Hysteroscopic Metroplasty for the Septate Uterus: Review and Meta-Analysis

doi:10.1016/j.jmig.2012.09.010

Journal of Minimally Invasive Gynecology

Volume 20, Issue 1, January–February 2013, Pages 22-42

https://doi.org/10.1016/j.jmig.2012.09.010 Get rights and content

Abstract

The introduction of hysteroscopy to diagnose and treat intrauterine conditions, specifically to divide the uterine septum, or metroplasty, has replaced the traditional laparotomy approach, and objective results demonstrate its salutary effects in women treated. Hysteroscopic metroplasty averts the implications of major invasive abdominal surgery, with good and satisfactory results in pregnancy and live-birth rates, despite the lack of prospective, randomized, controlled studies. A careful review of the published results supports this type of treatment when the uterine septum adversely affects normal reproductive function.

Section snippets

Incidence

It is difficult to determine the incidence of congenital uterine malformations in the general population because most affected women do not experience reproductive problems. The incidence has been calculated to be 1 or 2 per 1000 women and as high as 15 per 1000 women. Some studies have reported a 12% incidence 1, 2, 3, 4, 5.

Genetic Factors

The occurrence of congenital uterine malformations seems to be influenced by a genetic heterogeneity and/or polygenic multifactorial inheritance. Inasmuch as these

Classification of Uterine Anomalies

There are many classifications of developmental anomalies of the uterus. In 1979, Buttram and Gibbons [11] proposed a classification that was further revised in 1988 by the American Society of Reproductive Medicine, then known as the American Fertility Society [12] (Fig. 2). This classification groups anomalies in categories on the basis of similarities in clinical features, obstetric outcome, and treatment options [12]. While the American Society of Reproductive Medicine classification has

Vascularization and Muscular Components of the Uterine Septum

Few histologic evaluations of the uterine septum have been performed. It is clear that the composition of the septum varies according to site and level at which the tissue samples are obtained for study. In addition, the width of the septum is important inasmuch as some are very thin and others very thick; thus, the results obtained from studies vary considerably. The uterine septum, in general, is composed of fibromuscular tissue and may borrow vascularization from the adjacent uterine walls.

Diagnosis and Evaluation

Although the diagnosis of a malformed uterus can be made during physical examination when obvious anomalies of the vagina and cervix are present, the subtlest uterine anomalies can be discovered and confirmed only by other methods of evaluation such as hysterosalpingography, sonography in all its modes, and hysteroscopy (Figs. 3 and 4). Differentiation of a bicornuate from a septate uterus may require additional evaluation via ultrasonography and/or laparoscopy. Imaging techniques are discussed

Reproductive Problems Caused by Uterine Septum

Most women with müllerian anomalies, specifically of the septum, have efficient reproductive function; only about 20% to 25% may experience recurrent spontaneous abortions 22, 23. Of all of the uterine anomalies encountered, septate uterus is most often associated with reproductive wastage. The classic clinical finding is of repeated early mid-trimester pregnancy wastage with obvious signs of labor, including bleeding. Infertility rarely results from a uterine anomaly alone. Therefore, the mere

Why Do Some Women With Uterine Septum Abort?

Several theories have been offered to explain why repetitive abortions occur in women with uterine septum. These include decreased luminal space, impaired development of the endometrium such that it cannot support the pregnancy, decreased steroid estrogens receptors, decreased serum cystine aminopeptidase, and decreasing neutralization of circulating oxytocin [26]. Other theories include an alteration in cervical fibromuscular/connective tissue ratios. The hypermuscular cervix, with increased

Indications for Metroplasty

Most women with septate uterus reproduce successfully; only 20% to 25% may have pregnancy wastage, late first-trimester abortion, or early second-trimester abortion initiated with mini-labor and bleeding. This problem seems to correlate with the length of the septum, with longer septae posing the greatest risk. The most genuine indication for treatment is repeated abortion. However, with the advances in minimally invasive procedures such as hysteroscopy, other relative indications include

Preoperative Evaluation and Diagnosis

Multiple imaging methods have been used to delineate uterine anomalies. Because most women with uterine anomalies have normal external genitalia, most uterine anomalies are not apparent until the time of expected menarche or at work-up because of infertility or pregnancy loss.

Treatment of Uterine Septum

Because the original metroplastic procedures via laparotomy paved the way to the modern approach via hysteroscopy, a brief review of those methods is in order.

Prophylactic Antibiotic Therapy

Although various antibiotic regimens are used perioperatively with hysteroscopic metroplasty, no prospective randomized studies have been performed to demonstrate their efficacy.

