Clinical Insights into Operative Hysteroscopy Using the Bigatti Shaver: A Pioneer's Perspective From Indonesia.

To study perioperative and postoperative complications of a standardized ultrasound-guided hysteroscopic treatment for complete septate uterus with duplicated cervices and non-obstructive longitudinal vaginal septum, and to evaluate operative time, symptom changes, and reproductive outcomes. Between January 2021 and May 2025, patients diagnosed with complete septate uterus, duplicated cervices, and non-obstructive longitudinal vaginal septum at a tertiary referral center underwent hysteroscopic resection of the uterine and vaginal septum using a 15 Fr bipolar mini-resectoscope under real-time ultrasound guidance, with preservation of the duplicated cervices. Primary outcomes were perioperative and postoperative complications. Secondary outcomes included operative time trends over consecutive cases, symptom changes before and after surgery, and reproductive outcomes (clinical pregnancy rate, live birth rate, miscarriage rate, and pregnancy-related complications). Twenty-eight patients were included. Surgical correction was successfully completed in all cases, with no perioperative or postoperative complications. Median operative time was 61.5 min (range 21-94 min) and decreased modestly over consecutive procedures. At follow up, all patients showed a regular triangular uterine cavity on three-dimensional transvaginal ultrasound. Median follow up was 24 months (range 3-54 months). Symptoms improved in nearly all patients; only one patient (3.5%) reported persistent dyspareunia. Among the 11 patients who attempted conception, the clinical pregnancy rate was 100% (11/11). The live birth rate per pregnancy was 63.6% (7/11), with two pregnancies ongoing at last follow up. This standardized ultrasound-guided hysteroscopic approach using a 15 Fr bipolar mini-resectoscope for the treatment of complete septate uterus with duplicated cervices and non-obstructive longitudinal vaginal septum appears safe and reproducible, with favorable anatomic, symptom, and reproductive outcomes.

Background: Congenital uterine anomalies represent developmental disorders of the Mllerian ducts with potential impact on reproductive outcomes.This study investigates the association between specific uterine anomalies and fetal malpresentation, an area where comprehensive clinical characterization remains incomplete.Materials and methods: This retrospective case series examined 12 pregnant women with confirmed uterine anomalies who delivered at the Department of Obstetrics and Gynecology in MGM Kalamboli, Navi Mumbai.Uterine anomalies were classified according to ESHRE/ESGE criteria.Data collected included maternal demographics, anomaly type, fetal presentation, delivery mode, and neonatal outcomes.Descriptive statistical analysis was performed to evaluate associations between specific anomalies and malpresentation patterns.Results: Among the 12 cases, a bicornuate uterus was the most frequent (41.7%), followed by septate (33.3%), didelphys (16.7%), and arcuate uterus (8.3%).Malpresentation occurred in 83.3% of cases, with 58.3% breech and 25% transverse lie.A septate uterus was associated with 100% malpresentation (75% breech, 25% transverse), while a bicornuate uterus showed 80% malpresentation (60% breech, 20% transverse).The cesarean section rate was 91.7%, with malpresentation being the primary indication in 90.9% of these cases.Despite these challenges, neonatal outcomes were favorable, with 100% of neonates having APGAR scores 7 at 5 minutes and no congenital anomalies. Conclusion:This study demonstrates a strong association between uterine anomalies and fetal malpresentation, with septate and bicornuate uteri showing particularly high rates of non-cephalic presentations.The consequent high cesarean section rate highlights the significant impact of these anomalies on obstetric management.Early detection of uterine anomalies and appropriate antenatal surveillance are essential for optimizing outcomes in this high-risk population.

