Fig. 26.1
The operation is stopped when the muscular layer is reached. It is important to pay attention to not cut too deep into the muscular layer and to leave a safety thickness of 10 mm of the fundal wall, in order to avoid possible future uterine ruptures
Small Diameter Hysteroscopes and “Office Procedures”
Usually do not need general anaesthesia and most of the times neither local application of anaesthetics. The scope, complete with operative sheet is 5.5 mm thin or below. Different office operative hysteroscopes are available in the market, the most diffused are the Bettocchi scope and recently the TROPHY Campo scope. Several Authors prefer this method because of the facility to entry the uterus without cervical dilatation, use of saline solution as distension medium and, according to the Authors, reduced possibility of uterine perforation and thermal trauma. Authors, who prefer this technique, stress particularly the fact that, according to their opinion, office technique is safer and carrier of a lower incidence of complications. As will be reported below the adverse events during metroplasty and the clinical results are independent from the used techniques. Litta compared the results of resectoscopic metroplasty versus the same procedure using office hysteroscope with 5 Fr bipolar electrode, called Versapoint. The results were comparable but the rate of a residual septum of more than 1 cm was almost double higher in the Versapoint group [38]. A higher necessity for second surgery for incomplete septum resection by Versapoint was reported also by other authors [13].
The technique is called also “vaginoscopic”. The scope is introduced in vagina and, once visualized the external cervical ostium, the uterine cavity is reached without using specula and tenacula. The distension medium (warm saline solution) is used to facilitate the trespassing of the cervical canal. Since the visualization of the cavity is not as broad as in the resectoscopic technique, two incisions, as landmarks, must be done at both sides of the septum before starting the incision. The incision can be done by cold scissors or electric devices.
Fibre Optic Laser
Soon after first hysteroscopic metroplasties were successfully performed, Fiberoptic Nd:YAG laser, argon laser or KTP-532 lasers were introduced on the market and several studies were published reporting the feasibility, patients compliance, complications and clinical results of those tools [57]. In a series of 21 patients Candiani e co-workers report on a comparison between resectoscopy by argon laser versus the same procedure performed by micro scissors. Authors did not find significant differences in clinical outcome between the two groups. Nevertheless laser technique was more time consuming, complicated and more expensive than the micro scissors technique [7]. Similar results were reported by Fedele, comparing laser, micro scissors and resectoscope techniques [21]. In front of higher costs laser surgery did not evidenced better reproductive performances. More, thermal injuries may cause small uterine wall weakness or misdiagnosed perforations with subsequent risk of ruptures during pregnancy or labor [31, 39].
Outcomes and Clinical Results
Complications
Several original papers and reviews refer of a series of complications during surgical procedure or during subsequent pregnancy and labor. In a extensive review, Valle and Ekpo report different complications, mostly uterine perforations, during surgery. Such complications occurred either in case of use of resectoscopes or of small diameter hysteroscopes. Argumentations about the higher incidence of surgical complications by using resectoscope instead of small diameter scope with micro scissors or Versapoint seem more subjective impressions of some authors than facts proved by evidences [13, 38, 42].
Distension media may cause fluid overload due to intravasation into the vascular system. The overload may cause hyponatriemia, pulmonary and disseminated intravascular coagulation. It must be clear that each used distension medium may cause intravasation, either low viscosity fluids such Dextran and Glycin, or saline solution but the safety limit of saline solution is much higher than the others media. A consequence of this fact is that bipolar resectoscopes and small diameter hysteroscopes using bipolar energy such as Versapoint devices or even micro scissors which are, from this point of view, much more safe than monopolar devices. On the other hand metropasties are, in experienced hands, not time consuming procedures and the amount of fluid intravasation is minimal, non comparable to longer procedures such as hysteroscopic myomectomies.
In case of total uterine septum and the presence of a septate or double cervix, U2C1or U2C2, according to the ESHRE/ESGE Classification on female genital tract congenital malformations [29], persist the dilemma if the cervix should be resected together with the septum, or left in order to avoid cervical weakness during subsequent pregnancy. The anomaly is very rare and unclassified by most recognized international classifications [9, 47, 53].
