Septum In Women Research Articles

Hysteroscopic Metroplasty Using Holmium: YAG Laser for Treatment of Septate Uterus

To demonstrate the safety, efficacy, and ease of hysteroscopic metroplasty using holmium:YAG (Ho:YAG) laser for treatment of septate uterus. Stepwise demonstration of surgical technique with narrated video footage. Septate uterus is the most common type of uterine anomaly. The incidence of uterine septum in women presenting with infertility and recurrent abortions is 15.4% [1,2]. Hysteroscopic septal incision is associated with improvement in live-birth rate in these women [3]. Hysteroscopic metroplasty for septate uterus can be done with the use of scissors and energy sources such as monopolar and bipolar electrosurgery and lasers. Ho:YAG laser is commonly used by urologists for various surgeries because of its "Swiss Army Knife" action of cutting, coagulation, and vaporization [4]. Ho:YAG laser is known for its precision. It causes lesser depth of tissue injury and necrosis and minimal collateral thermal damage compared with the electrosurgical devices and other lasers used for hysteroscopic surgery [5-8]. This is advantageous in hysteroscopic metroplasty given that it reduces the risk of uterine perforation during surgery and hence uterine rupture in the subsequent pregnancy. Reduced collateral damage to the surrounding endometrium helps promote early endometrial healing and prevent postoperative intrauterine adhesions. A 28-year-old patient with history of 2 spontaneous abortions came to our hospital for investigations. 3D transvaginal sonography of the patient showed presence of partial septate uterus with a fundal indentation of 1.5 cm (Supplemental video 1). Diagnostic hysteroscopy followed by septal incision using Ho: YAG laser was planned. We used a 2.9 mm BETTOCCHI Hysteroscope (Karl Storz SE & Co.) with a 5 mm operative sheath. Normal saline was used as the distending medium and the intrauterine pressure was maintained at 80 to 100 mm Hg. The procedure was done under total intravenous anesthesia using propofol injection. Vaginoscopic entry into the uterus (without any cervical dilatation) showed evidence of a partial uterine septum with tubal ostia on either side of the septum. A 400 micron quartz fiber was passed through a laser guide into the 5-Fr working channel of the operative hysteroscope. Ho:YAG laser (Auriga XL 50-Watt, Boston Scientific) with power settings of 15 watts (1500 mJ energy at 10 Hz) was used. Incision of the septum was started at the apex of the septum in the midline and continued in a horizontal manner from side to side toward the base (Supplemental video 2). Incision of the septum is continued till the tip of the hysteroscope can move freely from one ostium to the other (Supplemental video 3). The operative time was 12 minutes. There were no intra- or postoperative complications. Postoperative estrogen therapy was given for 2 months in the form of estradiol valerate 2 mg (tablet, Progynova, Zydus Cadila) 12 hourly orally for 25 days and medroxyprogesterone acetate 10 mg (tablet, Meprate, Serum Institute of India, Ltd) 12 hourly orally added in the last 5 days [9]. 3D transvaginal ultrasound was done on day 8 of menses. It showed a triangular uterine cavity with a very small fundal indentation of 0.37 cm. A second look hysteroscopy that was done on day 9 of menses showed an uterine cavity of good shape and size [10]. Few fundal adhesions were seen and they were incised using Ho:YAG laser. The patient conceived 5 months after the primary surgery and delivered by cesarean section at 38 weeks, giving birth to a healthy baby of 2860 grams. There were no complications during her pregnancy and delivery. A comparative study is essential to prove its advantages over other energy sources for this surgery. Hysteroscopic metroplasty using Ho:YAG laser for treatment of septate uterus is a simple, precise, safe, and effective procedure. VIDEO ABSTRACT.

Uterine Septum Surgery

The management of uterine septum is a highly controversial subject. There are conflicting reports on the benefits of the procedure. The lecture will attempt to analyse the primary reasons behind the controversy, and put forward a pragmatic, modern approach to the management of uterine septum in women with reproductive failure, including precision in diagnosis, patient selection for expectant vs surgical options, various surgical techniques for different types of septum, recommended post-operative care to ensure optimal outcome, and proposed monitoring in a subsequent pregnancy.

