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.

Background: Recurrent miscarriage is a distressing reproductive problem, and uterine structural anomalies are recognized contributors. Early identification of these anomalies is essential for appropriate management and improvement of future pregnancy outcomes. Objective: To determine the frequency and types of uterine anomalies among women presenting with recurrent miscarriages. Study Design: Descriptive cross-sectional study. Setting: Conducted in a tertiary care gynecology department. Duration of Study: From January 2025 to August 2025. Methods: Eighty women with a history of two or more consecutive pregnancy losses were evaluated. All participants underwent transvaginal ultrasonography to detect uterine anomalies, including septate uterus, arcuate uterus, bicornuate uterus, didelphys uterus, and endometrial polyps, according to established ultrasonographic criteria. Data analysis was performed using SPSS version 27. Descriptive statistics were used to report frequencies, percentages, and mean values. Results: The mean age of the participants was 28.13 ± 5.16 years. More than half of the women (52.5%, n = 42) had experienced more than three miscarriages. Uterine anomalies were detected in 40% of the cohort (n = 32). The most frequent anomalies were a septate uterus (15% n = 12), an arcuate uterus (10% n = 8), and endometrial polyps (8.8% n = 7). Conclusion: Uterine anomalies were identified in a substantial proportion of women with recurrent miscarriages, emphasizing their role as a significant etiological factor. Septate uterus, arcuate uterus, and endometrial polyps were the most common findings. Early detection using transvaginal ultrasound may improve reproductive outcomes.

Predicting live birth rate in patients with a septate uterus

Guideline No. 464: Recurrent Pregnancy Loss.

The study aimed to evaluate the efficacy of hormone treatment, barrier gel and their combined application following hysteroscopic metroplasty in women with septate (U2) and T-shaped uteri (U1a). Hysteroscopic uterine septum resection was performed in 236 patients with U2, while lateral metroplasty was conducted in 191 patients with U1a. After surgery, 56 women with U2 and 58 women with U1a received hormone therapy (HT). Cross-linked hyaluronic acid (cHA) gel was applied to 54 women with U2 and 37 with U1a. Combined therapy (CT) using both HT and cHA gel was implemented for 48 women with U2 and 33 with U1a. Postoperative treatment was not performed in corresponding control groups. Reproductive outcomes were evaluated within 18 ± 6 months postoperatively. Compared to the control group, the clinical pregnancy rate was significantly higher in the U2-HT, U2-cHA and U2-CT groups, as well as in the U1a-HT and U1a-CT groups (p < 0.05). The miscarriage rate was significantly lower in the U2-cHA and U2-CT groups (p < 0.05). The live birth rate was significantly higher in the U2-cHA and U2-CT groups (p < 0.05). A second-look hysteroscopy revealed intrauterine adhesions in U2-HT (9%) and its respective control group (33%), as well as in the U1a control group (18%). Hysteroscopic metroplasty enhances reproductive outcomes in women with septate and T-shaped uteri. Postoperative treatment is necessary to prevent the development of intrauterine adhesions.

Protocol (2010): https://doi.org/10.1002/14651858.CD008576.pub2 Review (2011): https://doi.org/10.1002/14651858.CD008576.pub3 Review update (2017): https://doi.org/10.1002/14651858.CD008576.pub4.

