Müllerian Duct Anomalies: Role in Fertility and Pregnancy

Mullerian ducts anomaly of 2 divergent uterine horns with cervicovaginal hypoplasia: Is it considered unclassified or under the spectrum of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome?

The Mullerian ducts give rise to the upper part of the female reproductive system, including the uterus, cervix, upper two-thirds of the vagina, and fallopian tubes, which undergo specific processes of development, fusion, and resorption. Any failure in this process will lead to Mullerian duct anomaly (MDA). We present a unique and complex case of MDA, signifying the wide variability and simultaneous existence of combined abnormalities in 1 patient, which do not always fit under a single or particular class from the known classification systems. Therefore, subclassifications may be necessary for each part alone (uterus, cervix, and vagina) or incorporating more than 1 class for a single case. It also shows the role of imaging in the diagnosis; considering that magnetic resonance imaging (MRI) is the standard modality for a detailed description of the reproductive system and its anomalies.

Uterine Septum and Other Müllerian Anomalies in a Recurrent Pregnancy Loss Population: Impact on Reproductive Outcomes

STUDY OBJECTIVE

To study the impact of Müllerian anomalies on reproductive outcomes in a recurrent pregnancy loss (RPL) population and to evaluate the effect of surgical correction of uterine septum on the odds of achieving live birth in RPL patients with a septate uterus.

DESIGN

A retrospective cohort study.

SETTING

A specialized RPL clinic at a tertiary center.

PATIENTS

RPL patients with ≥ 2 pregnancy losses before 20 weeks' gestation who attended a specialized RPL clinic.

INTERVENTION

We aimed to assess the association between a possible risk factor (Müllerian anomalies) and reproductive outcomes and that between having surgery for septate uterus and achieving a live birth.

MEASUREMENTS AND MAIN RESULTS

The primary outcome is live birth rate in RPL patients with Müllerian anomalies compared with those without; secondary outcome measures include rates of full-term live birth, preterm live birth, first and second trimester pregnancy loss, and stillbirth. After adjusting for patient age at the initial RPL visit, the number of pregnancy losses, and the presence of any other abnormal RPL investigation, the odds of achieving live birth were on average 49.4% lower for patients with a septate uterus than those without Müllerian anomalies (odds ratio, 0.51; 95% confidence interval, 0.30-0.86) in the studied cohort (n = 377). A subanalysis of 72 patients with septate uterus demonstrated a higher likelihood of live birth in those who underwent septum resection (46/72; 63.9%) than those who elected to go for expectant management (26/72; 36.1%), yet this study was underpowered to establish a significant difference (52.2% vs 34.6%; p = .22).

CONCLUSION

In RPL patients, having a septate uterus significantly decreased the chances of achieving live birth. Patients with septate uterus who received hysteroscopic septum division had a higher tendency to achieve more live births than those who elected expectant management. However, our study was underpowered to detect a statistically significant difference.

Management of partial Müllerian agenesis: staged McIndoe procedure for the creation of a neovagina and utero-neovaginal unification

INTRODUCTION

The objectives of this video are to provide a brief overview of Müllerian agenesis, discuss a case of partial vaginal agenesis with a functional uterus, and present the steps of a staged McIndoe procedure for the creation of a neovagina and utero-neovaginal unification.

METHODS

We give an overview of Mayer-Rokitansky-Küster-Hauser syndrome, and review its incidence, clinical presentation, diagnostic evaluation, and treatment options. We present the case of a 23-year-old woman with partial vaginal agenesis, and her clinical course through conservative management with hormonal suppression and dilator therapy leading up to urogynecological surgical treatment. We describe a staged surgical approach that highlights the value of cystoscopy and laparoscopy to better delineate our patient's anatomical variations. Additionally, a mini-laparotomy and placement of an intrauterine Malecot catheter allowed for the drainage of prominent hematometra, relief of menstrual outflow obstruction, and epithelialization of a tract between the uterus and the planned neovaginal space. Ultimately, a neovagina was created using a staged McIndoe technique, leading to utero-neovaginal unification and unobstructed menses.

CONCLUSION

In conclusion, our approach should be considered a feasible option for anatomical restoration via the creation of a neovagina in patients with Müllerian anomalies, even in the presence of a functional uterus.

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