Thickness of the ventricles and interventricular septum in men and women of the mesomorphic body type with normal body mass index according to echocardiography

The aim of the study was to establish the thickness of the ventricles and interventricular septum in individuals of the mesomorphic body type with a normal body mass index according to echocardiography and to assess the presence or absence of a relationship of these parameters with the gender and age of the subjects. Material and methods. The analysis of the protocols of ultrasound examination of the heart of 202 conditionally healthy persons of adolescence, the first and second periods of adulthood of the mesomorphic body type with a body mass index of 18.5–24.99 kg/m² was carried out. They have no pulmonary and cardiac pathology and risks of cardiovascular diseases. All subjects were divided into three age groups according to the age periodization of human ontogenesis (Moscow, 1965). Echocardiography was performed using a scanner Aloka ProSound Alpha 6. Results. The thicknesses of the anterior wall of the right ventricle, the posterior wall of the left ventricle, and the interventricular septum in women of the second period of adulthood is greater, than in young girl and women of the first period of adulthood (p ˂ 0.05); the thickness of the interventricular septum in men of the second period of adulthood is greater, than in young men and men of the first period of adulthood (p ˂ 0.05). It has been established that the thickness of the anterior wall of the right ventricle and interventricular septum depends on person gender: it is greater in men. In women, moderate correlation was found between the thickness of both the left ventricle (r = 0.425; p < 0.001) and the right (r = 0.411; p < 0.001) with age. A direct relationship (moderate strength) of the thickness of the interventricular septum with age (r = 0.331; p = 0.014) was found in men. Conclusion. The results of this morphological study supplement the information available in the scientific literature on the thickness of the ventricles of the heart and interventricular septum in a conditionally healthy person of the mesomorphic body type with a normal body mass index.

Retrospective cohort study of the risk factors for secondary infertility following hysteroscopic metroplasty of the uterine septum in women with recurrent pregnancy loss.

PurposeA hysteroscopic metroplasty was performed for women with recurrent pregnancy loss owing to a uterine septum, following which some women became infertile. The aim of this study was to elucidate the risk factors of secondary infertility 1 year after hysteroscopic metroplasty for a uterine septum.MethodsA retrospective, single‐center, cohort study included women with a history of at least two miscarriages that had been attributed to a uterine septum who underwent a hysteroscopic metroplasty. The patients’ background data were compared between the patients who conceived and those who remained infertile at 1 year postoperatively. The data were analyzed by using the Mann–Whitney U‐test and multivariate analyses.ResultsThe postoperative live birth rate was 83.9% (n = 26), with persistent infertility in five women at 1 year. When comparing the pregnancy group with the infertile group, the women in the postoperative infertility group were significantly older than those in the postoperative pregnancy group. The multivariate analysis showed that age was an independent risk factor for persistent infertility.ConclusionAge was identified as an independent risk factor for postoperative secondary infertility. Therefore, surgery as early as possible is recommended.

Incidence of Septate Uterus in Reproductive-Aged Women With and Without Endometriosis