To analyze the incidence and characteristics of postoperative intrauterine adhesions (IUAs) and septal remnants (SRs) following hysteroscopic septum resection performed without anti-adhesion adjuvant therapies. This retrospective cohort study included patients with a septate uterus (U2a/U2b, ESHRE/ESGE classification) who underwent hysteroscopic septum resection without anti-adhesion adjuvant therapies between 2014 and 2023. Only patients with second-look hysteroscopy performed within 1-6 months postoperatively were included. Patients with pre-existing intrauterine adhesions, submucosal fibroids, prior septum resection, or adjuvant therapy use were excluded. Primary outcomes were the incidence, location, and type of postoperative IUAs and SRs. A total of 285 patients were included in the analysis. Postoperative IUAs were identified in two (0.7%) cases. SRs were observed in 98 (34.4%) patients, with 21 (7.4%) cases measuring <5 mm, 76 (26.7%) cases between 5-10 mm, and one (0.4%) case exceeding 10 mm. Among the 196 patients who attempted conception postoperatively, 161 (82.1%) achieved pregnancy. A total of 39 (24.2%) patients experienced miscarriage, three (1.9%) had an ectopic pregnancy, and live birth was achieved in 114 (58.2%) cases. Hysteroscopic septum resection without anti-adhesion therapies resulted in a low incidence of IUA and frequent SRs. Routine second-look hysteroscopy may aid early detection and treatment. Further studies are needed to clarify its role in optimizing reproductive outcomes.

13925 Diagnostic Imaging and Surgical Decision Making for Septum Resection in a Patient with a Bicornuate Vs Septate Uterus

14281 Strategies for Hysteroscopic Management of Retained Products of Conception in a Septate Uterus

Impact of hysteroscopic septum resection on pregnancy Outcomes: A 20-Year retrospective monocentric study.

To describe transabdominal cerclage indications and surgical technique and to illustrate a needleless laparoscopic abdominal cerclage placement in a patient with a complete septate uterus and duplicated cervices and important related considerations. Case report. This case describes a 33-year-old G2P0201 female, with a history of undergoing a loop electrosurgical excision procedure and longitudinal vaginal septum resection, and who was previously misdiagnosed with a didelphic uterus and duplicated cervices. She had a failed history-indicated transvaginal cerclage placed around the cervix connected to the gravid hemicavity during her second pregnancy and was referred to our practice for transabdominal cerclage placement. A preoperative magnetic resonance imaging scan was performed. (The patient(s) included in this video gave consent for publication of the video and posting of the video online including social media, journal website, scientific literature websites [such as PubMed, ScienceDirect, Scopus, etc.] and other applicable sites.) INTERVENTION: Needleless laparoscopic transabdominal cerclage. Preoperative workup, imaging, and surgical technique. Magnetic resonance imaging scan revealed a complete septate uterus with duplicated cervices. A needleless laparoscopic transabdominal cerclage was placed after careful dissection of the uterine vessels at the level of the internal cervical os and creation of a tunnel medial to them. Nonabsorbable, braided polyester suture was used. Transabdominal cerclage is a feasible alternative in patients with congenital uterine anomalies, as a transvaginal approach might increase the risk of failure. Accurate diagnosis through advanced imaging, multidisciplinary consultation, and individualized surgical planning are key to optimizing reproductive outcomes.

Background: Recurrent pregnancy loss affects 1–3 out of every 100 couples and has multifactorial etiology like uterine abnormalities, thrombophilia, and immune factors but often is unexplained. Uterine abnormalities are common in RPL and can cause implantation and placental growth problems but have a very good prognosis after surgical treatment. Diagnostic modalities like 3D transvaginal ultrasound are more accurate than 2D US in evaluating uterine abnormalities. Aim: The primary objective was to assess the diagnostic accuracy of hysteroscopy and 3D US in detecting uterine cavity abnormalities, specifically partial septate uterus, in cases with RPL. Patients and methods: This prospective investigation at Benha University Hospital comprised 36 cases of RPL with partial septate uterus, divided based on the uterine indentation angle. All underwent clinical examination, laboratory investigations, and imaging with 2D and 3D transvaginal US. Diagnostic hysteroscopy, being the gold standard, was noted to be beneficial for detecting subtle uterine anomalies that were missed by the other methods. Results: there was a significant agreement was observed between 3D US and hysteroscopy outcomes (Kappa = 0.833, p < 0.001). Hysteroscopy showed high accuracy in predicting outcomes consistent with 3D US, with an AUC of 0.917, sensitivity of 88.9%, and specificity of 94.4%. Conclusion: Hysteroscopy is a highly accurate and reliable tool for diagnosing partial septate uterus in RPL, with excellent concordance with 3D US. It was found to be exquisitely sensitive and specific, as good as advanced imaging. Hysteroscopy is especially useful in low-resource settings both as a diagnostic and therapeutic tool.

