A 24 year old woman visits the infertility clinic with a complaint of recurrent abortions. Upon investigations, she is found to have a septate uterus. Which of the following corrective procedures has the best obstetric outcome ?

Explanation

## Correct Answer: C. Transcervical resection of septum A septate uterus is the most common congenital uterine anomaly (35% of all anomalies) and the only one with significantly impaired fertility and recurrent pregnancy loss due to poor vascularization of the septum. Transcervical resection of the septum (hysteroscopic metroplasty) is the gold-standard corrective procedure because it: (1) directly removes the non-vascularized fibromuscular septum under direct visualization, (2) preserves the uterine fundus and myometrium integrity, (3) avoids abdominal incision and associated adhesions, and (4) has the best obstetric outcomes with live birth rates of 60–80% post-procedure. The hysteroscopic approach allows precise identification of the septum's extent and safe resection using electrosurgical instruments or laser. This is the preferred approach in modern Indian gynecological practice and aligns with international guidelines (ASRM, ESHRE). Abdominal metroplasties (Jones, Tompkins, Strassmann) are now largely obsolete for septate uterus because they involve opening the uterine fundus, creating significant myometrial scarring and weakening, leading to poor obstetric outcomes, increased cesarean delivery rates, and uterine rupture risk in subsequent pregnancies. ## Why the other options are wrong **A. Jones metroplasty** — Jones metroplasty (wedge resection of the uterine fundus) is an abdominal approach that requires opening the full thickness of the uterine fundus. This creates extensive myometrial scarring and weakens the uterine wall, leading to poor obstetric outcomes, increased cesarean delivery rates, and risk of uterine rupture in future pregnancies. It is now obsolete for septate uterus management. **B. Tompkins metroplasty** — Tompkins metroplasty involves a longitudinal incision on the uterine fundus with transverse closure, also creating significant myometrial scarring and weakening. Although it preserves more myometrium than Jones metroplasty, it still carries the risks of poor wound healing, adhesions, and compromised uterine integrity. It is outdated for septate uterus and reserved only for bicornuate uterus in select cases. **D. Strassmann metroplasty** — Strassmann metroplasty involves unification of two uterine horns through an abdominal approach, primarily used for bicornuate or didelphys uterus, not septate uterus. It requires extensive myometrial dissection and reconstruction, creating severe scarring and poor obstetric outcomes. It is inappropriate for septate uterus and carries high morbidity. ## High-Yield Facts - **Septate uterus** is the most common congenital uterine anomaly (35% of all anomalies) and the only one with significantly impaired fertility due to poor vascularization of the septum. - **Transcervical hysteroscopic metroplasty** is the gold-standard treatment for septate uterus with live birth rates of 60–80% post-procedure. - **Abdominal metroplasties** (Jones, Tompkins, Strassmann) are now obsolete for septate uterus because they create myometrial scarring, increase cesarean delivery rates, and risk uterine rupture. - The **septum is avascular** fibromuscular tissue with poor blood supply, explaining recurrent miscarriage and the rationale for direct hysteroscopic resection. - **Hysteroscopic approach** avoids abdominal incision, preserves myometrial integrity, and allows precise visualization and safe resection of the septum. ## Mnemonics **SAM: Septate uterus → Abdominal Metroplasty = Mistake** Septate uterus requires hysteroscopic (transcervical) resection, NOT abdominal metroplasty. Abdominal approaches (Jones, Tompkins, Strassmann) are reserved for bicornuate/didelphys uterus. Use this to avoid confusing septate with other anomalies. **HYSTER = Best for Septate** HYsteroscopic resection is the gold standard for septate uterus. Remember: Hysteroscopic = Hyper-good outcomes for septate uterus. Abdominal = Archaic and associated with poor outcomes. ## NBE Trap NBE may pair abdominal metroplasties (Jones, Tompkins, Strassmann) with septate uterus to trap students who confuse congenital uterine anomalies or who memorize procedure names without understanding their specific indications. The key discriminator is that septate uterus is the ONLY anomaly where hysteroscopic resection is superior; all abdominal approaches are now obsolete for this indication. ## Clinical Pearl In Indian clinical practice, a 24-year-old woman with recurrent first-trimester miscarriages and a septate uterus should be counseled for hysteroscopic metroplasty as the first-line treatment. Post-procedure, she can safely attempt vaginal delivery in most cases (unlike abdominal metroplasty patients), making this the preferred approach for young women planning future pregnancies. _Reference: DC Dutta's Textbook of Obstetrics (7th ed.) Ch. 8 (Congenital Anomalies of Uterus); ASRM Guidelines on Congenital Uterine Anomalies_