Hormone Therapy

Because hysteroscopic metroplasty is ideally performed in the early follicular phase of the menstrual cycle, when the endometrium is thin, occasionally hormone therapy may be required, and among the various options, gonadotropin-releasing hormone analogues are well suited for this task 96, 97. Postoperative hormone

Healing of the Uterus After Hysteroscopic Metroplasty

The high regenerative capacity of the normal endometrium helps in the healing process of the defect from septal division. Fedele et al [132] demonstrated the centripetal and centrifugal directions of the endometrial repair that occurs after division of the uterine septum. At 13 days after the procedure, they studied, via light microscopy and scanning electron microscopy, the histologic changes of the defect left after resection of the septum. Re-epithelialization of the defect proceeded

Treatment of Complete Septate Uterus With Septate Cervix

Treatment of complete septate uterus with septate cervix may be somewhat more challenging than treatment of the corporeal septum alone 109, 113, 134, 135, 136, 137. With the background of the embryologic origin of the uterus and arrest of reabsorption of the medial septum, the complete septum is thinner in the lower segment, close to the internal cervical os, where the original reabsorption begins. Therefore, by inserting a probe or indwelling catheter through one of the cervical openings and

Endoscopic Treatment of Bicornuate Uterus or Strassman Metroplasty

Bicornuate uterus is a defect that results from lack of fusion of the müllerian ducts and can be the cause of pregnancy wastage. The original treatment proposed by Strassman was laparotomy and hysterotomy. A transverse uterine fundal incision between the round ligaments is made to divide the uterine fundus until the uterine cavity is entered; then the incision is closed anteroposteriorly. Attempts have been made to perform this operation less invasively by using endoscopes. The methods used are

Early and Late Complications of Hysteroscopic Metroplasty

As with any surgical procedure, hysteroscopic metroplasty may have its complications. These include bleeding, fluid overload, uterine perforation, formation of adhesions, and uterine rupture in subsequent pregnancy.

Published Surgical Results of Hysteroscopic Metroplasty and Their Level of Evidence

Many reports in the literature have detailed the salutary effects of treatment of septate uterus on subsequent reproduction173, 174. However, all have uniformly used the patients as their own control, without prospective randomization or sufficient number of patients for comparison of treatment vs no treatment. Nonetheless, the accumulated experience and favorable results indicate the beneficial effect of surgery. Thus, perhaps a prospective randomized study comparing treatment vs no treatment

Meta-analysis of Reproductive Outcomes After Hysteroscopic Metroplasty

We identified studies that reported outcomes after hysteroscopic metroplasty from 1986 to 2011 by performing an extensive search of Medline and by hand searching cross-references and review articles. Keywords used in the search included “hysteroscopy,” “metroplasty,” “uterine septum,” “recurrent miscarriage,” “infertility,” and “uterine anomalies.” No randomized controlled trials were identified; thus, all included studies in the meta-analysis were categorized as Canadian Task Force

Future of Hysteroscopic Metroplasty

Innovations in instrumentation and safe energy sources will continue to improve the safety and simplicity of hysteroscopic metroplasty. The hysteroscopic scissors should be made sturdier without compromising diameter and semi-rigidity. They also should maintain their ability to cut after several uses. On the horizon is the introduction of endoscopes that are also capable of sonographic evaluation with sufficient resolution and penetration to aid in the safe, precise, and efficient division of

Summary and Conclusions

Septate uterus resulting from failure of reabsorption of the embryologic original fusion of the müllerian ducts may impair reproductive function in 20% to 25% of women with this anomaly. When this occurs, the septum may be amenable to surgical correction now performed via hysteroscopic or resectoscopic division. The limitations and inconveniences of laparotomy and hysterotomy are thus averted, and preservation of the integrity of the uterine walls does not require cesarean section in subsequent

Acknowledgments

We thank Drs. Alfred W. Rademaker (Professor, Department of Preventive Medicine) and Amy Wong (Fellow, Maternal-Fetal Medicine, Department of Obstetrics and Gynecology) at Northwestern University for assistance with the statistical analysis.

References (176)

P.C. Lin et al.
Female genital anomalies affecting reproduction
Fertil Steril
(2002)
V.C. Buttram et al.
Mullerian anomalies: a proposed classification (an analysis of 144 cases)
Fertil Steril
(1979)
G. Gubbini et al.
New outpatient sub-classification system for American Fertility Society classes V and VI uterine anomalies
J Minim Invasive Gynecol
(2009)
H. Dabirashrafi et al.
Septate uterus: new idea on the histologic features of the septum in this abnormal uterus
Am J Obstet Gynecol
(1995)
A. Agostini et al.
Adverse obstetric outcomes at term after hysteroscopic metroplasty
J Minim Invasive Gynecol
(2009)
F. Raga et al.
Expression of vascular endothelial growth factor receptors in the endometrium of septate uterus
Fertil Steril
(2009)
L. Fedele et al.
Ultrastructural aspects of endometrium in infertile women with septate uterus
Fertil Steril
(1996)
P.K. Heinonen et al.
Primary infertility and uterine anomalies
Fertil Steril
(1983)
H.A. Homer et al.
The septate uterus: a review of management and reproductive outcome
Fertil Steril
(2000)
T. Shokeir et al.
Determinants of fertility and reproductive success after hysteroscopic septoplasty for women with unexplained primary infertility: a prospective analysis of 88 cases
Eur J Obstet Gynecol Reprod Biol
(2011)

R. Pabuccu et al.

Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility

Fertil Steril

(2004)

E.A. Tonguc et al.

