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Etrusco A, Laganà AS, Chiantera V, Gerli S, Carugno J, Sorrentino F, Riemma G, Vitagliano A, Favilli A. Efficacy, safety, and feasibility of the treatment of intrauterine pathologies with the mini-resectoscope: A systematic review. Int J Gynaecol Obstet 2024; 166:527-537. [PMID: 38317479 DOI: 10.1002/ijgo.15393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 11/30/2023] [Accepted: 01/09/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Hysteroscopy represents the gold standard for the diagnosis and treatment of intrauterine pathologies. The advent of the mini-resectoscope heralded a new era in intrauterine surgery, both in inpatient and outpatient settings. OBJECTIVES To evaluate the effectiveness, safety, and feasibility of the mini-resectoscope for the treatment of intrauterine pathologies. SEARCH STRATEGY Electronic databases were searched for English-language trials describing surgical procedures for uterine pathologies performed with a mini-resectoscope until 30 April 2023. SELECTION CRITERIA Retrospective or prospective original studies reporting the treatment of uterine pathologies with mini-resectoscope were deemed eligible for the inclusion. DATA COLLECTION AND ANALYSIS Data about study features, characteristics of included populations, surgical procedures, complications, and results/outcomes were collected. RESULTS Seven papers that met the inclusion criteria were included in this systematic review. Quantitative analysis was not possible due to data heterogeneity. A descriptive synthesis of the results was provided accordingly to the pathology hysteroscopically removed/corrected: polyps and myomas, uterine septum, intrauterine synechiae, and isthmocele. CONCLUSIONS The mini-resectoscope is poised to play a leading role in hysteroscopic surgery for many pathologies, both in inpatient and outpatient settings. Since some applications of the mini-resectoscope have not yet been thoroughly investigated, future studies should address current knowledge gaps, designing high-quality comparative trials on specific applications.
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Affiliation(s)
- Andrea Etrusco
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, Palermo, Italy
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
- Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Sandro Gerli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Jose Carugno
- Department of Obstetrics, Gynecology and Reproductive Sciences, Minimally Invasive Gynecology Division, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Felice Sorrentino
- Department of Medical and Surgical Science, Institute of Obstetrics and Gynaecology, University of Foggia, Foggia, Italy
| | - Gaetano Riemma
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Amerigo Vitagliano
- 1st Unit of Obstetrics and Gynecology, Department of Interdisciplinary Medicine (DIM), University of Bari, Bari, Italy
| | - Alessandro Favilli
- Section of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Evidence-based diagnosis and treatment for uterine septum: a guideline. Fertil Steril 2024; 122:251-265. [PMID: 38556964 DOI: 10.1016/j.fertnstert.2024.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 02/19/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To provide evidence-based recommendations regarding the diagnosis and effectiveness of surgical treatment of a uterine septum. METHODS This guideline provides evidence-based recommendations regarding the diagnosis and effectiveness of surgical treatment of a uterine septum. This replaces the last version of the same name (Fertil Steril. 2016 Sep 1;106(3):530-40). MAIN OUTCOME MEASURE(S) Outcomes of interest included the impact of a septum on underlying fertility, live birth, clinical pregnancy, and obstetrical outcomes. RESULT(S) The literature search identified relevant studies to inform the evidence for this guideline. CONCLUSION(S) The treatment of uterine septa and subsequent outcomes associated with infertility, recurrent pregnancy loss, and adverse obstetrical outcomes are summarized. Resection of a septum has been shown to improve outcomes in patients with recurrent pregnancy loss and to decrease the likelihood of malpresentation. In the setting of infertility, it is recommended to use a shared decision-making model after appropriate counseling to determine whether or not to proceed with septum resection.
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Urman B, Ata B, Gomel V. Reproductive surgery remains an essential element of reproductive medicine. Facts Views Vis Obgyn 2024; 16:145-162. [PMID: 38950529 DOI: 10.52054/fvvo.16.2.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Background Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns. Objectives To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management. Materials and Methods Narrative review based on literature and the cumulative experience of the authors. Main outcome measures The paper does not address specific research questions. Conclusions Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology. What is new? A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.
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Hsieh CE, Huang MC, Weng SL. Natural conception and term pregnancy after hysteroscopic incision of complete septate uterus with septate cervix: A case report and literature review. Taiwan J Obstet Gynecol 2024; 63:402-404. [PMID: 38802207 DOI: 10.1016/j.tjog.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 05/29/2024] Open
Abstract
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.
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Affiliation(s)
- Cheng-En Hsieh
- Department of Obstetrics and Gynecology, HsinChu MacKay Memorial Hospital, HsinChu, Taiwan
| | - Ming-Chao Huang
- Department of Obstetrics and Gynecology, HsinChu MacKay Memorial Hospital, HsinChu, Taiwan; Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Shun-Long Weng
- Department of Obstetrics and Gynecology, HsinChu MacKay Memorial Hospital, HsinChu, Taiwan; MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan; Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
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Motan T, Cockwell H, Elliott J, Antaki R. Guideline No. 446: Hysteroscopic Surgery in Fertility Therapy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102400. [PMID: 38320665 DOI: 10.1016/j.jogc.2024.102400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
OBJECTIVE To evaluate the indications, benefits, and risks of hysteroscopy in the management of patients with infertility and provide guidance to gynaecologists who manage common conditions in these patients. TARGET POPULATION Patients with infertility (inability to conceive after 12 months of unprotected intercourse) undergoing investigation and treatment. BENEFITS, HARMS, AND COSTS Hysteroscopic surgery can be used to diagnose the etiology of infertility and improve fertility treatment outcomes. All surgery has risks and associated complications. Hysteroscopic surgery may not always improve fertility outcomes. All procedures have costs, which are borne either by the patient or their health insurance provider. EVIDENCE We searched English-language articles from January 2010 to May 2021 in PubMed/MEDLINE, Embase, Science Direct, Scopus, and Cochrane Library (see Appendix B for MeSH search terms). VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE Gynaecologists who manage common conditions in patients with infertility. TWEETABLE ABSTRACT When offering hysteroscopic surgery to patients with infertility, ensure it improves the live birth rate. SUMMARY STATEMENTS RECOMMENDATIONS.
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Motan T, Cockwell H, Elliott J, Antaki R. Directive clinique n o446 : Chirurgie hystéroscopique dans les traitements de fertilité. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102399. [PMID: 38325735 DOI: 10.1016/j.jogc.2024.102399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
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Xiong W, Tan X, Liu Y, Liu J, Dong X, Wang Z, Chen H. Comparison of clinical outcomes and second-look hysteroscopy of the complete and incomplete septate uterus after hysteroscopic septoplasty. Arch Gynecol Obstet 2024; 309:227-233. [PMID: 37816880 DOI: 10.1007/s00404-023-07243-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 09/17/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE Septate uterus is the most common congenital uterine malformation. This retrospective cohort study compared clinical outcomes and second-look hysteroscopy findings in patients with complete and incomplete septate uteri after septoplasty. METHODS We reviewed the medical records of patients with a septate uterus who underwent hysteroscopic septoplasty and second-look hysteroscopy at the West China Second University Hospital between September 2013 and September 2021. Information regarding pregnancy outcomes was collected through telephone interviews. The independent samples t-test, Mann-Whitney U test, Pearson's chi-square test, and Fisher's exact test were used to explore the differences between the complete and incomplete septate uterus groups. RESULTS A total of 64 patients were enrolled in this study. There was no significant difference in intrauterine adhesion (IUA) rates (16.7% and 32.1%), pregnancy rates (44.1% and 42.9%), term delivery rates (35.3% and 32.1%), premature delivery rates (2.9% and 0), placenta previa rates (2.9% and 3.6%), placenta implantation/adhesion rates (5.9% and 3.6%), and premature rupture of membranes rates (2.9% and 0) between the complete and the incomplete group after hysteroscopic septoplasty (P > 0.05). Endometrial polyps in the septate uterus were common, with an incidence of 33.3% and 25% in the complete and incomplete groups, respectively (P > 0.05). CONCLUSION The pregnancy outcomes of complete and incomplete septate uteri after hysteroscopic septoplasty were similar. There was no statistical difference in IUAs after surgery. Different treatment strategies may not be required for complete or incomplete septate uteri.
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Affiliation(s)
- Wei Xiong
- Day Surgery Department, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, 610041, China
| | - Xin Tan
- Day Surgery Department, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, 610041, China
| | - Yana Liu
- Day Surgery Department, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, 610041, China
| | - Jie Liu
- Day Surgery Department, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, 610041, China
| | - Xue Dong
- Day Surgery Department, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, 610041, China
| | - Zhilin Wang
- Day Surgery Department, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, 610041, China
| | - Hengxi Chen
- Day Surgery Department, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China.
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu, 610041, Sichuan, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Sichuan, 610041, China.
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Muñoz E, Fernández I, Pellicer N, Mariani G, Pellicer A, Garrido N. Reproductive outcomes of oocyte donation in patients with uterine Müllerian anomalies. Fertil Steril 2023; 120:850-859. [PMID: 37392783 DOI: 10.1016/j.fertnstert.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 06/08/2023] [Accepted: 06/23/2023] [Indexed: 07/03/2023]
Abstract
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).
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Affiliation(s)
- Elkin Muñoz
- IVIRMA Global Research Alliance, IVIRMA Vigo, Reproductive Medicine, Vigo, Spain; Department of Obstetrics and Gynecology, Universidad del Cauca, Popayán, Colombia.
| | - Iria Fernández
- IVIRMA Global Research Alliance, IVIRMA Vigo, Reproductive Medicine, Vigo, Spain
| | - Nuria Pellicer
- Department of Obstetrics and Gynecology, Hospital Politécnico la Fe, Valencia, Spain
| | - Giulia Mariani
- IVIRMA Global Research Alliance, IVIRMA Roma, Reproductive Medicine, Roma, Italy
| | - Antonio Pellicer
- IVIRMA Global Research Alliance, IVIRMA Roma, Reproductive Medicine, Roma, Italy
| | - Nicolas Garrido
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
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Mert SA, Dilbaz B, Akpinar F, Diktas EG, Kinay T, Ensari T, Tekin OM. Evaluation of the Success of Hysteroscopic Uterine Septum Resection. Gynecol Minim Invasive Ther 2023; 12:230-235. [PMID: 38034112 PMCID: PMC10683958 DOI: 10.4103/gmit.gmit_131_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/10/2023] [Accepted: 04/24/2023] [Indexed: 12/02/2023] Open
Abstract
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.
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Affiliation(s)
- Sule Atalay Mert
- Department of Reproductive Endocrinology, Etlik Zübeyde Hanim Women’s Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Berna Dilbaz
- Department of Reproductive Endocrinology, Etlik Zübeyde Hanim Women’s Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Funda Akpinar
- Gynecology and Obstetrics Clinic, Ankara Training and Research Hospital, Ankara, Turkey
| | - Elif Gulsah Diktas
- Department of Reproductive Endocrinology, Etlik Zübeyde Hanim Women’s Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Tugba Kinay
- Department of Reproductive Endocrinology, Etlik Zübeyde Hanim Women’s Health Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Tugba Ensari
- Gynecology and Obstetrics Clinic, Ankara City Hospital, Ankara, Turkey
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Chen J, Sun L, Qian H, Wu C, Jiang J, Guo X, Gao S. Hysteroscopic Fenestration with Precise Incision of the Cavity Septum: A Novel Minimally Invasive Surgery of Complete Septate Uterus with Double Cervix. J Minim Invasive Gynecol 2023; 30:716-724. [PMID: 37196886 DOI: 10.1016/j.jmig.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/19/2023]
Abstract
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.
