Surgical Correction of the Septate Uterus

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Vol. 25, No.4, April 1974 Printed in U.S.A.

FERTILITY AND STI!lULITY

Copyright

© 19740 The American Fertility Society

SURGICAL CORRECTION OF THE SEPTATE UTERUS V. C. BUTTRAM, JR., M.D., L. ZANOTTI, M.D., A. A. ACOSTA, M D AND R. R. FRANKLIN-,"iM.D.

J. S. VANDERHEYDEN, M.D., P. K. BESCH, PH.D.,

Department of Obstetrics and Gynecology, Baylor College of Medicine and Reproducti ve Research Laboratory, St. Luke's Episcopal Hospital, Houston, Texas 77025

Uterine anomalies and their relationship to infertility and pregnancy frequently stimulate interest and debate. The first reference to this subject was made in 1675 by Francois Mauriceau,1 In 1884, Ruge reported the surgical excision of uterine septum which was followed by a term pregnancy.2 Subsequently, a number of papers on congenital uterine malformations have emphasized classification of the anomalies, indications for surgery, surgical technique, and surgical results. HO Several different techniques have been advocated for the surgical correction of the septate uterus. 3 - I6 For many years the procedure for repair of bicornuate uteri has involved a transverse incision across the uterine fundus with reapproximation of the uterine edges in a longitudinal anteroposterior line; this procedure has also been recommended for the septate uterus. 3 Jones and Jones popularized a technique of wedging the uterine septum from the remaining uterine tissue. 5 To decrease blood loss, this surgical procedure was later modified by making a vertical midline incision into the uterine fundus down to the endometrial cavity with a subsequent incision of the septum and reapproximation of the uterine edges. 7 ,s In the United States, this procedure has been popularized by Pendleton Tompkins. 9 Over the past 6 years we have been Received June 22, 1973.

using a similar procedure, with a simple and effective technique of closure. Our success with this form of metroplasty encourages us to report our experience. MATERIALS AND METHODS

From 1966 through 1970, 28 patients underwent metroplasty for septate uteri at Methodist Hospital, Houston, Texas. Their average age was 26.4 years, the youngest being 20 and the oldest, 33. The average age of onset of menses was 12.6 years. A history of regular and normal menses was given by 21 patients (75%) and oligomenorrhea was reported by seven patients (25%). Dysmenorrhea was a complaint in 12 patients; it was mild in two patients, moderate in four, and severe in six. Among the 28 patients, 21 had previously conceived, and all had had at least one obstetrical complication. As far as could be determined, all pregn.ancies were from a single conception. The total number of pregnancies was 46, of which 32 e:uded in spontaneous abortion. One patIent had an ectopic pregnancy and one had delivered a premature stillborn infant. There were 12 full-term deliveries in. ' cludmg three stillbirths and nine live births, a preoperative fetal survival of only 19.5%. The patients who delivered nine live born infants had repeated miscarriages following delivery and before the diagnosis was made. Seven patients had primary infertility.

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The diagnosis of septate uterus was confirmed by hysterosalpingography in 27 patients; in the other patient the diagnosis was made incidentally at the time of D & C for incomplete abortion. Tubal patency was demonstrated in all patients either by hysterosalpingography or by the Rubin test. In 22 of the patients the uterus was sub septate-that is, the septum did not involve the lower portion of the uterine cavity; in four patients, the septum extended down to the internal os of the cervix; and in two patients, the septum extended to the external cervical os, the pelvic appearance being that of a double cervix. These latter six patients were classified as having a septate uterus. The sperm counts of all husbands were within normal limits.

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Surgical Technique. Prior to laparotomy, D & C was performed in all patients. The uterus was packed with iodoform gauze at the time of D & C to aid in delineating the uterine cavity in 16 patients; in six patients the gauze was left in place for 24 to 48 hours and in ten patients it was removed when the uterus was opened. A lower abdominal transverse incision was used for abdominal exploration. The uterus was first divided from above downward in an anteroposterior direction until the endometrial cavity was entered (Fig. 1). The incision was kept in the midline to minimize blood loss. Once the endometrial cavity was exposed, scissors were used to cut the septum bilaterally, without excising it. Care was taken not

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FIG. 1. Surgical correction of septate uterus, showing anteroposterior incision of uterus to expose endometrial cavity.

