P.O. Number Terms Rep Ship Via F.O.B. Project Quantity Item Code Description Price Each Amount Konjenital Uterus Anomalileri (Güncel Yaklaşım) Dr. Engin Oral İ.Ü. Cerrahpaşa Tıp Fakültesi Kadın Hastalıkları ve Doğum Anabilim Dalı ReprodüktifEndokrinoloji Bilim Dalı Total

Konjenital Uterus anomalileri Sıklığı nedir Sorular İnfertilite yapar mı Düşük (spontan, tekrarlayan) yapar mı Diğer sistem anomalileri beraberinde olur mu Tanı için hangi yöntemler kullanılmalı Ne zaman cerrahi yapılmalı Cerrahi tedavi hangi anomalilerde ne kadar başarılı Sağlıklı bebek olma ihtimali nedir

Saravelos SH, 2008

Out of 21.961 deliveries 116(0.45%) were in women with uterine anomalies: Septate uterus 37.1% Uterus didelphys 24.2% Bicornuate uterus 10.3% Unicornuate uterus 12.9% Arcuate uterus 15.5% Yan Z, 2010

Endometriozis Amenore İnfertilite

% 15-30 % 10-15 % 10-15

Tanı HSG USG TA, TV, Doppler SİS(Sonohisterografi) 2D-3D MRI H/S ve L/S (Altın standart)

Konjenital uterin anomaliler (Sınıflama) American Fertility Society Classification, 1988

AGENESIS/HYPOPLASIA On USG/MRI: Hematocolpos, rudimentary, absent uterus can be identified.

Müllerian Agenezi (Mayer- Rokitansky-Küster- Hauser Sendromu) Normal ssk, normal external genitalia Uterusve Fallopiantüplerin yokluğu, Vajeninhipoplazisi 46 XX Renalve iskelet anomalileri Primer Amenore Cerrahpasa deneyimi 80 olgu Mullerian agenezi 25 (31.2)

Uterus Unicornus A. Rudimenter horn var (%65) 1) Endometrial kavite var (%32) a) Kommunikan (%10) b) Non-kommunikan (%22) 2) Endometrial kavite yok (%33) B. Rudimenter horn yok (%35) Rudimenter horn da gebelik: % 13 % 40 ipsilateral renal agenezi

UNICORNUATE UTERUS HSG: banana shaped lat flexed cavity, if noncom. rudimentary cavity exists, can t be seen USG: It may easily be overlooked Small ut w ellipsoid fundal shape. Rud. Horn w.o cavity may be mistaken as fibroid in broad lig.

UNICORNUATE UTERUS Main etiologies explaining poor obstetrical outcomes: Small cavity Diminished muscle mass Abnormal uterine blood flow Cervical incompetence Management Expectant management Cervical lenght measurement Cervical suturing in selected cases Remove rudimentary horn if present Reichman D, 2009

Bikornuat Uterus Fundusa doğru birbirinden uzaklaşan endometrial kaviteler Aradaki doku muskuler, myometrium ekosunda değil Fundal notch derinliği >1cm

BICORNUATE UTERUS Obstetrical outcomes are reported to be better than unicornuate uterus. Cervical cerclage is often recommended, although there is no good evidence to support it.

UterusDidelfis HSG: Clearly shows but if either cavities cannot be detected mistaken as unicornuate

USG: Two widely spaced fundi, deep cleft separating two cavities

Resection of the vaginal septum using unipolar coagulation.

Arcuat uterus İnkomplet septum Komplet septum

USG/ Uterus Septum Uterus dış konturu genelde konveks ya da düz Bazen fundal konkavite (<1cm) Endometrial ekonun hipoekoik bir alan ile ikiye bölünmesi )fundus İnce, fibroz doku USG de ekojenik endometral kaviteler fundal kesimde myometriumun ekojenitesi ile ayrılmıştır.

BİKORNİS - SEPTUM

L/S MRI Sonohysterography Hysteroscopy

Septum infertilite yapar mı? Fertilve infertil populasyonda benzer prevelans İnfertil septumluolgularda izah edilemeyen infertilite sıklığı, genel infertil populasyondan farklı değil (Grimbizis et al. Hum Reprod 13: 1188-93, 1998)

Reproductive outcome after hysteroscopic metroplasty in infertility % 11.5 61 patients with septate uterus and otherwise unexplained infertility Recai Pabuccu and Victor Gomel, 2004

Hysteroscopic resection of the septum improves the pregnancy rate of women with unexplained infertility: a prospective controlled trial Surgery Antonio Mollo, 2008

RANDOMİZE ÇALIŞMALAR: Septum-İnfertilite 1 2 3 4 5 6 (Tedavi vs. Bekleme)

Histeroskopi Deneyim sınıflandırılması 1.seviye Diagnostik histeroskopi Biopsi Polipektomi RİA cıkartılması 2.seviye Pedinküle myom çıkarılması Basit adezyolizis Fallop tübü kanalizasyonu 3.seviye Septum rezeksiyonu Major adezyolizis Transservikal myom rezeksiyonu Endometrial rezeksiyon RCOG

