Study Objective: To evaluate whether aggressive cervical dilation is effective for creating the initial perforation between non-communicating cavities of the complete septate uterus, which serves as the first step of hysteroscopic cervix-preserving metroplasty.

Design: A retrospective cohort.

Setting: Tertiary referral center.

Patients: Fifty-three patients with complete septate uterus were diagnosed using vaginal examinations, combined 2-D/3-D vaginal ultrasounds, and office-based hysteroscopies.

Interventions: Patients that had received hysteroscopic cervix-preserving metroplasty with the initial perforation created by aggressive cervical dilation or by the traditional method of bougie-guided incisions were compared.

Measurements and Main Results: Of the 53 patients with complete septate uterus, 44 patients received hysteroscopic cervix-preserving metroplasty that required the creation of a perforation. Patients that received aggressive cervical dilation for creation of the perforation had non-significantly shorter surgical times (33.5 minutes, 95% CI: 28.4-38.6 vs 48.7 minutes, 95% CI: 28.2-71.3, p = .099), used significantly lower volumes of distending media (3.6 liters, 95% CI: 3.1-4.1 vs 6.8 liters, 95% CI: 4.2-9.3, p < .001), and had higher success rates (84.4%, 95% CI: 67.2-94.7 vs 50.0%, 95% CI: 21.1-78.9, p = .019). The sites of perforation all occurred on the endocervical septum, and were generally fibrous and avascular.

Conclusion: We present a novel, effective method for creating the initial perforation in hysteroscopic cervix-preserving metroplasty. The success may be due to the existence of a potential weakness in the septum of the duplicated cervix, which spontaneously tears upon aggressive mechanical dilation. The method forgoes the risks associated with sharp incisions based on potentially unreliable cues, and may greatly simplifies the procedure.