Update in Müllerian anomalies: diagnosis, management, and outcomes

Birth Outcomes in Pregnancies with Uterine Malformations: A Single-Center Retrospective Study

Background and objectives: The prevalence of uterine malformations, affecting up to 7% of the general population, is associated with high rates of pregnancy complications, such as infertility, miscarriage, preterm delivery, malpresentation, ectopic pregnancy, and other complications, with high rates of both maternal and fetal morbidity and mortality. Surgical procedures have been proposed to remediate these anomalies, with different outcomes. In this context, our study aimed to emphasize the complications encountered in our department and the pregnancy results. Materials and Methods: A retrospective cohort study was performed on all the women who delivered in one university-affiliated medical center between 2010 and 2017 with congenital uterine malformations. A total of 62 women were included: 26 with uterine malformations and 36 as controls. Statistical analyses were performed with the level of statistical significance set at p < 0.05. Results: Only 53.8% of the pregnancies in women with uterine malformations ended in a live birth. The cesarean section rate was 64.3% in the study group. The only successful surgical procedure performed to restore fertility was cerclage. A lower Apgar score and a higher rate of neonate admission into the intensive care unit were observed in the study group, at 11.5% compared to 0 in the control group. The most important complication encountered with statistical significance was preterm delivery. Conclusions: This study demonstrated that uterine congenital malformations are an independent risk factor for pregnancy complications.

Undiagnosed uterine anomalies revealed by breech on ultrasound prior to external cephalic version - A chance to take a closer look

OBJECTIVE

Uterine anomalies (UA) occur in up to 6.7% of women. Breech is eight times more likely to occur with UA which may not be diagnosed prior to pregnancy and may only be found in the third trimester with breech. The objective of the study is to assess the prevalence of both already known and newly sonographically diagnosed UA in breech from 36 weeks of gestation and its impact on external cephalic version (ECV), delivery options and perinatal outcomes.

STUDY DESIGN

We recruited 469 women with breech at 36 weeks of gestation over a 2-year period at the Charité University Hospital, Berlin. Ultrasound examination was performed to rule out UA. Patients with known and newly 'de novo' diagnosed anomalies were identified and delivery options and perinatal outcomes analyzed.

RESULTS

The 'de novo' diagnosis of UA at 36-37 weeks of pregnancy with breech was found to be significantly higher compared to the diagnosis prior to pregnancy with 4.5% vs 1.5% (p < 0.001 and odds ratio 4 with 95% confidence interval 2.12-7.69). Anomalies found included 53.6% bicornis unicollis, 39.3% subseptus, 3.6% unicornis and 3.6% didelphys. A trial of vaginal breech delivery was successful in 55.5% of cases when attempted. There were no successful ECVs.

CONCLUSION

Breech is a marker for uterine malformation. Diagnosis of UA with breech can be up to four times improved with focused ultrasound screening in pregnancy even from 36 weeks of gestation prior to ECV to identify missed anomalies. Timely diagnosis aids antenatal care and delivery planning. Importantly, definitive diagnosis and treatment can be planned postpartum to improve outcomes in future pregnancies. ECV plays a limited role in selected cases.

Innovating the conservative management of isolated cervical aplasia

Isolated cervical aplasia (ESHRE/ESGE U0C4V0) is a rare condition with an incidence of approximately 1:100,000 births.This congenital malformation of the female genital tract represents an impairment of the outflow tract and is an inevitable cause of infertility. Patients usually present with pelvic pain or haematometra and surgical treatment is needed. Conservative management is the first line of approach, allowing for future fertility. However, complications are not negligible. Choosing the best surgical technique remains controversial as few follow-up studies have been published.We describe a case report of isolated cervical aplasia diagnosed in a 16-year-old patient, managed by a canalisation procedure using a Foley catheter. Following failure of this approach, a levonorgestrel intrauterine system was inserted, which remained efficient after 4 years.This case adds to the few reports of success in the management of this challenging clinical entity and might guide clinicians to avoid non-conservative approaches in young patients.

Case Report: Uterine Didelphys and Cervical Agenesis in an 18 Year-Old Woman Presenting with a Pelvic Mass

BACKGROUND

Although Müllerian anomalies are relatively common they can be easily misdiagnosed as other gynecologic conditions leading to inappropriate treatment.