When shouldwe operate uterin terine septum? CUT IT or SEE IT Tekrarlayan gebelik kayıpları Düşükler 1 Düşük 2 Düşük 3 Düşük Erken doğum İnfertilite Primer Sekonder ART Öncesinde Başarısız denemeler sonrası Asemptomatik/primer dismenore

Septum surgery-clinical pearls timing of surgery Use of Misoprostol use of gonadotropin-releasing hormone (GnRH) agonist or agents such as danazol before surgery scissors, resectoscopic incision, laser metroplasty, and bipolar needle electrodes. Laparoscope (To differentiate accurately between a septate and a bicornuate uterus, To monitor hysteroscopic surgery (Perforation) Septum removal or incision End point Complet servical septum (use pediatric Foley and methylene blue in one of the cavities) fluid input and output Intravenous antibiotics balloon catheters or occasionally inert intrauterine devices (IUDs) Estrogen, routine antibiotic reevaluated with HSG or hysteroscopy there is no reason to delay attempts at pregnancy for >2 cycles

Intrauterine device or estrogen treatment after hysteroscopic uterine septum resection E A Tonguc, T Var, N Yilmaz, S Batioglu. IJOG; 109 (2010) 226 229 100 olgu,4 grup NeIUD uygulama, neestrogen tedavisi, ne de her ikisi intrauterin adezyonları önlemede ya da gebeliği arttırmada etkin değil

Preoperative preparation of the endometrium Progestins Danazol GnRH analogs OC Wide septa Complete septa

Teknik Mekanik (makas) Elektrocerrahi: Resektoskop (Monopolar), Versapoint (bipolar) Fiberoptik laser:argon-krypton(ktp532), Nd:YAG, Argon

Septum resection

Nerede durmalı? v Histeroskop kavitede serbestçe gezdirilebilince ve her iki tubal ostium aynı anda görünür hale gelince işleme son verilir. v Laparoskopi de yapılıyorsa fundusta ışığın görülmesi yeterli rezeksiyonu ifade eder. v Myometrium kanamaya başlayınca işleme son verilir. v Kalan septum 1 cm den küçükse fertiliteyi etkilemez. v Fundusun aşırı inceltilmesi gebelikte rüptür olasılığını arttırır.

Resectoscope or Versapoint for hysteroscopic metroplasty N:63 It could be used predominantly in nulligravida women, especially in those with cervical canal stenosis Pietro Litta, 2008

Complete Septate Uterus: Should the Cervical Septum Be Removed? The incidence of cervical incompetence after removal of the complete septum is rare. Possibly impeding vaginal delivery in a subsequent pregnancy.

Hysteroscopic metroplasty of the complete uterine septum, duplicate cervix, and vaginal septum n: 28 s Mohammad Ebrahim Parsanezhad, 2006

Complications q Wide septumcan cause more intraoperative bleeding.to decrease bleeding: Preoperative GnRH analogue ordanazol. Servical vasopressin. Fundal vasopressin injection. thinning technique for thick septa qif bleeding persists, the application of a Foley catheter balloon is needed for 6 hours to the cavity. q Peroperativeperforation q Liquid loading q Infection q Rupture during pregnancy and complications associated with placenta q Intrauterine syneshia(regardless of techniques)

Uterine malformation: diagnosis and results after hysteroscopic metroplasty 114 patients with uterine septa Septum size was evaluated septa consisting ¼ of the uterus (n=10) septa consisting ½ of the uterus (n=18) septa consisting greater than½ of the uterus (n=86) Istre et al, Fertil Steril 2010

Women with a septum occupying more than ½ of the uterine cavity have a very high chance of successful pregnancy after metroplasty Istre et al, Fertil Steril 2010

Finally, IVF is less successful in women with a septateuterus compared with women who have undergone metroplasty. For this reason, hysteroscopicmetroplastyshouldbe considered in women before undergoing IVF, an emotionallyand financiallyexpensiveprocedure However, women with a septateuterus and otherwise unexplained infertility may benefit from metroplasty, althoughthe improvement in pregnancy rate is relatively modestin comparison with those who experienced recurrentpregnancyloss Elizabeth Taylor and Victor Gomel, 2008

Uterine rupture at the 29th week of subsequent pregnancy after hysteroscopic resection of uterine septum Şatıroğlu MH, 2009

Most of studies report an increase in adverse reproductive outcomes, mostly second trimester loss. Tulandi et al., 1980; Acien, 1993; Raga et al., 1997; Woelfer et al., 2001, Zlopasa, 2009.

Arkuat uterus, fundan indentasyon < 10 mm

Inkomplet Uterin septum-ivf öncesi rutin düzeltilmelimi? 119 inkomplet septum olan hasta H/S insizyon uygulamış. H/S sonrası IVF sonuçları kontrol grubu ile benzer. Ancak inkomplet septum olgularda abortus oranları ve başarısız IVF siklus oranları daha fazla saptanmış Özgür K, 2007

DES HSG: Perfect imaging modality Hypoplasic uterus, constriction bands T configuration Bulbous lower ut segment