ORIGINAL ARTICLES: MENTAL HEALTH, SEXUALITY, AND ETHICS

Sexuality after sigmoid

vaginoplasty in patients with
Mayer-Rokitansky-K€ uster-Hauser
syndrome
Caroline Carrard, M.D.,a,b Marie Chevret-Measson, M.D.,a Aude Lunel, M.D.,a,b and Daniel Raudrant, M.D.a,b
a
 de Lyon, Lyon; and b Service d'Obste
Universite trique, de Chirurgie Gyne
cologique et Oncologique, Centre Hospitalier Lyon Sud, Hospices
nite, France
Civils de Lyon, Pierre-Be

Objective: To investigate the functional and sexual outcome of sigmoid vaginoplasty in patients with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.
Design: Prospective study.
Setting: University hospital.
Patient(s): Fifty-nine consecutive patients with MRKH syndrome.
Intervention(s): Forty-eight patients underwent sigmoid vaginoplasty, and 11 were treated using the Frank method of dilatation.
Main Outcome Measure(s): Functional results and sexuality were evaluated with the use of two standardized questionnaires: the Female Sexual
Function Index (FSFI) and the revised Female Sexual Distress Scale (FSDS-R). Questions were added to analyze depression, body image perception,
and desire of motherhood.
Result(s): Out of the 68% of patients who answered the questionnaire, 73% had regular sexual intercourse. The mean total FSFI score was
28
3.1 in the operated group and 30
5.3 in the group treated with the Frank method. Their mean FSDS-R scores were 21
12.1 and 18
13.8, respectively.
Conclusion(s): Sigmoid vaginoplasty is an effective technique providing a nearly normal sexual function to patients with vaginal aplasia. Despite this,
psychologic distress related to sexuality persists in most patients, demonstrating the need for a multidisciplinary support. (Fertil SterilÒ 2012;97:691–6.
Ó2012 by American Society for Reproductive Medicine.)
Key Words: Sigmoid vaginoplasty, MRKH, Rokitansky syndrome, sexuality, vaginal agenesis

T
he Mayer-Rokitansky-Kuster- associated with skeletal or urinary tract Several techniques of vaginal recon-
Hauser syndrome (MRKH) repre- anomalies (type II) in 10% and 40% of struction, surgical and nonsurgical, have
sents the primary cause of cases, respectively (1–3). been described: The Frank procedure (6),
vaginal aplasia, with an incidence of 1 Infertility and the lack of normal the McIndoe operation (7), the Vecchietti
in 4,500 female births (1). sexuality are the factors that seem to technique (8), and Bloch-Davydov vagi-
Mullerian duct agenesis results in have the greatest impact on the quality noplasty (9) are currently the most popu-
the congenital absence of uterus and of life. The confirmation of the diag- lar. According to the recommendations
vagina associated with a normal karyo- nosis has a profound psychologic im- of the American College of Obstetrics
type (46,XX) and functional ovaries. pact on body image and self-esteem, and Gynecology (10), the nonsurgical
The etiology of the MRKH syndrome and as a result one-third of patients Frank method must be favored wherever
remains unclear, and the diagnosis is suffer from depression (4). Gestational possible. However, owing to the lack of
usually established during adolescence, surrogacy is a possible option for prospective randomized trials, no con-
the first clinical sign being primary women diagnosed with MRKH syn- sensus has yet been established on the
amenorrhea associated with otherwise drome, the risk of recurrence of the best surgical treatment.
normal puberty development. The syn- MRKH syndrome in the offspring be- The technique presented in the
drome can be isolated (type I), and it is ing estimated at 1%–2% (5). present article is based on the use of
bowel graft to create a neovagina and
was first described by Baldwin in 1904
Received August 12, 2011; revised November 25, 2011; accepted December 12, 2011; published online (11). Historically, this method was not
January 14, 2012.
C.C. has nothing to disclose. M.C.-M. has nothing to disclose. A.L. has nothing to disclose. D.R. has used as a first-line treatment, owing to
nothing to disclose. its associated morbidity. However, the
Reprint requests: Daniel Raudrant, M.D., Service de Gynecologie Obste
trique, Centre Hospitalier Lyon
Sud, Chemin du Grand Revoyet, 69495 Pierre Be nite, France (E-mail: daniel.raudrant@chu-lyon.fr). progress in antibiotic prophylaxis and
in colorectal anastomosis has recently
Fertility and Sterility® Vol. 97, No. 3, March 2012 0015-0282/$36.00 permitted the use of sigmoid graft as
Copyright ©2012 American Society for Reproductive Medicine, Published by Elsevier Inc.
doi:10.1016/j.fertnstert.2011.12.015 first-line surgical therapy.

