Uterus didelphys with cervical agenesis associated with adenomyosis, a leiomyoma and ovarian endometriosis. A case report

BACKGROUND

Elevated level of serum CA-125 was detected in a 48-year-old woman who was diagnosed with a lateral fusion defect in association with congenital agenesis of the uterine cervix. This unusual case combined two developmental anomalies of the müllerian duct.

CASE REPORT

A 48-year-old woman consulted our outpatient department due to persistent abdominal pain for six months. Bimanual pelvic examination showed absence of the cervix, an anteverted uterus and a 6-cm, left adnexal mass. Ultrasound and computed tomography revealed a uterus didelphys with a 3-cm cystic mass over the right ovary. Serum level of CA-125 was 641.4 U/mL. The patient underwent exploratory laparotomy, and total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed. Pathology confirmed adenomyosis and a leiomyoma of the uterus with functional endometrium in conjunction with endometriosis of the right ovary.

CONCLUSION

Multiple müllerian anomalies associated with adenomyosis and endometriosis should be considered in patients presenting with primary amenorrhea. Thorough evaluation, careful planning, fertility preservation and postoperative outcomes should be reviewed.

Two cases of the caudal duplication anomaly including a discordant monozygotic twin

We present two unrelated patients with various duplications in the caudal region. One patient presented with a duplication of the distal spine from L4, left double ureter, duplication of the vagina and cervix, and duplication of the distal colon. The second patient was diagnosed with a duplication of the colon, bladder, vagina and uterus. The first patient had an unaffected monozygotic twin sister. Dominguez et al. [1993: Am J Dis Child 147:1048-1052] presented six similar cases, and introduced the name "caudal duplication syndrome." The pathogenesis of the caudal duplication anomaly is unclear. The possibility of a polytopic primary developmental field defect or a disruptive sequence are discussed. On the other hand, somatic or germline mutations in certain developmental genes could be involved, as illustrated by the mouse mutations disorganisation and fused. DNA-analysis of the AXIN1 gene, the human homologue of the gene responsible for fused, performed in our first patient, did not show any apparent pathogenic mutation.

Laparoscopic ultrasonography for uterovaginal canalization of a didelphic uterus with agenetic cervix

Mullerian duct anomaly is often characterized by any of a number of disorders of the outflow tract and uterus. A 17-year-old woman suffered from cyclic lower abdominal pain for 3 years. Pelvic examination showed a small uterus with blind-ended vaginal canal about 3 cm in length. Three-dimensional pelvic ultrasonography showed a compact uterine corpus with fundal notch regarded as bicornuate uterus, and no evidence of uterine cervix. The same features were also proved by magnetic resonance imaging. Intraoperative ultrasonography showed a small uterine cavity, and uterovaginal canalization was performed. The patient had regular menses without further low abdominal pain after 6 months of follow-up. Uterovaginal canalization with the aid of intraoperative ultrasonography may be effective in managing the difficult didelphic uterus with an agenetic cervix and hypoplastic vagina.

Pregnancy and transvaginal septation

Patients with an imperforate transverse vaginal septum typically present in adolescence with primary amenorrhea and require surgical correction. Pregnancy in these women is associated with a high spontaneous abortion rate, but no association with incompetent cervix has been reported. We describe a patient with a high transverse vaginal septum and a short cervix requiring transabdominal cerclage.

Management of missed abortion in a patient with congenital cervical atresia

OBJECTIVE

To describe a patient with congenital cervical atresia who became pregnant through IVF and thawed transmyometrial ET and then experienced a missed abortion.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A patient with congenital cervical atresia who underwent reconstructive surgery at 23 years of age and underwent IVF twice at 28 and 30 years of age.

INTERVENTION(S)

Abortion management.

MAIN OUTCOME MEASURE(S)

Medical follow-up of IVF-ET, resultant pregnancy, and abortion.

RESULT(S)

After the second cycle of IVF with frozen-thawed transmyometrial ET, the patient became pregnant but then experienced a missed abortion. Serum beta-hCG levels decreased, the two gestational sacs disappeared, and genital bleeding without signs of infection occurred 14 weeks after diagnosis of the abortion. The abortion was managed conservatively.

CONCLUSION(S)

When assisted reproductive techniques are used in patients with congenital cervical atresia, the risks (including those relating to the management of an abortion) should be explained in detail to the couple and sufficient informed consent should be obtained before starting IVF-ET procedures.

Uterocervicoplasty with a bladder mucosa layer for the treatment of complete cervical agenesis

OBJECTIVE

To create an endocervical canal in a patient with a complete cervical agenesis.

DESIGN

Case report.

SETTING

University hospital.

PATIENT(S)

A 12-year-old girl presented with lower abdominal pain. On examination, complete vaginal agenesis was noted, with a 2-cm vaginal dimple. A pelvic magnetic resonance imaging scan disclosed an hematometra and absence of the cervix and vagina.

