Reproductive performance of women with unicornuate uterus

The reproductive history of 19 women with a diagnosis of unicornuate uterus confirmed by laparoscopy or laparotomy is analyzed. The patients were followed for 2 to 10 years. One patient had a cavitary communicating rudimentary horn, four a cavitary noncommunicating rudimentary horn, seven a noncavitary rudimentary horn, and seven no rudimentary horn. Six of the patients presented with primary infertility. The other 13 women had a total of 29 pregnancies, 1 (3.4%) in a rudimentary horn determining rupture; abortions occurred in 17 (58.6%), premature labor in 3 (10.3%), and term births in 8 (27.6%), with a live birth rate of 38%. Of the 11 births, 6 (54.5%) were breech presentations, and 9 (81.8%) were cesarean sections. In five cases the rudimentary horn was removed, with associated salpingooophorectomy in three patients. Cervical cerclage was not performed in any of the patients.     

Obstetric outcome after endoscopic transection of the uterine septum

STUDY OBJECTIVE: To analyze results of endoscopic transection of uterine septum in women with primary infertility and history of recurrent abortion or late abortion. DESIGN: Observational study over 6 years (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Seventy women, 21 with primary infertility, 33 with recurrent abortions, and 16 with late abortion or preterm delivery. INTERVENTION: Hysteroscopic metroplasty with transection of uterine septum. MEASUREMENTS AND MAIN RESULTS: Hysteroscopic metroplasty was possibly effective for women with primary infertility, none of whom had had abortions. It was also effective in reducing the early abortion rate and in increasing term deliveries in the group with late abortion. CONCLUSION: Endoscopic transection of uterine septum may improve obstetric outcomes in women with late abortion, decrease abortion rates in those with recurrent abortions, and avoid pregnancy loss for patients with primary infertility.     

Gestational aspects of uterus didelphys

The reproductive history was analyzed of 13 women with a laparoscopic or laparotomy diagnosis of uterus didelphys and followed for two to six years. Two patients (15.4%) presented with primary infertility; the other 11 had a total of 27 pregnancies, the outcome of which was spontaneous abortion in 20 cases (74%), premature labor in 6 (22.2%) and term birth in 1 (3.7%), with a live birth rate of 18.5%. Metroplasty was performed in five cases, with live birth in three, spontaneous abortion in 1 and no postoperative conceptions in one. Cervical cerclage was performed in only one case and bilateral ovarian resection in one. The live birth rate, considering all pregnancies before and after treatment, was 35%. The compromised fertility of the uterus didelphys is probably attributable to congenital alterations in vascularization that may have a negative influence on developmental phases following implantation, particularly the structuralization of the fetomaternal relations that precede placentation.     

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.     

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.     

155例残角子宫合并单角子宫临床病例分析

目的:总结残角子宫合并单角子宫各型的临床特征、分析诊断及处理要点。方法:回顾分析我院收治的155例残角子宫合并单角子宫(U4型女性先天性生殖道畸形)的临床资料。结果:(1)U4a型与U4b型患者的就诊年龄、重度痛经、有自然流产史或不孕史、合并子宫内膜异位症等方面比较,差异均有统计学意义(P0.001)。(2)患者术前二维超声、三维超声、核磁共振诊断符合率分别为87.7%、97.2%和97.4%。(3)32例为妊娠晚期行子宫下段横切口剖宫产术;其余为妇科手术。U4a型中,2例行通液术或卵巢囊肿剥除术,其余均行腹腔镜或经腹残角子宫和/或输卵管切除。U4b型患者均未切除残角及输卵管。(4)与开腹组比较,腹腔镜组术中出血少、手术时间短、术后住院日短,差异有统计学意义。(5)术后随访60例妊娠,包括宫内妊娠55例,自然流产5例,无异位妊娠发生。结论:核磁共振检查及三维超声有助于提高残角子宫的诊断率。单角子宫合并残角子宫型别不同,其临床特征及手术治疗方案亦有差异。     

