Hysteroscopic Correction Research Articles

#199 : Does Hysteroscopic Evaluation of Uterine Characteristic Improve Outcome of Thin Endometrium in Patients with a History of Repeated Implantation Failures?

Background: Repeated implantation failure (RIF) is a problem for many patients suffering from infertility and their physicians. Despite numerous developments in the field of assisted reproduction, the implantation rate remains low. Among the various reasons of implantation failure, endometrial regularity has an important role. Recently, hysteroscopy is an accurate method for evaluating the endometrial integrity, with the ability to treat uterine pathology for repeated implantation failure patients. Objective: The aim of this study to evaluate the incidence of uterine pathology among infertile women with a history of two implantation failures after IVF and estimate the effect of diagnostic hysteroscopy and hysteroscopic procedures in uterine cavity on achieving a pregnancy in these patients in Mongolia. Materials and Methods: The retrospective study population included infertile women who attended the outpatient department of the Creation and Love Women’s infertility clinic, between August 2020 and July 2022 in Mongolia. The study inclusion criteria were women who had more than two RIF of IVF/ET cycle. Pregnancy and nonpregnancy rate after hysteroscopic procedures were analyzed included in patients reports archived in clinical data. Results: Hysteroscopy were performed on 35 women who had at least two RIFs. The participants’ mean age was 40.3±5.3 and mean duration of infertility year was evaluated 5.53±3.7. Mean AMH level was 1.4±1.6 ng/ml. All patients were diagnosed abnormal uterine cavity by hysteroscopy. Out of 35 patients participated in this study who underwent hysteroscopic evaluation, 20 patients (57.1%) showed synechiae (mild, moderate and severe synechiae). Second most frequent hysteroscopic finding was the endometrial polyp, accounting for 15 (42.9%) patients. Pregnancy rate after hysteroscopic procedures was 8 patients (23%) in this study group. The duration of infertility year was significantly different in pregnant and nonpregnant women underwent hysteroscopic correction (p<0.05). Conclusion: The intrauterine pathology diagnosed by hysteroscopy in patients with previous IVF failure were found all patients in this study. The synechiolysis was common abnormality in Mongolia may cause by artificial abortion. The correction of abnormalities such as and polyp synechiolysis might improve the outcome of successful pregnancy rate.

Effect Of Hysteroscopic Correction of Symptomatic Caesarian Scar Defect in Women with An Explained Secondary Infertility: Randomized Controlled Trial

Effect Of Hysteroscopic Correction of Symptomatic Caesarian Scar Defect in Women with An Explained Secondary Infertility: Randomized Controlled Trial

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)

7378 Correction of Uterine Anomalies and Its Effect on Infertility and Recurrent Miscarriages in a Study Including 10000 Patients over 6 Years

<h3>Study Objective</h3> use of hysteroscopic metroplasty to enhance and promote the uterine receptivity in infertile women and those who had recurrent miscarriages. <h3>Design</h3> prospective study for 6 years from 2016 including 12000 cases of primary infertility and recurrent miscarriages. <h3>Setting</h3> operative hysteroscopy both 5mm and 9mm, patient on lithotomy position under either general or spinal anaesthesia. <h3>Patients or Participants</h3> cases were selected as primary infertility for more than 2 years, recurrent IVF or ICSI failure, recurrent miscarriages who had 3D transvaginal ultrasound assessment that revealed anomalies including Narrow T shaped, tubular, subseptated and septated cavities. <h3>Interventions</h3> hysteroscopic metroplasty to reach the normal cavity shape and dimensions. If excessive raw area levonorgestril triple dose for 21 days used post operative to enhance healing and putting Foleys catheter size 10 F for 3 days post operative. <h3>Measurements and Main Results</h3> 3D transvaginal ultrasound +or - saline sono hystrography done post hysteroscopic correction by one cycle to compare the shape and dimensions with the preoperative one and to ensure absence of intrauterine adhesions. 88% of cases had successfully got pregnant and continued their pregnancy beyond 36 weeks, 6 % had preterm labour between 30-36 weeks, 2% had preterm labour 28-30 weeks and 4 % still under follow up. <h3>Conclusion</h3> correction of uterine anomalies has a strong significance on success of implantation in cases of infertility, recurrent IVF and ICSI failure and recurrent miscarriages after prober 3D transvaginal ultrasound.