INTERVENTION(S)

Initial surgical therapy consisted of a vaginoplasty with a sigmoid bowel segment and opening of the uterus by puncture and stenting. The cervical permeation failed, with immediate complete stenosis. A new attempt was made through a low sagittal hysterotomy by removing a central muscular cylinder and lining the channel with a free tubularized bladder mucosa graft. A stent was left in place.

MAIN OUTCOME MEASURE(S)

Hysteroscopy, hysterography, and clinical follow-up evaluation.

RESULT(S)

The cervical stent was removed after 5 months. A hysterography and hysteroscopy confirmed the permeability of the cervix, which was lined by a well-vascularized longitudinally folded mucosa. Regular menses had been noted for more than 3 years as of this report.

CONCLUSION(S)

Cervicoplasty with mucosal lining permits the creation of a patent cervical canal, even in the reputedly unfavorable forms of congenital cervical agenesis.

[Congenital agenesis of vagina and cervix]

A case of vaginal and cervical agenesis was presented. The mode of therapeutic procedure consisting of several stages was shown. Menstruation to abdominal cavity was stopped, using pharmacological agent. At the first step diagnostic laparoscopy was performed and artificial vagina was formed. During the second operation a junction of uterus with vagina was carried out. At present, the patient menstruates through vagina. The normal sexual function was achieved.

Findings in female offspring of women exposed in utero to diethylstilbestrol

OBJECTIVE

To examine a group of women (third-generation daughters) whose mothers were exposed in utero to diethylstilbestrol (DES) and compare their findings on pelvic examination with those noted in their mothers.

METHODS

Letters were mailed to women documented to have been exposed in utero to DES who had given birth to a female offspring, inviting them to have their daughters come in for a detailed history and pelvic examination. Records of the mothers whose daughters appeared for examination were reviewed, and findings noted at the time of their initial examination were recorded. Detailed pelvic examination of the third-generation daughters included colposcopic examination and iodine staining of the vagina and cervix and Papanicolaou smear. The findings observed in these women were compared with those noted in their mothers at the time of their mothers' first examination.

RESULTS

Twenty-eight third-generation daughters were examined. Three of the daughters were delivered from one mother. Review of the mothers' records indicated that 16 (61.5%) of the mothers exposed to DES during their pregnancy demonstrated structural changes of the cervix, upper vagina, or vaginal epithelial changes consisting of adenosis, nonstaining vaginal epithelium after application of iodine solution, or white epithelium within the vagina. None of the daughters were found to have changes usually associated with DES exposure.

CONCLUSION

The absence of abnormalities in the lower genital tract in third-generation women compared with the high frequency of these abnormalities in their mothers suggests that third-generation carryover effects of in utero DES exposure are unlikely.

Primary infertility associated with isolated cervical collecting diverticulum

OBJECTIVE

To describe a previously unreported isolated congenital cervical diverticulum and its gynecologic, reproductive, and obstetrical implications.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT

A 31-year-old woman presenting with menometrorrhagia and primary infertility. Investigation revealed an isolated collecting cervical diverticulum causing prolonged postmenstrual spotting, possibly interfering with sperm capacitation and access to the uterine cavity.

INTERVENTION(S)

The examination included hysterosalpingography and magnetic resonance imaging. The combined hysteroscopy and laparoscopy revealed a 5 x 5 cm cervical diverticulum, around 1 cm from the external cervical os, leading to a short cervical canal connected to a normal uterine cavity. The patient achieved a pregnancy after controlled ovarian hyperstimulation and ultrasonographically guided intrauterine insemination. MAIN OTUCOME MEASURE(S): Pregnancy and obstetrical outcome.

RESULT(S)

Extensive evaluation revealed the patient's condition to be a previously undescribed congenital cervical anomaly. The patient's infertility was corrected by ovulation induction and sonographically guided intrauterine insemination, which resulted in a twin pregnancy. After 27 weeks of gestation, preterm labor complicated the delivery.

CONCLUSION(S)

The diagnosis and management of this unusual congenital cervical diverticulum present a particular challenge, as this congenital abnormality has not been previously described or reported.

[Congenital absence of the vagina--its diagnostic-therapeutic implications--case report]

Issues relating to diagnosis and reconstructive therapy for developmental anomalies of female genital tract are controversial. The teratogenic influence during the 6th week of intrauterine life, the time for the development of structures such as fallopian tube, uterus and cervix from the Müllerian duct may lead to their defective formation. In a 14 year old girl congenital absence of vagina, cervix developed right half of uterus (rudimentary horn?) and a pelvic kidney was diagnosed by laparoscopy and laparotomy. The attempt to connect uterus with the artificial vagina during the laparotomy was unfortunately not successful, the main reason being prolonged distance between the apex of artificial passage and the rudimentary uterus. In our opinion ultrasound is a superior diagnostic tool for diagnosis of developmental anomalies in comparison to the palpatory methods. The corrective and reconstructive surgery for the developmental anomalies of the female genital tract should be the domain of a specialized center. Increased awareness of the parents and the public, increase in environmental pollution has led to more frequent and earlier diagnosis of these malformations, which in turn has led to the shift in age for therapeutic interventions.

