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Ultrasound-guided transcervical metroplasty
FERTILITY AND STERILITY
Vol. 54, No.6, December 1990
Copyright rD 1990 The American Fertility Society
Printed on acid-free paper in U.S.A.
Ultrasound-guided transcervical metroplasty
Denis Querleu, M.D.* Therese Leroy Brasme, M.D. Dominique Parmentier, M.D. Clinique Uniuersitaire de Gymicologie Obstetrique et Pathologie de la Reproduction, Pauillon Paul Gelle, Roubaix, France
A new technique of metroplasty is described. The septum is divided with 4-mm endoscopic scissors introduced into the uterine cavity through the cervix. The whole procedure is monitored by a real-time ultrasound scanner. Twenty-four patients were operated on with this technique. No complication was encountered. Fifteen patients had third trimester deliveries or ongoing pregnancies. Among 12 patients who had suffered repetitive pregnancy losses, 11 desired pregnancy: 10 have been successfully pregnant beyond the second trimester (91.7%), 8 are delivered, and the living birth rate is 72.7%. These results equal those obtained after hysteroscopic metroplasty. The procedure is short, safe, requires no special equipment, and does not necessitate concomitant laparoscopy. Fertil Steril54:995, 1990
Transcervical section of the uterine septa can be performed hysteroscopically .1 Hysteroscopic metroplasty results in low morbidity and has a good surgical outcome. 2 To prevent uterine perforation during division of the upper part of the septum, laparoscopic or ultrasonic monitoring has been proposed.3 We previously have described transcervical section of uterine septa, without concomitant hysteroscopy or laparoscopy, using a real-time abdominal ultrasound (US) scanner as a guide. 4 The first 24 patients operated on with this technique are reported in this paper.
MATERIALS AND METHODS
Twenty-four patients underwent US-guided metroplasty between June 1984 and June 1989. The uterine septum was diagnosed in every case by hysterography and/ or ultrasonography. Twelve of the patients h3:d previously suffered two or more spontaneous first- or second-trimester losses. Complete work-up included hysterosalpinReceived January 22, 1990; revised and accepted June 25, 1990. * Reprint requests: Denis Querleu, M.D., Pavilion Paul Gelle 91 Avenue Julien Lagache, 59100 Roubaix, France.
Vol. 54, No.6, December 1990
gography, endometrial biopsy, parental karyotype, plasma thyroid-stimulating hormone and 17a-hydroxyprogesterone. Uterine septum was the only factor of recurrent abortion in all cases. Nine patients presented with primary infertility of at least an 18-month duration. The mean age of these patients was 29 years. Work-up included hysterosalpingography, endometrial biopsy, postcoital test, and sperm analysis. A male factor was diagnosed in one case. Three patients registered in our in vitro fertilization program because of tubal infertility. Five patients presented with unexplained infertility. In the last three patients, uterine septa were asymptomatic, and metroplasty was performed as an additional procedure during section of a vaginal septum. All three patients had a complete division of cervix and corpus diagnosed by clinical examination and ultrasonography. No additional evaluation of fertility was done in this group. In the whole series, 18 patients had a complete septum to the internal (n = 11) or external os (n = 7), and 6 a partial septum reaching the lower third of the length of the uterine cavity. No case of arcuate uterus was included in this report. The operation was performed under general anesthesia or neuroleptanalgesia. The bladder was Querleu et al.
Ultrasound-guided metroplasty
995
distance from the anterior and posterior surface of the uterus. The posterior serosal wall always was seen, without necessitating the placement of liquid in the cul-de-sac. The procedure was considered complete when the distance between the upper limit of the section and the serosal surface of the uterine fundus was 10 mm (Fig. 2). The operating time was in some cases< 10 minutes. No intrauterine device was inserted because the efficacy of this procedure in maintaining the uterine shape is doubtful. 5 The patients were observed in hospital for 24 hours, but day-care surgery is a reasonable choice. Patients were given cyclic hormonal therapy (ethinyl estradiol 100 ~g/d for 21 days, norethisterone acetate 1 mg/d in addition for the final 7 days of estrogen therapy) over 3 months. The goal of this hormonal therapy is to help endometrial regeneration. However, the efficacy of such treatment is considered controver-
Figure 1 Ultrasound monitoring of metroplasty. Sagittal plane. Scissors are visible. 1, Serosal surface of the uterine fundus; 2, Endometrium; 3, Scissors; 4, Bladder.
