What is the appropriate workup and treatment for a septate uterus?

Workup and Treatment of Septate Uterus

MRI is the preferred diagnostic method for septate uterus evaluation due to its 100% accuracy in classifying Müllerian duct anomalies, followed by hysteroscopic treatment for symptomatic patients to improve reproductive outcomes.

Diagnostic Workup

Imaging Options

• MRI is the gold standard for diagnosing and classifying septate uterus with 100% accuracy in surgically proven Müllerian duct anomalies (MDAs) 1
• 3D transvaginal ultrasound (TVUS) is an excellent alternative with 92% accuracy in classification of MDAs 1
• Hysterosalpingography (HSG) has poor accuracy (only 16.7%) in characterizing MDAs and cannot reliably differentiate between septate and bicornuate uterus 1
• Sonohysterography can differentiate septate from bicornuate uterus and may eliminate the need for diagnostic laparoscopy 2

Key Diagnostic Criteria

• On both TVUS and MRI, a fundal cleft <1 cm indicates septate uterus while a cleft >1 cm suggests bicornuate uterus 1
• A fundal indentation <5 mm above the interostial line also helps identify septate versus bicornuate uterus 1
• Combined laparoscopy and hysteroscopy may be used for definitive diagnosis in complex cases 3

Treatment Approach

Indications for Treatment

• Septate uterus is associated with reproductive complications including:
  • Recurrent pregnancy loss
  • Premature deliveries
  • Abnormal fetal presentations
  • Potential infertility 4, 5

Surgical Management

• Hysteroscopic metroplasty (septoplasty) is the standard surgical treatment for septate uterus 4, 5
• The procedure involves resection of the uterine septum via operative hysteroscopy, often with laparoscopic assistance for safety and efficiency 3
• In cases with thick, broad-based septa that cannot be adequately addressed hysteroscopically, traditional transabdominal metroplasty may be considered 3
• For complex cases with cervical duplication and longitudinal vaginal septum, a combined approach may be necessary, including excision of the vaginal septum followed by septal resection 3

Expected Outcomes

• Hysteroscopic septoplasty improves fertility and obstetrical outcomes by:
  • Increasing pregnancy rates
  • Increasing live birth rates
  • Reducing miscarriage rates 4, 5

Special Considerations

Variant Anatomy

• Rare variants include septate uterus with double cervix and longitudinal vaginal septum, which challenges classical Müllerian developmental theory 3, 6
• Communicating septate uterus with double cervix is characterized by two separate uterocervical cavities connected by an isthmic communication 6

Prophylactic Treatment

• Resection of uterine septum is encouraged not only in symptomatic patients but also prophylactically in asymptomatic patients to increase chances of carrying pregnancy to term 4

Post-Treatment Monitoring

• Follow-up imaging (3D TVUS or MRI) is recommended to confirm adequate septal resection 2
• Patients should be counseled about improved but still present risks in future pregnancies 5

Common Pitfalls

• Misdiagnosis between septate and bicornuate uterus can lead to inappropriate surgical management 1, 2
• Relying solely on HSG for diagnosis is inadequate due to its poor accuracy in differentiating septate from bicornuate uterus 1
• Incomplete septal resection may not fully resolve reproductive issues 2