CASE

An 18-year-old woman presented to the hospital with abdominal pain and was found to have a 17-cm pelvic mass and absence of the cervix. Because of concern for recurrent endometrioma formation in the setting of a Müllerian anomaly, she underwent a hysterectomy. During surgery, she was noted to have complete uterine didelphys with cervical agenesis and a normal vagina.

SUMMARY AND CONCLUSION

This extremely rare Müllerian anomaly represents one of the only descriptions to date of uterine didelphys with cervical agenesis and normal vaginal development. Appropriate identification and management of Müllerian anomalies is essential for guiding the care of these young, complex patients.

A rare case of symptomatic hydrometrocolpos in a 5y old female

Late presentation of symptomatic hydrometrocolpos is uncommon. We present a 5 years old continent girl with prenatally diagnosed multicystic dysplastic left kidney and late-onset of lower abdominal pain. Investigations revealed a nonfunctioning left kidney with an ectopic ureter draining into the left hemivagina, and a vaginal duplication with an obstructed and urine-filled left hemivagina. Surgical therapy included resection of the vaginal septum and laparoscopic nephroureterectomy. Not only renal agenesis but also dysplasia or multicystic kidney may part of an OHVIRA syndrome. In girls with unilateral renal dysplasia, a duplication of the internal genitalia must always be considered.

Laparoscopic Approach Towards Non-Communicating Functional Rudimentary Uterine Horn: A Report of Two Cases

A unicornuate uterus is a relatively rare Müllerian anomaly with an incidence of 2.5-13%. It may lead to various gynecological or obstetric complications, and diagnosis can often be confusing and delayed. It is associated with varying clinical presentations depending on the presence of functional endometrium, which requires immediate surgical resection on the diagnosis.

We report two cases of the unicornuate uterus in young women who presented with severe progressive dysmenorrhoea. These cases highlight the challenges in diagnosing the condition by ultrasound, which was confirmed later by MRI. Both cases were managed by laparoscopic resection of the functional non-communicating uterine horn. On follow-up, both patients were found asymptomatic with normal menstrual cycles.

In patients of young age who present with abdominal pain, adnexal masses of unknown origin, and severely painful periods, we should consider Müllerian duct anomalies as one of the differential diagnoses. Early and proper preoperative diagnosis of these cases is essential to prevent complications and to offer adequate treatment. Operative laparoscopy is an excellent alternative to laparotomy for their management, particularly in young unmarried girls.

A Review of Mullerian Anomalies and Their Urologic Associations

Structural anomalies of the female reproductive tract, known as Mullerian anomalies, can occur in isolation or in association with anomalies of other organ systems. Due to shared embryology, the most common association in up to 40% of patients is with renal, ureteral, and bladder anomalies. Affected girls can have a wide range of genitourinary symptoms with urologists playing an integral role in their diagnosis and treatment. To facilitate the recognition and management of these conditions, we provide a review of Mullerian anomalies including the embryology, classifications, syndromes, evaluation, and treatments with attention to their urologic applicability.

Winter syndrome: about an uncommon case report

BACKGROUND

Congenital genital tract outflow obstruction may occur at different levels and with different clinical presentations. Winter syndrome was first described in 1968 as an association of renal, genital and middle ear anomalies. This syndrome is characterized by autosomal recessive transmission, unilateral or bilateral renal hypoplasia, distal vaginal atresia, and moderate to severe conductive hearing loss with malformation of the ossicles. The diagnosis is usually made when symptoms of obstruction are obvious. It presents most commonly with primary amenorrhea in a girl with a normal XX genotype, ovarian and hormone function; and cyclical abdominal pain. Ultrasound confirm the physical examination, revealing the presence of a normal uterus and cervix, normal ovaries and fallopian tubes, and a large hematocolpos.

CASE PRESENTATION

This case reports Winter syndrome in a 14-year-old girl which vaginal atresia was managed by a trans perineal vaginal pull through.

CONCLUSIONS

Winter syndrome is a rare congenital condition whose clinical picture is that of an adolescent girl with primary amenorrhea and cyclic pelvic pain due to vaginal atresia, varying degrees of renal dysgenesis and deafness due to malformation of the ossicles of the middle ear. Diagnosis is based on clinical examination and imaging. Magnetic resonance imaging allows assessing the importance of atresia and thus guiding surgical management. The goals of surgical intervention are to provide relief from pain, ensure normal sexual intercourse and to preserve fertility. A thorough knowledge of embryology, pre-operative imaging with MRI and clinical examination is essential to plan an appropriate surgical management.

