The septate uterus An enigma?

In this thesis, we assessed the efficacy and safety of uterine septum resection in women with a septate uterus and the pathophysiology behind the impaired reproductive outcome of the septate uterus, in an attempt to learn more about the rationale behind the procedure. As recruitment in our randomized trial took six years longer than planned, we additionally studied which variables are associated with such recruitment failure.
Uterine septum resection has been introduced 140 years ago, and has rapidly evolved into a common procedure in daily practice of gynaecologists who treat women with reproductive problems. Intuitively the rationale is obvious: removing something “abnormal” that is found during diagnostic work-up in women who are facing reproductive difficulties and in doing so, restoring the normal anatomy of the uterus. But intuition was not followed by proper, well designed clinical research. When the procedure became standard practice and was even advised to women without any gynaecological problems, we should have properly investigated its efficacy and safety. And where doctors have been negligent to do so for decades, we have ventured into this knowledge gap.
This thesis includes the results of the international TRUST trial (n=80) and an international cohort study (n=257), which both show no beneficial effect of septum resection in women with a septate uterus. We had four perioperative uterine perforations in women undergoing septum resection (one in the RCT and three in the cohort study). In view of the axiom ‘primum non nocere’, we do not recommend septum resection as a standard procedure.