Intra-cycle variation of the uterine cavity indentation assessed with three-dimensional ultrasound in natural and stimulated cycles

Automatic Segmentation and Alignment of Uterine Shapes from 3D Ultrasound Data

BACKGROUND

The uterus is the most important organ in the female reproductive system. Its shape plays a critical role in fertility and pregnancy outcomes. Advances in medical imaging, such as 3D ultrasound, have significantly improved the exploration of the female genital tract, thereby enhancing gynecological healthcare. Despite well-documented data for organs like the liver and heart, large-scale studies on the uterus are lacking. Existing classifications, such as VCUAM and ESHRE/ESGE, provide different definitions for normal uterine shapes but are not based on real-world measurements. Moreover, the lack of comprehensive datasets significantly hinders research in this area. Our research, part of the larger NURSE study, aims to fill this gap by establishing the shape of a normal uterus using real-world 3D vaginal ultrasound scans. This will facilitate research into uterine shape abnormalities associated with infertility and recurrent miscarriages.

METHODS

We developed an automated system for the segmentation and alignment of uterine shapes from 3D ultrasound data, which consists of two steps: automatic segmentation of the uteri in 3D ultrasound scans using deep learning techniques, and alignment of the resulting shapes with standard geometrical approaches, enabling the extraction of the normal shape for future analysis. The system was trained and validated on a comprehensive dataset of 3D ultrasound images from multiple medical centers. Its performance was evaluated by comparing the automated results with manual annotations provided by expert clinicians.

RESULTS

The presented approach demonstrated high accuracy in segmenting and aligning uterine shapes from 3D ultrasound data. The segmentation achieved an average Dice similarity coefficient (DSC) of 0.90. Our method for aligning uterine shapes showed minimal translation and rotation errors compared to traditional methods, with the preliminary average shape exhibiting characteristics consistent with expert findings of a normal uterus.

CONCLUSION

We have presented an approach to automatically segment and align uterine shapes from 3D ultrasound data. We trained a deep learning nnU-Net model that achieved high accuracy and proposed an alignment method using a combination of standard geometrical techniques. Additionally, we have created a publicly available dataset of 3D transvaginal ultrasound volumes with manual annotations of uterine cavities to support further research and development in this field. The dataset and the trained models are available at https://github.com/UL-FRI-LGM/UterUS.

Prevalence of T-shaped uterus among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria

RESEARCH QUESTION

What is the prevalence of T-shaped uteri among fertile women based on ESHRE/ESGE and Congenital Uterine Malformation by Experts (CUME) criteria?

DESIGN

A prospective cohort study of 258 women of reproductive age with a history of at least one natural pregnancy resulting in live birth. Participants were recruited from the family planning clinic between January 2018 and March 2020. The ESHRE/ESGE classification of congenital anomalies of the female genital tract was used for describing abnormal findings. CUME criteria were also used for diagnosing T-shaped uterus. Uterine cavity volume was measured.

RESULTS

Mean age of participants was 35.4 ± 6.2 years. Participants were diagnosed with the following: congenital uterine abnormality (n = 9 [3.6%]); partial septate uterus (n = 5 [2.0%]) and hemiuterus (n = 2 [0.8%]). Two women (0.8%) were diagnosed with T-shaped uterus and borderline T-shaped uterus based on the ESHRE/ESGE criteria and CUME. Mean lateral indentation angle, lateral indentation depth and T-angle were 156.2° ± 9.53°, 2.85 ± 0.93 mm and 73.3° ± 9.85° in patients with normal uterine cavity. In patients with T-shaped and borderline T-shaped uteri, respective figures were 115° versus 121°, 10 mm versus 7.6 mm and 27.5° versus 70°. Median volume of the uterine cavity in patients with normal uterine cavity and T-shaped uterus was 3.71 ml (minimum 2.0 to maximum 9.03 ml, interquartile range 1.93) and 3.2 ml (2.9 and 3.62 ml), respectively.

CONCLUSIONS

The prevalence of T-shaped uteri in fertile women is low, which corresponds to previous reports of women with poor reproductive history.

Diagnostic accuracy of hysteroscopy, ultrasound and magnetic resonance imaging in detecting congenital uterine anomalies

Congenital uterine malformations occur as a result of a defective uterine development. The formation of the uterus is a dynamic process that culminates after completing four phases (differentiation, fusion, migration and canalization). Because is an evolutionary process, the resulting uterine malformation is different depending on the uterine formation phase in which the failure occurs. To establish a correct diagnosis of uterine malformations, it is necessary to evaluate both the shape of the uterine cavity and the external contour of the uterus. In this review we will describe the imaging modalities used in current clinical practice for the evaluation of the patient with suspected congenital uterine anomalies. The current role of each modality is described.