Müllerian Anomalies Prevalence Diagnosed by Hysteroscopy and Laparoscopy in Mexican Infertile Women: Results from a Cohort Study

Background: To evaluate the prevalence of Müllerian anomalies (MAs) in a cohort of infertile Mexican women candidates for infertility treatments (intrauterine insemination or IVF (In vitro fertilization) cycles). Methods: We performed a retrospective observational study on a cohort of consecutive women, who underwent hysteroscopy and laparoscopy as part of the basic infertility workup from 2002 to 2014, at our center. Our aim was to calculate the prevalence of MAs and each subtype. Results: A total of 4005 women were included in the study. The MA prevalence was 4.4% (95% CI; 3.8–5.1; n = 177). Among women with MAs, the prevalence of different MA types was: septate uterus 54.2% (n = 96), arcuate uterus 15.8% (n = 28), bicornuate uterus 10.7% (n = 19), unicornuate uterus 8.5% (n = 15), didelphys uterus 6.2% (n = 11) and hypoplasia/agenesis 3.4% (n = 6), unclassifiable 1.1% (n = 2). Women with MAs who achieved pregnancy were: 33.3% (n = 59). The MA associated with the highest pregnancy rate was septate uterus after hysteroscopic correction, at 38.5% (37/96). Conclusions: The prevalence of MAs among infertile Mexican women can be considered as low, but not negligible. The septate uterus is the most common MA in women with infertility.

Gynecological anomalies in patients with anorectal malformations

PURPOSE

The association of gynecological anomalies in all anorectal malformations (ARM) is firmly established. Our goal is to study this pathology in our patients to focus attention to this important issue.

METHODS

Retrospective study of female patients operated for ARM and who underwent magnetic resonance imaging in our center. The type of malformation, the presence and type of vaginal, uterine, tubaric and urological anomalies were studied.

RESULTS

63 patients were included: 34.9% cloaca, 28.6% vestibular and 12.7% perineal. Half of patients had some type of müllerian anomaly; 19 vaginal, most frequent being the longitudinal vaginal septum (66.7%); 30 had uterine alterations, most frequent being the uterus didelphys (60%). Eighty percent of patients with complex ARM (cloaca, exstrophy) presented some type of gynecological malformation compared to 21.8% found in simple ARM (stenosis, perineal, vestibular) (p < 0.001). Vaginal anomalies are associated with a uterine anomaly in 100% of cases. Conversely, patients with uterine anomalies have concurrent vaginal anomaly in 63.3% of cases.

CONCLUSION

Screening for gynecological anomalies is indicated in all patients with ARM. We recommend a vaginal examination in any girl with ARM during definitive repair and a subsequent MRI during follow-up. Collaboration with a gynecologist is essential.

Diagnosis and Management of Ovarian Tumor in Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome

In the most recent publications on Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, the uterine remnants and ovaries in patients may develop uterine remnant leiomyoma, adenomyosis, or ovarian tumor, and this can lead to problems in differential diagnosis. Here we summarize the diagnosis methods and available interventions for ovarian tumor in MRKH syndrome, with emphasis on the relevant clinical findings and illustrative relevant case. According to the clinical findings and illustrative relevant case, with the help of imaging techniques, ovarian tumors can be detected in the pelvis in patients with MRKH syndrome and evaluated in terms of size. Laparoscopy could further differentiate ovarian tumors into different pathological types. In addition, laparoscopic surgery not only is helpful for the diagnosis of MRKH combined ovarian tumor, but also has a good treatment role for excising ovarian tumor at the same time. Moreover, laparoscopic removals of ovarian tumor can be considered as a safe and reliable treatment for conservative management.

Uterine Didelphys with Bilateral Cervical Agenesis in a 15-Year-Old Girl

BACKGROUND

Isolated uterine didelphys requires no treatment in contrast to cervical agenesis, which requires a hysterectomy. Because of this, correct diagnosis of Müllerian anomalies is paramount for making recommendations for patient care.

CASE

A 15-year-old girl presented to clinic with pelvic pain and primary amenorrhea. Uterine didelphys with bilateral cervical agenesis was diagnosed using imaging. Hysterectomy was recommended and diagnosis was confirmed at surgery and according to anatomic pathology.

