Uterine Malformations: An Update of Diagnosis, Management, and Outcomes

Müllerian anomalies in girls with congenital solitary kidney

BACKGROUND

The prevalence of Müllerian anomalies (MA) among patients with congenital solitary functioning kidney (SFK) is not well defined. A delay in diagnosis of obstructive MA can increase the risk of poor clinical outcomes. This study describes the prevalence of MA in patients with congenital SFK.

METHODS

A retrospective review was performed of patients within the Nationwide Children's Hospital system with ICD9 or ICD10 diagnostic codes for congenital SFK defined as either unilateral renal agenesis (URA) or multicystic dysplastic kidney (MCDK) and confirmed by chart review. Patients with complex urogenital pathology were excluded. Renal anomaly, MA, reason for and type of pelvic evaluation, and age of diagnosis of anomalies were evaluated.

RESULTS

Congenital SFK occurred in 431 girls due to URA (209) or MCDK (222). Pelvic evaluation, most commonly by ultrasound for evaluation of abdominal pain or dysmenorrhea, occurred in 115 patients leading to MA diagnosis in 60 instances. Among 221 patients ages 10 years and older, 104 underwent pelvic evaluation and 52 were diagnosed with an MA of which 20 were obstructive. Isolated uterine or combined uterine and vaginal anomalies were the most common MA. MA were five-fold more common in patients with URA compared to MCDK. In 75% of patients, the SFK was diagnosed prior to the MA.

CONCLUSIONS

The prevalence of MA in patients with congenital SFK was 24% among those age 10 years or older, and 38% were obstructive. This justifies routine screening pelvic ultrasound in girls with congenital SFK to improve early diagnosis.

Evaluation of the Success of Hysteroscopic Uterine Septum Resection

Objectives

The aim is to use three-dimensional transvaginal ultrasonography (3-D TVUS) to evaluate the success of hysteroscopic metroplasty for the uterine septum and to compare the pregnancy outcomes.

Materials and Methods

Thirty-eight patients with uterine septum who had hysteroscopic uterine septum resection were recruited. Preoperative 3-D TVUS measurements of the septal apex to the uterine fundus (s1), septal apex to internal os distance (s2), and intercornual distance (s3) were compared with the postoperative values. The pregnancies of the patients were followed up for a year postoperative period.

Results

Out of the 38 patients, thirty-five had partial uterine septum (class U2a), while 3 patients had complete uterine septum (class U2b). Eighteen (47.36%) of the patients who underwent uterine septum resection achieved pregnancy, and thirteen of these pregnancies were (72.2%) term pregnancies, and all term pregnancies resulted in a live birth. Natural conception was achieved in 77.7% (14 of 18) of the patients. Term pregnancy occurred in 68.7% (11 of 16) of the patients with a partial septum and in 66.6% (2 of 3) of the patients with a complete uterine septum. A comparison of the 3-D TVUS measurements of the uterus pre- and postoperatively showed a decrease in s1 and an increase in s2 (P < 0.05). The uterine cavity length of pregnant patients was found to be higher than nonpregnant patients (P < 0.05).

Conclusion

Reproductive results of hysteroscopic metroplasty were favorable in achieving live and term birth. three-dimensional TVUS can be preferred as a noninvasive effective method in objective evaluation of the success of the hysteroscopic surgery.

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.

Can ultrasound predict the delivery time of patients with previous cesarean section in the 37th gestational week? A prospective cross-sectional study

BACKGROUND

The aim was to investigate factors that predict when patients with previous cesarean section will undergo cesarean section (CS) using ultrasonography in the 37th gestational week.

MATERIAL AND METHODS

In this prospective cross-sectional study, a total of 166 patients with previous CS who presented to the hospital for routine checks at the 37^0/7th gestational week were included in the study. Uterine-related, fetus-related, and patient-related factors that affect labor time were analyzed by the same physician at admission, and the patients were then divided into two groups as those having CS at early term (37^0/7 to 38^{6/7 weeks} of gestation) and full-term (39^0/7 to 40^{6/7 weeks} of gestation). Ninety-four patients underwent CS at full-term and 72 patients underwent CS at the early term in the study.

