Dysmorphic Uterus Research Articles

Dysmorphic Uterus: More Questions than Answers.

A T-shaped uterus is a rare uterine malformation that is classically associated with diethylstilbesterol (DES) exposure. Surprisingly, the prevalence of T- and Y-shaped uterus has increased in recent years despite the absence of a diagnostic consensus and a correlation with the reproductive outcomes has been observed. A systematic electronic database search for all English-language studies published on reproductive outcomes associated with dysmorphic uteri over the past 10 years using PubMed, Google Scholar, and Scopus was performed. This uterine malformation is associated with impaired reproductive outcomes, including primary infertility, miscarriage, ectopic pregnancy, and preterm birth. Hysteroscopic metroplasty is a simple surgical procedure that could potentially improve outcomes in subfertile women, but the data are not robust. Studies reported significant improvements in implantation and pregnancy rates after corrective metroplasty in women undergoing in vitro fertilization. However, multicenter, prospective, randomized, and controlled trials are needed to validate these findings and to help define clear diagnostic criteria, surgical indications, and appropriate follow-up of reproductive outcomes after the procedure.

Proposal for Diagnostic Criteria of Y-Shaped Dysmorphic Uterus Based on 3-Dimensional Transvaginal Ultrasound Measurements

Study ObjectiveTo define objective and readily applied diagnostic criteria for Y-shaped uteri using 3-dimensional transvaginal ultrasound (3D-TVUS) volume recordings. DesignA retrospective case-control diagnostic measurements study. SettingA tertiary university hospital's reproductive health and research center. PatientsTwo hundred thirteen patients who presented with infertility between January 2020 and December 2022. InterventionsTwo blinded physicians re-evaluated the 3D-TVUS images of all patients for the presence of a uterine abnormality. The images of patients with a Y-shaped uterus were re-evaluated, and descriptive measurements were done. Measurements and Main ResultsThe most common uterine abnormality in this cohort was the Y-shaped uterus with a prevalence of 12.2%, followed by the arcuate, T-shaped, and septate uteri, respectively. Reviewers identified 26 and 28 Y-shaped uteri, respectively, and came to a consensus on 25 images. Diagnostic criteria for the Y-shaped uterus based on 3D-TVUS findings have been specified as: lateral indentation depths between 4 and 7 mm, fundal indentation depth between 5 and 9 mm, lateral indentation angles between 121° and 149°, fundal indentation angle between 121° and 145°, and Y-angles 25° to 46°. ConclusionSome subtypes of dysmorphic uteri, such as the Y-shaped uterus, whose clinical significance is unknown and may be variants of the normal, may actually be more common than thought. Determining objective diagnostic criteria with 3D-TVUS will allow standard research on these anomalies and their clinical significance.

O-056 Dysmorphic uterus: lateral angle might associate with euploid blastocyst implantation

Abstract Study question Are there a morphological features measured in coronal plane obtained by tridimensional transvaginal sonography (3D-TVS), associated with euploid blastocyst implantation? Summary answer Mean laeral angle (mLA) below 143 degrees was associated with lower clinical pregnancy rate among 47 euploid blastocyst transfers. What is known already The ESHRE/ESGE 2013 consensus on uterine malformation clustered in Class U1 (namely Dysmorphic uterus): T-shaped uterus (class U1a), uterus infantilis (Class U1b) and Class U1c including other minor abnormalities. Diagnostic criteria are still under major debate, however a few studies report an association between dysmorphic uterus and impaired fertility outcomes. In the literature, no evidence has been published on a selected population of euploid blastocyst transfers. Moreover, sonographic predictors of successful transfer in patients with dysmorphic uterus undergoing ART are not available. Study design, size, duration Cohort study involving 122 infertile couples undergoing ICSI with NGS-based PGT-A on trophectoderm biopsies between July-2022 and December-2023. A 3D-TVS was acquired in the luteal phase before starting ovarian stimulation. The primary outcome was to assess whether uterine morphological features associate with clinical pregnancy rate, defined as an ultrasonographic evidence of a gestational sac with fetal heartbeat per transfer. To date, 47 patients underwent vitrified-warmed single euploid blastocyst transfer. Participants/materials, setting, methods Uterine morphology was assessed in a coronal plane. Following measurements, we registered: (1) the distance between the two internal tubal ostia, (2) the width of the uterine cavity at corpus-isthmic level, (3) the lateral angle between the corpus-isthmic cavity, (4) the lateral indentation. The optimal cut-off values of mLA was evaluated with ROC curve; p < 0.05 was considered statistically significant. SPSS version 25.0 was used for statistics. Main results and the role of chance Median age was 38 (IR:26-43). The main cause of infertility was tubal/ovulatory in 22 cases (46%), severe male factor in 18 (39%) and idiopathic in 18 (39%). Thirteen women (28%) experienced a previous miscarriage, and half of them were submitted to a uterine cavity revision. The mLA ranged from 126 to 180 degrees (median:156 degrees), whereas mean indentation ranged from 0 to 7.2 mm (median: 3.0 mm). The patients were categorized in 2 groups by the optimal cutoff value of mLA calculated based on ROC curve analysis. Dysmorphic uterus was defined in case of mLA (mean between right and left lateral angle) below 143 degrees (sensitivity 90%, specificity 54%; AUC=0.67). mLA levels were higher than this threshold in 37 women (80%). Relative risk to have a clinical pregnancy was 0.35 (95%CI 0.15-0.83) in dysmorphic uterus. Two women (25%) got pregnant in dysmorphic uterus group compared to 18 (72%) in normal uterus (p:0.026). After adjusting blastocyst quality and day of transfer, mLA association with a clinical pregnancy remained significant (RR 7.38, 95%CI 1.09-50.18 p = 0.04, Post hoc power: 65.3%). Limitations, reasons for caution Preliminary results. A larger sample is required to confirm these data. Wider implications of the findings The strength of the study is the definition of the impact of a dysmorphic uterus in IVF cycles with PGT-A. If confirmed in larger multicenter datasets, these data may select patients who could benefit from hysteroscopic metroplasty. Trial registration number not applicable

