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Repair of the uterine cavity after hysteroscopic septal incision*
FERTILITY AND STERILITY
Vol. 54, No.6, December 1990
Copyright© 1990 The American Fertility Society
Printed on acid-free paper in U.S.A.
Repair of the uterine cavity after hysteroscopic septal incision*
Giovanni Battista Candiani, M.D.t Paolo Vercellini, M.D.t+ Luigi Fedele, M.D.t
Silvestro Giuliano Carinelli, M.D.§ Daniela Merlo, M.D.§ Luisa Arcaini, M.D.t
University of Milano School of Medicine and Istituti Clinici di Perfezionamento, Milano, Italy
We performed a follow-up hysteroscopy with multiple biopsies at different intervals after surgery in 19 women who underwent hysteroscopic septal incision. Seven days after operation the sectioned areas were very evident and not epithelialized (3 patients). At 14 days, the incised zone was depressed with scattered epithelialization (5 subjects). At 1 month, the sectioned surfaces were still depressed and uniformly covered by thin endometrium (5 cases). After 2 months the uterine cavity was almost normal with minimal tendency to central fundal adhesions (6 women). Thus, spontaneous healing processes after hysteroscopic metroplasty progressed regularly and completely and there is probably no reason to delay attempts at pregnancy for longer than two cycles after surgery. Fertil Steril54:991, 1990
Hysteroscopic incision seems to be the treatment of choice for septate uterus associated with abortions. 1- 4 After hysteroscopic section, wide areas lacking in endometrial covering are left on the anterior and posterior uterine walls, 5 unlike the various types of abdominal metroplasty in which the margins of the endometrial lining are brought together carefully when the uterine body is reconstructed.6 We performed a follow-up hysteroscopy at various intervals after septal incision to investigate the mode of repair of the uterine cavity. MATERIALS AND METHODS
Hysteroscopic metroplasty was performed between day 7 and day 10 of the cycle on 19 women Received November 20, 1989; revised and accepted July 30, 1990. * Presented at the 45th Annual Meeting of The American Fertility Society, San Francisco, California, November 13 to 16, 1989. t First Department of Obstetrics and Gynecology "L. Mangiagalli", University of Milano School of Medicine. :j: Reprint requests: Paolo Vercellini, M.D., First Department of Obstetrics and Gynecology "L. Mangiagalli", University of Milano School of Medicine, Via Commenda 12, 20122 Milan, Italy. § Department of Pathology, Istituti Clinici di Perfezionamento. Vol. 54, No.6, December 1990
aged 24 to 35 years (mean, 28 years) with two or more spontaneous abortions, a double uterine cavity at hysterosalpingography (HSG), and evidence of a normal uterine fundus at ultrasonography (Ansaldo 440 real-time scanner with 3.5 MHz convex transducer; Ansaldo, Genoa, Italy) with a halffull bladder. 7•8 The uteri were classified as American Fertility Society class Vain 5 cases (complete septate uterus) and Vb in 14 cases (partial septate uterus). 9 The patients received a single 2-g prophylactic dose of cefoxitin intramuscularly 1 hour before surgery. Under general endotracheal anesthesia and laparoscopic control, the cervix was dilated to 7 mm and a rigid Storz hysteroscope (model 26157 B; Storz Endoscopy, Tuttlingen, West Germany) with a 7-mm diameter operating sheath (model 26163 C and 26163 H; Storz) and rigid microscissors (model26158 EK; Storz) were introduced. The uterine cavity was distended with a 10% solution of dextran of molecular weight 40,000 (Rheomacrodex; Baxter-Travenol, Trieste, Italy). After visualization of the tubal ostia, the section was started from the inferior margin of the septum and carried cephalad with progressive horizontal cuts in the midline. Daly et al.'s 10 technique was used for the five women with complete septate uterus, and March and Israel's3 method for the four women Candiani et al.
Repair after metroplasty
991
l metrial specimens were fixed in Carnoy's solution and embedded in paraffin. The tissue sections were stained with hematoxylin and eosin and were examined at the light microscope at lOX and 40X magnifications. A residual fundal notch was corrected in nine patients (1 at 1 week, 2 at 2 weeks, 3 at 4 weeks, and 3 at 8 weeks), including the eight in whom the incision could not be completed in the first instance.
