PROF. ANTONIO PERINO CATTEDRA DI GINECOLOGIA OSTETRICIA E FISIOPATOLOGIA DELLA RIPRODUZIONE UMANA UNIVERSITA’ DEGLI STUDI DI PALERMO ENDOSCOPIC TREATMENT OF UTERINE MALFORMATIONS
PROF. ANTONIO PERINO
CATTEDRA DI GINECOLOGIA OSTETRICIA E FISIOPATOLOGIA DELLA RIPRODUZIONE UMANA
UNIVERSITA’ DEGLI STUDI DI PALERMO
ENDOSCOPIC TREATMENT OF UTERINE
MALFORMATIONS
Mullerian duct malformations delineate a
miscellaneous group of congenital anomalies
that result from arrested development,
abnormal formation, or incomplete fusion of the
paramesonephric ducts.
In many patients, uterine congenital anomalies
have been related to menstrual disorders,
infertility, recurrent pregnancy loss,
prematurity and other obstetrics complications
Incidence of uterine malformations among
patients willing to conceive during
reproductive age
F. Raga et al. – Human Reprod. 1997
Type of malformation Fertile
(n = 1289)
Infertile
(n = 868)
Sterile
(n = 1024)
Total
(n = 3181)
II Unicornuate 2 (0.2) 5 (0.6) 1 (0.1) 8 (0.3)
a 0 1 0 1
b 0 3 0 3
c 1 0 0 1
d 1 1 1 3
III Didelphys 1 (0.1) 6 (0.7) 1 (0.1) 8 (0.3)
IV Bicornuate 5 (0.4) 16 (1.9) 5 (0.5) 26 (0.7)
a 0 7 1 8
b 5 9 4 18
V Septate 20 (1.5) 17 (2) 6 (0.6) 43 (1.4)
a 4 6 0 10
b 16 11 6 33
VI Arcuate 21 (1.6) 9 (1.0) 12 (1.1) 42 (1.3)
VII Diethylstilboestrol 0 1 (0.1) 0 1
Total 49 (3.8)c 54 (6.3)b 25 (2.4)c 128 (4.0)
F. Raga et al. – Human Reprod. 1997
When class I and class VII uteri are thus
ruled out, it was observed that septate and
arcuate uteri represented 66% of the
malformations, while the bicornuate,
didelphys and unicornuate uteri
constituited the remaining 33%
This picture is of clinical interest
because of the fact that the former
malformations can be easily managed
by hysteroscopy, while the latter need
more complicated procedures or have
no surgical solution.
Uterine septum is the most common
Mullerian fusion defect.
Its overall incidence is estimated to be about
2 %.Ashton et al., 1988
Septate uterus has been linked to a high grade of
fetal loss generally occurring during the first half
of the pregnancy
AUTHORS N. PATIENTS FETAL LOSS (%)
Buttram et Gibbons - 88
Perino et coll. 64 93
March et Israel 57 95
Daly et coll. 17 90
Formerly, the removal of an intrauterine
septum was performed by transabdominal
metroplasty
McShane, 1983; Rock, 1992
Currently, operative hysteroscopy is
proposed as the procedure of choice for
the management of these disorders.DeCherney et al., 1986
March and Israel, 1987
Perino et al., 1987
Daly et al., 1989
HYSTEROSCOPIC METROPLASTY
MULTICENTRIC RETROSPECTIVE STUDY
SCISSORS RESECTO. LASER TOT
COLACURCI (NEAPLES) - 69 - 69
BUSACCA (MILAN) - 48 - 48
LA SALA (REGGIO EMILIA) 15 79 - 94
GUBBINI (BOLOGNA) 1 104 - 105
MENCAGLIA (FLORENCE) - 122 - 122
PERINO (PALERMO) 75 120 5 200
SCARSELLI (FLORENCE) - 22 - 22
