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Timmerman S, Stubbe L, Van den Bosch T, Van Schoubroeck D, Tellum T, Froyman W. Accessory cavitated uterine malformation (ACUM): A scoping review. Acta Obstet Gynecol Scand 2024; 103:1036-1045. [PMID: 38345425 PMCID: PMC11103141 DOI: 10.1111/aogs.14801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/09/2024] [Accepted: 01/28/2024] [Indexed: 05/21/2024]
Abstract
INTRODUCTION Accessory cavitated uterine malformation (ACUM) is a relatively recent term used to describe a noncommunicating, accessory uterine cavity. ACUM have been published under different terms ranging from juvenile cystic adenomyosis to "uterus-like mass". The objective of this study was to systematically identify all cases of ACUM and definitions described in the literature, regardless of label, and identify morphological, epidemiological, and clinical characteristics as well as management, while also highlighting knowledge gaps. MATERIAL AND METHODS A systematic literature search of three databases was performed, reviewing all records of cystic myometrial lesions. Cases that fitted common definitions for ACUM were included and clinical and imaging characteristics were documented in detail. This work was registered to PROSPERO and reporting followed PRISMA guidelines for scoping reviews. RESULTS A total of 53 articles were included, comprising 115 cases that met the minimal criteria for ACUM. The median age at onset of symptoms was 17 years, presenting with dysmenorrhea soon after menarche. A total of 19 women were parous. On ultrasound, ACUM appears as unilocular myometrial cysts, usually with ground-glass content. Hemorrhagic content is also observed on magnetic resonance imaging (MRI), with high signal intensity on both T2 and T1-weighted images. Ninety-five (83%) cases were managed surgically, with a trend towards primary nonsurgical options. Although no adverse outcomes were reported, long-term follow-up on subsequent fertility and pregnancy was rare. CONCLUSIONS Despite its increasing recognition as a clinical entity, ACUM often remains underdiagnosed as it shares similarities with other myometrial masses. We propose a unified terminology and definition for ACUM based on the data in this review. ACUM presents as a cavitated lesion, surrounded by a myometrial mantle, in continuity with the anterolateral uterine wall and located beneath the insertion of the round ligament and the interstitial portion of the fallopian tube. In contrast to other uterine abnormalities, a normal uterine cavity is visualized. Future studies are needed, using a clear definition for ACUM, and prospectively investigating management strategies, including long-term follow-up of patient-reported symptoms, fertility, and pregnancy outcomes.
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Affiliation(s)
- Stefan Timmerman
- Department of Development and Regeneration, KU LeuvenLeuvenBelgium
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Lauren Stubbe
- Department of Development and Regeneration, KU LeuvenLeuvenBelgium
| | - Thierry Van den Bosch
- Department of Development and Regeneration, KU LeuvenLeuvenBelgium
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Dominique Van Schoubroeck
- Department of Development and Regeneration, KU LeuvenLeuvenBelgium
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
| | - Tina Tellum
- Department of GynecologyOslo University HospitalOsloNorway
| | - Wouter Froyman
- Department of Development and Regeneration, KU LeuvenLeuvenBelgium
- Department of Obstetrics and GynecologyUniversity Hospitals LeuvenLeuvenBelgium
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Elshetry ASF, Assy MM, Zaid NA, El-Fawakry RM, Radwan MHSS, Hamed EM. Reproducibility of MRI Diagnosis of Female Genital Anomalies. Can Assoc Radiol J 2024:8465371241252793. [PMID: 38795028 DOI: 10.1177/08465371241252793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2024] Open
Abstract
Purpose: To assess and compare intrareader and interreader reproducibility of magnetic resonance imaging (MRI) diagnosis of female genital anomalies (FGAs) using the American Society for Reproductive Medicine-Mullerian anomalies classification 2021 (ASRM-MAC 2021) and European Society of Human Reproduction and Embryology-European Society for Gynecological Endoscopy (ESHRE-ESGE) 2016 classification. Methods: In this retrospective study, we searched our electronic MRI database from April 2021 to September 2023, selecting MRI studies with FGAs. Seventy-six consecutive studies were included and reviewed by 4 independent radiologists using both classifications. Studies were re-evaluated after 1 month. Reproducibility was assessed using kappa (κ) scores with 95% confidence intervals (CI). Results: Intrareader agreement for MRI diagnosis of FGAs was substantial to excellent, with κ scores ranging from 0.684 (95% CI, 0.534-0.834) to 0.985 (95% CI, 0.963-1.01) using the ASRM-MAC 2021 and from 0.743 (95% CI, 0.621-0.865) to 0.846 (95% CI, 0.719-0.973) using the ESHRE-ESGE 2016 classification. Pairwise interreader agreement was higher with the ASRM-MAC 2021, ranging from moderate (κ = 0.491; 95% CI, 0.341-0.642) to substantial (κ = 0.709; 95% CI, 0.597-0.821), compared to the ESHRE-ESGE 2016 classification, with weak (κ = 0.080; 95% CI, 0.068-0.228) to moderate (κ = 0.511; 95% CI, 0.344-0.678) agreement. Overall interreader agreement was moderate for both classifications (κ = 0.599; 95% CI, 0.562-0.638 for ASRM-MAC 2021 and κ = 0.429; 95% CI, 0.396-0.463 for ESHRE-ESGE 2016 classification), but with significant differences (non-overlapping CIs). Conclusion: The intrareader reproducibility was high for both classifications, whereas the interreader reproducibility was higher using the ASRM-MAC 2021, highlighting the impact of classification criteria on the reproducibility of MRI diagnosis of FGAs.
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Affiliation(s)
| | - Mostafa Mohamad Assy
- Radio-diagnosis Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | - Nesma Adel Zaid
- Radio-diagnosis Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
| | | | | | - Enas Mahmoud Hamed
- Radio-diagnosis Department, Faculty of Human Medicine, Zagazig University, Zagazig, Egypt
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Kang J, Qiao J. Impact of congenital uterine anomalies on reproductive outcomes of IVF/ICSI-embryo transfer: a retrospective study. Eur J Med Res 2024; 29:48. [PMID: 38212852 PMCID: PMC10782742 DOI: 10.1186/s40001-023-01544-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 01/13/2024] Open
Abstract
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.
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Affiliation(s)
- Jia Kang
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, China
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China
| | - Jie Qiao
- Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, 100191, China.
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China.
- Key Laboratory of Assisted Reproduction (Peking University), Ministry of Education, Beijing, China.
- Beijing Key Laboratory of Reproductive Endocrinology and Assisted Reproductive Technology, Beijing, China.
- Beijing Advanced Innovation Center for Genomics, Beijing, China.
- Peking-Tsinghua Center for Life Sciences, Peking University, Beijing, China.
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Muñoz E, Fernández I, Pellicer N, Mariani G, Pellicer A, Garrido N. Reproductive outcomes of oocyte donation in patients with uterine Müllerian anomalies. Fertil Steril 2023; 120:850-859. [PMID: 37392783 DOI: 10.1016/j.fertnstert.2023.06.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 06/08/2023] [Accepted: 06/23/2023] [Indexed: 07/03/2023]
Abstract
OBJECTIVE To evaluate live-birth rates per embryo transfer in patients with uterine Müllerian anomalies (UMAs). Secondary objectives were to compare reproductive outcomes between the normal uterus group, the different UMA types, and UMA subgroups with and without required surgery. DESIGN This retrospective study compared two cohorts, one with UMAs and other with normal uteri of our oocyte donation program at 12 Instituto Valenciano De Infertilidad/Reproductive Medicine Associates University affiliated clinics from January 2000 to 2020. The oocyte donation reduces confounding because of differences in embryo quality. The primary outcome was the live-birth rate per embryo transfer. Secondary outcomes included the rates of implantation, clinical pregnancy, miscarriage, and ongoing pregnancy. We calculated odds ratios with 95% confidence intervals. PATIENTS Infertile women undergoing oocyte donation with UMAs. INTERVENTION None. MAIN OUTCOME MEASURES The rates of implantation, clinical pregnancy, miscarriage, ongoing pregnancy, and live birth. RESULTS We analyzed 58,337 cycles of oocyte donation: 57,869 patients had no uterine malformation, and 468 women had UMAs. Compared with patients with normal uteri, patients with UMAs had lower rates of live births (36.67% [32.84-40.65] vs. 38.1% [95% confidence intervals {CI}: 37.82-38.42]) and ongoing pregnancy (39.74% [35.93-43.66] vs. 41.5% [41.24-41.83]). The miscarriage rate was higher in patients with UMAs (19.5% [16.55-22.85] vs. 16.6% [16.47-16.92]). Specifically, patients with a unicornuate uterus (n=29) had lower rates of implantation (24.07% [13.49-37.64] vs. 42.85% [95% CI: 42.6-43.09]), pregnancy (41.86% [27.01-57.87] vs. 59.51% [59.22-59.81]), ongoing pregnancy (16.67% [6.97-31.36] vs. 41.54% [41.24-41.83]), and live births (16.67% [6.97-31.36] vs. 38.12% [37.83-38.42]). In addition, patients with a partial septate uterus (n=91) had a higher miscarriage rate (26.50% [18.44-34.89] vs. 16.7% [16.47-16.92]). Compared with the normal uterus group, the live-birth rates were lower in the UMA without surgery group (33.09% [27.59-38.96] vs. 38.12% [37.83-38.42]). CONCLUSION Among patients who received embryos derived from donated oocytes, live birth and ongoing pregnancy rates were lower in patients with UMAs compared with patients with normal uteri. A higher miscarriage rate was found in patients with UMAs. Patients with a unicornuate uterus had worse reproductive outcomes. Our results show that the uterus is less competent in patients with UMAs. TRIAL REGISTRATION This study was registered at clinicaltrial.gov (NCT04571671).
