Dr Sarmad Khunda.pdf

Reproductive Performance after Repair ofMullerianSystem Anomalies.Prof. SarmadS. KhundaFRCOG FRCS (Ed)Sabuh k. AL OmariCABOG

merican Fertility Society Classification of Mullerian AnomaliesV. SeptateVI. ArcuateVII DES drug relatednsive standarized classification of Mullerian anomalies is of undeniae. Accurate classification is onlyacheivable by using laparoscontary HSG to distinguish septate frombicornute uteri and in the non comdiffreniate didelphus from unicornute uterus. The task of Mullerianion was adequately undertaken by a committe formed by AFS and thehich were apprroved by it and by the Society of Reproductive Surgeons ay corresponding editorial to accommodate any possible additional anomal

week mullerian ducts first appear as longitudinal invaganatiic epithelium.week mullerian ductsch each other and fuse ine, fusion is a matter ofal proximity and similarityhelia.week uterovaginal septumars in caudocrainialn.

n 10 and 13 week the sinovaginal bulbs form extending between tnd urogenital sinus obliterating vaginal lumen by vaginal plate.18- 20 weeks the plate begins tobreak down forming vaginal lumill be completely canalized by 222 weeks.eek the cervix is identified asf condensation of stromal cellsecific site around the fusedan ducts, its canalization is theevelopmental event in genitalrmation and may be completedally.

Origin of vaginal epitheliumepithelium represents a fluent transition between mullerian and sinm and this has led us to adopt a dynamic concept about the developmenof vaginal epithelium in which we think that mullerian contribution is ant in parallel with this hypothesis were our observations of the age differof Botryoides Sarcoma tumours which we encountered in the lower partal infancy withble ascend in the vagina reachingchildhood and to be confined toer women thus marking thean contribution to theginal canal from which theye.

• Arrest of mullerian development prior to the 5 th week resultsuterine and vaginal hypoplasia.• Failure of sinovaginal bulb development results in vaginalatresia with a small vaginal pouch originating from the mullerianductLack of fusion of mullerian duct in a localized area explainsifferent types of duplications of the uterus.

logyan anomalies are abundant because of the increasing numberof thntial errors, complex interactions are necessary for the developman derivatives and the relative lengthy duration needed to compl.

are the possible triggers?ssibility of rare recessive trait suggestedm the reported sibship and pedigreedies.appropriate production of mulleriangression factor in female embryonicnad.gional absence or deficiency of estrogenceptor limited to the site of anomaly.utero exposure of progestationalagentth intrinsic androgenic activitymaypede mullerian duct fusion.ascular accident proposed tonicornute uterus with contralateralbsence.explainovarian

The presentation ofuterine anomaliestilitytion and Preterm labour.ertrical complications.regardingg fertility.

Types of Fusional Repairpe Year Technical principlege 1884 Blindtranscervical septal excisionassmann 1907 Transverse fundal incisiones 1953 Wedge resection technique

Types of Fusional RepairTompkins 1962Median bivalving septal technique

hdad 1982 Neat septal excision

study performed by Duan et al (2005) [18] revealed that:mount of the endometrium glands on septum was less than that on the uendometrium un-synchronous growth between septum and uterinepositive index level of estrogen andprogestogen receptors on septum whan that on uterine wall.nsities of the smooth muscle cells were thicker, and the collagenous fit the base and the middle of the septum compared with the uterine wallount of the small arteries in septumwere rarer than in uterine wall.cture characters showed glandular epithelium cells distributed irregularon septum in the sterility patients.”concluded that the differences in pathological morphology and the ultrseptum and the uterine wall explainthe infertility or sterility cases relaof uterine septum. [18 ]

uoting the comment on “Uteroplasty” edited by John Srogress in Obstetrics and Gynaecology” Volume 8:eptate uterus is repaired by coronal fundal incision to diptum under vision (Strassamann).natively the septum may beexcised (Jones and Jones 1kins 1962, Khunda and Al-Juburi 1988)

s to ponder about the selection of type ofmetroplasty:-1- Uterine shapeSeptateBicornuate2- Size of the cavities concerned.3- Thickness and depth of the septum.sterosalpingogram finding should be att in 2 views 3 minutes apart to minimizeeffect of uterine contractions.

BEFOREAFTER

BEFOREAFTER

BEFOREAFTER

BEFOREAFTER

Post Metroplastic Synaechae and Ballooning

Severe Anomalies with acceptable performance

Reproductive Performanceafter Selective MetroplastyfonannnsednsdNo. ofNo. of No. of No. ofprimarily Total no. patients who patients patients withinfertile of lost pregnanciesinwith successfulwho patientsprimaryabortion orpregnanc-iesfailed to preterm infertilityconceive000111287647labour11875441001300200No. ofpatientsconceiving afteroperation965439No. ofpatientscontinuing toabort01111No ofpatientswho hadsecondaryinfertility21105Npriinwcon

Indications for hysteroscopy in septet uterus:Danielle Assaferative hysteroscopy is formally indicated in pregnancy complications such as second-trimesteregnancy loss, or preterm delivery. A possible indication would be the case of recurrent first-trimestontaneous abortion. But, using hysteroscopy as a preventative treatment before In-Vitro Fertilizatioontroversial indication with contradictory results. [20, 21, 22].wever, hysteroscopic metroplasty is contraindicated in the presence of pregnancy, in genitourinaryections, in contraindications to anesthesia, and is also contraindicated in the case of bicornuate utee to the possibility of uterine perforation, since ina bicornuate uterus the external uterine contour isncave or heart shaped, and the uterine horns are widely divergent.e Strassman abdominal metroplasty is the operation of choice destined to treat the bicornuate uteru] or uterus didelphys. [ 24 ]e MR imaging diagnostic criteria for bicornuate uterus are as follows

