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

Aim

To evaluate the reproductive outcomes of complete septate uterus with duplicated cervix and vaginal septum.

Methods

Twenty-one patients who have complete septate uterus with duplicated cervix and vaginal septum were retrospectively reviewed in this study. In Group I, 11 patients with a poor reproductive outcome (spontaneous miscarriage or infertility) or dyspareunia underwent hysteroscopic metroplasty and removal of vaginal septum with the preservation of cervical septum. In Group II, 10 patients without a history of spontaneous miscarriage did not undergo hysteroscopic transection of the uterine septum. Of 10, four underwent vaginal septum incision due to dyspareunia, two underwent mere laparoscopic pelvic adhesiolysis because of infertility, and four without symptoms had no intervention. The primary endpoints included the pregnancy rate and outcomes of pregnancies.

Results

In Group I, the pregnancy rate after surgery is 81.8 % (9/11). Of nine women who conceived, six had term delivery, one encountered induced abortion due to the malformation of the fetal heart, and two had ongoing pregnancy. In Group II, among six patients accepting surgery, three had term delivery. The pregnancy rate after operation is 50 % (3/6).

Conclusions

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.     

Treatment of twenty-two patients with complete uterine and vaginal septum

Study ObjectiveTo assess the fertility and obstetric outcome after surgical treatment of complete uterine and vaginal septum.DesignRetrospective study (Canadian Task Force Classification II-2).SettingTeaching hospital in France.PatientsTwenty-two women who have experienced infertility, pregnancy losses, dyspareunia, or dysmenorrhea.InterventionHysteroscopic section of complete uterine septum and resection of longitudinal vaginal septum.Measurements and Main ResultsImprovement of dyspareunia or dysmenorrhea and obstetric outcome, focusing on the miscarriage rate, obstetric complications, and the gestational age at delivery were assessed. Overall, 20 women had conceived a total of 37 pregnancies, with 10 and 8 deliveries before and after metroplasty, respectively. Median gestational age at delivery was not significantly different in both groups (36.5 [33–39.5] vs 38.0 weeks’ gestation [35–40], respectively). Preterm delivery occurred in 4 cases (25%) before the surgery and in 3 cases (14%) after (p = .44). The live birth rate was also not significantly different before and after surgery (62.5% and 38%, respectively) (p = .19). There was a decrease of caesarean section and significantly fewer breech deliveries after metroplasty (p = .01). A decrease in the prevalence of dyspareunia or dysmenorrhea was observed after metroplasty in the 19 patients originally displaying these symptoms. No perioperative complications were observed in this series.ConclusionResection of vaginal septum and hysteroscopic metroplasty for complete uterine septum with resection of the cervical septum is a safe procedure that may improve dyspareunia and dysmenorrhea when present. Reproductive and obstetric outcomes after this procedure do not appear to be compromised, even though a relatively high miscarriage rate remains after metroplasty, questioning its systematic practice in symptom-free women without any previous obstetric history.     

Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility

OBJECTIVE: To evaluate the reproductive outcome of hysteroscopic metroplasty performed in women with septate uterus and otherwise unexplained primary infertility. DESIGN: Prospective, observational study. SETTING: Tertiary center for reproductive medicine. PATIENT(S): Sixty-one patients with uterine septa and otherwise unexplained primary infertility. INTERVENTION(S): Hysteroscopic division of the uterine septum. MAIN OUTCOME MEASURE(S): Reproductive outcome after hysteroscopic metroplasty. RESULT(S): Of 61 women, 25 (41%) conceived within 8-14 (mean 11.2) months after hysteroscopic metroplasty. Of these, 18 (29.5% of the total group) had live births (13 carried to term and 5 had preterm deliveries), and 7 (11.5% of the total group) had spontaneous abortions. Cervical cerclage was performed in 9 women; only 1 (11.1%) of these patients and 4 (44.4%) of the 9 who did not have a cerclage had preterm deliveries. Twelve of the 18 women (66.6%) who had live births were delivered by cesarean section. CONCLUSION(S): Women with uterine septum and otherwise unexplained infertility might benefit from hysteroscopic metroplasty.     

