Missed Until Found: Diagnosis and Hysteroscopic Management of a Uterine Septum in a Woman With Primary Infertility

A 26-year-old nulligravid woman from Azerbaijan presented to the Department of Obstetrics and Gynecology of Azerbaijan Medical University with a three-year history of primary infertility. She had been married for three years and had been attempting spontaneous conception throughout this period without success. Her menstrual cycles were regular, occurring every 28 days with a duration of five days and normal menstrual flow. She denied dysmenorrhea, dyspareunia, abnormal uterine bleeding, intermenstrual bleeding, postcoital bleeding, or chronic pelvic pain. Her obstetric history was unremarkable (gravida 0, para 0), with no previous pregnancies, miscarriages, or ectopic pregnancies. She had no history of pelvic inflammatory disease, sexually transmitted infections, endometriosis, uterine surgery, or previous gynecological procedures. She had not previously undergone assisted reproductive techniques or fertility treatment. There was no history of hormonal contraceptive use immediately preceding infertility evaluation. Her medical history was otherwise unremarkable, with no known chronic illnesses including diabetes mellitus, hypertension, thyroid disease, autoimmune disorders, or thromboembolic disease. She had no previous surgical history and was not taking any regular medications. She reported no known drug allergies. She was a non-smoker and denied alcohol consumption and recreational drug use, and her family history was negative for CUAs, infertility, recurrent pregnancy loss, or hereditary genetic disorders. On physical examination, the patient appeared healthy and was in no acute distress. Her vital signs were stable, with a blood pressure of 125/78 mmHg, pulse rate of 73 beats/min, respiratory rate of 17 breaths/min, and body mass index of 27 kg/m². Abdominal examination was unremarkable, with no palpable masses or tenderness. Pelvic examination demonstrated normal external genitalia, a healthy cervix, and a normally sized anteverted uterus without cervical motion tenderness or adnexal masses. Bimanual examination revealed no pelvic tenderness or evidence of pelvic pathology. As part of the infertility evaluation, routine laboratory investigations, including complete blood count, renal and liver function tests, fasting blood glucose, and serum electrolytes, were within normal limits. Hormonal assessment demonstrated normal ovarian reserve and endocrine function, including follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, prolactin, thyroid-stimulating hormone (TSH), and anti-Müllerian hormone (AMH). Ovulatory function was considered normal based on hormonal evaluation and menstrual history. Semen analysis of the patient's partner demonstrated normal sperm concentration, morphology, and motility according to the World Health Organization laboratory manual for the examination and processing of human semen. Additional infertility investigations, including tubal patency assessment via hysterosalpingography (HSG), were unremarkable. Transvaginal ultrasonography demonstrated an abnormal uterine cavity, raising suspicion for a congenital Müllerian anomaly. Subsequent three-dimensional transvaginal ultrasonography confirmed the presence of a uterine septum extending into the endometrial cavity while maintaining a normal external uterine fundal contour, consistent with a septate uterus. Both ovaries appeared morphologically normal, with preserved ovarian reserve and no evidence of endometrioma or adnexal pathology. No associated renal anomalies were identified. Based on imaging findings, the anomaly was classified according to the ASRM Müllerian Anomalies Classification (2021). Following multidisciplinary discussion and detailed counseling regarding the diagnosis, available treatment options, expected reproductive outcomes, potential complications, and alternative management strategies, the patient elected to undergo hysteroscopic septum resection. The initial hysteroscopic findings and commencement of the operative procedure are demonstrated in Video 1 . The video shows a hysteroscopic procedure to remove a uterine septum. A camera, known as a hysteroscope, is placed inside the uterus, revealing the pink lining of the uterine cavity. A thick, whitish band of tissue-the septum-is visible in the center, dividing the cavity. A surgical instrument with a yellowish loop electrode is used to carefully cut away this septal tissue. As the loop slices through the septum, you can see bubbles and a smoke-like effect, which is caused by the electrical current used to cut the tissue. The goal of this surgery is to remove the division and create a single, unified uterine cavity. The procedure was performed under general anesthesia using a 5 mm hysteroscope. Uterine cavity distension was achieved using normal saline, and hysteroscopic evaluation confirmed the presence of a complete uterine septum extending from the uterine fundus into the endometrial cavity. Both tubal ostia were identified following complete septal resection. The septum was resected using cold scissors under direct hysteroscopic visualization until restoration of a single triangular uterine cavity was achieved. The operative time was approximately 40 minutes, with minimal estimated blood loss. The final hysteroscopic appearance following complete septum resection is shown in Video 2 . No intraoperative complications, including uterine perforation, excessive bleeding, fluid overload, or cervical trauma, were encountered. Histopathological examination was not performed because