Role of hysteroscopy in evaluation of recurrent pregnancy loss

Objective: to detect the uterine abnormalities missed in U/S scan and HSG using hysteroscopy, in females presenting with recurrent pregnancy loss &amp;to study hysteroscopic therapuatic potential to that pathology. Methodology: prospective cohort study, conducted in obstetrics &amp; gynecology department of, Beni-suef University Hospital.on one hundred women with recurrent 1st &amp;2nd trimester pregnancy loss recruited for hysteroscopy .A rigid fiberoptic 2.7mm, 0 and 30 degrees angled hysteroscopy along with an operative channel for grasping forceps or scissors were used for both diagnostic and operative indications. The findings, and different types of abnormalities, comparison between&lt;or=3 &amp;&gt;3 cosecutive miscarriage as regarding hysteroscopic findings &amp;impact of the procedure on management were recorded. Results: In this study In the normal hysteroscopy group, 24women (29.3%) achieved a successful ongoing pregnancy without additional treatment, 49 (59.8%) had recurrent miscarriages again, and 4(5%) had persistent secondary infertility .In women who needed and had hysteroscopic correction of a SUA, the number of successful ongoing pregnancies was significantly higher 13 (72.2%) vs (29.3%) in normal group and the number of new abortions significantly was lower than in those who had no pathology 3(16.7%)vs (59.8%) with statistically significance between the 2 groups (p value = 0.002).

Assessment of in vitro fertilization outcomes after hysteroscopic isthmoplasty in recurrent implantation failure.

The aim of this study was to assess the in vitro fertilization (IVF) treatments outcomes of women with recurrent implantation failure (RIF) after hysteroscopic isthmoplasty for isthmocele. This retrospective, observational study included 61 patients with RIF and isthmocele who presented to IVF Unit of Hüma Obstetrics and Gynecology Hospital between January, 2018 and December, 2020. Thirty-one patient who underwent hysteroscopic isthmoplasty-before IVF procedure-were included. Remaining 30 patients underwent IVF without hysteroscopic isthmoplasty were included as controls. The fertility outcome were compared between groups. After 3months, spontaneous pregnancy was achieved in 18.4% (7/38) of patients with isthmocele who underwent hysteroscopic isthmoplasty. In the isthmoplasty group, implantation rate, clinical pregnancy rate, biochemical pregnancy rate, and the miscarriage rate were 41.9% (13/31), 35.5% (11/31), 6.5% (2/31), and 9.7% (3/31), respectively. The live birth rate after in vitro fertilization was 25.8% (8/31) in the isthmoplasty group and 3.3% (1/30) 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 isthmoplasty and control groups. This study demonstrated that hysteroscopic isthmoplasty improves pregnancy and live birth rates for women with a history of RIF and isthmocele. Reproductive results of the IVF cycles after hysteroscopic correction of isthmocele were comparable to those of the patients without any uterine abnormalities and those with diagnosis of unexplained infertility.

Second look hysteroscopy following hysteroscopic septum resection improves reproductive outcomes in patients undergoing ICSI

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 STATEMENT What 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.

Gynecological and Obstetrical Outcomes after Laparoscopic Repair of a Cesarean Scar Defect in a Series of 15 Women

<h3>Study Objective</h3> To evaluate gynecological and obstetrical outcomes, as well as remaining myometrial thickness, after laparoscopic repair of a cesarean scar. <h3>Design</h3> Observational study and retrospective evaluation of the remaining myometrium before and after repair. <h3>Setting</h3> Obstetrics and Gynecology Department in a University hospital. <h3>Patients or Participants</h3> A series of 15 symptomatic women with cesarean scar defects and remaining myometrial thickness of less than 3 mm, according to transvaginal ultrasound scan imaging. <h3>Interventions</h3> Laparoscopic repair of the cesarean scar defect. <h3>Measurements and Main Results</h3> Increase in myometrial thickness at the site of cesarean section, gynecological and obstetrical outcomes. The mean thickness of the myometrium increased significantly from 2mm before surgery to 7mm after surgery. Six months after surgery, all but two patients were free of symptoms. The persistence of intermenstrual bleeding in of one of them required a posterior hysteroscopic correction. Among the 7 women with infertility, 3 (42%) became pregnant and delivered healthy babies by cesarean section at 38–39 weeks of gestation. Two of these pregnancies were obtained spontaneously and the other one was an in vitro fertilization. <h3>Conclusion</h3> In symptomatic women with residual myometrial thickness of less than 3mm who wish to conceive, laparoscopic repair could be considered an appropriate approach.