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Affiliation(s)
- Jialing Chen
- Center of Diagnosis and Treatment for Cervical and Uterine Cavity Diseases (Drs. Chen, Wu, and Gao), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Lin Sun
- Department of Gynecology (Dr. Sun), Lianshui County People's Hospital, Kangda College of Nanjing Medical University, Huai'an, China
| | - Huijun Qian
- Departments of Radiology (Dr. Qian), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Congquan Wu
- Center of Diagnosis and Treatment for Cervical and Uterine Cavity Diseases (Drs. Chen, Wu, and Gao), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Jiqin Jiang
- Department of Gynecology (Dr. Jiang), Shaoxing Central Hospital, Shaoxing, China
| | - Xiaolan Guo
- Department of Surgery, Obstetrics and Gynecology (Dr. Guo), Hospital of Fudan University, Shanghai, China
| | - Shujun Gao
- Center of Diagnosis and Treatment for Cervical and Uterine Cavity Diseases (Drs. Chen, Wu, and Gao), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Female Reproductive Endocrine-Related Disease (Dr. Gao), Fudan University, Shanghai, China..
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Murphy C, Wilcox A, Vash-Margita A. Diagnostic and surgical approaches to congenital uterine anomalies for the minimally invasive gynecologic surgeon. Curr Opin Obstet Gynecol 2023; 35:328-336. [PMID: 37266575 DOI: 10.1097/gco.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW Congenital uterine anomalies (CUAs) impact the physical and psychosocial wellbeing of affected patients. Managing these conditions depends on the clinical scenario, and in some cases, can involve the use of minimally invasive surgical techniques. The purpose of this review is to provide an update of the diagnosis, perioperative considerations, and treatment of CUAs. RECENT FINDINGS The American Society for Reproductive Medicine (ASRM) updated the guidelines for classification of CUAs to provide practitioners with a standardized classification system and have created an interactive tool designed for provider use. SUMMARY Gynecologic surgeons are likely to encounter CUAs during their career. This review provides updated guidance for the workup and treatment of CUAs.
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Affiliation(s)
| | | | - Alla Vash-Margita
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
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Mu F, Huo H, Wang M, Wang F. Omega-3 fatty acid supplements and recurrent miscarriage: A perspective on potential mechanisms and clinical evidence. Food Sci Nutr 2023; 11:4460-4471. [PMID: 37576058 PMCID: PMC10420786 DOI: 10.1002/fsn3.3464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/07/2023] [Accepted: 05/14/2023] [Indexed: 08/15/2023] Open
Abstract
Recurrent miscarriage (RM) affects approximately 1%-5% of couples worldwide. Due to its complicated etiologies, the treatments for RM also vary greatly, including surgery for anatomic factors such as septate uterus and uterine adhesions, thyroid modulation drugs for hyperthyroidism and hypothyroidism, and aspirin and low molecular weight heparin for antiphospholipid syndrome. However, these treatment modalities are still insufficient to solve RM. Omega-3 fatty acids are reported to modulate the dysregulation of immune cells, oxidative stress, endocrine disorders, inflammation, etc., which are closely associated with the pathogenesis of RM. However, there is a lack of a systematic description of the involvement of omega-3 fatty acids in treating RM, and the underlying mechanisms are also not clear. In this review, we sought to determine the potential mechanisms that are highly associated with the pathogenesis of RM and the regulation of omega-3 fatty acids on these mechanisms. In addition, we also highlighted the direct and indirect clinical evidence of omega-3 fatty acid supplements to treat RM, which might encourage the application of omega-3 fatty acids to treat RM, thus improving pregnancy outcomes.
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Affiliation(s)
- Fangxiang Mu
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
| | - Huyan Huo
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
| | - Mei Wang
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
| | - Fang Wang
- Department of Reproductive MedicineLanzhou University Second HospitalLanzhouChina
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13
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Lamari I, Ziogas AC, Thanasas I, Kotronis KV, Xydias EM. Spontaneous Pregnancy After Surgical Repair of Subseptate Uterus: A Case Report and Review of the Available Literature. Cureus 2023; 15:e43399. [PMID: 37706127 PMCID: PMC10495772 DOI: 10.7759/cureus.43399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2023] [Indexed: 09/15/2023] Open
Abstract
Septate uterus is the most common congenital uterine malformation. It has been associated with poor reproductive outcomes, such as infertility and recurrent miscarriage, in the context of both assisted and non-assisted reproduction, though the exact underlying pathophysiological reasons remain unclear. Diagnosis is based on two-dimensional and three-dimensional ultrasound, magnetic resonance imaging, or laparoscopic/hysteroscopic findings. Hysteroscopic repair of the uterine septum has been shown to confer several benefits to reproductive outcomes, though this fact remains in question, due to inconsistent and or low-quality evidence in the medical literature. An individualized approach to the treatment of infertility patients with septate uteri is imperative, given the plethora of possible underlying factors that may complicate management. In this report, we present the case of a patient with a subseptate uterus and a history of infertility, who, following hysteroscopic metroplasty, managed to conceive and ultimately successfully deliver a healthy child.
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Affiliation(s)
- Ioanna Lamari
- Department of Internal Medicine, Gennimatas General Hospital, Athens, GRC
- Faculty of Medicine, University of Thessaly, School of Health Sciences, Larissa, GRC
| | - Apostolos C Ziogas
- Department of Obstetrics and Gynaecology, IASO Thessalias Hospital, Larissa, GRC
- Faculty of Medicine, University of Thessaly, School of Health Sciences, Larissa, GRC
| | - Ioannis Thanasas
- Department of Obstetrics and Gynecology, General Hospital of Trikala, Trikala, GRC
| | | | - Emmanouil M Xydias
- Faculty of Medicine, University of Thessaly, School of Health Sciences, Larissa, GRC
- Department of Obstetrics and Gynaecology, EmbryoClinic IVF, Thessaloniki, GRC
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14
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Tomkiewicz J, Darmochwał-Kolarz D. The Diagnostics and Treatment of Recurrent Pregnancy Loss. J Clin Med 2023; 12:4768. [PMID: 37510883 PMCID: PMC10380966 DOI: 10.3390/jcm12144768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 06/21/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
Recurrent pregnancy loss is a common problem in the reproductive age population of women. It can be caused by many different conditions. This problem is addressed in international guidelines that take a slightly different approach to its diagnosis and treatment. The guidelines used in this review mainly use the guidelines of the Royal College of Obstetricians and Gynaecologists (RCOG), American Society of Reproductive Medicine (ASRM) and European Society of Human Reproduction and Embryology (ESHRE). This review shows how much the approach to miscarriages has changed and how much more needs to be explored and refined. The review also addresses the topic of unexplained pregnancy loss, which continues to be a challenge for clinicians.
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Affiliation(s)
- Julia Tomkiewicz
- Fryderyk Chopin University Hospital No 1, 35-055 Rzeszow, Poland
| | - Dorota Darmochwał-Kolarz
- Department of Obstetrics & Gynecology, Medical College, University of Rzeszow, 35-959 Rzeszow, Poland
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15
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Chang Y, Shen M, Wang S, Guo Z, Duan H. Reproductive outcomes and risk factors of women with septate uterus after hysteroscopic metroplasty. Front Endocrinol (Lausanne) 2023; 14:1063774. [PMID: 37361532 PMCID: PMC10285310 DOI: 10.3389/fendo.2023.1063774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
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.
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Affiliation(s)
- Yanan Chang
- Department of Minimally Invasive Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Minghong Shen
- Department of Minimally Invasive Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing, China
- Department of Gynecology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Sha Wang
- Department of Minimally Invasive Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Zhengchen Guo
- Department of Minimally Invasive Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing, China
| | - Hua Duan
- Department of Minimally Invasive Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University. Beijing Maternal and Child Health Care Hospital, Beijing, China
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16
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Giouleka S, Tsakiridis I, Arsenaki E, Kalogiannidis I, Mamopoulos A, Papanikolaou E, Athanasiadis A, Dagklis T. Investigation and Management of Recurrent Pregnancy Loss: A Comprehensive Review of Guidelines. Obstet Gynecol Surv 2023; 78:287-301. [PMID: 37263963 DOI: 10.1097/ogx.0000000000001133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Importance Recurrent pregnancy loss (RPL) is one of the most frustrating clinical entities in reproductive medicine requiring not only diagnostic investigation and therapeutic intervention, but also evaluation of the risk for recurrence. Objective The aim of this study was to review and compare the most recently published major guidelines on investigation and management of RPL. Evidence Acquisition A descriptive review of guidelines from the Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, the American Society for Reproductive Medicine, the French College of Gynecologists and Obstetricians, and the German, Austrian, and Swiss Society of Gynecology and Obstetrics on RPL was carried out. Results There is consensus among the reviewed guidelines that the mainstays of RPL investigation are a detailed personal history and screening for antiphospholipid syndrome and anatomical abnormalities of the uterus. In contrast, inherited thrombophilias, vaginal infections, and immunological and male factors of infertility are not recommended as part of a routine RPL investigation. Several differences exist regarding the necessity of the cytogenetic analysis of the products of conception, parental peripheral blood karyotyping, ovarian reserve testing, screening for thyroid disorders, diabetes or hyperhomocysteinemia, measurement of prolactin levels, and performing endometrial biopsy. Regarding the management of RPL, low-dose aspirin plus heparin is indicated for the treatment of antiphospholipid syndrome and levothyroxine for overt hypothyroidism. Genetic counseling is required in case of abnormal parental karyotype. The Royal College of Obstetricians and Gynaecologists, the European Society of Human Reproduction and Embryology, and the French College of Gynecologists and Obstetricians guidelines provide recommendations that are similar on the management of cervical insufficiency based on the previous reproductive history. However, there is no common pathway regarding the management of subclinical hypothyroidism and the surgical repair of congenital and acquired uterine anomalies. Use of heparin for inherited thrombophilias and immunotherapy and anticoagulants for unexplained RPL are not recommended, although progesterone supplementation is suggested by the American Society for Reproductive Medicine and the German, Austrian, and Swiss Society of Gynecology and Obstetrics. Conclusions Recurrent pregnancy loss is a devastating condition for couples. Thus, it seems of paramount importance to develop consistent international practice protocols for cost-effective investigation and management of this early pregnancy complication, with the aim to improve live birth rates.
