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Rotem R, Hirsch A, Ehrlich Z, Sela HY, Grisaru-Granovsky S, Rottenstreich M. Trial of labor following cesarean in patients with bicornuate uterus: a multicenter retrospective study. Arch Gynecol Obstet 2024; 310:253-259. [PMID: 37777621 DOI: 10.1007/s00404-023-07220-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/05/2023] [Indexed: 10/02/2023]
Abstract
OBJECTIVE This study aimed to evaluate whether a trial of labor after cesarean delivery (TOLAC) in women with a bicornuate uterus is associated with increased maternal and neonatal morbidity compared to women with a non-malformed uterus. METHODS A multicenter retrospective cohort study was conducted at two university-affiliated centers between 2005 and 2021. Parturients with a bicornuate uterus who attempted TOLAC following a single low-segment transverse cesarean delivery (CD) were included and compared to those with a non-malformed uterus. Failed TOLAC rates and the rate of adverse maternal and neonatal outcomes were compared using both univariate and multivariate analyses. RESULTS Among 20,844 eligible births following CD, 125 (0.6%) were identified as having a bicornuate uterus. The overall successful vaginal delivery rate following CD in the bicornuate uterus group was 77.4%. Failed TOLAC rates were significantly higher in the bicornuate group (22.4% vs. 10.5%, p < 0.01). Uterine rupture rates did not differ between the groups, but rates of placental abruption and retained placenta were significantly higher among parturients with a bicornuate uterus (9.8% vs. 4.4%, p < 0.01, and 9.8% vs. 4.4%, p < 0.01, respectively). Neonatal outcomes following TOLAC were less favorable in the bicornuate group, particularly in terms of neonatal intensive care unit admission and neonatal sepsis. Multivariate analysis revealed an independent association between the bicornuate uterus and failed TOLAC. CONCLUSIONS This study found that parturients with a bicornuate uterus who attempted TOLAC have a relatively high overall rate of vaginal birth after cesarean (VBAC). However, their chances of achieving VBAC are significantly lower compared to those with a non-malformed uterus. Obstetricians should be aware of these findings when providing consultation to patients.
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Affiliation(s)
- Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Ayala Hirsch
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Zvi Ehrlich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Hen Y Sela
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Sorina Grisaru-Granovsky
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Misgav Rottenstreich
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University School of Medicine, Jerusalem, Israel.
- Department of Obstetrics and Gynecology, McMaster University Medical Center, McMaster University, Hamilton, ON, Canada.
- Department of Nursing, Jerusalem College of Technology, Jerusalem, Israel.
- Department of Obstetrics and Gynecology and Medical Genetics Institute, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University, 3235, Jerusalem, Israel.
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Aslan B, Şükür YE, Özmen B, Sönmezer M, Berker B, Aytaç R, Atabekoğlu CS. Proposal for Diagnostic Criteria of Y-Shaped Dysmorphic Uterus Based on 3-Dimensional Transvaginal Ultrasound Measurements. J Minim Invasive Gynecol 2024; 31:504-510. [PMID: 38553000 DOI: 10.1016/j.jmig.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/18/2024] [Accepted: 03/19/2024] [Indexed: 04/14/2024]
Abstract
STUDY OBJECTIVE To define objective and readily applied diagnostic criteria for Y-shaped uteri using 3-dimensional transvaginal ultrasound (3D-TVUS) volume recordings. DESIGN A retrospective case-control diagnostic measurements study. SETTING A tertiary university hospital's reproductive health and research center. PATIENTS Two hundred thirteen patients who presented with infertility between January 2020 and December 2022. INTERVENTIONS Two blinded physicians re-evaluated the 3D-TVUS images of all patients for the presence of a uterine abnormality. The images of patients with a Y-shaped uterus were re-evaluated, and descriptive measurements were done. MEASUREMENTS AND MAIN RESULTS The most common uterine abnormality in this cohort was the Y-shaped uterus with a prevalence of 12.2%, followed by the arcuate, T-shaped, and septate uteri, respectively. Reviewers identified 26 and 28 Y-shaped uteri, respectively, and came to a consensus on 25 images. Diagnostic criteria for the Y-shaped uterus based on 3D-TVUS findings have been specified as: lateral indentation depths between 4 and 7 mm, fundal indentation depth between 5 and 9 mm, lateral indentation angles between 121° and 149°, fundal indentation angle between 121° and 145°, and Y-angles 25° to 46°. CONCLUSION Some subtypes of dysmorphic uteri, such as the Y-shaped uterus, whose clinical significance is unknown and may be variants of the normal, may actually be more common than thought. Determining objective diagnostic criteria with 3D-TVUS will allow standard research on these anomalies and their clinical significance.
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Affiliation(s)
- Batuhan Aslan
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Yavuz Emre Şükür
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey.
| | - Batuhan Özmen
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Murat Sönmezer
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Bülent Berker
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Ruşen Aytaç
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
| | - Cem Somer Atabekoğlu
- Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
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Rodríguez-Fuentes A, Hernández J, Rouleau JP, Martín-Vasallo P, Palumbo A. A follicular volume of >0.56 cm 3 at trigger is the cutoff to predict oocyte maturity: a starting point for novel volume-based triggering criteria. Fertil Steril 2024; 121:991-999. [PMID: 38295896 DOI: 10.1016/j.fertnstert.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 01/02/2024] [Accepted: 01/22/2024] [Indexed: 02/23/2024]
Abstract
OBJECTIVE To determine the minimum follicular volume on the day of trigger that will correspond to a mature oocyte at egg retrieval by individualized follicular puncture and to calculate the mean follicular growth from ovulation induction to egg retrieval using SonoAVCfollicle. DESIGN A prospective observational study of 53 women undergoing in vitro fertilization, in which it was possible to identify unequivocally one or more follicles at trigger and egg retrieval using three-dimensional ultrasound. SETTING University-affiliated private in vitro fertilization center. PATIENTS The final sample included 206 follicles from 14 oocyte donors and 39 patients. INTERVENTIONS A three-dimensional ultrasound with SonoAVCfollicle was performed at trigger and egg retrieval. The same operator selected follicles that were identified easily on both scans and verified that they were apt to be aspirated individually. Follicles were punctured individually, recording the real aspirated volume and the maturity stage of the oocyte. MAIN OUTCOME MEASURES The primary outcome was the relationship between follicular volume on the day of the trigger and the oocyte maturity stage. The secondary outcome was the rate of follicular growth from the day of trigger to the day of oocyte retrieval, as measured using SonoAVCfollicle. RESULTS On the day of trigger 206, follicles were selected. Of these, 5 could not be identified on the day of oocyte retrieval, probably because of follicular rupture (mean volume: 4 cm3, range: 2-7 cm3), and in 48, an oocyte was not obtained. The relationship between follicular volume and oocyte maturity was studied in 153 follicles: 125 (82%) contained mature and 28 (18%) contained immature oocytes. Receiver operating characteristic curves showed an area under the curve value of 0.73 (95% confidence interval: 0.65-0.80). A follicular volume of >0.56 cm3 is the cutoff point, with the highest Youden index having a sensitivity of 85% and a specificity of 64% to predict oocyte maturity. The mean follicular growth from trigger to egg retrieval was 26%-50% in 53% of cases. CONCLUSION A follicular volume of >0.56 cm3 at trigger is the cutoff point with the optimal balance between sensitivity and specificity for oocyte maturity. Follicles of >2-3 cm3 may undergo spontaneous rupture before egg retrieval. Given these findings, we propose new volume-based criteria for trigger: 70% of follicles of >0.6 cm3 and dominant follicles between 2 and 3 cm3. These findings need validation by randomized controlled trials.
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Affiliation(s)
- Adela Rodríguez-Fuentes
- Department of Reproductive Endocrinology, Centro de Asistencia a la Reproducción Humana de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Jairo Hernández
- Department of Reproductive Endocrinology, Centro de Asistencia a la Reproducción Humana de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Jean Paul Rouleau
- Department of Reproductive Endocrinology, Centro de Asistencia a la Reproducción Humana de Canarias, La Laguna, Santa Cruz de Tenerife, Spain
| | - Pablo Martín-Vasallo
- Department of Reproductive Endocrinology, Centro de Asistencia a la Reproducción Humana de Canarias, La Laguna, Santa Cruz de Tenerife, Spain; UD de Bioquímica y Biología Molecular and Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, La Laguna, Santa Cruz de Tenerife, Spain
| | - Angela Palumbo
- Department of Reproductive Endocrinology, Centro de Asistencia a la Reproducción Humana de Canarias, La Laguna, Santa Cruz de Tenerife, Spain.
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Urman B, Ata B, Gomel V. Reproductive surgery remains an essential element of reproductive medicine. Facts Views Vis Obgyn 2024; 16:145-162. [PMID: 38950529 DOI: 10.52054/fvvo.16.2.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
Background Reproductive surgery has long been neglected and is perceived to be simple surgery that can be undertaken by all gynaecologists. However, given the ever-expanding knowledge in the field, reproductive surgery now comprises surgical interventions on female reproductive organs that need to be carefully planned and executed with consideration given to the individuals symptoms, function of the organ and fertility concerns. Objectives To discuss the different perspectives of reproductive surgeons and other gynaecological surgeons, e.g., gynaecological oncologists, and advanced minimally invasive surgeons, regarding diagnosis and management of pelvic pathology that affects reproductive potential. Furthermore, to highlight the gaps in knowledge and numerous controversies surrounding reproductive surgery, while summarising the current opinion on management. Materials and Methods Narrative review based on literature and the cumulative experience of the authors. Main outcome measures The paper does not address specific research questions. Conclusions Reproductive surgery encompasses all reproductive organs with the aim of alleviating symptoms whilst restoring and preserving function with careful consideration given to alternatives such as expectant management, medical treatments, and assisted reproductive techniques. It necessitates utmost technical expertise and sufficient knowledge of the female genital anatomy and physiology, together with a thorough understanding of and respect to of ovarian reserve, tubal function, and integrity of the uterine anatomy, as well as an up-to-date knowledge of alternatives, mainly assisted reproductive technology. What is new? A holistic approach to infertile women is only possible by focusing on the field of reproductive medicine and surgery, which is unattainable while practicing in multiple fields.
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Elshetry ASF, Assy MM, Zaid NA, El-Fawakry RM, Radwan MHSS, Hamed EM. Reproducibility of MRI Diagnosis of Female Genital Anomalies. Can Assoc Radiol J 2024:8465371241252793. [PMID: 38795028 DOI: 10.1177/08465371241252793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2024] Open
Abstract
Purpose: To assess and compare intrareader and interreader reproducibility of magnetic resonance imaging (MRI) diagnosis of female genital anomalies (FGAs) using the American Society for Reproductive Medicine-Mullerian anomalies classification 2021 (ASRM-MAC 2021) and European Society of Human Reproduction and Embryology-European Society for Gynecological Endoscopy (ESHRE-ESGE) 2016 classification. Methods: In this retrospective study, we searched our electronic MRI database from April 2021 to September 2023, selecting MRI studies with FGAs. Seventy-six consecutive studies were included and reviewed by 4 independent radiologists using both classifications. Studies were re-evaluated after 1 month. Reproducibility was assessed using kappa (κ) scores with 95% confidence intervals (CI). Results: Intrareader agreement for MRI diagnosis of FGAs was substantial to excellent, with κ scores ranging from 0.684 (95% CI, 0.534-0.834) to 0.985 (95% CI, 0.963-1.01) using the ASRM-MAC 2021 and from 0.743 (95% CI, 0.621-0.865) to 0.846 (95% CI, 0.719-0.973) using the ESHRE-ESGE 2016 classification. Pairwise interreader agreement was higher with the ASRM-MAC 2021, ranging from moderate (κ = 0.491; 95% CI, 0.341-0.642) to substantial (κ = 0.709; 95% CI, 0.597-0.821), compared to the ESHRE-ESGE 2016 classification, with weak (κ = 0.080; 95% CI, 0.068-0.228) to moderate (κ = 0.511; 95% CI, 0.344-0.678) agreement. Overall interreader agreement was moderate for both classifications (κ = 0.599; 95% CI, 0.562-0.638 for ASRM-MAC 2021 and κ = 0.429; 95% CI, 0.396-0.463 for ESHRE-ESGE 2016 classification), but with significant differences (non-overlapping CIs). Conclusion: The intrareader reproducibility was high for both classifications, whereas the interreader reproducibility was higher using the ASRM-MAC 2021, highlighting the impact of classification criteria on the reproducibility of MRI diagnosis of FGAs.
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Affiliation(s)
| | - Mostafa Mohamad Assy
- Radio-diagnosis Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Nesma Adel Zaid
- Radio-diagnosis Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | | | - Enas Mahmoud Hamed
- Radio-diagnosis Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
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Dahiphale SM, Potdar J, Acharya N, Jyotsna G, Saloni, Desale R. Congenital Anomalies of the Female Genital Tract: A Comprehensive Review. Cureus 2024; 16:e56753. [PMID: 38654788 PMCID: PMC11037924 DOI: 10.7759/cureus.56753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/23/2024] [Indexed: 04/26/2024] Open
Abstract
This comprehensive review provides an in-depth examination of congenital anomalies of the female genital tract, explicitly focusing on the American Society for Reproductive Medicine (ASRM) Müllerian Anomalies Classification. The classification system is crucial for standardizing communication and guiding accurate diagnoses in clinical practice. The review explores the diverse clinical presentations, etiological factors, and diagnostic modalities associated with these anomalies. Management strategies, ranging from conservative approaches to advanced reproductive technologies, are discussed in the context of individualized treatment plans based on the ASRM classification. The psychosocial impact of female genital tract anomalies is thoroughly examined, emphasizing the importance of holistic care and patient-centered approaches. Looking toward the future, the review outlines emerging research areas, including advances in diagnosis techniques, innovative treatment modalities, and genetic studies. It ultimately underscores the need for a comprehensive understanding of physical and psychosocial dimensions, offering insights for healthcare professionals to navigate this complex landscape and improve the lives of affected individuals.
