BJOG: an International Journal of Obstetrics and Gynaecology

December 2002, Vol. 109, pp. 1331 1334

Reproductive performance after hysteroscopic metroplasty in the

hypoplastic uterus: a study of 29 cases
Emmanuel Barranger, Amelie Gervaise, Severin Doumerc, Herve Fernandez*
Objective To evaluate the reproductive performance after hysteroscopic metroplasty performed for
hypoplastic uterus.
Design Crossover study (15 patients) and descriptive analysis (14 patients).
Setting Tertiary care university hospital.
Population Twenty-nine women (mean age: 31.4 years; range: 27 38.5 years) with a hypoplastic malformed
uterus and a history of primary infertility and/or recurrent abortion and/or preterm delivery were included in
this study. Fourteen women suffered from primary infertility and 15 women had previous pregnancies.
Twenty-three women had been exposed to diethylstilboestrol in utero.
Methods Women underwent hysteroscopic metroplasty between January 1996 and May 1999.
Main outcome measures Rate of pregnancies and live births, anatomical results.
Results The mean follow up was 40 months (range: 13 67 months). Twenty-one women (72.4%) experienced
30 pregnancies. Thirteen women gave birth to 16 live infants. At the time of the follow up, four women were
pregnant in the second trimester. Compared with previous pregnancies, the rate of deliveries increased from
3.8% to 63.2%. No complications occurred during metroplasty. The hysteroscopic anatomical results were
good in all cases.
Conclusions Our results suggest that hysteroscopic metroplasty, with its simplicity and minimal postoperative sequelae, seems to be an operation of choice in women with a hypoplastic malformed uterus and a
history of severe infertility and/or recurrent pregnancy loss.
INTRODUCTION

METHODS

Congenital anomalies of the uterus can be associated with

reproductive failures such as recurrent abortion and preterm
birth1. Infertility has also been linked to uterine anomalies2.
The reported incidence of congenital anomalies range from
0.1% to 0.5% of all deliveries1. The most common forms are
septate, bicornuate and didelphic uterus. A hypoplastic
uterus is a rare uterine malformation, except in exposure to
diethylstilboestrol in utero3. The pathogenesis remains
unclear and its cause is still unknown. Several studies showed
very poor reproductive performances when the uterine malformation was not treated4,5. Reproductive performance after
hysteroscopic metroplasty in women with a hypoplastic
uterus has not been well established, concerning only three
reports6 8, in contrast to women with a septate uterus9.
The aim of this study was to evaluate the influence of
hysteroscopic metroplasty on reproductive performance of
women with a hypoplastic uterus.

Between January 1996 and May 1999, 29 women wishing a pregnancy (mean age: 31.4 years, range: 27 38.5
years) with a hypoplastic malformed uterus were treated by
hysteroscopic metroplasty. The malformation was classified
by hysterosalpingography and hysteroscopy. According to
the American Fertility Society Classification of Mullerian
anomalies10, a hypoplastic uterus (type VII) was defined
when a small cavity was seen in the hysterosalpingogram.
All patients underwent transvaginal ultrasound permitting a
better assessment in the diagnosis of the hypoplastic uterus.
By sagittal ultrasound, the length of the uterus did not
exceed 6 cm. The hysteroscopic findings revealed a cylindrical uterine cavity with a bulging of the uterine side walls
and no possibility to visualise the tubal ostia.
The uterine malformation was coincident with tubal
infertility in six cases, polycystic ovarian syndrome in
two cases and male infertility in one case.
Fourteen women suffered from primary infertility and 15
women had previous pregnancies (Table 1). Of these 29
women, 23 were known to have been exposed to diethylstilboestrol in utero. Among these 23 women, 12 suffered
from primary infertility.
The 15 women with previous pregnancies totalled 26
pregnancies with only one live birth at 29 weeks. The mean
duration of infertility was 27.2 months (range: 12 48

Department of Obstetrics and Gynaecology, Antoine

Becle`re Hospital, Clamart Cedex, France
* Correspondence: Professor H. Fernandez, Department of Obstetrics and
Gynaecology, Antoine Becle`re Hospital, 157 rue de la Porte de Trivaux,
92140 Clamart Cedex, France.
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E. BARRANGER ET AL.

Table 1. Fertility before and after hysteroscopic metroplasty. Values are given as n or n (%).
Women with previous pregnancies (n 15)

No. of pregnancies
No. of pregnant women
Pregnant at the time of follow up
Ectopic pregnancies
Miscarriage before 12 weeks
Miscarriage between 12 and 26 weeks
Death in utero
Legal abortion
Live birth
Term deliveries
Preterm deliveries between 32 and 37 weeks
Preterm deliveries before 32 weeks
a
b

Women with primary infertility (n 14)

Pregnancies before metroplasty

Outcome after metroplasty

Outcome after metroplasty

26

19
12
2 (10.5)
0
5 (26.3)a
0
0
0

11
9
2
1
4
0
0
0

12 (63.2)b
8
4
0

4
4
0
0

3
16
2
2
2

(11.5)
(61.6)
(7.7)
(7.7)
(7.7)