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Affiliation(s)
- Elkin Muñoz
- IVIRMA Global Research Alliance, IVIRMA Vigo, Reproductive Medicine, Vigo, Spain; Department of Obstetrics and Gynecology, Universidad del Cauca, Popayán, Colombia.
| | - Iria Fernández
- IVIRMA Global Research Alliance, IVIRMA Vigo, Reproductive Medicine, Vigo, Spain
| | - Nuria Pellicer
- Department of Obstetrics and Gynecology, Hospital Politécnico la Fe, Valencia, Spain
| | - Giulia Mariani
- IVIRMA Global Research Alliance, IVIRMA Roma, Reproductive Medicine, Roma, Italy
| | - Antonio Pellicer
- IVIRMA Global Research Alliance, IVIRMA Roma, Reproductive Medicine, Roma, Italy
| | - Nicolas Garrido
- IVIRMA Global Research Alliance, IVI Foundation, Instituto de Investigación Sanitaria La Fe (IIS La Fe), Valencia, Spain
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Wei L, Xu C, Zhao Y, Zhang C. Higher Prevalence of Chronic Endometritis in Women with Cesarean Scar Defect: A Retrospective Study Using Propensity Score Matching. J Pers Med 2022; 13:jpm13010039. [PMID: 36675699 PMCID: PMC9863930 DOI: 10.3390/jpm13010039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/15/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
(1) Background: A cesarean scar defect may cause localized inflammation of the endometrial tissue, and various researchers believe that the presence of a cesarean scar defect is associated with chronic endometritis. However, there is no report on the possible association between cesarean scar defects and chronic endometritis thus far. This study aimed to assess the role of having a cesarean scar defect in a person's susceptibility to chronic endometritis. (2) Methods: This retrospective propensity-score-matched study comprised 1411 patients with chronic endometritis that were admitted to Henan Provincial People's Hospital in China from 2020 to 2022. Based on whether a cesarean scar defect was present or not, all cases were assigned to the cesarean scar defect group or the control group. (3) Results: Of the 1411 patients, 331 patients with a cesarean scar defect were matched to 170 controls. All unbalanced covariates between groups were balanced after matching. Before matching, the prevalence of chronic endometritis in the cesarean scar defect group and in the control group was 28.8% and 19.6%, respectively. After correcting for all confounding factors, a logistic regression analysis showed that cesarean scar defect occurrence may increase the risk of chronic endometritis (odds ratio (OR), 1.766; 95% confidence interval (CI), 1.217-2.563; p = 0.003). After matching, the prevalence of chronic endometritis was 28.8% in the cesarean scar defect group and 20.5% in the control group. Thus, even after correcting for all confounding factors, the logistic regression analysis still showed that a cesarean scar defect remained an independent risk factor for chronic endometritis prevalence (OR, 1.571; 95% CI, 1.021-2.418; p = 0.040). The findings were consistent throughout the sensitivity analyses. (4) Conclusions: The present results suggest that the onset of a cesarean scar defect may increase the risk of chronic endometritis.
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Affiliation(s)
- Longlong Wei
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
| | - Chunyu Xu
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
| | - Yan Zhao
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
| | - Cuilian Zhang
- Zhengzhou University People’s Hospital, Zhengzhou 450052, China
- Department of Reproductive Medicine Center, Henan Provincial People’s Hospital, Zhengzhou 450003, China
- Correspondence:
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Kutlucan H, Işık G, Cevher Akdulum MF, Demirdağ E, Erdem Ö, Bozkurt N. Comparison of Two-Dimensional Transvaginal Ultrasound, Three-Dimensional Transvaginal Ultrasound and Hysteroscopy to Diagnose in Patients With Abnormal Uterine Bleeding: A Retrospective Observational Study. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2022. [DOI: 10.1177/87564793221140832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: The principal objective was to compare the diagnostic accuracy of two-dimensional transvaginal ultrasonography (2D TVUS), three-dimensional transvaginal ultrasonography (3D TVUS), and hysteroscopy with histopathology in patients with abnormal uterine bleeding. Materials and Methods: Fifty patients were included and underwent the three imaging methods. The negative predictive value, positive predictive value, sensitivity, and specificity of the methods were calculated. Determination of endometrial pathology and endometrial polyps by measuring the endometrial thickness, volume, and uterine area was examined. Results: The complaint of menorrhagia was reported by 72.0% of participants. Histopathologically, 70.0% of the patients had endometrial polyps and leiomyoma being monitored. An endometrial polyp was detected in 58.0% of the patients by 2D TVUS, 80.0% by 3D TVUS, and 68.0% by hysteroscopy. While 2D TVUS demonstrated 65.71% accuracy in the detection of an endometrial polyp, 3D TVUS had an 80.0% accuracy, and hysteroscopy had a 77.77% accuracy. An endometrial polyp was detected when the uterine area was ≥237 mm2. If the endometrial thickness was over 10.5 mm, it was found to be related to an endometrial polyp. According to the volume measurements by 3D TVUS, the detection of an endometrial polyp was made with 96.4% sensitivity, provided that the pathology volume was ≥0.082 cm3. Conclusion: In this cohort of patients, 3D TVUS achieved a high sensitivity to detect abnormalities and could be considered as an initial diagnostic modality, prior to the surgery, and may rival invasive procedures, such as hysteroscopy.
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Affiliation(s)
- Hazal Kutlucan
- Department of Gynecology and Obstetrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Gizem Işık
- Department of Gynecology and Obstetrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | | | - Erhan Demirdağ
- Department of Gynecology and Obstetrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Özlem Erdem
- Department of Pathology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Nuray Bozkurt
- Department of Gynecology and Obstetrics, Gazi University Faculty of Medicine, Ankara, Turkey
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Ludwin A, Tudorache S, Martins WP. ASRM Müllerian Anomalies Classification 2021: a critical review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:7-21. [PMID: 35678250 DOI: 10.1002/uog.24905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 06/15/2023]
Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - S Tudorache
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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Russo C, Conway F, Siciliano T, Selntigia A, Giuseppe Martire F, Soreca G, Ticconi C, Exacoustos C. 3D transvaginal ultrasound diagnosis of uterine septa according to different classifications: are there other measurements that correlate to reproductive outcome in small indentation length? Facts Views Vis Obgyn 2022; 14:129-138. [DOI: 10.52054/fvvo.14.2.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: High discrepancy between current classifications was observed in the definition of uterine septa, especially for indentation lengths >5 <10mm.
Objectives: To assess the discrepancy between current classifications in the diagnoses of septate uterus and to correlate them with reproductive outcomes; to detect 3D transvaginal ultrasound (TVS) additional measurements, which can better correlate small indentation lengths >5 <10mm to reproductive failures.
Material and methods: Observational study enrolling 664 women of reproductive age with 3D ultrasound diagnosis of an indentation length ≥3mm. For each patient a detailed reproductive history was taken before performing 3D transvaginal examination. Patients with previous uterine surgery or metroplasty were excluded.
Main Outcome Measure(s): Indentation lengths >5 <10mm showed high discrepancy in the diagnosis of uterine septum between different classifications. For these small indentations additional 3D measurements (indentation angle, septal width and septal length/ fundal myometrial thickness (L/M) ratio) were correlated to infertility and recurrent miscarriage.
Results: Among the cohort, 215 patients showed an indentation length >5 <10mm; 136 tried to conceive: 69 (51%) were infertile, 38 (28%) had recurrent miscarriages (≥2) and 5 (4%) had at least one delivery. Recurrent miscarriage significantly correlated to an indentation angle >134°; whereas infertility to an indentation width <32mm and a L/M ratio >75%.
Conclusions: Wide discrepancies between different classifications are more evident in indentation lengths >5 <10mm. Additional measurements on 3D coronal section may help to evaluate the risk of infertility or recurrent miscarriage.
What is new? Additional 3D TVS measurements, beyond septal lengths, in particular for small fundal indentation, may help in predicting the risk of developing adverse reproductive outcomes.
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Tokhunts K, Adamyan M, Chopikyan A, Kayfajyan K, Khudaverdyan A, Tumanyan A. Is I-shaped uterus more common in patients with hyperandrogenism? Eur J Obstet Gynecol Reprod Biol 2022; 272:116-122. [PMID: 35303673 DOI: 10.1016/j.ejogrb.2022.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 02/16/2022] [Accepted: 03/08/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Subtypes of T-shaped uterus are rare uterine cavity anomalies and there are no morphometric criteria for the diagnosis. Earlier we established a high frequency of I-shaped uterus in patients with adrenalhyperandrogenism, which is more common in Armenian populations. The aim of the study was to determine the frequency of I-shaped uterus as a subtype of T-shaped uterus in patients with ovarian and adrenal hyperandrogenism, accompanied by infertility and miscarriage, as well as the development of it's ultrasonic morphometric criteria. STUDY DESIGN We conducted an ultrasound of 486 patients aged 19-40 years (mean 30.1 ± 5.5) who applied for infertility or habitual pregnancy loss.74 of them were diagnosed with the PCOS (Polycystic ovary syndrome) and 43-CAH (congenital adrenal hyperplasia). Ultrasound was performed in early luteal phase. The classification of uterine cavities was carried out according ESHRE/ESGE. RESULTS 299 had normal ultrasound morphology of the uterine cavity, 20.7% various uterine cavity abnormalities. T-shaped uterus was observed in 3.7%, I-shaped uterus exclusively in patients with hyperandrogenism, 24.3% with PCOS and 39.5% with CAH. To determine the relevant morphometric features as diagnostic criteria for the I-shaped uterus some measurements were performed. The values of dist1-dist2 and dist1-dist3 in the normal cavity had a significant difference (P1-2 0.3), also the cavity width in the middle third and the isthmic section did not have a significant difference (P > 0.05), while in the normal cavity shape these values were significantly different (P < 0.05). CONCLUSION Frequency of occurrence of the T-shaped uterus did not exceed that in comparison with a group of women with other causes of infertility, while I-shaped congenital anomaly of the uterine cavity was found in 24.3-39.5% patients with hyperandrogenism. The difference between the interostial and corporal distances and the interostial and isthmic distances was the most relevant morphometric attribute of I-shaped uterus.
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Affiliation(s)
- Karine Tokhunts
- Yerevan State Medical University, Department of Obstetrics-Gynecology, Yerevan, Armenia.
| | - Marianna Adamyan
- Nairi Medical Center, Department of Gynecology, Yerevan, Armenia.
| | - Armine Chopikyan
- Yerevan State Medical University, Department of Public Health And Healthcare Organization, Yerevan, Armenia.
| | | | - Anna Khudaverdyan
- Yerevan State Medical University, Department of Obstetrics-Gynecology, Yerevan, Armenia.
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Diagnosis of Congenital Uterine Abnormalities: Practical Considerations. J Clin Med 2022; 11:jcm11051251. [PMID: 35268343 PMCID: PMC8911320 DOI: 10.3390/jcm11051251] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/03/2022] [Accepted: 02/23/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Peixoto C, Castro M, Carriles I, Arriba MD, Lapresa V, Alcazar JL. Diagnosing Septate Uterus Using Three-Dimensional Ultrasound Using Three Different Classifications: An Interobserver and Intraobserver Agreement Study. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2021; 43:911-918. [PMID: 34933384 PMCID: PMC10183891 DOI: 10.1055/s-0041-1740271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVE Currently, there are up to three different classifications for diagnosing septate uterus. The interobserver agreement among them has been poorly assessed. OBJECTIVE To assess the interobserver agreement of nonexpert sonographers for classifying septate uterus using the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), American Society for Reproductive Medicine (ASRM), and Congenital Uterine Malformations by Experts (CUME) classifications. METHODS A total of 50 three-dimensional (3D) volumes of a nonconsecutive series of women with suspected uterine malformation were used. Two nonexpert examiners evaluated a single 3D volume of the uterus of each woman, blinded to each other. The following measurements were performed: indentation depth, indentation angle, uterine fundal wall thickness, external fundal indentation, and indentation-to-wall-thickness (I:WT) ratio. Each observer had to assign a diagnosis in each case, according to the three classification systems (ESHRE/ESGE, ASRM, and CUME). The interobserver agreement regarding the ESHRE/ESGE, ASRM, and CUME classifications was assessed using the Cohen weighted kappa index (k). Agreement regarding the three classifications (ASRM versus ESHRE/ESGE, ASRM versus CUME, ESHRE/ESGE versus CUME) was also assessed. RESULTS The interobserver agreement between the 2 nonexpert examiners was good for the ESHRE/ESGE (k = 0.74; 95% confidence interval [CI]: 0.55-0.92) and very good for the ASRM and CUME classification systems (k = 0.95; 95%CI: 0.86-1.00; and k = 0.91; 95%CI: 0.79-1.00, respectively). Agreement between the ESHRE/ESGE and ASRM classifications was moderate for both examiners. Agreement between the ESHRE/ESGE and CUME classifications was moderate for examiner 1 and good for examiner 2. Agreement between the ASRM and CUME classifications was good for both examiners. CONCLUSION The three classifications have good (ESHRE/ESGE) or very good (ASRM and CUME) interobserver agreement. Agreement between the ASRM and CUME classifications was higher than that for the ESHRE/ESGE and ASRM and ESHRE/ESGE and CUME classifications.