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Affiliation(s)
| | - Ioannis Tsakiridis
- Consultant in Maternal-Fetal Medicine, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elisavet Arsenaki
- Foundation Trainee Doctor, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | | | | | - Evangelos Papanikolaou
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Themistoklis Dagklis
- Assistant Professor, Third Department of Obstetrics and Gynaecology, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, Greece
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17
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Petrozza JC, Fitz V, Bhagavath B, Carugno J, Kwal J, Mikhail E, Nash M, Barakzai SK, Roque DR, Bregar AJ, Findley J, Neblett M, Flyckt R, Khan Z, Lindheim SR. Surgical approach to 4 different reproductive pathologies by 3 different gynecologic subspecialties: more similarities or differences? Fertil Steril 2023; 119:377-389. [PMID: 36574916 DOI: 10.1016/j.fertnstert.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Affiliation(s)
- John C Petrozza
- Division of Reproductive Medicine and IVF, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victoria Fitz
- Division of Reproductive Medicine and IVF, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bala Bhagavath
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, Wisconsin
| | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida
| | - Jaclyn Kwal
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida
| | - Emad Mikhail
- Division of Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of South Florida Health Morsani College of Medicine, Tampa, Florida
| | - Moawad Nash
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, Florida
| | - Syem K Barakzai
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dario R Roque
- Division of Gynecologic Oncology, Feinberg School of Medicine, Northwestern University
| | - Amy J Bregar
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph Findley
- Department of Obstetrics and Gynecology, University Hospitals of Cleveland, Beachwood, Ohio
| | - Michael Neblett
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
| | - Rebecca Flyckt
- Department of Obstetrics and Gynecology, University Hospitals of Cleveland, Beachwood, Ohio
| | - Zaraq Khan
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
| | - Steven R Lindheim
- Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; Department of Obstetrics and Gynecology, University of Central Florida, Orlando, Florida; Center for Reproductive Medicine Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.
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18
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Alcázar JL, Carriles I, Cajas MB, Costa S, Fabra S, Cabrero M, Castro E, Tomaizeh A, Laza MV, Monroy A, Martinez I, Aguilar MI, Hernani E, Castellet C, Oliva A, Pascual MÁ, Guerriero S. Diagnostic Performance of Two-Dimensional Ultrasound, Two-Dimensional Sonohysterography and Three-Dimensional Ultrasound in the Diagnosis of Septate Uterus-A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:diagnostics13040807. [PMID: 36832295 PMCID: PMC9955687 DOI: 10.3390/diagnostics13040807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND The septate uterus is the most common congenital uterine anomaly, and hysteroscopy is the gold standard for diagnosing it. The goal of this meta-analysis is to perform a pooled analysis of the diagnostic performance of two-dimensional transvaginal ultrasonography, two-dimensional transvaginal sonohysterography, three-dimensional transvaginal ultrasound, and three-dimensional transvaginal sonohysterography for the diagnosis of the septate uterus. METHODS Studies published between 1990 and 2022 were searched in PubMed, Scopus, and Web of Science. From 897 citations, we selected eighteen studies to include in this meta-analysis. RESULTS The mean prevalence of uterine septum in this meta-analysis was 27.8%. Pooled sensitivity and specificity were 83% and 99% for two-dimensional transvaginal ultrasonography (ten studies), 94% and 100% for two-dimensional transvaginal sonohysterography (eight studies), and 98% and 100% for three-dimensional transvaginal ultrasound (seven articles), respectively. The diagnostic accuracy of three-dimensional transvaginal sonohysterography was only described in two studies, and we did not calculate the pooled sensitivity and specificity for this method. CONCLUSION Three-dimensional transvaginal ultrasound has the best performance capacity for the diagnosis of the septate uterus.
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Affiliation(s)
- Juan Luis Alcázar
- Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Isabel Carriles
- Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - María Belén Cajas
- Department of Obstetrics and Gynecology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain
| | - Susana Costa
- Department Obstetrics and Gynecology, Centro Hospitalar e Universitário de São João, 4200-319 Porto, Portugal
| | - Sofia Fabra
- Department of Obstetrics and Gynecology, Hospital Universitario Infanta Sofia, 28702 Madrid, Spain
| | - Maria Cabrero
- Department of Obstetrics and Gynecology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain
| | - Elena Castro
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Aida Tomaizeh
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de Valme, 41701 Sevilla, Spain
| | - María Victoria Laza
- Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil, 06010 Badajoz, Spain
| | - Alba Monroy
- Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil, 06010 Badajoz, Spain
| | - Irene Martinez
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de Valme, 41701 Sevilla, Spain
| | - Maria Isabel Aguilar
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de Valme, 41701 Sevilla, Spain
| | - Elena Hernani
- Department of Obstetrics and Gynecology, Hospital General Universitario de Castellón, 12004 Castellón, Spain
| | - Cristina Castellet
- Department of Obstetrics, Gynecology, and Reproduction, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Agustin Oliva
- Department of Obstetrics and Gynecology, Hospital Universitario San Carlos, 28040 Madrid, Spain
| | - María Ángela Pascual
- Department of Obstetrics, Gynecology, and Reproduction, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Stefano Guerriero
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico-Ginecologica, Azienda Ospedaliero Universitaria-Policlinico Duilio Casula, Monserrato, 09042 Cagliari, Italy
- Dipartimento di Scienze Chirurgiche, University of Cagliari, 09124 Cagliari, Italy
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19
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Erdem S, Baglı İ, Ege S, Aydın E, Ozgokce C, Kulahcıoglu MI. Efficacy of hysteroscopic septum resection in infertile women: a single center experience. MINIM INVASIV THER 2023; 32:62-65. [PMID: 36633550 DOI: 10.1080/13645706.2022.2164467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION We aimed to reveal the effectiveness of hysteroscopic septum resection on the reproductive outcomes of infertile patients. MATERIAL AND METHODS We included 46 infertile women who underwent hysteroscopic septum resection of septate uterus (complete: group 1, n = 21; incomplete: group 2, n = 25). Only patients with a septate uterus as the cause of infertility were included in the study. Patients' age, body mass, duration of infertility, type of infertility, duration of surgery, surgical complications, remnant septa, and postoperative reproductive results were recorded. RESULTS Preoperative abortion was found to be nine (42.9%) in group 1 and 15 (60.0%) in group 2. In the postoperative control HSG, remnant septa was found to be significantly higher in group 1 compared to group 2 (three patients or 14.3% and 0%, respectively). Pregnancy was detected in 13 patients (61.9%) in group 1 and 18 patients (72%) in group 2 at the postsurgical follow-up. Abortion occurred for two patients (9.5%) in group 1 and three patients (12%) in group 2. CONCLUSION We obtained positive growth results after hysteroscopic septum resection in both the complete and incomplete cases. However, we found that the duration of surgery was prolonged and the rate of remnant septa increased in cases with a complete septum.
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Affiliation(s)
- Selamı Erdem
- Department of Gynecology and Obstetrics, Sultan Hastanesi, Diyarbakir, Turkey
| | - İhsan Baglı
- Department of Gynecology and Obstetrics, Diyarbakır Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Serhat Ege
- Department of Gynecology and Obstetrics, Diyarbakır Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Edıp Aydın
- Department of Gynecology and Obstetrics, Diyarbakır Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
| | - Cagdas Ozgokce
- Department of Gynecology and Obstetrics, Zeynep Kamil Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Irfan Kulahcıoglu
- Department of Gynecology and Obstetrics, Diyarbakır Gazi Yasargil Training and Research Hospital, Diyarbakır, Turkey
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Jiang Y, Wang L, Wang B, Shen H, Wu J, He J, Liu A, Wang Y, Zhang X, Ma B. Reproductive outcomes of natural pregnancy after hysteroscopic septum resection in patients with a septate uterus: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023; 5:100762. [PMID: 36220552 DOI: 10.1016/j.ajogmf.2022.100762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/29/2022] [Accepted: 10/03/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The aim of this systematic review and meta-analysis was to analyze the reproductive outcomes of natural pregnancy after hysteroscopic septum resection in patients with recurrent miscarriage, primary infertility, or secondary infertility. DATA SOURCES The PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data Knowledge Service Platform, VIP Database, and Chinese Biomedical Literature Database (CBM) databases were electronically searched. The search time frame was from inception up to July 2021. The English search terms were (arcuate* and uter*), (sept* and uter*), (subseptate* and uter*), metroplast*, septoplast*, and resect*. STUDY ELIGIBILITY CRITERIA Selection criteria included randomized controlled trials, cohort studies, and case series that explored reproductive outcomes after hysteroscopic septum resection in patients with recurrent miscarriage, primary infertility, or secondary infertility with or without a control group. METHODS The primary outcomes were the live birth rate and eventual postoperative live birth rate after hysteroscopic septum resection. The secondary outcomes were the clinical pregnancy rate, preterm birth rate, and miscarriage rate. Study-level proportions of outcomes were transformed using the Freeman-Tukey double-arcsine transformation to calculate pooled values for the postoperative rates; the counted data were analyzed using relative risk as the effect analysis statistic, and each effect size was provided with its 95% confidence interval. Heterogeneity between the results of the included studies was analyzed using the I2 test. RESULTS Overall, 5 cohort studies and 22 case series involving 1506 patients were included. In patients with a septate uterus and recurrent miscarriage, hysteroscopic septum resection was associated with an increased live birth rate (relative risk, 1.77; 95% confidence interval, 1.26-2.49; P=.001; I2=0%), resulting in a postoperative live birth rate of 66% (95% confidence interval, 59-72), and septum resection was associated with a reduced preterm birth rate (relative risk, 0.15; 95% confidence interval, 0.04-0.53; P=.003; I2=0%) and miscarriage rate (relative risk, 0.36; 95% confidence interval, 0.20-0.66; P=.0009; I2=0%). In patients with a septate uterus and primary infertility, hysteroscopic septum resection was associated with an increased live birth rate (relative risk, 4.12; 95% confidence interval, 1.19-14.29; P=.03; I2=0%) and clinical pregnancy rate (relative risk, 2.28; 95% confidence interval, 1.04-4.98; P=.04; I2=0%). The postoperative live birth rate was 37% (95% confidence interval, 30-44), and the miscarriage rate of patients with primary infertility was reduced (relative risk, 0.19; 95% confidence interval, 0.06-0.56; P=.003). The efficacy of hysteroscopic septum resection in patients with secondary infertility was unclear. However, their postoperative live birth rate was found to be 41% (95% confidence interval, 2-88). CONCLUSION Hysteroscopic septum resection is associated with an increased live birth rate and a reduced miscarriage rate in patients with recurrent miscarriage or primary infertility, indicating that septum resection may improve the reproductive outcomes of these patients. The effectiveness of septum resection was unclear for patients with secondary infertility. These findings are limited by the quality of the included studies, warranting further randomized controlled trials, including only patients with recurrent miscarriage or primary infertility.