Study ObjectiveTo compare the incidence of a uterine septum in women with and without endometriosis and if such incidence correlates with the stage of endometriosis Although a correlation between obstructive Mullerian anomalies and endometriosis has been well established, its link with non-obstructive anomalies remains controversial. To elucidate whether there is a correlation between endometriosis and non-obstructive Mullerian anomalies, we conducted this prospective study on all patients admitted to our Reproductive Endocrinology and Infertility surgical service from February 1, 2010 through June 30, 2012. All patients underwent both hysteroscopy and laparoscopy. Surgical indications included: infertility, pain, and/or menorrhagia. The presence or absence of endometriosis and uterine anomalies were recorded immediately after each surgery and subsequently analyzed. Endometriosis was staged according to the r-ASRM Classification and treated by resection and ablation of deep and superficial lesions, respectively. Since uterine septum is the most common Mullerian anomaly, we considered only this anomaly to test the hypothesis that uterine septum may be associated with an increased incidence of endometriosis. DesignProspective Study. Evidence from a well-designed case-control study (Canadian Task Force classification II-2). SettingUniversity-affiliated tertiary care center. PatientsReproductive aged women admitted to our service for treatment of pelvic pain, abnormal uterine bleeding, and/or infertility. InterventionAll patients underwent both hysteroscopy and laparoscopy as part of their evaluation and treatment of pelvic pain, abnormal uterine bleeding, and/or infertility. Measurements and Main Results343 patients were included in the study. The diagnosis of each patient included infertility - 52, pain - 215, both - 30 and other - 46. The diagnosis of septate uterus was made at hysteroscopy when the endometrial cavity was separated by an avascular septum that obscured visualization of both cornua when the hysteroscope was advanced to the mid-uterine segment. The septum was lysed sharply from cornua to cornua restoring normal fundal configuration. In all cases, the septolysis was bloodless, confirming its avascular nature. The overall incidence of uterine septum was 33% in our patient population. In patients with a histologically confirmed diagnosis of endometriosis, the incidence of septum was 37% versus 27% in patients without endometriosis (P = .046). In patients with advanced endometriosis, Stage IV disease, the incidence of septate uterus was 41% (P = .022). The odds ratio of Stage IV endometriosis with a uterine septum was 1.94 (CI 1.09-3.44). ConclusionThe incidence of septate uterus in our population of women with infertility and/or pelvic pain ranges from 27% to 37%, being significantly higher in women with endometriosis and mores so with Stage IV disease. Our data suggests that the presence of a uterine septum may predispose to more advanced disease.

Reproductive outcome following hysteroscopic treatment of uterine septum.

Background:Septate uterus is the most common uterine anomaly and a cause for miscarriage and infertility. Existing data suggested a better reproductive outcome of uterine septum following hysteroscopic septum resection.Objective:Current study was administered to share our experience in hystroscopic septum resection for reproductive outcome following hysteroscopic treatment of uterine septum and specifically focusing on different treatment protocols after hysteroscopic septum resection.Methods& materials:This study was a cross-sectional study based on secondary data that was obtained from medical records of infertile women who had undergone transvaginal hysteroscopy and used different treatment protocols after hysteroscopic correction of uterine septum in Infertility and Reproductive Health Research Center between April 2005 and February 2014.Results:The total number of infertile women underwent hysteroscopy uterine septoplasty was 106. The hysteroscopy septoplasty resulted in an overall pregnancy rate of 67% and a live birth 57.5%. Pregnancy rate for patients who had not male infertility was 92.1%. The chi-square test did not reveal any statistically significant difference in side affect, pregnancy, live birth, abortion, preterm deliveries, and term deliveries rate between these patients either with consistent hormone therapy plus IUD insertion or with alternate hormone therapy plus IUD after hysteroscopic metroplasty.Conclusion:The findings of the present study indicated hysteroscopic septum resection to remove a uterine septum in women with infertility is safe and may be an efficacious procedure. Treatment following hysteroscopic septum resection, either the consistent or the alternate protocol is both beneficial to improve pregnancy rate.

Hysteroscopic Resection of Uterine Septum and Reproductive Outcome in Women with Unexplained Infertility

Background/Aims: To investigate the reproductive outcome after hysteroscopic resection of uterine septum in women with septate uterus and otherwise idiopathic primary infertility. Methods: Sixty-eight patients with septate uterus and idiopathic primary infertility were included in this prospective observational study. All patients underwent hysteroscopic metroplasty with scissors under general anesthesia. Main outcome measures were clinical pregnancy rate, live birth and abortion rate at 12 months’ follow-up and at mean follow-up time. Results: At 12 months’ follow-up, the clinical pregnancy rate, the live birth rate and the abortion rate were 44% (30/68), 36.8% (25/68) and 16.6% (5/30), respectively. At total follow-up time, the overall pregnancy rate, the live birth rate and the abortion rate were 53.8% (35/65), 41.5% and 14.2% (7/35), respectively, while the stillbirth rate was 2.8% (1/35). Conclusion: Hysteroscopic metroplasty in women with septate uterus and unexplained infertility could improve clinical pregnancy rate and live birth rate in patients with otherwise unexplained infertility. If such a patient is looking for a spontaneous pregnancy, this is more likely to occur during the first 15 months following the procedure.

