Septum Resection in Women With a Septate Uterus: A Cohort Study

Abstract

The septate uterus has an estimated prevalence of 0.2% to 2.3% in women of reproductive age and is associated with impaired reproductive outcomes, the biologic basis of which is unclear. The standard-of-care treatment for septate uterus is hysteroscopic septum resection. The evidence base for this procedure entails observational studies and nonrandomized comparative studies, resulting in relatively low-quality evidence and conflicting professional society guidelines.This large, multicenter cohort study aimed to determine whether hysteroscopic septum resection improves reproductive outcomes compared with expectant management in women with a septate uterus who wish to conceive. Data on women with septate uterus between January 2000 and August 2018 were obtained from 18 centers in the Netherlands, 2 centers in the United States, and 1 center in the United Kingdom. Additionally, women declining participation in a separate 2015 randomized controlled trial examining differences between septum resection and expectant management were invited for participation prospectively. Data involving baseline characteristics, treatment, and pregnancies that occurred prior to identification of septate uterus (OB history) and following septate uterus diagnosis (follow-up) were obtained via medical record. Septate uterus was defined by the treating physician and ascertained with hysterosalpinography, 3D ultrasound, MRI, saline or gel infusion sonohysterography, or hysteroscopy combined with laparoscopy. The primary outcome measurement was live birth, and secondary outcomes included ongoing pregnancy, early pregnancy loss, preterm birth, and fetal malpresentation. Comparative analysis between septum resection and expectant management arms involved only the first live birth or ongoing pregnancy in follow-up. Cox proportional regression was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs) for differences in live birth and ongoing pregnancy rate between women in the 2 arms while accounting for follow-up time.A total of 257 women were confirmed eligible and included in the study for analysis, of which 151 underwent septum resection, and 106 underwent expectant management. In women who underwent resection compared with expectant management, a lower proportion was of White origin, more women had a history of subfertility, a lesser percentage had previous live birth (16.6% vs 36.8%, P < 0.001), and ascertainment of the septate uterus was significantly different (P < 0.001). Themedian duration of follow-up was 46 months, and 53% of women who had septum resection had at least 1 live birth compared with 71.7% who had expectant management (HR, 0.71; 95% CI, 0.49-1.02). There was no significant difference in cumulative live birth between the groups. When restricting analysis to 1 year following septate uterus diagnosis, 32 women who underwent resection had a live birth (21.2%) compared with 36 women who underwent expectant management (37.1%) (HR, 0.45; 95% CI, 0.27-0.75). Womenwith 1 or more previous pregnancy losses undergoing septumresection were found to have an increased risk of pregnancy loss compared with women who had expectant management (OR, 2.65; 95% CI, 1.05-6.67).This multicenter cohort study demonstrates that more than 50% of women with a septate uterus who wish to conceive had a live birth. The results show that septum resection does not lead to improved birth outcomes or a decrease in risk of pregnancy loss or preterm birth compared with expectant management in these women.