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Affiliation(s)
- Carla Peixoto
- Department of Obstetrics and Gynecology, Centro Hospitalar São João, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Maite Castro
- Centro de Infertilidad y Reproduccion Humana, Barcelona, Spain
| | - Isabel Carriles
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Maria de Arriba
- Department of Obstetrics and Gynecology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Victoria Lapresa
- Department of Obstetrics and Gynecology, University Hospital, Salamanca, Spain
| | - Juan Luis Alcazar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain
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Marianna A, Karine T, Armine C, Anna K, Hripsime G. The impact of T-shaped uterine cavity anomaly on IVF outcomes: More questions than answers. J Gynecol Obstet Hum Reprod 2021; 51:102293. [PMID: 34929426 DOI: 10.1016/j.jogoh.2021.102293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/15/2021] [Indexed: 10/19/2022]
Abstract
RESEARCH QUESTION The aim of our study was the impact of T-shaped uterine anomaly on in vitro fertilization (per 1 IVF cycle per one embryo transfer) results and pregnancy outcomes. DESIGN Prospective cohort study included 388 somatically healthy patients at the age of 20-40 years old who underwent 3-dimensional ultrasound of uterine cavity before embryo transfer. The uterine cavities were classified based on morphometric criteria according to the CUME study. The comparison was performed between patients with normal uterine cavity (n = 266), patients with T-shaped anomaly of uterine cavity (n = 27), intermediate forms of T-shaped anomaly (n = 73), and patients with other uterine anomalies (n = 22). RESULTS The rates of biochemical pregnancy in Normal, T-shaped, Intermediate and Other groups were 58.6%, 51.9% 52.1% and 45.4%, respectively, but there weren't detected statistically significant differences (P > 0.05). CONCLUSIONS T-shaped uterus did not affect the percentage of occurring pregnancy, but was associated with increased rate of preterm deliveries, miscarriages and ectopic pregnancy. No differences in occurrence of pregnancy rates in cases of intermediate types, but an increased number of preterm deliveries and miscarriages in cases with increased myometrial thickness in lateral angle area.
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Affiliation(s)
- Adamyan Marianna
- Department of gynecology, Nairi Medical Center, Yerevan, Armenia.
| | - Tokhunts Karine
- Department of obstetrics-gynecology, Yerevan State Medical University, Yerevan, Armenia
| | - Chopikyan Armine
- Department of public health and healthcare organization, Yerevan State Medical University, Yerevan, Armenia
| | - Khudaverdyan Anna
- Department of obstetrics and gynecology, Yerevan State Medical University, Yerevan, Armenia.
| | - Grigoryan Hripsime
- Assistant of the Department of Obstetrics-Gynecology and Reproductive Health, NIH, Yerevan, Armenia.
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13
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Grigore M, Popovici R, Himiniuc LM, Scripcariu IS, Toma BF, Grigore AM, Oancea M, Micu R. The added value of three-dimensional ultrasonography in uterine pathology. Exp Ther Med 2021; 22:1261. [PMID: 34603529 DOI: 10.3892/etm.2021.10696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/30/2021] [Indexed: 11/06/2022] Open
Abstract
The rapid development achieved over the last decades in volume rendering of ultrasound data, known as three-dimensional (3D) ultrasound technique, leads to new opportunities for refining the diagnosis in many gynaecologic conditions. The aim of the present study was to evaluate the advantages of 3D ultrasound over two-dimensional (2D) ultrasound in uterine pathology and to establish the optimal time point during the menstrual cycle to perform 3D ultrasound examination in order to achieve the maximum of useful information. A cross-sectional study on 200 patients who underwent gynaecologic 2D and 3D ultrasound examinations was performed. The addition of 3D examination to 2D ultrasound in uterine pathology provided the most useful information concerning: Congenital uterine anomalies, intrauterine devices (IUDs), adenomyosis, and submucous myomas. The findings showed that the 3D ultrasound scan is a useful tool in gynaecology, especially in cases with congenital uterine anomalies, myoma, and IUD. Although initially it was used for research purposes only, recent findings suggest its usefulness in routine ultrasound scan and the possibility of witnessing its introduction as a recommended examination procedure in the foreseeable future. Further research should be conducted in order to establish the sensitivity of 3D ultrasound in the detection of minor endometrial conditions, by correlating the imaging findings with the hysteroscopic results.
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Affiliation(s)
- Mihaela Grigore
- Department of Obstetrics and Gynaecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania.,Clinical Hospital of Obstetrics and Gynaecology, 'Cuza Voda', 700038 Iasi, Romania
| | - Razvan Popovici
- Department of Obstetrics and Gynaecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania.,Clinical Hospital of Obstetrics and Gynaecology, 'Cuza Voda', 700038 Iasi, Romania
| | - Loredana Maria Himiniuc
- Department of Obstetrics and Gynaecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania.,Clinical Hospital of Obstetrics and Gynaecology, 'Cuza Voda', 700038 Iasi, Romania
| | - Ioana Sadiye Scripcariu
- Department of Obstetrics and Gynaecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania.,Clinical Hospital of Obstetrics and Gynaecology, 'Cuza Voda', 700038 Iasi, Romania
| | - Bogdan Florin Toma
- Department of Obstetrics and Gynaecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania.,Clinical Hospital of Obstetrics and Gynaecology, 'Cuza Voda', 700038 Iasi, Romania
| | - Ana Maria Grigore
- Department of Obstetrics and Gynaecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihaela Oancea
- Department of Obstetrics and Gynaecology, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Romeo Micu
- Department of Obstetrics and Gynaecology, 'Iuliu Hatieganu' University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
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14
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Detti L, Peregrin-Alvarez I, Roman RA, Levi D'Ancona R, Gordon JC, Christiansen ME. A comparison of four systems for uterine septum diagnosis and indication for surgical correction. Minerva Obstet Gynecol 2021; 73:376-383. [PMID: 34008393 DOI: 10.23736/s2724-606x.21.04789-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Existing guidelines do not settle on a specific length to indicate surgical incision of subseptations because of differences in the four published diagnostic methods: AFS-10 mm classification, 1988/2003, ESHRE-ESGE classification, 2013, ASRM criteria, 2016- and 5.9-mm length cut-off, 2017. With this review and data analysis we sought to identify the classification method with the most accurate association with early pregnancy loss, as to identify a subseptation length cut-off to indicate surgical correction. EVIDENCE ACQUISITION We performed an exhaustive literature search of PubMed (MEDLINE), Embase, and Cochrane Library databases until April 20, 2020 (limited to articles published in English) of the terms "uterine septum," "arcuate uterus," "subseptation," "Müllerian anomalies," from 1980-2020. After identifying all the available classifications for uterine subseptations, we performed a secondary data analysis of our departmental database on uterine subseptations and compared the identified classification criteria. Measurement of the subseptation's length was obtained on 2-D and 3-D ultrasound in accordance with the different methods. The incidence of uterine subseptations according to each method's specifications was compared among the groups and the association with pregnancy loss was evaluated. EVIDENCE SYNTHESIS The database comprised 125 women with uterine subseptations and all four diagnostic systems identified septate uteri within it. The 5.9-mm cut-off diagnosed 89 septate, and 36 normal uteri and was the most inclusive while the ASRM cut-off was the most restrictive one, diagnosing 92/125 as arcuate uteri, only 8/125 as septate, and 25 in the gray zone. The AFS-10 mm criteria diagnosed 92/125 as arcuate, and 33 (26.4%) as septate uteri. Subseptations were inconsistently diagnosed by the ESHRE-ESGE classification, as some subseptations longer than 10 mm would be classified as normal uteri. Five/24 women had had one previous early loss and 19/24 had recurrent pregnancy loss. The 5.9-mm system was the most sensitive, while the ASRM was the least sensitive in predicting pregnancy loss (71.2% vs. 9.5% of septate uteri). CONCLUSIONS The proposed 5.9-mm cut-off was the most sensitive in diagnosing a septate uterus and in predicting an associated early pregnancy loss. Conversely, the AFS-10 mm and the ASRM were the most restrictive, potentially missing treatment for hazardous subseptations. This update highlights the major weaknesses in the current diagnosis of uterine subseptations and indication for surgical treatment. Standardization of clinical practice is essential for reproductive clinicians and efforts should be made to prevent even one further early pregnancy loss to uterine subseptations.
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Affiliation(s)
- Laura Detti
- Department of Subspecialty Care for Women's Health, Ob/Gyn Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA -
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, USA -
| | - Irene Peregrin-Alvarez
- Department of Subspecialty Care for Women's Health, Ob/Gyn Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, USA
| | - Robert A Roman
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Augusta University, Augusta, GA, USA
| | - Roberto Levi D'Ancona
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Jennifer C Gordon
- Department of Obstetrics and Gynecology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Mary E Christiansen
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN, USA
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15
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Cekdemir YE, Mutlu U, Acar D, Altay C, Secil M, Dogan OE. The accuracy of three-dimensional ultrasonography in the diagnosis of Müllerian duct anomalies and its concordance with magnetic resonance imaging. J OBSTET GYNAECOL 2021; 42:67-73. [PMID: 33938374 DOI: 10.1080/01443615.2021.1877646] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
This retrospective study was performed to comparatively evaluate the diagnostic accuracies of three-dimensional ultrasonography (3D-US) and magnetic resonance imaging (MRI) for identification of Müllerian duct anomalies (MDAs). A total of 27 women with suspected MDAs underwent gynaecological examination, 2D-US, 3D-US and MRI, respectively. The MDAs were classified with respect to the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE/ESGE) and American Society of Reproductive Medicine (ASRM) systems. Based on the ESHRE/ESGE classification, there was a discrepancy for only one patient between US and MRI. Thus, the concordance between US and MRI was 26/27 (96.3%). With respect to ASRM classification, there was a disagreement between MRI and 3D-US in three patients, thus the concordance between MRI and 3D-US was 24/27 (88.9%). To conclude, the 3D-US has a good level of agreement with MRI for recognition of MDAs.Impact StatementWhat is already known on this subject? Müllerian duct anomalies (MDAs) are relatively common malformations of the female genital tract and they may adversely affect the reproductive potential. The establishment of accurate and timely diagnosis of these malformations is critical to overcome clinical consequences of MDAs.What the results of this study add? The concordance between US and MRI for diagnosis of MDAs based on ESHRE-ESGE classification and ASRM were 96.3% and 88.9%, respectively. These results indicate that 3D US has a satisfactory level of diagnostic accuracy for MDAs and it can be used in conjunction with MRI. Minimisation of diagnostic errors is important to improve reproductive outcome and to avoid unnecessary surgical interventions.What the implications are of these findings for clinical practice and/or further research? Efforts must be spent to eliminate the discrepancies between the clinical and radiological diagnosis of MDAs. Further trials should be implemented for establishment and standardisation of radiological images for identification and classification of MDAs.
