Uterine Septum and Congenital Uterine Anomalies Treatment Options

Uterine septum and other congenital uterine anomalies are anatomical malformations of the uterus that arise during embryonic development due to disruptions in the normal formation and configuration of the Müllerian ducts. These anomalies alter the structural integrity of the uterine cavity and may range in severity from minor cavity irregularities to complete duplication or agenesis of the uterine body. While some women remain asymptomatic throughout life, others may experience profound reproductive challenges due to compromised uterine function. These may manifest in the form of implantation failure, disrupted endometrial receptivity, or mechanical interference with embryo development and placental attachment. 

Despite their congenital origin, many uterine anomalies go undiagnosed until adulthood, often surfacing during evaluation for infertility or adverse obstetric outcomes. Their clinical relevance lies not only in their anatomical deviation but also in their potential impact on embryo retention, gestational development, and the capacity of the uterus to sustain pregnancy to term. A clear understanding of their anatomical presentation and functional implications is essential for guiding personalized reproductive care and optimizing maternal-fetal outcomes. 

Why Cuba 

In Cuba, the management of uterine septum and other congenital uterine anomalies is centered on optimizing reproductive outcomes, reducing pregnancy complications, and preserving uterine function. Care is delivered through a structured, evidence-based clinical pathway in which each patient undergoes a thorough gynecological evaluation, including detailed assessment of uterine morphology, reproductive history, fertility goals, and any associated pelvic abnormalities. This personalized approach allows Cuban specialists to determine whether conservative monitoring or surgical correction is most appropriate. 

Cuban gynecology teams are equipped with advanced diagnostic imaging and minimally invasive technologies to ensure accurate diagnosis and targeted treatment. The healthcare system emphasizes affordable, patient-centered care, offering precise surgical interventions like hysteroscopic metroplasty for septate uterus and other reconstructive procedures when indicated, all aimed at restoring normal uterine anatomy and improving the likelihood of a successful pregnancy. 

Causes 

Congenital uterine anomalies originate from disruptions in the development of the Müllerian ducts, paired embryological structures that give rise to the female reproductive tract, including the uterus, fallopian tubes, cervix, and upper vagina. 

Abnormalities arise due to: 

• Incomplete fusion of the Müllerian ducts (e.g., bicornuate uterus) 
• Incomplete resorption of the midline uterine septum (e.g., septate uterus) 
• Complete or partial agenesis (failure to form) of one or both ducts (e.g., unicornuate or absent uterus)

These developmental errors typically occur between the 6th and 12th weeks of gestation and are not influenced by maternal behavior or environmental exposures. 

Types and Classification  

There are several main types of congenital uterine anomalies, based on how the uterus failed to form, fuse, or resorb properly during embryonic development. Common types include:  

• Septate Uterus 
  • Characterized by a fibrous or muscular wall (septum) dividing the uterine cavity. 
  • Most common anomaly and frequently associated with miscarriage or infertility. 
• Arcuate Uterus 
  • A mild indentation of the uterine fundus. 
  • Usually asymptomatic and considered a normal variant. 
• Bicornuate Uterus 
  • Incomplete fusion of the Müllerian ducts creates a uterus with two horns. 
  • Can lead to miscarriage, malpresentation, and preterm labor. 
• Unicornuate Uterus 
  • Complete agenesis or underdevelopment of one Müllerian duct results in a single uterine horn. 
  • Often associated with renal anomalies and high risk of miscarriage. 
• Didelphys Uterus 
  • Complete failure of fusion results in two separate uteri, each with its own cervix and sometimes a vaginal septum. 
  • May lead to menstrual irregularities and reproductive challenges. 
• Aplastic or Hypoplastic Uterus (Müllerian Agenesis) 
  • Complete or partial absence of uterine tissue. 
  • Typically presents with primary amenorrhea and infertility. 