Successful pregnancy in an adolescent woman with a communicating double uterine anomaly

BACKGROUND

Women with communicating double uterine anomalies are at increased risk for obstetric complications, including early pregnancy loss, preterm delivery, and breech presentation. We present the pregnancy of a woman with a previously diagnosed communicating double uterine anomaly.

CASE

An 18-yr-old white female with a previous diagnosis at age 11 of a communicating double uterus, double cervix, and obstructed left hemivagina was followed during the course of her pregnancy. She experienced no complications until 36 6/7 weeks, when she was found to have signs and symptoms of mild preeclampsia. The fetus was in a breech presentation and a cesarean section was performed. Two hemiuteri were identified intraoperatively. The communication was not visualized. A viable male infant was delivered without complications.

CONCLUSION

This patient represents only the sixth report of successful pregnancy in a woman with a Toaff type 5A communicating uterine anomaly.

Double cervix and vagina with septate uterus: an uncommon müllerian malformation

BACKGROUND

The case of an unusual müllerian anomaly is described.

CASE

A nulligravida was found to have a septate uterus with double cervix and a vagina with partial longitudinal vaginal septum. The anomaly presented symptomatically, was suggested by clinical examination, and confirmed by magnetic resonance imaging and intraoperative visualization. Visualization of the anomaly was enhanced by magnetic resonance-based three-dimensional reconstruction techniques.

CONCLUSION

Description of double cervix and vagina in the setting of an anatomically normal or simple septate uterus is uncommon. This anomaly is inconsistent with the generally accepted understanding of müllerian development but fits with an alternative hypothesis. Magnetic resonance imaging and magnetic resonance-based three-dimensional reconstruction was useful in aiding visualization of the anomaly.

Cervico-isthmic pregnancy: an extremely rare case diagnosed during labour

This case report describes a cervico-isthmic pregnancy ending in a live vaginal birth at 37+2 weeks' gestation. The case remained undiagnosed throughout pregnancy when after a fairly normal labour a massive haemorrhage occurred. After an unsuccessful effort to control the bleeding conservatively, a total abdominal hysterectomy was carried out. During the operation the diagnosis of cervico-isthmic pregnancy was confirmed, which was in accordance with the pathology report.

Utero-vaginal anastomosis in women with uterine cervix atresia: long-term follow-up and reproductive performance. A study of 18 cases

BACKGROUND

Atresia of the uterine cervix is an uncommon Müllerian anomaly. Total hysterectomy remains the classical treatment of this malformation. The purpose of this study was to evaluate functional results and reproductive performance of women who had conservative surgical procedure.

METHODS AND RESULTS

The medical records of 18 patients admitted to our centre between 1969 and 1998 for the treatment of uterine cervix atresia, were reviewed. Seven women had an associated high vaginal aplasia. Fifteen women had a history of abdominal or pelvic surgery before referral, with an unsuccessful attempt at canalization in five cases. Associated pelvic endometriosis or adhesions were observed in 12 cases. The utero-vaginal anastomosis procedure was performed successfully in all cases. A secondary stenosis of the anastomosis occurred in one case and this required canalization. Median follow-up after surgery was 4.5 years. Sexual intercourse was satisfactory for the 12 patients who began sexual activity. Ten patients had a pregnancy, four of which resulted in a total of six successful spontaneous pregnancies. Of the six remaining women, five had an evident cause of infertility.

CONCLUSIONS

Utero-vaginal anastomosis should be proposed in women with congenital atresia of the uterine cervix, even when it is associated with vaginal aplasia. Early diagnosis and surgery appear necessary to avoid the development of pelvic associated lesions.

Classification for endoscopic treatment of mullerian anomalies with an obstructive cervix

STUDY OBJECTIVE

To describe our classification according to severity of developmental mullerian anomalies with obstructed cervix.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University-based, tertiary-level center for endoscopic surgery.

PATIENTS

Ten women with developmental mullerian anomalies with obstructed cervix.

INTERVENTION

Patients with didelphic uterus with a rudimentary nonfunctional horn and hypoplastic cervix (type 1) underwent hemihysterectomy or diagnostic endoscopy. Those with agenesis of cervix with normal uterus (type 2) had uterovaginal canalization or neocervix with full-thickness skin graft. Women with identical didelphic uteri and hypoplastic cervix (type 3) underwent uterovaginal canalization with or without endometrial ablation or hemihysterectomy. Patients with didelphic uterus with a rudimentary horn and hypoplastic cervix (type 4) had laparoscopic hemihysterectomy. Those with agenesis of the vagina and cervix but with functional endometrium (type 5) had laparoscopic-assisted full-thickness skin graft.

