Duplicate cervix and vagina associated with infertility, endometriosis, and chronic pelvic pain

BACKGROUND

Müllerian anomalies are associated with several gynecologic complications including endometriosis, infertility, and pelvic pain.

CASE

A woman with duplicate cervix and a non-communicating longitudinal vaginal septum, but no other uterine anomalies, presented with pelvic pain, secondary infertility, and a long history of endometriosis. She was treated with operative laparoscopy and excision of the vaginal septum.

CONCLUSION

A thorough evaluation, including history, physical examination, and appropriate imaging techniques (hysterosalpingography and magnetic resonance imaging) facilitates accurate diagnosis of anatomical defects and any associated disease in cases of unusual müllerian anomalies. An accurate preoperative diagnosis allows a planned, efficient surgical approach.

Human immunodeficiency virus type 1 seroconversion in women with genital ulcers

Genital ulcers are implicated as a risk factor enhancing susceptibility to human immunodeficiency virus type 1 (HIV-1) infection. A prospective study to determine the incidence of and risk factors associated with acquisition of HIV-1 in women with genital ulcers was done. HIV-1-seronegative women with genital ulcers attending a clinic for sexually transmitted diseases in Nairobi were followed to HIV-1 seroconversion over a 6-month period. Of 81 women, 10 seroconverted to HIV-1. The crude 6-month incidence of HIV-1 infection was 12%. Risk factors associated with seroconversion included cervical ectopy (rate ratio [RR], 4.9; 95% confidence interval [CI], 1.5-15.6) and pelvic inflammatory disease (RR, 6.3; 95% CI, 1.9-20.4). Thus, cervical ectopy and pelvic inflammatory disease may increase susceptibility to HIV-1 in women with genital ulcers.

Septate uterus with cervical duplication: a rare malformation

This previously unreported case of complete uterine septum, cervical duplication, and a longitudinal vaginal septum is best explained by the theory of Muller et al. (5), not by classically held views of unidirectional müllerian development. According to their theory, this anomaly could develop from failure of fusion of the most caudad müllerian ducts, resulting in a normal uterine fundus, with a complete septum, cervical duplication, and a longitudinal vaginal septum. This anomaly was accurately characterized using an endoscopic approach.

Management of vaginal agenesis with a functioning uterus. Is hysterectomy advisable?

Cryptomenorrhoea associated with vaginal agenesis is uncommon. However, when laparoscopy or ultrasound reveal the uterus to be present early laparotomy is mandatory unless there is clear evidence of haematocolpos, in order to define the cervix and undertake reconstructive surgery. Once a uterovaginal tract has been established prolonged use of a mould is necessary to maintain patency of the neovagina. If the cervix is absent or atretic then immediate hysterectomy is required.

Cervicography--an adjunct to Papanicolaou screening

Cervicography is a technically simple screening test for cervical abnormalities and can be used in conjunction with the Papanicolaou test. Cervicography may be performed by both physicians and paraprofessionals; experience in colposcopic techniques is not required. A significantly greater percentage of premalignant disease is detected when cervicography is used in conjunction with the Pap smear than when the Pap smear is used alone. Cervicography may also be used as an effective intermediate triage test to evaluate women with atypical findings on Pap smear.

[An ectopic ureter with communication to the duct of Gartner and opening into the cervix--a rare cause of uncontrolled urine loss]

This is a report of a 22-year-old woman who suffered from a loss of urine via the vagina of unknown origin since childhood. The diagnosis of a left ureteral and renal duplication with an opening of an ectopic ureter into the cervix was established. Due to the result of the retrograde pyelogram we came to the conclusion that the opening into the cervix must have been via a segment of a Gartner duct. The ectopic system and the Gartner duct were completely removed by a combined abdomino-vaginal operation. Genesis, diagnostics, differential diagnostics and therapy of ectopic ureters are described.

[Coexistence of genito-urinary system malformation and endometriosis in a 13 year old girl]

One presents the case of 13 aged girl with malformation of internal genitals in the form of double uterus, cervix and vagina (one vagina was obliterated) and total lack of kidney on the side of vaginal atresia. Simultaneously tumoral endometriosis of external genitals was found.

Bicornuate nonfused rudimentary uterine horns with functioning endometria and complete cervical-vaginal agenesis: magnetic resonance diagnosis

A case is reported of a 16-year-old adolescent with cryptomenorrhea. The patient had a congenital anomaly of a bicornuate, nonfused, separate rudimentary blind uterine horns with functioning endometria, and complete cervical-vaginal agenesis. Ultrasound, laparoscopy, and minilaparotomy for unilateral salpingectomy failed to accurately identify the exact classification of the anomaly. Magnetic resonance imaging, however, accurately correlated with operative findings of exploratory laparotomy and McIndoe procedure.

