Septate Uterus: Causes, Diagnosis and Fertility Considerations

A septate uterus is a congenital condition in which the uterine cavity is divided by a fibrous or muscular membrane, called a septum. This anomaly develops during fetal growth and is one of the most common uterine abnormalities in women.

While it usually does not cause major health problems on its own, a septate uterus can increase the risk of pregnancy complications, including miscarriage, preterm birth, pregnancy loss and fetal malpresentation (when the baby is not positioned head-down in the womb).

With early diagnosis and proper treatment, most women with a septate uterus can have a healthy pregnancy. Understanding the types, causes, symptoms, and treatment options is important for women planning to conceive or experiencing reproductive challenges.

What is a Septate Uterus?

A septate uterus occurs when the uterine cavity is divided by a septum, creating two smaller cavities instead of one. Normally, the uterus is a single, hollow, pear-shaped organ in the pelvis.

The septum can vary in thickness and length, starting at the top of the uterus and sometimes extending down toward the cervix, and in rare cases, into the vagina. Most women remain unaware of the condition until they face fertility issues or pregnancy complications.

It is crucial to distinguish a septate uterus from a bicornuate uterus, which has a heart-shaped outer contour. Correct identification ensures appropriate treatment and management.

Types of Septate Uteruses

A septate uterus is classified based on how far the septum extends:

• Partial Septate Uterus: The septum divides only part of the uterine cavity and does not include the cervix
• Complete Septate Uterus: The septum extends through the entire uterine cavity and includes the cervix
• Septate Uterus Extending into the Vagina: Rare cases where the septum reaches beyond the cervix into the vagina

Identifying the type of septate uterus is crucial for treatment planning and predicting fertility outcomes.

What are the Causes of Septate Uterus?

A septate uterus is a congenital anomaly, meaning it develops before birth. During early fetal development, the uterus starts as two separate tubes that normally fuse into a single cavity. When this fusion is incomplete, a septum remains, dividing the uterine cavity.

The septum can vary in size and thickness, affecting part or all of the uterus. While the condition is present from birth, the exact cause is not fully understood. Genetics or family history may play a role in some cases, but there is no definitive way to prevent it.

In summary, a septate uterus forms because the uterine septum fails to get absorbed during development, creating a divided cavity. Despite being relatively rare, it is one of the most common uterine abnormalities in women.

What are the Symptoms of Septate Uterus?

Many women with a septate uterus are asymptomatic and may not know they have the condition until they encounter fertility problems or recurrent pregnancy loss.

In most cases, it is discovered during evaluation for infertility, repeated miscarriages or occasionally during a routine pelvic exam.

Potential symptoms, when present, can include:

• Recurrent miscarriages
• Difficulty conceiving
• Irregular or painful menstrual bleeding
• Pelvic pain in some cases

The severity often depends on whether the septum is partial or complete. Partial septa can be harder to detect because the cavity shape is less affected. Not all women will have fertility issues, and early diagnosis and treatment can significantly improve outcomes.

How Is a Septate Uterus Diagnosed?

Accurate diagnosis is vital, especially for women planning pregnancy. Because the septum is often thin, it may not be visible during a routine pelvic exam unless it extends to the cervix or vagina. Imaging tests are usually required to determine the septum’s size, thickness and location.

Common diagnostic methods include:

Ultrasound (USG)

• Often, the first step in evaluation
• Can be performed externally on the abdomen or internally via a transvaginal probe
• 3D ultrasound provides more detailed images than 2D, helping to visualize the septum clearly

Hysterosalpingography (HSG)

• An X-ray test that outlines the shape of the uterine cavity
• Also checks if the fallopian tubes are open

Magnetic Resonance Imaging (MRI)

• Provides a detailed view of the uterine structure
• Useful for distinguishing between a septate uterus and a bicornuate uterus, which have different outer uterine shapes

Hysteroscopy

• A minimally invasive procedure that allows direct visualization of the uterine cavity
• It can also be combined with treatment to remove the septum if needed

After imaging, the septate uterus may be classified as:

• Complete septate uterus: The septum runs the entire length of the uterus, sometimes extending into the cervix or vagina
• Partial septate uterus: The septum does not reach the cervix and is considered less severe

Early and accurate diagnosis improves management and increases the chances of a successful pregnancy.

Bicornuate Uterus vs Septate Uterus

• Bicornuate uterus: Outer uterine contour is indented, with two separate upper cavities.
• Septate uterus: Outer contour normal, cavity divided by a fibrous septum.

Correct differentiation is crucial because a septate uterus can be surgically corrected, whereas a bicornuate uterus typically does not require surgery unless there are pregnancy complications.

What Are the Treatment Options for a Septate Uterus?

Treatment for a septate uterus depends on several factors, including symptoms, fertility goals, pregnancy history and the size of the septum. Not all cases require intervention, especially if a woman is asymptomatic or has not experienced pregnancy complications.

Surgical Treatment: Hysteroscopic Metroplasty

Surgery is the primary treatment. Hysteroscopic metroplasty is a minimally invasive procedure that restores a single uterine cavity and improves fertility outcomes.

How the procedure works:

• The surgeon inserts a thin, lighted tube called a hysteroscope through the vagina and cervix to view the inside of the uterus.
• A saline solution is used to expand the uterus, providing a clear view of the septum.
• Surgical tools are passed through the hysteroscope to cut and remove the septum, dividing the uterine cavity into a single open space.
• Ultrasound guidance may be used during surgery to ensure the complete removal of the septum.

Recovery and outcomes:

• Typically performed as an outpatient procedure, most women go home the same day
• Minor side effects may include mild cramping, period-like pain or light bleeding for a day or two
• Use sanitary pads instead of tampons initially to reduce infection risk
• Rare complications can include infection, reaction to anesthesia, or minor damage to the cervix or uterus

Effectiveness:

• Around 50-80% of women with a history of recurrent miscarriage have successful pregnancies after surgery.
• About 20% of women who previously could not conceive may become pregnant after the procedure.

Expectant Management

In cases where the septum is small, asymptomatic, or fertility is not affected, doctors may recommend monitoring without surgery. Women can continue with natural conception and only seek intervention if complications arise.

Complications of Uterine Septum

A septate uterus usually does not cause significant health problems on its own, but it can increase certain risks during pregnancy. Women with this condition may face:

• Miscarriage, particularly in the first or second trimester
• Preterm birth
• Low birth weight
• Preterm labor
• Breech presentation (baby positioned feet or buttocks first)
• Need for C-section delivery

There may also be a slightly higher risk of endometriosis.

With proper diagnosis, treatment and careful monitoring, women with a septate uterus can have healthy pregnancies and babies.