Middle East Fertility Society Journal (2010) 15, 259–264
Middle East Fertility Society
Middle East Fertility Society Journal www.mefsjournal.com www.sciencedirect.com
ORIGINAL ARTICLE
Reproductive outcomes after Versapoint hysteroscopic metroplasty Hossam Eldin Shawki
*
Obstetrics and Gynecology Department, Faculty of Medicine, El-Menya University, Suzan Moubark Maternity and Pediatric University Hospital, El-Menya, Egypt Received 11 February 2010; accepted 7 June 2010 Available online 9 November 2010
KEYWORDS Reproductive outcomes; Versapoint; Hysteroscopy; Septate uterus
Abstract Objective: To determine the feasibility, safety and the outcomes of hysteroscopic metroplasty with bipolar Versapoint electrode. Design: Prospective, observational study. Setting: Endoscopy Unit, Suzan Moubark Maternity and Pediatric University Hospital. Patient(s): Twenty-six patients with different degree of uterine septa and poor reproductive outcomes (spontaneous abortion, habitual abortion, preterm labor and unexplained primary infertility). Intervention(s): Versapoint hysteroscopic division of the uterine septum. Main outcome measure(s): Prospective evaluation of the reproductive outcomes during 24 months follow up. Result(s): There was significant changes in the results after metroplasty, as 23 (88.46%) patients became pregnant, of them 3/23 (13.04%) had habitual abortion, 2 patients (4.34%) ended in preterm labor, 14/23 (60.86%) had reached to term delivery with a total pregnancy loss of 5/23 (21.73%) and pregnancy complications occurred in 5/23 (21.73%), these results represent a statistically significant difference (P 6 0.05). The mean gestational age, the mean neonatal weight at delivery, early neonatal condition judged by apgar scores both in 1 and 5 min after delivery were significantly improved after hysteroscopic metroplasty (P < 0.05). There were no intraoperative or postoperative complications, and complete removal of the septum was achieved in 21 patients (80.67%), a residual septum was found in 5 woman (19.23%), and a 2nd intervention was done in only 2 patients (7.69%) with a residual septum >1 cm using office hysteroscopy.
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[email protected] 1110-5690 Ó 2010 Middle East Fertility Society. Production and Hosting by Elsevier B.V. All rights reserved. Peer-review under responsibility of Middle East Fertility Society. doi:10.1016/j.mefs.2010.06.012
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H.E. Shawki Conclusion(s): Hysteroscopic metroplasty using the Versapoint is a successful alternative to the resectoscope technique; it has the same effectiveness and broad safety profile with its simplicity, minimal postoperative squeal, and improved reproductive outcome, this approach should be recommended for metroplasty. Ó 2010 Middle East Fertility Society. Production and Hosting by Elsevier B.V. All rights reserved.
1. Introduction Among the Mullerian duct anomalies septate uterus is the most common and is associated with the highest incidence of poor reproductive outcome and obstetric complications (1), low fetal survival rates of 6–28% and a high rate of spontaneous abortion of up to 60% (2,3). The American Society for Reproductive Medicine (ASRM) classifies the uterine septa as class Va (complete septate uterus, with a frequency of 30– 35%) or class Vb (partial septate uterus, 65–70%) (2,4,5). The operative hysteroscopy introduced through transcervical approach, greatly simplified the treatment of septate uterus (6). In these cases, restoration of the uterine cavity is usually adequate with a pregnancy rate of 85% and term delivery rates of 60–75% (1,3,7,8). However, the resectoscopic technique is associated with risk of complications (fluid overload, perforation, hemorrhage) and side effects (cervical incompetence, lacerations), but technological innovation has allowed the development of more sophisticated devices such as bipolar electrodes which make physiological pregnancy and term delivery the optimal clinical outcomes after hysteroscopic transcervical resection of uterine septum. The aim of the study was to determine the feasibility, safety of hysteroscopic metroplasty with Versapoint (Gyncare Versapoint with Twizel knife electrode; Ethicon, Somerville, NJ, USA), and to evaluate prospectively the reproductive outcomes during 24 months follow up after hysteroscopic metroplasty for correction of septate uterus. 