Definition, prevalence, clinical relevance and treatment of T-shaped uterus: systematic review

Hysteroscopicmetroplasty as a treatment option for women with congenital dysmorphic uterus suffering from impaired reproductive performance

Congenital uterine anomalies have been proven to be associated with impaired reproductive performance. The 2013 ESHRE-ESGE classification of female genital tract malformations defines T shaped and infantalis uterus as dysmorphic uterus. Our aim was to examine whether the reproductive performance of patients with primary congenital dysmorphic uterus can be improved using hysteroscopic metroplasty. A retrospective cohort study of 35 patients suffering from 1 year of failed attempts to conceive, recurrent early pregnancy losses, or repeated implantation failures of in vitro fertilization cycles who were diagnosed with a dysmorphic uterus in both a diagnostic hysteroscopy procedure and three-dimensional transvaginal ultrasound (3D-TVS). All patients had undergone an operative hysteroscopic procedure for uterine anomaly repair and their reproductive performance is described before and after the procedure, so that the women acted as their own control. Within 3 years of the procedure, a total of 25 patients (71.4%) reported that they had achieved a pregnancy. A total of 15% of patients only conceived for the first time after the procedure, 15 patients (42.9%) conceived within 6 months and 18 (51.4%) within 1 year. A total of 12 of the 25 pregnant patients (48%) gave birth to a live newborn. We conclude that in non-DES exposed patients with impaired reproductive performance and congenital dysmorphic uterus, hysteroscopic metroplasty for uterine repair could serve as a treatment option for recurrent implantation failure, and may lead to improved reproductive performance and obstetric outcome.

Application effect of phloroglucinol injection in elderly patients with spastic abdominal pain in emergency department

BACKGROUND

Although norepinephrine injection is commonly used in emergency situations, it is associated with risks for elderly patients with spasmodic liver pain. This study explores the safety and effectiveness of mebendazole injection, an alternative treatment option, for the emergency management of spasmodic abdominal pain, while minimizing adverse reactions, in elderly patients.

AIM

To explore the development of norepinephrine injection and the adverse reactions of this drug in emergency elderly patients with spasmodic liver pain.

METHODS

The control group consisted of 56 elderly patients visiting our hospital from January 2021 to December 2021. After hospital admission, the control group was intravenously administered tolopin. The experimental group consisted of 56 emergency patients with spasmodic abdominal pain who visited our hospital until June 2022. After hospital admission, the experimental group was intravenously administered toloxazole. The two groups were treated for 3 d. The disappearance of clinical symptoms was observed before and after the treatment, and the difference in adverse reactions between the two groups was compared.

RESULTS

The pain of the wife, fire, diarrhea, drowning, and surrounding time disappeared in the experimental group. No statistical difference was observed between the experimental and control groups in visual pain analog scale (VAS) scores before and after the treatment (P > 0.05). The VAS scores of abdominal pain severity after 0.5 h, 1.0 h, and after 6.0 h of treatment were significantly lower for the experimental group than for the control group. After the treatment, the therapeutic effect in the experimental group was higher and statistically significant than that in the control group (P < 0.05). The probability of adverse reactions before the treatment was lower in the experimental group than in the control group.

CONCLUSION

During emergency, mebendazole injection exhibited a good therapeutic value when used for the clinical treatment of elderly patients with spasmodic stomach pain. It accelerated the disappearance of clinical symptoms such as stomach pain, reduced the stomach weight, and improved clinical activity. Reducing and promoting the frequency of high treatment safety with mebendazole injection is worthwhile.

Perinatal outcomes of women with Müllerian anomalies

PURPOSE

To investigate the perinatal outcomes of singleton pregnant women with Müllerian anomalies (MuAs).

METHODS

A retrospective cohort study was conducted on singleton pregnant women with MuAs who delivered at the West China Second University Hospital between January 1, 2009 and December 31, 2020.

RESULTS

Four hundred fifty-seven cases of MuAs were identified, with an incidence of 0.40%. The most common anomaly was a septate uterus (38.7%). Compared to the control group, the MuAs group had significantly higher incidences of perinatal complications, including preterm deliveries (PTDs) (27.4 vs. 9.8%, P < 0.001), preterm premature rupture of membranes (PPROM) (29.1 vs. 22.5%, P = 0.001), malpresentation (34.4 vs. 5.6%, P < 0.001), abruptio placentae (4.6 vs. 1.2%, P < 0.001), placental accreta/increta (19.7 vs. 11.8%, P < 0.001), and uterine rupture (2.8 vs. 1.6%, P = 0.035). The rates of in vitro fertilization and embryo transfer (IVF-ET), foetal growth restriction (FGR), and low birth weight were also significantly higher in the MuAs group (8.3 vs. 4.5%, P < 0.001; 2.6 vs. 0.9%, P = 0.001; 3.1 vs. 1.7%, P = 0.033, respectively). In the MuAs group, the incidence of PPROM was high in cases with unicornuate uterus (31.5%), and malpresentation was as high as 42.4 and 37.0% in cases with septate and didelphys uteri, respectively.