RESULTS

There was no significant difference for age (years), parity, weight gain, previous cesarean number, cervical length, myometrial thickness, estimated fetal weight, and full lower uterine segment thickness between the groups (p>.05). In the full-term group, 58% had a history of vaginal birth, whereas, in the early-term group, 42% had a history of vaginal birth (p < .05). Vaginal birth history was found to be independently associated with reaching full-term (respectively, OR: 2.876, 95% CI: [1.227-6.738]; p = .015) in all patients. Two different regression models were created to predict different CS times after the 37th week of pregnancy. Weight gain was found to be independently associated with CS time within the first seven days after admission (OR: 1.267, 95% CI: [1.003-1.599]; p = .047). Vaginal birth history and estimated fetal weight were found to be independently associated with CS time in the 8th day and further after admission (OR: 0.244, 95% CI: [0.089-0.675]; p = .007 and OR: 1.002, 95% CI: [1.000-1.003]; p = .047).

CONCLUSION

Vaginal birth history can be useful to predict reaching full-term in patients with previous CS. Determination of such risk factors is important in terms of reducing the frequency of emergency cesarean delivery.

Müllerian Duct Anomalies: Role in Fertility and Pregnancy

Müllerian duct anomalies (MDAs) have important implications for the reproductive health of female patients. In patients with both infertility and recurrent pregnancy loss, the incidence of MDAs is as high as 25%. Congenital uterine anomalies are often only part of a complex set of congenital anomalies involving the cervix, vagina, and urinary tract. Multiple classification systems for MDAs exist, each with different criteria that vary most for the diagnosis of septate uterus. Recognizing the features that guide clinical management is essential for interpretation. Identification of an MDA should prompt evaluation for associated urinary tract anomalies. In patients with infertility who seek to use assisted reproductive technologies such as intrauterine insemination, recognition of MDAs may have an affect on reproductive success, particularly in patients who have an incomplete and clinically occult septum that divides the cervix. Two-dimensional US is the first-line modality for evaluating the uterus and adnexa. Three-dimensional (3D) US or MRI may help to visualize the external uterine fundal contour and internal indentation of the endometrial cavity, which are two morphologic characteristics that are keys to the diagnosis of congenital uterine anomalies. Hysterosalpingo contrast-enhanced US may be performed in conjunction with 3D US to evaluate uterine morphologic characteristics, the endometrial cavity, and tubal patency in a single examination. MRI helps to characterize rudimentary uteri in patients with müllerian hypoplasia and allows assessment for ectopic ureters, abnormally positioned ovaries, or associated deep infiltrative endometriosis. Online supplemental material is available for this article. ©RSNA, 2021.

Association of a unicornuate uterus with adverse obstetric outcomes: A retrospective cohort study

OBJECTIVE

To estimate the association of unicornuate uterus (UU) with adverse obstetric outcomes.

METHODS

Using data from 26 737 singleton childbirths from a tertiary hospital from 1999 to 2019, we identified 44 births from women with a UU. A total of 367 births from women with a normal uterus were randomly selected as controls. The outcome measures were preterm birth (PTB), breech presentation, and cesarean delivery. The subdivisions of PTB and indications for cesarean delivery were described.

RESULTS

The presence of UU was associated with an increased risk of PTB (adjusted risk ratio [aRR], 2.3; 95% confidence interval [CI], 1.1-4.9), breech presentation (aRR, 6.2; 95% CI, 2.9-13.2), and cesarean delivery (aRR, 2.1; 95% CI, 1.8-2.7). For women with a UU, most PTBs (7/9) were moderate to late PTBs, and approximately half of the PTBs (4/9) were iatrogenic due to preeclampsia (PE). Breech presentation, PE, and prior surgery for rudimentary horn resection were UU-related indications for cesarean delivery.