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Affiliation(s)
- Swati M Dahiphale
- Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Jyotsana Potdar
- Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Neema Acharya
- Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Garapati Jyotsna
- Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Saloni
- Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
| | - Rahul Desale
- Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education & Research, Wardha, IND
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Chen J, Sun L, Qian H, Wu C, Jiang J, Guo X, Gao S. Hysteroscopic Fenestration with Precise Incision of the Cavity Septum: A Novel Minimally Invasive Surgery of Complete Septate Uterus with Double Cervix. J Minim Invasive Gynecol 2023; 30:716-724. [PMID: 37196886 DOI: 10.1016/j.jmig.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/19/2023]
Abstract
STUDY OBJECTIVE This study aimed to develop and describe a novel surgical procedure that involves hysteroscopic fenestration with precise incision of the complete uterine septum and double cervix preservation after magnetic resonance imaging (MRI) evaluation in patients and to evaluate its efficacy. DESIGN A prospective consecutive clinical study. SETTING A university teaching hospital. PATIENTS Twenty-four patients with complete septate uterus and double cervix. INTERVENTIONS Three-dimensional reconstruction of uterus was performed with pelvic MRI and three-dimensional SPACE sequence scanning. Hysteroscopic fenestration with precise incision of the cavity septum and double cervix preservation was performed in patients. Three months after operation, follow-up pelvic MRI and second-look hysteroscopy were performed conventionally. MEASUREMENTS AND MAIN RESULTS Operating time, blood loss, operative complications, MRI and hysteroscopic changes of uterus, symptoms improvement, and reproductive outcomes were assessed. The surgery was successfully completed without any intraoperative complications in all patients. Operating time was 21.71 ± 8.28 minutes (range, 10-40 minutes) and blood loss was 9.92 ± 7.14 mL (range, 5-30 mL). Postoperative MRI showed the uterine anteroposterior diameter (3.66 cm vs 3.92 cm; p <.05) was increased. Postoperative MRI and the second-look hysteroscopy showed the cavity shape and uterine volume were expanded to the normal. Symptoms of dysmenorrhea, abnormal uterine bleeding, and dyspareunia were ameliorated after the surgery in 70% of patients (7 of 10), 60% of patients (3 of 5), and 1 patient, respectively. The preoperative spontaneous abortion rate was 80% (4 of 5) and the postoperative spontaneous abortion rate was 11.11% (1 of 9). After the surgery, there were 2 ongoing pregnancies and 6 pregnancies ended in term births. Two live births were delivered by cesarean section and 4 by vaginal delivery without cervical incompetence during pregnancy. CONCLUSIONS Hysteroscopic fenestration with precise incision of the uterine septum and double cervix preservation is an effective surgical procedure.
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Affiliation(s)
- Jialing Chen
- Center of Diagnosis and Treatment for Cervical and Uterine Cavity Diseases (Drs. Chen, Wu, and Gao), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Lin Sun
- Department of Gynecology (Dr. Sun), Lianshui County People's Hospital, Kangda College of Nanjing Medical University, Huai'an, China
| | - Huijun Qian
- Departments of Radiology (Dr. Qian), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Congquan Wu
- Center of Diagnosis and Treatment for Cervical and Uterine Cavity Diseases (Drs. Chen, Wu, and Gao), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Jiqin Jiang
- Department of Gynecology (Dr. Jiang), Shaoxing Central Hospital, Shaoxing, China
| | - Xiaolan Guo
- Department of Surgery, Obstetrics and Gynecology (Dr. Guo), Hospital of Fudan University, Shanghai, China
| | - Shujun Gao
- Center of Diagnosis and Treatment for Cervical and Uterine Cavity Diseases (Drs. Chen, Wu, and Gao), Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China; Shanghai Key Laboratory of Female Reproductive Endocrine-Related Disease (Dr. Gao), Fudan University, Shanghai, China..
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Kiblboeck S, Oppelt P, Oppelt P, Stein R, Ommer S, Pavlik R, Rall K, Kongrtay K, Wagner H, Hermann P, Trautner PS. Can Classifications Adequately Represent Genital Malformations?: EVA Study ( E SHRE/ESGE | V CUAM | A FS) - A Prospective Multicenter Study to Evaluate the Current Female Genital Malformation Classifications. Geburtshilfe Frauenheilkd 2023; 83:827-834. [PMID: 37564897 PMCID: PMC10410643 DOI: 10.1055/a-2043-9982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/20/2023] [Indexed: 03/31/2023] Open
Abstract
Introduction Genital malformations are a common clinical occurrence that can be represented using different classifications. Reproducibility is an essential quality characteristic for a classification, and it plays an important role, especially in consultations and the treatment of infertile patients and in obstetric management. The aim of this study is to demonstrate the reproducibility and clinical practicality of three commonly used classifications: the ESHRE/ESGE (European Society of Human Reproduction and Embryology/ European Society for Gynecological Endoscopy), VCUAM (Vagina Cervix Uterus Adnex-associated Malformation), and AFS (American Fertility Society) classifications. Materials and Methods Sixty-five patients with female genital malformations were included in this prospective, multicenter, exploratory, observational study. All participants underwent a clinical examination and a medical interview. The investigators were instructed to classify the presenting malformations according to the ESHRE/ESGE, VCUAM, and AFS classifications using a structured questionnaire. Investigators were asked whether the malformation could be reproducibly classified (yes/no) and about the grade (grade 1-5 from "very good" to "deficient") they would assign to each classification. Classification assessment was queried for vagina, cervix, uterus, adnexa, and associated malformations and was scored from 1 to 5. Results Reproducibility was rated as 80% (n = 52/65), 92.3% (n = 60/65), and 56.9% (n = 37/65) for the ESHRE/ESGE, VCUAM, and AFS classification, respectively. ESHRE/ESGE, VCUAM and AFS were rated as "very good" or "good" for 83.3%, 89.2%, and 10.8% of vaginal malformations; for 75.8%, 87.5%, and 24.2% of cervical malformations; and for 89.7%, 89.5%, and 86.2% of uterine malformations, respectively. VCUAM was rated as "very good" or "good" for 77.8% and 69.6% of adnexal malformations and associated malformations, respectively. ESHRE/ESGE and AFS were rated as "sufficient" or "deficient" for 100% and 75% of adnexal malformations and for 77.3% and 69.6% of associated malformations, respectively. Conclusion The prospective multicenter EVA ( E SHRE/ESGE | V CUAM | A FS) study revealed that the organ-based ESHRE/ESGE and VCUAM classifications of female genital malformations perform better in terms of reproducibility as well as in the assessment of individual compartments than the non-organ-based AFS classification.
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Affiliation(s)
- Stephanie Kiblboeck
- Department of Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital Linz, Johannes Kepler Universität Linz, Linz, Austria
| | - Peter Oppelt
- Department of Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital Linz, Johannes Kepler Universität Linz, Linz, Austria
| | - Patricia Oppelt
- Department of Gynecology, Erlangen University Hospital, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Raimund Stein
- Department of Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University Medical Center Mannheim, Heidelberg University, Mannheim,
Germany
| | - Stefanie Ommer
- Department of Pediatric Surgery, University Hospital Jena, Jena, Germany
| | | | - Katharina Rall
- Department of Gynecology and Obstetrics, University Hospital Tübingen, Tübingen, Germany
| | - Kuralay Kongrtay
- Clinical Academic Department of Women’s Health, Corporate fund “University Medical Center”, Astana, Kazakhstan
| | - Helga Wagner
- Department of Applied Statistics, Johannes Kepler University Linz, Linz, Austria
- Center for Clinical Studies (CCS Linz), Johannes Kepler University Linz, Linz, Austria
| | - Philipp Hermann
- Center for Clinical Studies (CCS Linz), Johannes Kepler University Linz, Linz, Austria
| | - Philip Sebastian Trautner
- Department of Gynecology, Obstetrics and Gynecological Endocrinology, Kepler University Hospital Linz, Johannes Kepler Universität Linz, Linz, Austria
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Brandão P, Ceschin N, Romero JL, Ferro J. Incidental Finding of a Müllerian Malformation on Two-dimensional Ultrasound: What Now? J Med Ultrasound 2023; 31:162-164. [PMID: 37576426 PMCID: PMC10413391 DOI: 10.4103/jmu.jmu_118_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/06/2021] [Accepted: 09/17/2021] [Indexed: 08/15/2023] Open
Affiliation(s)
- Pedro Brandão
- Department of Reproductive Medicine, IVIRMA Valencia, Valencia, Spain
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Nathan Ceschin
- Department of Reproductive Medicine, IVIRMA Valencia, Valencia, Spain
| | | | - Jaime Ferro
- Department of Reproductive Surgery, IVIRMA Valencia, Valencia, Spain
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10
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Alcázar JL, Carriles I, Cajas MB, Costa S, Fabra S, Cabrero M, Castro E, Tomaizeh A, Laza MV, Monroy A, Martinez I, Aguilar MI, Hernani E, Castellet C, Oliva A, Pascual MÁ, Guerriero S. Diagnostic Performance of Two-Dimensional Ultrasound, Two-Dimensional Sonohysterography and Three-Dimensional Ultrasound in the Diagnosis of Septate Uterus-A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2023; 13:diagnostics13040807. [PMID: 36832295 PMCID: PMC9955687 DOI: 10.3390/diagnostics13040807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/16/2023] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND The septate uterus is the most common congenital uterine anomaly, and hysteroscopy is the gold standard for diagnosing it. The goal of this meta-analysis is to perform a pooled analysis of the diagnostic performance of two-dimensional transvaginal ultrasonography, two-dimensional transvaginal sonohysterography, three-dimensional transvaginal ultrasound, and three-dimensional transvaginal sonohysterography for the diagnosis of the septate uterus. METHODS Studies published between 1990 and 2022 were searched in PubMed, Scopus, and Web of Science. From 897 citations, we selected eighteen studies to include in this meta-analysis. RESULTS The mean prevalence of uterine septum in this meta-analysis was 27.8%. Pooled sensitivity and specificity were 83% and 99% for two-dimensional transvaginal ultrasonography (ten studies), 94% and 100% for two-dimensional transvaginal sonohysterography (eight studies), and 98% and 100% for three-dimensional transvaginal ultrasound (seven articles), respectively. The diagnostic accuracy of three-dimensional transvaginal sonohysterography was only described in two studies, and we did not calculate the pooled sensitivity and specificity for this method. CONCLUSION Three-dimensional transvaginal ultrasound has the best performance capacity for the diagnosis of the septate uterus.
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Affiliation(s)
- Juan Luis Alcázar
- Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - Isabel Carriles
- Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, 31008 Pamplona, Spain
| | - María Belén Cajas
- Department of Obstetrics and Gynecology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain
| | - Susana Costa
- Department Obstetrics and Gynecology, Centro Hospitalar e Universitário de São João, 4200-319 Porto, Portugal
| | - Sofia Fabra
- Department of Obstetrics and Gynecology, Hospital Universitario Infanta Sofia, 28702 Madrid, Spain
| | - Maria Cabrero
- Department of Obstetrics and Gynecology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain
| | - Elena Castro
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de la Arrixaca, 30120 Murcia, Spain
| | - Aida Tomaizeh
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de Valme, 41701 Sevilla, Spain
| | - María Victoria Laza
- Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil, 06010 Badajoz, Spain
| | - Alba Monroy
- Department of Obstetrics and Gynecology, Hospital Universitario Materno-Infantil, 06010 Badajoz, Spain
| | - Irene Martinez
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de Valme, 41701 Sevilla, Spain
| | - Maria Isabel Aguilar
- Department of Obstetrics and Gynecology, Hospital Universitario Virgen de Valme, 41701 Sevilla, Spain
| | - Elena Hernani
- Department of Obstetrics and Gynecology, Hospital General Universitario de Castellón, 12004 Castellón, Spain
| | - Cristina Castellet
- Department of Obstetrics, Gynecology, and Reproduction, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Agustin Oliva
- Department of Obstetrics and Gynecology, Hospital Universitario San Carlos, 28040 Madrid, Spain
| | - María Ángela Pascual
- Department of Obstetrics, Gynecology, and Reproduction, Hospital Universitari Dexeus, 08028 Barcelona, Spain
| | - Stefano Guerriero
- Centro Integrato di Procreazione Medicalmente Assistita (PMA) e Diagnostica Ostetrico-Ginecologica, Azienda Ospedaliero Universitaria-Policlinico Duilio Casula, Monserrato, 09042 Cagliari, Italy
- Dipartimento di Scienze Chirurgiche, University of Cagliari, 09124 Cagliari, Italy
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11
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Zhang B, Wu S, Zhao X, Zhu X, Xu D. Diagnosis of septate uterus. ZHONG NAN DA XUE XUE BAO. YI XUE BAN = JOURNAL OF CENTRAL SOUTH UNIVERSITY. MEDICAL SCIENCES 2022; 47:1479-1486. [PMID: 36481625 PMCID: PMC10930624 DOI: 10.11817/j.issn.1672-7347.2022.220507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Indexed: 12/13/2022]
Abstract
The septate uterus is the most common structural uterine anomalies and it is associated with the poor reproductive outcome. It is believed to be the result of the failure in resorption of the tissue connecting the 2 paramesonephric ducts prior to the 20th embryonic week. The true prevalence of uterine septum is difficult to ascertain, as many uterine septal defects are asymptomatic. The septate uterus is usually diagnosed during an infertility evaluation and affects reproductive health by impairing fertility and increasing adverse pregnancy outcomes. The variations in uterine and cervical/vaginal anomalies collectively referred to as Müllerian anomalies. No consistent gold standard for the diagnosis of Müllerian anomalies exists. The preferred diagnostic method for Müllerian anomalies is two-dimensional ultrasound, other methods such as three-dimensional ultrasound, magnetic resonance imaging, hysterosalpingo contrast sonography, hysterosalpingography, hysteroscopy, and laparoscopy are also used to improve accuracy.
