Septate Uterus. Resect or not? That is Not the Only Question

The septate uterus is the most common congenital anomaly of the uterus. The prevalence of septate uterus varies between 2.3 and 15.4% according to the population studied, with the percentages being higher in women with recurrent miscarriages combined with infertility.¹ A septate uterus increases adverse pregnancy outcomes such as miscarriage, preterm birth, and malpresentation of the fetus, although its direct association with infertility is likely but still controversial.²,³ This issue has also provoked a vivid debate on hysteroscopic resection of the septate uterus for treatment.⁴ Especially for the management of the partial uterine septum, the main point which affects the resection decision lies within the problem of diagnosis. There has been a continuous change in the diagnostic criteria of the partial septate uterus along with the new guidelines, since 1988, despite increasing diagnostic tools.⁵–⁹ Even in the same group of patients, the prevalence of septate uterus has been reported to vary from 5 to 31%, according to the criteria that have been used.¹⁰ One patient flying from Europe to the USA may lose her septum over the Atlantic Ocean. A patient with a 12 mm septal indentation, who used to have a septate uterus according to the American Fertility Society (1988),⁵ lost her septum in 2016, according to the American Society for Reproductive Medicine (ASRM) 2016⁷ guidelines and gained it back in the ASRM 2021 updated guidelines.⁹ The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy's (ESGE) shared guidelines (2016)⁷ boosted the number of patients with a diagnosis of the septate uterus, whereas ASRM (2016)⁷ underestimates the number of patients with partial septate uterus and leaves some patients in a gray zone. Some of this underestimation is due to the 90° angle criteria, which seem to be arbitrary and are not based on strong evidence.¹⁰ In the only randomized controlled The Randomised Uterine Septum Trial (TRUST) of uterine septum resection, 90% of the patients had a partial septate uterus, and three different criteria were used throughout the study. However, most importantly, the difference in the diagnosis reflects in the preference of the treatment regarding resection, and the interpretation of the outcomes of septum resection according to various diagnostic criteria lacks guidance in clinical practice.¹¹ After the TRUST results, we have the option to discuss expectant management with patients. In those patients who choose expectant management, we can find out cut-off values for septal indentation length and the angle for poor obstetric outcomes, if there is any relation.

References

• ¹
  Chan YY, Jayaprakasan K, Zamora J, Thornton JG, Raine-Fenning N, Coomarasamy A. The prevalence of congenital uterine anomalies in unselected and high-risk populations: a systematic review. Hum Reprod Update. 2011;17(06):761–771. Doi: 10.1093/humupd/dmr028
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• ²
  Carrera M, Pérez Millan F, Alcázar JL, et al. Effect of hysteroscopic metroplasty on reproductive outcomes in women with septate uterus: systematic review and meta-analysis. J Minim Invasive Gynecol. 2021;•••: [ahead of print]. Doi: 10.1016/j.jmig.2021.10.001
  » https://doi.org/10.1016/j.jmig.2021.10.001
• ³
  Panagiotopoulos M, Tseke P, Michala L. Obstetric complications in women with congenital uterine anomalies according to the 2013 European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy Classification: a systematic review and meta-analysis. Obstet Gynecol. 2022;139(01):138–148. Doi: 10.1097/AOG.0000000000004627
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• ⁴
  Alvero R, Burney RO, Khorshid A, et al. Surgical treatment of uterine septum to improve reproductive outcomes - resect or not? Fertil Steril. 2021;116(02):298–305. Doi: 10.1016/j.fertnstert.2021.06.009
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• ⁵
  The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, müllerian anomalies and intrauterine adhesions. Fertil Steril. 1988;49(06):944–955. Doi: 10.1016/s0015-0282(16)59942-7
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  Grimbizis GF, Gordts S, Di Spiezio Sardo A, et al. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod. 2013;28(08):2032–2044. Doi: 10.1093/humrep/det098
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• ⁷
  Grimbizis GF, Di Spiezio Sardo A, Saravelos SH, et al. The Thessaloniki ESHRE/ESGE consensus on diagnosis of female genital anomalies. Gynecol Surg. 2016;13:1–16. Doi: 10.1007/s10397-015-0909-1
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• ⁸
  Ludwin A, Martins WP, Nastri CO, et al. Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus? Ultrasound Obstet Gynecol. 2018;51(01):101–109. Doi: 10.1002/uog.18923
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• ⁹
  Pfeifer SM, Attaran M, Goldstein J, et al. ASRM müllerian anomalies classification 2021. Fertil Steril. 2021;116(05):1238–1252. Doi: 10.1016/j.fertnstert.2021.09.025
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• ¹⁰
  Ludwin A, Ludwin I, Coelho Neto MA, et al. Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare systems. Ultrasound Obstet Gynecol. 2019;54(06):800–814. Doi: 10.1002/uog.20291
  » https://doi.org/10.1002/uog.20291
• ¹¹
  Rikken JFW, Kowalik CR, Emanuel MH, et al. Septum resection versus expectant management in women with a septate uterus: an international multicentre open-label randomized controlled trial. Hum Reprod. 2021;36(05):1260–1267. Doi: 10.1093/humrep/deab037
  » https://doi.org/10.1093/humrep/deab037

Publication Dates

• Publication in this collection
  06 Jan 2023
• Date of issue
  2022

History

• Received
  02 Jan 2022
• Accepted
  13 Jan 2022
• Published
  29 Aug 2022