Clinical implications of uterine malformations and hysteroscopic treatment results

Reproductive performance of women with müllerian anomalies

PURPOSE OF REVIEW

This review discusses current diagnostic techniques for müllerian anomalies, reproductive outcome data, and management options in reproductive-age women.

RECENT FINDINGS

Multiple retrospective studies have investigated reproductive outcomes with müllerian anomalies, but few current prospective studies exist. Uterine anomalies are associated with normal and adverse reproductive outcomes such as recurrent pregnancy loss and preterm delivery, but not infertility. Furthermore, unicornuate, didelphic, bicornuate, septate, arcuate, and diethylstilbestrol-exposed uteri have their own reproductive implications and associated abnormalities. Common presentations of müllerian anomalies and current diagnostic techniques are reviewed. Surgical intervention for müllerian anomalies is indicated in women with pelvic pain, endometriosis, obstructive anomalies, recurrent pregnancy loss, and preterm delivery. Although surgery for most uterine anomalies is a major intervention, the uterine septum is preferentially managed with a hysteroscopic procedure. Several recent studies and review articles discuss management of the septate uterus in asymptomatic women, infertile women, and women with a history of poor reproductive outcomes. Current assessment of reproductive outcomes with uterine anomalies and management techniques is warranted.

SUMMARY

Müllerian anomalies, especially uterine anomalies, are associated with both normal and adverse reproductive outcomes, and management in infertile women remains controversial.

Obstructive mullerian anomalies and modern laparoscopic management

STUDY OBJECTIVE

Congenital uterine anomalies are common, although the majority are asymptomatic. When an obstructed system exists, women may present with abdominal pain, or dysmenorrhea. Removal of the obstructed horn may be required in the symptomatic patient. In the past, surgical treatment necessitated a laparotomy.

DESIGN

After preoperative diagnosis and planning using magnetic resonance imaging, laparoscopic removal of the obstructed uterine horn and tube was performed. Morcellation of tissue was used to permit removal through a 15mm port.

SETTING

A central London tertiary referral teaching hospital.

PARTICIPANTS

15 women aged between 13 and 41.

INTERVENTIONS

Between 1999 and 2005, all women underwent laparoscopic removal of the obstructed uterine horn and tube.

MAIN OUTCOME MEASURES

Recovery, hospital stay, length of operation.

RESULTS

All women recovered well, with an operation time of 80 to 300 minutes and an average hospital stay of 5 days.

CONCLUSIONS

A laparoscopic approach is a safe and appropriate technique for the removal of an obstructed uterine horn.

Office hysteroscopic metroplasty: Three “diagnostic criteria” to differentiate between septate and bicornuate uteri

STUDY OBJECTIVE

To evaluate the benefits of adopting 3 simple "diagnostic criteria" in the differential diagnosis between septate and bicornuate uteri, and the relative treatment by hysteroscopy in an office setting.

DESIGN

Prospective clinical study (Canadian Task Force classification III).

SETTING

University-affiliated hospital.

PATIENTS

Two hundred-sixty patients with a hysteroscopic diagnosis of a double uterine cavity were enrolled.

INTERVENTIONS

Office hysteroscopic metroplasty was performed without analgesia or anesthesia using 5F scissors.

MEASUREMENTS AND MAIN RESULTS

The presence of vascularized tissue, sensitive innervation, and the appearance of the tissue at the incision of a supposed septum during an office hysteroscopic procedure were the criteria used to differentiate a septate from a bicornuate uterus. In 93.1% of the cases, office hysteroscopic metroplasty was successfully performed during the same diagnostic procedure. In 15 of 18 patients scheduled for laparoscopic control of the uterine anatomy, the suspicion of a bicornuate uterus was confirmed. Hysteroscopic follow-up at 3 months showed a regular uterine cavity with a fundal notch less than 1 cm.

