Retrospective Clinical Research Report Journal of International Medical Research 48(3) 1–9 Reproductive outcome of a ! The Author(s) 2019 Article reuse guidelines: complete septate uterus after sagepub.com/journals-permissions DOI: 10.1177/0300060519893836 hysteroscopic metroplasty journals.sagepub.com/home/imr Zhenhong Wang1,*, Jian An1,2,* , Yanzhao Su1, Chaobin Liu1, Shunhe Lin1, Jinna Zhang1 and Xi Xie1 Abstract Objective: This study aimed to evaluate the reproductive outcomes of patients who underwent hysteroscopic metroplasty for correction of a complete septate uterus. Methods: The study population comprised 92 women with complete septate uteri. Hysteroscopic metroplasty and laparoscopy were performed simultaneously in these patients. The postoperative reproductive outcome of each patient was evaluated. Results: In the primary infertility group, there were 32 (40%) pregnancies. In the abortion group, the number of miscarriages decreased from 68 (94.44%) to 5 (10.42%), while the number of live births increased from 1 (1.39%) to 42 (87.50%) after resection compared with before resection. The cumulative probability of pregnancy and that of live-birth pregnancy in the abortion group were significantly higher than those in the primary infertility group after surgery. Furthermore, resection of the cervical septum resulted in a significantly higher cumulative probability of live birth compared with preservation of the cervical septum. Conclusion: Hysteroscopic uterine metroplasty may improve the reproductive performance of a septate uterus. Resection of the cervical septum may increase the probability of a live-birth pregnancy for patients with a cervical septum, and this procedure could be recommended for cases of a complete uterine septum. Keywords Septate uterus, hysteroscopic metroplasty, abortion, miscarriage, pregnancy, live birth Date received: 24 July 2019; accepted: 18 November 2019 *These authors contributed equally to this work. 1Department of Gynecology, Fujian Provincial Maternity Corresponding author: and Children’s Hospital, Affiliated Hospital of Fujian Xi Xie, Department of Gynecology, Fujian Provincial Medical University, Fuzhou, Fujian, China Maternity and Children’s Hospital, Affiliated Hospital of 2Laboratory of Gynecologic Oncology, Fujian Provincial Fujian Medical University, 18 Daoshan Road, Fuzhou, Maternity and Children’s Hospital, Affiliated Hospital of Fujian 350001, China. Fujian Medical University, Fuzhou, Fujian, China Email: [email protected] Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 Journal of International Medical Research Introduction suggests that sectioning of the cervical septum is safe and even associated with Since the first description of uterine anom- good obstetrical outcomes.8 Based on the alies in 1800,1 a septate uterus has been the above-mentioned findings, the present most common structural uterine anomaly.2 study aimed to evaluate and verify improve- A septate uterus, which is defined simply as a uterus with a division in the uterine cavity ment in reproductive outcomes of patients (septum) is associated with adverse repro- who undergo hysteroscopic metroplasty to ductive outcomes, including a high inci- correct a complete septate uterus, and to dence of abortion, premature delivery, and determine whether sectioning of the cervical infertility.3,4 Over the years, numerous clas- septum is worth recommending in clinical sification systems have been proposed to practice. classify female genital anomalies. According to the European Society of Materials and methods Human Reproduction and Embryology– European Society for Gynaecological The present study was approved by the Endoscopy classification system, any Research Ethics Committee of Fujian uterus with a normal outline and an inter- Provincial Maternity and Children nal fundal midline indentation exceeding Hospital, Affiliated Hospital of Fujian 50% of the uterine wall thickness is defined Medical University (approval no. as septate. A complete septate uterus is fur- 2016038). Because of the retrospective ther characterized by full division of the nature of the study, the requirement for uterine cavity up to the level of the internal informed consent was waived. cervical os.5 Although the septum is usually restricted to the uterine corpus, it may also Patients extend through the cervix and vagina, This study was a retrospective analysis potentially leading to infertility and comprising 92 women who visited our hos- miscarriage. pital with primary infertility (n¼35), recur- Traditionally, a septate uterus is diag- rent