Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of septate uterus: A prospective randomized study

Reproductive outcome after hysteroscopic septoplasty in patients with septate uterus--a retrospective cohort study and systematic review of the literature

BACKGROUND

Septate uterus, one of the most common forms of congenital uterine malformations, negatively affects female reproductive health.

METHODS

In a retrospective cohort study, we evaluated the reproductive outcome after hysteroscopic septoplasty in 64 women with septate uterus and primary or secondary infertility. We performed a systematic review of studies evaluating the reproductive outcome after hysteroscopic septoplasty.

RESULTS

Sixty-four women underwent hysteroscopic septoplasty. In 2/64 (3%) women, intraoperative uterine perforation occurred. Complete follow-up was available for 49/64 (76%) patients. Mean follow-up time was 68.6+/-5.2 months. The overall pregnancy rate after hysteroscopic septoplasty was 69% (34/49). The overall life birth rate (LBR) was 49% (24/49). The mean time interval between surgery and the first life birth was 35.8+/-22.5 months. Including our own data, we identified 18 studies investigating the effect of septoplasty on reproductive outcome in 1501 women. A pooled analysis demonstrated that hysteroscopic septoplasty resulted in an overall pregnancy rate of 60% (892/1501) and a LBR of 45% (686/1501). The overall rate of intra- and postoperative complications was 1.7% (23/1324) and the overall rate of re-hysteroscopy was 6% (79/1324).

CONCLUSIONS

In women with septate uterus and a history of infertility, hysteroscopic septoplasty is a safe and effective procedure resulting in a pregnancy rate of 60% and a LBR of 45%.

Congenital malformations of the female genital tract: the need for a new classification system

Current proposals for classifying female genital anomalies seem to be associated with limitations in effective categorization, creating the need for a new classification system that is as simple as possible, clear and accurate in its definitions, comprehensive, and correlated with patients' clinical presentation, prognosis, and treatment on an evidence-based foundation. Although creating a new classification system is not an easy task, it is feasible when taking into account the experience gained from applying the existing classification systems, mainly that of the American Fertility Society.

Office hysteroscopy: current trends and potential applications: a critical review

Office hysteroscopy is an excellent method of identifying and treating intracavitary uterine lesions. It has become easy to learn and perform; as an aid of modern technological applications, it is safe, accurate, provides immediate results under direct visualisation, and offers the additional benefit of histological confirmation and the discomfort of patients is minimal. We applied an extended literature search to explore the special features and details of the technique itself, as it evolved since it first appeared 30 years back. Our initial goal was to examine potential changes/improvements of the modality, in terms of the instrumentation used and the technique itself, the indications of use, its incorporation in daily practice, and patients' and clinicians' acceptability.

The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review

BACKGROUND

Although hysteroscopy is frequently used in the management of subfertile women, a systematic review of the evidence on this subject is lacking.

METHODS

We summarized and appraised the evidence for the benefit yielded by this procedure. Our systematic search was limited to randomized and controlled studies. The QUOROM and MOOSE guidelines were followed. Language restrictions were not applied.

RESULTS

We identified 30 relevant publications. Hysteroscopic removal of endometrial polyps with a mean diameter of 16 mm detected by ultrasound doubles the pregnancy rate when compared with diagnostic hysteroscopy and polyp biopsy in patients undergoing intrauterine insemination, starting 3 months after the surgical intervention [relative risk (RR) = 2.3; 95% confidence interval (CI): 1.6-3.2]. In patients with one fibroid structure smaller than 4 cm, there was a marginally significant benefit from myomectomy when compared with expectant management (RR = 1.9; 95% CI: 1.0-3.7). Hysteroscopic metroplasty for septate uterus resulted in fewer pregnancies in patients with subfertility when compared with those with recurrent pregnancy loss (RR = 0.7; 95% CI: 0.5-0.9). Randomized controlled studies on hysteroscopic treatment of intrauterine adhesions are lacking. Hysteroscopy in the cycle preceding a subsequent IVF attempt nearly doubles the pregnancy rate in patients with at least two failed IVF attempts compared with starting IVF immediately (RR = 1.7; 95% CI: 1.5-2.0).

CONCLUSIONS

Scarce evidence on the effectiveness of hysteroscopic surgery in subfertile women with polyps, fibroids, septate uterus or intrauterine adhesions indicates a potential benefit. More randomized controlled trials are needed before widespread use of hysteroscopic surgery in the general subfertile population can be justified.

Müllerian duct anomalies: review of current management

The aim of this paper was to discuss the embryological aspects of Müllerian duct anomalies and to analyze the current diagnostic methods and therapy. Müllerian anomalies are congenital defects of the female reproductive tract resulting from failure in the development of the Müllerian ducts and their associated structures. Their cause has yet to be fully clarified, and it is currently believed to be multifactorial. Symptoms appear principally during adolescence or early adulthood, and affect the reproductive capacity of these women. When clinically suspected, investigations leading to diagnosis include imaging methods such as hysterosalpingography, ultrasonography and magnetic resonance. The classification of these malformations relates to their embryogenesis, and defines the therapy and prognosis. Müllerian anomalies consist of a wide range of defects that may vary from patient to patient. Therefore, their management must also be individual, taking anatomical and clinical characteristics into consideration, as well as the patient's wishes.

Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial

OBJECTIVE

To assess fecundity of infertile women after surgical correction of uterine septum.

DESIGN

Prospective controlled trial.

SETTING

Three academic infertility clinics.

PATIENT(S)

Forty-four women affected by septate uterus and otherwise unexplained infertility represented the study group (group A), and 132 women with unexplained infertility were enrolled as control subjects (group B).

INTERVENTION(S)

Hysteroscopic metroplasty was performed in group A, and group B was managed expectantly. All women were followed-up for 1 year without any other intervention.

MAIN OUTCOME MEASURE(S)

Fecundity rate was calculated as the number of pregnancies per 100 person-months.

RESULT(S)

Pregnancy rate (38.6% vs. 20.4%) and live birth rate (34.1% and 18.9%) were significantly higher in group A than in group B. The survival analysis showed that the probability of a pregnancy in the twelve-months follow up was significantly higher in patients who had undergone metroplasty than in women with unexplained infertility. The corresponding fecundity (10-week pregnancy) rates were 4.27 and 1.92 person-months in women who had undergone metroplasty and in women with unexplained infertility, respectively.

CONCLUSION(S)

Hysteroscopic resection of the septum improves fecundity of women with septate uterus and otherwise unexplained infertility. Patients with septate uterus and no other cause of sterility have a significantly higher probability of conceiving after removal of the septum than patients affected by idiopathic sterility.

[Prevention of intrauterine adhesions after hysteroscopic surgery]

Intrauterine adhesions are the most frequent complications after hysteroscopic surgery in women of reproductive age. The prevalence of intrauterine adhesions after hysteroscopic surgery is correlated to intrauterine pathology (myoma, polyp, or adhesions). Few clinical trials have demonstrated the efficiency of barrier agents developed in order to prevent adhesions after operative hysteroscopy. Adhesion barriers are mechanic agent (intrauterine device), fluid agents (Seprafilm, Hyalobarrier) and postoperative systemic treatment (estroprogestative treatment). In this article, we evaluate the efficiency of these barrier agents for adhesion prevention in hysteroscopic surgery, undertaking a review of clinical trials published. The most frequent published studies evaluate the anatomic efficiency of antiadhesion agents after hysteroscopic surgery in order to evaluate the fertility. Data are still insufficient to evaluate them for clinical use. There is a need for other randomised controlled trials.