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to cut into the myometrium superiorly. The uterine walls were then reapproximated by simple interrupted no. 1 chromic catgut sutures that transversed serosa, myometrium, and endometrium. The first sutures were placed on the anterior and posterior aspects of the uterus just below the incision in the uterine wall. The remaining sutures were placed about 0.5 to 1.0 em apart; none were tied until all sutures were in place. Closure was in a longitudinal anteroposterior direction along the same line as the incision (Fig. 2,). Approximation of the serosal surface was further enhanced by a running inverting 3-9 chromic catgut suture. To prevent adhesions, a modified Coffey uterine suspension procedure was used in several patients. 17 This required approximation of the round ligaments in

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the midline overlying the uterine incision anteriorly with 3-0 black silk sutures; this also suspended the uterus anteriorly. The more superiorly were the ligaments joined to the uterine fundus the better was the suspension. Care was taken not to compromise tubal motility. In 16 patients, triplication of the round ligaments and plication of the uterosacral ligaments were performed. A presacral neurectomy was done in 13 patients. In 16 patients, an IUCD was placed in the uterine cavity before closure and left in place for 1 to 3 months. Endometriosis of varying degrees was found in nine patients. The implants were removed as far as was feasible. Mild adhesive disease of unknown etiology was noted in two patients; lysis of adhesions was performed when possible. In two patients mild intra-

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FIG. 2. Surgical correction of septate uterus, showing incision of septum, reapproximation of uterine walls, and approximation of serosal surface.

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uterine synechia were lysed. In five patients the ovaries appeared to be sclerocystic. RESULTS

Of these 28 patients, two were not interested in conceiving after operation. For them, metroplasty was done primarily because of dysmenorrhea, which had been severe and which subsided considerably after the surgical procedure. In fact, all 12 patients with dysmenorrhea obtained partial to complete relief of their menstrual discomfort. Seven of the patients complaining of dysmenorrhea had associated endometriosis. Of the 26 patients wishing to conceive, 19 (73%) became pregnant. .Of the seven patients who did not conceIve and who were infertile, four had associated endometriosis that probably hampered their fertility. Five of the nine patients with endometriosis conceived. The patient with pelvic inflammatory disease did not and neither have the two patients with no other pathologic condition. Both patients with intrauterine synechia conceived, as did all of the seven patients with oligomenorrhea who received ovulatory stimulants after operation. The total number of pregnancies was 24·, one woman had twins. From the 24 pregnancies there were 21 full-term live births (87.5%) and four spontaneous abortions. There were no premature births or stillbirths. All the babies were delivered by cesarean section. The average hospital stay for the metroplasty procedure was 8.1 days. Complications were minimal. DISCUSSION

For clinical purposes, Strassmann's classification of uterine anomalies is still the preferable one. 3 Too frequently a septate uterus is misdiagnosed as a bicornuate uterus; this latter diagnosis cannot

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be made unless one can palpate or see two definite uterine horns. A septate uterus frequently has the same appearance as a bicornuate uterus on hysterosalpingography. Some have the impression that there are more bicornuate uteri than septate uteri, but our impressi~n ~s that the reverse is true. The actual mCIdence of uterine malformation is unknown but Dunselman estimated it to be 1.5%.1.3 It is impossible to know just what proportion of malformed uteri are septate. The use of hysterography and a higher index of suspicion by physicians have led to the increased detection of these anomalies. A proper classification will eventually give us more information about frequency and type. The surgical procedure of choice for the bicornuate uterus remains the Strassmann operation. We believe, however, that our technique for correction of the septate uterus is superior to either the Strassmann or the Jones procedures. It is simpler and almost bloodless. Our experience with the transverse incision and the vertical wedge resection has been one of excessive blood loss. Hysterosalpingography performed 3 months after operation revealed not a single incidence of reunification of the septate edges or of intrauterine adhesions. The avascularity of the septum possibly helps to prevent reunification. Complete normal restoration of the uterine cavity was not the typical appearance on postoperative roentgenograms; instead, the cavity usually was arcuate. That 73 % of our patients did conceive and that 87.5% of the infants were born alive at term speaks well for the efficacy of the surgical procedure. Strassmann1.() and also DI,mselman,1.3 using the Strassmann procedure in 269 women, reported fetal survival rate of 86.3%. We are unclear from reviewing the literature in just how many of these patients the uterus was bicornuate and in how many

