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Clinical Guidelines From the Journals

Reproductive Guidelines Shift on Surgical Timing

Conexiant

The American Society for Reproductive Medicine (ASRM) released updated evidence-based guidelines for diagnosing and treating uterine septum, emphasizing shared decision-making between physicians and patients regarding surgical intervention.

The guidelines, published in Fertility and Sterility, identified three-dimensional transvaginal ultrasound (3D TVUS) as the first-line diagnostic tool for uterine shape assessment, with or without saline infusion. This recommendation carried moderate strength based on intermediate-quality evidence (Strength of Evidence: B).

Among patients with recurrent pregnancy loss, the guidelines recommended hysteroscopic septum incision within a shared decision-making framework. Surgical correction demonstrated improved outcomes, particularly in reducing spontaneous abortion rates and obstetrical complications (Strength of Evidence: B).

The relationship between septate uterus and infertility remained unclear. The guidelines found insufficient evidence to firmly associate a septate uterus with infertility (Strength of Evidence: C). Among infertile patients, septum incision was noted as a reasonable option, but resection may or may not improve live birth rates (Strength of Evidence: B).

Key clinical considerations included:

  • Septum characteristics: Size or shape did not determine adverse reproductive outcomes.
  • Adhesion prevention: Routine measures postsurgery lacked sufficient evidence for recommendation (Strength of Evidence: C).
  • Postsurgery fertility treatment: Patients may proceed with fertility treatments 1 to 2 months following septum resection (Strength of Evidence: C).
  • Prophylactic resection: Insufficient evidence exists to recommend resection in patients who have not yet attempted conception (Strength of Evidence: Insufficient).

Regarding surgical timing, the guidelines suggested performing the procedure during the follicular phase or after progesterone withdrawal to optimize visualization, a recommendation based on expert opinion rather than clinical studies (Strength of Evidence: C).

Uterine rupture following septum resection appeared to be rare but was inconsistently reported. No evidence linked resection of the unicollis cervical septum to increased risk of cervical insufficiency (Strength of Evidence: C).

The update replaced the 2016 version and adhered to a methodologic protocol established by ASRM leadership and an independent consulting epidemiologist. Recommendations were based on 49 studies published between April 2015 and November 2022, culled from an initial pool of 323 studies.

The ASRM Practice Committee emphasized that these guidelines were intended to inform but not dictate clinical decision-making, recognizing variations in patient needs, resources, and institutional limitations. The guidelines will be reviewed for currency within 5 years of publication.

Among the notable outcomes were:

  • Increased relative risk (RR) of first-trimester spontaneous abortion (RR = 2.65, 95% confidence interval [CI] = 1.39–5.06) in patients with septate uteri
  • Higher risk of preterm birth (OR = 4.06, 95% CI = 2.89–5.70) and malpresentation (OR = 13.76, 95% CI = 5.52–34.32) associated with septate uteri
  • Improved outcomes in reducing miscarriage rates following septum resection for recurrent pregnancy loss (OR = 0.45, 95% CI = 0.22–0.90).

This comprehensive review provided clinicians with updated insights into diagnosing and managing uterine septum while emphasizing evidence-based shared decision-making for optimal patient care.

ASRM task force members disclosed potential conflicts of interest, and those with identified conflicts did not participate in developing the guidelines.