Baseline characteristics
As shown in Figure 1, a total of 176 surgical patients were included in this study, and all cases had no complications such as uterine perforation or water intoxication. Among the included cases, 42 patients had a history of recurrent miscarriage (Group A), 60 patients were diagnosed as primary infertility (Group C) before surgery, and a total of 71 patients had a history of secondary infertility. A total of 35 patients underwent secondary surgical exploration, accounting for 19.89% of the all cases. The basic characteristics of the included cases are shown in Table 1. There were no significant differences in age, BMI, reoperation rate, live birth rate, or postoperative adjuvant treatment among the three groups. In Group A, women with complete uterine septum accounted for 21.43%, while in Group C, complete uterine septum accounted for 46.67%, there was a significant difference between the two groups. In the choice of surgical modalities, the numbers of hysteroscopy combined with laparoscopic exploration in the three groups were 6 (14.29%), 36 (48.65%), and 49 (81.67%), respectively, with statistical differences.
Table 1
Basic characteristics of the included patients.
| Total (n=176) | Group A 42 (23.86%) | Group B 74 (42.05%) | Group C 60 (34.09%) | Group Avs.B P value | Group Avs.C P value | Group Bvs.C P value |
Age (mean, SD) | 27.94±3.83 | 28.62±4.07 | 28.16±4.05 | 27.18±3.26 | 0.56 | 0.05 | 0.13 |
BMI (kg/m2) | 21.51±3.02 | 21.84±3.19 | 21.34±2.94 | 21.51±3.02 | 0.39 | 0.59 | 0.74 |
Reoperation n.(%) | 35 (19.89%) | 11 (26.19%) | 11 (14.86%) | 13 (21.67%) | 0.14 | 0.6 | 0.31 |
Endometriosis | | | | | | | |
Yes | 43/91 (47.25%) | 2/6 (33.33%) | 16/36 (44.44%) | 25/49 (51.02%) | 0.95 | 0.7 | 0.55 |
No | 48/91 (52.75%) | 4/6 (66.67%) | 20/36 (55.56%) | 24/49 (48.98%) | | | |
Infertility | | | | | | | |
Primary | 60/131 (45.80%) | / | / | 60 (100%) | / | / | / |
Secondary | 71/131 (54.20%) | 27 (64.29%) | 44 (59.46%) | / | 0.608 | / | / |
Menstruation | | | | | | | |
Irregular | 17 (9.66%) | 7 (16.67%) | 5 (6.76%) | 5 (8.33%) | 0.17 | 0.33 | 0.99 |
Regular | 159 (90.34%) | 35 (83.33%) | 69 (93.24%) | 55 (91.67%) | | | |
Classification | | | | | | | |
Partial septate uterus | 114 (64.77%) | 33 (78.57%) | 49 (66.22%) | 32 (53.33%) | 0.16 | 0.01 | 0.13 |
Complete septate uterus | 62 (35.23%) | 9 (21.43%) | 25 (33.78%) | 28 (46.67%) | | | |
Operation | | | | | | | |
Hysteroscope | 85 (48.30%) | 36 (85.71%) | 38 (51.35%) | 11 (18.33%) | 0 | 0 | 0 |
Hysteroscopy+laparoscopy | 91 (51.70%) | 6 (14.29%) | 36 (48.65%) | 49 (81.67%) | | | |
Adjuvant therapy | | | | | | | |
IUD | 70/117 (59.83%) | 15/31 (48.39%) | 25/43 (58.14%) | 30/43 (69.77%) | 0.41 | 0.06 | 0.26 |
Balloon | 47/117 (40.17%) | 16/31 (51.61%) | 18/43 (41.86%) | 13/43 (30.23%) | | | |
* |
Reproductive Outcomes
The overall pregnancy outcome of the included cases is shown in Table 2: The preoperative pregnancy rate was 65.91%, the postoperative rate was 77.27%; the preoperative spontaneous abortion rate was 46.59%, and the postoperative rate was 17.05%; the preoperative live birth rate was only 7.95%, the postoperative live birth rate reached 67.61%. Although the preterm birth rate increased from 1.70% before surgery to 10.23%, the preterm live birth rate also increased from 1.14–8.52%. According to Table 3, the pregnancy rate, spontaneous abortion rate, premature birth rate, and cesarean section rate of RSA patients (Group A) after hysteroscopic metroplasty were not significantly different from the other two groups, but the live birth rate and term birth rate were significantly lower.