Hysteroscopic metroplasty in patients with a uterine septum and otherwise unexplained infertility

Int J Gynaecol Obstet

(2011)

R. Paradisi et al.

Metroplasty in a large population of women with septate uterus

J Minim Invasive Gynecol

(2011)

T. Tomazevic et al.

Septate, subseptate and arcuate uterus decrease pregnancy and live birth rates in IVF/ICSI

Reprod Biomed Online

(2010)

P. Carrascosa et al.

Virtual hysterosalpingography in the diagnosis of bicornuate versus septate uterus

Fertil Steril

(2011)

U. Nicolini et al.

Can ultrasound be used to screen uterine malformations?

Fertil Steril

(1987)

L. Fedele et al.

Ultrasonography in the differential diagnosis of “double” uteri

Fertil Steril

(1988)

B. Woelfer et al.

Reproductive outcomes in women with congenital uterine anomalies detected by three-dimensional ultrasound screening

Obstet Gynecol

(2001)

S. Alborzi et al.

Differential diagnosis of septate and bicornuate uterus by sonohysterography eliminates the need for laparoscopy

Fertil Steril

(2002)

F. Raga et al.

Congenital Mullerian anomalies: diagnostic accuracy of three-dimensional ultrasound

Fertil Steril

(1996)

W. El-Sherbiny et al.

Value of 3-dimensional sonohysterography in infertility work-up

J Minim Invasive Gynecol

(2011)

E. Faivre et al.

Accuracy of three-dimensional ultrasonography in differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging

J Minim Invasive Gynecol

(2012)

A. Mollo et al.

Combined hysteroscopic findings and 3-dimensional reconstructed coronal view of the uterus to avoid laparoscopic assessment for inpatient hysteroscopic metroplasty: pilot study

J Minim Invasive Gynecol

(2011)

C. Coutifaris et al.

Histological dating of timed endometrial biopsy tissue is not related to fertility status

Fertil Steril

(2004)

H. Carp et al.

Karyotype of the abortus in recurrent miscarriage

Fertil Steril

(2001)

H.W. Jones et al.

Double uterus as an etiologic factor in repeated abortion: indications for surgical repair

Am J Obstet Gynecol

(1953)

J.A. Rock et al.

The clinical management of the double uterus

Fertil Steril

(1977)

P. Tompkins

Comments on the bicornuate uterus and twinning

Surg Clin North Am

(1962)

P.M. McShane et al.

Pregnancy outcomes following Tompkins metroplasty

Fertil Steril

(1983)

I. Kessler et al.

Indications and results of metroplasty in uterine malformations

Int J Gynaecol Obstet

(1986)

A. Ayhan et al.

Reproductive performance after conventional metroplasty: an evaluation of 102 cases

Fertil Steril

(1992)

E.P. Kirk et al.

Pregnancy after metroplasty for uterine anomalies

Fertil Steril

(1993)

D.C. Daly et al.

Hysteroscopic metroplasty: surgical technique and obstetric outcome

Fertil Steril

(1983)

C.M. March et al.

Hysteroscopic management of recurrent abortion caused by septate uterus

Am J Obstet Gynecol

(1987)

H.E. Shawki

Reproductive outcomes after Versapoint hysteroscopic metroplasty

Middle East Fertil Soc J

(2010)

J.K. Choe et al.

Hysteroscopic treatment of septate uterus with neodymium-YAG laser

Fertil Steril

(1992)

G.B. Candiani et al.

Argon laser versus microscissors for hysteroscopic incision of uterine septa

Am J Obstet Gynecol

(1991)

D. Querleu et al.

Ultrasound-guided transcervical metroplasty

Fertil Steril

(1990)

M. Simons et al.

Hysteroscopic morcellator system can be used for removal of a uterine septum

Fertil Steril

(2011)

A.M. El Saman et al.

Tactile cold scissor metroplasty as a novel back up method for hysteroscopic metroplasty

Fertil Steril

(2010)

E.E. Wallach

Evaluation and management of uterine causes of infertility

Clin Obstet Gynecol

(1979)

J.P. Semmens

Congenital anomalies of female genital tract: functional classification based on review of 56 personal cases and 500 reported cases

Obstet Gynecol

(1962)

E.O. Strassman

Fertility and unification of double uterus

Fertil Steril

(1966)

D. Hay

Uterus unicollis and its relationship to pregnancy

BJOG

(1961)

Uterine anomalies

S. Elias et al.

Genetic studies in incomplete Mullerian fusion

Obstet Gynecol

(1984)

K.L. Moore

The urogenital system

W.J. Larsen

Human Embryology

(1993)

P.E. Patton

Anatomic uterine defects

Clin Obstet Gynecol

(1994)

American Fertility Society

The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions

Fertil Steril

(1988)

Cited by (136)