RESULTS
Figure 1 Two weeks after surgery: the sectioned areas are depressed and partially epithelialized (e), and the margins of incision (arrows) are faint. A, anterior uterine wall; P, posterior uterine wall; T, left tubal ostium.
with broad septum (>3 em wide at the base on HSG planimetry). The incision was considered complete when a normal uterine cavity was obtained and the hysteroscope could be moved freely from one tubal ostium to the other. In eight women, intrauterine bleeding caused by the cervical dilatation and trauma to endometrium of the lateral walls prevented complete section of the upper portion of the septum. No intrauterine device was inserted, and no before or after operative hormone treatment was administered. After giving informed consent, the patients were randomly assigned to undergo follow-up hysteroscopy 1, 2, 4, or 8 weeks after surgery. No hysteroscopic, laparoscopic, or anesthetic complication occurred. Three patients were scheduled for repeat hysteroscopy 1 week after operation (secretory phase), five after 2 weeks (secretory phase), five after 1 month (proliferative phase), and six after 2 months (proliferative phase). This follow-up procedure was performed under local anesthesia (paracervical block with 15 cc of 1% mepivacaine hydrochloride in normal saline) on an outpatient basis. The cervix was dilated to 7 mm and the same hysteroscope, operating sheath, and distending medium previously described were used. Multiple biopsies were obtained with a rigid biopsy and grasping forceps (model26158 U; Storz) from the uterine fundus and posterior wall inside the margins of the formerly sectioned areas. Endo992
Candiani et al.
Repair after metroplasty
Seven days after operation the triangular sectioned areas were still very evident, with distinct endometrial margins and superficial unepithelialized connective tissue; histological examination demonstrated granulation tissue and fibrin and the absence of epithelial cells. At 14 days the incised zone was depressed on both uterine walls, with no tendency to adhesion and with wide areas lacking endometrial covering. The margins of the section were faint, with initial centripetal epithelialization (Fig. 1). Scattered areas covered by simple columnar and cuboidal epithelium were demonstrated at hystology, similar to the surface endometrium, in direct contact with myometrium or granulation tissue with no intervening cytogenic stroma (Fig. 2). Islands of epithelialization not connected to the borders of the incision were seen in the center of the sectioned areas. Four weeks after metroplasty
Figure 2 Same case as Figure 1. The sectioned area is partially covered by simple columnar epithelium (E) in contact with myometrium (M) with no intervening stroma (light microscope, hematoxylin and eosin, original magnification X40).
Fertility and Sterility
Figure 3 Eight weeks after surgery: the uterine cavity is almost normal. A slight depression of the incised areas is seen on the anterior (A) and posterior (P) wall, and there is a minimal central fundal adhesion (arrow). T, left tubal ostium.
the sectioned areas were still clearly depressed with respect to the surrounding endometrium and were uniformly covered by thin epithelium. The two patients in whom the operation was completed presented a limited central fundal adhesion a few millimeters wide and deep between the anterior and posterior uterine walls, which was not corrected. In all the biopsies we observed a regular proliferative endometrium with columnar epithelium and stroma. The uterine cavity was normal 8 weeks after surgery. Only in three cases could slight depressions be recognized at the areas of incision (Fig. 3). Two patients in whom the septum had been completely lysed presented a central fundal adhesion, minimal in one and 1.5 em deep in the other. The latter was corrected. The endometrium was histologically regular in all cases. DISCUSSION
The reproductive prognosis of a septate uterus is unfavorable, the abortion rate being 67%. 6 This is probably due to frequent implantation of the blastocyst on the scantily vascularized septum that is unsuited for metabolic exchanges with trophoblast.U·12 The septal mucosa may be analogous to the antimesometrial area in which nidation occurs in mammals with bicornuate uteri. 13 A septate uterus can be corrected by hysteroscopic metroplasty, with minimal morbidity. 1-4 Objective data Vol. 54, No.6, December 1990