1 (3.8)
0
0
1

P < 0.02.
P < 0.01.

months) for the 29 women and 33.3 months (range: 12 60

months) for the 14 women with primary infertility.
The indication for hysteroscopic metroplasty was a hypoplastic uterus in combination with a history of primary
infertility, recurrent abortion and/or preterm delivery before
30 weeks with or without live birth. Oral informed consent
was obtained from the women before this surgical procedure
was performed. Each woman served as her own control.
Surgery was scheduled to be done early in the follicular
phase. The surgical procedure was performed under general
anaesthesia by a senior surgeon after cervical dilatation, with
an operative hysteroscope (n 27), fitted with a monopolar
hook (Resectoscope 26 F, optical lens 2.9 mm, Ref.
260020FA; Iglesiass jacket, Ref. 26055 SL; monopolar
hook, Ref. 26055 L, Karl Storz, Tuttlingen, Germany). The
mean pre-operative hysterometry was 5.8 cm (range: 5
7 cm). The uterine cavity was distended using a glycocole
solution (Glycocolle 1.5%, Aguettant Laboratory, Lyon,
France), the flow of which was controlled electronically.
In two cases, we used the Versapoint bipolar vaporisation
system (Gynecare Laboratory, Issy-Les-Moulineaux,
France), effective in saline solution, through the 5F operating channel of a 5.5-mm hysteroscope, as previously
described by Fernandez et al.11 The hook was introduced
into the uterine horn and the incision was performed under
direct vision from the fundus to the isthmus, perpendicularly
to the lateral wall of the uterus and decreasing the depth of
the incision as the section advanced. The identical incision
was repeated on the other lateral wall of the uterus. This
procedure allowed the formation of a normal uterine triangular and symmetric cavity. The depth of incision did not
exceed 5 to 7 mm. A single intravenous dose of an antibiotic
(Ampicillin) was given during the surgical procedure. All
women were discharged on the day of surgery with postoperative medication including sequential oestroprogestative
medication for two months (50 Ag of ethinyloestradiol and
2.5 mg lynestrol; Ovanon, Organon Laboratory, Saint-Denis,

France). In all cases, diagnostic hysteroscopy was repeated

two months post-operatively to identify a marginal synechia
and to evaluate the configuration of the uterine cavity. The
criteria for second procedure was the presence of synechia
observed during the diagnostic hysteroscopy. Two women
have had a second procedure to achieve the metroplasty two
and six months after the initial procedure. To assess reproductive performance, the women were asked by phone to
complete a health history questionnaire. This questionnaire
concerned post-operative complications and pregnancies
including their number, results (live birth, legal abortion,
miscarriage and ectopic pregnancy), gestional age at delivery, mode of delivery and the use of assisted reproductive
techniques. For women requiring a second metroplasty,
follow up dates are derived from the time of the second
procedure.
Survival analysis using the Kaplan Meier estimator
was performed to calculate cumulative pregnancy rate.
According to the fertility studies, we studied the first
pregnancy after the surgical procedure, regardless of its
implantation, and also the first normally intrauterine pregnancy. Statistical analyses were performed using the m2
test. For all statistical analyses, Statview Version 4.57
Software (Abacus Concepts, Berkeley, California) was
used, and differences at P < 0.05 were considered statistically significant.

RESULTS
Subsequent fertility outcome was evaluated in all
women. The mean follow up was 40 months (range: 13
67 months). Three women (10.3%) without diethylstilboestrol in utero exposure, who initially wanted to become
pregnant, had no longer any pregnancy desire after the
surgical procedure (two women with previous pregnancies
and one with primary infertility). Figure 1 illustrates the
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HYSTEROSCOPIC METROPLASTY IN THE HYPOLASTIC UTERUS

1333

Fig. 1. Cumulative rate of first pregnancies and live birth after hysteroscopic metroplasty.

distribution of the first pregnancies and live birth over the

time after the surgical procedure.
Twenty-one women (72.4%) experienced 30 pregnancies
after metroplasty (Table 1). Twelve of these were in cases
of secondary infertility and 12 became pregnant without the
use of assisted reproductive techniques. The mean time
before the first conception was 14.6 months (range: 2 41
months ) after the metroplasty.
Nine women with primary infertility experienced 11
pregnancies, leading to four live born babies. These pregnancies were spontaneous except in six cases, four after
in vitro fertilisation and two after intrauterine insemination.
Of the 26 women wishing a pregnancy, 13 (50%) gave
birth to 16 live infants, conceived spontaneously in nine
cases (three women had given birth to two children). Nine of
them delivered 12 viable term neonates, requiring six
caesarean sections for five women. The modality of term
pregnancy deliveries was caesarean section in 50% of the
cases. At the time of the follow up, four women were
pregnant in the second trimester. Compared with previous
pregnancies, the rate of deliveries increased from 3.8% to
63.2% ( P < 0.01) and the abortion rate decreased from
61.6% to 26.3% ( P < 0.02). The neonatal courses were
good in all cases. The mean birthweight was 3.196 kg
(range: 2.100 4.170 kg).
Among 23 women exposed to diethylstilboestrol in utero,
17 experienced 26 pregnancies after the surgical procedure,
leading to 13 live born babies.
Hysteroscopic anatomical results were good in all cases.
No complications occurred during metroplasty. None of the
women needed readmission. In two cases, a Stage I intrauterine adhesion (according to the Classification of the
D RCOG 2002 Br J Obstet Gynaecol 109, pp. 1331 1334