The use of intra-operative saline sonovaginography to define the rectovaginal septum in women with suspected rectovaginal endometriosis: a pilot study.

Objectives: The aim of this study was to perform saline sonovaginography (SVG) in women with suspected rectovaginal endometriosis (RVE) in order to establish the thickness of the rectovaginal septum (RVS) in this population and to predict the presence or absence of RVE. Methods: Prospective observational pilot study. Women undergoing laparoscopy for possible endometriosis on the basis of history or clinical examination were offered to participate in the study. All women underwent saline SVG during general anesthesia just prior to their laparoscopy. RVS nodules were visualised as hypoechoic lesions of various shapes. The sonologist predicted whether or not a nodule was present in the retrocervical area or in the RVS. The thickness of the posterior vaginal wall ± RVS was then taken at three points in the mid‐sagittal plane: at the posterior fornix (retrocervical area), at the middle third of the vagina (upper RVS) and just above the perineal body (lower RVS). The diagnosis of RVE was established using the gold standards of laparoscopy and histological confirmation. The RVS thickness was then compared between women with RVE and the absence of RVE. Results: Twenty‐three women were enrolled in the study. Mean age was 38 years (33–44 years). A history of endometriosis was present in 72.7% (8/11). RVE was confirmed in 17.4% (4/23). Visualisation of a hypoechoic nodule at saline SVG demonstrated sensitivity and specificity of 75% and 95%, respectively. All rectovaginal nodules were located in the retrocervical region. Mean diameter (SD) of RVE nodules was 27.3 (± 9.4) mm. Mean thickness of vaginal wall ± RVS at the posterior fornix, at the middle third of the vagina and just above the perineal body was 5.1, 1.4 and 4.0 mm, respectively. These measurements were not significantly different in the presence of a rectovaginal nodule. Conclusions: Using saline SVG, we have established the mean RVS thickness in a small group of women with suspected RVE. Although the numbers are small, there was no correlation between RVS thickness and presence of RVE. The visualisation of hypoechoic lesions at saline SVG seems to be the best ultrasonographic predictor for RVE. SVG is a valuable pre‐operative tool for the assessment of RVS and for the prediction of RVE, which allows for the mapping and planning of advanced endometriosis surgery.

Ultrasound: new techniques and imaging in iatrogenic conditions.

