Uterine septum affects a large proportion of women but especially those experiencing infertility and miscarriages. The etiology of reproductive failure, i.e. the mechanism that causes early pregnancy loss and infertility is not yet established, and whether septate uterus is a cause of infertility is still a subject of debate. Patients with uterine septum usually can conceive, they can have and unproblematic pregnancy resulting in a live birth but the majority of the patients have missed or spontaneous miscarriage in late first trimester or early second trimester. Thus, we evaluated the time period between unprotected intercourse and operation. World Health Organization has defined this period as involuntary childlessness 18
. Furthermore, surgical intervention in all patients with septate uterus presenting no adverse pregnancy outcomes is controversial 13
. Although prospective randomized studies comparing pregnancy outcomes in patients undergoing or not undergoing surgical intervention would theoretically clarify this issue further probably it would not practically be possible due to ethical reasons. Nevertheless, in a study in which reproductive outcomes were evaluated in 102 and 25 patients who accepted and rejected undergoing a hysteroscopic septoplasty, respectively, a significant difference of pregnancy and full-term delivery rates between the groups. Despite the small number of patients who refused surgery and the lack of randomization 9,
this is the only study comparing operated and non-operated patients.
Although no consensus exists on the most appropriate diagnostic method; hysterosalpingography, two-dimensional ultrasound, MRI, hysteroscopy and 3D US are widely used for uterine septum diagnosis 5,19-21. 3D US enables and appropriate visualization of both the internal and external contour of the uterine fundus which is useful in the diagnosis of congenital anomalies. Compared with other imaging techniques, the sensitivity and specificity of 3D US are above 90% 22,23. In our study, all patients were evaluated using 3D US before the operation and during the post-operative follow-up. However, we were not able to differentiate between uterine septum and bicornuate uterus in one patient, and had to perform laparoscopy to distinguish between these two anomalies. In our hospital, all the patients with uterine septum were performed 3D US to identify the uterine fundus appropriately and the length of the septum and the distance between the uterine serosa and transvers plane extending between tubal ostiums. Metroplasty could be performed under laparoscopic vision, intraoperative transrectal ultrasonography 24 or abdominal ultrasound guidance 25 to avoid uterine perforation. In our study, we did not need to use any of these additional procedures. Recently, Malik et al. 25 represented a new hysteroscopic septoplasty technique using MyoSure Tissue Removal System. This is a novel technique used to treat submucous fibroids and polyps. However authors have showed that it could also be used for septoplasty.
The suggested conventional surgical intervention for septate uterus was transabdominal metroplasty as Strassman operation 27, but it has been replaced by hysteroscopy because of the formers high complication rates associated with postoperative adhesions potentially leading to infertility. Resectoscope and scissors are the mostly preferred techniques to perform uterine septoplasty. These techniques differ from each other by distending media, cervical dilatation and need of general anaesthesia. However, the experience of the surgeon is the most important factor in choosing the technique. In our study the operator chose the operation technique based on the thickness and length of the septum.
Hysteroscopic metroplasty obviously benefits pregnancy outcomes nevertheless different techniques have not been compared circumstantially. In a study, authors had compared resectoscope and cold scissors on pregnancy outcomes. They determined more pregnancies by cold scissors however they included only 70 patients and only 17 of them were operated by scissors 28. In another study authors stated the benefit of metroplasty on pregnancy rate regardless of the technique yet, the weakness of the study was the lack of equal distribution among the groups including 102 patients 29. Our study is unique in evaluating the pregnancy outcomes and comparing the techniques. There were 72 patients in the resectoscope group and 50 in the scissors group. The number of the included patients was one of the largest among relevant studies in the literature. The two groups did not have a statistically significant difference in pregnancy outcomes and live birth rates.
In our study, the overall pregnancy rate after hysteroscopic septoplasty was 77% and sixty-six of 122 patients (55%) had at least one live birth, similar to already published results 27. However, fifty-six (45%) patients were not able to have live birth after hysteroscopic septoplasty. There was a significant difference in age and involuntary childlessness duration between patients who had a live birth and patients who did not have a live birth. Older age adversely affected pregnancy rates after hysteroscopic septoplasty. Although we found no difference in pregnancy outcomes and history of miscarriage before hysteroscopic septoplasty, in a recent study authors stated that women with a history of recurrent miscarriages had a significantly higher pregnancy rate after uterine septoplasty compared to women without a history of recurrent miscarriages 30. Extra-uterine pathologies, including endometriosis, uterine receptivity and quality of oocyte may have played a role in the fecundity of the patients.
Despite the simplicity and minimal intraoperative and postoperative morbidity of the hysteroscopic approach, uterine perforation and pulmonary edema were two notable complications in our study, but no mortality occurred. Women undergoing hysteroscopic septoplasty are known to have a higher risk of uterine rupture in a subsequent pregnancy. In a recent study, a total of 14 cases of uterine rupture occurred after hysteroscopy 31, but none of our patients experienced uterine rupture during their pregnancies. It is possible that higher Caesarean section rates may have reduced the risk of uterine rupture in our study. Caesarean section was not recommended to any of the patients, however most of the patients decision was Caesarean section due to fear and anxiety of harming the baby.