Hysteroscopic septum resection in patients with recurrent abortions or infertility

Transcription

1 Human Reproduction vol.13 no.5 pp , 1998 Hysteroscopic septum resection in patients with recurrent abortions or infertility Grigoris Grimbizis, Michel Camus, Koen Clasen, Herman Tournaye, Luc De Munck and Paul Devroey 1 Centre for Reproductive Medicine, University Hospital, Dutchspeaking Brussels Free University, Laarbeeklaan 101, 1090 Brussels, Belgium 1 To whom correspondence should be addressed Fifty-seven patients who underwent hysteroscopic septum resection between January 1991 and December 1996 were studied; nine patients presented with recurrent abortions, 46 with infertility (26 primary and 20 secondary), one with dysmenorrhoea and one with an asymptomatic complete septum. Their reproductive history included 78 pregnancies: 69 (88.4%) abortions, two (2.6%) ectopics, two (2.6%) preterm deliveries and five (6.4%) term deliveries. In patients with infertility, the incidence of unexplained infertility was 19.6% and the incidence of endometriosis was 26.1%. After hysteroscopic septum resection, 42 patients were interested in pregnancy. All patients with recurrent abortions conceived spontaneously. Twenty-one (63.6%) infertile patients achieved a pregnancy, 13 (61.9%) of them after treatment with various assisted reproduction techniques. The reproductive outcome after septum resection yielded 44 pregnancies, including three sets of twins and one set of triplets reduced to twins: 11 (25%) abortions, one (2.3%) ectopic pregnancy, two (4.5%) preterm deliveries (both twins), 28 (63.7%) term deliveries and two (4.5%) as-yet ongoing pregnancies. It seems that the hysteroscopic treatment of uterine septum has a beneficial effect on pregnancy outcome. A septate uterus does not seem to be an infertility factor. The achievement of pregnancy is normal in patients with recurrent abortions, while the chances of conception in patients with infertility seem to be similar to those for the general infertile population. Key words: hysteroscopy/infertility/recurrent abortions/septum resection/uterine septum Introduction Müllerian defects are observed in 3 5% of the general population, but their frequency increases between 5 and 25% in women with recurrent miscarriages, late abortions and preterm deliveries (Acién, 1997; Pellicer, 1997). Uterine septum is the most common congenital anomaly of the female reproductive tract, with an incidence of 2 3% in the general population (Ashton et al., 1988; Simon et al., 1991). Its presence is associated with poor reproductive performance, including high incidence of first and second trimester abortion, preterm delivery (often as a result of premature rupture of the membranes), as well as abnormal presentations and increased Caesarean section rates (Heinonen et al., 1982; Buttram, 1983; McShane et al., 1983; Worthen and Gonzalez, 1984; Rock and Schlaff, 1985; Stein and March, 1990; Golan et al., 1992; Fedele and Bianchi, 1995). On the other hand, the interference of a septate uterus with the woman s fertility remains a controversial issue (Heinonen et al., 1982; Daly et al., 1989; Fedele and Bianchi, 1995; Goldenberg et al., 1995). The main and absolute indication for the treatment of patients with septate uteri is a reproductive history of recurrent abortions or fetal loss (McShane et al., 1983; DeCherney et al., 1986; Fayez, 1986; Valle and Sciarra, 1986; March and Israel, 1987; Candianni et al., 1991; Vercellini et al., 1993; Fedele and Bianchi, 1995). However, a group of patients with septate uteri may present with infertility, primary or secondary, and this will be discovered only during the infertility work-up (Fayez, 1986; Perino et al., 1987; Daly et al., 1989; Goldenberg et al., 1995). Hysteroscopic metroplasty in this group is applied mainly as a prophylactic procedure to prevent spontaneous abortions and complications during labour (Daly et al., 1989; Fedele and Bianchi, 1995). The transcervical route for the treatment of the septate uterus was initially proposed in 1884 by Ruge, but was later abandoned in favour of abdominal procedures. The introduction of operative hysteroscopy has renewed interest in the transcervical approach. In 1974, Edstrom performed the first hysteroscopic section