To study the differences in uterine contractility in women with septate uterus compared with those with a normal uterus throughout the menstrual cycle using a quantitative two-dimensional transvaginal ultrasound speckle tracking method. A multicenter prospective observational study was performed from February 2023 to July 2024. Fifty-seven patients with a diagnosis of septate uterus and seventy-one patients with a normal uterus, all of reproductive age, were enrolled at the Gynecology Departments of the University of Naples Federico II (Italy) and the Catharina Hospital in Eindhoven (Netherlands). A four-minute two-dimensional transvaginal ultrasound video in a median sagittal section of the uterus was performed throughout the various phases of the menstrual cycle to evaluate uterine contractility features, using a speckle tracking algorithm. Uterine contractility features were analyzed in all patients diagnosed with a septate uterus, including contraction frequency (in contractions per minute), amplitude, direction, median velocity (mm/sec), and coordination measured in mean squared error. Regardless of the cycle phase, patients with a septate uterus exhibited statistically significant trends of decreased contraction frequency, velocity, and amplitude, along with poorer contraction coordination, compared with patients with normal uterus. In the luteal phase, when contractions are typically quiescent to facilitate embryo implantation, an increase in contraction frequency (1.27 ± 0.21 vs. 1.10 ± 0.12), contraction velocity in posterior wall from cervix to fundus (0.90 ± 0.23 vs. 0.70 ± 0.09), contraction velocity in posterior wall from fundus to cervix (0.91 ± 0.23 vs. 0.71 ± 0.08) and a decrease in contraction coordination (0.41 ± 0.16 vs. 0.20 ± 0.08) were reported in septate uteri. Furthermore, when considering two subgroups-partial and complete septate uteri compared with normal uteri-data indicated a greater impairment of uterine contractility in partial septate uteri when compared with normal uteri. The presence of uterine pathologies, such as a septate uterus, may alter uterine peristalsis. A deeper understanding of uterine peristalsis in congenital anomalies could illuminate the link between the septate uterus and infertility. number NL52466.100.15.

Export Objective: To evaluate the diagnostic yield of combined laparoscopy and hysteroscopy (hysterolaparoscopy) in women with infertility and determine whether performing therapeutic interventions during the same session improves subsequent pregnancy rates. Methods: We conducted a prospective observational study at a tertiary university hospital in Aleppo, Syria, from August 2022 to July 2024. A total of 43 women (age 18–42) with primary or secondary infertility (≥1 year) underwent one-stage diagnostic laparoscopy with chromopertubation and hysteroscopy in the early proliferative phase of the menstrual cycle. Any detected abnormalities were managed during the same anesthesia (e.g., ovarian drilling for polycystic ovaries, adhesiolysis, endometriosis ablation, and septum resection). Preoperative evaluations included hormonal profiles and hysterosalpingography (HSG). The key outcomes recorded were the findings on HSG, laparoscopy, and hysteroscopy; the interventions performed; and the occurrence of pregnancy within 12 months post-procedure. Descriptive statistics were used for data analysis using SPSS, with pregnancy rates compared between those who did and did not receive interventions. Results: The mean age was 30.8±6.3 years, and 53.5% of women had primary infertility. HSG was abnormal in 58.3% of patients (most often revealing unilateral or bilateral tubal occlusion). Laparoscopy identified pelvic pathology in 81.4% of women, primarily peritoneal adhesions (46.5%), polycystic ovaries (32.5%), and tubal blockage (≈30%). Endometriosis lesions were observed in 13.9% and fibroids in 6.9%. Hysteroscopy detected intrauterine abnormalities in 37.2% of cases, with uterine septum (9.3%) being the most frequent finding, followed by intrauterine adhesions (4.6%), submucosal fibroids (4.6%), endometrial polyps (2.3%), and cesarean scar defect (2.3%). Therapeutic procedures were performed in 26 patients (60.5%), most commonly ovarian drilling (in 30.2% of all patients) and adhesiolysis (27.9%). Within 1-year post-surgery, 12 patients conceived, yielding an overall pregnancy rate of 27.9%. Notably, women who underwent therapeutic interventions had a higher conception rate (38.5%) compared to those who had only diagnostic examination with no intervention (11.8%). Conclusions: Combined hysterolaparoscopy provided a comprehensive evaluation of female infertility, detecting a range of tubal, peritoneal, and intrauterine pathologies with greater accuracy than HSG alone. The one-step approach allowed simultaneous treatment of correctable abnormalities, which was associated with improved fertility outcomes in our cohort. Hysterolaparoscopy is a valuable tool in infertility management, it enables diagnosis and therapy in the same session, and its use early in the infertility workup (especially for patients with normal basic investigations or abnormal HSG results) may enhance the chances of successful pregnancy.

