To the Editor:
We read with great interest the case reported by Goojha et al. (1), and we could not agree more with the authors regarding the necessity to adequately assess subsequent fertility following B-Lynch suture.
Whereas B-Lynch suture was promptly adopted throughout the world, we have been attempting to alert physicians to the possible hidden mid- or long-term effects of uterine compression sutures (2-5). The aim of a uterine-sparing procedure is not only to control postpartum hemorrhage (PPH) with the lowest morbidity, but also to preserve a theoretical functional uterus that will not compromise the patients’ subsequent fertility and obstetrical outcome.
It is essential to note that currently no studies have adequately assessed fertility following uterine compression sutures (2-5), whereas there are validated data showing that uterine artery ligation for PPH does not appear to compromise these two decisive parameters (6). In fact, there are only isolated cases that have reported successful (or unsuccessful) pregnancies following B-Lynch suture (4-5), and no studies have yet taken into consideration the evaluation of desire and attempts to conceive. Contrary to Goojha et al (1), we do not believe that a registry will be sufficient to resolve this issue, since no information will be available regarding women with presumed preserved fertility and desire for pregnancy who do not become pregnant, thus resulting to an impossibility to adequately assess subsequent fertility following B-Lynch suture. Unfortunately, only systematic follow-up of a relatively large cohort of women who have undergone a B-Lynch suture, as previously performed for long-term assessment of other uterine-sparing procedures (6), will determine whether B-Lynch suture is associated to hidden mid or long-term effects. These data are essential to establish the place of B-Lynch suture in the PPH surgical management algorithm (2-5).
We agree that there are reassuring data regarding mid-term effects of this procedure. In particular, we found normal postpartum hysteroscopic findings in a series of 11 women who had undergone a successful B-Lynch suture after a failed stepwise uterine devascularization (2).
Nevertheless, and although we have reported successful pregnancies following B-Lynch suture combined with other uterine-sparing procedures (4-5), we do believe that uterine artery ligation, which is a well-assessed procedure, and as simple, rapid, and effective as B-Lynch suture (3), should currently be the first-line uterine-sparing surgical procedure for PPH. However, this would be only as long as the impact on patient’s subsequent fertility and pregnancies following the B-Lynch suture remains insufficiently assessed.
Loïc Sentilhes, M.D., Ph.D.a
Loïc Marpeau, M.D., Ph.D.b
Philippe Descamps, M.D., Ph.D.a
aDepartment of Obstetrics and Gynecology
Rouen University Hospital
bDepartment of Obstetrics and Gynecology
Angers University Hospital
1. Goojha CA, Case A, Pierson R. Development of Asherman syndrome after conservative surgical management of intractable postpartum hemorrhage. Fertil Steril. 2010 Mar 25. doi:10.1016/j.fertnstert.2010.01.078
2. Sentilhes L, Gromez A, Razzouk K, Resch B, Verspyck E, Marpeau L. B-Lynch suture for persistent massive postpartum hemorrhage following vessel ligation. Acta Obstetricia et Gynecologica Scandinavica 2008; 87:1020-6.
3. Sentilhes L, Gromez A, Descamps P, Marpeau L. Why stepwise uterine devascularization should be the first-line conservative surgical treatment to control severe postpartum hemorrhage? Acta Obstetricia et Gynecologica Scandinavica 2009;88:490-2.
4. Sentilhes L, Gromez A, Trichot C, Ricbourg-Schneider A, Descamps P, Marpeau L. Fertility after B-lynch suture and stepwise uterine devascularization. Fertil Steril 2009;91:934.e5-9.
5. Sentilhes L, Gromez A, Marpeau L. Fertility after pelvic arterial embolization, stepwise uterine devascularization, hypogastric artery ligation and B-Lynch suture. Int J Gynaecol Obstet 2010;108:249.
6. Sentilhes L, Trichot C, Resch B, Sergent F, Marpeau L, Verspyck E. Fertility and pregnancy outcomes following uterine devascularization for postpartum hemorrhage. Hum Reprod 2008; 23:1087-92.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2010.06.021
The authors did not reply to requests for a response.