Hysteroscopic treatment of uterine septum

Authors report their 4 years experience in the treatment of uterine septum by hysteroscopic metroplasty. 35 patients underwent procedure; no complications occurred. Postoperative reproductive outcome was evaluated in 29 women with follow-up longer than 6 months. Patients were divided into 2 groups according to presence or absence of associated factors compromising fertility. Group A composed of 19 women in which uterine septum was the only cause of pregnancy wastage. Preoperatively they had 40 pregnancies all ending in spontaneous abortion. Postoperatively 15 (79%) patients conceived and 13 (68%) had a live baby. Totally they had 18 pregnancies, 2 (12%) ended in abortion, 1 in molar pregnancy, 1 in premature delivery, 11 delivered at term and 3 are currently beyond 20 weeks pregnant, for a live birth rate of 78%. Life table analysis showed an estimated pregnancy rate of 82% at 12 months, monthly fecundability was 0.13. Group B composed of 10 women in which other factors compromising fertility were present. Preoperatively only 5 experienced pregnancy. Totally they had 8 pregnancies 7 (86%) of which ended in abortions and one in extrauterine pregnancy. Postoperatively only 3 (30%) had pregnancy and all had a live baby. Totally they had 4 pregnancies, 1 ended in abortion and 3 at term for a live birth rate of 75%. Life table analysis showed an estimated pregnancy rate of 11% at 12 months, monthly fecundability rate was 0.01. Hysteroscopic metroplasty proved to be safe and effective for solving pregnancy wastage caused by uterine septum. If other factors compromising fertility were present metroplasty did not increase fecundability, but improved live birth rate.(ABSTRACT TRUNCATED AT 250 WORDS)     

Resectoscopic management of müllerian fusion defects

Of the 103 patients taken to the operating room for hysteroscopic resection of a septum, 72 underwent successful resection of the septum. The initial hysterogram can identify those patients who may benefit from the procedure but cannot discriminate between bicornuate and septate uteri. Knowledge of the size and contour of the uterus is essential to the final decision to proceed transcervically, opposed to transabdominally. In the transcervical repair group, at the time this article was written, there were 58 term deliveries and 5 ongoing pregnancies greater than 30 weeks (1 had a spontaneous abortion after surgery and subsequently conceived a term pregnancy), for a successful pregnancy rate of 86%. This correlated well with the pregnancy rates observed after metroplasty. Therefore, hysteroscopic resection constitutes a valuable alternative to the classical transabdominal approach.     

Retrospective cohort study of the risk factors for secondary infertility following hysteroscopic metroplasty of the uterine septum in women with recurrent pregnancy loss

Purpose

A hysteroscopic metroplasty was performed for women with recurrent pregnancy loss owing to a uterine septum, following which some women became infertile. The aim of this study was to elucidate the risk factors of secondary infertility 1 year after hysteroscopic metroplasty for a uterine septum.

Methods

A retrospective, single‐center, cohort study included women with a history of at least two miscarriages that had been attributed to a uterine septum who underwent a hysteroscopic metroplasty. The patients’ background data were compared between the patients who conceived and those who remained infertile at 1 year postoperatively. The data were analyzed by using the Mann–Whitney U‐test and multivariate analyses.

Results

The postoperative live birth rate was 83.9% (n = 26), with persistent infertility in five women at 1 year. When comparing the pregnancy group with the infertile group, the women in the postoperative infertility group were significantly older than those in the postoperative pregnancy group. The multivariate analysis showed that age was an independent risk factor for persistent infertility.

Conclusion

Age was identified as an independent risk factor for postoperative secondary infertility. Therefore, surgery as early as possible is recommended.     