HYSTEROSCOPIC CORRECTION OF INTRACAVITARY LESIONS DOES NOT AFFECT THE ENDOMETRIAL VOLUME AND SUBENDOMETRIAL VASCULARITY BEFORE ICSI

To evaluate the endometrial volume and subendometrial blood flow measured by three-dimensional power Doppler (3DPD) at the day of ovum pick-up after hysteroscopic correction of intracavitary lesions. A prospective cohort study enrolled 106 women undergoing their first ICSI cycles. All women had a history of previous hysteroscopic surgery for correction of intracavitary lesions within six months before ICSI trial. Fifty-five (51.9%) women had a history of polypectomy; 29 (27.4%) metroplasty, 12 (11.3%) adhesiolysis and ten (9.4%) had a history of myomectomy. A control group of 122 women with normal uterine cavity diagnosed by office hysteroscopy were included. On the day of ovum pick-up; endometrial volume and subendometrial blood flow was assessed using 3DPD, and vascularization index (VI), flow index (FI) and vascularization flow index (VFI) were calculated and compared between both groups. Additionally, pulsatility index (PI) and resistance index (RI) of uterine vessels were assessed. The endometrial volume was comparable between both groups (4.28 ± 1.62 vs. 4.78 ± 1.44, p=0.055). Additionally, no significant differences in subendometrial VI, FI and VFI between both groups (p= 0.44, 0.13, 0.717 respectively). Finally, the uterine PI and RI were comparable between both groups (0.83 ± 0.06 vs. 0.84 ± 0.05 and 2.39 ± 0.57 vs. 2.38 ± 0.50, p= 0.981 and 0.577 respectively) Hysteroscopic correction of intracavitary lesions does not affect the endometrial volume and subendometrial vascularity before ICSI cycles

P–746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Abstract Study question The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus. Summary answer The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os. What is known already Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os. Study design, size, duration This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 –2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment. Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups. Main results and the role of chance There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P = 0.002) and history of RPL (P = 0.017) in the study group. There was significant lower incidence of tubal factors infertility (P = 0.005) and endometriosis (P = 0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P = 0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P = 0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P = 0.000), and delivery by CS (69.6% vs 41.2%; P = 0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P = 0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively. Limitations, reasons for caution A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed. Wider implications of the findings: Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri. Trial registration number Not applicable

P-746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Abstract Study question The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus. Summary answer The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os. What is known already Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os. Study design, size, duration This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 -2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment. Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups. Main results and the role of chance There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P=0.002) and history of RPL (P=0.017) in the study group. There was significant lower incidence of tubal factors infertility (P=0.005) and endometriosis (P=0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P=0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P=0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P=0.000), and delivery by CS (69.6% vs 41.2%; P=0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P=0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively. Limitations, reasons for caution A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed. Wider implications of the findings Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri. Trial registration number Not Applicable

T-shaped uterus: what has been done, what should be done.

T-shaped uterus is a uterine malformation which has been suggested to be associated with poor reproductive performance. Over the years, different diagnostic methods have been used to determine the anatomical status of the female genital tract and to recognize any anomalies and the 3D-ultrasound is now considered the gold standard in diagnosing uterine anomalies. The importance of a correct diagnosis of the T-shaped uterus relates to the impact that such malformation has on female fertility. Although, to date, the prevalence does not seem to be so high, the fertility of the woman is reported to be somehow compromised by this uterine dysmorphism. Correcting the abnormal uterine morphology could be the main goal in order to optimize reproductive outcomes. To date, hysteroscopic correction of T-shaped uterus may be considered in patients with infertility, recurrent miscarriages or recurrent IVF failure. However, the absence of randomized controlled trials, multicentric data and the difficulty to state that metroplasty was the reason for improved outcome, make the data available inconclusive. More studies, led by an objective diagnosis, are urgently needed to understand the real impact of T-shaped uterus on the reproductive life of women and its effective prevalence in the population of infertile women.