the resected septal tissue was minimal and the diagnosis had already been established based on characteristic imaging and intraoperative hysteroscopic findings. This video shows the final stages and conclusion of the hysteroscopic uterine septum resection. A unified cavity: The most notable change from the beginning of the surgery is that the thick, dividing wall of tissue (the septum) has been completely cut away. The left and right sides of the uterus are now joined into a single, wide, and open cavity. Final adjustments: The surgical loop instrument is seen making final movements to smooth out the edges where the septum was attached to the uterine wall, ensuring no residual tissue blocks the cavity. Surgical debris and bubbles: The fluid inside the uterus appears somewhat cloudy with floating tissue fragments, small air bubbles, and minor bleeding. This is completely normal at the end of the procedure due to the electrosurgical cutting. The video concludes with a clear view of the restored, single uterine chamber, signaling a successful operation. The postoperative course was uneventful. The patient remained hemodynamically stable and was discharged on postoperative day 2 with routine postoperative instructions. She received analgesics (ibuprofen) and antibiotics and was advised to avoid sexual intercourse for two weeks to allow adequate endometrial healing. Follow-up transvaginal ultrasonography performed one month after surgery demonstrated restoration of a normal uterine cavity without evidence of residual septum or intrauterine adhesions (IUAs). The patient remained asymptomatic and was counseled regarding the optimal timing of future conception, including the option of spontaneous conception and assisted reproductive techniques if clinically indicated. At the most recent follow-up, she continued routine reproductive follow-up with plans for spontaneous conception.

Congenital uterine anomalies (CUAs) are structural abnormalities of the female reproductive tract resulting from abnormal development, fusion, or resorption of the Müllerian ducts during embryogenesis [ 1 ]. They are estimated to affect approximately 4%-7% of women in the general population, with substantially higher prevalence among women presenting with infertility, recurrent pregnancy loss, and adverse obstetric outcomes [ 2 ]. Among these anomalies, a septate uterus is the most common congenital uterine malformation and is characterized by incomplete resorption of the medial septum following normal fusion of the Müllerian ducts, resulting in a fibrous or fibromuscular partition that partially or completely divides the endometrial cavity [ 3 ]. Although many women with a septate uterus remain asymptomatic, the anomaly has been associated with infertility, recurrent miscarriage, preterm birth, fetal malpresentation, and other adverse reproductive outcomes [ 4 , 5 ]. The underlying mechanisms are not completely understood but are thought to involve impaired vascularization of the septal tissue, altered endometrial receptivity, and abnormal implantation, all of which may compromise embryo implantation and fetal development [ 5 ]. Given these potential reproductive consequences, accurate diagnosis and appropriate management are essential, particularly in women with otherwise unexplained infertility. Advances in diagnostic imaging have substantially improved the evaluation of CUAs [ 6 ]. Three-dimensional transvaginal ultrasonography has emerged as the preferred first-line imaging modality because of its high diagnostic accuracy, non-invasive nature, and ability to simultaneously assess both the endometrial cavity and the external uterine contour [ 6 , 7 ]. Magnetic resonance imaging serves as a valuable complementary modality in complex cases or when ultrasonographic findings are inconclusive. Accurate differentiation between a septate uterus and other Müllerian anomalies, particularly a bicornuate uterus, is crucial because treatment strategies and reproductive prognoses differ considerably [ 8 , 9 ]. Current guidelines from the American Society for Reproductive Medicine (ASRM) and the European Society of Human Reproduction and Embryology (ESHRE) emphasize standardized classification systems and individualized management of uterine anomalies [ 4 ]. Hysteroscopic septum resection is currently considered the treatment of choice for appropriately selected patients because it is minimally invasive, associated with low complication rates, and effectively restores normal uterine cavity anatomy. While growing evidence suggests that hysteroscopic septoplasty may improve reproductive outcomes, particularly by reducing miscarriage rates, its effect on live birth rates and fertility in all women with septate uterus remains an area of ongoing investigation. Consequently, careful patient selection and individualized clinical decision-making continue to play a central role in management [ 8 - 10 ]. Published literature describing septate uterus from the South Caucasus region remains limited, and reports highlighting the diagnostic evaluation and minimally invasive management of this condition are scarce. This case describes a young woman from Azerbaijan who presented with primary infertility secondary to a uterine septum and was successfully managed with hysteroscopic septum resection. By integrating current evidence with regional clinical experience, this report emphasizes the importance of comprehensive anatomical assessment during infertility evaluation, timely diagnosis using contemporary imaging techniques, and appropriate surgical management to optimize future reproductive outcomes.