To determine the frequency and types of Müllerian anomalies (MA) in women with various reproductive disorders and demonstrate three-dimensional transvaginal ultrasound's (3D TVUS) capabilities in MA diagnosis. A prospective, comparative, case-control study was conducted on 3,973 women aged 16 to 45 between 2019 and 2023. Among them, 2,394 women had primary infertility (Group I), 898 - recurrent pregnancy losses (Group II), 61 - primary amenorrhea (Group III), and 620 women with one or more full-term live births constituted control group (Group IV). All women underwent 2D TVUS and 3D TVUS examinations. Additionally, hysterosalpingography was conducted on 49 women, hystero-laparoscopy on 53 women, and magnetic resonance imaging (MRI) on 30 women. The most common MA identified in Group I and Group II was a septate uterus. In diagnosing this condition, the 3D TVUS demonstrated sensitivity of 95.83% and specificity of 100% compared to MRI, with Kappa index of 0.978. Compared to hystero-laparoscopy, 3D TVUS exhibited sensitivity of 97.5% and specificity of 100%, with Kappa index of 0.987. Compared to hysterosalpingography, MRI, and hystero-laparoscopy, the 3D TVUS showed 100% sensitivity and specificity for all other anomalies. Three-dimentional ultrasonography is a rapid, cost-effective, non-invasive, and highly informative method for evaluating Müllerian anomalies. It demonstrated good concordance with the magnetic resonance imaging method.

Hysteroscopic Repair of Robert's UterusUnifying the Divided: Hysteroscopic Treatment of Robert's Uterus, a Rare Congenital Challenge.

Müllerian duct anomalies: A retrospective case series focussing on outcomes in patients with a uterine septum

The primary objective of this study is to assess the impact of hysteroscopic metroplasty on symptom relief, including dysmenorrhea, dyspareunia, and menstrual blood flow in women with partial uterine septa (U2a class). Additionally, the study aims to investigate potential correlations between clinical and ultrasonographic characteristics and changes in these symptoms. This was a prospective cohort study conducted at a single center, enrolling women who underwent hysteroscopic metroplasty between March 2022 and September 2023. Participants presented with dysmenorrhea, dyspareunia, and abnormal menstrual blood flow and had expressed a desire for pregnancy. Preoperative symptom severity was measured using a visual analog scale, ranging from 0 to 100. Preoperative three-dimensional transvaginal ultrasonography was performed to assess septal characteristics. A 12-month follow-up was conducted to evaluate changes in symptoms postoperatively. Exclusion criteria included alternative causes of pelvic pain, incomplete septum correction necessitating further surgery, and pregnancy or hormonal therapy within 12 months prior to or following the surgery. A total of 52 symptomatic patients with U2a uterine septa underwent hysteroscopic metroplasty, and data from 44 patients were analyzed according to the inclusion and exclusion criteria. Postoperative assessments revealed a significant reduction in dysmenorrhea (mean ± standard deviation: 50.2 ± 20.5 vs. 33.1 ± 20.4, P < 0.001) and dyspareunia (mean ± standard deviation: 41.4 ± 9.5 vs. 28.6 ± 24.5, P < 0.028). However, no significant changes were observed in menstrual blood flow. Hysteroscopic metroplasty in patients with partial uterine septa results in significant symptom relief, particularly for dysmenorrhea and dyspareunia. These findings underscore the potential benefits of metroplasty beyond reproductive outcomes. Further large-scale studies are necessary to confirm these results.

Surgical interventions to optimize fertility.

Accessory Cavitated Uterine Malformation with Incomplete Septate Uterus.

The presence of a septate uterus combined with endometrial polyps significantly impacts women's fertility. There is currently no study on whether medication is needed after surgery and which postoperative regimen is more beneficial for uterine recovery and pregnancy outcomes. This study aims to compare the reproductive outcomes and complications of artificial cycle therapy with those of short-acting contraceptives or no hormonal treatment after hysteroscopic resection of the uterine septum with coexisting endometrial polyps. A retrospective study was conducted on 189 women with a history of infertility or adverse pregnancy who underwent hysteroscopic resection of uterine septum with endometrial polyps between December 2017 and February 2023 . According to the postoperative medication regimens, patients were divided into three groups: artificial cycle (Group A), short-acting contraceptive (Group B), and no hormonal treatment (Group C). The primary outcome was pregnancy rates leading to live birth within 12 months post-surgery. There were 92 patients in Group A, 52 in Group B, and 45 in Group C. The live birth rates were 40.2% in Group A, 34.6% in Group B, and 31.1% in Group C (χ 2=1.192, P=0.547). A multivariate logistic regression analysis was performed incorporating confounding variables including age, body mass index (BMI), types of fertility problems, and types of uterine septum. The results showed that only age (adjusted odds ratio (OR) = 0.892, 95%CI [0.822-0.968], P=0.006) was significantly associated with live birth after surgery. The mean time to pregnancy resulting in live birth was 9.6 months in Group A, 10.2 months in Group B, and 10.4 months in Group C (log-rank P=0.468). There were no significant differences in clinical pregnancy rate, pregnancy loss rate, preterm birth rate, placental abnormality rate, postoperative intrauterine adhesion rate, and endometrial polyp recurrence rate among the three groups (P>0.05). Hormonal therapy, including artificial cycles and short-acting contraceptives, may not be necessary after hysteroscopic septum resection with polypectomy for patients with short-term fertility requirements.