filled with 250 mL of saline isotonic solution through a balloon catheter. An assistant placed the transducer of a real-time US scanner in longitudinal or transversal position according to the needs of the surgeon. The uterine fundus was checked, and the differential diagnosis from bicornuate uterus was made. The septum was measured in width and in length. Endoscopic scissors with 4 mm diameter (26175 MS; Karl Storz, Tuttlingen, Germany), generally used for laparoscopic surgery, were used. The scissors were introduced into the uterine cavity through the cervix without any cervical dilatation. The entire operation was performed under US imaging of the position of the instrument (Fig. 1). The tip of the scissors came into contact with the lower edge of the septum. The scissors were opened, and the blades were placed on the right and on the left side, respectively, of the septum. The septum was divided at an equal 996
Querleu et al.
Ultrasound-guided metroplasty
Figure 2 Ultrasound monitoring of metroplasty. Frontal plane. The blades of scissors are opened and visible near the uterine fundus. 1, Serosal surface of the uterine fundus; 2, Endometrium; 3, Scissors; 4, Bladder.
Fertility and Sterility
Table 1
Anatomical Results
Group
Complete uterine and cervical septum
Complete uterine septum
Partial uterine septum
7
11
6
No. of patients No. with postoperative hysteroscopy or hysterography Normal uterine cavity Residual arcuate uterus Residual partial septum b Uterine synechiab
6 3
8 6 2a
4 2 2a
2c 1
a Two patients had a term pregnancy; one pregnancy is ongoing in the second trimester; one patient had a recurrent firsttrimester abortion. b Divided during second-look hysteroscopy. c One patient is not pregnant; one had a term pregnancy.
sial. A second-look hysteroscopy was proposed after the last withdrawal bleeding, 3 months after operation in all patients. The result was documented by hysterography only at the beginning of our experience. At the time of this report, we believe that control radiography is no longer justified. RESULTS
No significant bleeding or intraoperative complication was encountered in any of the 24 cases. Uterine perforation was never observed. The postoperative period was uneventful. In six patients, no postoperative hysteroscopy or hysterography is available: one does not want pregnancy at this time; the last five declined control hysteroscopy or hysterography; all five had term pregnancies. Eighteen patients had a morphological evaluation of the uterine cavity (Table 1). In 11 patients, the results were considered excellent, with no significant indentation of the uterine fundus. In 4 patients, the persistence of an arcuate fundus, without clinical significance, was noted. In 2 patients, a residual septum measuring 10 to 20 mm was divided under hysteroscopic control (these 2 patients had initially a complete septum to the external os). In the last case, the result was judged unsatisfactory because of the occurrence of an extensive synechia; after hysteroscopic division of the adhesion, the patient became pregnant. Because 2 patients do ·not want pregnancy, the obstetric outcome is available in 22 patients (Table 2). Eighteen patients have conceived. One spontaneous first-trimester abortion has been observed in a patient complaining of recurrent abortions, presenting with a partial uterine septum and in whom the postoperative control has shown a reVol. 54, No.6, December 1990
sidual arcuate uterus. One patient aborted a twin pregnancy at 22 weeks. Despite a history of cervical incompetence, her obstetrician had not performed a cervical cerclage; she conceived soon after this loss, underwent a cervical cerclage, and had a term delivery. Six pregnancies are in progress (two are in the second and four in the last trimester), and 12 patients delivered, including the case described above. Eight patients were delivered vaginally, and four cesarean sections were performed. The indications for cesarean section were cephalopelvic disproportion, premature rupture of the membranes with amniotic infection and prematurity, preeclampsia, and breech presentation and fetal macrosomia, respectively. Three premature deliveries occurred, all in the infertile patients group. Six patients are not pregnant. Two patients do not want pregnancy. Two patients from the infertility group have another cause of infertility (tubal factor). One additional patient has persistent unexplained infertility. DISCUSSION
Indication for surgical therapy of septate uteri associated with one or more spontaneous abortions is generally accepted, and the efficacy of treatment is good5 : in this series, 10 of 11 patients desiring pregnancy (91. 7%) have had a successful early pregnancy. Delivery rate is 72.7% (8 of 11), and 2 more patients are in the 27th and 32th week, respectively. Although six of nine patients presenting with primary infertility are pregnant or delivered, there is no evidence in this paper to affirm that infertility Table2
Pregnancy Outcome
Group No. of patients No. desiring pregnancy Pregnant Abortion Ongoing secondtrimester pregnancy Term or ongoing thirdtrimester pregnancy
Recurrent abortion
Primary infertility
Asymptomatic
12
9 9
3 2
2a 1 (27th week)
6 0 1 (23rd week)
1 0 0
9a,b
5c
1 (30th week)
11 11
a One patient had second-trimester abortion then term pregnancy. b Eight patients are delivered, one is in the 32nd week. cAll five delivered with living children. Three patients had premature deliveries, including a twin pregnancy with one living child and one neonatal death.
