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Uterine fundus
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Bowel
Evaluation and Management of the Uterine Septum — 137
ing, or use of media between the groups. In contrast, Fedele et al.
[25] compared GnRH agonist with danazol as pretreatment and
noted that use of danazol made the procedure simpler and also
allowed easier introduction of the resectoscope. Although we did
use these agents earlierinourexperience,most recently for simple
uterine septum cases, we prefer not to have patients endure the
side effects of these agents, as the net gain appears negligible, and
instead proceed more expediently to surgical correction. There
may, however, be unique situations in which pretreatment might
still be considered appropriate.
Pouch of Douglas
Figure 8.1.5. Culdoscopic view of posterior aspect of the uterus showing a normal fundal outline consistent with a nonbicornuate uterus.
diagnosis 96%, 85%, and 6% of the time, respectively. Given the
expense of MRI, its use might be most appropriate for situations
that are complicated or in which multiple anomalies may concomitantly exist.
Hysteroscopy remains the standard for evaluation of intracavitary abnormalities. It additionally offers the opportunity for
treatment as further discussed. Unfortunately, hysteroscopy does
not allow evaluation of the external uterine contour, and thus
a firm diagnosis of septate versus bicornuate uterus cannot be
established simply by hysteroscopy alone. Culdoscopy has also
been suggested as an alternative to laparoscopy or other imaging technologies as a means of directly inspecting the uterine
contour. Scott and Magos [23] reported a case in which ultrasound could not rule out a bicornuate uterus but on culdoscopy
a normal uterine contour was demonstrated and allowed a hysteroscopic septoplasty to then be performed in real time (Figure
8.1.5). Laparoscopy remains the gold standard for evaluation of
the uterusand theadnexa and also provides opportunity forconcomitant visualization during the operative hysteroscopic procedure.
PROCEDURE
Preoperative
Once the work-up has been completed and a decision made to
proceed with surgery, consideration as to the timing of surgery
should occur. Generally, we prefer to perform surgery in the follicular phase as early as possible after the patient has finished
menses. At thispoint, there is minimalendometrial tissuepresent
to obscure visualization during hysteroscopy as well as limited
vascularity. Cervical cultures may be performed on patients who
might beathigher risk, anda pregnancy testshouldbe performed
if there is any possibility of pregnancy.
An alternative to performance of the surgery during the
follicular phase that has been proposed by some is the use of
gonadotropin-releasing hormone (GnRH)agonistor agents such
as danazol before surgery. Results have been mixed with some
of these interventions, especially as they relate to metroplasty.
Perino et al. [24] compared the GnRH agonist leuprolide with
no treatment preoperatively in patients undergoing septoplasty
and noted no difference in operative time, intraoperative bleed-
Surgery
The surgical technique for metroplasty has evolved profoundly
since the time when the Tompkins or Jones procedure was standard treatment. Currently, hysteroscopic techniques have supplanted open techniques unless otherpathology dictates a laparotomy. However, even in this setting, hysteroscopic treatment of
the uterine septum would still be recommended secondary to the
decrease in potential subsequent risk.
Multiple methodologies exist for the actual performance of
the surgery, including operativehysteroscopy with scissors,resectoscopic incision, laser metroplasty, and bipolar needle electrodes. Not one of these techniques has been demonstrated to
be superior to another. There were early discussions that with the
use ofelectrosurgery orlaser, there might be lateralthermal damage, which might decrease healing or increase the likelihood of
subsequent adhesion formation. Fortunately, the uterus and the
endometrium in particular appear to have a high inherent ability
to heal, making these concerns largely unfounded. Advantages
of the use of scissors (or laser) include the ability to use isotonic
solutions such as normal saline or lactated Ringer’s, which are
electrolyte containing, because electrosurgery is not being used.
In addition, scissors may often be introduced through a relatively smalloperative hysteroscope versus the larger caliber of the
resectoscope. Alternatively, the 180
◦
loop may be used with the
resectoscope, and given the larger diameter, it may be easier to
havegreatermovementoffluids within thecavity, thusimproving
visualization.
Although data suggest it is possible to perform metroplasty
without a laparoscopy in patients in whom the diagnosis of a
uterine septum is assured, many surgeons still prefer to have a
laparoscope in place to guide the procedure. Initially, it must
be ascertained if the patient also has a concomitant vaginal septum. This may be removed in the same setting, allowing easier
access to the subcavities (Figure 8.1.6).[19] Assessment should
have already been performed to evaluate if the patient has one
or two cervices. Diagnostic evaluation may then be performed
to evaluate the extent of the septum, thickness of the septum,
position of the ostia, and relative size of the two subcavities, and
whether other concomitant pathologies, such as polyps, leiomyomata, or intrauterine adhesions, exists. Depending ontheir position within the cavity, it might be necessary tofirst deal with these
issues before beginning the septoplasty. It is important to both
understand theposition of theuterus and, preferably through the
use of a tenaculum, to bring the uterus into a midaxial position.