SUMMARY AND CONCLUSION

Our patient with uterine didelphys with bilateral cervical agenesis presented a diagnostic challenge, because, to our knowledge, it has never been reported before in the literature. Her pattern of anomalies had significant implications for future fertility. Radiology exam was vital to confirming this diagnosis in a young, virginal female patient.

A novel mutation of HOXA11 in a patient with septate uterus

BACKGROUND

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

RESULTS

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

CONCLUSION

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

Management of Reproductive Tract Anomalies

Reproductive tract malformations are rare in general population but are commonly encountered in women with infertility and recurrent pregnancy loss. Obstructive anomalies present around menarche causing extreme pain and adversely affecting the life of the young women. The clinical signs, symptoms and reproductive problems depend on the anatomic distortions, which may range from congenital absence of the vagina to complex defects in the lateral and vertical fusion of the Müllerian duct system. Identification of symptoms and timely diagnosis are an important key to the management of these defects. Although MRI being gold standard in delineating uterine anatomy, recent advances in imaging technology, specifically 3-dimensional ultrasound, achieve accurate diagnosis. Surgical management depend on the type of anomaly, its complexity and the proper embryological interpretation of the anomaly and involves multiple specialties; thus, patients should be referred to centres with experience in the treatment of complex genital malformations.

Novel mutations in the TP63 gene are potentially associated with Müllerian duct anomalies

STUDY QUESTION

Are mutations and/or polymorphisms in the TP63 gene associated with human Müllerian duct anomalies (MDAs)?

SUMMARY ANSWER

The novel mutation c.*374 G > A in the TP63 gene resulted in decreased expression of TP63 by generating new binding sites with miR-1260a/miR-532-3p and revealed the potential association between TP63 and human MDAs.

WHAT IS KNOWN ALREADY

It has been shown that mice lacking Tp63 exhibit hypoplastic genitalia, a single cloacal opening, and persistence of columnar epithelium at lower genital tract sites. It has also been reported that a nonsense mutation in EMX2 results in decreased TP63 expression in a woman with MDAs. However, generally in humans the association between TP63 and MDAs is unknown.

STUDY DESIGN, SIZE, DURATION

A total of 200 unrelated Chinese women with MDAs and 200 unrelated Chinese women with a normal uterus and vagina, as controls, were recruited in the Center for Reproductive Medicine of Shandong University. All participants had a normal karyotype (46, XX).

PARTICIPANTS/MATERIALS, SETTING, METHODS

The 20 exons of the TP63 gene were sequenced in 200 cases and 200 controls. Putative binding sites for microRNAs were validated by dual luciferase activity assays. The role of microRNAs was further examined by western blot.

MAIN RESULTS AND THE ROLE OF CHANCE

Sequence analysis revealed 15 known single-nucleotide polymorphisms. Additionally, three novel heterozygous variants, c.387 G > C, c.*374 G > A and c.*749 G > A, were identified in three patients with MDAs, none of which were detected in controls. Variant c.*374 G > A, located in the 3' untranslated region, was highly conserved among mammals and predicted to create microRNAs binding sites, which was confirmed by dual luciferase activity assays. Western blot demonstrated that the binding with miR-1260a/miR-532-3p resulting from the variation c.*374 G > A decreased the expression of TP63.

LARGE SCALE DATA

N/A LIMITATIONS, REASONS FOR CAUTION: Further study is needed to uncover the role of the EMX2-TP63 pathway in the development of the Müllerian duct.

WIDER IMPLICATIONS OF THE FINDINGS

This study revealed the possible association between TP63 and MDAs and suggested a potential contribution of microRNA-regulated expression of genes in the etiology of MDAs.

STUDY FUNDING/COMPETING INTERESTS

This research was supported by National Basic Research Program of China (973 Program) (2012CB944700), the State Key Program of National Natural Science Foundation of China (81430029), the National Natural Science Foundation of China (81270662, 81471509), China Postdoctoral Science Foundation (2014M561939) and the Scientific Research Foundation of Shandong Province of Outstanding Young Scientists (BS2014YY013, 2014BSE27022). The authors have no competing interests.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is Hysteroscopy Better than Ultrasonography for Uterine Cavity Evaluation? An Evidence-Based and Patient-Oriented Approach

Evaluation of the uterine cavity is an important part of the gynecological check, especially in symptomatic women and, over the last few decades, a number of technical and technological advancements has allowed a superb investigation of this organ. Traditionally, transvaginal ultrasound (TVUS) has been the first-line diagnostic tool for evaluating uterine diseases, also considering that gynecologists are familiar with the technique since it is included in the basic training in obstetrics and gynecology. Nevertheless, to date “office hysteroscopy” received growing attention since the development of smaller-diameter hysteroscopes which has made it possible to easily perform the hysteroscopy in ambulatory settings, obviating the need for anesthesia and dilatation of the cervical canal.

