Reproductive outcome following hysteroscopic septal resection in patients with infertility and recurrent abortions

Efficacy of hysteroscopic septum resection in infertile women: a single center experience

INTRODUCTION

We aimed to reveal the effectiveness of hysteroscopic septum resection on the reproductive outcomes of infertile patients.

MATERIAL AND METHODS

We included 46 infertile women who underwent hysteroscopic septum resection of septate uterus (complete: group 1, n = 21; incomplete: group 2, n = 25). Only patients with a septate uterus as the cause of infertility were included in the study. Patients' age, body mass, duration of infertility, type of infertility, duration of surgery, surgical complications, remnant septa, and postoperative reproductive results were recorded.

RESULTS

Preoperative abortion was found to be nine (42.9%) in group 1 and 15 (60.0%) in group 2. In the postoperative control HSG, remnant septa was found to be significantly higher in group 1 compared to group 2 (three patients or 14.3% and 0%, respectively). Pregnancy was detected in 13 patients (61.9%) in group 1 and 18 patients (72%) in group 2 at the postsurgical follow-up. Abortion occurred for two patients (9.5%) in group 1 and three patients (12%) in group 2.

CONCLUSION

We obtained positive growth results after hysteroscopic septum resection in both the complete and incomplete cases. However, we found that the duration of surgery was prolonged and the rate of remnant septa increased in cases with a complete septum.

Uterine Septum with or without Hysteroscopic Metroplasty: Impact on Fertility and Obstetrical Outcomes-A Systematic Review and Meta-Analysis of Observational Research

Objective: we performed a systematic review/meta-analysis to evaluate the impact of septate uterus and hysteroscopic metroplasty on pregnancy rate-(PR), live birth rate-(LBR), spontaneous abortion-(SA) and preterm labor (PL) in infertile/recurrent miscarriage-(RM) patients. Data sources: a literature search of relevant papers was conducted using electronic bibliographic databases (Medline, Scopus, Embase, Science direct). Study eligibility criteria: we included in this meta-analysis all types of observational studies that evaluated the clinical impact of the uterine septum and its resection (hysteroscopic metroplasty) on reproductive and obstetrics outcomes. The population included were patients with a diagnosis of infertility or recurrent pregnancy loss. Study appraisal and synthesis methods: outcomes were evaluated according to three subgroups: (i) Women with untreated uterine septum versus women without septum (controls); (ii) Women with treated uterine septum versus women with untreated septum (controls); (iii) Women before and after septum removal. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for the outcome measures. A p-value < 0.05 was considered statistically significant. Subgroup analysis was performed according to the depth of the septum. Sources of heterogeneity were explored by meta-regression analysis according to specific features: assisted reproductive technology/spontaneous conception, study design and quality of papers included Results: data from 38 studies were extracted. (i) septum versus no septum: a lower PR and LBR were associated with septate uterus vs. controls (OR 0.45, 95% CI 0.27−0.76; p < 0.0001; and OR 0.21, 95% CI 0.12−0.39; p < 0.0001); a higher proportion of SA and PL was associated with septate uterus vs. controls (OR 4.29, 95% CI 2.90−6.36; p < 0.0001; OR 2.56, 95% CI 1.52−4.31; p = 0.0004). (ii) treated versus untreated septum: PR and PL were not different in removed vs. unremoved septum(OR 1.10, 95% CI 0.49−2.49; p = 0.82 and OR 0.81, 95% CI 0.35−1.86; p = 0.62); a lower proportion of SA was associated with removed vs. unremoved septum (OR 0.47, 95% CI 0.21−1.04; p = 0.001); (iii) before-after septum removal: the proportion of LBR was higher after the removal of septum (OR 49.58, 95% CI 29.93−82.13; p < 0.0001) and the proportion of SA and PL was lower after the removal of the septum (OR 0.02, 95% CI 0.02−0.04; p < 0.000 and OR 0.05, 95% CI 0.03−0.08; p < 0.0001) Conclusions: the results show the detrimental effect of the uterine septum on PR, LBR, SA and PL. Its treatment reduces the rate of SA.

Uterine factor in recurrent pregnancy loss

OBJECTIVE

To review the current understanding of the role the uterus plays in recurrent pregnancy loss.

FINDINGS

Congenital and acquired uterine abnormalities are associated with recurrent pregnancy loss in the first and second trimester. Relevant congenital Mullerian tract anomalies include unicornuate, didelphys, bicornuate and septate uteri. Pregnancy loss has also been associated with acquired uterine abnormalities that distort the uterine cavity such as intrauterine adhesions and submucosal myomas. Initial evaluation of women with recurrent pregnancy loss should include a uterine assessment such as a pelvic ultrasound or sonohysterography. Uterine abnormalities such as uterine septum, intrauterine adhesions and submucosal myomas may be managed surgically with operative hysteroscopy.