August's issue represents a new dawn for the AJUM. This is the first time the AJUM has been filled from start to finish with original scientific work. This represents a significant move towards eventual Medline listing. The Editorial Board is pleased to present seven original manuscripts in total which present on an array of subjects including saline sonovaginography to measure the rectovaginal septum, ultrasound to classify Asherman's syndrome, dermoid cysts of the ovary and caesarean scar defects as well as cases of caesarean section scar ectopic pregnancies (CSEPs). Shannon Reid follows her recent publication in May's issue of the AJUM in which she described the use of real-time sonovaginography to not only detect posterior compartment deep infiltrating endometriosis (DIE) but also predict pouch of Douglas (POD) obliteration; both ultrasound findings often overlooked with convention transvaginal ultrasound. In this issue she describes the use of intra-operative saline sonovaginography to define the rectovaginal septum in women with suspected rectovaginal endometriosis. In this pilot study, the rectovaginal septum was measured in three points in the mid-sagittal plane (retrocervical area, at the middle third of the posterior vagina and just above the perineal body). Although the numbers were small in this pilot study, there was no significant difference in the thickness of the rectovaginal septum in the three points of interest in women with and without rectovaginal DIE. The best sonographic marker for posterior compartment DIE was the presence of a hypoechoic lesion. In the paper by Dickie, et al, they evaluated the completeness and quality of referral letters sent to their Fetal Medicine Unit (FMU). They clearly demonstrated that relevant medical information was indeed missing from referral letters sent to the FMU in 57% of cases. Their study also showed that a patient questionnaire was significantly better at highlighting additional pregnancy risk factors compared to the referral letter. In the descriptive paper by Tan and Robertson, they discuss the role of ultrasound and in particular saline infusion sonohysterography (SIS) along with hysterosalpingography (HSG) in the investigation of women with Asherman's syndrome. For the identification of intra-uterine adhesions, SIS is as good or superior to HSG. 3D transvaginal ultrasound can potentially provide additional information on the location and extent of intra-uterine adhesions. Although imaging plays a greater role in the work-up of women with potential Asherman's syndrome post curettage, larger studies are needed to fully evaluate the predictive power of SIS. Kite and Uppal present a case report of a 41 year old woman who had an hCG-secreting dermoid cyst of the ovary. They carefully describe the grey-scale ultrasonographic appearances which are classically seen in dermoid cysts of the ovary. Transvaginal sonographic pattern recognition by experienced operators holds the key not only to the accurate classification of dermoid cysts of the ovary pre-operatively. This approach is the optimal way to distinguish benign and malignant adnexal masses. The last three articles in August's issue discuss caesarean section (CS) scar defects and caesarean section scar ectopic pregnancies (CSEPs). CS scar defects are seen in up to 19% of women following lower segment caesarean section. Jane Fonda clearly describes how transvaginal ultrasound, with or without saline, is the imaging modality of choice to delineate such defects. The two case reports by Ebner, et al and Debra Paoletti focus on the rare but increasingly prevalent CSEP. Although rare, ectopic pregnancy in a previous caesarean section scar is seen in 1:1800 to 1:2216 pregnancies. CSEPs account for 6% of ectopic pregnancies among women who have had a previous caesarean section. Early diagnosis using transvaginal ultrasound holds the key for early intervention in these pregnancies, which have the potential to develop into aggressive forms of anterior placenta praevia. Currently there is no consensus on the management of women diagnosed with a CSEP. Medical, surgical and even interventional radiological approaches have been described in the literature. I think the challenge in modern practice is not making the ultrasound diagnosis of CSEP but rather deciding whether ALL CSEPs do need to have intervention as advocated by tertiary referral Early Pregnancy Units. My unit advocates the use of transrectal ultrasound guided surgical evacuation of the CSEP. Can we manage some CSEPs expectantly, i.e. allow these pregnancies to develop without intervention? Surely there must be some CSEPs which are relatively benign in their development and do not represent a grave risk to both mother and fetus? This issue showcases a new sonographic technique as well as the use of ultrasound in iatrogenic conditions. I hope you enjoy the time and effort put in by both authors and reviewers. Please feel free to write “Letters to the Editor” in response to the works presented in this issue of the AJUM.

Removal of a residual portion of a uterine septum in women of advanced reproductive age: obstetric outcome

To learn more about the obstetric outcome after initial septum resection and remnant septum (< or =1 cm) resection. In 94 patients with septate uteri who underwent uterine septum resection, the reproductive efficiency was analysed in a prospective observational study. The reproductive outcome was analysed after initial resection and (if required) consecutive procedures. A total of 94 women were enrolled in the study; all had had two or more miscarriages. The septum was completely removed during the first hysteroscopy in 58 (62%) cases. A residual septum was observed in 36 (38%) patients. Subsequent operative hysteroscopy was performed in the cases (29/36; 80.5%) involving repeated miscarriage and unsuccessful conception. The minimum observation time was 24 months. The difference in delivery rate after the first hysteroscopy between those with a normalized uterine cavity (26/58; 44.8%) and those with remnants (7/36; 19.4%) was statistically significant (P < 0.05). In fact, following the normalization of the uterine cavity, 62.1% (18/29) of the patients delivered, as compared with 19.4% of those (7/36) with a residue and Kaplan-Meyer curves revealed a statistically significant difference (P < 0.05). Women with a remnant uterine septum have an increased chance of successful pregnancy with an improved obstetric outcome after normalization of the uterine cavity.

