Daily practice management of septate uterus: reproductive outcome after septoplasty

Effect of hysteroscopic septum resection on IVF/ICSI outcomes in women with septate uterus: a propensity-score retrospective matching study

BACKGROUND

Hysteroscopic septum resection has been a widespread technique throughout the world in women with a septate uterus. The effectiveness of hysteroscopic septum resection before IVF was equivocal. This study aimed to investigate whether hysteroscopic septum resection could improve IVF outcomes for women with a septate uterus.

METHODS

This retrospective case-control study was carried out from January 2017 to December 2022. We included subfertile women with septate uterus (n = 147), including 113 women undergoing hysteroscopic septum resection and 34 women opting for expectant management before IVF/ICSI. In addition, we selected 147 women with normal uteri using propensity score matching (PSM). The clinical outcomes of IVF/ICSI were compared by logistic regression and Cox proportional regression in each group.

RESULTS

During follow-up time, clinical pregnancy occurred in 66 women who underwent hysteroscopic septum resection (58.41%), compared to 23 women opting for expectant management (67.65%, OR 1.783, 95% CI 0.725-4.380) and 87 women with normal uteri (59.18%, OR 2.601, 95% CI 1.202-5.631). Miscarriage occurred in 12 women who underwent hysteroscopic septum resection (18.18%) versus 5 women who had expectant management (21.74%, OR 1.098, 95% CI 0.323-3.734) and 8 women with normal uteri (9.20%, OR 0.278, 95% CI 0.078-0.997), while preterm birth occurred in 7 women who underwent hysteroscopic septum resection (10.61%) versus 1 women who had expectant management (4.35%, OR 0.509, 95% CI 0.056-4.666) and 9 women with normal uteri (10.34%, OR 1.472, 95% CI 0.291-7.447). Live birth occurred in 54 women following hysteroscopic septum resection (47.79%) compared to 18 women following expectant management (52.94%, OR 1.368, 95% CI 0.589-3.175) and 78 women with normal uteri (53.06%, OR 1.641, 95% CI 0.941-2.864).

CONCLUSIONS

Women who underwent hysteroscopic septum resection had lower clinical pregnancy rate and higher risk of miscarriage compared to those with normal uteri, but there was no significant difference in live birth rate between the groups.

TRIAL REGISTRATION

This is a retrospective case-control study.

Septate uterus discovery during an emergency cesarean section in the North Eastern of the Democratic Republic of Congo: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Septate uterus is the commonest of congenital structural uterine anomaly with highest failure rate reproductive. It is secondary to incomplete resorption of the Müllerian duct during embryogenesis. Pregnancy in septate uterus carries with it maternal-fetal risk. The importance of this report is to provide data and encourage report of similar conditions in this region.

CASE PRESENTATION

A 25-Year-old, female booked G7P3A3 at 39 weeks and 4 days with history of miscarriages and preterm delivery for second, fourth and fifth pregnancies. She had an emergency cesarean section on the last one due to a contracted pelvis on a term pregnancy. Delivered a male baby of 3000 g, APGAR score of 9, 10, 10 respectively at the first, fifth and tenth minutes. Intraoperative findings revealed a partial septate uterus. The abdominopelvic cavity organs were anatomically normal.

CLINICAL DISCUSSION

Septate uterus is associated with adverse obstetric outcomes, like recurrent miscarriages, premature delivery, fetal malposition, intrauterine growth retardation, postpartum hemorrhage. 9-35 % of women with this malformation may experience infertility. Although the efficacy of septoplasty and preconception interventions has not been fully established in improving obstetric outcomes, in current medical practice these procedures are suggested.

CONCLUSION

Septate uterus as congenital uterus malformations, should be suspected in any women with obstetric complications high risk such as miscarriage, preterm delivery and malpresentation.

Reproductive outcomes of oocyte donation in patients with uterine Müllerian anomalies

OBJECTIVE

To evaluate live-birth rates per embryo transfer in patients with uterine Müllerian anomalies (UMAs). Secondary objectives were to compare reproductive outcomes between the normal uterus group, the different UMA types, and UMA subgroups with and without required surgery.

DESIGN

This retrospective study compared two cohorts, one with UMAs and other with normal uteri of our oocyte donation program at 12 Instituto Valenciano De Infertilidad/Reproductive Medicine Associates University affiliated clinics from January 2000 to 2020. The oocyte donation reduces confounding because of differences in embryo quality. The primary outcome was the live-birth rate per embryo transfer. Secondary outcomes included the rates of implantation, clinical pregnancy, miscarriage, and ongoing pregnancy. We calculated odds ratios with 95% confidence intervals.

PATIENTS

Infertile women undergoing oocyte donation with UMAs.

INTERVENTION

None.

MAIN OUTCOME MEASURES

The rates of implantation, clinical pregnancy, miscarriage, ongoing pregnancy, and live birth.

RESULTS

We analyzed 58,337 cycles of oocyte donation: 57,869 patients had no uterine malformation, and 468 women had UMAs. Compared with patients with normal uteri, patients with UMAs had lower rates of live births (36.67% [32.84-40.65] vs. 38.1% [95% confidence intervals {CI}: 37.82-38.42]) and ongoing pregnancy (39.74% [35.93-43.66] vs. 41.5% [41.24-41.83]). The miscarriage rate was higher in patients with UMAs (19.5% [16.55-22.85] vs. 16.6% [16.47-16.92]). Specifically, patients with a unicornuate uterus (n=29) had lower rates of implantation (24.07% [13.49-37.64] vs. 42.85% [95% CI: 42.6-43.09]), pregnancy (41.86% [27.01-57.87] vs. 59.51% [59.22-59.81]), ongoing pregnancy (16.67% [6.97-31.36] vs. 41.54% [41.24-41.83]), and live births (16.67% [6.97-31.36] vs. 38.12% [37.83-38.42]). In addition, patients with a partial septate uterus (n=91) had a higher miscarriage rate (26.50% [18.44-34.89] vs. 16.7% [16.47-16.92]). Compared with the normal uterus group, the live-birth rates were lower in the UMA without surgery group (33.09% [27.59-38.96] vs. 38.12% [37.83-38.42]).

CONCLUSION

Among patients who received embryos derived from donated oocytes, live birth and ongoing pregnancy rates were lower in patients with UMAs compared with patients with normal uteri. A higher miscarriage rate was found in patients with UMAs. Patients with a unicornuate uterus had worse reproductive outcomes. Our results show that the uterus is less competent in patients with UMAs.

TRIAL REGISTRATION

This study was registered at clinicaltrial.gov (NCT04571671).

Diagnosis of septate uterus

The septate uterus is the most common structural uterine anomalies and it is associated with the poor reproductive outcome. It is believed to be the result of the failure in resorption of the tissue connecting the 2 paramesonephric ducts prior to the 20th embryonic week. The true prevalence of uterine septum is difficult to ascertain, as many uterine septal defects are asymptomatic. The septate uterus is usually diagnosed during an infertility evaluation and affects reproductive health by impairing fertility and increasing adverse pregnancy outcomes. The variations in uterine and cervical/vaginal anomalies collectively referred to as Müllerian anomalies. No consistent gold standard for the diagnosis of Müllerian anomalies exists. The preferred diagnostic method for Müllerian anomalies is two-dimensional ultrasound, other methods such as three-dimensional ultrasound, magnetic resonance imaging, hysterosalpingo contrast sonography, hysterosalpingography, hysteroscopy, and laparoscopy are also used to improve accuracy.