Metroplasty Research Articles

Клинико-морфологическая оценка эффективности амбулаторной гистероскопической метропластики при внутриматочной перегородке

Aim: Clinical and morphological evaluation of the effectiveness of the hysteroscopic metroplasty using the pulsed diode laser in case of the intrauterine septum. Design: Retrospective comparative study. Materials and methods. A comparative analysis of the effectiveness of the metroplasty, specific features of the course of the surgery, postoperative period, status of the endometrium and reproductive function was performed in 39 women (1st group) who underwent the surgery with the use of the pulsed diode laser and 19 patients (2nd group) who underwent bipolar electrosurgery. Results. When using the proposed method of metroplasty, the dissection of the intrauterine septum was statistically significantly more often optimal (82.05%) (p < 0.001). The morphological structure of the endometrium after metroplasty in patients of the 1st group significantly more often corresponded to the phase of the menstrual cycle (86.36%; p = 0.044) and was less often changed due to manifestations of perivascular fibrosis (12 (54.55%) of 22; p = 0.037). In most women of the 1st group, pregnancy ended in timely delivery — 15 (71.43%) out of 21 (p = 0.013). Conclusion. The proposed method of metroplasty is an effective and safe method of dissection of the intrauterine septum, which has a positive effect on reproductive function. Keywords: intrauterine septum, hysteroscopic metroplasty, reproductive function.

Evaluation of the Success of Hysteroscopic Uterine Septum Resection.

The aim is to use three-dimensional transvaginal ultrasonography (3-D TVUS) to evaluate the success of hysteroscopic metroplasty for the uterine septum and to compare the pregnancy outcomes. Thirty-eight patients with uterine septum who had hysteroscopic uterine septum resection were recruited. Preoperative 3-D TVUS measurements of the septal apex to the uterine fundus (s1), septal apex to internal os distance (s2), and intercornual distance (s3) were compared with the postoperative values. The pregnancies of the patients were followed up for a year postoperative period. Out of the 38 patients, thirty-five had partial uterine septum (class U2a), while 3 patients had complete uterine septum (class U2b). Eighteen (47.36%) of the patients who underwent uterine septum resection achieved pregnancy, and thirteen of these pregnancies were (72.2%) term pregnancies, and all term pregnancies resulted in a live birth. Natural conception was achieved in 77.7% (14 of 18) of the patients. Term pregnancy occurred in 68.7% (11 of 16) of the patients with a partial septum and in 66.6% (2 of 3) of the patients with a complete uterine septum. A comparison of the 3-D TVUS measurements of the uterus pre- and postoperatively showed a decrease in s1 and an increase in s2 (P < 0.05). The uterine cavity length of pregnant patients was found to be higher than nonpregnant patients (P < 0.05). Reproductive results of hysteroscopic metroplasty were favorable in achieving live and term birth. three-dimensional TVUS can be preferred as a noninvasive effective method in objective evaluation of the success of the hysteroscopic surgery.

Treatment of septate uterus.

Although there is insufficient evidence supporting the link between septate uterus and infertility, there are many studies demonstrated the effect of spetal incision on pregnancy in women diagnosed with septate uterus associated with infertility. Hysteroscopic metroplasty can significantly improve the reproductive performance of those with septate uterus. Some Müllerian malformations can be healed by surgery. The accurate diagnosis and appropriate therapeutic approch are fundamental for successful treatment. Any attempt at surgical correction of uterine abnormalities must be aimed at preserving or improving reproductive function. Among congenital uterine anomalies, septate uterus is the most amenable to simple hysteroscopic treatment. The resection of the septum is performed as standard treatment worldwide.

Septum Resection Prior to In Vitro Fertilization-Embryo Transfer: A Retrospective Controlled Study.

To investigate the effectiveness of surgery for septate uterus in infertile patients before in vitro fertilization-embryo transfer (IVF-ET). The data of 937 infertile patients with septate uterus and achieved singleton pregnancy after IVF-ET from January 2014 to December 2015 were retrospectively analyzed. Thousand five hundred seventy-eight infertile patients with a normal uterus who achieved singleton pregnancy during the same period were selected as the control group. Patients with septate uterus were divided into two groups according to whether the septum was resected. The pregnancy and perinatal outcomes of the surgical group and the nonsurgical group were compared with the control group. The secondary infertility patients who were surgically corrected septa were also chosen as self-controls and an analysis was performed on their fertility outcomes pre- and post-surgery. Compared with the control group, the surgical group had increased rates of early miscarriage, preterm delivery, and low birthweight and a significantly reduced live birth rate (P < .05). The outcomes of the nonsurgical and control groups were similar. Using secondary infertility patients who were surgically corrected septa as self-controls, after surgery, the rates of miscarriage and ectopic pregnancy were significantly lower and the live birth rate was significantly higher (P ≤ .001); however, perinatal mortality was not significantly different before and after surgery. Patients with a septum depth greater than 10 mm or 5-10 mm associated with a history of unexplained recurrent miscarriage, IVF failure, or infertility might benefit from resection of the uterine septum with hysteroscopic metroplasty.