BackgroundInfertility poses a substantial challenge in the realm of reproductive health, impacting numerous couples globally. Intrauterine abnormalities like polyps, submucosal fibroids, and uterine septa can impede the process of successful implantation and placentation, thereby contributing to infertility issues and miscarriages. Hysteroscopy has emerged as a promising therapeutic approach for addressing these intrauterine lesions. Our objective is to assess the efficacy of hysteroscopic surgery in treating intrauterine lesions and its impact on pregnancy rates among individuals experiencing primary infertility.ObjectivesOur primary objective is to assess the association between operative hysteroscopy for defined intrauterine lesions (polyps, submucous fibroids, septa) and subsequent pregnancy and live-birth rates in women with primary infertility. Secondary objectives: (i) quantify the proportion of previously undiagnosed lesions detected at hysteroscopy; (ii) explore predictors of pregnancy (age, BMI, infertility duration, and lesion type); and (iii) report outcomes stratified by conception method (spontaneous vs. assisted reproductive technology (ART)).Material and methodsThis retrospective cohort study was conducted in the Obstetrics and Gynaecology department at Salmaniya Medical Complex (SMC), Bahrain. The study included 113 patients with primary infertility due to intrauterine lesions, such as polyps, submucosal fibroids, and uterine septa, who underwent hysteroscopic surgery at SMC between September 2018 and February 2023. The primary outcome of interest was the achievement of pregnancy following hysteroscopic surgery. Secondary outcomes included the mode of conception (spontaneous or assisted). Pregnancy outcomes were confirmed through registry follow-up to ensure accuracy and reproducibility of the data.ResultsAfter operative hysteroscopy, 72 out of 113 patients (64%) achieved pregnancy. Among those who became pregnant, 73.6% had singleton pregnancies, while 26.4% had twin pregnancies. Of the patients who achieved pregnancy, 18.1% experienced miscarriage, 1.4% had an ectopic pregnancy, 62.2% carried to term, and 18.1% had preterm deliveries. The overall live birth rate was 80.6% (58 live births).The highest live birth rate was observed in the polypectomy group (37.9%), followed by the uterine septum resection group (31%), the diagnostic hysteroscopy and endometrial scratching group (15.5%), the hysteroscopic myomectomy group (8.6%), and the hysteroscopic polypectomy and myomectomy group (6.9%).ConclusionsHysteroscopic surgery for intrauterine lesions significantly improved pregnancy rates in patients with primary infertility, proving particularly effective for treating polyps, uterine septa, and submucosal fibroids. These findings underscore the importance of hysteroscopy as a valuable treatment option for patients with primary infertility and intrauterine abnormalities.

