Transcript asherman

-January 11-12 2014-
HYSTEROSCOPIC SEPTUM RESECTION
Recai PABUÇCU M.D.
Ufuk University Faculty of Medicine
Obstetrics and Gynaecology Department
1
Mullerian Anomalies
American Fertility Society classification of Mullerian anomalies.
2
Mullerian Anomalies
3
Mullerian Anomalies in infertil woman
4
Mullerian Anomalies in woman
who had habituel abortus
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Michael K Bohlmann Reproductive
BioMedicine Online (2010)
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Michael K Bohlmann Reproductive
BioMedicine Online (2010)
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Uterine Septum



Most common
mullerian anomaly is
UTERINE SEPTUM.
55% of Mullerian
anomalies.
Complet or partial
defect during
uterovaginal septum
resorpsion.
8
Uterine Septum
 Complet
 Partial (subseptus)
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Diagnosis
HSG
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Bicornuate uterus – septum difference
BICORNUATE UTERUS
UTERINE SEPTUM
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Arcuate uterus diagram
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SALINE SONOHYSTEROGRAPHY
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14
Diagnosis





HSG correctness : 20-60%
TVUSG sensitivity: 100%,
spesificity: 80%
3D USG correctness: 92%
Hysterosonography
correctness: 100%
MRI correctness: 50-100%
H/S+L/S: GOLD STANDART
Taylor & Gomel et al., 2008
15
Diagnostic accuracy of sonohysterography,
hysterosalpingography and diagnostic hysteroscopy in
diagnosis of arcuate, septate and bicornuate uterus.
(D) general detection of uterine abnormalities
SHG is a noninvasive, cost-effective method available in an
outpatient setting that is highly accurate in identifying
uterine anomalies, in particular septate uterus.
Artur Ludwin J. Obstet.
Gynaecol. March 2011
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(C) Bicornuate uterus: (C-1) SHG; (C-2) HSG; (C-3) DH; and (C-4)
laparoscopy. In HSG the angle between the two uteral cavities (b) is over
60°.
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(A) Arcuate uterus: (A-1) sonohysterography (SHG); (A-2) hysterosalpingography
(HSG); (A-3) diagnostic hysteroscopy (DH); and (A-4) laparoscopy. The distance (d)
between the middle of the fundus and the line connecting the cornues of the uterus
should be more than 10 mm, but not exceeding 15 mm. The external shape of the uterus
seen in laparoscopy might be normal.
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(B) Septate uterus: (B-1) SHG; (B-2) HSG; (B-3) DH; and (B-4)
laparoscopy. In HSG the angle between the cornues of the uterus (a)
should not exceed 60°.
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Uterine Septum
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
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Reproductive outcome rate decreases
Spontaneous abortion %26- %94
Premature labor %9-%33
Fetal survival %10-%75
Spontaneous abortion after resection %5,9
Toriano et al., 2004
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Hysteroscopic metroplasty


With general or
spinal anestesia.
Must be done at
early follicular
phase.
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Hysteroscopic metroplasty
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

Microscissor
Electrocautery
Septal incision with laser.
Homer et al., 2000
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Hysteroscopic metroplasty
Reproductive outcome after resection


Abortion rate decreases from 88% to %4 after resection.
Live birth rate increases from 3% to %80 after resection.
Homer et al., 2000
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Reproductive outcome after hysteroscopic
metroplasty in women with septate uterus
and otherwise unexplained infertility

61 infertil patient with uterine septum

After hysteroscopic metroplasty

After 11.2 months follow up, 41 % (n:25) pregnancy

18 live birth

7 spontaneous abortion
Pabuçcu R.,Gomel V, Fertil Steril, 2004
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Hysteroscopic resection of the septum improves the
pregnancy rate of women with unexplained infertility: a
prospective controlled trial
Group A
44 patient
Septum +Unexplained infertility
Hysteroscopic
metroplasty
Group B
132 patient
Unexplained infertility
Expectant
management
1 year follow up without any treatment
Mollo et al, Fertil Steril 2009
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Pregnancy and live birth rate is significantly
higher in metroplasty group.
Mollo et al, Fertil Steril 2009
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Hysteroscopic metroplasty in patients with a uterine
septum and otherwise unexplained infertility
Of the 102 patients who underwent hysteroscopic
metroplasty 44(%43.1) were able to achive pregnancy, as
compered with 5(%20) of the 25 patients who did not
undergo operation.
The results indicate that hysteroscopic metroplasty
improves outcomes for patients with a uterine septum
and otherwise unexplained infertility.
Tonguc et al, 2011
28
Determinants of fertility and reproductive success
after hysteroscopic septoplasty for women with
unexplained primary infertility: a prospective analysis
of 88 cases.
Results demonstrate that reproductive failure seems to
depend on patient age, duration of infertility before
septum size.
Women with a septum size larger than one-half of their
uterine lenght have a higher chance of successful
pregnancy after hysteroscopic septoplasty.
Shokeir et al., 2011
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Results after hysteroscopic metroplasty
If the septum size is >1/2 of uterine cavity, patient may
benefit from hysteroscopic metroplasty
Istre et al, Fertl Steril 2010
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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.
Gynecol Obstet Invest 2012
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If such a patient is looking for a spontaneous
pregnancy, this is more likely to occur during the
first 15 months following the procedure.
Gynecol Obstet Invest 2012
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Hysteroscopic metroplasty: reproductive
outcome in relation to septum size
Recent studies demonstrate that hysteroscopic
metroplasty in cases of partial uterine septum and
infertility significantly improves the reproductive
performance:
-irrespectively of septum size,
-reproductive performance is independent from
previous obstetrics history.
Paradisi et al., 2013
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Cervical septum must be cut or not?


