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

2. Mullerian Anomalies
American Fertility Society classification of Mullerian anomalies. 2

3. Mullerian Anomalies 3

4. Mullerian Anomalies in infertil woman4 4

5. Mullerian Anomalies in woman who had habituel abortus5 5

6. Michael K Bohlmann Reproductive BioMedicine Online (2010)6 6

7. Michael K Bohlmann Reproductive BioMedicine Online (2010)7 7

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

9. Uterine Septum
Complet
Partial (subseptus) 9

10. Diagnosis
HSG 10 10

11. Bicornuate uterus – septum difference
UTERINE SEPTUM 11

12. Arcuate uterus diagram12 12

13. SALINE SONOHYSTEROGRAPHY13 13

14. 14 14

15. Diagnosis HSG correctness : 20-60%
TVUSG sensitivity: 100%, spesificity: 80%
3D USG correctness: 92%
Hysterosonography
correctness: 100%
MRI correctness: %
H/S+L/S: GOLD STANDART
Taylor & Gomel et al., 2008 15

16. 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

17. (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

18. (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

19. (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

20. 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

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

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

23. Hysteroscopic metroplasty

24. 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

25. 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

26. 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

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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

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

37. Management and reproductive outcome of complete septate uterus with duplicated cervix and vaginal septum: review of 21 cases.
Group 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

38. 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
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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Management
Istre et al, Fertl Steril 2010 44 44

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