CONCLUSIONS

Women with a UU have a higher risk of PTB, breech presentation, and cesarean delivery. Understanding of the subdivisions of PTBs and indications for cesarean delivery might help clinicians when counseling women with pregnancy complicated by a UU.

A comparison of four systems for uterine septum diagnosis and indication for surgical correction

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.

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

OBJECTIVES

To summarize in a systematic review the current evidence regarding definitions, diagnosis, prevalence, etiology, clinical relevance and impact of surgical treatment for T-shaped uterus not related to diethylstilbestrol (DES) exposure, and to highlight areas on which future research should focus.

METHODS

A search of PubMed, Scopus and EMBASE was performed on 9 April 2020 using the search terms 't-shaped OR t-shape OR infantile OR (lateral indentation) OR (diethylstilbestrol OR DES) AND (uterus OR uterine OR uteri) AND (anomaly OR anomalies OR malformation OR malformations)'. Additionally, the reference lists of the included studies were searched manually for other relevant publications. All studies presenting data on T-shaped uterus not associated with DES exposure and including at least 10 women were considered eligible. Studies regarding DES-related T-shaped uterus were excluded because DES has not been used since 1971. There were no restrictions on language, date of publication or status of publication.

RESULTS

Of 2504 records identified by the electronic search, 20 studies were included in the systematic review. The majority of studies were of poor quality. In 11 of 16 studies reporting on the diagnosis of T-shaped uterus, the diagnostic method used was three-dimensional ultrasound. There is no consensus on the definition of T-shaped uterus, but the most cited criteria (4/16 studies) were of the European Society of Human Reproduction and Embryology and the European Society for Gynaecological Endoscopy (ESHRE/ESGE; 2013). The prevalence of T-shaped uterus varied from 0.2% to 10% in the four included studies reporting such data. With respect to etiology (except for DES), T-shaped uterus was considered a primary condition in three studies and secondary to adhesions in five and adenomyosis in one. T-shaped uterus was related to worse reproductive outcome based on subfertility (nine studies), miscarriage (seven studies), preterm delivery (two studies), ectopic pregnancy (one study) and repeat implantation failure (seven studies). Of the 12 studies that reported on the effects of surgical treatment of T-shaped uterus by hysteroscopic metroplasty, some mentioned an improvement in pregnancy rate (rates ranging from 49.6% to 88%; eight studies), live-birth rate (rates ranging from 35.1% to 76%; seven studies) and term-delivery rate (four studies) and a reduction in miscarriage (rates ranging from 7% to 49.6%; five studies) and ectopic pregnancy (one study). However, the evidence is of very low quality with serious/critical risk of bias toward overestimating the intervention effect. Some authors reported no complications related to the procedure, while others mentioned persistence of the dysmorphism (rates ranging from 1.4% to 11%; three studies), bleeding (1.3%; one study), infection (2.6%; one study) and adhesions (11.1% and 16.8%; two studies).

CONCLUSIONS

The prevalence, etiology and clinical relevance, with respect to reproductive outcome, of T-shaped uterus remain unclear and there is no consensus on the definition and diagnostic method for this condition. Expectant management should be considered the most appropriate choice for everyday practice until randomized controlled trials show a benefit of intervention. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Effects of bicornuate uterus on pregnancy and obstetric outcomes of in vitro fertilization / intracytoplasmic sperm injection

OBJECTIVE

A bicornuate uterus results from failure of the Müllerian ducts to completely fuse. If patients with bicornuate uterus are diagnosed with infertility, they can conceive with help from in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI). With few studies on the reproductive performances of bicornuate uterus following IVF/ICSI treatment, the aim of present study is to investigate whether a bicornuate uterus would affect pregnancy rates and obstetric outcomes of infertile women.

