Abstract
PurposeUterine septum in women with subfertility or previous poor reproductive outcomes presents a clinical dilemma. Hysteroscopic septum resection has been previously associated with adverse reproductive outcomes but the evidence remains inconclusive. We aimed to thoroughly and systematically appraise relevant evidence on the impact of hysteroscopically resecting the uterine septum on this cohort of women.MethodsAMED, BNI, CINAHL, EMBASE, EMCARE, Medline, PsychInfo, PubMed, Cochrane register of controlled trials, Cochrane database of systematic reviews and CINAHL were assessed to April 2020, with no language restriction. Only randomised control trials and comparative studies which evaluated outcomes in women with uterine septum and a history of subfertility and/or poor reproductive outcomes treated by hysteroscopic septum resection against control were included. The primary endpoint was live birth rate, whereas clinical pregnancy, miscarriage, preterm birth and malpresentation rates were secondary outcomes.ResultsSeven studies involving 407 women with hysteroscopic septum resection and 252 with conservative management were included in the meta-analysis. Hysteroscopic septum resection was associated with a lower rate of miscarriage (OR 0.25, 95% CI 0.07–0.88) compared with untreated women. No significant effect was seen on live birth, clinical pregnancy rate or preterm delivery. However, there were fewer malpresentations during labour in the treated group (OR 0.22, 95% CI 0.06–0.73).ConclusionOur review found no significant effect of hysteroscopic resection on live birth. However, given the limited evidence available, high-quality randomised controlled trials are recommended before any conclusive clinical guidance can be drawn.
Highlights
Septate uterus is the most common Müllerian anomaly in women with an estimated incidence of 0.2–2.3%, subject to the diagnostic methods and classification system [1, 2]
The analysis found no evidence of a significant difference in live birth rate between the groups
The analysis found a significantly lower miscarriage rate in women who had hysteroscopic septum resection compared to those who had opted for conservative management
Summary
Septate uterus is the most common Müllerian anomaly in women with an estimated incidence of 0.2–2.3%, subject to the diagnostic methods and classification system [1, 2]. It can be categorised into partial (subseptate) or complete septate groups [3] and is accountable for poor reproductive outcomes and obstetric problems, such as pregnancy loss, preterm birth and foetal malpresentations [1, 4]. The most commonly seen reproductive complication is spontaneous miscarriage, affecting more than 60% of women with uterine septum [5–7]. The mechanism by which uterine septum causes pregnancy loss is not fully understood. It has been proposed that abnormal implantation dynamics caused by poor blood supply to the septum leads to spontaneous miscarriages [8–10]. It can be hypothesised that basis of treatment should be restoration of normal uterine cavity
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