on the spontaneous mode of reconstruction of the uterine cavity after septal incision are scanty. 5 We perform a postoperative HSG or hysteroscopy routinely before advising patients to attempt a pregnancy. In the present study, the sole modification to our usual practice was programming only a hysteroscopy at different times. The study was performed on a small series of patients, but the gross and hystological findings did not differ in the groups of subjects studied at the various times. This would suggest that the anatomic events after hysteroscopic metroplasty follow a regular course. The two parts of the incised septum retract under the plane of the surrounding endometrium, hindering secondary adhesions. We noted a tendency to form minimal central fundal adhesions at the basis of the sectioned triangle where contact between unepithelialized surfaces is inevitable due to the wide area of section. Of the 19 hysteroscopic metroplasties performed, 11 were judged complete at the end of the operation. These latter included only one case of fundal septal adhesion 1.5 em deep at follow-up hysteroscopy. Thus, postoperative insertion of an intrauterine device does not seem indispensable for a favorable morphological result. 14 The nine sections performed during repeat hysteroscopy were to correct the only neoformed fundal spur and the eight septa that were not completely incised in the first instance. Epithelialization· of the cut surfaces was slow and irregular in the 2 weeks after the operation. This confirms our previous observation5 and could possibly be due to impending ovulation and scanty mitotic activity during the secretory phase. At 14 days, in addition to epithelialization from the margins of the incision, we observed islands of epithelial cells not connected to the margins. This may be related to an implantation on the denuded collagen matrix of endometrial cells released during the operation. The gross and microscopic examinations performed during the cycle after surgery always demonstrated a complete epithelial lining of the intrauterine cavity, suggesting that administration of estrogens after hysteroscopic metroplasty is probably superfluous. 14 Moreover, since the uterine cavity was morphologically normal and the covering endometrium ofthe sectioned area regular 2 months after surgery, there do not seem to be reasons for delaying attempts at pregnancy beyond that date. Candiani et al.
Repair after metroplasty
993
REFERENCES 1. Valle RF, Sciarra JJ: Hysteroscopic treatment of the septate uterus. Obstet Gynecol 67:253, 1986 2. Fayez JA: Comparison between abdominal and hysteroscopic metroplasty. Obstet Gynecol 68:399, 1986 3. March CM, Israel R: Hysteroscopic management of recurrent abortion caused by septate uterus. Am J Obstet Gynecol156:834, 1987 4. Daly DC, Mayer D, Soto-Albors C: Hysteroscopic metroplasty: six years' experience. Obstet Gynecol 73:201, 1989 5. Fedele L, Marchini M, Baglioni A, Carinelli SG, Candiani GB: Endometrial reconstruction after hysteroscopic incisional metroplasty. Obstet Gynecol 73:492, 1989 6. Buttram VC, Reiter RC: Uterine anomalies. In Surgical Treatment of the Infertile Female. Baltimore, Williams & Wilkins, 1985, p 149 7. Candiani GB, Ferrazzi E, Fedele L, Vercellini P, Dorta M: Sonographic evaluation of uterine morphology: a new scanning technique. Acta Eur Fertil17:345, 1986 8. Fedele L, Ferrazzi E, Dorta M, Vercellini P, Candiani GB: Ultrasonography in the differential diagnosis of "double" uteri. Fertil Steri150:361, 1988
994
Candiani et al.
Repair after metroplasty
9. The American Fertility Society: The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 49:944, 1988 10. Daly DC, Tohan N, Walters C, Riddick DH: Hysteroscopic resection of the uterine septum in the presence of a septate cervix. Fertil Steril 39:560, 1983 11. Fedele L, D' Alberton A, Vercellini P, Candiani GB: Gestational aspects of uterus didelphys. J Reprod Med 33:353, 1988 12. Fedele L, Dorta M, Brioschi D, Giudici MN, Candiani GB: Pregnancies in septate uteri: outcome in relation to site of uterine implantation as determined by sonography. Am J Roentgenol152:781, 1989 13. Mossmann HW: Comparative morphology of the fetal membranes and accessory uterine structures. Contrib Embryo! Carnegie Inst 26:129, 1937 14. Vercellini P, Fedele L, Arcaini L, Rognoni MT, Candiani GB: Value of intrauterine device insertion and estrogen administration after hysteroscopic metroplasty. J Reprod Med 34:447, 1989
Fertility and Sterility
Vol. 54, No.6, December 1990
Copyright© 1990 The American Fertility Society
Printed on acid-free paper in U.S.A.