宫腔镜电切术治疗完全中隔子宫双宫颈阴道纵隔64例生殖预后分析

目的 探讨宫腔镜下子宫中隔电切除术对完全中隔子宫、双宫颈、阴道纵隔患者的治疗效果。方法 2004年9月至2013年8月浙江大学医学院附属妇产科医院完全中隔子宫、双宫颈、阴道纵隔住院患者64例,均行宫腔镜下子宫中隔电切除术及阴道纵隔切除术,分为反复流产组（26例）和不孕组（38例）,电话或门诊随访妊娠结局。结果 反复流产组25例妊娠,累计妊娠31次,自然流产率由术前83.1%（54/65）下降为41.9%（13/31）,足月产率、早产率和活产率分别为35.5%（11/31）、19.3 %（6/31）和54.8%（17/31）,与术前比较差异均有统计学意义（P<0.05）;不孕组18例妊娠,妊娠率47.4%（18/38）,其中12例足月分娩。研究对象中早产及足月产共32例,早产率28.1%（9/32）,足月产率71.9%（23/32）。研究对象胎盘粘连、植入发生率21.9%（7/32）,产后出血发生率25.0%（8/32）。结论 宫腔镜下子宫中隔电切除术可提高完全中隔子宫、双宫颈、阴道纵隔患者的妊娠率及生殖预后。     

The outcome of singleton pregnancies after IVF/ICSI in women before and after hysteroscopic resection of a uterine septum compared to normal controls

Objective(s)

To evaluate the effect of hysteroscopic resection of a large uterine septum (Class V according to the American Fertility Society (AFS) classification) and of a small partial uterine septum (Class VI according to AFS classification or arcuate uterus) on the abortion rate in pregnancies after IVF and ICSI.

Study design

The retrospective matched control study included 31 women who conceived following IVF or ICSI before hysteroscopic resection of a large (12 women) or small partial (19 women) uterine septum and 106 women who conceived following IVF or ICSI after hysteroscopic resection of a large (49 women) or small partial (57 women) uterine septum. For each pregnancy in the study group, we found two consecutive pregnant control women from the IVF/ICSI registry who had a normal uterus and were matched for age, BMI, stimulation protocol and the use of IVF or ICSI and for various infertility causes. The abortion/pregnancy rate was the main outcome measure. Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4 cm long yellow tip of the electric knife to the length of the resected septum.

Results

The abortion rate before hysteroscopic metroplasty was significantly higher, both in women with a small partial septum (78.9% before resection vs. 23.7% in the normal controls, OR 12.08) and a large septum (83.3% before resection vs. 16.7% in normal controls, OR 25.00) compared to women with a normal uterus. After the surgery, the abortion rate was comparable to the abortion rate in women with normal uterus: in both women with a small partial and women with a larger septum.

Conclusion(s)

Similar to a large uterine septum, a small partial uterine septum is an important and hysteroscopically preventable risk factor for spontaneous abortion in pregnancies after IVF and ICSI.     

Ultrasound-guided transcervical metroplasty

A new technique of metroplasty is described. The septum is divided with 4-mm endoscopic scissors introduced into the uterine cavity through the cervix. The whole procedure is monitored by a real-time ultrasound scanner. Twenty-four patients were operated on with this technique. No complication was encountered. Fifteen patients had third trimester deliveries or ongoing pregnancies. Among 12 patients who had suffered repetitive pregnancy losses, 11 desired pregnancy: 10 have been successfully pregnant beyond the second trimester (91.7%), 8 are delivered, and the living birth rate is 72.7%. These results equal those obtained after hysteroscopic metroplasty. The procedure is short, safe, requires no special equipment, and does not necessitate concomitant laparoscopy.     