CONCLUSION

The study demonstrates the possibility of obtaining complete, safe removal of uterine septae in most cases by office hysteroscopy confirmation, using mechanical instruments, in an office setting. This was achieved by relating the diagnosis and treatment to simple anatomic and physiologic diagnostic criteria.

Ultra-sonografia tridimensional em ginecologia: malformações uterinas

As malformações uterinas são achados pouco comuns na clínica ginecológica. As estatísticas nesta área são muito falhas. Corrobora, ainda, a falta de uniformização na terminologia empregada e as dificuldades diagnósticas. A partir da década de oitenta, a ultra-sonografia tornou-se um procedimento indispensável à prática toco-ginecológica, contribuindo e modificando conceitos e procedimentos dentro dessa especialidade. O advento dos transdutores endocavitários, a análise com Doppler colorido de amplitude e espectral, assim como a melhoria crescente da qualidade de imagem contribuíram para isso. Nos últimos dez anos muito se tem pesquisado, publicado e discutido sobre o papel da ultra-sonografia tridimensional. Os autores fazem uma revisão do tema e ressaltam a importância dessa metodologia como modalidade diagnóstica.

Management of recurrent miscarriage: evaluating the impact of a guideline

BACKGROUND

Little is known on the actual diagnostic and therapeutic management of recurrent miscarriage and the impact of introducing guidelines on this topic. The objective of this study was to evaluate any changes in the management of recurrent miscarriage among Dutch gynaecologists after the introduction of the Dutch guideline 'Recurrent Miscarriage' in 1999.

METHODS

Questionnaires were sent to all practices for obstetrics and gynaecology in the Netherlands. Data concerned definition, diagnosis and treatment of recurrent miscarriage. Results were compared with a similar study conducted before the introduction of the guideline and with the recommendations in the guideline.

RESULTS

The response rate was 83%. Regarding gestational age, only 3% of the respondents used the definition as advised in the guideline. After the introduction of the guideline, thrombophilia factors were tested more frequently, anticoagulants were prescribed more frequently and more respondents reported to correct uterine malformations. Therapies not described in the guideline, e.g. donor insemination and oocyte donation, were still applied.

CONCLUSIONS

The adherence to the Dutch guideline 'Recurrent Miscarriage' was rather poor, presumably due to guideline-related as well as physician-related barriers. Too many diagnostic tests and ineffective therapeutic interventions were performed. This study demonstrates the importance of appropriate implementation and revision.

An incidental finding of unicornuate uterus with unilateral ovarian agenesis during cesarean delivery

INTRODUCTION

The association of müllerian anomalies with concomitant gonadal development abnormalities is very rare. The literature revealed only a few cases of unicornuate uterus with unilateral ovarian agenesis. The pathophysiology of this rare combination is not clear.

CASE REPORT

A 31-year-old primiparous woman at 38 weeks' gestation admitted to our labor room due to painful uterine contractions. An emergency cesarean section was performed and a 3,100-g healthy male infant was delivered. At cesarean delivery, she was found to have unicornuate uterus with no evidence of a rudimentary horn and the absence of a left (unilateral) ovary. The right fallopian tube, round ligament, and ovary were all normal. The left fallopian tube, round ligament, and ovary were all absent. Intraabdominal exploration, intravenous pyelography, postoperative abdominal and transvaginal ultrasonography were failed to reveal additional gynecologic, renal and urinary tract anomalies.

CONCLUSION

To our best knowledge this case is unique since the incidental diagnosis of unicornuate uterus with ipsilateral ovary was made during cesarean delivery.

Is hysteroscopic correction of an incomplete uterine septum justified prior to IVF?