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Affiliation(s)
- Yasin Ertug Cekdemir
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Uygar Mutlu
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Demet Acar
- Department of Obstetrics and Gynecology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Canan Altay
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Mustafa Secil
- Department of Radiology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
| | - Omer Erbil Dogan
- Department of Obstetrics and Gynecology, Dokuz Eylül University Faculty of Medicine, Izmir, Turkey
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16
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Catena U, Campo R, Bolomini G, Moruzzi M, Verdecchia V, Nardelli F, Romito I, Camolo F, La Manna V, Ianieri M, Scambia G, Testa A. New approach for T-shaped uterus: Metroplasty with resection of lateral fibromuscular tissue using a 15 Fr miniresectoscope. A step-by-step technique. Facts Views Vis Obgyn 2021. [DOI: 10.52054/fvvo.13.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
T-shaped uterus is a congenital uterine malformation (CUM), only recently defined by the ESGE ESHRE classification as Class U1a. The uterus is characterised by a narrow uterine cavity due to thickened lateral walls with a correlation 2/3 uterine corpus and 1/3 cervix (Grimbizis et al, 2013). Although the significance of this dysmorphic malformation on reproductive performance has been questioned, recent studies reported significant improvement of life birth rates after surgical correction in patients with failed in-vitro fertilisation (IVF) or recurrent miscarriage (Ferro et al, 2018; Di Spiezio Sardo et al, 2020; Alonso Pacheco et al. 2019). The classical surgical technique to treat a T-shaped uterus is by performing a sidewall incision with the micro scissor or bipolar needle, resulting in a triangular cavity.
In this video article, we describe a new surgical technique with a step-by-step method combining three-dimensional ultrasound (3D-US) and hysteroscopic metroplasty in an office setting, using a 15 Fr office resectoscope (Karl Storz, Tuttlingen, Germany), to treat a T-shaped uterus by resecting the lateral fibromuscular tissue of the uterine walls. No complications occurred and the postoperative hysteroscopy showed a triangular and symmetrical uterine cavity without any adhesions.
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Affiliation(s)
- U. Catena
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - R. Campo
- Department of Obstetrics and Gynecology, ZOL Hospitals, Genk, Belgium
| | - G. Bolomini
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - M.C. Moruzzi
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - V. Verdecchia
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - F. Nardelli
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - I. Romito
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - F. Camolo
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - V. La Manna
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - M.M. Ianieri
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - G. Scambia
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy; Istituto di Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A.C. Testa
- Department of Women’s and Children’s Health, Fondazione Policlinico Universitario “A. Gemelli”- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy; 3Istituto di Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, Rome, Italy
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17
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Catena U, Campo R, Bolomini G, Moruzzi MC, Verdecchia V, Nardelli F, Romito I, Camolo F, La Manna V, Ianieri MM, Scambia G, Testa AC. New approach for T-shaped uterus: Metroplasty with resection of lateral fibromuscular tissue using a 15 Fr miniresectoscope. A step-by-step technique. Facts Views Vis Obgyn 2021; 13:67-71. [PMID: 33889862 PMCID: PMC8051189 DOI: 10.52054/fvvo.13.1.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
T-shaped uterus is a congenital uterine malformation (CUM), only recently defined by the ESGE ESHRE classification as Class U1a. The uterus is characterised by a narrow uterine cavity due to thickened lateral walls with a correlation 2/3 uterine corpus and 1/3 cervix. Although the significance of this dysmorphic malformation on reproductive performance has been questioned, recent studies reported significant improvement of life birth rates after surgical correction in patients with failed in-vitro fertilisation (IVF) or recurrent miscarriage. The classical surgical technique to treat a T-shaped uterus is by performing a sidewall incision with the micro scissor or bipolar needle, resulting in a triangular cavity. In this video article, we describe a new surgical technique with a step-by-step method combining three- dimensional ultrasound (3D-US) and hysteroscopic metroplasty in an office setting, using a 15 Fr office resectoscope (Karl Storz, Tuttlingen, Germany), to treat a T-shaped uterus by resecting the lateral fibromuscular tissue of the uterine walls. No complications occurred and the postoperative hysteroscopy showed a triangular and symmetrical uterine cavity without any adhesions.
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Affiliation(s)
- U Catena
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - R Campo
- Department of Obstetrics and Gynecology, ZOL Hospitals, Genk, Belgium
| | - G Bolomini
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - M C Moruzzi
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - V Verdecchia
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - F Nardelli
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - I Romito
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - F Camolo
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - V La Manna
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - M M Ianieri
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy
| | - G Scambia
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy.,Istituto di Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, Rome, Italy
| | - A C Testa
- Department of Women's and Children's Health, Fondazione Policlinico Universitario "A. Gemelli"- IRCCS, Largo Francesco Vito 1, 00168, Rome, Italy.,Istituto di Ginecologia e Ostetricia, Università Cattolica del Sacro Cuore, Rome, Italy
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18
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Odibo AO. UOG now and beyond! ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:7-8. [PMID: 33387409 DOI: 10.1002/uog.23567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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19
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Detti L, Christiansen ME, Levi D’Ancona R, Gordon JC, Van de Velde N, Peregrin-Alvarez I. Restoration of Uterine Cavity Measurements after Surgical Correction. J Imaging 2020; 6:58. [PMID: 34460651 PMCID: PMC8321055 DOI: 10.3390/jimaging6070058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
Objective: We sought to define the uterine and uterine cavity dimensions of subseptate uteri before and after hysteroscopic surgical incision, and compare them to those obtained in normal uteri with 3-D ultrasound. Methods: Two cohorts of consecutive women with normal-appearing uterine cavity and women diagnosed with uterine subseptations, before and after undergoing hysteroscopic incision. 3-D ultrasound was used to measure the uterine cavity width, length, and area on a frozen coronal view of the uterus. Results: A total of 215 women were included: 89 in the normal, and 126 in the subseptate uterus, groups. Uterine length and height were similar in the pre-operative, post-operative subseptate uteri, and in the normal uteri, while the uterine width was significantly greater in the pre-operative (5.1 + 0.8 cm) than post-operative (4.7 + 0.8 cm) and normal uterus (4.6 + 0.7 cm; p < 0.001) groups. The pre-operative uterine cavity length (3.3 + 0.5 cm), width (3.2 + 0.7 cm), and area (4.4 + 1.2 cm2), were significantly greater than the post-operative ones (length 2.9 + 0.4 cm; width 2.6 + 0.6 cm; area 3.7 + 0.8 cm; overall p < 0.001), and became similar to the dimensions of the normal uterus. Of the patients who subsequently conceived, 2.6% miscarried in the corrected subseptation group and 28.8% miscarried in the normal uterus group. Conclusions: We defined the ultrasound dimensions of the uterine cavity in subseptate uteri and their change after surgical correction. Uterine cavity length, width, and area show very little variability in adult normal uteri, while they are increased in uteri with a subseptation greater than 5.9 mm in length, and regain normal measurements after surgical correction.
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Affiliation(s)
- Laura Detti
- Cleveland Clinic, Department of Subspecialty Care for Women’s Health, Ob/Gyn Women’s Health Institute, Cleveland, OH 44195, USA
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Mary Emily Christiansen
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Roberto Levi D’Ancona
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Jennifer C. Gordon
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Nicole Van de Velde
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
| | - Irene Peregrin-Alvarez
- Department of Obstetrics and Gynecology, University of Tennessee Health Science Center, Memphis, TN 38163, USA; (M.E.C.); (R.L.D.); (J.C.G.); (N.V.d.V.); (I.P.-A.)
