1. Extract

• Patient Profile: International patient referred from the United Kingdom with a history of extreme reproductive complexity: 13 pregnancy losses (7 of which were late second-trimester losses due to severe cervical incompetence).

• Diagnostic Findings: Macroscopically polymyomatous uterus with severe cavitary deformation, diffuse adenomyosis, enlargement of the uterus extending to the umbilical region, and a previous abdominal cerclage in a distal/suboptimal position.
• Surgical and Medical Approach:

1. 1. OBTAINING a euploid embryo via IVF–ICSI with PGT-A using the patient’s own oocytes.
   2. Multiple laparoscopic myomectomy (removal of 6–7 myomas whilst preserving the endometrium).
   3. REMOVAL and repositioning of laparoscopic abdominal cerclage via the high (isthmo-cervical) approach.
   4.  Hysteroscopy for review and endometrial regenerative treatment with PRP.

• Obstetric Outcome: Birth of a healthy live female infant at 34 weeks’ gestation via planned caesarean section in June 2026.

2. Clinical History and Reproductive Anamnesis

Patient with a reproductive history of high obstetric complexity characterised by repeated spontaneous pregnancies without a live-born infant.

History of Pregnancy Losses:

• 13 pregnancy losses in total:
• 6 miscarriages in the first trimester.
• 7 late pregnancy losses (weeks 16 to 22) secondary to severe isthmocervical insufficiency.
• Assisted Reproductive Treatments: 2 biochemical pregnancies following previous cycles.
• Previous Interventions: Abdominal cerclage via laparotomy/laparoscopy performed in 2019 in her country of origin, which failed to prevent subsequent pregnancy losses.

3. Anatomical Diagnosis of the Uterus

On admission to our clinic, a comprehensive morphological assessment was carried out using three-dimensional (3D) ultrasound with hysterosonography and pelvic magnetic resonance imaging.

Initial uterine diagnosis

• Polymyomatous uterus (umbilical volume)
• Adenomyosis of the posterior uterine wall
• Severe deformation of the uterine cavity
• Previously performed, poorly positioned abdominal cerclage

4. Main Findings

1. Polymyomatous uterus and uterine adenomyosis: Severely enlarged uterus (equivalent to a gestational age of 18–20 weeks, extending to the umbilical scar), with multiple leiomyomas of intramural and subendometrial distribution, associated with extensive posterior adenomyosis.
2. Cavity Deformation: Intrinsic compression and distortion of the endometrial cavity, preventing proper implantation and placental growth.
3. Failure of Previous Cerclage: The previous cerclage band was positioned too low (distally), rendering it ineffective in the face of the patient’s mechanofunctional cervical incompetence.
4. Step-by-Step Treatment Strategy

Due to the extremely high risk of uterine rupture and implantation failure, a four-phase sequential protocol was designed:

Phase 1: Embryo Genetic Testing and Obtaining a Euploid Embryo (October 2024)

Before subjecting the patient to major invasive surgery, it was essential to ensure the genetic viability of the embryo.

• Ovarian Stimulation: 16 mature oocytes were retrieved.
• IVF + PGT-A: A single euploid (chromosomally healthy) embryo was obtained. The entire subsequent strategy was designed to maximise the chances of success with this single embryo.

Phase 2: Surgical Reconstruction of the Uterine Wall and Recerclage (March 2025)

A complex multi-level laparoscopic surgery was performed:

1. Laparoscopic myomectomy: Enucleation of 6 to 7 large fibroids in the anterior and fundal walls, whilst preserving the integrity of the endometrial mucosa (without opening the uterine cavity).
2. Correction of Cervical Incompetence: Removal of the previous cerclage band and placement of a new laparoscopic abdominal cerclage at the upper isthmocervical junction, above the uterosacral ligaments.

Phase 3: Hysteroscopic Optimisation and Endometrial Regenerative Therapy (July 2025)

• Surgical Resectoscopic Hysteroscopy: Treatment of intra-cavitary scar tissue and release of microadhesions formed following myometrial surgery.
• Regenerative Treatment: Intrauterine application of Revitalize (PRP) to restore the endometrial stroma damaged by myometrial pathology.

Phase 4: Endometrial Preparation and Embryo Transfer (October 2025)

• Transfer: On 22/10/2025, the single euploid embryo was devitrified and transferred under high-resolution ultrasound guidance, being placed atraumatically in the upper anterior wall of the endometrium.

5. Outcome and Obstetric Course

Pregnancy Test (β𝛽-hCG): Positive with adequate doubling of plasma levels.

• High-Risk Pregnancy: Referral for management to a Maternal-Fetal Medicine unit with fortnightly ultrasound scans, monitoring of cervical length and relative bed rest.

• Outcome of the Pregnancy: In June 2026, upon reaching 34 weeks’ gestation and after confirming foetal lung maturity, a scheduled elective caesarean section was performed, resulting in the birth of a healthy baby girl with no immediate neonatal complications.

6. Conclusions and Clinical Relevance

This case represents one of the most complex scenarios in reproductive and maternal medicine:

1. Efficacy of High Abdominal Cerclage in Severe Cervical Incompetence: Laparoscopic correction and repositioning of the cerclage at the level of the uterine isthmus is the technique of choice when previous vaginal or abdominal cerclages have failed.
2. Conservative Uterine Reconstructive Surgery: It is possible to perform multiple myomectomies on uteri severely deformed by adenomyosis and fibroids without compromising the endometrial cavity, thereby enabling subsequent full-term pregnancies.
3. Optimisation with a Single Embryo: The combination of PGT-A + Structured Surgery + Endometrial Regenerative Medicine (PRP) enables success rates of 100 per cent per transfer to be achieved, even in cases where only a single euploid embryo is available.