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the uterus was septate. It is our impression that these two different conditions are considered synonymous too frequently. Capraro and associates l5 reported a fetal survival rate of 82% in ten patients with septate uteri, but also found a 9% incidence of premature deliveries. A similar metroplasty technique was used in two of these ten patients. Jones and Jones, 12 using their technique in 22 women with septate uteri, reported a fetal survival rate of 67.5% and a prematurity rate of 8.1 %. The fact that there were no premature deliveries in our series may be significant. Cutting the cervical septum usually leaves the" cervix appearing as a normal single cervix. It is possible that this could result in an incompetent cervix, but this did not occur with our two patients with cervical septum and Strassmann reported that he saw none such develop.10 During pregnancy frequent examinations should be made to rule out such an occurrence. A cerclage procedure should be performed if there are any indications of cervical thinning or dilatation. Although not mandatory, we now routinely perform a suspension procedure to enhance conception and, more importantly, to reduce the chances of adhesions developing between the uterus anteriorly and other pelvic and abdominal viscera. A modified Coffey uterine suspension17 procedure has become our choice. Presacral neurectomy performed in conjunction with the unification procedure was primarily to relieve dysmenorrhea. The value of this ancillary procedure is questionable. It did alleviate, or at least ameliorate, discomfort in these patients, but whether it enhanced the likelihood of conception is unknown. It is possible that this procedure may be harmful in that it might mask early labor or uterine rupture. We doubt the latter, however, and believe that it is a worthwhile procedure in patients with infertility, dys-

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menorrhea, or endometriosis, or all of these. We believe that prepacking of the uterine cavity with gauze is generally not needed. In the 12 patients in whom. this was not performed it was not difficult to delineate the uterine cavity. Jones 5 recommended injecting blue dye into the cavity of t}Ie uterus before opening the abdomen so that the uterine cavity can be more readily recognized; this may be a worthwhile procedure. The surgical procedure we have used is not unique, but most operators have used a different uterine closure technique. Bret 7 closed the uterine wall in three layers with nylon sutures-a somewhat complex procedure, as is closure of the uterine wall in two layers advocated by Palmer.s Both of these authors recommended that suture material should not be placed in the uterine cavity. Genell and SjovalP4 used figure-8 sutures of plain catgut. Admittedly there are several satisfactory ways of closing the uterine wall provided hemostasis is secured, but the method we have used still appears to be simplest. Some prefer apposition of the muscular layers with an interrupted nonabsorbable suture of strong silk or nylon/,16,ls reasoning that if only catgut is used uterine rupture is more likely. If we were sewing fascial layer to fascial layer, we would agree; instead, we sew muscle to muscle and the strength of the ensuing scar depends primarily on a good healing process and not on the sutures used to reunite the uterine walls. Oral contraceptives are given during the first 3 months after operation in order to prevent conception until the uterine walls have healed well. Hysterosalpingography is done regularly 3 months after operation in order to detect any problem before conception is advised. The incidence of associated endometriosis in our group was high-32% (nine patients) . This should point to the need

