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.