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The Role of Hysteroscopy in Diagnosis and Management of Uterine Anomalies

  • Jaime FerroEmail author
  • Sunita Tandulwadkar
  • Pedro Montoya-Botero
  • Sejal Naik
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Abstract

Congenital Müllerian anomalies (CMA) are the result of a developmental anomaly of the Müllerian ducts because of a failure during the fusion. The estimated prevalence of CMA in the general population is around 6.7%, whereas in the infertile population is about 7.3% and 16.7% in those women with recurrent miscarriage. Arcuate and septate uteri are the most common forms of anomalies both in fertile and infertile patients. The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) created the Congenital Uterine Anomalies Group (CONUTA). The American Society for Reproductive Medicine (ASRM) proposed their classification in 1988. The reason for infertility, although not fully understood, lies in the altered characteristics of the endometrium lining in the malformed uteri, ending in low implantation rates. Hysteroscopy remains the gold standard method for the evaluation of the uterine cavity, so it is of paramount importance to correctly diagnose these alterations and treat them when appropriate.

Keywords

Hysteroscopy Uterine anomalies Müllerian anomalies Uterine adhesions Implantation failure 

Supplementary material

Video 7.1

Normal uterine cavity: The normal morphology of the uterine cavity is triangular with the small variants depending on the parity from the triangle isosceles to the equilateral. The normal characteristic is to be able to draw an imaginary diagonal line that goes freely from the isthmic region, immediately above the ICO, to the tubular orifice. The fundus is more or less flat and allows the hysteroscope to pass freely from horn to horn (MP4 26263 kb)

Video 7.2

Arcuate uterine cavity: When this small anomaly is associated with symptoms related to fertility alteration it is advisable to normalize the bottom of the cavity by a cut that leaves the bottom flat or slightly domed depending on the thickness of the uterine wall at this level (MP4 109327 kb)

Video 7.3

Partial uterine septum: This septum corresponds to the anomaly in which the medial septum of the cavity does not reach the internal cervical orifice. It usually occurs from the middle third but may also be of the upper third. We practice the resection of the septum with the hysteroscopic microscissors until the bottom of the cavity leaving it with the appearance slightly domed. With a 5-Fr bipolar HF tip we practice the direct and selective coagulation of the bleeding vessels to reduce the collateral thermal damage (MP4 290167 kb)

Video 7.4

Complete uterine septum: We practice the complete resection of the septum with the hysteroscopic microscissors until the bottom of the cavity leaving it with the appearance slightly domed depending on the thickness of the uterine wall at this level. With a 5-Fr bipolar HF tip we practice the direct and selective coagulation of the bleeding vessels to reduce the collateral thermal damage (MP4 210815 kb)

Video 7.5

Cervical and uterine septum: This anomaly corresponds to the presence of a uterine cavity septum along with the cervical portion and appears as a simple cervical septum as a double cervix. It can also be accompanied by a vaginal septum. A Foley catheter No. 8–10 is placed in one of the cavities of the uterus (usually the right) and the ball of the probe is inflated with 1–2 mL of methylene blue and with the hysteroscopy microscissors is practiced a cut in the septal wall at the level of the isthmus region where you can see the bulge that shows the ball. When the vaginal septum does not cause sexual dysfunction there is no need to resect it. If you have to dry it, if the wall of the cervical septum is not very thick (no more than 10 mm) it can also be dried as well as the septum of the uterine cavity (MP4 52605 kb)

Video 7.6

Second-look resection uterine septum left cervical septum: For two cycles of HTS after resection of the uterine septum we recommend the practice of the second look. It is the time to evaluate the possible remnant septum fundus of the cavity and complete the resection (MP4 104142 kb)

Video 7.7

T-shape uterine cavity: The T-shaped cavity shows the prominent side walls that give the image of tubular with narrow and deep horns. The fundus has variants with the most common type being the arcuate or septate. It can also be flat and more rarely slightly biseptate (MP4 208591 kb)

Video 7.8

Anti-adhesion acid hyaluronic acid gel: It is possible to use the acid hyaluronic gel to avoid the adhesions. The evidence is not conclusive but it is favorable (MP4 30075 kb)

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Jaime Ferro
    • 1
    Email author
  • Sunita Tandulwadkar
    • 2
    • 3
    • 4
    • 5
  • Pedro Montoya-Botero
    • 6
  • Sejal Naik
    • 7
  1. 1.IVI ValenciaValenciaSpain
  2. 2.Solo Clinic, Centre of Excellence Infertility & EndoscopyPuneIndia
  3. 3.Solo Stem Cells, Stem Cells Research & Application CentrePuneIndia
  4. 4.Department of Obstetrics & GynaecologyRuby Hall ClinicPuneIndia
  5. 5.Ruby Hall IVF & Endoscopy CentrePuneIndia
  6. 6.Reproductive Medicine at Conceptum, Unidad de Fertilidad del CountryBogotáColombia
  7. 7.Rahul Hospital & Well Women ClinicSuratIndia

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