O-057 Prevalence of T-shaped uterus among women undergoing fertility treatments based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria.

Abstract Study question What is the prevalence of a T-shaped uterus among women undergoing fertility treatments based on ESHRE/ESGE (Grimbizis et al.,2013) and CUME (Ludwin et al.,2020)? Summary answer The prevalence of T-shaped uterus was 4.1% according to the ESHRE/ESGE, and according to the CUME, 1.1% T-shaped uterus and 0.9% borderline T-shaped uterus. What is known already The definition of a T-shaped uterus by the ESHRE/ESGE consensus (Grimbizis et al., 2013) was based on three-dimensional ultrasound (3D-US) images, defining it as a narrow uterine cavity caused by thickened lateral walls with a ratio of two-thirds uterine body and one-third cervix. This definition is subjective and therefore makes giving an objective diagnosis difficult. The CUME group (Ludwin et al., 2020) described practical diagnostic criteria for a T-shaped uterus according to 3D-US images. As there is no consensus regarding the definition, the overall prevalence according to different studies varied from 0.2 to 10.0%. Study design, size, duration A retrospective cohort study with prospective analysis of 3D-US images was conducted. All women who were admitted to our unit for fertility treatments and underwent 3D-US between 12/2017-12/2021 were included. Women were grouped according to infertility type. All 3D-US images of uteri suspected to be T-shaped according to ESHRE/ESGE were assessed according to the CUME criteria, based on the following three measurements: lateral indentation angle ≤130°, lateral indentation depth ≥7 mm, and T-angle ≤40°. Participants/materials, setting, methods The study was conducted in a single university-affiliated hospital. Women who underwent fertility treatments due to various indications were included. The exclusion criteria were women undergoing fertility preservation, egg donation and oocyte recipients. All 3D-US were performed by well-trained ultrasound technicians. We first screened all images and calculated the prevalence of T-shaped uteri in our population based on the ESHRE/ESGE consensus. Next, we performed the three measurements according to the CUME criteria. Main results and the role of chance Altogether 451 women were admitted to our fertility unit. Nine cases were excluded due to unsatisfactory 3D-US images because of technical difficulties. Finally, 442 women were included in the study and divided into in the following groups: anovulation 10.6% (n = 47), mechanical factor 11.1% (n = 49), male factor 38.7% (n = 171), and unexplained infertility 39.6% (n = 175). The prevalence of T-shaped uterus according to the ESHRE/ESGE was 4.1% (n = 18). Among them, 3.2% (n = 3) were from the female factor groups (anovulation + mechanical), 4.1% (n = 7) from the male factor group, and 4.6% (n = 8) from the unexplained infertility group. Afterwards, the 3D-US images were analyzed according to the CUME criteria. T-shaped uterus was defined when all three criteria were met, and borderline T-shaped uterus was defined when two out of three criteria were met. According to CUME criteria, the prevalence of T-shaped uterus was only 1.1% (n = 5), three being from the male factor group and two from the unexplained infertility group. No T-shaped uteri were found in the female factor groups. Additionally, 0.9% (n = 4) were considered borderline T-shaped. Limitations, reasons for caution The ESHRE/ESGE consensus is subjective and may lead to either under- or over-diagnosis. On the other hand, the CUME criteria are objective and well-defined, but due to their strictness, dysmorphic uteri with very narrow uterine cavities and thickened lateral walls may not be diagnosed as T-shaped uteri. Wider implications of the findings Diagnosis and management of women with T-shaped uteri are very controversial topics. Therefore, making the diagnosis more precise and objective can help us to screen for the most significant cases and tailor the management accordingly. The similar prevalence among different infertility groups reflects the incidental nature of this diagnosis. Trial registration number Not applicable.

