Hysteroscopic Correction of Mllerian Anomalies

Ferdhy Suryadi Suwandinata

ISGE Asian Pacific Meeting 2016
IGES 5th National Congress
15 -17th September 2016
Nusa Dua, Bali

Background

Outlines

CLASSIFICATION

DIAGNOSTIC APPROACH

INDICATION OF TREATMENT

HYSTEROSCOPIC TREATMENT

SUMMARY

CLASSIFICATION

S. Kives

S. Kives

The Jones Classification system

Jones & Rock Classification (1953)

CHART

ASRM Classification (1988)

2. ETIOLOGICAL BASIS OF ANOMALY

TYPE 1. DEFECT OF FUNDUS (With single cervix & vagina)

A.

Septate Uterus:
Complete septum with non-communicating cavities.
Partial septum with communicating cavities.

B.

Bicornuate Uterus.

TYPE 2.

Defect of
Midline Fusion

DEFECT OF CERVIX AND/OR VAGINA (Single fundus)

A. Septate vagina, with single cervix.

B.

Single or septate vagina, with septate cervix.

C. Single or septate vagina, with double cervix.

D. Double vagina, with double cervix.
TYPE 3. FAILURE OF FUSION AT ALL LEVELS.
A. Double uterus, double cervix, double vagina.
(Classical "uterus didelphys")
MATURATION OF SINGLE MULLERIAN SYSTEM

Unilateral
Maturation

A. Unilateral development, with absence of opposite tract.

Unilateral maturation, with rudimentary opposite tract,
which may or may not communicate with the functioning side

Defect of
Canalization

DEFECT OF LONGITUDINAL CANALIZATION OF VAGINA.

A.

Transverse vaginal shelves or septa.

B. Complete atresia of the vagina is the extreme degree of this type.

Jones W. Congenital Malformations Trans New Eng J Obs Gyn 1953 p. 83

Fig. 1.1 The Jones classification system. Jones W. Congenital Malformations Trans New Eng J Obs Gyn 1953 p. 83

1 Mllerian Anomaly Classification Systems

system and contains seven basic groups based on
the embryology of the mullerian system. The
anomalies were organized according to the major
uterine anatomic types, specifically the presence
of each segment of the female reproductive tract,
the outer contour of the uterine fundus, and the
presence of a septum [6]. Vaginal anomalies are
not a part of this classification system. However,
the ASRM classification system allowed the user
to indicate the uterine malformation type but in
addition describe the associated variations of the
vagina, cervix, tubes, ovaries, and urologic system [6]

Acien (2011)

7
An additional category for arcuate uterus was
added to Buttrams original classification.
The ASRM classification system is based
mainly on uterine malformations, which make
up the vast majority of cases, making utilization of this classification easier. The classifi cation, however, is rather subjective as it relies on
pictures depicting these anomalies without any
clear descriptive definitions. In response to this
subjective diagnostic criteria, several authors have
proposed supplementing the ASRM classification
with additional morphometric criteria [79]

2040

ESHRE / ESGE (2012)

Grimbizis et al.

Fig. 1.2 AFS/ASRM classification of mullerian anomalies

Definitions: uterine main classes and
sub-classes
Class U0 incorporates all cases with normal uterus. A normal uterus
is any uterus having either straight or curved interostial line but with
an internal indentation at the fundal midline not exceeding 50% of

Downloaded from http://humrep.oxfordjournals.org/ by guest on June 22, 2014

Figure 2 ESHRE/ESGE classification of uterine anomalies: schematic representation (Class U2: internal indentation .50% of the uterine wall thickness and external contour straight or with indentation ,50%, Class U3: external indentation .50% of the uterine wall thickness, Class U3b: width of
the fundal indentation at the midline .150% of the uterine wall thickness).

Jones W. New Eng J Obs Gyn. 1953

1988
2004
2013

- Class U1b or uterus infantilis characterized also by a narrow

American
Fertility
Society.
uterine cavity without
lateral wall thickening
and an
inverse cor- Fertil Steril.
relation of 1/3 uterine body and 2/3 cervix. Acien P. Hum Reprod.
- Class U1c or others which is added to include all minor deformGrimbizis
Hum Reprod.
ities of the uterine cavity including those
with an innerGF.
indentation at the fundal midline level of ,50% of the uterine wall

CLASSIFICATION
2040

Grimbizis et

Human Reproduction, Vol.28, No.8 pp. 2032 2044, 2013

Advanced Access publication on June 14, 2013

doi:10.1093/humrep/det098

ORIGINAL ARTICLE ESHRE pages

S. Kive

The ESHRE/ESGE consensus on the

classification of female genital tract
congenital anomalies,
2036

Grigoris F. Grimbizis1,2,*, Stephan Gordts1, Attilio Di Spiezio Sardo 1,

Sara Brucker1, Carlo De Angelis 1, Marco Gergolet 1, Tin-Chiu Li1,
Vasilios Tanos 1, Hans Brolmann 1, Luca Gianaroli 1, and Rudi Campo 1

Grimbizis et al.