of uterine septum, and in 1981 Chervenak and Neuwirth reported the first successful reproductive outcome after hysteroscopic metroplasty. Nowadays, the septate uterus can be effectively treated by operative hysteroscopy (Jacobsen and DeCherney, 1997). The incision of the septum can be carried out by scissors, resectoscope or laser, with no obvious advantage from any of these techniques (Candianni et al., 1991; Vercellini et al., 1993; Fedele and Bianchi, 1995; Goldenberg et al., 1995). The aim of this study was to assess the achievement of pregnancy as well as the reproductive outcome after hysteroscopic septum resection in women with recurrent abortions or infertility. Materials and methods Patients In all, 57 patients who underwent hysteroscopic septum resection from January 1991 until December 1996 were included in the study. The patients mean age was 31 5 years (range 22 45). The diagnosis of the uterine septum was based on a combination of 1188 European Society for Human Reproduction and Embryology

2 Hysteroscopic septum resection hysteroscopy and laparoscopy (although in some cases a hysterosalpingography was also available), in order to differentiate between complete septate uterus (American Fertility Society class V a ) and uterus didelphys (class III) or between partially septate uterus (class V b ) and bicornuate uterus (class IV) (American Fertility Society, 1988). Laparoscopy also allowed a more objective assessment of the patient s status in cases of infertility. The uterine septa were classified as class V a in 12 (21%) patients and as class V b in 45 (79%) patients (Table I). The preoperative reproductive performance included 78 pregnancies; 69 (88.4%) ended in abortion ( 24 weeks of gestation), two (2.6%) were ectopic, two (2.6%) ended in preterm deliveries ( 37 weeks of gestation) and only five (6.4%) were term deliveries ( 37 weeks of gestation). Indications The patients were also studied in terms of their main clinical problem. Infertility Forty-six out of 57 patients presented with infertility; 26 with primary infertility and 20 with secondary infertility (Table II). The patients mean age and the mean duration of infertility are shown in Table II. The diagnosis of the septum was made during their infertility investigation. The uterine septa were classified as class V a in 10 (21.7%) patients and as class V b in 36 (78.3%); seven (26.9%) out of 26 patients with primary infertility and three (15%) out of 20 with Table I. Reproductive performance in women with uterine septa before resection Infertility Recurrent Others Total abortions Patients (n) Type V a (n) (21.0) V b (n) (79.0) Age (years) (mean SD) Pregnancies (n) 45 a Abortions (n) 40 (88.9) 29 (87.9) 69 (88.4) Ectopics (n) 1 (2.2) 1 (3.0) 2 (2.6) Preterm deliveries (n) 0 (0.0) 2 (6.1) 2 (2.6) Term deliveries (n) 4 (8.9) 1 (3.0) 5 (6.4) a Patients with secondary infertility; V a complete septate uterus; V b partial septate uterus; n, number. Values in parentheses are percentages. secondary had a class V a septum, while the rest had a class V b septum (Table II). All couples with infertility underwent a thorough evaluation of their problem before their treatment. In all, 37 (80.4%) out of 46 patients with infertility had one or more other infertility factors, while in nine (19.6%) cases the infertility was unexplained. The number of couples with other infertility factors was significantly higher in patients with primary infertility than in those with secondary infertility: 25 (96.5%) out of 26 and 12 (60%) out of 20 respectively (P 0.05). Interestingly, 12 (26.1%) out of 46 patients had laparoscopic findings of endometriosis, seven (26.9%) out of 26 women with primary infertility and five (25%) out of 20 with secondary infertility. Twenty (43.5%) out of 46 patients had been previously treated by various assisted reproduction techniques for their infertility problem, 14 (53.8%) out of 26 patients with primary infertility and six (30%) out of 20 with secondary infertility (Table II). The numbers of these assisted reproduction technique cycles are shown in Table II. The patients with primary infertility had received less advanced therapy than those with secondary infertility, since the numbers of in-vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) cycles