P-749 Increased accuracy in infertility workup by the additional use of new modern diagnostic methods (“diagnostic TRIO”): results from a large retrospective analysis

Abstract Study question Is there any positive effect of adding new modalities to the traditional infertility work-up, like 3D sonography, office hysteroscopy and endometrial biopsy? Summary answer During infertility workup conventional diagnostic tests should be combined with new approaches (3D-TVS, OHSC and endometrial biopsy) to achieve more accurate and less invasive diagnostics. What is known already Female infertility can be explained by functional or organic abnormalities affecting the reproductive system. The most common organic causes include abnormalities within the uterine cavity (e.g. endometrial polyp, submucosal fibroid, intrauterine adhesion), morphological disorders (e.g. dysmorphic uterus, uterine septum) and abnormalities of the endometrium (e.g. chronic endometritis). Study design, size, duration In our retrospective study, we examined patients with primary and secondary infertility. All the patients were assessed by 3D-TVS and OHSC to detect morphological and intrauterine disorders, and in special cases (repeated implantation failure – RIF), endometrial biopsies were carried out to detect endometrial disorders. Participants/materials, setting, methods Data of 606 patients examined between 2018 and 2022 were analyzed retrospectively. Main results and the role of chance In 606 cases 3D-TVS and OHSC were performed in patients (65.51 % primary, 34.49 % secondary infertility), who had unknown reason to infertility. By the combination of 3D-TVS and OHSC we could verify uterine disorders in 39.93 % of cases. Together these two diagnostic methods found the probable infertility causing lesion almost 40 % of our patients. In the subgroup of 40 repeated implantation failure (RIF) patients, the “diagnostic TRIO” confirmed a disorder in 57.50 % of the cases. Limitations, reasons for caution Number of patients should be more to conclude more accurate data. Wider implications of the findings The proper condition of the uterine milieu, through correction of uterine cavity if necessary, endometrial receptivity are of paramount importance for the success of the treatment; as a result, intrauterine surgery as a new subspecialty has been developing. Trial registration number DE RKEB/IKEB: H.0250-2020

Does metroplasty on dysmorphic uterus improve displaced and disrupted implantation window? A Case Report

Does metroplasty on dysmorphic uterus improve displaced and disrupted implantation window? A Case Report

Hysteroscopic metroplasty for the treatment of the dysmorphic uterus: A SWOT analysis.

Dysmorphic uterus or T-shaped uterus is an increasingly frequent diagnosis among the infertile population that has been associated to worse reproductive results. Hysteroscopic metroplasty is a safe and simple procedure that can improve the reproductive outcomes in this group of patients, although the benefits of this procedure remains controversial due to the lack of adequate scientific evidence. To analyze the hysteroscopic metroplasty using the SWOT (Strengths, Weaknesses, Opportunities and Threats) methodology. An electronic search from inception each database up to December 2021 including the following databases was conducted: PubMed-MEDLINE, EMBASE, Web of Science, The Cochrane Library, and Google Scholar. Studies reporting outcomes of patients undergoing hysteroscopic metroplasty were included. Not applicable. Clinical evidence from the included studies suggests an improvement in reproductive results after performing hysteroscopic metroplasty especially in women with recurrent pregnancy loss and previous infertility, but all of them have relevant methodological limitations. For this reason, benefits, risks and alternatives of this intervention should be considered with caution. Evidence from published data shows a probable association between dysmorphic uterus and poor reproductive outcomes. Hysteroscopic metroplasty in patients with dysmorphic uterus could improve pregnancy outcomes, but there is need of properly designed prospective controlled studies to determine the benefits of this technique.

Hysteroscopicmetroplasty as a treatment option for women with congenital dysmorphic uterus suffering from impaired reproductive performance

Congenital uterine anomalies have been proven to be associated with impaired reproductive performance. The 2013 ESHRE-ESGE classification of female genital tract malformations defines T shaped and infantalis uterus as dysmorphic uterus. Our aim was to examine whether the reproductive performance of patients with primary congenital dysmorphic uterus can be improved using hysteroscopic metroplasty. A retrospective cohort study of 35 patients suffering from 1 year of failed attempts to conceive, recurrent early pregnancy losses, or repeated implantation failures of in vitro fertilization cycles who were diagnosed with a dysmorphic uterus in both a diagnostic hysteroscopy procedure and three-dimensional transvaginal ultrasound (3D-TVS). All patients had undergone an operative hysteroscopic procedure for uterine anomaly repair and their reproductive performance is described before and after the procedure, so that the women acted as their own control. Within 3 years of the procedure, a total of 25 patients (71.4%) reported that they had achieved a pregnancy. A total of 15% of patients only conceived for the first time after the procedure, 15 patients (42.9%) conceived within 6 months and 18 (51.4%) within 1 year. A total of 12 of the 25 pregnant patients (48%) gave birth to a live newborn. We conclude that in non-DES exposed patients with impaired reproductive performance and congenital dysmorphic uterus, hysteroscopic metroplasty for uterine repair could serve as a treatment option for recurrent implantation failure, and may lead to improved reproductive performance and obstetric outcome.