Once the anatomy has been well defined, incision of the septum
may be started. Historically,itwas believed that theseptumwould
need to be resected. It is now apparent that in almost all cases,
even with thick septum, removal israrely required. As theseptum
138 — Eric J. Bieber and Edie L. Derian
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Figure 8.1.6. View of double cervix after resectionof longitudinal septum. Double cervices are labeled A and B. From Hundley AF et al.[4]
is slowlyincised, thetissues will retract anteriorly and posteriorly
and thus obviate the need for resection or removal. It is crucial to
stay inthe midsectionof theseptum asthe incisionproceeds. It is
relatively easy to begin incising ever moreposteriorly and eventually into the endo-ormyometrium.Bymaking slow progress with
the incisionand continuously backingawayfrom the septum and
reassessing progress, it may be easier to maintain the correct area
of incision. It is also critical as the procedure progresses to continuously monitor the position ofthe ostia tobest appreciate how
far cephalad to carry the incision. Some authors have suggested
that most uterine septa are relatively avascular and thus ata point
where bleeding is seen, the upper margin of the incision may be
reached. Unfortunately, the previously presented data regarding
the morphology of uterine septa do not exactly correlate with
the clinical picture of little bleeding and avascularity. If a laparoscope is in place, this may also help to elucidate the breadth of
the incision. Occasional transillumination will demonstrate the
relative thickness of the remaining myometrium. Unfortunately,
there is no foolproof method for gauging if the incision is not
far enough and whether a residual septum will result, possibly
requiring additional surgery, versus extending the incision too
far into the myometrium and increasing the risk of subsequent
uterine rupture. Allowing the intrauterine pressure to decrease
will also allow the surgeon a further assessment of need for additional incision and whether there are bleeding points that need
to be controlled.
In the case of a complete septum, with or without duplicated
cervices, it will be more difficult to begin the procedure. In these
situations, a Foley catheter bulb may be placed in one of the
subcavities and an incision will be required from one subcavity
to the other through the septum (Figure 8.1.7).[26] Although
some authors have advocated avoiding incisions to unifycervices,
more recent data have suggested this is unnecessary and may
increase the duration of procedures as well as difficulty, without
a substantive change in outcome.[27]
It is critical during septolysis that fluid input and output be
continuously measured. This is true for all cases, but is especially
true if using electrosurgery and hypotonic media such as glycine
or sorbitol. Although most metroplasty procedures will be of
relatively short duration, if a venous sinus is entered, fluid may
be lost at a much quicker pace.
Intravenous antibiotics may be used during metroplasty,
although little good evidence exists to support this practice in
patients who have negative cervical cultures. However, as most
patients undergoing these procedures are desirous of subsequent
fertility, risk of subacute infection may cause many surgeons to
treat with a broad-spectrum antibiotic during surgery as well as
for a period of time postoperatively.
Gynecoradiologic Procedures
Karande and Gleicher [28] reported analternate method oftreatment of the uterine septum using fluoroscopic techniques. They
reported on 14 patients who underwent incision of their septa
using hysteroscopic scissors and a special balloon cannula or
microlaparoscopy scissors and a cervical cannula. They were able
to successfully complete these procedures in the ambulatory setting. Unfortunately, long-term results are not known and this
is a small case series. The advantage of avoidance of anesthesia
and complications of fluid media must be weighed against the
exposure to ionizing radiation and the limited experience.
Postoperative Management
Postoperatively, patients may require little if any specific
treatment. Historically, balloon catheters or occasionally inert
intrauterine devices (IUDs)were placed within theuterine cavity
in an effort to keep the denuded areas where the septal incision
was performed from adhering together. Limitedspecificdataexist
to support or refute these practices. Fortunately, in the majority
of cases, few adhesions will exist postoperatively and rarely will
the walls fuse together.
Estrogen has also been administered after septoplasty in an
effort to promote endometrial regrowth into the denuded areas.
Typically, in patients who did not otherwise have a contraindication to estrogen,a relativelyhighdoseofdailyconjugatedestrogen
1.25 to 5.0 mg would be prescribed for 1 to 2 months, followed
by progestin on the last 10 days. More recently, Dabirashrafi et al.
[29] evaluated this practice by performing a randomized prospective trial on 50 patients undergoing septoplasty. At follow-up
postoperative exam, no patients in either the estrogen treatment
group or the no-treatmentgroup were noted tohave intrauterine
adhesions or septal fusion. Nawroth et al. [30] similarly retrospectively evaluated postoperative treatment via either cyclical
hormone replacement therapy (HRT) and an IUD, HRT alone,
or no treatment. Similar subsequent ongoing pregnancy rates
were seen between the groups, and the authors suggest no need
for specific postoperative treatment.
After several months, patients may be reevaluated with HSG
or hysteroscopy to assess completeness of septal removal. It has
generally been believed that a small residual septum 1 cm or less
may have a negligible impact on subsequent reproductive outcome. Fedele et al. [31] evaluated this issue studying subsequent
reproductive history in patients with a residual septum between
0.5 and 1 cm in size. In this trial, they noted no difference in
outcome between the groups with a normal cavity versus a larger
defect. Kormanyos et al. [32] evaluated this issue prospectively
by studying 94 patients who had two or more miscarriages and
Illumination
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Evaluation and Management of the Uterine Septum — 139
A
C
Figure 8.1.7. Hysteroscopic resection of a uterine septum in a patient with a class Va septate uterus. (A) Foley catheter inserted into the right
cervix. The septum is incised until the bulb is identified. (B) The remaining septum is cut with electrocautery. (C) The septum has been cut and
the cavities are united. From Rock et al.[26]
B
were undergoing hysteroscopic metroplasty. In 62%, the septum
could be removed in its entirety with the initial surgery. Followup of the group of patients with normalized cavities versus those
with a residual septum demonstrated a significant difference in
reproductive loss inthe residual group.Given these numbers,it is
worthwhile to make patientsawarethat more thenone procedure
may be required to completely restore the cavity to normal.