Repair of the uterine cavity after hysteroscopic septal incision*
Giovanni Battista Candiani, M.D.t Paolo Vercellini, M.D.t+ Luigi Fedele, M.D.t
Silvestro Giuliano Carinelli, M.D.§ Daniela Merlo, M.D.§ Luisa Arcaini, M.D.t
University of Milano School of Medicine and Istituti Clinici di Perfezionamento, Milano, Italy
We performed a follow-up hysteroscopy with multiple biopsies at different intervals after surgery in 19 women who underwent hysteroscopic septal incision. Seven days after operation the sectioned areas were very evident and not epithelialized (3 patients). At 14 days, the incised zone was depressed with scattered epithelialization (5 subjects). At 1 month, the sectioned surfaces were still depressed and uniformly covered by thin endometrium (5 cases). After 2 months the uterine cavity was almost normal with minimal tendency to central fundal adhesions (6 women). Thus, spontaneous healing processes after hysteroscopic metroplasty progressed regularly and completely and there is probably no reason to delay attempts at pregnancy for longer than two cycles after surgery. Fertil Steril54:991, 1990
Hysteroscopic incision seems to be the treatment of choice for septate uterus associated with abortions. 1- 4 After hysteroscopic section, wide areas lacking in endometrial covering are left on the anterior and posterior uterine walls, 5 unlike the various types of abdominal metroplasty in which the margins of the endometrial lining are brought together carefully when the uterine body is reconstructed.6 We performed a follow-up hysteroscopy at various intervals after septal incision to investigate the mode of repair of the uterine cavity. MATERIALS AND METHODS
Hysteroscopic metroplasty was performed between day 7 and day 10 of the cycle on 19 women Received November 20, 1989; revised and accepted July 30, 1990. * Presented at the 45th Annual Meeting of The American Fertility Society, San Francisco, California, November 13 to 16, 1989. t First Department of Obstetrics and Gynecology "L. Mangiagalli", University of Milano School of Medicine. :j: Reprint requests: Paolo Vercellini, M.D., First Department of Obstetrics and Gynecology "L. Mangiagalli", University of Milano School of Medicine, Via Commenda 12, 20122 Milan, Italy. § Department of Pathology, Istituti Clinici di Perfezionamento. Vol. 54, No.6, December 1990
aged 24 to 35 years (mean, 28 years) with two or more spontaneous abortions, a double uterine cavity at hysterosalpingography (HSG), and evidence of a normal uterine fundus at ultrasonography (Ansaldo 440 real-time scanner with 3.5 MHz convex transducer; Ansaldo, Genoa, Italy) with a halffull bladder. 7•8 The uteri were classified as American Fertility Society class Vain 5 cases (complete septate uterus) and Vb in 14 cases (partial septate uterus). 9 The patients received a single 2-g prophylactic dose of cefoxitin intramuscularly 1 hour before surgery. Under general endotracheal anesthesia and laparoscopic control, the cervix was dilated to 7 mm and a rigid Storz hysteroscope (model 26157 B; Storz Endoscopy, Tuttlingen, West Germany) with a 7-mm diameter operating sheath (model 26163 C and 26163 H; Storz) and rigid microscissors (model26158 EK; Storz) were introduced. The uterine cavity was distended with a 10% solution of dextran of molecular weight 40,000 (Rheomacrodex; Baxter-Travenol, Trieste, Italy). After visualization of the tubal ostia, the section was started from the inferior margin of the septum and carried cephalad with progressive horizontal cuts in the midline. Daly et al.'s 10 technique was used for the five women with complete septate uterus, and March and Israel's3 method for the four women Candiani et al.
Repair after metroplasty
991
l metrial specimens were fixed in Carnoy's solution and embedded in paraffin. The tissue sections were stained with hematoxylin and eosin and were examined at the light microscope at lOX and 40X magnifications. A residual fundal notch was corrected in nine patients (1 at 1 week, 2 at 2 weeks, 3 at 4 weeks, and 3 at 8 weeks), including the eight in whom the incision could not be completed in the first instance.
