risk factors for cervical stenosis after laser cone biopsy. Eur J Obstet Gynecol Reprod Biol. 2002 Sep 10;104(2):144-7.
  • Grund D, Köhler C, Krauel H, Schneider A. A new approach to preserve fertility by using a coated nitinol stent in a patient with recurrent cervical stenosis. Fertil Steril. 2007 May;87(5):1212.e13-6.

12 responses to “Cervical Stenosis from a Cone or LEEP”

  1. Anonymous says:

    My husband and I are both 32 y.o. I tested normal and his SA results were very low count/ morphology/motility so we were advised to go straight to IVF.

    I overstimulated; the Dr. retrieved 31 eggs, 15 mature, and with ICSI, only 8 fertilized and all were frozen, while I recovered from horrible overstimulation. Thereafter, we did 2 separate FETs. Our embryos were frozen at the pronuclei stage. The first FET, we transferred after 3 days (4, 6, 8 cell and good quality); I had a biochemical pregnancy. The 2nd FET, they transferred after 2 days (2 2-cells). Both FETs were done with assisted hatching.

    My question is- we have 3 frozen embryos left. Should we repeat assisted hatching, and which day do you think we should do the transfer after thaw so as to maximize our chances of implantation??

    (As an aside, we really have lost faith in our doctor after he changed the transfer date at the last minute because the embyrologist was suddenly “busy” on the scheduled date, and he said to us that he would never advise hatching in our circumstances BUT hatching was done prior to both transfers!! We desperately tried to find another clinic to take our last frozen embryos to, but no one would take them, so we will transfer with the *bad* doctor and if it doesn’t work, move on to another doctor).

    Thank you so much for your time. This has been the hardest journey. Lolo

  2. Anonymous says:

    Hi there, I am one of the unlucky group that is interested in your Cervical Stenosis information. I have never had a procedure on my cervix. I have had 2 c-sections. After my second, I started having issues with menstrual blood not all coming out during my period, and subsequently shedding out around the time of ovuation in my cervical mucus. (very dark brown/almost black mucus….)I have struggled with secondary infertility as well for the last 3 years. I have seen an RE. On my ultrasounds, he could always the backed up blood in my cervix/uterus.Fluid is aways present in my uterus at the time of ovulation. We tried numerous in office dilations, laminaria placement, hysteroscopy (no pathology found), and leaving a foley catheter in my cervix for 10 days. None of these has been sucessful at all. Do you have any other ideas? I feel like my RE is sort of out of ideas. I also have a very retroverted uterus…..have you ever seen an issue where position of the uterus sort of “kinks” off the exit into the cervix? I just wonder b/c he never had major issues passing a catheter (either for HCG or for attempted IUI), and yet, it seems that there is some sort of outflow obstruction…..

  3. Anonymous says:

    Thank you for all this info! I had a c-section due to cervical stenosis, although I have never had an abnormal pap or LEEP. Are you still going to discuss how to treat cervical stenosis? I am having trouble getting pregnant again and wondering if there’s anything I can do. I still get regular periods although I have a lot of spotting before and after.

  4. Anonymous says:

    I have cervical stenosis from a past Leep procedure – lots of bleeding etc. I have had it opened several times to relieve mentral cramp pain from blood not able to get out — but now I believe that it is also the cause of my infertility. My husband and I have been trying for over 3 years, we have done artificial insem 4xs and no luck. Is there anything else I can do to fix the stenosis? Also, we want to do IVF but it would finanically be difficult – after reading that it might not work, should I continue with that idea? This blog has brought me some peace that I am not alone. Thank you so much for helping.

  5. Anonymous says:

    I’m awaiting the part about treatment. Also, can you mention the symptoms? I think I have some cervical stenosis because I get ‘premenstrual spotting’ (brown/black) and a feeling of heaviness like blood trapped in my uterus. I also get a lot of pelvic and lower back pain during periods especially after lying down a long time e.g. in the morning and there is little bleeding overnight even on the first day. The blood only comes out when I’m standing or sitting. I’ve had a hysteroscopy and the Dr said “everything’s fine inside the uterus” but it was painful and difficult to get the equipment past the internal os. I also have recurring endometritis from the pooled blood, usually after my period which doesn’t all come out.

  6. the owings says:

    This comment has been removed by the author.

  7. Anonymous says:

    I am one also interested in your cervical stenosis post. After passing the HSG, saline sono, 3 failed IUIs…we just attempted our firt IVF. Everything was picture perfect until ET. The dr was unable to get the cathedar (tried many different things) through my cervix. The transfer didn’t happen. We later went in to do a mock transfer for a possible FET…still unable to pass through my cervix. They inserted some saline and think there is some stenosis. I am now scheduled for a hysterscopy and a cervical dilation next week. We’ve always had issues with my cervix during previous procedures. They say it is like a ‘corkscrew’. They are now thinking they have never passed entirely through the cervix (even with the IUIs). Obviously, it’s not completely blocked…I get my period, the dye (from the HSG) went through, and so did the saline. Well, I’ve also had cyro and a LEEP. Will these procedures help at all? If they can’t get through my cervix normally, how will they in surgery?

    Thank you!

  8. Better understanding from the discussion surely…surgery has also come of age and has a leap from what it was long back.

  9. sammy says:

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  10. Anonymous says:

    sharing this wonderful site-funny and informative, for couples who want to be pregnant-this might help. thanks.

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  11. Anonymous says:

    I have one daughter who will be 11 next month. Me and my husband have actively been trying to get pregnant since she was 2. The doctor just told me after my HSG that my cervix was stenosed. She prescribed a medicine used to dialate the cervix to be followed with another medicine to promote ovulation. My question is 1) I’ve never had any surgeries so why the stenosis in the first place and 2) will the one dose of medicine to dialate the cervix keep my cervix open enough for conception?

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