Evaluation of the Success of Hysteroscopic Uterine Septum Resection

Objectives

The aim is to use three-dimensional transvaginal ultrasonography (3-D TVUS) to evaluate the success of hysteroscopic metroplasty for the uterine septum and to compare the pregnancy outcomes.

Materials and Methods

Thirty-eight patients with uterine septum who had hysteroscopic uterine septum resection were recruited. Preoperative 3-D TVUS measurements of the septal apex to the uterine fundus (s1), septal apex to internal os distance (s2), and intercornual distance (s3) were compared with the postoperative values. The pregnancies of the patients were followed up for a year postoperative period.

Results

Out of the 38 patients, thirty-five had partial uterine septum (class U2a), while 3 patients had complete uterine septum (class U2b). Eighteen (47.36%) of the patients who underwent uterine septum resection achieved pregnancy, and thirteen of these pregnancies were (72.2%) term pregnancies, and all term pregnancies resulted in a live birth. Natural conception was achieved in 77.7% (14 of 18) of the patients. Term pregnancy occurred in 68.7% (11 of 16) of the patients with a partial septum and in 66.6% (2 of 3) of the patients with a complete uterine septum. A comparison of the 3-D TVUS measurements of the uterus pre- and postoperatively showed a decrease in s1 and an increase in s2 (P < 0.05). The uterine cavity length of pregnant patients was found to be higher than nonpregnant patients (P < 0.05).

Conclusion

Reproductive results of hysteroscopic metroplasty were favorable in achieving live and term birth. three-dimensional TVUS can be preferred as a noninvasive effective method in objective evaluation of the success of the hysteroscopic surgery.

The effect of hysteroscopic metroplasty on fertility in T-shaped and Y-shaped dysmorphic uterus

OBJECTIVE

T/Y-shaped dysmorphic uterus is frequently associated with subfertility, abortion, preterm delivery, and recurrent implantation failure. In this study, the impact of hysteroscopic metroplasty for a T/Y-shaped uterus on obstetric outcomes was investigated in patients with infertility and recurrent pregnancy loss (RPL) and compared the uterine anomaly subgroups.

METHOD

Cases with infertility and/or RPL diagnosed with T/Y-shaped uterus by hysterosalpingography (HSG) and 3D transvaginal ultrasonography (3D TVUSG) with no other male or female pathology have recruited the study. Medical history and the obstetric outcome after two years of follow-up were recorded.

RESULTS

Out of the 92 cases recruited, T-shaped uteri (Group-1) were observed in 30, while 62 (67.3%) patients had Y-shaped uteri. Pregnancy was achieved in 50 (54.3%) of the cases, 28 (56%) of the pregnancies occurred spontaneously, and in 22 (44%) pregnancy was achieved through assisted reproductive techniques (ART). Term delivery occurred in 29 (76.3%) of the pregnancies while 9 (23.6%) had preterm deliveries and a total of 38 (76%) resulted in a live birth. Out of the 31 patients with previous RPL history, 13 (41.9%) achieved pregnancy and 11 out of 13 (84.6%) had a term pregnancy followed by live birth.

CONCLUSION

Spontaneous pregnancy, and term pregnancy rates after surgery were found to be promising in these uterine anomalies. The pregnancy outcome of the primary infertile patients was found the same in two groups (50%-46.1%), but the results of the RPL patients were found to be better in the T-shaped group than in the Y-shaped group (70%-28.5%).

The added value of three-dimensional ultrasonography in uterine pathology

The rapid development achieved over the last decades in volume rendering of ultrasound data, known as three-dimensional (3D) ultrasound technique, leads to new opportunities for refining the diagnosis in many gynaecologic conditions. The aim of the present study was to evaluate the advantages of 3D ultrasound over two-dimensional (2D) ultrasound in uterine pathology and to establish the optimal time point during the menstrual cycle to perform 3D ultrasound examination in order to achieve the maximum of useful information. A cross-sectional study on 200 patients who underwent gynaecologic 2D and 3D ultrasound examinations was performed. The addition of 3D examination to 2D ultrasound in uterine pathology provided the most useful information concerning: Congenital uterine anomalies, intrauterine devices (IUDs), adenomyosis, and submucous myomas. The findings showed that the 3D ultrasound scan is a useful tool in gynaecology, especially in cases with congenital uterine anomalies, myoma, and IUD. Although initially it was used for research purposes only, recent findings suggest its usefulness in routine ultrasound scan and the possibility of witnessing its introduction as a recommended examination procedure in the foreseeable future. Further research should be conducted in order to establish the sensitivity of 3D ultrasound in the detection of minor endometrial conditions, by correlating the imaging findings with the hysteroscopic results.

The accuracy of three-dimensional ultrasonography in the diagnosis of Müllerian duct anomalies and its concordance with magnetic resonance imaging

