hysteroscopic septum resection · the reason for high rates of miscarriage, small-for-date infants,...

HYSTEROSCOPIC SEPTUM RESECTION

Recai PABUÇCU M.D.Ufuk University Faculty of Medicine

Obstetrics and Gynaecology Department

-January 11-12 2014-

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Mullerian AnomaliesAmerican Fertility Society classification of Mullerian anomalies.

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Mullerian Anomalies

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Mullerian Anomalies in infertil woman

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Mullerian Anomalies in womanwho had habituel abortus

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Michael K Bohlmann Reproductive BioMedicine Online (2010)

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Michael K Bohlmann Reproductive BioMedicine Online (2010)

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Uterine Septum

Most common mullerian anomaly is UTERINE SEPTUM.

55% of Mullerian anomalies.

Complet or partial defect during uterovaginal septum resorpsion.

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Uterine Septum

Complet

Partial (subseptus)

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Diagnosis

HSG

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Bicornuate uterus – septum difference

BICORNUATE UTERUS UTERINE SEPTUM

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Arcuate uterus diagram

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SALINE SONOHYSTEROGRAPHY

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Diagnosis

HSG correctness : 20-60%

TVUSG sensitivity: 100%, spesificity: 80%

3D USG correctness: 92%

Hysterosonography

correctness: 100%

MRI correctness: 50-100%

H/S+L/S: GOLD STANDART

Taylor & Gomel et al., 200815

(D) general detection of uterine abnormalities

Artur Ludwin J. Obstet. Gynaecol. March 2011

Diagnostic accuracy of sonohysterography, hysterosalpingography and diagnostic hysteroscopy in

diagnosis of arcuate, septate and bicornuate uterus.

SHG is a noninvasive, cost-effective method available in an

outpatient setting that is highly accurate in identifying

uterine anomalies, in particular septate uterus.

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(C) Bicornuate uterus: (C-1) SHG; (C-2) HSG; (C-3) DH; and (C-4) laparoscopy. In HSG the angle between the two uteral cavities (b) is over 60°.

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(A) Arcuate uterus: (A-1) sonohysterography (SHG); (A-2) hysterosalpingography(HSG); (A-3) diagnostic hysteroscopy (DH); and (A-4) laparoscopy. The distance (d)between the middle of the fundus and the line connecting the cornues of the uterusshould be more than 10 mm, but not exceeding 15 mm. The external shape of the uterusseen in laparoscopy might be normal.

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(B) Septate uterus: (B-1) SHG; (B-2) HSG; (B-3) DH; and (B-4) laparoscopy. In HSG the angle between the cornues of the uterus (a) should not exceed 60°.

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Uterine Septum

Reproductive outcome rate decreases Spontaneous abortion %26- %94

Premature labor %9-%33

Fetal survival %10-%75

Spontaneous abortion after resection %5,9

Toriano et al., 2004

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Hysteroscopic metroplasty

With general or spinal anestesia.

Must be done at early follicular phase.

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Hysteroscopic metroplasty

Microscissor Electrocautery

Septal incision with laser.

Homer et al., 2000

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Hysteroscopic metroplasty

Abortion rate decreases from 88% to %4 after resection.

Live birth rate increases from 3% to %80 after resection.

Reproductive outcome after resection

Homer et al., 200024

61 infertil patient with uterine septum

After hysteroscopic metroplasty

After 11.2 months follow up, 41 % (n:25) pregnancy

18 live birth

7 spontaneous abortion

Pabuçcu R.,Gomel V, Fertil Steril, 2004

Reproductive outcome after hysteroscopic metroplasty in women with septate uterus

and otherwise unexplained infertility

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Hysteroscopic resection of the septum improves the

pregnancy rate of women with unexplained infertility: a

prospective controlled trial

Group A44 patientSeptum +Unexplained infertility

Group B132 patientUnexplained infertility

Hysteroscopic metroplasty

Expectantmanagement

1 year follow up without any treatment

Mollo et al, Fertil Steril 200926

Mollo et al, Fertil Steril 2009

Pregnancy and live birth rate is significantlyhigher in metroplasty group.

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

Of the 102 patients who underwent hysteroscopic metroplasty 44(%43.1) were able to achive pregnancy, as compered with 5(%20) of the 25 patients who did not undergo operation.

The results indicate that hysteroscopic metroplasty improves outcomes for patients with a uterine septum and otherwise unexplained infertility.

Tonguc et al, 2011

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Determinants of fertility and reproductive success

after hysteroscopic septoplasty for women with

unexplained primary infertility: a prospective analysis

of 88 cases.

Shokeir et al., 2011

Results demonstrate that reproductive failure seems to depend on patient age, duration of infertility before septum size.