Congenital Uterine Malformations (CONUTA) common ESHRE/ESGE Working Group, ESGE Central Office, Diestsevest 43/0001, 3000 Leuven,
Belgium 2First Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Tsimiski 51 Street, Thessaloniki 54623, Greece

Downloaded from http://humrep.oxfordjournals.org/ by guest on June 22, 2014

*Correspondence address. First Department of Obstetrics & Gynecology, Aristotle University of Thessaloniki, Tsimiski 51 Street,

Thessaloniki
grimbi@med.auth.gr;
grigoris.grimbizis@gmail.com
Table II Development
of54623,
theGreece.
newE-mail:
classification
system:
CONUTA proposal for the classification of female genital tract
Submitted
on
February
22,
2013;
resubmitted
on
February
22,
2013;
March
12, 2013of the first round just before the questionnaire
malformations; it has been sent to the participants togetheraccepted
with on
the
results
of the second round.

study question: What classification system is more suitable for the accurate, clear, simple and related to the clinical management
categorization of
female
genital anomalies?
Main
class
Main sub-class
Co-existent sub-class
summary answer:
The new ESHRE/ESGE classification system of female genital anomalies is presented.
Uterine anomaly

Figure 2 ESHRE/ESGE classification of uterine anomalies: schematic representation (Class U2: internal indentation .50% of the uterine wall thick
ness and external contour straight or with indentation ,50%, Class U3: external indentation .50% of the uterine wall thickness, Class U3b: width o
the fundal indentation at the midline .150% of the uterine wall thickness).

Cervical/vaginal anomaly

.............................................................................................................................................................................................
what is known already: Congenital malformations of the female genital tract are common miscellaneous deviations from normal

Class
0 with health
Normal
Cervix
anatomy
anduterus
reproductive consequences. Until now, three systems have been proposed for their categorization
but all of them
Definitions: uterine main classes and
are
associated
with
serious
limitations.
C0:
Normal
Class I
Dysmorphic uterus
a. T-shaped
sub-classes
C1:
study design, size and duration: The European Society ofb.Human
Reproduction and Embryology (ESHRE)
andSeptate
the European
Infantilis

Class U0 incorporates all cases with normal uterus. A normal uterus

C2: Double
normal
Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA
(CONgenital
Class II
Septate uterus
a. Partial
is any uterus having either straight or curved interostial line but with
C3:been
Unilateral
aplasia/dysplasia
UTerine Anomalies), with the goal of developing a new updated classification system. A scientific committee (SC) has
appointed
b. Complete
an internal indentation at the fundal midline not exceeding 50% of
to run the project, looking also for consensus within the scientists working in the field.
C4: Aplasia/dysplasia
the uterine wall thickness. The use of absolute numbers (e.g. indenClass
III
Dysfused uterus (including
dysfused
septate)The newa. system
Partialis designed and developed based on Vagina
participants/materials,
setting,
methods:
(i) scientific research
tation of 5 mm) is avoided in definitions as uterine dimensions as
b.
Complete
Normal
vagina
through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (ii)V0:
consensus
measurewell as uterine wall thickness could normally vary from one
Longitudinal
ment among
experts through
the use
of the DELPHI procedure and (iii)
development
by the
SC, taking intoV1:
account
the resultsnon-obstructing vaginal septum
Class
IV theUnilaterally
formed
uterus
a. consensus
Rudimentary
horn with
cavity
patient to another. Thus, it was decided to define uterine deformity
of the DELPHI procedure and the comments of the experts. Almost 90 participants
took part
the process of development
of the ESHRE/obstructing vaginal septum
V2: Longitudinal
(communicating
orinnot)
as proportions of uterine anatomical landmarks (e.g. uterine wall
ESGE classification system, contributing with their structured answers and
V3: Transverse vaginal septum/imperforate hymen thickness). The addition of normal uterus gives the opportunity
b.comments.
Rudimentary horn without
Vaginalareaplasia
main results and the role of chance: The ESHRE/ESGE
classification(no
system
is based on anatomy. V4:
Anomalies
clasto independently classify congenital malformations of the cervix
cavity/aplasia
horn)

(bi- or unilateral)/aplasia
limitations, reasons for caution: The ESHRE/ESGE classification of female genital anomalies seems to fulfill the expectaClass
VI the needs
Unclassified
malformations
tions and
of the experts
in the field, but its clinical value needs to be proved in everyday practice.

and vagina (Rock et al., 2010; Grimbizis et al., 2004; Strawbrigde

et al., 2007).
Class U1 or Dysmorphic uterus incorporates all cases with normal
uterine outline but with an abnormal shape of the uterine cavity excluding septa. Class I is further subdivided into three categories:

wider implications of the findings: The ESHRE/ESGE classification system of female genital anomalies could be used as a
starting point for the development of guidelines for their diagnosis and treatment.

study funding/competing interest(s): None.

