Hysteroscopic enlargement metroplasty for T-shaped uterus

24 years’ experience at the Strasbourg Medico-Surgical and Obstetrical Centre (CMCO)

These T-shaped uteruses are most commonly observed in patients who were exposed in utero to diethylstilbestrol (DES). DES is a nonsteroidal synthetic oestrogen that was marketed in France between 1948 and 1977 and prescribed to almost 200,000 women to prevent various obstetrical complications. The number of female infants exposed in utero to DES in France is estimated at 80,000. It was shown to be ineffective for these obstetrical indications in 1953 but its prescription was banned in France only in 1977, long after it had been established that this treatment was harmful: it is associated with an increased risk of clear-cell adenocarcinoma of the vagina. In addition to its cancer-inducing risk, this treatment has been found to cause uterine malformations (in particular, T-shaped uterus) and Fallopian tube dysfunction, with a reduced fertility and increased risk of miscarriage and premature delivery.

Abstract

STUDY QUESTION
What is the impact of hysteroscopic enlargement metroplasty for T-shaped uterus on the live birth rate?

SUMMARY ANSWER
Performing enlargement metroplasty appears to improve the obstetrical prognosis and fertility in patients with a T-shaped uterus.

WHAT IS KNOWN ALREADY
T-shaped uterus is linked to an excess of myometrium in the uterine walls giving rise to a subcornual constriction ring which causes dysmorphism and hypoplasia of the uterine cavity. It is commonly associated with infertility or a sequence of repeated miscarriages.

STUDY DESIGN
Single-centre observational cohort study in 112 patients who underwent enlargement metroplasty for T-shaped uterus between 1992 and 2016 in a Strasbourg university hospital centre.

MAIN RESULTS
The mean age of patients was 33.2; they had been attempting to conceive on average for 56 months for subfertile patients and 42.2 months for infertile patients. Prior to surgery, patients had succeeded in becoming pregnant 161 times, i.e. a mean gravidity of 1.4 pregnancies. For subfertile patients the mean gravidity was 2.67. Mean parity was 0.04. In the overall population, one hundred pregnancies occurred following enlargement metroplasty. The live birth rate increased in a statistically significant manner following enlargement metroplasty: 4 (2.5%) vs. 60 (60%), p < 0.05. In parallel, the miscarriage rate was statistically reduced: 126 (78.3%) vs. 22 (22%), pnull< .05. Intraoperative complications were 1 case of cervical laceration (0.9%) and 1 case of false passage (0.9%). Subsequent pregnancies remained at risk of miscarriage (22%) and premature delivery (20%) but not extra uterine gestation. Delivery took place by Caesarean section in 61% of cases. In the subgroup of infertile patients, the live birth rate was also markedly increased and 49% of pregnancies which occurred were spontaneous.

LIMITATIONS
This study was descriptive and retrospective.

WIDER IMPLICATIONS
These results are consistent with those in the literature. Hysteroscopic enlargement metroplasty is now a well-established technique with few complications but which should nevertheless be reserved for symptomatic patients.

References

  • Hysteroscopic enlargement metroplasty for T-shaped uterus: 24 years’ experience at the Strasbourg Medico-Surgical and Obstetrical Centre (CMCO), European journal of obstetrics, gynecology, and reproductive biology, NCBI PubMed PMID: 29804025, 2018.
  • Image copyright © Pr P-J Weiller.
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