Symptoms 

Symptoms of congenital uterine anomalies vary depending on the specific defect and may include: 

• Recurrent miscarriage or unexplained infertility 
• Menstrual irregularities (e.g., light, absent, or painful periods) 
• Abnormal pelvic pain 
• Preterm labor or abnormal fetal positioning 
• Difficulty with embryo implantation in assisted reproductive technology (ART) 

Some anomalies remain asymptomatic and are discovered incidentally during imaging, pregnancy, or evaluation for infertility. 

Diagnosis 

Diagnosis typically involves a combination of imaging and direct visualization techniques: 

• Transvaginal Ultrasound:
  Provides initial assessment of uterine shape and endometrial contour. 

• Sonohysterography (Saline Infusion Sonography):
  Enhances uterine cavity visualization by infusing saline during ultrasound. 

• Magnetic Resonance Imaging (MRI):
  Highly accurate in differentiating anomalies, especially when external contour evaluation is needed (e.g., septate vs. bicornuate uterus). 

• Hysterosalpingography (HSG):
  An X-ray study using contrast dye to outline the uterine cavity and fallopian tubes. 

• Hysteroscopy and/or Laparoscopy:
  Allow direct visualization of the uterine cavity and external contour; considered gold standard in ambiguous cases. 

Conservative Treatment 

Many uterine anomalies, particularly arcuate or mild bicornuate forms, may not require surgical correction, especially if the patient is asymptomatic and not experiencing infertility or recurrent pregnancy loss. 

Conservative management may include:  

• Expectant monitoring in asymptomatic cases 
• Fertility support with assisted reproductive technologies 
• Obstetric surveillance in pregnancy to manage risk of miscarriage or preterm labor 

Surgical Treatment 

Surgical correction is generally recommended when a uterine anomaly is clearly linked to reproductive complications such as: 

• Repeated early or second-trimester pregnancy loss 
• Infertility after other causes have been excluded 
• Severe menstrual obstruction or pain due to structural deformities 
• Failed embryo implantation during IVF with a diagnosed cavity defect 

Types of surgical treatments include: 

Hysteroscopic Metroplasty (for Septate Uterus) 

Type: Minimally invasive (hysteroscopic) 

• A procedure performed using a hysteroscope (a thin camera-equipped instrument inserted through the vagina and cervix into the uterus). 
• The uterine septum, a fibrous or muscular wall dividing the uterine cavity, is incised under direct visualization. 
• No abdominal incisions are required. 
• Recovery is quick, and fertility outcomes significantly improve after correction. 
• Considered the first line and standard approach for treating septate uterus due to its high safety and success rate. 

Laparoscopic Metroplasty (for Bicornuate Uterus) 

Type: Minimally invasive (laparoscopic) 

• Performed using small incisions in the abdomen through which a laparoscope and surgical instruments are inserted. 
• The goal is to unify the two horns of the bicornuate uterus into a single uterine cavity. 
• Often combined with hysteroscopy for accurate preoperative assessment and intraoperative guidance. 
• This technique is less commonly performed than hysteroscopic metroplasty and is reserved for specific anatomical indications. 
• Recovery time is shorter than open surgery, and the risk of complications is reduced. 

Strassman Metroplasty (for Severe Bicornuate Uterus) 

Type: Open surgery 

• A traditional, more invasive surgical technique involving an abdominal incision (laparotomy). 
• The surgeon makes a transverse incision across the uterine fundus to open and reshape the divided horns of the uterus, converting it into a single unified cavity. 
• Primarily indicated in severe or complex cases of bicornuate uterus where minimally invasive approaches are not sufficient. 
• This procedure requires longer hospitalization and recovery time compared to laparoscopic methods. 
• Fertility and pregnancy outcomes often improve following successful reconstruction. 

Excision of Vaginal Septum (in Uterus Didelphys with Obstruction) 

Type: Minimally invasive or vaginal approach 

• Indicated in patients with uterus didelphys who have a vaginal septum causing pain, obstruction, or difficulty with intercourse or menstruation. 
• The septum can be excised through the vaginal canal, sometimes under endoscopic guidance, depending on its thickness and position. 
• This intervention does not alter the dual uterine structure but relieves symptoms and improves reproductive and sexual function.