Querleu et al.
Ultrasound-guided metroplasty
997
is caused by the uterine anomaly and can be cured by metroplasty. Primary infertility is not by itself an indication for metroplasty. However, it seems reasonable to propose US-guided metroplasty to infertile patients to reduce the risk of miscarriage in this context of reproductive failure. Asymptomatic patients with a septate uterus do not need any surgical treatment. This indication is clearly controversial. However, when surgery is indicated for division of a vaginal septum, division of the uterine septum can be proposed with a low additional risk and cost. The results of this new technique of metroplasty are comparable with those obtained after hysteroscopic incision, presently considered the procedure of choice to correct a septate uterus. 6 The technique offers the same advantages as hysteroscopy because it leaves no myometrial scar and no pelvic adhesions. It is not time-consuming, can be carried out with a standard real-time sonograph, and is performed without additionallaparoscopy, thus reducing the morbidity and potential mortality of the whole procedure. However, some investigators do not routinely perform hysteroscopic incision under laparoscopic control. There is no need for referral if the gynecologist is at ease with procedures under US monitoring. There is no technical limitation to the procedure-most wide uterine septa can be incised in a single operation. Some investigators have advised against the incision of the cervical septum to minimize the risk of creating a single incompetent cervix from two single cervices. 5 In our experience, surgical incision of the cervical septum at the external os followed by US-guided division of the remaining cervical and uterine septum has been performed in seven cases. Six of these patients have been pregnant;
998
Querleu et al.
Ultrasound-guided metroplasty
one of them suffered a second-trimester abortion and later had a term pregnancy with the help of a cervical cerclage. The hypothesis of iatrogenic cervical incompetence in this case must be raised. As a consequence, a method avoiding incision of the cervical septum may be preferable in such patients. 7 Transcervical metroplasty is at this time the procedure of choice for the treatment of septate uteri with reproductive failure. Ultrasound scanning enhances the safety of the procedure because it allows precise checking of the thickness of myometrium left intact. 3 Progress in US imaging has led us to investigate the possibility of doing without hysteroscopic vision. In this preliminary experience, the absence of complications and the observation of results, comparable with those obtained by abdominal as well as hysteroscopic metroplasty, provides evidence that US-guided transcervical metroplasty is feasible and gives a satisfactory pregnancy outcome. REFERENCES 1. Edstrom KGB: Intra-uterine surgical procedures during hysteroscopy. Endoscopy 6:175, 1979 2. Fayez JA: Comparison between abdominal and hysteroscopic metroplasty. Obstet Gynecol68:399, 1986 3. Lin BL, Iwata Y, Myamoto N, Hayashi S: Three contrasts method: an ultrasound technique for monitoring transcervical operations. Am J Obstet Gynecol156:469, 1987 4. Querleu D, Decocq J, Boutteville C, Locquet F, Crepin G: Section retrograde de cloison uterine sous controle echographique. Presse Med 42:2253, 1988 5. Rock JA, Jones HW: The clinical management of the double uterus. Fertil Steril 28:798, 1977 6. Daly DC, Maier D, Soto-Albors C: Hysteroscopic metroplasty: six years' experience. Obstet Gynecol 73:201, 1989 7. Rock JA, Murphy AA, Cooper WH IV: Resectoscopic techniques for the lysis of a class V: complete uterine septum. Fertil Steril48:495, 1987
Fertility and Sterility
Vol. 54, No.6, December 1990
Copyright rD 1990 The American Fertility Society
Printed on acid-free paper in U.S.A.
