Introduction
The uterus, a part of a women's reproductive system, is a hollow cavity present inside the pelvic region of a female. It has the shape of an upside-down pear. The primary function of the uterus is during pregnancy as it provides the site of implantation of an embryo, and the baby's growth and development occur inside the uterus. This small uterine cavity extends and gets bigger as the baby grows inside. In the case of congenital uterine anomalies, the functions of the uterus get disturbed, leading to adverse reproductive outcomes.
The prevalence rate of congenital uterine anomalies is 5.5 percent in the general population, approximately 8 percent in infertile women, and 13.3 percent in women with a miscarriage history. Moreover, the prevalence is probably underrated because many affected women do not have any reproductive problems, therefore remaining undetected. Among congenital uterine anomalies, the septate uterus is among the commonest findings.
What Is the Septate Uterus?
A septate uterus is when a septum divides the uterine cavity without any restrictions to its length. This condition does not alter the external shape of the uterus. The Septate uterus accounts for 35 percent of all identified uterine anomalies; hence it is the most common anomaly of the uterus. A septate uterus occurs due to incomplete degeneration of the midline septum between the two tissues forming the uterus. The extent of the septum varies; some may present as a slight midline septum, while some cases can have a complete septate uterus with the involvement of the endocervical canal (a canal connecting the uterus to the vagina).
What Are the Types of the Septate Uterus?
Septate uteruses are of three types as followings:
- Partial Septate Uterus: When the septum does not include the cervix (the narrow lower end of the uterus).
- Complete Septate Uterus: When the septum involves the cervix.
What Are the Symptoms of the Septate Uterus?
The septate uterus is associated with the symptoms of poor reproductive outcomes such as:
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Infertility.
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Recurrent pregnancy loss.
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Preterm birth.
The mechanism for these impaired reproductive outcomes is not yet clear. However, an embryo's implantation needs different conditions, such as adequate uterine motility, normal morphology of the cavity, and a receptive endometrium (inner lining of the uterus) for successful embryo implantation inside the uterus.
In the case of the septate uterus, these essential requirements might not be met as connective tissues and muscle fibers are the main components of a uterine septum. Thus this septum lacks vascularization as rich as endometrium, which may lead to implantation failure.
How Is Septate Uterus Diagnosed?
The septate uterus usually remains undiagnosed until the affected woman consults the doctor regarding pregnancy difficulties.
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Ultrasound Scan: On ultrasound scan, an echogenic stripe (produces light areas on ultrasound) is separated at the fundus (upper part of the uterus) by the intermediate echogenicity of the septum that shows the same degree of echogenicity as the muscular structure of the uterus. In addition, color Doppler may show some vascularity in the septum.
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MRI (Magnetic Resonance Imaging): The current imaging method of choice to detect the septate uterus. On MRI, two uterine cavities smaller than the size of a normal cavity appear. The septum can be seen as composed of fibrous tissue, myometrial tissue, or both.
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Hysteroscopy: In addition, the doctor may perform a hysteroscopy to confirm the diagnosis of the septum inside the uterus.
How Is Septate Uterus Treated?
The gold standard treatment for septate uterus is hysteroscopic septoplasty. The doctor performs this procedure under general anesthesia. Hysteroscopy is a procedure of examining the inside of the uterus using a device called a hysteroscope consisting of a narrow telescope along with a camera and light at the tip. This procedure is also called hysterolaparoscopy. It provides the advantage of combining hysteroscopy with laparoscopy. It offers dual benefits of assessing the pelvis and the uterine cavity. It helps diagnose, correlate, and confirm all findings crucial to treatment procedures in cases of uterine anomalies.
Hysterolaparoscopy:
In cases where elicited history and ultrasound examination indicate a septate uterus, the hysterolaparoscopy, a gold standard in evaluating infertile females, enables the doctor to assess and resect the uterine septum in a single sitting. Clear, pre-procedure awareness and consent before this surgery avoids a second look and another hysteroscopy, saving time and expenses for the couple.
Hysterolaparoscopy Outcomes: Several studies have established that it improves fertility and lowers the miscarriage rate. The procedure's success depends not on the size, length, and width of the uterine septum. Hysterolaparoscopy is a safe and minimally invasive procedure that most gynecologists perform routinely. Moreover, a hysteroscopic-guided septum resection eliminates an unsuitable implantation site and improves endometrial function. This improvement in endometrial vascularization can result from a re-vascularization of the connective tissues of the uterus.
Hysterolaparoscopy Complications: The chances of complications during this procedure are significantly less; however, it may occur, and the difficulties may be as below:
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Perforation of the uterus.
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Excessive bleeding.
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Fluid overload.
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Thermal injury due to excessive use of cautery.
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Excessive septal incision.
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Penetration of the myometrium (muscular outer layer of the uterus).
Post-Procedure Management: The doctor will prescribe a hormone replacement therapy for one or two cycles to enhance recovery of the endometrium, which is done with incremental doses of estrogen (Estradiol Valerate 2 mg) starting from day two or day three of the cycle up to a maximum of 8 mg per day with the initiation of natural micronized progesterone 200 mg three times a day. The female wishing to be pregnant subsequently can opt for natural conception or assisted reproductive technology.
Conclusion
Septate uterus is a very common type of congenital anomaly of the uterus. The woman may or may not have symptoms depending on the extent and position of the septum inside the uterine cavity. However, the most common issues associated with uterine septum are fertility and poor pregnancy outcomes. The treatment of the uterine septum is hysteroscopic septum resection. This treatment is advantageous in case of recurrent pregnancy loss and infertility. In addition, it is a simple, minimally invasive procedure with low morbidity. Surgical removal is beneficial as some studies have established that the septum inside the uterus is the primary cause of miscarriages.
