Metroplasty Research Articles

Safe and Effective Surgery for Septate Uterus: 21 Cases Treated By Hysteroscopic Metroplasty With Hysterography and Custom-Made Intra-Uterine Silicone Plate

Safe and Effective Surgery for Septate Uterus: 21 Cases Treated By Hysteroscopic Metroplasty With Hysterography and Custom-Made Intra-Uterine Silicone Plate

Hysteroscopic Metroplasty

Hysteroscopic Metroplasty

Hysteroscopic Metroplasty in Women With Unexplained Primary Infertility: A Prospective Cohort Study.

Hysteroscopic Metroplasty in Women With Unexplained Primary Infertility: A Prospective Cohort Study.

Assessment of Abdominal Ultrasound Guidance in Hysteroscopic Metroplasty

Study ObjectivesTo compare the rates of re-intervention, and immediate and later complications associated with abdominal ultrasound-guided versus unguided hysteroscopic metroplasty in the surgical repair of European Society of Human Reproduction and Embryology/European Society for Gynecological Endoscopy class II intrauterine septa. DesignWe performed a large observational retrospective study (Canadian Task Force Classification II-2) in a selection of patients who underwent metroplasty in a tertiary university center between 2009 and 2013. PatientsA total of 108 patients were included in the study. InterventionsPatients were categorized as having abdominal ultrasound-guided metroplasty (n = 46) or unguided metroplasty (n = 62). Measurements and Main ResultsData were collected with regard to medical and reproductive histories, diagnosis of septate uterus, surgical procedures, and complications. Using these data, the need for re-intervention and complication rates were compared between groups. Statistical analysis was performed using Fisher's exact test and Student's t-test. The characteristics of the 2 groups were comparable. A persistent septum of >10 mm, defined by 3-dimensional ultrasound hysterosonography, with a need for re-intervention, was found in 16 patients (39.0 %) in the unguided group versus 7 patients (18.4 %) in the ultrasound guidance group (p = .04). Risk of a persistent septum after resection (>10 mm) was reduced with ultrasound guidance (odds ratio = 0.35; 95% confidence interval 0.13–0.99). Two uterine perforations occurred in our series; both were in the unguided group. ConclusionsA systematic abdominal ultrasound-guided metroplasty by hysteroscopy seems to reduce the rates of re-intervention.

Reproductive Outcomes of Patients with Septate Uterus after Hysteroscopic Metroplasty: A Retrospective Clinical Study

Reproductive Outcomes of Patients with Septate Uterus after Hysteroscopic Metroplasty: A Retrospective Clinical Study

Intraoperative Transrectal Ultrasonography for Hysteroscopic Metroplasty: Feasibility and Safety.

The primary objective of this prospective comparative nonrandomized study was to assess the feasibility and safety of intraoperative transrectal ultrasonography (TRUS) during hysteroscopic metroplasty (HM). The secondary objective of the study was to assess whether TRUS facilitates complete removal of the uterine septum. Septate uterus was diagnosed by 3-dimensional transvaginal ultrasonography (3D-TVS) and confirmed by magnetic resonance imaging. In the control group (HM group; n = 18), patients underwent HM according to the traditional standard of operative hysteroscopy. In the study group (HM+TRUS group; n = 27), HM and TRUS were performed simultaneously; the hysteroscopic procedure was continued until a normal uterine fundus was observed. At 6 to 8 weeks after HM, 3D-TVS was performed to identify the numbers of complete resections (residual septum absent or <5 mm), suboptimal resections (residual septum 5-10 mm), and incomplete resections (residual septum > 10 mm). The 2 study groups did not differ significantly in terms of demographic and clinical characteristics, or in the volume of fluid infused and absorbed. There were no severe intraoperative or postoperative complication in either group; 2 patients in the HM+TRUS group and 1 patient in the HM group experienced urinary tract infection (p = .807). At 6 to 8 weeks after HM, the number of suboptimal resections and incomplete resections was higher in the HM group than in the HM+TRUS group (p = .031). Residual septum >10 mm (incomplete resection) was seen in 1 patient in the HM group but in no patients in the HM+TRUS group. Intraoperative TRUS can be performed safely during HM, and may increase the likelihood of complete resection of the uterine septum; however, this finding should be confirmed by larger studies.

