Interpretation
There are two significant concerns for MRKH patients after diagnosis.
The first one is the ability for sexual intercourse, and the second one
is the ability to have a child. For the first one, the solution is
creating a functional vagina. The first-line therapy is the
self-dilatation technique which requires patient compliance, regular
exercises, long-term patience.19-21 Surgical treatment
is an option when the non-surgical methods are unresponsive, or patients
directly request surgery. There are numerous surgical techniques mainly
in three subgroups; Mc Indoe, Vechietti, and Davydov
surgeries.3,12,15
Mc Indoe technique is the historical method that was first used for the
creation of a neovagina. This procedure involves the careful dissection
of the space between the bladder and rectum and a stent covered with an
autologous skin graft placed through the dissected space. Dilatation
exercises must continue after surgery to avoid collapsing of the
neovagina. There are developed methods like Mc Indoe using different
materials instead of skin graft. Small intestine mucosa, absorbable
adhesion barrier, buccal mucosa, amnion membrane, peritoneum, tilapia
fish skin, in vitro cultured vaginal tissue are the published materials
that were used to create a vagina.4-11 This technique
has a short recovery period because of not involving any abdominal
process. However, using graft materials increases the cost of the
operation.
The Vechietti technique is based on performing a laparotomy with
dissection of the vesicorectal septum and fixation of the vaginal
”dilatation olive” using two sutures passing the vaginal stump and after
that externalizing the threads to a traction device through the
abdominal wall.12 With the developing technology, this
technique is also developed, and instead of laparotomy, laparoscopy or
robotic modified Vechietti techniques were also
reported.13-14 The traction device is approximately
being used for 2-4 weeks. This period may be painful and uncomfortable
for the patients, although reaching at least 6 cm length vagina at the
end of the procedure.
The last procedure is the Davydov operation which is mainly based on
pulling down the parietal peritoneum and suturing it to the vaginal
introitus. This method has many advantages; firstly, this method has a
shorter recovery time than the Vechietti procedure and cost-effective
procedure than Vechietti and Mc Indoe operations. Using peritoneum
eliminates the possible graft complications like; hairy formation due to
skin graft, heavy vaginal discharge due to intestinal graft, foreign
body reaction, and granulation for synthetic grafts.
Our Uncu Modified Remnant-Supported Laparoscopic Double-Layer Peritoneal
Pull-Down Vaginoplasty Operation procedure seems to provide a robust
vaginal dome with remnant supported double-layer suturation, also an
adequate vaginal length with a mean length of 8.4 cm at one-year
control. Most of the studies accept enough vaginal length as 6 cm.
Beyond the vaginal length, FSFI scores of our patients (mean FSFI; 31.4
+ 3.9) are higher than patients operated either Davydov, Vechietti or Mc
Indoe technique.22-26 Thus, the first problem of our
MRKH patients was solved. Now we need to solve the other major problem,
motherhood.
There are two main options for MRKH patients to have children. Also,
there may be another option; child adoption. Nevertheless, patients
mostly want their own genetical children. The first method is to find a
gestational carrier. This method involves IVF&ICSI procedure, later
than embryo transfer to the gestational carrier. There are two forms of
surrogacy process; commercial or voluntary. Countries such as France,
Germany, Italy, Spain, Portugal, Bulgaria, and Turkey prohibit all forms
of surrogacy in our country. In countries including the United Kingdom,
Ireland, Denmark, and Belgium, surrogacy is allowed where the surrogated
mother is not paid, voluntary. Commercial form is legal in some US
states, India, Russia, Ukraine, and Georgia. Some countries have
criminalized going to another country for commercial surrogacy, while
others permit it. Also, this process may be costly. Moreover, another
issue is that the surrogate mother is recognized as the legal mother.
This idea is based on ancient Roman law. ”Mater semper certa est.” (”The
mother is always certain”) is a Roman-law principle that has the power
of praesumptio iuris et de iure, meaning that no counter-evidence can be
made against this principle. It provides that the mother of the child is
conclusively established, from the moment of birth, by the mother’s role
in the birth.27
Thus, the best choice for having own child for MRKH seems as Uterine
Transplantation (UTx) in countries which prohibited all forms of
surrogacy. More than 70 UTx was performed worldwide since the first
successful UTx from a multiorgan donor in 2012 in
Turkey.17,28 This patient gave a healthy birth on June
2020 after several embryo transfers. There are another 23 reported live
births from UTx worldwide (Sweden, United States (Dallas, Cleveland),
Germany, Brazil, Serbia, Czech Republic, China, and
India).28 There are many reasons for the low numbers
of UTx worldwide. Firstly, because of not being a life-saving organ, the
uterus transplantation procedure was not investigated as much as other
solid organ transplantation procedures. Graft dysfunction risk,
increased gestational complications (preterm delivery, fetal growth
restriction, hypertensive disorders) compared to the general population,
immune-suppression during pregnancy are the general concerns for UTx.
However, it’s known that fetal congenital abnormality risk is not
elevated in transplant pregnancies.29 Although these
concerns, increasing numbers of live births (mostly from US - Dallas)
give us hope for spreading this process.