Guideline No. 446: Hysteroscopic Surgery in Fertility Therapy
2024, Journal of Obstetrics and Gynaecology Canada
To evaluate the indications, benefits, and risks of hysteroscopy in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients.
Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment.
Hysteroscopic surgery can be used to diagnose the etiology of infertility and improve fertility treatment outcomes. All surgery has risks and associated complications. Hysteroscopic surgery may not always improve fertility outcomes. All procedures have costs, which are borne either by the patient or their health insurance provider.
We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix B for MeSH search terms).
The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations).
Gynaecologists who manage common conditions in patients with infertility.
When offering hysteroscopic surgery to patients with infertility, ensure it improves the live birth rate.
- 1.
  Hysteroscopy, sonohysterography, and 3-D sonohysterography are comparable for diagnosing intracavitary pathology in patients with unexplained infertility (high).
- 2.
  The beneficial effects of hysteroscopy on conception and live birth rates in patients with unexplained infertility remains uncertain as numerous studies report contradictory results (low).
- 3.
  Improvements in imaging modalities means that the majority of müllerian anomalies can be diagnosed non-invasively, with hysteroscopy and laparoscopy being reserved for cases where imaging is inconclusive (high).
- 4.
  There is no evidence of improved reproductive outcomes following the correction of most müllerian anomalies (low).
- 5.
  Published literature supports resection or correction of a uterine septum or a T-shaped uterus to improve reproductive and obstetrical outcomes; however, a small, randomized controlled trial did not show a benefit (moderate).
- 6.
  FIGO types 0–2 (submucosal) fibroids are associated with lower pregnancy and higher miscarriage rates (moderate).
- 7.
  Hysteroscopic myomectomy appears to be associated with improved unassisted and assisted pregnancy rates (low).
- 8.
  Fertility outcomes are similar between the various hysteroscopic myomectomy techniques (low).
- 9.
  Hysteroscopy can reliably diagnose intrauterine adhesions in patients with a normal transvaginal ultrasound and hysterosalpingogram (moderate).
- 10.
  Hysteroscopic correction of intrauterine adhesions increases conception rates in patients with infertility or recurrent pregnancy loss (high).
- 11.
  Although hysteroscopy improves the live birth rate in patients known to have intrauterine adhesions, the effect on live birth rates in patients with infertility or recurrent pregnancy loss is uncertain (low).
- 12.
  In patients with infertility, hysteroscopy can diagnose previously unrecognized polyps in patients with normal investigations (high).
- 13.
  Hysteroscopic polypectomy improves unassisted and intrauterine insemination conception and live birth rates in asymptomatic patients with infertility (moderate).
- 14.
  Hysteroscopic polypectomy has limited evidence of benefit for pregnancy or live birth rates in asymptomatic infertility patients undergoing IVF (low).
- 15.
  Although limited fertility data exist, intrauterine barriers may reduce intrauterine adhesions following hysteroscopic surgery (low).
- 16.
  There are no data to support the use of medications to improve uterine blood flow or antibiotics in hysteroscopic surgery (low).
- 17.
  The use of steroid hormones, estrogen with or without progestin, may reduce intrauterine adhesions following hysteroscopic surgery (low).
- 1.
  Patients with unexplained infertility may benefit from uterine cavity evaluation by either hysteroscopy, sonohysterography, or 3-D sonohysterography (conditional, low).
- 2.
  In patients with unexplained infertility, correction of intracavitary pathology may improve live birth rates (conditional, low).
- 3.
  Diagnostic imaging (sonohysterography, 3-D sonohysterography, and MRI) should be the first-line investigation of müllerian anomalies, reserving invasive surgical procedures for cases where imaging studies are inconclusive (strong, high).
- 4.
  Hysteroscopic correction of müllerian anomalies should be limited to septate and T-shaped uteri, unless functional or pain concerns are present (e.g., cervical agenesis, obstructed uterine horn) (conditional, low).
- 5.
  Hysteroscopic myomectomy may be considered in patients attempting conception whether unassisted or with assisted reproductive technology (conditional, low).
- 6.
  Patients with infertility or recurrent pregnancy loss diagnosed with intrauterine adhesions on routine investigation should have hysteroscopic adhesiolysis to increase the likelihood of conception (strong, high).
- 7.
  Patients planning to conceive and known to have intrauterine adhesions should have hysteroscopic adhesiolysis to improve the likelihood of a live birth (conditional, moderate).
- 8.
  Hysteroscopic polypectomy to improve reproductive outcomes is recommended in patients attempting unassisted conception, ovulation induction, or mild ovarian stimulation (conditional, moderate).
- 9.
  Hysteroscopic polypectomy is recommended to improve fertility outcomes in patients planning intrauterine insemination (conditional, moderate).
Directive clinique n<sup>o</sup> 446: Chirurgie hystéroscopique dans les traitements de fertilité
2024, Journal of Obstetrics and Gynaecology Canada
Évaluer les indications, les risques et les bénéfices de l’hystéroscopie dans la prise en charge des patientes atteintes d’infertilité et fournir des conseils aux gynécologues qui prennent en charge les problèmes les plus fréquents chez ces patientes.
Patientes atteintes d’infertilité (incapacité à concevoir après 12 mois de rapports sexuels non protégés) en processus diagnostique ou sous traitement.
