1 / 45

HYSTEROSCOPIC SEPTUM RESECTION

-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.

beth
Download Presentation

HYSTEROSCOPIC SEPTUM RESECTION

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. -January 11-12 2014- HYSTEROSCOPIC SEPTUM RESECTION Recai PABUÇCU M.D. Ufuk University Faculty of Medicine Obstetrics and Gynaecology Department 1

  2. Mullerian Anomalies American Fertility Society classification of Mullerian anomalies. 2

  3. Mullerian Anomalies 3

  4. Mullerian Anomalies in infertil woman 4

  5. Mullerian Anomalies in woman who had habituel abortus 5

  6. Michael K Bohlmann Reproductive BioMedicine Online (2010) 6

  7. Michael K Bohlmann Reproductive BioMedicine Online (2010) 7

  8. Uterine Septum • Most common mullerian anomaly is UTERINE SEPTUM. • 55% of Mullerian anomalies. • Complet or partial defect during uterovaginal septum resorpsion. 8

  9. Uterine Septum • Complet • Partial (subseptus) 9

  10. Diagnosis HSG 10

  11. Bicornuate uterus – septum difference BICORNUATE UTERUS UTERINE SEPTUM 11

  12. Arcuate uterus diagram 12

  13. SALINE SONOHYSTEROGRAPHY 13

  14. 14

  15. 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

  16. Diagnostic accuracy of sonohysterography, hysterosalpingography and diagnostic hysteroscopy in diagnosis of arcuate, septate and bicornuate uterus. (D) general detection of uterineabnormalities Artur Ludwin J. Obstet. Gynaecol. March 2011 SHG is a noninvasive, cost-effective method available in an outpatient setting that is highly accurate in identifying uterine anomalies, in particular septate uterus. 16

  17. (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°. 17

  18. (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 thecornues 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. 18

  19. (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°. 19

  20. UterineSeptum • 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 20

  21. Hysteroscopic metroplasty With general or spinal anestesia. Must be done at early follicular phase. 21

  22. Hysteroscopicmetroplasty • Microscissor • Electrocautery • Septal incision with laser. Homer et al., 2000 22

  23. Hysteroscopic metroplasty

  24. 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 24

  25. 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 25

  26. Hysteroscopic resection of the septum improves thepregnancy rate of women with unexplained infertility: a prospective controlled trial Group A 44 patient Septum +Unexplained infertility Group B 132 patient Unexplained infertility Expectant management Hysteroscopic metroplasty 1 year follow up without any treatment Mollo et al, Fertil Steril 2009 26

  27. Pregnancy and live birth rate is significantly higher in metroplasty group. Mollo et al, Fertil Steril 2009 27

  28. 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

  29. Determinants of fertilityandreproductivesuccessafterhysteroscopicseptoplastyforwomenwithunexplainedprimaryinfertility: a prospectiveanalysis 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 29

  30. Resultsafterhysteroscopicmetroplasty If the septum size is >1/2 of uterine cavity, patient may benefit from hysteroscopic metroplasty Istre et al, Fertl Steril 2010 30

  31. 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 31

  32. 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 32

  33. 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 33

  34. 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

  35. Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum Multicenter, randomized, controlled study Group B Cervical septum+ N=14 Group A Cervical septum- N=14 35

  36. Cervical septum resection is suggested for the patient with complet septum Parsanezhad et al., Fertil Steril 2006 36

  37. 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

  38. 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 5-mm hysteroscope and Versapoint n=80 Less time, more fluid absorbtion Less complication Reproductive outcome is similar for both groups Colacurci N, 2007 38

  39. 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 39

  40. The reason for high rates of miscarriage, small-for-date 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

  41. 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. 41

  42. 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 42

  43. 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 43

  44. Management Istre et al, Fertl Steril 2010 44

  45. Conclusion • Hysteroscopic metroplasty is GOLD STANDART. • For better reproductive outcome hysteroscopic metroplasty must be performed before fertility treatment 45

More Related