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HYSTEROSCOPIC SEPTUM RESECTIONHYSTEROSCOPIC SEPTUM RESECTION
Recai PABUÇCU M.D.Recai PABUÇCU M.D.Ufuk University Faculty of Ufuk University Faculty of
MedicineMedicineObstetrics and Gynaecology Obstetrics and Gynaecology
DepartmentDepartment
-January 11-12 2014-
1
Mullerian AnomaliesMullerian AnomaliesAmerican Fertility Society classification of Mullerian anomalies.
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Mullerian AnomaliesMullerian Anomalies
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Mullerian Anomalies in infertil womanMullerian Anomalies in infertil woman
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Mullerian Anomalies in womanMullerian Anomalies in womanwho had habituel abortuswho had habituel abortus
5
Michael K Bohlmann Reproductive BioMedicine
Online (2010)
6
Michael K Bohlmann Reproductive BioMedicine
Online (2010)
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Uterine SeptumUterine Septum
Most common mullerian anomaly is UTERINE SEPTUM.
55% of Mullerian anomalies.
Complet or partial defect during uterovaginal septum resorpsion.
8
Uterine SeptumUterine Septum
Complet Partial (subseptus)
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DiagnosisDiagnosis
HSG
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Bicornuate uterus – septum Bicornuate uterus – septum differencedifference
BICORNUATE UTERUS
UTERINE SEPTUM
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Arcuate uterus diagram
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SALINE SONOHYSTEROGRAPHYSALINE SONOHYSTEROGRAPHY
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DiagnosisDiagnosis
HSG correctness : 20-60% TVUSG sensitivity: 100%,
spesificity: 80% 3D USG correctness: 92% Hysterosonography correctness: 100% MRI correctness: 50-100%
H/S+L/S: GOLD STANDART Taylor & Gomel et al.,
200815
(D) general detection of uterine abnormalities
Artur Ludwin J. Obstet. Gynaecol.
March 2011
Diagnostic accuracy of sonohysterography, hysterosalpingography and diagnostic hysteroscopy
in diagnosis of arcuate, septate and bicornuate uterus.
SHG is a noninvasive, cost-effective method available in an outpatient setting that is highly accurate in identifying uterine anomalies, in particular septate uterus.
16
(C) Bicornuate uterus: (C-1) SHG; (C-2) HSG; (C-3) DH; and (C-4) laparoscopy. In HSG the angle between the two uteral cavities (b) is over 60°.
17
(A) Arcuate uterus: (A-1) sonohysterography (SHG); (A-2) hysterosalpingography (HSG); (A-3) diagnostic hysteroscopy (DH); and (A-4) laparoscopy. The distance (d) between the middle of the fundus and the line connecting the cornues of the uterus should be more than 10 mm, but not exceeding 15 mm. The external shape of the uterus seen in laparoscopy might be normal. 18
(B) Septate uterus: (B-1) SHG; (B-2) HSG; (B-3) DH; and (B-4) laparoscopy. In HSG the angle between the cornues of the uterus (a) should not exceed 60°.
19
Uterine Uterine SeptumSeptum
Reproductive outcome rate decreases Spontaneous abortion %26- %94 Premature labor %9-%33 Fetal survival %10-%75 Spontaneous abortion after resection
%5,9
Toriano et al., 200420
Hysteroscopic metroplastyHysteroscopic metroplasty
With general or spinal anestesia.
Must be done at early follicular phase.
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Hysteroscopic metroplastyHysteroscopic metroplasty
Microscissor Electrocautery Septal incision with laser.
Homer et al., 2000
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Hysteroscopic Hysteroscopic metroplastymetroplasty
Abortion rate decreases from 88% to %4 after resection. Live birth rate increases from 3% to %80 after resection.
Reproductive outcome after Reproductive outcome after resectionresection
Homer et al., 2000
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61 infertil patient with uterine septum After hysteroscopic metroplasty
After 11.2 months follow up, 41 % (n:25) pregnancy
18 live birth
7 spontaneous abortion
Pabuçcu R.,Gomel V, Fertil Steril, 2004
Reproductive outcome after Reproductive outcome after hysteroscopic metroplasty in hysteroscopic metroplasty in
women with septate uterus and women with septate uterus and otherwise unexplained otherwise unexplained
infertilityinfertility
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Hysteroscopic resection of the septum Hysteroscopic resection of the septum improves theimproves the pregnancy rate of women with pregnancy rate of women with
unexplained infertility:unexplained infertility: a prospective a prospective controlled trialcontrolled trial
Group A44 patientSeptum +Unexplained infertility
Group B132 patientUnexplained infertility
Hysteroscopic metroplasty
Expectantmanagement
1 year follow up without any treatment
Mollo et al, Fertil Steril 2009
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Mollo et al, Fertil Steril 2009
Pregnancy and live birth rate is significantlyhigher in metroplasty group.
27
Hysteroscopic metroplasty in patients Hysteroscopic metroplasty in patients with a uterine septum and otherwise with a uterine septum and otherwise
unexplained infertilityunexplained infertility
Of the 102 patients who underwent hysteroscopic metroplasty 44(%43.1) were able to achive pregnancy, as compered with 5(%20) of the 25 patients who did not undergo operation.
The results indicate that hysteroscopic metroplasty improves outcomes for patients with a uterine septum and otherwise unexplained infertility.
Tonguc et al, 2011
28
Determinants of fertility and Determinants of fertility and reproductive success after hysteroscopic reproductive success after hysteroscopic septoplasty for women with unexplained septoplasty for women with unexplained primary infertility: a prospective analysis primary infertility: a prospective analysis
of 88 casesof 88 cases. .