This retrospective study examined the effect of hysteroscopic correction of an incomplete uterine septum on IVF outcome. Measurement of the Fm (fundal myometrial thickness) and Cm (cornual myometrial thickness) was performed by sonohysterography. Group 1 included patients diagnosed with incomplete septum (n = 119), fulfilling the two criteria of Fm >11 mm and Fm-Cm >5 mm, who underwent hysteroscopic incision of the incomplete septum. Group 2 consisted of 116 age-matched control patients with a normal uterine cavity who underwent IVF within the same time period. Main outcome measures were clinical pregnancy and spontaneous abortion rates. Patients in group 1 had a history of more spontaneous abortions than patients in group 2 (14.20 versus 6.03%, P = 0.04) as well as higher previous IVF failure (32.7 versus 20.6%, P = 0.04). After surgical correction of the septum in group 1, IVF pregnancy outcome was similar in both groups (clinical pregnancy and pregnancy loss of 47.80 versus 46.50% and 10.52 versus 20.3% respectively). A similar pregnancy outcome was found after the incision of the incomplete septum compared with a group with normal uterine cavity. Larger prospective and randomized controlled studies are needed to prove the positive effect of correction of an incomplete uterine septum on IVF outcome.

Small uterine septum is an important risk variable for preterm birth

OBJECTIVE(S)

To evaluate whether a uterus with a small septum (arcuate uterus or class VI according to the American Fertility Society (AFS) classification) behaves similarly to a uterus with a larger septum (septate or subseptate uterus or AFS class V).

STUDY DESIGN

Observational study included 826 singleton deliveries to 730 women with a history of hysteroscopic resection of the uterine septum. Data on deliveries were obtained from the National Perinatal Registry of Slovenia (NPIS). Multiple gestations were excluded. We analysed and compared perinatal outcomes before and after hysteroscopic resection in two groups of women: in women with a small uterine septum (Group A) and in those with a larger uterine septum (Group B). Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4-cm long yellow tip of the electric knife to the length of the resected septum. A small uterine septum was defined as having a length of 1.3-1.5 cm.

RESULTS

The preterm birth rate in Group A (n=420) was 33.9% before and 7.2% after hysteroscopic resection (P<0.001); the preterm birth rate in Group B (n=406) was 36.5% before and 8.0% after hysteroscopic resection (P<0.001). The very preterm birth rate in Group A was 12.5% before and 3.1% after hysteroscopic resection (P<0.001); the very preterm birth rate in Group B was 15.0% before and 2.9% after hysteroscopic resection (P<0.001). After surgery, we registered a decreased need for neonatal intensive care, as well as a significant decrease in stillbirth and neonatal death rates in both groups of patients.

CONCLUSION(S)

Similarly to a large uterine septum, a small uterine septum or arcuate uterus is an important hysteroscopically preventable risk variable for preterm birth.

Prise en charge chirurgicale des patientes présentant un utérus cloisonné total

INTRODUCTION

Septate uterus is the principal müllerian anomaly, but complete septate uterus is uncommon and often associated with frequent obstetrical complications. Surgical section of the septum is however possible.

MATERIAL AND METHOD

We report patients with a complete septum uterus operated in our department between 2002 and 2006. We performed a hysteroscopic section of the cervical, uterine and vaginal septum at discovery of the anomaly. The accuracy of imaging exams, frequency of associated malformations, past obstetrical events and reproductive outcome post surgery were analyzed.

RESULTS

The surgical technique was based on section of the cervical part with scissors and hysteroscopic section of the uterine septum; no perforation was noted. Four patients required a second procedure to achieve complete uterine section. Five patients became pregnant after surgery, 8 pregnancies are reported: 2 term delivery, 1 preterm delivery, 4 miscarriages and 1 ectopic pregnancy.

CONCLUSION

Complete surgical section of the cervical and uterine septum in case of complete septum uterus is safe. However, we cannot conclude about the obstetrical benefit of this surgical technique. A longer follow-up is needed.

Reproductive Outcome of Septate Uterus after Hysteroscopic Treatment with Neodymium:YAG Laser

OBJECTIVE

The aim of this study was to assess fertility outcome and obstetrical prognosis of 46 patients after hysteroscopic section of uterine septa with neodysmium:yttrium-aluminum-garnet (Nd:YAG) laser.