MEASUREMENTS AND MAIN RESULTS

Average duration of surgery was 60 to 210 minutes. There were no intraoperative complications. Patients with type 1 anomaly are continuing infertility treatment. All three patients in type 2 continue to have regular menses without dysmenorrhea. In those with type 3 conditions, hemihysterectomy was performed in one woman and uterovaginal canalization was performed on the hypoplastic cervix in another. After the neocervix was created, endometrial ablation was performed. No evidence of cervical obstruction or hematometra was found in either patient. The patient with type 4 anomaly continues to have regular menstrual periods without dysmenorrhea. Women with type 5 disorder had good healing of vaginal skin grafts.

CONCLUSION

This classification helps identify mullerian anomalies in relation to obstructive cervix. It is useful in categorizing the disorders and determines management strategies and prognosis.

Septate uterus with double cervix and longitudinal vaginal septum. A case report

BACKGROUND

Congenital uterine anomalies in the general population are estimated to have an incidence of 0.001-10%. The septate uterus, the most common form of structural uterine anomaly, has the highest reproductive failure rate. A rare developmental variant is a septate uterus with cervical duplication and a complete longitudinal vaginal septum. The existence of this anomaly challenges classical müllerian developmental theory. Traditional transabdominal metroplasty has been replaced by operative hysteroscopy in the surgical correction of a septate uterus, with laparoscopy aiding in the diagnosis and contributing to the safety and efficiency of the procedure.

CASE

A 28-year-old, nulliparous woman with a septate uterus with cervical duplication and complete longitudinal vaginal septum was diagnosed by combined laparoscopy and hysteroscopy. Excision of the complete longitudinal vaginal septum followed by hysteroscopic partial resection of a thick uterine septum with laparoscopic assistance was performed. However, because of the septum's broad base and the rigidity of the operative resectoscope, we opted to proceed with transabdominal metroplasty.

CONCLUSION

Only six cases of septate uterus with cervical duplication and complete longitudinal vaginal septum have been reported. Although its counterpart, the septate uterus, has effects on preterm labor, fetal presentation, infertility and spontaneous abortion, its reproductive outcome has not been assessed. Review of the literature suggests that surgical correction in the setting of poor reproductive outcome has been beneficial. Laparoscopically assisted hysteroscopic resection of the uterine septum is a safe, effective surgical technique of uterine reunification and is preferable to transabdominal methods. However, in certain cases, conventional transabdominal metroplasty may still be required.

Uterovaginal canalization and endometrial ablation of the obstructed uterine horn with hypoplastic cervix in the didelphic uterus

Maldevelopment of the mullerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix. Two women with this anomaly experienced symptoms including recurrent lower abdominal pain off and on of 1 to 2 years' duration. Magnetic resonance imaging revealed a double uterus with right hematometrium both patients. After hysteroscopic identification of hypoplasia of right uterine cervix, laparoscopic resection of the hematosalpinx, followed by uterovaginal canalization and prophylactic endometrial ablation of the right uterus was successfully performed by resectoscope. Normal menstruation ensued during follow-up of 18 and 24 months, respectively. Our experience suggests that uterovaginal canalization with prophylactic endometrial ablation may be an efficacious alternative to hysterectomy for management of didelphic uterus with a hypoplastic cervix. (J Am Assoc Gynecol Laparosc 8(1):151-153, 2001)

Successful pregnancy by transmyometrial and transtubal embryo transfer after IVF in a patient with congenital cervical atresia who underwent uterovaginal canalization during Caesarean section: case report

Successful pregnancy in a patient with congenital cervical atresia is a great challenge for assisted reproductive techniques and reproductive medicine. We report a case of successful pregnancy by transmyometrial and transtubal embryo transfer simultaneously after in-vitro fertilization (IVF) in a 33 year-old patient with congenital cervical atresia diagnosed at the age of 18 years. The patient had experienced cyclic abdominal pain and amenorrhoea since she was 13 years old. She had had two unsuccessful attempts to create a new uterovaginal canal in another hospital. At the age of 32 years, she was referred to our unit and had a successful pregnancy after transmyometrial and transtubal embryo transfer. Caesarean section was performed at 36 weeks gestation due to progressive pre-eclampsia and gestational diabetes. A healthy male baby weighing 2812 g was safely delivered. Uterovaginal canalization with amniotic membrane for the covering of the neo-endocervical wall was performed during Caesarean section. Normal menstrual outflow and symptomatic relief have continued for 5 months after the operation. To the best of our knowledge, this is the first reported case of successful pregnancy by transmyometrial and transtubal embryo transfer as well as uterovaginal canalization performed during Caesarean section in a patient with congenital cervical atresia.

