The final cohort included 78 women with complete septate uterus. Among these women, 34 women underwent hysteroscopic septum incision and 60 embryo transfer cycles, and the 44 women underwent expectant treatment and 76 embryo transfer cycles (Fig.
1).
Baseline characteristics
The baseline characteristics of these two groups are summarized in Table
1. The average age in the hysteroscopic septum incision group was 32.3 ± 3.2 years old, which was comparable with that in the expectant treatment group (31.7 ± 3.8 years old). Age, infertility type, infertility years, BMI, FSH levels, luteinizing hormone (LH) levels, estradiol levels and anti-Müllerian hormone (AMH) levels were comparable between the two groups (
P > 0.05).
Table 1
Patient characteristics at baseline
No. of patients | 34 | 44 | |
Age (years) * | 32.3 ± 3.2 | 31.7 ± 3.8 | 0.233 |
Infertility type£ | 0.765 |
Primary infertility | 25 (73.5%) | 31 (70.5%) | |
Secondary infertility | 9 (26.6%) | 13 (29.5%) | |
Infertility duration (years) * | 3.6 ± 1.9 | 3.6 ± 2.5 | 0.533 |
BMI (kg/m2) * | 23.94 ± 4.12 | 22.42 ± 3.36 | 0.113 |
Baseline serum FSH (IU/ml) * | 6.32 ± 1.92 | 6.81 ± 2.19 | 0.348 |
Baseline serum LH (IU/ml) * | 5.65 ± 3.63 | 4.79 ± 3.94 | 0.487 |
Baseline serum E2 (pmol/ml) * | 169.35 ± 55.94 | 158.67 ± 64.48 | 0.559 |
AMH (ng/ml) * | 4.49 ± 3.68 | 3.67 ± 2.41 | 0.116 |
Cause of infertility£ | 0.800 |
Unexplained reason | 4(11.8%) | 3(6.8%) | |
Male factor | 9(26.5%) | 15(34.1%) | |
Tubal factor | 12(35.3%) | 17(38.6%) | |
PCOS | 8(23.5%) | 7(15.9%) | |
Endometriosis | 1(2.9%) | 2(4.5%) | |
The surgical group underwent 60 embryo transfer cycles, and the expectant treatment group underwent 76 embryo transfer cycles. The clinical characteristics and cycle parameters in these two groups are summarized in Table
2. The surgical group was significantly older (32.7 ± 3.4 vs. 31.4 ± 3.5 years,
P = 0.028), had a higher BMI level (24.64 ± 3.46 vs. 23.22 ± 4.21,
P = 0.011) and a higher AMH level compared to the expectant treatment group. In the surgical group, the 60 embryo transfer cycles corporate 22 (36.7%) fresh embryo transfer cycles and 38 (63.3%) frozen-thawed embryo transfer cycles. There were 33 (43.3%) fresh cycles and 43 (56.5%) frozen-thawed cycles in the expectant management group.
Table 2
Clinical characteristics and cycle parameters in patients with complete septate uterus
No. of cycles | 60 | 76 | | |
Age (years old)* | 32.7 ± 3.4 | 31.4 ± 3.52 | 0.028 | |
BMI (kg/m2)* | 24.64 ± 3.46 | 23.22 ± 4.21 | 0.011 | |
Baseline serum FSH (IU/ml)* | 6.42 ± 1.96 | 6.92 ± 2.32 | 0.201 | |
Baseline serum LH (IU/ml)* | 5.66 ± 4.12 | 5.04 ± 3.67 | 0.724 | |
Baseline serum E2 (pmol/ml)* | 160.41 ± 50.5 | 166.5 ± 59.9 | 0.820 | |
AMH (ng/ml)# | 4.95 (2.25, 6.54) | 2.84 (1.41, 5.50) | 0.029 | |
Embryo transfer cycles£ | 0.425 | |
Fresh cycle | 22 (36.7%) | 33(43.3%) | | |
Frozen-thawed cycle | 38 (63.3%) | 43(56.6%) | | |
Thickness of endometrium (mm)# | 10 (9,11) | 10 (9,11) | 0.259 | |
Type of embryos/blastocysts transferred£ | 0.188 | |
Single cleavage embryo | 6 (10%) | 8 (10.5%) | | |
Double cleavage embryos | 28 (46.7%) | 31 (40.8%) | | |
Single blastocyst | 20 (33.3%) | 35 (46.1%) | | |
Double blastocysts | 6 (10%) | 2 (2.6%) | | |
Mean number of transferred embryos# | 2 (1,2) | 1 (1,2) | 0.126 | |
Comparison of the reproductive outcomes between the surgical group and the expectant management group
All hysteroscopic septate incisions were performed smoothly without complications such as uterine perforation or water intoxication. Three-dimensional ultrasonography was performed 2 months after hysteroscopic septate incision and revealed residual septum in two women, who subsequently underwent a second hysteroscopic septate incision. Hysteroscopy was performed 2 months after the hysteroscopic septate incision, and no intrauterine adhesions were found.