BACKGROUND DATA

Approximately 15-25% of spontaneous miscarriages are related to Müllerian fusion defects, most of which are associated with uterine septa. Operative hysteroscopy is a safe and effective treatment for uterine septa.

METHODS

Forty-six sterile patients with septate uterus received hysteroscopic metroplasty with Nd:YAG laser. Forty-one patients with incomplete septate uterus were under the guidance of B-ultrasonography, while the other 5 patients with complete septate uterus were treated by laparoscopy.

RESULTS

The metroplasty was successfully conducted in 45 patients, with a success rate of 98% (45 /46). Postoperative follow-up examinations of 28 patients revealed pregnancy within 12 months in 20 patients, 16 of whom acquired term delivery. The pregnancy rate within 1 year was 71%.

CONCLUSION

Hysteroscopic treatment of septate uterus with Nd:YAG laser is effective. The cervix may not be excessively dilated, the intraoperative bleeding can be thoroughly controlled, and the procedure under local anesthesia is relatively safe.

Recurrent miscarriage

Many human conceptions are genetically abnormal and end in miscarriage, which is the commonest complication of pregnancy. Recurrent miscarriage, the loss of three or more consecutive pregnancies, affects 1% of couples trying to conceive. It is associated with psychological morbidity, and has often proven to be frustrating for both patient and clinician. A third of women attending specialist clinics are clinically depressed, and one in five have levels of anxiety that are similar to those in psychiatric outpatient populations. Many conventional beliefs about the cause and treatment of women with recurrent miscarriage have not withstood scrutiny, but progress has been made. Research has emphasised the importance of recurrent miscarriage in the range of reproductive failure linking subfertility and late pregnancy complications and has allowed us to reject practice based on anecdotal evidence in favour of evidence-based management.

Fertility and pregnancy outcomes following hysteroscopic septum division

OBJECTIVES

We sought to evaluate retrospectively the efficacy of hysteroscopic metroplasty in a population of women with a history of recurrent pregnancy loss or infertility who were also known to have a uterine septum.

METHODS

Hysteroscopic metroplasty was performed on 26 women with a uterine septum and a history of either recurrent pregnancy loss or infertility. The metroplasty was performed using a Versapoint bipolar needle device (in 23% of cases) or a resectoscopic knife electrode with cutting current (in 77% of cases). The main outcome measures were rates of clinical pregnancy and live birth.

RESULTS

Nineteen women had a hysteroscopic metroplasty because of recurrent pregnancy loss. Postoperatively, the pregnancy rate was 95%, and the live birth rate was 72%. The seven infertile patients had pregnancy and live birth rates of 43% and 29%, respectively.

CONCLUSION

Hysteroscopic metroplasty using either the Versapoint bipolar needle device or a knife electrode is both safe and effective. In women with recurrent pregnancy loss, future fertility is not impaired, and live birth rates are significantly improved.

Complete septate uterus with longitudinal vaginal septum

OBJECTIVE

To review clinical implications, reproductive outcome, and long-term consequences in women with complete septate uterus and longitudinal vaginal septum.

DESIGN

A retrospective study.

SETTING

A university hospital.

PATIENT(S)

Sixty-seven patients who had a complete septate uterus including the cervix and a longitudinal vaginal septum.

INTERVENTION(S)

The longitudinal vaginal septum was incised in 36 cases and metroplasty for uterine septum was undertaken in 4 patients.

MAIN OUTCOME MEASURE(S)

Fertility, outcome of pregnancies, possible late consequences, and presence of other anomalies.