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for earlier surgical intervention in patients with congenital utenne anomalies and associated infertility. Furthermore, it raises the question of whether there is abnormal uterine activity that would enhance the development of this pathologic process in these women. Several authors have emphasized that a double uterus itself is not an indication for plastic unification. 3-5 ,7-Il,13,14 We concur. Conversely, it is thought that any woman with a septate or bicornuate uterus who has been unable to give birth to a living child-because of premature labor, abortion, or infertility-deserves the benefit of surgical intervention. Moreover, it is not necessary that a woman should not have to suffer repeated fetal losses before a definitive procedure is performed. Controversy persists regarding the mode of delivery in patients who have undergone metroplasty. Many believe there are no contraindications to vaginal delivery.3-5,7-S,13,1'4 Of the 269 subsequent pregnancies reviewed by Strassmann10 and by Dunselman,13 232 had living children and 37 aborted or delivered prematurely. The majority of the deliveries were vaginal. There were no reported cases of uterine rupture during pregnancy or delivery. They both concluded that the uterine scar following unification is reliable. Strassmann4 explained that scar formation from a cesarian section develops under entirely different biologic conditions and therefore is not so reliable. Sindram and SikkeP9 reported one case of uterine rupture during pregnancy following a Strassmann reunification procedure. Reiss20 reported that the Strassmann metroplasty procedure was followed by uterine rupture at 37 weeks of gestation in one patient and at 23 weeks of gestation in another. All our patients were delivered by cesarean section. We believe that no chance, however minimal, should be taken in the delivery of a woman who has al-

ready undergone major surgery to potentiate her fertility status. SUMMARY

Metroplasty for septate uterus was performed in 28 patients. A simple surgical technique was used. The preoperative fetal survival rate was 19.5%, compared with a postoperative rate of 87.5%. The frequency of associated endometriosis was high (32.1 %). Delivery was by cesarean section. REFERENCES 1. Mauriceau, F: Traite des Maladies des Femmes Grones. Paris, 1675 2. Ruge P: Fall von Schwangerschaft bei Uterus Septus. Z Geburtshilfe Gynaekol 10: 141, 1884 3.

Strassmann P: Die operative Vereinigung eines doppelten Uterus. Zentralbl Gynaekol. 43: 1322, 1907

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Strassmann EO: Plastic unification of double uterus: a study of 123 collected and five personal cases. Am J Obstet Gynecol 64:25, 1952

5.

Jones HW Jr, Jones CES: Double uterus as an etiological factor of repeated abortion, indication for surgical repair. Am J Obstet Gynecol 65:325, 1953

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Jones HW Jr, Delfs MD, Jones CES: Reproductive difficulties in double uterus: the place of plastic reconstruction. Am J Obstet Gynecol 72:865, 1956

7. Bret AJ, Guillet B: Hysteroplastie reconstitutive sans resestion musculaire, dans les malformations uterines cause d'avortements a'repetition. La Presse Medicale 67:394, 1959 8. Palmer MR: Le traitement chirurgical des avortements recidivants par bifidite uterine. Fed Soc Gynecol Obstet Bull 14:107, 1962 9.

Tompkins P: Comments on the bicornuate uterus and twinning. Surg Clin North Am 42: 1049, 1962

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Strassmann EO: Fertility and unification of double uterus. Fertil Steril 17: 165, 1966

11. Jones HW Jr: Operations for congenital anomalies of the uterus and vagina. Clin Obstet Gynecol 2: 1053, 1959

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12. Jonl;!s HW Jr, Wheeless CR: Salvage of the reproductive potential of women with anomalous development of the Miillerian ducts: 1868-1968-2068. Am J Obstet Gynecol 104: 348, 1969 13. Dunselman GAJ: Congenital Malformations of the Uterus. Results of the Strassmann Metroplastic Operation. Holland, N. V. Helmond, 1959 14. Genell S, Sjovall A: The Strassmann operation: results obtained in 58 cases. Acta Obstet Gynecol Scand 38:477, 1959 15. Capraro VJ, Chuang JT, Randall CL: Improved fetal salvage after metroplasty. Obstet Gynecol 31:97, 1968

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16. White MM: Uteroplasty in infertility. Proc R Soc Med 53: 1006, 1960 17. Coffey RC: Surgical treatment of displace· ments of uterus. Denver Med Times 24:339, 1904 18. Green-Armytage VB: Discussion on Uteroplasty in infertility. Proc R Soc Med 53: 1009, 1960 19. Sindram IS, Sikkel A: Uterus ruptuur na operatie volgens Strassmann. Ned Tijdschr Verlosk Gynaecol 52:426, 1953 20. Reiss HE: Discussion on uteroplasty in infertility. Proc R Soc Med 53: 1009, 1960