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

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.

Obstetric outcomes of women with congenital uterine anomalies in the United States

BACKGROUND

Due to the rarity, congenital uterine anomaly type-specific evaluation of pregnant women has been relatively understudied.

OBJECTIVE

To describe national-level obstetric outcomes in women with congenital uterine anomalies.

STUDY DESIGN

This cross-sectional study queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample. Pregnant women with diagnosis of congenital uterine anomalies who had hospital delivery between 2016 and 2019 were examined. The World Health Organization's International Classification of Disease, 10th revision coding was used to delineate type of congenital uterine anomaly, diagnoses, and procedures performed during the index admission. Primary outcomes included pregnancy outcome, which was classified as full-term live birth, preterm live birth, abortion/stillbirth, or ectopic pregnancy. Secondary outcomes included obstetric comorbidities and severe maternal morbidity, which were compared between different subtypes of congenital uterine anomalies with multivariable logistic regression model.

RESULTS

A total of 50,180 pregnant women with congenital uterine anomalies were identified. Bicornuate was the most common subtype (73.5%), followed by arcuate (13.5%) and unicornuate (10.0%). 70.6% of women with congenital uterine anomalies had a full-term live birth, 26.8% had a preterm live birth, 2.1% had an abortion or stillbirth, and 0.4% had an ectopic pregnancy. 61.8% of preterm births occurred between 33 and 36 weeks, 16.9% between 30 and 32 weeks, and 21.3% at <30 weeks. There were 1,440 (2.9%) periviable births. The preterm (34.5%) and periviable (6.9%) birth rates were highest in the uterine didelphys group. Overall, two-thirds (65.7%) of patients with congenital uterine anomalies were delivered via cesarean section. When compared to arcuate uterus, risk of severe maternal morbidity in septate uterus (4.8% vs 2.6%, adjusted-odds ratio [aOR] 2.60, 95% confidence interval [CI] 1.49-4.52) was increased, including hemorrhage (14.5% vs 7.7%, aOR 2.16, 95% CI 1.51-3.07). This was followed by uterine didelphys (4.2% vs 2.6%, aOR 1.75, 95% CI 1.24-2.47), unicornuate uterus (3.8% vs 2.6%, aOR 1.61, 95% CI 1.29-2.01), and bicornuate uterus (3.0% vs 2.6%, aOR 1.23, 95% CI 1.04-1.47).

CONCLUSION

While the majority of patients with congenital uterine anomalies result in full-term viable deliveries, each subtype of congenital uterine anomalies confers different obstetric risks. Uterine didelphys was associated with the highest risk of preterm birth, while septate uterus was associated with the highest risk of severe maternal morbidity. While this hospital delivery dataset likely overrepresents bicornuate uteri, this populational data may help inform patients with congenital anomalies considering pregnancy. El resumen está disponible en Español al final del artículo.

Developmental uterovaginal anomalies and histologic findings in transgender patients receiving gender-affirming hysterectomies: A large case series

OBJECTIVE

To describe the incidence of uterovaginal anomalies and histologic findings in transgender and nonbinary (TGNB) patients seeking hysterectomies.

METHODS

All patients receiving gender-affirming hysterectomies between 2013 and 2023 were retrospectively reviewed. Primary outcomes included uterovaginal anomalies and histological findings. Multivariable logistic regressions were performed to evaluate relationships between variables of interest and whether they predict findings of uterovaginal anomalies, inactive endometrium, adenomyosis, leiomyoma, endometriosis, and cervical atrophy.

RESULTS

278 patients received hysterectomies at an average age of 29.2 ± 8.3 years. Seven patients (2.5%) were found to have a developmental anomaly, including two bicornuate uterus (0.7%), two unicornuate uterus (0.7%), one septate uterus (0.4%), and two vaginal septum (0.7%). 60 patients (21.6%) were found to have inactive endometrium and 26 patients (9.4%) had cervical atrophy. Although 262 patients (94.2%) were on testosterone therapy, hormone duration was not a significant predictor of any uterine findings.

