HYSTEROSCOPIC SEPTUM RESECTION -January 11-12 2014- HYSTEROSCOPIC SEPTUM RESECTION Recai PABUÇCU M.D. Ufuk University Faculty of Medicine Obstetrics and Gynaecology Department 1

Mullerian Anomalies American Fertility Society classification of Mullerian anomalies. 2

Mullerian Anomalies 3

Mullerian Anomalies in infertil woman 4 4

Mullerian Anomalies in woman who had habituel abortus 5 5

Michael K Bohlmann Reproductive BioMedicine Online (2010) 6 6

Michael K Bohlmann Reproductive BioMedicine Online (2010) 7 7

Uterine Septum Most common mullerian anomaly is UTERINE SEPTUM. 55% of Mullerian anomalies. Complet or partial defect during uterovaginal septum resorpsion. 8

Uterine Septum Complet Partial (subseptus) 9

Diagnosis HSG 10 10

Bicornuate uterus – septum difference UTERINE SEPTUM 11

Arcuate uterus diagram 12 12

SALINE SONOHYSTEROGRAPHY 13 13

14 14

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., 2008 15

Artur Ludwin J. Obstet. Gynaecol. March 2011 Diagnostic accuracy of sonohysterography, hysterosalpingography and diagnostic hysteroscopy in diagnosis of arcuate, septate and bicornuate uterus. (D) general detection of uterine abnormalities SHG is a noninvasive, cost-effective method available in an outpatient setting that is highly accurate in identifying uterine anomalies, in particular septate uterus. Artur Ludwin J. Obstet. Gynaecol. March 2011 16 16

(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°. 17 17

(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 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°. 19 19

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 20

Hysteroscopic metroplasty With general or spinal anestesia. Must be done at early follicular phase. 21

Hysteroscopic metroplasty Microscissor Electrocautery Septal incision with laser. Homer et al., 2000 22

Hysteroscopic metroplasty

Reproductive outcome after resection Abortion rate decreases from 88% to %4 after resection. Live birth rate increases from 3% to %80 after resection. Homer et al., 2000 24

61 infertil patient with uterine septum Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility 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 25

Hysteroscopic metroplasty Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial Group A 44 patient Septum +Unexplained infertility Group B 132 patient Unexplained infertility Expectant management Hysteroscopic metroplasty 1 year follow up without any treatment Mollo et al, Fertil Steril 2009 26

higher in metroplasty group. Pregnancy and live birth rate is significantly higher in metroplasty group. Mollo et al, Fertil Steril 2009 27

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. 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. Shokeir et al., 2011 29

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 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 31

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: reproductive outcome in relation to septum size 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. Paradisi et al., 2013 33

Cervical septum must be cut or not? Less complication Higher reproductive outcome CURRENT PRACTICE Valli et al., 2004 Patton et al., 2004 Parsanezhad et al., 2006 Bleeding Cervical incompetence Rock et al., 1999 Valle et al., 1996 34

Multicenter, randomized, controlled study Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum Multicenter, randomized, controlled study Group A Cervical septum- N=14 Group B Cervical septum+ N=14 35

Cervical septum resection is suggested for the patient with complet septum Parsanezhad et al., Fertil Steril 2006 36

Management and reproductive outcome of complete septate uterus with duplicated cervix and vaginal septum: review of 21 cases. 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. 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. Chen SQ. et al., 2013 37

Less time, more fluid absorbtion 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 scissor n=80 5-mm hysteroscope and Versapoint n=80 Less time, more fluid absorbtion Less complication Reproductive outcome is similar for both groups Colacurci N, 2007 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 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 Abu Rafea et al, 2013 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. 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. 41

Metroplasty for AFS Class V and VI septate uterus in patients with infertility or miscarriage: reproductive outcomes study. 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 42

RCOG 2003: No results of RCTs are available 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 43

Management Istre et al, Fertl Steril 2010 44 44

Conclusion Hysteroscopic metroplasty is GOLD STANDART. For better reproductive outcome hysteroscopic metroplasty must be performed before fertility treatment 45 45