Communicating septate uterus with double cervix: a rare malformation

The class of uterine malformations known as communicating uteri is characterized by two separate uterocervical cavities connected by an isthmic communication. Nine types have been described. We report the second proven case of a septate communicating uterus with double cervix. Investigation of secondary infertility in a woman with a history of second-trimester spontaneous abortion revealed two cervices on a speculum examination. A work-up for uterine anomaly began with endovaginal sonography, which demonstrated a normal fundal contour. A septum symmetrically dividing the endometrial cavity and two cervical canals were seen. The separated endometrial echoes converged at the isthmus, indicating a communicating uterus. Hysterosalpingography confirmed the diagnosis; injection of each cervix resulted in opacification of both hemicavities via the isthmic defect. Laparoscopy confirmed the normal fundal contour. It is believed that the etiology of this malformation involves failure of fusion of the distal müllerian ducts and arrested septal resorption above the isthmus.

Observations on the genital tract of cull ewes

Genital tracts were collected from non-pregnant cull ewes in early April and examined for macroscopic abnormalities. An assessment was made of the possible effect of any abnormality on the ability of the animal to become pregnant. It was found that 23.2 per cent of the tracts had abnormalities and it was considered that 16.8 per cent had abnormalities likely to interfere with the establishment of pregnancy.

Transvaginal cerclage under ultrasound guidance in cases of severe cervical hypoplasia

Transabdominal cervical cerclage has been advocated for patients with cervical incompetence whose cervix is flush against the vaginal wall. Although several series of successful transabdominal cerclage have been reported, the morbidity of this technique precludes its routine use. We describe five pregnancies in four patients with extreme cervical hypoplasia who underwent successful prophylactic transvaginal cerclage placement at 12-13 weeks' gestation. All patients had a history of intrauterine diethylstilbestrol exposure, and three patients had also undergone cervical conization. In each case, using continuous transabdominal ultrasound guidance, the supravaginal cervix was dissected and two nonabsorbable sutures were placed through the cervix at right angles at the level of the anatomical internal os. There were no perioperative complications, and except for one patient who developed severe preeclampsia at 33 weeks, all patients delivered at term. We believe that the use of ultrasound in cases of severe cervical hypoplasia allows safe transvaginal cerclage placement, obviating the need for abdominal cerclage.

Hysteroscopy in a program of in vitro fertilization

Two hundred twenty-four women underwent hysteroscopic evaluation without anesthesia after at least two failed attempts of in vitro fertilization and embryo transfer. One hundred fifty-three (68%) women were diagnosed as having mechanical infertility, and abnormal hysteroscopic findings were observed in 32 (21%). Forty-one women were diagnosed as having unexplained infertility (18%) and six (15%) had abnormal findings with hysteroscopy. Of the 30 couples who entered the in vitro fertilization regimen program because of male infertility, 4 (13%) had abnormal findings. The overall rate of abnormal findings was 19%; cervical canal and intrauterine abnormalities were found in 10 and 32 patients, respectively. Ten patients were treated during hysteroscopic evaluation procedure, and four patients subsequently underwent operative hysteroscopy under general anesthesia. We suggest that diagnostic hysteroscopy should be a routine procedure before in vitro fertilization and embryo transfer therapy.

[Sacral epidural anesthesia as a method in technically complicated abortions]

An experience is reported with the use of epidural-sacral anesthesia for artificial abortion in 102 primiparae+- and nulligravidas and in 86 patients with scarring deformity or partial atresia of the endocervix. Two percent trimecaine was used in a single dose 6 mg/kg. A high efficiency of anesthesia was seen in 92% of cases. There was a significant relaxation of the cervix which facilitated cervical dilation and reduced the incidence of tissue injury. The population under study showed a lower incidence of intraoperative blood loss and early postabortal complications as compared with a population which received other anesthesia. These results suggest that epidural-sacral anesthesia is a promising technique for artificial abortion in primiparae+- and nulliparous women and in women with scarring cervical lesions.