Hysteroscopic management of recurrent abortion caused by septate uterus

Between April 1982 and April 1986, 91 patients underwent hysteroscopy for treatment of septate uteri. In 88 patients simultaneous laparoscopy was performed and one patient had a simultaneous laparotomy. Ninety procedures were performed on an outpatient basis with the patients under general anesthesia. The septum was incised with flexible scissors. Sequential estrogen-gestagen therapy was used immediately after operation to reepithelialize the freshly dissected surfaces. Patients were permitted to conceive in the first month after operation. The indications for hysteroscopy were multiple but included recurrent abortion in 79 patients. Among those patients in this category the pretreatment reproductive wastage was 95%. Most losses were in the first trimester. Among those patients who conceived after therapy, the gestational outcome markedly improved. Eighty-seven percent of the pregnancies have resulted in a living infant or have progressed beyond 20 weeks of gestation. Because the gestational outcome equals or exceeds that achieved by transabdominal metroplasty and because of its lower morbidity and the option for vaginal delivery, hysteroscopic incision of the symptomatic septate uterus should replace transabdominal metroplasty.     

Reproductive performance in women with uterus didelphys

The reproductive history of 19 women with the diagnosis of uterus didelphys is reported. With this goal the patients were divided into two groups: A) composed of 15 patients who did not undergo any surgical correction of uterine anomaly; B) composed of 4 patients where metroplasty was performed. Diagnosis was made in 17 cases (85.9%) for reasons not related to the uterine anomaly, only in 2 cases did patients present with infertility complaints. Vaginal malformation was associated in 16 (85%) cases; in 11 cases longitudinal septum was present; whereas in 5 hemivagina atretica was found. Eleven group A patients had a total of 23 pregnancies of which 3 (13%) ended in spontaneous abortions, 2 (8.7%) were voluntarily interrupted, 3 ended in premature birth and 15 in term births, with 17 live babies for a live birth rate of 74%. If we consider that two pregnancies were voluntarily interrupted, we had 17 live babies out of 21 naturally evolved pregnancies, for a live birth rate of 81%. In group B 3 patients before treatment had 3 pregnancies all ending in spontaneous abortion. After treatment all had a live baby. Reproductive and gestational performances of women with uterus didelphys are preserved. In patients with infertility complaints, all associated causes must be ruled out before surgical correction. If these are present its correction must be attempted as first therapeutic step, and term pregnancy with live baby is the rule. Only if repeated abortions are not related to any other cause, can metroplasty, according to Bret-Palmer technique, be performed.     

Hysteroscopic metroplasty under laparoscopic guidance in infertile women with septate uteri: follow-up of reproductive outcome

OBJECTIVE: To evaluate the effectiveness of hysteroscopic metroplasty under laparoscopic guidance in the treatment of infertile women with a diagnosis of septate uterus and the impact of this surgical procedure on reproductive outcome. STUDY DESIGN: From January 1996 to December 2000, 36 women referred to our endoscopy center underwent hysteroscopic metroplasty. Follow-up covered the incidence of pregnancy, term pregnancies and mode of delivery. RESULTS: The mean age of the patients was 31.9 +/- 3.9 years (range, 23-39). One patient (3%) dropped out during follow-up. There were no intraoperative or postoperative complications. The mean interval from metroplasty to conception was 11.3 +/- 9.2 months (range, 2.0-35.5). Twenty of 35 (57%) women had a history of > or = 1 spontaneous abortions, and 18 of the 20 (90%) achieved pregnancy, with 15 of 18 (83%) term deliveries (10 vaginal deliveries and 5 cesarean sections). Fifteen of 35 patients (43%) were nulliparous, and 8 of 15 (53.3%) had term deliveries (1 cesarean section). CONCLUSION: Hysteroscopic metroplasty under laparoscopic guidance is safe, allows spontaneous delivery and short-term pregnancy planning, is particularly successful in infertile women with a history of > or = 1 spontaneous abortions.     