Resection of a Complete Uterine and Cervical Septum

Study Objective This video demonstrates a technique for the surgical correction of a complete uterine and cervical septum. Design 1. Overview of the background, clinical presentation and relevant pre-operative planning. 2. An illustration and instruction for surgical correction. 3. Discussion of the post-operative care and long-term outcomes. Setting The patient is positioned in lithotomy with their legs in yellow fin stirrups to allow for concurrent laparoscopic and hysteroscopic surgery. Patients or Participants The procedure is demonstrated using a patient's single surgery. Interventions A technique for resecting a complete uterine and cervical septum using vaginal and hysteroscopic surgery under laparoscopic guidance. The septum is delineated using a Foley catheter balloon in the contralateral uterine cavity, allowing for the incision and resection of the septum. The septum is resected from the level internal cervical os to the fundus to avoid future mechanical cervical insufficiency. Measurements and Main Results N/A Conclusion This video clearly demonstrates a technique for the hysteroscopic correction of a complete uterine and cervical septum under laparoscopic guidance. The septum is delineated by using a Foley catheter balloon in the contralateral uterine cavity to create a bulge at the level of the fibrous septum.

Demonstration of Isthmocele Surgical Repair

To describe the surgical treatment of a uterine isthmocele. Demonstration of the laparoscopic technique with narrated video footage. Cesarean section rate has been increasing despite the World Health Organization's recommendation of a maximum 15%, with some countries reaching rates as high as 50%. The choice of delivery method is a complex topic based on physical and psychologic health, social and cultural context, and quality of maternity care. With the increasing number of cesarean sections, a new entity was recognized, the isthmocele [1]. A uterine isthmocele is a dilatation of the uterine cesarean scar and functions as a reservoir collecting blood during menstruation. Isthmocele prevalence ranges from 19% to 84%[2]. The most frequent complaint relates to intermittent postmenstrual bleeding (30%). Isthmocele can be a cause of infertility and pelvic pain [3]. Interstitial pregnancy is a known complication with a mortality rate up to 2.5%. The diagnosis can be made by transvaginal ultrasound and/or magnetic resonance imaging but also by hysteroscopy or hysterosalpingography. Treatment can be done by controlling the symptoms with oral combined contraceptive (decreasing metrorrhagia) or with surgical correction improving symptoms and/or fertility [4-7]. Isthmocele correction seems to improve secondary infertility in patients in whom a fertility workup did not find other cause [8,9]. Surgical approach can be done by vaginal route with hysteroscopy; abdominal route with laparoscopy, robotic or laparotomy; or through a combine procedure with both routes. Hysterectomy is the definitive treatment, but for those who want to preserve fertility, isthmocele correction can be offered. For laparoscopic surgery, several ways have been described to detect the isthmocele such as Foley catheter, hysteroscopy, methylene blue, and Hegar probe. When we do laparoscopy, we prefer concomitant use of hysteroscopy. There is a trending opinion that patients with a smaller isthmocele could be treated hysteroscopically (2.5 mm according to Jeremy etal [10] and 3.0 mm described by Marotta etal [11]). The goal of hysteroscopy correction is to remove the inflammatory infiltration in the endocervix, cutting the superior and inferior edges of the defect enabling normal blood evacuation of the uterus. By contrast, those with a larger isthmocele (with <2.5-3.0-mm residual myometrium) and a risk of perforation during hysteroscopy could be better treated by laparoscopy. This is especially important in patients interested in pregnancy because of the risk of uterine perforation [12]. There is still no strong evidence that hysteroscopic correction leads to an increased number of uterine ruptures compared with laparoscopy, but myometrium thickness seems to be greater after laparoscopic correction. Myometrium thickness is an independent risk factor for uterine rupture [13], and therefore, laparoscopic correction is preferred over hysteroscopic in women with a pregnancy desire. Finally, after surgical correction of an isthmocele, we recommend a 6-month interval before attempting pregnancy. Laparoscopic treatment is important in women who are symptomatic, have thin endometrium, and desire a pregnancy. Key strategies are (1) dissection of the vesicouterine pouch laterally to avoid entering the bladder wall; (2) transillumination with hysteroscopy; (3) cut with cold scissors avoiding thermal damage of remaining myometrium; and (4) suture with figure 8 in multiple layers. No evidence of using a specific suture is available. Surgical treatment of a uterine isthmocele is a good option in women who are symptomatic and infertile. Laparoscopic treatment guided by hysteroscopy is a good option if residual myometrium is <3 mm.