2. Patients and methods This prospective case control study was carried out at the endoscopy unit of the department of obstetrics and gynecology, Suzan Moubark Maternity and Pediatric University Hospital between the period of December 2006 to December 2008, including 26 patients attending our tertiary referral center complaining of primary infertility, recurrent pregnancy loss, recurrent preterm labor or complications during pregnancy (bleeding in early pregnancy, ante partum hemorrhage, preterm delivery or premature rupture of membrane). These patients were diagnosed with different degrees of sepetate uterus according to the ASRM guidelines (9). Preliminary diagnosis was based on pervious hysterosaplingogram with suspected different degrees of septate uterus, also transvaginal ultrasound and diagnostic office hysteroscopy (Versascope of Gyncare, USA, with diameter of 2.9 mm) were done to all patients for inspection of the uterine cavity morphology and other associated pathology using the vaginoscopic non-touch technique. When septate uterus was suspected, laparoscopy was performed consequently to confirm the final diagnosis by inspection of the external contour of the fundus in order to identify septate uterus from the bicornuate uterus, also the tubes, ovaries and abdominal cavity were inspected to de-
fine any concurrent pathologies such as endometriosis, polycystic ovary, unilateral or/and bilateral tubal occlusion, hydrosalpinx and adhesion related to infertility. In patients with 1ry infertility, the male factor was evaluated by semen analysis. The patient charts for age, main complaints, obstetric history and reproductive outcome were reviewed. 2.1. Ethical approval The study protocol was approved by scientific ethical committee research of the department of obstetrics and gynecology, faculty of Medicine, El-Menya University at its monthly meeting on October 2006. Also approval was ascertained from the Institutional Review Board of the University Hospital-Quality control unit of the faculty of Medicine, El-Menya University on November 2006. All patients were counseled about the procedure and signed an informed consent before treatment. 2.2. Inclusion criteria All women diagnosed with complete or incomplete uterine septum affecting their reproductive performance and no contraindications for surgery or pregnancy were eligible to be included in the study. All procedures were performed in day surgery. All the patients received 400 mic vaginal Mizoprostole (2 tablets Mizotak) at the night of the operation for cervical ripening, no drugs were used for preoperative preparation of the endometrium and the hysteroscopic metroplasty was performed during the early follicular phase of the menstrual cycle. All patients received antibiotic for prophylaxis in order to reduce the risk of secondary pelvic inflammatory disease. All the procedures were performed under general anesthesia by the same surgeon. 2.3. Intervention Under laparoscopic guidance women underwent metroplasty without dilation of cervical os (vaginoscopic approach) using operative hysteroscopy (5.5 mm outer sheath diameter, using a Versapoint device-5 Fr., 1.6 mm, with bipolar electrode – Twizel knife, adjusted at 200 W-vapour cut mode). The uterine cavity was distended with 0.6 normal saline at an inflow pressure of 60–90 mmHg, using a special machine, hysterometer, that was used to adjust the pressure of the follow, the amount of the distension media fluid used and the deficit after the operation. After visualizing both the tubal ostia, the incision of septa was started from the lower margin and continued upward with horizontal section until the hysteroscope could be moved freely from one tubal ostium to the other without obstruction and both tubal ostia could be visualized in the same panoramic view with visualization of the first pale pink myometrial bundles. In patients with complete septum, there was some modification of the technique, and the details of this procedure have