Logistic regression analyses of factors affecting fertility of intrauterine adhesions patients

Background

Intrauterine adhesion (IUA) prevalence is difficult to measure, but appears to have increased over the last few decades. The reproductive outcomes following hysteroscopic adhesiolysis (HA) for moderate-severe IUAs were unsatisfactory, and few studies have analyzed the clinical characteristics pre-, intra- and post-HA to determine the main risk factors for infertility in patients with IUAs.

Methods

This retrospective observational study included 406 patients, desiring fertility, who had undergone HA between January 1st, 2016 to May 31st, 2017, and had moderate-to-severe IUA [5-12 on the American Fertility Society (AFS) classification scale]. Logistic regression was performed to analyze the data of the clinical characteristics associated with IUA.

Results

A total of 406 IUA patients were initially collected. Twenty-six [26] were lost during follow-up or excluded by other criteria; 380 were included in the study with a follow-up period ranging from 2 to 3 years. There were 215 patients (56.6%) that became pregnant, of whom 18 spontaneously miscarried, 5 birthed prematurely (31-36 gestational weeks), 182 delivered at term, and 10 were pregnant at the end of the study. A bivariate and binary logistic regression analysis showed that an age of >30 years, cohesive IUA, lack of increased menstrual volume, and more than 2 times undergoing HA procedure were the risk factors for infertility in IUA patients (P<0.05).

Conclusions

Age, severity of IUA, increased menstrual volume, and HA procedures were the dominant factors affecting reproductive outcomes and may be regarded as potential predictors for evaluating IUA prognosis.

Septate uterus according to ESHRE/ESGE, ASRM and CUME definitions: association with infertility and miscarriage, cost and warnings for women and healthcare systems

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.

The pathophysiology of the septate uterus: a systematic review

BACKGROUND

Little is known about the pathophysiology underlying the increased risk for impaired reproductive outcomes in women with a septate uterus.

OBJECTIVES

We explored the available evidence on the pathophysiology of the septate uterus in an attempt to find a biological basis for these effects.

SEARCH STRATEGY

We performed a systematic literature search in OVID MEDLINE and OVID EMBASE from inception to January 2018.

SELECTION CRITERIA

We selected studies that investigated the pathophysiology of the septate uterus. Case reports or reviews without original data were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently evaluated potentially eligible papers.

MAIN RESULTS

Thirty-eight studies were included for analysis. The overall findings were that the intrauterine septum consists of endometrium and myometrium similar to the uterine wall. All five imaging studies that evaluated vascularity found that most of the intrauterine septa were vascularised. Histological studies found that the intrauterine septum consisted of myometrium and was covered by endometrium (n = 9). The endometrium covering the septum showed differences in histological composition in four studies and in gene expression in three studies compared with the normal uterine wall.

CONCLUSIONS

We found no clear biological basis for the impaired reproductive outcomes in women with a septate uterus. Either the gross anatomy of the septum itself or differences in histology or gene expression of the septum could account for the increased risk of reproductive waste observed after implantation in the septum.

TWEETABLE ABSTRACT

In women with a septate uterus differences in histology or gene expression could account for impaired reproductive outcome.

Surgical correction of T-shaped uteri in women with reproductive failure: Long term anatomical and reproductive outcomes

OBJECTIVE

To evaluate the long term anatomical and reproductive outcomes of hysteroscopic treatment for T shaped uterus in patients presenting with reproductive failure.

METHODS

This prospective cohort study included 56 patients with a history of long-standing unexplained infertility, recurrent implantation failure (RIF), and/or recurrent pregnancy loss (RPL) who were eligible for metroplasty by office hysteroscopy. Office hysteroscopy under conscious sedation was performed. Anatomical outcomes were assessed with pre- and postoperative measurements of the transostial, isthmic and myometrial diameters and the uterine volume using three-dimensional transvaginal sonography (3D-TVS). Reproductive outcome was assessed after spontaneous or assisted conception.

RESULTS

Hysteroscopic treatment significantly increased the volume of the uterus from a mean of 2.5+1mL before surgery to 3.2±1mL by the end of 1 year as measured by 3D-TVS. According to the main indication to perform metroplasty, 20 of 32 (62.5%) patients with long standing unexplained infertility, 9 of 14 (64%) patients with RIF, and 8 of 10 (80%) patients with RPL conceived either spontaneously or with assisted reproduction.

CONCLUSIONS

Office hysteroscopic metroplasty results in a significant long-term expansion of the uterine cavity and improved reproductive outcomes in women presenting with a T shaped uterus and poor reproductive history.