or spontaneous pregnancy loss (n¼45), nosed by laparoscopy and hysteroscopy, and for whom a health examination showed and hysteroscopic metroplasty is considered uterine anomalies (n¼12) and who were the first-line therapy for restoring the uter- diagnosed with a complete septate uterus. ine cavity, with high levels of improvement to subsequent reproductive outcomes.6,7 The patients’ charts were reviewed for age, However, there is still uncertainty of the main complaints, obstetric history, and effectiveness of resecting the uterine postoperative reproductive outcome. septum because the evidence is mainly Eighty patients with medical complaints in based on retrospective studies. our series were divided into two groups. Unfortunately, data of prospective studies The first group consisted of patients with are extremely limited. the complaint of primary infertility who To date, most retrospective studies have failed to achieve pregnancy for over 1 shown that septate resection has a signifi- year. The second group consisted of cant positive effect on women’s fertility.3,6,7 patients who had one or more abortions. However, sectioning of the cervical portion The patients with recurrent or spontaneous of the septum has traditionally been pregnancy loss were all negative for anti- avoided because of fear of causing cervical phospholipid antibodies, antinuclear anti- incompetence. However, recent evidence bodies, and anti-DNA antibody. Wang et al. 3 Nevertheless, chromosomal analysis was Management of a septate cervix not performed in our study population. Among our 92 patients with complete sep- tate uteri, 38 had a septate cervix. Surgical procedure Additionally, to investigate the effect of Hysteroscopic metroplasty and laparoscopy resection of the cervical septum on the were performed simultaneously in all of the reproductive outcomes of patients compli- patients. The aim of surgery was to differ- cated by a septate cervix, 38 patients with a entiate a septate uterus from a bicornuate septate cervix were additionally divided into uterus by checking the serosal surface of the two groups on the basis of whether the uterus. The tubes, ovaries, and abdominal septum was removed. There was no signif- cavity were also observed to define any con- icant difference in age between the two current pathologies, such as endometriosis, groups. The patients were allocated to polycystic ovary syndrome, unilateral and/ either of the groups by using a heads–tails or bilateral tubal occlusion, and hydrosal- binary result coin toss method before sur- pinx or adhesions related to infertility. Male gery and the allocation was not masked. A factors were also evaluated by semen anal- Foley catheter was inserted into one side of ysis in our study. Patients with the infertil- the uterine cavity and 3 mL of normal ity factors mentioned above were excluded saline solution was injected into the bal- from this study. loon. A hysteroscope was placed in the The hysteroscopic procedure was per- other side of the uterine cavity. A small formed during the early follicular phase of incision was then made in the uterine the menstrual cycle. All patients received septum at the level of the internal orifice antibiotics for prophylaxis to prevent sec- of the cervix to expose the catheter balloon. ondary pelvic inflammatory disease. All After this incision, an incision of the septa procedures were performed under general was started from the incision opening and anesthesia and in sterile conditions. continued upward with the same method Surgery was performed through a 6.5-mm and principle as the other incision. operating hysteroscope with a bipolar VersaPoint Electro-Surgical system Postoperative management and follow-up (Gynecare, division of Ethicon, Inc., After resection was completed, an intrauter- Menlo Park, CA, USA). Distention and ine device was inserted into the uterine irrigation were performed using normal cavity in all patients after the procedure, saline solution at a pressure of 90 to 110 and the patients were treated with cyclic mm Hg. The cutting current was set at 80 estrogen–gestagen therapy for 3 months to to 100 W. After visualizing both tubal ostia, reduce formation of adhesions and ensure an incision of the septa was started from the rapid epithelialization. The intrauterine lower margin and continued upward with device was removed 3 months after the the horizontal section until the hystero- operation and re-hysteroscopy was per- scope could be moved freely from one formed to evaluate the effectiveness of the tubal ostium to the other without obstruc-