Divergent uterine horns with an inter cornual distance > 4cm) Concavity of the fundalntourOr, an external fundal cleft >1 cm deep.g 6. Bicornuate Uterus (Adapted from www.geocities.com)e-Operative Periode pre-operative work up is important and includes hysterography, diagnostic hysteroscopy, and pelnography. Vaginal sonography with accentuated contrasts may be added.ese exams should confirm that the patient has a septate uterus and not a bicornuate uterus, and checr the presence of other infertility factors such as myomas, endometriosis,….

wroth F (2006) [25] reported the presence of a higher incidence of endometriosis reaching 25.8% itients with septate uteri.ring sonography, it is essential to measure the thickness of the uterine septum, its height and the dethe healthy myometrium above the septum up to the serosa. If the ultrasound reveals a groove in thrner facing the posterior surface of the bladder between the two half uteri, the malformation isgnosed as bicornuate uterus. Fig 7 . Classification criteria for Ultrasound differentiation of sepm bicornuate uteri:* A When apex (3) of the fundal external contour occurs below a straight line between theTubal ostia (1, 2) or,* B 5 mm (arrow) above it, the uterus is bicornuate.* C When apex is more than 5 mm (arrow) above the line, uterus is septate.

Patients Pregnancies Ectopics Abortions Preterm Term L(+Ongoing)Delivery Delivery BN n n%n% n% n% ny (1986)a 72 67 (+3) 0 11.9% 1.5% 85.6% 85.86)a 19 16 0 12.5% 0% 87.5% 87.arra(1986)a 12 10 (+3) 0 20.0% 20.0% 60.0% 80rael(1987)a 66 56 (+7) 0 14.3% 7.1% 78.6% 85l(1987)a 24 11 (+5) 0 9.1% 0% 90.9% 901989)a 66 84 (+4) 0 20.2% 6.0% 73.8% 77ggish(1992) 14 12 (+3) 0 8.3% 8.3% 83.4% 83.l(1993) 66 66 0 15.2% 15.2% 68.2% 83.et al(1998) 42 44 2.3% 25.0% 4.5% 68.8% NMal(2003)b 31 27 0 44.4% 11.1% 44.4% 55lmaz(2003)c 361 180 0 16.0% 18.8% 57.2% 75t al (2004)d 61 25 0 28.0% 20.0% 52.0% 72al(2006)e 10 8 12.5% 50.0% 12.5% 25.0% N

Short study2008-2011te : charts of 26 patients lost during2003- 2006 due to war eventstients who presented with bicornuate Uterus and operative treatment was offered (ivate patients)total number of patients consulted 43patients operated upon 28total previous miscarriages 69operations preformed 28-6 strassman21 tompkins1 hemi hysterectomy for uncanalized hornpost operative abortions 2 tompkinsStrassman

20 pregnancy: Alive birth 18Ongoing 2Infertility 2Associated factorsaiting pregnancyaiting pregnancytompkins – no pregnancyStrassman – no pregnancy1 myomectomy + Strassman1 previous hysteroscopy resection- Tompkins1 tompkins+ +myomectomy refered to IVF1 badly damaged tubes – strassman refered to IV

Overall fetal salvage before and after MetropNumber ofPregnanciesBefore MetroplastyNumberofViableiufautsFetalsurvivalrate%Number ofpregnanciesAfter MetroplastyNumber ofviableInfansSur270 20.744 % 100 94 9Note: Eleven patients had cervicalbefore the repair and no viable probtained. None of the patients neededafter the repair.

Pre and Post-Surgical fetal survival rate of different studiesReporter (s) Year No. ofcasesPreoperativefetal survivalPostoperativefetal survivalrateStrassmann 1966 262 % 85 %Capraro V. J. et. al. 1968 1421 % 82 %Buttram V.C. et. al. 1974 2819.5 % 87.5 %Zourias P. A. 1975 1331.4 % 73.7 %Rock J.A. et. al. 1977 433 % 70 %Kusuda M. 1982 320 % 92.6 %Heinonen 1982 182 10 % 88 %Kesseir 1986 1714.3 % 85.2 %Khunda 2000 820.74 % 94 %

Lower Mullerian Atresia

Cervical Atresia in literatureYear Author Surgical Procedure1900 Ludwing Hysterotomy and Uterovaginal fistulacreated by trocar1939 Duyzings Hysterotomy and drain insertion intothe vagina.1939 Engelhens Cervix excised; Hysterotomy sitesutured to vaginal vault.1958 Zarou Uterovaginal fistula through atreticcervix using stent, subsequent termpregnancy1986 Cukier Constructed a splint with splitthickness graft into neocervical canal1998 Khunda Laparoscopically guided selectivecervicaldimple probing.

Totalnumberofpatients16Karyotype46xxfemalePatients and PresentationAge14-17yearsSite ofmullerianobstructionVagina 11otherAnomalies2 renalagensis1 ovarianagensis1 occularanomalyCervix 5 nonePresentationsPrimaryAmenorrheaPrimaryAmenorrheaInfertilityDysparunia

Vaginagram

Surgical Technique

16 LowerMullerian Atresia14 Normal menstruation2 hysterectomies9 Vaginal atresia 5 Cervical atresia6 no sex activity 3 married4 married1 no sex activity3 no pregnancy 1 tenm pregnancy3 term pregnancies

Zarou (1973)enhanced epithelialization of creatostium by using indwelling polyethelene stent, achfirst reported pregnancy.Cukier (1986) used split thickness graft withinendocervical canal.Khunda (1998) selective probing of cervical dimpwhich is invariably present, achieved second reportpregnancy.Hysterectomy reserved for cases with lower mulleratresia combined with other uterine anomalies.