Influence of hysteroscopic metroplasty on reproductive outcome in patients with infertility and recurrent pregnancy loss.

Patients with congenital uterine anomalies (CUA) have decreased reproductive potential and an unfavourable reproductive outcome compared to the population with normal uterine cavity. Patients with untreated CUA have a higher abortion rate, higher foetal loss rate and decreased live birth rate. Hysteroscopic metroplasty is a standard, safe and minimally invasive method for the treatment of correctible types of congenital uterine anomalies. The aim of the study was to analyse the reproductive outcome in certain groups of patients with CUA and infertility, before and after hysteroscopic metroplasty. We analyzed 115 patients on whom 129 hysteroscopic metroplasty interventions were performed at the University Clinic of Obstetrics and Gynaecology in Skopje over a oneyear period, between 01.01.2011 and 31.12.2011. Patients and their reproductive outcome were monitored over a two-year period and the same group served as a control group, taking into account their previous reproductive history before and after metroplasty. Statistical analysis was performed using the Chi-square test and p < 0.05 was considered to be statistically significant. The most common CUA were types 5b and 6, represented by 83.3%. In a follow-up period of two years, there were 55 patients with previous foetal loss treated by hysteroscopic metroplasty, and 31 of them had pregnancies. There was a statistically significant decrease of abortion rate from 88.5% to 19.3%, and a significant increase in term delivery rate from 2.3% to 71%. Hysteroscopic metroplasty significantly improves the reproductive outcome in patients with previous foetal loss.

Is Prophylactic Hysteroscopic Metroplasty for the Septate Uterus Justified?

Background: A septate uterus is a relatively common Müllerian defect that has an impact on fertility; this effect has been debated. Operative hysteroscopy is the preferred method of treatment in patients with recurrent abortions or poor obstetric histories, but it has not yet been determined whether or not to perform prophylactic metroplasty when a septum is incidentally diagnosed in an otherwise healthy patient. Methods: This article reviews existing literature on the clinical significance of a septate uterus, its diagnosis, surgical treatment, and reproductive outcome after hysteroscopic metroplasty. Complications and the controversy surrounding this procedure are also discussed. Results: Available literature suggests that untreated Müllerian defects could impair pregnancy outcomes significantly. Hysteroscopic metroplasty is generally preferred over expectant management in patients with septate uteri and poor obstetrical histories. Conclusions: Although controversial, prophylactic metroplasty may be recommended for nulliparous patients with incidentally diagnosed uterine septa if there is unexplained infertility in patients>35 years of age and in whom assisted reproductive technologies are used. (J GYNECOL SURG 30:325)

Safety, Efficacy and Reproductive Outcomes of Hysteroscopic Outpatient Metroplasty to Expand Dysmorphic Uteri (HOME-DU Technique)

Safety, Efficacy and Reproductive Outcomes of Hysteroscopic Outpatient Metroplasty to Expand Dysmorphic Uteri (HOME-DU Technique)

Intraoperative Bidimensional and 4-D Transrectal Ultrasonography for Hysteroscopic Metroplasty

Intraoperative Bidimensional and 4-D Transrectal Ultrasonography for Hysteroscopic Metroplasty

Outcome of fertility and pregnancy following hysteroscopic resection of septum using versapoint needle

Aim: The aim of the present study was to assess the safety and efficacy of hysteroscopic septum resection by Versapoint and future fertility outcome. 105 subfertile patients who underwent hysteroscopic septum resection using the Bipolar Versapoint system were analysed. Methods: Hysteroscopic Metroplasty was performed on 105 patients with uterine septum and history of infertility. The metroplasty procedure was performed on 105 patients using versapoint. The outcome was evaluated based on fertility outcomes. Study Design: Retrospective study Results: The pregnancy rates were noted to be around 96.5% following the procedure and live birth rate were around 82%. Conclusion: Hysteroscopic metroplasty using Bipolar Versapoint had better fertility outcomes and less risks. Future fertility and live birth rates had significantly improved.DOI: http://dx.doi.org/10.3126/ajms.v6i3.10904Asian Journal of Medical Sciences Vol.6(3) 2015 63-65

Cervical assessment in women with hysteroscopic uterine septum resection: a retrospective cohort study

