Müllerian Duct Anomalies: Imaging and Clinical Issues

Müllerian anomalies and recurrent miscarriage

PURPOSE OF REVIEW

To review the prevalence of congenital uterine anomalies and pregnancy outcomes in patients with these anomalies.

RECENT FINDINGS

Women with a history of recurrent miscarriage have been estimated to have a 3.2-10.4% likelihood of having a major uterine anomaly except arcuate uterus. Hysterosalpingography and/or 2D ultrasound can be used as the initial screening tools. The American Fertility Society classification of Müllerian anomalies is the most commonly utilized standardized classification. However, there is still no international consensus to distinguish between septate and bicornuate uteri. A total of 35.1-65.9% of patients with bicornuate or septate uteri give live births after correctional surgery. In regard to the live birth rate in the absence of surgery, it has been reported that 33.3-59.5% of patients with such anomalies had a successful first pregnancy after the examination, as compared to 71.7% of individuals with normal uteri (P=0.084), with no significant difference in the cumulative live birth rate (78.0 and 85.5%, respectively) between the two groups.

SUMMARY

Randomized controlled trials comparing the pregnancy outcomes between cases treated and not treated by surgery among patients with a history of recurrent miscarriage are needed because it is not established whether surgery could improve live birth rate.

Transperineal ultrasonography

Transperineal US has increased in use in the last decade. It is helpful in the evaluation of distal genitourinary structures, the rectum and overlying soft tissues. When used in conjunction with transabdominal US, transperineal US can further delineate anatomy and assess abnormalities that affect the lower pelvis. This paper describes optimal technique and common indications for transperineal US in children with examples of congenital and acquired lesions in pediatric patients.

A rare cause of acute abdominal pain: Herlyn-Werner-Wunderlich syndrome

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare müllerian duct anomaly with uterus didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis. Patients with this syndrome generally present after menarche with pelvic pain and mass and, rarely, primary infertility in later years. Strong suspicion and knowledge of this syndrome are mandatory for an accurate diagnosis. A 14-year-old female patient presented with acute retention of urine and abdominopelvic pain. Her condition was diagnosed with the use ultrasonography and magnetic resonance imaging as a case of HWW syndrome. She was treated with vaginal hemiseptal resection. The HWW syndrome should be considered among the differential diagnoses in girls with renal anomalies presenting with pelvic mass, symptoms of acute abdominal pain, and acute urinary retention.

Diagnostic imaging modalities for Müllerian anomalies: the case for a new gold standard

Female reproductive tract anomalies are difficult to number in the general population but are often discovered in evaluations of menstrual complications or fertility disorders. Traditionally, assessment of the reproductive tract entailed hysterosalpingography to image the uterine cavity with the final diagnosis provided by combined hysteroscopy/laparoscopy. These approaches, while providing important information, were uncomfortable and invasive and for HSG, involved radiation exposure. Magnetic resonance imaging (MIR) allowed for the avoidance of these issues while offering accuracy, thus becoming the gold standard diagnostic imaging modality but entailing cost, patient discomfort, and inconvenience. Current advances in ultrasound technology, specifically 3-dimensional ultrasound, achieve the same benefits of MRI in being accurate and noninvasive but also offer the following advantages: they are available in the office, they are cost-effective, and they provide immediate results. As 3-dimensional technology continues to become more accessible and more providers become proficient in using it, ultrasound may replace MRI as the new gold imaging standard in diagnosing müllerian anomalies.

Combined laparoscopic and hysteroscopic approach for the treatment of a hybrid Müllerian duct anomaly: a case report

Müllerian duct anomalies include a wide spectrum of genital tract defects resulting from a development alteration of the genital tract. An 11-year-old girl with a hybrid septate variety uterus with left hemi-obstruction was identified. Beside preoperative imaging evaluation done with ultrasound, magnetic resonance, and hysterosalpingography, a combined laparoscopic and hysteroscopic procedure was fundamental for the diagnosis. The surgical procedure also allowed us to perform a successful and safe treatment. We propose that the American Fertility Society classification of these anomalies should be revised and that hybrid entities should be considered in the differential diagnosis of genital tract malformations.