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Affiliation(s)
- Yanbiao Jiang
- First Clinical Medical College, Lanzhou University, Lanzhou, China (XX Jiang, Dr B Wang and Shen, XX Wu, XX He, Dr Liu, and Zhang)
| | - Liyan Wang
- The First Hospital of Lanzhou University, Lanzhou University, Lanzhou, China (Dr L Wang, Y Wang, and Zhang); Key Laboratory for Reproductive Medicine and Embryo of Gansu Province, Lanzhou, China (Dr L Wang, Y Wang, and Zhang)
| | - Bin Wang
- First Clinical Medical College, Lanzhou University, Lanzhou, China (XX Jiang, Dr B Wang and Shen, XX Wu, XX He, Dr Liu, and Zhang)
| | - Haofei Shen
- First Clinical Medical College, Lanzhou University, Lanzhou, China (XX Jiang, Dr B Wang and Shen, XX Wu, XX He, Dr Liu, and Zhang)
| | - Jingyuan Wu
- First Clinical Medical College, Lanzhou University, Lanzhou, China (XX Jiang, Dr B Wang and Shen, XX Wu, XX He, Dr Liu, and Zhang)
| | - Juanjuan He
- First Clinical Medical College, Lanzhou University, Lanzhou, China (XX Jiang, Dr B Wang and Shen, XX Wu, XX He, Dr Liu, and Zhang)
| | - Ahui Liu
- First Clinical Medical College, Lanzhou University, Lanzhou, China (XX Jiang, Dr B Wang and Shen, XX Wu, XX He, Dr Liu, and Zhang)
| | - Yiqing Wang
- The First Hospital of Lanzhou University, Lanzhou University, Lanzhou, China (Dr L Wang, Y Wang, and Zhang); Key Laboratory for Reproductive Medicine and Embryo of Gansu Province, Lanzhou, China (Dr L Wang, Y Wang, and Zhang)
| | - Xuehong Zhang
- The First Hospital of Lanzhou University, Lanzhou University, Lanzhou, China (Dr L Wang, Y Wang, and Zhang); Key Laboratory for Reproductive Medicine and Embryo of Gansu Province, Lanzhou, China (Dr L Wang, Y Wang, and Zhang).
| | - Bin Ma
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China (Dr B Ma)
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Does Hysteroscopic Dissection of Partial Uterine Septum Represent a Risk Factor for Placental Abnormalities in Subsequent Pregnancy Compared with Controls Undergoing Other Hysteroscopic Surgery? Results from a Large Case-Control Analysis. J Clin Med 2022; 12:jcm12010177. [PMID: 36614977 PMCID: PMC9821216 DOI: 10.3390/jcm12010177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Hysteroscopic septum dissection (HSD) is thought to improve fertility and pregnancy outcomes. However, the available literature suggests that uterine surgery can cause placental abnormalities in subsequent pregnancies. METHODS A case-control study was performed at the University Medical Center of Ljubljana, Department of Human Reproduction, from 1 January 2016 to 31 December 2018. The primary outcome was the association between HSD and the occurrence of placental abnormalities. We included women who underwent HSD due to infertility. Age-matched women who underwent hysteroscopic surgery for other issues were considered as controls. In addition, we divided the groups according to conception method. Only singleton pregnancies and first delivery were considered. RESULTS A total of 1286 women (746 who underwent HSD and 540 controls) were included in the analysis. HSD had no influence on placental abnormalities since the ratio was comparable regardless of the method of conception (113/746 vs. 69/540; p = 0.515). Infertile women who conceived naturally after HSD had a normal placentation rate comparable to women who did not undergo HSD (380/427 vs. 280/312; p = 0.2104). The rate of placental abnormalities in women who achieved pregnancy with IVF/ICSI procedures following HSD was comparable to that of women who did not undergo HSD (52/319 vs. 33/228; p = 0.5478). Placenta previa occurred significantly more often in infertile women without HSD after IVF/ICSI compared to natural conception (2/312 vs. 7/228; p = 0.0401). CONCLUSIONS HSD was not associated with higher rate of placental abnormalities in the first singleton pregnancy compared with other hysteroscopic procedures. A higher rate of placenta previa in pregnancies following IVF/ICSI procedures, which was shown by our research, is corroborated by previous research findings.
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CEVHER AKDULUM MF, DEMİRDAĞ E, ARIK Sİ, ERDEM M, BOZKURT N, OKTEM M, GÜLER İ, ERDEM A. Does uterine septum resection improve IVF treatment success? JOURNAL OF HEALTH SCIENCES AND MEDICINE 2022. [DOI: 10.32322/jhsm.1133577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | - Mehmet ERDEM
- GAZI UNIVERSITY, SCHOOL OF MEDICINE, MEDICINE PR
| | | | - Mesut OKTEM
- GAZI UNIVERSITY, SCHOOL OF MEDICINE, MEDICINE PR
| | - İsmail GÜLER
- GAZI UNIVERSITY, SCHOOL OF MEDICINE, MEDICINE PR
| | - Ahmet ERDEM
- GAZI UNIVERSITY, SCHOOL OF MEDICINE, MEDICINE PR
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Wu X, Zhang M, Sun P, Jiang JJ, Yan L. Pregnancy and Adverse Obstetric Outcomes After Hysteroscopic Resection: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:889696. [PMID: 35832500 PMCID: PMC9271824 DOI: 10.3389/fsurg.2022.889696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveAlthough 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 MethodsFrom 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.Results22 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.ConclusionHysteroscopic 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
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Affiliation(s)
- Xue Wu
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Mei Zhang
- Qufu Maternity and Infant health Hospital, Qufu, China
| | - Ping Sun
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing-jing Jiang
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
- Key laboratory of Reproductive Endocrinology, Ministry of Education, Shandong University, Jinan, China
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
- Correspondence: Lei Yan Jing-jing Jiang
| | - Lei Yan
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- National Research Center for Assisted Reproductive Technology and Reproductive Genetics, Shandong University, Jinan, China
- Key laboratory of Reproductive Endocrinology, Ministry of Education, Shandong University, Jinan, China
- Shandong Provincial Clinical Medicine Research Center for Reproductive Health, Shandong University, Jinan, China
- Correspondence: Lei Yan Jing-jing Jiang
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Noventa M, Spagnol G, Marchetti M, Saccardi C, Bonaldo G, Laganà AS, Cavallin F, Andrisani A, Ambrosini G, Vitale SG, Pacheco LA, Haimovich S, Di Spiezio Sardo A, Carugno J, Scioscia M, Garzon S, Bettocchi S, Buzzaccarini G, Tozzi R, Vitagliano A. Uterine Septum with or without Hysteroscopic Metroplasty: Impact on Fertility and Obstetrical Outcomes-A Systematic Review and Meta-Analysis of Observational Research. J Clin Med 2022; 11:jcm11123290. [PMID: 35743362 PMCID: PMC9224595 DOI: 10.3390/jcm11123290] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 12/04/2022] Open
Abstract
Objective: we performed a systematic review/meta-analysis to evaluate the impact of septate uterus and hysteroscopic metroplasty on pregnancy rate-(PR), live birth rate-(LBR), spontaneous abortion-(SA) and preterm labor (PL) in infertile/recurrent miscarriage-(RM) patients. Data sources: a literature search of relevant papers was conducted using electronic bibliographic databases (Medline, Scopus, Embase, Science direct). Study eligibility criteria: we included in this meta-analysis all types of observational studies that evaluated the clinical impact of the uterine septum and its resection (hysteroscopic metroplasty) on reproductive and obstetrics outcomes. The population included were patients with a diagnosis of infertility or recurrent pregnancy loss. Study appraisal and synthesis methods: outcomes were evaluated according to three subgroups: (i) Women with untreated uterine septum versus women without septum (controls); (ii) Women with treated uterine septum versus women with untreated septum (controls); (iii) Women before and after septum removal. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for the outcome measures. A p-value < 0.05 was considered statistically significant. Subgroup analysis was performed according to the depth of the septum. Sources of heterogeneity were explored by meta-regression analysis according to specific features: assisted reproductive technology/spontaneous conception, study design and quality of papers included Results: data from 38 studies were extracted. (i) septum versus no septum: a lower PR and LBR were associated with septate uterus vs. controls (OR 0.45, 95% CI 0.27−0.76; p < 0.0001; and OR 0.21, 95% CI 0.12−0.39; p < 0.0001); a higher proportion of SA and PL was associated with septate uterus vs. controls (OR 4.29, 95% CI 2.90−6.36; p < 0.0001; OR 2.56, 95% CI 1.52−4.31; p = 0.0004). (ii) treated versus untreated septum: PR and PL were not different in removed vs. unremoved septum(OR 1.10, 95% CI 0.49−2.49; p = 0.82 and OR 0.81, 95% CI 0.35−1.86; p = 0.62); a lower proportion of SA was associated with removed vs. unremoved septum (OR 0.47, 95% CI 0.21−1.04; p = 0.001); (iii) before-after septum removal: the proportion of LBR was higher after the removal of septum (OR 49.58, 95% CI 29.93−82.13; p < 0.0001) and the proportion of SA and PL was lower after the removal of the septum (OR 0.02, 95% CI 0.02−0.04; p < 0.000 and OR 0.05, 95% CI 0.03−0.08; p < 0.0001) Conclusions: the results show the detrimental effect of the uterine septum on PR, LBR, SA and PL. Its treatment reduces the rate of SA.
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Affiliation(s)
- Marco Noventa
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
- Correspondence: ; Tel.: +39-347-6527255
| | - Giulia Spagnol
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Matteo Marchetti
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Carlo Saccardi
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Giulio Bonaldo
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Antonio Simone Laganà
- Unit of Gynecology Oncology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialities (PROMISE), University of Palermo, 90127 Palermo, Italy;
| | | | - Alessandra Andrisani
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Guido Ambrosini
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, 95124 Catania, Italy;
| | | | - Sergio Haimovich
- Hillel Yaffe Medical Center, Technion-Israel Technology Institute, Hadera 38100, Israel;
| | - Attilio Di Spiezio Sardo
- Department of Public Health, School of Medicine, University of Naples Federico II, 80138 Naples, Italy;
| | - Jose Carugno
- Minimally Invasive Gynecology Unit, Obstetrics, Gynecology and Reproductive Sciences Department, Miller School of Medicine, University of Miami, Miami, FL 33136, USA;
| | - Marco Scioscia
- Unit of Gynecology, Mater Dei Hospital, 70125 Bari, Italy;
| | - Simone Garzon
- Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, 37126 Verona, Italy;
| | - Stefano Bettocchi
- Inter-Departmental Project Unit of Minimal-Invasive Gynecological Surgery, Policlinico of Bari, University of Bari Aldo Moro, 70121 Bari, Italy;
| | - Giovanni Buzzaccarini
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Roberto Tozzi
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
| | - Amerigo Vitagliano
- Unit of Gynecology and Obstetrics, Department of Women and Children’s Health, University of Padua, 35100 Padua, Italy; (G.S.); (M.M.); (C.S.); (G.B.); (A.A.); (G.A.); (G.B.); (R.T.); (A.V.)
