Abstract
Study question
Is hysteroscopic wedge septectomy (HWS) an effective and safe method for reducing the risk of miscarriage and improving the reproductive outcome in patients with recurrent pregnancy loss or infertility history?
Summary answer
HWS is a safe and effective method for RPL and infertility cases with statistically significant improvement in pregnancy chances and reproductive outcomes.
What is known already
With regard to the persisting uncertainty around the effectiveness of septum resection in recurrent miscarriage and infertility cases, there may be alternative methods to better address the pathophysiology of septum. There are different explanations for the poor reproductive performance with uterine septum: poor vascularisation of a highly fibrous implantation site, low sensitivity of endometrial receptors covering the septa, its “myoma-like” composition, and finally higher uterine vascular resistance. Complete removal of this abnormal tissue rather than just incising it may not only enhance challenging the pathogenesis but also expand the endometrial volume, an objective parameter by which to predict endometrial receptivity.
Study design, size, duration
In this retrospective cohort study, 214 consecutive patients, aged 33.3±4.8, diagnosed with a septate uterus based on ESHRE classification who had been under HWS between April 2017 and January 2020 due to recurrent miscarriage or at least one failed embryo transfer, met the enrollment criteria. With 11 to 36 months follow up, gathering of follow up data was managed between August till the end of Nov 2020, when the last new information was included.
Participants/materials, setting, methods
Patients with a history of RPL or at least one failed ET who were diagnosed as septate uterus by 2D, 3D, or hysteroscopy have been under HWS in a tertiary infertility and recurrent abortion treatment/educational setting. Those with BMI≥32, day 3 FSH≥13 mIU/mL, acquired or hereditary thrombophilia, thyroid disease, and myomatous uterus were excluded. HWS’s goal was to remove the septum as a wedge, cutting with 7Fr scissors, in its entirety as much as possible.
Main results and the role of chance
39 patients who experienced 1 to 8 failed ET and 175 with 2 to 10 miscarriages, were enrolled in the study. The average septum size based on the depth of the removed wedge was 1.73±0.86 cm. There was an increase of 1.68±0.9 cm in uterine depth and 2.28±0.6 ml in uterine capacity measured by uterine sound and inflation of 8F Folley catheter balloon inside the cavity, respectively. The procedure took 35.75±8.7 minutes. Intraoperative, postoperative, or late complications during the next pregnancies were not reported. 7 patients (17.9%) in failed ET group, conceived spontaneously, before another embryo transfer attempt. Embryo transfer in the remaining 32 cases resulted in 25 (78.1%) clinical pregnancies. 2 miscarried (6.2%), 5(15.6%) are ongoing after 20 weeks of gestation and 25 (78.1%) have resulted in live births. Among 126 clinical pregnancies in RPL group, 16 patients (12.6%) experienced another miscarriage; 6%, 11.3%, and 25% in patients with a previous history of 2, 3, and 4 or more miscarriages, respectively. There was a significant drop in odds of post-procedure miscarriage from 22.7% to 6% (p:0.005) and from 27.8% to 11.3% (p:0.27) with 2 and 3 miscarriage history, respectively. This reduction was not significant with more than 3 losses.
Limitations, reasons for caution
We acknowledge the inherent limitations of this retrospective observational study, confining direct inferences. Our goal is to encourage future prospective studies to compare the effectiveness of different methods of hysteroscopy with or without involving the removal of septal tissue. An RCT comparing metroplasty vs expectant management seems infeasible, though.
Wider implications of the findings
Our findings suggest that timely removal of the uterine septal tissue with hysteroscopy will result in favorable reproductive outcomes in patients with RPL and/or infertility. Also, a history of a normal term pregnancy before subsequent successive losses does not rule out the uterine septum and calls for a thorough assessment.
Trial registration number
not applicable
The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum in patients with recurrent pregnancy loss in the era of transvaginal 3D ultrasound scan