Müllerian duct and related anomalies in children and adolescents

Although many Müllerian duct anomalies do not require treatment, surgical intervention is sometimes necessary to enable sexual activity or to preserve fertility. The identification of these anomalies is important for optimal clinical management or surgical treatment. Magnetic resonance (MR) imaging is a robust method for adequately evaluating and characterizing uterine and vaginal anomalies. The information provided by MR imaging allows for a more complete understanding of the malformation, facilitating management decisions and potentially changing the outcome. In this article, the embryology, classification, and MR imaging findings of Müllerian duct and related anomalies in children and adolescents are reviewed.

Accessory and cavitated uterine mass with functional endometrium in an adolescent: diagnosis and laparoscopic excision technique

STUDY OBJECTIVE

Accessory and cavitated uterine masses (ACUM) with functional endometrium can be treated successfully with laparoscopic excision. The objectives of this report are to illustrate the surgical technique used for the removal of this uterine wall mass and to discuss the patient's clinical course and outcomes.

DESIGN

Surgical technique and description of 1 case.

SETTING

Department of Obstetrics and Gynecology, University Hospitals Case Medical Center.

PARTICIPANT(S)

A 16-year-old adolescent presented with severe dysmenorrhea and pelvic pain. Ultrasonographic examination and MRI demonstrated a cystic uterine wall mass distinct from the endometrial cavity.

INTERVENTION(S)

Laparoscopic excision of uterine mass.

RESULTS

Pathologic examination of the mass was consistent with an accessory and cavitated uterine mass. A 9-month follow-up after surgical excision of the mass confirmed complete symptom resolution.

CONCLUSIONS

ACUM is a unique and not uncommon pathologic category in the adolescent and young adult population. It is associated with severe and intractable dysmenorrhea and pelvic pain. Laparoscopic excision of these masses is justifiable, safe and feasible.

The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies

STUDY QUESTION

What classification system is more suitable for the accurate, clear, simple and related to the clinical management categorization of female genital anomalies?

SUMMARY ANSWER

The new ESHRE/ESGE classification system of female genital anomalies is presented.

WHAT IS KNOWN ALREADY

Congenital malformations of the female genital tract are common miscellaneous deviations from normal anatomy with health and reproductive consequences. Until now, three systems have been proposed for their categorization but all of them are associated with serious limitations.

STUDY DESIGN, SIZE AND DURATION

The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. A scientific committee (SC) has been appointed to run the project, looking also for consensus within the scientists working in the field.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The new system is designed and developed based on (i) scientific research through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (ii) consensus measurement among the experts through the use of the DELPHI procedure and (iii) consensus development by the SC, taking into account the results of the DELPHI procedure and the comments of the experts. Almost 90 participants took part in the process of development of the ESHRE/ESGE classification system, contributing with their structured answers and comments.

MAIN RESULTS AND THE ROLE OF CHANCE

The ESHRE/ESGE classification system is based on anatomy. Anomalies are classified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified independently into sub-classes having clinical significance.

LIMITATIONS, REASONS FOR CAUTION

The ESHRE/ESGE classification of female genital anomalies seems to fulfill the expectations and the needs of the experts in the field, but its clinical value needs to be proved in everyday practice.

WIDER IMPLICATIONS OF THE FINDINGS

The ESHRE/ESGE classification system of female genital anomalies could be used as a starting point for the development of guidelines for their diagnosis and treatment.

STUDY FUNDING/COMPETING INTEREST(S)

None.