女性生殖管道发育异常225例临床分析

目的 探讨子宫发育异常的发病情况、临床特征、诊治方法及其对生育的影响.方法 选取1990年3月-2005年1月北京大学人民医院收治的子宫发育异常患者225例的临床资料,进行回顾性分析,总结不同类型子宫发育异常的构成比、临床特征、诊治方法及对生育的影响.结果 (1)225例子宫发育异常患者中,中隔子宫125例,占55.6%,其中122例(97.6%,122/125)患者妊娠,但影响其妊娠结局,出现流产、胎位异常、早产、前置胎盘、胎膜早破等并发症.(2)双子宫51例,占22.7%(51/225);其中50例(98%,50/51)患者妊娠,对妊娠无明显影响;5例(10%,5/51)合并泌尿系统畸形.(3)残角子宫26例(11.6%,26/225),发生残角子宫妊娠4例(15%,4/26),残角子宫同侧输卵管妊娠1例(4%,1/26);2例(8%,2/26)合并泌尿系统畸形;合并不孕4例(15%,4/26).(4)双角子宫14例,占6.2%(14/225),无不孕患者,出现早产、胎膜早破等并发症;1例(7%,1/14)合并泌尿系统畸形.(5)其他类型:鞍状子宫4例(1.8%,4/225),无不孕患者;无子宫3例(1.3%,3/225),均以原发闭经就诊;单角子宫2例(0.9%,2/225),均合并不孕.结论 子宫发育异常中以中隔子宫最多见.中隔子宫、双子宫、双角子官、残角子宫、鞍状子宫对生育无明显影响,但在妊娠期可出现不同的并发症.子宫发育异常常合并泌尿系统畸形.无症状的子宫发育异常,可不予处理.     

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.     

Diagnosis and treatment of rudimentary uterine horn complicating pregnancy

During the period from (May 1980 to July 1985), six cases of rudimentary uterine horn complicating pregnancy were presented. Artificial abortion failed in five cases, one case complained of lower abdominal mass only. The other 5 cases were correctly diagnosed preoperatively. In one case the pregnant horn ruptured with profuse internal haemorrhage and deep shock. The horn cavity was separated from the normal uterine cavity by a connective tissue cord in all 6 cases. Two of the cases had dysmenorrhea and congenital abnormally of ureter in the same side of the rudimentary horn. Diagnosis was discussed in detail B-ultrasound scanning is useful for the early diagnosis of rudimentary horn pregnancy. The rudimentary horn should be resected together with the fallopian tube on the same side with preservation of ovary. Its round ligament must be cut and fixed to the normal uterus.     

Reproductive performance after transabdominal metroplasty: a review of 157 consecutive cases

OBJECTIVE: To evaluate the impact of conventional transabdominal metroplasty on the reproductive outcome of symmetric uterine anomalies and to determine the complications of this procedure. STUDY DESIGN: A retrospective clinical analysis of 157 consecutive women who underwent surgery during a 25-year period. One hundred fifty-seven patients with a subseptate, septate or bicornuate uterus and history of recurrent abortions (124 cases) or infertility (33 cases) were included in this study. Operative technique was similar to the procedure first described by Bret and Guillet and by Tompkins. RESULTS: The fetal survival rate increased from 0.0% before surgery to 81.9% postoperatively in the recurrent abortion group and to 92.8% in the infertility group. Among women having undergone surgery, 63.8% gave birth to at least 1 healthy child, the proportion of previous habitually miscarrying and infertile women was 70.2% and 32.0%, respectively. No uterine rupture or any other complication was observed. CONCLUSION: Conventional transabdominal metroplasty seems to be a safe procedure in women with symmetric uterine anomalies and a history of recurrent miscarriages or otherwise unexplained primary infertility. No perioperative or subsequent peripartum complications were observed. Even in the era of operative hysteroscopy, transabdominal metroplasty remains the only approach in cases of bicornuate uterus.     

