Reproductive Implications and Management of Congenital Uterine Anomalies: Scientific Impact Paper No. 62 November 2019

Prevalence of Septate Uterus in a Large Population of Women of Reproductive Age: Comparison of ASRM 2016 and 2021, ESHRE/ESGE, and CUME Diagnostic Criteria: A Prospective Study

In this study, we aimed to assess and compare the prevalence of septate uterus using the diagnostic criteria of the ESHRE-ESGE, ASRM 2016, ASRM 2021, and CUME classifications. This prospective observational study included 977 women of reproductive age. Each participant underwent a transvaginal ultrasound, and a 3D volume of the uterus was obtained for further analysis. Offline assessment of the uterine coronal plane was conducted to measure uterine wall thickness, fundal indentation length, and indentation angle. The diagnosis of a septate uterus was determined according to the criteria of the ESHRE-ESGE, ASRM, and CUME classifications. The prevalence of septate uterus was then calculated and compared across these classifications. The ESHRE-ESGE classification identified 132 women (13.5%) with a septate uterus. The 2016 ASRM classification identified nine women (0.9%), with an additional nine women falling into a grey zone. The 2021 ASRM classification identified fourteen women (1.4%), with eleven women in the grey zone. The CUME classification identified 23 women (2.4%). The prevalence of septate uterus was significantly higher when using the ESHRE-ESGE criteria compared to the 2016 ASRM [relative risk (RR): 7.33 (95% CI: 4.52-11.90)], the 2021 ASRM [RR: 5.28 (95% CI: 3.47-8.02)], and the CUME [RR: 5.94 (95% CI: 3.72-8.86)] (p < 0.001). Our findings indicate that the ESHRE-ESGE criteria result in a significantly higher prevalence of septate uterus compared to the ASRM and CUME criteria. The ASRM 2016 criteria may underdiagnose more than half of the cases.

Assisted reproductive technology outcomes in women with congenital uterine anomalies: a systematic review

PURPOSE

The present systematic review aimed to assess the fecundity of women with congenital uterine anomalies (CUAs) undergoing assisted reproductive technology (ART).

METHODS

The present systematic review of the literature was reported according to the PRISMA guidelines. We systematically searched PubMed, MEDLINE, Embase and Scopus, from database inception to 17th October 2023. Studies were deemed eligible only if they included women with CUAs clearly fitting into one of the categories of the ASRM Müllerian anomalies classification 2021.

RESULTS

Data relevant to the reproductive outcomes of women with CUAs who underwent ART were extracted from 55 studies. Regarding Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, studies on gestational surrogacy reported a live birth rate (LBR) ranging from 37 to 54%. Uterus transplant, although still experimental, showed promising results. Most studies reported a negative impact of unicornuate uterus and partial or complete septate uterus on both the miscarriage rate (MR) and the live birth rate (LBR). The reproductive prognosis of women with unicornuate uterus was shown to be particularly poor in case of twin pregnancy. Uterus didelphys, bicornuate and arcuate uterus seem not to negatively impact the ART reproductive outcomes. Uterus didelphys was associated with an increased risk of preterm birth (PTB), cesarean section and low birth weight (LBW).

CONCLUSION

Women with CUAs should be informed regarding the impact (if any) of their congenital anomaly on both the chances of success of ART and on pregnancy-related complications. Elective single embryo transfer (eSET) should always be the first choice in patients with an increased baseline obstetric risk.

Immunologic insights in recurrent spontaneous abortion: Molecular mechanisms and therapeutic interventions

Recurrent spontaneous abortion refers to the occurrence of two or more spontaneous abortions before or during the early stages of pregnancy. The immune system plays a crucial role in the maintenance of pregnancy and embryo implantation. Various immune cells, cytokines, and immune regulatory pathways are involved in the complex immune balance required for a stable pregnancy. Studies suggest that immune abnormalities may be associated with some recurrent spontaneous abortion cases, particularly those involving the dysregulation of immune cell function, autoimmune responses, and placental immunity. In terms of treatment, interventions targeting immune mechanisms are crucial. Various therapeutic approaches, including immunomodulatory drugs, immunoadsorption therapies, and immunocellular therapies, are continually being researched and developed. These approaches aim to restore the immune balance, enhance the success rate of pregnancies, and provide more effective treatment options for patients with recurrent spontaneous abortion.

Evaluation of Recurrent Pregnancy Loss

Recurrent pregnancy loss (RPL) affects approximately 5% of couples. Although RPL definitions vary across professional societies, an evaluation after a second clinically recognized first-trimester pregnancy loss is recommended. Good quality evidence links parental chromosomal rearrangements, uterine anomalies, and antiphospholipid syndrome (APS) to RPL. In contrast, the relationship between RPL and other endocrine, hematologic, and immunologic disorders or environmental exposures is less clear. Anticoagulant therapy and low-dose aspirin are recommended for patients with RPL who have also been diagnosed with APS. Vaginal progesterone supplementation may be considered in patients experiencing vaginal bleeding during the first trimester. Surgical correction may be considered for patients with RPL in whom a uterine anomaly is identified. Evaluation and management of additional comorbidities should be guided by the patient's history rather than solely based on the diagnosis of RPL, with the goal of improving overall health to reduce complications in the event of pregnancy. Most people with RPL, including those without identifiable risk factors, are expected to achieve a live birth within 5 years from the initial evaluation. Nevertheless, clinicians should be sensitive to the psychological needs of individuals with this condition and provide compassionate and supportive care across all stages.

Impact of congenital uterine anomalies on reproductive outcomes of IVF/ICSI-embryo transfer: a retrospective study

OBJECTIVE

To study the impact of congenital uterine anomalies on reproductive outcomes after in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI)-embryo transfer (ET).

METHODS

A retrospective study including a total of 865women with congenital uterine anomalies and 865 age and admission time matched controls who underwent the first IVF/ICSI-ET cycle between January 2010 and December 2019 was conducted. Women with uterine anomalies were classified into canalization defect (complete septate uterus and subseptate uterus) and unification defect (unicornuate uterus, bicornuate uterus, and didelphus uterus) according to the processes of abnormal embryological development. Control women were selected by age (± 1.0 year) and admission time (± 6 months) matched with a 1:1 ratio. The reproductive outcomes were compared between women with uterine anomalies and the controls. The primary outcome was live birth; secondary outcomes were clinical pregnancy, ectopic pregnancy, preterm delivery, and spontaneous pregnancy loss.