Reproductive outcomes after Versapoint hysteroscopic metroplasty been described by Rock et al. (6). In brief, after dilatation of the cervix, a pediatric Foley catheter was inserted into one cavity and the balloon was inflated. This balloon catheter served as a means of orientation for the first incision of the corporal septum and prevents leakage of fluid from the opposite uterine cavity. A Versapoint hysteroscopy was placed in the other cavity, and the cavity was distended with 0.6% saline. The septum was incised with a needle electrode at a level above the internal cervical os until the balloon was visualized. After the first incision, the corporal part of the septum was incised as routine until the hysteroscope could be moved freely all around the uterine cavity and both tubal ostia could be visualized. At the end of the operation, operative time, amount of fluid used, amount of fluid deficit, amount of blood loss, any intraoperative or postoperative complications and hospital stay were recorded. 2.4. Follow up Patients were advised to use cyclic estrogen and progesterone (CyclopregnovaÒ, Sherring, Egypt) for a month after the operation. In all women a second-look office hysteroscopy was performed after the next menstrual cycle of surgery for the diagnosis of any uterine adhesion or the presence of residual septum. Patients were followed up for pregnancy rate, at-term pregnancies, abortion, preterm labors, mode of delivery, and neonatal outcome during 24 months follow up. 2.5. Postoperative evaluation and treatment of residual septum When 2nd look office hysteroscopy demonstrated the presence of residual septum, its length was measured, and if this length was more than >1 cm, rehysteroscopy was performed using office hysteroscopy with Versapoint under mild sedation after flushing of the uterine cavity with 10 ml of 10% xylocain solution to minimize pain expression and the procedure was done as an outpatient one. This residual septum can also be measured by evaluation of the uterine cavity using the uterine cavity ratio at HSG (10). The uterine cavity ratio was calculated: as a distance in millimeters between the uterine horns, divided by the length of the uterine septum, and multiplied by 100 (Fig. 1). When the above-mentioned ratio is 10% or less, reproductive failure is not expected but there is a higher incidence of spontaneous abortion when the ratio is more than 10%, as residual septum or notch more than 10% uterine index at HSG equivalent to >1 cm at office hysteroscopy.
Figure 1
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2.6. Statistical analysis Statistical analysis was performed by using the 2 test. The cumulative pregnancy rate for 24 months follow-up period was by Kaplan–Maier analysis. The comparison of pregnancy probability between three groups was evaluated by using log Rank test and P < 0.05 was considered as statistically significant. 3. Results This study included 26 patients, the mean age of the patients was 29.73 ± 6.12 years (range, 24–39), the mean parity was 1.15 ± 1.22 (1–2), 6 patients were nulligravida and 3 patients (15%) had undergone spontaneous abortions (1 or 2 abortions), 8 patients (40%) had recurrent (habitual) abortions, 7 patients (35%) had preterm delivery, and 2 patients had (10%) had a previous full term pregnancy with pregnancy complications. In this study there were 5 cases with arcuate uterus, 4 cases with complete septum and single cervix, 2 cases with complete septum and double cervix, and 15 cases with subsepetate uterus according to the ASRM guidelines (9) (see Tables 1–3). 3.1. Neonatal outcome As regarding neonatal outcome, the number of full term delivers and the neonatal weight was significantly higher after hysteroscopic metroplasty {7/20 (35%) before metroplasty vs. 15/ 23 (62.21%), and 2261.13 ± 2.14 g before metroplasty vs. 2850.77 ± 8.51 g, P < 0.001}, with a significant increase in the mean gestational age at delivery after hysteroscopic metroplasty (31.21 ± 3.45 wks vs. 38.85 ± 7.65 wks before metroplasty, P < 0.05). Early neonatal condition judged by apgar scores both in 1 and 5 min after delivery was significantly improved after hysteroscopic metroplasty {5/7 (71.42%) before metroplasty vs. 3/15 (20%) after metroplasty} for low apgar score in 1 min and it was {5/7 (71.42%) before metroplasty vs. 1/15 (6.66%) after metroplasty} (P < 0.001). Consequently the admission to NICU was significantly lower after hysteroscopic metroplasty {5/7 (71.42%) before metroplasty vs. 2/15 (13.33%) after metroplasty, P < 0.05}. 3.2. The cumulative pregnancy rate The cumulative pregnancy probability in the primary infertility group during the first 6 months was 13.4%, 22.3% during 6–
Preoperative and postoperative hysterographic representation of uterine cavity ratio. (After Eduard Kucera (10), with permission.)
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H.E. Shawki
Table 1
Reproductive outcomes before and after Versapoint hysteroscopic metroplasty.