The diagnosis and reproductive outcome after surgical treatment of the complete septate uterus, duplicated cervix and vaginal septum

OBJECTIVE: This study was undertaken to evaluate the diagnostic management and the reproductive outcome after surgical repair of a rare reproductive malformation. STUDY DESIGN: Sixteen women with a complete septate uterus, double cervix, and a longitudinal vaginal septum were referred for evaluation. Presenting complaints were chiefly pregnancy loss in parous women (n=9) and dyspareunia in nulligravid women (n=7). The combination of hysterosalpingography, ultrasonography, and/or magnetic resonance imaging was used to correctly identify the anomaly in 15 of the 16 cases. Both hysteroscopic (n=11) and transabdominal (n=5) surgical techniques were used to repair the uterine septum. RESULTS: In no case was the correct diagnosis made before referral; the uterus didelphys was the most common misdiagnosis. The preoperative pregnancy loss was 81%. Postoperatively, 12 women conceived for a total of 17 pregnancies; there were 14 term live births or ongoing pregnancies in the third trimester (82%), with a first trimester spontaneous abortion rate of 18%. In 9 women who conceived after hysteroscopic surgery, term live births occurred in 9 of 12 (75%) conceptions. A modified Tompkins metroplasty was performed in 5 women with subsequent term live births or ongoing third trimester pregnancies in 5 of 5 (100%) patients. CONCLUSION: The identification of a duplicated cervix and a vaginal septum is consistent with several uterine malformations, which leads to frequent misdiagnosis and errors in management. Significant pregnancy wastage, obstetric complications, and dyspareunia are common, and surgical treatment is therefore advisable. Making the best choice between hysteroscopic or transabdominal metroplasty depends on the anatomic features of the cervix and the uterine cavity, but optimal patient management requires familiarity with both techniques.     

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。     

女性不孕症合并盆腔粘连腹腔镜诊治临床分析

目的探讨盆腔粘连与女性不孕症的关系，以及腹腔镜在诊治盆腔粘连相关的女性不孕症中的意义。方法回顾性分析2003年6月至2005年6月在我院因不孕症行腹腔镜诊治的481例不孕患者。其中原发不孕175例，继发不孕306例。分析腹腔镜下不孕症患者盆腔粘连、盆腔粘连合并输卵管阻塞发生率和盆腔粘连腹腔镜术后妊娠情况。结果腹腔镜检查发现原发和继发不孕患者盆腔粘连发生率分别为45．7％和65％，差异有显著性（P〈0．05）。盆腔粘连合并输卵管阻塞在原发不孕中发生率为65．0％，在继发不孕中发生率为58．7％。原发不孕盆腔粘连患者腹腔镜术后宫内自然妊娠率为32．5％（26／80），其中术后6个月内自然妊娠占76，9％（20／26）；继发不孕盆腔粘连患者腹腔镜术后宫内自然妊娠率为27.1％（54／199），其中术后6个月内自然妊娠占66．7％（36／54）。结论盆腔粘连是引起女性不孕症最常见盆腔病变之一。腹腔镜可及时准确地发现不孕症患者的盆腔粘连情况，并同时行镜下盆腔粘连的分离，是诊治不孕患者较为理想的方法。     

Surgical treatment of uterine malformations]

Clinical data of 29 patients with uterine malformation treated at the Fertility Unit, Service and Department of Obstetrics and Gynecology, Dr. G. Grant B. Clinical Hospital, Concepción Chile from January 1978 to May 1990 are presented. Uterine septa (19 cases, 65.5%) were the most common uterine malformation found. Less frequent were: uterus bicornuous 7 cases (24.1%) and uterus didelphis 3 cases (10.4%). The high frequency (92.8%) of pregnancy wastage is detached. Surgical treatment was practiced in 24 patients. Thirteen Tompkins and 5 Jones techniques were performed in 18 uterine septa. Five Strassman techniques and one extirpation of a rudimentary not communicated horn were practised in the 6 cases with uterus bicornuous. In patients with adequate follow-up, the overall term birth rate after metroplasty is 84.6% compared with only 2.4% before surgical treatment. This study concludes that in despite of the lack of hysteroscopy as a new method of uterine septa treatment our patient's infertility was benefited with surgical treatment of uterine anomalies.     

Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of septate uterus: a prospective randomized study

STUDY OBJECTIVE: To compare 2 procedures for metroplasty: resectoscopy with monopolar knife versus small-diameter hysteroscopy fitted with a Versapoint device. DESIGN: Prospective randomized study (Canadian Task Force classification I). SETTING: Endoscopic gynecology units at tertiary care university hospitals. PATIENTS: One hundred-sixty patients with septate uterus and a history of recurrent abortion or primary infertility undergoing hysteroscopic metroplasty from 2001 to 2005. INTERVENTIONS: Hysteroscopic resection of the uterine septum performed with either a 26F resectoscope with unipolar knife (80 women, group A) or a 5-mm diameter hysteroscope with Versapoint device (80 women, group B). All patients were managed expectantly, with follow-up lasting 1 year. MEASUREMENTS AND MAIN RESULTS: Operative parameters (operative time, fluid absorption, complications, need for second intervention) and reproductive outcome parameters (pregnancy, abortion, term and preterm delivery, modality of delivery, cervical cerclage) were measured. Operative time and fluid absorption were significantly greater in group A than in group B (23.4 +/- 5.7 vs 16.9 +/- 4.7 minutes and 486.4 +/- 170.0 vs 222.1 +/- 104.9 mL, respectively). The cumulative complication rate was significantly lower in group B than in group A. No difference in any of the reproductive parameters was observed between the 2 groups: pregnancy and delivery rates were 70% and 81.6% in group A vs 76.9% and 84% in group B. Nine women (18.4%) from group B and 8 women (16%) from group B experienced spontaneous abortions. Most patients (54/82) delivered by cesarean section without differences according to the hysteroscopic technique used for metroplasty (65% in group A vs 67.7% in group B) or to the gestational age (65.1% of term and 68.7% of preterm deliveries). CONCLUSIONS: Small-diameter hysteroscopy with bipolar electrode for the incision of uterine septum is as effective as resectoscopy with unipolar electrode regarding reproductive outcome and is associated with shorter operating time and lower complication rate.     

Immunologic tests in the evaluation of reproductive disorders: a critical review.

OBJECTIVE: The purpose of this study was to evaluate the clinical usefulness of immunologic assays proposed to assist in the diagnosis of alloimmune causes of recurrent spontaneous abortion. STUDY DESIGN: Human leukocyte antigen typing, maternal antipaternal lymphocytotoxic antibody testing, and mixed lymphocyte culture assays were performed on 609 couples with recurrent spontaneous abortion, 92 infertile couples, and 43 fertile couples. The frequency of HLA antigen sharing and the presence of lymphocytotoxic antibodies and mixed lymphocyte culture inhibitors was compared among the populations. RESULTS: Sharing of two or more HLA-A, HLA-B, HLA-C, or HLA-DR antigens was observed in 41% (252/609) couples with recurrent spontaneous abortion and in 34% (31/92) with infertility compared with 63% (27/43) of fertile couples. The frequency of lymphocytotoxic antibodies to paternal cells was significantly greater in the fertile population (27/143, 63%) (p < 0.0001) than in couples with recurrent spontaneous abortion (160/609, 26%) and in infertile couples (7/92, 8%). Mixed lymphocyte culture inhibitors were also more prevalent in sera from fertile women (19/43, 44%) compared with those with recurrent spontaneous abortion (122/609, 20%) and infertile women (4/92, 4%). CONCLUSION: Human leukocyte antigen sharing does not predict pregnancy outcome, and the presence of lymphocytotoxic antibodies and mixed lymphocyte culture inhibitors is a function of the number and duration of pregnancies. More sensitive and specific assays are needed to identify alloimmunologic causes of reproductive disorders.     