American Fertility Society10) was observed after metroplasty and was easily lysed at two months (time of control
diagnostic hysteroscopy for all women). The first patient
who had a synechia experienced two pregnancies eight
months after the hysteroscopic metroplasty (one pregnancy
ended in miscarriage and one ended in preterm delivery).
The second patient did not want to become pregnant.

DISCUSSION
Different methods and instruments for the hysteroscopic
metroplasty have been used, including scissors6 and a
resectoscope with a monopolar hook7,8. The choice of the
technique seems to depend on operating time, cost of
instrumentation and rate of complication. For two more
recent cases, we used the Versapoint bipolar electrode
system, which seems to have multiple benefits. In contrast
with the bipolar electrosurgical system, the normal saline
used has ion concentrations similar to human plasma and
may reduce electrolyte changes and hyponatraemia. A
second advantage is that cervical dilatation is not
required11, decreasing the risk of cervical incompetence.
In the case of uterine dysmorphism, infertility and
obstetric complications are believed to be more common
compared with those with a normal uterine cavity12.
Our results are encouraging in terms of fertility. Twentyone women (72.4%) became pregnant after the metroplasty.
Thirteen women gave birth to 16 live infants. Nine of them
delivered 12 viable term neonates. Among these 13 women,
one woman with primary infertility gave birth to two live
infants. These results are in accordance with other studies

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E. BARRANGER ET AL.

using hysteroscopic metroplasty6 8. To the best of our

knowledge, this is the largest series to date (with the longest
follow up) which details the reproductive performance of
patients with hypoplastic uterus after hysteroscopic metroplasty. Nagel and Malo6 published the first study of eight
women with a history of recurrent pregnancy loss. Their
results showed a successful outcome of term deliveries in
three out of six women with recurrent miscarriages, and no
success in two women with primary infertility. In the same
way, Katz et al.7 published a study concerning eight women
with a T-shaped uterus. The post-operative performance
available for seven of the eight women showed four term
pregnancies and one ectopic pregnancy in three women with
secondary infertility. The more recent series concerning
24 women showed that 10 women had 12 intrauterine
pregnancies (10 term deliveries, 1 preterm delivery and
1 miscarriage before 12 weeks)8. Among these women,
three with primary infertility gave birth to three live infants.
These results suggest that an improved uterine contour may
result in an improved pregnancy outcome and term deliveries in women with prior spontaneous pregnancy losses or
primary infertility.
Homer et al.13 reviewed the literature on the reproductive performance of septate uterus after hysteroscopic
metroplasty. The overall results concerning a total of 658
patients show an impressive improvement after hysteroscopy. Data obtained from retrospective series suggest that
the hysteroscopic metroplasty for the septate uterus is
associated with a favourable outcome. Evaluation of the
efficacy of hysteroscopic metroplasty for the hypoplastic
uterus presents a number of problems, being the small size
of reported series and as the septate uterus the lack of any
prospective, randomised, controlled trial. However, our
study does provide some information on the reproductive
performance of women who have undergone hysteroscopic
metroplasty for hypoplastic uterus.
With regard to the modality of delivery, in our study, the
caesarean section rate of the term pregnancies was high.
Indeed, only seven women delivered vaginally, without
complications. Nevertheless, in seven women, the indication for a caesarean section was neither the metroplasty
itself nor an obstetric indication, but the preciousness of the
pregnancy after a personal history of infertility. Delivery
can be per vaginam after metroplasty, but in the light of the
literature, we recommend not to hesitate to practice a
caesarean section as a mode of delivery. This type of
surgery probably induces a uterine fragility. The obstetric
management should be careful, although no uterine rupture
arose in the literature6 8. The cases of uterine rupture after
hysteroscopic metroplasty concerned septate uterus13,14.
Post-operative diagnostic hysteroscopy showed that hysteroscopic metroplasty gives good anatomical results in the
majority of cases according to different authors6 8.

CONCLUSION
Our results show that the hysteroscopic metroplasty
seems to be an operation that improves the rate of live
births for women with a hypoplastic uterus and a history of
primary infertility and/or recurrent abortion and/or preterm
delivery. These results also confirm the preliminary experiences previously published in retrospective, uncontrolled
pilot studies6 8. In the past, however, correction of these
uterine abnormalities was not undertaken. Ideally, in order
to evaluate the efficiency of this new technique, a randomised study ought to be undertaken in multiple centres,
taking into account a larger number of women suffering
from this type of abnormality.

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Accepted 20 September 2002

D RCOG 2002 Br J Obstet Gynaecol 109, pp. 1331 1334