Results
Multiple studies have retrospectively evaluated the impact of septolysis on reproductive outcome. Unfortunately, no prospective,
randomized trials exist to help better define if there is a group
of patients who should not be treated. Many of these trials contain a cornucopia of patients ranging from primary infertility
to multiple pregnancy losses. One of the largest reported trials
evaluated 10 years of an Italian experience.[33] They noted that
in the late 1980s, procedures were evenly divided between use of
scissors and the resectoscope. Since then, the majority of procedures have been performed resectoscopically. In reporting on
pregnancy outcome after metroplasty, they note 78% of patients
reached term, 14% had miscarriages at 12 weeks or earlier, and
4% had miscarriages after 12 weeks gestation. Of interest, 88 of
808 patients had a postoperative evaluation that demonstrated a
fundal notch 1 cm or greater in size. Valle [34] reported on 124
patients with uterine septa (115 of whom had reproductive loss
140 — Eric J. Bieber and Edie L. Derian
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and nine of whom had infertility) who underwent hysteroscopic
treatment. Preoperatively, pregnancy results were poor, with 258
prior miscarriages (86.6%) and 28 preterm births (9.6%). After
hysteroscopic treatment, results were markedly improved, with
81% of patients achieving pregnancy; of these, 83% were term, 7%
were preterm but viable, and only 12% ended in first-trimester
losses. Valle also reported favorable results in a small subset of
patients who had a septum that continued through the cervix.
Homer et al. [35] reported on an analysis of multiple studies
published in the literature and found a miscarriage rate of 88%
in 658 patients prior to septoplasty with a term delivery rate of
only 3%. After surgery, this improved to a term delivery rate of
80%, with 14% miscarriages and 6% preterm. These results are
typical of the many smaller trials that are reported throughout
the literature.[36–40]
Most recently, Parsanezhad et al. [27] performed a randomized trial in patients with a complete septum extending to the
cervix, comparing incision versus preservation of the cervical
septum. They noted that preservation of the cervical septum was
associated with longer operating times, greater fluid loss during
surgery, and several cases of significant bleeding and pulmonary
edema thatwerenotseeninthegroupthathadthecervicalseptum
removed. Additionally, no differences were subsequently seen in
reproductive function.
What remains unclear is the need for surgery in a nulligravid
patient who is considering pregnancy and has been diagnosed
with a uterine septum. Undoubtedly, many such patients are
never diagnosed with an abnormality and carry their pregnancies uneventfully. Unfortunately, there again are no good data on
how to best manage this scenario. When treatment required a
laparotomy, and even early on in the hysteroscopic experience,
many investigators recommended that patients have at least three
miscarriages before entertaining treatment. As the technique has
evolved, with excellent results and low morbidity, the prior recommendations have decreased to the present time, when some
would advocate for the patient mentioned previously to undergo
surgery as a means for decreasing the potential risk of miscarriage. Contrary to this opinion, investigators in Finland retrospectively evaluated 67 patients with a complete septate uterus
and longitudinal vaginal septum.[9] In this cohort, only 36 of the
patients had their vaginal septum incised and only four underwent metroplasty. Eight of 51 women (15.7%) attempting conception were diagnosed with nonuterine infertility, whereas 49
women who did not undergo metroplasty had 115 pregnancies
(live birth, 72%; preterm, 12%; and miscarriages, 27%). Figure
8.1.8 demonstrates an ultrasound in a pregnant patient with a
displaced uterine septum.[9] In an in vitro fertilization (IVF)
unit in Israel, a 29-year-old patient with a complete uterine septum hadone embryoreplaced in each subcavity, with subsequent
pregnancies in both.[16] Interestingly, at the time of cesarean
delivery, metroplasty was attempted but subsequent evaluation
demonstrated a residual septum through 40% of the cavity
(Figure 8.1.2).
Although there is reasonable agreement that uterine septa
increase pregnancy wastage, there remain questions regarding
the impact of a septum on fertility itself. Pabuccu and Gomel
[41] evaluated this issue in a prospective observational study on
the impact of hysteroscopic metroplasty in 61 patients with primary unexplained infertility. They reported that after surgery,
41% conceived within 8 to 14 months, with 29.5% of the group
Figure 8.1.8. Sonographic image at 13th week of pregnancy reveals
lateral displacement of the uterine septum (arrows) in a woman with
a complete uterine septum and a longitudinal vaginal septum. From
Heinonen PK.[9]
having live births. They concluded thatsurgery might benefit this
cohort of patients.
A further question is the issue of management before assisted
reproductive technology (ART) treatments. Dicker et al. [42]
studied 144 women who had elevations in human chorionic
gonadotropin-beta (hCG-β) after treatment but no other clinical evidence of pregnancy, that is, preclinical spontaneous abortions. Hysteroscopydemonstrated that 14 of144 ofthese patients
(9.7%) had at least small uterine septa. Lavergne et al. [43] evaluated the pregnancy rates in patients undergoing ART treatments
who had been noted to have congenital uterine anomalies. They
found that compared with a control group with a normal uterus,
the pregnancy rate per embryo transfer wasdecreasedfrom24.9%
to 13.6% and implantation rate decreased from 11.7% to 5.8%.
