Management and reproductive outcome of complete septate uterus with duplicated cervix and vaginal septum: review of 21 cases

Cervical Septum Incision Adversely Impacts Clinical Outcomes in Women with Complete Uterine Septum and Duplicated Cervix

STUDY OBJECTIVE

To investigate the reproductive outcomes of women with complete septate uterus and duplicated cervix who either did or did not receive cervical septum incision during hysteroscopic transcervical incision of the uterine septum.

DESIGN

Retrospective study approved by the hospital ethics committee.

SETTING

Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.

PATIENTS

Women with complete septate uterus and duplicated cervix who underwent hysteroscopic transcervical incision of the uterine septum in Obstetrics and Gynecology Hospital of Fudan University between January 2008 and December 2020 (n = 105).

INTERVENTIONS

Hysteroscopic incision of the septum.

MEASUREMENTS AND MAIN RESULTS

Included patients were grouped according to whether or not cervical septum incision was performed. Reproductive outcomes including gravidity, abortion rate, preterm birth rate, full-term birth rate, premature rupture of membranes, and cervical incompetence were assessed. In the no incision group, the abortion rate (7.4%) was significantly lower than that of the incision group (27.6%, p = .01); the preterm birth rate (4.6%) was significantly lower than that of the incision group (36.8%); and the full-term birth rate (95.5%) exceeded that of the incision group (63.2%, p <.01). Incidence of premature rupture of membranes and cervical incompetence during pregnancy was higher in the incision group (15.8% and 10.5%, p <.01 and p = .03).

CONCLUSION

Significantly improved reproductive outcomes were observed among patients with complete septate uterus and duplicated cervix whose cervical septum was preserved during the hysteroscopic transcervical incision of the uterine septum procedure.

Natural conception and term pregnancy after hysteroscopic incision of complete septate uterus with septate cervix: A case report and literature review

OBJECTIVE

To discuss several techniques of hysteroscopic surgery for complete septate uterus.

CASE REPORT

A 40-year-old female with unexplained primary infertility was diagnosed with complete septate uterus with septate cervix. Hysteroscopic incision of complete septate uterus was performed by using ballooning technique. The patient conceived naturally shortly after the operation and delivered a healthy, term infant.

CONCLUSION

Hysteroscopic incision of complete septate uterus is a safe and prompt way of metroplasty. With the knowledge obtained from a pre-operative MRI, it can be completed without laparoscopy and the need for hospitalization.

Hysteroscopic management of complete septate uterus with septate cervix, and longitudinal vaginal septum: a case report

Mullerian anomalies occur as a result of errors during embryogenesis. The estimated incidence of these anomalies is around 1% in the general population and 3% in women complaining of suboptimal reproductive outcomes and infertility. A 21-year-old female patient was referred to our hospital due to primary infertility for 18 months. After a proper history, physical examination and further diagnostic steps, including ultrasound and magnetic resonance imaging, a diagnosis of complete septate uterus with septate cervix and longitudinal vaginal septum was made. Following hysteroscopic resection of all the septa and two cycles of ovulation induction, the patient was able to conceive. However, she needed cervical cerclage later due to cervical insufficiency. The baby was delivered at term and was healthy. A uterine, cervical and longitudinal vaginal septum is a unique entity of Mullerian anomalies. Resection of all septa through a hysteroscopic approach resulted in a good outcome for our patient.

Impact of congenital uterine anomalies on obstetric and perinatal outcomes: systematic review and meta-analysis

Background

Congenital uterine anomalies (CUA) can be associated with impairments of early and late pregnancy events.

Objective

To assess the impact of CUA on reproductive outcomes in pregnancies conceived spontaneously or after assisted reproduction.

Materials and Methods

Systematic review and meta-analysis of cohort studies comparing patients with CUA versus women with normal uterus. A structured literature search was performed in leading scientific databases to identify prospective and retrospective studies. The Newcastle-Ottawa scale, adapted to AHRQ standards, was used to assess the risk of bias. Pooled odds ratios (OR) were calculated. Publication bias and statistical heterogeneity were assessed, and meta-regression was used to analyse the heterogeneity.