Objective: To estimate whether cervical length measured by transvaginal ultrasonography in women with a history of hysteroscopic uterine septum resection predicts spontaneous preterm birth <35 weeks’ gestation.Methods: This retrospective cohort study compared women who had undergone hysteroscopic metroplasty, and were subsequently pregnant with singleton gestations delivered January 2003 to December 2012, to a low-risk control group. Transvaginal ultrasonographic cervical lengths were measured 16–30 weeks’ gestation. The primary outcome was spontaneous preterm birth <35 weeks’ gestation and the primary exposure variable of interest was cervical length.Results: Women with a uterine septum resected (N = 24) had a shorter cervical length (2.90 cm) than the low-risk control group (N = 141, 4.31 cm, p < 0.0001); and were more likely to have a cervical length <3.0 cm (41.7% versus 1.4%, p < 0.0001), <2.5 cm (33.3% versus 0%, p < 0.0001), <2.0 cm (16.7% versus 0%, p < 0.0001) and <1.5 cm (12.5% versus 0%, p = 0.003). Women with septum resected were more likely to receive corticosteroids (33.3% versus 11.3%, p = 0.010), but were not more likely to have a spontaneous preterm birth <35 weeks (4.2% versus 0.7%, p = 0.27). There were no differences noted in secondary outcomes including neonatal morbidity.Conclusion: Pregnant women with a history of a hysteroscopic uterine septum resection have shorter cervical lengths than low-risk controls but may not be at a higher risk of spontaneous preterm birth <35 weeks’ gestation. Further research with a larger sample size is needed to evaluate this group of women to determine if transvaginal ultrasonographic cervical length assessment is of benefit.

Efficacy of Transrectal Three-Dimensional Ultrasound-Guided Hysteroscopic Metroplasty

Background: Transabdominal ultrasound is not the standard for scanning pelvic structures, and the transvaginal route can result in repeated removals and reinsertions of the hysteroscope, with subsequent uterine refilling. Objective: The goal of this research was to evaluate the efficacy of transrectal 3-D ultrasound for intraoperative guidance during hysteroscopic metroplasty. Design: This pilot, prospective, randomized comparative study (Canadian Task Force classification I) was conducted in the Shatby Maternity University Hospital in Alexandria, Egypt. Materials and Methods: The study involved 60 patients with infertility or recurrent pregnancy-loss problems, who were diagnosed by hysterosalpingogram (HSG) and 3-D vaginal ultrasound to have uterine septa. The patients were randomized into two groups. Group A (30 patients) had hysteroscopic metroplasty with transrectal 3-D ultrasound performed intermittently during the procedure. Group B (30 patients) had hysteroscopic metroplasty without ultrasound guidance. All patients had postoperative HSG 3 months later. Results: A statistically significant longer operative time was found in group A (p=0.001). No statistically significant difference was found between both groups regarding volume of fluid deficit and intraoperative complications. No residual septa were found on HSG 3 months postoperatively in group A, while 4 cases (13.3%) of residual septa were seen in group B, with a significant statistical difference between both groups (p=0.04). Conclusions: Transrectal, 3D, ultrasound-guided hysteroscopic metroplasty seems to be a reliable, safe noninvasive tool that enables complete precise removal of a uterine septum in one session with no residual tissue remaining and no myometrium injury, thus eliminating the risk of uterine rupture in subsequent pregnancies. Moreover, there is no need for intraoperative laparoscopic monitoring or postoperative HSG. (J GYNECOL SURG 30:209)

The techniques and outcomes of hysteroscopic metroplasty

To evaluate the reproductive outcomes and surgical techniques of the hysteroscopic metroplasty in women with septate uterus and recurrent abortions or primary unexplained infertility. Septate uterus is the most frequent congenital uterine anomaly caused by inadequate resorption of the Müllerian ducts. Hysteroscopic metroplasty has replaced the traditional laparotomy approach because of its positive and satisfactory outcomes in pregnancy and live-birth rates, and also many different postoperative benefits. The aim of metroplasty is to restore a normal anatomy of the uterine cavity as a prerequisite for a positive implantation and subsequent good obstetrical outcomes. This treatment clearly demonstrates its effectiveness both in recurrent abortion and in primary unexplained infertility. The hysteroscopic metroplasty with its simplicity, safety, and improved reproductive outcomes has liberalized the approach to treatment. Today, hysteroscopic metroplasty is a common practice to treat septate uterus with salutary effects both in infertile patients and in patients with recurrent pregnancy loss or premature labor, especially if in-vitro fertilization is being contemplated. Decisions on when to treat uterine septa are discussed in particular because of lack of prospective, randomized controlled trials.