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Affiliation(s)
- Baiyun Zhang
- Department of Gynecology, Third Xiangya Hospital, Central South University, Changsha 410013.
- Department of Ultrasonography, Hunan Guangxiu Hospital, Changsha 410205, China.
| | - Si Wu
- Department of Gynecology, Third Xiangya Hospital, Central South University, Changsha 410013.
| | - Xingping Zhao
- Department of Gynecology, Third Xiangya Hospital, Central South University, Changsha 410013
| | - Xiuting Zhu
- Department of Gynecology, Third Xiangya Hospital, Central South University, Changsha 410013.
| | - Dabao Xu
- Department of Gynecology, Third Xiangya Hospital, Central South University, Changsha 410013.
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12
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Zhang H, Zheng Y, Ning G, Fu C, Bao L. Preoperative MRI presentations of Herlyn-Werner-Wunderlich syndrome. Congenit Anom (Kyoto) 2022; 62:228-235. [PMID: 35941518 DOI: 10.1111/cga.12489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/22/2022] [Accepted: 06/18/2022] [Indexed: 11/28/2022]
Abstract
Herlyn-Werner-Wunderlich (HWW) syndrome is a rare complex female urogenital anomaly, with diverse anatomical presentations. Due to obstruction, most patients with HWW syndrome need to be addressed surgically. The treatment strategy should be tailored to the different anatomical variants of each patient. Therefore, a detailed and comprehensive preoperative evaluation is needed. In this review, we describe the embryology and clinical manifestations of HWW syndrome and discuss and illustrate its diverse preoperative magnetic resonance imaging presentations to guide clinical treatment.
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Affiliation(s)
- Heng Zhang
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, National Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ying Zheng
- Department of Gynecology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, National Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Gang Ning
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, National Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chuan Fu
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, National Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li Bao
- Department of Radiology, Key Laboratory of Obstetric & Gynecologic and Pediatric Diseases and Birth Defects of Ministry of Education, National Key Laboratory of Biotherapy, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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13
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Al Najar MS, Al Ryalat NT, Sadaqah JS, Husami RY, Alzoubi KH. MRI Evaluation of Mullerian Duct Anomalies: Practical Classification by the New ASRM System. J Multidiscip Healthc 2022; 15:2579-2589. [PMID: 36388626 PMCID: PMC9659481 DOI: 10.2147/jmdh.s386936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/25/2022] [Indexed: 11/11/2022] Open
Abstract
Objective To describe variable mullerian duct anomalies using magnetic resonance imaging (MRI) and to classify these anomalies according to the available classification systems, namely the American Fertility Society (AFS) system, the European Society of Human Reproduction and Embryology (ESHRE) system, and the new American Society for Reproductive Medicine (ASRM) system. Design Retrospective chart review. Subjects The pelvic MRI studies and the clinical records of 64 females with mullerian congenital anomalies were retrospectively reviewed between January 2010 and December 2021. The mean age was 22 years (age range 2–63 years). Main Outcome Measures Detailed imaging findings were recorded, and the resulting mullerian anomalies were then classified according to the three classification systems of interest. Results Variable mullerian anomalies were found among patients with multiple frequencies. Mullerian agenesis and hypoplasia were found in 12 patients (19%) and 16 patients (25%), respectively. Uterus didelphys was found in 5 patients (8%). Twelve (19%) patients had septate uterus, while 8 (12.5%) had a bicornuate anomaly. Unicornuate uterus was present in 7 patients (11%). Isolated vaginal anomaly was diagnosed in 4 patients (6%). Renal/urinary tract imaging was available for 27 (42%) patients, and accompanying urinary tract anomalies were noted in 10 of them (37%). Few ovarian and other extra-renal anomalies were observed. Conclusion MRI could efficiently delineate the mullerian anomalies regardless of their complexity. Most of these anomalies were more efficaciously categorized by the ESHRE and the new ASRM systems, compared to the originally widely used AFS system. The new ASRM classification was found to be more practical as it is a modification of the original AFS system, using drawings with clear descriptions instead of symbols. This is particularly helpful in the radiological era, saving time and effort.
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Affiliation(s)
- Mahasen S Al Najar
- Department of Diagnostic Radiology, The University of Jordan Hospital, Amman, Jordan
| | - Nosaiba T Al Ryalat
- Department of Diagnostic Radiology, The University of Jordan Hospital, Amman, Jordan
| | - Jaffer S Sadaqah
- Department of Diagnostic Radiology, The University of Jordan Hospital, Amman, Jordan
| | - Rawand Y Husami
- Department of Diagnostic Radiology, The University of Jordan Hospital, Amman, Jordan
| | - Karem H Alzoubi
- Department of Pharmacy Practice and Pharmacotherapeutics, University of Sharjah, Sharjah, United Arab Emirates
- Department of Clinical Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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14
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Ludwin A, Tudorache S, Martins WP. ASRM Müllerian Anomalies Classification 2021: a critical review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:7-21. [PMID: 35678250 DOI: 10.1002/uog.24905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 06/15/2023]
Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - S Tudorache
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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15
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Russo C, Conway F, Siciliano T, Selntigia A, Giuseppe Martire F, Soreca G, Ticconi C, Exacoustos C. 3D transvaginal ultrasound diagnosis of uterine septa according to different classifications: are there other measurements that correlate to reproductive outcome in small indentation length? Facts Views Vis Obgyn 2022; 14:129-138. [DOI: 10.52054/fvvo.14.2.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: High discrepancy between current classifications was observed in the definition of uterine septa, especially for indentation lengths >5 <10mm.
Objectives: To assess the discrepancy between current classifications in the diagnoses of septate uterus and to correlate them with reproductive outcomes; to detect 3D transvaginal ultrasound (TVS) additional measurements, which can better correlate small indentation lengths >5 <10mm to reproductive failures.
Material and methods: Observational study enrolling 664 women of reproductive age with 3D ultrasound diagnosis of an indentation length ≥3mm. For each patient a detailed reproductive history was taken before performing 3D transvaginal examination. Patients with previous uterine surgery or metroplasty were excluded.
Main Outcome Measure(s): Indentation lengths >5 <10mm showed high discrepancy in the diagnosis of uterine septum between different classifications. For these small indentations additional 3D measurements (indentation angle, septal width and septal length/ fundal myometrial thickness (L/M) ratio) were correlated to infertility and recurrent miscarriage.
Results: Among the cohort, 215 patients showed an indentation length >5 <10mm; 136 tried to conceive: 69 (51%) were infertile, 38 (28%) had recurrent miscarriages (≥2) and 5 (4%) had at least one delivery. Recurrent miscarriage significantly correlated to an indentation angle >134°; whereas infertility to an indentation width <32mm and a L/M ratio >75%.
Conclusions: Wide discrepancies between different classifications are more evident in indentation lengths >5 <10mm. Additional measurements on 3D coronal section may help to evaluate the risk of infertility or recurrent miscarriage.
What is new? Additional 3D TVS measurements, beyond septal lengths, in particular for small fundal indentation, may help in predicting the risk of developing adverse reproductive outcomes.
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Tokhunts K, Adamyan M, Chopikyan A, Kayfajyan K, Khudaverdyan A, Tumanyan A. Is I-shaped uterus more common in patients with hyperandrogenism? Eur J Obstet Gynecol Reprod Biol 2022; 272:116-122. [PMID: 35303673 DOI: 10.1016/j.ejogrb.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/16/2022] [Accepted: 03/08/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Subtypes of T-shaped uterus are rare uterine cavity anomalies and there are no morphometric criteria for the diagnosis. Earlier we established a high frequency of I-shaped uterus in patients with adrenalhyperandrogenism, which is more common in Armenian populations. The aim of the study was to determine the frequency of I-shaped uterus as a subtype of T-shaped uterus in patients with ovarian and adrenal hyperandrogenism, accompanied by infertility and miscarriage, as well as the development of it's ultrasonic morphometric criteria. STUDY DESIGN We conducted an ultrasound of 486 patients aged 19-40 years (mean 30.1 ± 5.5) who applied for infertility or habitual pregnancy loss.74 of them were diagnosed with the PCOS (Polycystic ovary syndrome) and 43-CAH (congenital adrenal hyperplasia). Ultrasound was performed in early luteal phase. The classification of uterine cavities was carried out according ESHRE/ESGE. RESULTS 299 had normal ultrasound morphology of the uterine cavity, 20.7% various uterine cavity abnormalities. T-shaped uterus was observed in 3.7%, I-shaped uterus exclusively in patients with hyperandrogenism, 24.3% with PCOS and 39.5% with CAH. To determine the relevant morphometric features as diagnostic criteria for the I-shaped uterus some measurements were performed. The values of dist1-dist2 and dist1-dist3 in the normal cavity had a significant difference (P1-2 0.3), also the cavity width in the middle third and the isthmic section did not have a significant difference (P > 0.05), while in the normal cavity shape these values were significantly different (P < 0.05). CONCLUSION Frequency of occurrence of the T-shaped uterus did not exceed that in comparison with a group of women with other causes of infertility, while I-shaped congenital anomaly of the uterine cavity was found in 24.3-39.5% patients with hyperandrogenism. The difference between the interostial and corporal distances and the interostial and isthmic distances was the most relevant morphometric attribute of I-shaped uterus.
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Affiliation(s)
- Karine Tokhunts
- Yerevan State Medical University, Department of Obstetrics-Gynecology, Yerevan, Armenia.
| | - Marianna Adamyan
- Nairi Medical Center, Department of Gynecology, Yerevan, Armenia.
| | - Armine Chopikyan
- Yerevan State Medical University, Department of Public Health And Healthcare Organization, Yerevan, Armenia.
| | | | - Anna Khudaverdyan
- Yerevan State Medical University, Department of Obstetrics-Gynecology, Yerevan, Armenia.
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Feng Y, Zhang S, Zhou Y, He G, Hong L, Shi L, Wang J, Zhang P, Zhai L. Three-dimensional measurement and analysis of morphological parameters of the uterus in infertile women. Quant Imaging Med Surg 2022; 12:2224-2237. [PMID: 35371941 PMCID: PMC8923859 DOI: 10.21037/qims-21-812] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 12/13/2021] [Indexed: 11/16/2023]
Abstract
BACKGROUND To determine differences in endometrial cavity anteroposterior diameter, thickness, volume, and diameter lines of uterine body and thickness, and volume of upper, middle, and lower regions of the endometrium in infertile women using a new method for three-dimensional (3D) reconstruction based on two-dimensional (2D) ultrasound images. METHODS This retrospective cross-sectional study included a total of 81 infertile women, who underwent 2D ultrasound standard examination. We created 3D models of the uterine body, endometrial cavity, and endometrium based on 2D ultrasound images. The parameters that were measured and analyzed in a 3D plane included volume and diameter lines of endometrial cavity, surface area, thickness, volume, and diameter lines of uterine body, and surface area, thickness, and volume of upper, middle, and lower region of the endometrium. These parameters were used for comparisons between normal and arcuate uterus, between non-pregnant and pregnant infertile women, and between nulliparous and multiparous infertile women. The differences between the different regions of the endometrium and the correlations between age and the parameters were also determined in this study. RESULTS Endometrial cavity length, and middle and lower regions of the endometrial volume in the normal uterus were 39.63±7.61 mm, 1,307.92±1,034.40 mm3, and 653.98±460.41 mm3, respectively. For arcuate uterus, these parameters were 32.96±4.69 mm, 539.89±298.94 mm3, and 347.90±129.61 mm3, respectively. The parameters were significantly higher in normal uterus compared with arcuate uterus (P=0.000, 0.001, and 0.006, respectively). Upper, middle, and lower regions of endometrial thickness in normal uterus were 7.79±3.26, 8.18±3.33, and 6.41±2.60 mm, respectively. Both upper and middle regions of endometrial thickness were significantly greater than the lower regions of endometrial thickness with P=0.009 and P=0.001, respectively. Correlation analysis revealed that age positively correlated with volume of upper endometrial regions (r=0.274, P=0.028). CONCLUSIONS This study provides references for the volume and thickness of the endometrium in the different anatomical regions of normal and arcuate uterus. Age mainly affects the upper region of the endometrium. The 3D measurement provides a precise way to quantify the morphological parameters of gynecological diseases.