RESULTS

Compared with women with a normal uterus, women with canalization defects were less likely to experience live birth [84/332 (25.3%) vs 128/332 (38.6%), RR: 0.647, 95% CI 0.513-0.815, P < 0.001]. They also had a lower clinical pregnancy rate [126/332 (38.0%) vs 206/332 (62.0%), RR: 0.829, 95% CI 0.690-0.997, P = 0.046] and experienced a higher first-trimester pregnancy loss rate [25/126 (19.8%) vs 11/206 (5.3%), RR: 2.716, 95% CI 1.393-5.295, P = 0.003]. Compared with women with a normal uterus, women with a unification defect were also less likely to experience live birth [132/533 (24.8%) vs 219/533 (41.1%), RR: 0.713, 95% CI 0.586-0.868, P = 0.001]. Women with a unification defect had lower clinical pregnancy rates [182/533 (34.1%) vs 263/533 (49.1%), RR: 0.813, 95% CI 0.695-0.952, P = 0.010] and increased first-trimester pregnancy loss [36/182 (19.8%) vs 20/263 (7.6%), RR: 3.288, 95% CI 1.776-6.085, P < 0.001]. While uterine anomaly seemed not increase the risk of preterm birth, ectopic pregnancy and second-trimester pregnancy loss.

CONCLUSIONS

Both canalization defects and unification defects were associated with lower fertility outcomes, including lower live birth rates, lower clinical pregnancy rates, and higher early miscarriage rates.

Comparison of clinical outcomes and second-look hysteroscopy of the complete and incomplete septate uterus after hysteroscopic septoplasty

PURPOSE

Septate uterus is the most common congenital uterine malformation. This retrospective cohort study compared clinical outcomes and second-look hysteroscopy findings in patients with complete and incomplete septate uteri after septoplasty.

METHODS

We reviewed the medical records of patients with a septate uterus who underwent hysteroscopic septoplasty and second-look hysteroscopy at the West China Second University Hospital between September 2013 and September 2021. Information regarding pregnancy outcomes was collected through telephone interviews. The independent samples t-test, Mann-Whitney U test, Pearson's chi-square test, and Fisher's exact test were used to explore the differences between the complete and incomplete septate uterus groups.

RESULTS

A total of 64 patients were enrolled in this study. There was no significant difference in intrauterine adhesion (IUA) rates (16.7% and 32.1%), pregnancy rates (44.1% and 42.9%), term delivery rates (35.3% and 32.1%), premature delivery rates (2.9% and 0), placenta previa rates (2.9% and 3.6%), placenta implantation/adhesion rates (5.9% and 3.6%), and premature rupture of membranes rates (2.9% and 0) between the complete and the incomplete group after hysteroscopic septoplasty (P > 0.05). Endometrial polyps in the septate uterus were common, with an incidence of 33.3% and 25% in the complete and incomplete groups, respectively (P > 0.05).

CONCLUSION

The pregnancy outcomes of complete and incomplete septate uteri after hysteroscopic septoplasty were similar. There was no statistical difference in IUAs after surgery. Different treatment strategies may not be required for complete or incomplete septate uteri.

Preterm Birth: Screening and Prediction

Preterm birth (PTB) affects approximately 10% of births globally each year and is the most significant direct cause of neonatal death and of long-term disability worldwide. Early identification of women at high risk of PTB is important, given the availability of evidence-based, effective screening modalities, which facilitate decision-making on preventative strategies, particularly transvaginal sonographic cervical length (CL) measurement. There is growing evidence that combining CL with quantitative fetal fibronectin (qfFN) and maternal risk factors in the extensively peer-reviewed and validated QUanititative Innovation in Predicting Preterm birth (QUiPP) application can aid both the triage of patients who present as emergencies with symptoms of preterm labor and high-risk asymptomatic women attending PTB surveillance clinics. The QUiPP app risk of delivery thus supports shared decision-making with patients on the need for increased outpatient surveillance, in-patient treatment for preterm labor or simply reassurance for those unlikely to deliver preterm. Effective triage of patients at preterm gestations is an obstetric clinical priority as correctly timed administration of antenatal corticosteroids will maximise their neonatal benefits. This review explores the predictive capacity of existing predictive tests for PTB in both singleton and multiple pregnancies, including the QUiPP app v.2. and discusses promising new research areas, which aim to predict PTB through cervical stiffness and elastography measurements, metabolomics, extracellular vesicles and artificial intelligence.

Hysteroscopicmetroplasty as a treatment option for women with congenital dysmorphic uterus suffering from impaired reproductive performance

Congenital uterine anomalies have been proven to be associated with impaired reproductive performance. The 2013 ESHRE-ESGE classification of female genital tract malformations defines T shaped and infantalis uterus as dysmorphic uterus. Our aim was to examine whether the reproductive performance of patients with primary congenital dysmorphic uterus can be improved using hysteroscopic metroplasty. A retrospective cohort study of 35 patients suffering from 1 year of failed attempts to conceive, recurrent early pregnancy losses, or repeated implantation failures of in vitro fertilization cycles who were diagnosed with a dysmorphic uterus in both a diagnostic hysteroscopy procedure and three-dimensional transvaginal ultrasound (3D-TVS). All patients had undergone an operative hysteroscopic procedure for uterine anomaly repair and their reproductive performance is described before and after the procedure, so that the women acted as their own control. Within 3 years of the procedure, a total of 25 patients (71.4%) reported that they had achieved a pregnancy. A total of 15% of patients only conceived for the first time after the procedure, 15 patients (42.9%) conceived within 6 months and 18 (51.4%) within 1 year. A total of 12 of the 25 pregnant patients (48%) gave birth to a live newborn. We conclude that in non-DES exposed patients with impaired reproductive performance and congenital dysmorphic uterus, hysteroscopic metroplasty for uterine repair could serve as a treatment option for recurrent implantation failure, and may lead to improved reproductive performance and obstetric outcome.