Table 2
Comparison of reproductive outcome before and after hysteroscopic septoplasty
n=176 | Before septum resection | After septum resection | P value | RR | OR |
Pregnant | 116 (65.91%) | 136 (77.27%) | 0.02 | 1.17 | 1.76 |
Spontaneous abortion | 82 (46.59%) | 30 (17.05%) | 0.00 | 0.37 | 0.24 |
Live birth | 14 (7.95%) | 119 (67.61%) | 0.00 | 8.50 | 24.16 |
Term delivery | 13 (7.39%) | 104 (59.09%) | 0.00 | 8.00 | 18.11 |
Preterm birth | 3 (1.70%) | 18 (10.23%) | 0.00 | 6.00 | 6.57 |
Preterm live births | 2 (1.14%) | 15 (8.52%) | 0.00 | 7.50 | 8.11 |
Table 3
Obstetric outcome after hysteroscopic septoplasty in three group
After septum resection | GroupA n=42 | GroupB n=74 | GroupC n=60 | Group Avs.B P value | Group Avs.C P value | Group Bvs.C P value |
Pregnant | 30 (71.43%) | 61 (82.43%) | 45 (75.00%) | 0.17 | 0.69 | 0.29 |
Live birth | 21 (50.00%) | 55 (74.32%) | 43 (71.67%) | 0.01 | 0.03 | 0.73 |
Abortions | 9 (21.43%) | 13 (17.57%) | 8 (13.33%) | 0.61 | 0.28 | 0.50 |
Term delivery | 16 (38.10%) | 52 (70.27%) | 36 (60.00%) | 0.00 | 0.03 | 0.21 |
Preterm births | 7 (16.67%) | 3 (4.05%) | 8 (13.33%) | 0.05 | 0.64 | 0.10 |
Preterm live births | 5 (11.90%) | 3 (4.05%) | 7 (11.67%) | 0.22 | 1.00 | 0.18 |
Cesarean section | 16/23 (69.57%) | 45/55 (81.82%) | 32/44 (72.73%) | 0.23 | 0.79 | 0.28 |
Subgroup Analyses
Table 4 categorizes the fertility status of the included cases before and after surgery according to factors such as age, septum size, endometriosis, surgical methods, and infertility types: the preoperative live birth rate of septate uterus patients younger than 30 years old was only 4.07% (5/123), which was significantly lower than that of patients older than 30 (16.98%, 9/53, p=0.01). But after hysteroscopic uterine septum resection, the live birth rate of patients younger than 30 has a very significant boost, reaching 73.17% (90/123, p=0.02).
Table 4
| | Before septum resection | After septum resection |
| n. | Pregnancy | P | Life birth | P | Abortions | P | Pregnancy | P | Life birth | P | Abortions | P |
Age | | | 0.08 | | 0.01 | | 0.92 | | 0.05 | | 0.02 | | 0.67 |
<30 | 123 | 76(61.79%) | | 5(4.07%) | | 57(46.34%) | | 100(81.30%) | | 90(73.17%) | | 20(16.26%) | |
≥30 | 53 | 40(75.47%) | | 9(16.98%) | | 25(47.17%) | | 36(67.92%) | | 29(54.72%) | | 10(18.87%) | |
Classification | | | 0.02 | | 0.16 | | 0.06 | | 0.06 | | 0.09 | | 0.81 |
Partial septate | 114 | 82(71.93%) | | 12(10.53%) | | 59(51.75%) | | 83(72.81%) | | 72(63.16%) | | 20(17.54%) | |
Complete septate | 62 | 34(54.84%) | | 2(3,23%) | | 23(37.10%) | | 53(85.48%) | | 47(75.81%) | | 10(16.13%) | |
Endometriosis | | | 0.44 | | 0.15 | | 0.49 | | 0.39 | | 0.33 | | 0.84 |
Yes | 43 | 18(41.86%) | | 1(2.33%) | | 9(20.93%) | | 33(76.74%) | | 31(72.09%) | | 6(13.95%) | |
No | 48 | 24(50.00%) | | 6(12.50%) | | 13(27.08%) | | 33(68.75%) | | 30(62.50%) | | 6(12.50%) | |
Operation | | | 0.00 | | 0.89 | | 0.00 | | 0.12 | | 0.87 | | 0.16 |
H | 85 | 74(87.06%) | | 7(8.24%) | | 60(70.59%) | | 70(82.35%) | | 58(68.24%) | | 18(21.18%) | |
H+L | 91 | 42(46.15%) | | 7(7.69%) | | 22(24.18%) | | 66(72.53%) | | 61(67.03%) | | 12(13.19%) | |
Adjuvant therapy | | | 0.10 | | 1.00 | | 0.06 | | 0.44 | | 0.11 | | 0.98 |
IUD | 70 | 40(57.14%) | | 4(5.71%) | | 28(40.00%) | | 59(84.29%) | | 53(75.71%) | | 15(21.43%) | |
Balloon | 47 | 34(72.34%) | | 2(4.26%) | | 27(57.45%) | | 37(78.72%) | | 29(61.70%) | | 10(21.28%) | |
Infertility | | | 0.00 | | 0.00 | | 0.00 | | 0.74 | | 0.24 | | 0.18 |
