J Minim Invasive Gynecol .

Abstract Study objective: To investigate the effect of hysteroscopic metroplasty on spontaneous reproductive outcomes in women with a T-shaped uterus and recurrent pregnancy loss (RPL). Design: Matched case-control study conducted between January 2014 and December 2024. Setting: Two Italian university hospitals. Patients: Women aged 25-42 years with primary RPL (≥ 2 first-trimester intrauterine pregnancy losses) and a diagnosis of T-shaped uterus based on Q AZthe Congenital Uterine Malformation by Experts (CUME) criteria. Exclusion criteria included prior uterine surgery, identifiable causes of RPL, or use of assisted reproductive technologies (ART). Interventions: Cases were women who underwent hysteroscopic metroplasty using a standardized surgical protocol combining 3D transvaginal ultrasound and hysteroscopy; controls were matched by age (±1 year) and did not undergo surgery. The primary outcome was the live birth rate (LBR) within 12 months of spontaneous conception attempts. Secondary outcomes were the clinical pregnancy rate (CPR) and the first trimester pregnancy loss rate (PLR). Measurements and main results: A total of 86 women (43 cases and 43 controls) were included. The CPR was similar between cases and controls (67% (95% confidence interval (CI): 53%, 79.5%) vs 77% (95% CI: 62%, 87%) p=0.34; crude odds ratio (OR) 1.59, 95% CI: 0.62, 4.13). The first-trimester PLR was significantly lower (31% (95% CI: 17.3%, 49.2%) vs 70% (95% CI: 52.7%, 82.6%), p = 0.005; crude OR 0.20, 95% CI: 0.07-0.58), and the LBR significantly higher (47% (95% CI: 33%, 61%) vs 21 % (95% CI: 10%, 36%), p = 0.012; crude OR 3.29, 95% CI: 1.27, 8.48) in the metroplasty group compared to the unoperated group. Adjusted analyses controlling for smoking status and education level confirmed these findings. Conclusions: Hysteroscopic metroplasty may increase the LBR in women with T-shaped uterus and unexplained RPL by reducing the PLR. Randomized controlled trials (RCTs) are needed to confirm causality.