This retrospective study was performed to comparatively evaluate the diagnostic accuracies of three-dimensional ultrasonography (3D-US) and magnetic resonance imaging (MRI) for identification of Müllerian duct anomalies (MDAs). A total of 27 women with suspected MDAs underwent gynaecological examination, 2D-US, 3D-US and MRI, respectively. The MDAs were classified with respect to the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE/ESGE) and American Society of Reproductive Medicine (ASRM) systems. Based on the ESHRE/ESGE classification, there was a discrepancy for only one patient between US and MRI. Thus, the concordance between US and MRI was 26/27 (96.3%). With respect to ASRM classification, there was a disagreement between MRI and 3D-US in three patients, thus the concordance between MRI and 3D-US was 24/27 (88.9%). To conclude, the 3D-US has a good level of agreement with MRI for recognition of MDAs.Impact StatementWhat is already known on this subject? Müllerian duct anomalies (MDAs) are relatively common malformations of the female genital tract and they may adversely affect the reproductive potential. The establishment of accurate and timely diagnosis of these malformations is critical to overcome clinical consequences of MDAs.What the results of this study add? The concordance between US and MRI for diagnosis of MDAs based on ESHRE-ESGE classification and ASRM were 96.3% and 88.9%, respectively. These results indicate that 3D US has a satisfactory level of diagnostic accuracy for MDAs and it can be used in conjunction with MRI. Minimisation of diagnostic errors is important to improve reproductive outcome and to avoid unnecessary surgical interventions.What the implications are of these findings for clinical practice and/or further research? Efforts must be spent to eliminate the discrepancies between the clinical and radiological diagnosis of MDAs. Further trials should be implemented for establishment and standardisation of radiological images for identification and classification of MDAs.

Definition, prevalence, clinical relevance and treatment of T-shaped uterus: systematic review

OBJECTIVES

To summarize in a systematic review the current evidence regarding definitions, diagnosis, prevalence, etiology, clinical relevance and impact of surgical treatment for T-shaped uterus not related to diethylstilbestrol (DES) exposure, and to highlight areas on which future research should focus.

METHODS

A search of PubMed, Scopus and EMBASE was performed on 9 April 2020 using the search terms 't-shaped OR t-shape OR infantile OR (lateral indentation) OR (diethylstilbestrol OR DES) AND (uterus OR uterine OR uteri) AND (anomaly OR anomalies OR malformation OR malformations)'. Additionally, the reference lists of the included studies were searched manually for other relevant publications. All studies presenting data on T-shaped uterus not associated with DES exposure and including at least 10 women were considered eligible. Studies regarding DES-related T-shaped uterus were excluded because DES has not been used since 1971. There were no restrictions on language, date of publication or status of publication.

RESULTS

Of 2504 records identified by the electronic search, 20 studies were included in the systematic review. The majority of studies were of poor quality. In 11 of 16 studies reporting on the diagnosis of T-shaped uterus, the diagnostic method used was three-dimensional ultrasound. There is no consensus on the definition of T-shaped uterus, but the most cited criteria (4/16 studies) were of the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy (ESHRE/ESGE; 2013). The prevalence of T-shaped uterus varied from 0.2% to 10% in the four included studies reporting such data. With respect to etiology (except for DES), T-shaped uterus was considered a primary condition in three studies and secondary to adhesions in five and adenomyosis in one. T-shaped uterus was related to worse reproductive outcome based on subfertility (nine studies), miscarriage (seven studies), preterm delivery (two studies), ectopic pregnancy (one study) and repeat implantation failure (seven studies). Of the 12 studies that reported on the effects of surgical treatment of T-shaped uterus by hysteroscopic metroplasty, some mentioned an improvement in pregnancy rate (rates ranging from 49.6% to 88%; eight studies), live-birth rate (rates ranging from 35.1% to 76%; seven studies) and term-delivery rate (four studies) and a reduction in miscarriage (rates ranging from 7% to 49.6%; five studies) and ectopic pregnancy (one study). However, the evidence is of very low quality with serious/critical risk of bias toward overestimating the intervention effect. Some authors reported no complications related to the procedure, while others mentioned persistence of the dysmorphism (rates ranging from 1.4% to 11%; three studies), bleeding (1.3%; one study), infection (2.6%; one study) and adhesions (11.1% and 16.8%; two studies).

CONCLUSIONS

The prevalence, etiology and clinical relevance, with respect to reproductive outcome, of T-shaped uterus remain unclear and there is no consensus on the definition and diagnostic method for this condition. Expectant management should be considered the most appropriate choice for everyday practice until randomized controlled trials show a benefit of intervention. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

The effectiveness of uterine parametrics measured by three-dimensional transvaginal sonography in the diagnosis of uterine cavity distortions

Background

To analyze the application values of quantitative parametrics measured by three-dimensional transvaginal sonography (3D-TVS) in the diagnosis of uterine cavity distortions.

Methods

A retrospective analysis was performed on consecutive 113 patients with septate uteruses, as diagnosed consistently by both 3D-TVS and hysteroscopic surgery, between Jan 2016 and Jan 2018. The intrauterine quantitative parametrics were compared between an infertility group and a miscarriage group. Receiver operating characteristic (ROC) curve analysis and evaluation indicators of diagnostic tests were plotted to analyze the relationships between parametrics and uterine cavity distortions.

Results

There were no significant differences in septum width, septum length, uterine angle, remaining uterine cavity length, and distortion rate between the infertility and miscarriage groups (P>0.05). The distortion rate was positively correlated with septum length, but showed a negative correlation with uterine angle and remaining uterine cavity length (all P<0.05). The area under the curve (AUC) of septum length for predicting a distortion rate higher than 50% was 0.969; with a cutoff value of 2.15 cm, and a diagnostic accuracy of 97.14%, sensitivity was 81.80% and specificity was 98.90%, respectively. Patients with lower septum length coupled with a higher remaining uterine cavity length had a lower risk of uterine cavity distortion.

Conclusions

Septum length was shown to have the most important effect on uterine cavity distortion of all the uterine parametrics measured by 3D-TVS. Patients with septum lengths higher than 2.15 cm indicated a distortion rate of more than 50%, and tend to experience adverse pregnancy outcomes.