Comparison of three-dimensional ultrasound and magnetic resonance imaging diagnosis in surgically proven Müllerian duct anomaly cases

The accuracy of three-dimensional ultrasonography in the diagnosis of Müllerian duct anomalies and its concordance with magnetic resonance imaging

This retrospective study was performed to comparatively evaluate the diagnostic accuracies of three-dimensional ultrasonography (3D-US) and magnetic resonance imaging (MRI) for identification of Müllerian duct anomalies (MDAs). A total of 27 women with suspected MDAs underwent gynaecological examination, 2D-US, 3D-US and MRI, respectively. The MDAs were classified with respect to the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE/ESGE) and American Society of Reproductive Medicine (ASRM) systems. Based on the ESHRE/ESGE classification, there was a discrepancy for only one patient between US and MRI. Thus, the concordance between US and MRI was 26/27 (96.3%). With respect to ASRM classification, there was a disagreement between MRI and 3D-US in three patients, thus the concordance between MRI and 3D-US was 24/27 (88.9%). To conclude, the 3D-US has a good level of agreement with MRI for recognition of MDAs.Impact StatementWhat is already known on this subject? Müllerian duct anomalies (MDAs) are relatively common malformations of the female genital tract and they may adversely affect the reproductive potential. The establishment of accurate and timely diagnosis of these malformations is critical to overcome clinical consequences of MDAs.What the results of this study add? The concordance between US and MRI for diagnosis of MDAs based on ESHRE-ESGE classification and ASRM were 96.3% and 88.9%, respectively. These results indicate that 3D US has a satisfactory level of diagnostic accuracy for MDAs and it can be used in conjunction with MRI. Minimisation of diagnostic errors is important to improve reproductive outcome and to avoid unnecessary surgical interventions.What the implications are of these findings for clinical practice and/or further research? Efforts must be spent to eliminate the discrepancies between the clinical and radiological diagnosis of MDAs. Further trials should be implemented for establishment and standardisation of radiological images for identification and classification of MDAs.

The value of three-dimensional ultrasound in identifying Mullerian anomalies at risk of adverse pregnancy outcomes

OBJECTIVE

To examine the reliability of three-dimensional ultrasound (3 D-US) in the differentiation between subseptate and arcuate uteri, due to the different associated pregnancy outcomes; refine the existing 3 D-US parameters and evaluate the concordance between 3 D-US and MRI in diagnosing these anomalies.

STUDY DESIGN

This was a prospective cohort study of 455 women suspected of having a Mullerian anomaly. The diagnosis of subseptate, bicornuate or arcuate uterus was made by 3 D-US in 55 women. Two independent examiners manipulated the 3 D-US volume datasets and recorded the internal intercornual distance, indentation length, indentation tip angle, and myometrial wall thickness in the coronal plane of the uterus. Subsequently, 48 women underwent MRI which was used as the reference test for diagnosis. We calculated the degree of correlation between the two ultrasound assessors' 3 D-US measurements using interclass correlation coefficient and as well as a Bland-Altman plot. The mean values of the four parameters were used to create receiver operating characteristic curves for determining the best cutoff values for differentiation between subseptate and arcuate uterui. We used the Cohen's Kappa test to measure the level of agreement between 3 D-US and MRI.

RESULTS

There was good interobserver agreement between the two 3 D-US assessors for all four parameters. There was a substantial level of agreement between 3 D-US and MRI in differentiating between bicornuate, subseptate and arcuate uteri with a kappa value of 0.727 (95% CI 0.443-0.856). Distinction between subseptate and arcuate uterus was improved when using an indentation length ≥12.5 mm (AUC 0.99) and indentation tip angle ≤89.25 degrees (AUC 0.97) as cutoffs for diagnosis but not the internal intercornual distance or myometrial wall thickness.

CONCLUSION

3 D-US evaluation of the coronal view of the uterus can be relied upon to make a noninvasive, accurate differentiation between subseptate and arcuate uteri. The fundal indentation length and indentation tip angle cut offs of ≥12.5 mm and ≤88 mm, respectively were found to be most accurate for distinction. Thus, allowing for individualizing pre-pregnancy management plans and patient-informed healthcare choices. Highlights There are no agreed upon criteria for differentiating arcuate from subseptate uteri. Such differentiation is critical for counseling and management due to the substantial difference in pregnancy outcome. We aimed to propose cut off values for ultrasound measurements standardized against MRI diagnostic criteria for accurate differentiation between arcuate and subseptate uteri. We demonstrated substantial agreement between 3D-US and MRI in differentiating between bicornuate, subseptate and arcuate uteri. 3D-US evaluation of the coronal view of the uterus is reliable to make an accurate differentiation between subseptate and arcuate uteri. Using the indentation length ≥12.5 mm and indentation tip angle ≤89.25 degrees as parameters to be measured on the coronal view by 3D-US increases its diagnostic accuracy for distinction between arcuate and subseptate uteri.

Screening for Mullerian anomalies in patients with unilateral renal agenesis: Leveraging early detection to prevent complications

BACKGROUND

Mullerian anomalies have a known association with renal agenesis yet, to date, there are no formal recommendations for screening women with certain renal anomalies for associated genital tract disorders.