Frozen-Thawed Blastocysts Transfer Cycle in Patients with Dysmorphic Uteri After Hysteroscopic Metroplasty: A Case-Controlled Study in a Single In-Vitro Fertility Center

Objective: Dysmorphic uterus, a rare uterine malformation characterized by an abnormal uterine cavity, may lead to reproductive failures, such as infertility and adverse pregnancy outcomes. Results of hysteroscopic correction of this uterine malformation on reproductive outcomes are poorly reported. This study evaluated reproductive outcomes of frozen-thawed electives single-blastocyst transfers (eSBTs) in patients who underwent hysteroscopic metroplasty for dysmorphic uteri, and compared these results with those of a control group. Materials and Methods: This study included 78 patients with primary infertility who had dysmorphic uterine anomalies and 379 age- and body mass index–matched infertile patients with normal uterine cavities (controls). All patients were enrolled in an in-vitro fertilization program. Selected top/good-quality blastocysts were frozen and then transferred in another cycle after hysteroscopic metroplasty. Reproductive and obstetric outcomes of all cases and characteristics of frozen embryo transfer (FET) cycles were analyzed retrospectively. Results: Demographic characteristics of both groups were similar. There were no statistically significant differences between the study and control groups for implantation rates, clinical pregnancy rates, and live birth rates (LBRs): 63.2% versus 64.8%, 57% versus 55%, and 39.8% versus 40.3%, respectively; all p > 0.05. Rates of clinical pregnancy losses were higher in the study group, but this difference was not statistically significant (27.1% versus 19.5%; p > 0.05). Preterm deliveries were significantly higher in the study group than in the control group (23.5% versus 10.9%; p = 0.03). Type of endometrial preparation, day of embryo transfer, and grade of transferred embryos were similar in both groups, except endometrial thickness was significantly lower in the study group (8.9 ± 1.4 mm versus 10.1 ± 1.7 mm; p < 0.001). Conclusions: Patients who underwent hysteroscopic metroplasty of the uterine cavity, reproductive outcomes of FET cycles as were successful as in patients with normal uterine cavities. eSBTs with top/good quality embryos after hysteroscopic metroplasty in patients with dysmorphic uteri improves LBRs but preterm births are higher, compared to patients with normal uterine cavities. (J GYNECOL SURG 39:36)

The effect of hysteroscopic metroplasty on fertility in T-shaped and Y-shaped dysmorphic uterus

Objective T/Y-shaped dysmorphic uterus is frequently associated with subfertility, abortion, preterm delivery, and recurrent implantation failure. In this study, the impact of hysteroscopic metroplasty for a T/Y-shaped uterus on obstetric outcomes was investigated in patients with infertility and recurrent pregnancy loss (RPL) and compared the uterine anomaly subgroups. Method Cases with infertility and/or RPL diagnosed with T/Y-shaped uterus by hysterosalpingography (HSG) and 3D transvaginal ultrasonography (3D TVUSG) with no other male or female pathology have recruited the study. Medical history and the obstetric outcome after two years of follow-up were recorded. Results Out of the 92 cases recruited, T-shaped uteri (Group-1) were observed in 30, while 62 (67.3%) patients had Y-shaped uteri. Pregnancy was achieved in 50 (54.3%) of the cases, 28 (56%) of the pregnancies occurred spontaneously, and in 22 (44%) pregnancy was achieved through assisted reproductive techniques (ART). Term delivery occurred in 29 (76.3%) of the pregnancies while 9 (23.6%) had preterm deliveries and a total of 38 (76%) resulted in a live birth. Out of the 31 patients with previous RPL history, 13 (41.9%) achieved pregnancy and 11 out of 13 (84.6%) had a term pregnancy followed by live birth. Conclusion Spontaneous pregnancy, and term pregnancy rates after surgery were found to be promising in these uterine anomalies. The pregnancy outcome of the primary infertile patients was found the same in two groups (50%–46.1%), but the results of the RPL patients were found to be better in the T-shaped group than in the Y-shaped group (70%–28.5%).

IVF outcomes after T-shaped uterine metroplasty in patients with recurrent implantation failure

BackgroundThe aim of this study was to assess the in vitro fertilization (IVF) treatments outcomes of women with recurrent implantation failure (RIF) after hysteroscopic metroplasty for T-shaped uterus. MethodsThis retrospective, observational study included 85 patients with RIF and T-shaped uterus who presented to In Vitro Fertilization Unit of Hüma Obstetrics and Gynecology Hospital between January, 2018 and August, 2021. The hysteroscopic metroplasty was performed before IVF procedure in 43 of patients included. Remaining 42 patents underwent IVF without hysteroscopic metroplasty were included as controls. The fertility outcome were compared between groups. ResultsAfter 3 months, spontaneous pregnancy was achieved in 10.4% (5/48) of patients with T-shaped uterus underwent hysteroscopic metroplasty. In the hysteroscopy group, implantation rate, clinical pregnancy rate, biochemical pregnancy rate and the miscarriage rate were 55.8% (24/43), 41.9% (18/43), 14% (6/43) and 11.6% (5/43, respectively. The live birth rate after in vitro fertilization was 30.2% (13/43) in the hysteroscopy group and 9.5% (4/42) in the control group (p<0.05). There were no significant differences in the IVF outcomes such as the biochemical pregnancy rate and miscarriage rate between the hysteroscopy and control groups. ConclusionThis study demonstrates that hysteroscopic metroplasty improves pregnancy and live birth rates for women with a history of RIF and dysmorphic uterus. Correction of T-shaped uterus with hysteroscopic metroplasty ensured favorable reproductive outcomes in RIF cases. However, conclusions must be taken carefully as this is an observational study. A prospective, randomized and controlled study is necessary to support these results.