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Abstract
Importance Recurrent spontaneous abortion (RSA) is a distressing condition experienced by approximately 1% of women trying to conceive. However, the treatment of RSA is a challenge both for clinicians and patients. Objective The aim of this review is to discuss the medical and surgical approach to the management of RSA, including those caused by anatomical, genetic, male, infectious, endocrine, and immune factors. Evidence Acquisition A literature search using MeSH terms for each topic was undertaken using PubMed, supplemented by hand searching for additional references. Retrieved articles were reviewed, synthesized, and summarized. Results Available treatments target hypothetical risk factors for RSA, although the effectiveness of many treatment options is controversial. Intervention should depend on the benefit-to-risk ratio of the proposed treatment. Conclusions and Relevance The etiology of RSA is heterogeneous, and patients often lack specific clinical manifestations, which has hindered the progress in predicting and preventing RSA to some extent. Despite intensive workup, at least 50% of couples do not have a clear underlying pathology. In addition, an evidence-based treatment is not available in most patients even if abnormal test results are present. Many new treatment directions are also still actively exploring; empirical and combined multiple treatments are still the main methods. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After completing this activity, the learner should be better able to describe common risk factors for RSA; formulate individualized treatment plans to improve pregnancy outcomes; and propose supportive treatment recommendations for patients with unclear causes.
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Daniilidis A, Papandreou P, Grimbizis G. Uterine septum and reproductive outcome. From diagnosis to treatment. How, why, when? Facts Views Vis Obgyn 2022; 14:31-36. [DOI: 10.52054/fvvo.14.1.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Septate uterus is a benign congenital malformation and represents the most common uterine anomaly in women with poor reproductive outcome.
Objectives: To review the available scientific data concerning the biological context of the intrauterine septum and the association with poor reproductive outcome, the best methods for diagnosis and treatment.
Materials and methods: From July 2020 to October 2020, we searched for relevant free full text articles in PubMed, written in English, and published from the 1st of January 2000 to 31st of July 2020.
Main outcome measures: Association of the pathophysiology of septate uterus with poor reproductive outcome, evaluation of the different classification systems, the accuracy of diagnostic methods and the efficacy of the available treatment options.
Results: 259 articles were screened, and 22 articles were finally included in our study. Many theories regarding the pathophysiology of this congenital anomaly and its’ association with reproductive problems have been proposed along the recent decades. Combination of diagnostic methods should be used to avoid misclassification of this congenital anomaly.
Conclusions: Lack of uniformity in the different classification systems makes the diagnosis of septate uterus challenging as there is no universally accepted definition. Data regarding the reproductive outcome of women with septate uterus are still limited, thus recommendations regarding optimal treatment of these women are biased.
What is new? According to new insights regarding the pathophysiology of the uterine septum, differences in the underlying embryological defects are associated with changes in the histological composition and vascularisation of septa, as well as in clinical significance.
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Sık BA, Ozdamar O, Ozolcay O, Sismanoglu A, Aba YA, Oral S, Koc M. Second look hysteroscopy following hysteroscopic septum resection improves reproductive outcomes in patients undergoing ICSI. J OBSTET GYNAECOL 2022; 42:2265-2271. [PMID: 35275047 DOI: 10.1080/01443615.2022.2038105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The aim of this study was to compare the reproductive outcomes between infertile women who underwent hysteroscopic uterine septum resection and those who required a second look hysteroscopy due to residual septum prior to intracytoplasmic sperm injection (ICSI) cycles with selective single 'Grade A' embryo transfer (ET). All second look hysteroscopies were performed due to partial remnant septum in a control three dimensional transvaginal ultrasonography (3D TVUSG) after the first hysteroscopic resection. Miscarriage and biochemical pregnancy rates were not different between the groups while clinical pregnancy and live birth rates were significantly higher in Group 2 than in Group 1. Second look hysteroscopic metroplasty performed to restore remnant septum significantly improves live birth rate as well as clinical pregnancy rates while it appears not to alleviate abortion and biochemical pregnancy rates in women undergoing ICSI-ET.IMPACT STATEMENTWhat is already known on this subject? The effect of hysteroscopic septum resection on reproductive outcomes in IVF treatment in infertile patients with uterine septum is not clearly known.What do the results of this study add? With the selective single ET strategy, complete or partial hysteroscopic correction of the uterine septum before ICSI and subsequent resection of the residual septum with control hysteroscopy significantly increases the live birth rates in the infertile population.What are the implications of these findings for clinical practice and/or further research? In the group of infertile patients with uterine septum, second control hysteroscopy should be performed 1 month later for residual septum or adhesions after hysteroscopic septum resection performed once.
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Affiliation(s)
- Bulat Aytek Sık
- Department of Reproductive Endocrinology and Infertility, Sisli Kolan International Hospital, Istanbul, Turkey
| | - Ozkan Ozdamar
- Department of Reproductive Endocrinology and Infertility, Memorial Bahcelievler Hospital, Istanbul, Turkey
| | - Ozan Ozolcay
- Department of Reproductive Endocrinology and Infertility, Istanbul IVF Centre, Istanbul, Turkey
| | - Alper Sismanoglu
- Department of Reproductive Endocrinology and Infertility, Sisli Kolan International Hospital, Istanbul, Turkey
| | - Yilda Arzu Aba
- Health Sciences Faculty, Bandirma Onyedi Eylul University, Balikesir, Turkey
| | - Serkan Oral
- Department of Reproductive Endocrinology and Infertility, Sisli Kolan International Hospital, Istanbul, Turkey
| | - Mehmet Koc
- Department of Reproductive Endocrinology and Infertility, Sisli Kolan International Hospital, Istanbul, Turkey
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Chen H, Sun P, Zhang N, Lv S, Cao Y, Yan L. Effects of Septum Resection for Secondary Infertility on Subsequent Reproductive Outcomes of in vitro Fertilization–Intracytoplasmic Sperm Injection. Front Med (Lausanne) 2022; 9:765827. [PMID: 35186988 PMCID: PMC8850346 DOI: 10.3389/fmed.2022.765827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 01/03/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo assess the effect of uterine septum resection on reproductive outcomes of in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) in patients with secondary infertility complicated with uterine septum.MethodsA retrospective cohort study included 269 patients. Surgical group included 169 patients with secondary infertility complicated with uterine septum, who underwent 252 embryo-transfer (ET) cycles following septum resection. Control group consisted of 100 patients with secondary infertility and uterine septum, who underwent 178 ET cycles. Cumulative pregnancy rate and cumulative live birth rate after one complete assisted reproductive technology (ART) cycle were the primary outcomes.ResultsThe results showed that the cumulative pregnancy rate was higher in the surgery group, and statistically significant difference was observed in the cumulative pregnancy rate between the two groups (71.0 vs. 59%, P = 0.044). In fresh ET cycle, no statistically significant difference between the two groups was evident (54.9 vs. 40.6%, P = 0.061). Statistical analysis of other results of the fresh ET cycle did not differ significantly between the two groups. In terms of frozen embryo transfer (FET) cycle outcomes, the clinical pregnancy rate and delivery rate in surgery group were 52.7 and 38.2%, respectively, which were significantly higher than those in the control group (38.2 and 22.5%, respectively) (P = 0.028 and P = 0.011).ConclusionThe reproductive outcomes of IVF/ICSI after septum resection in patients with secondary infertility were better than that in the untreated group, suggesting that uterine septum resection can be performed in patients with uterine septum combined with infertility to improve their reproductive outcomes.
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Affiliation(s)
- Huixiao Chen
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Department of Gynecology and Obstetrics, Liaocheng People's Hospital, Liaocheng, China
| | - Ping Sun
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Na Zhang
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Shangge Lv
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yongzhi Cao
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Yongzhi Cao
| | - Lei Yan
- School of Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- Center for Reproductive Medicine, Cheeloo College of Medicine, Shandong University, Jinan, China
- *Correspondence: Lei Yan
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Peixoto C, Castro M, Carriles I, Arriba MD, Lapresa V, Alcazar JL. Diagnosing Septate Uterus Using Three-Dimensional Ultrasound Using Three Different Classifications: An Interobserver and Intraobserver Agreement Study. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:911-918. [PMID: 34933384 PMCID: PMC10183891 DOI: 10.1055/s-0041-1740271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Currently, there are up to three different classifications for diagnosing septate uterus. The interobserver agreement among them has been poorly assessed. OBJECTIVE To assess the interobserver agreement of nonexpert sonographers for classifying septate uterus using the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), American Society for Reproductive Medicine (ASRM), and Congenital Uterine Malformations by Experts (CUME) classifications. METHODS A total of 50 three-dimensional (3D) volumes of a nonconsecutive series of women with suspected uterine malformation were used. Two nonexpert examiners evaluated a single 3D volume of the uterus of each woman, blinded to each other. The following measurements were performed: indentation depth, indentation angle, uterine fundal wall thickness, external fundal indentation, and indentation-to-wall-thickness (I:WT) ratio. Each observer had to assign a diagnosis in each case, according to the three classification systems (ESHRE/ESGE, ASRM, and CUME). The interobserver agreement regarding the ESHRE/ESGE, ASRM, and CUME classifications was assessed using the Cohen weighted kappa index (k). Agreement regarding the three classifications (ASRM versus ESHRE/ESGE, ASRM versus CUME, ESHRE/ESGE versus CUME) was also assessed. RESULTS The interobserver agreement between the 2 nonexpert examiners was good for the ESHRE/ESGE (k = 0.74; 95% confidence interval [CI]: 0.55-0.92) and very good for the ASRM and CUME classification systems (k = 0.95; 95%CI: 0.86-1.00; and k = 0.91; 95%CI: 0.79-1.00, respectively). Agreement between the ESHRE/ESGE and ASRM classifications was moderate for both examiners. Agreement between the ESHRE/ESGE and CUME classifications was moderate for examiner 1 and good for examiner 2. Agreement between the ASRM and CUME classifications was good for both examiners. CONCLUSION The three classifications have good (ESHRE/ESGE) or very good (ASRM and CUME) interobserver agreement. Agreement between the ASRM and CUME classifications was higher than that for the ESHRE/ESGE and ASRM and ESHRE/ESGE and CUME classifications.
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Affiliation(s)
- Carla Peixoto
- Department of Obstetrics and Gynecology, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Maite Castro
- Centro de Infertilidad y Reproduccion Humana, Barcelona, Spain
| | - Isabel Carriles
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Maria de Arriba
- Department of Obstetrics and Gynecology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Victoria Lapresa
- Department of Obstetrics and Gynecology, University Hospital, Salamanca, Spain
| | - Juan Luis Alcazar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
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Effect of hyteroscopic uterine septum resection on pregnancy outcomes. J Gynecol Obstet Hum Reprod 2021; 51:102275. [PMID: 34852309 DOI: 10.1016/j.jogoh.2021.102275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/15/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare the reproductive outcome following hysteroscopic resection versus usual care in nulliparous women with a septate uterus. METHODS A retrospective cohort study of nulliparous women with a history of uterine septum and had singleton pregnancies at >20 weeks gestation between Jan. 2016 and Dec. 2019 were conducted. Follow-up was performed through medical record reviews and telephone conversations. The primary outcome was preterm birth at<37weeks gestation, and the secondary outcomes include cesarean delivery, malpresentation, preeclampsia, and birth weight<10th percentile for gestational age. Multivariate logistic regressions were performed to evaluate the effect of hysteroscopic resection on primary and secondary outcomes, after controlling for potential confounding factors. RESULTS Totally 198 women were included in this study, among which 112 women underwent a hysteroscopic resection and 86 women received usual care. Preterm birth incidence (7.1% vs. 18.6%, P = 0.03) and malpresentation (10.7% vs. 23.3%, P = 0.03) was significantly lower in women treated with hysteroscopic resection compared with those received usual care. Multivariate logistic regression indicated that hysteroscopic resection was significantly associated with decreased risks of preterm birth (OR = 0.36, 95% CI: 0.13-0.68; P < 0.01) and malpresentations (OR = 0.47, 95% CI: 0.25-0.71; P < 0.01), after controlling for potential confounding factors. CONCLUSION Hysteroscopic resection could significantly reduce the risks of preterm birth and malpresentations compared to usual care for nulliparous women with a septate uterus.
