Creation of a Neovagina for patients with MRKH, AIS or Vaginal Agenesis

The diagnosis of MRKH (Mayer-Rokitansky-Kuster-Hauser) or AIS (Androgen Insensitivity Syndrome) may be difficult for many young women, however the good news is there are treatment options to allow patients to achieve full vaginal length and experience a normal sexual life. Reproductive technologies also allow these women to have their own biologic children eventually if they so choose.

Miklos and Moore Urogynecology is considered one of the world’s LEADING Center’s of Excellence in the Laparoscopic creation of a new vagina for patients that are born without a functioning vagina or uterus. Surgeons from throughout the United States and worldwide (including many Top Academic Centers and Universities) send their patients to Drs. Miklos & Moore for this minimally invasive outpatient surgical procedure.

Drs. Miklos and Moore on TV

Drs. Miklos and Moore were recently featured on the internationally syndicated Doctor’s TV show in a two part series highlighting their technique.

Doctor show

Click Here to Watch Episode

 

Drs. Miklos and Moore complete more of these procedures than any other center in the United States and has over a 90% success rate. The procedure is by far the least invasive technique available for the creation of a full-length functioning vagina and does NOT require lifelong dilation.

MRKH Show

Click Here to Watch Episode

 

Drs. Moore and Miklos also utilize the procedure to successfully treat women that have had previous procedures, such as the McIndoe, that have failed. Patients have travelled from throughout the US, Canada, South America and as far away as Saudi Arabia for the expertise of Miklos and Moore Urogynecology.

“You are all wonderful!!! We are full of gratitude and appreciation for your skills and kindness. Dr. Miklos and Dr. Moore…you have improved our daughters quality of life. We will forever be grateful. Thank you for being wonderful!”
MRKH Family Member
Florida

Tell me more about MRKH?

Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKH) is a condition where the uterus and the vaginal canal do not form properly, resulting in a very short vaginal canal or no vagina at all in the developing female. This condition, which is also called Vaginal Agenesis, affects 1 in 5,000 females. It is a randomly occurring event, i.e. it is not known to be a genetic condition nor caused by anything that the mother was exposed to during pregnancy.

A MRKH patient is a genetic female with normal female chromosomes and ovaries, and therefore develops typical external female characteristics – including breasts and external vulva and vagina. The patient looks and appears like a women, because she is 100% female, however the vaginal canal and the uterus just do not fully develop inside her body. The ovaries are normal and still produce estrogen and hormones, which results in the female characteristics.

Diagnosis of MRKH is usually made during adolescence when menstruation is delayed, or it may be discovered with the first attempts at having sex.

Figures 1 A & B

Figure 1A shows normal female development with normal uterus and full-length vagina.

Figure 1B demonstrates a patient with MRKH in the fact that the uterus does not fully develop nor does the vaginal canal. There is a very short vaginal opening and sometimes just a “dimple”.

figure 1a

MRKH Figure-1A-02

figure 1b

MRKH Figure-1B-03

Figure 1C

Figure 1C demonstrates a patient with MRKH. There is no uterus and no vaginal canal where it typically should develop. Additionally, the bladder and the rectum are fused together with no intervening vaginal canal.

Figure 1C

MRKH Figure-1C

What are the treatment options for MRKH?

While there are multiple surgical procedures described for the creation of a new vagina in women with this condition, the laparoscopic Davydov procedure is considered by far the least invasive procedure to create a full-length functioning vagina. Procedures such as the McIndoe procedure utilize external skin and require the patient to wear a surgical mold in the vagina for as long as 4-6 weeks.
 
The McIndoe also requires lifelong dilation and has high rates of scarring down and becoming non-functional. Other approaches such as utilizing a segment of bowel or skin grafts from the inside of the cheek have been described, but again are much more invasive and carry much higher risks of complications compared to the Davydov.

Dr. Miklos and Dr. Moore are considered world leaders in this laparoscopic approach to create a neovagina and complete more of these procedures than any other center in the United States on an annual basis. They also utilize the procedure in patients with failed previous neovagina procedures, such as the McIndoe.
 
Drs. Moore and Miklos utilize a laparoscopic modification of the Davydov procedure. The doctors travelled to Russia and were trained by Dr. L.V. Adamyan, who developed this original technique. They have used their laparoscopic expertise and suturing skills to modify the procedure, making it less invasive than most of the alternative surgical options. Studies have shown the Davydov to result in the development of normal vaginal tissue and normal sexual function including lubrication, sensation and orgasm.

“I did not feel like a woman at all. My diagnosis freaked me out. I tried dilation for many years and I still couldn’t have normal sex. I felt abnormal since I didn’t have a vagina and my labia were huge! I had surgery with Dr Moore and Miklos and it went great. They are miracle workers! Now I feel like a woman.”
MRKH Patient
California

Surgical Procedures

The Davydov procedure utilizes the patient’s own peritoneum (the cellular layer that lines the walls of the pelvis and the abdominal cavity) as the new vaginal canal. The procedure usually takes between 1-2 hours and is completed in an outpatient surgical setting.