RESULT(S)

Eight (15.7%) of 51 women attempting pregnancy had primary infertility of nonuterine causes. Forty-nine women not undergoing metroplasty produced 115 pregnancies, abortion rate 27%, preterm delivery 12%, and live birth rate 72%. Only five women with no metroplasty had only miscarriages and 44 women at least one delivery. One of four women undergoing metroplasty delivered preoperatively and three after metroplasty. During the follow-up period endometriosis was observed in two (3%) of 61 cases and two patients had borderline ovarian tumors. Kidney abnormalities were found in 11 (20%) of 55 patients studied, double ureter being the most common.

CONCLUSION(S)

Complete septate uterus with longitudinal vaginal septum is not associated with primary infertility, and pregnancy may progress successfully without surgical treatment. The results do not support elective hysteroscopic incision of the septum in asymptomatic patients or before first pregnancy.

Laparoscopic metroplasty for bicornuate uterus

This is a case study of a 29-year-old nulliparous woman with a bicornuate uterus who had a poor obstetric history in whom we performed a laparoscopic metroplasty. She was advised to use barrier contraception for 3 months. A repeat hystero-laparoscopy performed 3 months later revealed a single large uniform uterine cavity without any adhesions. The patient had an incompetent cervical os after surgery and was advised to undergo cervical cerclage on conception.

Preterm Torsion of a Gravid Uterus Didelphys Horn of a Twin Pregnancy

BACKGROUND

Simultaneous pregnancy in each horn of a uterus didelphys is a rare and complex clinical situation.

CASE

Torsion of one horn of a gravid didelphic uterus during a twin pregnancy was diagnosed during cesarean delivery after erroneous diagnosis of abruptio placentae.

CONCLUSION

Localization of the placenta in a pregnancy complicated by uterine didelphys may improve the ability to diagnose hemiuterus torsion.

Is there an association between septate uterus and endometriosis?

BACKGROUND

The question of whether Müllerian anomalies are significantly more often combined with endometriosis is a controversially discussed problem. Some publications described this association in patients with obstructive but not non-obstructive Müllerian anomalies or controls without Müllerian anomalies. The aim of this study was to evaluate the incidence of endometriosis in patients with a septate uterus as a non-obstructive form of Müllerian anomalies.

METHODS

In a retrospective study, we evaluated 120 patients (29.4 +/- 4.7 years; mean +/- SD) with a septate uterus. The control group consisted of 486 consecutive infertile patients (30.8 +/- 6.3 years) with a normal hysteroscopy and laparoscopy.

RESULTS

The incidence of dysmenorrhoea was comparable in both groups, but the incidence of endometriosis was significantly higher in patients with a septate uterus (25.8 versus 15.2%, P = 0.006).

CONCLUSION

Our results suggest a higher incidence of endometriosis in patients with a septate uterus. If it can be confirmed by others, the initial finding of a septate uterus in infertile patients should be followed by a combined hysteroscopy and laparoscopy.

Is hysterosalpingography able to diagnose all uterine malformations correctly? A retrospective study

BACKGROUND

Mullerian duct anomalies are an uncommon but often a treatable cause of infertility.

MATERIAL AND METHODS

From January 2002 until November 2003, a total of 705 hysterosalpingographies were realised of which 658 were analysed retrospectively in order to determine the importance of uterine malformations in infertile and sterile patients. In ten cases, the results of hysterosalpingography were compared with hysteroscopy and laparoscopy.

RESULTS

The frequency of uterine malformations in infertile and sterile women was 10%. In this population, arcuate uterus (57.6%) was the most common malformation, followed by subseptate uterus (18.2%), uterus bicornis unicollis (10.6%), uterus bicornis bicollis (3.0%), septate uterus (6.1%), unicornuate uterus (3.0%) and unicornuate uterus with double vagina (1.5%).

DISCUSSION

Our bibliographic research confirmed that arcuate uterus is the most frequent congenital malformation, but in gestations it does not show a significantly reduced live birth rate. Nevertheless, the septate uterus presents an important decrease of live birth rate that can be improved significantly by doing hysteroscopic metroplasty. As this is a completely different surgical intervention compared to bicornuate uterus, a correct diagnosis is very important. Differentiation of these two malformations is quite difficult by hysterosalpingographic exploration, wherefore an additional exploration by means of endovaginal or three-dimensional ultrasound is recommended.