OBJECTIVE

The objective of this study is to review current data regarding the association between renal and Mullerian anomalies, and propose screening recommendations.

STUDY DESIGN

A comprehensive review of the literature was performed to identify relevant articles using the keywords "unilateral renal agenesis," "renal anomalies," and "Mullerian anomalies."

RESULTS

Over 30% of patients with unilateral renal agenesis have an associated Mullerian anomaly. However, diagnosis is frequently delayed in this population until after menarche when complications of retrograde menstruation with obstructive anomalies lead to significant problems including endometriosis, pelvic inflammatory disease, and infertility. No clear guidelines exist for communication among the antenatal sonographer, the obstetrician, the parents, and the child's pediatrician, which creates a barrier to effective screening and follow-up. Further, no current guidelines exist for screening women with certain renal anomalies for Mullerian anomalies.

DISCUSSION

The complications of Mullerian anomalies are easily preventable if identified early. We propose new guidelines for education and screening for Mullerian anomalies in patients with unilateral renal agenesis (URA) and multicystic dysplastic kidney (MCDK) to guide providers, patients, and parents on proper identification and management (Table).

CONCLUSIONS

Screening young women with URA and MCDK for Mullerian anomalies has the potential to prevent long-term complications from untreated obstructive malformations. Identification of unilateral renal agenesis on antenatal ultrasound must be clearly articulated with parents and the child's pediatrician so that proper screening can be performed before menarche. Pelvic sonography is a low-cost, high-yield screening tool to identify these anomalies.

Preimplantation 3D ultrasound: current uses and challenges

The preimplantation ultrasound (US) refers to targeted imaging of the uterus and adnexa prior to assisted reproductive techniques (ART) to optimize the infertility treatment outcomes. After a thorough evidence based literature review, we propose the use of transvaginal three-dimensional (3D) US during the early follicular phase. A systematic approach for 3D US examination consists of a detailed examination of the uterine shape, size and contour, evaluation of the endometrial thickness, volume, pattern and vascularity, and assessment of the junctional zone regularity, echogenicity and thickness. Uterine anatomy is explored in the coronal plane by simultaneous visualization of the uterine cavity, the external surface of the fundus and cervix. Saline infusion sonogram (SIS) is recommended for patients with increased endometrial volume, abnormal endometrial pattern and irregular uterine cavity shape suggestive of Müllerian duct anomalies or acquired intracavitary abnormalities. Myometrial lesions should be recognized and proper dimensions and locations should be ascertained. Ovarian dimensions and volume are measured and the antral follicle count is recorded. Adnexa are carefully assessed for masses, endometriosis and dilated tubes. Color power Doppler US may be applied to evaluate vascularity of the ovaries and pelvic lesions. Hysterosalpingo-contrast-sonography (Hy-Co-Sy) should be optimally utilized for assessment of tubal patency. Accessibility and mobility of the ovaries should be checked in real time for better planning of the ultrasound-guided oocyte retrieval. The cul-de-sac is assessed for the presence of free fluid or masses.

The Diagnosis and Surgical Approach of Uterine Septa

Uterine septa are a class of müllerian duct anomaly that, similar to other classes, are associated with poor reproductive outcomes; however, they are unique because these poor outcomes, particularly recurrent pregnancy loss, may be responsive to surgical correction. The current evidence regarding septoplasty is difficult to interpret because the definitions of a uterine septum, methods to diagnose it, and hysteroscopic techniques used for treatment are variable and generally of poor to moderate quality. Robust data on outcomes, particularly live births, after septoplasty are not available at this time. This review aims to examine the evidence on this contentious issue. A search of the literature was conducted using the MEDLINE, Embase, and Cochrane databases from 2002 to present with included articles reporting on clinical and/or imaging diagnosis of a uterine septum, operative techniques for uterine septoplasty, or clinical outcomes for women with uterine septa. The initial search revealed 4997 potentially relevant articles with 36 full-text articles included after the removal of nonrelevant titles, including 16 diagnostic studies, 17 surgical studies, and 3 studies on clinical outcomes. Where access to 3-dimensional transvaginal ultrasound or magnetic resonance imaging exists, these imaging modalities offer a highly sensitive and specific method of diagnosing a uterine septum without invasive diagnosis although this is operator dependent. Despite hysteroscopic septoplasty being described for over 40 years, there remains a lack of high-quality data to support hysteroscopic septoplasty and which women would most benefit from the procedure. There is no evidence for pre- or postoperative treatments nor has a single surgical approach been identified as superior than another although an important end point of live birth rates is largely unreported in these trials. Although several classification systems have been described, the diagnostic categorization of septal variants has limited a meaningful approach to this issue in both the clinical and research setting.

MR Imaging of Müllerian Fusion Anomalies

Müllerian duct anomalies, also called congenital uterine anomalies, are developmental structural disorders of the female genital tract. These anomalies are clinically relevant in patients with a history of infertility and pregnancy-related complications. The American Society for Reproductive Medicine classification system is the most well known, although newer systems, such as from the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy, are becoming more widely accepted. MR imaging remains the optimal imaging modality due to its superior multiplanar capability and spatial resolution. This review article describes the typical MR appearance of congenital uterine anomalies.