CONCLUSION

The data suggest that pregnancy with MuAs may increase adverse perinatal outcomes, which calls for intensive supervision during pregnancy and delivery to reduce maternal and foetal complications. Individualized considerations should be emphasized according to the different categories of MuAs in pregnancies.

Hysteroscopic metroplasty for the treatment of the dysmorphic uterus: A SWOT analysis

Introduction

Dysmorphic uterus or T-shaped uterus is an increasingly frequent diagnosis among the infertile population that has been associated to worse reproductive results. Hysteroscopic metroplasty is a safe and simple procedure that can improve the reproductive outcomes in this group of patients, although the benefits of this procedure remains controversial due to the lack of adequate scientific evidence.

Objective

To analyze the hysteroscopic metroplasty using the SWOT (Strengths, Weaknesses, Opportunities and Threats) methodology.

Data sources

An electronic search from inception each database up to December 2021 including the following databases was conducted: PubMed-MEDLINE, EMBASE, Web of Science, The Cochrane Library, and Google Scholar.

Methods of study selection

Studies reporting outcomes of patients undergoing hysteroscopic metroplasty were included.

Tabulation

Not applicable.

Integration and Results

Clinical evidence from the included studies suggests an improvement in reproductive results after performing hysteroscopic metroplasty especially in women with recurrent pregnancy loss and previous infertility, but all of them have relevant methodological limitations. For this reason, benefits, risks and alternatives of this intervention should be considered with caution.

Conclusions

Evidence from published data shows a probable association between dysmorphic uterus and poor reproductive outcomes. Hysteroscopic metroplasty in patients with dysmorphic uterus could improve pregnancy outcomes, but there is need of properly designed prospective controlled studies to determine the benefits of this technique.

A Common Path: Magnetic Resonance Imaging of Müllerian and Wolffian Duct Anomalies

PURPOSE OF REVIEW

This review summarizes the pathway of Mullerian and Wolffian duct development, anomalies that result from disruptions to this pathway, and the characteristics on advanced imaging that identify them.

RECENT FINDINGS

In-office evaluation for reproductive anomalies is usually inadequate for the diagnosis of congenital reproductive anomalies. Magnetic resonance imaging (MRI) has usurped invasive diagnostic methods including laparoscopy, hysteroscopy, and vasography as the new gold standard. Because of its superior soft-tissue delineation and the availability of advanced functional sequences, MRI offers a sophisticated method of distinguishing reproductive anomalies from one another, characterizing the degree of defect severity, and evaluating for concomitant urogenital anomalies non-invasively and without radiation exposure to the patient. Congenital anomalies of the Mullerian and Wolffian duct can be incredibly nuanced, requiring prompt and accurate diagnosis for management of infertility. Definitive diagnosis should be made early with MRI.

The effect of hysteroscopic metroplasty on fertility in T-shaped and Y-shaped dysmorphic uterus

OBJECTIVE

T/Y-shaped dysmorphic uterus is frequently associated with subfertility, abortion, preterm delivery, and recurrent implantation failure. In this study, the impact of hysteroscopic metroplasty for a T/Y-shaped uterus on obstetric outcomes was investigated in patients with infertility and recurrent pregnancy loss (RPL) and compared the uterine anomaly subgroups.

METHOD

Cases with infertility and/or RPL diagnosed with T/Y-shaped uterus by hysterosalpingography (HSG) and 3D transvaginal ultrasonography (3D TVUSG) with no other male or female pathology have recruited the study. Medical history and the obstetric outcome after two years of follow-up were recorded.

RESULTS

Out of the 92 cases recruited, T-shaped uteri (Group-1) were observed in 30, while 62 (67.3%) patients had Y-shaped uteri. Pregnancy was achieved in 50 (54.3%) of the cases, 28 (56%) of the pregnancies occurred spontaneously, and in 22 (44%) pregnancy was achieved through assisted reproductive techniques (ART). Term delivery occurred in 29 (76.3%) of the pregnancies while 9 (23.6%) had preterm deliveries and a total of 38 (76%) resulted in a live birth. Out of the 31 patients with previous RPL history, 13 (41.9%) achieved pregnancy and 11 out of 13 (84.6%) had a term pregnancy followed by live birth.

CONCLUSION

Spontaneous pregnancy, and term pregnancy rates after surgery were found to be promising in these uterine anomalies. The pregnancy outcome of the primary infertile patients was found the same in two groups (50%-46.1%), but the results of the RPL patients were found to be better in the T-shaped group than in the Y-shaped group (70%-28.5%).