Rudimentary horn pregnancy: first-trimester prerupture sonographic diagnosis and confirmation by magnetic resonance imaging

OBJECTIVE

Two cases of rudimentary horn pregnancy diagnosed in the first trimester by sonography and confirmed by magnetic resonance imaging (MRI) are reported. We suggest criteria for early, prerupture sonographic diagnosis of this rare condition.

METHODS

We report a case in which pregnancy in a rudimentary horn was suspected on routine sonographic examination. In the second case, sonographic examination at 11 weeks' gestation revealed a right unicornuate uterus and a noncommunicating left rudimentary horn containing a gestational sac. In both cases, MRI clearly confirmed the sonographic diagnosis, showing an empty cavity of the uterine body and a pregnant uterine horn without an endometrial communication to the uterine body.

RESULTS

Both patients underwent surgery, and the pregnant rudimentary horns were resected with no complications.

CONCLUSIONS

We suggest the following criteria for sonographic diagnosis of rudimentary horn pregnancy: (1) a pseudopattern of a asymmetrical bicornuate uterus, (2) absent visual continuity tissue surrounding the gestational sac and the uterine cervix, and (3) the presence of myometrial tissue surrounding the gestational sac. Typical hypervascularization of placenta accreta may support the diagnosis. Additionally, MRI can be used to confirm the diagnosis before an invasive procedure is undertaken.

An unusual anatomic variation of a unicornuate uterus with normal external uterine morphology

OBJECTIVE

To describe a case of a unicornuate uterus with a normal external uterine morphology.

DESIGN

Case report.

SETTING

University-based fertility center.

PATIENT(S)

A 30-year-old nulligravid woman with a 1-year history of infertility found to have a right proximal tubal occlusion on hysterosalpingogram.

INTERVENTION(S)

Laparoscopy, hysteroscopy, and magnetic resonance imaging.

MAIN OUTCOME MEASURE(S)

External and internal morphology of the uterus.

RESULT(S)

Laparoscopy showed a normal external uterine morphology and normal fallopian tubes and ovaries, but chromopertubation failed to demonstrate a fill and spill from the right fallopian tube. Hysteroscopy showed a single tubular uterine cavity projecting to the left with a single left tubal ostium, consistent with a unicornuate uterus. Magnetic resonance imaging confirmed a normal external uterine fundal contour and an internal uterine morphology consistent with a unicornuate uterus.

CONCLUSION(S)

This is the first reported case of a unicornuate uterus presenting with a normal external uterine morphology and an internal morphology consistent with a unicornuate uterus, and we propose inclusion of this anomaly in the classification of mullerian anomalies.

Possible role of bacterial and viral infections in miscarriages

OBJECTIVE

To determine the role of infections in miscarriages. Chorionic villi from aborted material were subjected to cytogenetic evaluation and analyzed for the presence of Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma hominis, human cytomegalovirus (HCMV), adeno-associated virus (AAV), and human papillomaviruses (HPV).

DESIGN

Retrospective study.

SETTING

University hospital and academic research institution.

MAIN OUTCOME MEASURE(S)

Karyotyping and detection of bacterial and viral DNA by means of polymerase chain reaction (PCR) in placenta specimens.

RESULT(S)

In 54 (50%) of 108 samples the karyotype was normal, in 38 (35%) samples it was abnormal, and in 16 (15%) samples karyotype was undetermined. No U. urealyticum, M. hominis, HCMV, or AAV-2 DNA was detected, while C. trachomatis DNA was detected in one (1%) and HPV DNA in eight (7%) samples. No significant correlation of HPV-positive findings with karyotype status was established.