Incidence of congenital uterine abnormalities in polycystic ovarian syndrome (CONUTA Study)

ObjectiveTo investigate whether the frequency of uterine cavity abnormalities in PCOS patients higher than the normo-ovulatory patients. Study designThis retrospective cohort study was conducted at the ART center of a tertiary university hospital. A total of 103 patients; 51 PCOS, and 52 male factor infertility were enrolled in the study between the years 2011–2019. HSG images of all patients were numbered and evaluated by ten senior reproductive endocrinologists and surgeons whom were blinded to the research and choose the most appropriate figure for each patient’s HSG image and marked the shape of cavity according to the ASRM and ESGE/ESHRE classification. Results and demographic parameters were compared between PCOS and male factor infertility groups. ResultsThe percentage of the normal uterine cavity was significantly lower in the PCOS group than control group as 51 % and 66.7 %, 77 % and 94.2 % according to the ASRM and ESHRE/ESGE classifications, respectively. The frequency of Partial Septate Uterus (ESHRE-ESGE U2a / ASRM Va, 21.6% vs 5.8 % p < 0.05), Complete Septate Uterus (ESHRE-ESGE U2b / ASRM Vb, 7.8% vs 0% p < 0.01) and Dysmorphic Uterus (ESHRE-ESGE U1c) / ASRM VII) 3.9 % vs 0p < 0.05) were significantly higher in PCOS patients than controls. The frequency of arcuate uterus classified as VI in ASRM and considered as normal in ESHRE/ESGE was 16 % and 17.3 % in PCOS and control groups, respectively, without statistically significant difference. ConclusionsThis study provides that, compared to the healthy population, the frequency of uterine cavity abnormality is clearly higher in PCOS patients.

Changes in the Expression of Endometrial Receptivity Genes after Hysteroscopic Metroplasty in Infertile Women with Uterine Malformation

Study Objective To determine the effect of hysteroscopic metroplasty on the expression of endometrial receptivity genes, such as HOX family and LIF gene, in infertile women with congenital uterine malformations. Design a prospective observational study conducted between June 2016 and March 2020. Setting Tertiary care University hospital in Italy. Patients or Participants Forty-four patients with a diagnosis of dysmorphic uterus or uterine septum (according to the ESHRE/ESGE classification), with history of primary unexplained infertility, repeated (>2) early miscarriages, or severe preterm labor (<25w) were enrolled in the study. Interventions All patients underwent hysteroscopic metroplasty either in office or OR settings, in the proliferative phase. Endometrial hysteroscopic biopsy was performed immediately before the metroplasty and at the two-month follow up. The endometrial samples were immediately stored at -80°C and RT-PCR was used to evaluate the expression of each gene. Measurements and Main Results The metroplasty was completed in all cases, resulting in a significant optimization of uterine morphology (44/44). After hysteroscopic metroplasty, overall, 1.05-fold increase in endometrial HOX-10 expression and overall 1.09-fold increase in endometrial HOX-11 expression were detected in comparison with baseline values. The mRNA expression level of LIF gene resulted under expressed, with a -1.12-fold decrease. Conclusion Our data demonstrate that hysteroscopic metroplasty provides favorable effect on endometrial HOXA-10 and 11 mRNA expression. These preliminary data suggest that hysteroscopic metroplasty could induce an important uterine remodeling involving not only macroscopic but also microscopic changes. To determine the effect of hysteroscopic metroplasty on the expression of endometrial receptivity genes, such as HOX family and LIF gene, in infertile women with congenital uterine malformations. a prospective observational study conducted between June 2016 and March 2020. Tertiary care University hospital in Italy. Forty-four patients with a diagnosis of dysmorphic uterus or uterine septum (according to the ESHRE/ESGE classification), with history of primary unexplained infertility, repeated (>2) early miscarriages, or severe preterm labor (<25w) were enrolled in the study. All patients underwent hysteroscopic metroplasty either in office or OR settings, in the proliferative phase. Endometrial hysteroscopic biopsy was performed immediately before the metroplasty and at the two-month follow up. The endometrial samples were immediately stored at -80°C and RT-PCR was used to evaluate the expression of each gene. The metroplasty was completed in all cases, resulting in a significant optimization of uterine morphology (44/44). After hysteroscopic metroplasty, overall, 1.05-fold increase in endometrial HOX-10 expression and overall 1.09-fold increase in endometrial HOX-11 expression were detected in comparison with baseline values. The mRNA expression level of LIF gene resulted under expressed, with a -1.12-fold decrease. Our data demonstrate that hysteroscopic metroplasty provides favorable effect on endometrial HOXA-10 and 11 mRNA expression. These preliminary data suggest that hysteroscopic metroplasty could induce an important uterine remodeling involving not only macroscopic but also microscopic changes.