Is I-shaped uterus more common in patients with hyperandrogenism?

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.

Reproductive outcome of hysteroscopic metroplasty for women with T-shaped uterus: a retrospective study

Background

T-shaped uterus is a Müllerian malformation with unapparent clinical manifestations. Intrauterine adhesion and tuberculosis may lead to T-shaped uterus, too. Hysteroscopic metroplasty is a treatment option for T-shaped uterus, while the postoperative reproductive outcomes have not been thoroughly investigated. The aim of this study was to determine the reproductive outcome in Chinese women with T-shaped uterus who had hysteroscopic metroplasty with cold scissors.

Methods

This retrospective cohort study was conducted in the reproductive surgery unit of a university-affiliated hospital. One hundred and eleven patients with T-shaped uterus who underwent hysteroscopic metroplasty from Jan. 2017 to Sept. 2019 were followed-up by telephone in Apr. 2021. All patients received hysteroscopic metroplasty using microcissors, followed by estrogen-progesterone sequential treatment, with or without intrauterine device (IUD) implantation. According to whether they had had history of intrauterine operation, patients were divided into congenital group and acquired group. The main outcome measure was postoperative live birth rate. χ² test and t test were used for comparison between groups. Cochran-Mantel–Haenszel test were used for stratified analysis. P < 0.05 was considered statistically significant.

Results

One hundred and eleven patients were included in total, with 46 in congenital group and 65 in acquired group. After hysteroscopic metroplasty, in the congenital group, the pregnancy rate increased from 28.3% to 87.0% (P < 0.001) and the live birth rate increased from 23.1% to 79.5% (P = 0.001); in the acquired group, the pregnancy rate slightly dropped from 98.5% to 72.3% (P < 0.001) while the live birth rate increased from 20.8% to 74.5% (P < 0.001). No statistically significant difference was observed in postoperative reproductive outcome indicators between the two subgroups except mode of conception.

Conclusions

For both groups, hysteroscopic metroplasty may improve reproductive outcomes for patients with T-shaped uterus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01381-2.

As a Müllerian malformation, T-shaped uterus is named for the shape of the uterine cavity. According to cause of the disease and patients’ intrauterine operation history, T-shaped uterus can be divided into congenital and acquired types.

This study was conducted in the reproductive surgery unit in a university-affiliated hospital. Data were collected from medical records, and patients were followed up via telephone.

One hundred and eleven patients were included in this study, with 46 in congenital group and 65 in acquired group. Whether infertility/subfertility patients had had intrauterine operation history or not, their rates of giving live birth increased after the hysteroscopic metroplasty.

In conclusion, hysteroscopic metroplasty is an effective intervention for T-shaped uterus patients with fertility intention.

Diagnosis of Congenital Uterine Abnormalities: Practical Considerations

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.

The Rule of 10: a simple 3D ultrasonographic method for the diagnosis of T-shaped uterus

PURPOSE

To investigate and propose a new simple tridimensional (3D) ultrasonographic method to diagnose a T-shaped uterus (Class U1a).

METHODS

A multicenter non-experimental case-control diagnostic accuracy study was conducted between January 2018 and December 2019, including 50 women (cases) diagnosed with T-shaped uterus (U1a class) and 50 women with a "normal uterus" (controls). All the enrolled women underwent 3D ultrasound, drawing four lines and recording the length of three of them as follow: draw and measure the interostial line (R0); draw from the midpoint of R0 a perpendicular line length 20 mm; draw and measure in the uterine cavity a line parallel to R0 at 10 mm below R0 (R10) and a second line parallel to R0 at 20 mm below R0 (R20). The diagnostic performance of all sonographic parameters statistically significantly different between T-shaped and normal uteri was estimated using the receiver operator characteristic (ROC) curve analysis.

RESULTS

R10 and R20 were statistically significantly shorter in the T-shaped than the normal uterus. R10 reported the highest diagnostic accuracy with an area under the ROC curve of 0.973 (95% CI 0.940-1.000). R10 length maximizing the Youden's J statistic was 10.5 mm. Assuming R10 length equal to or shorter than 10 mm as the cut off value for defining a woman as having a T-shaped uterus, the new ultrasonographic method following the proposed protocol (R0, R10, and R20) reported sensitivity for T-shaped uterus of 91.1% (95% CI 0.78-0.97%) and a specificity of 100% (95% CI 0.89-100%). The positive likelihood ratio was higher than 30, and the negative likelihood ratio was 0.09 (95% CI 0.04-0.26).

CONCLUSIONS

Measuring the length of the intracavitary line parallel to the interostial line at 10 mm from it and using a length ≤ of 10 mm as cut off value (the "Rule of 10") appears a simple and accurate 3D ultrasonographic method for the diagnosis of a T-shaped uterus.