Congenital uterine anomalies — structured oral station (12 minutes)

Opening prompt — "Tell me how you classify this woman's anomaly and how you would confirm it."

Model response — say it in this order:[2][4]

• "Three classification systems exist: the 1988 American Fertility Society classification, the 2013 ESHRE/ESGE CONUTA system — which is anatomy-based with classes U0 to U6, where septate is U2 — and the 2021 ASRM Müllerian Anomalies Classification, which is built on the 1988 system but expanded to include the vagina and cervix."[1][2][3]
• "Before I label this a septate uterus I need to confirm it under a defined criterion and, critically, assess the external fundal contour. The ESHRE/ESGE Thessaloniki consensus recommends 3D transvaginal ultrasound as first-line for a symptomatic, high-risk woman — it renders the coronal plane and shows both the cavity and the external contour in one view."[4]
• "If the external contour is normal with an internal indentation, it is a septate uterus. If there is an external fundal cleft, it is a bicornuate uterus — and that distinction changes everything."[4]

Probe 1 — "The report says the indentation is about 1 cm. Is that a septate uterus?"

• "It depends entirely on which criteria I apply. Under the CUME definition — internal indentation at least 1 cm with external indentation under 1 cm — yes. Under the ASRM criterion it needs to be at least 1.5 cm with an angle under 90 degrees. Under ESHRE/ESGE it must exceed 50% of the uterine wall thickness."[6]
• "This discordance is well described: in the Ludwin CUME study only 2.7% of women met all three definitions, and the ESHRE/ESGE criteria diagnosed septate about six times more often than ASRM. I would want the 3D volumes reviewed by someone experienced before committing to a diagnosis and certainly before surgery."[6]

Probe 2 — "She has had three miscarriages. How does that change your prevalence thinking?"

• "The prevalence of uterine anomalies rises with reproductive risk. In the Chan meta-analysis, by optimal tests it is about 5.5% in the unselected population, 8% in infertile women, 13.3% in those with miscarriage, and 24.5% in women with both miscarriage and infertility."[5]
• "Septate uterus is the commonest anomaly in high-risk groups like hers, which is why it is the anomaly we most often operate on. Arcuate uterus is the commonest in the unselected population but behaves near-normally."[5]

Probe 3 — "She asks whether she should have the septum resected. What do you tell her about the evidence?"

• "I would tell her that observational studies suggest benefit — the Wu meta-analysis found a higher term-delivery rate after resection, with an odds ratio of about 2.3 — but that the evidence is mainly from before-and-after studies, which inherently favour the intervention."[8]
• "The 2025 Cochrane review is explicit about this flaw, and the definitive randomised trial, TRUST, was still accruing at protocol publication. So the benefit is plausible but not yet randomised-trial-proven, and I would counsel her honestly on that before she decides."[7]
• "For a woman with three losses and a confirmed septate uterus under agreed criteria, I would offer hysteroscopic metroplasty, because recurrent loss is the clearest indication — but I would frame it as a reasonable offer on observational evidence, not a guaranteed fix."[2][7]

Probe 4 — "She is frightened about the surgery itself. What are the risks, and how will you follow her up?"

Rapport and respect are scored domains — demonstrate the counselling out loud:[2]

• "I would move to her eye level, use her name, and explain plainly: hysteroscopic metroplasty is a day-case keyhole procedure through the cervix, with no abdominal incision. The main risks are uterine perforation, fluid overload, cervical trauma, and postoperative intrauterine adhesions — which occur in roughly a quarter of women after septum resection."[7]
• "I would plan adhesion prevention and a second-look hysteroscopy where practised. And I would tell her that even after resection, she remains at higher risk of preterm birth and placental complications, so her pregnancies will be consultant-led with a surveillance plan."[7][8]
• "I would also image her renal tract, because Müllerian and renal development share embryological proximity, and offer her a follow-up appointment to revisit the decision and answer her questions."[4]

Probe 5 — "How would your answer change if the external contour showed a cleft?"

• "Then this is a bicornuate uterus, not a septate uterus, and hysteroscopic resection is the wrong operation — it would resect functional myometrium and risk perforation."[2]
• "A bicornuate uterus with significant reproductive morbidity, if surgery is warranted, needs an abdominal unification metroplasty — the Strassman procedure — now usually laparoscopic. The defence is always the same: see the external contour before you cut."[2]