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)

Surgical and Reproductive Outcomes in Patients with Complete Septate Uterus and Cervical Anomalies after Metroplasty

<h3>Study Objective</h3> to evaluate surgical and reproductive outcomes in patients with complete uterine septa with or without cervical anomalies undergone hysteroscopic metroplasty. <h3>Design</h3> Multicenter prospective observational cohort study. <h3>Setting</h3> Gynecological departments of participating centers. <h3>Patients or Participants</h3> 64 infertile women with ultrasonographic and hysteroscopic diagnosis of complete septate uterus with or without cervical anomalies (group A: U2bC1 + U2bC2 (n=34); group B (n=30): U2bC0 according to ESHRE/ESGE classification system) from January 2018 to December 2021. <h3>Interventions</h3> in-patient hysteroscopic metroplasty with 26Fr or 15Fr resectoscope or 5mm hysteroscope with 5Fr instruments; a second surgical step was performed when at postsurgical 3D ultrasonography a residual septum was detected (Y + Z > 15 mm). <h3>Measurements and Main Results</h3> Surgical outcomes (operative times; intra- and post-operative complications; surgical satisfaction); Reproductive outcomes (clinical pregnancy rate [CPR], live birth rate [LBR], miscarriage rate [MR]). All the surgical procedures were performed without any significant complication. 18/27 (67%) patients in group A and 9/18 (50%) in group B required a second surgical step. Operative times were statistically lower in group B (12.4 min ± 2 SD vs 27min ± 8 SD, p-value:0.034); less surgical difficulty was reported by clinicians in group B. Reproductive outcomes were evaluated for 36 patients (mean follow-up 20 months) and have shown significant differences between two groups; indeed, CPR was 36% in group A and 64% in group B (p. value 0.01). <h3>Conclusion</h3> Hysteroscopic metroplasty is an effective and safe procedure for the treatment of complete septate uterus with or without cervical abnormalities; a second surgical step is often required for the optimal treatment of these anomalies. Surgical outcomes are better in the group of patients without cervical anomalies, regardless of the instrumentation used. The presence of cervical anomalies seems to significantly affect reproductive outcomes.

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.

Reproductive and ICSI outcomes after hysteroscopic metroplasty for T-shaped uterus, a prospective follow up study

BackgroundThe incidence of uterine anomalies is approximately 0.5–4.7%. In infertile women, this rises to 6.3%. T-shaped uterine anomalies have been associated with infertility, recurrent implantation failure (RIF), and recurrent miscarriage (RM). Hysteroscopic metroplasty (HM) may improve the reproductive outcomes of such cases. Study objectiveWe assessed the effects of hysteroscopic metroplasty on the reproductive and in vitro fertilization (IVF) outcomes in women with T-shaped uteri. DesignA prospective controlled study. SettingA teaching hospital. PatientsThe reproductive outcomes of 182 patients with primary infertility (PI), RIF, or RM who underwent hysteroscopic metroplasty to treat T-shaped uteri were prospectively analyzed. InterventionsBetween January 2017 and April 2021, hysteroscopic metroplasty was performed by a single experienced surgeon. The primary outcome was the live birth rate (either spontaneous or assisted). Measurements and principal resultsIn all, 182 patients who underwent bilateral, longitudinal, uterine-lateral wall incisions without complications were included. The clinical pregnancy rates after metroplasty were 50.9% (primary infertility group), 71.4% (RM group), and 39.5% (RIF group). During the 1-year follow-up, 25.5% of patients conceived spontaneously (all groups). ConclusionHysteroscopic metroplasty should be considered for women with primary infertility, RIF, and RM with T-shaped uteri.

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%).

Uterine Septum with or without Hysteroscopic Metroplasty: Impact on Fertility and Obstetrical Outcomes-A Systematic Review and Meta-Analysis of Observational Research.