Shokeir et al., 2011
Results demonstrate that reproductive failure seems to depend on patient age, duration of infertility before septum size.
Women with a septum size larger than one-half of their uterine lenght have a higher chance of successful pregnancy after hysteroscopic septoplasty.
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Results after hysteroscopic Results after hysteroscopic metroplastymetroplasty
If the septum size is >1/2 of uterine cavity, patient may benefit from hysteroscopic
metroplasty Istre et al, Fertl Steril 2010 30
Hysteroscopic metroplasty in women with septate uterus and unexplained infertility could improve clinical pregnancy rate and live birth rate in patients with otherwise unexplained infertility.
Gynecol Obstet Invest 2012
31
If such a patient is looking for a spontaneous pregnancy, this is more likely to occur during the first 15 months following the procedure.
Gynecol Obstet Invest 2012 32
Hysteroscopic metroplasty: Hysteroscopic metroplasty: reproductive outcome in relation to reproductive outcome in relation to
septum sizeseptum size
Paradisi et al., 2013
Recent studies demonstrate that hysteroscopic metroplasty in cases of partial uterine septum and infertility significantly improves the reproductive performance:
-irrespectively of septum size,-reproductive performance is independent from previous obstetrics history.
33
Cervical septum must be cut or Cervical septum must be cut or not?not?
Bleeding Cervical
incompetence
Rock et al., 1999Valle et al., 1996
Less complication Higher
reproductive outcome
CURRENT PRACTICE
Valli et al., 2004Patton et al., 2004
Parsanezhad et al., 200634
Multicenter, randomized, controlled study
Hysteroscopic metroplasty of the Hysteroscopic metroplasty of the complete uterine septum, duplicate complete uterine septum, duplicate
cervix, and vaginal septumcervix, and vaginal septum
Group ACervical
septum-N=14
Group BCervical
septum+N=14
35
Cervical septum resection is suggested for the patient with complet septum
Parsanezhad et al., Fertil Steril 2006
36
Group 1 - 11 patient – uterine septum+ -hysteroscopic metroplasty -vaginal septum cut -cervical septum preserved Group 2 – 10 patient – uterine septum+ - 4 patient – vaginal septum cut - 2 patient – L/S adhesiolysis - 4 patient – No intervention
In group 1, the pregnancy rate is 81.8%, where ıt ıs 50% ın group 2.
Management and reproductive outcome of Management and reproductive outcome of complete septate uterus with duplicated complete septate uterus with duplicated cervix and vaginal septum: review of 21 cervix and vaginal septum: review of 21
cases.cases.
Chen SQ. et al., 2013
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.
37
Small-diameter hysteroscopy with Small-diameter hysteroscopy with Versapoint versus resectoscopy with a Versapoint versus resectoscopy with a
unipolar knife for the treatment of septate unipolar knife for the treatment of septate uterus: a prospective randomized studyuterus: a prospective randomized study
Patients with uterine septum 2001-2005
26F resectoscope and unipolar
scissorn=80
5-mm hysteroscope
and Versapointn=80
Less time, more fluid absorbtion
Less complication
Colacurci N, 2007
Reproductive outcome is similar for both groups
38
Fertility and pregnancy outcomes following Fertility and pregnancy outcomes following resectoscopic septum division with and resectoscopic septum division with and without intrauterine balloon stenting: a without intrauterine balloon stenting: a
randomized pilot studyrandomized pilot study
26F resectoscope with monopolar electrical knife of 120 watts power
14F Foley catheter for five
days after resectoscopic
septum division
No baloon after prusedure
Abu Rafea et al, 2013
Following resectoscopic septum division with monopolar knife electrode, splinting the uterine cavity with Foley catheter provided no advantage in septum reformation, clinical pregnancy rate, and pregnancy outcomes
39
The reason for high rates of miscarriage, small-for-date infants, fetal death and dystocia in woman with septated uterus might be mechanical and due to less of a blood supply in the septum.
Other theories include reduced vascular endothelial growth factor receptors in septal tissue compared with lateral endometrium.
Semin Reprod Med 2011;29:101–112. 40
There are data demonstrating the benefit of metroplasty in reducing miscarriage rates, preterm delivery, and fetal death in patients with a history of recurrent miscarriage.
Semin Reprod Med 2011;29:101–112.
41
After metroplasty, 60.9% of patients became pregnant, 52% of them resulted from assisted reproductive technology.
Outcomes (miscarriages and FLBs) differed significantly according to anatomical type of septum after surgery.
Hysteroscopic septum resection is accompanied by safe improvement in reproductive performance in patients with symptoms of AFS class V/VI septate uterus.
Bendifallah et al, 2013
Metroplasty for AFS Class V and VI septate uterus in patients with infertility or miscarriage: reproductive outcomes
study.
42
ACOG 2001: Women with pregnancy loss and a uterine septum should undergo hysteroscopic evaluation and resection (evidence level C)
RCOG 2003: No results of RCTs are available NVOG: 2007: Do not perform uterine surgery
unless in the context of a clinical trial
● Hysteroscopy for treating subfertility associated with
● suspected major uterine cavity abnormalities (Review)
● COCHRANE 2013: No results of RCTs are available
43
ManagementManagement
Istre et al, Fertl Steril 2010 44
ConclusionConclusion
Hysteroscopic metroplasty is GOLD STANDART.
For better reproductive outcome hysteroscopic metroplasty must be performed before fertility treatment
45