VOL. 97 NO. 3 / MARCH 2012 691

ORIGINAL ARTICLE: MENTAL HEALTH, SEXUALITY, AND ETHICS
The aim of the present study was to evaluate the func-
tional outcome and the influence on sexuality provided by
this technique. Therefore, two standardized questionnaires
were used: the Female Sexual Function Index (FSFI) (12)
and the revised Female Sexual Distress Scale (FSDS-R) (13,
14). Questions were added to assess body image perception,
desire of motherhood, and signs of depression. We also
reported the anatomic results and complications of patients
who underwent sigmoid colpoplasty.
MATERIALS AND METHODS
Patients
Between August 1992 and July 2010, 59 patients with MRKH
syndrome were referred to the H^otel Dieu and Lyon Sud Uni-
versity Hospitals. Eleven were treated by the Frank method,
and 48 underwent sigmoid vaginoplasty, all of which were
performed by the same surgeon (D.R.). Only patients who
had been operated >6 months before the time of study were
included. In two cases, the sigmoid colpoplasty was not the
first procedure used to create a neovagina: One woman had
already undergone an unsuccessful split-thickness skin graft,
and another had already been operated on twice (McIndoe
procedure followed by a Vecchietti operation).
The mean age at the time of surgery was 19 years; 22% of
the patients had renal malformations; 9 patients showed skel-
etal abnormalities; 69% of patients had an isolated MRKH
syndrome.
Surgical Procedure
Fifty-nine patients, who had previously been proposed the di-
latation method, were referred to our center for surgical treat-
ment. The nonsurgical Frank method was once again
systematically suggested. All patients were informed of the sur-
gical and nonsurgical alternatives of neocolpopoeisis and of
the potential benefits and risks of each technique. In 11 pa-
tients, Hegar dilatations were chosen; 48 of the 59 patients un-
derwent sigmoid colpoplasty. All of these patients opted for
surgery to engage in sexual activity as soon as possible.
The surgical procedure applied was described by Commu-
nal et al. in an earlier report (15). A standard abdominal Pfan-
nenstiel incision was used in 47 cases, and a laparoscopic
approach was used in one case.
At the stage of the perineal dissection, a U-shaped inci-
sion was made in the vaginal dimple to protect the urethra
and to provide a flap large enough to allow for a colovestibu-
lar anastomosis.
To prevent a prolapse of the sigmoid transplant, the neo-
vagina was fixed to the sacral promontory with two polyester
stitches.
The mean operating time was 183
36 minutes.
Assessment of Anatomic and Functional Results
Anatomic results were assessed by a first clinical examination
under general anaesthesia 1 month after surgery. Wound
healing and vaginal patency were evaluated using Hegar
dilators (nos. 28–32).
692
Patients were encouraged to become sexually active. In the
absence of sexual intercourse, they were instructed to practice
dilatation with Hegar dilators (no. 26 or 27) every 2–3 days.
A postoperative clinical follow-up was proposed at 6
months after surgery and then yearly.
Functional results were assessed with the use of a question-
naire designed in collaboration with a sexologist consultant
(M.C.-M.). The questionnaire mailed to each patient consisted
of 44 questions. It included Rosen’s FSFI (12): 19 items analyz-
ing six separate domains of the functional aspect of female
sexuality: desire, arousability, orgasm, lubrication, comfort,
and quality of sexual life. The total FSFI score was obtained
by adding up the six domain scores and could be 36 at most.
Patients having a total score of %26.55 were defined as having
sexual dysfunction (16). The subsequent 13 questions were
those of the FSDS-R (13, 14) assessing psychologic distress in
women with hypoactive sexual desire disorder. A score of
>11 out of 52 suggested sexual distress.
We included 12 additional questions concerning details
of sexual intercourse, vaginal discharge, pelvic pain, self-
esteem, depression, and gestational surrogacy.
Statistical Analysis
Statistical analysis was performed using SAS software (SAS In-
stitute). Mann-Whitney test was used to compare questionnaire
scores between the two groups. Parameters from the additional
questions were analyzed using c2 test and Fisher exact test.
RESULTS
Complications
A major complication was encountered in two patients, who
developed pelvic hematomas due to bleeding in the perineal
cleavage, requiring surgical reexploration and hemostasis.
Rectal injury occurred in two patients. The wounds were
immediately detected and sutured without any further
complication.
One patient developed a left tubal abscess 2 years after
surgery. It was drained by laparoscopy and the left tube was
removed, allowing a rapid recovery.
In two patients, prolapse of the neovagina occurred. In
each case, the promontory stitch was still in the correct posi-
tion and the prolapse was due to an oversized graft. This was
managed by the vaginal resection of the prolapsed tissue.
Anatomic Results
Anatomic results were satisfactory in 83% of patients. Eight
(17%) had a stenosis of the colovestibular anastomosis, of
which five required dilatation under general anesthesia.
Functional Results
The mean age of patients at the time of investigation was 24
years, and the mean time after surgery was 6 years (range 10
months–17.8 years).
Forty patients (68%) answered the questionnaire: 35 (73%)
of the 48 who had received surgery and 5 (45%) of the 11 who
had been treated by the Frank method. Six (10%) were lost to
VOL. 97 NO. 3 / MARCH 2012
 Fertility and Sterility®