were and respectively (P 0.05). The reproductive history of the women with secondary infertility was poor. They had achieved 45 pregnancies before septum resection: 40 (88.9%) of these had ended in spontaneous abortions, one (2.2%) had been ectopic and only four (8.9%) had ended in term deliveries (Table I). Recurrent abortions Nine out of 57 patients presented with recurrent abortions (two or more previous miscarriages). The women s mean age was years. All patients had undergone a complete work-up for their clinical problem. The diagnosis of uterine septum was made during their evaluation. The uterine septa were classified as class V b in all patients (Table I). The reproductive history included 33 pregnancies: 29 (87.9%) of these had been abortions, one (3%) had been an ectopic pregnancy, two (6.1%) had ended in preterm deliveries and only one (3%) had ended in a term delivery (Table I). Other indications Two out of 57 patients were treated for other clinical problems. Both had a class V a septum which in one case was combined with a vaginal septum. In the latter patient, the main clinical problem was severe dysmenorrhoea. In the other patient, the diagnosis of the septum was made by chance and the septum resection was applied as a prophylactic Table II. Clinical characteristics of patients with infertility Primary Secondary Total a versus b infertility a infertility b Patients (n) Type V a (n) 7 (26.9) 3 (15) 10 (21.7) NS V b (n) 19 (73.1) 17 (85) 36 (78.3) NS Age (years) (mean SD) NS Duration of infertility (mean SD) NS (years) Other infertility factors (n) 25 (96.2) 12 (60.0) 37 (80.4) P factor (n) factors (n) Patients with ART (n) 14 (53.8) 6 (30.0) 20 (43.5) cycles (mean SD) NS not significant; V a complete septate uterus; V b partial septate uterus; n number; ART assisted reproductive treatment. Values in parentheses are percentages. 1189

3 G.Grimbizis et al. procedure, taking into account the wishes of the couple for an uneventful course of a subsequent pregnancy. Procedure The hysteroscopic incision of the uterine septum was scheduled either in the early proliferative phase or after pretreatment of the patients with gonadotrophin-releasing hormone agonists. In the beginning, the operation was performed under general anaesthesia and laparoscopic control. However, the general anaesthesia was later replaced by epidural and the simultaneous laparoscopic control has been abandoned as experience has gradually increased. The cervix was dilated to 10 mm, and then a 4 mm/12 rigid hysteroscope (model A2011A; Olympus, Winter and IBE GMBH, Hamburg, Germany) mounted with a rotatable 9 mm resectoscope (Olympus models A4720, A4721, A2751, A2183, A2193) was introduced. The uterine cavity was distended with a sorbitol 5% solution (Baxter B7850, Lessines, Belgium). The septum resection was performed with an angled electrode at 90, equidistantly between the anterior and the posterior wall. After visualization of the tubal ostia, the resection was started from the lower margin of the septum and continued upwards with progressive horizontal incisions in the midline. The incision was considered complete when a normal cavity was obtained and the hysteroscope could be moved freely from one tubal ostium to the other without an intervening obstruction (March and Israel, 1987; Fedele et al., 1993; Vercellini et al., 1993; Fedele and Bianchi, 1995). In cases of complete septate uterus, the uterine septum was removed, starting from the cervical part with scissors and followed by hysteroscopic resection of the intrauterine part (Donnez and Nisolle, 1997). Although some authors believe that it is better not to remove the cervical part in order to prevent cervical incompetence (Daly et al., 1989; Römer and Lober, 1997), we do not agree with this hypothesis, as also supported by Donnez and Nisolle (1997). Postoperatively, the patients received a contraceptive pill for 2 months. A second-look hysteroscopy, on an outpatient basis, under local anaesthesia, was performed 2 or 3 months after the operation. Statistics The differences between the variables were compared using the unpaired Student s t-test or the χ 2 test, where appropriate. Results All septa were successfully removed. During the procedure, two operations were