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Ludwin A, Coelho Neto MA, Ludwin I, Nastri CO, Costa W, Acién M, Alcazar JL, Benacerraf B, Condous G, DeCherney A, De Wilde RL, Diamond MP, Emanuel MH, Guerriero S, Hurd W, Levine D, Lindheim S, Pellicer A, Petraglia F, Saridogan E, Martins WP. Congenital Uterine Malformation by Experts (CUME): diagnostic criteria for T-shaped uterus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:815-829. [PMID: 31432589 DOI: 10.1002/uog.20845] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 06/23/2019] [Accepted: 08/01/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To identify uterine measurements that are reliable and accurate to distinguish between T-shaped and normal/arcuate uterus, and define T-shaped uterus, using Congenital Uterine Malformation by Experts (CUME) methodology, which uses as reference standard the decision made most often by several independent experts. METHODS This was a prospectively planned multirater reliability/agreement and diagnostic accuracy study, performed between November 2017 and December 2018, using a sample of 100 three-dimensional (3D) datasets of different uteri with lateral uterine cavity indentations, acquired from consecutive women between 2014 and 2016. Fifteen representative experts (five clinicians, five surgeons and five sonologists), blinded to each others' opinions, examined anonymized images of the coronal plane of each uterus and provided their independent opinion as to whether it was T-shaped or normal/arcuate; this formed the basis of the CUME reference standard, with the decision made most often (i.e. that chosen by eight or more of the 15 experts) for each uterus being considered the correct diagnosis for that uterus. Two other experienced observers, also blinded to the opinions of the other experts, then performed independently 15 sonographic measurements, using the original 3D datasets of each uterus. Agreement between the diagnoses made by the 15 experts was assessed using kappa and percent agreement. The interobserver reliability of measurements was assessed using the concordance correlation coefficient (CCC). The diagnostic test accuracy was assessed using the area under the receiver-operating-characteristics curve (AUC) and the best cut-off value was assessed by calculating Youden's index, according to the CUME reference standard. Sensitivity, specificity, negative and positive likelihood ratios (LR- and LR+) and post-test probability were calculated. RESULTS According to the CUME reference standard, there were 20 T-shaped and 80 normal/arcuate uteri. Individual experts recognized between 5 and 35 (median, 19) T-shaped uteri on subjective judgment. The agreement among experts was 82% (kappa = 0.43). Three of the 15 sonographic measurements were identified as having good diagnostic test accuracy, according to the CUME reference standard: lateral indentation angle (AUC = 0.95), lateral internal indentation depth (AUC = 0.92) and T-angle (AUC = 0.87). Of these, T-angle had the best interobserver reproducibility (CCC = 0.87 vs 0.82 vs 0.62 for T-angle vs lateral indentation depth vs lateral indentation angle). The best cut-off values for these measurements were: lateral indentation angle ≤ 130° (sensitivity, 80%; specificity, 96%; LR+, 21.3; LR-, 0.21), lateral indentation depth ≥ 7 mm (sensitivity, 95%; specificity, 77.5%; LR+, 4.2; LR-, 0.06) and T-angle ≤ 40° (sensitivity, 80%; specificity, 87.5%; LR+, 6.4; LR-, 0.23). Most of the experts diagnosed the uterus as being T-shaped in 0% (0/56) of cases when none of these three criteria was met, in 10% (2/20) of cases when only one criterion was met, in 50% (5/10) of cases when two of the three criteria were met, and in 93% (13/14) of cases when all three criteria were met. CONCLUSIONS The diagnosis of T-shaped uterus is not easy; the agreement among experts was only moderate and the judgement of individual experts was commonly insufficient for accurate diagnosis. The three sonographic measurements with cut-offs that we identified (lateral internal indentation depth ≥ 7 mm, lateral indentation angle ≤ 130° and T-angle ≤ 40°) had good diagnostic test accuracy and fair-to-moderate reliability and, when applied in combination, they provided high post-test probability for T-shaped uterus. In the absence of other anomalies, we suggest considering a uterus to be normal when none or only one criterion is met, borderline when two criteria are met, and T-shaped when all three criteria are met. These three CUME criteria for defining T-shaped uterus may aid in determination of its prevalence, clinical implications and best management and in the assessment of post-surgical morphologic outcome. The CUME definition of T-shaped uterus may help in the development of interventional randomized controlled trials and observational studies and in the diagnosis of uterine morphology in everyday practice, and could be adopted by guidelines on uterine anomalies to enrich their classification systems. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - M A Coelho Neto
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - C O Nastri
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - W Costa
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - M Acién
- San Juan University Hospital/Miguel Hernández University, Alicante, Spain
| | - J L Alcazar
- Department of Obstetrics and Gynecology, University of Navarra, Pamplona, Spain
| | | | - G Condous
- Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - A DeCherney
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - R-L De Wilde
- Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - M P Diamond
- Department of Obstetrics & Gynecology, Augusta University, Augusta, GA, USA
| | - M H Emanuel
- Department of Gynaecology and Reproductive Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Gynaecology, University Hospital Ghent, Ghent, Belgium
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
| | - W Hurd
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - D Levine
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - S Lindheim
- Department of Obstetrics & Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
| | - A Pellicer
- Instituto Valenciano de Infertilidad, Valencia, Spain
| | | | - E Saridogan
- University College London Hospital, London, UK
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynaecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
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Ludwin A, Ludwin I, Coelho Neto MA, Nastri CO, Bhagavath B, Lindheim SR, Martins WP. Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare systems. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:800-814. [PMID: 30977223 DOI: 10.1002/uog.20291] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 03/05/2019] [Accepted: 04/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES To estimate the differences in frequency of diagnosis of septate uterus using three different definitions and determine whether these differences are significant in clinical practice, and to examine the association between diagnosis of septate uterus, using each of the three definitions, and infertility and/or previous miscarriage as well as the cost of allocation to surgery. METHODS This was a secondary analysis of data from a prospective study of 261 consecutive women of reproductive age attending a private clinic focused on the diagnosis and treatment of congenital uterine malformations. Reanalysis of the datasets was performed according to three different means of defining septate uterus: following the recommendations of the American Society for Reproductive Medicine (ASRM), a 2016 update of those of the American Fertility Society from 1988 (ASRM-2016: internal fundal indentation depth ≥ 1.5 cm, angle of internal indentation < 90° and external indentation depth < 1 cm); following the recommendations of the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy (ESHRE/ESGE), published in 2013 and reaffirmed in 2016 (ESHRE/ESGE-2016: internal fundal/uterine indentation depth > 50% of uterine-wall thickness and external indentation depth < 50% of uterine-wall thickness, with uterine-wall thickness measured above interostial/intercornual line); and using a definition published last year which was based on the decision made most often by a group of experts (Congenital Uterine Malformation by Experts; CUME) (CUME-2018: internal fundal indentation depth ≥ 1 cm and external fundal indentation depth < 1 cm). We compared the rate of diagnosis of septate uterus using each of these three definitions and, for each, we estimated the association between the diagnosis and infertility and/or previous miscarriage, and anticipated the costs associated with their implementation using a guesstimation method. RESULTS Although 32.6% (85/261) of the subjects met the criteria for one of the three definitions of septate uterus, only 2.7% (7/261) of them were defined as having septate uterus according to all three definitions. We diagnosed significantly more cases of septate uterus using ESHRE/ESGE-2016 than using ASRM-2016 (31% vs 5%, relative risk (RR) = 6.7, P < 0.0001) or CUME-2018 (31% vs 12%, RR = 2.6, P < 0.0001) criteria. We also observed frequent cases that could not be classified definitively by ASRM-2016 (gray zone: neither normal/arcuate nor septate; 6.5%). There were no significant differences (P > 0.05) in the prevalence of septate uterus in women with vs those without infertility according to ASRM-2016 (5% vs 4%), ESHRE/ESGE-2016 (35% vs 28%) or CUME-2018 (11% vs 12%). Septate uterus was diagnosed significantly more frequently in women with vs those without previous miscarriage according to ASRM-2016 (11% vs 3%; P = 0.04) and CUME-2018 (22 vs 10%; P = 0.04), but not according to ESHRE/ESGE-2016 (42% vs 28%; P = 0.8) criteria. Our calculations showed that global costs to the healthcare system would be highly dependent on the criteria used in the clinical setting to define septate uterus, with the costs associated with the ESHRE/ESGE-2016 definition potentially being an extra US$ 100-200 billion over 5 years in comparison to ASRM-2016 and CUME-2018 definitions. CONCLUSIONS The prevalence of septate uterus according to ESHRE/ESGE-2016, ASRM-2016 and CUME-2018 definitions differs considerably. An important limitation of the ASRM classification, which needs to be addressed, is the high proportion of unclassifiable cases originally named, by us, the 'gray zone'. The high rate of overdiagnosis of septate uterus according to ESHRE/ESGE-2016 may lead to unnecessary surgery and therefore unnecessary risk in these women and may impose a considerable financial burden on healthcare systems. Efforts to define clinically meaningful and universally applicable criteria for the diagnosis of septate uterus should be encouraged. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - M A Coelho Neto
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - C O Nastri
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - B Bhagavath
- Department of Obstetrics and Gynecology, School of Medicine and Dentistry, University of Rochester Medical Center, Rochester, NY, USA
| | - S R Lindheim
- Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
- Shanghai Jiaotong University School of Medicine, Shanghai, People's Republic of China
| | - W P Martins
- Department of Obstetrics and Gynecology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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Akhtar MA, Saravelos SH, Li TC, Jayaprakasan K. Reproductive Implications and Management of Congenital Uterine Anomalies: Scientific Impact Paper No. 62 November 2019. BJOG 2019; 127:e1-e13. [PMID: 31749334 DOI: 10.1111/1471-0528.15968] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Congenital uterine anomalies (CUAs) are malformations of the womb that develop during fetal life. When a baby girl is in her mother's womb, her womb develops as two separate halves from two tubular structures called 'müllerian ducts', which fuse together before she is born. Abnormalities that occur during the baby's development can be variable from complete absence of a womb through to more subtle anomalies, which are classified into specific categories. While conventional ultrasound is good in screening for CUAs, 3D ultrasound is used to confirm a diagnosis. If a complex womb abnormality is suspected, MRI scanning may also be used, with a combination of laparoscopy in which a camera is inserted into the cavity of the abdomen, and hysteroscopy, when the camera is placed in the womb cavity. As there can be a link between CUAs and abnormalities of the kidney and bladder, scans of these organs are also usually requested. Although CUAs are present at birth, adult women typically do not have any symptoms, although some may experience painful periods. Most cases of CUA do not cause a woman to have difficulty in becoming pregnant and the outcome of pregnancy is good. However, these womb anomalies are often discovered during investigations for infertility or miscarriage. Moreover, depending upon the type and severity of CUA, there may be increased risk of first and second trimester miscarriages, preterm birth, poor growth of the baby in the mother's womb (fetal growth restriction), pre-eclampsia and difficult positioning of the baby for birth (fetal malpresentation). Surgical treatment is only recommended to a woman who has had recurrent miscarriages and has a septate uterus, i.e., the womb cavity is divided by a partition. In this case, surgery may improve her chances for a successful pregnancy, although the risks of surgery, especially scarring of the womb should be considered. However, further evidence from randomised controlled trials are required to provide conclusive evidence-based recommendations for surgical treatment for septate uterus. Surgical treatment for other types of CUAs is not usually recommended as the risks outweigh potential benefits, and evidence for any benefits is lacking. Women with CUAs may be at an increased risk of preterm birth even after surgical treatment for a septate uterus. These women, if suspected to be at an increased risk of preterm birth based on the severity of CUA, should be followed up using an appropriate protocol for preterm birth as outlined in UK Preterm Birth Clinical Network Guidance.1 >.
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du Fossé N, van der Hoorn ML, Eikmans M, Heidt S, le Cessie S, Mulders A, van Lith J, Lashley E. Evaluating the role of paternal factors in aetiology and prognosis of recurrent pregnancy loss: study protocol for a hospital-based multicentre case-control study and cohort study (REMI III project). BMJ Open 2019; 9:e033095. [PMID: 31727666 PMCID: PMC6887057 DOI: 10.1136/bmjopen-2019-033095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Recurrent pregnancy loss (RPL) is defined as the spontaneous demise of two or more pregnancies before the fetus reaches viability. Despite investigation of multiple known maternal risk factors, in more than 50% of couples, this condition remains unexplained. Studies focusing on paternal factors in RPL are scarce, and therefore, paternal evaluation in RPL is currently very limited. However, regarding single miscarriage, there are multiple publications suggesting a contributive role of paternal factors. In this project, we aim to identify paternal factors associated with RPL and to improve couple-specific prediction of future pregnancy outcomes by developing a prediction model containing both maternal and paternal factors. METHODS AND ANALYSIS In a case-control design, the relation between unexplained RPL and paternal age, lifestyle factors, sperm DNA damage and immunomodulatory factors in peripheral blood and semen will be studied. Prospectively, 135 couples with naturally conceived unexplained RPL (cases) and 135 fertile couples without a history of pregnancy loss (controls) will be included, with collection of paternal blood and semen samples and documentation of clinical and lifestyle characteristics. In addition, 600 couples from both groups will be included retrospectively. To adjust for confounders, multivariate logistic regression will be used. The predictive value of paternal and maternal factors will be studied in the total RPL cohort consisting of approximately 735 couples. The primary outcome of the cohort study is live birth within 5 years after initial visit of the clinic. Secondary outcomes are ongoing pregnancy, time interval until next pregnancy and pregnancy complications. ETHICS AND DISSEMINATION This project is approved by the Medical Research Ethics Committee of the Leiden University Medical Center. No risks or burden are expected from the study. The findings of this study will be disseminated via peer-reviewed publications and presentations at international conferences. TRIAL REGISTRATION NUMBER NL7762.