STUDY DESIGN

A retrospective cohort study contained 232 women (58 with bicornuate uterus and 174 with normal uterus) was conducted. Patient data for IVF/ICSI treatment and follow-up were collected and analyzed. Cumulative pregnancy rate and cumulative live birth rate after one complete assisted reproductive technology (ART) cycle were the primary outcomes.

RESULTS

Baseline characteristics were comparable between the bicornuate uterus group and the control group. Ovarian response to stimulation and embryological results were similar between the two groups. In fresh embryo transfer cycles, embryo implantation rate (32.7 % vs. 42.9 %, P = 0.176), biochemical pregnancy rate (54.1 % vs. 64.9 %, P = 0.236), and clinical pregnancy rate (45.9 % vs. 58.8 %, P = 0.172) did not differ significantly between the bicornuate uterus group and the control group. Live birth rate (40.5 % vs. 43.9 %, P = 0.723), term delivery rate (93.3 % vs. 90.0 %, P = 0.696), cesarean section rate (73.3 % vs. 76.0 %, P = 0.833), and newborn birth weight (3.35 ± 0.56 vs. 3.32 ± 0.51, P = 0.524) also did not differ significantly between the two groups. In frozen-thawed embryo transfer cycles, there were no significant differences in outcomes between the two groups. Upon completion of one IVF/ICSI cycle, cumulative pregnancy rate (59.6 % vs. 71.0 %, P = 0.112) and cumulative live birth rate (58.2 % vs. 64.8 %, P = 0.375) were similar between the two groups.

CONCLUSION

There were no significant differences in ovarian responses, pregnancy outcomes, and obstetric outcomes after IVF/ICSI treatment between women with bicornuate uterus and women with normal uterus. Bicornuate uterus had no significant negative effects on cumulative IVF/ICSI outcomes of infertile patients.

Laparoscopic Hysterectomy and Bilateral Salpingectomy in a Patient with Microduplication Syndrome (20p13p12.1) and a Bicornuate Uterus: An Unreported Association

Trisomy 20p is a chromosomal anomaly resulting from whole or partial duplication of the short arm of chromosome 20. It is a rarely reported syndrome and it is estimated that there are only a few cases of this condition worldwide, which hampers the phenotypic characterization of this entity. Conversely, müllerian anomalies include a group of congenital malformations of the uterus, vagina, cervix, and fallopian tubes resulting from alterations in the embryological development of the müllerian ducts. We report a case of pure trisomy 20p diagnosed using array comparative genomic hybridization (CGH) accompanied by a müllerian anomaly in a female patient with abnormal growth pattern, round face, coarse hair, broad nose, long palpebral fissure, epicanthus, and megaureter.

Uterine didelphys with dicavitary twin gestation: A case report

Uterine didelphys is a rare type of congenital uterine anomaly resulting from incomplete fusion of the paramesonephric ducts during embryogenesis. We report the case of a 27-year-old multiparous woman who presented with ovulation-induced dicavitary dichorionic diamniotic twins in known uterine didelphys. At 29 + 5 weeks of gestation, the patient had preterm prelabour rupture of membranes followed by threatened preterm labour in the right uterus only, which settled with tocolysis. The pregnancy continued for a further 9 days, at which time uterine tightenings returned and the right cervix was fully dilated, resulting in successful vaginal delivery of the first twin, leaving the placenta in situ. The left uterus and cervix remained quiescent for a further 24 h before contractions returned, resulting in emergency caesarean section, with the successful delivery of the second twin. As a rare phenomenon, there is sparse literature on the management of dicavitary twin gestation in uterine didelphys. This case report adds to the evidence for independent functioning of uteri and cervices in cases of uterine didelphys which may enable interval delivery delay in this cohort with known increased risk of preterm birth.