Main outcome measures

Miscarriage, ectopic pregnancy, placental abruption, term, and premature rupture of membranes (PROM), malpresentation at delivery, preterm delivery prior to 37, 34 and 32 weeks, caesarean delivery, intrauterine growth restriction/small for gestational age, foetal mortality and perinatal mortality.

Results

32 studies were included. CUAs increased significantly the risk of first/second trimester miscarriage (OR:1.54;95%CI:1.14-2.07), placental abruption (OR:5.04;3.60-7.04), PROM (OR:1.71;1.34-2.18), foetal malpresentation at delivery (OR:21.04;10.95-40.44), preterm birth (adjusted OR:4.34;3.59-5.21), a caesarean delivery (adjusted OR:7.69;4.17-14.29), intrauterine growth restriction/small for gestational age (adjusted OR:50;6.11-424), foetal mortality (OR:2.07;1.56-2.73) and perinatal mortality (OR:3.28;2.01-5.36).

Conclusions

CUA increases the risk of complications during pregnancy, delivery, and postpartum. Complications most frequent in CUA patients were preterm delivery, foetal malpresentation, and caesarean delivery.

What is new?

Bicornuate uterus was associated with the highest number of adverse outcomes, followed by didelphys, subseptate and septate uterus.

Hysteroscopic Fenestration with Precise Incision of the Cavity Septum: A Novel Minimally Invasive Surgery of Complete Septate Uterus with Double Cervix

STUDY OBJECTIVE

This study aimed to develop and describe a novel surgical procedure that involves hysteroscopic fenestration with precise incision of the complete uterine septum and double cervix preservation after magnetic resonance imaging (MRI) evaluation in patients and to evaluate its efficacy.

DESIGN

A prospective consecutive clinical study.

SETTING

A university teaching hospital.

PATIENTS

Twenty-four patients with complete septate uterus and double cervix.

INTERVENTIONS

Three-dimensional reconstruction of uterus was performed with pelvic MRI and three-dimensional SPACE sequence scanning. Hysteroscopic fenestration with precise incision of the cavity septum and double cervix preservation was performed in patients. Three months after operation, follow-up pelvic MRI and second-look hysteroscopy were performed conventionally.

MEASUREMENTS AND MAIN RESULTS

Operating time, blood loss, operative complications, MRI and hysteroscopic changes of uterus, symptoms improvement, and reproductive outcomes were assessed. The surgery was successfully completed without any intraoperative complications in all patients. Operating time was 21.71 ± 8.28 minutes (range, 10-40 minutes) and blood loss was 9.92 ± 7.14 mL (range, 5-30 mL). Postoperative MRI showed the uterine anteroposterior diameter (3.66 cm vs 3.92 cm; p <.05) was increased. Postoperative MRI and the second-look hysteroscopy showed the cavity shape and uterine volume were expanded to the normal. Symptoms of dysmenorrhea, abnormal uterine bleeding, and dyspareunia were ameliorated after the surgery in 70% of patients (7 of 10), 60% of patients (3 of 5), and 1 patient, respectively. The preoperative spontaneous abortion rate was 80% (4 of 5) and the postoperative spontaneous abortion rate was 11.11% (1 of 9). After the surgery, there were 2 ongoing pregnancies and 6 pregnancies ended in term births. Two live births were delivered by cesarean section and 4 by vaginal delivery without cervical incompetence during pregnancy.

CONCLUSIONS

Hysteroscopic fenestration with precise incision of the uterine septum and double cervix preservation is an effective surgical procedure.

Does uterine septum resection improve IVF treatment success?

Aim: Uterine septum is the most common type of congenital uterine malformation. The septum has also been suggested as a potential cause of infertility. The role of the septum in infertility and whether the septum can be resected is debatable. We aimed to reveal the results of assisted reproductive techniques in patients with septate uterus according to whether or not resection is performed. Material and Method: 7790 patients were scanned retrospectively. 110 patients with the uterine septum and unexplained infertility were included in the study. Patients who underwent uterine septum resection were recorded. The clinical pregnancies of patients were compared according to whether or not resection was performed. In addition, patients with complete septum were evaluated according to whether or not resection was performed, and their clinical pregnancies were evaluated. Results: It was revealed that 79 of the patients with uterine septum underwent septum resection operation. It was determined that 31 patients were not treated. Clinical pregnancy rates were found to be statistically significantly higher in the expectant management group (p=0.02). In addition, comparing the clinical pregnancy rates of the resection and expectant management groups in patients with a complete septum, no significant difference was found between the groups (p=0.134). Conclusion: In our study, the success of treatment with assisted reproductive techniques did not change after septum resection. Although uterine septum resection is a simple and safe method, it has disadvantages such as the development of adhesions and rupture in the uterus. There is insufficient evidence to perform septum resection in patients with uterine septum prior to infertility treatment.