Intrauterine exposure to diethylstilbestrol: long-term effects in humans

DES is the most carefully scrutinized EDC and its history provides valuable insights into the current evaluation of less well-studied EDCs. This review summarizes the health effects of prenatal exposure to diethylstilbestrol (DES) and emphasizes the role of DES as the first endocrine disrupting chemical (EDC). Vaginal clear cell adenocarcinoma (CCAC), the most severe consequence of prenatal exposure to DES, affected only 0.1% of exposed females, while the far more prevalent teratogenic and reproductive effects of DES were only discovered when DES daughter were screened for CCAC. Initial studies, conducted before most DES daughters had tried to conceive, examined vaginal cancer and vaginal, cervical and uterine abnormalities. Subsequently, several controlled studies demonstrated the increased risk of adverse reproductive outcomes in DES daughters. While most DES daughters can eventually experience a live birth, this is less likely in women with genital tract abnormalities, in whom there is a two-thirds chance that each pregnancy will be unsuccessful. In DES sons, who have been far less studied, results suggest male reproductive toxicity, but are less consistent. The importance of dose and gestational age at initial exposure are discussed, and the implications of DES findings for the evaluation of risks from current EDCs emphasized.

Clear cell adenocarcinoma of the cervix associated with a rare genitourinary malformation

BACKGROUND

Cervical adenocarcinoma and genitourinary malformations are relatively common disorders, yet their coexistence is rare.

CASE

A 49-year-old woman developed clear cell adenocarcinoma in the atretic hemicervix of a communicating uterus type 7 and had ipsilateral renal agenesis. Compared with the unaffected right hemicervix, only the tumor-involved glands of the atretic left hemicervix contained ciliated tuboendometrial cells. Four and a half years after radical hysterectomy and pelvic radiation, she showed no evidence of recurrence.

CONCLUSION

In contrast to current opinion, communicating uteri type 7 are associated with ipsilateral renal agenesis. Our histologic findings support the hypothesis that tuboendometrial cells are the cells of origin for cervical clear-cell adenocarcinoma.

Combined congenital absence of the vagina and cervix. Diagnosis with magnetic resonance imaging and surgical management

The combination of congenital absence of the cervix and vagina is an extremely infrequent anatomic abnormality. We report a patient in whom this combination was diagnosed preoperatively by magnetic resonance imaging and managed surgically in a two-stage procedure using a modified McIndoe vaginoplasty followed by the creation of a uterovaginal fistula.

Pregnancies after reconstructive surgery for congenital cervicovaginal atresia

Eighteen women aged 12 to 20 years with congenital cervicovaginal atresia were treated with a new technique of surgical canalization. All are now having regular menses. Two pregnancies have been achieved, with delivery of viable neonates. Surgical correction of this anomaly during adolescence may aid in restoration of menstrual and reproductive function.

Septate uterus associated with cervical duplication and vaginal septum

A woman had an unusual müllerian anomaly with a septate uterus, cervical duplication, and longitudinal vaginal septum. Gynecologists should be aware of the possibility of cervical duplication associated with uterine septum and not didelphic uterus, as this disorder in a patient with infertility or recurrent miscarriages can be treated surgically by resection of the uterine and vaginal septum. Embryologic explanations may account for the occurrence of the anomaly.

Histologic development of cervical ectopy: relationship to reproductive hormones

BACKGROUND AND OBJECTIVES

Cervical ectopy has been proposed as a risk factor for chlamydial infection, HIV, and other sexually transmitted diseases (STDs). Ectopy is a histologic phenomenon resulting from a complex interplay of morphologic and hormonal processes. Reproductive hormones influence the production of ectopy during late fetal life, puberty, pregnancy, and with use of oral contraceptives. Ectopy is modified over time by squamous metaplasia and epitheliazation, low pH, trauma, and possibly by cervical infection.

STUDY DESIGN

The authors review the histologic development of ectopy from late fetal life to menopause to understand STD risk.

RESULTS

Ectopy is often assessed and quantified by direct, unaided observation during speculum examinations. This method may result in inaccurate estimates and misclassification with the transformation zone.

CONCLUSION

Valid, reproducible measures of ectopy are necessary for epidemiologic studies to examine the impact of exogenous hormonal contraceptives on the development of ectopy and on potential infection risk.

Congenital malformations of the genital tract

Congenital abnormalities of the genital tract are a source of major morbidity for teenage girls. Careful counseling is as important as the surgical approach to management. It is imperative that specialist centers are established worldwide to deal with these problems. Centralization of services will ensure these girls receive the highest quality care.

Genetics of the female reproductive ducts

Familial aggregates of the most common disorders of müllerian differentiation in females-Müllerian aplasia, incomplete Müllerian fusion-are best explained on the basis of polygenic/multifactorial inheritance. No information exists on the number and chromosomal location of responsible genes. Single mutant genes (Mendelian) are responsible for the McKusick-Kaufman syndrome (MKS) and the hand-foot-genital syndrome. The molecular basis for the latter condition involves HOXA13, but the molecular basis of MKS and other disorders of the female reproductive ducts is unknown. Vaginal atresia, Müllerian aplasia, and incomplete Müllerian fusion are not infrequently observed in malformation syndromes.