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Kim MA, Kim HS, Kim YH. Reproductive, Obstetric and Neonatal Outcomes in Women with Congenital Uterine Anomalies: A Systematic Review and Meta-Analysis. J Clin Med 2021; 10:4797. [PMID: 34768344 PMCID: PMC8584292 DOI: 10.3390/jcm10214797] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 11/16/2022] Open
Abstract
Congenital uterine anomalies (CUA) may influence reproductive performance, resulting in adverse pregnancy associated complications. This study aimed to assess the association of CUA subtypes with reproductive, obstetric, and perinatal outcomes. We performed a systematic search of the MEDLINE, EMBASE, and Cochrane libraries for studies comparing pregnancy outcomes between women with CUA and those with a normal uterus. The random effects model was used to estimate the odds ratios (ORs) with a 95% confidence interval (CI). Women with CUA had a lower rate of live births (OR 0.47; 95% CI 0.33-0.69), and a higher rate of first trimester miscarriage (OR, 1.79; 95% CI 1.34-2.4), second trimester miscarriage (OR 2.92; 95% CI 1.35-6.32), preterm birth (OR 2.98; 95% CI 2.43-3.65), malpresentation (OR 9.1; 95% CI 5.88-14.08), cesarean section (OR 2.87; 95% CI 1.56-5.26), and placental abruption (OR 3.12; 95% CI 1.58-6.18). Women with canalization defects appear to have the poorest reproductive performance during early pregnancy. However, unification defects were associated with obstetric and neonatal outcomes throughout the course of pregnancy. It may be beneficial for clinicians to advise on potential complications that may be increased depending on the type and severity of CUA.
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Affiliation(s)
- Min-A Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul 03722, Korea; (M.-A.K.); (H.S.K.)
| | - Hyo Sun Kim
- Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul 03722, Korea; (M.-A.K.); (H.S.K.)
| | - Young-Han Kim
- Department of Obstetrics and Gynecology, Severance Hospital, Institute of Women’s Life Medical Science, Yonsei University College of Medicine, Seoul 06273, Korea
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Romero-Matas M, Frías-Sánchez Z, del Río-Romero I. Esterilidad de origen uterino. Revisión narrativa de la bibliografía. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2021. [DOI: 10.1016/j.gine.2021.100681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rousseau L, Brichant G, Timmermans M, Nisolle M, Tebache L. Daily practice management of septate uterus: reproductive outcome after septoplasty. Facts Views Vis Obgyn 2021; 13:253-259. [PMID: 34555879 PMCID: PMC8823278 DOI: 10.52054/fvvo.13.3.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Septate uterus is the most common uterine malformation found in women presenting poor reproductive history. Hysteroscopic septoplasty (HS) restores the uterine anatomy in a safe procedure. Objectives The goal of our study is to determine the reproductive outcomes after HS of symptomatic septate uterus. Materials and Methods In a retrospective observational single centre study the reproductive outcomes and complications after HS were evaluated in 31 women with symptomatic septate uterus. The patients were separated into two groups according to the symptoms - infertility or recurrent pregnancy loss (RPL). Main outcome measures were the pregnancy and live birth rate and secondarily the complication rate. Furthermore, the results were analysed depending on the need of assisted reproductive techniques (ART). Results The treatment has resulted in an overall pregnancy rate of 71% for both groups. The spontaneous pregnancy rate is 45% and 8 pregnancies resulted from ART (26%). The overall first live birth rate is 51.6%. A decrease has been noticed in the miscarriage rate from 95.24% to 24% (p<0.001) in the overall population. Conclusions In patients with a symptomatic septate uterus hysteroscopic septoplasty is a safe and effective procedure. The favourable results pointing out the benefits of surgery on the reproductive outcomes as well as the relatively simple and safe technique of HS make the intervention attractive.
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Surgical treatment of uterine septum to improve reproductive outcomes - resect or not? Fertil Steril 2021; 116:298-305. [PMID: 34274115 DOI: 10.1016/j.fertnstert.2021.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/22/2022]
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Successful Vaginal Delivery after External Cephalic Version in a Woman with a Large Partial Uterine Septum. Case Rep Obstet Gynecol 2021; 2021:9912271. [PMID: 34104501 PMCID: PMC8159644 DOI: 10.1155/2021/9912271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/22/2021] [Accepted: 05/03/2021] [Indexed: 12/03/2022] Open
Abstract
Septate uteri have been associated with adverse pregnancy outcomes including spontaneous abortion, preterm delivery, and malpresentation. It is unclear if uterine septa are associated with infertility. Although some studies have shown improved pregnancy outcomes after septum resection, indications for resection are not well established. We describe a case of a woman with a large partial uterine septum diagnosed during workup for infertility who conceived without septum resection. Both of her subsequent pregnancies were initially breech presentations for which the patient underwent external cephalic version followed by full-term vaginal deliveries. This case adds evidence that an unresected uterine septum should not be considered a contraindication to external cephalic version.
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Vomstein K, Aulitzky A, Strobel L, Bohlmann M, Feil K, Rudnik-Schöneborn S, Zschocke J, Toth B. Recurrent Spontaneous Miscarriage: a Comparison of International Guidelines. Geburtshilfe Frauenheilkd 2021; 81:769-779. [PMID: 34276063 PMCID: PMC8277441 DOI: 10.1055/a-1380-3657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/01/2021] [Indexed: 01/11/2023] Open
Abstract
While roughly 30% of all women experience a spontaneous miscarriage in their lifetime, the incidence of recurrent (habitual) spontaneous miscarriage is 1 – 3% depending on the employed definition. The established risk factors include endocrine, anatomical, infection-related, genetic, haemostasis-related and immunological factors. Diagnosis is made more difficult by the sometimes diverging recommendations of the respective international specialist societies. The present study is therefore intended to provide a comparison of existing international guidelines and recommendations. The guidelines of the ESHRE, ASRM, the DGGG/OEGGG/SGGG and the recommendations of the RCOG were analysed. It was shown that investigation is indicated after 2 clinical pregnancies and the diagnosis should be made using a standardised timetable that includes the most frequent causes of spontaneous miscarriage. The guidelines concur that anatomical malformations, antiphospholipid syndrome and thyroid
dysfunction should be excluded. Moreover, the guidelines recommend carrying out pre-conception chromosomal analysis of both partners (or of the aborted material). Other risk factors have not been included in the recommendations by all specialist societies, on the one hand because of a lack of diagnostic criteria (luteal phase insufficiency) and on the other hand because of the different age of the guidelines (chronic endometritis). In addition, various economic and consensus aspects in producing the guidelines influence the individual recommendations. An understanding of the underlying decision-making process should lead in practice to the best individual diagnosis and resulting treatment being offered to each couple.
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Affiliation(s)
- Kilian Vomstein
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Anna Aulitzky
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Laura Strobel
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | - Michael Bohlmann
- Zentrum für Gynäkologie und Geburtshilfe, St Elisabethen-Krankenhaus Lörrach gGmbH, Lörrach, Germany
| | - Katharina Feil
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
| | | | - Johannes Zschocke
- Zentrum für medizinische Genetik, Medizinische Universität Innsbruck, Innsbruck, Austria
| | - Bettina Toth
- Medical University Innsbruck, Department of Gynaecological Endocrinology and Reproductive Medicine, Innsbruck, Austria
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Rikken JFW, van der Veen F, van Wely M, Goddijn M. Reply: Septum resection, seriously? Hum Reprod 2021; 35:2630-2631. [PMID: 32974641 DOI: 10.1093/humrep/deaa231] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J F W Rikken
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam University Medical Centre, Location AMC and VUMC, 1100 DE Amsterdam, the Netherlands
| | - F van der Veen
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam University Medical Centre, Location AMC and VUMC, 1100 DE Amsterdam, the Netherlands
| | - M van Wely
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam University Medical Centre, Location AMC and VUMC, 1100 DE Amsterdam, the Netherlands
| | - M Goddijn
- Department of Obstetrics and Gynaecology, Centre for Reproductive Medicine, Amsterdam University Medical Centre, Location AMC and VUMC, 1100 DE Amsterdam, the Netherlands
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Ludwin A. Septum resection does not improve reproductive outcomes: truly? Hum Reprod 2021; 35:1495-1498. [PMID: 32568394 DOI: 10.1093/humrep/deaa142] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 05/04/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Artur Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow 31-501, Poland.,Ludwin & Ludwin Gynecology, Private Medical Center, Krakow 31-511, Poland
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PROSPECTIVE EVALUATION OF MEDIUM-TERM OUTCOMES OF PATIENTS UNDERGOING HYSTEROSCOPIC UTERINE SEPTUM RESECTION. INTERNATIONAL JOURNAL OF HEALTH SERVICES RESEARCH AND POLICY 2021. [DOI: 10.33457/ijhsrp.821619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Xiao F, Gao S, Tang X, Chen Y, Fang F. Oblique Cervical Septum with Complete Uterine Septum: Diagnosis and Treatment of a Rare Case. J Pediatr Adolesc Gynecol 2021; 34:84-87. [PMID: 32473321 DOI: 10.1016/j.jpag.2020.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Müllerian anomalies take many forms of manifestation. The oblique cervical septum with a complete uterine septum (OCSCUS), as a rare form of Müllerian anomaly, has never been reported in the literature. CASE A 10-year-old female adolescent presented with progressive abdominal pain after the onset of menarche was diagnosed as OCSCUS using magnetic resonance imaging and treated with hysteroscopic dissection of the uterine part of the septum. SUMMARY AND CONCLUSION Greater awareness of the OCSCUS will lead to earlier detection and is the key to alleviating patient suffering and avoiding potentially severe complications, such as endometriosis and infertility. For the treatment of OCSCUS, hysteroscopic dissection of the uterine part of the septum is a minimally invasive treatment choice with low surgical risk.