FROZEN-THAWED EMBRYO TRANSFER CYCLE OUTCOMES OF PATIENTS WITH DYSMORPHIC UTERUS FOLLOWING HYSTEROSCOPIC METROPLASTY: CASE-CONTROLLED STUDY IN A SINGLE IVF CENTER

Dysmorphic uterus is a rare uterine malformation characterized by an abnormal uterine cavity, and may lead to several reproductive failures such as infertility and adverse pregnancy outcomes. Currently, surgical correction of the dysmorphic uterus has been approved as the standard modality of treatment by many authors. However, this is a new topic and there are scarce data showing the impact of an expanded uterine cavity with intervention on reproductive and obstetric outcomes in the dysmorphic uterus.

P-748 Diode laser hysteroscopic metroplasty for dysmorphic uterus: a pilot study

Abstract Study question Whether diode laser hysteroscopic metroplasty for dysmorphic uterus is a safe and efficacious procedure and its effect on reproductive outcomes. Summary answer Diode laser hysteroscopic metroplasty is a safe and effective procedure for infertile women with dysmorphic uterus with comparable results to those reported in the literature. What is known already A T-shaped uterine anomaly is categorized by the ESHRE/ESGE consensus as dysmorphic uterus class U1a, characterized by an abnormal hypoplastic uterine cavity. A Y-shaped uterus is a dysmorphic uterus with a fundal subseptum. Dysmorphic uteri are associated with infertility, recurrent implantation failure (RIF), recurrent pregnancy loss (RPL), and adverse pregnancy outcomes. According to several studies, it seems that hysteroscopic metroplasty may improve the chances of conception and live birth. Previous studies described the procedure using bipolar systems, monopolar needle or scissors. The purpose is to achieve a uterine cavity of normal shape and volume by cutting the thickened lateral walls. Study design, size, duration This was a retrospective pilot study with a prospective follow-up. We retrospectively evaluated all cases operated between February 2018 to February 2020, at Hillel Yaffe Medical Center, Hadera, Israel. Reproductive outcomes for women who underwent the procedure were followed until September 2020. Pregnancies that were ongoing on September 2020 were followed until January 31st 2021. Participants/materials, setting, methods Nulliparous women with a diagnosis of infertility or RPL, who were diagnosed with dysmorphic uterus by three-dimensional ultrasound (3D-US) and underwent diode laser hysteroscopic metroplasty were included. All the metroplasties were done in one tertiary center by the same specialist. Reproductive outcomes were evaluated retrospectively and prospectively for a total follow-up time of 32 months. Reproductive performances before and after metroplasty were compared where possible. Main results and the role of chance Twenty-five women underwent diode laser hysteroscopic metroplasty for dysmorphic uterus in our institute. No perforations, excessive bleeding, or other complications were encountered during the procedures. Follow-up hysteroscopy and 3D-US were satisfactory in all cases 2 months after the metroplasty. A total of 15 nulliparous women returned to fertility treatments afterwards, among whom 9 conceived (60% pregnancy rate). Their infertility period before the procedure was 56.6 ± 36.1 months. The duration between the metroplasty to pregnancy was 5.2 ± 3.5 months. The rate of deliveries and ongoing pregnancies (pregnancies beyond 20 weeks of gestation) was 78% (7/9), with five successful liveborn deliveries and two ongoing pregnancies. All deliveries were between 36-37 weeks. The 10 women who were not treated by our infertility unit were contacted, among whom 6 discontinued their attempt to conceive. The other 4 conceived; three of them spontaneously. Among those 4 women,the rate of deliveries and ongoing pregnancies was 75%, with one term delivery and two ongoing pregnancies. Limitations, reasons for caution First, we included both T-shaped and Y-shaped uteri as both represent close versions of dysmorphic uteri, but in fact they differ. The subseptum might interfere with reproduction in a different mechanism. Second, the small and heterogeneous sample as well as the short duration of follow-up limit the conclusions. Wider implications of the findings We present the first application of diode laser in hysteroscopic metroplasty for dysmorphic uteri. This technique seems promising and our results are comparable with other series using different cutting devices. Only larger controlled trials with a longer follow-up can confirm the safety, efficacy, and impact on reproductive outcomes. Trial registration number Not Applicable