CONCLUSION(S)

Our findings do not support a role of C. trachomatis, U. urealyticum, M. hominis, HCMV, or AAV infections in miscarriages during the first trimester of pregnancy. However, further investigation should be made to determine a possible involvement of HPVs in the development of genetic abnormalities of the fetus and in miscarriages.

Assessing congenital uterine anomalies: the role of three-dimensional ultrasonography

Congenital uterine anomalies are associated with a range of adverse reproductive outcomes but may also be found incidentally. Their significance in women with normal reproductive histories, who do not have a history of recurrent miscarriage or infertility, has been uncertain. The absence of these data has made it difficult to understand the true significance of congenital uterine anomalies found in women with adverse pregnancy outcomes. The advent of transvaginal three-dimensional ultrasonography has enabled the accurate, non-invasive, outpatient diagnosis of congenital uterine anomalies. It has enabled large-scale screening and morphological analysis of congenital uterine anomalies.

Facteurs prédictifs de rupture utérine obstétricale après hystéroscopie opératoire

OBJECTIVES

To identify factors predictive of uterine rupture after operative hysteroscopy. When these factors are present, to search for means to prevent a later uterine rupture. Lastly to specify criteria allowing extraction of the fetus before rupture.

PATIENTS AND METHODS

Dramatic description of a case of uterine rupture, in a patient who presented a history of uterine perforation secondary to operative hysteroscopy and retrospective analysis of 12 similar observations reported in the literature.

RESULTS

Two types of situations must be differentiated: uncomplicated hysteroscopic resection of a polyp or sub-mucous fibroid does not seem to modify the obstetrical outcome; metroplasty for uterine malformation, complex synechia resections, and uterine perforations using monopolar current section are high-risk situations predictive of uterine rupture during pregnancy.

CONCLUSION

Uterine ruptures secondary to operative hysteroscopy are rare but serious. They can occur before onset of labor, and compromise vital maternofetal outcome. Risk factors can be identified, but nothing can prevent natural history towards uterine rupture during pregnancy. The obstetrician's vigilance in this context must be extreme searching for the least clinical sign in favor of a pre-rupture of the uterus. Furthermore, systematic caesarean is not justified.

Clinical use of sonohysterography in the evaluation of infertility

Assessment of tubal patency and evaluation of the uterine cavity should be part of all infertility investigations. Sonohysterography (SHSG), also referred to as saline-enhanced ultrasonography, is being used with increasing frequency for investigation of infertility and other gynaecological indications. Sonohysterography is similar to hysterosalpingography (HSG) in its effectiveness for evaluating tubal patency, and superior to HSG for assessing intrauterine abnormalities. Advantages of SHSG over HSG include the ability to assess extrauterine structures, lack of ionizing radiation, and often better tolerability by the woman being examined. Sonohysterography can offer detailed assessment of the female pelvis, and has the potential to replace HSG as a routine, first-line infertility investigation. This paper discusses the technique and indications for SHSG, and reviews its use in infertility investigation, in particular in the assessment of the uterine cavity and tubal patency.

Intrauterine pregnancy following transperitoneal oocyte and/or sperm migration in a woman with an ectopic (undescended) ovary

This is the first report of an intrauterine pregnancy following timed coitus, resulting from transperitoneal sperm and/or oocyte migration as the oocyte originated from an ectopic (undescended) ovary. The patient was treated in the infertility clinic after a history of primary infertility for 2 years. Diagnosis of a moderate teratozoospermia and the presence of a unicornuate uterus with one right-sided normal ovary was made. During the first intrauterine insemination (IUI) treatment cycle with clomiphene citrate stimulation, a discrepancy between oestradiol concentrations and follicular growth was observed. Magnetic resonance imaging (MRI) was carried out because the presence of an ectopic ovary was suspected. The diagnosis of a left-sided undescended ovary was made, containing several follicles, the largest measuring 16 mm in diameter. Because of a spontaneous LH surge 2 days later without substantial follicular growth in the normal right-sided ovary, IUI was cancelled and timed intercourse was planned. Surprisingly, and although the largest follicle in the normally located ovary reached a maximum diameter of only 12 mm on repetitive ultrasound monitoring, this patient became pregnant and gave birth to a healthy baby boy.

