The Diagnosis and Surgical Approach of Uterine Septa

Uterine septa are a class of müllerian duct anomaly that, similar to other classes, are associated with poor reproductive outcomes; however, they are unique because these poor outcomes, particularly recurrent pregnancy loss, may be responsive to surgical correction. The current evidence regarding septoplasty is difficult to interpret because the definitions of a uterine septum, methods to diagnose it, and hysteroscopic techniques used for treatment are variable and generally of poor to moderate quality. Robust data on outcomes, particularly live births, after septoplasty are not available at this time. This review aims to examine the evidence on this contentious issue. A search of the literature was conducted using the MEDLINE, Embase, and Cochrane databases from 2002 to present with included articles reporting on clinical and/or imaging diagnosis of a uterine septum, operative techniques for uterine septoplasty, or clinical outcomes for women with uterine septa. The initial search revealed 4997 potentially relevant articles with 36 full-text articles included after the removal of nonrelevant titles, including 16 diagnostic studies, 17 surgical studies, and 3 studies on clinical outcomes. Where access to 3-dimensional transvaginal ultrasound or magnetic resonance imaging exists, these imaging modalities offer a highly sensitive and specific method of diagnosing a uterine septum without invasive diagnosis although this is operator dependent. Despite hysteroscopic septoplasty being described for over 40 years, there remains a lack of high-quality data to support hysteroscopic septoplasty and which women would most benefit from the procedure. There is no evidence for pre- or postoperative treatments nor has a single surgical approach been identified as superior than another although an important end point of live birth rates is largely unreported in these trials. Although several classification systems have been described, the diagnostic categorization of septal variants has limited a meaningful approach to this issue in both the clinical and research setting.