Objective
To assess the postoperative restoration of a normal uterine cavity, uterine cavity measurements were obtained in patients with arcuate or septate uteri in the periods before and after resection.
Study Design
Twenty-eight women diagnosed with arcuate or septate uteri were evaluated with 3-dimensional ultrasound before and after undergoing surgical resection by hysteroscopic resection, in a university center. In addition to the conventional parameters, measurements of the subseptum’s length and width, and cavity width, were obtained on a frozen coronal view of the uterus. Postoperatively, uterine cavity width was measured.
Results
Twelve patients were diagnosed with arcuate uterus and 16 with septate uterus and subsequently underwent surgical correction. Of them, 50% had a retroverted uterus and 61% had a diagnosis of polycystic ovary syndrome (7/28, or 25%, had both). Uterine length, width, and height, before and after resection, were similar between arcuate and septate, as were the subsepti base widths, despite the different lengths. However, cavity width was significantly decreased after resection only in the septate uterus group: 3.6 cm, 95% confidence interval, 3.3–3.9, preoperatively vs 2.8 cm, 95% confidence interval, 2.5–3.1, postoperatively, respectively; P < .001. The postoperative difference in cavity width was directly correlated with the length of the subseptation (r –0.59, P = .05).
Conclusion
Postoperative measurements of the uterine cavity revealed a remarkable uterine remodeling capacity: we speculate this could represent the most important single change to explain improved pregnancy outcomes after surgical correction of subseptations.
Arcuate (20%, category VI in American Fertility Society classification) and septate (35%, category V) uteri taken together account for most cases of müllerian anomalies. Embryologically, both anomalies are due to defective resorption of the midline uterine septum after müllerian duct fusion has occurred. The uterus exhibits a normal, convex, or flattened outer contour of the fundus. Differentiation between these anomalies is artificially established by the definition of an arcuate uterus as having a subseptation <10 mm long, and a septate uterus as having a subseptation ≥10 mm long, sometimes associated with a cervical septum (complete uterine septum) and/or a vaginal septum ( Figure 1 ). Final diagnosis is made by laparoscopy/hysteroscopy; however, it can be noninvasively established by magnetic resonance or 3-dimensional (3D) ultrasound imaging, and at the current time 3D ultrasound is gradually replacing magnetic resonance because of its higher accuracy.
The incidence of arcuate and septate is higher in patients with infertility and recurrent pregnancy loss. Arcuate uterus was found to be more frequent in women with infertility: 15% of 600 patients diagnosed with infertility vs 3% of 409 women with normal fertility.
When left untreated, arcuate and septate uteri have a higher risk of miscarriage and adverse pregnancy outcomes than normal uteri. However, restoration of normal fertility and pregnancy outcomes are achieved with surgical correction. A recent Cochrane systematic review including only 2 publications found that in women with unexplained infertility there is no benefit in the hysteroscopic resection of the subseptations. However, the role of surgical resection in improving pregnancy outcomes remains pivotal. For these reason, hysteroscopic resection of subseptations has become routine in clinical practice, especially in fertility clinics, where surgery is undertaken prior to performing fertility treatments in an attempt to decrease the risk of miscarriage should pregnancy occur. In addition, a recent large retrospective study underscored the importance of septum resection in patients with infertility for the sole purpose of ameliorating fertility outcomes, independently from obstetric outcomes. It is unclear what postoperative changes would determine the improved pregnancy outcomes after surgical correction of the subseptations. We hypothesized that postoperative restoration of a normally shaped cavity would possibly be the most important single change to explain it.
We sought to evaluate uterine cavity measurements in patients with septate, as well as arcuate, uteri in the periods before and after resection using 3D ultrasound. This would allow us to explore possible differences between the artificially distinctive categories of subseptations.
Materials and Methods
This was a prospective cohort study. The conduct of this study was approved by the University of Tennessee Health Science Center Human Investigation Committee. Patients signed an informed consent form.
A cohort of women diagnosed with arcuate or septate uteri were evaluated with 3D ultrasound before undergoing surgical resection by hysteroscopic resection. In addition to all the standard measurements including uterine length, height, and width, measurements of the subseptum’s length (measured from the base to the tip: <10 mm defines arcuate, and ≥10 mm defines septate uterus, respectively) and width (measured at the subseptum’s base), and cavity width (measured between the tubal ostia), were obtained on a frozen coronal view of the uterus ( Figure 1 ). The frozen coronal view was rotated around the x-axis to evaluate the outer contour of the uterus and to obtain the most accurate subseptation measurements.
Surgical resection was performed regardless of the menstrual cycle phase, following standard operative technique with either cold scissors, without diathermy, or with a bipolar cutting needle with 30- to 50-W cutting current ( Figure 2 , B). Subseptations were resected from the lower tip going toward the fundus up to the line connecting the tubal ostia. All patients had an intrauterine balloon placed at the end of the surgical resection, which was kept in the cavity for a maximum of 4 days and removed in the office. Postoperatively, all patients received broad spectrum antibiotics and transdermal estrogen supplementation for 7 days (200 μg/d estradiol Vivelle-Dot estradiol transdermal system; Novartis Pharmaceutical, East Hanover, NJ).
Two to 4 weeks after undergoing surgical resection, at the time of the first postoperative visit after intrauterine balloon removal, a second 3D ultrasound was obtained to measure the cavity width, in addition to all the standard measurements.
Paired and independent sample t test and Pearson correlations (SPSS v21; IBM Corp, Armonk, NY) were used, with 95% confidence intervals (CIs), to define internal estimates associated with each probability; a P < .05 defined significance.
Results
Twenty-eight patients were diagnosed with either arcuate (n = 12) or septate (n = 16) uterus and underwent surgical correction. Most patients presented to our clinic reporting infertility (27/28, 96%); 1 had experienced 3 consecutive losses after a term pregnancy and was also heterozygous for Factor V of Leiden and of advanced age, being 42 years old. The average age of the patients was 31.4 years (95% CI, 29.1–33.8). Of them, 50% had a retroverted uterus and 61% had a diagnosis of polycystic ovary syndrome (PCOS). Twenty-five percent had both PCOS and a retroverted uterus, and 1 also had uterine leiomyomas and endometriosis. Uterine length, width, and height (cm) before and after resection were not different between arcuate and septate uteri. Beyond the obvious difference in length, subseptations of arcuate uteri had a wider base than the ones of septate uteri. Preoperative and postoperative uterine measurements are reported in Table 1 .
| Variable | Arcuate, average (95% CI) n = 12 | Subseptate, average (95% CI) n = 16 | P value |
|---|---|---|---|
| Uterine length, cm | 7.4 (7.0–7.7) | 7.4 (7.1–7.8) | .83 |
| Height, cm | 3.5 (3.2–3.8) | 3.4 (3.0–3.8) | .46 |
| Width, cm | 4.8 (4.5–5.2) | 5.6 (5.2–5.9) | .19 |
| Cavity width, cm | 3.0 (2.9–3.2) | 3.6 (3.3–3.9) | .004 |
| Subseptation width, mm | 19.9 (17.2–22.7) | 24.1 (22.1–26.1) | .02 |
| Subseptation length, mm | 7.2 (6.4–8.1) | 17.6 (10.4–24.7) | .02 |
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