Surgical treatment of uterine septum to improve reproductive outcomes - resect or not?

Hysteroscopic metroplasty and its reproductive impact among the social networks: A cross-sectional analysis on video quality, reliability and creators' opinions on YouTube, TikTok and Instagram

BACKGROUND

Usefulness of hysteroscopic metroplasty to improve reproductive outcomes is controversial and debated among reproductive specialists and, consequently, patients.

METHODS

We performed a cross-sectional analysis to assess the quality, reliability, and level of misinformation in YouTube, Instagram, and TikTok videos about hysteroscopic metroplasty. Videos on each social network retrieved using "hysteroscopy" and "septate uterus" or "uterine septum" as keywords were assessed using Patient Education Materials Assessment Tool for audio-visual (PEMAT A/V) content, the modified DISCERN (mDISCERN), Global Quality Scale (GQS), Video Information and Quality Index (VIQI) and Misinformation assessment.

RESULTS

One hundred fifteen videos (47 from YouTube, 35 from TikTok, and 33 from Instagram) were included. Median PEMAT A/V Understandability and Actionability scores were 50.0 % (IQR: 0-63.3) and 20 % (IQR: 0.0-50.0). Actionability was higher YouTube relative to TikTok and Instagram (50.0 % [IQR: 0-75.0] vs. 0 % [IQR: 0-66.0]; p < 0.001 and 0 % [IQR: 0-33.0], p < 0.001), with no significant differences for Understandability. Median mDISCERN was 3 (IQR: 0-3), with higher score for YouTube compared to TikTok and Instagram (3 [IQR: 0-3] vs. 0 [IQR: 0-23], p < 0.001 and 1 [IQR 0-3.0], p < 0.001 respectively). VIQI showed low-level content (median 9; IQR: 4-19) and no differences among social media platforms. GQS was low (median 2 [IQR 1-4.5]), with no differences in subgroup analysis. Videos on YouTube (97.9 %) and TikTok (62.9 %) favored hysteroscopic metroplasty, while Instagram content was against in 63.6 % of cases (p < 0.001). While most videos were found to be either completely or partially accurate, significant differences in misinformation levels were observed across platforms, with YouTube exhibiting the lowest rate of inaccuracies compared to TikTok and Instagram. (8.5 % vs. 42.9 % and 36.4 %; p < 0.001, respectively).

CONCLUSION

Quality of social networks' videos on hysteroscopic metroplasty seems unsatisfactory, but with low levels of misinformation. YouTube and TikTok were more favorable than Instagram regarding the usefulness of metroplasty. In contrast, a favorable opinion regarding its efficacy in fertility improvement was retrieved in each social.

Reproductive outcomes and risk factors of women with septate uterus after hysteroscopic metroplasty

Background

Hysteroscopic metroplasty of the uterine septum has been the standard treatment strategy to improve reproductive outcomes, but there are still controversies about the appropriateness of metroplasty. In addition, there have been few studies of the factors related to reproductive outcomes of women after surgery. The study aimed to evaluate the reproductive outcomes and the associated risk factors that influence reproductive outcomes after hysteroscopic metroplasty of women with septate uterus and the desire to conceive.

Methods

This study was an observational study. Cases were screened by searching electronic patient files, and demographic factors were collected. We conducted telephone follow-ups to collect the postoperative reproductive outcomes. The primary outcome of this study was live birth, and secondary outcomes were ongoing pregnancy, clinical pregnancy, early miscarriage, and preterm birth. Demographic variables included patients' age, body mass index (BMI), the type of septum, infertility and miscarriage history, and complications including intrauterine adhesions, endometrial polyps, endometriosis, and adenomyosis were collected to perform univariate and multivariate analyses to predict the risk factors of reproductive outcomes after surgery treatment.