Key words: female tract / classification system / anatomy

(i) There was an agreement consensus among the participants that

Thus, the main conclusions from the first round of the DELPHI prothe new system fulfills their needs and expectations with an
cedure
were
that
there
was
a
need
for
a
new
classification
system,
ESHRE pages content is not externally peer reviewed. The manuscript has been approved by the Executive committee of ESHRE.
This
manuscript
is
being
published
simultaneously
in
the
journals
of
Human
Reproduction
and
Gynecological
Surgery.
agreement rate as high as 84.5%,
which had to be clear and accurate in its definitions, correlated with

Downloaded from http://humrep.oxfordjou

sified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus;
Aplastic/dysplastic
a. Rudimentary horn with cavity
U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes
(bi- or unilateral)
have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified
b. Rudimentary horn without cavity
independently into sub-classes having clinical significance.

Class V

Class U1a or T-shaped uterus characterized by a narrow uterine

cavity due to thickened lateral walls with a correlation 2/3
uterine corpus and 1/3 cervix.

Class U1b or uterus infantilis characterized also by a narr

uterine cavity without lateral wall thickening and an inverse c
relation of 1/3 uterine body and 2/3 cervix.
- Class U1c or others which is added to include all minor defor
ities of the uterine cavity including those with an inner inden
tion at the fundal midline level of ,50% of the uterine w
thickness. This aims to facilitate groups who want to stu
patients with minor deformities and to clearly differenti
them from patients with septate uterus (Tomazevic et
2007; Gergolet et al., 2012). Usually, dysmorphic uteri a
smaller in size.
Class U2 or septate uterus incorporates all cases with norm
fusion and abnormal absorption of the midline septum. Septa
is defined as the uterus with normal outline and an internal
dentation at the fundal midline exceeding 50% of the uter
wall thickness. This indentation is characterized as septum a
it could divide partly or completely the uterine cavity includ
in some cases cervix and/or vagina (see cervical and vagi
anomalies).
Class U2 is further divided into two sub-classes according to
degree of the uterine corpus deformity:

Grimbizis GF. Hum Reprod. 2013

Norm
a. Complete

Straight, convex fundal contourb or internal indentation ,1 cmc,d

b. Partial
Class I hypoplasia/agenesis
Class V septate uterus
Class II uterus unicornuate
a. Complete

b. Division above the single normal cervix

a. vaginal, b. cervical, c. fundal, d. tubal, e. combined
Internal indentation 1.5 cm
External cleft ,1 cmb,c
Asymmetric ellipsoidal shape (banana-shaped)e with or without
Single well-formed uterine cavity with a single interstitial portion of Fallopian
b
Totally
division
of uterine
cavity and cervical canal
smaller horn
tube and
concave
fundal contour

b.
a. Partial
Communicating
Class VI arcuate uterus
b. Non-communicating
Class
VII T-shaped uterus
Anomaly without classification
c. No cavity

Human Reproduction, Vol.30, No.3 pp. 569 580, 2015

Advanced Access publication on December 22, 2014 doi:10.1093/humrep/deu344

or external
,1 cmb,c
a.Straight,
Divisionconvex
up to single
normalcleft
cervix

CLASSIFICATION

Partially
or totally
divisioncontralateral
of uterine cavity
without
orwith
withor
partially
septate
cervix External cleft .1 cm dividing the two horns
Connected
with smaller
uterine
cavity
without
interstitial
c
portion indentation
of Fallopian 1
tubecm; 1.5 cm
Internal
External cleft ,1 cmb,c
c
Unconnected
withcavity
contralateral
uterine cavity with or without interstitial portion External cleft .1 cm dividing the two hornb/variable if
T-shaped
uterine
576
hemi-hematometra is present in rudimentary horn
of Fallopian tube
Hybrid form, non-characteristic conjunction of uterine, cervical and vaginal malformations b
Without uterine cavity in rudimentary horn
External cleft .1 cm dividing the two horns

f ORIGINAL ARTICLE Gynaecology

d.ESGE
No horn
Rudimentary horn absent
ESHRE
Class
III uterus
didelphys
Two separate
uterine
cavities
Two corpus
bodies
with double
cervix of uterine wall thickness
Comparison
of the ESHREESGE
ESHRE Class
ESGE classifications
of uterus
Mullerian anomalies
575
U0:
Normal
Straight,
curvedunicornuate
interostial line
or internal
indentation ,50% myometrial thickness
Normal
outline
or external
cleft ,50%
c
b,c
and
ASRM classifications
Mullerian
Class IV uterus
bicornuate
Internalofindentation
1.5 cm
External cleft 1 cm

duct anomalies in everyday practice

a. Complete
Class
U1: Dysmorphic uterus
Abnormal

Table VI Characteristics1,2,of
septate uterus
recognized by the ASRM and ESHREESGE criteria.a
1,2
*
A. Ludwin

a. Division
up toorsingle
normal
Normal
outline
external
cleftcervix
,50% of uterine wall thickness

