HYSTEROSCOPIC SEPTUM RESECTIONHYSTEROSCOPIC SEPTUM RESECTION

Recai PABUÇCU M.D.Recai PABUÇCU M.D.Ufuk University Faculty of Ufuk University Faculty of

MedicineMedicineObstetrics and Gynaecology Obstetrics and Gynaecology

DepartmentDepartment

-January 11-12 2014-

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Mullerian AnomaliesMullerian AnomaliesAmerican Fertility Society classification of Mullerian anomalies.

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Mullerian AnomaliesMullerian Anomalies

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Mullerian Anomalies in infertil womanMullerian Anomalies in infertil woman

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Mullerian Anomalies in womanMullerian Anomalies in womanwho had habituel abortuswho 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 SeptumUterine 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 SeptumUterine Septum

Complet Partial (subseptus)

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DiagnosisDiagnosis

HSG

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Bicornuate uterus – septum Bicornuate uterus – septum differencedifference

BICORNUATE UTERUS

UTERINE SEPTUM

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Arcuate uterus diagram

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SALINE SONOHYSTEROGRAPHYSALINE SONOHYSTEROGRAPHY

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DiagnosisDiagnosis

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 uterus should be more than 10 mm, but not exceeding 15 mm. The external shape of the uterus seen in laparoscopy might be normal. 18

(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 Uterine SeptumSeptum

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., 200420

Hysteroscopic metroplastyHysteroscopic metroplasty

With general or spinal anestesia.

Must be done at early follicular phase.

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Hysteroscopic metroplastyHysteroscopic metroplasty

Microscissor Electrocautery Septal incision with laser.

Homer et al., 2000

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Hysteroscopic Hysteroscopic metroplastymetroplasty

Abortion rate decreases from 88% to %4 after resection. Live birth rate increases from 3% to %80 after resection.

Reproductive outcome after Reproductive outcome after resectionresection

Homer et al., 2000

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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 Reproductive outcome after hysteroscopic metroplasty in hysteroscopic metroplasty in

women with septate uterus and women with septate uterus and otherwise unexplained otherwise unexplained

infertilityinfertility

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Hysteroscopic resection of the septum Hysteroscopic resection of the septum improves theimproves the pregnancy rate of women with pregnancy rate of women with

unexplained infertility:unexplained infertility: a prospective a prospective controlled trialcontrolled 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 2009

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Mollo et al, Fertil Steril 2009

Pregnancy and live birth rate is significantlyhigher in metroplasty group.

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

unexplained infertilityunexplained 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 Determinants of fertility and reproductive success after hysteroscopic reproductive success after hysteroscopic septoplasty for women with unexplained septoplasty for women with unexplained primary infertility: a prospective analysis primary infertility: a prospective analysis

of 88 casesof 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 Results after hysteroscopic metroplastymetroplasty

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

metroplasty Istre et al, Fertl Steril 2010 30

Hysteroscopic metroplasty in women with septate uterus and unexplained infertility could improve clinical pregnancy rate and live birth rate in patients with otherwise unexplained 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 32

Hysteroscopic metroplasty: Hysteroscopic metroplasty: reproductive outcome in relation to reproductive outcome in relation to

septum sizeseptum 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 Cervical septum must be cut or not?not?

Bleeding Cervical

incompetence

Rock et al., 1999Valle et al., 1996

Less complication Higher

reproductive outcome

CURRENT PRACTICE

Valli et al., 2004Patton et al., 2004

Parsanezhad et al., 200634

Multicenter, randomized, controlled study

Hysteroscopic metroplasty of the Hysteroscopic metroplasty of the complete uterine septum, duplicate complete uterine septum, duplicate

cervix, and vaginal septumcervix, 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 Management and reproductive outcome of complete septate uterus with duplicated complete septate uterus with duplicated cervix and vaginal septum: review of 21 cervix and vaginal septum: review of 21

cases.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 Small-diameter hysteroscopy with Versapoint versus resectoscopy with a Versapoint versus resectoscopy with a

unipolar knife for the treatment of septate unipolar knife for the treatment of septate uterus: a prospective randomized studyuterus: 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, 2007

Reproductive outcome is similar for both groups

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

randomized pilot studyrandomized 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. 40

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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ManagementManagement

Istre et al, Fertl Steril 2010 44

ConclusionConclusion

Hysteroscopic metroplasty is GOLD STANDART.

For better reproductive outcome hysteroscopic metroplasty must be performed before fertility treatment

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