According to our overview, none of the available methods for endometrial evaluation are ideal and each one has pros and cons. TVUS allows assessment of both the myometrium and the endometrium and typically offers greater patient comfort, but it has a higher false-negative rate in diagnosing focal intrauterine pathology. On the other hand, office hysteroscopy has the advantage of providing (most of the time) a real-time diagnosis avoiding anxiety, inconvenience and costs associated with follow-up appointments. The main advantage of the office hysteroscopy on the TVUS is the possibility to perform an operative phase if necessary during the examination itself. In fact, the modern smaller-diameter hysteroscopes have a working channel through which operative miniaturized instruments (mechanical instruments or bipolar electrodes) can be introduced, allowing the performance of target-eye biopsies and the “instant” treatment of most of uterine diseases in outpatient settings.

The robotic metroplasty in a patient with hybrid septate variant anomaly

Complete uterovaginal septum is unusually associated with an obstructed left hemivagina and hemiuteri. Herein we present a case report of "hybrid septate variant" anomaly diagnosed in a 16-year-old girl. The uterine septum could not be completely removed hysteroscopically because of the obstructed vagina and thick uterine septum; therefore an abdominal approach, robotic metroplastic surgery was performed. We propose that the robotic technology has advantages over the classical laparoscopy related with the surgical correction of Müllerian anomaly.

Obstructed Hemivagina with Ipsilateral Renal Anomaly

The association of obstructed hemivagina with ipisilateral renal anomaly (OHVIRA) is a well-described entity. While there has been an increased familiarity with this disorder, the exact incidence of OHVIRA is unknown. Our aim was to review the available literature on this topic, look at common presentations, and uncommon presentations. This condition is a well-described entity but requires careful evaluation, because unique presentations do occur. Diagnostic challenges include time of presentation and symptoms associated with presentation. Surgical challenges include microperforation of the hemivaginal septum, pelvic inflammatory disease, thick septum, or high septum. Each of these must be managed carefully. Although a solitary kidney is frequently thought to be associated with OHVIRA, dysplastic kidneys, pelvic kidneys, or ectopic ureters can occur. Prompt and accurate diagnosis is essential for relief of symptoms and prevention of complications. To minimize problems associated with delayed diagnosis, magnetic resonance imaging evaluation is recommended along with referral to a center with expertise in these conditions.

Uterine conserving surgery in a case of cervicovaginal agenesis with unicornuate uterus

The presence of cervicovaginal agenesis with unicornuate uterus is a very rare mullerian anomaly. Its true incidence is still unknown. The presence of functioning unicornuate uterus poses a great challenge for a gynecologist because a successful repair could restore normal menses and may preserve a patient's fertility. Hence, we report a case of 16-year-old unmarried female who presented with chief complaints of primary amenorrhea with cyclical lower abdominal pain. On clinical and radiological evaluation, she was diagnosed with complete cervicovaginal agenesis with right unicornuate uterus (hematometra and hematosalpinx). She underwent vaginoplasty (McIndoes method) along with uterovaginal anastomosis by neocervix formation, in order to preserve her uterus. On follow-up, her vagina was completely healed, and she was menstruating normally.

A Case of Obstructed Hemivagina with Ectopic Ureter Leading to Severe Hydrocolpos and Contralateral Renal Outflow Tract Obstruction in a Neonate

BACKGROUND

Renal and Müllerian anomalies are frequently associated. Young age at presentation can present challenges in diagnosis and management. We report a case with an unusual presentation and management of this association in the neonatal period.

CASE

A 2-day-old girl had hydronephrosis with a large pelvic fluid collection. Magnetic resonance imaging of the pelvis demonstrated right hydronephrosis and uterine didelphys with an obstructed left hemivagina with hydrocolpos. A tube vaginostomy was used to decompress the vagina. Fluid was consistent with urine from an ectopic ureteral implantation from a dysgenetic left kidney, which was removed.