Reproductive outcomes 1-One or two abortions 2-Reccurent (habitual) abortions 3-Preterm delivery(s) 4-Term delivery(s) 5-Complications during pregnancy 6-Total pregnancy loss 7-Live baby(s) 8-Infertilityc a b c
N% N% N% N% N% N% N% N%
Before metroplastya
After metroplastyb
P value
3/20 8/20 7/20 2/20 15/20 16/20 2/20 6/26
3/23 3/23 2/23 14/23 5/23 5/23 13/23 3/26
NS S S S S S S S
(15%) (40%) (35%) (10%) (75%) (80%) (10%) (23.07%)
Total number 20 patients have achieved pregnancy before metroplasty. Total number 23 patients have achieved pregnancy after metroplasty. Out of 26 patients included in the study group.
Table 2
Pregnancy complications and mode of delivery before and after Versapoint hysteroscopic metroplasty. Before metroplastya
1-Bleeding in early pregnancy 2-Antepartum hemorrhage – Placenta previa – Abruptio placenta 3-Preterm labor 4-Prematuer rapture of membrane 5-Deliveryc – NSVD – Instrumental – CS a b c
(13.04%) (13.04%) (8.69%) (60.86 5) (21.73%) (21.73%) (56.52%) (11.53%)
7/20 3/20 2/20 1/20 7/20 3/20 9/20 4/20 2/20 3/20
After metroplastyb (35%) (15%) (10%) (5%) (35%) (15%) (45%) (20%) (10%) (15%)
3/23 3/23 2/23 1/23 2/23 3/23 16/23 6/23 3/23 7/23
P value (13.04%) (13.04%) (8.69%) (4.34%) (8.69%) (13.04%) (69.56%) (26.08%) (13.04%) (30.43%)
S NS NS NS S NS S NS NS S
Total number = 20. Total number = 23. Including preterm and full term deliveries.
Table 3 Operative and postoperative data of Versapoint hysteroscopic metroplasty in the study. Operative and postoperative data 1-Operative time (min) 2-Hospital stay (h) 3-Cervical dilatation 4-Cervical laceration 5-Fluid over load 6-Plumonary edema 7-Uterine perforation 8-Blood lose – Minimal – Moderate – Sever 9-Posoperative pelvic pain – No pain – Minimal – Sever 10-Posoperative fever 11-posttraoperative adhesion 12-Residual septum 6I cm (610% UI at HSG) PI cm (P10% UI at HSG) 13-Rehysteroscopy
Range (mean ± SD) Range (mean ± SD) N% N% N% N% N% N%
13–35 (19.6 ± 4.32) 12–48 (13.7 ± 2.12) 7/26 (26.92%) 3/26 (11.53%) 0 0 0 20/26 (76.92%) 6/26 (23.07%) 0
N%
N% N% N%
N%
10/26 (38.46%) 16/26 (61.53%) 0 4/26 (15.38%) 3/26 (11.53%) 5/26 (19.23%) 3/26 (11.53%) 2/26 (7.69%) 2/26 (7.69%)
12 months and 32.3% after 24 months. The cumulative pregnancy probability in the habitual abortion group was 45.8% for the first 6 months, 75.4% during 6–12 months and 87.1% after 24 months. The cumulative pregnancy probability in the preterm group was 25.5% for the first 6 months, 48.7% during 6–12 months and 82.3% after 18 months. All these statistically significant difference between these three groups in pregnancy probability (P < 0.001, log rank test). 4. Discussion Among the different types of structural uterine anomalies, septate uterus is the most common (35%) with an incidence of 1– 2% in the general population, while in women with repeated pregnancy loss it is significantly higher (3.3%) (1,2). Hysteroscopic metroplasty has outdated and replaced Tran abdominal metroplasty by enabling vaginal approach to the correction of septate uterus and providing several advantages such as simple and short surgery with shorter hospitalization time, such factors make hysteroscopic metroplasty a superior approach to abdominal metroplasty (11). In this study, after metroplasty, there were impressive changes in the results, as 23 patients out of 26 (88.46%) became pregnant, 3 patients (13.04%) ended in one early abortion, 3/23 (13.04%) had habitual abortion, 2 patients (4.34%) ended in preterm labor, 14/23 (60.86%) had reached to term delivery
Reproductive outcomes after Versapoint hysteroscopic metroplasty with a total pregnancy loss of 5/23 (21.73%) and pregnancy complications in 5/23 (21.73%) and of these patients 13/23 (56.52%) living babies were recorded, and these results represent a statistically significant difference than before metroplasty (P 6 0.05). Retrospective studies (1,8,12) have shown an improvement in the rate of live births following hysteroscopic metroplasty, however, a controlled prospective study on women having malformed uteri and recurrent spontaneous abortions found no benefit to hysteroscopic surgery (13), while on the other hand some (4) reported that hysteroscopic septum resection in 25 patients was followed by lower rates of first-trimester and total pregnancy loss, as after correction, the total rate of spontaneous abortion fell from 93.2% to 40.4% and only 2 of 44 pregnancies