Hysteroscopic metroplasty for dysmorphic uterus: form over function?

Diagnosis of dysmorphic uterus is challenging; three-dimensional ultrasound is considered the most effective tool, although uterine shape can vary with the phase of the menstrual cycle, affecting image appearances. Using stringent criteria, the prevalence of dysmorphic uterus is low and has mostly been studied in women with reproductive problems. Surgical treatment involves lateral incisions to enlarge the uterine cavity by incising fibromuscular constriction bands. However, evidence for its effectiveness in improving reproductive outcomes is limited, and mainly derives from retrospective case series. Most available studies used non-standardized diagnostic criteria, and often did not include control groups, limiting the reliability of conclusions about the benefits of surgery. Questions remain regarding whether correcting uterine form restores function. These include the role of the junctional zone and uterine peristalsis, which are important for embryo implantation but have not been studied in dysmorphic uteri. Incisions may disrupt these functional units. Furthermore, hysteroscopic surgery is associated with potential complications that include intrauterine adhesions and uterine perforation. There is a critical need for prospective cohort studies and randomized controlled trials to clarify the association between dysmorphic uterus and reproductive outcomes, standardize diagnostic criteria to avoid overdiagnosis and unnecessary interventions, and identify which patients may benefit from surgery.