Recurrent MiscarriageGreen-top Guideline No. 17

In this guideline, recurrent miscarriage has been defined as three or more first trimester miscarriages. However, clinicians are encouraged to use their clinical discretion to recommend extensive evaluation after two first trimester miscarriages, if there is a suspicion that the miscarriages are of pathological and not of sporadic nature. Women with recurrent miscarriage should be offered testing for acquired thrombophilia, particularly for lupus anticoagulant and anticardiolipin antibodies, prior to pregnancy. [Grade C] Women with second trimester miscarriage may be offered testing for Factor V Leiden, prothrombin gene mutation and protein S deficiency, ideally within a research context. [Grade C] Inherited thrombophilias have a weak association with recurrent miscarriage. Routine testing for protein C, antithrombin deficiency and methylenetetrahydrofolate reductase mutation is not recommended. [Grade C] Cytogenetic analysis should be offered on pregnancy tissue of the third and subsequent miscarriage(s) and in any second trimester miscarriage. [Grade D] Parental peripheral blood karyotyping should be offered for couples in whom testing of pregnancy tissue reports an unbalanced structural chromosomal abnormality [Grade D] or there is unsuccessful or no pregnancy tissue available for testing. [GPP] Women with recurrent miscarriage should be offered assessment for congenital uterine anomalies, ideally with 3D ultrasound. [Grade B] Women with recurrent miscarriage should be offered thyroid function tests and assessment for thyroid peroxidase (TPO) antibodies. [Grade C] Women with recurrent miscarriage should not be routinely offered immunological screening (such as HLA, cytokine and natural killer cell tests), infection screening or sperm DNA testing outside a research context. [Grade C] Women with recurrent miscarriage should be advised to maintain a BMI between 19 and 25 kg/m2 , smoking cessation, limit alcohol consumption and limit caffeine to less than 200 mg/day. [Grade D] For women diagnosed with antiphospholipid syndrome, aspirin and heparin should be offered from a positive test until at least 34 weeks of gestation, following discussion of potential benefits versus risks. [Grade B] Aspirin and/or heparin should not be given to women with unexplained recurrent miscarriage. [Grade B] There are currently insufficient data to support the routine use of PGT-A for couples with unexplained recurrent miscarriage, while the treatment may carry a significant cost and potential risk. [Grade C] Resection of a uterine septum should be considered for women with recurrent first or second trimester miscarriage, ideally within an appropriate audit or research context. [Grade C] Thyroxine supplementation is not routinely recommended for euthyroid women with TPO who have a history of miscarriage. [Grade A] Progestogen supplementation should be considered in women with recurrent miscarriage who present with bleeding in early pregnancy (for example 400 mg micronised vaginal progesterone twice daily at the time of bleeding until 16 weeks of gestation). [Grade B] Women with unexplained recurrent miscarriage should be offered supportive care, ideally in the setting of a dedicated recurrent miscarriage clinic. [Grade C].

Intraoperative Three-Dimensional Transvaginal Ultrasound for Hysteroscopic Metroplasty: a Controlled Study

This study aims to evaluate the role of intraoperative transvaginal three-dimensional ultrasound (3DUS) during hysteroscopic metroplasty. This is a prospective cohort of consecutive patients with septate uterus undergoing hysteroscopic metroplasty with intraoperative transvaginal 3DUS guidance compared to a historical control group of patients undergoing hysteroscopic metroplasty without 3DUS. We conducted our research in a tertiary care university hospital in Rome, Italy. This study involved nineteen patients undergoing 3DUS-guided hysteroscopic metroplasty for recurrent abortion or infertility compared to 19 age-matched controls undergoing metroplasty without 3DUS guidance. During hysteroscopic metroplasty, 3DUS was performed in the study group when the operator considered the procedure to be completed, according to standards of operative hysteroscopy. If 3DUS diagnosed a residual septum, the procedure was continued until a 3DUS diagnosis of a normal fundus was obtained. The patients were followed with a 3DUS performed 3 months after the procedure. The numbers of complete resections (residual septum absent), suboptimal resections (measurable residual septum of less than 10 mm), and incomplete resections (residual septum > 10 mm) in the intraoperative 3DUS group were compared to the numbers in the control group with no intraoperative 3DUS. At follow-up, measurable residual septa were obtained in 0% of the patients in the 3DUS-guided group versus 26% in the control group (p = 0.04). Residual septa of > 10 mm were obtained in 0% of the 3DUS group versus 10.5% in the control group (p = 0.48). Intraoperative 3DUS reduces the incidence of suboptimal septal resections at hysteroscopic metroplasty.

An atypical Müllerian duct anomaly: Duplicated cervices and vaginas with a single uterine cavity

Müllerian duct anomalies include a wide variety of developmental abnormalities involving the female reproductive system, many of which are not adequately represented by the current classification system used in the United States. Diagnosis can be made with imaging, but initial evaluation first requires a thorough physical exam. A 19-year-old female received a pelvic MRI for evaluation of a Müllerian duct anomaly following an abnormal pelvic exam. Imaging demonstrated a single uterine cavity which divides into 2 distinct cervices and vaginas. The patient received a hysteroscopic resection of her vaginal septum. This type of anomaly is extremely rare and associated clinical outcomes of potential infertility or complications with vaginal delivery are uncertain. Use of a more comprehensive classification system for Müllerian duct anomalies may assist with identification and research of such rare subtypes.

Spontaneous Pregnancy After Surgical Repair of Subseptate Uterus: A Case Report and Review of the Available Literature

Septate uterus is the most common congenital uterine malformation. It has been associated with poor reproductive outcomes, such as infertility and recurrent miscarriage, in the context of both assisted and non-assisted reproduction, though the exact underlying pathophysiological reasons remain unclear. Diagnosis is based on two-dimensional and three-dimensional ultrasound, magnetic resonance imaging, or laparoscopic/hysteroscopic findings. Hysteroscopic repair of the uterine septum has been shown to confer several benefits to reproductive outcomes, though this fact remains in question, due to inconsistent and or low-quality evidence in the medical literature. An individualized approach to the treatment of infertility patients with septate uteri is imperative, given the plethora of possible underlying factors that may complicate management. In this report, we present the case of a patient with a subseptate uterus and a history of infertility, who, following hysteroscopic metroplasty, managed to conceive and ultimately successfully deliver a healthy child.

Perinatal outcomes in nulliparous women with a history of multiple pregnancy losses according to number of previous pregnancy losses

BACKGROUND

While it is widely acknowledged that pregnancy losses can lead to negative outcomes for both mothers and fetuses, there is limited information available on the specific levels of risk associated with each additional pregnancy loss.

OBJECTIVE

This study aimed to investigate the effect of number of previous pregnancy losses among nulliparous women on maternal and neonatal adverse outcomes.

STUDY DESIGN

This was a multicenter retrospective cohort study. The study population included all nulliparous women with singleton pregnancies who delivered in all university-affiliated obstetrical centers in a single geographic area between 2003 and 2021. Maternal and neonatal outcomes of women who delivered at our medical centers and had varying numbers of previous pregnancy losses were compared with women who had no previous pregnancy loss. The primary outcome of this study was preterm delivery rate at <37 weeks of gestation. The secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was performed using multiple logistic regression modeling.

RESULTS

During the study period, 97,904 nulliparous women met the inclusion and exclusion criteria. Of those women, 84,245 (86%) had no previous pregnancy losses (reference group), 10,724 (11%) had 1 previous pregnancy loss, 2150 (2.2%) had 2 previous pregnancy losses, 516 (0.5%) had 3 previous pregnancy losses, 160 (0.2%) had 4 previous pregnancy losses, and 99 (0.1%) had ≥5 previous pregnancy losses. Women who had previous pregnancy losses had significantly higher rates of preterm delivery, hypertensive disorders of pregnancy, diabetes mellitus (pregestational and gestational), unplanned cesarean delivery, perinatal death, neonatal intensive care unit admissions, and neonatal hypoglycemia. The risks of preterm delivery and most other adverse obstetrical outcomes correlated with the number of previous pregnancy losses. Multivariate analyses showed that each previous pregnancy loss was associated with an additional, significant, increased risk of preterm delivery of 14% at <37 weeks of gestation, 37% at <34 weeks of gestation, 45% at <32 weeks of gestation, and 77% at <28 weeks of gestation.