resulted in the delivery of a viable neonate before metroplasty and 59.6% after the procedure–– although only 44.2% of deliveries occurred at term. Similarly, better pregnancy outcomes were noted by Grimbizis and coworkers (8) and Pabuc¸cu and Gomel (1) after hysteroscopic metroplasty in women with recurrent spontaneous abortion and septate uteri as in this study, and also, they reported spontaneous abortions rates about (11–25%) and rate of term delivery about (64–72%). Choe and Baggish (14), and Fedele and Vercellini (15) evaluate the effectiveness of hysteroscopic metroplasty for the reproductive outcome of septate uterus suggested that this procedure decreased the miscarriage rate from 60% down to 15% and increased the pregnancy rate significantly from 5–20% to 81–91%, also, the results of SaygiliYilmaz et al. (11) were compatible with the results of this study as the total miscarriage rate dropped down to 16.1% from 94.3% and the total term pregnancy rate of our cases increased to 65% from 0.4%. The results of this study and the data of other several studies confirm that the hysteroscopic metroplasty should be considered as the most effective approach in women with septate uterus when there is a history of miscarriage, preterm labor or complicated pregnancy and support theories that consider the structural alteration of a uterine septum and a different vascularization of the endometrium as the main reasons for the poor pregnancy outcomes, and expect better pregnancy outcome in anomalous uteri without septa (16). In this study, as regarding neonatal outcome, there was significant improvement in the neonatal weight, apgar scores, and the mean gestational age at delivery, before and after hysteroscopic metroplasty (P < 0.05). These results were proved also by many other retrospective and prospective studies (1,8), and this supported the theory of inadequate intrauterine nourishment due to congenital alterations of the uterine vascularization, which may compromise uteroplacental blood flow, that may be the cause of intrauterine growth retardation seen in malformed uteri (17). Also, in the author opinion, in addition to the improvement of the uterine anatomy and uterine reproductive physiology after metroplasty whatever the approach, there was improvement in the level of the obstetric care received by the patients as before diagnosis (and spontaneous abortion), most women do not receive high-risk obstetric care and after one or more spontaneous abortions, they are more likely to receive high-level obstetric care. Furthermore, after metroplasty, these pregnancies are managed by different physicians using different treatment protocols, therefore, it is difficult to ascribe a better pregnancy outcome after metroplasty solely to the operative procedure (18). In this study, there was no significant difference between normal spontaneous and instrumental vaginal deliveries before
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and after metroplasty (P > 0.05), while paradoxically CS rate was significantly higher after hysteroscopic metroplasty {2/20 (10%) before metroplasty vs. 7/23 (30.43%) after metroplasty, P < 0.001}, which was higher than in the general population and this can be explained by that although the patients were informed about the possibility of vaginal delivery; the majority of them – especially the term group – preferred cesarean delivery not because of obstetrical indications but for the preciousness of the pregnancy due to their history of infertility and poor reproductive outcome. The significant improvement in the reproductive outcomes in the study group after hysteroscopic metroplasty may be due to the difference between the pathomorphology and the ultra-structure between uterine septum and uterine wall, as the amount of the endometrial glands on septum was less than that on the uterine wall, also the positive index level of estrogen and progestogen receptors on the septum was weaker than that on the uterine wall, as well as the densities of the smooth muscle cells were thicker and the collagenous fibers were sparser in the base and the middle of the septum compared with uterine wall, with rare amount of small arteries in the septum (17). Also, in the study of uterine artery Doppler velocimetry indices after metroplasty in arcuate uteri demonstrated that metroplasty, as well as making the uterine cavity wider, leads to