Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare systems

Abstract

Objectives To estimate the differences in frequency of diagnosis of septate uterus using three different definitions and determine whether these differences are significant in clinical practice, and to examine the association between diagnosis of septate uterus, using each of the three definitions, and infertility and/or previous miscarriage as well as the cost of allocation to surgery. Methods This was a secondary analysis of data from a prospective study of 261 consecutive women of reproductive age attending a private clinic focused on the diagnosis and treatment of congenital uterine malformations. Reanalysis of the datasets was performed according to three different means of defining septate uterus: following the recommendations of the American Society for Reproductive Medicine (ASRM), a 2016 update of those of the American Fertility Society from 1988 (ASRM‐2016: internal fundal indentation depth ≥ 1.5 cm, angle of internal indentation < 90° and external indentation depth < 1 cm); following the recommendations of the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), published in 2013 and reaffirmed in 2016 (ESHRE/ESGE‐2016: internal fundal/uterine indentation depth > 50% of uterine‐wall thickness and external indentation depth < 50% of uterine‐wall thickness, with uterine‐wall thickness measured above interostial/intercornual line); and using a definition published last year which was based on the decision made most often by a group of experts (Congenital Uterine Malformation by Experts; CUME) (CUME‐2018: internal fundal indentation depth ≥ 1 cm and external fundal indentation depth < 1 cm). We compared the rate of diagnosis of septate uterus using each of these three definitions and, for each, we estimated the association between the diagnosis and infertility and/or previous miscarriage, and anticipated the costs associated with their implementation using a guesstimation method. Results Although 32.6% (85/261) of the subjects met the criteria for one of the three definitions of septate uterus, only 2.7% (7/261) of them were defined as having septate uterus according to all three definitions. We diagnosed significantly more cases of septate uterus using ESHRE/ESGE‐2016 than using ASRM‐2016 (31% vs 5%, relative risk (RR) = 6.7, P < 0.0001) or CUME‐2018 (31% vs 12%, RR = 2.6, P < 0.0001) criteria. We also observed frequent cases that could not be classified definitively by ASRM‐2016 (gray zone: neither normal/arcuate nor septate; 6.5%). There were no significant differences (P > 0.05) in the prevalence of septate uterus in women with vs those without infertility according to ASRM‐2016 (5% vs 4%), ESHRE/ESGE‐2016 (35% vs 28%) or CUME‐2018 (11% vs 12%). Septate uterus was diagnosed significantly more frequently in women with vs those without previous miscarriage according to ASRM‐2016 (11% vs 3%; P = 0.04) and CUME‐2018 (22 vs 10%; P = 0.04), but not according to ESHRE/ESGE‐2016 (42% vs 28%; P = 0.8) criteria. Our calculations showed that gl...

Septum resection in women with a septate uterus: a cohort study

“…Second, we collected the data of women with a septate uterus between 1981 and 2018, and during that period the ideas and concepts on the classification of uterine anomalies and the best diagnostic tool to differentiate between septate, arcuate and bicornuate uterus changed ( Ludwin and Ludwin, 2015 ). In fact, the discussion about the most accurate definition of the septate uterus is still ongoing (Grimbizis et al ., 2013; ASRM, 2016 ; Ludwin et al ., 2018 ; Ludwin et al ., 2019 ). In addition, saline or gel infusion sonohysterography and 3D-ultrasound is currently considered as the most accurate test for diagnosing the septate uterus, but this was not available in the time period in which some of our patients were diagnosed ( Ludwin et al ., 2014a ).…”

Ultrasound at the intersection of art, science and technology: complete septate uterus with longitudinal vaginal septum

“…When external fundal uterine indentation is absent in a uterus with internal complete division of the uterine cavity, as in the present case, then the diagnosis of a complete septate uterus is made 1,3,4 . If an external cleft is present, its depth should be measured and a diagnosis made according to the used classification system 1,4 . The differentiation between a septate and a double cervix is based on subjective impression, because so far there is no specific classification with measurable criteria and cut‐offs for the description of cervical deformities 1,2 .…”

“…The differentiation between complete septate, bicornuate and didelphic uterus is based on assessment of the external uterine fundal contour and the presence or absence of external fundal division and its degree, respectively 1,3 . When external fundal uterine indentation is absent in a uterus with internal complete division of the uterine cavity, as in the present case, then the diagnosis of a complete septate uterus is made 1,3,4 . If an external cleft is present, its depth should be measured and a diagnosis made according to the used classification system 1,4 .…”

Uterine ‘anomalies’ by ESHRE/ESGE classification: are more than half of women really sick?

“…Such a 'septum' commonly has depth of 4 mm or even less. According to their criteria, approximately 30% of women will have a septate uterus, with the potential to create a billion-dollar market performing often unnecessary hysteroscopic metroplasty in women who would have a normal/arcuate uterus according to other classifications ( Figure 1) 5 . The problem is even greater for the ESHRE/ESGE classification of dysmorphic uterus and its subclasses: T-shaped uterus (defined as a narrow cavity and thickened lateral walls); uterus infantilis (defined as a narrow cavity without lateral wall thickening); and subclass U1c (defined as internal indentation depth < 50% of myometrial thickness).…”