The ESHRE-ESGE consensus on the classification of female genital tract congenital anomalies

The new ESHRE/ESGE classification system of female genital anomalies is presented, aiming to provide a more suitable classification system for the accurate, clear, correlated with clinical management and simple categorization of female genital anomalies. Congenital malformations of the female genital tract are common miscellaneous deviations from normal anatomy with health and reproductive consequences. Until now, three systems have been proposed for their categorization, but all of them are associated with serious limitations. The European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynaecological Endoscopy (ESGE) have established a common Working Group, under the name CONUTA (CONgenital UTerine Anomalies), with the goal of developing a new updated classification system. A scientific committee has been appointed to run the project, looking also for consensus within the scientists working in the field. The new system is designed and developed based on: (1) scientific research through critical review of current proposals and preparation of an initial proposal for discussion between the experts, (2) consensus measurement among the experts through the use of the DELPHI procedure and (3) consensus development by the scientific committee, taking into account the results of the DELPHI procedure and the comments of the experts. Almost 90 participants took part in the process of development of the ESHRE/ESGE classification system, contributing with their structured answers and comments. The ESHRE/ESGE classification system is based on anatomy. Anomalies are classified into the following main classes, expressing uterine anatomical deviations deriving from the same embryological origin: U0, normal uterus; U1, dysmorphic uterus; U2, septate uterus; U3, bicorporeal uterus; U4, hemi-uterus; U5, aplastic uterus; U6, for still unclassified cases. Main classes have been divided into sub-classes expressing anatomical varieties with clinical significance. Cervical and vaginal anomalies are classified independently into sub-classes having clinical significance. The ESHRE/ESGE classification of female genital anomalies seems to fulfil the expectations and the needs of the experts in the field, but its clinical value needs to be proved in everyday practice. The ESHRE/ESGE classification system of female genital anomalies could be used as a starting point for the development of guidelines for their diagnosis and treatment.

Ultrasonography and MRI features of the Mayer-Rokitansky-Küster-Hauser syndrome

Although Mayer-Rokitansky-Küster-Hauser syndrome is a rare condition with a reported incidence of 1/4500 female live births, it represents the second most common cause of primary amenorrhea and has psychologically devastating consequences. The radiologist plays a pivotal role in both making the accurate initial diagnosis of this condition and assessing findings that may contribute to treatment planning. The purpose of this article is to provide an overview of the capabilities of ultrasound and magnetic resonance imaging (MRI) for the diagnosis and management of this syndrome with emphasis on the relevant clinical and surgical findings and to describe potential associated abnormalities and differential diagnosis.

Role of imaging in the diagnosis and management of complete androgen insensitivity syndrome in adults

Complete androgen insensitivity syndrome is an X-linked recessive androgen receptor disorder characterized by a female phenotype with an XY karyotype. Individuals affected by this syndrome have normal female external genitalia but agenesis of the Müllerian duct derivatives, that is, absence of the Fallopian tubes, uterus, cervix, and the proximal part of the vagina, with presence of endoabdominal, labial, or inguinal testes. The estimated prevalence is between 1 and 5 in 100,000 genetic males. Complete androgen insensitivity syndrome can be diagnosed as a result of mismatch between the prenatal sex prediction and the phenotype at birth, can be detected by chance, or remain undetected until investigations for primary amenorrhea. Imaging can be important both to diagnose the pathology and to localize gonads prior to surgical treatment. In this paper, we present three cases of complete androgen insensitivity syndrome in adult women of 34, 22, and 38 years old.

Complex mullerian duct anomaly in a young female with primary amenorrhoea, infertility, and chronic pelvic pain

Mullerian duct anomalies, though rare, can be a treatable cause of pelvic pain and infertility. Various complex Mullerian duct anomalies may exist with combination of features of more than one class. Since there are no precise clinical or imaging criteria to enable specific categorisation, there is ambiguous classification of these anomalies by various radiologists and clinicians. A young female presented with complaints of chronic pelvic pain, primary amenorrhoea and infertility. The patient was evaluated by sonography and Magnetic Resonance Imaging and diagnosed as case of complex mullerian duct anomaly, a unicornuate uterus with cervical dysgenesis and cavitated, noncommunicating, rudimentary right horn. The findings were confirmed on laprohysteroscopy and the patient underwent hystertectomy. There should be an integrated clinico-radiological classification scheme and familiarity with rare and complex anomalies for appropriate diagnosis and management of complex Mullerian duct anomalies.

