Mounir M. Fawzy El-HaoProf. in Ob/Gyn

Ain Shams UniversityCairo - Egypt

Incidence of Mullerian Abnormalities

General population Unknown0.1 1.5% (Rudigozand Dorgent, 1985)

HSG in infertility 1-3% (Ludmir et al., 1990)

Women with reproductive difficulties1-12% (Rock and Schlaff, 1985)

Incidence:

15 – 25% of spontaneous abortions are

caused by Mullerian fusion defects

(Portuonodo et al., 1986)

Simple classification of Mullerian anomalies:

1. Agenesis (R-K.H-Syndrome)

2. Problems of vertical fusion Obstructive Non-obstructive

3. Problems of lateral fusion Obstructive Non-obstructive

Agenesis (RKH syndrome)

Surgically corrected for sexual function

Mc indoe’s

William’s

Modified vicchietti

Remember …

Problems with vertical fusion represent a fault in the function between the down-growing Mullerian ducts (tubercle) and the up-growing derivative from the urogenital sinus

Remember …

Problems of lateral fusion of the two Mullerian ducts are especially note worthy in that obstructive lesions seem to have been observed clinically only when the obstruction was unilateral (absent kidney) i.e. (if bilateral = nonviable)

Remember …

Attention to obstructive lesions is often urgently necessary to prevent deterioration of reproductive capacity from retained mucous or menstrual blood

Classification of LFD.

Septum Resction

Pregnancy rate

Topkins laparotomy procedure is 71.4%

Hysteroscopic resection of septum is 84%

(Fayez, 1986)

Vaginal delivery

Topkins laparotomy 80%

Hysteroscopic metroplasty

76%(Fayez, 1986)

Hysteroscopic resection of the

uterine septum was first

described by Edstrom in 1974

DIAGNOSIS.HSG.LAPAROSCOPY.HYSTEROSCOPY.MRI.3DIMENSION US.

Diagnosis:Difference between the data obtained by HSG and those by hysteroscopy as regards the length of the septum, was due to dispersion of the dye around the septum on both sides, which faded the septum that disappears especially in the lower part

(Kesler and Lancet, 1986)

LAPAROSCOPY.

VISUALISES THE OUTSIDE OF THE UTERUS.

HYSTEROSCOPY

VISUALISES THE INSIDE OF THE UTERUS.

THREE DIMENSION US VISUALISES THE INSIDE OF THE UTERUS,THE CAVITY AND THE OUUTSIDE..

Septate uterus.

MRI septate uterus ?

Laparoscopy broad fundus.

SEPTATE BY 3D.

LARGE BASE SEPTUM

DISTORTED SEPTATE ? TB.

Septate with two cervicies.

Told unicornuate.

Told unicornuate.

WRONG DIAGNOSIS BY HSG(end on x ray)

(Portuonod(Portuonodo (Portuonod(Portuonodo

et al., 1986)et al., 1986)

o et al., 1986)o et al., 1986)

Unicornuate uterus by HSG.

Laparoscopy unicornuate uterus.

Unicornuate uterus.

URINARY BLADDER.

HAEMATOMETREIA

Abnormal uterus by three D US.

Endometrium of each uterus shows triangular cavity.

Unequal double uterus.

Remember …

Primary infertility in a patient with a symmetrical double uterus (bicornuate or septate) is sometimes observed, but the etiological relationship between the infertility and the anomaly is an unresolved problem

(Howard Jones, 1983)

Remember …

It is seldom that a bicornuate uterus needs surgical reconstruction. It follows that almost invariably if a double uterus gives reproductive problems which require surgical correction, it is the septate uterus which will be involved

(Howard Jones, 1983)

Recurrent pregnancy loss in septate uterus

Poor blood supply

Poorly developed endometrium

Inability to expand

Abnormal uterine contraction

(De Cherney et al., 1986)

Timing

Follicular phase, when

pregnancy is unlikely and the

endometrium is thin, tubal

ostea are well apparent

Technique

Down up or side to side?

Knife or loop?

Diathermy or scissor

One or two sittings?

Technique Medium used:

Gas: smoke and bubbles and thermal effectGlycine: no electric conduction, cooling effect

of electric current

Technique Because the resectoscopic electrode also provides coagulation while the septum is incised, vessels at the fundal region may not bleed upon division, depriving the hysteroscopist of their landmark when the myometrium is reached

SEPTUM RESECTION.

Complications PerforationPerforation33 casescases

HemorrhageHemorrhageNoneNone InfectionInfectionNoneNone

IUSIUSMinor (7 cases)Minor (7 cases)

Major (None)Major (None)

Complications Cervical laceration and uterine perforation

during introduction of the scope

Distention media complications

Deep dissection problems (bleeding, IUS)

Incidence of different complaints in patients with uterine septum

Main ComplaintMain ComplaintNo of No of patientspatients%%

Repeated abortions*Repeated abortions*636366.366.3

Unexplained infertilityUnexplained infertility242425.225.2

DysmenorrheaDysmenorrhea555.35.3

Irregular uterine bleedingIrregular uterine bleeding333.23.2

TotalTotal*repeated abortions=2 or *repeated abortions=2 or more spontaneous more spontaneous miscarriages.miscarriages.

9595100100

Correlation between hysteroscopy and HSG in women with uterine septae

Degree of the septumDegree of the septumHSGHSGHysteroscopyHysteroscopy

CompleteComplete36364141

2/32/3 40403838

1/31/319191616

TotalTotal95959595

Correlation of number of repeated abortions and number of patients (63 cases)

No of abortionsNo of abortionsNo of patientsNo of patients%%

22383860.360.3

33191930.230.2

> >44669.59.5

TotalTotal6363100100

Operative details of 95 cases of uterine septae resection with resectoscope

Operative detailsOperative detailsMean dataMean data Operating timeOperating time1515 ± ±44( ( minmin)) Average amount of distention Average amount of distention mediamedia12751275 ± ±5656( ( mlml))

Deficit of mediumDeficit of medium210210 ± ±550550( ( mlml)) Intra-uterine FoleyIntra-uterine Foley’’s catheters catheter1919 casescases None intra-uterine None intra-uterine 7676 casescases Postoperative antibioticsPostoperative antibiotics 87cases87cases

Obstetric performance (follow up 24 months)

DefaultersDefaulters2323 casescases24.2%24.2% Spontaneous Spontaneous abortionabortion66 casescases6.3%6.3%

Preterm laborPreterm labor77 casescases7.4%7.4% Term laborTerm labor4848 casescases50.5%50.5%

No pregnancyNo pregnancy1111 casescases11.6%11.6%

TotalTotal9595 casescases100%100%

Remember …

The main reason for performing hysteroscopic metroplasty is for poor pregnancy outcome, recurrent pregnancy loss and infertility

Why hysteroscopic?Outpatient basis

No abdominal or uterine scar

Minimal postoperative morbidity

No reduction in uterine volume

Pregnancy attempted soon after the operation

(Fayez, 1986 – Daly, 1983)

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