Results

In total, 348 women were evaluated and followed up. There were 95 cases (27.3%, 95/348) with combined infertility, 195 cases (56.0%, 195/348) with miscarriage history, and cases combined with intrauterine adhesions, endometrial polyps, endometriosis, and adenomyosis were 107 (30.7%, 107/348), 53 (15.2%, 53/348), 28 (8.0%, 28/348), and 5 (1.4%), respectively. Following surgery, the live birth rate and clinical pregnancy rate were significantly higher than prior to surgery (84.6% vs 3.7%, p= 0.000; and 78.2% vs 69.5%, p= 0.01, respectively), early miscarriage rate and preterm delivery rate were significantly lower (8.8% vs 80.6%, p= 0.000; and 7.0% vs 66.7%, p=0.000, respectively). After adjusting for body mass index, miscarriage history, and complications, multivariable logistic regression analysis revealed age ≥ 35 years and primary infertility as independent factors that affected postoperative clinical pregnancy (OR 4.025, 95% CI 2.063-7.851, p= 0.000; and OR 3.603, 95% CI 1.903-6.820, p= 0.000; respectively) and ongoing pregnancy (OR 3.420, 95% CI 1.812-6.455, p= 0.000; and OR 2.586, 95% CI 1.419-4.712, p= 0.002; respectively).

Conclusions

Hysteroscopic metroplasty could lead to improved reproductive outcomes of women with septate uterus. Both age and primary infertility were independent factors for postoperative reproductive outcomes.

Trial registration

Chi ECRCT20210343.

The current and future state of surgery in reproductive endocrinology

PURPOSE OF REVIEW

The last decade has witnessed a radical change in the field of reproductive surgery. The increasing success of in-vitro fertilization (IVF) has caused a huge shift in emphasis with many downstream consequences. This review outlines the changes and provides insight into the future of reproductive surgery.

RECENT FINDINGS

With compelling evidence that IVF overcomes the detrimental effects of endometriosis on infertility and with two new oral medications available for management of endometriosis, momentum is shifting towards nonsurgical management of endometriosis. There is increasing recognition that except for submucous myomas, other myomas are unlikely to affect fertility and miscarriage. This, in addition to many emerging alternative modalities for management of myomas (oral GnRH antagonists, radiofrequency ablation), is likely to further decrease classic myomectomies but provide alternative, less invasive options. Caesarean scar defects have been recognized as having significant reproductive consequences and surgical management has become the standard of care. Fallopian tubes are now implicated in development of ovarian cancer, and as a result, salpingectomies are being performed in lieu of tubal ligations. Tubal anastomosis will soon become a historical surgery. Division of uterine septum remains controversial, and a clear answer will remain elusive. Uterine transplant is the single most significant advance in reproductive surgery in the past century.

SUMMARY

Reproductive surgery is evolving with the times. Although some surgical techniques will become historical, others will become mainstream.

3D transvaginal ultrasound diagnosis of uterine septa according to different classifications: are there other measurements that correlate to reproductive outcome in small indentation length?

Background: High discrepancy between current classifications was observed in the definition of uterine septa, especially for indentation lengths >5 <10mm. Objectives: To assess the discrepancy between current classifications in the diagnoses of septate uterus and to correlate them with reproductive outcomes; to detect 3D transvaginal ultrasound (TVS) additional measurements, which can better correlate small indentation lengths >5 <10mm to reproductive failures. Material and methods: Observational study enrolling 664 women of reproductive age with 3D ultrasound diagnosis of an indentation length ≥3mm. For each patient a detailed reproductive history was taken before performing 3D transvaginal examination. Patients with previous uterine surgery or metroplasty were excluded. Main Outcome Measure(s): Indentation lengths >5 <10mm showed high discrepancy in the diagnosis of uterine septum between different classifications. For these small indentations additional 3D measurements (indentation angle, septal width and septal length/ fundal myometrial thickness (L/M) ratio) were correlated to infertility and recurrent miscarriage. Results: Among the cohort, 215 patients showed an indentation length >5 <10mm; 136 tried to conceive: 69 (51%) were infertile, 38 (28%) had recurrent miscarriages (≥2) and 5 (4%) had at least one delivery. Recurrent miscarriage significantly correlated to an indentation angle >134°; whereas infertility to an indentation width <32mm and a L/M ratio >75%. Conclusions: Wide discrepancies between different classifications are more evident in indentation lengths >5 <10mm. Additional measurements on 3D coronal section may help to evaluate the risk of infertility or recurrent miscarriage. What is new? Additional 3D TVS measurements, beyond septal lengths, in particular for small fundal indentation, may help in predicting the risk of developing adverse reproductive outcomes.