Women with a septum size larger than one-half of their uterine lenght have a higher chance of successful pregnancy after hysteroscopic septoplasty.

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Results after hysteroscopic metroplasty

If the septum size is >1/2 of uterine cavity, patient may benefit from hysteroscopic metroplasty

Istre et al, Fertl Steril 2010

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Hysteroscopic metroplasty in women with septate uterus andunexplained infertility could improve clinical pregnancyrate and live birth rate in patients with otherwiseunexplained infertility.

Gynecol Obstet Invest 2012

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If such a patient is looking for a spontaneous

pregnancy, this is more likely to occur during the

first 15 months following the procedure.

Gynecol Obstet Invest 2012

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Hysteroscopic metroplasty: reproductive

outcome in relation to septum size

Paradisi et al., 2013

Recent studies demonstrate that hysteroscopic metroplasty in cases of partial uterine septum and infertility significantly improves the reproductive performance:

-irrespectively of septum size,-reproductive performance is independent from previous obstetrics history.

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Cervical septum must be cut or not?

Bleeding

Cervical

incompetence

Rock et al., 1999

Valle et al., 1996

Less complication

Higher reproductive

outcome

CURRENT PRACTICE

Valli et al., 2004

Patton et al., 2004

Parsanezhad et al., 2006

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Multicenter, randomized, controlled study

Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum

Group ACervical

septum-N=14

Group BCervical

septum+N=14

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Cervical septum resection is suggested for the

patient with complet septum

Parsanezhad et al., Fertil Steril 2006

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Group 1 - 11 patient – uterine septum+

-hysteroscopic metroplasty

-vaginal septum cut

-cervical septum preserved

Group 2 – 10 patient – uterine septum+

- 4 patient – vaginal septum cut

- 2 patient – L/S adhesiolysis

- 4 patient – No intervention

In group 1, the pregnancy rate is 81.8%, where ıt ıs 50% ın group 2.

Management and reproductive outcome of complete septate uterus with duplicated cervix and vaginal septum:

review of 21 cases.

Chen SQ. et al., 2013

The uterine septum may not necessarily be transected for patients who have complete septate uterus with duplicated cervix and vaginal septum, and meanwhile have no a history of poor reproductive outcome.

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Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment

of septate uterus: a prospective randomized study

Patients with uterine septum 2001-2005

26F resectoscope and unipolar

scissorn=80

5-mm hysteroscope and

Versapointn=80

Less time, more fluid absorbtion

Less complication

Colacurci N, 2007Reproductive outcome is similar for both groups

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Fertility and pregnancy outcomes following resectoscopic septum division with and without intrauterine balloon

stenting: a randomized pilot study

26F resectoscope with monopolar electrical knife of 120 watts power

14F Foley catheter for five days after

resectoscopic septum division

No baloon after prusedure

Abu Rafea et al, 2013

Following resectoscopic septum division with monopolar knife electrode, splinting the uterine cavity with Foley catheter provided no advantage in septum reformation, clinical pregnancy rate, and pregnancy outcomes

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The reason for high rates of miscarriage, small-for-

date infants, fetal death and dystocia in woman with

septated uterus might be mechanical and due to less

of a blood supply in the septum.

Other theories include reduced vascular endothelial

growth factor receptors in septal tissue compared with

lateral endometrium.

Semin Reprod Med 2011;29:101–112.

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There are data demonstrating the benefit of

metroplasty in reducing miscarriage rates, preterm

delivery, and fetal death in patients with a history of

recurrent miscarriage.

Semin Reprod Med 2011;29:101–112.

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After metroplasty, 60.9% of patients became pregnant, 52% of them resulted from assisted reproductive technology.

Outcomes (miscarriages and FLBs) differed significantly according to anatomical type of septum after surgery.

Hysteroscopic septum resection is accompanied by safe improvement in reproductive performance in patients with symptoms of AFS class V/VI

septate uterus.

Bendifallah et al, 2013

Metroplasty for AFS Class V and VI septate uterus in patients with infertility or

miscarriage: reproductive outcomes study.

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ACOG 2001: Women with pregnancy loss and a

uterine septum should undergo hysteroscopic

evaluation and resection (evidence level C)

RCOG 2003: No results of RCTs are available

NVOG: 2007: Do not perform uterine surgery unless

in the context of a clinical trial

● Hysteroscopy for treating subfertility associated with

● suspected major uterine cavity abnormalities (Review)

● COCHRANE 2013: No results of RCTs are available

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Management

Istre et al, Fertl Steril 2010

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Conclusion

Hysteroscopic metroplasty

is GOLD STANDART.

For better reproductive

outcome hysteroscopic

metroplasty must be

performed before fertility

treatment

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