L’hystéroscopie peut être utilisée pour diagnostiquer l’étiologie de l’infertilité et améliorer les résultats des traitements de fertilité. Toute intervention chirurgicale comporte des risques et des complications associées, et l’hystéroscopie n’améliore pas toujours les résultats de fertilité. Toutes les interventions entraînent des coûts, lesquels sont assumés par la patiente ou son assureur.
Des recherches ont été faites dans les bases de données PubMed-Medline, Embase, Science Direct, Scopus et Cochrane Library pour répertorier les articles publiés en anglais dans la période de janvier 2010 à mai 2021 (voir les termes de recherche MeSH à l’annexe B).
Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l’annexe A (tableau A1 pour les définitions et tableau A2 pour l’interprétation des recommandations fortes et faibles).
Gynécologues qui prennent en charge les affections courantes chez les patientes atteintes d’infertilité.
Il y a lieu de s’assurer que l’intervention améliore la probabilité d’une naissance vivante avant de proposer l’hystéroscopie à une patiente atteinte d’infertilité.
- 1.
  L’hystéroscopie, l’hystérosonographie et l’hystérosonographie 3D sont comparables pour diagnostiquer une pathologie intracavitaire chez les patientes présentant une infertilité inexpliquée (élevée).
- 2.
  Les effets bénéfiques de l’hystéroscopie sur les probabilités de conception et de naissance vivante chez les patientes présentant une infertilité inexpliquée restent incertains, car les nombreuses études font état de résultats contradictoires (faible).
- 3.
  L’amélioration des technologies d’imagerie signifie que la majorité des anomalies müllériennes peuvent être diagnostiquées de manière non invasive, l’hystéroscopie et la laparoscopie étant réservées aux cas où l’imagerie n’est pas concluante (élevée).
- 4.
  Il n’existe aucune donnée probante démontrant l’amélioration des résultats reproductifs après la correction de la plupart des anomalies müllériennes (faible).
- 5.
  La littérature publiée soutient la résection ou la correction en cas d’utérus septé (cloisonné) ou en T pour améliorer les résultats reproductifs et obstétricaux; cependant, un petit essai clinique randomisé n’a observé aucun bénéfice (moyenne).
- 6.
  Les fibromes de types 0-2 (sous-muqueux), selon la classification FIGO, sont associés à une moindre probabilité de grossesse et à un risque accru de fausse couche (moyenne).
- 7.
  La myomectomie par hystéroscopie semble associée à une amélioration de la probabilité de grossesse spontanée ou assistée (faible).
- 8.
  Les résultats en matière de fertilité sont similaires entre les différentes techniques de myomectomie par hystéroscopie (faible).
- 9.
  L’hystéroscopie permet de diagnostiquer de manière fiable les synécheis intra-utérines chez les patientes dont les résultats d’échographie endovaginale et d’hystérosalpingographie s’avèrent normaux (moyenne).
- 10.
  La lyse des synéchies intra-utérines par hystéroscopie augmente la probabilité de conception chez les patientes atteintes d’infertilité ou éprouvant des fausses couches à répétition (élevée).
- 11.
  Bien que l’hystéroscopie améliore la probabilité de naissance vivante chez les patientes connues pour avoir des synéchies intra-utérines, l’effet est incertain chez les patientes atteintes d’infertilité ou éprouvant des fausses couches à répétition (faible).
- 12.
  Chez les patientes atteintes d’infertilité, l’hystéroscopie peut permettre de déceler la présence de polypes non détectés par les examens habituels (élevée).
- 13.
  La polypectomie par hystéroscopie améliore la probabilité de conception spontanée ou par insémination intra-utérine et la probabilité de naissance vivante chez les patientes asymptomatiques atteintes d’infertilité (moyenne).
- 14.
  Les données probantes sont limitées en ce qui concerne les bénéfices de la polypectomie par hystéroscopie sur la probabilité de grossesse ou de naissance vivante chez les patientes asymptomatiques atteintes d’infertilité se soumettant à la fécondation in vitro (faible).
- 15.
  Bien que les données sur la fertilité soient limitées, les barrières intra-utérines peuvent réduire le risque de synéchies intra-utérines après une hystéroscopie opératoire (faible).
- 16.
  Il n’y a pas de données qui soutiennent l’utilisation d’antibiotiques ou de médicaments pour améliorer le flux sanguin utérin après l’hystéroscopie opératoire (faible).
- 17.
  L’utilisation d’hormones stéroïdiennes : œstrogènes avec ou sans progestatif, peut réduire le risque de synéchies intra-utérines après une hystéroscopie opératoire (faible).
- 1.
  L’évaluation de la cavité utérine par hystéroscopie, hystérosonographie ou hystérosonographie 3D peut s’avérer utile chez les patientes présentant une infertilité inexpliquée (conditionnelle, faible).
- 2.
  Chez les patientes présentant une infertilité inexpliquée, la correction des pathologies intracavitaires peut améliorer la probabilité de naissance vivante (conditionnelle, faible).
- 3.
  L’imagerie diagnostique (hystérosonographie, hystérosonographie 3D et imagerie par résonance magnétique) constitue l’examen de première intention pour détecter les anomalies müllériennes, les interventions chirurgicales invasives étant réservées aux cas où l’analyse de l’imagerie s’est avérée inconcluante (forte, élevée).
- 4.
  Il y a lieu de limiter la correction des anomalies müllériennes par hystéroscopie aux cas d’utérus septé (cloisonné) ou en T, sauf en cas de préoccupations fonctionnelles ou douloureuses (par exemple, agénésie cervicale, corne utérine borgne) (conditionnelle, faible).
- 5.
  La myomectomie par hystéroscopie est envisageable chez les patientes qui tentent de concevoir, de manière spontanée ou en recourant aux technologies de procréation assistée (conditionnelle, faible).
- 6.
  La lyse de synéchies par hystéroscopie est recommandée chez les patientes atteintes d’infertilité ou éprouvant des fausses couches à répétitions en présence de synéchies intra-utérines diagnostiquées lors d’un examen de routine afin d’augmenter la probabilité de conception (forte, élevée).
- 7.
