112 The association between ovarian maldescent and uterine septum

Abstract

Maldescended ovaries are rarely encountered and frequently associated with unicornuate uterus and Mϋllerian agenesis. Clinical presentation varies and may mimic other conditions and pathologies; therefore, diagnoses can be challenging. The most common setting of ovarian maldescent is during infertility workup. The aim of this case series study is to increase the awareness of practitioners regarding the association between ovarian maldescent and septate uterus and significant arcuate anomaly in infertile patients or patients with chronic pelvic pain (CPP). Our study is a retrospective case series of four patients; three of whom presented with primary infertility and one with CPP (2014-2018). As part of our basic workup imaging studies were obtained. In all patients it was difficult to visualize the ovaries on trans-vaginal 2D ultrasound (TV 2D US). Hysterosalpingogram in one patient demonstrated fallopian tubes to be elongated and drawn cephalad. Uterine anomalies were suspected on TV 3D US in all four patients. All patients had laparoscopy and hysteroscopy. Hysteroscopy confirmed uterine anomalies, which included one septate uterus, two subseptate uteri, and one significant arcuate anomaly. Septoplasty was performed in all cases. Diagnostic laparoscopy showed patent elongated fallopian tubes and oval-shaped ovaries reaching the pelvic brim in all patients. Three patients had stage 1 endometriosis requiring argon beam coagulation and two required minimal ovariolysis. All three patients who had primary infertility underwent controlled ovarian stimulation (COS) and intrauterine insemination. Monitoring of follicular growth by TV 2D US was sometimes difficult and therefore, trans-abdominal US was also utilized on some occasions. Two patients achieved pregnancy, and both had singleton live birth at term. The remaining patient did not achieve pregnancy after one cycle of COS, and for social reasons discontinued treatment. Our fourth patient who initially presented for CPP and septate uterus was not seeking pregnancy and her symptoms improved after surgery. In conclusion ovarian maldescent is a rare pathology where the ovaries may be found outside the ovarian fossa. Our data suggests that this rare entity can occur in association with septate uterus, subseptate uterus and significant arcuate uterine anomaly. In addition, endometriosis is frequently present in patients with ovarian maldescent. Our experience also suggests a good reproductive outcome after septoplasty and appropriate fertility treatment in such patients. During in-vitro fertilization treatment of patients with ovarian maldescent, trans-abdominal US guided oocyte retrieval may be required if the trans-vaginal US guided retrieval proves to be difficult.