CONCLUSION

Uterine abnormalities, both congenital and acquired, can be responsible for recurrent pregnancy loss.

A womb like a broken heart

Uterine perforation during hysteroscopic operative procedures is a potential complication well known to gynaecologists. Uterine septa are a commonly encountered Müllerian anomaly related to pregnancy loss and infertility. Hysteroscopic resection of septa has shown to improve pregnancy outcome. There are limited case reports of uterine rupture in subsequent pregnancies after hysteroscopic septal resection. Our patient had a hysteroscopic septal resection done a year prior which was complicated by a uterine fundal perforation, left to spontaneously heal after immediate sealing with cautery. The patient conceived spontaneously soon after and underwent an emergency caesarean section for severe pre-eclampsia. Intraoperatively, after removal of the placenta, we discovered a 3 cm symmetrical circular defect at the fundus of the uterus with no myometrium or serosa. The potentially disastrous consequences of this silent uterine rupture were mitigated due to another life-threatening condition which prevented the onset of labour.

Hysteroscopic septal resection using unipolar resectoscope versus bipolar resectoscope: Prospective, randomized study

AIM

To compare the operation and reproductive outcome of hysteroscopic septal resection using unipolar resectoscope verses bipolar resectoscope.

METHODS

In this prospective randomized study, 70 women underwent hysteroscopic septal resection using either unipolar resectoscope or bipolar resectoscope. Intraoperative parameters (operation time, fluid deficit and complications) and pre- and postoperative serum sodium levels were compared between the two groups. A second-look hysteroscopy was performed after 6 weeks. All pregnancies occurring during the follow-up period were recorded.

RESULTS

There was no statistically significant difference between the two groups in terms of operation parameters and second-look hysteroscopy findings. Six patients in the unipolar group were found to have hyponatremia in the postoperative period compared to none in the bipolar group (P = 0.025). Regarding reproductive outcome, the difference between the two groups was not significant.

CONCLUSION

The use of bipolar resectoscope is associated with lesser risk of hyponatremia compared to unipolar resectoscope. Bipolar resectoscopy is a safe alternative to unipolar resectoscopy with similar reproductive outcome.

Reproductive outcome following hysteroscopic treatment of uterine septum

BACKGROUND

Septate uterus is the most common uterine anomaly and a cause for miscarriage and infertility. Existing data suggested a better reproductive outcome of uterine septum following hysteroscopic septum resection.

OBJECTIVE

Current study was administered to share our experience in hystroscopic septum resection for reproductive outcome following hysteroscopic treatment of uterine septum and specifically focusing on different treatment protocols after hysteroscopic septum resection.

METHODS& MATERIALS

This study was a cross-sectional study based on secondary data that was obtained from medical records of infertile women who had undergone transvaginal hysteroscopy and used different treatment protocols after hysteroscopic correction of uterine septum in Infertility and Reproductive Health Research Center between April 2005 and February 2014.

RESULTS

The total number of infertile women underwent hysteroscopy uterine septoplasty was 106. The hysteroscopy septoplasty resulted in an overall pregnancy rate of 67% and a live birth 57.5%. Pregnancy rate for patients who had not male infertility was 92.1%. The chi-square test did not reveal any statistically significant difference in side affect, pregnancy, live birth, abortion, preterm deliveries, and term deliveries rate between these patients either with consistent hormone therapy plus IUD insertion or with alternate hormone therapy plus IUD after hysteroscopic metroplasty.

CONCLUSION

The findings of the present study indicated hysteroscopic septum resection to remove a uterine septum in women with infertility is safe and may be an efficacious procedure. Treatment following hysteroscopic septum resection, either the consistent or the alternate protocol is both beneficial to improve pregnancy rate.

Early prediction of spontaneous twin very preterm birth: a population based study 2002-2012

OBJECTIVE

The aim of this study was to establish early pregnancy risk indicators for spontaneous twin very preterm birth.

METHODS

We conducted a retrospective observational population-based study. Twenty-one potential early pregnancy risk factors were analyzed using multivariable logistic regression to determine which of them was independently associated with spontaneous twin very preterm birth.