Preventing the O in OHVIRA (Obstructed Hemivagina Ipsilateral Renal Agenesis): Early Diagnosis and Management of Asymptomatic Herlyn-Werner-Wunderlich Syndrome

INTRODUCTION

Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian ductal anomaly associated with ipsilateral renal agenesis. Most patients are diagnosed after menarche with complications of uterovaginal obstruction, genitourinary infection and pelvic adhesions. Patients often undergo additional operations for misdiagnosis or treatment of complications. Our institution manages several HWWS patients diagnosed before symptoms by screening for antenatally-diagnosed renal agenesis. This study aims to improve the presymptomatic management of HWWS patients.

METHODS

We carried out retrospective case review of patients diagnosed with HWWS from 2010 to 2017 on patient demographics, symptoms, clinical course and operative management and summarize the sparse literature published to date.

RESULTS

There were 8 patients with HWWS but only 2 symptomatic patients presented acutely with hematocolpos requiring urgent vaginal surgery. The other six patients had early diagnosis through postnatal ultrasound screening. No patient required further operation for diagnosis or complications related to obstructed hemivagina.

CONCLUSION

Our case series and literature review show that the majority of prepubertal patients with HWWS do not require early gynecological surgery. We recommend that female babies with renal agenesis should be screened for HWWS syndrome with ultrasound. Early diagnosis and presymptomatic elective surgery may prevent urogynecological complications that cause fertility and renal impairment.

STUDY DESIGN

Case series, level IV evidence.

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.

Management of Mullerian Development Anomalies: 9 Years' Experience of a Tertiary Care Center

Objectives:

This study aimed to analyze the clinical and imaging findings as well as the outcomes of patients with Mullerian duct anomalies.

Materials and Methods:

A retrospective analysis of 41 patients with Mullerian development anomalies treated in a tertiary care center in the past 9 years was done. The presenting symptoms, radiological findings, management, and the outcomes were evaluated.

Results:

According to the American Fertility Society's classification, 11 patients presented in Class I, 6 in Class II, and 24 in Class III of the classification. It was found that some of the defects such as the unicornuate uterus, a unicornuate uterus with noncommunicating rudimentary horn, and longitudinal vaginal septum were usually asymptomatic whereas disorders such as Mayer-Rokitansky-Küster-Hauser (MRKH), cervicovaginal atresia, and transverse vaginal septum presented with the absence of menarche, cyclical abdominal pain, and abdominal mass, respectively. Defects such as the bicornuate uterus, didelphys uterus, and septate uterus present with poor reproductive performance. Unicornuate uterus with communicating horn presented with rupture of the horn in the antenatal period, which was managed vigorously. Vaginoplasty with a skin graft and amnion graft had excellent results in MRKH syndrome. Patients with cervicovaginal atresia had a poor prognosis and ultimately required a hysterectomy. Hysteroscopic septal resection improved the reproductive performance in the patients with septate uterus.

Conclusion:

This study concluded that the management of uterine malformations is individualized depending on the symptoms and fertility concerns. Cervicovaginal atresia was associated with restenosis after surgery ultimately required a hysterectomy. MRKH had excellent results with McIndoe vaginoplasty. Optimal and timely management may lead to better outcomes.

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.

Uterine anomalies and endometriosis

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.

Twin gestation in a uterus didelphys with only one functional cervix: A case report

Introduction

Twin gestation in a uterus didelphys with one fetus in each uterine cavity is rare and presents unique challenges in antepartum and intrapartum care.

Case Presentation

A 35-year-old woman with a uterus didelphys became pregnant with twins, with one fetus in each uterus, after intrauterine insemination of a single visible cervix. Multiplanar ultrasonography showed the presence of one complete cervix and a second hypoplastic cervix; it was unclear whether she could deliver both twins vaginally. Her pregnancy was complicated by fetal growth restriction of twin B. At 38 weeks, the patient underwent scheduled cesarean section and delivered two viable twins.

Conclusion

Determining the precise anatomy of Mullerian duct anomalies, including the cervix and vagina, is important for obstetrical management.

•

Twin pregnancy in a uterus didelphys is very rare and presents unique obstetric challenges.

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The presence of a Mullerian duct anomaly is not necessarily an indication for cesarean section, but it may increase the risk.