A septate uterus is the most common congenital Müllerian anomaly and results from incomplete resorption of the medial septum following normal fusion of the paired Müllerian ducts during embryogenesis [ 1 ]. Depending on the extent of resorption failure, the septum may be partial or complete, dividing the endometrial cavity while preserving a normal external uterine contour. Although many women remain asymptomatic, a septate uterus has been consistently associated with infertility, recurrent pregnancy loss, preterm birth, malpresentation, and other adverse obstetric outcomes [ 8 ]. The precise mechanism underlying impaired reproductive performance remains incompletely understood but is believed to involve poor vascularization of the septal tissue, altered endometrial receptivity, abnormal implantation, and impaired placentation, all of which may negatively influence embryo implantation and pregnancy maintenance [ 3 , 5 , 11 ]. Figure 1 schematically illustrates the normal embryological development of the Müllerian ducts and the failure of septal resorption that results in the formation of a septate uterus. Schematic illustration showing normal fusion of the paired Müllerian ducts followed by complete resorption of the intervening septum to form a single uterine cavity. Failure of septal resorption after normal duct fusion results in the formation of a partial or complete septate uterus. The authors used Claude (Anthropic, San Francisco, CA, USA) to assist in the creation of this figure. Accurate classification of CUAs is essential because management and reproductive prognosis vary among different malformations. The ASRM Müllerian Anomalies Classification (2021) and the ESHRE/European Society for Gynaecological Endoscopy (ESGE) classification remain the most widely accepted systems for categorizing uterine anomalies [ 1 , 2 , 4 , 10 ]. These standardized classifications facilitate appropriate diagnosis, improve communication among clinicians, and guide individualized management. In the present case, imaging findings were consistent with a septate uterus according to contemporary classification criteria, supporting hysteroscopic septum resection as the preferred treatment strategy [ 2 - 4 ]. The classification and diagnostic pathway for septate uterus, including the recommended sequence of imaging modalities and differentiation from other Müllerian anomalies, is illustrated in Figure 2 . Schematic illustration summarizing the contemporary classification systems (ASRM and ESHRE/ESGE) and the recommended diagnostic approach for septate uterus, including initial clinical evaluation, 3D transvaginal ultrasonography as the preferred first-line imaging modality, complementary use of MRI in selected cases, differentiation from other Müllerian anomalies, and confirmation of the diagnosis to guide appropriate management. 1. 3D-TVUS is the preferred first-line modality. 2. Differentiate septum from bicornuate uterus: septum → normal/convex fundal contour; bicornuate → external fundal indentation. Accurate classification predicts reproductive risk and guides management. The authors used Claude (Anthropic, San Francisco, CA, USA) to assist in the creation of this figure. MRI: magnetic resonance imaging; 3D: three-dimensional; ASRM: American Society for Reproductive Medicine; ESHRE/ESGE: European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy The diagnosis of a septate uterus has evolved considerably with advances in imaging technology. Three-dimensional transvaginal ultrasonography is currently regarded as the preferred first-line imaging modality because it provides excellent visualization of both the endometrial cavity and the external uterine contour while remaining non-invasive and widely accessible [ 12 ]. Figure 3 provides a schematic overview of the clinical presentation of septate uterus, highlighting its variable manifestations and associated reproductive complications. Schematic illustration summarizing the spectrum of clinical manifestations associated with a septate uterus. While some women remain asymptomatic, others may present with primary infertility, recurrent pregnancy loss, recurrent implantation failure, preterm birth, fetal malpresentation, abnormal uterine bleeding, dysmenorrhea, pelvic pain, or adverse obstetric outcomes. The severity and presentation vary depending on the extent of the septum and individual patient characteristics. The authors used Claude (Anthropic, San Francisco, CA, USA) to assist in the creation of this figure. RPL: recurrent pregnancy loss; Tx: treatment; ESHRE/ESGE: European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy; MRI: magnetic resonance imaging; Mx: medical management; LA/GA: local anesthesia/general anesthesia Magnetic resonance imaging serves as an important complementary investigation when sonographic findings are inconclusive or complex Müllerian anomalies are suspected. Accurate differentiation between a septate uterus and other CUAs, particularly a bicornuate uterus, is essential because treatment strategies differ substantially [ 13 , 14 ]. Unlike a septate uterus, which is effectively treated by hysteroscopic septoplasty, a bicornuate uterus generally does not benefit from hysteroscopic correction. Therefore, careful preoperative anatomical assessment is fundamental to avoid inappropriate management [ 6 , 7 , 12 , 13 ]. Table 1 provides a summary of the differential diagnosis of congenital Müllerian anomalies, emphasizing the key distinguishing embryological, imaging, clinical, and management features that facilitate accurate diagnosis and guide appropriate clinical decision-making. Sources: adapted from ASRM Müllerian Anomalies Classification (2021), ESHRE/ESGE classification, and published reviews on congenital uterine anomalies [ 2 - 4 , 11 ]. 