They note that implantation rates increased when the underlying
anomaly could be surgically treated. These data might support
intervention before attempted ART in this higher-risk group.
Complications
Complications for hysteroscopic metroplasty include general
complications of hysteroscopy that are detailed elsewhere
throughout thetext and includethose of fluidmedia as alluded to
previously as well as traumatic and hemorrhagic complications.
Kazer et al. [44] reported on two cases of late hemorrhage after
metroplasty, an uncommon complication. In one of the larger
series to be published on operative hysteroscopic complications,
Propst et al. [45] noted a complication rate of 9.5% for uterine
septum resection. Unfortunately, there were only 21 metroplasties in this case series, two of which had complications.
One recognized complication of septoplasty is subsequent
uterine rupture. It is felt that the general risk of this complication is low given that the active myometrium is likely minimally disrupted. For this reason, cesarean section is not usually recommended unless an obstetric indicationexists. However,
there are now several case reports of uterine rupture after prior
Figure 8.1.9. Transvaginal ultrasound: one uterine fundus with two
https://t.me/med1917
uterine cavities. A gestationalsac approximately 20 mm was seenin the
right portion of the cavity, and an intrauterine device was seen in the
left portion of the cavity. [48]
hysteroscopicresection. Interestingly,they include cases in which
no electrosurgery was used and there was no evidence of uterine
perforation at the time of surgery. Conturso et al. [46] reported
on a patient who had undergone a hysteroscopic resection of
a septum that was complicated by a fundal perforation. In the
subsequent pregnancy, the patient was noted at 28 weeks to
have a uterine rupture with protrusion of the amniotic sac. In
another report, Angell [47] described a patient who underwent
an uncomplicatedhysteroscopicmetroplastywithscissors.Subsequent evaluation demonstrated a residual septum, suggesting that
the procedure did not involve active entry into the myometrium.
During the patient’s subsequent pregnancy, a perforation of the
fundus from cornua tocornua was noted, causing exteriorization
of the fetus and placenta. Given these reports, it is advisable to
monitor patients who have undergone prior uterine surgery with
a heightened sense during labor. Should there be abnormalities
in fetal heart patterns or maternal abdominal pelvic pain, consideration should be given to the possibility of uterine rupture,
with appropriate intervention if necessary.
The potential risk ofauterine septum must also beconsidered
in cases of intrauterine contraception. If the diagnosis has not
been previously made, an IUD may be placed into one subcavity.
Dikensoy et al. [48] reported on a pregnant patient in whom the
IUD was readily visible in the one subcavity while the pregnancy
was visible in the other (Figure 8.1.9).
CONCLUSION
The management oftheuterine septum haschangeddramatically
in the last quarter-century, and patients have certainly benefited
from the evolution of minimally invasive techniques. In spite of
these advances, many questions remain to be answered regarding which patients should undergo treatment and at what point.
Recent case reports have generatedquestions regarding theapplicability of prior hypotheses on embryogenesis that have caused
Evaluation and Management of the Uterine Septum — 141
reevaluation of these older theories. Given the wide variety of
manifestations that may be seen with urogenital anomalies, the
astute clinician will needtocontinuallyreaddresshisor her thinking on these relatively common entities.
REFERENCES
1. Troiano RN. Magnetic resonance imaging of mullerian duct
anomalies of the uterus. Top Magn Reson Imaging . 2003;14:269–
279.
2. The American Fertility Society. Classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal
ligation, tubal pregnancies, mullerian anomalies and intrauterine
adhesions. Fertil Steril. 1988;49:944–955.
3. Salim R, ReganL, Woelfer B, Backos M, Jurkovic D. Acomparative
study ofthemorphology ofcongenitaluterineanomaliesinwomen
with and without a history of recurrent first trimester miscarriage.
Hum Reprod. 2003;18:162–166.
4. Hundley AF, Fielding JR, Hoyte L. Double cervix and vagina with
septate uterus: an uncommon mullerian malformation. Obstet
Gynecol. 2001;98:982–985.
5. Chang AS, Siegel CL, Moley KH, Ratts VS, Odem RR. Septate
uterus with cervical duplication and longitudinal vaginal septum:
a report of five new cases. Fertil Steril. 2004;81:1133–1136.
6. Muller P, Musset R, Netter A, Solal R, Vinourd JC, Gillet JY. [State
of the upper urinary tract in patients with uterine malformations.
Study of 133 cases.] Presse Medicale. 1967;75(26):1331–1336.
7. Fedele L, Bianchi S, Agnoli B, Tozzi L, Vignali M. Urinary
tract anomalies associated with unicornuate uterus. JUrol.
1996;155:847–848.
8. Valle RF, Sciarra JJ. Hysteroscopic treatment of the septate uterus.
Obstet Gynecol. 1986;67:253–257.
9. Heinonen PK. Complete septate uterus with longitudinal vaginal
septum. Fertil Steril. 2006;85:700–705.
10. Sparac V, Kupesic S, Ilijas M, Zodan T, KurjakA. Histologic architecture and vascularization of hysteroscopically excised intrauterine septa. J Am Assoc Gynecol Laparosc. 2001;8:111–116.
11. Fedele L, Bianchi S, Marchini M, Franchi D, Tozzi L, Dorta M.
Ultrastructural aspects of endometrium in infertile women with
septate uterus. Fertil Steril. 1996;65:750–752.