Pregnancy and Adverse Obstetric Outcomes After Hysteroscopic Resection: A Systematic Review and Meta-Analysis

Objective

Although the randomized controlled trial (RCT) of the efficacy of hysteroscopic resection in women with uterine septum has not shown any significant correlation in recent research, motivation for deeper study remains insufficient. In this study, the objective was to determine pregnancy-related outcomes, along with adverse obstetric outcomes, following hysteroscopic resection and also to determine whether women with hysteroscopic resection bear the same outcomes as women with normal uterine cavities.

Search Methods

From January 1995 to February 2022, a systematic literature review was conducted to identify all studies published concerning the gestation outcomes of women with and without hysteroscopic resection while comparing the gestation outcomes of women after hysteroscopic resection and with a normal uterine cavity. Our primary outcome was the live birth rate (LBR). The secondary outcomes were term delivery, preterm delivery, spontaneous miscarriage, malpresentation, cesarean section, and other adverse obstetric outcomes.

Results

22 studies were included in this meta-analysis. The control groups of 14 studies were treated women, and the control groups of the other 8 studies were patients bearing a normal uterine cavity. Hysteroscopic resection was related to a higher rate of term delivery (OR = 2.26, 95% CI, 1.26–4.05), and a lower rate of spontaneous abortion (OR = 0.50, 95% CI, 0.27–0.93), and a lower rate of malpresentation (OR = 0.31, 95% CI, 0.19–0.50). Nevertheless, in comparison with the normal uterus group, the rates of preterm birth, cesarean section, and postpartum hemorrhage after resection did not return to normal levels.

Conclusion

Hysteroscopic resection can effectively reduce the risk of abortion and malpresentation in patients possessing a uterine septum while increasing the term delivery rate. Although well-designed RCTs should confirm our meta-analysis, it still bears recommending to patients

Transcorporal septal dissection using the balloon technique in complete uterine septums, pre- and postoperative results. A follow up from 2007 to 2020

OBJECTIVE

The aim of the study is to show the pre- and postoperative results of transcorporal septal dissection using the balloon technique in complete uterine septums, which is a rare pathology.

STUDY DESIGN

It is a retrospective analysis. In this study 21 patients with a complete uterine septum were included. All patient underwent the transcorporal septal dissection using the balloon technique. Data analysis was based on patient history, surgical reports and telephone contact with the patients and supervising gynecologists.

RESULTS

73% patients with a current desire to become pregnant managed to do so and 75% of them were able to give birth on time. One patient was pregnant at the time of the analysis. In 17 patients the results of the control hysteroscopy were available. In eight patients (47%) a normal cavity was found. In nine cases (53%) a residual septum of 1-2 cm was found, so that an operative hysteroscopy with a residual septum dissection was performed. The operative time was average 30.6 min in the group without laparoscopy and 56.8 min in the group with laparoscopy.

CONCLUSION

The transcorporal septum dissection using the balloon technique is a safe method with a good fertility outcome and requires an experienced surgeon.

Does hysteroscopic resection of uterine septum improve reproductive outcomes: a systematic review and meta-analysis

PURPOSE

Uterine septum in women with subfertility or previous poor reproductive outcomes presents a clinical dilemma. Hysteroscopic septum resection has been previously associated with adverse reproductive outcomes but the evidence remains inconclusive. We aimed to thoroughly and systematically appraise relevant evidence on the impact of hysteroscopically resecting the uterine septum on this cohort of women.