3D: three-dimensional; TVUS: transvaginal ultrasonography; MRI: magnetic resonance imaging; ASRM: American Society for Reproductive Medicine; ESHRE/ESGE: European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy Hysteroscopic septum resection has become the standard minimally invasive treatment for symptomatic women with a septate uterus because it restores normal uterine cavity anatomy while avoiding abdominal surgery [ 15 ]. The procedure is associated with low complication rates, rapid postoperative recovery, and preservation of reproductive potential. Nevertheless, the impact of septoplasty on fertility outcomes remains an area of ongoing investigation [ 15 , 16 ]. Recent systematic reviews and meta-analyses have demonstrated that hysteroscopic septum resection is consistently associated with a reduction in miscarriage rates and improved reproductive outcomes in appropriately selected patients [ 5 , 6 , 10 , 17 ]. However, evidence regarding improvement in live birth rates and overall fertility remains less definitive. The international randomized controlled trial conducted by Rikken et al. reported no statistically significant benefit of routine septum resection for all women with a septate uterus, highlighting the importance of individualized patient selection rather than universal surgical intervention [ 10 ]. Conversely, multiple observational studies have reported favorable improvements in clinical pregnancy rates, live birth rates, and reduction in pregnancy loss following hysteroscopic septoplasty [ 9 ]. These differences likely reflect variations in patient selection, study design, septum characteristics, and duration of follow-up [ 7 , 9 , 10 ]. A summary of recent evidence on the diagnosis and management of septate uterus, including current guidelines, systematic reviews, meta-analyses, and key clinical studies, is presented in Table 2 . ASRM: American Society for Reproductive Medicine; ESHRE: European Society of Human Reproduction and Embryology; ESGE: European Society for Gynaecological Endoscopy; CUME: Congenital Uterine Malformation by Experts; MRI: magnetic resonance imaging; 3D TVUS: three-dimensional transvaginal ultrasonography; ART: assisted reproductive technology Complete excision of the septum appears to be an important determinant of successful reproductive outcomes [ 16 ]. Residual septal tissue may impair implantation and has been associated with persistent infertility or recurrent pregnancy loss. Consequently, careful intraoperative visualization and, in selected cases, postoperative assessment using three-dimensional ultrasonography or second-look hysteroscopy may optimize surgical outcomes, particularly among women undergoing assisted reproductive techniques [ 16 - 18 ]. The management of a septate uterus primarily relies on hysteroscopic correction (septoplasty or metroplasty), which has been shown to improve reproductive outcomes. However, as highlighted by Dason et al. [ 18 ], while numerous surgical variations exist, there remains a notable lack of high-quality, standardized evidence supporting one specific technique over another. Guidelines from the Society of Laparoscopic and Robotic Surgeons (SLS) underscore the importance of meticulous evaluation and careful technique to prevent intraoperative and postoperative complications during septum resection. A primary concern following any hysteroscopic intervention is the formation of IUAs, which can negatively impact future fertility. Hafizi et al. [ 19 ] emphasized the necessity of evaluating post-surgical IUA formation, noting that endometrial healing plays a critical role in overall success. The choice of surgical energy modality is central to this debate. Recent data from Piriyev et al. [ 13 ] evaluating electrosurgical hysteroscopic metroplasty demonstrated favorable perioperative safety profiles, though post-operative adhesion rates remain a key metric of long-term success. To minimize thermal damage and subsequent adhesion formation, many surgeons advocate for mechanical instruments. This is supported by broader hysteroscopic data; a 2021 meta-analysis in Medicine (Baltimore) [ 20 ] and a multicenter randomized controlled trial in the International Journal of Surgery comparing cold scissors to electrosurgery found that mechanical "cold" techniques (such as the cold scissors ploughing technique) significantly reduce postoperative adhesion scores and preserve surrounding healthy