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Affiliation(s)
- Yankun Feng
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Shaojing Zhang
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Ying Zhou
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Guibing He
- Department of Urology, Jinhua People’s Hospital, Jinhua, China
| | - Liting Hong
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Li Shi
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Jianmei Wang
- Department of Family Planning, The Second Hospital of Tianjin Medical University, Tianjin, China
| | - Ping Zhang
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Lidong Zhai
- Department of Anatomy and Histology, School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
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18
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Diagnosis of Congenital Uterine Abnormalities: Practical Considerations. J Clin Med 2022; 11:jcm11051251. [PMID: 35268343 PMCID: PMC8911320 DOI: 10.3390/jcm11051251] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/03/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
As most congenital uterine abnormalities are asymptomatic, the majority of them are detected incidentally. While most women with uterine anomalies have a normal reproductive outcome, some may experience adverse reproductive outcomes. Accurate diagnosis and correct classification help in the appropriate counselling of women about their potential reproductive prognosis and risks and for planning any intervention. Evaluation of the internal and external contours of the uterus is the key in making a diagnosis and correctly classifying a uterine anomaly. Considering this, the gold standard test has been the combined laparoscopy and hysteroscopy historically, albeit invasive. However, 3D ultrasound has now become the diagnostic modality of choice for uterine anomalies due to its high degree of diagnostic accuracy, less invasive nature and it being comparatively less expensive. While 2D ultrasound and HSG are adequate for screening for uterine anomalies, MRI and combined laparoscopy and hysteroscopy are reserved for diagnosing complex Mullerian anomalies. Imaging for renal anomalies is recommended if a uterine anomaly is diagnosed.
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Magnetic resonance imaging of Müllerian anomalies in girls: concepts and controversies. Pediatr Radiol 2022; 52:200-216. [PMID: 34152437 DOI: 10.1007/s00247-021-05089-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 02/28/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
Female Müllerian anomalies are the result of failure of formation, fusion or resorption of the Müllerian ducts and are relatively common, with a prevalence of 5.5-7.0% in the general population. While some of these anomalies are asymptomatic, those presenting with obstruction require accurate identification for optimal clinical management including potential surgical treatment. MRI is a useful adjunct to sonography in the evaluation of Müllerian anomalies, typically allowing a more complete characterization of the malformation. Technical aspects, embryologic concepts and controversies regarding classification systems are highlighted in this review. Several Müllerian anomalies are discussed and illustrated in more detail utilizing various cases with pelvic MRI studies.
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20
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Peixoto C, Castro M, Carriles I, Arriba MD, Lapresa V, Alcazar JL. Diagnosing Septate Uterus Using Three-Dimensional Ultrasound Using Three Different Classifications: An Interobserver and Intraobserver Agreement Study. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:911-918. [PMID: 34933384 PMCID: PMC10183891 DOI: 10.1055/s-0041-1740271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Currently, there are up to three different classifications for diagnosing septate uterus. The interobserver agreement among them has been poorly assessed. OBJECTIVE To assess the interobserver agreement of nonexpert sonographers for classifying septate uterus using the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), American Society for Reproductive Medicine (ASRM), and Congenital Uterine Malformations by Experts (CUME) classifications. METHODS A total of 50 three-dimensional (3D) volumes of a nonconsecutive series of women with suspected uterine malformation were used. Two nonexpert examiners evaluated a single 3D volume of the uterus of each woman, blinded to each other. The following measurements were performed: indentation depth, indentation angle, uterine fundal wall thickness, external fundal indentation, and indentation-to-wall-thickness (I:WT) ratio. Each observer had to assign a diagnosis in each case, according to the three classification systems (ESHRE/ESGE, ASRM, and CUME). The interobserver agreement regarding the ESHRE/ESGE, ASRM, and CUME classifications was assessed using the Cohen weighted kappa index (k). Agreement regarding the three classifications (ASRM versus ESHRE/ESGE, ASRM versus CUME, ESHRE/ESGE versus CUME) was also assessed. RESULTS The interobserver agreement between the 2 nonexpert examiners was good for the ESHRE/ESGE (k = 0.74; 95% confidence interval [CI]: 0.55-0.92) and very good for the ASRM and CUME classification systems (k = 0.95; 95%CI: 0.86-1.00; and k = 0.91; 95%CI: 0.79-1.00, respectively). Agreement between the ESHRE/ESGE and ASRM classifications was moderate for both examiners. Agreement between the ESHRE/ESGE and CUME classifications was moderate for examiner 1 and good for examiner 2. Agreement between the ASRM and CUME classifications was good for both examiners. CONCLUSION The three classifications have good (ESHRE/ESGE) or very good (ASRM and CUME) interobserver agreement. Agreement between the ASRM and CUME classifications was higher than that for the ESHRE/ESGE and ASRM and ESHRE/ESGE and CUME classifications.
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Affiliation(s)
- Carla Peixoto
- Department of Obstetrics and Gynecology, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Maite Castro
- Centro de Infertilidad y Reproduccion Humana, Barcelona, Spain
| | - Isabel Carriles
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Maria de Arriba
- Department of Obstetrics and Gynecology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Victoria Lapresa
- Department of Obstetrics and Gynecology, University Hospital, Salamanca, Spain
| | - Juan Luis Alcazar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
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Marianna A, Karine T, Armine C, Anna K, Hripsime G. The impact of T-shaped uterine cavity anomaly on IVF outcomes: More questions than answers. J Gynecol Obstet Hum Reprod 2021; 51:102293. [PMID: 34929426 DOI: 10.1016/j.jogoh.2021.102293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
RESEARCH QUESTION The aim of our study was the impact of T-shaped uterine anomaly on in vitro fertilization (per 1 IVF cycle per one embryo transfer) results and pregnancy outcomes. DESIGN Prospective cohort study included 388 somatically healthy patients at the age of 20-40 years old who underwent 3-dimensional ultrasound of uterine cavity before embryo transfer. The uterine cavities were classified based on morphometric criteria according to the CUME study. The comparison was performed between patients with normal uterine cavity (n = 266), patients with T-shaped anomaly of uterine cavity (n = 27), intermediate forms of T-shaped anomaly (n = 73), and patients with other uterine anomalies (n = 22). RESULTS The rates of biochemical pregnancy in Normal, T-shaped, Intermediate and Other groups were 58.6%, 51.9% 52.1% and 45.4%, respectively, but there weren't detected statistically significant differences (P > 0.05). CONCLUSIONS T-shaped uterus did not affect the percentage of occurring pregnancy, but was associated with increased rate of preterm deliveries, miscarriages and ectopic pregnancy. No differences in occurrence of pregnancy rates in cases of intermediate types, but an increased number of preterm deliveries and miscarriages in cases with increased myometrial thickness in lateral angle area.
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Affiliation(s)
- Adamyan Marianna
- Department of gynecology, Nairi Medical Center, Yerevan, Armenia.
| | - Tokhunts Karine
- Department of obstetrics-gynecology, Yerevan State Medical University, Yerevan, Armenia
| | - Chopikyan Armine
- Department of public health and healthcare organization, Yerevan State Medical University, Yerevan, Armenia
| | - Khudaverdyan Anna
- Department of obstetrics and gynecology, Yerevan State Medical University, Yerevan, Armenia.
| | - Grigoryan Hripsime
- Assistant of the Department of Obstetrics-Gynecology and Reproductive Health, NIH, Yerevan, Armenia.
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Effect of hyteroscopic uterine septum resection on pregnancy outcomes. J Gynecol Obstet Hum Reprod 2021; 51:102275. [PMID: 34852309 DOI: 10.1016/j.jogoh.2021.102275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/15/2021] [Accepted: 11/26/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare the reproductive outcome following hysteroscopic resection versus usual care in nulliparous women with a septate uterus. METHODS A retrospective cohort study of nulliparous women with a history of uterine septum and had singleton pregnancies at >20 weeks gestation between Jan. 2016 and Dec. 2019 were conducted. Follow-up was performed through medical record reviews and telephone conversations. The primary outcome was preterm birth at<37weeks gestation, and the secondary outcomes include cesarean delivery, malpresentation, preeclampsia, and birth weight<10th percentile for gestational age. Multivariate logistic regressions were performed to evaluate the effect of hysteroscopic resection on primary and secondary outcomes, after controlling for potential confounding factors. RESULTS Totally 198 women were included in this study, among which 112 women underwent a hysteroscopic resection and 86 women received usual care. Preterm birth incidence (7.1% vs. 18.6%, P = 0.03) and malpresentation (10.7% vs. 23.3%, P = 0.03) was significantly lower in women treated with hysteroscopic resection compared with those received usual care. Multivariate logistic regression indicated that hysteroscopic resection was significantly associated with decreased risks of preterm birth (OR = 0.36, 95% CI: 0.13-0.68; P < 0.01) and malpresentations (OR = 0.47, 95% CI: 0.25-0.71; P < 0.01), after controlling for potential confounding factors. CONCLUSION Hysteroscopic resection could significantly reduce the risks of preterm birth and malpresentations compared to usual care for nulliparous women with a septate uterus.
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Ueda M, Ota K, Takahashi T, Suzuki S, Suzuki D, Kyozuka H, Jimbo M, Soeda S, Watanabe T, Fujimori K. Successful pregnancy and term delivery after treatment of unicornuate uterus with non-communicating rudimentary horn pregnancy with local methotrexate injection followed by laparoscopic resection: a case report and literature review. BMC Pregnancy Childbirth 2021; 21:715. [PMID: 34702216 PMCID: PMC8547051 DOI: 10.1186/s12884-021-04195-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
Background Pregnancy in a rudimentary horn is an extremely rare type of ectopic pregnancy. A rudimentary uterine horn pregnancy is associated with a risk of spontaneous rupture and bleeding during surgery due to the increased uterine blood flow. Recent advances in imaging modalities have enabled laparoscopic surgery to be performed in cases without rupture in the early stages of pregnancy. However, there are few reports of successful pregnancies and deliveries after treatment of rudimentary horn pregnancies. We report the successful management of a case of non-communicating rudimentary horn pregnancy by local injection of methotrexate followed by complete laparoscopic excision along with a review of the literature. Case presentation The patient was a 29-year-old Japanese woman, gravida 2, nullipara. She was diagnosed with a left unicornuate uterus with a right non-communicating rudimentary horn on hysterosalpingography and magnetic resonance imaging. A gestational sac with a heartbeat was observed in the right rudimentary uterine horn at 6 weeks of gestation. A diagnosis of ectopic pregnancy in a non-communicating rudimentary horn was made. Color Doppler detected multiple blood flow signals around the gestational sac, which were clearly increased compared to the left unicornuate uterus. Her serum human chorionic gonadotropin level was 104,619 mIU/ml. A 100 mg methotrexate injection into the gestational sac was administered, and laparoscopic surgery was performed on day 48 after the methotrexate treatment. The right rudimentary horn and fallopian tube were successfully excised with minimal bleeding. A spontaneous normal pregnancy was established 6 months after the surgery. The pregnancy was uneventful, and a baby girl was born by elective cesarean section at 38w0d. Conclusion Combined local methotrexate injection and laparoscopic surgery are safe treatment options for patients with a unicornuate uterus with a non-communicating rudimentary horn pregnancy.
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Affiliation(s)
- Makiko Ueda
- Department of Obstetrics and Gynecology, Fukushima medical University, Fukushima, 960-1295, Japan
| | - Kuniaki Ota
- Fukushima Medical Center for Children and Women, Fukushima medical University, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan.,Department of Obstetrics and Gynecology, Toho University, Tokyo, 143-8541, Japan
| | - Toshifumi Takahashi
- Fukushima Medical Center for Children and Women, Fukushima medical University, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan.
| | - Satoshi Suzuki
- Department of Obstetrics and Gynecology, Fukushima medical University, Fukushima, 960-1295, Japan
| | - Daisuke Suzuki
- Fukushima Medical Center for Children and Women, Fukushima medical University, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
| | - Hyo Kyozuka
- Department of Obstetrics and Gynecology, Fukushima medical University, Fukushima, 960-1295, Japan
| | - Masatoshi Jimbo
- Fukushima Medical Center for Children and Women, Fukushima medical University, 1 Hikarigaoka, Fukushima City, Fukushima, 960-1295, Japan
| | - Shu Soeda
- Department of Obstetrics and Gynecology, Fukushima medical University, Fukushima, 960-1295, Japan
| | - Takafumi Watanabe
- Department of Obstetrics and Gynecology, Fukushima medical University, Fukushima, 960-1295, Japan
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, Fukushima medical University, Fukushima, 960-1295, Japan
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Carrera M, Pérez Millan F, Alcázar JL, Alonso L, Caballero M, Carugno J, Dominguez JA, Moratalla E. Effect of Hysteroscopic Metroplasty on Reproductive Outcomes in Women with Septate Uterus: Systematic Review and Meta-Analysis. J Minim Invasive Gynecol 2021; 29:465-475. [PMID: 34648934 DOI: 10.1016/j.jmig.2021.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this systematic review with meta-analysis is to evaluate the impact of hysteroscopic metroplasty on adverse reproductive outcomes such as miscarriage, preterm birth, and fetal malpresentation in patients with history of infertility or previous poor obstetrical outcomes. DATA SOURCES A systematic electronic search from inception each database up to April 2021 including the following databases was conducted: PubMed-MEDLINE, EMBASE, Web of Science, The Cochrane Library, the CGF Specialized Register of Controlled Trials, Google Scholar, and trial registries. A combination of the following keywords was used: uterine septum, septate uterus, congenital uterine malformation, class 2 uterus, class V uterus, metroplasty, hysteroscopic, pregnancy, clinical pregnancy, ongoing pregnancy, miscarriage, live birth, preterm birth, cesarean section, 'cesarean delivery, and fetal malpresentation. METHODS OF STUDY SELECTION Studies comparing reproductive outcomes between women undergoing hysteroscopic resection of the uterine septum and those with expectant management were included. Eligible population consisted of infertile women, women with poor obstetrical history, or women without previous pregnancy failures and a diagnosis of septate uterus. TABULATION, INTEGRATION, AND RESULTS The systematic electronic search retrieved 1076 studies; after elimination of duplicates, 688 titles and abstracts were screened, and 55 were assessed for eligibility. Eleven studies were included in the quantitative synthesis: one randomized controlled trial and 10 observational studies involving reproductive outcomes from 1589 patients with either complete or partial uterine septum. The pooled OR for miscarriage was 0.45, (95% CI, 0.22-0.90). When the analysis was performed considering subgroups according to the type of septum, pooled OR in complete septum subgroup was 0.16 (95% CI, 0.03-0.78), OR = 0.36 (95% CI, 0.19-0.71) in the partial septum subgroup and 0.58 (95% CI, 0.20-1.67) in those studies not differentiating between complete or partial septum. No significant differences were found between the 2 groups in OR of clinical pregnancy, term live birth, or risk of cesarean delivery. There was a significant decrease in the frequency of preterm birth in patients who underwent partial septum resection (OR = 0.30, 95% CI, 0.11-0.79). This difference was detected neither in patients with complete septum nor in studies not differentiating between partial or complete septum. The risk of fetal malpresentation was also significantly reduced (OR = 0.32, 95% CI, 0.16-0.65). CONCLUSION The results of the present meta-analysis support that hysteroscopic metroplasty is effective in reducing the risk of miscarriage in patients with complete or partial uterine septum, although these data should be confirmed with a well-designed randomized controlled trial.