and I. Ludwin

b. Partial
b. Division above the single normal cervix
Septate uterus by ASRM (n 5 16)
Septate uterus by ESHRE ESGE (n 5 44)
P
c
a. T-shaped
Narrow
thickened
.............................................................................................................................................................................................
Class
V septate uterus
Internal cavity;
indentation
1.5lateral
cm walls; correlation of two-third uterine corpus
External cleft ,1 cmb,c
b
Myometrial thickness (mm)
12.3one-third
[9.813.7] (8.719.7)
12.5 [10.814.0] (8.719.7)
0.5
and
cervix
a. Complete
Totally
division
of 72)
uterine cavity and
cervical (572)
canal
Internal fundal
indentation (mm)
21.1 [18.8
33.1] (16
10.7 [8.120.0]
,0.01b
study question: Does the European Society of Human Reproduction and Embryology European Society for Gynaecological Endoscopy
b. Infantilis
Narrow
cavity
without
wall thickening;
correlation
of one-third uterine body
b
ESGE) classification
of female genital tract malformations significantly increase the1.9
frequency
of septate uterus
diagnosis
relative to the
Rate of(ESHRE
internal
fundal indentation/myometrial
[1.42.6]
(0.9
8.1)
0.8 [0.61.5]
(0.5 8.1)or with partially septate
,0.01
b. Partial
Partially
or totally
division
of uterine
cavity without
cervix
American Society for Reproductive Medicine (ASRM) classification?
and
two-third
cervix
thickness
summary answer: Use of the ESHRE ESGE classification, compared with the ASRM classification, significantly increased the frequency of
septate uterus
recognition.
Class
VI
arcuate
uterus
Internal indentation 1 cm; 1.5 cmc
External cleft ,1 cmb,c
Length
of the
uterine
septum
what
is known already:
The ESHREESGE criteria were supposed to eliminate
the subjective
diagnoses of septate uterus
by the
c.
Others
(?)
Internal
indentation
,50%
myometrial
thickness
(?)
ASRM criteria and replace the complementary absolute morphometric criteria. However, the clinical value of the ESHRE ESGE classification
c
1Class
cm VII
16 (100%) increased recognition
28 (63.6%)
,0.01c
T-shaped
cavity
in daily practice
is difficult
to appreciate. Theuterus
application of the ESHRE ESGE criteria has T-shaped
resulted in a significantlyuterine
of residual
septum
after
hysteroscopic
metroplasty,
with
a
possible
risk
of
overdiagnosis
of
septate
uterus
and
problems
for
its
management.
Class
Internal
indentation .50% myometrial
thickness
Normal outline or external cleft ,50% of uterine wall thickness
1.5
cm U2: Septate uterus
16 (100%)
15 (34.1%)
,0.01c
study design, size, and duration: A prospective observational study was performed with 261 women consecutively enrolled
Anomaly
without
classification
Hybrid
form,
non-characteristic
conjunction
of uterine, cervical and vaginal malformations
between June and September 2013.
a. Partial
a.women
Division
above
ofevaluation
the
cervical
osEuropean Society for Gynaecological Endoscopy.
setting, and
methods:
Non-pregnant
of reproductive
age
presented
for
tointernal
a
ASRM,participants/materials,
American
Society of Reproductive
Medicine;
ESHRE
ESGE,
European
Society
of Human
Reproduction
and
Embryology
1

Department of Gynecology and Oncology, Jagiellonian University, ul. Kopernika 23, Krakow 31-501, Poland 2Ludwin & Ludwin Gynecology,
Private Medical Center, Krakow 31-511, Poland
*Correspondence address. Tel: +48-12-424-8560; Fax: +48-12-424-85-84; E-mail: ludwin@cm-uj.krakow.pl

Submitted on September 7, 2014; resubmitted on November 1, 2014; accepted on December 1, 2014

private medical center. A gynecological examination and 3D ultrasonography were performed to assess the anatomy of the uterus, cervix and
Data reported
as number (%), mean + SD (range), or median [lowerupper quartile] (range).
vagina. Congenital anomalies were diagnosed using the ASRM classification with additional morphometric criteria as well as with the ESHRE
c
fcomparedand
b.classification.
Complete
Division
up tomalformations
the internal
Test
Mann

Whitney
Fishersandexact
test. of diagnoses ofb.
ESGE
WeU-test
the frequency
concordance
septate
uterus and all congenital
of the
ESHRE
ESGE

cervical os

uterus according to both classifications. The morphological characteristics of septate uterus recognized by both criteria were compared.

Class
U3:
Bicorporeal
uterus
.50%
myometrial
(6.1%) patients
using Normal
the ESGEESHRE and
ASRM criteria, respectively [relative risk (RR)
2.74; 95% confidence
interval (CI),
Class
U0:
uterus
Straight, curved
interostial
line or internal indentation ,50% myometrial thickness External
Normal cleft
outline
or external
cleft thickness
,50% of uterine wall thickness
1.6 4.72; P , 0.01]. At least one congenital anomaly were diagnosed in 58 (22.2%) and 43 (16.5%) patients using the ESHREESGE and
ASRM
classifications
(RR
, 1.35; 95% CI, 0.95 1.92, P 0.1), respectively.
The two criteriaabove
had moderate strength
of agreement
a.
Partial
Division
of
the
internal
cervical
os
Division
above
the
cervix
in the diagnosis of septate uterus (k 0.45, P , 0.01). There was good agreement in differentiation between anomaly and norm between the two
main results and role of chance: Of the 261 patients enrolled in this study, septate uterus was diagnosed in 44 (16.9%) and 16
ESHRE ESGE:ASRM