better uterine perfusion, as uterine artery Doppler velocimetry (was studied transvaginally before and after metroplasty), was improved as assessed by lower mean pulsitality index (PI) (18). So, the improvement in the pathomorphology and the ultra-structure of the uterine wall after metroplasty will increase the reproductive prognostic index of patients with uterine septum. In this study, 2nd look office hysteroscopy revealed 5 women (19.23%) with residual septum, 2nd film of hysterosalpingogram demonstrated that 3 patients (11.53%) of them with the septum 1 cm and a 2nd intervention using office hysteroscopy was done. These results were comparable to that of Litta et al. (19) using the same technique. Fedele et al. (20) published that a small residual septum (10%. In this study, the efficacy and safety of the hysteroscopic procedure with a bipolar electrode system were assessed compared with a resectoscope technique; the reproductive outcome rates after metroplasty were 77% using the resectoscope and 74% with Versapoint (19), and 60.86% full term deliveries in this study. The operating time was significantly shorter {19.6 ± 4.32 min (range 13–35 min)}, in this study compared with the resectoscope procedures (1,8). In this study intrauterine adhesions were observed in 3 patients (11.53%) which were very thin and small, removed easily using office hysteroscopy. Among the different instruments available for resection of the septum, 4 mm endoscopic scissors, the resectoscope, rigid micro scissors or lasers (18,20), were used, recently bipolar energy has been introduced, keeping the same outcome rate but with broad safety profile (19). Current techniques of operative hysteroscopy used for treating septate or subsepetate uterus use a monopolar electrosurgical system, the distension medium is usually sorbitol and glycine; this limits the operative time in order to decrease the incidence of fluid overload, which may lead
264 to hyponatraemia and subsequent cerebral edema and death. In contrast with the bipolar electrosurgical system, the normal saline used has ion concentrations similar to human plasma and may reduce electrolyte changes and hyponatraemia (21). A second advantage of the bipolar electrode system is that cervical dilatation is not required. Such dilatation is often difficult in nulliparous women with a stenotic cervix. Avoiding cervical dilatation should prove advantageous in reducing the risk of cervical laceration and uterine perforation and in postoperative analgesia requirements. A third potential advantage is that this bipolar system might prevent electrosurgical genital tract burns with excellent haemostasis was achieved in the vapour cut mode which is likely to be advantageous in infertility surgery (22). The previous data and the results of this study, demonstrated that Versapoint hysteroscopic metroplasty is a simple, prompt and less invasive procedure with minimal intraoperative and postoperative morbidity, with a shorter hospital stay, a reduced recuperation time, a decreased need for analgesia, a shorter interval before conception, a lower risk of uterine rupture during pregnancy, and the possibility of planning a vaginal delivery. In conclusion, hysteroscopic metroplasty using the Versapoint is a successful alternative to the resectoscope technique; it has the same effectiveness and broad safety profile with its simplicity, minimal postoperative squeal, and improved reproductive outcomes, this approach should be recommended for metroplasty.
Acknowledgements To all my colleges and junior assistant in the endoscopy unit, Suzan Mubark Maternity and Pediatric Hospital, El-Mina University about their support, and also to all my patients for their cooperation. References (1) Pabuc¸cu R, Gomel V. Reproductive outcome after hysteroscopic metroplasty in women with septate uterus and otherwise unexplained infertility. Fertil Steril 2004;81:1675–8. (2) Raga F, Bauset C, Remohi J. Reproductive impact of congenital Mullerian anomalies. Hum Reprod 1997;12:2277–81. (3) Homer HA, Li TC, Cooke ID. The septate uterus: a review of management and reproductive outcome. Fertil Steril 2000;73:1–14. (4) Zlopasa G, Skrablin S, Kalafatic D, Banovic V, Lesin J. Uterine anomalies and pregnancy outcome following resectoscope metroplasty. Int J Gynecol Obstet 2007;98:129–33. (5) Sanders B. Uterine factors and infertility. J Reprod Med 2006;51:169–76.