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Affiliation(s)
- Maria Carrera
- Hospital Universitario Doce de Octubre (Dr. Carrera)
| | | | | | | | - Miguel Caballero
- Hospital General Universitario Gregorio Marañón (Drs. Millan and Caballero)
| | - Jose Carugno
- Minimally Invasive Gynecology Division, University of Miami, Miami, Florida (Dr. Carugno).
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25
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Sugi MD, Penna R, Jha P, Pōder L, Behr SC, Courtier J, Mok-Lin E, Rabban JT, Choi HH. Müllerian Duct Anomalies: Role in Fertility and Pregnancy. Radiographics 2021; 41:1857-1875. [PMID: 34597219 DOI: 10.1148/rg.2021210022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Müllerian duct anomalies (MDAs) have important implications for the reproductive health of female patients. In patients with both infertility and recurrent pregnancy loss, the incidence of MDAs is as high as 25%. Congenital uterine anomalies are often only part of a complex set of congenital anomalies involving the cervix, vagina, and urinary tract. Multiple classification systems for MDAs exist, each with different criteria that vary most for the diagnosis of septate uterus. Recognizing the features that guide clinical management is essential for interpretation. Identification of an MDA should prompt evaluation for associated urinary tract anomalies. In patients with infertility who seek to use assisted reproductive technologies such as intrauterine insemination, recognition of MDAs may have an affect on reproductive success, particularly in patients who have an incomplete and clinically occult septum that divides the cervix. Two-dimensional US is the first-line modality for evaluating the uterus and adnexa. Three-dimensional (3D) US or MRI may help to visualize the external uterine fundal contour and internal indentation of the endometrial cavity, which are two morphologic characteristics that are keys to the diagnosis of congenital uterine anomalies. Hysterosalpingo contrast-enhanced US may be performed in conjunction with 3D US to evaluate uterine morphologic characteristics, the endometrial cavity, and tubal patency in a single examination. MRI helps to characterize rudimentary uteri in patients with müllerian hypoplasia and allows assessment for ectopic ureters, abnormally positioned ovaries, or associated deep infiltrative endometriosis. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Mark D Sugi
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Rubal Penna
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Priyanka Jha
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Liina Pōder
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Spencer C Behr
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Jesse Courtier
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Evelyn Mok-Lin
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Joseph T Rabban
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
| | - Hailey H Choi
- From the Department of Radiology and Biomedical Imaging, Division of Abdominal Imaging and Ultrasound (M.D.S., R.P., P.J., L.P., S.C.B., H.H.C.), Department of Radiology and Biomedical Imaging, Division of Pediatric Radiology (J.C.), Department of Obstetrics, Gynecology, and Reproductive Sciences (E.M.L.), and Department of Pathology (J.T.R.), University of California, San Francisco, 505 Parnassus Ave, 3rd Floor, M391, Box 0628, San Francisco, CA 94143
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26
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Rousseau L, Brichant G, Timmermans M, Nisolle M, Tebache L. Daily practice management of septate uterus: reproductive outcome after septoplasty. Facts Views Vis Obgyn 2021; 13:253-259. [PMID: 34555879 PMCID: PMC8823278 DOI: 10.52054/fvvo.13.3.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background Septate uterus is the most common uterine malformation found in women presenting poor reproductive history. Hysteroscopic septoplasty (HS) restores the uterine anatomy in a safe procedure. Objectives The goal of our study is to determine the reproductive outcomes after HS of symptomatic septate uterus. Materials and Methods In a retrospective observational single centre study the reproductive outcomes and complications after HS were evaluated in 31 women with symptomatic septate uterus. The patients were separated into two groups according to the symptoms - infertility or recurrent pregnancy loss (RPL). Main outcome measures were the pregnancy and live birth rate and secondarily the complication rate. Furthermore, the results were analysed depending on the need of assisted reproductive techniques (ART). Results The treatment has resulted in an overall pregnancy rate of 71% for both groups. The spontaneous pregnancy rate is 45% and 8 pregnancies resulted from ART (26%). The overall first live birth rate is 51.6%. A decrease has been noticed in the miscarriage rate from 95.24% to 24% (p<0.001) in the overall population. Conclusions In patients with a symptomatic septate uterus hysteroscopic septoplasty is a safe and effective procedure. The favourable results pointing out the benefits of surgery on the reproductive outcomes as well as the relatively simple and safe technique of HS make the intervention attractive.
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Carbonnel M, Pirtea P, de Ziegler D, Ayoubi JM. Uterine factors in recurrent pregnancy losses. Fertil Steril 2021; 115:538-545. [PMID: 33712099 DOI: 10.1016/j.fertnstert.2020.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/15/2020] [Accepted: 12/02/2020] [Indexed: 12/29/2022]
Abstract
Congenital and acquired uterine anomalies are associated with recurrent pregnancy loss (RPL). Relevant congenital Müllerian tract anomalies include unicornuate, bicornuate septate, and arcuate uterus. Recurrent pregnancy loss has also been associated with acquired uterine abnormalities that distort the uterine cavity such as, notably, intrauterine adhesions, polyps, and submucosal myomas. Initial evaluation of women with RPLs should include an assessment of the uterine anatomy. Even if proof of efficacy of surgical management of certain uterine anomalies is often lacking for managing RPLs, surgery should be encouraged in certain circumstances for improving subsequent pregnancy outcome. Uterine anomalies such as uterine septa, endometrial polyps, intrauterine adhesions, and submucosal myomas are the primary surgical indications for managing RPLs.
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Affiliation(s)
- Marie Carbonnel
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch, Faculté de Médecine Paris Ouest, Suresnes, France
| | - Paul Pirtea
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch, Faculté de Médecine Paris Ouest, Suresnes, France
| | - Dominique de Ziegler
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch, Faculté de Médecine Paris Ouest, Suresnes, France.
| | - Jean Marc Ayoubi
- Department of Obstetrics and Gynecology and Reproductive Medicine, Hopital Foch, Faculté de Médecine Paris Ouest, Suresnes, France
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28
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Ballabh S, Simon B, Ebenezer ED, John RA, Chandramohan A. Imaging features of Robert's uterus: Case series of a rare Mullerian duct anomaly. Trop Doct 2021; 51:553-560. [PMID: 34313499 DOI: 10.1177/00494755211034061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The diagnosis of Mullerian duct anomaly is crucial because of strong association with infertility, endometriosis and miscarriage. Robert's uterus is a rare variant of septate uterus. Patients present with recurrent abdominal pain and severe dysmenorrhoea. Magnetic resonance imaging is the investigation of choice. In this case series, we present the imaging features of four such cases.
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Affiliation(s)
- Saket Ballabh
- Assistant Professor, Department of Radiology, Christian Medical College, Vellore, India
| | - Betty Simon
- Professor, Department of Radiology, Christian Medical College, Vellore, India
| | - Emily Divya Ebenezer
- Associate Professor, Department of Obstetrics and Gynaecology, Christian Medical College, Vellore, India
| | - Reetu A John
- Associate Professor, Department of Radiology, Christian Medical College, Vellore, India
| | - A Chandramohan
- Professor, Department of Radiology, Christian Medical College, Vellore, India
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29
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Cekdemir YE, Mutlu U, Acar D, Altay C, Secil M, Dogan OE. The accuracy of three-dimensional ultrasonography in the diagnosis of Müllerian duct anomalies and its concordance with magnetic resonance imaging. J OBSTET GYNAECOL 2021; 42:67-73. [PMID: 33938374 DOI: 10.1080/01443615.2021.1877646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Yasin Ertug Cekdemir
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Uygar Mutlu
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Demet Acar
- Department of Obstetrics and Gynecology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Canan Altay
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Mustafa Secil
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Omer Erbil Dogan
- Department of Obstetrics and Gynecology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
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Dhanawat J, Pape J, Stuhlmann‐Laeisz C, Maass N, Freytag D, Gitas G, Alkatout I. Ectopic pregnancy in noncommunicating horn of unicornuate uterus: 3D-ultrasound and primary laparoscopic management. Clin Case Rep 2021; 9:e04261. [PMID: 34084520 PMCID: PMC8142796 DOI: 10.1002/ccr3.4261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/23/2021] [Indexed: 11/12/2022] Open
Abstract
Unicornuate uterus with pregnancy in the noncommunicating rudimentary horn is extremely rare. Diagnosis requires awareness, high suspicion index, 3D ultrasound, and MRI. If missed, it can be catastrophic. Treatment varies across literature. We present a case where detection was done by 3D ultrasound and primary laparoscopic surgery done for treatment.
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Affiliation(s)
- Juhi Dhanawat
- Department of Gynecology and ObstetricsUniversity Hospitals Schleswig‐HolsteinKielGermany
| | - Julian Pape
- Department of Gynecology and ObstetricsUniversity Hospitals Schleswig‐HolsteinKielGermany
| | | | - Nicolai Maass
- Department of Gynecology and ObstetricsUniversity Hospitals Schleswig‐HolsteinKielGermany
| | - Damaris Freytag
- Department of Gynecology and ObstetricsUniversity Hospitals Schleswig‐HolsteinKielGermany
| | - Georgios Gitas
- Department of Gynaecology and ObstetricsUniversity Hospitals Schleswing‐HolsteinLeubeckGermany
| | - Ibrahim Alkatout
- Department of Gynecology and ObstetricsUniversity Hospitals Schleswig‐HolsteinKielGermany
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Coelho Neto MA, Ludwin A, Petraglia F, Martins WP. Definition, prevalence, clinical relevance and treatment of T-shaped uterus: systematic review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:366-377. [PMID: 32898287 DOI: 10.1002/uog.23108] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/26/2020] [Accepted: 08/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To summarize in a systematic review the current evidence regarding definitions, diagnosis, prevalence, etiology, clinical relevance and impact of surgical treatment for T-shaped uterus not related to diethylstilbestrol (DES) exposure, and to highlight areas on which future research should focus. METHODS A search of PubMed, Scopus and EMBASE was performed on 9 April 2020 using the search terms 't-shaped OR t-shape OR infantile OR (lateral indentation) OR (diethylstilbestrol OR DES) AND (uterus OR uterine OR uteri) AND (anomaly OR anomalies OR malformation OR malformations)'. Additionally, the reference lists of the included studies were searched manually for other relevant publications. All studies presenting data on T-shaped uterus not associated with DES exposure and including at least 10 women were considered eligible. Studies regarding DES-related T-shaped uterus were excluded because DES has not been used since 1971. There were no restrictions on language, date of publication or status of publication. RESULTS Of 2504 records identified by the electronic search, 20 studies were included in the systematic review. The majority of studies were of poor quality. In 11 of 16 studies reporting on the diagnosis of T-shaped uterus, the diagnostic method used was three-dimensional ultrasound. There is no consensus on the definition of T-shaped uterus, but the most cited criteria (4/16 studies) were of the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy (ESHRE/ESGE; 2013). The prevalence of T-shaped uterus varied from 0.2% to 10% in the four included studies reporting such data. With respect to etiology (except for DES), T-shaped uterus was considered a primary condition in three studies and secondary to adhesions in five and adenomyosis in one. T-shaped uterus was related to worse reproductive outcome based on subfertility (nine studies), miscarriage (seven studies), preterm delivery (two studies), ectopic pregnancy (one study) and repeat implantation failure (seven studies). Of the 12 studies that reported on the effects of surgical treatment of T-shaped uterus by hysteroscopic metroplasty, some mentioned an improvement in pregnancy rate (rates ranging from 49.6% to 88%; eight studies), live-birth rate (rates ranging from 35.1% to 76%; seven studies) and term-delivery rate (four studies) and a reduction in miscarriage (rates ranging from 7% to 49.6%; five studies) and ectopic pregnancy (one study). However, the evidence is of very low quality with serious/critical risk of bias toward overestimating the intervention effect. Some authors reported no complications related to the procedure, while others mentioned persistence of the dysmorphism (rates ranging from 1.4% to 11%; three studies), bleeding (1.3%; one study), infection (2.6%; one study) and adhesions (11.1% and 16.8%; two studies). CONCLUSIONS The prevalence, etiology and clinical relevance, with respect to reproductive outcome, of T-shaped uterus remain unclear and there is no consensus on the definition and diagnostic method for this condition. Expectant management should be considered the most appropriate choice for everyday practice until randomized controlled trials show a benefit of intervention. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M A Coelho Neto
- Department of Obstetrics and Gynecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - F Petraglia
- Department of Clinical and Experimental Biomedical Sciences, University of Florence, Florence, Italy
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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Ludwin A. Ultrasound at the intersection of art, science and technology: complete septate uterus with longitudinal vaginal septum. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:512-514. [PMID: 33646634 DOI: 10.1002/uog.23609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 01/31/2021] [Accepted: 02/03/2021] [Indexed: 06/12/2023]
Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
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Liu Y, Wang S, Hong Y, Wang J, Niu J, Li X, Li H, Wang Y. Pregnancy in the blind hemi-cavity of Robert's uterus: a case report. Radiol Case Rep 2021; 16:1085-1088. [PMID: 33717388 PMCID: PMC7921196 DOI: 10.1016/j.radcr.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/05/2021] [Accepted: 02/06/2021] [Indexed: 12/01/2022] Open
Abstract
Robert's uterus is a rare Müllerian malformation first characterized by a French gynecologist Héléne Robert in 1969. It represents an asymmetric division of the uterine cavity. A 45-year-old female patient presented with vaginal bleeding and vague abdominal pain for the course of 20 days, with a blood human chorionic gonadotropin level of 10331.00 mIU/mL, and a gestational sac in the right uterine horn without a fetal heart beat revealed by the ultrasound. Ectopic pregnancy in the right uterine horn seemed to be the most likely diagnosis. Laparoscopic and hysteroscopic attempts to terminate the pregnancy failed. A pelvic magnetic resonance imaging (MRI) performed after the surgery demonstrated Robert's uterus with pregnancy in the blind hemicavity. When a pregnancy sac has been revealed by an ultrasound but nothing has been found by a hysteroscopy, a possibility of uterine malformation should be considered. Radiologists and gynecologists should consider the application of MRI for diagnosis of congenital Müllerian uterine anomalies.