complicated by small perforations that did not require any further treatment. Follow-up after surgery was done either in the outpatient clinic or by phone to evaluate the interest in pregnancy, the achievement of pregnancy and the reproductive outcome. A patient was considered for inclusion if: (i) she could be reached either directly or by phone, (ii) she wanted to conceive and (iii) she had had 12 months of unprotected intercourse or at least one assisted reproductive treatment cycle, irrespective of the follow-up period. Forty-two out of 57 patients were included; five were lost to follow-up, six did not wish to conceive (personal, social or medical reasons) and in four cases the follow-up period was too short. The mean period of follow-up, for those interested in pregnancy, was months. Thirty (71.4%) out of 42 became pregnant; 17 spontaneously and 13 after various assisted reproductive treatments (Table III). In all, 44 pregnancies ensued, including three twins and one 1190 triplet later reduced to a twin. Eleven (25%) pregnancies ended in abortion; including one pregnancy after frozen embryo transfer and one abortion occurring shortly after amniocentesis. One (2.3%) pregnancy was ectopic. Two (4.5%) pregnancies, both twins, ended in preterm deliveries. Twenty-eight (63.7%) pregnancies ended in term deliveries, including one twin gestation and one triplet reduced to twin. Two (4.5%) are still ongoing; one of them 24 weeks of gestation. Patients with infertility Thirty-three out of 46 patients were included; 19 out of 26 with primary infertility and 14 out of 20 with secondary infertility. Four (three with primary and one with secondary infertility) were lost to follow-up, five (three with primary and two with secondary infertility) did not wish to become pregnant and four (one with primary and three with secondary) had too short follow-up period of unprotected intercourse. The mean follow-up period was months; for patients with primary infertility and for patients with secondary infertility (Table III). Postoperatively, 26 (78.8%) out of 33 patients were treated by various assisted reproductive treatments (Table III). The numbers of assisted reproductive treatment cycles according to the different types of infertility are shown in Table III. Twenty-one (63.6%) out of 36 patients achieved a pregnancy; 11 (57.9%) out of 19 patients with primary infertility and 10 (71.4%) out of 14 with secondary. Thirteen (63.6%) out of 21 pregnant women conceived after treatment with assisted reproductive treatment; eight (72.7%) out of 11 patients with primary infertility and five (50%) out of 10 with secondary infertility. In all, 34 pregnancies ensued, including three twins and one triplet reduced to a twin; 16 by women with primary infertility and 18 by those with secondary infertility (Table III). Ten (29.4%) out of 34 pregnancies ended in abortions, including one after frozen embryo transfer and one shortly after amniocentesis; four (25%) out of 16 pregnancies in patients with primary infertility and six (33.3%) out of 18 in patients with secondary infertility. One ectopic pregnancy was observed in a patient with primary infertility. Two (4.5%) twin pregnancies ended in preterm deliveries, each in one group. Nineteen (55.9%) out of 34 pregnancies ended in term deliveries; 10 (62.5%) out of 16 in patients with primary infertility and nine (50%) out of 18 in patients with secondary infertility. Two (5.9%) pregnancies are still ongoing in patients with secondary infertility; one of them is 24 weeks of gestation (Table III). Patients with recurrent abortions Eight out of nine patients were included, while one was lost to follow-up. The mean period of follow up was months. All women became pregnant spontaneously. In all, nine pregnancies ensued (Table III). One (11.1%) ended in abortion and eight (88.9%) ended in term deliveries. Others The patient with severe dysmenorrhoea was not interested in pregnancy but the hysteroscopic septum resection resulted in a significant improvement of her clinical problem. The remaining

