Müllerian duct anomalies: review of current management

Rare and Occult Müllerian Deformity Diagnosed Intraoperatively During Lower Segment Caesarean Section

Uterine anomalies are the rare entities seen due to fusion defects or agenesis of Müllerian ducts in embryonic life. They are usually associated with renal defects. If non-obstructive in nature, they hardly become symptomatic until the beginning of their obstetric carrier, when they present with infertility, recurrent pregnancy loss, preterm pregnancy, rudimentary horn rupture, an ectopic baby, and numerous more negative effects. We are presenting a case report of a patient who was suffering from infertility, attempted IUI treatment five times, then stopped the treatment due to economic affordability issues, conceived spontaneously, and underwent preterm lower segment cesarean section (LSCS) due to fetal distress. During LSCS, it was found to be type 2C of the American Fertility Society (AFS) Müllerian anomaly. The post-operative period was uneventful; both mother and baby were fine, and they were discharged.

Müllerian Duct Anomalies and Anti-Müllerian Hormone Levels in Women With Polycystic Ovary Syndrome

BACKGROUND

Significant associations between the presence of polycystic ovary syndrome (PCOS) and uterine anomalies have been reported. It is unclear whether high anti-Müllerian hormone (AMH) levels coexist with the development of uterine malformations in women with PCOS. This study sought to investigate the association between Müllerian duct anomalies and anti-Müllerian hormone (AMH) levels in women with PCOS.

METHODS

In this retrospective cohort study, the records of 1,391 women with PCOS were analyzed. The cohort was divided into a low-AMH group (n = 700) and a high-AMH group (n = 691), based on an AMH cutoff value of 8.45 ng/ml. Müllerian duct anomalies were classified into four subtypes based on three-dimensional ultrasonography: septate uterus, bicornuate uterus, uterus didelphys, unicornuate uterus, and arcuate uterus. The primary outcome was the overall incidence of Müllerian duct anomalies. The secondary outcome was the prevalence of the abovementioned specific types of Müllerian duct anomalies. The prevalence of Müllerian duct anomalies was analyzed using the chi-squared test or Fisher's exact test.

RESULTS

Among the patients with PCOS, the prevalence of unicornuate uterus anomalies was higher in the high-AMH group than in the low-AMH group (1.0% vs. 0.1%, P = 0.04). No statistically significant difference in the overall incidence of uterine malformations was found between the two AMH groups (4.3% vs. 5.7%, P = 0.22).

CONCLUSIONS

Our study confirmed a higher prevalence of unicornuate uterus in PCOS women with high AMH levels. Clinicians might decide to investigate the possibility of a unicornuate uterus in PCOS women with high AMH levels.

O-005 Mullerian anomalies overview

Mullerian Duct Anomalies- An Overview

Prof. Sudha Prasad

President Indian Fertility Society, Director, Matritava Advanced IVF & Training Centre, New Delhi, India

Congenital anomalies of the mullerian duct system is one of the complex disorder encountered in gynecological practice. Mullerian ducts are paired embryological structures which undergo fusion and resorption in utero to form the uterus, fallopian tubes, cervix and upper two-thirds of the vagina. Disruption in the mullerian duct development throughout embryogenesis could result a large spectrum of inherent abnormalities identified as mullerian duct anomalies (MDAs).

There is a wide variation in the prevalence of MDAs across various studies, ranging from 1–10% in the general population to 2–8% among infertile women and 5–30% among women with a history of miscarriage. These discrepancies in the reported prevalence are mainly attributed to lack of a universal classification system.

Different varieties of malformations can occur when this system is not well developed. It ranges from absence of uterus, cervix or vagina, septum/duplication of vagina to of the uterus and vagina to minor uterine cavity abnormalities. Mullerian malformations are frequently associated with abnormalities of the renal and axial skeletal systems. Therefore, on initial examination of MDAs patients, these points should be kept in mind.

Most mullerian duct anomalies (MDAs) are associated with functioning ovaries and age-appropriate external genitalia. These abnormalities are often recognized after the onset of puberty. After the onset of puberty, young women often present to the gynecologist with menstrual disorders. Late presentations include infertility and obstetric complications.

A meta-analysis of nine studies comprising 3805 women with congenital uterine anomalies reviewed the obstetric outcome. The study reported that canalization defects such as septate and partial septate uteri had reduce fertility and increase rates of miscarriage and preterm delivery. None of the unification defects (bicornuate, unicornuate and didelphic uteri) reduce fertility but some are related to miscarriage and prematurity. Arcuate uteri are specifically associated with second-trimester miscarriage. All uterine abnormalities increase the risk of fetal malformation during delivery1.

A retrospective longitudinal study concluded that reproductive performance of the unicornuate and didelphys uteri was poor (20–30% chance of carrying a pregnancy to term), while that of the septate and bicornuate uteri (live birth rate of 62%) was better than expected. The arcuate uterus had no impact on reproductive performance of women2.