follow-up and 13 (22%) who had received the questionnaire did

18.40
15.4
21.35
12.2
not answer. One of them replied that the subject was too

FSDS-R

.72
intimate to be discussed in a mailed questionnaire.
Table 1 shows FSFI and FSDS-R scores. Table 2 presents
answers to the additional questions concerning intercourse
30.25
6.2
frequency, vaginal discharge, pelvic pain, self-esteem,
28.00
3.1
Total score

depression, and surrogacy.

.13
Sigmoid vaginoplasty group. In the operated group, one
patient only partly answered the questionnaire so that the
FSDS-R was the only score interpretable. Three patients had
never had sexual intercourse, and another one had not been
5.20
1.1
3.93
1.2
Comfort

sexually active for several years. Among the 30 others, 22

.06

(73%) had regular sexual intercourse (at least two to three

times a week). The mean time before the first sexual relation
after surgery was 7 months (range 1–42 months).
Satisfaction

5.40
1.2
5.35
0.6

The mean FSDS-R score was 21. Only 15% had a score
<11, indicating the absence of anxiety related to sexuality.
.57

The mean total FSFI score was 28 in the operated group

(excluding patients who had not yet or did not currently en-
gage in sexual intercourse). Twenty-one patients (70%) had
4.80
0.9
4.44
1.1

a score >26.55. Considering each domain mean score, women

Orgasm
FSFI

.61

with MRKH syndrome treated by sigmoid vaginoplasty could

be considered ‘‘normal’’ in terms of desire, arousability, lubri-
cation, orgasm, and global sexual satisfaction. However, dis-
Lubrication

comfort or pain scores were higher in these patients (P¼ .06).

5.10
1.1
5.18
0.9

Only 20% said they never experienced dyspareunia, and 35%

.93
Functional results (FSFI and FSDS-R scores) of patients treated by sigmoid colpoplasty or the Frank method.

never had abdominal pain. We noted that the comfort score of

patients whose graft had shrunk was similar to that of other
patients (4 and 3.9, respectively). Unsurprisingly, the only sig-
Arousability

5.10
1.0
4.74
0.7

nificant between-group difference was in terms of vaginal

.34

discharge discomfort.
Frank method group. In the group treated by the Frank pro-
cedure, one patient had never had sexual intercourse; 75% of
the remaining patients had regular sexual activity. The mean
4.65
1.3
4.36
0.9
Desire

time before the first sexual relation after the first dilatation
.64

was 5 months (range 2–12 months).

The mean FSDS-R score was 18. Two patients had a score
of <11, indicating the absence of sexual distress.
No of responses

Note: FSDS-R ¼ revised Female Sexual Distress Scale; FSFI ¼ Female Sexual Function Index.