4 Hysteroscopic septum resection Table III. Reproductive outcome of women after septum resection Primary Secondary Recurrent Others Total infertility infertility abortions Patients (n) Interest in pregnancy (n) Others 1. Lost to follow-up (n) No interest (n) Too short follow-up period (n) Follow-up (months) (mean SD) Patients with ART (n) 17 (89.5) 9 (64.3) (78.8) cycles (mean SD) Pregnant (n) 11 (57.9) 10 (71.4) 8 (100.0) 1 30 (71.4) Spontaneously (n) 3 (27.3) 5 (50.0) 8 (100.0) 1 17 (56.7) After ART (n) 8 (72.7) 5 (50.5) 0 (0.0) 0 13 (43.3) Pregnancies (n) twins 1 twin 3 twins 1 triplet-red 1 triplet-red Abortions (n) 4 (25.0) 6 (33.3) 1 (11.1) 0 11 (25.0) 1 FRET 1 FRET 1 amniocent 1 amniocent Ectopics (n) 1 (6.2) 0 (0.0) 0 ( (2.3 Preterm deliveries (n) 1 (6.2) 1 (5.6) 0 (0.0) 0 2 (4.5) 1 twin 1 twin 2 twins Term deliveries (n) 10 (62.5) 9 (50.0) 8 (88.9) 1 28 (63.7) 1 twin 1 triplet-red 1 twin 1 triplet-red Ongoing (n) 2 (11.1) 2 (4.5) 1 24 weeks 1 24 weeks NS not significant; FRET frozen embryo transfer; triplet-red triplet reduced to twin; n number; ART assisted reproductive treatment. Values in parentheses are percentages. patient achieved a spontaneous pregnancy which ended in a term delivery (Table III). Discussion The American Fertility Society (1988), based on the previous work by Buttram and Gibbons (1979), classified the anomalies of the female reproductive tract according to the degree of failure of normal development into groups with similar clinical manifestations, treatment and possible prognoses for their reproductive performance. The various Müllerian anomalies are the consequence of four major disturbances in the development of the female genital system during fetal life: (i) failure of one or more Müllerian ducts to develop (agenesis class I; unicornuate uterus without rudimentary horn class II d ), (ii) failure of the ducts to canalize (unicornuate uterus with rudimentary horn without proper cavities class II a c ), (iii) failure to fuse or abnormal fusion of the ducts (uterus didelphys class III; bicornuate uterus class IV), and (iv) failure of reabsorption of the midline uterine septum (septate uterus class V a,b ; arcuate uterus class VI). The identification of these anomalies has historically been made by hysterosalpingography, but this approach allows only the diagnosis of a double uterus (Buttram, 1983; Rock and Schlaff, 1985; Fedele and Bianchi, 1995). An accurate diagnosis should also be based on the estimation of the uterine serosal surface. Thus, a combination of laparoscopy and hysteroscopy, which is the diagnostic approach used in this study, seems to be necessary for the precise classification of uterine malformations (Buttram, 1983; Rock and Schlaff, 1985; Fedele and Bianchi, 1995). Nevertheless, some authors have reported the use of abdominal ultrasonography in the luteal phase for the differential diagnosis of double uterus (Fedele et al., 1988; Fedele and Bianchi, 1995). Although congenital uterine malformations are associated with poor reproductive performance, each type may have a different impact on reproduction (Buttram, 1983). Unicornuate uterus and uterus didelphys seem to have a similar effect on pregnancy outcome, since uterus didelphys may be considered as a symmetrical duplication of a unicornuate uterus (Buttram, 1983; Moutos et al., 1992; Marcus et al., 1996). Bicornuate and septate uterus may also be considered another group, characterized generally by poorer reproductive performance (Buttram, 1983; Rock and Schlaff, 1985; Marcus et al., 1996). In patients with septate uteri, Buttram (1983) has reported a 67% abortion rate, 33% prematurity and 28% live births. The preoperative reproductive performance in our study population was characterized by an 88.5% abortion rate and only 6.4% term delivery rate. High miscarriage rates and low term delivery rates have also been described by several authors in patients with septate uteri before metroplasty (McShane et al., 1983; Fayez, 1986; March and Israel, 1987; Perino et al., 1987; Choe and Baggish, 1992). Several mechanisms have been proposed to explain the adverse effect of a septate uterus on the course of pregnancy. The diminished size of the uterine cavity as well as cervical 1191