Primary | 60 | 0(0.00%) | | 0(0.00%) | | 0(0.00%) | | 45(75.00%) | | 43(71.67%) | | 8(13.33%) | |
Secondary | 71 | 71(100.00%) | | 11(15.49%) | | 51(71.83%) | | 55(77.46%) | | 44(61.97%) | | 16(22.54%) | |
Table 5
Case-control study for patients combined with primary infertility or RSA
Primary infertility n=60 | Postoperative pregnancy group (n=45) | Postoperative infertility group (n=15) | P value |
Age (y) | 26.96±3.31 | 27.87±3.11 | 0.35 |
BMI (kg/m2) | 21.69±3.12 | 20.94±2.70 | 0.41 |
Complete septate uterus | 24 (53.33%) | 4 (26.67%) | 0.07 |
Endometriosis | 19 (42.22%) | 6 (40.00%) | 0.88 |
Endometrial polyps | 19 (42.22%) | 4 (26.67%) | 0.28 |
Laparoscope | 37 (82.22%) | 12 (80.00%) | 1.00 |
Reoperation | 10 (22.22%) | 3 (20.00%) | 1.00 |
IUD | 23 (51.11%) | 7 (46.67%) | 0.77 |
Balloon | 11 (24.44%) | 2 (13.33%) | 0.59 |
RSA n=42 | Postoperative live birth group (n=21) | Postoperative Non-live birth group (n=21) | P value |
Pregnancy (n) | 2.57±0.87 | 3.29±1.27 | 0.04 |
Abortions (n) | 2.33±0.66 | 2.71±0.90 | 0.13 |
Age (y) | 28.19±3.33 | 29.05±4.74 | 0.50 |
BMI (kg/m2) | 21.32±2.23 | 22.35±3.91 | 0.30 |
Complete septate uterus | 5 (23.81%) | 4 (19.05%) | 1.00 |
Endometriosis | 2 (9.52%) | 0 (0.00%) | 0.47 |
Endometrial polyps | 3 (14.29%) | 3 (14.29%) | 1.00 |
Laparoscope | 4 (19.05%) | 2 (9.52%) | 0.66 |
Reoperation | 7 (33.33%) | 4 (19.05%) | 0.29 |
IUD | 8 (38.10%) | 7 (33.33%) | 0.75 |
Balloon | 7 (33.33%) | 9 (42.86%) | 0.53 |
For patients with complete uterine septum, the preoperative pregnancy rate was 54.84% (34/62), which was significantly lower than that of patients with partial uterine septum (71.93%, P=0.02). After surgery, the pregnancy rate of patients with complete uterine septum increased to 85.48% (53/63), however, there were no statistical differences compared to the patients with partial uterine septum.
Among the included cases, 85 cases (48.30%) underwent hysteroscopic uterine septum resection, 91 cases (51.70%) underwent hysteroscopy combined with laparoscopy. For patients who underwent only hysteroscopic surgery, the preoperative pregnancy rate and miscarriage rate were both significantly higher than the other group. However there was no statistical difference was observed in the pregnancy rate and miscarriage rate between the two groups after the operation.
Case-control Study
In the 60 patients with primary infertility, 15 were still unsuccessful conceived during the follow-up after the operation, the remaining 45 were successful pregnancy; Early miscarriages occurred in 8 women after the operation, and there were 43 live births, including 7 preterm births and 36 full-term births; The cesarean section rate was 76.74% (33/43). Univariate analysis found that there were no significant differences in age, BMI, septum size, surgical methods, endometriosis, and endometrial polyps between the postoperative pregnancy group and the postoperative infertility group.
Among 42 patients with recurrent miscarriage, the postoperative live birth rate was 50% (21/42), including 5 preterm births and 16 full-term births, and the cesarean section rate was 76.19% (16/21). Early miscarriages occurred in 9 women after surgery. Univariate study found that the number of pre-operative pregnancies in the RSA live birth group was significantly less than that in the RSA non-live birth group (p=0.04). The remaining factors like number of miscarriages, age, BMI, septum size, surgical methods, and endometriosis or endometrial polyps showed no significant differences between the two groups.