The mean total FSFI score was 30, and each domain score
40 (68%)
5 (45%)
35 (73%)

was similar to ‘‘normal’’ women’s score. Three patients (75%)

had a score >26.55.
Two patients experienced dyspareunia, and one suffered
from abdominal pain.
Conflicting results between the FSFI and the FSDS-R were
No. of patients

obtained in 38% of cases, in the vaginoplasty group as well as in

Carrard. Sexuality after sigmoid vaginoplasty. Fertil Steril 2012.

the group treated by the Frank method. This demonstrates that

59
11
48

the two scales analyze different aspects, which is why we chose

to implement complementary questionnaires. Whereas the FSFI
evaluates the functional aspect of sexual disorders, the FSDS-R
aims to detect psychologic distress linked to sexuality.
P value (Wilcoxon exact test)
Sigmoid vaginoplasty

Psychological Results
Within the two groups, 28% of the patients showed signs of
Frank method
TABLE 1

depression (as concluded by a positive response to questions

Procedure

27 and 28 of the questionnaire).

Total

Regarding body image, 70% of the patients who under-

went sigmoid colpoplasty said they felt ‘‘completely

VOL. 97 NO. 3 / MARCH 2012 693

ORIGINAL ARTICLE: MENTAL HEALTH, SEXUALITY, AND ETHICS

TABLE 2

Answers to additional questions concerning intercourse frequency, vaginal discharge, pelvic pain, self-esteem, depression, and surrogacy.
Question Sigmoid vaginoplasty Frank method All patients P value
Mean time before first intercourse after 7 5 .54
treatment (mo)
Vaginal intercourse frequency
Occasionally 8 (27%) 1 (25%)
1–2/wk 12 (40%) 0
2–3/wk 7 (23%) 2 (50%)
Daily 3 (10%) 1 (25%)
Vaginal discharge discomfort 23 (68%) 0 .01
Abdominal pain 22 (65%) 1 (20%) .69
Dyspareunia 24 (80%) 2 (50%) .22
Thinking of adoption 27 (79%) 3 (60%) 30 (77%) 1.00
Thinking of surrogacy 27 (79%) 5 (100%) 32 (82%) .57
Depression signs
Feel depressed or desperate? 10 (29%) 1 (20%) 11 (28%) 1.00
Decreased interest or pleasure in
everyday life?
Femininity feeling 24 (70%) 3 (60%) .59
Changes in body image since treatment 15 (44%) 3 (60%) .65
Body image perception
Positive 17 (50%) 2 (40%)
Neither positive nor negative 13 (38%) 3 (60%)
Negative 4 (12%) 0
Carrard. Sexuality after sigmoid vaginoplasty. Fertil Steril 2012.

feminine’’ versus 60% of the patients treated by the Frank
method (P¼ .59). Approximately one-half of the women esti-
mated that their treatment had ‘‘almost or entirely’’ changed
their body image (44% of the operated, 60% of the nonoper-
ated; P¼ .65) and that they perceived this change as ‘‘positive’’
(50% of the operated, 40% of the nonoperated).
Regarding motherhood, 77% wished to or had already ap-
plied for adoption; 82% (32/39) would consider surrogacy. It
needs to be added that among the 11 patients presenting signs
of depression, four had good FSFI and/or FSDS-R scores,
which suggests a psychologic distress linked to a cause inde-
pendent of their sexuality. One patient emphasized that her
depression had ‘‘nothing to do with her sexuality,’’ and six
others specified that it was due to the unfulfilled desire for
motherhood.
DISCUSSION
In the past 20 years, numerous studies have evaluated the an-
atomic results of the various techniques of creating a neova-
gina in patients with MRKH syndrome. However, the
functional outcome was usually simply assessed according
to the presence or absence of sexual relations, and few studies
provided a more thorough and profound analysis.
The aim of creating a neovagina is to enable satisfactory
sexual activity and thus to achieve a physical and psychologic
equilibrium. In this study we used two standardized question-
naires (FSFI and FSDS-R) to describe the sexual results of pa-
tients with MRKH syndrome who had a sigmoid neovagina.
We included additional questions to evaluate psychological
distress, infertility and body image problems.
Anatomic results of sigmoid colpoplasty are good.
Shrinkage of the graft remains the primary complication
(17%). It is, however, easy to repair. A prolapse of the neovagina
(4% of patients in our series), which is also described in other
techniques (5, 17), is now rare because a promontory fixation
is systematically performed.
Even if vaginal discharge is sometimes perceived as un-
comfortable, sigmoid colploplasty is the only technique pro-
viding natural lubrication of the neovagina (2).
Another advantage of this procedure is the possibility of
coitus shortly after surgery. Whereas techniques of passive di-
latation require an average delay of 11.8
1.6 months (18)
before the first sexual intercourse, sigmoid vaginoplasty al-
lows sexual activity after 1 month. It can also be supposed
that surgery is often chosen because it is psychologically
complicated for these young patients to go through repeated
self-dilatations sometimes experienced as embarrassing or
shameful (19).
Furthermore, as the laparoscopic approach increasingly
replaces laparotomy, postoperative inconveniences should
gradually become negligible, provided the surgeons have ex-
tensive experience in both gynecologic and digestive laparo-
scopic surgery (20–22).
In the first 16 patients of this study, analyzed by Commu-
nal et al. (15), functional results of sigmoid colpopoeisis were
good and similar to those of ‘‘normal’’ women, with the ex-
ception of the comfort criterion. The present report, based
on a larger series, confirms these findings with slight differ-
ences: The mean total FSFI score was 28
3.1 among oper-
ated patients, i.e., slightly lower than in the previous
investigation. The mean FSDS-R was 21
12.1 indicating
psychologic distress related to sexuality.
Several factors may explain these results. First, one may
question the relevance of comparing patients with the normal
population. Rather, pre- and postoperative results should be
evaluated, which would provide a more precise indication
of the effect of the surgery.