12. Proctor JA, Haney AF. Recurrent first trimester pregnancy loss is
associated with uterine septum but not with bicornuate uterus.
Fertil Steril. 2003;80:1212–1215.
13. Reuter KL, Daly DC, Cohen SM. Septate versus bicornuate uteri:
errors in imaging diagnosis. Radiology. 1989;172:749–752.
14. Pellerito JS, McCarthy SM, Doyle MB, Glickman MG, DeCherney
AH. Diagnosisof uterine anomalies: relative accuracy ofMRimaging, endovaginal sonography, and hysterosalpingography. Radiol-
ogy. 1992;183:795–800.
15. Alborzi S, Dehbashi S, Parsanezhad ME. Differential diagnosis of
septate and bicornuate uterus by sonohysterographyeliminatesthe
need for laparoscopy. Fertil Steril. 2002;78:176–178.
16. Weissman A, Eldar I, Malinger G, Sadan O, Glezerman M, Levran D. Successful twin pregnancy in a patient with complete
uterine septum corrected during cesarean section. Fertil Steril.
2006;85(2):494.e11–4.
17. Raga F, Bonilla-MusolesF,Blanes J, Osborne NG.Congenitalmullerian anomalies: diagnostic accuracy of three-dimensional ultrasound. Fertil Steril. 1996;65(3):523–528.
18. Ayida G, Harris P, Kennedy S, Seif M, Barlow D, Chamberlain P.
Hysterosalpingo-contrast sonography (HyCoSy) using Echovist200 in the outpatient investigation of infertility patients. Br J
Radiol. 1996;69:910–913.
142 — Eric J. Bieber and Edie L. Derian
https://t.me/med1917
19. CarringtonBM,Hricak H, Nuruddin RN, Secaf E, Laros RK Jr,Hill
EC. Mullerianduct anomalies: MRimaging evaluation.Radiology.
1990;176:715–720.
20. Patton PE, NovyMJ, Lee DM, HickokLR. The diagnosis andreproductive outcome after surgical treatment of the complete septate
uterus, duplicated cervix and vaginal septum.AmJ Obstet Gynecol.
2004;190:1669–1675.
21. Fedele L, Dorta M, Brioschi D, Massari C, Candiani GB. Magnetic
resonanceevaluation of doubleuteri. Obstet Gynecol. 1989;74:844–
847.
22. Doyle MB. Magnetic resonance imaging in mullerian fusion
defects. JReprodMed. 1992;37:33–38.
23. Scott P, Magos A. Culdoscopy to examine the contour of the
uterus before hysteroscopicmetroplastyforuterineseptum. BJOG.
2002;109:591–592.
24. Perino A, ChianchianoN, PetronioM, Cittadini E. Role of leuprolide acetatedepotinhysteroscopic surgery: a controlledstudy.Fertil
Steril. 1993;59:507–510.
25. Fedele L, Bianchi S, Gruft L, Bigatti G, Busacca M. Danazol versus a gonadotropin-releasing hormone agonist as preoperative
preparation for hysteroscopic metroplasty. Fertil Steril. 1996;65:
186–188.
26. Rock JA, Roberts CP, Hesla JS. Hysteroscopic metroplasty of the
Class Va uterus with preservation of the cervical septum. Fertil
Steril. 1999;72:942–945.
27. Parsanezhad ME, Alborzi S, Zarei A, et al. Hysteroscopic metroplasty of the completeuterineseptum,duplicatecervix,andvaginal
septum. Fertil Steril. 2006;85:1473–1477.
28. Karande VC, Gleicher N. Resection of uterine septum
using gynaecoradiological techniques. Hum Reprod . 1999;14:
1226–1229.
29. Dabirashrafi H, Mohammad K, Moghadami-Tabrizi N, Zandinejad K, Moghadami-Tabrizi M. Is estrogen necessary after hysteroscopic incision of theuterineseptum? J AmAssoc Gynecol Laparosc.
1996;3:623–625.
30. Nawroth F, Schmidt T, Freise C, Foth D, Romer T. Is it possible to recommend an “optimal” postoperative management after
hysteroscopic metroplasty? A retrospective study with 52 infertile patients showing a septate uterus. Acta Obstet Gynecol Scand.
2002;81:55–57.
31. Fedele L, Bianchi S, Marchini M, Mezzopane R, Di Nola G, Tozzi
L. Residual uterine septum of less than 1 cm after hysteroscopic
metroplasty does not impair reproductive outcome. Hum Reprod .
1996;11:727–729.
32. Kormanyos Z, Molnar BG, Pal A. Removalof a residual portion ofa
uterine septum in women of advanced reproductive age: obstetric
outcome. Hum Reprod . 2006;21:1047–1051.
33. Colacurci N,DePlacidoG,PerinoA,Mencaglia L,Gubbini G. Hysteroscopic metroplasty. J Am Assoc Gynecol Laparosc. 1998;5:171–
174.
34. Valle RF. Hysteroscopic treatment of partial and complete uterine
septum. Int J Fertil Menopausal Stud. 1996;41:310–315.
35. Homer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril. 2000;73:1–14.
36. Saygili-Yilmaz E, Yildiz S, Erman-Akar M, Akyuz G, Yilmaz Z.
Reproductiveoutcomeofseptateuterus after hysteroscopicmetroplasty. Arch Gynecol Obstet. 2003;268:289–292.