SUMMARY AND CONCLUSION

For obstructed hemivagina in a newborn, expanding fluid collections may be addressed with a drain to avoid mass effect and to aid in the diagnosis. Resection of the vaginal obstruction is performed when the patient is older. A nonfunctional kidney can be removed to eliminate fluid accumulation in the obstructed space.

The techniques and outcomes of hysteroscopic metroplasty

PURPOSE OF REVIEW

To evaluate the reproductive outcomes and surgical techniques of the hysteroscopic metroplasty in women with septate uterus and recurrent abortions or primary unexplained infertility.

RECENT FINDINGS

Septate uterus is the most frequent congenital uterine anomaly caused by inadequate resorption of the Müllerian ducts. Hysteroscopic metroplasty has replaced the traditional laparotomy approach because of its positive and satisfactory outcomes in pregnancy and live-birth rates, and also many different postoperative benefits. The aim of metroplasty is to restore a normal anatomy of the uterine cavity as a prerequisite for a positive implantation and subsequent good obstetrical outcomes. This treatment clearly demonstrates its effectiveness both in recurrent abortion and in primary unexplained infertility.

SUMMARY

The hysteroscopic metroplasty with its simplicity, safety, and improved reproductive outcomes has liberalized the approach to treatment. Today, hysteroscopic metroplasty is a common practice to treat septate uterus with salutary effects both in infertile patients and in patients with recurrent pregnancy loss or premature labor, especially if in-vitro fertilization is being contemplated. Decisions on when to treat uterine septa are discussed in particular because of lack of prospective, randomized controlled trials.

Torsion of fallopian tube remnant associated with noncommunicating rudimentary horn in adolescent girl with unicornuate uterus

BACKGROUND

The prevalence of müllerian anomalies may be as high as 7% in the general population, yet there is scant published literature on adnexal torsion occurring in these patients.

CASE

A 14-year-old female presented with right lower quadrant pain. Pelvic ultrasonography demonstrated a 2-cm simple right adnexal cyst. Diagnostic laparoscopy revealed a unicornuate uterus with a normal left uterine horn and fallopian tube but atretic and cordlike müllerian structures on the right side. Torsion of the right tubal remnant and two paratubal cysts were noted and the structures were then excised.

SUMMARY AND CONCLUSION

Agenesis, hypoplasia, or maldevelopment of müllerian structures may predispose patients to an increased risk of adnexal torsion secondary to looser ligamentous attachments and consequent lack of fixation to the pelvic sidewall.

Do measurements of uterine septum using three-dimensional ultrasound and magnetic resonance imaging agree?

OBJECTIVE

To evaluate the agreement between measurements of uterine septum by 3-D ultrasound (3-D US) and magnetic resonance imaging.

METHODS

Fourteen women with a uterine septum underwent both a 3-D US and an MRI followed by hysteroscopic metroplasty in a tertiary care infertility clinic within a university teaching hospital. The agreement between 3-D US and MRI measurements of septum length (SL), septum width (SW) and the distance between fundal serosa and septal tip (SSD) was compared using the Bland Altman limit of agreement analysis.

RESULTS

3-D US correctly identified all women who had a uterine septum identified with MRI. The mean difference in SL was 2.7 mm (upper limit of agreement and lower limit of agreement were 10.3 mm and -4.8 mm, respectively). The mean difference in SW was 2.3 mm (upper limit of agreement and lower limit of agreement of 10.4 mm and -9.2 mm, respectively). The SSD mean difference was 2.8 mm (upper limit of agreement and lower limit of agreement of 10.6 mm and -5 mm, respectively).

CONCLUSIONS

Categorical agreement in diagnosis was 100% and agreement between 3-D US and MRI measurements was good with narrow differences. Variations were unlikely to be greater than intra- and inter-observer variations anticipated in MRI readings. 3-D US can replace MRI for diagnosis and measurement of uterine septa.

Double cervix: clarifying a diagnostic dilemma

OBJECTIVE

Although double cervix is often considered to indicate uterus didelphys, it may be challenging to determine the true associated anomaly as double cervix occurs with other müllerian anomalies. Our purpose is to report the frequency of uterine müllerian anomalies that occur with a double cervix and identify imaging or clinical criteria to help classify the associated anomaly.