Müllerian anomalies are a collection of heterogeneous anatomical disorders of the female genital tract that present with complex clinical features of which severe subtypes like congenital aplasia of the vagina and uterus, may present with primary amenorrhea and dyspareunia, while mild cases like septate uterus, are often asymptomatic. Regardless of the types, the Müllerian anomalies impose both psychological and physical burdens on patients. Currently, the etiology of Müllerian anomalies remains largely unclear, which hinders early diagnosis and intervention. Although the advent of next-generation sequencing technologies has promoted a more comprehensive depiction of genetic features of Müllerian anomalies, there is still a lack of experimental validation for the functions of these genes, where some novel preclinical models having been applied in cancer fields may provide potentially available strategies. Thus, in this review, we aim to summarize the genetic defects and novel validation techniques associated with Müllerian anomalies. Elucidating the genetic mechanisms involving Müllerian anomalies can pave the way for the development of early diagnostic strategies and preventional measures in the future.

Extreme Intrauterine Surgery: Multiple-step Hysteroscopic Approach to Treat a 4 cm Fibroid in a Complete Uterine Septum with Cervical Septum.

Background: A complete septate uterus is the most common Müllerian anomaly and is strongly associated with recurrent pregnancy loss and adverse obstetric outcomes. However, antenatal diagnosis may be missed, and incidental intraoperative detection during Caesarean section is rare. Case Presentation: A 35-year-old gravida 4 para 3 living 1 abortion 0 woman at 30 weeks of gestation was referred with antepartum haemorrhage secondary to placenta previa. She had a history of two previous stillbirths at 26 and 28 weeks of gestation. In her third pregnancy, McDonald&#39;s cervical cerclage resulted in preterm vaginal delivery at 35 weeks of a healthy 2.5 kg neonate. In the present pregnancy, prophylactic cerclage was placed at 14 weeks. Due to recurrent bleeding, an emergency Caesarean section was performed. Intraoperatively, two completely separate uterine cavities were visualized with a septum extending from the fundus to the internal cervical os. The external uterine contour was smooth with no fundal indentation, confirming a complete septate uterus. Septal resection was deferred. Postoperative recovery was uneventful. Conclusion: This case underscores the importance of evaluating congenital uterine anomalies in women with recurrent mid-trimester loss. Accurate intraoperative differentiation between a septate and bicornuate uterus is essential, as management strategies differ significantly.

Factors Affecting Reproductive Outcomes of Hysteroscopic Septum Incision: A Retrospective Cohort Study.

To show a minimally invasive surgical approach for managing a retained intrauterine device (IUD) in a patient with severe cervical stenosis and a cesarean scar defect. Tertiary care center with expertise in complex gynecologic surgery. A 33-year-old G1P1001 with a history of cesarean delivery. She had a prior LEEP and IUD insertion, followed by cold-knife conization where IUD strings were transected. She presented with pelvic pain, irregular bleeding, and cervical stenosis. She underwent multiple failed IUD removal attempts complicated by uterine and rectovaginal septum perforations. Imaging revealed an isthmocele with minimal residual myometrium and cervical shortening. The patient underwent laparoscopic transuterine IUD removal, transuterine cervical dilation with intrauterine catheter placement to maintain cervical patency, isthmocele repair, and transabdominal cerclage. A transabdominal approach was selected over transvaginal cerclage or expectant management because of severe cervical distortion from previous excisional procedures and cervical shortening. A multidisciplinary team guided preoperative evaluation and counseling. Discussions included reproductive implications, potential improvement in symptoms and fertility optimization following isthmocele repair, the need for cesarean delivery after transabdominal cerclage, and limited evidence supporting cerclage in patients without prior preterm birth [1]. Key operative steps included lysing bladder adhesions, using the isthmocele as the uterine entry point for IUD removal, dilating the cervix through the uterus and placing an intrauterine catheter, repairing the isthmocele in two layers [2,3], and placing the cerclage. At her two-week postoperative visit, the catheter was removed, and office hysteroscopy was performed without complication or need for dilation. This video emphasizes the importance of patient-centered care and shared decision-making in managing complex reproductive surgical cases. It highlights multidisciplinary collaboration in guiding evidence-informed yet individualized care, aligning with fertility preservation goals. The surgical approach shows how minimally invasive techniques can be adapted to address multiple pathologies simultaneously, minimizing risk and optimizing reproductive potential. VIDEO ABSTRACT.