P–748 Diode laser hysteroscopic metroplasty for dysmorphic uterus: a pilot study

Abstract Study question Whether diode laser hysteroscopic metroplasty for dysmorphic uterus is a safe and efficacious procedure and its effect on reproductive outcomes. Summary answer Diode laser hysteroscopic metroplasty is a safe and effective procedure for infertile women with dysmorphic uterus with comparable results to those reported in the literature. What is known already A T-shaped uterine anomaly is categorized by the ESHRE/ESGE consensus as dysmorphic uterus class U1a, characterized by an abnormal hypoplastic uterine cavity. A Y-shaped uterus is a dysmorphic uterus with a fundal subseptum. Dysmorphic uteri are associated with infertility, recurrent implantation failure (RIF), recurrent pregnancy loss (RPL), and adverse pregnancy outcomes. According to several studies, it seems that hysteroscopic metroplasty may improve the chances of conception and live birth. Previous studies described the procedure using bipolar systems, monopolar needle or scissors. The purpose is to achieve a uterine cavity of normal shape and volume by cutting the thickened lateral walls. Study design, size, duration This was a retrospective pilot study with a prospective follow-up. We retrospectively evaluated all cases operated between February 2018 to February 2020, at Hillel Yaffe Medical Center, Hadera, Israel. Reproductive outcomes for women who underwent the procedure were followed until September 2020. Pregnancies that were ongoing on September 2020 were followed until January 31st 2021. Participants/materials, setting, methods Nulliparous women with a diagnosis of infertility or RPL, who were diagnosed with dysmorphic uterus by three-dimensional ultrasound (3D-US) and underwent diode laser hysteroscopic metroplasty were included. All the metroplasties were done in one tertiary center by the same specialist. Reproductive outcomes were evaluated retrospectively and prospectively for a total follow-up time of 32 months. Reproductive performances before and after metroplasty were compared where possible. Main results and the role of chance Twenty-five women underwent diode laser hysteroscopic metroplasty for dysmorphic uterus in our institute. No perforations, excessive bleeding, or other complications were encountered during the procedures. Follow-up hysteroscopy and 3D-US were satisfactory in all cases 2 months after the metroplasty. A total of 15 nulliparous women returned to fertility treatments afterwards, among whom 9 conceived (60% pregnancy rate). Their infertility period before the procedure was 56.6 ± 36.1 months. The duration between the metroplasty to pregnancy was 5.2 ± 3.5 months. The rate of deliveries and ongoing pregnancies (pregnancies beyond 20 weeks of gestation) was 78% (7/9), with five successful liveborn deliveries and two ongoing pregnancies. All deliveries were between 36–37 weeks. The 10 women who were not treated by our infertility unit were contacted, among whom 6 discontinued their attempt to conceive. The other 4 conceived; three of them spontaneously. Among those 4 women,the rate of deliveries and ongoing pregnancies was 75%, with one term delivery and two ongoing pregnancies. Limitations, reasons for caution First, we included both T-shaped and Y-shaped uteri as both represent close versions of dysmorphic uteri, but in fact they differ. The subseptum might interfere with reproduction in a different mechanism. Second, the small and heterogeneous sample as well as the short duration of follow-up limit the conclusions. Wider implications of the findings: We present the first application of diode laser in hysteroscopic metroplasty for dysmorphic uteri. This technique seems promising and our results are comparable with other series using different cutting devices. Only larger controlled trials with a longer follow-up can confirm the safety, efficacy, and impact on reproductive outcomes Trial registration number Not applicable

Diode Laser Hysteroscopic Metroplasty for Dysmorphic Uterus: a Pilot Study.

This paper aims to study the efficacy and safety of diode laser hysteroscopic metroplasty for dysmorphic uterus and the impact on reproductive outcomes. This is a retrospective, single-center pilot study with prospective follow-up. The study was performed at a university-affiliated, tertiary hospital. From February 2018 to February 2020, all nulliparous women with a 3D ultrasound diagnosis of T-shaped or Y-shaped dysmorphic uterus and diagnosis of infertility, recurrent implantation failure, or recurrent pregnancy losses were referred for hysteroscopic metroplasty. Diode laser hysteroscopic metroplasty was performed under general anesthesia in an ambulatory setting. Main outcome measures included operative time, complications, hysteroscopic appearance of the cavity in a follow-up hysteroscopy, and reproductive outcomes in terms of pregnancy and live birth. A total of 25 infertile women with mean duration of infertility of 56.6 ± 36.1 months underwent hysteroscopic metroplasty. No complications were reported, and subsequent 3D ultrasound and follow-up hysteroscopic appearance were satisfactory in all cases. Maximum follow-up was 32 months (mean ± standard deviation 11.5 ± 9.2 months). Fifteen nulliparous women returned for fertility treatments in our institute, among whom nine conceived (60% pregnancy rate). The rate of deliveries and ongoing pregnancies (pregnancies beyond 24 weeks of gestation) was 78% (7/9), with six successful liveborn deliveries at 36-38 weeks and one ongoing pregnancy. One had spontaneous abortion at week 19 and one had a spontaneous abortion at week 7. Hysteroscopic metroplasty in an ambulatory setting, using diode laser, is a safe and effective procedure, improving reproductive outcomes in cases of T-shaped or Y-shaped uterus.