CONCLUSION

A history of previous pregnancy losses increased the risk of preterm delivery and other perinatal outcomes in a dose-dependent manner. To minimize perinatal complications, obstetricians should be aware of the risks and complications in this unique population, consider close monitoring of the cervical length, and maintain high vigilance in case of complications with special attention to other potentially modifiable risks.

Reproductive outcomes and risk factors of women with septate uterus after hysteroscopic metroplasty

Background

Hysteroscopic metroplasty of the uterine septum has been the standard treatment strategy to improve reproductive outcomes, but there are still controversies about the appropriateness of metroplasty. In addition, there have been few studies of the factors related to reproductive outcomes of women after surgery. The study aimed to evaluate the reproductive outcomes and the associated risk factors that influence reproductive outcomes after hysteroscopic metroplasty of women with septate uterus and the desire to conceive.

Methods

This study was an observational study. Cases were screened by searching electronic patient files, and demographic factors were collected. We conducted telephone follow-ups to collect the postoperative reproductive outcomes. The primary outcome of this study was live birth, and secondary outcomes were ongoing pregnancy, clinical pregnancy, early miscarriage, and preterm birth. Demographic variables included patients' age, body mass index (BMI), the type of septum, infertility and miscarriage history, and complications including intrauterine adhesions, endometrial polyps, endometriosis, and adenomyosis were collected to perform univariate and multivariate analyses to predict the risk factors of reproductive outcomes after surgery treatment.

Results

In total, 348 women were evaluated and followed up. There were 95 cases (27.3%, 95/348) with combined infertility, 195 cases (56.0%, 195/348) with miscarriage history, and cases combined with intrauterine adhesions, endometrial polyps, endometriosis, and adenomyosis were 107 (30.7%, 107/348), 53 (15.2%, 53/348), 28 (8.0%, 28/348), and 5 (1.4%), respectively. Following surgery, the live birth rate and clinical pregnancy rate were significantly higher than prior to surgery (84.6% vs 3.7%, p= 0.000; and 78.2% vs 69.5%, p= 0.01, respectively), early miscarriage rate and preterm delivery rate were significantly lower (8.8% vs 80.6%, p= 0.000; and 7.0% vs 66.7%, p=0.000, respectively). After adjusting for body mass index, miscarriage history, and complications, multivariable logistic regression analysis revealed age ≥ 35 years and primary infertility as independent factors that affected postoperative clinical pregnancy (OR 4.025, 95% CI 2.063-7.851, p= 0.000; and OR 3.603, 95% CI 1.903-6.820, p= 0.000; respectively) and ongoing pregnancy (OR 3.420, 95% CI 1.812-6.455, p= 0.000; and OR 2.586, 95% CI 1.419-4.712, p= 0.002; respectively).

Conclusions

Hysteroscopic metroplasty could lead to improved reproductive outcomes of women with septate uterus. Both age and primary infertility were independent factors for postoperative reproductive outcomes.

Trial registration

Chi ECRCT20210343.

Septum Resection Prior to In Vitro Fertilization-Embryo Transfer: A Retrospective Controlled Study

OBJECTIVES

To investigate the effectiveness of surgery for septate uterus in infertile patients before in vitro fertilization-embryo transfer (IVF-ET).

METHODS

The data of 937 infertile patients with septate uterus and achieved singleton pregnancy after IVF-ET from January 2014 to December 2015 were retrospectively analyzed. Thousand five hundred seventy-eight infertile patients with a normal uterus who achieved singleton pregnancy during the same period were selected as the control group. Patients with septate uterus were divided into two groups according to whether the septum was resected. The pregnancy and perinatal outcomes of the surgical group and the nonsurgical group were compared with the control group. The secondary infertility patients who were surgically corrected septa were also chosen as self-controls and an analysis was performed on their fertility outcomes pre- and post-surgery.

RESULTS

Compared with the control group, the surgical group had increased rates of early miscarriage, preterm delivery, and low birthweight and a significantly reduced live birth rate (P < .05). The outcomes of the nonsurgical and control groups were similar. Using secondary infertility patients who were surgically corrected septa as self-controls, after surgery, the rates of miscarriage and ectopic pregnancy were significantly lower and the live birth rate was significantly higher (P ≤ .001); however, perinatal mortality was not significantly different before and after surgery.

CONCLUSIONS

Patients with a septum depth greater than 10 mm or 5-10 mm associated with a history of unexplained recurrent miscarriage, IVF failure, or infertility might benefit from resection of the uterine septum with hysteroscopic metroplasty.

Evaluation of the relationship between ovarian reserve with congenital anomalies and intramural uterine leiomyoma among infertile women: a cross-sectional study

BACKGROUND

Ovarian reserve is a crucial indicator of a woman's fertility potential, which is determined by the quality and quantity of antral follicles and oocytes. However, certain factors such as endometriosis, pelvic inflammatory disease, myoma, and the natural process of aging can lead to a poor ovarian response to stimulation, reducing a woman's chances of conceiving.

OBJECTIVE

To evaluate the effect of uterus congenital anomalies and uterine leiomyoma are associated on ovarian reserve.

METHODS

The present cross-sectional study was performed on 321 infertile women in three groups consisted of 97 infertile women with intramural uterine leiomyoma and 81 infertile women with uterine anomalies and 143 infertile women without uterine anomalies and uterine leiomyoma during 2017-2019 in Royan Center. Sampling method was continuous and available. Data collection tool in this study was a questionnaire which was in two parts of individual variables and the second part was related to ultrasound results (number of antral follicles and ovarian volume) and laboratory tests (Anti-Mullerian Hormone (AMH) and Follicle-stimulating Hormone (FSH)). Ovarian reserve parameters were measured in three groups on the third day of the cycle in both groups. Data analysis was performed using SPSS software version 21. Quantitative variables were analyzed using t-test, qualitative variables were analyzed using chi-square test.

RESULTS

The results of in laboratory parameters showed that there was no statistically significant difference between the three groups in FSH (2.35 ± 1.55, 2.07 ± 1.81, 2.31 ± 1.93) and AMH (6.84 ± 2.75,7.52 ± 3.14,6.93 ± 3.04), respectively (P > 0.05). The results of sonographic variables also showed that the variables include number of antral follicles in right ovarian, number of antral follicles in left ovarian have statistically significant between the three groups (5.73 ± 2.69,4.84 ± 3.14,6.66 ± 3.13), respectively (P < 0.05).

