European Journal of Obstetrics & Gynecology and Reproductive Biology
Cervical regeneration after diathermy excision of cervical intraepithelial neoplasia as assessed by transvaginal sonography
Introduction
The incidence of cervical intraepithelial neoplasia (CIN) has increased in younger women over the past 20 years. Cold knife conization now has a rather limited use for the treatment of CIN because of the need for hospitalisation and general anaesthetic, as well as its effect on subsequent pregnancies due to cervical incompetence and cervical stenosis which may result in premature delivery and difficulties in labour [1], [2], [3].
Excisional outpatient methods, particularly diathermy loop conization are being increasingly used worldwide. One of the advantages of these methods is that they eradicate the preinvasive lesion with minimal cervical trauma, thus maintaining the potential for childbearing. Some recent controlled retrospective studies examining the possible complications in subsequent pregnancies following diathermy loop excision showed no adverse effect in subsequent pregnancies [4], [5]. These studies have not examined the volume of the removed specimen nor the interval between the operation and conception or delivery. In one retrospective study, the size of the cervical specimen was measured by a ruler immediately following the loop conization and larger diameter specimen were not associated with increased complications in subsequent pregnancies [6]. Other controlled studies however, report an increased incidence of preterm delivery in women who had undergone carbon dioxide laser conization [7], [8]. There is apparently some controversy over the subject of pregnancy complications, which has led many gynaecologists to very conservative loop excisions, and consequently to the high rates of incomplete excision reported [9], [10].
Since cervical shortening has been reported to be a significant risk factor for preterm delivery [11], [12], [13] the purpose of this prospective study was to investigate patterns of cervical regeneration in women who had undergone diathermy loop cervical conization, depending on the size of the excised tissue.
Section snippets
Materials and methods
The study population comprised 100 consecutive nulliparous women scheduled for large loop excision of the transformation zone (LLETZ) for CIN and who completed the entire follow up protocol. They gave written informed consent to undergo serial transvaginal ultrasound assessment of their cervix, before and immediately after the conization, as well as 3, 6 and 12 months post-operatively. None had had previous surgery to the cervix, while nine who defaulted from follow up, four who became pregnant
Results
The mean age of the women of the two groups did not differ significantly (group A: 28.2±3.2 S.D. years, group B: 27.6±4.1 years), (P=0.61 non-significant, t-test). There was no significant difference in lesion grade between the two groups (P=0.148 (ns), Fisher’s exact test). In group A the pathology report showed CIN 1 in 12 cases and CIN 2–3 in 13 cases, while in group B CIN 1 was found in 18 cases and CIN 2–3 in seven. In only one of the women of group A there was a histologic report of
Comment
Cervical shortening is associated with preterm labour [11], [12], [13]. Previous studies have however shown no adverse effects of LLETZ in general use on future fertility or pregnancy outcomes [4], [5], [6]. This study does not present data on pregnancy outcome after loop; it offers however a possible explanation for the results of the above mentioned studies, since it was concerned with the extent of regeneration of the cervix in nulliparous women undergoing routine LLETZ. It has shown that
Acknowledgements
The authors wish to thank Dr. A Kofinas for the critical evaluation and comments on this study.
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