REPRODUCTIVE SURGERY

Psychosexual and functional outcomes after creation

of a neovagina with laparoscopic Davydov in patients
with vaginal agenesis
Lisa M. Allen, M.D.,a,c Kerith L. Lucco, M.D.,a,e Cortney M. Brown, M.D.,b Rachel F. Spitzer, M.D.,a,c
and Sari Kives, M.D.a,d
a

Department of Obstetrics and Gynecology, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada;
Department on Obstetritics/Gynecology, Maryland General Hospital, Baltimore, Maryland; c Mount Sinai Hospital and
d
St. Michaels Hospital, Toronto, Ontario, Canada; and e Department of Obstetrics and Gynecology and Reproductive
Sciences, University of California, San Francisco, San Francisco General Hospital, San Francisco, California
b

Objective: To describe sexual function and satisfaction after laparoscopic Davydov vaginoplasty in patients with an
absent vagina due to Mayer-Rokitansky-Kuster-Hauser syndrome or androgen insensitivity syndrome compared
with a control female population.
Design: A descriptive study of standardized, validated psychosexual and functional outcomes using a self-report
questionnaire.
Setting: Two tertiary care hospitals at an academic medical center.
Patient(s): Six women with Mayer-Rokitansky-Kuster-Hauser syndrome or androgen insensitivity syndrome who
underwent laparoscopic Davydov.
Intervention(s): Patients postoperatively completed a self-report survey of their medical, surgical, and sexual history and the standardized, validated Female Sexual Function Index (FSFI) and select questions from the Golombok
Rust Inventory of Sexual Satisfaction (GRISS).
Main Outcome Measure(s): Total scores and domain scores (desire, arousal, lubrication, orgasm, pain, satisfaction) on the FSFI were compared with a published control population of women. Descriptive results of domain
questions on the selected questions of the GRISS were identified.
Result(s): Six patients, aged 2052 years, returned the questionnaires. Responses to the modified GRISS are represented by visual frequency of response bar graphs. Compared with the control population, the patients scores
were lower for arousability, lubrication, orgasm, and comfort on the FSFI.
Conclusion(s): Sexual function appears impaired in these six women who underwent laparoscopic Davydov as assessed by the FSFI. This may reflect characteristics of the patient population, as well as the inclusion of all patients
data even if they did not attempt vaginal intercourse in the previous month. (Fertil Steril 2010;94:22726. 2010
by American Society for Reproductive Medicine.)
Key Words: Mullerian agenesis, Mayer-Rokitansky-Kuster-Hauser syndrome, androgen insensitivity syndrome,
Davydov, sexual function, vaginoplasty, surgical therapy, neovagina

Vaginal agenesis due to Mayer-Rokitansky-Kuster-Hauser (MRKH)

syndrome or androgen insensitivity syndrome occurs in approximately 1 in 5,000 and 1 in 20,000 live female births, respectively.
The standard technique recommended by experts for creation of
a neovagina is by gradual self-dilation with the support of a multidisciplinary team (1). In the rare cases of failed vaginal dilation, various
surgical methods have been used for creation of a neovagina. Most
surgical methods involve creating a neovaginal space and lining the
space with different materials: split-thickness skin graft (McIndoe
Received June 28, 2009; revised January 3, 2010; accepted February 2,
2010; published online March 16, 2010.
L.M.A. has nothing to disclose. K.L.L. has nothing to disclose. C.M.B. has nothing to disclose. R.F.S. has nothing to disclose. S.K. has nothing to disclose.
Reprint requests: Lisa M. Allen, M.D., Ontario Power Generation Building,
700 University Avenue, 3rd Floor, Toronto, Ontario M5G 1Z5, Canada
(FAX: 416-586-8287; E-mail: lallen@mtsinai.on.ca).

2272

procedure) (2), buccal mucosa or artificial skin; colovaginoplasty

(3); or the Davydov procedure using pelvic peritoneum (46). The
Vecchietti procedure is an alternative whereby the neovagina is
created by dilation with a traction device attached with wires to
a Lucite olive placed at the vestibule (7).
Davydov vaginoplasty may be performed by laparotomy (6) or with
laparoscopic assistance. At least five case series have described creation
of a neovagina by laparoscopic Davydov (4, 811). Several studies
report patients sexual function after surgical creation of a neovagina
(2, 3, 7, 1218). At present only one study, however, reports validated
psychosexual outcomes after laparoscopic Davydov (5).
The objective of this study is to describe patients self reported
sexual function and satisfaction after laparoscopic Davydov vaginoplasty and compare them to a control (no disorder of sexual
development, nonsurgical) female population described in the
literature (19).

Fertility and Sterility Vol. 94, No. 6, November 2010

Copyright 2010 American Society for Reproductive Medicine, Published by Elsevier Inc.