Agenesis of uterus and vagina requires surgical techniques, such as the Vecchietti and McIndoe procedures, have enabled many women to have normal sexual relations. Uterine transplant has changed the perspective of all other surgical advances and assisted reproductive technologies to improve fertility and obstetric outcomes3, 4,5.

Müllerian Duct Anomalies- Diagnostic Imaging in Pediatric and Adolescent Population

Müllerian duct anomalies (MDAs) are congenital entities that result from the non-development, defective vertical or lateral fusion, or the resorption failure of the Müllerian (paramesonephric) ducts. MDAs represent a more frequent entity than previously believed. Few recent meta-analyses reported a prevalence of 5.5 - 6.7%. MDAs are commonly associated with other anomalies, specially kidneys, so identification of both kidneys is important. In pediatric and adolescent population MDAs are discovered incidentally at patients observed for some other reason or because of the primary amenorrhea and low abdominal pain related to hematometra (colpos). Imaging is essential for a diagnosis, management, and reproductive counseling in patients with MDA. Patients suspected of having the MDA are often initially referred to pelvic ultrasonography (US). Field-of-view restrictions with US, patient body habitus and artifact from bowel gas may result in a request for the further MagneticRresonance Iimaging (MRI). Also US cannot help identify the type of the MDA. MRI is the imaging standard of reference because it is non-invasive, does not involve ionizing radiation, has a multiplanar capability, allows an excellent soft-tissue characterization, detailed delineation of the uterovaginal anatomy and accurate classification of the type of anomaly. This is especially true for young female patients, in whom the use of vaginal US probes is avoided. Establishing an accurate diagnosis is essential for planning treatment and management strategies. The surgical management of MDAs is specific to the type of malformation and may vary in a specific group.

A novel mutation of HOXA11 in a patient with septate uterus

BACKGROUND

The etiology of Müllerian duct anomalies (MDAs) is poorly understood at present. The HOXA11 gene is crucial for the development of the Müllerian duct. The objective of this study is to report a unique case of MDAs with a novel mutation in HOXA11.

RESULTS

We identified a potential disease-causing mutation (p. E255K) in a patient with a septate uterus. The mutation was not detected in 169 control subjects or listed in any databases of variations. Bioinformatic predictions and functional studies showed that the mutation reduces the DNA binding affinity and disrupts transactivation ability of HOXA11.

CONCLUSION

In conclusion, this is the first report to describe a HOXA11 mutation in Chinese women with MDAs. The results demonstrated that mutation in HOXA11 can contribute to the etiology of MDAs, especially the septate uterus, but might not be a common cause.

A review of paediatric and adolescent gynaecology services in a tertiary outpatient clinic

Adolescence is a distinctive stage in human development during which many simple and complex medical conditions can present for the first time. Paediatric and adolescent gynaecological conditions need careful multidisciplinary clinical management with a sensitive approach understanding the patients' psychological and physiological circumstances. The objective of this study is to review the tertiary paediatric and adolescent gynaecology service in Leeds, United Kingdom and to present an overview of the various conditions that present to such a clinic. A total of 985 patients were seen over a 16-year period and the increasing number of patients seen over this time establishes the need for such a service to exist. Complex developmental anomalies of the genital tract and disorders of sexual differentiation formed a major portion of the referrals. Presence of a significant number of referrals for simple gynaecological conditions including menstrual irregularities, gynaecological pain, vulvovaginitis, polycystic ovary syndrome and concerns about labial appearance indicates the reluctance of general gynaecologists and general practitioners to manage such conditions in young patients. This emphasizes the need for continued education of primary health care professionals and establishment of clear guidelines and care pathways for the management of this special patient group.

Genetic association between PAX2 and mullerian duct anomalies in Han Chinese females

PURPOSE

The study aims to investigate the genetic association between paired box gene 2 (PAX2) and mullerian duct anomalies (MDA) in Chinese Han females.

METHODS

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) was used to identify the genotypes of three tag single nucleotide polymorphisms (SNPs) in PAX2 in 362 MDA cases and 406 controls.

RESULTS

We found that one tag SNP (rs12266644) of PAX2 was associated with susceptibility to MDA. The genotype distributions of the SNP rs12266644 have a statistically significant difference in the MDA patients and controls with a p value = 0.008. In the dominant model, we also observed that the GT + TT genotype increased the risk for MDA (p = 0.015, OR = 1.637, 95 % CI = 1.096-2.443).

CONCLUSION

The polymorphism rs12266644 of PAX2 might be a risk factor for MDA in Chinese Han females.