Subfertility: causes, treatment and outcome

Common causes of subfertility include ovulatory disorders, tubal disease, peritoneal adhesions, endometriosis, uterine abnormalities, abnormalities of sperm and advancing female age. Infertility is unexplained after thorough evaluation in about 5-10% of cases. Significant caveats must be attached to the interpretation of available data regarding infertility treatments. Successful ovulation induction in anovulatory women is possible for nearly all women except in cases of ovarian failure. Surgery is an option for some patients with tubal damage, adhesions, endometriosis and uterine abnormalities. Male factor infertility may be amenable to treatment of a specific cause, but is often empirical with the use of intra-uterine insemination (IUI) or in vitro fertilization (IVF). Egg donation is currently the most effective treatment available for age-related infertility when other treatments have not been successful. Couples with unexplained infertility may be effectively treated with ovulation induction plus IUI or IVF.

Risk factors in miscarriage: a review

Miscarriage is one of the most frequent problems in human pregnancy. The most widely accepted definition is that proposed by the World Health Organization (WHO) in 1977. The incidence among clinical pregnancies is about 12-15% but including early pregnancy losses it is 17-22%. The only two etiologic factors recognized by all authors are uterine malformations and parental balanced chromosomal rearrangements. There have been many other suggested risk factors. In this revision we discuss these.

Is it possible to recommend an "optimal" postoperative management after hysteroscopic metroplasty? A retrospective study with 52 infertile patients showing a septate uterus

BACKGROUND

The aim of the retrospective study was to evaluate the "optimal" postoperative management after hysteroscopic metroplasty. METHODS. FIFTY-TWO: infertile patients with a septate uterus were included. Hysteroscopic metroplasty was performed using electrocautery (dissection needle) with postoperative cyclical hormone replacement therapy (HRT) + intrauterine device (IUD) insertion for 3 months (Group 1, n = 22), or HRT alone for 3 months (Group 2, n = 13), or without postoperative therapy (Group 3, n = 17).

RESULTS

During a median follow-up of 21+/-16.9 months 40.9% in Group 1, 53.8% in Group 2 and 41.2% in Group 3 (p > 0.05) resulted in ongoing pregnancies. The rates of delivery at term were 53.3%, 64.4% and 88.9%, respectively.

CONCLUSIONS

A postoperative 3-months HRT + IUD insertion or a HRT alone after hysteroscopic metroplasty are not necessary.

Clinical implications of sonographic detection of uterine anomalies for reproductive outcome

The purpose of this review article was to analyze the literature on the prevalence, diagnosis and treatment of the congenital uterine anomalies and to discuss current dilemmas on their influence on reproductive outcome. Congenital uterine anomalies are commonly associated with repeated pregnancy failure, in particular an increased risk of first- and second-trimester miscarriages and preterm delivery. Recent reports on two-dimensional and three-dimensional transvaginal ultrasound and saline contrast sonohysterography appear promising for diagnosis and classification of congenital uterine anomalies. The ability to visualize both the uterine cavity and the fundal uterine contour on a three-dimensional scan facilitates the diagnosis of uterine anomalies and enables differentiation between septate and bicornuate uteri. Color Doppler ultrasound allows visualization of intraseptal vascularity and may help in distinguishing the avascular from the vascular septum. Less connective tissue in the septum may result in poor decidualization and placentation, while an increased amount of muscle tissue in the septum can cause miscarriage by the production of local uncoordinated myometrial contractility. Hysteroscopic septum excision is an effective procedure which improves live-birth rates. Because of its simplicity, minimal invasiveness, low morbidity and low cost, a more liberal approach to the treatment of uterine anomalies is being advocated.