0015-0282/$36.00
doi:10.1016/j.fertnstert.2010.02.008

RESULTS

Allen. Sexual outcomes after laparoscopic Davydov. Fertil Steril 2010.

No
Yes
Yes (no IC)
None
White
Filipino/Asian
No
No
Amenorrhea
Sexual problems
Vaginal agenesis
Dont know
23
27
5
6

Note: FSFI Female Sexual Function Index; AIS androgen insensitivity syndrome; MURCS Mullerian duct aplasia, renal aplasia, and cervicothoracic somite dysplasia; IC intercourse.

19
Yes
White
Amenorrhea
19
4

Fertility and Sterility

With Research Ethics Board approval at Mount Sinai Hospital and St. Michaels Hospital, (REB# 04-0282-E and 04-251C respectively) nine patients
with MRKH or androgen insensitivity syndrome who underwent laparoscopic Davydov with the same surgical team in Toronto, Canada, between
September 2004 and May 2006 were mailed a study questionnaire after
obtaining verbal consent. The study design allowed women to complete
a validated survey instrument anonymously, remote from any clinic visits
with their surgeons.
The questionnaire contained short answer and multiple choice sections on
the patients diagnosis, medical, surgical, and sexual histories. Nineteen
questions were included from the Female Sexual Function Index (FSFI)
and 17 questions were included from the Golombok Rust Inventory of Sexual
Satisfaction (GRISS) adapted with permission (Copyright Pearson Assessment 2009). The FSFI and GRISS are standardized, validated self-report
questionnaires with six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain (19, 20).
Reponses to the modified GRISS are represented by visual frequency of response bar graphs. The FSFI responses were analyzed using Students t-tests
with a pooled estimate of the SD. The control population consisted of nondisorder of sexual development (DSD), nonsurgical, North American women
published in the literature.

19.4
27.8

13.5
22.4
26.4
Yes
No
Yes

Attempted
No
Yes (after
first surgery)
None

Common law
No partner
Single (with
sexual partner)
Single (with
sexual partner)
No partner
Sexual partner
White
Greek
White

Vaginoplasty
No
McIndoe
vaginoplasty
No
Birth
Amenorrhea
Amenorrhea

AIS
Dont Know
Hypoplastic vagina,
no uterus
MURCS
24
23
52
1
2
3

Reason for diagnosis

Diagnosis
Age (y)
Patient

Demographics, sexual activity, and total FSFI per patient.

TABLE 1

Previous surgery

Ethnicity

Relationship status

Sexual activity
(before surgery)

Sexual activity
(previous 4 wk)

FSFI (total score)

MATERIALS AND METHODS

Of nine patients contacted, all of whom had verbally agreed to

receive the study questionnaire, six returned the questionnaire, for
a response rate of 67%.
Patients self-reported diagnoses included androgen insensitivity,
hypoplastic vagina, Mullerian-renal-cervicosomite abnormalites
(MURCS) association, vaginal agenesis, and dont know (2 respondents). The diagnosis was made at birth (1 patient), due to primary amenorrhea (4 patients), and secondary to sexual problems (1
patient). Patients ages at laparoscopic Davydov were 19, 22, 23,
23, 26, and 52 years, respectively, for a mean age of 27.5 years
(SD 12.2 years). The 52 year-old woman had previous colpopoesis
with a McIndoe procedure at age 26 years, and another patient with
androgen insensitivity syndrome had undergone prior vaginoplasty.
The remaining 4 patients had no previous genital surgeries. Selfreported ethnicity for the respondents was white (4 patients), Greek
(1 patient), and Filipino/Asian (1 patient) (Table 1).
All six patients wore a stent or used a dilator after surgery. At the
time of the questionnaire two patients reported that they were still
wearing the mold; the remaining participants reported using the
mold for 612 months postoperatively.
Self-reported complications after surgery included no problems
(1 patient), persistent vaginal discharge (3 patients), narrowing of
the vagina (3 patients), recurrent urinary tract infections (1 patient),
pain with intercourse (1 patient), difficulty with intercourse due to
vagina seeming too small (2 patients), and difficulty with intercourse
due to lack of lubrication (2 patients). The average number of complications reported per patient was 2.1 with a range of 06.
Patients reported thinking their vaginas were presently OK/normal (2 patients), smaller than average (2 patients), narrow (1
patient), short (1 patient), and small (2 patients). Three patients
indicated that they would like (their) vaginas longer. Regarding
the appearance of their genital area, patients were generally happy
with it (4 patients), thought everything seems fine (2 patients),
and thought a sexual partner would notice that it is different
from other women (1 patient).
With regard to sexual activity before surgery, the most common
response was that they were not (3/6 respondents). One respondent
had attempted to be sexually active, one was sexually active but
without penetration, and one woman with a previous McIndoe

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TABLE 2
Responses to modified Golombuk-Russ Inventory of Sexual Satisfaction (GRISS) questions.
Theme

Question

Interest and desire

Arousal

Always

Usually

Occasionally

Hardly ever

*
*
**

****
*
*
*

*
**
*

Do you feel interested in sex?