CONCLUSION

The results of the present study showed that uterine abnormalities and uterine leiomyoma with different mechanisms such as reduce of antral follicle numbers and the effect on uterine and ovarian blood flow lead to a decrease in ovarian reserve and infertility. Therefore, treatment and surgery can reduce these effects and improve the fertility of the affected women.

A Case Report on a Left Unicornuate Uterus With Communicating Right Rudimentary Horn Associated With Hematometra and Hematosalpinx

Congenital uterine anomalies (CUAs) or Müllerian duct anomalies are rare and can be either complete failure or partial failure in the development of the Mullerian duct, and they have a probability to result in a condition known as the unicornuate uterus. Partial development of one of the horns results in a rudimentary horn, which may be communicating consisting of category II A or noncommunicating consisting of category II B. This report illustrates a rare case of a 23-year-old female, unmarried, nulligravida, who presented to the outpatient department with chief complaints of acute abdominal pain and dysmenorrhea associated with an average menstrual flow. Pelvic ultrasound and magnetic resonance imaging (MRI) confirmed the diagnosis of a left unicornuate uterus with communicating right rudimentary horn associated with hematometra and hematosalpinx. As a treatment option, the surgical intervention mainly involved laparoscopic excision of the rudimentary horn and right salpingectomy that was performed by aspiration of blood from the rudimentary horn of around 25cc. Then, the right hydrosalpinx was removed, followed by right salpingectomy and excision of the rudimentary horn to reduce the risk of ectopic pregnancy having an incidence of 10% for which laparoscopic or robotic-assisted removal is preferable and practicable for young girls, compared with the open procedure. The patient adhered well to the surgical intervention.

Uterine torsion in twin pregnancy with complete bicorporeal uterus, double cervix, longitudinal non-obstructing vaginal septum - a case report

Even though uterine torsion is a rare obstetric complication in humans, it has been linked to severe complications like placental abruption, uterine rupture, foetal bradycardia, or even death. Here, we present a rare case of maternal shortening and prolonged foetal bradycardia. The patient suffered from congenital malformations of the female genital tract, which were classified as a complete bicorporeal uterus, a double "normal" cervix, and a longitudinal non-obstructing vaginal septum (U3b/C2/V1). The patient had an emergency caesarean section due to suspected placental abruption. Uterine torsion was found during the surgery, and the postoperative recovery was good. Obstetricians should be aware of the possibility of uterine torsion as a complication of pregnancy to avoid a delayed diagnosis of uterine torsion, especially in patients with genital malformations. During the surgery, there could be serious damage to blood vessels and tissues around the uterus due to an unclear surgical field, and difficulties in exposing the uterine body should be considered.

Preterm Birth, Developmental Smoke/Nicotine Exposure, and Life-Long Pulmonary Sequelae

This review delineates the main pulmonary issues related to preterm birth, perinatal tobacco/nicotine exposure, and its effects on offspring, focusing on respiratory health and its possible transmission to subsequent generations. We review the extent of the problem of preterm birth, prematurity-related pulmonary effects, and the associated increased risk of asthma later in life. We then review the impact of developmental tobacco/nicotine exposure on offspring asthma and the significance of transgenerational pulmonary effects following perinatal tobacco/nicotine exposure, possibly via its effects on germline epigenetics.

A rare case report of uterine didelphys, in which one uterus carried a pregnancy while the other prolapsed, with a successful pregnancy outcome resulting in an alive-term delivery

Uterine didelphys is a rare congenital anomaly of the female reproductive organs, designated by the presence of the uterus as a pair of organs. This occurs as a result of the failure of the embryonic fusion of Müllerian ducts. Women with this abnormality have a paired uterus with two cervices and usually a double vagina. The chance of having a pregnancy in one of the pairs along with prolapse of the other is very low in a didelphic uterus. To the best of the author's knowledge, only one case of such an event has been reported so far. In this case report, we are reporting on a 28-year-old gravida four para three (all are vaginal deliveries, 2 are alive, healthy, and term deliveries without any compilation; 1 is an early neonatal death delivered at 8 months) woman who presented to our hospital with a complaint of a protruding mass per vagina for 14 days in the presence of pregnancy. After she was evaluated and investigated, she was diagnosed with pelvic organ prolapse and late-preterm pregnancy. The prolapse reduced gradually as the gestational age advanced. Cesarean section was done at the gestational age of 38 weeks plus 2 days for the indication of infected pelvic organ prolapse in labor, with the outcome of a 3000 gram male alive neonate. Intraoperatively, there was uterine didelphys, one uterus holding the pregnancy while the other was prolapsing.

A Successful Pregnancy in a Hemihysterectomized Patient-A Case Report

Introduction

Didelphys uterus, two separate uterine horns or a double uterus with two separate cervices, is one of several congenital uterine anomalies (CUA), accounting for 5% of CUA. CUA could be associated with dysmenorrhea, pelvic pain, and decreased fertility. During pregnancy, it has been associated with higher risk of miscarriage, preterm birth, malpresentation, and fetal growth restriction. There still is insufficient evidence on the efficacy and safety of surgical interventions in CUA, including hemihysterectomy, in what improvement of reproductive performance is concerned.

Objective

The aim of the present case report is to review the literature and complement information on pregnancy outcomes after hemihysterectomy, contributing to a better counseling of women planning a pregnancy under these circumstances. Case Presentation. This paper case reports a successful pregnancy in a woman previously submitted to a hemihysterectomy and removal of a vaginal septum by hysteroscopy, due to a symptomatic didelphys uterus. An ipsilateral renal agenesis was also present. A cesarean was performed at 38 weeks' gestation and a healthy baby was born. Discussion. This paper reports an exceptional clinical situation, with only 9 cases described in the last 6 decades. As in previously reported cases, a cesarean was performed at term, resulting in a live childbirth. In these cases, a higher live birth rate and a lower incidence of preterm deliveries was found, comparing with uterine didelphys pregnancies.

Conclusion

Understanding both the exact nature of a uterine anomaly before a surgical treatment and the prognosis for a future pregnancy after the intervention are of paramount importance for precise counseling of future parents.

Preliminary application of three-dimensional printing in congenital uterine anomalies based on three-dimensional transvaginal ultrasonographic data

Background

The three-dimensional (3D) printing technology has remarkable potential as an auxiliary tool for representing anatomical structures, facilitating diagnosis and therapy, and enhancing training and teaching in the medical field. As the most available diagnostic tool and it is routinely used as the first approach in diagnosis of the uterine anomalies, 3D transvaginal ultrasonography (3D-TVS) has been proposed as non-invasive “gold standard” approach for these malformations due to high diagnostic accuracy. Despite holding promise of manufacturing 3D printed models based on 3D-TVS data, relevant reports about 3D-TVS derived gynecological 3D printing haven’t been reported to the best of our knowledge. We found an opportunity to explore the feasibility of building 3D printed models for the abnormal uterus based on the data acquired by 3D-TVS.

