Septum resection does not improve reproductive outcomes: truly?

Does septum resection improve reproductive outcomes for women with a septate uterus? A systematic review and meta-analysis

Objective

To investigate whether incising the septum facilitates reproductive outcomes for patients with a septate uterus compared to expectant management.

Methods

Research was retrieved from three electronic databases: PubMed, Embase, and the Cochrane Library, with no time or language restrictions. Two authors independently selected the articles and extracted data regarding study characteristics, quality, and results. A random-effects model was employed, and summary risk ratios (RR) with 95% confidence intervals (CI) were calculated.

Results

A total of 468 patients from two randomized controlled trials and one cohort study were included in the systematic review and meta-analysis. Pooled results showed that septum resection did not improve the live birth rate for patients with a septate uterus (RR = 0.84, 95% CI = 0.56 - 1.25, P = 0.39). Additionally, no significant differences were found between the septum resection and expectant management groups in terms of clinical pregnancy (RR = 1.08, 95% CI 0.81 - 1.44, P = 0.60), abortion (RR = 1.99, 95% CI 0.80 - 4.98, P = 0.14), and preterm delivery rates (RR = 0.99, 95% CI 0.42 - 2.31, P = 0.98).

Conclusion

Our data provide clear evidence that septum resection does not improve the reproductive outcomes of patients with a septate uterus. These findings might be useful for revising current clinical guidelines.

3D transvaginal ultrasound diagnosis of uterine septa according to different classifications: are there other measurements that correlate to reproductive outcome in small indentation length?

Background: High discrepancy between current classifications was observed in the definition of uterine septa, especially for indentation lengths >5 <10mm. Objectives: To assess the discrepancy between current classifications in the diagnoses of septate uterus and to correlate them with reproductive outcomes; to detect 3D transvaginal ultrasound (TVS) additional measurements, which can better correlate small indentation lengths >5 <10mm to reproductive failures. Material and methods: Observational study enrolling 664 women of reproductive age with 3D ultrasound diagnosis of an indentation length ≥3mm. For each patient a detailed reproductive history was taken before performing 3D transvaginal examination. Patients with previous uterine surgery or metroplasty were excluded. Main Outcome Measure(s): Indentation lengths >5 <10mm showed high discrepancy in the diagnosis of uterine septum between different classifications. For these small indentations additional 3D measurements (indentation angle, septal width and septal length/ fundal myometrial thickness (L/M) ratio) were correlated to infertility and recurrent miscarriage. Results: Among the cohort, 215 patients showed an indentation length >5 <10mm; 136 tried to conceive: 69 (51%) were infertile, 38 (28%) had recurrent miscarriages (≥2) and 5 (4%) had at least one delivery. Recurrent miscarriage significantly correlated to an indentation angle >134°; whereas infertility to an indentation width <32mm and a L/M ratio >75%. Conclusions: Wide discrepancies between different classifications are more evident in indentation lengths >5 <10mm. Additional measurements on 3D coronal section may help to evaluate the risk of infertility or recurrent miscarriage. What is new? Additional 3D TVS measurements, beyond septal lengths, in particular for small fundal indentation, may help in predicting the risk of developing adverse reproductive outcomes.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Reproductive Performance Following Hysteroscopic Surgery for Uterine Septum: Results from a Single Surgeon Data

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.