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Affiliation(s)
- Yan Liu
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
| | - Shanshan Wang
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
| | - Yue Hong
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
| | - Jia Wang
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
| | - Junqiao Niu
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
| | - Xiaojuan Li
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
| | - Hui Li
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
| | - Yan Wang
- Department of Radiology, People's Hospital of Xinjiang Uygur Autonomous region, China
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Krishnan M, Narice BF, Ola B, Metwally M. Does hysteroscopic resection of uterine septum improve reproductive outcomes: a systematic review and meta-analysis. Arch Gynecol Obstet 2021; 303:1131-1142. [PMID: 33550465 PMCID: PMC8053150 DOI: 10.1007/s00404-021-05975-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/19/2021] [Indexed: 10/29/2022]
Abstract
PURPOSE Uterine septum in women with subfertility or previous poor reproductive outcomes presents a clinical dilemma. Hysteroscopic septum resection has been previously associated with adverse reproductive outcomes but the evidence remains inconclusive. We aimed to thoroughly and systematically appraise relevant evidence on the impact of hysteroscopically resecting the uterine septum on this cohort of women. METHODS AMED, BNI, CINAHL, EMBASE, EMCARE, Medline, PsychInfo, PubMed, Cochrane register of controlled trials, Cochrane database of systematic reviews and CINAHL were assessed to April 2020, with no language restriction. Only randomised control trials and comparative studies which evaluated outcomes in women with uterine septum and a history of subfertility and/or poor reproductive outcomes treated by hysteroscopic septum resection against control were included. The primary endpoint was live birth rate, whereas clinical pregnancy, miscarriage, preterm birth and malpresentation rates were secondary outcomes. RESULTS Seven studies involving 407 women with hysteroscopic septum resection and 252 with conservative management were included in the meta-analysis. Hysteroscopic septum resection was associated with a lower rate of miscarriage (OR 0.25, 95% CI 0.07-0.88) compared with untreated women. No significant effect was seen on live birth, clinical pregnancy rate or preterm delivery. However, there were fewer malpresentations during labour in the treated group (OR 0.22, 95% CI 0.06-0.73). CONCLUSION Our review found no significant effect of hysteroscopic resection on live birth. However, given the limited evidence available, high-quality randomised controlled trials are recommended before any conclusive clinical guidance can be drawn.
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Affiliation(s)
- Monica Krishnan
- The Assisted Conception Unit, Sheffield Teaching Hospitals and the University of Sheffield, Sheffield, S10 2SF, UK.
| | - Brenda F Narice
- The Assisted Conception Unit, Sheffield Teaching Hospitals and the University of Sheffield, Sheffield, S10 2SF, UK
| | - Bolarinde Ola
- The Assisted Conception Unit, Sheffield Teaching Hospitals and the University of Sheffield, Sheffield, S10 2SF, UK
| | - Mostafa Metwally
- The Assisted Conception Unit, Sheffield Teaching Hospitals and the University of Sheffield, Sheffield, S10 2SF, UK
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Anwari L. Prerupture diagnosis of a pregnant rudimentary uterine horn. Radiol Case Rep 2021; 16:764-768. [PMID: 33537105 PMCID: PMC7841222 DOI: 10.1016/j.radcr.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 11/26/2022] Open
Abstract
This clinical case reports prerupture diagnosis of a rudimentary horn pregnancy in a 27-year-old formerly healthy woman presented with moderate to severe suprapubic abdominal pain at the gestational age of 12 + 0 weeks. The suspected diagnosis of this pregnant rudimentary horn via transvaginal ultrasound was acknowledged during an emergency exploratory laparotomy. The simple transvaginal ultrasound criteria suggested by the present study would help clinicians avoid time-consuming inefficient investigative procedure and rule out this rare life-threatening condition by taking into account the rudimentary horn pregnancy as a differential diagnosis in patients presenting with abdominal pain.
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Affiliation(s)
- Lida Anwari
- Department of Obstetrics and Gynecology, Darent Valley Hospital, Dartford, Kent, UK
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Abd elsalam SM, Abd elmegeed NE, Said AHM, Sayed MAE. Role of three-dimensional transvaginal sonography compared with magnetic resonance imaging in diagnosis of Mullerian duct anomalies. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00156-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Mullerian duct anomalies are a heterogenous group of congenital anomalies due to abnormalities during the ductal development, fusion, or alteration of septal resorption. These lead to the occurrence of different uterine anomalies. The present study aimed to assess the value of three-dimensional transvaginal sonography (3DTVS) in comparison with pelvic MRI to diagnose uterine anomalies. We prospectively evaluated 30 female patients, from January 2016 to May 2017. Their ages ranged from 18 to 40 years. Cases were referred from obstetrics and gynecology clinic with suspected uterine anomalies by 2DUS or with HSG done for infertility workup. 3DTVS and MRI examination were done for all patients.
Results
The final diagnosis of patients by MRI according to The European Society of Human Reproduction and Embryology–European Society for Gynaecological Endoscopy consensus classification included 2/30 (6.7%) patients classified as class U0, 4/30 (13.3%) patients classified as class U1, 17/30 (56.7%) cases classified as class U2, 2/30 (6.7%) patients classified as class U3, 3/30 (10%) patients classified as class U4, and 2/30 (6.7%) patients were classified as class U5. There was a significant strong agreement between the diagnosis by 3D-transvaginal ultrasound and MRI (P < 0.01).
Conclusion
3DTVS proved to be highly accurate in the diagnosis of uterine anomalies and showed strong agreement with MRI, as both can provide valuable information about both the internal details and the external contour of the uterus.
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Ludwin A, Martins WP. Uterine 'anomalies' by ESHRE/ESGE classification: are more than half of women really sick? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:951-952. [PMID: 31994244 DOI: 10.1002/uog.21986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Revised: 01/18/2020] [Accepted: 01/20/2020] [Indexed: 06/10/2023]
Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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38
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Schaible B, Annie F, Seybold D, Calhoun BC. Ecological study of effects of industrial watershed on Müllerian anomalies in an obstetric population. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2020; 202:110819. [PMID: 32590208 DOI: 10.1016/j.ecoenv.2020.110819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/26/2020] [Accepted: 05/26/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To ascertain the prevalence of Müllerian anomalies within an obstetrical population in relation to official hazardous waste sites designated by the Environmental Protection Agency (EPA) in West Virginia. METHODS Observational study of obstetric patients in a tertiary care center with uterine ultrasounds from January 2006 to June 2017. An Optimized Hot Spot analysis and Ripley's K- Function was constructed to ascertain if there is an association with environmental exposures. RESULTS The prevalence of Müllerian anomalies in our obstetric study sample was 0.9% (118/13,040). The most common were septate (47; 39.8%) and bicornuate (46; 39.0%). The distribution of Müllerian anomalies was non-random illustrated by Optimized Hot Spot Analysis locating several statistically significant zip codes of Müllerian anomalies in relation to zip codes that include EPA facilities. CONCLUSION The distribution of Müllerian anomalies was clustered in watershed areas along the Kanawha River in West Virginia that have been designated as EPA FRS Sites and Superfund Sites.
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Affiliation(s)
- Burk Schaible
- Charleston Area Medical Center Women and Children's Hospital, 800 Pennsylvania Ave, Charleston, WV, 25302, United States.
| | - Frank Annie
- Charleston Area Medical Center Health Education and Research Institute, 3211 McCorkle Ave, SE Charleston, WV, 25304, United States.
| | - Dara Seybold
- Charleston Area Medical Center Health Education and Research Institute, 3211 McCorkle Ave, SE Charleston, WV, 25304, United States.
| | - Byron C Calhoun
- West Virginia University/Charleston Area Medical Center Women and Children's Hospital, 800 Pennsylvania Ave, Charleston, WV, 25302, United States.
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Negm SM, Kamel RA, El-Zayat HA, Elbigawy AF, El-Toukhy MM, Amin AH, Nicolaides KH. The value of three-dimensional ultrasound in identifying Mullerian anomalies at risk of adverse pregnancy outcomes. J Matern Fetal Neonatal Med 2020; 35:3201-3208. [PMID: 32873098 DOI: 10.1080/14767058.2020.1815189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Sherif M Negm
- Maternal-Fetal Medicine Unit, Cairo University, Cairo, Egypt.,Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | - Rasha A Kamel
- Maternal-Fetal Medicine Unit, Cairo University, Cairo, Egypt.,Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | | | - Adel F Elbigawy
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
| | | | - Ahmed H Amin
- Department of Obstetrics and Gynecology, Cairo University, Cairo, Egypt
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Ludwin A, Lindheim SR, Bhagavath B, Martins WP, Ludwin I. Longitudinal vaginal septum: a proposed classification and surgical management. Fertil Steril 2020; 114:899-901. [PMID: 32826051 DOI: 10.1016/j.fertnstert.2020.06.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 06/05/2020] [Accepted: 06/08/2020] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To demonstrate various types of longitudinal vaginal septa (LVS), their classification, and the surgical management of typical and unique morphologic conditions of LVS. DESIGN Video presentation of clinical appearance and surgical techniques for treatment of LVS. SETTING University hospital and two private. PATIENT(S) Representative cases from 121 consecutive women treated from 2013 to 2018 with LVS as a part of complex uterovaginal malformations or in isolated forms with [1] typical morphologic configuration of LVS, [2] rarer variants, or [3] specific anatomic restrictions. INTERVENTION(S) Resection of LVS performed as a main surgical procedure in cases with didelphys and bicornuate uterus in symptomatic women and as a part of corrective surgery of complete septate uterus. The three main nonsuturing techniques used were speculoscopy and septum excision using three different electrosurgical modalities; speculoscopy with laparoscopic devices; and vaginoscopy with hysteroscopic instruments. MAIN OUTCOME MEASURE(S) Clinical appearance and suggested classification, feasibility of surgery, and perioperative and anatomic results in a short follow-up period (3 months). RESULT(S) We identified distinct types of longitudinal vaginal septa. Considering clinical appearance, we suggest classification of LVS based on four main features: [2] completeness of vaginal division: partial and complete type; [2] the symmetricity: symmetric and asymmetric position (with dominant left and right side); [3] association with the cervix: merged and isolated forms; and [4] concomitant vaginal openings: normal, and narrow openings: vaginal stenosis and hymen persistent (Fig. 1). Vaginoscopic techniques by hysteroscope were successful in atraumatic treatment of women with substantial anatomic restrictions, and all of the presented techniques can be effectively used for typical LVS. However, vessel-sealing systems allow for bloodless surgery in contrast with other methods. This study was based on previously acquired data during large prospective study approved by the local ethics committee, and written informed consent to participate in the prospective study and permit publishing anonymous data regarding the medical images, videos of procedures, and results was obtained from all patients. CONCLUSION(S) A new classification of longitudinal vaginal septum allows better characterization compared with the currently available classification systems. Different surgical modalities are discussed with their respective advantages and disadvantages. Vaginoscopic incision using resectoscope is a reasonable alternative for women with an intact hymen and vaginal stenosis. The impact of vaginal septum resection on obstetric, reproductive, and sexual outcomes should be assessed in randomized controlled trials and large well-designed studies.