Pregnancy outcomes were assessed based on the embryo transfer cycle. Among the 60 embryo transfer cycles in the surgical group, there were 26 cycles resulting in clinical pregnancies, 8 cycles with first-trimester miscarriages, 2 cycles with ectopic pregnancies, and 15 cycles resulting in live births, all occurring at term. In the surgical group, one of the two women with residual septa did not conceive post-operation, while the other underwent cesarean section and delivered at full term after frozen-thawed embryo transfer. In the expectant management group, consisting of 76 embryo transfer cycles, there were 36 cycles with clinical pregnancies, 8 cycles with first-trimester miscarriages, and 19 cycles resulting in live births. No premature births were observed in this group.
Comparison between women undergoing hysteroscopic septum incision and those under expectant management revealed similar chances of live birth (25% vs. 25%, RR: 1.000, 95% CI: 0.822 to 1.216). Additionally, the clinical pregnancy rate in the surgical group did not significantly differ from that of the expectant group (43.3% vs. 47.4%, RR: 0.993, 95% CI: 0.684 to 1.263). Similarly, the ongoing pregnancy rate in the surgical group (26.7%) was comparable to that of the expectant group (26.7% vs. 36.8%, RR: 0.861, 95% CI: 0.684 to 1.083).
Pregnancy loss in the surgical group totaled 8 cases, including 2 mid-trimester and 6 first-trimester losses, whereas all 8 pregnancy losses in the expectant group occurred in the first trimester. Due to the limited sample size, a combined analysis of first and mid-trimester pregnancy losses was conducted to preserve statistical power. Hysteroscopic septum incision did not result in a decreased miscarriage rate compared to expectant management in the surgical group (30.8% vs. 22.2%, RR: 1.123, 95% CI: 0.824 to 1.532) (Table
3).
Table 3
Reproductive outcomes of the septum resection group and expectant management group
Clinical pregnancy | 26 (43.3%) | 36 (47.4%) | 0.639 | 0.993 (0.684,1.263) | 0.638 |
Miscarriage | 8 (30.8%) | 8 (22.2%) | 0.448 | 1.123 (0.824, 1.532) | 0.462 |
Ongoing pregnancy | 16 (26.7%) | 28 (36.8%) | 0.208 | 0.861 (0.684,1.083) | 0.202 |
Live birth | 15 (25%) | 19 (25%) | 1.000 | 1.000 (0.822, 1.216) | 1.000 |
Subgroup analysis by type of embryo transferred is shown in Table
4. In a total of 73 cycles, cleavage stage embryos were transferred, and blastocysts were transferred in 63 cycles. The live birth rate, clinical pregnancy rate, ongoing pregnancy rate and miscarriage rate were similar between the two groups when either cleavage-stage embryos or blastocysts were transferred (Table
4).
Table 4
Subgroup analysis of reproductive outcomes stratified by the type of embryo transferred
Cleavage embryo | (N( = 34) | (N = 39) | | | |
Clinical pregnancy | 14 (41.2%) | 17 (43.6%) | 0.835 | 0.959 (0.647, 1.422) | 0.835 |
Miscarriage | 2 (14.3%%) | 3 (17.6%) | 1.000 | 0.397 (0.025,6.200) | 0.510 |
Ongoing pregnancy | 10 (29.4%) | 14 (35.9%) | 0.556 | 0.908 (0.660,1.250) | 0.555 |
Live birth | 9 (26.5%) | 9 (23.1%) | 0.737 | 1.046 (0.803, 1.364) | 0.739 |
Blastocyst | (N = 26) | (N = 37) | | | |
Clinical pregnancy | 12 (46.2%) | 19 (51.4%) | 0.685 | 0.903 (0.556, 1.469) | 0.682 |
Miscarriage | 6 (50%) | 5 (26.3%) | 0.339 | 1.474 (0.788, 2.757) | 0.225 |
Ongoing pregnancy | 6 (23.1%) | 14 (37.8%) | 0.215 | 0.808 (0.582,1.122) | 0.203 |
Live birth | 6 (23.1%) | 10 (27.0%) | 0.727 | 0.949 (0.711,1.265) | 0.720 |