Bleeding
Cervical
incompetence
Rock et al., 1999
Valle et al., 1996
Less complication
 Higher reproductive
outcome
CURRENT PRACTICE

Valli et al., 2004
Patton et al., 2004
Parsanezhad et al., 2006
34
Hysteroscopic metroplasty of the complete uterine
septum, duplicate cervix, and vaginal septum
Multicenter, randomized, controlled study
Group A
Cervical
septumN=14
Group B
Cervical
septum+
N=14
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Cervical septum resection is suggested for the
patient with complet septum
Parsanezhad et al., Fertil Steril 2006
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Management and reproductive outcome of complete
septate uterus with duplicated cervix and vaginal septum:
review of 21 cases.


Group 1 - 11 patient – uterine septum+
-hysteroscopic metroplasty
-vaginal septum cut
-cervical septum preserved
Group 2 – 10 patient – uterine septum+
- 4 patient – vaginal septum cut
- 2 patient – L/S adhesiolysis
- 4 patient – No intervention
In group 1, the pregnancy rate is 81.8%, where ıt ıs 50% ın group 2.
The uterine septum may not necessarily be transected for patients who
have complete septate uterus with duplicated cervix and vaginal septum,
and meanwhile have no a history of poor reproductive outcome.
Chen SQ. et al., 2013
37
Small-diameter hysteroscopy with Versapoint versus
resectoscopy with a unipolar knife for the treatment
of septate uterus: a prospective randomized study
Patients with uterine septum 2001-2005
26F resectoscope
and unipolar
scissor
n=80
Less time, more fluid
absorbtion
5-mm
hysteroscope and
Versapoint
n=80
Less complication
Reproductive outcome is similar for both groups
Colacurci N, 2007
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Fertility and pregnancy outcomes following resectoscopic
septum division with and without intrauterine balloon
stenting: a randomized pilot study
26F resectoscope with monopolar electrical knife of 120 watts power
14F Foley catheter
for five days after
resectoscopic
septum division
No baloon after
prusedure
Following resectoscopic septum division with monopolar knife electrode, splinting
the uterine cavity with Foley catheter provided no advantage in septum reformation,
clinical pregnancy rate, and pregnancy outcomes
Abu Rafea et al, 2013
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The reason for high rates of miscarriage, small-fordate infants, fetal death and dystocia in woman with
septated uterus might be mechanical and due to less
of a blood supply in the septum.
Other theories include reduced vascular endothelial
growth factor receptors in septal tissue compared with
lateral endometrium.
Semin Reprod Med 2011;29:101–112.
40

There are data demonstrating the benefit of
metroplasty in reducing miscarriage rates, preterm
delivery, and fetal death in patients with a history of
recurrent miscarriage.
Semin Reprod Med 2011;29:101–112.
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Metroplasty for AFS Class V and VI septate
uterus in patients with infertility or
miscarriage: reproductive outcomes study.
After metroplasty, 60.9% of patients became pregnant, 52% of them resulted
from assisted reproductive technology.
Outcomes (miscarriages and FLBs) differed significantly according to
anatomical type of septum after surgery.
Hysteroscopic septum resection is accompanied by safe improvement in
reproductive performance in patients with symptoms of AFS class V/VI
septate uterus.
Bendifallah et al, 2013
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

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ACOG 2001: Women with pregnancy loss and a
uterine septum should undergo hysteroscopic
evaluation and resection (evidence level C)
RCOG 2003: No results of RCTs are available
NVOG: 2007: Do not perform uterine surgery unless
in the context of a clinical trial
●
Hysteroscopy for treating subfertility associated with
●
suspected major uterine cavity abnormalities (Review)
●
COCHRANE 2013: No results of RCTs are available
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Management
Istre et al, Fertl Steril 2010
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Conclusion

Hysteroscopic metroplasty
is GOLD STANDART.

For better reproductive
outcome hysteroscopic
metroplasty must be
performed before fertility
treatment
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