Septum resection for women of reproductive age with a septate uterus.
Level 1 - systematic review of randomized trials
Systematic review of randomized controlled trials and non-randomized comparative studies.
PubMed 41268817 · doi:10.1002/14651858.CD008576.pub5
What was done
This Cochrane review evaluated the benefits and harms of hysteroscopic septum resection compared to expectant management in reproductive-aged women with a septate uterus. Databases including CENTRAL, MEDLINE, and Embase were searched up to September 2025. Randomised controlled trials (RCTs) and non-randomised comparative cohort studies were included, excluding uncontrolled or before-after designs. Primary outcomes were live birth rate and surgical complications; secondary outcomes included ongoing pregnancy, clinical pregnancy, and miscarriage. RCT and observational data were analyzed separately using fixed-effect models.
What was found
The review included 13 studies (1 RCT with 79 participants; 12 non-randomised studies with 1,826 participants). In the single RCT (39 resection vs 40 expectant management), septum resection showed little to no difference in live birth rate (OR 0.83, 95% CI 0.32 to 2.11; low certainty), ongoing pregnancy (OR 0.93, 95% CI 0.37 to 2.35; low certainty), or clinical pregnancy (OR 1.43, 95% CI 0.59 to 3.47; low certainty). Miscarriage odds were higher with resection in the RCT, though the confidence interval spanned no effect (OR 2.75, 95% CI 0.86 to 8.84; low certainty). Two surgical complications occurred in the RCT (one uterine perforation, one residual septum). In non-randomised studies, evidence was very low certainty across all outcomes, showing no clear effect on live birth (OR 1.15, 95% CI 0.90 to 1.48; 8 studies, n=1,383), clinical pregnancy (OR 1.37, 95% CI 0.96 to 1.97; 5 studies, n=724), or miscarriage (OR 0.74, 95% CI 0.53 to 1.04; 7 studies, n=1,259), and lower odds of ongoing pregnancy in one study (OR 0.47, 95% CI 0.27 to 0.81; n=257).
Why it matters
Despite widespread surgical practice, rigorous trial evidence does not support routine hysteroscopic septum resection to improve fertility or pregnancy outcomes in women with a septate uterus, and the procedure carries surgical risks.
Limits
The evidence base is severely limited by a scarcity of trial data, relying on a single small RCT (79 women) with very serious imprecision (wide confidence intervals). Observational studies suffered from very serious risk of bias, inconsistency, and unmeasured confounding.
Cited by
- supports A uterine septum causes recurrent miscarriages and infertility.