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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.
2
Mullerian Anomalies
3
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
28
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.
37
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
38
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
39
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.
42
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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