Mini-Scissor Versus Bipolar Twizzle in Ambulatory Hysteroscopic Metroplasty: A Prospective Randomized Study

Objective: The goal of this study was to compare mechanical (cold scissor) and electrosurgical metroplasty (bipolar twizzle) in terms of feasibility and pain scoring during ambulatory-based hysteroscopic metroplasty for short, narrow-based uterine septae. Materials and Methods: Forty women, with recurrent abortions or infertility, with short narrow-based septae <2 cm diagnosed by transvaginal ultrasound and hysterosalpingogram (HSG) were included in the study. The patients were randomized into two groups of 20 patients each. In group A, metroplasty was performed with a cold mini-scissor (mechanical resection). In group B, metroplasty was performed with a bipolar twizzle (electrosurgical resection). None of the patients were given anesthesia or analgesia. Metroplasty was scheduled in the early proliferative phase of each patient's menstrual cycle, without pharmacologic preparation. The Versascope® hysteroscopy system was used. Through the expanding plastic collapsible channel, insertion of a 7-Fr semirigid mechanical instrument (the mini-scissor) or a 5-Fr bipolar electrode (the twizzle) was performed, allowing ambulatory metroplasty to be performed. All patients had postoperative HSGs 3 months later, after exclusion of pregnancy, to evaluate objectively the complete resection of their septae. Results: No significant difference was found between both groups in terms of operative time and fluid deficit (12.68±2.08 versus 12.08±2.62) and (519±118.59 versus 480±106.01), respectively. Pain scores were significantly higher in the bipolar twizzle group than in the mini-scissor group. The pain scores had (4.01±0.68 versus 6.98±1.28) a p significance of <0.05. Conclusions: Ambulatory-based hysteroscopic metroplasty, using either a mini-scissor or bipolar twizzle, is a safe and effective procedure. Electrosurgical electrodes induce significantly higher pain scores than mechanical cold instruments, necessitating careful instrument selection when treating patients in whom more pain is anticipated (e.g., previous cesarean section, chronic pelvic pain, or anxious or menopausal women). If an electrosurgical electrode is the only available device, a preoperative analgesic is recommended, especially for such patients. (J GYNECOL SURG 30:147)

Role of morphologic characteristics of the uterine septum in the prediction and prevention of abnormal healing outcomes after hysteroscopic metroplasty.