A rare mullerian duct anomaly not included in the classification system by the american society for reproductive medicine

This is a case report of a 37-year-old female with a uterine septum (two cavities), a normal single fundal contour, two cervices, and a longitudinal vaginal septum. This is a rare finding that is not described in the current classification system by the American Society for Reproductive Medicine.

Large leiomyoma in a woman with Mayer-Rokitansky-Kuster-Hauser syndrome

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare congenital anomaly characterized as aplasia or hypoplasia of uterus and vagina in women with normal development of secondary sex characteristics. It affects 1 in 4000-5000 female births. Women with this syndrome present with primary amenorrhoea. MRKH syndrome may be associated with renal, skeletal, cardiac and auditory anomalies. Women with MRKH syndrome may develop leiomyoma from a rudimentary uterus, though very rare. Initial investigation in women having MRKH syndrome with leiomyoma is ultrasonography (USG). However, CT and MRI are more accurate to evaluate the pelvic anatomy and pathologies.

Müllerian duct anomalies and their effect on the radiotherapeutic management of cervical cancer

Radiotherapy plays a major role in the treatment of cervical cancer. A successful radiotherapy program integrates both external beam and brachytherapy components. The principles of radiotherapy are strongly based on the anatomy of the organ and patterns of local and nodal spread. However, in patients with distorted anatomy, several practical issues arise in the delivery of optimal radiotherapy, especially with brachytherapy. Müllerian duct anomalies result in congenital malformations of the female genital tract. Though being very commonly studied for their deleterious effects on fertility and pregnancy, they have not been recognized for their potential to interfere with the delivery of radiotherapy among patients with cervical cancer. Here, we discuss the management of cervical cancer among patients with Müllerian duct anomalies and review the very sparse amount of published literature on this topic.

Mayer-rokitansky-kuster-hauser syndrome: embryology, genetics and clinical and surgical treatment

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a pathological condition characterized by primary amenorrhea and infertility and by congenital aplasia of the uterus and of the upper vagina. The development of secondary sexual characters is normal as well as that the karyotype (46,XX). Etiologically, this syndrome may be caused by the lack of development of the Müllerian ducts between the fifth and the sixth weeks of gestation. To explain this condition, it has been suggested that in patients with MRKH syndrome, there is a very strong hyperincretion of Müllerian-inhibiting factor (MIF), which would provoke the lack of development of the Müllerian ducts from primitive structures (as what normally occurs in male phenotype). These alterations are commonly associated with renal agenesis or ectopia. Specific mutations of several genes such as WT1, PAX2, HOXA7-HOXA13, PBX1, and WNT4 involved in the earliest stages of embryonic development could play a key role in the etiopathogenesis of this syndrome. Besides, it seems that the other two genes, TCF2 (HNF1B) and LHX1, are involved in the determinism of this pathology. Currently, the most widely nonsurgical used techniques include the “Frank's dilators method,” while the surgical ones most commonly used are those developed by McIndoe, Williams, Vecchietti, Davydov, and Baldwin.

Bilateral ectopic hypoplastic uteri attached to bilateral pelvic sidewalls in a 21-year-old patient with primary amenorrhea: the first published report

Müllerian duct anomalies (MDAs) encompass a group of anatomical malformations resulting from defective development, fusion, migration, or resorption of Müllerian (paramesonephric) ducts during embryonic life. Herein, we report the first case of an exceedingly uncommon MDA (bilateral ectopic hypoplastic uteri attached to bilateral pelvic sidewalls) in a 21-year-old woman who was referred to our tertiary care center as a case of primary amenorrhea for workup and further management.