Are there weeks when you dont have sex?
Do you avoid having sex with your partner?
Do you become tense and anxious when
you & your partner want to have sex?
Do you refuse to have sex with your partner?

Do you become easily aroused?

Do you enjoy having your genitals stroked?
Does your vagina become moist during
intercourse?

Vaginal Size

Orgasm

Satisfaction

**

Do you find your vagina is so tight that your

partners penis cant enter it?
Is it impossible to insert your finger into your
vagina without discomfort?
Is it impossible for your partners penis to
enter your vagina without discomfort?

Never

**
*
**

**
**
**

**

**

*
**
*

**

Are you able to experience an orgasm with

your partner?
Do you find it possible to have an orgasm?
Can you reach orgasm when your partner
stimulates your clitoris?
Do you find your sexual relationship with
your partner satisfactory?
Do you enjoy having sexual intercourse
with your partner?
Do you feel there is love and affection in
your sexual relationship with your partner?

**

**

**

*
**

**
**

***

**

**

***

Note: See text for explanation of asterisks.

Allen. Sexual outcomes after laparoscopic Davydov. Fertil Steril 2010.

vaginoplasty was sexually active before the current surgery after an

earlier vaginoplasty. After surgery, 67% (4/6) were sexually active
within the 4 weeks immediately before completing the survey.
When questioned with regard to their relationship status, one woman
was in a common-law relationship, one had a sexual partner although did not indicate relationship status, two women were single
with a sexual partner, and two indicated that they had no current
sexual partner (Table 1).
Responses to the modified GRISS are represented visually in
Table 2. Each response to a question is indicated by an asterisk. In
each row, the left side represents a poorer outcome, and the right
side, a better outcome. Not each respondent answered each question
of the survey. The first row illustrates responses to questions on the
theme of interest/desire. Four patients never refuse to have sex with
their partners, however, three usually or always become tense and
anxious when their partner wishes to have sex. Row 2 depicts
responses to questions about arousal. Five women occasionally, usually, or always become easily aroused, with a similar proportion of
women reporting lubrication with intercourse. All of those who responded to the question usually or always enjoy genital contact in
a nonpenetrative manner. Row 3 illustrates responses to questions
about vaginal size. Although all patients hardly ever or never have
difficulty inserting fingers into their vaginas, three occasionally or
usually find their vaginas too tight for penile entry, and four occa-

2274

Allen et al.

sionally or usually find penile entry uncomfortable. Row 4 depicts

responses to questions about orgasm. Three patients reported that
they hardly ever or never experience an orgasm with their partner.
However, three women answered that they usually or always achieve
orgasm with clitoral stimulation. Finally, row 5 illustrates responses
to questions about satisfaction. Three patients hardly ever find their
relationship with their partner satisfactory, and three patients hardly
ever or never feel love and affection in their sexual relationship with
their partner. Three women reported that they usually or always
enjoy having sexual intercourse with their partner.
Table 3 shows the FSFI scores of the patients compared with the
scores of the control population. The FSFI scores are calculated with
a maximum of 6 for each domain and 36 for the total. Compared
with the control population, the patients scores were statistically
significantly lower in the domains of arousability, lubrication,
orgasm, and comfort.
Total scores less than 23 are considered poor, scores of 2429
are considered good, and scores more than 30 are considered
very good (3, 5). Total FSFI scores in patients were 13.527.8,
mean 21.4  5.3 versus 30  5 in the control population (P .005).

DISCUSSION
For women with vaginal agenesis who fail dilation therapy for creation
of a neovagina, there exist many potential surgical alternatives. The

Sexual outcomes after laparoscopic Davydov

Vol. 94, No. 6, November 2010

TABLE 3
Female Sexual Function Index (FSFI) scores.
Controls, mean SD (n [ 131)
Desire
Arousability
Lubrication
Orgasm
Satisfaction
Comfort
Full score
a

4.1  1.1
5.0  1.0
5.5  0.9
5.0  1.2
5.1  1.2
5.5  1.1
30  5

Patients, mean SD (n [ 6)
3.9  1.2 (range 2.46)
4.0  1.1 (range 2.15.1)
4.4  1.0 (range 3.35.4)
3.3  1.6 (range 1.24.8)
4.0  1.8 (range 2.16)
1.9  1.9 (range 05.2)
21.4  5.3 (range 13.527.8)

t-value

P value

0.40
2.3
2.8
2.6
1.5
4.6
3.9

.4
.03a
.02a
.02a
.1
.003a
.005a

Statistically significant differences from the control population.