Ultrasound-guided transcervical metroplasty
Denis Querleu, M.D.* Therese Leroy Brasme, M.D. Dominique Parmentier, M.D. Clinique Uniuersitaire de Gymicologie Obstetrique et Pathologie de la Reproduction, Pauillon Paul Gelle, Roubaix, France
A new technique of metroplasty is described. The septum is divided with 4-mm endoscopic scissors introduced into the uterine cavity through the cervix. The whole procedure is monitored by a real-time ultrasound scanner. Twenty-four patients were operated on with this technique. No complication was encountered. Fifteen patients had third trimester deliveries or ongoing pregnancies. Among 12 patients who had suffered repetitive pregnancy losses, 11 desired pregnancy: 10 have been successfully pregnant beyond the second trimester (91.7%), 8 are delivered, and the living birth rate is 72.7%. These results equal those obtained after hysteroscopic metroplasty. The procedure is short, safe, requires no special equipment, and does not necessitate concomitant laparoscopy. Fertil Steril54:995, 1990
Transcervical section of the uterine septa can be performed hysteroscopically .1 Hysteroscopic metroplasty results in low morbidity and has a good surgical outcome. 2 To prevent uterine perforation during division of the upper part of the septum, laparoscopic or ultrasonic monitoring has been proposed.3 We previously have described transcervical section of uterine septa, without concomitant hysteroscopy or laparoscopy, using a real-time abdominal ultrasound (US) scanner as a guide. 4 The first 24 patients operated on with this technique are reported in this paper.
MATERIALS AND METHODS
Twenty-four patients underwent US-guided metroplasty between June 1984 and June 1989. The uterine septum was diagnosed in every case by hysterography and/ or ultrasonography. Twelve of the patients h3:d previously suffered two or more spontaneous first- or second-trimester losses. Complete work-up included hysterosalpinReceived January 22, 1990; revised and accepted June 25, 1990. * Reprint requests: Denis Querleu, M.D., Pavilion Paul Gelle 91 Avenue Julien Lagache, 59100 Roubaix, France.
Vol. 54, No.6, December 1990
gography, endometrial biopsy, parental karyotype, plasma thyroid-stimulating hormone and 17a-hydroxyprogesterone. Uterine septum was the only factor of recurrent abortion in all cases. Nine patients presented with primary infertility of at least an 18-month duration. The mean age of these patients was 29 years. Work-up included hysterosalpingography, endometrial biopsy, postcoital test, and sperm analysis. A male factor was diagnosed in one case. Three patients registered in our in vitro fertilization program because of tubal infertility. Five patients presented with unexplained infertility. In the last three patients, uterine septa were asymptomatic, and metroplasty was performed as an additional procedure during section of a vaginal septum. All three patients had a complete division of cervix and corpus diagnosed by clinical examination and ultrasonography. No additional evaluation of fertility was done in this group. In the whole series, 18 patients had a complete septum to the internal (n = 11) or external os (n = 7), and 6 a partial septum reaching the lower third of the length of the uterine cavity. No case of arcuate uterus was included in this report. The operation was performed under general anesthesia or neuroleptanalgesia. The bladder was Querleu et al.
Ultrasound-guided metroplasty
995
distance from the anterior and posterior surface of the uterus. The posterior serosal wall always was seen, without necessitating the placement of liquid in the cul-de-sac. The procedure was considered complete when the distance between the upper limit of the section and the serosal surface of the uterine fundus was 10 mm (Fig. 2). The operating time was in some cases< 10 minutes. No intrauterine device was inserted because the efficacy of this procedure in maintaining the uterine shape is doubtful. 5 The patients were observed in hospital for 24 hours, but day-care surgery is a reasonable choice. Patients were given cyclic hormonal therapy (ethinyl estradiol 100 ~g/d for 21 days, norethisterone acetate 1 mg/d in addition for the final 7 days of estrogen therapy) over 3 months. The goal of this hormonal therapy is to help endometrial regeneration. However, the efficacy of such treatment is considered controver-
Figure 1 Ultrasound monitoring of metroplasty. Sagittal plane. Scissors are visible. 1, Serosal surface of the uterine fundus; 2, Endometrium; 3, Scissors; 4, Bladder.