37. Valli E, Vaquero E, Lazzarin N, Caserta D, MarconiD, Zupi E.Hysteroscopic metroplasty improves gestational outcome in women
with recurrent spontaneous abortion. JAm Assoc Gynecol Laparosc.
2004;11:240–244.
38. Venturoli S, Colombo FM, Vianello F, Seracchioli R, Possati G,
Paradisi R. A study of hysteroscopic metroplasty in 141 women
with a septate uterus. Arch Gynecol Obstet. 2002;266:157–159.
39. Grimbizis G, Camus M, Clasen K, Tournaye H, De Munck L,
Devroey P. Hysteroscopic septum resection in patients with recurrent abortions or infertility. Hum Reprod . 1998;13:1188–1193.
40. Litta P, Pozzan C, Merlin F, et al. Hysteroscopic metroplasty
under laparoscopic guidancein infertile women with septateuteri:
follow-up of reproductive outcome. JReprodMed. 2004;49:274–
278.
41. Pabuccu R, Gomel V. Reproductive outcome after hysteroscopic
metroplasty in women with septate uterus and otherwise unexplained infertility. Fertil Steril. 2004;81:1675–1678.
42. Dicker D, Ashkenazi J, Dekel A, et al. The value of hysteroscopic
evaluation in patients with preclinical in-vitro fertilization abortions. Hum Reprod. 1996;11:730–731.
43. Lavergne N, Aristizabal J, Zarka V, Erny R, Hedon B. Uterine
anomalies and in vitro fertilization: what are the results? Eur J
Obstet Gynecol Reprod Biol. 1996;68:29–34.
44. Kazer RR, Meyer K, Valle RF. Late hemorrhage after transcervical
division of a uterine septum: a report of two cases. Fertil Steril.
1992;57:930–932.
45. Propst AM,LibermanRF,Harlow BL, Ginsburg ES. Complications
of hysteroscopicsurgery:predicting patientsatrisk.ObstetGynecol.
2000;96:517–520.
46. Conturso R, Redaelli L, Pasini A, Tenore A. Spontaneous uterine
rupture with amniotic sac protrusion at 28 weeks subsequent to
previous hysteroscopic metroplasty. Eur J Obstet Gynecol Reprod
Biol. 2003;107:98–100.
47. Angell NF, Tan Domingo J, Siddiqi N. Uterine rupture at term
after uncomplicated hysteroscopic metroplasty. Obstet Gynecol .
2002;100:1098–1099.
48. Dikensoy E, Kutlar I, Gocmen A, Graves CR. Two cases of uterine
septum with intrauterine device. Br J Radiol. 2005;78:952–953.
Section 8.2. Intrauterine Adhesions: Hysteroscopic Evaluation
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and Treatment
R afael F. Va l l e
Intrauterine adhesions may interfere with bothnormalreproduction and menstrual patterns. When surgical treatment is undertaken under direct visualization using a hysteroscope, the altered
menstrual patterns and the impaired reproductive function are
markedly improved.
ETIOLOGY AND PATHOPHYSIOLOGY
Intrauterine adhesions are scars that result from trauma to a
recently pregnant uterus. In over 90% ofthe cases, they arecaused
by curettage.[1–3] Usually, the trauma has occurred because of
excessivebleeding requiring curettage1 to 4weeks after adelivery
of a term or preterm pregnancy orafteraninducedabortion.During this vulnerable phase of the endometrium, any trauma may
denude or remove the basalis endometrium, causing the uterine
walls to adhere to each other and form a permanent bridge, distorting the symmetry of the uterine cavity. Inrare circumstances,
conditions such as abdominal metroplasties or myomectomies
may cause intrauterine adhesions, butthese adhesions are usually
the result of misplaced sutures rather than the true coaptation of
denuded areas ofmyometrium that occurs following postpartum
or postabortal curettage.[3]
The type and consistency of these adhesions vary: Some are
focal, some extensive, some mild, and some thickened and dense,
with extensive fibromuscular or connective tissue components.
The extent and type of uterine cavity occlusion correlate well
with the extent of trauma during the vulnerable phase of the
endometrium following a recent pregnancy. Some adhesions are
focal; others completely occlude the uterine cavity. Consistency
usually follows thelongevity and duration of these adhesions, the
older ones being thickened and dense and formed by connective
tissue.[4–7]
Reproductive outcome seems to correlate well with the type
of adhesions andtheextentof uterine cavity occlusion.Therefore,
it is usefulto have a way ofclassifying these adhesionsas filmy and
composed of endometrial tissue, fibromuscular, or composed of
connective tissue. The degree of uterine cavity occlusion is also
important. Attempts to classify intrauterine adhesions by hysterosalpingography (HSG) give a good appraisal of the extent of
uterine cavity occlusion,but it isimpossible to determine byHSG
the type of adhesions that are present. When using hysteroscopy
alone, it is difficult to assess the extent of uterine cavity occlusion
by visualization because the axis to the hysteroscopist is from the
cervix to the fundus and not perpendicular to the uterine body
as hysterography is, outlining the uterine cavity from a different
axis. For this reason, the combination of HSG and hysteroscopy
has been used most commonly to assess not only the extent of
uterine cavity occlusion, but also the type of adhesions found by
hysteroscopy atthe time of treatment. Valle andSciarra [3]used a
three-stage classification of the extent andseverity ofintrauterine
adhesions (mild, moderate, and severe) based on the degree of
involvementshown on HSG and theextent and type ofadhesions
found on hysteroscopy. Three stagesof intrauterine adhesions are
defined as follows [3]:
Mild adhesions: filmy adhesions composed of basalis endometrial tissue producing partial or complete uterine cavity occlusion.