合并阴道纵隔双宫颈的完全中隔子宫27例临床分析

目的：探讨宫腹腔镜联合矫治合并阴道纵隔双宫颈的完全子宫中隔的临床效果。方法：收集2012—2013年首都医科大学附属北京妇产医院妇科微创中心27例宫腹腔镜联合矫治合并阴道纵隔双宫颈的完全中隔子宫患者的临床资料,其中原发不孕7例,自然流产10例,稽留流产3例,不良孕史7例。结果：27例患者一次手术成功率为100%,未发生术中、术后并发症。27例随访30～53个月,平均（41.56±6.33）个月。足月活产18例,早产1例,自然流产2例,未孕3例,因胎儿畸形引产1例,术后1例失访,3例术后因个人或疾病原因暂无妊娠计划,一直避孕。本组患者妊娠率由术前52.17%（11/23）上升至术后86.96%（20/23, χ2=6.33,P=0.01）,而活产率由术前0（0/23）上升至术后82.61%（19/23,P=0.000）,流产率由术前47.83%（11/23）下降至术后8.70%（2/23, χ2=6.86,P=0.008）,差异均有统计学意义。结论：宫腹腔镜联合矫治合并阴道纵隔双宫颈的完全中隔子宫安全、有效,能显著改善患者生殖预后,提高妊娠率和活产率,降低流产率。     

Reproductive performance in women with complete septate uteri

Of 11 women with a diagnosis of complete septate uterus, 7 did not undergo any surgical correction, whereas 4 underwent metroplasty. The diagnosis was made in eight cases (73%) for reasons not related to the anomaly. In only three cases did the patients present with infertility complaints. Eight patients, one of whom was subsequently treated, had a total of 13 pregnancies, 3 (27%) of which ended in abortion, 4 (31%) in premature delivery and 6 (42%) in term births, for a live birth rate of 61.5%. The cumulative pregnancy rate was 80% at 12 months. The cumulative probability of carrying a pregnancy to term and giving birth to a live infant was 75% and 88%, respectively, for the second pregnancy. After metroplasty one patient still did not conceive, while three had a total of five pregnancies, one of which ended in abortion and four at term, for a live birth rate of 80%. With a complete septate uterus the ability to conceive is preserved, and the gestational ability is impaired only moderately. Metroplasty, if indicated, can yield good results in terms of the live birth rate.     

Pregnancy and delivery after hysteroscopic metroplasty

AIM OF THE STUDY: Outcomes of treatment of habitual miscarriages and course of pregnancy and delivery in women after hysteroscopic metroplasty i.e. hysteroscopic resection of uterine septum. MATERIAL AND METHODS: Material consisted of 31 women with uterine septum operated between years of 1995-2002 because of habitual miscarriage by surgical hysteroscopic technique. The control group consisted of 26 women treated between years of 1990-1997 by Strassman's operation. Outcomes of treatment of habitual abortions, course of pregnancy and delivery were analyzed in both groups. The statistical analysis was performed by Chi 2 test (p < 0.05). RESULTS: After such treatment 27 out of 31 hysteroscopic treated women became pregnant. In first pregnancy in 12 women miscarriages and in 3 cases premature delivery were observed. Twelve pregnant women delivered pregnancy till 37 week. 15 infants survived (3 premature baby). Out of 26 women in control group after Strassman's operation 24 became pregnant, but 12 had miscarried. All pregnancy in control group i.e. ten mature pregnancy and 2 during premature delivery were ended by Cesarean section. The efficacy of treatment of habitual miscarriage due to uterine septum by hysteroscopic surgery was 55.5%, and there was no statistical significant difference between hysteroscopic surgery and Strassman's operation (50.0%). CONCLUSIONS: On the basis of result obtained the hysteroscopic metroplasty should be method of choice in the treatment of the uterine septum. Although the vaginal delivery is preferred one should have in mind the late complications of hysteroscopic surgery.     

Septate uterus: reproductive outcome after hysteroscopic metroplasty

OBJECTIVE: To evaluate hysteroscopic metroplasty and its effect on reproductive outcome. STUDY DESIGN: Seventy-five patients consulted for uterine septum between January 1996 to December 2000 at "La Sapienza" University in Rome were included in the study. RESULTS: Forty patients attempted pregnancy and a total of 30 spontaneous pregnancies resulted (75% pregnancy rate). The uterine cavity was normal at hysteroscopic follow-up in 68% of cases. CONCLUSION: Correction of uterine septum improves pregnancy outcome of patients. Broadening the indications for hysteroscopic metroplasty should be encouraged for patients who desire to conceive.     