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Affiliation(s)
- Artur Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland; Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland; Centermed Private Hospital and Clinic, Krakow, Poland.
| | - Steven R Lindheim
- Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - Bala Bhagavath
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, New York
| | - Wellington P Martins
- Department of Obstetrics and Gynecology, Ribeirao Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil; SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - Inga Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland; Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland; Centermed Private Hospital and Clinic, Krakow, Poland
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King AL, Pixton S, Lanzarone V. Uterine didelphys with dicavitary twin gestation: A case report. Case Rep Womens Health 2020; 27:e00199. [PMID: 32322536 PMCID: PMC7163069 DOI: 10.1016/j.crwh.2020.e00199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 04/02/2020] [Indexed: 11/01/2022] Open
Abstract
Uterine didelphys is a rare type of congenital uterine anomaly resulting from incomplete fusion of the paramesonephric ducts during embryogenesis. We report the case of a 27-year-old multiparous woman who presented with ovulation-induced dicavitary dichorionic diamniotic twins in known uterine didelphys. At 29 + 5 weeks of gestation, the patient had preterm prelabour rupture of membranes followed by threatened preterm labour in the right uterus only, which settled with tocolysis. The pregnancy continued for a further 9 days, at which time uterine tightenings returned and the right cervix was fully dilated, resulting in successful vaginal delivery of the first twin, leaving the placenta in situ. The left uterus and cervix remained quiescent for a further 24 h before contractions returned, resulting in emergency caesarean section, with the successful delivery of the second twin. As a rare phenomenon, there is sparse literature on the management of dicavitary twin gestation in uterine didelphys. This case report adds to the evidence for independent functioning of uteri and cervices in cases of uterine didelphys which may enable interval delivery delay in this cohort with known increased risk of preterm birth.
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Affiliation(s)
- Alison Laura King
- Department of Obstetrics and Gynaecology, Nepean Hospital, Penrith, Australia
| | - Sarah Pixton
- Department of Obstetrics and Gynaecology, Nepean Hospital, Penrith, Australia
| | - Valeria Lanzarone
- Department of Obstetrics and Gynaecology, Nepean Hospital, Penrith, Australia
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Rikken JFW, Verhorstert KWJ, Emanuel MH, Bongers MY, Spinder T, Kuchenbecker W, Jansen FW, van der Steeg JW, Janssen CAH, Kapiteijn K, Schols WA, Torrenga B, Torrance HL, Verhoeve HR, Huirne JAF, Hoek A, Nieboer TE, van Rooij IAJ, Clark TJ, Robinson L, Stephenson MD, Mol BWJ, van der Veen F, van Wely M, Goddijn M. Septum resection in women with a septate uterus: a cohort study. Hum Reprod 2020; 35:1578-1588. [PMID: 32353142 PMCID: PMC7368397 DOI: 10.1093/humrep/dez284] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/20/2019] [Accepted: 12/05/2019] [Indexed: 11/25/2022] Open
Abstract
STUDY QUESTION Does septum resection improve reproductive outcomes in women with a septate uterus? SUMMARY ANSWER In women with a septate uterus, septum resection does not increase live birth rate nor does it decrease the rates of pregnancy loss or preterm birth, compared with expectant management. WHAT IS KNOWN ALREADY The septate uterus is the most common uterine anomaly with an estimated prevalence of 0.2-2.3% in women of reproductive age, depending on the classification system. The definition of the septate uterus has been a long-lasting and ongoing subject of debate, and currently two classification systems are used worldwide. Women with a septate uterus may be at increased risk of subfertility, pregnancy loss, preterm birth and foetal malpresentation. Based on low quality evidence, current guidelines recommend removal of the intrauterine septum or, more cautiously, state that the procedure should be evaluated in future studies. STUDY DESIGN, SIZE, DURATION We performed an international multicentre cohort study in which we identified women mainly retrospectively by searching in electronic patient files, medical records and databases within the time frame of January 2000 until August 2018. Searching of the databases, files and records took place between January 2016 and July 2018. By doing so, we collected data on 257 women with a septate uterus in 21 centres in the Netherlands, USA and UK. PARTICIPANTS/MATERIALS, SETTING, METHODS We included women with a septate uterus, defined by the treating physician, according to the classification system at that time. The women were ascertained among those with a history of subfertility, pregnancy loss, preterm birth or foetal malpresentation or during a routine diagnostic procedure. Allocation to septum resection or expectant management was dependent on the reproductive history and severity of the disease. We excluded women who did not have a wish to conceive at time of diagnosis. The primary outcome was live birth. Secondary outcomes included pregnancy loss, preterm birth and foetal malpresentation. All conceptions during follow-up were registered but for the comparative analyses, only the first live birth or ongoing pregnancy was included. To evaluate differences in live birth and ongoing pregnancy, we used Cox proportional regression to calculate hazard rates (HRs) and 95% CI. To evaluate differences in pregnancy loss, preterm birth and foetal malpresentation, we used logistic regression to calculate odds ratios (OR) with corresponding 95% CI. We adjusted all reproductive outcomes for possible confounders. MAIN RESULTS AND THE ROLE OF CHANCE In total, 257 women were included in the cohort. Of these, 151 women underwent a septum resection and 106 women had expectant management. The median follow-up time was 46 months. During this time, live birth occurred in 80 women following a septum resection (53.0%) compared to 76 women following expectant management (71.7%) (HR 0.71 95% CI 0.49-1.02) and ongoing pregnancy occurred in 89 women who underwent septum resection (58.9%), compared to 80 women who had expectant management (75.5%) (HR 0.74 (95% CI 0.52-1.06)). Pregnancy loss occurred in 51 women who underwent septum resection (46.8%) versus 31 women who had expectant management (34.4%) (OR 1.58 (0.81-3.09)), while preterm birth occurred in 26 women who underwent septum resection (29.2%) versus 13 women who had expectant management (16.7%) (OR 1.26 (95% CI 0.52-3.04)) and foetal malpresentation occurred in 17 women who underwent septum resection (19.1%) versus 27 women who had expectant management (34.6%) (OR 0.56 (95% CI 0.24-1.33)). LIMITATIONS, REASONS FOR CAUTION Our retrospective study has a less robust design compared with a randomized controlled trial. Over the years, the ideas about the definition of the septate uterus has changed, but since the 257 women with a septate uterus included in this study had been diagnosed by their treating physician according to the leading classification system at that time, the data of this study reflect the daily practice of recent decades. Despite correcting for the most relevant patient characteristics, our estimates might not be free of residual confounding. WIDER IMPLICATIONS OF THE FINDINGS Our results suggest that septum resection, a procedure that is widely offered and associated with financial costs for society, healthcare systems or individuals, does not lead to improved reproductive outcomes compared to expectant management for women with a septate uterus. The results of this study need to be confirmed in randomized clinical trials. STUDY FUNDING/COMPETING INTEREST(S) A travel for JFWR to Chicago was supported by the Jo Kolk Studyfund. Otherwise, no specific funding was received for this study. The Department of Obstetrics and Gynaecology, University Medical Centre, Groningen, received an unrestricted educational grant from Ferring Pharmaceutical Company unrelated to the present study. BWM reports grants from NHMRC, personal fees from ObsEva, personal fees from Merck, personal fees from Guerbet, other payment from Guerbet and grants from Merck, outside the submitted work. The other authors declare no conficts of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- J F W Rikken
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - K W J Verhorstert
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - M H Emanuel
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - M Y Bongers
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Eindhoven, the Netherlands
| | - T Spinder
- Department of Obstetrics and Gynaecology, Leeuwarden Medical Centre, Leeuwarden, the Netherlands
| | - W Kuchenbecker
- Department of Obstetrics and Gynaecology, Isala Hospital Zwolle, Zwolle, the Netherlands
| | - F W Jansen
- Department of Obstetrics and Gynaecology, University Medical Centre Leiden, Leiden, the Netherlands
| | - J W van der Steeg
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, Den Bosch, the Netherlands
| | - C A H Janssen
- Department of Obstetrics and Gynaecology, Groene Hart Hospital, Gouda, the Netherlands
| | - K Kapiteijn
- Department of Obstetrics and Gynaecology, Reinier de Graaf Gasthuis, Delft, the Netherlands
| | - W A Schols
- Department of Obstetrics and Gynaecology, Meander Medical Centre, Amersfoort, the Netherlands
| | - B Torrenga
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands
| | - H L Torrance
- Department of Reproductive Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - H R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG Oost, Amsterdam, the Netherlands
| | - J A F Huirne
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - A Hoek
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - T E Nieboer
- Department of Obstetrics and Gynaecology, Nijmegen, the Netherlands
| | - I A J van Rooij
- Department of Obstetrics and Gynaecology, Elisabeth Hospital Tweesteden, Tilburg, the Netherlands
| | - T J Clark
- Department of Obstetrics and Gynaecology, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - L Robinson
- Department of Obstetrics and Gynaecology, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - M D Stephenson
- Department of Obstetrics and Gynaecology, University of Illinois, CA, USA
| | - B W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Monash Medical Centre, Clayton, Victoria, Australia
| | - F van der Veen
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - M van Wely
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
| | - M Goddijn
- Centre for Reproductive Medicine and Department of Obstetrics and Gynaecology, Amsterdam University Medical Centre, Location AMC and VUMC, PO Box 22700, 1100 DE, Amsterdam, the Netherlands
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Abstract
The association between obstructed müllerian duct anomalies and endometriosis has been well established and the pathogenesis is attributed to the theory of retrograde menstruation. However, this relationship with endometriosis is less clear in women with unobstructed müllerian duct anomalies and in those with rudimentary uterine structures that lack functioning endometrial tissue. This article reviews the embryology, genetics, pathophysiology, and American Society for Reproductive Medicine (ASRM) classification for müllerian duct anomalies together with the genetics and pathophysiology of endometriosis to provide a framework for understanding the complex relationship between these two entities. Available published data examining the coexistence of endometriosis in relationship to müllerian duct anomalies, including studies that stratify this relationship according to specific classes of anomalies, are reviewed and organized. Awareness of the increased prevalence of endometriosis among patients with uterine anomalies, particularly those with outflow obstruction, may facilitate early diagnosis of endometriosis and subsequent intervention, with the potential to reverse disease symptoms and arrest disease progression.