CONCLUSION

This study describes uterovaginal anomalies in a large cohort of patients receiving gender-affirming hysterectomies. Although long-term testosterone use is commonly believed to be associated with endometrial and cervical atrophy, this study shows no such association.

Impact of congenital uterine anomalies on obstetric and perinatal outcomes: systematic review and meta-analysis

Background

Congenital uterine anomalies (CUA) can be associated with impairments of early and late pregnancy events.

Objective

To assess the impact of CUA on reproductive outcomes in pregnancies conceived spontaneously or after assisted reproduction.

Materials and Methods

Systematic review and meta-analysis of cohort studies comparing patients with CUA versus women with normal uterus. A structured literature search was performed in leading scientific databases to identify prospective and retrospective studies. The Newcastle-Ottawa scale, adapted to AHRQ standards, was used to assess the risk of bias. Pooled odds ratios (OR) were calculated. Publication bias and statistical heterogeneity were assessed, and meta-regression was used to analyse the heterogeneity.

Main outcome measures

Miscarriage, ectopic pregnancy, placental abruption, term, and premature rupture of membranes (PROM), malpresentation at delivery, preterm delivery prior to 37, 34 and 32 weeks, caesarean delivery, intrauterine growth restriction/small for gestational age, foetal mortality and perinatal mortality.

Results

32 studies were included. CUAs increased significantly the risk of first/second trimester miscarriage (OR:1.54;95%CI:1.14-2.07), placental abruption (OR:5.04;3.60-7.04), PROM (OR:1.71;1.34-2.18), foetal malpresentation at delivery (OR:21.04;10.95-40.44), preterm birth (adjusted OR:4.34;3.59-5.21), a caesarean delivery (adjusted OR:7.69;4.17-14.29), intrauterine growth restriction/small for gestational age (adjusted OR:50;6.11-424), foetal mortality (OR:2.07;1.56-2.73) and perinatal mortality (OR:3.28;2.01-5.36).

Conclusions

CUA increases the risk of complications during pregnancy, delivery, and postpartum. Complications most frequent in CUA patients were preterm delivery, foetal malpresentation, and caesarean delivery.

What is new?

Bicornuate uterus was associated with the highest number of adverse outcomes, followed by didelphys, subseptate and septate uterus.

Metroplasty increases the take-home baby rate by reducing pregnancy loss without changing the chance of conception in women with septate uterus: a retrospective, single-center, observational study

BACKGROUND

Although abdominal or hysteroscopic metroplasty for septate uterus is considered to reduce pregnancy loss and increase the take-home baby (THB) rate in women with a history of recurrent pregnancy loss, there exists an inherent risk of impaired fertility. This study aimed to clarify the reproductive outcomes of women with septate uterus who underwent abdominal and hysteroscopic metroplasty in a single center.

METHODS

This retrospective observational study enrolled 27 women who underwent metroplasty between 2007 and 2019. The analysis included women with septate uterus [European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) type U2)] or septate-bicornuate uterus (ESHRE/ESGE type U3b) who underwent either abdominal or hysteroscopic metroplasty. Women who did not have an immediate desire to conceive were excluded from the analysis. As a rule, we recommended pregnancy without surgery for women who had not experienced repeated pregnancy loss. Abdominal metroplasty (ABM) was performed using the modified Tompkins' method and hysteroscopic metroplasty was performed using hysteroscopic transcervical resection of the septum [transcervical metroplasty (TCM)]. The conception ratio was calculated as the number of women who achieved ≥ 1 conception/total number of women, the pregnancy loss ratio was calculated as the number of women who experienced ≥ 1 pregnancy loss/the number of women who conceived, and the THB ratio was calculated as the number of women who achieved ≥ 1 THB/total number of women.