Dysmorphic Uteri: Obstetric Results after Hysteroscopic Office Metroplasty in Infertile and Recurrent Pregnancy Loss Patients. A Prospective Observational Study.

To compare the obstetric results achieved after hysteroscopic office metroplasty (HOME-DU) in infertile and recurrent pregnancy loss (RPL) patients diagnosed with dysmorphic uterus, women hysteroscopically diagnosed with dysmorphic uterus who underwent uterine-enlargement metroplasty were prospectively enrolled from June 2016 until April 2020. Patients were followed up and obstetric outcomes were recorded (pregnancy and live birth rate). Sixty-three women (30 infertile; 33 RPL) were enrolled, of which 48 became pregnant post-HOME-DU, with an overall pregnancy rate of 76.2% (66.7% among infertile participants; 84.9% among those with RPL). Overall, 64.3% (n = 36/63) achieved live birth. Among infertile women, 62.07% (n = 18/29) achieved live birth, as well as 66.7% of women with RPL (n = 18/27). The difference in live birth rates between both cohorts was 4.6% (p > 0.05). The rate of miscarriage amongst infertile patients was 3.3% (n = 1/30) and 12.1% amongst women with RPL (n = 4/33). Office metroplasty via the HOME-DU technique improves obstetric results (namely increasing live birth rate) in patients with dysmorphic uterus and a history of reproductive failure. No significant difference was found in the clinical efficacy of HOME-DU in infertile and RPL patients.

Impact of Hysteroscopic Metroplasty on Reproductive Outcomes of Women with a Dysmorphic Uterus and Recurrent Miscarriages: A Systematic Review and Meta-Analysis

The aim of this systematic literature review and meta-analysis is to assess the impact of hysteroscopic metroplasty for dysmorphic uteri on reproductive outcomes in women with recurrent miscarriages.Available studies were identified through a PubMed, Scopus, and Cochrane search until June 2019. Live-birth rate, clinical pregnancy and miscarriage rate after hysteroscopic metroplasty was evaluated. DerSimonian and Laird’s random-effect model was used for relative risks, Freeman-Tukey Double Arcsine for pooled estimates and exact method to stabilize variances and CIs. Heterogeneity was quantified using I2-statistics. Six out of 164 published studies met the inclusion criteria. All (n = 221) women underwent metroplasty, using 5Fr-hysteroscope with bipolar electrodes or 26Fr/28Fr-resectoscope in outpatient or inpatient settings. After 6 to 60-month follow-up, reported live-birth rate was 50% (0.37-0.63 95% CI) from a clinical pregnancy rate of 73% (0.51-0.91 95% CI) and miscarriage rate was 23% (0.15-0.30 95% CI).Hysteroscopic metroplasty for dysmorphic uteri led half of the women who experienced recurrent miscarriages at least one live birth and is correlated to few surgical and obstetric complications. However, randomized clinical trials and case-control studies are unavailable due to ethical constrains; inhomogenity of follow-up durations and standardized protocols regarding preoperative diagnosis and post-surgical management resrict our conclusions.

Hysteroscopic Metroplasty may Improve Fertility Performance in Patients with Dysmorphic Uterus

Study Objective The new ESHRE/ESGE classification system of female genital anomalies defines class U1 or dysmorphic uterus as anomalies that have been associated with poor reproductive performance. Hysteroscopic metroplasty may improve reproductive performance in these patients. Design Retrospective cohort study. Setting A tertiary medical center. Patients or Participants A cohort of 40 women who have a dysmorphic uterus (non DES) and infertility or repeated IVF failures (RIF). Interventions These patients underwent hysteroscopic metroplasty between the years 2014 and 2016. The patients from the study group served as their own control, comparing fertility performance before and after the hysteroscopy, respectively. Measurements and Main Results Average follow-up time lasted three years. All women were identified as having U1 type dysmorphic uterus according to ESHRE-ESGE classification by diagnostic hysteroscopy. The average time to conception was 3.028±2.756 years, compared to 1.003±0.91 years post procedure (P=0.001). A total of 27 women (67.5%) conceived during the three years after the hysteroscopy. Six (15%) conceived only after the intervention. Abortion rate declined from 1.45±1.276 prior to hysteroscopy to 0.45±0.510 post hysteroscopy (P=0.006). The cumulative pregnancy rate during the first three years post hysteroscopy increased significantly. Studying time intervals of six months, a year and three years: cumulative pregnancy rate increased from 1.042%, 15.63% and 52.1%, respectively, prior to hysteroscopy to 45%, 53.182% and 67.5% post hysteroscopy (P=0.038). The cumulative live birth rate also increased significantly during the study period, from 0, 5% and 15%, respectively, prior to hysteroscopy to 27.5%, 30% and 30% post hysteroscopy (P=0.001). Conclusion Remodeling dysmorphic uterus by hysteroscopic metroplasty is a new approach to treat infertile patients, especially those with RIF. This new and promising approach may assist in shortening the time to pregnancy, increasing both cumulative pregnancy rates and cumulative live birth rates, and decreasing abortion rates in these patients. A larger study cohort is needed.