IN THE NAME OF GOD

Surgical management of congenital uterine anomalies

Surgical repair of congenital uterine anomalies is primarily directed toward women with uterine septa, bicornuate uteri, and obstructed hemi-uteri. Women with unicornuate or arcuate uteri are generally not candidates for reconstructive procedures because surgery does not improve pregnancy outcome

The most common indications for repair of congenital uterine anomalies are pelvic pain and repetitive pregnancy loss. Prior to surgical intervention, however, other causes of these problems should be excluded.

Dysmenorrhea in women with septate uteri may be considered an indication for hysteroscopic metroplasty if medical therapy is not effective. Laparoscopic evaluation for coexistent endometriosis (common in women with structural abnormalities of the reproductive tract) should be undertaken

Do not believe abdominal repair of the didelphic uterus to improve pregnancy outcome is sufficiently supported by existing data. Pregnancy outcomes in women with bicornuate uteri have been reported to be close to those of the general population. However, since some of these women have recurrent pregnancy loss, surgical treatment with uterine reunification via laparoscopy or laparotomy may be indicated after other possible causes of recurrent pregnancy loss have been addressed

Surgical correction is not warranted in asymptomatic women or those with primary infertility. Uterine abnormalities typically don't prevent conception and implantation.

As an example, one series of 228 women with uterine anomalies noted that 9.1 percent had primary infertility, and most of these cases could be explained by other defects Most authorities agree that primary infertility in the presence of uterine anomalies is not an indication for metroplasty.

However, metroplasty may be considered after a complete diagnostic evaluation has been performed and appropriate therapeutic interventions have failed.

OBSTRUCTED UTERINE RUDIMENTARY HORNS Women with müllerian aplasia or a unicornuate uterus and cyclic or chronic abdominal or pelvic pain may have a noncommunicating uterine horn with functional endometrium MRI or ultrasound are useful in identifying the noncommunicating uterine horn and determining whether an endometrial stripe is present.

Right hemiuterus does not communicate with the cervix and should be removed laparoscopically.

Patients with an obstructed uterine horn are at increased risk of endometriosis, but the endometriosis usually resolves after the removal of the obstructed hemiuterus. Excision of the obstructed rudimentary blind horn will prevent endometriosis by eliminating reflux, and will also prevent development of a pregnancy (and pregnancy complications) in the obstructed uterine horn The obstructed rudimentary noncommunicating uterine horn should be removed laparoscopically

HYSTEROSCOPIC REPAIR OF THE SEPTATE UTERUS Hysteroscopic metroplasty has become the method of choice for repair of most uterine septa. Benefits to the transcervical approach include less morbidity, no abdominal or transmyometrial incisions, and faster return to normal activity. As there is no abdominal incision, possible infections and intra-abdominal adhesions that may cause future infertility problems or pain are avoided. Women may attempt pregnancy sooner after a vaginal/transcervical approach than after abdominal procedures. Vaginal delivery is not contraindicated.

Smooth broad fundus of septate uterus viewed through a laparoscope

Uterine septum separating uterine cavity into two horns

Various techniques and instruments are used either to incise or remove the septum, including semirigid or rigid scissors (7 French) or unipolar wire loop (8 mm) urologic resectoscope (21 to 26 French sheath); Versapoint bipolar electrode (1.6 mm; 5 mm sheath); or Potassium-titan-phosphate (KTP/532), neodynamic:yttrium aluminum garnet (Nd:YAG), or argon lasers.

Use of any of the above instruments is associated with good success rates and infrequent complications. Use of microscissors or bipolar electrode may decrease operating time

Postoperative care No further treatment is required postoperatively. Intrauterine devices, Foley balloons, high-dose estrogen, and antibiotics are not necessary Formation of intrauterine synechiae is rare, as are postoperative infections. Endogenous estrogen is sufficient to promote new endometrium within two months of hysteroscopic metroplasty

An HSG should be performed two months after surgery to assess success. Typically, over 90 percent of the septum is removed during the procedure. Attempts at pregnancy may begin two months postoperatively if the procedure is deemed adequate

Outcome A meta-analysis of 29 observational studies that evaluated hysteroscopic metroplasty in women who were not treated with in vitro fertilization found a pregnancy rate of 64 percent and a live birth rate of 54 percent after the procedure

LAPAROSCOPIC/ABDOMINAL TRANSMYOMETRIAL REPAIR OF THE SEPTATE UTERUS Most uterine septums can be successfully surgically addressed hysteroscopically. If however the septum cannot be safely removed hysteroscopically, then an abdominal or laparoscopic approach, such as the Jones or Tompkins metroplasty, can be used

Jones metroplasty AB

Jones metroplasty CD

Tompkins metroplasty (A and B)

Tompkins metroplasty (C and D)

UTERINE TRANSPLANTATION Uterine transplant is a potential option for patients with Müllerian agenesis and fusion defects (eg, Mayer-Rokitansky-Küster-Hauser syndrome [MRKH], congenital absence of the uterus). For women with MRKH, approaches to having a child include adoption, gestational carrier, or uterine transplant.

Extensive counseling and discussion should occur due to the risks and benefits of each option. In some parts of the world, gestational carriers are not legal and thus adoption and transplant are the only options. If a uterine transplant is a possibility, the decision process includes consideration of the surgical risk to the donor and recipient, immunosuppressive medications for the recipient, and the potential unknown risk to the baby due to in-utero exposure to the antirejection medications.

There have been only a few reports of human uterine transplantation [19-23]. Donors were deceased [21,24], from mothers to daughters [20], and from an unrelated friend [23]. The first live birth after uterine transplantation occurred in 2014 [23]. The uterus donor was a 61 year-old unrelated family friend. The transplant recipient, a 35 year-old woman with congenital Müllerian agenesis, was delivered via cesarean at 32 weeks of gestation because of preeclampsia. The healthy 1775 gram infant was appropriately grown for gestational age. However, in one case, uterine necrosis developed 99 days after the transplant and required hysterectomy [25].

OUTCOME Fetal salvage — Improved fetal survival has been demonstrated for all of the above described procedures. The successful pregnancy rate after hysteroscopic metroplasty is 85 to 90 percent, which compares favorably with preoperative fetal salvage rates of 5 to 10 percent

Reduction in pregnancy complications The frequency of malpresentation, retained placenta, and intrauterine growth restriction associated with müllerian abnormalities should return to that of the general population after repair. It is unclear whether there is an improvement in preterm birth rate

Reduction in dysmenorrhea A prospective study of dysmenorrhea reported by women who underwent Tompkins (n = 28) or hysteroscopic (n = 62) metroplasty for septate uteri found that the frequency of dysmenorrhea fell from 50 to 32 percent after the Tompkins procedure and from 55 to 18 percent after hysteroscopic treatment [42].

COMPLICATIONS There is an increased risk of uterine rupture with procedures requiring fundal hysterotomy. Most authors recommend cesarean delivery for these women. attempted vaginal delivery is generally recommended after these procedures in the absence of other obstetrical indications for cesarean birth In complex uterine anomaly cases, an option of adoption or gestational carrier should be addressed with the patient.