RESULTS
Figure 1 Two weeks after surgery: the sectioned areas are depressed and partially epithelialized (e), and the margins of incision (arrows) are faint. A, anterior uterine wall; P, posterior uterine wall; T, left tubal ostium.
with broad septum (>3 em wide at the base on HSG planimetry). The incision was considered complete when a normal uterine cavity was obtained and the hysteroscope could be moved freely from one tubal ostium to the other. In eight women, intrauterine bleeding caused by the cervical dilatation and trauma to endometrium of the lateral walls prevented complete section of the upper portion of the septum. No intrauterine device was inserted, and no before or after operative hormone treatment was administered. After giving informed consent, the patients were randomly assigned to undergo follow-up hysteroscopy 1, 2, 4, or 8 weeks after surgery. No hysteroscopic, laparoscopic, or anesthetic complication occurred. Three patients were scheduled for repeat hysteroscopy 1 week after operation (secretory phase), five after 2 weeks (secretory phase), five after 1 month (proliferative phase), and six after 2 months (proliferative phase). This follow-up procedure was performed under local anesthesia (paracervical block with 15 cc of 1% mepivacaine hydrochloride in normal saline) on an outpatient basis. The cervix was dilated to 7 mm and the same hysteroscope, operating sheath, and distending medium previously described were used. Multiple biopsies were obtained with a rigid biopsy and grasping forceps (model26158 U; Storz) from the uterine fundus and posterior wall inside the margins of the formerly sectioned areas. Endo992
Candiani et al.
Repair after metroplasty
Seven days after operation the triangular sectioned areas were still very evident, with distinct endometrial margins and superficial unepithelialized connective tissue; histological examination demonstrated granulation tissue and fibrin and the absence of epithelial cells. At 14 days the incised zone was depressed on both uterine walls, with no tendency to adhesion and with wide areas lacking endometrial covering. The margins of the section were faint, with initial centripetal epithelialization (Fig. 1). Scattered areas covered by simple columnar and cuboidal epithelium were demonstrated at hystology, similar to the surface endometrium, in direct contact with myometrium or granulation tissue with no intervening cytogenic stroma (Fig. 2). Islands of epithelialization not connected to the borders of the incision were seen in the center of the sectioned areas. Four weeks after metroplasty
Figure 2 Same case as Figure 1. The sectioned area is partially covered by simple columnar epithelium (E) in contact with myometrium (M) with no intervening stroma (light microscope, hematoxylin and eosin, original magnification X40).
Fertility and Sterility
Figure 3 Eight weeks after surgery: the uterine cavity is almost normal. A slight depression of the incised areas is seen on the anterior (A) and posterior (P) wall, and there is a minimal central fundal adhesion (arrow). T, left tubal ostium.
the sectioned areas were still clearly depressed with respect to the surrounding endometrium and were uniformly covered by thin epithelium. The two patients in whom the operation was completed presented a limited central fundal adhesion a few millimeters wide and deep between the anterior and posterior uterine walls, which was not corrected. In all the biopsies we observed a regular proliferative endometrium with columnar epithelium and stroma. The uterine cavity was normal 8 weeks after surgery. Only in three cases could slight depressions be recognized at the areas of incision (Fig. 3). Two patients in whom the septum had been completely lysed presented a central fundal adhesion, minimal in one and 1.5 em deep in the other. The latter was corrected. The endometrium was histologically regular in all cases. DISCUSSION
The reproductive prognosis of a septate uterus is unfavorable, the abortion rate being 67%. 6 This is probably due to frequent implantation of the blastocyst on the scantily vascularized septum that is unsuited for metabolic exchanges with trophoblast.U·12 The septal mucosa may be analogous to the antimesometrial area in which nidation occurs in mammals with bicornuate uteri. 13 A septate uterus can be corrected by hysteroscopic metroplasty, with minimal morbidity. 1-4 Objective data Vol. 54, No.6, December 1990