Genetic analysis of DACT1 in 100 Chinese Han women with Müllerian duct anomalies

Dapper antagonist of catenin-1 (DACT1) plays an important role in embryogenesis and organogenesis of the female reproductive tract in mouse models. The aim of this study was to investigate the association between DACT1 mutations and human Müllerian duct anomalies (MDA). One hundred clinically well-defined Chinese Han patients with MDA and 200 healthy controls were recruited in this study. All four exons coding for DACT1 were amplified and sequenced. A missense mutation (c.G1084A, p.V362M) was identified in a patient who had a didelphic uterus and was absent from the control group. This variant changed the hydrophilicity of the amino acid residue and was predicted to be deleterious to the structure and function of DACT1 protein. The data indicate that the p.V362M mutation of DACT1 may be an underlying cause of MDA.

Currarino triad with Müllerian duct anomaly in mother and daughter without MNX1 gene mutation

The Currarino triad is a unique complex of congenital caudal anomalies, including anorectal malformation, sacral bony defect and presacral mass. This triad may be associated with Müllerian duct anomalies, such as duplication of the vagina and uterus. Each of these diseases has a familial tendency and sometimes coexist within families. But, when coexisting in familial cases, nearly all reported cases revealed mutations of the motor neuron and pancreas homeobox 1 (MNX1) gene. Familial cases of Currarino triad combined with Müllerian duct anomaly without MNX1 gene mutation are very rare. Here we report cases of mother and daughter, who had Currarino triad and Müllerian duct anomaly without MNX1 gene mutation, along with a brief literature review.

Obstructive reproductive tract anomalies

BACKGROUND

Approximately 7% of girls will have an anatomic abnormality in their reproductive tract, diagnosed before or after puberty.

OBJECTIVE

It is important for providers to be aware of the obstructive reproductive tract conditions, the way in which various conditions present, and the way in which such conditions should be managed.

DESIGN

Systematic review of the literature using the GRADE evidence system.

RESULTS

There is limited data in most areas of obstructive reproductive tract anomalies; however, some retrospective and prospective series with small numbers are still useful to guide clinical practice.

CONCLUSIONS

Recommendations are based on limited or inconsistent scientific evidence. Recommendations are based primarily on consensus and expert opinion.

Concomitant imperforate hymen and transverse vaginal septum complicated with pyocolpos and abdominovaginal fistula

A 13-year-old patient with a complaint of worsening lower abdominal pain during the past 4 months was admitted to the emergency department. An abdominopelvic ultrasound scan revealed a distended uterocervical cavity suggestive of hematometrocolpos. Imperforate hymen was observed on examination of the external genitalia. MRI scan revealed an air-fluid level representing pyometrocolpos within a distended vagina. Posterior vaginal extraperitoneal leakage as the sign of a fistula between the vagina and the rectovaginal space was detected. Although laparoscopic approach was planned, malodorous pus expelled after the insertion of the Veress needle, it was decided to proceed to laparotomy. Pus with peritoneal microabscess formations was observed at laparotomy. The imperforate hymen and TVS were excised vaginally. A more complex anomaly should be suspected in cases with hematometra and concomitant imperforated hymen without any bulging and thorough evaluation using radiological imaging techniques should be performed before surgical approach.

Combined laparoscopic and hysteroscopic approach for the treatment of a hybrid Müllerian duct anomaly: a case report

Müllerian duct anomalies include a wide spectrum of genital tract defects resulting from a development alteration of the genital tract. An 11-year-old girl with a hybrid septate variety uterus with left hemi-obstruction was identified. Beside preoperative imaging evaluation done with ultrasound, magnetic resonance, and hysterosalpingography, a combined laparoscopic and hysteroscopic procedure was fundamental for the diagnosis. The surgical procedure also allowed us to perform a successful and safe treatment. We propose that the American Fertility Society classification of these anomalies should be revised and that hybrid entities should be considered in the differential diagnosis of genital tract malformations.

Imaging of female infertility: a pictorial guide to the hysterosalpingography, ultrasonography, and magnetic resonance imaging findings of the congenital and acquired causes of female infertility

Hysterosalpingography is the gold standard in assessing the patency of the fallopian tubes, which is among the most common causes of female factor infertility, making this technique the most frequent first-choice imaging modality in the assessment of female infertility. Ultrasonography and magnetic resonance imaging are typically used for evaluation of indeterminate or complicated cases of female infertility and presurgical planning. Imaging also plays a role in the detection of the secondary causes of ovarian factor infertility, including endometriosis and polycystic ovarian syndrome.

Analysis of PBX1 mutations in 192 Chinese women with Müllerian duct abnormalities

We examined the PBX1 gene in 192 Chinese women with Müllerian duct abnormalities and revealed 2 known single nucleotide polymorphisms: c.61 > A in exon 1 and c.998-1330A>G in intron 7. Future studies in large cohorts of different ethnic populations are warranted to establish definite associations between the PBX1 gene and Müllerian duct abnormalities.