Infertility in adult hypodactyly mice is associated with hypoplasia of distal reproductive structures

Hypodactyly (Hoxa13(Hd)) mice have a 50-base-pair deletion in Hoxa13, and rare surviving homozygotes of both sexes are infertile. Heterozygous mutant mice are fertile; however, Hoxa13(Hd/+) females exhibit an anterior transformation of cervical tissue to a uterine stromal phenotype that is accentuated in the homozygote and occasionally includes uterine-specific glands in the transformed cervical region. The columnar-to-squamosal epithelial transition that characterizes mature cervical-vaginal tissue is positioned within uterine-like stroma rather than cervical tissue in these mutants, suggesting that this postnatal developmental transition occurs independent of the underlying stromal characteristics. Hoxa13(Hd/Hd) adult females produce apparently functional germ cells as determined by superovulation and ovarian histology, but they exhibit profound hypoplasia of the cervix and vaginal cavity. Using whole-mount in situ hybridization, we localized Hoxa13 expression to the cervical and vaginal tissues, consistent with the observed defects. In Hoxa13(Hd/Hd) males, the penian bone is severely hypoplastic and misshapen. The penian bone develops by a combination of endochondral and intramembranous ossification, but the defects observed in Hoxa13(Hd/Hd) males are limited to the region of endochondral bone formation. Our results indicate that infertility in Hypodactyly mutants is related to hypoplasia of the vaginal cavity and cervix in females and deficiency of the os penis in males.

Outcome of patients undergoing transabdominal cerclage: a descriptive study

OBJECTIVE

Transabdominal cerclage is now evolving as an alternative to transvaginal cerclage in patients with cervical incompetence. The purpose of our study was to evaluate and describe our experience in patients selected to undergo transabdominal cerclage placement.

METHODS

Outcome data for all patients who underwent transabdominal cerclage from January, 1990, through December, 1994, was collected. Indications for transabdominal cerclage included patients with prior failed vaginal cerclage, extremely shortened cervix, or anatomical defects judged unsuitable for transvaginal cerclage.

RESULTS

Eleven patients underwent 12 transabdominal cerclage procedures. The mean gestational age at the time of cerclage placement was 12.5 weeks (range 10-14 weeks). The mean gestational age at delivery was 34 weeks. There were two neonatal deaths, which were related to extreme prematurity. The mean birthweight was 2,622 g. The fetal salvage rate was 83%.

CONCLUSIONS

These findings suggest that in a highly select group of patients, the transabdominal cerclage can be a safe and effective procedure.

Laparoscopic hemi-hysterectomy in treatment of a didelphic uterus with a hypoplastic cervix and obstructed hemivagina

Maldevelopment of the Müllerian duct system may result in various urogenital anomalies including didelphic uterus with a hypoplastic cervix and obstructed hemivagina. We report a patient with this anomaly who was treated by laparoscopic hemi-hysterectomy and hysteroscopic resection of hemivagina. A 17 year old patient who had complained of vaginal pus-like discharge on and off for 1 year was diagnosed by MRI to have a double uterus with obstructed right hemivagina and ipsilateral renal agenesis. After hysteroscopic identification of hypoplasia of the right uterine cervix, laparoscopic resection of the right uterus and right Fallopian tube and hysteroscopically assisted resection of the vaginal septa were performed successfully. From our experience, combined laparoscopy and hysteroscopy may be an efficacious alternative in the management and diagnosis of Müllerian anomalies.

Successful pregnancy after in-vitro fertilization and transmyometrial embryo transfer in a patient with congenital atresia of cervix: case report

A case report of a patient with congenital cervical atresia diagnosed at the age of 24 years is given. The attempts to create a neocervix were unsuccessful. Since no signs of retrograde menstruation or haematometra were observed, in agreement with the patient hysterectomy was not performed. At the age of 32 years, a successful pregnancy was achieved after an in-vitro fertilization and transmyometrial embryo transfer. Due to rapidly progressing pre-eclampsia, an elective Caesarean section was performed at 32 weeks gestation. A 1610 g healthy male infant in breech presentation was born. The post-partum period was uneventful.

[Primary amenorrhea caused by impaired cervical development: report of 3 cases]

We report 3 cases of primary amenorrhea accompanied by cyclic abdominal pain. In presented cases primary amenorrhea was caused by the absence of normally developed cervix. We applied surgical treatment--hysterectomy. In 1 case before hysterectomy we tried to reconstruct cervical canal. This effort was unsuccessfull.

Laparoscopically assisted full thickness skin graft for reconstruction in congenital agenesis of vagina and uterine cervix

In patients with agenesis of the vagina and cervix but with a functional endometrium, the traditional treatment is hysterectomy with construction of a neovagina. We report successful treatment by laparoscopically assisted full thickness skin graft for reconstruction in a patient with congenital agenesis of the vagina and uterine cervix concomitant with haematometra and ovarian endometrioma in a 12 year old girl. Postoperatively, the vaginal skin graft healed well, and menstruation first appeared 4 weeks later. In our opinion, a combined laparoscopic and vaginal procedure with full thickness skin graft is an efficacious alternative in managing such genital defects.