The utility of ultrasound and magnetic resonance imaging versus surgery for the characterization of müllerian anomalies in the pediatric and adolescent population

STUDY OBJECTIVE

To evaluate the utility of transabdominal ultrasound and magnetic resonance imaging in the evaluation of American Society for Reproductive Medicine (†)(ASRM)-classified müllerian anomalies compared to surgical findings in the pediatric and adolescent population.

DESIGN

Retrospective chart review.

SETTING

Tertiary academic center.

PARTICIPANTS

Thirty-eight patients with müllerian anomalies seen in our pediatric and adolescent gynecology clinic were identified both on the basis of ICD-9 codes and having magnetic resonance imaging at Texas Children's Hospital between 2004 and 2009.

INTERVENTIONS

None.

MAIN OUTCOMES MEASURE

Correlation among transabdominal ultrasound and magnetic resonance imaging findings with surgical findings.

RESULTS

Mean age was 12.2 (± 4.1) years. Twenty-eight patients underwent magnetic resonance imaging and required surgical intervention, and 88.5% demonstrated correlative consistency with surgical findings. Twenty-two patients underwent ultrasound, magnetic resonance imaging, and surgery, which revealed consistency among ultrasound and surgical findings (59.1%) and consistency among magnetic resonance imaging and surgical findings (90.9%). In ASRM diagnoses evaluated by magnetic resonance imaging, surgical findings correlated in 92% (Pearson 0.89). Overall, 55.2% of patients had a renal malformation.

CONCLUSIONS

Magnetic resonance imaging is the gold standard imaging modality for müllerian anomalies and is an effective technique for noninvasive evaluation and accurate classification of the type of anomaly in the pediatric and adolescent population. Magnetic resonance imaging should be considered as an adjunct to transabdominal ultrasound to evaluate müllerian anomalies.

Incidence of ovarian maldescent in women with mullerian duct anomalies: evaluation by MRI

OBJECTIVE

The objective of our study was to evaluate the incidence of ovarian mal-descent in patients with and in those without müllerian duct anomalies.

MATERIALS AND METHODS

Multiplanar MRI examinations of patients with (n = 65) and those without (n = 64) congenital uterine anomalies were evaluated for ovarian size, position, follicle count, and associated renal anomalies. Patients who were pregnant, had known prior pelvic surgery, or had large uterine leiomyomas were excluded. Two criteria were used to determine ovarian malposition: Was the upper pole of the ovary above the pelvic brim, as defined by the pubic symphysis-sacral promontory line, or was the upper pole of the ovary at or above the iliac artery bifurcation?

RESULTS

The müllerian duct anomalies identified in the study group included hypoplasia, unicornuate, didelphys, bicornuate, and septate uterus. Ovarian maldescent was identified in 12 of 65 women with uterine anomalies (17%) as compared with two of 64 women with normal uterine anatomy (3%) using the criterion of the ovarian pole being above the iliac bifurcation. Among the women with müllerian duct anomalies, only three of 29 with septate uterus (10%) had ovarian maldescent compared with the remaining nine of 36 women with other anomalies (25%). Ovarian size did not vary significantly between the two groups. Follicle count was increased in women with müllerian duct anomalies. Renal anomalies were present in 16 of 65 patients, five of whom had concomitant ovarian maldescent.

CONCLUSION

The incidence of ovarian maldescent is increased in patients with müllerian duct anomalies, with the highest association seen in those with didelphys, unicornuate, or bicornuate uterus.

Ultrasound of the gravid uterus

The ultrasound findings involving the gravid uterus will be described with a focus on differentiating normal from pathologic conditions. Topics pertaining to the gravid uterus include uterine fibroids, müllerian anomalies, cervical shortening, the normal and pathologic appearance of cesarean delivery scars, and uterine rupture. Clinical management and therapeutic implications based on sonographic findings will be emphasized.