Methods

The women suspected with congenital uterine anomalies (CUAs) were enrolled in the study. The diagnose of CUAs were made by 3D-TVS scanning and further confirmed under the hysteroscopy examination. One volunteer with normal uterus was enrolled as control. All subjects underwent 3D-TVS scanning for 3D printing data collection. Acquired images were stored and extracted as DICOM files, then processed by professional software to portray and model the boundary of the uterine inner and outer walls separately. After the computer 3D models were constructed, the data were saved and output as STL files for further surface restoration and smoothing. The colors of endometrium and uterine body were specified, respectively, in the print preview mode. Then the uncured photosensitive resin was cleaned and polished to obtain a smooth and transparent solid model after printed models were cooled down.

Results

3D printing models of normal uterus, incomplete septate uterus, complete septate uterus, uterus didelphys and unicornuate uterus were produced on ultrasonographic data of 3D-TVS.

Conclusions

Our research and practice made the first try in modeling CUAs successfully based on ultrasonographic data entirely, verifying that it’s a feasible way to build 3D printed models of high-quality through 3D-TVS scanning.

Diagnosis and Management of Mullerian Anomalies Across Differing Resource Settings: Worldwide Adaptations

BACKGROUND

Mullerian anomalies affect 7% of reproductive age women. It is important to have a basic understanding of these conditions, given they can affect women at any stage of life and have potential impacts on fertility and pregnancy. This article seeks to review these anomalies as well as specific diagnostic pitfalls and strategies to approach these conditions in both high- and low-resource environments.

METHODS

This review was undertaken with a PubMed focused search, using terms related to the diagnosis and management of Mullerian anomalies in many worldwide settings. Consideration was made to assess the medical resources available in low- and middle-income countries (LMICs), which could impact diagnostic and management decisions, compared with high-income countries (HICs). Concurrent medical conditions and both gynecologic and obstetric outcomes were also searched. Practice recommendations from international societies were also reviewed and compared. Finally, 4 conditions were evaluated more closely to assess management differences based on geographic locations and whether the countries were LMICs or HICs; specifically, those evaluated were lower vaginal atresia, uterovaginal agenesis, bicornuate uterus, and septate uterus.

DISCUSSION

Mullerian anomalies encompass a wide variety of conditions, ranging from subtle anatomic changes without concurrent anomalies to complex conditions, associated with anomalies of the kidney or spine, which could impact the ability to manage certain conditions based on medical resources available geographically. A systematic approach and provider expertise is important for appropriate diagnosis and management, independent of geographic location. Counseling is critical for medical and surgical decision-making and might be limited or guided by the resources available in certain settings or even by existing laws.

CONCLUSIONS

Limited outcomes are available among patients with Mullerian anomalies in LMICs; however, the management varies based on the basic tools available to address acute needs, as well as long-term fertility and obstetric concerns. More research is needed in this population, which could help drive the importance of early diagnosis and management not only in HICs but also in LMICs, where individualization strategies are key.

Pregnancy and Adverse Obstetric Outcomes After Hysteroscopic Resection: A Systematic Review and Meta-Analysis

Objective

Although the randomized controlled trial (RCT) of the efficacy of hysteroscopic resection in women with uterine septum has not shown any significant correlation in recent research, motivation for deeper study remains insufficient. In this study, the objective was to determine pregnancy-related outcomes, along with adverse obstetric outcomes, following hysteroscopic resection and also to determine whether women with hysteroscopic resection bear the same outcomes as women with normal uterine cavities.

Search Methods

From January 1995 to February 2022, a systematic literature review was conducted to identify all studies published concerning the gestation outcomes of women with and without hysteroscopic resection while comparing the gestation outcomes of women after hysteroscopic resection and with a normal uterine cavity. Our primary outcome was the live birth rate (LBR). The secondary outcomes were term delivery, preterm delivery, spontaneous miscarriage, malpresentation, cesarean section, and other adverse obstetric outcomes.

Results

22 studies were included in this meta-analysis. The control groups of 14 studies were treated women, and the control groups of the other 8 studies were patients bearing a normal uterine cavity. Hysteroscopic resection was related to a higher rate of term delivery (OR = 2.26, 95% CI, 1.26–4.05), and a lower rate of spontaneous abortion (OR = 0.50, 95% CI, 0.27–0.93), and a lower rate of malpresentation (OR = 0.31, 95% CI, 0.19–0.50). Nevertheless, in comparison with the normal uterus group, the rates of preterm birth, cesarean section, and postpartum hemorrhage after resection did not return to normal levels.

Conclusion

Hysteroscopic resection can effectively reduce the risk of abortion and malpresentation in patients possessing a uterine septum while increasing the term delivery rate. Although well-designed RCTs should confirm our meta-analysis, it still bears recommending to patients

Diagnosis of Congenital Uterine Abnormalities: Practical Considerations

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.

Effects of Septum Resection for Secondary Infertility on Subsequent Reproductive Outcomes of in vitro Fertilization-Intracytoplasmic Sperm Injection

OBJECTIVE

To assess the effect of uterine septum resection on reproductive outcomes of in vitro fertilization (IVF) / intracytoplasmic sperm injection (ICSI) in patients with secondary infertility complicated with uterine septum.

METHODS

A retrospective cohort study included 269 patients. Surgical group included 169 patients with secondary infertility complicated with uterine septum, who underwent 252 embryo-transfer (ET) cycles following septum resection. Control group consisted of 100 patients with secondary infertility and uterine septum, who underwent 178 ET cycles. Cumulative pregnancy rate and cumulative live birth rate after one complete assisted reproductive technology (ART) cycle were the primary outcomes.

RESULTS

The results showed that the cumulative pregnancy rate was higher in the surgery group, and statistically significant difference was observed in the cumulative pregnancy rate between the two groups (71.0 vs. 59%, P = 0.044). In fresh ET cycle, no statistically significant difference between the two groups was evident (54.9 vs. 40.6%, P = 0.061). Statistical analysis of other results of the fresh ET cycle did not differ significantly between the two groups. In terms of frozen embryo transfer (FET) cycle outcomes, the clinical pregnancy rate and delivery rate in surgery group were 52.7 and 38.2%, respectively, which were significantly higher than those in the control group (38.2 and 22.5%, respectively) (P = 0.028 and P = 0.011).

CONCLUSION

The reproductive outcomes of IVF/ICSI after septum resection in patients with secondary infertility were better than that in the untreated group, suggesting that uterine septum resection can be performed in patients with uterine septum combined with infertility to improve their reproductive outcomes.

Impact of uterine malformations on pregnancy and neonatal outcomes of IVF/ICSI–frozen embryo transfer

STUDY QUESTION

What is the impact of uterine malformations on reproductive and neonatal outcomes of IVF/ICSI–frozen embryo transfer?