  La lyse de synéchies par hystéroscopie est recommandée pour améliorer la probabilité de naissance vivante chez les patientes qui prévoient de concevoir et présentent des synéchies intra-utérines connues (conditionnelle, moyenne).
- 8.
  La polypectomie par hystéroscopie est recommandée pour améliorer les résultats reproductifs chez les patientes qui tentent une conception spontanée ou se soumettent à une induction de l’ovulation ou à une stimulation ovarienne modérée (conditionnelle, moyenne).
- 9.
  La polypectomie par hystéroscopie est recommandée pour améliorer les résultats en matière de fertilité chez les patientes qui envisagent une insémination intra-utérine (conditionnelle, moyenne).
Evidence-based diagnosis and treatment for uterine septum: a guideline
2024, Fertility and Sterility
To provide evidence-based recommendations regarding the diagnosis and effectiveness of surgical treatment of a uterine septum.
This guideline provides evidence-based recommendations regarding the diagnosis and effectiveness of surgical treatment of a uterine septum. This replaces the last version of the same name (Fertil Steril. 2016 Sep 1;106(3):530-40).
Outcomes of interest included the impact of a septum on underlying fertility, live birth, clinical pregnancy, and obstetrical outcomes.
The literature search identified relevant studies to inform the evidence for this guideline.
The treatment of uterine septa and subsequent outcomes associated with infertility, recurrent pregnancy loss, and adverse obstetrical outcomes are summarized. Resection of a septum has been shown to improve outcomes in patients with recurrent pregnancy loss and to decrease the likelihood of malpresentation. In the setting of infertility, it is recommended to use a shared decision-making model after appropriate counseling to determine whether or not to proceed with septum resection.
Reproductive outcomes of oocyte donation in patients with uterine Müllerian anomalies
2023, Fertility and Sterility
To evaluate live-birth rates per embryo transfer in patients with uterine Müllerian anomalies (UMAs). Secondary objectives were to compare reproductive outcomes between the normal uterus group, the different UMA types, and UMA subgroups with and without required surgery.
This retrospective study compared two cohorts, one with UMAs and other with normal uteri of our oocyte donation program at 12 Instituto Valenciano De Infertilidad/Reproductive Medicine Associates University affiliated clinics from January 2000 to 2020. The oocyte donation reduces confounding because of differences in embryo quality. The primary outcome was the live-birth rate per embryo transfer. Secondary outcomes included the rates of implantation, clinical pregnancy, miscarriage, and ongoing pregnancy. We calculated odds ratios with 95% confidence intervals.
Infertile women undergoing oocyte donation with UMAs.
None.
The rates of implantation, clinical pregnancy, miscarriage, ongoing pregnancy, and live birth.
We analyzed 58,337 cycles of oocyte donation: 57,869 patients had no uterine malformation, and 468 women had UMAs. Compared with patients with normal uteri, patients with UMAs had lower rates of live births (36.67% [32.84–40.65] vs. 38.1% [95% confidence intervals {CI}: 37.82–38.42]) and ongoing pregnancy (39.74% [35.93–43.66] vs. 41.5% [41.24–41.83]). The miscarriage rate was higher in patients with UMAs (19.5% [16.55–22.85] vs. 16.6% [16.47–16.92]). Specifically, patients with a unicornuate uterus (n=29) had lower rates of implantation (24.07% [13.49–37.64] vs. 42.85% [95% CI: 42.6–43.09]), pregnancy (41.86% [27.01–57.87] vs. 59.51% [59.22–59.81]), ongoing pregnancy (16.67% [6.97–31.36] vs. 41.54% [41.24–41.83]), and live births (16.67% [6.97–31.36] vs. 38.12% [37.83–38.42]). In addition, patients with a partial septate uterus (n=91) had a higher miscarriage rate (26.50% [18.44–34.89] vs. 16.7% [16.47–16.92]). Compared with the normal uterus group, the live-birth rates were lower in the UMA without surgery group (33.09% [27.59–38.96] vs. 38.12% [37.83–38.42]).
Among patients who received embryos derived from donated oocytes, live birth and ongoing pregnancy rates were lower in patients with UMAs compared with patients with normal uteri. A higher miscarriage rate was found in patients with UMAs. Patients with a unicornuate uterus had worse reproductive outcomes. Our results show that the uterus is less competent in patients with UMAs.
This study was registered at clinicaltrial.gov (NCT04571671).
Resultados reproductivos de la donación de ovocitos en pacientes con anomalías mullerianas
Evaluar la tasa de nacido vivo por transferencia embrionaria en pacientes con diagnóstico de anomalías müllerianas uterinas (AMU). Los objetivos secundarios fueron comparar los resultados reproductivos entre el grupo de útero normal, los distintos tipos de AMU y los subgrupos de AMU con y sin necesidad de cirugía.
Estudio retrospectivo que comparó dos cohortes, una con AMUs y otra con úteros normales, dentro de nuestro programa de donación de ovocitos en 12 clínicas afiliadas al Instituto Valenciano De Infertilidad/Reproductive Medicine Associates University, desde enero de 2000 hasta 2020. La donación de ovocitos reduce las diferencias en la calidad embrionaria. El resultado primario fue la tasa de nacido vivo por transferencia embrionaria. Los resultados secundarios incluyeron las tasas de implantación, embarazo clínico, aborto espontáneo y embarazo en curso. Se calculó el odd ratio con intervalos de confianza del 95%.
Mujeres infértiles con indicación de donación de ovocitos y diagnóstico de AMU.
Ninguna.
Las tasas de implantación, embarazo clínico, aborto espontáneo, embarazo en curso y nacido vivo.