Extranasopharyngeal angiofibroma of the head and neck in women

Extranasopharengeal angiofibroma of the head and neck in women is very rare, and clinical characteristics do not confirm to that of nasopharyngeal angiofibroma. We present clinical characteristics, etiology, preoperative evaluation, and management of 3 unusual cases of angiofibroma, 1 case originating from larynx and the other 2 cases from nasal septum in women. Endolaryngeal endoscopic excision for laryngeal and local excision for septal angiofibromas were performed. The patients are free of disease. In the etiology of extranasopharyngeal angiofibroma, we suspect that ectopic tissue may become located further away than usual place and may have been the cause of the extranasopharyngeal location. Computed tomography scan, magnetic resonance imaging, and carotid angiogram are valuable in the diagnosis of extranasopharyngeal angiofibroma. Excision of the mass is the treatment of choice, and recurrence is rare.

Obstetric Outcome after Endoscopic Transection of the Uterine Septum

Study Objective To analyze results of endoscopic transection of uterine septum in women with primary infertility and history of recurrent abortion or late abortion. Design Observational study over 6 years (Canadian Task Force classification II-2). Setting University hospital. Patients Seventy women, 21 with primary infertility, 33 with recurrent abortions, and 16 with late abortion or preterm delivery. Intervention Hysteroscopic metroplasty with transection of uterine septum. Measurements and Main Results Hysteroscopic metroplasty was possibly effective for women with primary infertility, none of whom had had abortions. It was also effective in reducing the early abortion rate and in increasing term deliveries in the group with late abortion. Conclusion Endoscopic transection of uterine septum may improve obstetric outcomes in women with late abortion, decrease abortion rates in those with recurrent abortions, and avoid pregnancy loss for patients with primary infertility.

Reproductive impairment and the malformed uterus

The reproductive potential of the malformed uterus is assessed, with emphasis on problems of vertical and lateral fusion. An obstructive transverse vaginal septum, which appears to result from a rare autosomal recessive gene, can be encountered in infancy or may not manifest symptoms until the onset of menstruation when menstrual blood accumulates. Hysterectomy is the recommended treatment, except in rare cases where there is only partial failure of the cervix to develop or there is a very short distance between the vagina and the endometrial cavity. Only 1 case of successful reproduction has been documented among women with this condition. Pregnancies have been reported in instances of partial transverse vaginal septum; however, postpartum pyometra and pyocolpos can develop, requiring emergency surgical drainage. Symptoms in women with obstructed lateral fusion are related to the site of obstruction. Reproduction may occur after removal of the vaginal septum in women with a uterus didelphys with a double vagina and low vaginal obstruction. Ectopic pregnancies have been reported inw women with an obstructed rudimentary horn. Unilateral obstruction is almost always accompanied by absence of the ipsilateral kidney, suggesting that bilateral obstruction is associated with bilateral kidney agenesis with consequent nonviability of the developing embryo. Reproduction appears to be somewhat compromised by infertility, pregnancy wastage, and premature labor in patients with either a didelphic or a unicornuate uterus. The bicornuate uterus causes only minimal reproductive problems, while the septate uterus is almost always associated with reproductive failure. Examination under anesthesia or laparoscopy may be required to distinguish between these 2 types of double uterus. Excision of the septum by wedge is the recommended operative treatment of a septate uterus. After this procedure, 77% of patients in 1 series had a term delivery. 73% of all pregnancies following the surgery were carried to term.

Surgical significance of the rectovaginal septum

Gross and microscopic studies of 262 patients have shown that there is a definite rectovaginal septum in women which is probably the homologue of the rectovesical fascia of Denonvilliers in the man. The septum is difficult to demonstrate by histologic methods alone because it is adherent to the posterior vaginal wall. During posterior colporrhaphy, immediately following vaginal hysterectomy, the finger dissecting between the vagina and rectum will come upon a thin but strong membrane at the vaginal vault preventing the finger from proceeding into the rectouterine pouch of Douglas. This is the rectovaginal septum and evidence for its existence and a detailed description of its anatomic nature are given. Significant use is made of this tissue in the Bullard-Goff posterior colporrhaphy. This technique is described.