Pregnancy Outcomes following Hysteroscopic Septoplasty of Incomplete Uterine Septum

INTRODUCTION

The septate uterus (SU) is a congenital anomaly defined by the persistence of a partition in the uterus caused by a fusion defect of paramesonephric ducts during development.¹ It was reported that there is a significant link between SU and many reproductive failures, including abnormal fetal presentation, intrauterine growth retardation, habitual abortion, and miscarriage.² It is possible to have a partly septated or complete septated uterus depending on the size of the septum. In the case of an incomplete SU, the uterine cavity is separated into two distinct components, including two cervical openings and eventually a vaginal septum.³ It is challenging to detect the exact incidence of SU; however, it may reach up to 15 per 1000 population.⁴ The prevalence of uterine abnormalities is estimated to be around 4.3% and 3.5%.⁵ Furthermore, the SU is the most prevalent reproductive abnormality, accounting for 5.3%.⁶

In women who have had multiple abortions, premature births, and infertility, hysteroscopic septoplasty (HS) is an effective and safe surgery.⁷ In addition, several studies have demonstrated that HS for uterine abnormalities can improve pregnancy outcomes.⁸ On the other hand, because their effectiveness has not been established in well-designed, prospective, randomized trials, postoperative hormonal treatment with estrogen and progesterone is controversial. Following surgery, estrogen and progesterone are used to stimulate endometrial development, allowing normal endometrial growth and ovulation to occur naturally.⁹

There is a lack of available data regarding the effectiveness of alternative treatment procedures following septum resection, despite extensive research on infertility. Therefore, the aim of this study was to evaluate pregnancy outcomes pre- and post-HS of the uterine septum, based on the size of the septum.

PATIENTS AND METHODS

Study design and population

A single-center, retrospective study was conducted at Al-Azhar University Hospital, New Damietta, Egypt, over two years from April 2018 till April 2020. The study was approved by the Institutional Review Board (IRB) of the Faculty of Medicine, Al-Azhar University, New Damietta, Egypt. Informed consent was obtained from all included patients.

Inclusion and exclusion criteria

According to the American Fertility Society classification of Mullerian duct anomalies, the study included adult (22-37 years) female patients with the incomplete uterine septum (Class Vb: partial).¹⁰ Patients with other causes of infertility, including the tubal factor of infertility, endometriosis, polycystic ovary syndrome, and other concomitant diseases, were excluded.

Data collection

Age, complaints, obstetric history, and postoperative pregnancy outcomes were all examined in the patients' charts. Patients were classified into two groups; Spontaneous abortion (SA: n=50) and primary infertility (PI: n= 40). Anti-DNA antibodies, antinuclear antibodies, and anti-phospholipid antibodies were all negative. This population was not subjected to chromosomal analysis.

Surgical procedure

In all of the patients, HS and laparoscopy were done at the same time. The goal of laparoscopy was to evaluate the serosal surface of the uterus to distinguish a septate uterus from a bicornuate uterus. In addition, it was used to diagnosed other causes of infertility, including the tubal factor of infertility. Endometriosis, polycystic ovary syndrome, and other concomitant diseases were also investigated in the ovaries and abdominal cavity. This study also performed a semen analysis to assess male variables. In the early proliferative phase, all patients were admitted to the hospital and had surgery 2 to 7 days postmenstrual. Misoprostol suppository 400 μg was inserted in the posterior vaginal fornix the night before surgery for simple cervical dilatation. To avoid subsequent pelvic inflammatory disease, all patients were given prophylactic antibiotics. All procedures were carried out under general anesthesia and in a very sterile environment. The surgeon utilized a cervical dilator to dilate the cervical os after administering anesthesia and placing a vaginal speculum after cleaning the external cervical os with a cotton soaked in iodine solution.

A 3.5-mm mini-hysteroscope (KARL STORZ, Germany) was used in some cases. As a factor of distending media, normal saline was employed. The pressure of uterine distention was adjusted between 110 and 150 mm Hg. An electrical resectoscope was used to confirm the size, range, and placement of the septum. A cutting current of 80 to 100 W was used. After examining both tubal ostia, the septa were incised with the horizontal section from the bottom edge upward until the hysteroscope could easily travel from one tubal ostium to the other, and both tubal ostia were visible. The surgeries were completed in 7 to 13 minutes by the same surgeon, who has over nine years of hysteroscopic surgery expertise.

Postoperative management and follow-up

After septoplasty, all patients had an intrauterine device put into their uterus, and they were given cyclic estrogen-progesterone treatment for three months to prevent adhesions and guarantee fast endometrial creep. Three months following the operation, the intrauterine device was removed, and a re-hysteroscopy was performed to assess the procedure's efficacy. Re-hysteroscopy was used to correct patients who had a residual portion bigger than 1 cm. During a follow-up period, I assessed the reproductive result of each patient for whom re-hysteroscopy was done via telephone or outpatient clinic visits.

Statistical Analysis

Data were collected and then coded and analyzed using Statistical Package of Social Science (SPSS, Widnose version 22). Continuous data were presented as mean and standard deviation, while categorical data were presented as numbers and percentages.

RESULTS

The age of both groups was comparable (SA: 28.3±3.46 vs. PI: 25.3±4.3 years). There was no evidence of volume overload syndrome in any of the patients. None of the patients experienced uterine perforation. However, three (3.33%) individuals required a second operation due to the presence of a residual notch bigger than 1 cm. Preoperatively, 50 women in the SA group had 86 pregnancies, resulting in 65 (75.5%) miscarriages, 19 (22.09%) preterm deliveries, and 2 (2.32%) term deliveries. However, there was a significant difference in the results after the septum was resected. During the 24-month follow-up period after septum resection, 94 pregnancies in 90 individuals were achieved. In the PA group, 41 women had pregnancies, whereas, in the SA group, 49 women had 53 pregnancies. In the SA group, the number of miscarriages was lower after HS than before resection. Furthermore, the number of live births in the SA group was significantly greater after HS than before resection (Table 1).

Table 1: Comparison of the reproductive outcome before and after hysteroscopic septoplasty in patients with PI and history of SA; Data are expressed as the number of patients (number of times)