ObjectiveThe benefits of surgical treatment of uterine septum malformation have recently been questioned. The aim of our study is to compare pregnancy outcomes following hysteroscopic resection of minor versus major septum.MethodsA retrospective cohort study was conducted at a single tertiary university-affiliated medical center. All women who underwent hysteroscopic resection of uterine septum followed by a documented pregnancy between March 2010 to March 2019, were included. The septum size was assessed by ultrasound or during operative hysteroscopy by the surgeons. Two groups were defined based on septum size: 1. minor (< 50% uterine cavity); 2. major (≥ 50% uterine cavity). Cases with additional uterine malformations were excluded from the study. Data were compared between the groups before and following septum resection. A univariate and multivariate analyses were conducted.ResultsDuring the study period, 57 women met inclusion criteria, of these, 19 (33.3%) and 38 (66.7%) with minor and major septum, respectively. Baseline parameters were comparable between the groups. The rates of composite pregnancy complications before and following septum resection were also comparable between the two groups. Logistic regression analysis did not find septum size to be associated with pregnancy complications; however, comparing composite pregnancy complications prior and following septum resection revealed a trend of rate reduction in composite complications in the minor group (36.8% and 21.1% respectively) and a trend of increase in the major group (23.7% and 44.7% respectively).ConclusionsPregnancy outcomes following hysteroscopic resection of uterine septum were comparable between minor and major septum groups. Our results do not support septum removal to reduce pregnancy complications. However, due to the small sample size, further studies are required to strengthen our findings.

Background The aim of this study is to investigate the association between uterine septum and dysmenorrhea and to assess the effect of hysteroscopic resection on the severity of dysmenorrhea. Method The study group (N:50) consisted of women who underwent hysteroscopic septum resection, and the control group (N:74) consisted of women who underwent diagnostic hysteroscopy and had no significant uterine pathologies. The presence and severity of dysmenorrhea were assessed by using a 10 cm visual analog scale (VAS). The main outcome measurement was the difference between preoperative and postoperative dysmenorrhea VAS scores. Results The mean preoperative VAS score was significantly higher in the study group than the control group (4.6 ± 2.6 cm vs. 3.2 ± 2.4 cm, respectively; p = 0.023). The rates of moderate to severe dysmenorrhea were 52% in the study group and 17.5% in the control group (p = 0.025). The mean dysmenorrhea VAS score of women with uterine septum was significantly improved in postoperative 3rd and 6th months when compared to the preoperative period (3.4 ± 2.4 cm and 3.1 ± 2.3 vs. 4.6 ± 2.6 cm, respectively; P1 = 0.025 and P2 = 0.003). Conclusions Uterine septum seems to be an etiological factor for dysmenorrhea. Although there is no significant relationship between septum depth and dysmenorrhea severity, hysteroscopic resection of the uterine septum improves dysmenorrhea in the infertile study group.

Didelphic and septate uteri are congenital uterine anomalies caused by the failure of fusion of the Müllerian ducts or resorption of the median septum after fusion, respectively. These can occasionally be associated with a longitudinal vaginal septum. The combination with a transverse vaginal septum is rare, leads to menstrual obstruction, and presents with severe abdominal pain in early adolescence. We present the cases of two 12-year-old girls presenting with a uterine anomaly and concomitant longitudinal vaginal septum and hematocolpos due to the presence of a transverse vaginal septum. Congenital uterine anomalies can coexist with a longitudinal septum and rarely with a transverse vaginal septum causing obstruction. Early diagnosis and surgical correction of a transverse vaginal septum are decisive for the relief of symptoms and the prevention of future complications. Physicians should always consider the presence of complex congenital anomalies in cases of menstrual obstruction. The coexistence of uterine and vaginal anomalies in this study is not adequately described by the existing classification systems, underlining the need for a more inclusive classification system. Obstetrics & Gynecology, Pediatrics, Pediatric & Adolescent Gynecology.

Surgical and reproductive outcomes of hysteroscopic metroplasty for complete septate uterus with or without associated cervical anomalies and/or vaginal septa.

Three-dimensional transvaginal ultrasound versus MRI in the diagnosis and classification of congenital uterine anomalies: A systematic review and meta-analysis.