What is the management of a septate uterus?

Management of Septate Uterus

Hysteroscopic septum resection is not recommended for women with a septate uterus as it does not improve reproductive outcomes compared to expectant management. 1

Diagnosis

• A septate uterus is a congenital uterine anomaly characterized by a fibrous septum dividing the uterine cavity, which can be partial or complete 1
• Accurate diagnosis requires a combination of imaging modalities:
  • Hysterosalpingography (HSG) alone has only 55% diagnostic accuracy 2
  • Combined protocol using HSG and ultrasound improves diagnostic accuracy to 90% 2
  • If the angle of divergence between two straight uterine cavities is ≤75 degrees on HSG, this indicates a septate uterus 2

Impact on Reproduction

• Septate uterus has historically been associated with:
  • Increased risk of subfertility 1
  • Higher rates of pregnancy loss 1
  • Increased risk of preterm birth 1
• Some studies have suggested an association with recurrent miscarriages, with historical data showing up to 79% miscarriage rate among affected pregnancies 3

Treatment Recommendations

• The highest quality evidence from a recent randomized controlled trial shows that hysteroscopic septum resection does not improve reproductive outcomes 1
• Live birth rates were 31% in the septum resection group versus 35% in the expectant management group (RR 0.88,95% CI 0.47-1.65) 1
• Surgical intervention carries risks including uterine perforation (reported in 2.6% of cases) 1

Surgical Technique (When Indicated)

• When septum resection is performed (despite lack of evidence for improved outcomes), hysteroscopic metroplasty is the preferred approach over traditional abdominal metroplasty 4
• In rare cases with a very thick septum or broad base, conventional transabdominal metroplasty may still be required 4
• Laparoscopic assistance during hysteroscopic resection can aid in diagnosis and improve safety 4

Special Considerations

• Rare variants include septate uterus with cervical duplication and complete longitudinal vaginal septum, which may require more complex surgical management 4
• For patients with recurrent pregnancy loss (≥2 miscarriages) who strongly desire intervention despite the evidence, a thorough discussion of risks and benefits is essential 3

Current Evidence and Guidelines

• A 2021 international multicenter randomized controlled trial found no benefit of septum resection over expectant management 1
• A Cochrane review confirmed the lack of high-quality evidence supporting hysteroscopic septum resection 5
• The lack of improvement in reproductive outcomes from surgical intervention questions the rationale behind surgery 1

Follow-up Care

• For women who have undergone septum resection, regular gynecological follow-up is recommended to monitor for any complications 4
• For those choosing expectant management, standard prenatal care should be provided during pregnancy 1