Introduction: Infertility affects 10-15% of reproductive age couples. Diagnostic hystero-laparoscopy is the important diagnostic modality for evaluation of infertility which has additional advantage of direct visualization of pelvic pathology along with performing therapeutic surgery at same setting, compared to other diagnostic modalities. This study aims to determine the role of diagnostic hystero-laparoscopy in evaluation of infertile women. Methods: This descriptive study was conducted from 25th April to 24th July 2025 including women presenting with infertility and planned for diagnostic hystero-laparoscopy in department of infertility at Paropakar Maternity and Women’s Hospital. Any abnormalities detected during laparoscopy and hysteroscopy were recorded. If any therapeutic procedure was done, that was also noted. A structured proforma was used to collect data and descriptive analysis was done. Results: During the study period 36 underwent diagnostic hystero-laparoscopy among which, 20 (55.55%) had primary infertility and 16 (44.44%) had secondary infertility. The mean age was 30.44±4.70 years and the mean duration of infertility was 3.76±3.71 years. The most common pathologies determined on hysteroscopy were uterine polyp and septate uterus, both being 6 in number (16.66%). On laparoscopy tubal block was noted in 22 (61.11%) women followed by pelvic adhesions which was seen in 19 (52.77%) cases. Most frequent therapeutic intervention done during laparoscopy was adhesiolysis (16, 44.44%) and during hysteroscopy were polypectomy and septal resection (6 each, 16.66%). Eleven women (30.55%) had undergone multiple procedures. Conclusions: The study showed that tubal and peritoneal abnormalities were the two main factors determined on laparoscopy and most prevalent finding on hysteroscopy were uterine polyp and septate uterus. Adhesiolysis, polypectomy and septal resection were the main procedures performed.

Müllerian development anomalies encompass a heterogeneous group of congenital malformations of the female reproductive tract, resulting from failures in the fusion, canalization, or resorption of the Müllerian ducts. Among them, the longitudinal vaginal septum (LVS) is a rare entity characterized by the partial or complete division of the vaginal cavity into two compartments. Diagnosis can be challenging due to its frequently asymptomatic course or delayed presentation with dysmenorrhea, dyspareunia, or obstetric complications. This report describes the case of a 16-year-old adolescent who was presented with abnormal uterine bleeding and loss of consciousness following recent onset of sexual activity. Clinical evaluation and gynecological ultrasound revealed an incomplete LVS with tearing and intracavitary debris. An emergency surgical procedure was performed, including uterine curettage, vaginal repair, and septum resection, with a favorable postoperative course and no anatomical sequelae. LVS requires a multidisciplinary approach integrating clinical assessment, imaging studies—preferably magnetic resonance imaging, which is considered the diagnostic gold standard—and individualized surgical treatment. Timely diagnosis is essential to prevent complications, preserve gynecological health, and improve the quality of life of affected patients.