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Affiliation(s)
- Nadia du Fossé
- Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Michael Eikmans
- Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Sebastiaan Heidt
- Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - Saskia le Cessie
- Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Annemarie Mulders
- Gynaecology and Obstetrics, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan van Lith
- Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Eileen Lashley
- Gynaecology and Obstetrics, Leiden University Medical Center, Leiden, The Netherlands
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Abstract
INTRODUCTION Endometriosis is a common disease in women of reproductive age. In addition to causing pain, it may also reduce fertility. The coexistence of endometriosis and congenital uterine anomalies (CUA) has been frequently reported in the published literature. The present report is a review of existing studies on the subject and our own hitherto unpublished data. EVIDENCE ACQUISITION The electronic search was conducted using the Pubmed database with specific keyword combinations including endometriosis, adenomyosis, infertility, Müllerian malformations/anomalies, and septate uterus. The principal aspects addressed in the present study were: diagnosis, management, and classification of CUA, their impact on fertility and coexistence with endometriosis. EVIDENCE SYNTHESIS Endometriosis and CUA are frequently detected in the exploration of infertility, because both of these are liable to impair fertility. Endometriosis is associated with obstructive anomalies and nonobstructive malformations, especially those concerning the septate uterus. The diagnosis and management of CUA have been discussed for several years. Various classification systems have been proposed. CONCLUSIONS The analysis of the existing literature has revealed the absence of any consensus about the management, diagnosis, and classification of CUA, especially with regard to the septate uterus. We need to find and speak a common language in order to avoid inappropriate or unnecessary surgery and optimize the individual patient's treatment. The combined presence of endometriosis or adenomyosis and CUA is a reason to perform precise diagnostic imaging investigations and early surgery for the purpose of enhancing the chances of pregnancy in infertile patients. Further research is needed on the subject.
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Affiliation(s)
- Damaris Freytag
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Liselotte Mettler
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Nicolai Maass
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Veronika Günther
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany
| | - Ibrahim Alkatout
- Clinic for Obstetrics and Gynecology, UKSH Campus Kiel, Kiel, Germany -
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Using game controller as position tracking sensor for 3D freehand ultrasound imaging. Med Biol Eng Comput 2019; 58:889-902. [DOI: 10.1007/s11517-019-02044-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/26/2019] [Indexed: 11/28/2022]
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Reproductive surgery for müllerian anomalies: a review of progress in the last decade. Fertil Steril 2019; 112:408-416. [DOI: 10.1016/j.fertnstert.2019.07.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/21/2022]
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Şimşek D, Güven Ç, Şahin Ç, Akdemir A, Ergenoğlu AM, Yeniel AÖ, Şendağ F. Histeroskopik septoplasti sonrası gebelik sonuçları ve farklı cerrahi tekniklerin karşılaştırılması: Retrospektif kohort çalışma. EGE TIP DERGISI 2019. [DOI: 10.19161/etd.416612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Three-dimensional ultrasound in the diagnosis and the classification of congenital uterine anomalies using the ESHRE/ESGE classification: a diagnostic accuracy study. Arch Gynecol Obstet 2019; 299:779-789. [DOI: 10.1007/s00404-019-05050-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Accepted: 01/05/2019] [Indexed: 10/27/2022]
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Pleş L, Alexandrescu C, Ionescu CA, Arvătescu CA, Vladareanu S, Moga MA. Three-dimensional scan of the uterine cavity of infertile women before assisted reproductive technology use. Medicine (Baltimore) 2018; 97:e12764. [PMID: 30313087 PMCID: PMC6203555 DOI: 10.1097/md.0000000000012764] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The primary objective was to assess the utility of routine 3-dimensional (3D) ultrasound in the evaluation of infertile women and to estimate the prevalence of uterine anomalies before the use of assisted reproductive technology (ART), using the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy classification system. A second objective was to assess the effect of uterine anomalies on the pregnancy rate in patients who underwent assisted reproductive techniques.We retrospectively studied 668 patients treated in the Department Obstetrics Gynecology and Neonatology "Sf Ioan" Clinical Emergency Hospital and in the Department of Medical and Surgical Specialties, Faculty of Medicine "'Transilvania" University of Brasov between July 2016 and February 2017 for subfertility. Patients were examined using 2-dimensional (2D) and 3-dimensional (3D) transvaginal ultrasound. Müllerian duct anomalies were present in 6.13% of patients, with the most common anomaly being a dysmorphic uterus (class U1c in 42.68% of patients), 17 patients (20.73%) with incompletely septate uterus (class U2a), 12 patients (14.63%) with a completely septate uterus (classU2b), 8 patients (9.75%) with a partly bicorporeal uterus (classU3a), and 6 patients (7.31%) with a completely bicorporeal uterus (class U3b). Only 1 (1.21%) patient had an aplastic uterus without a rudimentary cavity (class U5b). The pregnancy rate in the presence of uterine anomalies was 55% and the pregnancy rate in control group patients was 39.8%. The incidence of pregnancy in the group with uterine anomalies was statistically similar with the control group of normal uterus (P < .11). For ongoing pregnancy rate and live birth rate, our data indicated a slightly elevated rate for both of those indexes in the anomalies group. The incidence of miscarriage in the presence of uterine anomalies was 24% and 6.7% in the control group, which is statistically significant (P = .05).3D ultrasound evaluation of the uterus should be considered before ART in order to make an accurate diagnosis of the uterine congenital anomaly and improve ART results.
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Affiliation(s)
- Liana Pleş
- University of Medicine and Pharmacy, “Carol Davila” Department of Obstetrics Gynecology, “Sf Ioan” Clinical Emergency Hospital, Bucharest
| | | | - Cringu Antoniu Ionescu
- University of Medicine and Pharmacy, “Carol Davila” Department of Obstetrics Gynecology, “Sf Pantelimon” Clinical Emergency Hospital, Bucharest
| | - Cristian Andrei Arvătescu
- Department of Medical and Surgical Specialties, Faculty of Medicine, “Transilvania” University of Brasov, Brasov
| | - Simona Vladareanu
- University of Medicine and Pharmacy, “Carol Davila”, Department of Obstetrics Gynecology, Elias Emergency Clinical Hospital, Bucharest, Romania
| | - Marius Alexandru Moga
- Department of Medical and Surgical Specialties, Faculty of Medicine, “Transilvania” University of Brasov, Brasov
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ESHRE-ESGE versus ASRM classification in the diagnosis of septate uterus: a retrospective study. Arch Gynecol Obstet 2018; 298:845-850. [PMID: 30159673 DOI: 10.1007/s00404-018-4878-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND The European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE-ESGE) system is designed mainly for clinical orientation; its overdiagnosis of septate uteri was confirmed in a general population in comparison to the American Society of Reproductive Medicine (ASRM) supplemental classification proposed by Ludwin. However, the agreement among septate uterus recognition using the ESHRE-ESGE and the supplemental ASRM classifications and the rate of overdiagnosis of septate uterus by ESHRE-ESGE in infertile women remain unclear. METHODS We conducted a retrospective study of 53,540 infertile patients in our reproductive centre from June 2013 to December 2016, to compare septate uterus recognition using three systems. The data were analysed by the ESHRE-ESGE system, the ASRM by Salim and the ASRM by Ludwin separately. The concordance of diagnoses of septate uteri using these three systems was compared. RESULTS ESHRE-ESGE classification significantly increased the frequency of septate uteri (11.31%, 6056 vs. 7.20%, 3854 vs. 3.80%, 2034). Good agreement was observed between the ESHRE-ESGE and the ASRM by Salim (k = 0.686, p < 0.001) and between the ASRM by Salim and that by Ludwin (k = 0.671, p < 0.001), while moderate agreement was found between the ESHRE-ESGE and ASRM by Ludwin systems (k = 0.444, p < 0.001). These results suggest that Ludwin's criteria are the strictest, while the ESHRE-ESGE system is much more relaxed for septate uterus diagnosis. CONCLUSION A risk of overtreatment may also exist in infertile patients when using the ESHRE-ESGE system. Therefore, the ESHRE-ESGE system should be used with caution when guiding hysteroscopic metroplasty in infertile patients.
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Endometrial and Myometrial Multidimensional Growth During the Cycle. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2018. [DOI: 10.1177/8756479318758323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Three-dimensional sonography enables assessment of uterine morphology. While the pattern of endometrial growth has been well described, little information is available on changes in endometrial and myometrial volume, area, and perimeters. We evaluated the ratio between myometrial and endometrial dimensions and its relation to endometrial thickness of inpatients with normal uterine morphology from our hospital. Routine hormonal assessment on the day of the sonographic exam was extracted from electronic medical records. Correlations between different dimensions of the uterus were examined. A total of 38 3D sonographic data sets were reviewed. A significant correlation was found between estradiol blood levels and endometrial thickness, area, and volume (R = 0.35, 0.53, 0.55, respectively; P < .05). The ratio between the endometrial and myometrial area remained constant regardless of endometrial thickness. The findings of this study suggest that endometrial thickness, area, and volume may correlate with circulating estradiol levels. Endometrial and myometrial changes correlated in more than one dimension.
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Knez J, Saridogan E, Van Den Bosch T, Mavrelos D, Ambler G, Jurkovic D. ESHRE/ESGE female genital tract anomalies classification system—the potential impact of discarding arcuate uterus on clinical practice. Hum Reprod 2018. [DOI: 10.1093/humrep/dey043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Knez
- Institute for Women’s Health, University College Hospital, 250 Euston Road, London NW1 6BU, UK
- Department of Gynaecology, University Medical Centre Maribor, Ljubljanska 5, 2000 Maribor, Slovenia
| | - E Saridogan
- Institute for Women’s Health, University College Hospital, 250 Euston Road, London NW1 6BU, UK
| | - T Van Den Bosch
- Department of Obstetrics and Gynaecology, University Hospital Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - D Mavrelos
- Institute for Women’s Health, University College Hospital, 250 Euston Road, London NW1 6BU, UK
| | - G Ambler
- Department of Statistical Science, University College London, Gower Street, London WC1E 6BT, UK
| | - D Jurkovic
- Institute for Women’s Health, University College Hospital, 250 Euston Road, London NW1 6BU, UK
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Abstract
PURPOSE OF REVIEW This review discusses current diagnosis, management and outcomes of obstructive anomalies of the gynecologic tract. RECENT FINDINGS In this review, we will discuss the clinical presentation of obstructive anomalies, surgical management and reproductive outcomes following surgical intervention. SUMMARY Identification of obstructive anomalies of the gynecologic tract is crucial when evaluating patients presenting with or without menses and cyclical pain. Surgical management is often the preferred modality for treatment, although menstrual suppression is recommended in certain circumstances.