filled with 250 mL of saline isotonic solution through a balloon catheter. An assistant placed the transducer of a real-time US scanner in longitudinal or transversal position according to the needs of the surgeon. The uterine fundus was checked, and the differential diagnosis from bicornuate uterus was made. The septum was measured in width and in length. Endoscopic scissors with 4 mm diameter (26175 MS; Karl Storz, Tuttlingen, Germany), generally used for laparoscopic surgery, were used. The scissors were introduced into the uterine cavity through the cervix without any cervical dilatation. The entire operation was performed under US imaging of the position of the instrument (Fig. 1). The tip of the scissors came into contact with the lower edge of the septum. The scissors were opened, and the blades were placed on the right and on the left side, respectively, of the septum. The septum was divided at an equal 996
Querleu et al.
Ultrasound-guided metroplasty
Figure 2 Ultrasound monitoring of metroplasty. Frontal plane. The blades of scissors are opened and visible near the uterine fundus. 1, Serosal surface of the uterine fundus; 2, Endometrium; 3, Scissors; 4, Bladder.
Fertility and Sterility
Table 1
Anatomical Results
Group
Complete uterine and cervical septum
Complete uterine septum
Partial uterine septum
7
11
6
No. of patients No. with postoperative hysteroscopy or hysterography Normal uterine cavity Residual arcuate uterus Residual partial septum b Uterine synechiab
6 3
8 6 2a
4 2 2a
2c 1
a Two patients had a term pregnancy; one pregnancy is ongoing in the second trimester; one patient had a recurrent firsttrimester abortion. b Divided during second-look hysteroscopy. c One patient is not pregnant; one had a term pregnancy.
sial. A second-look hysteroscopy was proposed after the last withdrawal bleeding, 3 months after operation in all patients. The result was documented by hysterography only at the beginning of our experience. At the time of this report, we believe that control radiography is no longer justified. RESULTS
No significant bleeding or intraoperative complication was encountered in any of the 24 cases. Uterine perforation was never observed. The postoperative period was uneventful. In six patients, no postoperative hysteroscopy or hysterography is available: one does not want pregnancy at this time; the last five declined control hysteroscopy or hysterography; all five had term pregnancies. Eighteen patients had a morphological evaluation of the uterine cavity (Table 1). In 11 patients, the results were considered excellent, with no significant indentation of the uterine fundus. In 4 patients, the persistence of an arcuate fundus, without clinical significance, was noted. In 2 patients, a residual septum measuring 10 to 20 mm was divided under hysteroscopic control (these 2 patients had initially a complete septum to the external os). In the last case, the result was judged unsatisfactory because of the occurrence of an extensive synechia; after hysteroscopic division of the adhesion, the patient became pregnant. Because 2 patients do ·not want pregnancy, the obstetric outcome is available in 22 patients (Table 2). Eighteen patients have conceived. One spontaneous first-trimester abortion has been observed in a patient complaining of recurrent abortions, presenting with a partial uterine septum and in whom the postoperative control has shown a reVol. 54, No.6, December 1990
sidual arcuate uterus. One patient aborted a twin pregnancy at 22 weeks. Despite a history of cervical incompetence, her obstetrician had not performed a cervical cerclage; she conceived soon after this loss, underwent a cervical cerclage, and had a term delivery. Six pregnancies are in progress (two are in the second and four in the last trimester), and 12 patients delivered, including the case described above. Eight patients were delivered vaginally, and four cesarean sections were performed. The indications for cesarean section were cephalopelvic disproportion, premature rupture of the membranes with amniotic infection and prematurity, preeclampsia, and breech presentation and fetal macrosomia, respectively. Three premature deliveries occurred, all in the infertile patients group. Six patients are not pregnant. Two patients do not want pregnancy. Two patients from the infertility group have another cause of infertility (tubal factor). One additional patient has persistent unexplained infertility. DISCUSSION
Indication for surgical therapy of septate uteri associated with one or more spontaneous abortions is generally accepted, and the efficacy of treatment is good5 : in this series, 10 of 11 patients desiring pregnancy (91. 7%) have had a successful early pregnancy. Delivery rate is 72.7% (8 of 11), and 2 more patients are in the 27th and 32th week, respectively. Although six of nine patients presenting with primary infertility are pregnant or delivered, there is no evidence in this paper to affirm that infertility Table2
Pregnancy Outcome
Group No. of patients No. desiring pregnancy Pregnant Abortion Ongoing secondtrimester pregnancy Term or ongoing thirdtrimester pregnancy
Recurrent abortion
Primary infertility
Asymptomatic
12
9 9
3 2
2a 1 (27th week)
6 0 1 (23rd week)
1 0 0
9a,b
5c
1 (30th week)
11 11
a One patient had second-trimester abortion then term pregnancy. b Eight patients are delivered, one is in the 32nd week. cAll five delivered with living children. Three patients had premature deliveries, including a twin pregnancy with one living child and one neonatal death.