H.E. Shawki (6) Rock JA, Murphy A, Cocain WH. The resectoscopic techniques for the lysis of class V: complete uterine septum. Fertil Steril 1997;48(3):495–6. (7) Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN, Devroey P. Clinical implications of uterine malformations and hysteroscopic treatment results. Hum Reprod Update 2001;7:161–74. (8) Grimbizis G, Camus M, Clasen K, Tournaye H, De Munck L, Devroey P. Hysteroscopic septum resection in patients with recurrent abortions and infertility. Hum Reprod 1998;13:1188–93. (9) Nahum GG. Uterine anomalies: how common are they, and what is their distribution among subtypes? J Reprod Med 1998;43:877–87. (10) Kucera Eduard. Anatomical changes after hysteroscopic transcervical uterine septum resection––is there a place for hysterography? Gynecol Surg 2005;2:15–20. (11) Saygili-Yilmaz Esra, Yildiz Sema, Erman-Akar Munire, Akyuz Gulcan, Yilmaz Zarif. Reproductive outcome of septate uterus after hysteroscopic metroplasty. Arch Gynecol Obstet 2003;268:289–92. (12) Litta P, Pozzan C, Merlin F, Sacco G, Saccardi C, Ambrosini G. Hysteroscopic metroplasty under laparoscopic guidance in infertile women with septate uteri: follow-up of reproductive outcome. J Reprod Med 2004;49:274–8. (13) Saygili-Yilmaz ES, Erman-Akar M, Yilmaz Z. A retrospective study on the reproductive outcome of the septate uterus corrected by hysteroscopic metroplasty. Int J Gynecol Obstet 2002;78:59–60. (14) Choe JK, Baggish M. Hysteroscopic treatment of septate uterus with neodymium-YAG laser. Fertil Steril 1992;57:81–4. (15) Fedele L, Vercellini P. Reproductive prognosis after hysteroscopic metroplasty in 102 women: life-table analysis. Fertil Steril 1993;59:768–72. (16) Fedele L, Bianchi S, Marchini M, Franchi D, Tozzi L, Dorta M. Ultrastructural aspects of endometrium in infertile women with septate uterus. Fertil Steril 1996;65:750–2. (17) Duan H, Zhao Y, Yu D, Xia El. Study on the mechanism of infertility or sterility caused by uterine septa and reproductive prognosis after hysteroscopic meteroplasty. Zhonghua Fu Chan Ke Za Zhi 2005;40(11):703–8. (18) Pace S, Cerekja A, Stentella P, Frega A, Pace G, La Torre R, Piazze J. Improvement of uterine artery Doppler velocimetry indices after metroplasty in arcuate uteri. Eur J Obstet Gynecol Reprod Biol 2007;131(1):81–4. (19) Litta Pietro, Spiller Elena, Saccardi Carlo, Ambrosini Guido, Caserta Donatella, Cosmi Erich. Resectoscope or Versapoint for hysteroscopic metroplasty. Int J Gynecol Obstet 2008;101:39–42. (20) Fedele L, Bianchi S, Marchini M, Mezzopane R, Di Nola G, Tozzi L. Residual uterine septum of less than 1 cm after hysteroscopic metroplasty does not impair reproductive outcome. Hum Reprod 1996;11:727–9. (21) Colacurci N, De Franciscis P, Mollo A, Litta P, Perino A, Cobellis L, De Placido G. Small-diameter hysteroscopy with Versapoint versus resectoscopy with a unipolar knife for the treatment of sepetate uterus: a prospective randomized study. J Minim Invasive Gynecol 2007;14(5):622–7. (22) Fernandez H, Gervaise A, de Tayrac R. Operative hysteroscopy for infertility using normal saline solution and a coaxial bipolar electrode: a pilot study. Hum Reprod 2000;15(8):1773–5.