5 G.Grimbizis et al. incompetence have been suggested as possible aetiological factors (Fedele and Bianchi, 1995; Marcus et al., 1996). However, according to the most widely accepted theory, the septum is thought to consist of fibroelastic tissue with inadequate vascularization and altered relations between myometrial and endometrial vessels, thus exerting a negative effect on fetal placentation (Buttram, 1983; Fayez, 1987; Fedele et al., 1989; Fedele and Bianchi, 1995). Contrary to this classical concept, Dabirashrafi et al. (1995) found significantly less connective tissue, a higher amount of muscle tissue and more vessels in the septum. Thus, they suggested that pregnancy wastage is caused by poor decidualization and placentation, due to the reduced amounts of connective tissue, as well as by higher or uncoordinated contractility due to the increased muscle content. In our study population, the hysteroscopic resection of the septum was accompanied by a significant improvement in pregnancy outcome: the abortion rate dropped to 25% and the term delivery rate increased to 63.7%, while 4.5% of the pregnancies are still ongoing. It is possible that the type of conception in our patients might have a negative influence on the results: 13 (43.3%) out of 30 patients conceived after various assisted reproductive treatments and it is known that these pregnancies have unusually high abortion rates, approximating 20% (Testart et al., 1992). Moreover, one pregnancy ended in abortion shortly after amniocentesis, probably as a result of a complication from this procedure, while two twin pregnancies ended in preterm deliveries, which is also expected. A significant improvement in pregnancy outcome after hysteroscopic metroplasty was also described by other investigators, with postoperative abortion rates between 5 and 20% and live birth rates between 73 and 87% (Fayez, 1986; Valle and Sciarra, 1986; March and Israel, 1987; Perino et al., 1987; Daly et al., 1989; Choe and Baddish, 1992; Fedele et al., 1993; Jacobsen and DeCherney, 1997). However, this is only a retrospective analysis and the absence of a control group (consisting of patients with symptomatic untreated septate uterus) represents a serious limitation in the more precise evaluation of the efficacy of the hysteroscopic metroplasty, but the assisted reproductive treatment procedures done before and after the operation were exactly the same and the improvement of pregnancy outcome seems to be really impressive, as also described by Fedele and Bianchi (1995). The achievement of pregnancy is another important parameter in estimating the effect of hysteroscopic metroplasty on reproduction. In our group, all patients with recurrent abortions and normal fertility who were interested in pregnancy conceived spontaneously at least once after their treatment. Daly et al. (1989) have reported normal postoperative monthly fecundity rates. Thus, it seems that the application of hysteroscopic metroplasty does not impair the fertility potential of the women with a history of recurrent abortions. Although hysteroscopic metroplasty seems to be indicated in patients with recurrent abortions and normal fertility, in view of its efficacy and the absence of any harmful effect on the achievement of pregnancy, there is always a debate concerning the patients presenting with infertility (Fedele and Bianchi, 1995; Marcus et al., 1996). Patients with secondary 1192 infertility usually have a history of spontaneous abortions, and hysteroscopic metroplasty is applied as a treatment for their poor reproductive performance (March and Israel, 1987; Choe and Baggish, 1992; present study). On the other hand, in patients with primary infertility, hysteroscopic treatment is applied as a prophylactic procedure. The application of hysteroscopic septum resection in our patients with primary infertility was accompanied by a 25% abortion rate and 62.5% termdelivery rate. It should be noted that eight (72.7%) out of 11 patients conceived after assisted reproductive treatment and one abortion was observed shortly after amniocentesis. The results should be considered to be at least satisfactory when compared with the poor reproductive performance of the women with secondary infertility before their treatment. Moreover, Marcus et al. (1996) observed increased abortion and preterm delivery rates as well as low term delivery rates in patients with bicornuate and septate uterus presenting with primary infertility and treated by in-vitro fertilization without