endometrium compared to electrosurgical excision (Table 3 ). Source: Piriyev et al. [ 13 ], Hafizi et al. [ 19 ], and Yang et al. [ 20 ] Consequently, while electrosurgery remains a widely utilized and efficient approach for septum resection, the integration of cold scissors or anti-adhesion barriers should be strongly considered to optimize tissue healing and protect the patient's reproductive potential. The present case illustrates several important clinical principles. The patient presented with prolonged unexplained primary infertility despite normal hormonal evaluation and a normal partner assessment. Comprehensive anatomical evaluation ultimately identified a septate uterus as the underlying structural abnormality. Successful hysteroscopic septum resection restored a normal uterine cavity without perioperative complications, and postoperative imaging confirmed complete correction of the anomaly. This clinical course is consistent with current recommendations emphasizing the importance of evaluating uterine anatomy in women with otherwise unexplained infertility before proceeding to more invasive fertility treatments. Although a septate uterus is a well-recognized congenital anomaly, published case reports and clinical data from the South Caucasus region remain limited. To our knowledge, detailed reports describing the diagnosis and hysteroscopic management of uterine septum in women with primary infertility from Azerbaijan are scarce. This case therefore contributes valuable regional clinical experience by demonstrating the successful application of contemporary diagnostic imaging and minimally invasive hysteroscopic management within a resource-variable healthcare setting. In many developing and transitional healthcare systems, delayed diagnosis may occur because advanced imaging modalities such as three-dimensional transvaginal ultrasonography and magnetic resonance imaging are not uniformly available, and specialized reproductive medicine services may be limited [ 12 ]. Consequently, women with CUAs may undergo prolonged infertility evaluation before the underlying anatomical abnormality is identified. This case emphasizes the importance of improving access to specialized gynecologic imaging and infertility services to facilitate earlier diagnosis and appropriate intervention. This case reinforces the importance of including CUAs in the differential diagnosis of women presenting with unexplained primary infertility, even when endocrine evaluation, ovulatory function, and male factor assessment are normal. Comprehensive assessment of uterine anatomy should be considered an integral component of infertility investigations because early identification of correctable structural abnormalities may reduce unnecessary delays in treatment and improve reproductive planning [ 9 ]. Hysteroscopic septum resection remains a safe, minimally invasive procedure that can effectively restore normal uterine anatomy with minimal perioperative morbidity. The strengths of this report include comprehensive infertility evaluation, confirmation of the diagnosis using advanced imaging, successful minimally invasive surgical management, and postoperative documentation of restoration of a normal uterine cavity. Furthermore, the discussion integrates contemporary evidence and international guideline recommendations with regional clinical experience. The principal limitation of this report is its single-patient design, which precludes generalization of clinical outcomes. In addition, long-term reproductive outcomes, including pregnancy and live birth, were not available at the time of manuscript preparation. Larger prospective studies with extended follow-up are needed to further clarify the impact of hysteroscopic septum resection on fertility and obstetric outcomes and to better define the patients most likely to benefit from surgical intervention.

In summary, this case highlights the successful management of a 26-year-old nulligravid woman who presented with primary infertility of three years' duration attributed to a complete septate uterus. Prompt diagnosis utilizing three-dimensional transvaginal ultrasonography and accurate anatomical categorization facilitated targeted intervention via a hysteroscopic septum resection using cold scissors. Post-operatively, follow-up evaluation confirmed the restoration of a normal uterine cavity, and the patient completely recovered without any intraoperative or postoperative complications. Ultimately, this report underscores the critical importance of utilizing standardized classification frameworks to guide appropriate anatomical correction in congenital Müllerian anomalies. Bridging the gap between precise radiological assessment and definitive, minimally invasive clinical execution remains paramount for restoring normal uterine anatomy and optimizing future reproductive outcomes. Furthermore, increased clinical awareness and timely access to advanced diagnostic imaging are essential, particularly within resource-variable healthcare settings where these correctable structural anomalies may otherwise remain underdiagnosed.