Re: Laproscopic metroplasty in bicornuate and didelphic uteri

5 08 2009

To the Editor:

Alborzi et al. (1) described the technique of laparoscopic metroplasty for didelphic uteri and bicornuate uteri. The indication for the metroplasty is history of recurrent spontaneous abortions in less than 5 months of pregnancy. Three months after metroplasty, they did laparoscopic and hysterscopic examination. The laproscopic examination of the pelvic cavity revealed filmy adhesions of the uterus to the omentum; the hysteroscopy revealed spacious uniform cavity. They also found a sub-septum at the fundus of the unified uteri.

The authors also concluded that laproscopic metroplasty is an acceptable alternative for abdominal metroplasty.

The whole principle of unifying a didelphic uterus or a bicornuate uterus is very debatable and there are no data about the outcome of pregnancy after such unification, except in one case that the authors cited. The situation here is completely different from a septate uterus, where the septum is removed and there are data in the literature to support the validity of this procedure for patients with recurrent miscarriages due to the septate uterus.

In addition, hysterscopic metroplasty for a septate uterus saves patients from an abdominal procedure and a large scar that represents a weak point in the uterus predisposing patients to rupture during pregnancy or delivery.

This unification procedure for a didelphic uterus with a wide gap between uterine horns and for a bicornuate uterus will lead to a very large scar that has not been tested during pregnancy and delivery, and this might not be the answer for patients with recurrent miscarriages due to these two anomalies. The spacious uterine cavity that is created by unification of a didelphic or a bicornuate uterus might not solve the issue of recurrent miscarriages. This situation is different with the uterine septum because the septum has a poor blood supply and poor decidual reaction during pregnancy, and if implantation occurs on the septum it will not receive the same support as the normal uterus. Therefore, the removal of the septum will allow and facilitate the implantation to be in the normal endometrium of the main uterus. I hope the authors would explain why unification in two such anomalies is successful for prevention of recurrent pregnancy losses, especially in that there are no data. Furthermore, it causes a large scar in the uterine wall that might give way during pregnancy or delivery.

Unless we know the etiology of recurrent miscarriages in a didelphic uterus or a bicornuate uterus, it is difficult to recommend unification of such anomalies to cure this pathology.

Shawky Z.A. Badawy, M.D.
Professor and Chairman
Director, Div. of Reproductive and Endocrinology & Infertility
Department of Obstetrics and Gynecology
Upstate Medical University
Syracuse, New York

Reference
1. Alborzi S, Asadi N, Zolghadri J, Alborzi S, Alborzi M. Laparoscopic metroplasty in bicornuate and didelphic uteri. Feril Steril; 2009; 92:352-5.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.08.004

The Authors Respond:

We appreciate the editorial invitation to respond to the letter of Badawy regarding our article (1). Two major concerns have been noted. The first one is reproductive outcome of patients with bicornuate or didelphic uteri, and the second one is production of a large scar which may rupture during pregnancy or delivery.

The mean incidence of bicornuate uterus in müllerian duct anomalies is approximately 25%. This figure for the didelphic uterus is 11%. It seems that patients with bicornuate and didelphic uterus have a poor pregnancy outcome. In patients with bicornuate uterus, the rates of abortion, preterm delivery, and term delivery are 36%, 23%, and 40.6%, respectively, and in those with didelphic uterus, the rates of abortion, preterm delivery, and term delivery are 37%, 16.4%, and 43.3%, respectively (2). Therefore, for a woman with repeated pregnancy losses, surgical intervention may be the only option available.

The percentage of full-term pregnancies with various types of double uteri in an unselected series of women who have not been operated is unknown. It is approximately 25% taking all types together. In patients selected for operation, it probably increases from approximately 5%- 10% to approximately 80%-90% (3). A study by Heinonen in Finland of 182 women with uterine anomalies indicated that pregnancies in the septate uterus had a better fetal survival rate (86%) than they did in the complete bicornuate uterus (50%) or in the unicornuate uterus (40%) (4).

As mentioned in our article, to evaluate uterine compliance, we increased intrauterine pressure up to 150 mm Hg with a continuous positive pressure flow of DW5% and confirmed that the uterine wall could tolerate (1). Lolis and colleagues reported the reproductive outcome of 22 women who underwent the Strassman metroplasty by laparotomy for a bicournuate uterus; 88% achieved pregnancies that ended with the delivery of a viable infant. All were delivered by cesarean section without evidence of scar rupture (5). In fact, two of our four reported patients became pregnant and underwent cesarean section at term without a significant scar and a well-formed uterine cavity. One woman did not have desire for pregnancy at present time and one woman lost to the follow-up.

In conclusion, laparoscopic metroplasty is an acceptable alternative for abdominal metroplasty, which results in a good unified uterine cavity and minimal adhesion formation.

Saeed Alborzi, M.D
Nasrin Asadi, M.D
Jaleh Zolghadri, M.D
Soroosh Alborzi, M.D
Mehrnoosh Alborzi
Division of Infertility and Gynecologic Endoscopy
Department of Obstetrics and Gynecology
Shiraz University of Medical Sciences
Shiraz, Iran

References
1. Alborzi S, Asadi N, Zolghadri J, Alborzi S, Alborzi M. Laparoscopic metroplasty in bicornuate and didelphic uteri. Fertil Steril 2009;92:352-5.

2. 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.

3. Rock JA, Breech LL. Surgery for anomalies of the müllerian ducts. In: Rock JA, Jones Ш HW. Telinde’s Operative Gynecology. Lippincott Williams & Wilkins: Philadelphia. 2008; 539-84.

4. Heinonen PK, Saarikoski S, Pystynen P. Reproductive performance of women with uterine anomalies. Acta Obstet Gynecol Scand 1982;61:157-62

5. Lolis DE, Paschopoulos M, Makrydimas G, Zikopoulos K, Sotiriadis A, Paraskevaidis F. Reproductive outcome after Strassman metroplasty in women with a bicornuate uterus. J Reprod Med 2005;50:297-301.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.08.005

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