RESULTS

Seventeen women underwent ABM and 10 women underwent TCM. Thirty-three conceptions and 26 babies were taken home after surgery. ABM did not change the ≥ 1 conception ratio (76% vs. 83% before and after surgery, respectively; RR = 1.08, p = 0.80). Meanwhile, ABM decreased the ≥ 1 pregnancy loss ratio (100% vs. 36%, RR = 0.36, p < 0.001) and increased the ≥ 1 THB ratio (12% vs. 71%, RR = 6.00, p < 0.01). Similarly, TCM did not change the ≥ 1 conception ratio, decreased the ≥ 1 pregnancy loss ratio, and increased the ≥ 1 THB ratio.

CONCLUSIONS

Both abdominal and hysteroscopic metroplasty for septate uterus increased the THB rate by preventing pregnancy loss without affecting the chance of pregnancy.

TRIAL REGISTRATION

Not applicable.

Analysis of hemi-uterus pregnancy outcomes in uterine malformations: a retrospective observational study

BACKGROUND

The association between uterine malformations and adverse pregnancy outcomes is well recognized. However, studies on adverse pregnancy outcomes based on one kind of anatomical commonality between different uterine anomalies have not been reported. This study aimed to investigate pregnancy outcomes in pregnancies with uterine malformations when the pregnancy is confined to a hemi-uterus.

METHODS

A retrospective observational study of 336 women who gave birth at our hospital from 2015 to 2021 was performed. Women (n = 112) with a unicornuate, complete bicornuate, or didelphic uterus were set as the study group, and women (n = 224) with a normal uterus were set as the reference group. Maternal and neonatal outcomes were evaluated and compared between the two groups using Student's t-test, one-way ANOVA, Chi-squared test, Yates correction for continuity, or Fisher's exact test. Modified Poisson regression analyses were used to estimate the relationships between the hemi-uterus pregnancy and preterm birth, preterm premature rupture of membranes, and cesarean section rates by adjusting for potential confounders. A P value < 0.05 was considered significant.

RESULTS

Women in the study group had a higher history of spontaneous abortion (24.1% vs. 10.7%, P = 0.002) and intrauterine fetal death (5.4% vs. 0.4, P = 0.006). Compared with the reference group, the study group had significantly higher rates of assisted reproductive technology (9.4% vs. 2.2%, P = 0.001) and cord-around-the neck (54.5% vs. 29.9%, P = 0.000). Modified Poisson regression analyses showed that the study group was at higher risk for preterm birth (aRR, 6.8; 95% CI 2.7-16.7), preterm premature rupture of membranes (aRR, 14.1; 95% CI 3.2-62.5), malpresentation (aRR, 13.2; 95% CI 6.3-27.7), and cesarean section (aRR, 4.4; 95% CI 3.3-5.7).

CONCLUSION

Women with a unicornuate, didelphic, or complete bicornuate uterus are at higher risk for some adverse pregnancy outcomes than those with a normal uterus.

Pregnancy Outcomes in Patients with Obstructed Hemivagina Ipsilateral Renal Agenesis

STUDY OBJECTIVE

Obstructed hemivagina with ipsilateral renal agenesis (OHVIRA) is a rare congenital Müllerian anomaly. We sought to explore the impact of OHVIRA on pregnancy outcomes.

METHODS

A retrospective chart review identified 8 patients with an OHVIRA diagnosis and at least 1 documented pregnancy. Data collected included demographic characteristics, age at diagnosis and repair, gynecologic history, and pregnancy outcomes. Descriptive analysis was performed.

RESULTS

Twenty-three pregnancies were identified among the 8 patients (range 1-5 pregnancies per patient), resulting in 9 term births, 6 preterm births, and 8 first-trimester spontaneous abortions. The most common pregnancy complications were fetal growth restriction (2/15) and preeclampsia with severe features (2/15). The average gestational age at delivery was 37 2/7 weeks; however, 60% (9/15) of live births were at term. Two patients delivered after going into preterm labor, one of whom also had preterm premature rupture of membranes. Of the 15 live births, there were 10 cesarean deliveries, 4 vaginal deliveries, and 1 forceps-assisted vaginal delivery. Three patients (30%) underwent primary cesarean deliveries due to fetal malpresentation. Five live births were repeat cesarean deliveries, and 2 were unscheduled cesareans, at 34 and 36 weeks, due to preeclampsia with severe features.