The pin-hole cervical os; a small fertility problem

24 women with a so-called pin-hole cervical os during the pre-ovulatory phase of the menstrual cycle were detected in a group of 850 infertile couples. This cervical condition is rarely seen and is often combined with extreme oligomucorrhea and poor cervical mucus qualities. Sperm quality was so poor in four couples that they were excluded. Nine women were likely to have been exposed to diethylstilbestrol (DES) in utero. The pregnancy rate in this group was poor, only two pregnancies by coitus and none by intra-uterine AIH. In the other eleven women there was a strong correlation between a good result of the post-coital test (PCT) and the chance to achieve pregnancy. Four of the eight women with a good result of the PCT became pregnant by coitus. The three women with a poor result of the PCT became pregnant by intra-uterine AIH. It is possible that the fertility prognosis of a woman with a pin-hole cervical os during the pre-ovulatory phase of the menstrual cycle is unfavourably influenced by DES exposure in utero. A pin-hole cervical os in the pre-ovulatory phase of the menstrual cycle, without DES exposure, has probably no influence on fertility.

Successful pregnancy after ZIFT in a patient with congenital cervical atresia

We report the third patient with a successful pregnancy following operative correction of congenital cervical atresia. The pregnancy was achieved through zygote intrafallopian transfer (ZIFT). Although stenosis of the newly formed cervical canal causes considerable morbidity, therapy should be aimed at the creation of a conduit for menstrual blood and for possible future pregnancy. New techniques in assisted reproduction such as in vitro fertilization-embryo transfer, gamete intrafallopian transfer, and ZIFT increase the chances of pregnancy in patients with congenital cervical atresia. A hysterectomy, as advocated until very recently, should not, in our opinion, be the first treatment of choice.

Pregnancy after successful vaginoplasty and cervical stenting for partial atresia of the cervix

We previously reported surgical correction of vaginal agenesis and partial cervical atresia in an 11-year-old girl with amenorrhea and a pelvic mass. This patient, the subject of this report, conceived 7 years later and delivered at term. An abdominal cerclage was placed at 12 weeks' gestation to protect the cervix, and delivery was by cesarean.

Double cervices in two llamas

Double cervices were diagnosed in 2 female llamas that were infertile. The condition is uncommon in other species. The condition results from the failure of fusion of the müllerian ducts during embryonic development. Diagnosis was facilitated by vaginoscopy. One case was verified as didelphia, with 2 uterine bodies and 2 cervices.

Recurrent miscarriage. II: Clinical associations, causes, and management

Firm evidence on the causes of recurrent miscarriage is scant. The true rate is probably artificially heightened by a reproductive compensation effect. The commonest direct cause is probably repeated sporadic chromosome abnormalities, which occur consecutively merely by chance. Congenital and acquired anatomical defects of the uterine fundus and cervix, parental chromosomal rearrangements, gene mutations, antibodies to cardiolipin, and luteal phase defects each make a small contribution. Other causes, such as polycystic ovaries and immune rejection, may play some part but the evidence is not clear. Psychological stress, subclinical infections, thyroid disorders, and diabetes mellitus are probably not relevant. Reassurance and clear statements about prognosis are important and psychological support must be offered throughout investigation and subsequent pregnancy. Much more rigorous scientific studies from which clearer conclusions can be drawn are vital for better understanding of this important clinical problem.

Gynecological abnormalities following allogeneic bone marrow transplantation

Forty-four post-pubertal women were studied 261-4628 days after allogeneic transplantation to determine the nature and degree of gynecological abnormalities following bone marrow transplantation. Evaluations included pelvic examinations, exfoliative cytology, serum gonadotropin levels, direct preparations for micro-organisms, and microbial cultures. Pelvic abnormalities were detected in 35 of 44 (80%) women and resembled atrophic changes known to occur after ovarian failure. Findings included reduced vaginal elasticity and rugal folds, pale tissues, small vaginal, uterine and cervical size, atrophic vulvovaginitis, introital stenosis, and loss of pubic hair. Atrophic abnormalities were noted in 33 of 36 recipients of total body irradiation (TBI) compared to two of eight women not prepared with TBI (p = 0.02). Vasomotor symptoms were reported in 67% of TBI recipients compared to 38% of those not given TBI. Elevated serum gonadotropin levels suggested that TBI had caused the ovarian failure. Recognition of these gynecological abnormalities can lead to earlier hormone replacement, alleviating unnecessary discomfort and improving the well-being of the marrow transplant recipient.

Magnetic resonance imaging to diagnose a müllerian anomaly during pregnancy

An adolescent woman presented with a paravaginal mass during pregnancy. Magnetic resonance imaging was useful in diagnosing a müllerian anomaly consisting of a double uterus and cervix and blind vaginal pouch. Magnetic resonance imaging can be an important modality in the diagnosis of gynecologic conditions in the obstetric patient.