SUMMARY ANSWER

Unification defective uteri are associated with poorer neonatal outcomes including higher preterm delivery rate and lower birthweight, and septate uteri are associated with worse fertility outcomes including higher miscarriage and lower live birth rates (LBRs).

WHAT IS KNOWN ALREADY

Several studies have investigated the negative effects of uterine malformations on pregnancy outcomes. However, an all-round and definitive conclusion has not been reached yet owing to the relatively low incidence of the disease and the heterogeneity of study populations, especially among women undergoing ART.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study including 411 women with congenital uterine anomalies and 14 936 women with a normal uterus who underwent first frozen-thawed embryo transfer cycles of IVF/ICSI from July 2008 to August 2019. We compared reproductive outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Reproductive outcomes of women with uterine malformations were studied through three propensity score-matched comparisons (patients with bicorporeal uterus, septate uterus and hemi-uterus [bicorporeal, septate and hemi-uterus groups, respectively] along with corresponding control groups without uterine malformations). We also compared pregnancy and neonatal outcomes, and performed subgroup analysis addressing didelphus, bicornuate uteri and septate uteri before and after surgery independently.

MAIN RESULTS AND THE ROLE OF CHANCE

Compared to the matched control group, women with a bicorporeal uterus had a significantly lower LBR (24.4% versus 34.8%, odds ratio (OR) 0.61 [95% CI: 0.37, 1.00], P = 0.048). The incidence of miscarriage and preterm delivery was higher but not statistically significant (29.0% versus 18.1%, OR 1.85 [95% CI: 0.82, 4.19], P = 0.135; 22.6% versus 9.9%, OR 2.64 [95% CI: 1.07, 6.52], P = 0.063, respectively). In addition, the bicorporeal group had a significantly lower gestational age, higher caesarean rate and lower birthweight than bicorporeal control. Women with a septate uterus had comparable clinical pregnancy rates to controls (43.3% versus 49.9%, OR 0.77 [95% CI: 0.57, 1.04], P = 0.091), increased miscarriage rates (23.5% versus 13.0%, OR 2.05 [95% CI: 1.18, 3.58], P = 0.010) and lower LBRs (29.4% versus 42.2%, OR 0.57 [95% CI: 0.41, 0.79], P = 0.001). In both singleton and twins pregnancies, pregnancy and neonatal outcomes were comparable between women with a septate uterus and control. Women with a hemi-uterus had a tendency for lower clinical pregnancy rate (36.8% versus 42.3%, OR 0.80 [95% CI: 0.52, 1.21], P = 0.287) and LBR (29.8% versus 33.1%, OR 0.86 [95% CI: 0.55, 1.34], P = 0.502), compared to women without malformations. The incidences of miscarriage and preterm delivery, respectively, were 16.7% versus 16.6% (OR 1.01 [95% CI: 0.41, 2.47], P = 0.989), and 9.5% versus 11.4% (OR 0.82 [95% CI: 0.27, 2.51], P = 1) in women with a hemi-uterus as compared to control.

LIMITATIONS, REASONS FOR CAUTION

This was a single-centre, retrospective study in which neonatal data were extracted from parental questionnaires. The information on uteri septum type and surgery methods was poorly presented, with limited detail. In patients with uterine malformations, the number of babies with birth defects and twin pregnancies was relatively small, limiting the power of the study.

WIDER IMPLICATIONS OF THE FINDINGS

Compared to patients with a normal uterus, women with uterine malformation have poorer reproductive outcomes. Pregnant women with a uterine anomaly need to be managed as high-risk pregnancies and followed with appropriate obstetric review.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Ministry of Technology (2018YFC1003000), the Elite Team Project of Ninth People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JY201801), Shanghai Sailing Program (21YF1423200) and the Fundamental Research Program Funding of Ninth People’s Hospital affiliated to Shanghai Jiao Tong University School of Medicine (JYZZ117). B.W.M. is supported by an NHMRC Investigatorgrant (GNT1176437). B.W.M. reports consultancy (with stock options) for ObsEva. B.W.M. has received research funding from Ferring and Merck. The authors declare no other competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Unicornuate Uterus with Rudimentary Horn as a Rare Etiology of Secondary Dysmenorrhea: A Case Report

Congenital uterine anomalies are an uncommon type of female genital malformations caused by abnormal development of müllerian ducts during embryogenesis. Patients with an obstructive uterine anomaly have a higher risk of developing gynecological and obstetric complications that may present at menarche or later in life. We present a case of severe dysmenorrhea in a young teenager caused by obstructive hematometra in a noncommunicating horn of the unicornuate uterus. A differential diagnosis of a possible anomaly was made using 2-dimensional pelvic ultrasonography, which was later confirmed using MRI that revealed an anomalous uterine cavity with a single left-sided cornua communicating with the cervix and a distended right-sided rudimentary horn. She underwent a right salpingectomy with rudimentary horn excision, which was successfully managed laparoscopically. This case emphasizes the importance of physicians being cognizant in identifying patients with uterine anomaly to provide appropriate treatment and prevent adverse reproductive outcomes.

Reproductive, Obstetric and Neonatal Outcomes in Women with Congenital Uterine Anomalies: A Systematic Review and Meta-Analysis

Congenital uterine anomalies (CUA) may influence reproductive performance, resulting in adverse pregnancy associated complications. This study aimed to assess the association of CUA subtypes with reproductive, obstetric, and perinatal outcomes. We performed a systematic search of the MEDLINE, EMBASE, and Cochrane libraries for studies comparing pregnancy outcomes between women with CUA and those with a normal uterus. The random effects model was used to estimate the odds ratios (ORs) with a 95% confidence interval (CI). Women with CUA had a lower rate of live births (OR 0.47; 95% CI 0.33-0.69), and a higher rate of first trimester miscarriage (OR, 1.79; 95% CI 1.34-2.4), second trimester miscarriage (OR 2.92; 95% CI 1.35-6.32), preterm birth (OR 2.98; 95% CI 2.43-3.65), malpresentation (OR 9.1; 95% CI 5.88-14.08), cesarean section (OR 2.87; 95% CI 1.56-5.26), and placental abruption (OR 3.12; 95% CI 1.58-6.18). Women with canalization defects appear to have the poorest reproductive performance during early pregnancy. However, unification defects were associated with obstetric and neonatal outcomes throughout the course of pregnancy. It may be beneficial for clinicians to advise on potential complications that may be increased depending on the type and severity of CUA.

Effect of Hysteroscopic Metroplasty on Reproductive Outcomes in Women with Septate Uterus: Systematic Review and Meta-Analysis

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.

Müllerian Duct Anomalies: Role in Fertility and Pregnancy

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.