CONCLUSION

This study is among the first to examine pregnancy outcomes in patients with OHVIRA. Among these patients, there were 23 total pregnancies, with higher incidences of spontaneous abortion, preterm birth, breech presentation, and cesarean delivery compared with the general population. This descriptive data set addresses a knowledge gap to help clinicians more effectively advise patients with OHVIRA about pregnancy outcomes.

Unicornuate Uterus with a Non-Communicating Rudimentary Horn: Challenges and Management of a Rare Pregnancy

We present a unique case of pregnancy developed in a unicornuate uterus with a non-communicating rudimentary horn, emphasizing the importance of early identification, careful management, and counseling. Our patient, a 28-year-old woman, presented with abdominal pain and premature rupture of membranes at 37 weeks of gestation. She had a history of one previous normal vaginal delivery and no significant medical or genetic factors. An emergency cesarean section was performed, and a baby boy weighing 2900 grams was delivered without complications. The uterine anomaly was identified as a unicornuate uterus with a non-communicating rudimentary horn. This case report highlights the challenges and risks associated with unicornuate pregnancies, such as fetal growth restriction and preterm labor. Timely identification, meticulous monitoring, and comprehensive counseling are crucial for optimal outcomes in such cases. Further research and larger-scale studies are needed to enhance our understanding of these rare and complex pregnancies.

Shapes of the uterine cavity are different in women with polycystic ovary syndrome

Purpose

A cross-sectional study was conducted to evaluate differences in uterine morphology between women with or without polycystic ovary syndrome.

Methods

The authors recruited 333 infertile reproductive-age women including 93 with polycystic ovary syndrome diagnosed using the criteria of the Japanese Society of Obstetrics Gynecology-2007. Shapes of uterine cavity were measured by transvaginal three-dimensional ultrasound.

Results

The polycystic ovary syndrome group had a significantly deeper indentation (2.2 ± 0.4 mm vs. 0.0 ± 0.2 mm, p < 0.0001) and a significantly more acute indentation angle (162.9 ± 2.2 deg vs. 175.2 ± 1.3 deg, p < 0.0001) than the control group.

Conclusion

The depth and the apical angle of fundal indentation of uterine cavity are different in women with polycystic ovary syndrome.

Does Hysteroscopic Dissection of Partial Uterine Septum Represent a Risk Factor for Placental Abnormalities in Subsequent Pregnancy Compared with Controls Undergoing Other Hysteroscopic Surgery? Results from a Large Case-Control Analysis

BACKGROUND

Hysteroscopic septum dissection (HSD) is thought to improve fertility and pregnancy outcomes. However, the available literature suggests that uterine surgery can cause placental abnormalities in subsequent pregnancies.

METHODS

A case-control study was performed at the University Medical Center of Ljubljana, Department of Human Reproduction, from 1 January 2016 to 31 December 2018. The primary outcome was the association between HSD and the occurrence of placental abnormalities. We included women who underwent HSD due to infertility. Age-matched women who underwent hysteroscopic surgery for other issues were considered as controls. In addition, we divided the groups according to conception method. Only singleton pregnancies and first delivery were considered.

RESULTS

A total of 1286 women (746 who underwent HSD and 540 controls) were included in the analysis. HSD had no influence on placental abnormalities since the ratio was comparable regardless of the method of conception (113/746 vs. 69/540; p = 0.515). Infertile women who conceived naturally after HSD had a normal placentation rate comparable to women who did not undergo HSD (380/427 vs. 280/312; p = 0.2104). The rate of placental abnormalities in women who achieved pregnancy with IVF/ICSI procedures following HSD was comparable to that of women who did not undergo HSD (52/319 vs. 33/228; p = 0.5478). Placenta previa occurred significantly more often in infertile women without HSD after IVF/ICSI compared to natural conception (2/312 vs. 7/228; p = 0.0401).

