I have a well-vascularized septum extending one-third of the way down my uterus. I have suffered recurrent pregnancy loss, apparently because of the septum, as no other causes have been found. My doctor has recommended surgery. This would be preceded by a couple of months of hormones to put me into a menopause-like state, and followed by a couple of months of estrogen to reverse the process. The doctor said it is unlikely they could remove more than half the septum because there would be too much bleeding. To me this surgery sounds very risky. The doctor is very cavalier about the whole thing, but I am concerned about the hormones having long-term adverse effects, that the surgery would not be particularly helpful, and in the worst-case scenario, that the septum would hemorrhage and I would end up infertile. What can you tell me about the safety and effectiveness of this procedure?

Sarah

An intrauterine septum results from incomplete formation of the uterus. Normally the uterus forms after two separate tubes of embryologic tissue join and merge into one hollow tube. A bicornuate or heart-shaped uterus is the result of incomplete fusion of these two tubes, while a uterine septum is the result of incomplete breakdown of the walls between the tubes after they merge. The difference is significant, yet it is often hard to distinguish between the two. Uterine anomalies such as these are often diagnosed by hysterosalpingogram (HSG) as part of the medical evaluation of recurrent pregnancy loss.

The septum is usually avascular (lacking blood supply). It is this lack of blood supply that is believed to lead to miscarriage if a fertilized egg implants on the septum. I am uncertain as to how your physician determined that it is a "well-vascularized septum." While a color doppler ultrasound can show blood flow, this technique is not commonly used to evaluate this condition.

The uterine septum is best managed by hysteroscopic resection. A tiny telescope and cutting instrument is passed into the uterus through the dilated cervix. The uterus is distended with fluid under pressure to enable the doctor to see the septum. Usually simply snipping the septum causes it to "unzip" -- meaning the tissue separates easily to the level of the top of the uterus. This procedure is technically easy. The doctor may have an assistant monitor the procedure at the same time by performing a laparoscopy (a procedure in which a miniature viewing device is inserted through a tiny slit in the abdomen).

The use of two or three months of a GnRH-agonist such as Zoladex, Lupron or Synarel can decrease the thickness of the uterine lining or reduce the vascularity of the septum. While hot flashes associated with the use of these medications are a pesky nuisance, there are no long-term side effects from brief use. Their use reduces the amount of bleeding at the time of surgery. Too much blood can make it hard for the doctor to see what is going on and can interfere with surgical resection.

The likelihood of any serious complication either from the medication or this type of surgery is very low if it is performed by a skilled surgeon. Unfortunately, true informed consent involves a description of every "what-if" scenario associated with a potential surgery. Before deciding about this surgery, you need to do a risk-benefit analysis, weighing the risk of another miscarriage or a premature birth against the unlikely event of a surgical complication. While it is impossible for me to comment on your physician's skill level or to recommend a procedure without evaluating you personally, it appears that the appropriate steps are being considered to minimize any risk to your health.