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Affiliation(s)
- Fengyi Xiao
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Shujun Gao
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xindi Tang
- Shaoxing Shangyu Maternal and Child Health Hospital, Shaoxing, China
| | - Yisong Chen
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Fang Fang
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
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Casadio P, Magnarelli G, La Rosa M, Alletto A, Arena A, Fontana E, Morra C, Talamo MR, Fabbri M, Giovannico K, Virgilio A, Raimondo D, Guasina F, Paradisi R, Seracchioli R. Uterine Fundus Remodeling after Hysteroscopic Metroplasty: A Prospective Pilot Study. J Clin Med 2021; 10:jcm10020260. [PMID: 33445663 PMCID: PMC7828148 DOI: 10.3390/jcm10020260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/30/2020] [Accepted: 01/02/2021] [Indexed: 11/16/2022] Open
Abstract
The septate uterus is the most common congenital uterine malformation and is treated by hysteroscopic metroplasty. There are few studies on the fundal uterine changes that occur after surgery. We designed a pilot prospective observational study to evaluate by three-dimensional transvaginal ultrasound (3D-TVS) the changes not only of the internal fundal uterine profile, but also of the external one, after hysteroscopic metroplasty. Sixty women who underwent hysteroscopic metroplasty for partial or complete uterine septum (U2a and U2b subclasses of ESHRE/ESGE classification) were enrolled. We performed 3D-TVS after surgery confirming optimal removal of the septum. However, at ultrasound follow-up after three months, we observed a significant increase (p < 0.001) in the residual septum (Zr) (3.7 mm (95% CI: 3.1-4.4)), the myometrial wall thickness (Y) (2.5 mm (95% CI: 2.0-3.0)) and the total fundal wall thickness (Y + Zr) (6.2 mm (95% CI: 5.5-6.9)). Forty-three patients (72%) required a second step of hysteroscopic metroplasty. Moreover, the shape of uterine fundus changed in 58% of cases. We actually observed a remodeling of the uterine fundus with modifications of its external and internal profiles. Therefore, we propose to always perform a second ultrasound look at least three months after the metroplasty to identify cases that require a second- step metroplasty.
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Affiliation(s)
- Paolo Casadio
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Giulia Magnarelli
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
- Correspondence:
| | - Mariangela La Rosa
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Andrea Alletto
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Alessandro Arena
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Enrico Fontana
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Ciro Morra
- Department of Gynecology and Obstetrics, Maggiore Hospital, 40133 Bologna, Italy; (C.M.); (M.R.T.)
| | - Maria Rita Talamo
- Department of Gynecology and Obstetrics, Maggiore Hospital, 40133 Bologna, Italy; (C.M.); (M.R.T.)
| | - Matilde Fabbri
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Kevin Giovannico
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Agnese Virgilio
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Diego Raimondo
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Francesca Guasina
- Department of Gynecology and Obstetrics, Santa Chiara Regional Hospital, 38122 Trento, Italy;
| | - Roberto Paradisi
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (P.C.); (M.L.R.); (A.A.); (A.A.); (E.F.); (M.F.); (K.G.); (A.V.); (D.R.); (R.P.); (R.S.)
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Konar H. Mullerian Malformations and Reconstructive Surgery: Clinicians' Approach. J Obstet Gynaecol India 2021; 71:11-20. [PMID: 33814794 DOI: 10.1007/s13224-020-01400-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 11/07/2020] [Indexed: 10/22/2022] Open
Abstract
Mullerian malformations are not uncommon. Overall incidence ranges widely between 1 in 200 women and 4 in 100 women (Chan et al. in Hum Reprod Update 17:761-771, 2011; Grimbizis et al. in Hum Reprod 28:2032-2044, 2013). Other way, these observations suggest presently an increased number of Mullerian abnormalities are diagnosed with more details, following the use of newer diagnostic modalities. Most classifications that are available have limitations. Diagnosis was based on imaging studies that had low diagnostic accuracy. It was focused mainly on the anomalies of the uterus. Less is known about the anomalies of the cervix or the vagina in isolation or in combination with the utero-cervical and vaginal malformations. Improved diagnostic modalities and incorporation of assisted reproductive technology have improved the outcome further. Therefore, a more expanded classification needs to be introduced with wider criteria for the clinicians. This will make clinicians' approach for the management more simple.
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Affiliation(s)
- Hiralal Konar
- Department of Obstetrics and Gynecology, Agartala Government Medical College and G. B Pant Hospital, Agartala, Tripura India.,Kolkata, India
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43
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Saridogan E, Salman M, Direk LS, Alchami A. Reproductive Performance Following Hysteroscopic Surgery for Uterine Septum: Results from a Single Surgeon Data. J Clin Med 2021; 10:jcm10010130. [PMID: 33401655 PMCID: PMC7795865 DOI: 10.3390/jcm10010130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 12/02/2022] Open
Abstract
Uterine septum can negatively affect reproductive outcomes in women. Based on evidence from retrospective observational studies, hysteroscopic incision has been considered a solution to improve reproductive performance, however there has been recent controversy on the need for surgery for uterine septum. High quality evidence from prospective studies is still lacking, and until it is available, experts are encouraged to publish their data. We are therefore presenting our data that involves analysis of the patient characteristics, surgical approach and long-term reproductive outcomes of women who received treatment for uterine septum under the care of a single surgeon. This includes all women (99) who underwent hysteroscopic surgery for uterine septum between January 2001 and December 2019. Of those 99 women treated for intrauterine septum who were trying to conceive, 91.4% (64/70) achieved pregnancy, 78.6% (55/70) had live births and 8.6% (6/70) had miscarriages. No statistically significant difference was found in the live birth rates when data was analyzed in subgroups based on age, reason for referral/aetiology and severity of pathology. Our study results support the view that surgical treatment of uterine septa is beneficial in improving reproductive outcomes.
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Jansa V, Laganà AS, Ferrari F, Ghezzi F, Burnik Papler T, Vrtacnik Bokal E, Ban Frangež H. Uterine rupture in pregnancy after hysteroscopic septum resection: a 20-year retrospective analysis. MINIM INVASIV THER 2020; 31:448-455. [PMID: 33331203 DOI: 10.1080/13645706.2020.1837884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In this study, we reviewed the cases of uterine rupture in our setting, identified which of them had previously undergone hysteroscopic septum resection (HSR), and evaluated the main clinical characteristics for each case. MATERIAL AND METHODS We retrospectively analyzed (ClinicalTrial ID: NCT04449640) the delivery outcomes from the National Perinatal Information System of the National Institute of Public Health of the Republic of Slovenia of the last 20 years (1 January 1999 - 31 December 2019) and cross-linked the patients with surgical data from our electronic database. We collected baseline characteristics, surgical details and obstetrical outcomes. We excluded women who had undergone previous myomectomy or cesarean section (CS) and described the clinical course of each case since no statistical analysis was performed. RESULTS We found four patients who had uterine rupture in pregnancy after HSR. Median time to pregnancy was 17 months (range 1-60), all the women underwent CS and fetal-maternal outcomes were acceptable in half of the cases. Symptoms were nonspecific and included pain, fetal distress and vaginal bleeding. CONCLUSION Uterine rupture in pregnancy after a previous HSR is a very rare, but life-threatening event. Prompt diagnosis can ensure successful management and avoid adverse maternal-fetal outcomes.
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Affiliation(s)
- Vid Jansa
- Department of Human Reproduction, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Federico Ferrari
- Department of Obstetrics and Gynecology, Spedali Civili of Brescia, Brescia, Italy
| | - Fabio Ghezzi
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Tanja Burnik Papler
- Department of Human Reproduction, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Eda Vrtacnik Bokal
- Department of Human Reproduction, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Helena Ban Frangež
- Department of Human Reproduction, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Passos IDMPE, Britto RL. Diagnosis and treatment of müllerian malformations. Taiwan J Obstet Gynecol 2020; 59:183-188. [PMID: 32127135 DOI: 10.1016/j.tjog.2020.01.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2019] [Indexed: 11/27/2022] Open
Abstract
Anomalies in the müllerian ducts are congenital alterations with more prevalence than it is imagined, varying from 0.5 to 6.7% in the general population and up to 16.7% in women with recurrent miscarriage. The main findings are primary amenorrhea, dysmenorrhea, pelvic pain, endometriosis, sexual difficulties and low self-esteem. The major impact on the quality of life in women stricken by these problems justifies this study, whose objective is to analyze their most important aspects such as etiopathogeny, classification, diagnostic methods and proposed treatments. The research was performed on the Medline-PubMed database from 1904 to 2018. The American Fertility Society, European Society of Human Reproduction and Embryology, and the European Society of Gynaecological Endoscopy classify malformations as: Class 1/U5bC4V4: agenesis or hypoplasia of uterus and vagina; Class 1/U5aC4V4: cervical hypoplasia, associated with total or partial vaginal agenesis; Class 2/U4: unicornuate uterus; Class 3/U3bC2V1 or Class3/U3bC2V2: uterus didelphys; Class 4/U3C0: bicornuate uterus; Class 5/U2: septate uterus; Class 6: arcuate uterus; Class 7/U1: induced by diethylstilbestrol, represented by a T-shaped uterus; and V3: transverse vaginal septum. The diagnostic methods are the two-dimensional or three-dimensional ultrasound, MRI, hysterosalpingo-contrast-sonography, X-ray hysterosalpingography, hysteroscopy and laparoscopy. Some müllerian malformations are healed with surgery and/or self-dilatation. For vaginal agenesis, dilatation by Frank technique shows good results while malformations with obstruction of the menstrual flow need to be rapidly treated by surgery.
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Affiliation(s)
- Itana de Mattos Pinto E Passos
- Center for Women's Health, University Hospital Professor Edgard Santos, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil.
| | - Renata Lopes Britto
- Center for Women's Health, University Hospital Professor Edgard Santos, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil; Department of Gynecology and Obstetrics, Faculty of Medicine, Federal University of Bahia (UFBA), Salvador, Bahia, Brazil
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Carugno J, Alonso L. Fertility and pregnancy outcomes following hysteroscopic metroplasty of uterine septa. Minerva Obstet Gynecol 2020; 74:24-30. [PMID: 33306286 DOI: 10.23736/s2724-606x.20.04724-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The septate uterus is still a matter of debate and discussion today in different medical forums. The controversy is divided between 2 different quite divergent opinions: on the one hand, those who promote its surgical correction; and on the other hand, those who advocate expectant management with no recommended surgical intervention. It is extremely difficult to determine the association between septum and infertility. Infertility is a multifactorial condition; furthermore, the mechanism by which the septate uterus is associated with infertility is still unknown, although the most probable causes seem to be related to implantation alterations. There is lack of high-quality randomized controlled studies with an adequate number of patients demonstrating the efficacy of the surgical treatment of patients with septated uterus. However, the limited available data based on observational studies, support minimally-invasive treatment using hysteroscopy as the method of choice for the treatment of patients with septated uterus and history of infertility or poor obstetrical outcomes.
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Affiliation(s)
- Jose Carugno
- Miller School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Minimally-Invasive Gynecology, University of Miami, Miami, FL, USA -
| | - Luis Alonso
- Unit of Hysteroscopy, Gutenberg Center, Malaga, Spain
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Stamenov GS, Vitale SG, Della Corte L, Vilos GA, Parvanov DA, Nikolova DN, Ganeva RR, Haimovich S. Hysteroscopy and female infertility: a fresh look to a busy corner. HUM FERTIL 2020; 25:430-446. [PMID: 33261529 DOI: 10.1080/14647273.2020.1851399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hysteroscopy has evolved from the traditional art of examining the uterine cavity for diagnostic purposes to an invaluable modality to concomitantly diagnose and (see and) treat a multitude of intrauterine pathologies, especially in the field and clinics specialising in female reproduction. This article reviews the literature on the most common cervical, endometrial, uterine and tubal pathologies such as chronic endometritis, endometrial polyps, adenomyosis, endometriosis, endometrial atrophy, adhesions, endometrial hyperplasia, cancer, and uterine malformations. The aim is to determine the efficiency of hysteroscopy compared with other available techniques as a diagnostic and treatment tool and its association with the success of in vitro fertilisation procedures. Although hysteroscopy requires an experienced operator for optimal results and is still an invasive procedure, it has the unique advantage of combining great diagnostic and treatment opportunities before and after ART procedures. In conclusion, hysteroscopy should be recommended as a first-line procedure in all cases with female infertility, and a special effort should be made for its implementation in the development of new high-tech procedures for identification and treatment infertility-associated conditions.