Objective: we performed a systematic review/meta-analysis to evaluate the impact of septate uterus and hysteroscopic metroplasty on pregnancy rate-(PR), live birth rate-(LBR), spontaneous abortion-(SA) and preterm labor (PL) in infertile/recurrent miscarriage-(RM) patients. Data sources: a literature search of relevant papers was conducted using electronic bibliographic databases (Medline, Scopus, Embase, Science direct). Study eligibility criteria: we included in this meta-analysis all types of observational studies that evaluated the clinical impact of the uterine septum and its resection (hysteroscopic metroplasty) on reproductive and obstetrics outcomes. The population included were patients with a diagnosis of infertility or recurrent pregnancy loss. Study appraisal and synthesis methods: outcomes were evaluated according to three subgroups: (i) Women with untreated uterine septum versus women without septum (controls); (ii) Women with treated uterine septum versus women with untreated septum (controls); (iii) Women before and after septum removal. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for the outcome measures. A p-value < 0.05 was considered statistically significant. Subgroup analysis was performed according to the depth of the septum. Sources of heterogeneity were explored by meta-regression analysis according to specific features: assisted reproductive technology/spontaneous conception, study design and quality of papers included Results: data from 38 studies were extracted. (i) septum versus no septum: a lower PR and LBR were associated with septate uterus vs. controls (OR 0.45, 95% CI 0.27–0.76; p < 0.0001; and OR 0.21, 95% CI 0.12–0.39; p < 0.0001); a higher proportion of SA and PL was associated with septate uterus vs. controls (OR 4.29, 95% CI 2.90–6.36; p < 0.0001; OR 2.56, 95% CI 1.52–4.31; p = 0.0004). (ii) treated versus untreated septum: PR and PL were not different in removed vs. unremoved septum(OR 1.10, 95% CI 0.49–2.49; p = 0.82 and OR 0.81, 95% CI 0.35–1.86; p = 0.62); a lower proportion of SA was associated with removed vs. unremoved septum (OR 0.47, 95% CI 0.21–1.04; p = 0.001); (iii) before-after septum removal: the proportion of LBR was higher after the removal of septum (OR 49.58, 95% CI 29.93–82.13; p < 0.0001) and the proportion of SA and PL was lower after the removal of the septum (OR 0.02, 95% CI 0.02–0.04; p < 0.000 and OR 0.05, 95% CI 0.03–0.08; p < 0.0001) Conclusions: the results show the detrimental effect of the uterine septum on PR, LBR, SA and PL. Its treatment reduces the rate of SA.

Reproductive outcome of hysteroscopic metroplasty for women with T-shaped uterus: a retrospective study

BackgroundT-shaped uterus is a Müllerian malformation with unapparent clinical manifestations. Intrauterine adhesion and tuberculosis may lead to T-shaped uterus, too. Hysteroscopic metroplasty is a treatment option for T-shaped uterus, while the postoperative reproductive outcomes have not been thoroughly investigated. The aim of this study was to determine the reproductive outcome in Chinese women with T-shaped uterus who had hysteroscopic metroplasty with cold scissors.MethodsThis retrospective cohort study was conducted in the reproductive surgery unit of a university-affiliated hospital. One hundred and eleven patients with T-shaped uterus who underwent hysteroscopic metroplasty from Jan. 2017 to Sept. 2019 were followed-up by telephone in Apr. 2021. All patients received hysteroscopic metroplasty using microcissors, followed by estrogen-progesterone sequential treatment, with or without intrauterine device (IUD) implantation. According to whether they had had history of intrauterine operation, patients were divided into congenital group and acquired group. The main outcome measure was postoperative live birth rate. χ2 test and t test were used for comparison between groups. Cochran-Mantel–Haenszel test were used for stratified analysis. P < 0.05 was considered statistically significant.ResultsOne hundred and eleven patients were included in total, with 46 in congenital group and 65 in acquired group. After hysteroscopic metroplasty, in the congenital group, the pregnancy rate increased from 28.3% to 87.0% (P < 0.001) and the live birth rate increased from 23.1% to 79.5% (P = 0.001); in the acquired group, the pregnancy rate slightly dropped from 98.5% to 72.3% (P < 0.001) while the live birth rate increased from 20.8% to 74.5% (P < 0.001). No statistically significant difference was observed in postoperative reproductive outcome indicators between the two subgroups except mode of conception.ConclusionsFor both groups, hysteroscopic metroplasty may improve reproductive outcomes for patients with T-shaped uterus.

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.

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.

352 Hysteroscopic metroplasty for septate uterus: A retrospective bicentric study involving 519 women

Introduction and aims: Women with a septate uterus have an increased risk of infertility and impair outcomes. Hysteroscopic metroplasty is a well-described procedure. The need for metroplasty is however controversial. A recent study concluded that metroplasty didn’t improve reproductive outcomes and lead to less chance of ongoing pregnancy than expectant management. Aim of this study is then to evaluate reproductive outcomes and risks of hysteroscopic metroplasty in women of reproductive age. Methods: We performed a retrospective bicentric study in the gynaecologic unit of two teaching hospitals with expertise in hysteroscopy.