CONCLUSIONS

HSD was not associated with higher rate of placental abnormalities in the first singleton pregnancy compared with other hysteroscopic procedures. A higher rate of placenta previa in pregnancies following IVF/ICSI procedures, which was shown by our research, is corroborated by previous research findings.

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.

Understanding recurrent pregnancy loss: recent advances on its etiology, clinical diagnosis, and management

Recurrent pregnancy loss (RPL) has become an important reproductive health issue worldwide. RPL affects about 2%-3% of reproductive-aged women, and makes serious threats to women's physical and mental health. However, the etiology of approximately 50% of RPL cases remains unknown (unexplained RPL), which poses a big challenge for clinical management of these patients. RPL has been widely regarded as a complex disease where its etiology has been attributed to numerous factors. Heretofore, various risk factors for RPL have been identified, such as maternal ages, genetic factors, anatomical structural abnormalities, endocrine dysfunction, prethrombotic state, immunological factors, and infection. More importantly, development and applications of next generation sequencing technology have significantly expanded opportunities to discover chromosomal aberrations and single gene variants responsible for RPL, which provides new insight into its pathogenic mechanisms. Furthermore, based upon patients' diagnostic evaluation and etiologic diagnosis, specific therapeutic recommendations have been established. This review will highlight current understanding and recent advances on RPL, with a special focus on the immunological and genetic etiologies, clinical diagnosis and therapeutic management.

Treatment of septate uterus

Although there is insufficient evidence supporting the link between septate uterus and infertility, there are many studies demonstrated the effect of spetal incision on pregnancy in women diagnosed with septate uterus associated with infertility. Hysteroscopic metroplasty can significantly improve the reproductive performance of those with septate uterus. Some Müllerian malformations can be healed by surgery. The accurate diagnosis and appropriate therapeutic approch are fundamental for successful treatment. Any attempt at surgical correction of uterine abnormalities must be aimed at preserving or improving reproductive function. Among congenital uterine anomalies, septate uterus is the most amenable to simple hysteroscopic treatment. The resection of the septum is performed as standard treatment worldwide.

Application of hysteroscopy in female fertility preservation

Under the background of the trend in late marriage and the relaxation of family planning policy, the reproductive behavior of women has changed and the proportion of elderly pregnant women has increased progressively year by year. Thus the female fertility preservation is particularly important. As the cradle of life, uterine malformation and uterine cavity diseases may have adverse effects on embryo implantation and development. Several common intrauterine diseases, such as uterine submucosal fibroids, endometrial polyps, intrauterine adhesions, uterine malformation, cesarean scar diverticulum, and embryo residues, may affect female fertility. Hysteroscopy is the gold standard for the diagnosis and treatment for intrauterine diseases. With the progress in science and technology, the refinement of hysteroscopy instruments and the promotion of transvaginal endoscopic technology, hysteroscopy will yield brilliant results in female fertility preservation. The knowledge and training related to hysteroscopy should be continuously promoted and popularized, so that it can be mastered by more clinicians and applied in clinical practice to benefit more female patients.

Diagnosis of septate uterus

The septate uterus is the most common structural uterine anomalies and it is associated with the poor reproductive outcome. It is believed to be the result of the failure in resorption of the tissue connecting the 2 paramesonephric ducts prior to the 20th embryonic week. The true prevalence of uterine septum is difficult to ascertain, as many uterine septal defects are asymptomatic. The septate uterus is usually diagnosed during an infertility evaluation and affects reproductive health by impairing fertility and increasing adverse pregnancy outcomes. The variations in uterine and cervical/vaginal anomalies collectively referred to as Müllerian anomalies. No consistent gold standard for the diagnosis of Müllerian anomalies exists. The preferred diagnostic method for Müllerian anomalies is two-dimensional ultrasound, other methods such as three-dimensional ultrasound, magnetic resonance imaging, hysterosalpingo contrast sonography, hysterosalpingography, hysteroscopy, and laparoscopy are also used to improve accuracy.