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Ludwin A, Coelho Neto MA, Ludwin I, Nastri CO, Costa W, Acién M, Alcazar JL, Benacerraf B, Condous G, DeCherney A, De Wilde RL, Diamond MP, Emanuel MH, Guerriero S, Hurd W, Levine D, Lindheim S, Pellicer A, Petraglia F, Saridogan E, Martins WP. Congenital Uterine Malformation by Experts (CUME): diagnostic criteria for T-shaped uterus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:815-829. [PMID: 31432589 DOI: 10.1002/uog.20845] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/23/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To identify uterine measurements that are reliable and accurate to distinguish between T-shaped and normal/arcuate uterus, and define T-shaped uterus, using Congenital Uterine Malformation by Experts (CUME) methodology, which uses as reference standard the decision made most often by several independent experts. METHODS This was a prospectively planned multirater reliability/agreement and diagnostic accuracy study, performed between November 2017 and December 2018, using a sample of 100 three-dimensional (3D) datasets of different uteri with lateral uterine cavity indentations, acquired from consecutive women between 2014 and 2016. Fifteen representative experts (five clinicians, five surgeons and five sonologists), blinded to each others' opinions, examined anonymized images of the coronal plane of each uterus and provided their independent opinion as to whether it was T-shaped or normal/arcuate; this formed the basis of the CUME reference standard, with the decision made most often (i.e. that chosen by eight or more of the 15 experts) for each uterus being considered the correct diagnosis for that uterus. Two other experienced observers, also blinded to the opinions of the other experts, then performed independently 15 sonographic measurements, using the original 3D datasets of each uterus. Agreement between the diagnoses made by the 15 experts was assessed using kappa and percent agreement. The interobserver reliability of measurements was assessed using the concordance correlation coefficient (CCC). The diagnostic test accuracy was assessed using the area under the receiver-operating-characteristics curve (AUC) and the best cut-off value was assessed by calculating Youden's index, according to the CUME reference standard. Sensitivity, specificity, negative and positive likelihood ratios (LR- and LR+) and post-test probability were calculated. RESULTS According to the CUME reference standard, there were 20 T-shaped and 80 normal/arcuate uteri. Individual experts recognized between 5 and 35 (median, 19) T-shaped uteri on subjective judgment. The agreement among experts was 82% (kappa = 0.43). Three of the 15 sonographic measurements were identified as having good diagnostic test accuracy, according to the CUME reference standard: lateral indentation angle (AUC = 0.95), lateral internal indentation depth (AUC = 0.92) and T-angle (AUC = 0.87). Of these, T-angle had the best interobserver reproducibility (CCC = 0.87 vs 0.82 vs 0.62 for T-angle vs lateral indentation depth vs lateral indentation angle). The best cut-off values for these measurements were: lateral indentation angle ≤ 130° (sensitivity, 80%; specificity, 96%; LR+, 21.3; LR-, 0.21), lateral indentation depth ≥ 7 mm (sensitivity, 95%; specificity, 77.5%; LR+, 4.2; LR-, 0.06) and T-angle ≤ 40° (sensitivity, 80%; specificity, 87.5%; LR+, 6.4; LR-, 0.23). Most of the experts diagnosed the uterus as being T-shaped in 0% (0/56) of cases when none of these three criteria was met, in 10% (2/20) of cases when only one criterion was met, in 50% (5/10) of cases when two of the three criteria were met, and in 93% (13/14) of cases when all three criteria were met. CONCLUSIONS The diagnosis of T-shaped uterus is not easy; the agreement among experts was only moderate and the judgement of individual experts was commonly insufficient for accurate diagnosis. The three sonographic measurements with cut-offs that we identified (lateral internal indentation depth ≥ 7 mm, lateral indentation angle ≤ 130° and T-angle ≤ 40°) had good diagnostic test accuracy and fair-to-moderate reliability and, when applied in combination, they provided high post-test probability for T-shaped uterus. In the absence of other anomalies, we suggest considering a uterus to be normal when none or only one criterion is met, borderline when two criteria are met, and T-shaped when all three criteria are met. These three CUME criteria for defining T-shaped uterus may aid in determination of its prevalence, clinical implications and best management and in the assessment of post-surgical morphologic outcome. The CUME definition of T-shaped uterus may help in the development of interventional randomized controlled trials and observational studies and in the diagnosis of uterine morphology in everyday practice, and could be adopted by guidelines on uterine anomalies to enrich their classification systems. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - M A Coelho Neto
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - C O Nastri
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - W Costa
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - M Acién
- San Juan University Hospital/Miguel Hernández University, Alicante, Spain
| | - J L Alcazar
- Department of Obstetrics and Gynecology, University of Navarra, Pamplona, Spain
| | | | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - A DeCherney
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - R-L De Wilde
- Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - M P Diamond
- Department of Obstetrics & Gynecology, Augusta University, Augusta, GA, USA
| | - M H Emanuel
- Department of Gynaecology and Reproductive Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Gynaecology, University Hospital Ghent, Ghent, Belgium
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
| | - W Hurd
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - D Levine
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - S Lindheim
- Department of Obstetrics & Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
| | - A Pellicer
- Instituto Valenciano de Infertilidad, Valencia, Spain
| | | | - E Saridogan
- University College London Hospital, London, UK
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
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Maciel C, Bharwani N, Kubik-Huch RA, Manganaro L, Otero-Garcia M, Nougaret S, Alt CD, Cunha TM, Forstner R. MRI of female genital tract congenital anomalies: European Society of Urogenital Radiology (ESUR) guidelines. Eur Radiol 2020; 30:4272-4283. [PMID: 32221681 PMCID: PMC7338830 DOI: 10.1007/s00330-020-06750-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 01/22/2020] [Accepted: 02/04/2020] [Indexed: 11/24/2022]
Abstract
Objective To develop imaging guidelines for the MR work-up of female genital tract congenital anomalies (FGTCA). Methods These guidelines were prepared based on a questionnaire sent to all members of the European Society of Urogenital Radiology (ESUR) Female Pelvic Imaging Working Group (FPI-WG), critical review of the literature and expert consensus decision. Results The returned questionnaires from 17 different institutions have shown reasonable homogeneity of practice. Recommendations with focus on patient preparation and MR protocol are proposed, as these are key to optimised examinations. Details on MR sequences and planning of uterus-orientated sequences are provided. Conclusions The multiplanar capabilities and soft tissue resolution of MRI provide superb characterisation of the wide spectrum of findings in FGTCA. A standardised imaging protocol and method of reporting ensures that the salient features are recognised, contributing to a correct diagnosis and classification of FGTCA, associated anomalies and complications. These imaging guidelines are based on current practice among expert radiologists in the field and incorporate up to date information regarding MR protocols and essentials of recently published classification systems. Key Points • MRI allows comprehensive evaluation of female genital tract congenital anomalies, in a single examination. • A dedicated MRI protocol comprises uterus-orientated sequences and vaginal and renal evaluation. • Integration of classification systems and structured reporting helps in successful communication of the imaging findings. Electronic supplementary material The online version of this article (10.1007/s00330-020-06750-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cristina Maciel
- Serviço de Imagiologia, CHVNG/E, Rua Conceição Fernandes, 4434-502, Vila Nova de Gaia, Portugal
- Departamento de Medicina, Faculdade de Medicina, Universidade do Porto, Alameda Prof. Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Nishat Bharwani
- Department of Radiology, St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1 NY, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Rahel A Kubik-Huch
- Institut für Radiologie, Kantonsspital Baden AG, CH-5404, Baden-Dättwil, Switzerland
| | - Lucia Manganaro
- Dipartimento di Scienze Radiologiche, Oncologiche e Anatomo Patologiche, Sapienza Università di Roma, Vle Regina Elena 324, 00161, Rome, Italy
| | - Milagros Otero-Garcia
- Department of Radiology, Hospital Universitario de Vigo, Planta 3 Vela A, Vigo, Spain
| | - Stephanie Nougaret
- Department of Radiology, Montpellier Cancer institute, INSERM, U1194, University of Montpellier, 208 Ave des Apothicaires, 34295, Montpellier, France
| | - Celine D Alt
- Department of Diagnostic and Interventional Radiology, Medical Faculty, University Dusseldorf, Duesseldorf, Germany
| | - Teresa Margarida Cunha
- Serviço de Radiologia, Instituto Português de Oncologia de Lisboa Francisco Gentil, Rua Prof. Lima Basto, 1099-023, Lisbon, Portugal
| | - Rosemarie Forstner
- Department of Radiology, Universitätsklinikum Salzburg, PMU, Müllner-Hauptstr. 48, A-5020, Salzburg, Austria.
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Abuzeid O, LaChance J, Zaghmout O, Corrado J, Hebert J, Ashraf M, Abuzeid MI. The role of diagnostic hysteroscopy in diagnosis of incomplete uterine septum/significant arcuate uterine anomaly in infertile patients in the era of transvaginal 3D ultrasound scan. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2020. [DOI: 10.1186/s43043-019-0009-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
To determine the accuracy of measurement of internal indentation length on transvaginal 3D ultrasound scan (TV 3D US) in detecting patients with an incomplete uterine septum (IUS) or a significant arcuate uterine anomaly (AUA) based on the actual length as measured on diagnostic hysteroscopy. We compared the mean internal indentation length on TV 3D US and on diagnostic hysteroscopy in patients with IUS or a significant AUA.
Results
This is a retrospective study of 546 patients who were found to have IUS (134) or significant AUA (412) on diagnostic hysteroscopy and who had TV 3D US prior to surgery. The mean internal indentation length measured in millimeter on hysteroscopy was significantly higher than the mean internal indentation length measured on TV 3D US in patients with IUS (16.7 + 5.5 vs 5.5 + 4.2; P < 0.001), in patients with significant AUA (12.9 + 2.8 vs 3.9 + 4.6; P < 0.001), and in the overall population (13.8 + 4.0 vs 4.3 + 4.5; P < 0.001). The same findings were obtained when the comparison was limited to patients who had moderate significant internal indentation length (10–14 mm) and those with significant internal indentation length (15–25 mm).
Conclusion
Data in this study suggests that the mean internal indentation length in patients with IUS or AUA can be underestimated on TV 3D US. A diagnostic hysteroscopy is the only gold standard to make the correct diagnosis in these patients.
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Ludwin A, Ludwin I, Coelho Neto MA, Nastri CO, Bhagavath B, Lindheim SR, Martins WP. Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare systems. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:800-814. [PMID: 30977223 DOI: 10.1002/uog.20291] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/05/2019] [Accepted: 04/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To estimate the differences in frequency of diagnosis of septate uterus using three different definitions and determine whether these differences are significant in clinical practice, and to examine the association between diagnosis of septate uterus, using each of the three definitions, and infertility and/or previous miscarriage as well as the cost of allocation to surgery. METHODS This was a secondary analysis of data from a prospective study of 261 consecutive women of reproductive age attending a private clinic focused on the diagnosis and treatment of congenital uterine malformations. Reanalysis of the datasets was performed according to three different means of defining septate uterus: following the recommendations of the American Society for Reproductive Medicine (ASRM), a 2016 update of those of the American Fertility Society from 1988 (ASRM-2016: internal fundal indentation depth ≥ 1.5 cm, angle of internal indentation < 90° and external indentation depth < 1 cm); following the recommendations of the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), published in 2013 and reaffirmed in 2016 (ESHRE/ESGE-2016: internal fundal/uterine indentation depth > 50% of uterine-wall thickness and external indentation depth < 50% of uterine-wall thickness, with uterine-wall thickness measured above interostial/intercornual line); and using a definition published last year which was based on the decision made most often by a group of experts (Congenital Uterine Malformation by Experts; CUME) (CUME-2018: internal fundal indentation depth ≥ 1 cm and external fundal indentation depth < 1 cm). We compared the rate of diagnosis of septate uterus using each of these three definitions and, for each, we estimated the association between the diagnosis and infertility and/or previous miscarriage, and anticipated the costs associated with their implementation using a guesstimation method. RESULTS Although 32.6% (85/261) of the subjects met the criteria for one of the three definitions of septate uterus, only 2.7% (7/261) of them were defined as having septate uterus according to all three definitions. We diagnosed significantly more cases of septate uterus using ESHRE/ESGE-2016 than using ASRM-2016 (31% vs 5%, relative risk (RR) = 6.7, P < 0.0001) or CUME-2018 (31% vs 12%, RR = 2.6, P < 0.0001) criteria. We also observed frequent cases that could not be classified definitively by ASRM-2016 (gray zone: neither normal/arcuate nor septate; 6.5%). There were no significant differences (P > 0.05) in the prevalence of septate uterus in women with vs those without infertility according to ASRM-2016 (5% vs 4%), ESHRE/ESGE-2016 (35% vs 28%) or CUME-2018 (11% vs 12%). Septate uterus was diagnosed significantly more frequently in women with vs those without previous miscarriage according to ASRM-2016 (11% vs 3%; P = 0.04) and CUME-2018 (22 vs 10%; P = 0.04), but not according to ESHRE/ESGE-2016 (42% vs 28%; P = 0.8) criteria. Our calculations showed that global costs to the healthcare system would be highly dependent on the criteria used in the clinical setting to define septate uterus, with the costs associated with the ESHRE/ESGE-2016 definition potentially being an extra US$ 100-200 billion over 5 years in comparison to ASRM-2016 and CUME-2018 definitions. CONCLUSIONS The prevalence of septate uterus according to ESHRE/ESGE-2016, ASRM-2016 and CUME-2018 definitions differs considerably. An important limitation of the ASRM classification, which needs to be addressed, is the high proportion of unclassifiable cases originally named, by us, the 'gray zone'. The high rate of overdiagnosis of septate uterus according to ESHRE/ESGE-2016 may lead to unnecessary surgery and therefore unnecessary risk in these women and may impose a considerable financial burden on healthcare systems. Efforts to define clinically meaningful and universally applicable criteria for the diagnosis of septate uterus should be encouraged. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - M A Coelho Neto
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - C O Nastri
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - B Bhagavath
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, USA
| | - S R Lindheim
- Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
- Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - W P Martins
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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Akhtar MA, Saravelos SH, Li TC, Jayaprakasan K. Reproductive Implications and Management of Congenital Uterine Anomalies: Scientific Impact Paper No. 62 November 2019. BJOG 2019; 127:e1-e13. [PMID: 31749334 DOI: 10.1111/1471-0528.15968] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital uterine anomalies (CUAs) are malformations of the womb that develop during fetal life. When a baby girl is in her mother's womb, her womb develops as two separate halves from two tubular structures called 'müllerian ducts', which fuse together before she is born. Abnormalities that occur during the baby's development can be variable from complete absence of a womb through to more subtle anomalies, which are classified into specific categories. While conventional ultrasound is good in screening for CUAs, 3D ultrasound is used to confirm a diagnosis. If a complex womb abnormality is suspected, MRI scanning may also be used, with a combination of laparoscopy in which a camera is inserted into the cavity of the abdomen, and hysteroscopy, when the camera is placed in the womb cavity. As there can be a link between CUAs and abnormalities of the kidney and bladder, scans of these organs are also usually requested. Although CUAs are present at birth, adult women typically do not have any symptoms, although some may experience painful periods. Most cases of CUA do not cause a woman to have difficulty in becoming pregnant and the outcome of pregnancy is good. However, these womb anomalies are often discovered during investigations for infertility or miscarriage. Moreover, depending upon the type and severity of CUA, there may be increased risk of first and second trimester miscarriages, preterm birth, poor growth of the baby in the mother's womb (fetal growth restriction), pre-eclampsia and difficult positioning of the baby for birth (fetal malpresentation). Surgical treatment is only recommended to a woman who has had recurrent miscarriages and has a septate uterus, i.e., the womb cavity is divided by a partition. In this case, surgery may improve her chances for a successful pregnancy, although the risks of surgery, especially scarring of the womb should be considered. However, further evidence from randomised controlled trials are required to provide conclusive evidence-based recommendations for surgical treatment for septate uterus. Surgical treatment for other types of CUAs is not usually recommended as the risks outweigh potential benefits, and evidence for any benefits is lacking. Women with CUAs may be at an increased risk of preterm birth even after surgical treatment for a septate uterus. These women, if suspected to be at an increased risk of preterm birth based on the severity of CUA, should be followed up using an appropriate protocol for preterm birth as outlined in UK Preterm Birth Clinical Network Guidance.1 >.
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Alonso L, Haimovich S, Di Spiezio Sardo A, Carugno J. Dysmorphic Uterus: Do We Need a T-Y-I Subclassification? J Minim Invasive Gynecol 2019; 27:4-6. [PMID: 31518710 DOI: 10.1016/j.jmig.2019.08.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 08/31/2019] [Indexed: 11/17/2022]
Affiliation(s)
- Luis Alonso
- Endoscopy Unit, Centro Gutenberg, Malaga, Spain
| | - Sergio Haimovich
- Hillel Yaffe Medical Center, Technion-Israel Technology Institute, Hadera, Israel
| | - Attilio Di Spiezio Sardo
- Department of Public Health, School of Medicine, Unit of Obstetrics and Gynecology, University of Federico II, Naples, Italy
| | - Jose Carugno
- Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, Miami, Florida..
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Reproductive surgery for müllerian anomalies: a review of progress in the last decade. Fertil Steril 2019; 112:408-416. [DOI: 10.1016/j.fertnstert.2019.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/21/2022]
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