女性生殖道畸形患者发生泌尿系统畸形的临床特点分析

目的 探讨生殖道畸形患者发生泌尿系统畸形的临床特点、诊断和治疗。方法对我院近4年来收治的生殖道畸形患者的临床资料进行回顾性分析。结果289例生殖道畸形患者,年龄在13—47岁,平均年龄(23.4±2.8)岁。根据生殖道畸形发生的情况分为对称性畸形及不对称性畸形两类。其中对称性生殖道畸形213例,包括子宫完全或不完全纵隔135例,处女膜或阴道闭锁20例,先天性无子宫无阴道58例。对称性生殖道畸形中只有1例合并同侧肾脏缺如,发生率为0.50％(1/213),占总生殖道畸形的0.35％(1/289)。不对称性生殖道畸形76例,包括阴道斜隔综合征59例,其中伴同侧肾脏缺如43例,盆腔异位单肾畸形2例,双侧马蹄肾1例,左侧马蹄肾伴右侧肾代偿性增大1例,双侧各有1对肾盂、肾盏,输尿管中下段合并1例;残角子宫13例及单角子宫4例,均合并同侧肾脏缺如。不对称性生殖道畸形合并泌尿系统畸形发生率为85.53％(65/76),占总生殖道畸形的22.49％(65/289)。结论生殖道畸形尤其是不对称性生殖道畸形合并肾脏畸形并非少见,但其临床表现也各有差异。患者就诊时已为成人期,且多以生殖系统异常症状就诊,因此及早发现生殖系统畸形有重要的临床意义。     

CO2 laser myomectomy in an infertile population

Thirty-two infertility patients with uterine myomas underwent laser myomectomy with the CO2 laser. Twenty-four patients (75%) had persistent primary infertility, with 8 (25%) experiencing recurrent abortions. Twenty (63%) of the 32 conceived (14/24 [58%] with primary infertility and 6/8 [75%] with secondary infertility); 17 (59%) ultimately had a viable term pregnancy. The mean interval from surgery to pregnancy was 8.5 months. The risk factors of age, duration of infertility, size and number of fibroids, and menorrhagia did not appear to influence the success rate or increase the complication rate. The advantages of the CO2 laser for myoma surgery are decreased adhesion formation, improved hemostasis, precision of application and improved reproductive performance.     

Metroplasty for AFS Class V and VI Septate Uterus in Patients With Infertility or Miscarriage: Reproductive Outcomes Study

Study ObjectiveTo assess reproductive outcomes in patients after surgical correction of septate uterus.DesignObservational retrospective study (Canadian Task Force classification II-2).SettingTwo university hospitals.PatientsOne hundred twenty-eight patients with primary infertility or recurrent miscarriage with partial (American Fertility Society [AFS] class Va), complete (AFS class Vb), or fundic (AFS class VI) septate uterus. Metroplasty is the current method of choice for surgically correcting septate uterus. The procedure and its indications are a matter of debate.InterventionsMetroplasty via hysteroscopy.Measurements and Main ResultsOutcomes including the numbers of pregnancies, first live births (FLBs), and miscarriages were determined. After metroplasty, 78 women (60.9%) became pregnant, and 70 live neonates were delivered. The FLB rate in infertile women was 53.1%. Of the 25 pregnancies, 13 (52%) resulted from assisted reproductive technology. In women who experienced recurrent miscarriage, the miscarriage rate was significantly improved. Outcomes (miscarriages and FLBs) differed significantly according to anatomical type of septum after surgery.ConclusionHysteroscopic septum resection is accompanied by safe improvement in reproductive performance in patients with symptoms of AFS class V/VI septate uterus.