ESHRE ESGE:ASRM

assessment criteria (k 0.79, P , 0.01). The percentages of all congenital malformations and results of the differentiation between the anomaly
and norm were obtained after excluding the confounding original ESHRE ESGE criterion of dysmorphic uterus (internal indentation ,50%
uterine wall thickness). The morphology of septa identified by the ESHRE ESGE [length of internal fundal indentation (mm): median 10.7;
lowerupper quartile, 8.120] significantly differed (P , 0.01) from that identified by the ASRM criteria [length of internal fundal indentation
(mm): median, 21.1; lowerupper quartile, 18.8 33.1]. Internal fundal indentation in 16 out of 44 (36.4%) cases was ,1 cm in the septate
uterus by ESHRE ESGE and met the criteria for normal uterus by ASRM.

Class
U1: Dysmorphic uterus
b. Complete

Abnormal
Division
up to the internal cervical os

Normalup
outline
external cleft ,50% of uterine wall thickness
Division
to theorcervix

c. Bicorporeal septate
a. T-shaped

Midline fundal indentation (myometrial thickness at the central point of the external cleft) .150% uterine wall thickness (average myometrial thickness)
Narrow cavity; thickened lateral walls; correlation of two-third uterine corpus
specialized in uterine congenital malformations for a medical assessment, not from the general public.
and one-third
cervix
wider implications of the findings: Septate uterus diagnosis by ESHREESGE
was quantitatively dominated
by morphological

a.Subjective
Subjectiveimpression
impression
and measurements
b. Subjective impression
Subjective impression
Measurements
Subjective impression
a. Subjective impression
b.a.Subjective
impression
Measurements

Measurements
b. Measurements/subjective
Subjective
impressionLudwin and Ludw
impression
Subjective impression
c. Measurements
and
measurements
d. Subjective impression
Subjectiveimpression
impression
Subjective
Measurements
and
measurements
a. Subjective
impression
Subjective
impression
and
measurements
b. Subjective impression
Measurements
a. Subjective impression
b. Subjective impression
Measurements
Subjective impression
Measurements
Subjective impression
a.and
Subjective
impression
measurements
b. Subjective impression

Measurements
Subjective impression
measurements
a.and
Subjective
impression
b.Subjective
Subjectiveimpression
impression
and measurements
c. Measurements

limitations and reasons for caution: The study participants were women who visited a diagnostic and treatment center

b. Infantilis

and two-third cervix

& The Author 2014. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits
non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

c. Others (?)
Class U2: Septate uterus
a. Partial

Continued

Figure 3 Common morphological forms of the uterus in 3D ultrasonography. Top row: (A) Interostial line at the height of the lowest point of the fundus
Ludwin and Ludwin
Narrow cavity without wall thickening; correlation of one-third uterine body 578

states corresponding to arcuate uterus or cases that were not diagnosed as congenital malformations by ASRM. Relative overdiagnosis of septate
uterus by ESHREESGE in these cases may lead to unnecessary overtreatment without the expected benefits. The ESHREESGE classification

Internal indentation ,50% myometrial thickness (?)

Internal indentation .50% myometrial thickness
a. Division above of the internal cervical os

of the cavity, (B) slightly below and (C) clearly below is not the most frequently encountered morphological form; therefore, it cannot be regarded as a
primary exponent of the norm. Bottom row: (D F) The presence of internal fundal indentation ,50% of uterine wall thickness, which was much
more frequent, is a confounding criterion for the diagnosis of dysmorphic uterus by the ESHRE ESGE classification system.

Normal outline or external cleft ,50% of uterine wall thickness

Measurements

of the female reproductive organ

in clinical practice.
The ESHRE ESG
The diagnosis of septate uterus by both classifications showed modera. Subjective
impression
classification was associated with an extraordinary (almost 3) increa
ate agreement (k 0.45, standard error, 0.08, 95% CI, 0.3 0.6, P ,
b. Complete
b. Division up to the internal cervical os
b. Subjective impression
in the frequency of septate uterus recognition [44 (16.9%) versus
0.01; Table V; Altman 1991; Fleiss et al., 2003). The diagnosis of
Class U3: Bicorporeal uterus
External
cleft
.50%
myometrial
thickness
Measurements
(6.1%) by the ASRM classification].
The diagnosis of septate uterus
septate uterus
by ESHRE
ESGE
showed
good agreement
with the diagboth
classifications
showed
moderate
agreement.
The morphology
noses
of
arcuate
and
septate
uterus
by
ASRM
(
k

0.70,
standard
error,
a. Partial
Division above of the internal cervical os
Division above the cervix
a. Subjective
impression
septa differed between the ESHRE ESGE and ASRM criteria (medi
0.06, 95% interval, 0.6 0.8, P , 0.01). Strength of agreement in general
b. Complete
Division up to the internal cervical os
upmorphology
to the cervix
impression
length of the septum: "1 andb.2Subjective
cm, respectively).
Most diagnoses
classificationsDivision
of uterine
in terms of congenital anomaly/
septate
uterus
according
to
the
ESHRE
ESGE
system
correspond
normal
was
good
(
k