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Ludwin A. Re: Outcome of assisted reproduction in women with congenital uterine anomalies: a prospective observational study. M. Prior, A. Richardson, S. Asif, L. Polanski, M. Parris-Larkin, J. Chandler, L. Fogg, P. Jassal, J. G. Thornton, N. J. Raine-Fenning. Ultrasound Obstet Gynecol 2018; 51: 110-117. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:22-23. [PMID: 29297614 DOI: 10.1002/uog.18971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
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Prior M, Richardson A, Asif S, Polanski L, Parris-Larkin M, Chandler J, Fogg L, Jassal P, Thornton JG, Raine-Fenning NJ. Outcome of assisted reproduction in women with congenital uterine anomalies: a prospective observational study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:110-117. [PMID: 29055072 DOI: 10.1002/uog.18935] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 10/11/2017] [Accepted: 10/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess the prevalence of congenital uterine anomalies, including arcuate uterus, and their effect on reproductive outcome in subfertile women undergoing assisted reproduction. METHODS Consecutive women referred for subfertility between May 2009 and November 2015 who underwent assisted reproduction were included in the study. As part of the initial assessment, each woman underwent three-dimensional transvaginal sonography. Uterine morphology was classified using the modified American Fertility Society (AFS) classification of congenital uterine anomalies proposed by Salim et al. If the external contour of the uterus was uniformly convex or had an indentation of < 10 mm, but there was a cavity indentation, it was defined as arcuate or septate. Arcuate uterus was further defined as the presence of a concave fundal indentation with a central point of indentation at an obtuse angle. Subseptate uterus was defined as the presence of a septum, not extending to the cervix, with the central point of the septum at an acute angle; if the septum extended to the internal cervical os, the uterus was defined as septate. Reproductive outcomes, including live birth, clinical pregnancy and preterm birth, were compared between women with a normal uterus and those with a congenital uterine anomaly. Subgroup analysis by type of uterine morphology and logistic regression analysis adjusted for age, body mass index, levels of anti-Müllerian hormone, antral follicle count and number and day of embryo transfer were performed. RESULTS A total of 2375 women were included in the study, of whom 1943 (81.8%) had a normal uterus and 432 (18.2%) had a congenital uterine anomaly. The most common anomalies were arcuate (n = 387 (16.3%)) and subseptate (n = 16 (0.7%)) uterus. The rate of live birth was similar between women with a uterine anomaly and those with a normal uterus (35% vs 37%; P = 0.47). The rates of clinical pregnancy, mode of delivery and sex of the newborn were also similar between the two groups. Preterm birth before 37 weeks' gestation was more common in women with uterine anomalies than in controls (22% vs 14%, respectively; P = 0.03). Subgroup analysis by type of anomaly showed no difference in the incidence of live birth and clinical pregnancy for women with an arcuate uterus, but indicated worse pregnancy outcome in women with other major anomalies (P = 0.042 and 0.048, respectively). CONCLUSIONS Congenital uterine anomalies as a whole, when defined using the modified AFS classification, do not affect clinical pregnancy or live-birth rates in women following assisted reproduction, but do increase the incidence of preterm birth. The presence of uterine abnormalities more severe than arcuate uterus significantly worsens all pregnancy outcomes. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M Prior
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
- Department of Child Health, Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, UK
| | - A Richardson
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
| | - S Asif
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
| | - L Polanski
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
| | - M Parris-Larkin
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
| | - J Chandler
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
| | - L Fogg
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
| | - P Jassal
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
| | - J G Thornton
- Department of Child Health, Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, UK
| | - N J Raine-Fenning
- Nurture Fertility, The East Midlands Fertility Centre, Bostock's Lane, Sandiacre, Nottingham, UK
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Ludwin A, Martins WP, Nastri CO, Ludwin I, Coelho Neto MA, Leitão VM, Acién M, Alcazar JL, Benacerraf B, Condous G, De Wilde RL, Emanuel MH, Gibbons W, Guerriero S, Hurd WW, Levine D, Lindheim S, Pellicer A, Petraglia F, Saridogan E. Congenital Uterine Malformation by Experts (CUME): better criteria for distinguishing between normal/arcuate and septate uterus? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:101-109. [PMID: 29024135 DOI: 10.1002/uog.18923] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/26/2017] [Accepted: 09/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To assess the level of agreement between experts in distinguishing between septate and normal/arcuate uterus using their subjective judgment when reviewing the coronal view of the uterus from three-dimensional ultrasound. Another aim was to determine the interobserver reliability and diagnostic test accuracy of three measurements suggested by recent guidelines, using as reference standard the decision made most often by experts (Congenital Uterine Malformation by Experts (CUME)). METHODS Images of the coronal plane of the uterus from 100 women with suspected fundal internal indentation were anonymized and provided to 15 experts (five clinicians, five surgeons and five sonologists). They were instructed to indicate whether they believed the uterus to be normal/arcuate (defined as normal uterine morphology or not clinically relevant degree of distortion caused by internal indentation) or septate (clinically relevant degree of distortion caused by internal indentation). Two other observers independently measured indentation depth, indentation angle and indentation-to-wall-thickness (I:WT) ratio. The agreement between experts was assessed using kappa, the interobserver reliability was assessed using the concordance correlation coefficient (CCC), the diagnostic test accuracy was assessed using the area under the receiver-operating characteristics curve (AUC) and the best cut-off value was assessed using Youden's index, considering as the reference standard the choice made most often by the experts (CUME). RESULTS There was good agreement between all experts (kappa, 0.62). There were 18 septate and 82 normal/arcuate uteri according to CUME; European Society of Human Reproduction and Embryology (ESHRE)-European Society for Gynaecological Endoscopy (ESGE) criteria (I:WT ratio > 50%) defined 80 septate and 20 normal/arcuate uteri, while American Society for Reproductive Medicine (ASRM) criteria defined five septate (depth > 15 mm and angle < 90°), 82 normal/arcuate (depth < 10 mm and angle > 90°) and 13 uteri that could not be classified (referred to as the gray-zone). The agreement between ESHRE-ESGE and CUME was 38% (kappa, 0.1); the agreement between ASRM criteria and CUME for septate was 87% (kappa, 0.39), and considering both septate and gray-zone as septate, the agreement was 98% (kappa, 0.93). Among the three measurements, the interobserver reproducibility of indentation depth (CCC, 0.99; 95% CI, 0.98-0.99) was better than both indentation angle (CCC, 0.96; 95% CI, 0.94-0.97) and I:WT ratio (CCC, 0.92; 95% CI, 0.90-0.94). The diagnostic test accuracy of these three measurements using CUME as reference standard was very good, with AUC between 0.96 and 1.00. The best cut-off values for these measurements to define septate uterus were: indentation depth ≥ 10 mm, indentation angle < 140° and I:WT ratio > 110% . CONCLUSIONS The suggested ESHRE-ESGE cut-off value overestimates the prevalence of septate uterus while that of ASRM underestimates this prevalence, leaving in the gray-zone most of the uteri that experts considered as septate. We recommend considering indentation depth ≥ 10 mm as septate, since the measurement is simple and reliable and this criterion is in agreement with expert opinion. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
- Department of Obstetrics and Gynecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - C O Nastri
- Department of Obstetrics and Gynecology, Faculty of Medicine of Ribeirão Preto, University of São Paulo (DGO-FRMP-USP), Ribeirão Preto, Brazil
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - M A Coelho Neto
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - V M Leitão
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
| | - M Acién
- San Juan University Hospital/Miguel Hernández University, Alicante, Spain
| | - J L Alcazar
- Department of Obstetrics and Gynecology, University of Navarra, Pamplona, Spain
| | | | - G Condous
- Obstetrics and Gynaecology, Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Hospital, Sydney Medical School Nepean, University of Sydney, Sydney, NSW, Australia
| | - R-L De Wilde
- Carl-von-Ossietzky-University Oldenburg, Oldenburg, Germany
| | - M H Emanuel
- University Medical Center Utrecht, Utrecht, The Netherlands
- University Hospital Ghent, Ghent, Belgium
| | - W Gibbons
- Baylor College of Medicine, Houston, TX, USA
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Cagliari, Italy
| | - W W Hurd
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - D Levine
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - S Lindheim
- Department of Obstetrics & Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA
| | - A Pellicer
- Instituto Valenciano de Infertilidad, Valencia, Spain
| | | | - E Saridogan
- University College London Hospital, London, UK
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Li X, Ouyang Y, Yi Y, Lin G, Lu G, Gong F. Pregnancy outcomes of women with a congenital unicornuate uterus after IVF–embryo transfer. Reprod Biomed Online 2017; 35:583-591. [DOI: 10.1016/j.rbmo.2017.07.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 06/30/2017] [Accepted: 07/25/2017] [Indexed: 12/01/2022]
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Detti L, Hickman H, Levi D'Ancona R, Wright AW, Christiansen ME. Relevance of Uterine Subseptations: What Length Should Warrant Hysteroscopic Resection? JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:757-765. [PMID: 27943370 DOI: 10.7863/ultra.15.07073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 05/25/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Existing recommendations warrant correction of uterine subseptations longer than 10 mm. We assessed whether a different subseptation length is indicated for intervention by evaluating the postoperative decrease in cavity width. METHODS We conducted a prospective controlled cohort study at a university center. Healthy women and women with subseptations were evaluated with three-dimensional ultrasound before and after undergoing surgical resection of uterine subseptations by hysteroscopy. Measurement of the subseptum's length and width, and total cavity width, were obtained in both groups of women. We created a receiver operating characteristic curve using 7-mm cavity postoperative width change as the reference variable, and subseptation length as the outcome variable. Identifying a new subseptation length that warrants surgical intervention. RESULTS Seventy-six women with subseptations and 77 with healthy uteri were included in the study. In the subseptate group, 50 had a subseptum less than 10 mm, and 26 were greater than 10 mm. Uterine and uterine cavity widths were significantly greater than in healthy women. The postoperative cavity width (28 ± 0.9 mm) was correlated with the preoperative subseptum length (R = 0.42; P = .016) and width (R = 0.54; P = .001) and was similar to healthy uteri. The receiver operator characteristic curve identified 5.9 mm (sensitivity = 100%, specificity = 41.4%) as a new threshold length of subseptation, which shows a postoperative cavity adjustment comparable to a subseptation greater than 10 mm. CONCLUSIONS The relevance of subseptations shorter than 10 mm is currently undetermined and underestimated. Our data indicate a new subseptation cutoff length with postoperative remodeling and statistical relevance similar to longer subseptations. We propose a revision of the recommendations for surgical correction to include the objectively obtained subseptation length greater than or equal to 5.9 mm.
