Hysteroscopic Metroplasty

Hysteroscopic Metroplasty is a minimally invasive surgical procedure to remove a uterine septum(also called a septate uterus). A uterine septum is a congenital condition (present from birth) where a wall or band of fibrous and muscular tissue divides part or all of the uterine cavity.

This “wall” can reduce the space available for a pregnancy to grow, which is associated with an increased risk of:

• Recurrent miscarriages (particularly in the second trimester).
• Preterm birth.
• Infertility.
• Irregular menstrual bleeding in some cases.

This Procedure involves using a thin telescope (hysteroscope) inserted through the vagina and cervix, the surgeon carefully cuts away this dividing tissue to create a single, normal-shaped uterine cavity. No abdominal incisions are made.

Preparing for Surgery

Pre-operative Assessment

• Diagnosis Confirmation: The septum is usually diagnosed via a pelvic ultrasound (2D or 3D) or an MRI scan. These images help plan the surgery.
• Consultation: Your surgeon will discuss the potential benefits of the procedure for your specific pregnancy goals and review the risks.
• Fertility Discussion: If you are seeking to improve pregnancy outcomes, this is a key time to discuss your overall fertility plan.

• Timing: The surgery is scheduled for the first half of your menstrual cycle (after your period ends and before ovulation) to ensure you are not pregnant and to have the best view of the cavity.
• Medications: You may be prescribed hormonal tablets (like oestrogen) for a few weeks before surgery to thicken the uterine lining, which can aid healing.
• Fasting: You will be asked to have no food or drink (fast) for 6-8 hours before the procedure if having general anaesthesia.
• Anaesthesia: The procedure is typically done under general anaesthesia. Sometimes spinal or deep sedation is used.
• Support: Arrange for someone to drive you home and stay with you for the first night.

During the Procedure

• Setting: Usually performed as a day-case procedure in an operating theatre.
• Duration: The surgery itself typically takes 20 to 45 minutes.
• Steps:
  1. You are given anaesthesia.
  2. The hysteroscope (with a camera and light) is gently passed through the cervix into the uterus.
  3. Fluid is used to gently expand the uterus for a clear view.
  4. Using fine instruments passed through the hysteroscope (often hysteroscopic scissors or a resectoscope loop), the surgeon meticulously cuts the septum from tip to base until the cavity looks normal.
  5. No stitches are needed inside the uterus.
• After the Procedure: You will recover in a post-op area for a few hours before being discharged.

Recovery After Surgery

First 24-72 Hours

• Pain: You may experience mild to moderate period-like cramping, managed with over-the-counter pain relief like ibuprofen or paracetamol.
• Bleeding/Discharge: Light bleeding or watery discharge is normal for 3-7 days. Use pads, not tampons.
• Activity: You can walk and do light activities. Most women feel able to return to desk work within 1-2 days.

First 2 Weeks

• Avoid sexual intercourse, swimming, baths, and using tampons to prevent infection. Your doctor will advise when it is safe, usually after 1-2 weeks.
• Avoid strenuous exercise and heavy lifting.

Healing & Follow-up

• Internal Healing: The raw areas inside your uterus where the septum was removed will heal over 4-6 weeks, forming new lining.
• Follow-up Scan: A crucial follow-up ultrasound or hysteroscopy is usually scheduled 6-8 weeks after surgery to check the shape of the uterine cavity and confirm successful healing.

Long-Term Outlook and Fertility

• Goal: The primary goal is to improve pregnancy outcomes by providing a normal space for a baby to grow.
• Success Rates: The procedure significantly reduces the risk of miscarriage and preterm birth for women whose previous losses were due to the septum.
• Timing for Pregnancy: It is generally recommended to wait until after the follow-up scan confirms good healing before trying to conceive. This is usually one full menstrual cycle after the scan.
• Mode of Delivery: For most women who become pregnant after a metroplasty, a normal vaginal delivery is possible. In some complex cases, a Caesarean section may be recommended.

Risks and Potential Complications

While considered low-risk, potential complications include:

• Perforation: A small hole in the uterine wall (rare, often heals on its own).
• Bleeding: Usually minimal.
• Infection (endometritis).
• Fluid overload: From the fluid used during surgery (carefully monitored by the anaesthetist).
• Asherman’s Syndrome: The formation of scar tissue (intrauterine adhesions) inside the uterus after surgery. This is a known risk and is why a follow-up scan is essential.
• Incomplete Resection: Sometimes, a very broad or thick septum may require a second procedure.

Frequently Asked Questions (FAQs)

Q: Will this procedure improve my fertility?
A: If infertility is thought to be due to the septate uterus, removing it may improve your chances. However, it is most strongly recommended to prevent miscarriage in women with a history of pregnancy loss.

Q: Is the surgery painful?
A: You will be asleep during the procedure. Afterwards, cramping is common but usually mild and manageable with simple painkillers.

Q: Are there alternatives to surgery?
A: For a true septum causing pregnancy loss, surgery is the only treatment. Monitoring without surgery may be an option if you have a small septum with no history of pregnancy complications.

Q: Can the septum grow back?
A: No, the tissue does not regenerate. However, scar tissue (adhesions) can sometimes form, which is why the follow-up check is so important.

Q: What happens if I get pregnant before the follow-up scan?
A: It is important to wait for medical clearance. A pregnancy in a recently operated uterus may have higher risks. Please use contraception until your doctor advises it is safe.

eGynaecologist Advice

• Women who are diagnosed with uterine septum must seek gynaecological review to understand how a specific septum might affect your reproductive health.
• Women who are known to have uterine septum and become pregnant must seek close monitoring with gynaecologist due to high risk of miscarriages and obstetric complications including preterm birth or placental abruption.
• You must seek gynaecological consultation if you develop heavy bleeding, worsening abdominal pain, signs of infection including fever, chills or foul-smelling vaginal discharge after undergoing this procedure.