Mayer-Rokitansky-Kuster-Hauser syndrome diagnosed by magnetic resonance imaging. Role of imaging to identify and evaluate the uncommon variation in development of the female genital tract

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a spectrum of Müllerian duct anomalies characterized by congenital aplasia of the uterus and of the upper part (2/3) of the vagina, in young women presenting otherwise with normal endocrine status. The ovaries and fallopian tubes are present. It is one of the most common causes of primary amenorrhea and affects at least 1 out of 4500 women. Its penetrance varies, as does the involvement of other organ systems and itcan be isolated (type I) or associated with other malformations (type II). The MRKH syndrome usually remains undetected until the patient presents with primary amenorrhea despite normal development of secondary sexual characteristics, so imaging evaluation can demonstrate in one setting, non invasively, the anomalies in development of genital tract. We report a case of MRKH syndrome in a 16-year-old woman who presented with primary amenorrhea, stressing the role and benefit of imaging in the differential diagnosis.

OHVIRA syndrome (obstructed hemivagina and ipsilateral renal anomaly) with uterus didelphys, an unusual presentation

BACKGROUND

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA), or Herlyn-Werner-Wunderlich syndrome, is a rare Mullerian duct anomaly with uterus didelphys, unilateral obstructed hemivagina, and ipsilateral renal agenesis. Patients with this anomaly usually present after menarche with pelvic pain and/or a mass and rarely, in later years, with primary infertility. Strong suspicion and knowledge of this anomaly are essential for a precise diagnosis.

CASE

A 14-year-old female presented with acute retention of urine and was diagnosed as a case of OHVIRA syndrome with uterus didelphys. Acute retention of urine as the initial clinical presentation has been rarely reported in this syndrome. She was treated with hemivaginal septal resection.

SUMMARY AND CONCLUSION

OHVIRA syndrome should be considered among the differential diagnoses in young females with renal anomalies presenting with pelvic mass, symptoms of acute abdomen, and acute urinary retention.

Clinical approach for the classification of congenital uterine malformations

A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field.

No clinical relevance of the height of fundal indentation in subseptate or arcuate uterus: a prospective study

The American Fertility Society has classified the arcuate uterus as a minor malformation with a benign clinical behaviour. The aim of this prospective study was to verify whether there is any scientific basis for this differentiation. Patients with at least one early miscarriage and a subseptate or arcuate uterus were admitted for hysteroscopic metroplasty. Patients were allocated to a subseptate uterus group, with an indentation of 1.5 cm or more, or an arcuate uterus group, with a smaller indentation. The miscarriage rates after metroplasty were similar between the two groups (14.0% in the subseptate uterus group versus 11.1% in the arcuate uterus group). Before metroplasty, the miscarriage rates were significantly higher in subseptate uterus group, as well as in the arcuate uterus group (both P<0.001). According to these results, there is no evidence to support that the arcuate uterus has a different effect on the reproductive outcome in comparison to the subseptate uterus, neither before nor after surgical correction of the anomaly. Since there is no scientific basis for a separate classification of the arcuate uterus, a review of the classifications of uterine congenital anomalies should be considered as necessary. Congenital uterine malformations have been classified by the American Fertility Society (AFS) since 1988. Although the AFS classification received wide acceptance and is still the most broadly used system, it is associated with various limitations in effective categorization of the anomalies. It is interesting that, until now, none of the other available options have been able to effectively replace the AFS system. Numerous papers indicate septate or subseptate (partial septate) uterus (AFS class V) is a possible cause of an unfavourable pregnancy outcome. Arcuate uterus (AFS class VI), a slight malformation similar to septate uterus, should differ from septate or subseptate uterus, because this 'minor' malformation should behave benignly with respect to the septate uterus. The aim of this study was to scientifically validate the difference between the arcuate and subseptate uterus in their effect on reproductive outcome through the results of a metroplasty in both groups of patients. A group of 96 patients, who underwent metroplasty after at least one early miscarriage, was divided into two groups according to the severity of the congenital uterine malformation. Our results indicate that there are no differences in pregnancy outcome after metroplasty either in patients with septate or arcuate utera. The poor pregnancy outcome in women with septate uterus seems not to be correlated to the dimension of the septum itself. There are no scientific bases for a separate classification of the arcuate uterus and it is proposed that a review of the classification of uterine congenital anomalies is necessary.