Clinical Results
Septate uterus may cause, according to numerous authors, infertility (often classified as unexplained), miscarriage and preterm delivery and malpresentations. Clinical results of hysteroscopic metroplasties are generally good and seem to be independent from the tools, the type of energy and the techniques used. Improvement in fertility and pregnancy outcomes in patients operated with resectoscopes are as good as in those operated by micro scissors or Versapoint [4, 8, 13, 25–27, 33, 35, 38, 56].
Infertility
Almost 40 % of women with so-called idiopathic infertility have a septate uterus and up to 60 % of these patients spontaneously conceive after metroplasty of septa larger than 1 cm [18, 28, 61]. In a series of forty patients, Pace reports a 75 % of spontaneous pregnancy rate after surgery for septate uterus. Uterine artery pulsatility index after metroplasty was find to be significantly lower than before on Doppler velocimetry [43, 44]. According to Mollo, metroplasty improved the spontaneous pregnancy rate after surgery in a population with septum and no other cause of infertility. The life birth rate was significantly higher, comparing to a similar population of idiopathic infertility but without a septum [41]. In a review by Homer, a general improvement of spontaneous pregnancy rate is reported after surgery in a population of patients with primary infertility [32]. In their meta-analysis of studies published from 1986 to 2011, Valle and Ekpo report an overall pregnancy rate of 63.5 % and a live-birth rate of 50.2 % [58].
On the other hand, Daly published in 1989 a series of 70 patients treated for uterine septum. He recorded a significant improvement in first and second trimester miscarriage rate, but did not find a reduced incidence of preterm labor neither an improvement of fecundity in patients with primary infertility [15]. Homer [32] compared the reproductive outcome before and after hysteroscopic metroplasty resulting in a decrease in miscarriage rate from 88 % before to 14 % after metroplasty and an increase in live birth rate from 3 % before to 80 % after. Although the role of metroplasty in unexplained infertility still remains controversial, he reported an overall crude pregnancy rate of 48 % after metroplasty. According to Porcu, the spontaneous pregnancy rate in women who underwent metroplasty for septate uterus is similar to the pregnancy rate obtained with Assisted reproductive techniques (ART) [49].
ART may represent a model in order to study uterine factor of infertility, since tubal and male factor have been by-passed by the ART procedures. In a retrospective study done on patients undergoing ART in a period of 10 years, pregnancy rate (PR) and live birth rate (LBR) were significantly lower in patients with septate uterus, comparing to other patients. On contrary, PR and LBR were similar in patients who underwent metroplasty before ART comparing to the controls [56].
Recurrent Miscarriage
In a retrospective study the presence of chromosomal anomalies in aborted concepti was significantly lower in a group of patients with septate or disfused uterus versus those with a normal uterus (15.4 % versus 57.5 %). The same authors found a higher probability to a repeated miscarriage in cases with a higher ratio between the length of the indentation and the remaining uterine cavity, according to Salim and co-workers [52, 55]. Other studies did not find a significant correlation in the miscarriage rate between the grade of distortion of the cavity and the dimension of the uterine septation either before or after metroplasty [4, 25, 26, 46]
In a series of 70 patients either with primary infertility, repeated miscarriage, second trimester pregnancy loss or preterm delivery, Doridot reports a significant improvement of pregnancy outcomes in the population of women suffering for repeated miscarriage or in those who experienced second trimester pregnancy loss or preterm delivery after metroplasty for septate uterus. The paper evidences also a reduced risk for miscarriage in primary infertility patients who conceived after metroplasty. The author concludes that an expecting policy in patients with a septate uterus who suffered for a miscarriage or other obstetric complication is not a wise management [18]. Patients with two ore more consecutive miscarriage who never gave birth are more likely to have a septate uterus, comparing to those who gave birth at least once. On contrary, the presence of acquired uterine anomalies are not influenced, according to Jaslow and Kutteh, from previous deliveries [36]. Miscarriage rate is lower after metroplasty independently from the obstetric history before surgery and is independent from the dimension of the septum [5]. After stratifying 288 patients according the deepness of the uterine septation (less than 1.5 cm and 1.5 cm or more), the outcomes of spontaneous pregnancies were analyzed. The miscarriage rate did not differ between the two groups either before metroplasty (75 % vs. 75.2 %) or after metroplasty (13.6 % vs. 16.7 %). According to the results it seems that the dimension of the septum is not influencing the severity of the obstetric complication of septate uterus [25].