694 VOL. 97 NO. 3 / MARCH 2012


Psychologic results may also explain the relative weak-
ness of these scores. In fact, the responses to the questions re-
lating to depression and to body image show that neither the
Frank method nor the surgery, even if satisfactory, solve all
problems.
As emphasized by Berman et al. (23), a nonnegligible
number of patients (10% of the present cases) perceive their
body negatively with a feeble sense of femininity despite
having achieved a satisfying sexuality. Signs of depression
are frequently encountered: Infertility and the frustration
concerning the difficulties of attaining motherhood cer-
tainly play a role in these findings. In a recent study in-
volving patients treated by sigmoid vaginoplasty, Labus
et al. (24) reported 22% with depression. Other authors
have found that regardless of their treatment, patients
with MRKH have more pathologic scores regarding depres-
sion, anxiety (25), psychoticism, psychologic distress, and
self-esteem (26). Thus, it is evident that a multidisciplinary
management with emphasis on psychologic support is in-
dispensable for these patients (5). Whatever technique is
chosen, psychologic care should be proposed at the time
of diagnosis with the possibility of prolonged treatment
over several years.
Very few studies have clearly evaluated the sexual results
of the other techniques. In a study based on 28 patients treated
with the Davydov laparascopic procedure, Giannesi et al. (27)
reported an anatomically satisfying result in 92% of patients
and an average FSFI of 26.54
5.6, with no significant dif-
ference compared with the control group. Seven out of 25 pa-
tients (28%) had a score >30, showing results similar to the
operated patients in our study.
Regarding the Vecchietti operation, Fedele et al. (28) ob-
served good anatomic results in 98% of cases (104/106) with
an average total FSFI of 29
3.2, 12 patients out of 27 (44%)
having obtained a score >30. However, the scores of comfort,
orgasm, and lubrication were significantly inferior to those of
the control group.
In a recent study evaluating a modified McIndoe tech-
nique with amnion transplant, Fotopoulou et al. (29) obtained
an average FSFI of 30
6.9 in a series of five patients, with
domain scores similar to those of ‘‘normal’’ women (12).
Nevertheless, in the absence of an ‘‘ideal’’ and consensual
treatment strategy concerning MRKH, and as recommended
by the American College of Obstetrics and Gynecology (10),
the nonsurgical Frank procedure must be proposed as
a first-line treatment as far as possible. In case of failure or
of refusal by the patient, sigmoid vaginoplasty appears to
be an attractive alternative, presenting rapid and satisfactory
anatomic and sexual results. Further studies should now be
carried out using pre and posttreatment evaluations to precise
the functional results and to better identify patients who
might benefit from this technique. However, whatever
method is used to create a neovagina, the psychologic impact
of the diagnosis and its treatment must be managed by a mul-
tidisciplinary team, thus, by a global approach, improving
psychosexual as well as anatomic results.
Acknowledgments: The authors thank Daniela Berg and
Touria Hajri for technical support.
VOL. 97 NO. 3 / MARCH 2012
Fertility and Sterility®
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