The unicornuate uterus and its variants: clinical presentation, imaging findings, and associated complications

This article will describe the different variants of the unicornuate uterus, their clinical presentation and imaging findings, as well their associated complications. We will also review the associated renal anomalies. Patients' symptoms and their imaging findings will vary depending on the unicornuate subtype. Radiologic evaluation includes a combination of hysterosalpingography, sonography, and magnetic resonance imaging. Complications include obstetric ones related to the small uterine size and endometriosis and ectopic pregnancies when a cavitary rudimentary uterine horn is present. Radiologists should be familiar with all variants of the unicornuate uterus as well as their clinical presentation and associated imaging findings.

Normal and variant pelvic anatomy on MRI

The superior tissue contrast and flexible imaging planes afforded by magnetic resonance imaging (MRI) versus competing technologies permit optimal depiction of the pelvic viscera. Targeted protocols developed for specific pelvic visceral organs highlight important anatomic features that may not be imaged by other modalities. Therefore, a solid understanding of normal and variant pelvic anatomy is crucial for appropriate interpretation of pelvic MRI studies. This article discusses the protocol strategies and relevant anatomy with commonly encountered anatomical variants in a segmented/organ-specific manner, using gender as a broad split given the substantial variance in relevant organs.

Mullerian duct anomalies: MR imaging

Mullerian duct anomalies (MDAs) are rare, affecting approximately 1% of all women and about 3% of women with poor reproductive outcomes. These congenital anomalies usually result from one of the following categories of abnormalities of the mullerian ducts: failure of formation (no development or underdevelopment) or failure of fusion of the mullerian ducts. The American Fertility Society (AFS) classification of uterine anomalies is widely accepted and includes seven distinct categories. MR imaging has consolidated its role as the imaging modality of choice in the evaluation of MDA. MRI is capable of demonstrating the anatomy of the female genital tract remarkably well and is able to provide detailed images of the intra-uterine zonal anatomy, delineate the external fundal contour of the uterus, and comprehensively image the entire female pelvis in multiple imaging planes in a single examination. The purpose of this pictorial essay is to show the value of MRI in the diagnosis of MDA and to review the key imaging features of anomalies of formation and fusion, emphasizing the relevance of accurate diagnosis before therapeutic intervention.

Reproductive outcome of septate uterus following hysteroscopic septum resection

OBJECTIVE

To evaluate the reproductive outcome following hysteroscopic septum resection in patients with primary and secondary (recurrent pregnancy loss [RPL] and bad obstetric history [BOH]) infertility.

STUDY DESIGN

Retrospective study.

MATERIALS AND METHODS

Hysteroscopic septum resection was performed on 26 patients with a history of either recurrent pregnancy loss, BOH or infertility. The septum resection was performed using a bipolar versapoint system. Reproductive performance of these patients after septum resection was analyzed. The main outcome measures were clinical pregnancy and live birth rates.

RESULTS

Hysteroscopic septum resection was performed on seven patients with the history of secondary infertility. Post operatively, the pregnancy rate was 86% (n=6), and the live birth rate was 67% (n=4). After septum resection in 19 primary infertile patients, 6 (32%) patients conceived which resulted in live birth rates of 67% (n=4).

CONCLUSION

Hysteroscopic septum resection using bipolar versapoint system is an effective and safe approach for the removal of septum. Hysteroscopic septum resection in women with septate uterus significantly improves the live birth rates and future fertility is not impaired.