Second-look hysteroscopy after metroplasty for uterine septum: Shedding light on an overlooked step-A systematic review

Background: Second-look hysteroscopy is proposed after hysteroscopic metroplasty to assess healing, identify residual septa or intrauterine adhesions (IUAs), and optimize reproductive outcomes. However, its timing, indications, and clinical utility remain unclear. Objectives: To evaluate the role of second-look hysteroscopy after metroplasty for septate uterus, focusing on the incidence of residual septum and IUAs, reproductive outcomes, and preferred timing and indications for follow-up. Search Strategy: A systematic search of PubMed, Scopus, Web of Science, and Cochrane CENTRAL (from inception to March 2025) was conducted using terms related to “second-look hysteroscopy” and “septate uterus.” Reference lists of included articles were also screened manually. Selection Criteria: Studies reporting on women with a diagnosis of septate uterus who underwent hysteroscopic metroplasty followed by second-look hysteroscopy were included. Eligible designs were randomized controlled trials (RCTs), cohort studies, cross-sectional studies, case series, and case reports. Data Collection and Analysis: Two independent reviewers extracted data on study characteristics, surgical approach, second-look findings, reproductive outcomes, and timing between procedures. The Joanna Briggs Institute tools were used to assess methodological quality. Main Results: A total of 15 studies involving 1409 women undergoing metroplasty were included. Among them, 933 (66.2%) underwent second-look hysteroscopy at a mean of 10 weeks (range: 4–20). Residual septa ≥1 cm were found in 2.6% of cases. IUAs were reported in 1%–35% of patients but fell below 10% in studies using antiadhesion barriers. Reproductive outcomes were reported for 637 women actively trying to conceive: 422 pregnancies (66.2%), a live birth rate of 56.2%, and a pregnancy loss rate of 9.6%. Selective use of three-dimensional (3D) sonohysterography showed high diagnostic concordance with hysteroscopy, potentially reducing the need for routine invasive follow-up. Conclusions: Second-look hysteroscopy provides diagnostic and therapeutic value, particularly in patients at risk for residual septum or IUAs. Its selective use, combined with adjunctive tools such as 3D imaging and adhesion barriers, may improve outcomes while avoiding unnecessary procedures. High-quality prospective trials are needed to better define timing and patient selection.