Management of recurrent miscarriages: an overview of current evidence

PURPOSE OF REVIEW

Recurrent miscarriage (RM) or recurrent pregnancy loss (RPL) is defined as the consecutive loss of two or more pregnancies before the age of viability. The exact prevalence of RM is unknown, but it has been reported between 1% and 2%. The objective of this review is to provide a critical summary of the latest evidence for the investigation and management of women with RM.

RECENT FINDINGS

RMs are associated with multiple factors including increased female age and lifestyle habits, as well as genetic factors, hereditary and acquired thrombophilia and infections. Metabolic and endocrine factors, in addition to anatomical causes such as uterine malformations have also been suggested as a causative factors of RM.

SUMMARY

The management of RM would be expected to cause specific, however, in the majority of the cases no cause is identified, and the factors associated with RM may not be causally related with the condition.

Prevalence of T-shaped uterus among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria

RESEARCH QUESTION

What is the prevalence of T-shaped uteri among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria?

DESIGN

A prospective cohort study of 258 women of reproductive age with a history of at least one natural pregnancy resulting in live birth. Participants were recruited from the family planning clinic between January 2018 and March 2020. The ESHRE/ESGE classification of congenital anomalies of the female genital tract was used for describing abnormal findings. CUME criteria were also used for diagnosing T-shaped uterus. Uterine cavity volume was measured.

RESULTS

Mean age of participants was 35.4 ± 6.2 years. Participants were diagnosed with the following: congenital uterine abnormality (n = 9 [3.6%]); partial septate uterus (n = 5 [2.0%]) and hemiuterus (n = 2 [0.8%]). Two women (0.8%) were diagnosed with T-shaped uterus and borderline T-shaped uterus based on the ESHRE/ESGE criteria and CUME. Mean lateral indentation angle, lateral indentation depth and T-angle were 156.2° ± 9.53°, 2.85 ± 0.93 mm and 73.3° ± 9.85° in patients with normal uterine cavity. In patients with T-shaped and borderline T-shaped uteri, respective figures were 115° versus 121°, 10 mm versus 7.6 mm and 27.5° versus 70°. Median volume of the uterine cavity in patients with normal uterine cavity and T-shaped uterus was 3.71 ml (minimum 2.0 to maximum 9.03 ml, interquartile range 1.93) and 3.2 ml (2.9 and 3.62 ml), respectively.

CONCLUSIONS

The prevalence of T-shaped uteri in fertile women is low, which corresponds to previous reports of women with poor reproductive history.

Effect of hysteroscopic septum resection on subsequent in vitro fertilization-intracytoplasmic sperm injection outcomes in cases of primary infertility

OBJECTIVE

Women with septate uteri are at risk for subfertility, recurrent miscarriage, and preterm birth. It is not clear if hysteroscopic septum resection is beneficial to subsequent in vitro fertilization-intracytoplasmic sperm injection o (IVF/ICSI) outcomes in women with primary infertility.

STUDY DESIGN

We analyzed all 278 women with uterine septum and primary infertility between January 2011 and January 2019. In this retrospective cohort study, the patients were divided into a surgery group and an expectant (non-surgery) group.

RESULTS

Among them, 87 had a complete and 191 a partial septate uterus. The IVF-ET characteristics of the two groups showed no significant differences in the patients' age, body mass index, or basal follicle-stimulating hormone, luteinizing hormone, and estradiol levels (P>0.05). The miscarriage rate in those who underwent hysteroscopic septum resection, however, was significantly reduced (5.1% vs. 12.9%, P = 0.035). In contrast, the live birth rate between the two groups revealed no significant difference (51.4% vs. 43.6%, P = 0.1771), nor did the obstetric and neonatal outcomes (P>0.05).

CONCLUSIONS

Hysteroscopic septum resection can be recommended prior to IVF/ICSI.

Uterine didelphys: diagnosis, management and pregnancy outcome

This report addresses and discusses two cases of uterine didelphys in pregnancy. The first case describes the diagnosis, management and subsequent pregnancies in a 28-year-old woman, para 2, with known didelphys uterus, left-obstructed hemi-vagina and ipsilateral renal agenesis. This uterine anomaly was diagnosed at 13 years of age, after pelvic imaging identified a haematocolpos and two uteri. To drain this haematocolpos, a hymenectomy was performed. In the second case, an incidental finding of uterine didelphys and vaginal septum in a 28-year-old primigravida is described. Both patients delivered healthy male infants at term via emergency and planned lower segment caesarean sections, indicating women with major uterine anomalies can have successful obstetric outcomes.

Reproductive Performance Following Hysteroscopic Surgery for Uterine Septum: Results from a Single Surgeon Data

Uterine septum can negatively affect reproductive outcomes in women. Based on evidence from retrospective observational studies, hysteroscopic incision has been considered a solution to improve reproductive performance, however there has been recent controversy on the need for surgery for uterine septum. High quality evidence from prospective studies is still lacking, and until it is available, experts are encouraged to publish their data. We are therefore presenting our data that involves analysis of the patient characteristics, surgical approach and long-term reproductive outcomes of women who received treatment for uterine septum under the care of a single surgeon. This includes all women (99) who underwent hysteroscopic surgery for uterine septum between January 2001 and December 2019. Of those 99 women treated for intrauterine septum who were trying to conceive, 91.4% (64/70) achieved pregnancy, 78.6% (55/70) had live births and 8.6% (6/70) had miscarriages. No statistically significant difference was found in the live birth rates when data was analyzed in subgroups based on age, reason for referral/aetiology and severity of pathology. Our study results support the view that surgical treatment of uterine septa is beneficial in improving reproductive outcomes.

Recurrent pregnancy loss

Recurrent pregnancy loss is a distressing pregnancy disorder experienced by ~2.5% of women trying to conceive. Recurrent pregnancy loss is defined as the failure of two or more clinically recognized pregnancies before 20-24 weeks of gestation and includes embryonic and fetal losses. The diagnosis of an early pregnancy loss is relatively straightforward, although progress in predicting and preventing recurrent pregnancy loss has been hampered by a lack of standardized definitions, the uncertainties surrounding the pathogenesis and the highly variable clinical presentation. The prognosis for couples with recurrent pregnancy loss is generally good, although the likelihood of a successful pregnancy depends on maternal age and the number of previous losses. Recurrent pregnancy loss can be caused by chromosomal errors, anatomical uterine defects, autoimmune disorders and endometrial dysfunction. Available treatments target the putative risk factors of pregnancy loss, although the effectiveness of many medical interventions is controversial. Regardless of the underlying aetiology, couples require accurate information on their chances of having a baby and appropriate support should be offered to reduce the psychological burden associated with multiple miscarriages. Future research must investigate the pathogenesis of recurrent pregnancy loss and evaluate novel diagnostic tests and treatments in adequately powered clinical trials.