0.79,
0.05,
95%
CI,
0.7
0.9,
P
,
0.01;
Table
V).
c. Bicorporeal septate
Midline fundal indentation (myometrial thickness at the central point of the external cleft) .150% uterine wall thickness (average myometrial thickness)
c. Measurements
to arcuate or normal uterus diagnosed by ASRM (Fig. 2). Thus, t
The morphology of septate uterus identified by ESHRE ESGE signifiESHRE ESGE classification is associated with a seriousContinued
risk of overdia
cantly differed from that identified by ASRM (Table VI, Fig. 2). Internal
nosis and potential overtreatment of patients, which validates our init
fundal indentation and the ratio of the internal fundal indentation to thicksuggestions
(Ludwinsystem.
et al.,(A
2014b,c).
ness of theFigure
myometrium
were significantly
lowerand
in bicorporeal
the ESHRE
ESGE5 Differentiation
of normal, septate
uterus
by the ESHRE
ESGE classification
C) The use of uterine wall thickness to
uterine
deformity
is a serious
in the ESHRE septate
ESGE classification
because,
as an
independent
and variable
parameter
(B), it malformation
does not
The
overall
distinction
between
congenital
uterine
a
diagnoseddefine
septate
uterus
compared
withshortcoming
the ASRM-diagnosed
reflect the
degree
of deformation
thecm
uterine
cavity (A)
and theuterus
degree of deformation
the outer
structure
(C). good agreement, if the confoundi
norm byofboth
systems
showed
uterus. Internal
fundal
indentation
was of,1
in 16/44
septate
criterion for dysmorphic uterus (U1c by ESHREESGE, Fig. 3) diagno
cases diagnosed by ESHRE ESGE, and met the criteria for normal
was excluded (Tables III and V). Despite this modification, the ESHRE
uterus by ASRM. Thickness of the myometrium did not differ between
ESGE classification more often classified the morphological state as a m
both
systems.
Figure 2 Septate uterus by ESHRE ESGE includes three morphological classes by ASRM; Top row, norm (internal indentation ,1 cm); middle row,
arcuate; and bottom row, septate uterus.
formation than the ASRM classification (P , 0.1). According to the origin
Excellent intrarater reliability was obtained for measurements of
ESHREESGE classification,
uterine
malformation was
prese
internal fundal indentation and uterine wall thickness (interclass correlLudwin et congenital
al. Human
Reproduction.
2015

in
as
many
as
195
of
261
(74%)
patients
compared
with
43
(16.5%)
ation
coefficient,
0.96;
P
,
0.01;
Fleiss
et
al.,
2003).
95% CI, 1.64.72; P , 0.01). The frequency of septate uterus diagnosis
ASRM criteria were lower but not of statistical significance (RR, 0.09, 95%

Diagnostic approach
Tailored based on the patients age, level of comprehension, and
cognitive level

HISTORY TAKING

Open ended discussion,menstrual

history, bowel and bladder function,
sexual activity, pelvic pain, and
reproductive history

CLINICAL
PRESENTATION

Obstructive : Hydrocolpos, mucocolpos,

primary amenorrhoe w/ or w/o cyclic pain

Non Obstructive : associated extragenital

malformations i.e. skeletal abnormalities,
auditory canal defects, congenital heart
disease, inguinal hernias, anorectal malform

HYSTEROSALPHINGOGRAPHY

T shape uterus

DES exposed uterus

No ability to evaluate the fundal

contour

ULTRASOUND

Transabdominal ultrasound

Transperieal ultrasound

Transabdominal ultrasound

3D ultrasound

MRI

Excellent noninvasive imaging

technique that allows for greater
tissue detail in dierent imaging
planes

Pfeifer. Congenital Mllerian Anomalies. 2016

Indication of treatment

1
The majority of women with uterine septa
reproduce successfully; only 2025% suffer
pregnancy wastageusually late first-trimester
or early second-trimester miscarriages initiated
by mini labors and bleeding.

Patients with primary infertility requiring assisted

reproductive technologies or difficult treatments
for infertility have been considered candidates
for treatment of the uterine septation.

2
The relationship between the septate
uterus and infertility remains controversial
The consensus is that this type of uterine
anomaly does not cause infertility.

Evaluation of other factors that may cause

pregnancy wastage i.e. karyotyping,
maturation of the endometrium, luteal phase
defect, endocrine conditions (hypothyroidism,
autoimmune and alloimmune conditions),
lupus anticoagulant, PTT, ACA and ANA.