STUDY DESIGN

After institutional review board approval, an electronic search was performed to identify patients with double cervix and pelvic magnetic resonance imaging (MRI) between 1976-2010 (using International Statistical Classification of Diseases and Related Health Problems, Edition 9 and Hospital International Classification of Diseases Adapted codes). MRIs were reviewed to classify the müllerian anomaly. Clinical characteristics including cervical canal thickness, intercervical distance and orientation were recorded. Kruskal-Wallis and χ(2) tests were used to test for differences in patient and imaging characteristics across müllerian anomalies.

RESULTS

There were 64 patients who met inclusion criteria: 32 (50%) septate uterus, 27 (42%) uterus didelphys and 5 (8%) bicornuate uterus. Cervical canal divergence was present in 34% (11/32) with septate uterus, 26% (7/27) with uterus didelphys, and none with bicornuate uterus. Mean intercervical distance was significantly greater (P < .001) in uterus didelphys (12.05 mm) compared with septate (5.43 mm) or bicornuate uterus (5.40 mm).

CONCLUSION

Septate uterus is as common as uterus didelphys, and considerably more common than bicornuate uterus, in women with a double cervix. Although a widened intercervical distance may support the MRI diagnosis of uterus didelphys, careful evaluation of the uterine fundus is required for correct diagnosis when encountering a double cervix.

WNT9B in 542 Chinese women with Müllerian duct abnormalities: mutation analysis

The WNT9B gene is a common organizing signal regulating different segments of the mammalian urogenital system and plays a primary role in the development of the female reproductive tract. The aim of the present work was to examine the presence of WNT mutations in a population of women with Müllerian duct abnormalities (MDA) in order to elucidate whether mutations in WNT9B are causative for MDA in Chinese women. Initially, 191 Chinese MDA patients and 192 healthy individuals (controls) were recruited. All coding regions were amplified by PCR and sequenced to search for variants. To verify the initial results, the numbers of patients and ethnic-matched controls were expanded to 542 and 563, respectively. One known single-nucleotide polymorphism and four novel variants were identified in the first stage: two were synonymous; the other two were rare nonsynonymous novel variants (c.566G>A (p.Arg189Gln) and c.773G>A (p.Arg258His)). None of the four novel variants was found in controls. In the second stage, both novel nonsynonymous variants were detected in MDA cases and controls. The results indicate that mutations in the coding sequence of WNT9B are not responsible for MDA in the Chinese population.

Diagnostic imaging modalities for Müllerian anomalies: the case for a new gold standard

Female reproductive tract anomalies are difficult to number in the general population but are often discovered in evaluations of menstrual complications or fertility disorders. Traditionally, assessment of the reproductive tract entailed hysterosalpingography to image the uterine cavity with the final diagnosis provided by combined hysteroscopy/laparoscopy. These approaches, while providing important information, were uncomfortable and invasive and for HSG, involved radiation exposure. Magnetic resonance imaging (MIR) allowed for the avoidance of these issues while offering accuracy, thus becoming the gold standard diagnostic imaging modality but entailing cost, patient discomfort, and inconvenience. Current advances in ultrasound technology, specifically 3-dimensional ultrasound, achieve the same benefits of MRI in being accurate and noninvasive but also offer the following advantages: they are available in the office, they are cost-effective, and they provide immediate results. As 3-dimensional technology continues to become more accessible and more providers become proficient in using it, ultrasound may replace MRI as the new gold imaging standard in diagnosing müllerian anomalies.

Müllerian duct and related anomalies in children and adolescents

Although many Müllerian duct anomalies do not require treatment, surgical intervention is sometimes necessary to enable sexual activity or to preserve fertility. The identification of these anomalies is important for optimal clinical management or surgical treatment. Magnetic resonance (MR) imaging is a robust method for adequately evaluating and characterizing uterine and vaginal anomalies. The information provided by MR imaging allows for a more complete understanding of the malformation, facilitating management decisions and potentially changing the outcome. In this article, the embryology, classification, and MR imaging findings of Müllerian duct and related anomalies in children and adolescents are reviewed.

Müllerian duct anomalies and their effect on the radiotherapeutic management of cervical cancer

Radiotherapy plays a major role in the treatment of cervical cancer. A successful radiotherapy program integrates both external beam and brachytherapy components. The principles of radiotherapy are strongly based on the anatomy of the organ and patterns of local and nodal spread. However, in patients with distorted anatomy, several practical issues arise in the delivery of optimal radiotherapy, especially with brachytherapy. Müllerian duct anomalies result in congenital malformations of the female genital tract. Though being very commonly studied for their deleterious effects on fertility and pregnancy, they have not been recognized for their potential to interfere with the delivery of radiotherapy among patients with cervical cancer. Here, we discuss the management of cervical cancer among patients with Müllerian duct anomalies and review the very sparse amount of published literature on this topic.