Se analizaron 58,337 ciclos de donación de ovocitos: 57,869 pacientes no tenían malformaciones uterinas y 468 mujeres tenía diagnóstico de AMU. En comparación con las pacientes con úteros normales, las pacientes con AMU tuvieron tasas más bajas de nacidos vivos (36.67% [32.84-40.65] frente a 38.1% [intervalos de confianza del 95% {IC}:37.82-38.42]) y de embarazos en curso (39.74% [35.93-43.66] frente a 41.5% [41.24-41.83]). La tasa de abortos fue mayor en las pacientes con AMU (19.5% [16.55-22.85] frente a 16.6% [16.47-16.92]). En concreto, las pacientes con útero unicorne (n=29) presentaron tasas más bajas de implantación (24.07% [13.49-37.64] frente a 42.85% [IC 95%: 42.6-43.09]), embarazo (41.86% [27.01-57.87] frente a 59.51% [59.22-59.81]) y embarazo (16.67% [6.97-31.36] frente a 41.54% [41.24-41.83]), y nacido vivo (16.67% [6.97-31.36] frente a 38.12% [37.83 – 38.42]) Además, las pacientes con útero parcialmente septado (n=91) presentaron una mayor tasa de aborto espontáneo (26.50% [18.44-34.89] frente a 16.7% [16.47-16.92]). En comparación con el grupo de útero normal, las tasas de nacidos vivos fueron inferiores en el grupo de AMU sin cirugía (33.09% [27.59-38.96] frente a 38.12% [37.83-38.42]).
Entre las pacientes que recibieron embriones provenientes de ovocitos donados, las tasas de nacidos vivos y de embarazos en curso fueron inferiores en pacientes con AMUs en comparación con las pacientes con úteros normales. Se observó una mayor tasa de abortos espontáneos en las pacientes con AMU. Las pacientes con útero unicorne tuvieron peores resultados reproductivos. Nuestros resultados muestran que el útero es menos competente en las pacientes con diagnóstico de UMA.
Hysteroscopic Fenestration with Precise Incision of the Cavity Septum: A Novel Minimally Invasive Surgery of Complete Septate Uterus with Double Cervix
2023, Journal of Minimally Invasive Gynecology
This study aimed to develop and describe a novel surgical procedure that involves hysteroscopic fenestration with precise incision of the complete uterine septum and double cervix preservation after magnetic resonance imaging (MRI) evaluation in patients and to evaluate its efficacy.
A prospective consecutive clinical study.
A university teaching hospital.
Twenty-four patients with complete septate uterus and double cervix.
Three-dimensional reconstruction of uterus was performed with pelvic MRI and three-dimensional SPACE sequence scanning. Hysteroscopic fenestration with precise incision of the cavity septum and double cervix preservation was performed in patients. Three months after operation, follow-up pelvic MRI and second-look hysteroscopy were performed conventionally.
Operating time, blood loss, operative complications, MRI and hysteroscopic changes of uterus, symptoms improvement, and reproductive outcomes were assessed. The surgery was successfully completed without any intraoperative complications in all patients. Operating time was 21.71 ± 8.28 minutes (range, 10–40 minutes) and blood loss was 9.92 ± 7.14 mL (range, 5–30 mL). Postoperative MRI showed the uterine anteroposterior diameter (3.66 cm vs 3.92 cm; p <.05) was increased. Postoperative MRI and the second-look hysteroscopy showed the cavity shape and uterine volume were expanded to the normal. Symptoms of dysmenorrhea, abnormal uterine bleeding, and dyspareunia were ameliorated after the surgery in 70% of patients (7 of 10), 60% of patients (3 of 5), and 1 patient, respectively. The preoperative spontaneous abortion rate was 80% (4 of 5) and the postoperative spontaneous abortion rate was 11.11% (1 of 9). After the surgery, there were 2 ongoing pregnancies and 6 pregnancies ended in term births. Two live births were delivered by cesarean section and 4 by vaginal delivery without cervical incompetence during pregnancy.
Hysteroscopic fenestration with precise incision of the uterine septum and double cervix preservation is an effective surgical procedure.
Diagnostic and therapeutic evaluation of recurrent abortions
2023, FMC Formacion Medica Continuada en Atencion Primaria
- •
  Se define aborto de repetición, cuando se producen 2 o más abortos, con independencia de que se haya producido algún recién nacido vivo anterior o entre los abortos.
- •
  Las causas que se proponen son múltiples, incluyendo anormalidades endocrinológicas y metabólicas, factores genéticos, trombofilias, factores ambientales, infecciones, causas anatómicas. Las únicas causas de aborto recurrente que han sido demostradas son las genéticas y el síndrome antifosfolípido.
- •
  Ni las infecciones vaginales y/o cervicales ni la presencia de anticuerpos antifosfolípidos sin criterios de síndrome antifosfolípidos ni las trombofilias hereditarias (mutación del factor V de Leiden) se relacionan con los abortos de repetición, por lo que no se precisa cribado en el estudio de abortos de repetición.
- •
  El abordaje del embarazo de una mujer con abortos de repetición se basa en una adecuada anamnesis, descartar un síndrome antifosfolípido (establecido por criterios clínicos (obstétricos y por antecedentes trombóticos) y por criterios analíticos (la presencia de anticuerpos antifosfolípidos –anticoagulante lúpico, anticuerpos anticardiolipinas, anticuerpos anti-β2 glicoproteína−) y descartar hipotiroidismo. Se recomiendan pruebas de imagen para descartar malformaciones. La histeroscopia, ecografía (en especial 3D) y la sonohisterografía son las pruebas para valorar la cavidad uterina. Ocasionalmente se puede recurrir a la resonancia magnética o a la laparoscopia.
- •
  No parece indicado el despistaje de trombofilias hereditarias incluida la mutación del factor V de Leiden, ni la determinación de serologías. Se aconseja un estudio genético de los padres y estudio de los restos abortivos en caso de aborto.
- •
  En relación con el tratamiento preventivo de los abortos de repetición, la progesterona solamente se ha mostrado eficaz en el caso de sangrado vaginal temprano durante el embarazo. En el caso de embarazadas con síndrome antifosfolípido (SAF) el tratamiento de elección es la aspirina junto con heparinas de bajo peso molecular. El hipotiroidismo clínico hay que tratarlo, no habiendo evidencia sobre el beneficio del tratamiento del hipotiroidismo subclínico, se acompañe o no de la presencia de anticuerpos antitiroideos.