Moderate adhesions: fibromuscular adhesions – characteristically thick and still covered with endometrium that may bleed
upon division – that partially or totally occlude the uterine
cavity.
Severe adhesions: adhesions composed of connective tissue
only, lacking any endometrial lining, and not likely to bleed
upon division. Theseadhesionsmaypartially or totally occlude
the uterine cavity.
Recently, the American Fertility Society (now the American Society of Reproductive Medicine) proposed a classification of intrauterine adhesions based on the findings at HSG and
hysteroscopy and their correlation with menstrual patterns.[8]
Using a uniform classification for intrauterine adhesions greatly
enhances our ability to evaluate, report, and compare results of
different treatments of intrauterine adhesions, particularly when
using these modalities following the hysteroscopic approach.
DIAGNOSIS AND INDICATIONS
FOR TREATMENT
Intrauterine adhesions frequently result in menstrual abnormalities, such as hypomenorrhea or evenamenorrhea, depending on
the extent of uterinecavity occlusion. Patients with long-standing
intrauterine adhesions may also develop dysmenorrhea. Over
75% of women with moderateor severe adhesions will have either
amenorrhea or hypomenorrhea. Patients with significant uterine
cavity occlusion secondary to intrauterine adhesions experience
menstrual abnormalities more frequently, particularly amenorrhea (37%) and hypomenorrhea (31%). Patients with minimal or focal intrauterine adhesions may not demonstrate obvious menstrual abnormalities and may continue to have normal
menses.[9]
Patients may also exhibit problems in reproduction, particularly pregnancy wastage, should theadhesions nottotally occlude
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the uterine cavity. When total amenorrhea and total uterine cavity occlusion exist, the patient will generally be infertile. Other
problems associated with intrauterine adhesions are premature
labor, fetal demise, and ectopic pregnancy. When pregnancy is
carried to term, placental insertion abnormalities, such as placenta accreta, percreta, or increta, may occur. Schenker and Margalioth [9] evaluated 292 patients who did not receive treatment
for intrauterine adhesions. Of these, 133 women (45.5%) conceived, and of these, only 50 (30%) achieved a term pregnancy;
38 (23%) had preterm labor, and 66 patients had a spontaneous
abortion (40%). In 21 patients (13%), placenta previa, ectopic
pregnancy, and abnormal placental insertions, such as placenta
accreta, were diagnosed.
The most important clue to the diagnosis of intrauterine
adhesions is a history of trauma to the endometrial cavity, particularly following delivery or abortion. Secondary to that is a
history of amenorrhea or hypomenorrhea. Because intrauterine adhesions are not related to hormonal events, an intact
hypothalamic–pituitary–ovarian axis should result in a biphasic basal body temperature curve demonstrating ovulation; failure to withdraw from a progesterone challenge test in a patient
who has a history of postpartum or postabortion intrauterine
manipulation and who is amenorrheic will strengthen the diagnosis. Uterine sounding has been used to ascertain obstruction
of the internal cervical os, but this test should be abandoned
because of an increased danger of uterine perforation as well
as inaccuracy of diagnosis. The most useful screening test for
intrauterine adhesionsis a hysterosalpingogram. It provides evaluation of the internal cervical os and uterine cavity, delineation
of the adhesions, and information about the condition of the
rest of the uterine cavity if adhesions do not completely occlude
this area. About 1.5% of hysterosalpingograms performed for
infertility evaluation demonstrate intrauterine adhesions.[10]
When hysterosalpingograms are performed for repeated abortions, about 5% demonstrate intrauterineadhesions.[9]Ahistory
compatible with intrauterine adhesions will increase the yield of
HSG for intrauterine adhesions in about 39% of patients.[11]
These adhesions are stellate, irregular-shaped filling defects with
ragged contours and variable locations in the uterine cavity.
They are most commonly found in the central corporeal cavity and, less frequently, at the uterotubal cones and lower uterine
segment.
Despite the usefulness of HSG as a screening method
for patients suspected of having intrauterine adhesions, the
final diagnosis is determined only by direct visualization with
hysteroscopy because about 30% of abnormal hysterosalpingograms may be excluded and corrected by hysteroscopy.[12]
The diagnosis can be confirmed by visualization, and the appropriate treatment can be provided oncethe adhesions are observed
endoscopically.
HSG is useful in determining the extent of uterine cavity
occlusion, but it cannot provide an appraisal of the consistency
and type of intrauterine adhesions. For this reason, hysteroscopy
becomes a useful adjunct to HSG by confirming the extent and
type of intrauterine adhesions.
Other techniques, such as ultrasonography and MRI, have
been used to make this diagnosis, but their accuracy is not well
determined, and not enough experience exists with these techniques to supplant HSG and hysteroscopy.[13,14] Furthermore,
the cost of MRI may be prohibitive.
