A uterine septum is a congenital abnormality that has been associated with poor reproductive outcome that can be readily corrected by hysteroscopic surgery. For this debate article we argue that all women with a uterine septum should have hysteroscopic septal resection before undergoing any fertility treatment. A uterine septum is a congenital uterine anomaly arising from the failure of canalisation of the uterus during embryological development. Uterine septa are more prevalent in women with a history of pregnancy loss, but not infertility alone, and are associated with an increased risk of first and second trimester miscarriage and preterm birth [1,2]. Diagnosis is straightforward with three-dimensional ultrasound. Adequate assessment of uterine morphology requires concurrent imaging of the external and internal controls of the uterus. Three-dimensional ultrasound facilitates such views and is safer and more acceptable to women than surgical assessment with hysteroscopy and laparoscopy which are required to see the internal and external fundal contours.

A 22-year-old female, gravida 3, para 0, presents to the office for evaluation of recurrent pregnancy loss. Her obstetric history is significant for three prior first-trimester losses, all managed expectantly. She has regular menstrual cycles and has not had difficulty with conceiving in the past. She has been in a relationship with her partner for four years and they desire to conceive at this time. She has no significant past medical or family history and has not had prior surgery. She takes no medications and has no allergies.

Uterine and tubal abnormalities alone or in combination with other factors are present in 17%–25% of all couples who seek care for infertility treatment. The prevalence is higher in older women and in those with secondary infertility. Although suspected at the history, it is usually confirmed by ultrasound/ laparoscopy and/or MRI depending on the cause. Multiple pathologies are identified under the umbrella of tubal and uterine factors, some are associated with infertility but very few are proven to be the only cause of infertility. Treatment depends on the condition. It ranges from no intervention to surgery to in vitro fertilisation (IVF). With advances in the technology of IVF, surgery is becoming a lost art, especially for tubal factors. Various surgical techniques have been suggested for uterine factors. Given most tubal and uterine factors have association rather than causation for infertility, the effect of surgery on improving fertility is debatable. We will discuss the causes of uterine and tubal factors, their implications on fertility, diagnostic modalities and treatment options with limitations of the available evidence. A good history and a high index of suspicion along with primary and secondary prevention of tubal and uterine factor infertility are important to prevent long-term implications.