What is a uterine septum?
A uterine septum is an upside-down, triangular shaped piece of tissue which divides all or part of the uterine cavity in two. The tissue is a left over remnant from normal, embryonic uterine development and is most commonly discovered with an HSG (hysterosalpingogram). A septum can also be discovered with a 3D ultrasound and a skilled observer will also detect the septum using a regular 2D ultrasound machine in a correct plane. The septum may frequently be overseen on routine ultrasound scans, particularly in cases when it is very small/short. It important that your doctor is a fertility subspecialist, since I have seen many patients that had ultrasounds before and the septum was noted. It might be helpful to perform the ultrasound when the endometrium is very thick and the cavity can be seen best.
At 6 weeks gestation, the uterus forms from 2 hollow, parallel cylinders which fuse together. The internal walls of the cylinders are supposed to subsequently dissolve in an inferior to superior manner, leaving a single uterine cavity. If the internal walls do not dissolve completely, some tissue remains towards the top of the uterus. This tissue comprises the uterine septum.
How does a septum affect fertility and miscarriage?
Women with infertility and recurrent miscarriage are more likely to have uterine septum. However, it is not known how many women with normal reproductive histories also have uterine aseptum. This is important, because, a uterine septum does not always cause problems. With that being said, in women with history of miscarriage or infertility or pre-term delivery, with a uterine septum, we believe that the septum likely contributes to their difficulties.
There are 2 theories as to how a uterine septum is detrimental to reproduction. First, because the tissue of a uterine septum tends to be fibrous and mostly avascular it does not have the same rich blood supply as the rest of the uterus . An embryo that implants over the septum, therefore, may not be able to obtain the nutrients it needs to grow, eventually leading to miscarriage. Some experts believe that this phenomenon may occur very early in gestation preventing detection or even a positive pregnancy test. In most cases however, a positive urine or blood pregnancy test will confirm pregnancy if this is checked at the correct day, ideally 10-14 days after ovulation.
The second manner in which a septum can be detrimental is by decreasing the space for the pregnancy inside the uterus. As the pregnancy grows, the limited space can cause uterine contractions leading to miscarriage or preterm delivery. I had several patients where the septum caused an abnormal presentation of the baby during pregnancy.
What can be done about a uterine septum?
Patients with a uterine septum and history of miscarriage, pre-term delivery or those planning an advanced fertility treatment such as IVF may undergo surgical correction of their septum. It is important to choose a board certified reproductive endocrinologist with experience in this procedure. During this outpatient procedure, a camera (hysteroscope) is inserted into the uterus through the cervix. A wire loop with electrical current is extended through the camera and applied to the septum tissue. As septum is incised, the tissue springs back into the uterine wall creating a normal uterine cavity. The same procedure can be performed using saline distension and no electricity at all using hysteroscopic scissors. Since there are many different types of septum and also different ways to manage it, we will be glad to provide you with a consultation and suggestion how to manage this condition.
The procedure is relatively straightforward and usually uncomplicated. As with all surgical procedures however, there are some risks. If you are going to have a septum surgery, some of the risks you may want to ask your doctor about include; scarring of the uterine cavity, perforation of the uterus, incomplete resection of the septum and fluid overload.
If you have any questions about uterine septum or other reproductive issues, feel free to contact Dr. Jovanovic or Dr. Vermesh and review your specific case. We have performed numerous septum correction and are specialized in hysteroscopic surgery. It is a day surgery that does not require hospitalization and we will be very happy to review your sitation. Even if you can not present in person, we can arrange a Skype software or telephone consultation.