Preterm Delivery
In 1994 a French study concluded that resecting the septum is the only way to increase the pregnancy outcome and should be preferable to cervical cerclage [24]. In a review of the literature, Homer reports an overall incidence of preterm delivery of 9 % in patients before metroplasty and a reduction to 6 % of preterm delivery after surgery.
In a systematic review of a British group the paper reports a 2.3-fold risk for preterm delivery in patients with septate uterus [10]. According to Zlopasa, small uterine septa and bicornuate uteri are mostly implicated in the aetiology of preterm delivery [63]. Zhang reports a 19.8 % of preterm delivery in women with septate uterus [62]. In a population of women undergoing hysteroscopy due to abnormal uterine bleeding, Maneschi reports that women with uterine malformations showed a significantly lower term delivery rate [40]. Hua reports an adjusted Odds ratio (aOR) of 7.4 for preterm delivery before 34th week of pregnancy and a 5.9 aOR for delivery before 37th week. On the other hand Agostini worries about increased risk for fetal malpresentations at term, low birth weight infants, and delivery by caesarean section after metroplasty for septate uterus [3].
Conclusions
The estimated prevalence of congenital uterine anomalies, and septate uterus in particularly, varies from author to author. Even using same or similar diagnostic tools, the lack of uniformity between papers seems to indicate a different interpretation of examination results, more than to real differences in the studied populations [2, 12, 37, 51].
According to most of the related papers, septate uterus is cause of repeated miscarriage, second trimester pregnancy loss and malpresentations. Septate uterus is not generally admitted to be a cause of infertility, even if several papers report a longer time to conceive in patients with septate uterus before metroplasty. Similarly, septum may impair the results of assisted reproductive techniques.
Randomized controlled trials are needed to confirm the beneficial effects of metroplasty reported by numerous publications. Such trials are difficult to carry on, not only because of a relative difficulty to randomize the patients, but also because of an objective difficulty to design an appropriate study.
In the era of internet, women candidate to enter the randomization who are aware of dozens of non randomized publication which confirm the improvement of pregnancy and live birth rates after metroplasty would decline to enter the study. More, a multicentre randomized trial would be difficult also because of a lack of uniformity in the distinction between a normal uterine cavity and a small septate uterus. The new ESHRE-ESGE classification on congenital uterine anomalies may result a helpful tool to reach a greater homogeneity of studies or almost of the interpretation of uterine imaging procedures, since the terminology “arcuate” uterus has been abandoned by this classification. Waiting for the highest level of evidence, according to prospective and retrospective epidemiological studies, is seem that hysteroscopic resection of uterine septum may improve the pregnancy outcome, the outcome of ART techniques and may shorten the pregnancy seeking time in couples with prolonged primary or secondary infertility.
References
1.
Acién P. Reproductive performance of women with uterine malformations. Hum Reprod. 1993;8(1):122–6. PubMed PMID: 8458914.PubMed
2.
3.
4.
Ban-Frangez H, Tomazevic T, Virant-Klun I, Verdenik I, Ribic-Pucelj M, Bokal EV. The outcome of singleton pregnancies after IVF/ICSI in women before and after hysteroscopic resection of a uterine septum compared to normal controls. Eur J Obstet Gynecol Reprod Biol. 2009;146(2):184–7.PubMedCrossRef
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