METHODS

AMED, BNI, CINAHL, EMBASE, EMCARE, Medline, PsychInfo, PubMed, Cochrane register of controlled trials, Cochrane database of systematic reviews and CINAHL were assessed to April 2020, with no language restriction. Only randomised control trials and comparative studies which evaluated outcomes in women with uterine septum and a history of subfertility and/or poor reproductive outcomes treated by hysteroscopic septum resection against control were included. The primary endpoint was live birth rate, whereas clinical pregnancy, miscarriage, preterm birth and malpresentation rates were secondary outcomes.

RESULTS

Seven studies involving 407 women with hysteroscopic septum resection and 252 with conservative management were included in the meta-analysis. Hysteroscopic septum resection was associated with a lower rate of miscarriage (OR 0.25, 95% CI 0.07-0.88) compared with untreated women. No significant effect was seen on live birth, clinical pregnancy rate or preterm delivery. However, there were fewer malpresentations during labour in the treated group (OR 0.22, 95% CI 0.06-0.73).

CONCLUSION

Our review found no significant effect of hysteroscopic resection on live birth. However, given the limited evidence available, high-quality randomised controlled trials are recommended before any conclusive clinical guidance can be drawn.

New Ambulatory Hysteroscopic Septoplasty using Ballooning in a Woman with Complete Septate Uterus: A Case Report

A 40-year-old G1 P0 L0 A1 woman was referred to our clinic with 6-year history of infertility. Before visiting the clinic, she had 3 cycles of In-Vitro Fertilization (IVF) procedures (2 cycles of Controlled Ovarian Stimulation-IVF and 1 cycle of frozen-thawed Embryo Transfer (ET)) at other clinic. She had medical history of abortion at early gestation following FET (frozen-thawed-ET). The patient had complete type of septate uterus, double cervix and longitudinal vaginal septum. Vaginal septotomy was done first and 1 month later, hysteroscopic septoplasty was followed using ballooning filled with dye. After septoplasty, we inserted ballooning and left for several days to compress septal endometrium on the septectomy area. All procedures were done in the ambulatory operating room without laparoscopy or admission. 3 months later, she had in vitro fertilization-embryo transfer (IVF-ET) and FET procedures in our clinic. She had successful pregnancy and now is at 22 weeks of gestation. New ambulatory septoplasty using dye-filled ballooning is easy, safe and minimally invasive surgery for treatment of complete septate uterus.

Rare Müllerian Anomaly: Complete Septate Uterus with Simultaneous Longitudinal and Transverse Vaginal Septa

BACKGROUND

We present a patient with primary amenorrhea and a rare combination of anomalies. She was found to have a septate uterus, double cervix, and a longitudinal and a low transverse vaginal septum.

CASE

An 18-year-old girl with primary amenorrhea presented with severe monthly pelvic pain. Examination and imaging revealed a thin transverse vaginal septum, complete septate uterus, double cervix, and a longitudinal vaginal septum. The transverse and longitudinal vaginal septa were excised and repaired.

SUMMARY AND CONCLUSION

Although repetitive pregnancy loss and preterm birth are associated with various Müllerian duct anomalies, clinicians should also be suspicious of the presented anomaly in cases of primary amenorrhea and cyclic pelvic pain. To our knowledge, this is the only case of simultaneous septate uterus with longitudinal and transverse vaginal septum and the second case of combined longitudinal and transverse septum, which caused primary amenorrhea. This rare anomaly further supports the bidirectional regression theory of Müllerian development.

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.

Light-guided hysteroscopic resection of complete septate uterus with preservation of duplicated cervix

The objective of the present study, performed at a tertiary university hospital, was to propose a novel method of hysteroscopic resection of complete septate uterus with preservation of duplicated cervix. The retrospective study included 5 women with complete septate uterus and cervical duplication and who also experienced infertility with or without pregnancy loss. All patients underwent bougie-guided or light-guided hysteroscopic perforation of the uterine septum above the endocervix, followed by septum resection. The success rate of complete uterine septum perforation under bougie guidance was 60% (3 of 5 procedures), and of light guidance was 100% (2 procedures). After hysteroscopic septum resection, 2 of 5 women achieved pregnancy within 3 months and delivered uneventfully at term. It is concluded that light guidance is superior to bougie guidance for hysteroscopic perforation of complete septate uterus with preservation of the duplicated cervix.