Querleu et al.
Ultrasound-guided metroplasty
997
is caused by the uterine anomaly and can be cured by metroplasty. Primary infertility is not by itself an indication for metroplasty. However, it seems reasonable to propose US-guided metroplasty to infertile patients to reduce the risk of miscarriage in this context of reproductive failure. Asymptomatic patients with a septate uterus do not need any surgical treatment. This indication is clearly controversial. However, when surgery is indicated for division of a vaginal septum, division of the uterine septum can be proposed with a low additional risk and cost. The results of this new technique of metroplasty are comparable with those obtained after hysteroscopic incision, presently considered the procedure of choice to correct a septate uterus. 6 The technique offers the same advantages as hysteroscopy because it leaves no myometrial scar and no pelvic adhesions. It is not time-consuming, can be carried out with a standard real-time sonograph, and is performed without additionallaparoscopy, thus reducing the morbidity and potential mortality of the whole procedure. However, some investigators do not routinely perform hysteroscopic incision under laparoscopic control. There is no need for referral if the gynecologist is at ease with procedures under US monitoring. There is no technical limitation to the procedure-most wide uterine septa can be incised in a single operation. Some investigators have advised against the incision of the cervical septum to minimize the risk of creating a single incompetent cervix from two single cervices. 5 In our experience, surgical incision of the cervical septum at the external os followed by US-guided division of the remaining cervical and uterine septum has been performed in seven cases. Six of these patients have been pregnant;
998
Querleu et al.
Ultrasound-guided metroplasty
one of them suffered a second-trimester abortion and later had a term pregnancy with the help of a cervical cerclage. The hypothesis of iatrogenic cervical incompetence in this case must be raised. As a consequence, a method avoiding incision of the cervical septum may be preferable in such patients. 7 Transcervical metroplasty is at this time the procedure of choice for the treatment of septate uteri with reproductive failure. Ultrasound scanning enhances the safety of the procedure because it allows precise checking of the thickness of myometrium left intact. 3 Progress in US imaging has led us to investigate the possibility of doing without hysteroscopic vision. In this preliminary experience, the absence of complications and the observation of results, comparable with those obtained by abdominal as well as hysteroscopic metroplasty, provides evidence that US-guided transcervical metroplasty is feasible and gives a satisfactory pregnancy outcome. REFERENCES 1. Edstrom KGB: Intra-uterine surgical procedures during hysteroscopy. Endoscopy 6:175, 1979 2. Fayez JA: Comparison between abdominal and hysteroscopic metroplasty. Obstet Gynecol68:399, 1986 3. Lin BL, Iwata Y, Myamoto N, Hayashi S: Three contrasts method: an ultrasound technique for monitoring transcervical operations. Am J Obstet Gynecol156:469, 1987 4. Querleu D, Decocq J, Boutteville C, Locquet F, Crepin G: Section retrograde de cloison uterine sous controle echographique. Presse Med 42:2253, 1988 5. Rock JA, Jones HW: The clinical management of the double uterus. Fertil Steril 28:798, 1977 6. Daly DC, Maier D, Soto-Albors C: Hysteroscopic metroplasty: six years' experience. Obstet Gynecol 73:201, 1989 7. Rock JA, Murphy AA, Cooper WH IV: Resectoscopic techniques for the lysis of a class V: complete uterine septum. Fertil Steril48:495, 1987
Fertility and Sterility