Allen. Sexual outcomes after laparoscopic Davydov. Fertil Steril 2010.

ideal surgical procedure should be simple, with minimal complications, a short recovery, create a vagina of adequate depth and width,
ideally of stratified squamous epithelium (vaginal mucosa), and
most important allow for satisfying sexual function. At present limited
data are available on psychosexual surgical outcomes using validated
measures to guide patient and surgical choices.
Based on the results of a self administered questionnaire, at 6
months postoperative, sexual function appears impaired in the current study of six women who underwent laparoscopic Davydov
compared with controls. The FSFI scores of the patients were statistically significantly lower, both as a total value and in the domains of
arousability, lubrication, orgasm, and comfort.
A validated psychosexual assessment using the FSFI, after neovaginal surgery has been applied following the Vechietti procedure, sigmoid colpopoesis, and the laparoscopic Davydov (3, 5, 7). A study of
the Vechietti procedure administered the FSFI to 27 women with
MRKH 12 months after surgery. These patients had similar scores
as controls in the domains of desire, arousal, and satisfaction, but
statistically lower in lubrication, orgasm, and comfort (7). Communal
et al., (3) reported on sexual function in 16 consecutive patients with
MRKH after sigmoid colpopoeisis. Their overall mean FSFI score
was 28  5, with little difference from healthy patients for each domain of sexual function. Giannesi et al. (5) applied the FSFI to 28
women after a laparoscopic Davydov procedure. The full score did
not differ from their control group, nor did they find statistically significant differences in any of the domains between the patients undergoing surgery and their controls; however, they did find a trend to less
satisfying sexuality in the patients undergoing surgery, with the most
difference in the domain related to comfort and lubrication.
The desire domain on the FSFI was one of the two domains not statistically significantly different from women without DSD (controls in
the current study). The GRISS questions on how easily women
become aroused, enjoyment of nonpenetrative sex, and lubrication
were answered more positively than other question groupings overall.
Hence interest in sexuality after surgery is maintained; however, challenges persist with regard to the physical aspects of the vagina.
Three of the patients reported that they would like (their) vaginas longer. This is consistent with the GRISS responses with regard
to penetrative intercourse, where 66% answered that it is impossible
for the penis to enter their vagina without discomfort and with the
lower scores on the FSFI domain of comfort. It may therefore be appropriate for our team to reassess the length and width of the vaginal
mold used in our setting, something that varies among different
surgeons performing this procedure.
Despite that the surgery pertained to only the vagina, orgasmic
capacity was reported dichotomously. Half the GRISS responses
Fertility and Sterility

indicated good orgasmic response with clitoral stimulation, yet

50% of women reported that they never or usually never were
able to achieve orgasm with their partner. The orgasm domain of
the FSFI was statistically lower than controls. Another series assessing patients with MRKH using the FSFI after Vechietti vaginoplasty demonstrated similar differences in the orgasm domain
from patient controls (7). Given that neither surgical procedure
should impact on the sensate nature of the clitoris, these results
emphasize that for women with DSD diagnoses the assumption
that creation of a vagina will resolve any sexual dysfunction is incorrect. Women might have discomfort after surgical colpoeisis
related to functional length of the neovagina; however, the discomfort could also relate to emotional barriers with secondary vaginismus. Although the first explanation may require a change in
surgical technique, the latter requires a different, multidisciplinary
management approach that may include psychology, psychiatry,
and sexual therapy.
A limitation to our study design is the fact that the current study
protocol only assessed the women postoperatively. We have no
knowledge of the womens sexual function on the six domains assessed before surgery. It is conceivable that the surgery enhanced
the womens sexual function and decreased disorder in these domains but not to the level of a non-DSD, nonsurgical population
(the control group) (19).
In conclusion, sexual function appears impaired in these six
women who underwent laparoscopic Davydov compared with controls. These results differ from a previous report on sexual functioning after laparoscopic Davydov (5). Poorer scores may be attributed
to the inclusion of all patients data, even if they reported no attempt
at vaginal intercourse in the past 4 weeks. Lower scores may also reflect differences in the study patient population; more patients in this
group had failed dilation or undergone previous surgery. Our patient
population consisted solely of women who had failed vaginal dilation and in 33% also failed previous surgical procedures. Overall,
however, these results require reflection on current surgical technique and on surgical neovaginoplasty compared with vaginal
dilation. They also emphasize the need for perioperative support,
not only from the surgeon but ideally from psychology and sexual
therapy to optimize outcomes.
Future studies should address preoperative sexual function compared with postoperative sexual function after creation of a neovagina, and should compare sexual function in women using vaginal
dilation exclusively versus women who have undergone each of
the various surgical approaches. We advise assessment of sexuality
separate from clinical assessments by surgeons to allow women to
answer in a more forthright manner.

2275

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