The significance of hysteroscopic treatment of congenital uterine malformations

Hysteroscopic surgery replaced abdominal metroplasty and is today the treatment of choice for congenital uterine malformations. This is not just because of its reproductive results, which are comparable to those achieved with the abdominal approach, but mainly because of several post-operative benefits (reduced morbidity, convalescence and costs, and no scar tissue on the abdominal and uterine walls), improved reproductive performance (no reduction in uterine volume, shorter interval to conception after operation) and the mode of delivery (avoiding Caesarean section). Decisions on when and how to treat uterine septa, in relation to the type of malformation, are discussed. In particular, indications for treatment have been broadened to include not only the septate uterus associated with adverse reproductive outcome, but also patients before any potential obstetric accidents, especially in those with declining fecundity (>35 years), with reproductive problems (unexplained infertility) and before assisted reproductive techniques, as well as in women with no actual desire of pregnancy. Two types of hysteroscopic treatment are available: resectoscopic and office hysteroscopic surgery. The indications for resectoscopic surgery are broad-based septa and complete septa with single or double cervix. The resectoscope allows an excellent continuous flow system, providing continuous washing of the uterine cavity and a clear view, removing bubbles and debris during the procedure. However, an exact measurement of fluid balance must be performed to avoid excessive fluid intravasation. Laparoscopic or sonographic monitoring is mandatory. Treatment of limited-based small septa whose apex is easily visible can be achieved with an outpatient approach using office mini-hysteroscopic surgery and the vaginoscopic technique. The intra-operative check of the fundus is performed by ultrasonography. No preparation of the endometrium is required, except for large, broad-based septa, and hormonal therapy and intrauterine devices are not utilized post-operatively. The post-operative follow-up consists of a hysteroscopic check performed 1-3 months after surgery.