•

Not all Mullerian duct anomalies fall under the 1988 American Society for Reproductive Medicine (ASRM) classification system.

•

Adequate imaging to determine the anatomy of a Mullerian duct anomaly is crucial for counseling pregnant patients.

•

Three-dimensional multiplanar ultrasound imaging may be of special use.

Advanced Imaging for the Diagnosis and Treatment of Coexistent Renal and Müllerian Abnormalities

PURPOSE OF REVIEW

Abnormal development of the uterus, cervix, and proximal 2/3 of the vagina results in Müllerian duct anomalies. Because of the close embryologic relationship between the developing female genital and urinary tracts, abnormalities of the urinary tract often accompany Müllerian duct anomalies. Magnetic resonance imaging (MRI) is the current gold standard-imaging modality in the evaluation of the anomalies of the female reproductive tract. This article discusses the imaging evaluation of Müllerian duct and accompanying urinary tract anomalies with a particular focus on the MRI findings.

RECENT FINDINGS

Several studies have shown high concordance between MRI and three-dimensional ultrasound (3D US) in the evaluation of Müllerian duct abnormalities. 3D US is more cost effective than MRI but has not yet been fully substantiated as a comparable modality to MRI. Additionally, 3D US does not help elucidate concomitant anomalies of the urologic system. Müllerian duct anomalies are often associated with abnormalities of the urinary tract. Evaluation with MRI is important for the diagnosis of Müllerian duct anomalies and also helps with potential surgical planning.

Brachytherapy for cervical cancer in septate uterus: Dose-volume differences with tandem implant placement in right vs. left uterine canal: A case report

Brachytherapy is a standard treatment modality for locally advanced cervical cancer. In patients with uterine anomalies, the radiation dose to the target volume and the organs at risk can vary depending on the positioning of the brachytherapy tandem implant. However, there have been few reports concerning the use of brachytherapy in patients with uterine anomalies. The present study reports the case of a 55-year-old woman with locally advanced squamous cell carcinoma of the cervix and complete septate uterus. The patient was treated with external-beam radiation therapy, cisplatin chemotherapy, and brachytherapy. Computed tomography-based planning was performed for image-guided brachytherapy with the tandem implant alternately in the right and left uterine canals and using the right and left point A. A comparison of the resulting dose-volume histograms revealed wide variations in the projected dose to the clinical target volume and organs at risk. Tandem implant positioning for brachytherapy was chosen to optimize the dose-volume distribution. At the point of writing, the patient has not experienced local recurrence.

Uterus unicornis and pregnancy in two feline littermates

Case series summary

A queen, tom and four 1-year-old female offspring presented for routine neuter. Two of the littermates (cats 1 and 2) were diagnosed with a uterine abnormality during surgery. The left uterine horn of both cats appeared as a thin, solid, cord-like structure, whereas the right uterine horn of both cats appeared to have intermittent bulges consistent with pregnancy. The two other littermates, queen and tom were reproductively normal. The uteruses of the affected cats were nearly identical with a gross and histopathologic diagnosis of uterus unicornis with concurrent pregnancy. Ovaries were present, bilaterally. An oviduct was present only on the single normally developed and pregnant uterine horn in both cats. At a postoperative follow-up evaluation, abdominal ultrasound was performed on the two cats with uterine abnormalities. Cat 1 was ultrasonographically within normal limits. Cat 2 was diagnosed with ipsilateral renal agenesis on the same side as the absent uterine horn.

Relevance and novel information

The complexity of uterus unicornis and renal aplasia is demonstrated by this unique presentation of five related cats for ovariohysterectomy. This report raises questions regarding the genetic, environmental, hormonal or other underlying causes of this anatomic abnormality in cats that may spur additional research. This is the first publication describing uterus unicornis in gravid feline littermates, with one of the cats having ipsilateral renal agenesis. This is also the first publication to describe oviduct agenesis on the affected uterine horn in feline uterus unicornis.