Hysteroscopic Metroplasty for T-Shaped Uterus: A Systematic Review and Meta-analysis of Reproductive Outcomes.

To date, a comprehensive review on the safety and effectiveness of hysteroscopic metroplasty for T-shaped uterus is still missing. To provide a robust synthesis of the available studies investigating reproductive outcomes after hysteroscopic metroplasty for T-shaped uterus. We performed a systematic review and meta-analysis (CRD42019143291), using the proportion method with 95% confidence interval (CI). Statistical heterogeneity was assessed by Higgins test (I2). We included 11 cohort studies embedding 937 women who underwent hysteroscopic metroplasty. After surgery, the pooled percentage of live birth was 44.54% (95% CI, 36.12%-53.12%; I2 = 46.22%) and 56.88% (95% CI, 46.48%-66.98%; I2 = 36.38%) in women with primary infertility and recurrent miscarriage, respectively. In women with recurrent miscarriage, the pooled proportion of miscarriage was 21.46% (95% CI, 15.09%-28.61%; I2 = 30.18%). The pooled clinical pregnancy proportion in women with primary infertility was 57.19% (95% CI, 43.83%-70.03%; I2 = 77.81%). The pooled rate of surgical complications was 0.65% (95% CI, 0.20%-1.33%; I2 = 11.44%). The hysteroscopic correction of T-shaped uteri was associated with high live birth rate and low miscarriage rate, both in case of primary infertility and recurrent miscarriage. Hysteroscopic metroplasty can be considered a safe and effective strategy to improve reproductive outcomes in case of T-shaped uterus.

From hysteroscopy to laparoendoscopic surgery: what is the best surgical approach for symptomatic isthmocele? A systematic review and meta-analysis.

To investigate the effectiveness and risks of different surgical therapies for isthmocele in symptomatic women with abnormal uterine bleeding, infertility, or for the prevention of obstetric complications, considering safety and surgical complications. PubMed/MEDLINE, Scopus, Embase, Science Direct, and Cochrane Library were systematically searched (n° CRD4201912035) for original articles on the surgical treatment of isthmocele published between 1950 and 2018. Data synthesis was completed using MedCalc 16.4.3. The body of evidence was assessed using the GRADE methodology. We retrieved 33 publications: 28 focused on a single surgical technique, and five comparing different techniques. Meta-analysis showed an improvement of symptoms in 85.00% (75.05-92.76%) of women after hysteroscopic correction, 92.77% (85.53-97.64%) after laparoscopic/robotic correction, and 82.52% (67.53-93.57%) after vaginal correction. Hysteroscopic surgery was associated with the lowest risk of complications (0.76%, 0.20-1.66%). We found adequate evidence supporting the use of surgery for the treatment of symptomatic isthmocele, as it was found to improve the bleeding symptoms in more than 80% of patients. Differently, we found a lack of evidence regarding the role of surgery with the purpose of improving fertility or reducing the risk of obstetric complications in women with asymptomatic isthmocele. The hysteroscopic correction of isthmocele may be the safest and most effective strategy in those patients with adequate residual myometrial thickness overlying the isthmocele. Laparoscopic and vaginal surgeries may be the preferred options for patients with a thinner residual myometrium over the defect (< 2.5mm) and when hysteroscopic treatment is inconclusive.

IVF outcomes after hysteroscopic metroplasty in patients with T- shaped uterus

BackgroundT- shaped uterus may be associated with infertility and adverse pregnancy outcomes. Hysteroscopic metroplasty may improve the reproductivity for these cases. To our knowledge, there is no data in literature about the clinical consequences of in vitro fertilization (IVF) in patients undergoing hysteroscopic metroplasty for T-shaped uterus. The principal objective of the current study is to assess the impact of hysteroscopic metroplasty for T-shaped uterus on the reproductive outcomes of IVF.MethodsIVF outcomes of 74 patients who underwent hysteroscopic metroplasty for T- shaped uterus and 148 patients without any uterine abnormalities and with diagnosis of unexplained infertility (control group) were retrospectively analyzed.ResultsPatients in metroplasty and control groups were comparable with respect to age, BMI, partner’s age and duration of infertility. Number of patients with a history of pregnancy beyond 20 weeks of gestation was significantly lower in the metroplasty group (4.1% vs 18.2%; p < 0.05). Number of previous unsuccessful cycles and percentage of patients with ≥3 unsuccessful IVF cycles (35.1% vs 17.6%; p < 0.05) were significantly higher in the metroplasty group. There were no significant differences in the reproductive outcomes such as the pregnancy rate, clinical pregnancy or live birth rate between the metroplasty and control groups. There were non-significant trends for higher rates of miscarriage (18.8% vs 8%, p > 0.05) and biochemical pregnancy (20.0% vs 10.7%, p > 0.05) in the metroplasty group compared to the control group.ConclusionsReproductive results of the IVF cycles after hysteroscopic correction of T-shaped uterus were comparable to those of the patients without any uterine abnormalities and with diagnosis of unexplained infertility. Hysteroscopic metroplasty may contribute to improved IVF outcomes in patients with T-shaped uterus.

