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Assisted Reproduction and Infertility
between septate uterus and spontaneous miscarriages and/or hyperstimulation syndrome (OHSS) and multiple pregnancies with
Hysteroscopic metroplasty dramatically neonatal complications.
improves the pregnancy outcome, decreasing the abortion rate and
increasing term deliveries.
Successful surgery offers the couple multiple cycles in which to
achieve conception naturally and the opportunity to have more than
Only a few authors consider uterine septum to be an independent one pregnancy after a single surgical intervention.
factor of infertility. Nawroth observed an increased interval of
pregnancy seeking in patients with septa with otherwise unexplained Infertility work-up and diagnosis requires an endoscopic exploration.
primary and secondary infertility.
Hysteroscopic metroplasty has a Where and when it should be performed must be decided according
positive effect on spontaneous conception and pregnancy outcome in to the couple involved, the duration of infertility and the age of
this kind of patient.
Although uterine septum is not an absolute the patient.
sterility factor, congenital anomalies of the uterus can affect
endometrial receptivity, resulting in implantation failure with pregnancy During diagnostic laparoscopy, possible operative corrections can be
loss or infertility.
These anomalies can be the reason for prolonged performed in cases of pelvic pathology. If the patient is not pregnant
pregnancy seeking in women with so-called ‘idiopathic infertility’. after six to eight months and in the absence of male subfertility, a
repeat surgery or IVF cycle can be considered.
In one study, Homer et al.
compared the reproductive outcome
before and after hysteroscopic metroplasty, resulting in a The transvaginal approach offers the possibility of performing
decrease in abortion rate from 88% before to 14% after metroplasty a hysteroscopic and laparoscopic exploration in a ambulatory
and an increase in live birth rate from 3% before to 80% ‘one-stop’ fertility setting.
after. Although the role of metroplasty in infertility remains
controversial, this study reported an overall crude pregnancy rate The systematic liberal referral to IVF programmes holds a potential
of 48% after metroplasty. danger in that it results in a lack of expertise and that at the
time of diagnostic laparoscopy the skills for adequate surgery are
IVF has been reported to be less successful in women with a septate not available.
uterus compared with women who have undergone metroplasty.
According to Heinonen,
the confirmation of these data in a Specific training programmes in reproductive surgery should be
population of sterile couples will also prove the need for such an promoted and must become part of education for all those involved
approach before ART is performed in sterile couples. in reproductive medicine. These programmes are, except for the basic
techniques, different from other surgical endoscopic training
As hysteroscopy greatly simplified the management of intra-uterine programmes in that in the case of reproductive surgery it is of utmost
pathology, nowadays hysteroscopic metroplasty is the standard importance to restore normal anatomy and to conserve the potential
surgical procedure. Congenital anomalies and acquired uterine for further reproduction. IVF should not become an alibi for
pathology may negatively interfere with embryo implantation. inadequate surgery. ■
Therefore, hysteroscopic surgery with correction of uterine septa,
intrauterine synechiae and myomas that distort the uterine cavity
Stephan Gordts is Scientific Director of the Leuven
may benefit women with infertility or recurrent pregnancy loss.
Institute for Fertility and Embryology (LIFE), which he
founded in 1984. His main clinical interest and his career
focus is reproductive medicine, and he is an expert in
microsurgical interventions and operative laparoscopies.
Surgery and ART are not competing treatment options but
Dr Gordts has always been interested in minimally
complementary treatment options. Their approach is different: invasive techniques and in 1998 he pioneered the
surgery tries to resolve the problem by meticulous restoration of a
technique of transvaginal laparoscopy and the concept of
the ‘one-stop’ fertility clinic. As clinician in charge of the in
quasi normal fecundity whereever it is possible, while in case of
vitro fertilisation (IVF) program he was closely involved in the birth of the first IVF baby in
ART the problem is bypassed. The statement that “infertility Belgium, born in May 1983. Dr Gordts has served as co-ordinator of the European Society
surgery is dead”
does not take into consideration the
of Human Reproduction and Embryology (ESHRE) special interest group on reproductive
surgery and is a member of many fertility societies. He is reviewer for several
advantages of a spontaneous conception and the disadvantages
international journals and has published many papers in peer-reviewed journals.
of treatments with ART, such as complications of ovarian
1. Kelly SM, Sladkevicius P, Campbell S, Nargund G, evaluationfollowing failure to achieve pregnancy after 9. Watrelot A, Dreyfus JM, Andine JP, Evaluation of the
Investigation of the infertile couple: a one stop ultrasound ovulation induction with clomiphenecitrate, Fertil Steril, performance of fertililoscopy in 160 consecutive infertile
based approach, Hum Reprod, 2001;16:2481–4. 2003;80:1450–53. patients with no obvious pathology, Hum Reprod, 1999;14:
2. Gordts S, Campo R, Puttemans P, et al., Investigation of 6. Oliveira FG, Abdelmassih VG, Diamond MP, et al., Uterine 707–11.
the infertile couple: a one-stop outpatient cavity findings and hysteroscopic interventions in patients 10. Tetering EAA, Bongers MY, Wiegerinck MAHM, et al.,
endoscopy-based approach, Hum Reprod, 2002;17:1684–7. undergoing in vitro fertilization-embryo transfer who Prognostic capacity of transvaginal hydrolaparoscopy to
3. Bosteels J, Van Herendael B, Weyers S, The position of repeatedly cannot conceive, Fertil Steril, 2003;80:1371–5. predict spontaneous pregnancy, Hum Reprod, 2007;22:
diagnostic laparoscopyin current fertility practice, Hum 7. Gordts S, Campo R, Rombauts L, Brosens I, Transvaginal 1091–4.
Reprod Update, 2007;13:477–85. hydrolaparoscopy as an outpatient procedure for 11. Adamson GD, Treatment of endometriosis-associated
4. Tanahatoe S, Lambalk C, McDonell J, et al., Diagnostic infertility investigation, Hum Reprod, 1998;13:99–103. infertility, Semin Reprod Endocrinol, 1997;15:263–71.
laparoscopy is needed afterabnormal 8. Campo R, Molinas R, Rombauts L, et al., Prospective 12. Akande VA, Hunt LP, Cahill DJ, Jenkins JM, Differences in
hysterosalpingography toprevent over-treatment with IVF, multicentre randomized controlled trial to evaluate factors time to natural conception between women with
RBM Online, 2008;16:410–15. influencing the success rate of office diagnostic unexplained infertility and infertile women with minor
5. Capelo FO, Kumar A, Steinkampf MP, Azziz R, Laparoscopic hysteroscopy, Hum Reprod, 2005;20:258–63. endometriosis, Hum Reprod, 2004;19:96–103.
24 EUROPEAN OBSTETRICS & GYNAECOLOGY
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