View all citing articles on Scopus

: The authors have no commercial, proprietary, or financial interest in the products or companies described in this article.

View full text

Review ArticleHysteroscopic Metroplasty for the Septate Uterus: Review and Meta-Analysis

Abstract

Section snippets

Incidence

Genetic Factors

Classification of Uterine Anomalies

Vascularization and Muscular Components of the Uterine Septum

Diagnosis and Evaluation

Reproductive Problems Caused by Uterine Septum

Why Do Some Women With Uterine Septum Abort?

Indications for Metroplasty

Preoperative Evaluation and Diagnosis

Treatment of Uterine Septum

Prophylactic Antibiotic Therapy

Hormone Therapy

Healing of the Uterus After Hysteroscopic Metroplasty

Treatment of Complete Septate Uterus With Septate Cervix

Endoscopic Treatment of Bicornuate Uterus or Strassman Metroplasty

Early and Late Complications of Hysteroscopic Metroplasty

Published Surgical Results of Hysteroscopic Metroplasty and Their Level of Evidence

Meta-analysis of Reproductive Outcomes After Hysteroscopic Metroplasty

Future of Hysteroscopic Metroplasty

Summary and Conclusions

Acknowledgments

Fertil Steril

Fertil Steril

J Minim Invasive Gynecol

Am J Obstet Gynecol

J Minim Invasive Gynecol

Fertil Steril

Fertil Steril

Fertil Steril

Fertil Steril

Eur J Obstet Gynecol Reprod Biol

Fertil Steril

Int J Gynaecol Obstet

J Minim Invasive Gynecol

Reprod Biomed Online

Fertil Steril

Fertil Steril

Fertil Steril

Obstet Gynecol

Fertil Steril

Fertil Steril

J Minim Invasive Gynecol

J Minim Invasive Gynecol

J Minim Invasive Gynecol

Fertil Steril

Fertil Steril

Am J Obstet Gynecol

Fertil Steril

Surg Clin North Am

Fertil Steril

Int J Gynaecol Obstet

Fertil Steril

Fertil Steril

Fertil Steril

Am J Obstet Gynecol

Middle East Fertil Soc J

Fertil Steril

Am J Obstet Gynecol

Fertil Steril

Fertil Steril

Fertil Steril

Evaluation and management of uterine causes of infertility

Clin Obstet Gynecol

Congenital anomalies of female genital tract: functional classification based on review of 56 personal cases and 500 reported cases

Obstet Gynecol

Fertility and unification of double uterus

Fertil Steril

Uterus unicollis and its relationship to pregnancy

BJOG

Uterine anomalies

Genetic studies in incomplete Mullerian fusion

Obstet Gynecol

The urogenital system

Human Embryology

Anatomic uterine defects

Clin Obstet Gynecol

The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions

Review Article
Hysteroscopic Metroplasty for the Septate Uterus: Review and Meta-Analysis