Obstructive anomalies of the female reproductive tract

Obstructive anomalies of the female reproductive tract preclude the outflow of menstruation and may allow the collection of blood in the uterus and/or vagina and increase the likelihood of retrograde flow. These conditions occur in young women and may result in pelvic masses, endometriosis and/or pain. In addition, the long-term sequelae of endometriosis may influence fertility. Pediatricians, primary care physicians and gynecologists need to maintain a high index of suspicion in order to aggressively diagnose these congenital anomalies in young adolescents. In order to maintain this vigilance and assist in maintaining future fertility, it is important to review the embryologic sources of these anomalies, understand the modes of diagnosis and recognize the treatment options currently available.

A combined surgical and radiologic technique for creating a functional neo-endocervical canal in a case of partial congenital cervical atresia

OBJECTIVE

To recanalize the endocervical canal in a patient with partial congenital cervical atresia.

DESIGN

Case report.

SETTING

University hospital.

PATIENT

A 16-year-old girl referred with a history of primary amenorrhea, polycystic ovaries, and intermittent abdominal pain. Physical examination revealed a normal vagina and external cervical os, but magnetic resonance imaging revealed a solid endocervical tract.

INTERVENTION(S)

At laparotomy the endometrial cavity was accessed transfundally and outlined by injection of water-soluble contrast. A trocar needle was guided transvaginally into the uterus, the tract was dilated, and a 12F stent was placed. Oral contraceptives (OCs) and antibiotics were continued postoperatively.

MAIN OUTCOME MEASURE(S)

Hysterosalpingography and clinical follow-up.

RESULT(S)

The operation and postoperative course were uneventful. Withdrawal bleeding occurred at 8 weeks, after discontinuation of the OCs, at which time the stent was expelled. Later follow-up revealed recurrent narrowing, and the stent was replaced for 14 more weeks. After stent removal, regular menses continued (7 months to date).

CONCLUSION

In select cases of congenital cervical atresia, recanalization may be safely performed with the use of the combined surgical-radiologic technique described, with good short-term outcome.

[Septate uterus with cervical duplication and vaginal partition: a rare malformation]

It presents three cases of Mullerian anomalies with septate uterus and cervical duplication and longitudinal vaginal septum. There are a few previous cases reported. The cases are discussed and the literature is revised.

Sonographic evaluation of the uterine cervix

Ultrasonographic evaluation of the uterine cervix has been shown to help predict patients who may be at an increased risk for preterm delivery. The use of ultrasound in at-risk patients may improve the selection of those needing obstetric intervention, which therefore, may improve outcome and lower overall health care costs. Cervical competence, once thought to be a categorical variable, should now be thought of as a continuous variable, as the shortest cervical lengths are found in those women with a history of very early preterm delivery (> 24 weeks). Adjunctive tests, such as fetal fibronectin Bishop scoring and bacterial vaginosis may help to improve the accuracy of prediction of preterm birth; therefore a multifaceted risk approach to preterm birth is suggested in this article.

Lateral cervical displacement is associated with endometriosis

OBJECTIVE

To report on a series of cases of lateral cervical displacement and uterosacral ligament scarring associated with endometriosis.

DESIGN

Case series.

SETTING

Academic medical center.

PATIENT(S)

Three nulliparous women with chronic pelvic pain, lateral cervical displacement, and uterosacral nodularity.

INTERVENTION(S)

Physical examination to evaluate for lateral cervical displacement. Laparoscopic surgery to evaluate for endometriosis and uterosacral ligament involvement.

MAIN OUTCOME MEASURE(S)

Displacement of the entire cervix lateral to the midline of the vagina. Presence of endometriosis on the affected uterosacral ligament.

RESULT(S)

All three patients had lateral cervical displacement and implants of endometriosis and scarring on the uterosacral ligament ipsilateral to the displaced cervix.

CONCLUSION(S)

In women with pelvic pain, lateral cervical displacement due to uterosacral scarring may be a physical finding associated with endometriosis.

Uterus didelphys, a rare cause for tubal sterilization failure

Uterus didelphys is a rare congenital anomaly. It can result in a variety of misadventures even in the hands of an expert. The present case reports uterus didelphys as the cause for tubal sterilization failure. This is the first case of this type seen in our institution in 35 years.

Congenital cervical atresia: report of seven cases and review of the literature

OBJECTIVE

Our aim was to evaluate the clinical course and management of congenital cervical atresia.

STUDY DESIGN

This retrospective analysis included 7 patients referred to our clinic and a review of the medical literature.

RESULTS

Including this case series, 58 cases of congenital cervical atresia have been reported in the literature. Forty-eight percent of patients had isolated congenital cervical atresia with a normal vagina whereas the remainder had either complete or partial vaginal atresia ("shortened blind vaginal pouches"). Surgical management has included abdominal hysterectomy or uterovaginal cannulation with or without vaginoplasty. In 59% of patients who underwent uterovaginal canalization procedures (23/39), normal menstrual bleeding was achieved. Four of these patients subsequently became pregnant and were delivered at term.