TANTINI (FLORENCE) 12 101 - 113
TOTALE 103 665 5 773
PRETREATMENT
No cases = 557
Analogue (20%)
Danazol (34%)
None (44%)
E/P (3.1%)
245
12
111
1890
50
100
150
200
1994 1996 1998 2000 2002 2004 2006 2008
PREOPERATIVE TREATMENT
No cases = 636
None
Analogue
Danazol
E/P
None (49%)
Laparoscopic
(32%)
USG (19%)
INTRAOPERATIVE CONTROL
No cases = 557
273
104
180
0
50
100
150
200
1994 1996 1998 2000 2002 2004 2006 2008
INTRAOPERATIVE CONTROL
No cases = 557
None
Laparoscopy
USG
INTRAOPERATIVE COMPLICATIONS
MINOR
Difficult dilatation n. 5
Bleeding n. 4
False way n. 1
MAJOR
Perforations n. 8
E.P.A. n. 1
TOTAL PREGNANCIES (469)
Abortion >12 <28w
(2%)
Ongoing pregnancies
(7%)
Term pregnancies
(80%)
Preterm deliveries
(2%)
Abortion < 12w (9%)
361
45 4213
8
The septate uterus: a review of
management and reproductive outcome
Hayden A. Homer et al. Fertil Steril 2000
BEFORE METROPLASTY
Author (ref.)
No. of
patients
No. of
Pregnancies
No. of
miscarriage
s
(%)
No. of
preterm
deliveries
(%)
No. of
term
deliveries
(%)
Chervenak and Neuwirth 2 3 3(100) 0 0
Daly et al. 17 40 34(85) 5(12.5) 1(2.5)
De Cherney and Polan 15 NR >30 NR NR
Israel and March 12 28 26(93) 0 2(7)
De Cherney et al. 103 NR >206 NR NR
Valle and Sciarra 12 42 30(71) 12(29) 0
Fayez 12 21 19(90) 2(10) 0
March and Israel 57 240 212(88) 21(9) 7(3)
Perino et al. 24 27 24(89) 3(11) 0
Daly et al. 55 150 130(87) 13(9) 7(5)
Choe and Baggish 14 38 31(82) 6(16) 1(3)
Fedele et al. 71 >139 >139 NR NR
Cararach et al. 62 176 160(91) 11(10) 1(1)
Pabuccu et al. 49 108 96(89) 11(10) 1(1)
Valle 115 299 258(86.3) 28(9.4) 13(4.3)
TOTAL 658 1,062 933(88) 95(9) 34(3)
AFTER METROPLASTY
Author (ref.)
No. of
patients
No. of
miscarriages
(%)
No. of
preterm
deliveries
(%)
No. of
term
deliveries
(%)
Chervenak and Neuwirth 2 0 0 2(100)
Daly et al. 9 2(22) 1(11) 6(67)
De Cherney and Polan 11 2(18) 0 9(82)
Israel and March 2 1(50) 0 1(50)
De Cherney et al. >71 >8 1 NR
Valle and Sciarra 10 2(20) 2(20) 6(60)
Fayez 16 2(13) 0 14(87.5)
March and Israel 56 8(14) 4(7) 44(79)
Perino et al. 15 1(7) 0 14(93)
Daly et al. 75 15(20) 5(7) 55(73)
Choe and Baggish 12 1(8.3) 1(8.3) 10(83.3)
Fedele et al. 65 10(16) 10(16) 45(69.2)
Cararach et al. 41 12(29) 0 29(48)
Pabuccu et al. 44 2(4.5) 2(4.5) 40(9.1)
Valle 103 12(12) 7(7) 84(81)
TOTAL 491 67(14) 29(6) 395(80)
Therefore hysteroscopic metroplasty results
seem to be at least as good as those obtained
after the abdominal metroplasty. However,
hysteroscopic technique is associated with
less morbidity, shorter hospital stay and the
possibility of the vaginal route at delivery.
OFFICE HYSTEROSCOPY
Recently technological improvements have
led to the introduction of “office
hysteroscopes” of small diameter (5 mm)
fitted with mini-telescopes and bipolar
electrodes working in saline solution.