Reproductive Outcome after Hysteroscopic Metroplasty for Septate Uterus

Reproductive Outcome after Hysteroscopic Metroplasty for Septate Uterus

Resectoscopic Surgery Part III: Advanced Resectoscopic Surgery.

In this final section of our three-part series, we will apply the basic and intermediate skills described in the first two parts to advance the gynecologist's skills to accomplish the most demanding of resectoscopic surgical challenges. In Part I of this series, we reviewed the benefits of the continuous flow gynecologic resectoscope (CFGR) and how the motivated gynecologist can assemble an operative team and overcome the impediments to learning the use of this versatile and minimally invasive instrument. In this first section, we outlined and analyzed basic resectoscopic surgery-endometrial ablation, the resection of small submucous myomas and endometrial polyps, as well as the treatment of mild Asherman's syndrome and the removal of retained products of conception. In Part II-intermediate level resectoscopic surgery-we introduced procedures such as endomyometrial resection, the resection of intermediate-size submucous leiomyomas, hysteroscopic metroplasty, and endocervical resection. Though it is not considered an absolute requirement to accomplish procedures at this level, sonographic guidance was introduced in preparation for more challenging cases. In Part III, the author reviews advanced resectoscopic procedures in which sonographic guidance is a requirement for the management of severe intrauterine adhesions and late-onset endometrial ablation failures, the management of FIGO Type 3 and 4 intramural myomas, as well as large submucous myomas.

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.

Ultrasound-Guided Hysteroscopic Metroplasty

<h3>Study Objective</h3> This video abstract will demonstrate simultaneous use of pelvic ultrasound and hysteroscopic metroplasty. <h3>Design</h3> N/A. <h3>Setting</h3> The procedure was performed in the operating room under general anesthetic with the patient positioned in the dorsal lithotomy position. Bedside pelvic ultrasound was performed by a skilled assistant. A 2.9mm operative hysteroscope with a 30-degree lens and a bipolar electrosurgery device were selected. Normal saline was used as distention media. <h3>Patients or Participants</h3> The patient was selected based on her history of septate uterus and desire to undergo metroplasty and insertion of levonorgestrel-containing intrauterine system. <h3>Interventions</h3> The procedure performed was ultrasound-guided hysteroscopic resection of uterine septum. <h3>Measurements and Main Results</h3> Ultrasound-guided hysteroscopic resection of uterine septum was demonstrated. <h3>Conclusion</h3> This video demonstrated that simultaneous use of pelvic ultrasound and hysteroscopic metroplasty improves visualization during resection of uterine septum and has been demonstrated to increase the rates of complete resection. It is a useful tool that can be added to hysteroscopic resection of uterine septum.

Complete Longitudinal Vaginal Septum Resection and Hysteroscopic Metroplasty

<h3>Study Objective</h3> To provide a brief overview of the negative fertility and pregnancy implications of a uterine septum, as well as to demonstrate the surgical management of a complete uterine and vaginal septum. <h3>Design</h3> Surgical video. Women with septate uterus have an increased relative risk of first trimester spontaneous abortion, second trimester spontaneous abortion, pre-term delivery, fetal growth restriction, malpresentation at delivery, and placental abruption. <h3>Setting</h3> Academic tertiary care hospital. <h3>Patients or Participants</h3> 31-year-old nulligravida who presents for consultation for a septate uterus. Pelvic MRI showed a subtle concavity of the external fundal uterine contour, with a complete fibromuscular septum which extended through the cervix. <h3>Interventions</h3> A hysteroscopic metroplasty was planned. An exam under anesthesia showed a previously unidentified complete longitudinal vaginal septum, which extended and communicated with a complete cervical/uterine septum. Kelly clamps were used to demarcate the anterior and posterior attachments of the vaginal septum and a dilute solution of vasopressin along with bupivacaine/epinephrine was injected. The Bovie cautery was used to excise the intervening septum progressively up to the cervix. Diagnostic hysteroscopy showed normal hemi-cavities with fluffy endometrium. The 24.5 French bipolar resectoscope with a roller barrel was used to divide the cervical and uterine septum. Care was taken to stay midline, and once the tubal ostia could be easily seen bilaterally, a slight convexity to the fundus was maintained ensuring integrity of the fundal myometrium. An intrauterine balloon stent was left in place for one week. <h3>Measurements and Main Results</h3> Office hysteroscopy after natural menses showed a normal vagina, cervix, and endometrial cavity. <h3>Conclusion</h3> MRI is the imaging of choice for identifying Müllerian anomalies and for surgical planning; however, a vaginal septum could be missed, reaffirming the importance of a careful examination under anesthesia. Hysteroscopic metroplasty is a safe and relatively simple procedure in those experienced with operative hysteroscopy and results in an improvement in fertility and pregnancy outcomes.