The procedure is completed with both a vaginal and laparoscopic approach. Tiny incisions are made in the belly to allow access to the abdominal cavity.

Diagnosis of MRKH is usually made during adolescence when menstruation is delayed, or it may be discovered with the first attempts at having sex.

figure 2a

MRKH Figure-2A

figure 2b

MRKH Figure-2B

figure 2c

MRKH Figure-2C

Figures 2 A-E

Figures 2 A-E demonstrate where the incision is made in the vaginal dimple, which becomes the new vaginal opening. The probe is then pushed up into the pelvis
 
(Figure E)
to incise the last layer (peritoneum).

figure 2d

MRKH Figure-2D

figure 2E

MRKH Figure-2E

figure 3a

MRKH Figure-3A

figure 3b

MRKH Figure-3B

Figures 3 A & B

Figure 3 A and B – Once the top of the vagina is opened into the pelvic cavity, the edges of the incised peritoneum is pulled down to the vaginal epithelium and the edges are sutured together around the opening.
 
(Figure E)
to incise the last layer (peritoneum).

figure 4

The depth of the new vagina can be visualized in Figure 4.
MRKH Figure-4

Figures 5 A & B

Figure 5A shows the beginning of the suture grasping the pelvic peritoneum just under the ovary. When this suture is tied down Figure 5B this becomes the top of the new vaginal canal.

figure 5a

MRKH Figure-5A

figure 5b

MRKH Figure-5B

figure 6a

MRKH Figure-6A

figure 6b

MRKH Figure-6B

Figures 6 A & B

Figure 6A (before) shows patient with vaginal agenesis or very shortened vagina.
 
Figure 6B (after) shows result after Laparoscopic Neovagina technique that utilizes the pelvic peritoneum to create a new vaginal.

Drs. Miklos and Moore can typically achieve a vaginal length of 9 to 11 cm with this technique. Patients are able to have normal sexual function including arousal, lubrication, and orgasm as a result of this procedure.

Recovery

Patients will spend the night in the outpatient center or a recovery center with nursing support for 24 hours and then are discharged to go home or to the hotel. Packing is left in place for 48 hours and then removed. Dilators are passed for the first few months or until the patient becomes sexually active. (Patients do not have to become sexually active after the procedure, they can wait as long as they would like). Pain is typically minimal and is controlled by pain medications for the first few days. Usually after a couple days the patient is up and moving around and by 1 week, doing most of her normal daily activities. Vigorous activities such as sports or hard exercise are limited for the first few months after the procedure. Patients can start walking for exercise in as early as 2 weeks following the procedure.
 
Patients usually stay for about one week and see the doctors several times throughout their stay. Drs. Moore and Miklos will communicate with the patients’ doctor at home and the follow-up visits can be completed with a home gynecologist. After healing, the patient should see her gynecologist on an annual basis for normal female care including pap smears, however there is no special care needed after healing.

Future Pregnancy?

Since women with MRKH typically have normal ovaries, they CAN have their own biologic children through in-vitro-fertilization and a surrogate carrier. They would see a specialist in Reproductive Endocrinology for this type treatment. There are studies currently being completed in Sweden on Uterine transplant surgery, and there have been successful pregnancies reported, however these studies are still very early in the investigative phase.

“I was a patient of Drs. Miklos and Moore a year ago and wanted to take a minute to convey my gratitude to everyone in your office and especially say thank you to you for helping get all the logistics in place. A year after surgery to correct MRKH, I found myself a great guy and life is pretty damn great and getting to feel like a “normal” college student is largely thanks to the people in your office.”
MRKH Patient
Washington

Where do I go from here?

Finding out that you or your daughter has MRKH can be very difficult for a family. Finding a physician that can answer all your questions regarding this rare syndrome can be difficult.
 
At Miklos and Moore, we’re available to help guide you during this journey. But if you would like to reach out and connect with other women with MRKH, there are support groups available all over the United States and internationally. Below are some communities that Dr. Moore and Dr. Miklos have connected other patients with. Some of these groups are open to the public and some are private. Finding the right one is up to you.

Frequently Asked Questions

Learn More

MRKH Support pages

www.beautifulyoumrkh.org
 
www.mrkh.org
 
mrkhuh.blogspot.com
 
www.mrkhconnect.org – 
MRKH Connect is a registered charity in England and Wales that aims to connect women with MRKH worldwide. It provides members with an online support system, allowing you to receive and offer support to women in similar situations.
 
www.mid-atlanticmrkh.org
 – Mid-Atlantic MRKH Foundation provides opportunities for women with MRKH in the Mid-Atlantic region to meet and make connections face to face