Pfeifer. Congenital Mllerian Anomalies. 2016

igid. Flexible scissors are difficult to manipulate. Semirigid scissors are most commonly
sed as they permit a targeted division of the tissue, they can be selectively directed to
he area in need of dissection, and they can be retrieved at will when a better panoramic
iew is required. The semirigid scissors can be directed easily without much force or
manipulation through the operating channel of the hysteroscope, facilitating
ysteroscopic surgery, but they must be sharpened and tightened frequently. Scissors of
he hook type are most helpful to divide the uterine septum, particularly when reaching
he broad fundal area where small superficial cuts must be made on the remaining septum
o sculpture this fundal area and avoid deep penetration (Figures 35).
Rigid scissors, often called optical scissors and fixed to the end of the hysteroscope,
an also be used to divide fibrotic and broad septa. When using the fixed instrument, it is
mportant to have a perfect panoramic view while performing the division. The scissors
hould be introduced with utmost care to avoid uterine damage as their sharp tips can
asily perforate the uterus if force is exerted against the uterine wall.
With the use of mechanical tools in operative hysteroscopy, the best medium to distend
he uterine cavity is one that contains electrolytes,

Hysteroscopic Metroplasty

Less-invasive approach than abdominal metroplasty

Septum is divided under direct vision

Avascular consistency of this embryological remnant

inhibiting significant bleeding

Ambulatory procedure

Minimal discomfort and morbidity.

Re-epithelialization healing in 45 weeks, so patients

are allowed to conceive sooner than with abdominal
metroplasty.

Hospitalization not required, reduce cost

Figure 2 Hysteroscopic metroplasty: (a) scissors; (b) resectoscope; (c)

fiberoptic laser
Valle et al. Hysteroscopy, Resectoscopy and Endometrial Ablation. 2005

Hysteroscopic scissors
Hysteroscopic metroplasty with scissors is the easiest and
most common method

Operative hysteroscope with 5 Fr operative channel is

required

Targeted division of the tissue

Better panoramic view is required

Can also be used to divide fibrotic and broad septa

A perfect panoramic view while performing the division

Avoid uterine damage with sharp tips which can easily

perforate the uterus if force is exerted against the uterine
wall

The best medium to distend the uterine cavity is one that

contains electrolytes
Valle et al. Hysteroscopy, Resectoscopy and Endometrial Ablation. 2005

Hysteroscopic scissors

Figure 6 Hysteroscopic division of partial uterine septum

Table 1 Hysteroscopic division of uterine septa with scissors
Advantages
Simple
Quick
Applicable to all septa
Media with electrolytes can be used
No energy sources required
Disadvantages
Scissors get dull
Bleeding if not in midline
Possible perforation
No washing effect unless double-channel hysteroscope used

Because electricity is used with the resectoscope, only fluids devoid of electrolytes can
be utilized (see Chapter 6). A specific amount of non-recovered fluid must be maintained
Valle et al. Hysteroscopy, Resectoscopy and Endometrial Ablation. 2005

Hysteroscopic scissors
32 y.o.
Failed IVF 2x

Hysteroscopy resectoscope
Provides hemostasis in midline incision

But involve more lateral tissue destruction

Hysteroscopic resectoscope, 89 mm outer diameter, with a

narrow and thin electrode (cutting loop, preferably pointed
forward, knife electrode, or wire electrode)

Perfect continuous-flow system permits clear view,

removing bubbles and debris during the procedure

Valle et al. Hysteroscopy, Resectoscopy and Endometrial Ablation. 2005

Hysteroscopic resectoscope
Figure 13 Resectoscopic division of uterine septum with 180 loop. See also
Color Plate IV

Table 2 Hysteroscopic division of uterinesepta with resectoscope

Advantages
No bleeding
Cuts easily
Washing of uterine cavity
Excellent visibility
Easy manipulation
Disadvantages
Electrosurgery required (monopolar)
Possible lateral coagulation
Landmarks of myometrium lost
Fluids without electrolytes must be used
Difficult to divide septa with small uterine cavities

Valle et al. Hysteroscopy, Resectoscopy and Endometrial Ablation. 2005

Hysteroscopic resectoscope
36 y.o.
Infertility 3 years

Hysteroscopic Metrorplasty

Valle and Ekpo.

Valle and Ekpo.

Fig. 9

Hysteroscopic Metroplasty for Septate Uterus

37

Hysteroscopic Metroplasty for Septate Uterus

37

Fig. 9

Live-birth rate after hysteroscopic metroplasty. Initial meta-analysis was performed on all studies (groups 1 and 2) with live-birth rate reported as percentstudiesmetroplasty.
with inconsistent
definition
of pregnancy
rate (i.e., allon
post-metroplasty
pregnancies
not just index
Live-birthage.
rateAfter
afterexcluding
hysteroscopic
Initial
meta-analysis
was performed
all studies (groups
1 and reported,
2) with live-birth
rate pregnancy)
reported as percentstudies with
a substantial
number of subjects
lost to of
follow-up
or with
ongoing
a second analysis
was performed
on the
studiespregnancy)
age. Afterand
excluding
studies
with inconsistent
definition
pregnancy
rate
(i.e., pregnancies,
all post-metroplasty
pregnancies
reported,
notclean
just index
(group 1).

and studies with a substantial number of subjects lost to follow-up or with ongoing pregnancies, a second analysis was performed on the clean studies
(group 1).
Statistics for each study
Source, Year
Group 1

Event
Rate (%)