STUDY QUESTIONCan morphologic measurements (width, length and surface area) of the uterine septum predict healing-dependent abnormal anatomic results [ARs; residual septum (RS) and intrauterine adhesions in other locations (IUA-OLs)] after complete hysteroscopic metroplasty (HM)?SUMMARY ANSWERSignificant predictors of ARs are the septal width and, to a lesser extent, septal surface area.WHAT IS KNOWN ALREADYAnatomic results after hysteroscopic metroplasty have very large variation. A RS >1 cm and IUA-OLs can aggravate reproductive outcomes, resulting in the need for reoperation. New criteria for diagnosing a uterine septum according to the European Society of Human Reproduction and Embryology (ESHRE) and European Society for Gynaecological Endoscopy (ESGE) have been suggested (ESHRE-ESGE criteria). Autocross-linked hyaluronic acid gel (autocross-linked polysaccharide) has an antiadhesive effect.STUDY DESIGN, SIZE, DURATIONA prospective, observational cohort study was performed with 96 women consecutively enrolled between 2007 and 2012.PARTICIPANTS/MATERIALS, SETTING, METHODSWomen who had uterine septum and previous miscarriage or infertility presented for evaluation at a university hospital, private hospital or private medical center were included. Preoperative septal width, length and surface area were determined with three-dimensional sonohysterography. Women were treated by hysteroscopy in a standardized manner with three- or four-dimensional transrectal ultrasound guidance (complete resection). Patients received either no adhesion barrier (49 patients) or adhesion barrier with autocross-linked polysaccharide (47 patients). Anatomic results were assessed with three-dimensional sonohysterography and second-look hysteroscopy. Healing-dependent ARs were reported using both American Society of Reproductive Medicine (ASRM) criterion of RS length >1 cm (ASRM>1 cm criterion) and ESHRE-ESGE criteria. Univariate and multivariate logistic regression were used to identify predictors of RS, IUA-OLs and ARs.MAIN RESULTS AND ROLE OF CHANCEIn patients who had no adhesion barrier, ARs were diagnosed in 11 of 49 patients (23%) using the ASRM > 1 cm criterion and in 20 of 49 patients (41%) using the ESHRE-ESGE criteria for RS [odds ratio (OR)ESHRE-ESGE:ASRM, 2.4, P = 0.05]. In the patients who had autocross-linked polysaccharide, ARsASRM > 1 cm were diagnosed in 2 of 47 patients (4%) and ARsESHRE-ESGE in 4 of 47 patients (9%). RSESHRE-ESGE was diagnosed significantly more often than RSASRM > 1 cm 19 of 96 (20%) versus 5 of 96 (5%) in all patients (ORESHRE-ESGE:ASRM > 1 cm = 4.5, P < 0.01). In patients who had no adhesion barrier, logistic regression with ASRM > 1 cm and ESHRE-ESGE criteria showed that the width and surface area were predictors of ARs. Models adjusted by patient group confirmed the significance of width as a predictor of ARsASRM > 1 cm [OR for width, 3.5 (P < 0.01); OR for group, 0.22 (P < 0.01)], width as a predictor of ARsESHRE-ESGE [OR for width, 2.2 (P < 0.01); OR for group, 0.26 (P < 0.01)] and surface area as a predictor of ARsASRM > 1 cm [OR for surface area, 1.5 (P < 0.01)]; OR for group, 0.32 (P < 0.01). In patients who had autocross-linked polysaccharide, these predictors were not significant. Receiver-operating characteristic curves showed cutoff values for ARsASRM > 1 cm (septal width, 3.42 cm; septal surface area, 4.68cm2) and ARsESHRE-ESGE (septal width, 3.42 cm; septal surface area, 3.51cm2).LIMITATIONS AND REASONS FOR CAUTIONPatients were enrolled in the adhesion barrier group in a time-dependent, consecutive and non-randomized manner.WIDER IMPLICATIONS OF THE FINDINGSA wide septum and large surface area may be indications for adhesion barrier. The use of autocross-linked polysaccharide reduces the risk of ARs. The ESHRE-ESGE criteria may cause greater frequency of recognition of RS than the ASRM > 1 cm criterion, which could result in more frequent reoperations with use of the ESHRE-ESGE criteria, possibly without any significant effect on reproductive performance.STUDY FUNDING/COMPETING INTEREST(S)This work was supported by Jagiellonian University (grant no. K/ZDS/003821). The authors have no competing interest to declare.

Do Measurements of Uterine Septum Using Three-Dimensional Ultrasound and Magnetic Resonance Imaging Agree?

ObjectiveTo evaluate the agreement between measurements of uterine septum by 3-D ultrasound (3-D US) and magnetic resonance imaging. MethodsFourteen women with a uterine septum underwent both a 3-D US and an MRI followed by hysteroscopic metroplasty in a tertiary care infertility clinic within a university teaching hospital. The agreement between 3-D US and MRI measurements of septum length (SL), septum width (SW) and the distance between fundal serosa and septal tip (SSD) was compared using the Bland Altman limit of agreement analysis. Results3-D US correctly identified all women who had a uterine septum identified with MRI. The mean difference in SL was 2.7mm (upper limit of agreement and lower limit of agreement were 10.3mm and −4.8mm, respectively). The mean difference in SW was 2.3mm (upper limit of agreement and lower limit of agreement of 10.4mm and −9.2mm, respectively). The SSD mean difference was 2.8mm (upper limit of agreement and lower limit of agreement of 10.6mm and −5mm, respectively). ConclusionsCategorical agreement in diagnosis was 100% and agreement between 3-D US and MRI measurements was good with narrow differences. Variations were unlikely to be greater than intra- and inter-observer variations anticipated in MRI readings. 3-D US can replace MRI for diagnosis and measurement of uterine septa.