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Affiliation(s)
- Laura Detti
- University of Tennessee Health Science Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Memphis, Tennessee, USA
| | - Holly Hickman
- University of Tennessee Health Science Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Memphis, Tennessee, USA
| | - Roberto Levi D'Ancona
- University of Tennessee Health Science Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Memphis, Tennessee, USA
| | - Alicia W Wright
- University of Tennessee Health Science Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Memphis, Tennessee, USA
| | - Mary E Christiansen
- University of Tennessee Health Science Center, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Memphis, Tennessee, USA
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Imaging Unusual Pregnancy Implantations: Rare Ectopic Pregnancies and More. AJR Am J Roentgenol 2016; 207:1380-1392. [DOI: 10.2214/ajr.15.15290] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Itchimouh S, Khabtou K, Mahdaoui S, Boufettal H, Samouh N. [Uterine rupture in a patient with bicornuate uterus at 12 weeks of amenorrhea: about a case]. Pan Afr Med J 2016; 24:153. [PMID: 27642490 PMCID: PMC5012789 DOI: 10.11604/pamj.2016.24.153.9697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 05/05/2016] [Indexed: 11/11/2022] Open
Abstract
The incidence of uterine malformations affecting reproduction is difficult to assess. Their identification requires a specific assessment (hysterosalpingography, hysteroscopy, laparoscopy). Spontaneous fertility can be affected depending on the type of uterine abnormality. All these abnormalities can affect the evolution of pregnancy causing early and late miscarriage, ectopic pregnancy, threat of premature labour, premature labour, vascular pathologies during pregnancy and inadequate intra-uterine growth. Bicornuate uterus is the most common uterine malformation and represents about half of all uterine anomalies The occurrence of this type of pregnancy is associated with an increased risk of maternal mortality, but early diagnosis and proper monitoring can lead pregnancies to term on malformed uterus. Ultrasound screening should allow for a systematic identification of such cases in order to take the necessary preventive measures. We report a case of uterine rupture in a patient with unicervical bicornuate uterus at 12 weeks of amenorrhea.
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Affiliation(s)
- Sanaa Itchimouh
- Service de Gynécologie Obstétrique ''C'', CHU Ibn Rochd, Maroc
| | - Karima Khabtou
- Service de Gynécologie Obstétrique ''C'', CHU Ibn Rochd, Maroc
| | - Sakher Mahdaoui
- Service de Gynécologie Obstétrique ''C'', CHU Ibn Rochd, Maroc
| | | | - Naima Samouh
- Service de Gynécologie Obstétrique ''C'', CHU Ibn Rochd, Maroc
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Smith A, Chudleigh T, Maxwell D. Incorporating 3D and 4D Ultrasound into Clinical Practice. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2016. [DOI: 10.1179/174313405x27445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
3D ultrasound has been slow to make significant impact in clinical practice. In a large part, this is because 2D ultrasound is of such superior quality that sonographers have not seen any gain in adopting the new technology. More recently, however, diverse application of 3D technology has taken place in many branches of medicine, with obstetrics and gynaecology at the forefront. Several manufacturers now produce machines of remarkable sophistication and utility. Hardware and software have been integrated to allow the release of information from the ultrasound examination that has hitherto not been possible. In addition, virtual real time 3D images (4D ultrasound) have captured the imagination of both public and media. We report our preliminary clinical experience with 3 and 4D ultrasound in a limited clinical environment. While not suitable for wide scale application at present, we believe this technology has inherent advantages that will secure its clinical role and that this role will widen rapidly in the near future.
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Sadek SM, Ahmad RA, Atia H. Performance of the ESHRE/ESGE classification in differentiating anomalies of double uterine cavity in comparison with the ASRM classification. MIDDLE EAST FERTILITY SOCIETY JOURNAL 2016. [DOI: 10.1016/j.mefs.2015.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Ergenoglu AM, Sahin Ç, Şimşek D, Akdemir A, Yeniel AÖ, Yerli H, Sendag F. Comparison of three-dimensional ultrasound and magnetic resonance imaging diagnosis in surgically proven Müllerian duct anomaly cases. Eur J Obstet Gynecol Reprod Biol 2016; 197:22-6. [DOI: 10.1016/j.ejogrb.2015.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 10/07/2015] [Accepted: 11/17/2015] [Indexed: 01/27/2023]
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Wong L, White N, Ramkrishna J, Júnior EA, Meagher S, Costa FDS. Three-dimensional imaging of the uterus: The value of the coronal plane. World J Radiol 2015; 7:484-493. [PMID: 26753063 PMCID: PMC4697122 DOI: 10.4329/wjr.v7.i12.484] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/01/2015] [Accepted: 11/04/2015] [Indexed: 02/06/2023] Open
Abstract
Advent in three-dimensional (3D) imaging technology has seen 3D ultrasound establish itself as a useful adjunct complementary to traditional two-dimensional imaging of the female pelvis. This advantage largely arises from its ability to reconstruct the coronal plane of the uterus, which allows further delineation of many gynecological disorders. 3D imaging of the uterus is now the preferred imaging modality for assessing congenital uterine anomalies and intrauterine device localization. Newer indications include the diagnosis of adenomyosis. It can also add invaluable information to delineate other endometrial and myometrial pathology such as fibroids and endometrial polyps.
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Ali O, Hakimi I, Chanana A, Habib MAB, Guelzim K, Kouach J, Rahali DM, Dehayeni M. [Term pegnancy on septate uterus: report of a case and review of the literature]. Pan Afr Med J 2015; 22:219. [PMID: 26955410 PMCID: PMC4760728 DOI: 10.11604/pamj.2015.22.219.7790] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 09/21/2015] [Indexed: 11/11/2022] Open
Abstract
L'utérus cloisonné est la malformation utérine la plus fréquente, comptant pour 30 à 50% des cas, suivie par les malformations utérines de type utérus bicorne et utérus unicorne. Nous rapportons un cas d'utérus cloisonné total suspecté lors de l'examen obstétrical d'une parturiente en travail, et confirmé à l'exploration au cours d'une césarienne réalisé pour le même motif. L'intérêt de ce cas est de montrer le pronostic obstétrical chez les femmes fertiles porteuses de cette malformation utérine.
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Affiliation(s)
- Osman Ali
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
| | - Ihssane Hakimi
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
| | - Adil Chanana
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
| | - My Abdellah Baba Habib
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
| | - Khalid Guelzim
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
| | - Jaouad Kouach
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
| | - Driss Moussaoui Rahali
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
| | - Mohammed Dehayeni
- Service de Gynécologie-Obstétrique, Hôpital Militaire d'Instruction de Mohamed V, Rabat, Maroc
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Graupera B, Pascual MA, Hereter L, Browne JL, Úbeda B, Rodríguez I, Pedrero C. Accuracy of three-dimensional ultrasound compared with magnetic resonance imaging in diagnosis of Müllerian duct anomalies using ESHRE-ESGE consensus on the classification of congenital anomalies of the female genital tract. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 46:616-622. [PMID: 25690307 DOI: 10.1002/uog.14825] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 01/21/2015] [Accepted: 02/13/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To establish the accuracy of three-dimensional ultrasound (3D-US), compared with magnetic resonance imaging (MRI), for diagnosing uterine anomalies, using the European Society of Human Reproduction and Embryology-European Society for Gynaecological Endoscopy (ESHRE-ESGE) consensus on the classification of congenital anomalies of the female genital tract. METHODS Sixty women with uterine anomalies suspected after examination by conventional two-dimensional ultrasound were evaluated with 3D-US and MRI. These data were analyzed retrospectively to confirm the presence and type of uterine malformation in accordance with the ESHRE-ESGE consensus. Sensitivity, specificity and positive (PPV) and negative (NPV) predictive values were calculated, using MRI as the gold standard, and agreement between the two methods was evaluated by kappa index. RESULTS Compared with MRI, for the diagnosis of normal uteri, 3D-US had a sensitivity of 83.3%, specificity of 100%, PPV of 100%, NPV of 98.2% and kappa index of 0.900. For dysmorphic uteri and for hemi-uteri, the sensitivity, specificity, PPV and NPV were all 100%, and kappa was 1.00. For septate uteri, the sensitivity was 100%, specificity was 88.9%, PPV was 95.5%, NPV was 100% and kappa was 0.918. For bicorporeal uteri, the sensitivity was 83.3%, specificity was 100%, PPV was 100%, NPV was 98.2% and kappa was 0.900. CONCLUSIONS 3D-US is highly accurate for diagnosing uterine malformations, having a good level of agreement with MRI in the classification of different anomaly types based on the ESHRE-ESGE consensus.
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Affiliation(s)
- B Graupera
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - M A Pascual
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - L Hereter
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - J L Browne
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - B Úbeda
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - I Rodríguez
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Quiron Dexeus, Barcelona, Spain
| | - C Pedrero
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitari Quiron Dexeus, Barcelona, Spain
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Ong CL. The current status of three-dimensional ultrasonography in gynaecology. Ultrasonography 2015; 35:13-24. [PMID: 26537304 PMCID: PMC4701368 DOI: 10.14366/usg.15043] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/24/2015] [Accepted: 09/25/2015] [Indexed: 12/18/2022] Open
Abstract
Ultrasonography (US) is the most recent cross-sectional imaging modality to acquire three-dimensional (3D) capabilities. The reconstruction of volumetric US data for multiplanar display took a significantly longer time to develop in comparison with computed tomography and magnetic resonance imaging. The current equipment for 3D-US is capable of producing high-resolution images in three different planes, including real-time surface-rendered images. The use of 3D-US in gynaecology was accelerated through the development of the endovaginal volume transducer, which allows the automated acquisition of volumetric US data. Although initially considered an adjunct to two-dimensional US, 3D-US is now the imaging modality of choice for the assessment of Müllerian duct anomalies and the location of intrauterine devices.
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Affiliation(s)
- Chiou Li Ong
- Department of Diagnostic and Interventional Imaging, KK Women's and Children's Hospital, Singapore
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50
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Ludwin A, Ludwin I, Kudla M, Kottner J. Reliability of the European Society of Human Reproduction and Embryology/European Society for Gynaecological Endoscopy and American Society for Reproductive Medicine classification systems for congenital uterine anomalies detected using three-dimensional ultrasonography. Fertil Steril 2015; 104:688-97.e8. [DOI: 10.1016/j.fertnstert.2015.06.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 05/29/2015] [Accepted: 06/08/2015] [Indexed: 11/27/2022]
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