RESULTS

Of 1815 spontaneous twin births 15.3% (277) occurred before 32 weeks. Previous preterm delivery (aOR 3.73; 95% CI, 2.52-5.52), nulliparity (aOR 2.94; 95% CI, 2.09-4.14), body mass index <18.5 (aOR 1.86; 95% CI, 1.12-3.10), body mass index ≥30 (aOR 1.87; 95% CI, 1.21-2.89), hysteroscopic metroplasty (aOR 1.63; 1.07-2.49), conization (aOR 2.05; 95% CI, 1.07-3.94) and monochorionicity (aOR 1.83; 95% CI, 1.28-2.63) were significantly associated with twin very preterm birth.

CONCLUSIONS

Pending verification in other populations, twin pregnancies at significant risk for spontaneous very preterm birth can be identified in early pregnancy using several risk indicators.

Cervical assessment in women with hysteroscopic uterine septum resection: a retrospective cohort study

OBJECTIVE

To estimate whether cervical length measured by transvaginal ultrasonography in women with a history of hysteroscopic uterine septum resection predicts spontaneous preterm birth <35 weeks' gestation.

METHODS

This retrospective cohort study compared women who had undergone hysteroscopic metroplasty, and were subsequently pregnant with singleton gestations delivered January 2003 to December 2012, to a low-risk control group. Transvaginal ultrasonographic cervical lengths were measured 16-30 weeks' gestation. The primary outcome was spontaneous preterm birth <35 weeks' gestation and the primary exposure variable of interest was cervical length.

RESULTS

Women with a uterine septum resected (N = 24) had a shorter cervical length (2.90 cm) than the low-risk control group (N = 141, 4.31 cm, p < 0.0001); and were more likely to have a cervical length <3.0 cm (41.7% versus 1.4%, p < 0.0001), <2.5 cm (33.3% versus 0%, p < 0.0001), <2.0 cm (16.7% versus 0%, p < 0.0001) and <1.5 cm (12.5% versus 0%, p = 0.003). Women with septum resected were more likely to receive corticosteroids (33.3% versus 11.3%, p = 0.010), but were not more likely to have a spontaneous preterm birth <35 weeks (4.2% versus 0.7%, p = 0.27). There were no differences noted in secondary outcomes including neonatal morbidity.

CONCLUSION

Pregnant women with a history of a hysteroscopic uterine septum resection have shorter cervical lengths than low-risk controls but may not be at a higher risk of spontaneous preterm birth <35 weeks' gestation. Further research with a larger sample size is needed to evaluate this group of women to determine if transvaginal ultrasonographic cervical length assessment is of benefit.

Reproductive Outcome after Hysteroscopic Metroplasty in Patients with Infertility and Recurrent Pregnancy Loss

Introduction: Reproductive outcome can be negatively affected in patients with congenital uterine anomalies (CUA), increasing the number of unsuccessful pregnancies and obstetric complications. Compared with the population with normally formed uterus, patients with CUA have higher abortion rate, higher fetal loss rate and decreased live birth rate. Hysteroscopic metroplasty (HM) is a standard, safe and minimally invasive method for the treatment of correctible types of congenital uterine anomalies.Aim: The aim of the study was to analyze the reproductive outcome in group of patients with infertility and recurrent pregnancy loss and present CUA, before and after hysteroscopic metroplasty.Material and Methods: We analyzed 67 patients to whom 78 interventions hysteroscopic metroplasty were performed at the University Clinic of Obstetrics and Gynecology in Skopje during a two year period, between 01.01.2010 and 31.12.2011. Their reproductive outcome was monitored during a two-year period and the same group served as a control group, taking into account their previous reproductive history. Statistical analysis was performed using Chi-square test and p < 0.05 was considered to be statistically significant.Results: Most common CUA were types 5b and 6 represented by 88 %. In a follow up period of two years, 33 of the patients become pregnant. There was a statistically significant decrease of abortion rate from 92% to 21.2%, as well as an increase in the term delivery rate from 0% to 69.7%.Conclusion: Treatment with hysteroscopic metroplasty is significantly improving the reproductive outcome in patients with CUA and previous fetal loss.

Hysteroscopic metroplasty for the septate uterus: review and meta-analysis

The introduction of hysteroscopy to diagnose and treat intrauterine conditions, specifically to divide the uterine septum, or metroplasty, has replaced the traditional laparotomy approach, and objective results demonstrate its salutary effects in women treated. Hysteroscopic metroplasty averts the implications of major invasive abdominal surgery, with good and satisfactory results in pregnancy and live-birth rates, despite the lack of prospective, randomized, controlled studies. A careful review of the published results supports this type of treatment when the uterine septum adversely affects normal reproductive function.