METHODS OF TREATMENT
Treatment of intrauterine adhesions is surgical, consisting of
removing those adhesions by division. In the past, blind methods of division were used with curettes, probes or dilators, or
hysterotomy-assisted division of these adhesions under direct
vision, but these techniques have failed to produce acceptable
results and largely have been abandoned. Introduction of modern hysteroscopy has permitted transcervical division of adhesions under visual guidance; hysteroscopic methods have used
mechanical means, such as hysteroscopic scissors, the resectoscope, and fiberoptic lasers.
Treatment of intrauterine adhesions with hysteroscopic scissors is the most common method employed. Because intrauterine adhesions, in general, are avascular, they may be divided (not
removed); the treatment has been similar to that for division of
a uterine septum. The adhesions are divided centrally, allowing
the uterine cavity to expand upon division of the adhesions. This
is performed using flexible, semirigid, and, occasionally, rigid or
optical scissors. The most commonly used method is the semirigid hysteroscopic scissors because of the increased facility in
manipulating the scissors, selectively dividing these adhesions
when they retract upon cutting. Occasionally, thick connective
tissue adhesions arepresent that formvery thick stumps and benefit not only from division but also from removal. To achieve this
effect, a sharp punch-biopsy forceps becomes most useful when
lateral thick adhesions are present and the technique involves not
only division of the adhesions butalso removal. It is important to
use asharp biopsyforceps to selectively sculpture the uterine cavity to achieve a uniform symmetry. This technique is also useful
at the uterotubal cones, particularly at the junction of the tubal
openings and the uterus.
Although the semirigid and flexible scissors are most useful
for the division of adhesions by hysteroscopy, the rigid optical
scissors are less helpful in this endeavor. Because of the thick,
sturdy configuration of these adhesions, when the uterine wall is
thin and sclerotic, there is greater chance of uterine perforation,
particularly because a panoramic view is impaired. Targeted dissection, which is easily obtained with the flexible and semirigid
scissors, is hampered and difficult with optical scissors (Figures
8.2.1–8.2.8).
Fluids with electrolytes should be used when dividing these
adhesions mechanically with scissors, because the adhesions are
cut close to the myometrial tissue and the extensive area of
denudation may predispose to fluid intravasation.Normal saline,
dextrose 5% in half normal saline, and Ringer’s lactate are most
appropriate. Care must be taken to measure the amount of fluid
used and the amount recovered when using the hysteroscope,
particularly if the instrument has inflow and outflow, permitting
an estimate of the amount of fluid that has not been recovered.
Care also must be taken to measure the total inflow and outflow
of fluids and ascertain that the intrauterine pressure does not
exceed the mean arterial pressure of about 100 mm Hg. These
procedures must be expedited to avoid excessive intravasation of
fluid.
Depending on the extent of uterine cavity occlusion, division
is done under visual controlbycuttingtheadhesionsinthemiddle
toavoiduterinedamageattheleveloftheuterinewall.Whenthere
is total uterine cavity occlusion, selective dissection of adhesions
begins at the internal cervical os until a neocavity is created, then
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Figure 8.2.1. Semirigid 7F hysteroscopic operative instruments (left to right: grasping forceps, sharp and pointed scissors, cup biopsy forceps).
the dissection progresses until the uterotubal conesarefree.When
extensiveadhesions are present, the hysteroscopistshould be alert
to perforation. Concomitant laparoscopy or sonography should
be considered in all cases. Upon completion of the procedure,
indigo carmine isinjected transcervically to test for tubalpatency.
The procedure is performed by systematically dividing the
adhesions and cutting asmuchasfeasible, particularly when there
is total uterine cavity occlusion.[3,15]
The advantages of using hysteroscopic scissors for the
division of intrauterine adhesions are those of mechanical
Figure 8.2.2. Hysterosalpingogram showing focal adhesion at the right cornual region.
146 — Rafael F. Valle
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Figure 8.2.3. Hysteroscopic view of the tip of scissors approaching the
adhesion for division.
methods. Mechanical tools provide excellent landmarks when
dividing these adhesions, particularly when approaching the
juxtaposed myometrium. Bleeding may be observed at the
myometrium, and this warns the hysteroscopist to stop the dissection so astoavoidperforation. No scattering ofenergies is produced to damage the small areas of healthy endometrium, which
are the reservoir for future reepithelialization. This is an important consideration because no extensive healthy endometrium
can be found when extensive intrauterine adhesions are present.
Figure 8.2.5. Hysteroscopic view of the resultant symmetric uterine
cavity following division of the adhesion.
The disadvantagesarethatitmaysometimes bedifficultto manipulate semirigid instrumentation, particularly to the lateral walls
of the uterine cavity. Scissors may not provide the sharpness or
mechanism to cut these adhesions, as the scissors do not close
well distally and need to be readjusted and sharpened frequently.
Treatment of intrauterine adhesions using the resectoscope
is an alternative to mechanical tools. The resectoscope can be
used to divide intrauterine adhesions either with a resetting
loop, aloop bent forward, or specifically designed electrodes that
can be directly applied to the adhesions, dividing them easily.
These are in the form of knives or wires that must be specifically and selectively directed to the adhesions, particularly those
in the lateral portion of the uterus or at the uterotubal cones.
When using the resectoscope, fluids without electrolytes must be
used – for example, dextrose 5% in water, glycine 1.5%, sorbitol
Figure 8.2.4. Hysteroscopic division of the adhesion.
Figure 8.2.6. Hysterosalpingogram showing focal adhesions in the
lower portion of the uterus.
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