Hysteroscopic treatment of septate uterus with Neodymium-YAG laser.

OBJECTIVE: To determine the effectiveness of Neodymium-YAG (Nd-YAG) laser for hysteroscopic transection of the septate uterus to improve pregnancy outcome. DESIGN: Patients treated for recurrent pregnancy loss and/or infertility were evaluated for before versus after treatment pregnancy outcomes. SETTING: All patients were referred to a University Reproductive Endocrine and Infertility practice from 1986 through 1990. PATIENTS, PARTICIPANTS: Nineteen patients underwent hysteroscopic transection of uterine septa after exclusion of other factors that may cause recurrent fetal wastages and/or infertility. They were allowed to conceive 8 weeks after surgery after a postoperative hysterosalpingogram. Fourteen women attempted conception during a time span of 11 to 42 months; 3 patients declined to conceive, and 2 were lost to follow-up. INTERVENTIONS: Hysteroscopic transection of the uterine septum with a Nd-YAG laser was performed in all patients. The Nd-YAG laser delivered via a 600-microns bare fiber or an 800-microns sculpted fiber through operative hysteroscopy. MAIN OUTCOME MEASURES: To evaluate the success and complications of this new laser technique. RESULTS: (1) Thirteen patients conceived; 10 delivered a live infant at term; (2) 87% of the postoperative pregnancies were considered successful as compared with 11% preoperative; (3) complications included a small perforation of the uterus (no treatment needed) and development of uterine adhesions (1 case only). CONCLUSIONS: Hysteroscopic metroplasty with the Nd-YAG laser is a valuable alternative new technique for the treatment of uterine septum.     

Hysteroscopic incision of the septate uterus

Fifteen women underwent hysteroscopic incision of symptomatic septate uteri between April, 1982, and July, 1983. All procedures were performed on an outpatient basis with general anesthesia, by means of dextran hysteroscopy with direct-vision scissors incision of the septa under external laparoscopic guidance. No significant intraoperative nor postoperative complications occurred. Preoperative indications included repetitive pregnancy loss (eight), repetitive pregnancy loss and infertility (four), infertility and total uterine septum (one), preinsemination by donor (one), and intractable dysmenorrhea (one). A total of 72 hysteroscopic septal incision/resection procedures unassociated with any significant morbidity have been reported in the literature. Compared to transabdominal metroplasty, hysteroscopy is an outpatient procedure that avoids abdominal and uterine incisions and requires no long-term postoperative delay in attempting pregnancy. In addition, subsequent pregnancy does not require cesarean section. With these advantages, hysteroscopic incision of the symptomatic septate uterus can replace transabdominal metroplasty and allow liberalization of operative indications.     

Comparison between abdominal and hysteroscopic metroplasty

Thirty-three patients were diagnosed by hysterosalpingography and laparoscopy as having septate uteri, which were assumed to be responsible for their infertility, recurrent abortions, or premature labor. Fourteen of these had Tompkins metroplasty (group 1) while the other 19 had their repairs done by hysteroscopic metroplasty (group 2). Post-operative hysterosalpingography for patients in group 1 revealed normal uterine cavities in 72%, incomplete septum excision in 14%, and intrauterine filling defects in 14%. The corresponding figures in group 2 were 88, 12, and 0%. In group 1, 71.0% became pregnant; of these, 70% continued to term (with delivery by cesarean section), 20% aborted, and 10% were tubal pregnancies. In group 2, 84% became pregnant; of these, 87% had term vaginal deliveries, and 13% miscarried. Patients in group 2 had less operative time, less blood loss, and shorter hospital stays. These findings demonstrate that hysteroscopic metroplasty may be preferable to the transabdominal procedure based on cost and morbidity considerations as well as on anatomic and reproductive outcome.