Clarifying the role of three-dimensional transvaginal sonography in reproductive medicine: an evidenced-based appraisal

The Female Snark Is Still a Boojum: Looking toward the Future of Studying Female Reproductive Biology

Philosophical truths are hidden in Lewis Carroll's nonsense poems, such as "The hunting of the snark." When the poem is used as a scientific allegory, a snark stands for the pursuit of scientific truth, while a boojum is a spurious discovery. In the study of female biology, boojums have been the result of the use of cultural stereotypes to frame hypotheses and methodologies. Although female reproduction is key for the continuation of sexually reproducing species, not only have females been understudied in many regards, but also data have commonly been interpreted in the context of now-outdated social mores. Spurious discoveries, boojums, are the result. In this article, we highlight specific gaps in our knowledge of female reproductive biology and provide a jumping-off point for future research. We discuss the promise of emerging methodologies (e.g., micro-CT scanning, high-throughput sequencing, proteomics, big-data analysis, CRISPR-Cas9, and viral vector technology) that can yield insights into previously cryptic processes and features. For example, in mice, deoxyribonucleic acid sequencing via chromatin immunoprecipitation followed by sequencing is already unveiling how epigenetics lead to sex differences in brain development. Similarly, new explorations, including microbiome research, are rapidly debunking dogmas such as the notion of the "sterile womb." Finally, we highlight how understanding female reproductive biology is well suited to the National Science Foundation's big idea, "Predicting Rules of Life." Studies of female reproductive biology will enable scholars to (1) traverse levels of biological organization from reproductive proteins at the molecular level, through anatomical details of the ovum and female reproductive tract, into physiological aspects of whole-organism performance, leading to behaviors associated with mating and maternal care, and eventually reaching population structure and ecology; (2) discover generalizable rules such as the co-evolution of maternal-offspring phenotypes in gestation and lactation; and (3) predict the impacts of changes to reproductive timing when the reliability of environmental cues becomes unpredictable. Studies in these key areas relative to female reproduction are sure to further our understanding across a range of diverse taxa.

Clinical approach for the classification of congenital uterine malformations

A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field.

Three-dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging

OBJECTIVES

To demonstrate the value of three-dimensional (3D) ultrasound in the diagnosis of uterine malformations and its concordance with magnetic resonance imaging (MRI).

METHODS

This study included 286 women diagnosed with uterine malformation by 3D ultrasound, having been referred to our clinics on suspicion of uterine malformation following clinical and/or conventional two-dimensional ultrasound examination. With the exception of three with intact hymen, patients underwent both bimanual examination and speculoscopy before and/or after sonography. MRI was performed in 65 cases. We analyzed the diagnostic concordance between the techniques in the study of uterine malformations.

RESULTS

Using 3D ultrasound we diagnosed: one case with uterine agenesis; 10 with unicornuate uterus, four of which also underwent MRI; six with didelphic uterus, one of which had MRI; 45 with bicornuate uterus, 12 of which had MRI; 125 with septate uterus (18 with two cervices), 42 of which had MRI (six with two cervices); 96 with arcuate uterus, three of which had MRI; and three with diethylstilbestrol (DES) iatrogenic uterine malformations, all of which had MRI. Among the 65 which underwent MRI, the diagnosis was: four cases with unicornuate uterus, 10 with bicornuate uterus (two with two cervices), 45 with septate uterus (five with two cervices), three with arcuate uterus and three with DES-related uterine malformations. The concordance between 3D ultrasound and MRI was very good (kappa index, 0.880 (95% CI, 0.769-0.993)). Discrepancies in diagnosis between the two techniques occurred in four cases. There was very good concordance in the diagnosis of associated findings (kappa index, 0.878 (95% CI, 0.775-0.980)), this analysis identifying differences in two cases.

CONCLUSIONS

There is a high degree of concordance between 3D ultrasound and MRI in the diagnosis of uterine malformations, the relationship between cavity and fundus being visualized equally well with both techniques. 3D ultrasound should be complemented by careful gynecological exploration in order to identify any alterations in the cervix.

Congenital malformations of the female genital tract: the need for a new classification system

Current proposals for classifying female genital anomalies seem to be associated with limitations in effective categorization, creating the need for a new classification system that is as simple as possible, clear and accurate in its definitions, comprehensive, and correlated with patients' clinical presentation, prognosis, and treatment on an evidence-based foundation. Although creating a new classification system is not an easy task, it is feasible when taking into account the experience gained from applying the existing classification systems, mainly that of the American Fertility Society.

The role of 3-dimensional ultrasonography and magnetic resonance imaging in the diagnosis of müllerian duct anomalies: a review of the literature

OBJECTIVE

The purpose of this article is to review the published literature and determine the roles that magnetic resonance imaging (MRI) and endovaginal 3-dimensional ultrasonography (3DUS) play in the diagnosis of müllerian duct anomalies (MDAs).

METHODS

A PubMed search was performed to identify all of the articles pertaining to the use of MRI or 3DUS for the evaluation or diagnosis of MDAs. Clinical studies, review articles, case reports, and descriptive studies were reviewed.

RESULTS

Magnetic resonance imaging and 3DUS are highly sensitive and specific in identifying women with MDAs. Magnetic resonance imaging is 100% to 28.6% sensitive and 100% to 66% specific in correctly categorizing MDAs. Three-dimensional ultrasonography is 100% to 98% sensitive and 100% specific in correctly categorizing MDAs.

CONCLUSIONS

In experienced hands, both MRI and 3DUS are adequate modalities for identifying women with MDAs. There is a lack of studies comparing MRI with 3DUS for the diagnosis and categorization of MDAs. However, it seems likely that 3DUS is more sensitive and specific than MRI in categorizing specific types of MDAs. The high sensitivity and specificity of 3DUS make it an ideal tool for identifying women with MDAs that are amenable to hysteroscopic resection. Therefore, we believe that as practitioners become more experienced, 3DUS will emerge as the reference standard for the diagnosis of MDAs.

The pathogenetic enigma of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex disease with heterogeneous clinical and anatomical features that were first described in 1721 by Antonio Vallisneri. There is still a lack of consensus regarding the criteria to be used for diagnosis of PCOS. Transvaginal ultrasonography with Doppler studies of the ovarian and pelvic vasculature plays an important role in its diagnosis, but findings must be interpreted in light of the patient's symptoms and laboratory findings.