CONCLUSION

Surgical canalization in selected patients with congenital cervical atresia can be successfully performed to provide patients an opportunity for conservative management, resulting in normal menstrual bleeding, resolution of cyclic pelvic pain, and some potential (albeit limited) for fertility.

Congenital cervicovaginal aplasia with septate uterus and functioning endometrium

A 14-year-old adolescent girl presented with primary amenorrhea and uncontrolled pelvic pain. Evaluation using pelvic sonogram, magnetic resonance imaging, and laparoscopy confirmed the diagnosis of cervicovaginal aplasia with functioning endometrium and a vaginal fistulous tract. At age 19 years, hysterectomy and vaginoplasty allowed the patient to be free of pain and to have normal sexual function.

Rare urogenital anomaly causing discharge and pain. A case report

BACKGROUND

Patients with müllerian anomalies usually seek help because of poor reproductive performance.

CASE

A 16-year-old, white woman presented with a persistent, brown vaginal discharge and right lower quadrant pain. Because of voluntary guarding, the uterus could not be palpated on bimanual examination. However, transvaginal sonography showed a right cystic mass and a slightly binodular contour of the uterus. Laparoscopic evaluation revealed the presence of a bicornuate uterus. A hysterosalpingogram showed a double uterine cavity and cervical canal below the right uterine cavity, leading to a cystic, paravaginal mass. Incision of the mass and drainage of its chocolate-brown fluid content revealed a small, blind vagina leading to a second cervix. Using a wire probe, an isthmic communication was demonstrated between the two uterine cavities, leading to the final diagnosis of bicornuate uterus, laterally communicating, with a double cervix and vagina, unilaterally blind.

CONCLUSION

Awareness of the possibility of this clinically puzzling anomaly will avoid delayed or unnecessary surgical treatment.

Primary amenorrhea: evaluation with MR imaging

PURPOSE

To determine the accuracy of magnetic resonance (MR) imaging in the evaluation of patients with a history of primary amenorrhea.

MATERIALS AND METHODS

Twenty-nine patients with primary amenorrhea underwent T2-weighted MR imaging in the axial and sagittal planes. Contrast material-enhanced and unenhanced T1-weighted MR imaging was performed in selected cases. MR imaging findings were correlated with surgical findings in 23 patients and with clinical findings in six patients.

RESULTS

Surgical correlation was available in 14 of 17 patients with female anatomic anomalies (Mayer-Rokitansky-Küster-Hauser syndrome [n = 9], transverse vaginal septum [n = 3], imperforate hymen [n = 1], cervical agenesis [n = 1]), which confirmed MR imaging findings. In nine of 12 patients with congenital disorders of sexual differentiation (testicular feminization [n = 5], true hermaphrodite [n = 2], gonadal dysgenesis [n = 2]) who underwent surgical correlation, 13 of 16 (81%) gonads were correctly localized with MR imaging. Overall, there was excellent correlation between the classification of patients with MR imaging versus classification with the combination of surgical and laboratory findings (K = 0.88).

CONCLUSION

MR imaging is useful in the work-up of patients who present with primary amenorrhea both for accurate diagnosis of pathologic conditions and for surgical planning.

Measuring cervical ectopy: direct visual assessment versus computerized planimetry

OBJECTIVE

Cervical ectopy has been identified as a possible risk factor for heterosexual transmission of human immunodeficiency virus. To accurately assess the importance of cervical ectopy, methods for measuring ectopy with precision need to be developed. The objective of this study was to evaluate the reliability of two methods of measuring cervical ectopy: direct visual assessment and computerized planimetry.

STUDY DESIGN

Cervical photographs of 85 women without cervical disease were assessed for cervical ectopy by three raters using direct visual assessment and a computer planimetry method. Agreement between the two methods, among the three raters, and among measurements by each rater over time was calculated with use of intraclass correlation coefficients, where 1.0 represents perfect agreement and 0 represents no agreement except by chance.

RESULTS

The intraclass correlation coefficient among the three raters (interrater agreement) was 0.58 for direct visual assessment without application of acetic acid to the cervix compared with 0.72 for direct visual assessment with acetic acid and 0.82 for computerized planimetry with acetic acid. The intraclass correlation coefficient among measurements by each rater over time (intrarater agreement) was 0.66 for direct visual assessment without acetic acid compared with 0.77 for direct visual assessment and 0.83 for computerized planimetry after application of acetic acid. When acetic acid was used, the intraclass correlation coefficient between the two methods was 0.69.

CONCLUSIONS

Computerized planimetry of cervical photographs may provide the most consistent estimate of the percent of ectopy. However, if time and resources make the use of computer planimetry difficult, direct visual assessment after application of 5% acetic acid appears to provide comparable estimates.