Congenital uterine anomalies are the result of abnormal development of the Müllerian ducts and occur in approximately 5% of the general female population. These malformations often remain asymptomatic and undiagnosed until complications arise, especially during reproductive years. Accurate diagnosis and classification are crucial for counseling, reproductive planning, and appropriate surgical management. Recent advances in three-dimensional (3D) imaging and printing technology have enhanced diagnostic and therapeutic strategies in complex gynecologic cases. This report aims to present a rare postpartum complication associated with a congenital uterine anomaly, characterize the histopathological and radiological features of the case, and assess the role of printed three-dimensional (3D) anatomical modeling in supporting accurate post hoc classification and surgical decision-making. A 25-year-old primiparous woman with a congenital uterine malformation underwent cesarean section at 28 weeks of gestation due to premature rupture of membranes and regular uterine contractions. One month postpartum, the patient presented with vaginal discharge and reported a palpable resistance in the vagina. Pelvic examination revealed a lobulated, dark pink, nonbleeding, firm mass measuring approximately 15 × 10 cm protruding into the vagina, along with an intact vaginal septum located 2-3 cm from the introitus. Ultrasound demonstrated an irregular mass in the right uterine cavity with indistinct margins suggestive of a necrotic fibroid. The patient underwent surgery involving removal of the vaginal mass and resection of the vaginal septum. Histopathological examination revealed fascicularly arranged, shadowed spindle cells consistent with necrotic smooth muscle tissue of myometrial origin, indicative of degenerative tissue of the uterine septum. Subsequently, a patient-specific 3D printed uterine model was generated using imaging and surgical data to facilitate detailed postoperative anatomical assessment. Postoperative assessment using the 3D printed model enabled a precise classification of the malformation as a "double septate uterus with cervix and septate vagina" (ESHRE/ESGE classification U2bC2V1) with an intracavitary FIGO type 2 submucosal leiomyoma. The 3D model provided a tangible visualization of the uterine architecture, improving anatomical understanding, facilitating retrospective diagnosis, and supporting interdisciplinary evaluation. This case demonstrates the diagnostic and educational utility of 3D printing in the management of rare Müllerian anomalies. Integration of patient-specific 3D models into clinical practice may improve diagnostic precision and surgical planning, particularly in complex gynecological malformations.

Müllerian malformations result from failures in the formation, fusion, or resorption of the Müllerian ducts, occurring between the 6th and 12th weeks of embryogenesis. The septate uterus is the most common anomaly, associated with dysmenorrhea, dyspareunia, and infertility. Early diagnosis is essential to prevent reproductive complications. This case report describes a 23-year-old patient with a complete uterine septum, true cervical duplication, and a longitudinal vaginal septum. The investigation included pelvic ultrasound and magnetic resonance imaging, confirming the complex malformation. Treatment involved hysteroscopic surgery with septoplasty and intrauterine device insertion to prevent synechiae. Postoperative follow-up revealed a residual septum, requiring a second septoplasty, which successfully restored the uterine cavity. The hysteroscopic approach proved effective, improving reproductive prognosis and symptom relief. This case highlights the importance of clinical suspicion, detailed diagnosis, and early intervention to enhance patients’ quality of life and pregnancy outcomes.

Second-look hysteroscopy is proposed after hysteroscopic metroplasty to assess healing, identify residual septa or intrauterine adhesions (IUAs), and optimize reproductive outcomes. However, its timing, indications, and clinical utility remain unclear. To evaluate the role of second-look hysteroscopy after metroplasty for septate uterus, focusing on the incidence of residual septum and IUAs, reproductive outcomes, and preferred timing and indications for follow-up. A systematic search of PubMed, Scopus, Web of Science, and Cochrane CENTRAL (from inception to March 2025) was conducted using terms related to "second-look hysteroscopy" and "septate uterus." Reference lists of included articles were also screened manually. Studies reporting on women with a diagnosis of septate uterus who underwent hysteroscopic metroplasty followed by second-look hysteroscopy were included. Eligible designs were randomized controlled trials (RCTs), cohort studies, cross-sectional studies, case series, and case reports. Two independent reviewers extracted data on study characteristics, surgical approach, second-look findings, reproductive outcomes, and timing between procedures. The Joanna Briggs Institute tools were used to assess methodological quality. A total of 15 studies involving 1409 women undergoing metroplasty were included. Among them, 933 (66.2%) underwent second-look hysteroscopy at a mean of 10 weeks (range: 4-20). Residual septa ≥1 cm were found in 2.6% of cases. IUAs were reported in 1%-35% of patients but fell below 10% in studies using antiadhesion barriers. Reproductive outcomes were reported for 637 women actively trying to conceive: 422 pregnancies (66.2%), a live birth rate of 56.2%, and a pregnancy loss rate of 9.6%. Selective use of three-dimensional (3D) sonohysterography showed high diagnostic concordance with hysteroscopy, potentially reducing the need for routine invasive follow-up. Second-look hysteroscopy provides diagnostic and therapeutic value, particularly in patients at risk for residual septum or IUAs. Its selective use, combined with adjunctive tools such as 3D imaging and adhesion barriers, may improve outcomes while avoiding unnecessary procedures. High-quality prospective trials are needed to better define timing and patient selection.