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

Laparotomic Metroplasty

Term-Pregnancy (%)

Bret-Palmer

or

Tompkins80

Jones 70

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

Other (5%)

Sterility (32%)

Recurrent

abortion (63%)

INDICATIONS

No cases = 636

410

197

29

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

None (89%)

E/P (9%)

Other (2%)

POSTOPERATIVE TREATMENT

No cases = 636

566

58

9

ISG-HSC (11%)

USG (19,5%)

HSC (69%)

ISG (0,5%)

FOLLOW-UP

No cases = 636

440

693

124

TOTAL PREGNANCIES (469)

Abortion >12 <28w

(2%)

Ongoing pregnancies

(7%)

Term pregnancies

(80%)

Preterm deliveries

(2%)

Abortion < 12w (9%)

361

45 4213

8

Vaginal

deliveries (57%)

Caesarian

sections (43%)

Modality of delivery

206155

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)

Complete septate uterus, duplicated cervix, vaginal

septum

N cases: 24

Hysteroscopic procedure

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

Versapoint instrumentations

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).

Pregnancy rate (PR) in the study groups

according to reproductive history.

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

THANK YOU