Fayez, Year
1966
Source,

Event7.37
Fedele etal, 1993
5.39
Rate (%)
Valle,
1996
7.34
Group 1
Romer and Loper, 1997
Fayez, 1966
7.375.00
Kupesic and Kurjak, 1998
4.14
Fedele et
al, 1993et al, 1998
5.396.67
Jourdain
Valle, 1996
Saygiili-Yilmaz et al, 20027.343.74
Romer and
Loper,
1997
5.003.23
Jakiel
et al, 2004
and Gomel,
Kupesic Pabuccu
and Kurjak,
1998 2004
4.142.95
al, 2006
JourdainPace
et al,et1998
6.676.75
Hollet-Caines
et
al,
2006
Saygiili-Yilmaz et al, 2002
3.74 5.77
Yang et al, 2006
5.71
Jakiel etColacurci
al, 2004et al, 2007
3.236.07
PabuccuLitta
andetGomel,
2.956.00
al, 20082004
Pace et Mollo
al, 2006
6.75
et al, 2009
3.41
Hollet-Caines
et 2009
al, 2006
5.774.53
Pai et al,
et al, 2010
Yang et Nouri
al, 2006
5.714.90
Sendag
et
al,
2010
Colacurci et al, 2007
6.074.33
Tonguc et al, 2011
Litta et al, 2008
6.003.53
5.02
Mollo et
al, 2009
3.41
Group
2
Pai et al,Valle,
20091986
4.537.78
Nouri et Decherney
al, 2010 et al, 1986 4.908.66
et al, 1987
SendagetPerino
al, 2010
4.336.09
Guarino
et
al,
1989
Tonguc et al, 2011
3.535.20
Choe and Baggish, 1992 5.028.33
Marabini et al, 1994
5.91
Group 2
Cararach et al, 1994
4.83
Valle, 1986
7.785.54
Colacurci et al, 1996
Decherney
et et
al,al,
1986
8.665.19
Porcu
2000
Perino etVenturoli
al, 1987
6.094.49
et al, 2002
Guarino et al, 1989
5.206.03
Overall
Choe and Baggish, 1992
8.335.35
Marabini et al, 1994
Cararach et al, 1994
Colacurci et al, 1996
Porcu et al, 2000

5.91
4.83
5.54
5.19

95% CI

Z Value

Event Rate and 95% CI

p Value

Statistics for each study

5.028.86
1.98
95%
CI
Z Value

4.426.33
6.498.04
1.688.32
5.028.86
3.285.05
4.426.33
4.068.54
6.498.04
3.264.25
1.688.32
1.835.03
1.944.21
3.285.05
5.178.01
4.068.54
3.857.48
3.264.25
3.877.38
1.835.03
5.236.86
1.944.21
4.527.31
5.178.01
2.174.91
3.857.48
3.365.75
3.546.27
3.877.38
2.716.12
5.236.86
2.674.50
4.527.31
4.345.71

.79
4.50
0
1.98
1.85
.79
1.27
4.50
4.74
0
1.93
3.10
1.85
2.17
1.27
.78
4.74
.75
1.93
2.48
3.10
1.33
2.17
2.07
.78
7.49
0.14
.75
0.73
2.48
2.93
1.33
0.07

3.827.72
3.616.08
4.219.44
4.326.69
7.629.29
3.876.47
4.027.82
3.655.36
5.036.94
3.317.04
4.785.91
5.239.58

0.85
0.26
1.56
0.87
5.20
0.27
1.03
1.15
2.02
2.00
1.20
2.08

2.174.91
3.365.75
4.219.44
3.546.27
7.629.29
4.027.82
2.716.12
3.317.04
2.674.50
5.239.58
4.345.71

3.827.72
3.616.08
4.326.69
3.876.47

2.07
7.49
1.56
0.14
5.20
1.03
0.73
2.00
2.93
2.08
0.07

0.85
0.26
0.87
0.27

Event Rate and 95% CI

p.048
Value
.43
0
1.00
.048
.07
.43
.21
00
1.00
.49
.002
.07
.03
.21
.44
0
.45
.49
.01
.002
.18
.03
.04
.44
.45
.89
.45
.47
.01
.003
.18
.95

.04
.45
.12
.89
0
.30
.47
.84
.003
.04
.95
.40
.80
.12
.39
0
.79
.30
.25
.04
.84
.23
.04

.40
.80
.39
.79

-1.00

-0.50
Favors A

0.00

0.50

1.00

Favors B
Valle et al. JMIG. 2013

Adjunctive Therapy
Antibiotic regimens

Hormone therapy

Postoperative hormone therapy (E2/P4) has not been

demonstrated in well-designed, prospective, randomized
studies.

Artificial stimulation of endometrial growth postoperatively may

assist in the overall healing process by artificially enhancing
endometrial growth by use of estrogen and subsequent
shedding by use of terminal progesterone

Stent

No standard treatment

Antiadhesive agents

Unnecessary due to high potential regeneration endometrium

Valle et al. JMIG. 2013

Conclusion

Failure of reabsorption of the embryologic original fusion of

the Mllerian ducts may impair reproductive function in
20% to 25%.

Hysteroscopic treatment can be accomplished via scissors,

electrosurgical electrodes guided or resectoscopy

Hysteroscopic metroplasty recommended than abdominal

metroplasty procedures

Rate of viable pregnancies 80%

Thank you