previous correction of the congenital anomaly. The interference of the septate uterus with infertility is another debatable issue. A possible contribution from the uterine septum can only be suggested in patients with unexplained infertility. In our study, other factors of infertility were not detected in 19.6% of the patients with infertility. This prevalence of unexplained infertility is similar to that observed in the general infertile population (ESHRE Capri Workshop, 1996). These data do not support the notion that uterine septum is a factor in infertility. On the other hand, the incidence of unexplained infertility was significantly higher (40%) in the patients with secondary infertility. Thus, a contribution from the uterine septum in delayed conception of patients with secondary infertility cannot be excluded. Although many investigators have reported the hysteroscopic treatment of infertile women (Fayez, 1986; March and Israel, 1987; Perino et al., 1987; Daly et al., 1989; Choe and Baddish, 1992; Fedele et al., 1993; Goldenberg et al., 1995), the data on infertility factors are rather limited and, where mentioned, the number of patients is low (Fayez, 1986; Perino et al., 1987; Daly et al., 1989). In our population 12 (26.1%) out of 46 patients with infertility had laparoscopic findings of endometriosis. Fedele et al. (1993) also found endometriosis in 11 (35%) out of 31 patients with uterine septum and infertility, and Fayez (1986) found this in three (45%) out of seven patients. The achievement of pregnancy in patients with uterine septum and infertility is also important. Marcus et al. (1996) have reported the treatment of 24 patients with various congenital anomalies by in-vitro fertilization without previous metroplasty; 19 (70.8%) of them became pregnant after a mean of 2.1 attempts/patient, while the pregnancy rates were similar irrespective of the type of anomaly. In another study, Guirgis and Shrivastar (1990) treated 14 patients with bicornuate uterus by gamete intra-fallopian transfer without previous metroplasty; eight (51.7%) of them achieved a pregnancy after a mean of 2.1 attempts/patient. The ovarian response to stimulation, the implantation rates and the pregnancy rates observed in these two studies were similar to those for the general infertile population. In our patients with uterine septum and infertility, 21 (63.6%) out of 33 conceived after hystero-

6 Hysteroscopic septum resection scopic metroplasty; most of them (78.8%) were treated with various assisted reproductive treatment, while many (43.5%) had a long history of previous assisted reproductive treatment cycles. Furthermore, Daly et al. (1989) reported that seven (53.8%) out of 13 patients with infertility conceived after septum resection and, more recently, Goldenberg et al. (1995) have observed pregnancies after hysteroscopic metroplasty in 18 (54%) out of 34 patients with uterine septum and infertility. Thus, the chances of conception in patients with septate uterus and infertility seem to be similar to those of the general infertile population either with or without septum resection. This may also be an indirect sign that uterine septum is not an infertility factor in itself. However, the treatment has a beneficial effect on pregnancy outcome. In conclusion, it seems that the hysteroscopic septum resection is accompanied by a significant improvement in the reproductive performance of the patients. There is no adverse effect in the achievement of pregnancy in women with a history of recurrent abortions. Septate uterus does not seem to be an infertility factor, although it may contribute to the delayed natural conception of patients with secondary infertility. Patients with septate uterus and infertility should be treated mainly for the improvement of their reproductive performance and not for the enhancement of their fertility potential, especially those treated with various types of assisted reproductive treatment. Acknowledgements The authors would like to thank Mrs Caroline Vergauwe for her assistance in the collection of the data, Mr Frank Winter of the Language Education Centre for correcting the manuscript and Mrs Ann Nys for her secretarial support. References Acien, P. 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