on the spontaneous mode of reconstruction of the uterine cavity after septal incision are scanty. 5 We perform a postoperative HSG or hysteroscopy routinely before advising patients to attempt a pregnancy. In the present study, the sole modification to our usual practice was programming only a hysteroscopy at different times. The study was performed on a small series of patients, but the gross and hystological findings did not differ in the groups of subjects studied at the various times. This would suggest that the anatomic events after hysteroscopic metroplasty follow a regular course. The two parts of the incised septum retract under the plane of the surrounding endometrium, hindering secondary adhesions. We noted a tendency to form minimal central fundal adhesions at the basis of the sectioned triangle where contact between unepithelialized surfaces is inevitable due to the wide area of section. Of the 19 hysteroscopic metroplasties performed, 11 were judged complete at the end of the operation. These latter included only one case of fundal septal adhesion 1.5 em deep at follow-up hysteroscopy. Thus, postoperative insertion of an intrauterine device does not seem indispensable for a favorable morphological result. 14 The nine sections performed during repeat hysteroscopy were to correct the only neoformed fundal spur and the eight septa that were not completely incised in the first instance. Epithelialization· of the cut surfaces was slow and irregular in the 2 weeks after the operation. This confirms our previous observation5 and could possibly be due to impending ovulation and scanty mitotic activity during the secretory phase. At 14 days, in addition to epithelialization from the margins of the incision, we observed islands of epithelial cells not connected to the margins. This may be related to an implantation on the denuded collagen matrix of endometrial cells released during the operation. The gross and microscopic examinations performed during the cycle after surgery always demonstrated a complete epithelial lining of the intrauterine cavity, suggesting that administration of estrogens after hysteroscopic metroplasty is probably superfluous. 14 Moreover, since the uterine cavity was morphologically normal and the covering endometrium ofthe sectioned area regular 2 months after surgery, there do not seem to be reasons for delaying attempts at pregnancy beyond that date. Candiani et al.
Repair after metroplasty
993
REFERENCES 1. Valle RF, Sciarra JJ: Hysteroscopic treatment of the septate uterus. Obstet Gynecol 67:253, 1986 2. Fayez JA: Comparison between abdominal and hysteroscopic metroplasty. Obstet Gynecol 68:399, 1986 3. March CM, Israel R: Hysteroscopic management of recurrent abortion caused by septate uterus. Am J Obstet Gynecol156:834, 1987 4. Daly DC, Mayer D, Soto-Albors C: Hysteroscopic metroplasty: six years' experience. Obstet Gynecol 73:201, 1989 5. Fedele L, Marchini M, Baglioni A, Carinelli SG, Candiani GB: Endometrial reconstruction after hysteroscopic incisional metroplasty. Obstet Gynecol 73:492, 1989 6. Buttram VC, Reiter RC: Uterine anomalies. In Surgical Treatment of the Infertile Female. Baltimore, Williams & Wilkins, 1985, p 149 7. Candiani GB, Ferrazzi E, Fedele L, Vercellini P, Dorta M: Sonographic evaluation of uterine morphology: a new scanning technique. Acta Eur Fertil17:345, 1986 8. Fedele L, Ferrazzi E, Dorta M, Vercellini P, Candiani GB: Ultrasonography in the differential diagnosis of "double" uteri. Fertil Steri150:361, 1988
994
Candiani et al.
Repair after metroplasty
9. The American Fertility Society: The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Mullerian anomalies and intrauterine adhesions. Fertil Steril 49:944, 1988 10. Daly DC, Tohan N, Walters C, Riddick DH: Hysteroscopic resection of the uterine septum in the presence of a septate cervix. Fertil Steril 39:560, 1983 11. Fedele L, D' Alberton A, Vercellini P, Candiani GB: Gestational aspects of uterus didelphys. J Reprod Med 33:353, 1988 12. Fedele L, Dorta M, Brioschi D, Giudici MN, Candiani GB: Pregnancies in septate uteri: outcome in relation to site of uterine implantation as determined by sonography. Am J Roentgenol152:781, 1989 13. Mossmann HW: Comparative morphology of the fetal membranes and accessory uterine structures. Contrib Embryo! Carnegie Inst 26:129, 1937 14. Vercellini P, Fedele L, Arcaini L, Rognoni MT, Candiani GB: Value of intrauterine device insertion and estrogen administration after hysteroscopic metroplasty. J Reprod Med 34:447, 1989
Fertility and Sterility