Mayer-rokitansky-kuster-hauser syndrome: embryology, genetics and clinical and surgical treatment

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a pathological condition characterized by primary amenorrhea and infertility and by congenital aplasia of the uterus and of the upper vagina. The development of secondary sexual characters is normal as well as that the karyotype (46,XX). Etiologically, this syndrome may be caused by the lack of development of the Müllerian ducts between the fifth and the sixth weeks of gestation. To explain this condition, it has been suggested that in patients with MRKH syndrome, there is a very strong hyperincretion of Müllerian-inhibiting factor (MIF), which would provoke the lack of development of the Müllerian ducts from primitive structures (as what normally occurs in male phenotype). These alterations are commonly associated with renal agenesis or ectopia. Specific mutations of several genes such as WT1, PAX2, HOXA7-HOXA13, PBX1, and WNT4 involved in the earliest stages of embryonic development could play a key role in the etiopathogenesis of this syndrome. Besides, it seems that the other two genes, TCF2 (HNF1B) and LHX1, are involved in the determinism of this pathology. Currently, the most widely nonsurgical used techniques include the “Frank's dilators method,” while the surgical ones most commonly used are those developed by McIndoe, Williams, Vecchietti, Davydov, and Baldwin.

Ultrasound of the gravid uterus

The ultrasound findings involving the gravid uterus will be described with a focus on differentiating normal from pathologic conditions. Topics pertaining to the gravid uterus include uterine fibroids, müllerian anomalies, cervical shortening, the normal and pathologic appearance of cesarean delivery scars, and uterine rupture. Clinical management and therapeutic implications based on sonographic findings will be emphasized.

PAX2 in 192 Chinese women with Müllerian duct abnormalities: mutation analysis

The paired box gene 2 (PAX2) has been proven to be a crucial gene during organogenesis of the urogenital system in mice models. This study was aimed to explore the relationship between PAX2 mutations and human Müllerian duct abnormalities (MDA). A total of 192 Chinese MDA patients (15 cases of uterine aplasia and 177 of incomplete Müllerian fusion) and 192 ethnic-matched controls were recruited from 2009 to 2011. Coding regions of PAX2 of MDA cases were amplified and sequenced. One rare novel synonymous variant (c.320G>A) was discovered in one patient with uterus didelphys, whereas this variant was not found in the control group. Mutations in PAX2 may be not a common cause of MDA.

Laparoscopic-assisted perineal pull-through vaginoplasty

Hematometrocolpos is the result of vaginal obstruction and can become an emergency in the pubertal period. The treatment of imperforate hymen is well defined, but the treatment of vaginal atresia is more complex. We report a case of hematometrocolpos secondary to distal vaginal atresia that was operated on in the pubertal period. The patient had isolated distal atresia without persistence of the urogenital sinus. A combined abdominal laparoscopic and perineal approach and a posterior vaginoplasty were carried out. Finally, an abdominoperineal pull-through was successfully performed. Neovagina was successfully developed with this method. The embryology and literature are reviewed. The classification, indications, and surgical technique are discussed. We suggest that this procedure is suitable for patients with vaginal agenesis and a normal uterus.

Twin Gestation in a Septate Bicornuate Uterus

Bicornuate and septate uteri are among the commonest Mullerian anomalies. They are sporadic and fairly distinguished, but hybrid deformities can occur. This combination creates aetiological and clinical difficulties. The alternative theory of concurrent fusion and septal resorption of the Mullerian duct is seen as the basis of the altered foetal embryology, while the favourable outlook of a bicornuate uterus may be offset by the suboptimal implantation across the avascular septum. Obstetric care is based on empirical interventions deduced from case series, with varied and inconsistent outcomes. We present a 32-year-old primipara with a dizygotic twin gestation in separate compartments of a septate bicornuate uterus. She had an elective bilateral caesarean delivery at term with an accidental septal resection for morbidly adherent placenta. Although a summation of obstetric risks is a possibility, an excellent outcome was observed.

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

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