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Affiliation(s)
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - George Angelos Vilos
- Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Western University, London, Canada
| | | | | | | | - Sergio Haimovich
- Hillel Yaffe Medical Center/Technion - Israel Technology Institute, Hadera, Israel
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Esteban Manchado B, Lopez-Yarto M, Fernandez-Parra J, Rodriguez-Oliver A, Gonzalez-Paredes A, Laganà AS, Garzon S, Haimovich S. Office hysteroscopic metroplasty with diode laser for septate uterus: a multicenter cohort study. MINIM INVASIV THER 2020; 31:441-447. [DOI: 10.1080/13645706.2020.1837181] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Berta Esteban Manchado
- Department of Obstetrics and Gynecology, Section of Minimally Invasive Surgery, Hospital Del Mar, Barcelona, Spain
| | - Maite Lopez-Yarto
- Department of Obstetrics and Gynecology, Section of Minimally Invasive Surgery, Hospital Del Mar, Barcelona, Spain
| | - Jorge Fernandez-Parra
- Department of Obstetrics and Gynecology, Hospital Virgen de las Nieves, Granada, Spain
| | | | - Aida Gonzalez-Paredes
- Department of Obstetrics and Gynecology, Hospital Virgen de las Nieves, Granada, Spain
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Sergio Haimovich
- Department of Obstetrics and Gynecology, Section of Minimally Invasive Surgery, Hospital Del Mar, Barcelona, Spain
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Rikken JFW, Verhorstert KWJ, Emanuel MH, Bongers MY, Spinder T, Kuchenbecker W, Jansen FW, van der Steeg JW, Janssen CAH, Kapiteijn K, Schols WA, Torrenga B, Torrance HL, Verhoeve HR, Huirne JAF, Hoek A, Nieboer TE, van Rooij IAJ, Clark TJ, Robinson L, Stephenson MD, Mol BWJ, van der Veen F, van Wely M, Goddijn M. Septum resection in women with a septate uterus: a cohort study. Hum Reprod 2020; 35:1578-1588. [PMID: 32353142 PMCID: PMC7368397 DOI: 10.1093/humrep/dez284] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/20/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022] Open
Abstract
STUDY QUESTION Does septum resection improve reproductive outcomes in women with a septate uterus? SUMMARY ANSWER In women with a septate uterus, septum resection does not increase live birth rate nor does it decrease the rates of pregnancy loss or preterm birth, compared with expectant management. WHAT IS KNOWN ALREADY The septate uterus is the most common uterine anomaly with an estimated prevalence of 0.2-2.3% in women of reproductive age, depending on the classification system. The definition of the septate uterus has been a long-lasting and ongoing subject of debate, and currently two classification systems are used worldwide. Women with a septate uterus may be at increased risk of subfertility, pregnancy loss, preterm birth and foetal malpresentation. Based on low quality evidence, current guidelines recommend removal of the intrauterine septum or, more cautiously, state that the procedure should be evaluated in future studies. STUDY DESIGN, SIZE, DURATION We performed an international multicentre cohort study in which we identified women mainly retrospectively by searching in electronic patient files, medical records and databases within the time frame of January 2000 until August 2018. Searching of the databases, files and records took place between January 2016 and July 2018. By doing so, we collected data on 257 women with a septate uterus in 21 centres in the Netherlands, USA and UK. PARTICIPANTS/MATERIALS, SETTING, METHODS We included women with a septate uterus, defined by the treating physician, according to the classification system at that time. The women were ascertained among those with a history of subfertility, pregnancy loss, preterm birth or foetal malpresentation or during a routine diagnostic procedure. Allocation to septum resection or expectant management was dependent on the reproductive history and severity of the disease. We excluded women who did not have a wish to conceive at time of diagnosis. The primary outcome was live birth. Secondary outcomes included pregnancy loss, preterm birth and foetal malpresentation. All conceptions during follow-up were registered but for the comparative analyses, only the first live birth or ongoing pregnancy was included. To evaluate differences in live birth and ongoing pregnancy, we used Cox proportional regression to calculate hazard rates (HRs) and 95% CI. To evaluate differences in pregnancy loss, preterm birth and foetal malpresentation, we used logistic regression to calculate odds ratios (OR) with corresponding 95% CI. We adjusted all reproductive outcomes for possible confounders. MAIN RESULTS AND THE ROLE OF CHANCE In total, 257 women were included in the cohort. Of these, 151 women underwent a septum resection and 106 women had expectant management. The median follow-up time was 46 months. During this time, live birth occurred in 80 women following a septum resection (53.0%) compared to 76 women following expectant management (71.7%) (HR 0.71 95% CI 0.49-1.02) and ongoing pregnancy occurred in 89 women who underwent septum resection (58.9%), compared to 80 women who had expectant management (75.5%) (HR 0.74 (95% CI 0.52-1.06)). Pregnancy loss occurred in 51 women who underwent septum resection (46.8%) versus 31 women who had expectant management (34.4%) (OR 1.58 (0.81-3.09)), while preterm birth occurred in 26 women who underwent septum resection (29.2%) versus 13 women who had expectant management (16.7%) (OR 1.26 (95% CI 0.52-3.04)) and foetal malpresentation occurred in 17 women who underwent septum resection (19.1%) versus 27 women who had expectant management (34.6%) (OR 0.56 (95% CI 0.24-1.33)). LIMITATIONS, REASONS FOR CAUTION Our retrospective study has a less robust design compared with a randomized controlled trial. Over the years, the ideas about the definition of the septate uterus has changed, but since the 257 women with a septate uterus included in this study had been diagnosed by their treating physician according to the leading classification system at that time, the data of this study reflect the daily practice of recent decades. Despite correcting for the most relevant patient characteristics, our estimates might not be free of residual confounding. WIDER IMPLICATIONS OF THE FINDINGS Our results suggest that septum resection, a procedure that is widely offered and associated with financial costs for society, healthcare systems or individuals, does not lead to improved reproductive outcomes compared to expectant management for women with a septate uterus. The results of this study need to be confirmed in randomized clinical trials. STUDY FUNDING/COMPETING INTEREST(S) A travel for JFWR to Chicago was supported by the Jo Kolk Studyfund. Otherwise, no specific funding was received for this study. The Department of Obstetrics and Gynaecology, University Medical Centre, Groningen, received an unrestricted educational grant from Ferring Pharmaceutical Company unrelated to the present study. BWM reports grants from NHMRC, personal fees from ObsEva, personal fees from Merck, personal fees from Guerbet, other payment from Guerbet and grants from Merck, outside the submitted work. The other authors declare no conficts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- J F W Rikken
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - K W J Verhorstert
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - M H Emanuel
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M Y Bongers
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Eindhoven, the Netherlands
| | - T Spinder
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - W Kuchenbecker
- Department of Obstetrics and Gynaecology, Isala Hospital Zwolle, Zwolle, the Netherlands
| | - F W Jansen
- Department of Obstetrics and Gynaecology, University Medical Centre Leiden, Leiden, the Netherlands
| | - J W van der Steeg
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - C A H Janssen
- Department of Obstetrics and Gynaecology, Groene Hart Hospital, Gouda, the Netherlands
| | - K Kapiteijn
- Department of Obstetrics and Gynaecology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - W A Schols
- Department of Obstetrics and Gynaecology, Meander Medical Centre, Amersfoort, the Netherlands
| | - B Torrenga
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands
| | - H L Torrance
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - H R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG Oost, Amsterdam, the Netherlands
| | - J A F Huirne
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - A Hoek
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - T E Nieboer
- Department of Obstetrics and Gynaecology, Nijmegen, the Netherlands
| | - I A J van Rooij
- Department of Obstetrics and Gynaecology, Elisabeth Hospital Tweesteden, Tilburg, the Netherlands
| | - T J Clark
- Department of Obstetrics and Gynaecology, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - L Robinson
- Department of Obstetrics and Gynaecology, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - M D Stephenson
- Department of Obstetrics and Gynaecology, University of Illinois, CA, USA
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - F van der Veen
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - M van Wely
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - M Goddijn
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
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Detti L, Christiansen ME, Levi D’Ancona R, Gordon JC, Van de Velde N, Peregrin-Alvarez I. Restoration of Uterine Cavity Measurements after Surgical Correction. J Imaging 2020; 6:58. [PMID: 34460651 PMCID: PMC8321055 DOI: 10.3390/jimaging6070058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
Objective: We sought to define the uterine and uterine cavity dimensions of subseptate uteri before and after hysteroscopic surgical incision, and compare them to those obtained in normal uteri with 3-D ultrasound. Methods: Two cohorts of consecutive women with normal-appearing uterine cavity and women diagnosed with uterine subseptations, before and after undergoing hysteroscopic incision. 3-D ultrasound was used to measure the uterine cavity width, length, and area on a frozen coronal view of the uterus. Results: A total of 215 women were included: 89 in the normal, and 126 in the subseptate uterus, groups. Uterine length and height were similar in the pre-operative, post-operative subseptate uteri, and in the normal uteri, while the uterine width was significantly greater in the pre-operative (5.1 + 0.8 cm) than post-operative (4.7 + 0.8 cm) and normal uterus (4.6 + 0.7 cm; p < 0.001) groups. The pre-operative uterine cavity length (3.3 + 0.5 cm), width (3.2 + 0.7 cm), and area (4.4 + 1.2 cm2), were significantly greater than the post-operative ones (length 2.9 + 0.4 cm; width 2.6 + 0.6 cm; area 3.7 + 0.8 cm; overall p < 0.001), and became similar to the dimensions of the normal uterus. Of the patients who subsequently conceived, 2.6% miscarried in the corrected subseptation group and 28.8% miscarried in the normal uterus group. Conclusions: We defined the ultrasound dimensions of the uterine cavity in subseptate uteri and their change after surgical correction. Uterine cavity length, width, and area show very little variability in adult normal uteri, while they are increased in uteri with a subseptation greater than 5.9 mm in length, and regain normal measurements after surgical correction.
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Affiliation(s)
- Laura Detti
- Cleveland Clinic, Department of Subspecialty Care for Women’s Health, Ob/Gyn Women’s Health Institute, Cleveland, OH 44195, USA
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Mary Emily Christiansen
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Roberto Levi D’Ancona
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Jennifer C. Gordon
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Nicole Van de Velde
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Irene Peregrin-Alvarez
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
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