Endoscopic Septectomy for RPL Patients

According to ASRM, recurrent pregnancy loss (RPL) is a distinct disorder, defined by two or more clinical pregnancy losses documented by either ultrasonography or approved in a histopathologic examination. It is a common problem, occurring in approximately 5% of women, with various etiological factors, such as endocrinal, AFS, anatomic, genetic and idiopathic. Anatomic abnormalities cause 10-15% of all RPL cases and includes congenital uterine anomalies, Asherman sundrome/intrauterine synechiae, uterine fibroids and uterine polyps. This Presentation is focused on congenital mullerian anomalies, precisely - on uterine septum and the diagnosis and management reviews.

The classification of mullerian anomalies in our presentation is based on The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Uterine septum is classified as Class U2 and is subdivided as Class U2a – partial septum and Class U2b – complete septum. The definition criterium of uterine septum is an internal indentation extending >50% of myometrial wall thickness. Septated uterus is the most common congenital abnormality, accounting for approximately 55-66% of all uterine abnormalities in women with RPL.

Assessing the external uterine contour as well as the internal configuration of the endometrial cavity is important when confirming the diagnosis of septate uterus. As radiologic methods have improved over past 20 years, the diagnosis of a septate uterus is typically made using radiographic rather than surgical techniques and it is recommended that imaging with hysteroscopy should be used to diagnose uterine septa rather than laparoscopy with hysteroscopy, as this approach is less invasive.

The uterine septum may be repaired with the hysteroscopic septoplasty. Commonly used techniques include incision of the septum utilizing cold scissors, unipolar or bipolar cautery, or laser, or resection of the septum. Laparoscopy and, more recently, transabdominal ultrasound have been used concurrently with hysteroscopic incision to confirm uterine contour, decrease the risk of uterine perforation, and assess complete removal of the septum and the presence of other anomalies.