This technique allows a simple and safe
treatment of intrauterine pathology
including uterine septa
Type of hysteroscope
For 5 FR. electrode
continous flow rigid
5 mm hysteroscope
with at least 5 FR.
working channel
For 24 FR. electrode
Resectoscope 10 mm
continuous flow
Small-diameter hysteroscopy with Versapoint
versus resectoscopy with a unipolar knife for the
treatment of septate uterus: A prospective
randomized study
A. Perino et al. Journal of Minimally Invasive Gynecology (2007) 14, 622–627
Table 1 Main characteristics of the patients
Group A
(resectoscope)
(n 80)
Group B
(minihysteroscope)
(n 80)
Mean age (yrs) 28.1 4.8 29.1 4.5
95% CI 26.98–29.14 28.15–30.15
Mean duration of
infertility (yrs)
2.8 0.9 3.1 1.1
95% CI 2.58–3.06 2.83–3.33
Recurrent pregnancy
loss (No.)
55 47
Primary infertility
(No.)
25 33
Table 2 Operative parameters
Group A
(resectoscope)
(n 80)
Group B
(minihysteroscope)
(n 80)
Mean operative time
(min)
23.4 5.6 15.7 4.7*
95% CI 22.11–24.63 14.83–16.92
Mean fluid absorption
(mL)
486.4 169.9 222.1 104.9*
95% CI 448.55–524.20 198.77–245.48
Second surgery (No.) 2 4
*p .05 (difference between groups).
Table 3 Complications
Group A
(resectoscope)
(n 80)
Group B
(minihysteroscope)
(n 80)
Intraoperative
Cervical tears/traumas 3 ---
Uterine false track 1 ---
Uterine perforation --- ---
Fluid overload --- ---
Thermal injuries --- ---
Significant blood loss 2 1
Postoperative
Intrauterine synechiae 1 ---
Uterine rupture in
pregnancy
--- ---
Total 7 1*
*p .05 (difference between groups).
CONCLUSIONS
Small-diameter hysteroscopy with bipolar
electrode for the incision of uterine septum is
as effective as resectoscopy with unipolar
electrode regarding reproductive outcome and
is associated with:
shorter operating time
lower complication rate
Hysteroscopic resection of the septum improves the
pregnancy rate of women with unexplained infertility:
a prospective controlled trial
A. Mollo, P. De Franciscis, N. Colacurci, L. Cobellis,
A. Perino, R. Venezia, C. Alviggi, and G. De Placido
Fertil Steril. 2009 Jun;91(6):2628-31.
Results: Pregnancy rate (38.6% vs. 20.4%) and live birth rate were
significantly higher in group A than in group B.
The survival analysis showed that the probability of a pregnancy in the
twelve-months follow up was significantly higher in patients undergone
metroplasty than in women with unexplained infertility .
The corresponding fecundity (10-week pregnancy) rates were 4.27 and 1.92
person-months in women who had undergone metroplasty and in women
with unexplained infertility, respectively.
Cumulative probability of a pregnancy in the 12 months after
the control visit scheduled 1 month after the metroplasy in
study group A (red line) and 1 month after the diagnostic
laparoscopy in control group B (black line)
Fertil Steril. 2009 Jun;91(6):2628-31.
Conclusions
Hysteroscopic resection of the septum
improves fecundity of women with septate
uterus and otherwise unexplained
infertility.
Patients with septate uterus and no other
cause of sterility have a significantly higher
probability of conceiving after removal of
the septum than patients affected by
idiopathic sterility.
Fertil Steril. 2009 Jun;91(6):2628-31.
CONCLUSION
Of the utmost importance is to get clear indication of who, when and how to operate
if a uterine malformation is diagnosed.
Hysteroscopic metroplasty is now the reccomended treatment for most septate
uteri due to its relative simplicity, low morbidity and excellent reproductive
outcome