Müllerian Anomalies Prevalence Diagnosed by Hysteroscopy and Laparoscopy in Mexican Infertile Women: Results from a Cohort Study.

Background: To evaluate the prevalence of Müllerian anomalies (MAs) in a cohort of infertile Mexican women candidates for infertility treatments (intrauterine insemination or IVF (In vitro fertilization) cycles). Methods: We performed a retrospective observational study on a cohort of consecutive women, who underwent hysteroscopy and laparoscopy as part of the basic infertility workup from 2002 to 2014, at our center. Our aim was to calculate the prevalence of MAs and each subtype. Results: A total of 4005 women were included in the study. The MA prevalence was 4.4% (95% CI; 3.8–5.1; n = 177). Among women with MAs, the prevalence of different MA types was: septate uterus 54.2% (n = 96), arcuate uterus 15.8% (n = 28), bicornuate uterus 10.7% (n = 19), unicornuate uterus 8.5% (n = 15), didelphys uterus 6.2% (n = 11) and hypoplasia/agenesis 3.4% (n = 6), unclassifiable 1.1% (n = 2). Women with MAs who achieved pregnancy were: 33.3% (n = 59). The MA associated with the highest pregnancy rate was septate uterus after hysteroscopic correction, at 38.5% (37/96). Conclusions: The prevalence of MAs among infertile Mexican women can be considered as low, but not negligible. The septate uterus is the most common MA in women with infertility.

Pregnancy outcomes following hysteroscopic correction of T-shaped uteri

Pregnancy outcomes following hysteroscopic correction of T-shaped uteri

Long-Term Reproductive Outcomes after Hysteroscopic Treatment of Dysmorphic Uteri in Women with Reproductive Failure: An European Multicenter Study

To evaluate the long-term reproductive outcomes in patients with dysmorphic uterus treated by hysteroscopic metroplasty with miniaturized instruments. Retrospective multicenter cohort study. Tertiary care university hospitals. The study was conducted on 214 women with a dysmorphic uterus (T-shaped, infantilis, or other type of dysmorphic uterus according to the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy classification system) with history of primary unexplained infertility (group 1) or repeated (>2) early miscarriages (group 2). Dysmorphic uteri were diagnosed by office hysteroscopy and 3-dimensional transvaginal ultrasound (3D-TVS). All patients underwent in office hysteroscopic metroplasty using a continuous-flow hysteroscope with a 5 Fr operating channel introduced into the uterine cavity using the vaginoscopic approach. Longitudinal incisions were performed on the fibromuscular constriction rings in the isthmic area and in some cases on the other uterine walls with a 5 Fr bipolar electrode or scissors. At the end of the procedure, an antiadhesive gel was applied into the uterine cavity to minimize adhesion formation. Postsurgical assessment of the uterine cavity was carried out through office hysteroscopy and 3D-TVS. All patients were followed for at least 24 months. The metroplasty was completed in all cases, resulting in a significant increase of uterine cavity volume (100%) and optimization of uterine morphology in 211 of 214 women (98.6%). After 60 months, the overall clinical pregnancy rate was 72.9% (n = 156/214), and the live birth rate was 80.1% (n = 125/156). Specifically, 74 of 156 women (47.4%) conceived spontaneously (with a median time to pregnancy of 5.5 months), of whom 32.4% had previously failed 1 or more attempts at in vitro fertilization/intracytoplasmic sperm injection. Our long-term follow-up data demonstrate that the hysteroscopic correction of dysmorphic uteri may result in a high live birth rate in women suffering from unexplained infertility or repeated miscarriages.