Reproductive Outcome after Hysteroscopic Metroplasty in Patients with Infertility and Recurrent Pregnancy Loss

Introduction: Reproductive outcome can be negatively affected in patients with congenital uterine anomalies (CUA), increasing the number of unsuccessful pregnancies and obstetric complications. Compared with the population with normally formed uterus, patients with CUA have higher abortion rate, higher fetal loss rate and decreased live birth rate. Hysteroscopic metroplasty (HM) is a standard, safe and minimally invasive method for the treatment of correctible types of congenital uterine anomalies.Aim: The aim of the study was to analyze the reproductive outcome in group of patients with infertility and recurrent pregnancy loss and present CUA, before and after hysteroscopic metroplasty.Material and Methods: We analyzed 67 patients to whom 78 interventions hysteroscopic metroplasty were performed at the University Clinic of Obstetrics and Gynecology in Skopje during a two year period, between 01.01.2010 and 31.12.2011. Their reproductive outcome was monitored during a two-year period and the same group served as a control group, taking into account their previous reproductive history. Statistical analysis was performed using Chi-square test and p < 0.05 was considered to be statistically significant.Results: Most common CUA were types 5b and 6 represented by 88 %. In a follow up period of two years, 33 of the patients become pregnant. There was a statistically significant decrease of abortion rate from 92% to 21.2%, as well as an increase in the term delivery rate from 0% to 69.7%.Conclusion: Treatment with hysteroscopic metroplasty is significantly improving the reproductive outcome in patients with CUA and previous fetal loss.

Reproductive Outcome after Hysteroscopic Metroplasty in Patients with Infertility and Recurrent Pregnancy Loss

Introduction: Reproductive outcome can be negatively affected in patients with congenital uterine anomalies (CUA), increasing the number of unsuccessful pregnancies and obstetric complications. Compared with the population with normally formed uterus, patients with CUA have higher abortion rate, higher fetal loss rate and decreased live birth rate. Hysteroscopic metroplasty (HM) is a standard, safe and minimally invasive method for the treatment of correctible types of congenital uterine anomalies.Aim: The aim of the study was to analyze the reproductive outcome in group of patients with infertility and recurrent pregnancy loss and present CUA, before and after hysteroscopic metroplasty.Material and Methods: We analyzed 67 patients to whom 78 interventions hysteroscopic metroplasty were performed at the University Clinic of Obstetrics and Gynecology in Skopje during a two year period, between 01.01.2010 and 31.12.2011. Their reproductive outcome was monitored during a two-year period and the same group served as a control group, taking into account their previous reproductive history. Statistical analysis was performed using Chi-square test and p &lt; 0.05 was considered to be statistically significant.Results: Most common CUA were types 5b and 6 represented by 88 %. In a follow up period of two years, 33 of the patients become pregnant. There was a statistically significant decrease of abortion rate from 92% to 21.2%, as well as an increase in the term delivery rate from 0% to 69.7%.Conclusion: Treatment with hysteroscopic metroplasty is significantly improving the reproductive outcome in patients with CUA and previous fetal loss.

Role of three-dimensional ultrasound in the diagnosis of double uterine cavity anomalies and concordance with laparoscopic and hysteroscopic diagnosis

ObjectivesTo determine whether three-dimensional (3D) ultrasound can replace combined hysteroscopic–laparoscopic role in differentiating bicornuate, septate and arcuate uterus. Patient(s)Seventy-two patients with history of infertility, recurrent abortions or preterm labor with hysterosalpingographic and/or two dimensional ultrasound diagnosis of double uterine cavity anomaly were included in this study. Intervention(s)Three-dimensional ultrasound (3D US) was done to all patients. Laparoscopy was done to differentiate bicornuate, septate and arcuate uterine anomalies. Simultaneous hysteroscopic metroplasty was done in patients with septate uteri. ResultsThere was absolute concordance between 3D ultrasound and combined laparoscopic and hysteroscopic gold-standard in differentiation between bicornuate, septate and arcuate uteri in all our seventy two patients. Conclusion(s)3D US can differentiate septate, bicornuate and arcuate uteri and can eliminate the need for invasive laparoscopic diagnosis of these uterine anomalies.