Septum Resection

Types of Uterine Septum

The uterine septum is classified into types based mainly on the length of the tissue in the uterus.

• Partial Septate uterus (partial septum): It doesn’t go all the way to the cervix, but it does go from the top of the uterus.
• Complete Septum: Here, the septum runs from the uterine cavity to the cervix, effectively separating the uterus into two separate chambers.
• Septate Uterus and Vagina: Where the septum continues past the cervix and also divides the upper portion of the vagina.

Who Needs Septum Resection?

The procedure is for women with a congenital uterine septum who are experiencing recurrent miscarriages, infertility, or preterm labor. Also, individuals with a vaginal septum that obstructs menstruation, causes severe dysmenorrhea, or blocks sexual function require surgical removal.

Symptoms of a Septate Uterus

Many women with a septate uterus are asymptomatic and only discover the condition while trying to conceive. When symptoms do occur, they typically include recurrent miscarriages, infertility, severe menstrual cramps (dysmenorrhea), pelvic pain, and abnormal or unusually heavy bleeding.

• Recurrent pregnancy loss: This is the most common symptom. The septum is often made of fibrous tissue and is poorly vascularised. This can mean that an embryo implanted on it may not be able to receive sufficient nutrition, and can increase the risk of miscarriage in the first or second trimester.
• Infertility: Failure of an embryo to implant and develop may be caused by an abnormal uterine cavity.
• Painful periods (dysmenorrhea) and pelvic pain: The dividing tissue (septum) can cause severe cramps or a constant pressure and discomfort in the pelvic area.
• Heavy bleeding: Some people may have heavier-than-normal bleeding or irregular periods.
• Obstetric complications: If the shape is deformed, it can cause fetal growth restriction, breech presentation, and increased risk of preterm labor in a living pregnancy.

How is a Septate Uterus Diagnosed?

Diagnosis is primarily by advanced imaging modalities that can visualize the inner and outer contours of the uterus. It typically involves specialized pelvic imaging (such as a 3D transvaginal ultrasound or MRI) and a diagnostic hysteroscopy combined with a laparoscopy to accurately map the shape of the uterine cavity and rule out other Müllerian anomalies. The preoperative evaluation for a septate uterus is highly tailored to planning a successful hysteroscopic resection (metroplasty).

How is the Uterine Septum Resection Procedure performed?

Uterine septum resection (hysteroscopic metroplasty) is a minimally invasive outpatient procedure. It follows the steps mentioned below:

• Anesthesia and dilation: The procedure is typically done under general anesthesia. The surgeon dilates the cervix to allow insertion of the instruments.
• Visualization and expansion: The hysteroscope is passed into the uterus. The walls are filled with fluid or saline so that the view on the monitor is clear.
• Resection: The doctor uses special thin instruments to carefully cut away or shave off the fibrous tissue from the septum. The section is made slowly between the openings of the fallopian tubes until a single triangular cavity is formed. Surgery lasts 30 to 60 minutes. Sometimes a small, temporary balloon stent (like a Foley catheter) is put in the uterus for a few days to keep the walls from sticking together while it heals. Sometimes estrogen or antibiotics are given for a short time to help with recovery.

How is Recovery from Surgery for a Uterine Septum?

Recovery after resection of a uterine septum is generally short. Since the procedure is minimally invasive and performed through a hysteroscope, you usually go home a few hours after the surgery. You may have some slight cramping and some spotting for up to a week. You will be fully healed in two to four weeks. The cramping is mild to moderate and like a heavy period and can be easily managed with over-the-counter pain relievers such as ibuprofen. You can return to light desk work or normal daily tasks in a day or two. Your doctor will probably tell you to avoid intercourse, tampons, and strenuous exercise so your uterine lining can heal properly and to avoid infection.

What are the Benefits of Removing a Uterine Septum?

• Minimally invasive: The procedure is routinely performed through a hysteroscope (a thin camera inserted through the vagina and cervix), so there is no open abdominal incision (laparotomy).
• Fast recovery: Because it requires no incisions on the outer walls of the uterus, most women return home on the same day as the procedure and can resume normal activities within a few days.
• Less miscarriages: The enlarging fetus has less space to move through the septum. Its elimination also leads to a healthier and more conducive environment for fetal growth, thereby significantly lowering the rates of early miscarriage and recurrent miscarriage.
• Better obstetric outcomes: Reshaping the uterus may help prevent pregnancy complications such as abnormal fetal presentation (breech position) and preterm delivery.

Risks and Complications

Risks involved in the procedure of resection of the uterine septum are:

• Uterine perforation: This is the most common surgical risk and occurs when operating instruments (scissors or a resectoscope) puncture the wall of the uterus. It is usually quickly identified and treated.
• Intrauterine adhesions (Asherman’s Syndrome): Damage to the lining of the uterus during resection can result in the walls sticking together, which can interfere with future embryo implantation.
• Infection and bleeding: As with any surgery involving the uterus, there is a risk of pelvic infection or abnormal post-operative bleeding.
• Uterine rupture: The septum is cut, which can weaken the wall of the uterus, but this is rare. Excessive excision, injury to the muscle layer (myometrium), or improper use of energy/lasers may increase the risk of uterine rupture slightly in a future pregnancy or delivery.
• Cervical incompetence: Sometimes the instruments used to dilate the cervix in surgery can weaken it, increasing the risk of premature opening or delivery.

When Should You See a Doctor?

It is normal and expected to have mild cramping and light spotting for 3 to 4 days. If you experience any unusual symptoms, do not hesitate to go to your doctor. If you have severe pelvic pain, very heavy bleeding (a pad soaked every hour), fever/chills, or foul-smelling vaginal discharge, call your doctor right away. You will have a follow-up appointment scheduled for about 2 to 4 weeks after surgery to make sure you are healing well before trying to get pregnant.